Does aerobic exercise benefit persons with tetraplegia from spinal cord injury? A systematic review.

CONTEXT: This review synthesizes the findings of previous research studies on the cardiovascular and metabolic benefits of aerobic exercise for individuals with tetraplegia secondary to spinal cord injury. They are often less active due to muscular paralysis, sensory loss, and sympathetic nervous system dysfunction that result from injury. Consequently, these persons are at higher risk for exercise intolerance and secondary health conditions. OBJECTIVE: To evaluate the evidence concerning efficacy of aerobic exercise training for improving health and exercise performance in persons with tetraplegia from cervical injury. METHODS: The search engines PubMed and Google Scholar were used to locate published research. The final 75 papers were selected on the basis of inclusion criteria. The studies were then rank-ordered using Physiotherapy Evidence Database. RESULTS: Studies combining individuals with tetraplegia and paraplegia show that voluntary arm-crank training can increase mean peak power output by 33%. Functional electrical stimulation leg cycling was shown to induce higher peak cardiac output and stroke volume than arm-crank exercise. A range of peak oxygen uptake (VO2peak) values have been reported (0.57-1.32 L/min). Both VO2peak and cardiac output may be enhanced via increased muscle pump in the legs and venous return to the heart. Hybrid exercise (arm-crank and functional electrical stimulation leg cycling) can result in greater peak oxygen uptake and cardiovascular responses. CONCLUSION: Evidence gathered from this systematic review of literature is inconclusive due to the lack of research focusing on those with tetraplegia. Higher power studies (level 1-3) are needed with the focus on those with tetraplegia.

Peripheral Artery Disease: What You Need to Know.

Synopsis Claudication from peripheral artery disease (PAD) may mimic or coexist with musculoskeletal conditions and represents an important diagnostic consideration in patients over 50 years of age. Physical therapists are optimally positioned to recognize this condition by incorporating a vascular history and physical examination in appropriately selected patients. Recognition of PAD is important both from the standpoint of addressing the ischemic risk to the limb and because PAD is associated with high cerebrovascular and cardiovascular risk. Therefore, multidisciplinary management of patients with PAD is essential. Extensive evidence supports treatment of PAD-related claudication with supervised exercise, and physical therapists are well positioned to play an important role in this treatment. J Orthop Sports Phys Ther 2017;47(12):957-964. Epub 9 Oct 2017. doi:10.2519/jospt.2017.7442.

Influence of Functional Capacity Evaluation on Physician's Assessment of Physical Capacity of Veterans With Chronic Pain: A Retrospective Analysis.

BACKGROUND: Physicians have difficulty predicting patients' occupational limitations, abilities, and success from clinical evaluation (CE) of pathology and impairments, especially in the presence of chronic pain. Additional information from a functional capacity evaluation (FCE) may improve the accuracy of their physical capacity assessments. It is not known whether FCE information will change these assessments. No such study has been published using Veterans or non-Veterans. OBJECTIVE: To determine the influence of FCE data on the physician's assessment of the US Department of Labor's Dictionary of Occupational Titles (DOT) work capacity levels of Veterans with chronic moderate-intensity pain. DESIGN: Retrospective analysis. SETTING: Tertiary care medical center. PARTICIPANTS: Veterans aged 18-60 years with moderate chronic musculoskeletal pain who were seeking employment. METHODS: Two kinesiotherapists performed FCEs on all participants, namely, the lumbar protocol of the EvalTech Functional Testing System (BTE, Inc, Hanover, MD). One physiatrist performed CEs in all participants. Two other physiatrists assessed DOT physical capacity levels using CE data alone and later using combined CE and FCE data. MAIN OUTCOME MEASUREMENTS: DOT physical capacity level (sedentary = 1, light = 2, medium = 3, heavy = 4, very heavy = 5). RESULTS: Of 55 charts reviewed, 27 met inclusion/exclusion criteria. The mean age was 38 years, and there were 25 male and 2 female participants. The predominant pain location was the lower back. DOT scores for 2 physicians were averaged. The mean ± SD DOT scores for CE only and CE+FCE conditions were 2.04 ± 0.33 and 2.40 ± 0.90, respectively. In all, 65% of DOT scores changed (17% decreased and 48% increased at least 1 level) after FCE data were considered. A 1-sample t test revealed that the mean CE+FCE DOT score was significantly greater than the mean CE-only score (by 20%, P = .02). Interrater agreement (weighted κ) for CE+FCE-based DOT scores was much higher than for CE alone (0.715 versus 0.182). CONCLUSION: The addition of FCE data to CE changed the majority of physician-assigned DOT levels. FCE significantly increased the mean DOT physical work capacity level provided by the physician to Veterans with chronic moderate-intensity pain, especially if the initial assessment was designated as "light." FCE may facilitate a more objective and accurate determination of Veterans' work capacity. LEVEL OF EVIDENCE: III.

