Survey of Canadian critical care physicians' knowledge and attitudes towards legislative aspects of the deceased organ donation system.

PURPOSE: We surveyed Canadian critical care physicians who may care for patients who are potential organ donors to understand their attitudes and knowledge of legislation governing the deceased organ donation system. METHODS: We used a web-based, self-administered survey that included questions related to opt-out consent and mandatory referral legislation. Potential participants were identified through membership lists of professional societies and manual searches. We designed our survey using standardized methods and administered it in February and March 2018. RESULTS: Fifty percent (263/529) of potential participants completed the questionnaire. A majority (61%; 144/235) supported a change towards an opt-out consent model, and 77% (181/235) stated they believe it would increase donation rates. Asked if opt-out consent would change their practices, 71% (166/235) stated an opt-out model would not change how or if they approach families to discuss donation. Fifty-six percent (139/249) supported mandatory referral laws, while only 42% (93/219) of those working in provinces with mandatory referral correctly stated that such laws exist in their province. Respondents gave variable responses on who should be accountable when patients are not referred, and 16% (40/249) believed no one should be held accountable. CONCLUSIONS: While a majority of critical care physicians supported opt-out consent and mandatory referral, many were neutral or against it. Many were unaware of existing laws and had variable opinions on how to ensure accountability. Efforts to increase understanding of how legislative models influence practice are required for any law to achieve its desired effect.

RéSUMé: OBJECTIF