Calf tissue oxygenation during exercise in men with and without risk factors for developing peripheral arterial disease.

OBJECTIVE: This study aimed to compare calf tissue oxygenation responses to calf exercise in men without diagnosed peripheral arterial disease but with selected risk factors for peripheral arterial disease with those without risk factors. DESIGN: A cross-sectional quasi-experimental design was used. The no-risk group (n = 20) had none of the risk factors (diabetes, hypertension, hyperlipidemia, obesity, current or 10 pack-yr smoking history, or age ≥65 yrs). The at-risk group (n = 45) had one to six risk factors. Medial calf tissue oxygenation (percentage saturation) was determined using near-infrared spectroscopy during seven consecutive 5-min test stages: rest, 0-W active plantar/dorsiflexion, rest, 4-W resistive plantar flexion, rest, 8-W resistive plantar flexion, and rest. Resistive exercise was performed on the Stresst'er calf ergometer. RESULTS: Compared with the no-risk group, decrements in calf tissue oxygenation induced by light-to-moderate resistive calf exercise in the at-risk group was significantly greater (by 9% saturation) (4-W: P < 0.001; 8-W: P = 0.002). CONCLUSIONS: Men with risk factors for developing peripheral arterial disease but without such diagnosis demonstrated greater decrements in calf tissue oxygenation during calf exercise compared with men without risk factors. Further development of this test may lead to early diagnosis and intervention to modify risk factors and prevent co-morbidities.

Ergometric performance during exercise training in men with intermittent claudication.

OBJECTIVE: To determine and describe changes in weekly work, power, exercise times, and recovery times during an exercise training intervention in men with peripheral arterial disease (PAD) and intermittent calf claudication. DESIGN: Tracking of weekly exercise training parameters involved repeated measures over time in one group of participants. Other outcomes of this pilot study used a one-group, pretest-posttest design. SETTING: Tertiary-care medical center. PARTICIPANTS: Fifteen male veterans (mean age, 69 years) with Fontaine stage IIa PAD and classic intermittent calf claudication. MAIN OUTCOME MEASUREMENTS: Participants completed graded treadmill exercise tests before and after intervention from which maximal walking power was calculated. Work, power, and exercise and recovery times for each exercise training session were computed and averaged for each week. INTERVENTION: The intervention consisted of an intensive 3-month exercise training program involving walking and calf muscle exercises: 3 sessions per week at the clinic (treadmill walking and calf ergometry) and 2 sessions per week at home (free walking and standing heel raises). RESULTS: After training, participants increased treadmill maximal walking power from 220 to 414 W (by 87%). Treadmill and calf exercise work, power, and exercise time per session increased linearly during 13 weeks of training, whereas recovery time per session of treadmill exercise decreased. During the same period, treadmill and calf exercise training power outputs increased by averages of 227% and 92%, respectively. CONCLUSION: Calculation of work and power during exercise training can be used to track progress quantitatively at short intervals. Weekly linear increases in training work and power per exercise session suggest that optimal intervention duration may be longer than 3 months for men with PAD and intermittent calf claudication.

Preamputation evaluation of lower-limb skeletal muscle perfusion with H(2) (15)O positron emission tomography.

OBJECTIVE: To establish whether muscle blood flow (MBF) measurements with O-water positron emission tomography could reliably identify patients with critical limb ischemia and detect and quantify a distal deficit in skeletal MBF in these cases. DESIGN: O-water positron emission tomography scans were performed at rest or during unloaded ankle plantar and dorsiflexion exercise of the diseased leg in 17 subjects with leg ischemia or on a randomly selected leg of 18 age-matched healthy control subjects. TcPO2 was evaluated with Novametrix monitors and perfusion of skin topically heated to 44 degrees C and adjacent nonheated areas with a Moor Instruments laser Doppler imaging scanner. RESULTS: The enhancement of MBF induced by exercise was significantly lower in ischemic than in normal legs, and the sensitivity and specificity of this phenomenon were similar to those of laser Doppler imaging or TcPO2 in identifying ischemia subjects. In addition, the exercise MBF deficit was predominant at the distal-leg levels, indicating the ability of the technique to help determine the correct level of amputation. CONCLUSIONS: Skeletal MBF of legs with severe ischemia can be detected accurately with O-water positron emission tomography and could add valuable information about viability of skeletal muscle in the residual limb when deciding the level of an amputation.

Effects of exercise training on calf tissue oxygenation in men with intermittent claudication.

OBJECTIVE: To determine the effects of exercise training on calf tissue oxygenation in men with peripheral arterial disease and intermittent calf claudication. DESIGN: This pilot study was prospective and longitudinal and used a one-group, pretest-posttest design. SETTING: Tertiary care medical center for veterans. PARTICIPANTS: Fifteen male veterans (mean age 69 years) with Fontaine stage IIa peripheral arterial disease and classic intermittent claudication. MAIN OUTCOME MEASUREMENTS: Before and after intervention, participants performed graded treadmill exercise tests while medial calf tissue oxygenation (StO(2), % oxyhemoglobin saturation) was monitored continuously with near-infrared spectroscopy. INTERVENTION: The intervention consisted of a 3-month exercise training program involving 3 sessions per week at the clinic (treadmill walking, calf ergometry) and 2 sessions per week at home (free walking, standing heel raises). RESULTS: After completion of the intervention, participants significantly increased their maximal treadmill exercise time from 7.19 to 11.27 minutes. Mean exercise StO(2) decreased from 29% to 19% saturation, StO(2) x time area increased from 421% * min to 730% * min StO(2) nadir, and StO(2) recovery time did not change significantly. CONCLUSIONS: After the exercise intervention, the improved treadmill walking performance was accompanied by greater calf tissue deoxygenation during exercise. Given the continued presence of ischemia, this finding may represent increased capillarization and diffusion-based enhancement of arteriovenous O(2) extraction.

Exploring the health of women with mobility impairments.

This study examined health surveys of 109 midwestern women (mean age 44.6 +/- 8.2 years) with impaired mobility to determine whether mobility impairment severity was related to self-reported health, health care use, and engaging in health behaviors. The study also assessed which health factors were associated with pain. Women with severe mobility impairments reported poorer physical functioning, but better mental health than less severely impaired women after controlling for age, disability duration, and/or bodily pain. Degree of mobility impairment level was not significantly related to health behaviors, except having a checkup in the past year; more moderately impaired women reported these visits than mildly impaired women. Furthermore, pain was significantly associated with social functioning, general health, and secondary conditions. The findings suggest that factors beyond impairment level, such as pain, age, and disability duration, are related to the health of mobility-impaired women.

Scanning laser-Doppler imaging of leg- and foot-skin perfusion in normal subjects: analysis of age, gender, site, and laser-type effects.

OBJECTIVES: To report normal values of skin perfusion in healthy subjects in three age groups using a laser Doppler imager; to determine differences attributable to gender, age, site, and use of red or near-infrared lasers; and to correlate transcutaneous oxygen with laser flux values. DESIGN: Flux and transcutaneous oxygen were measured at ten sites in the lower extremity in 60 subjects from three age groups. Heated and unheated sites were scanned with red and near-infrared lasers. RESULTS: Heat hyperemia was prominent at all sites. Small, statistically significant mean +/- SD differences were found between heated and nonheated sites for the red and near-infrared lasers (P = 0.02). All flux ratios were independent of gender but were higher in the oldest group. Plantar sites demonstrated higher flux in unheated areas and lower flux ratios compared with leg sites. Transcutaneous oxygen did not correlate significantly with flux for either laser type. CONCLUSIONS: Scanning laser-Doppler imaging flux values provide a reference for identifying patients at risk for tissue ischemia and poor healing potential caused by impaired circulatory reserve in the legs and distal feet. The lack of correlation between flux and transcutaneous oxygen in healthy individuals suggests that they measure different physiologic processes.

Preamputation evaluation of limb perfusion with laser Doppler imaging and transcutaneous gases.

We studied 31 subjects with severe leg ischemia and 29 age-matched nonischemic control subjects to compare preamputation assessments of leg ischemia using laser Doppler imaging (LDI), transcutaneous partial pressure of oxygen (TcPO(2)), and transcutaneous partial pressure of carbon dioxide (TcPCO(2)). TcPO(2) and TcPCO(2) were evaluated with Novametrix Medical Systems, Inc, monitors (Wallingford, Connecticut) and perfusion (flux) of skin topically heated to 44 degrees C, and adjacent nonheated areas were evaluated with a Moor Laser Doppler Imager (Moor Instruments, Ltd; Devon, England). LDI flux of heated areas, its ratio to nonheated areas, and TcPO(2) (not TcPCO(2)) were lower in ischemic subjects than in control subjects. LDI flux ratio performed better than TcPO(2) in identifying ischemia, with fewer false positive and false negative results. Moreover, LDI flux of heated skin detected a proximal to a distal gradient of perfusion in ischemic subjects, while TcPO(2) did not. LDI was superior to TcPO(2) in discriminating correctly between ischemic and nonischemic skin. The results suggest that an LDI ratio below 5 indicates nonviable skin.

The physical activity scale for individuals with physical disabilities: development and evaluation.

OBJECTIVE: To evaluate the construct validity of a new 13-item physical activity survey designed to assess physical activity in individuals with physical disabilities. DESIGN: Mail survey requesting information on physical activity, basic demographic characteristics, self-rated health, and self-rated physical activity. SETTING: In February 2000, surveys were sent to 1176 individuals who had used rehabilitative services at a major midwestern university between 1950 and 1999. PARTICIPANTS: Two hundred twenty-seven men and 145 women with disabilities responded to the mail survey (80%, spinal cord or other locomotor injuries; 13%, visual and auditory injuries; 7%, other; 92%, white; mean age +/- standard deviation, 49.8 +/- 12.9y; mean length of disability, 36.9 +/- 14.9y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Physical activity was assessed with the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD). The PASIPD requests the number of days a week and hours daily (categories) of participation in recreational, household, and occupational activities over the past 7 days. Total scores were calculated as the average hours daily times a metabolic equivalent value and summed over items. RESULTS: Pearson correlations between each survey item and the total PASIPD score were all statistically significant (P < .05) and >or= .20 (range, .20- .67). Factor analysis with principal component extraction and varimax orthogonal rotations revealed 5 latent factors (eigenvalues >or= 1, factor loadings >or= .40): home repair and lawn and garden, housework, vigorous sport and recreation, light sport and recreation, and occupation and transportation. These 5 factors accounted for 63% of the total variance. Cronbach alpha coefficients ranged from.37 to.65, indicating low-to-moderate internal consistency within factors. Those who reported being "active/highly active" had higher total and subcategory scores compared with those "not active at all." Those in "excellent" health had higher total, vigorous sport and recreation, and occupation and transportation subcategory scores compared with those who rated their health "fair/poor" (all P < .05). CONCLUSION: These results provide preliminary support for the construct validity of the PASIPD. Additional validation studies using an external criterion and in more generalizable samples are warranted.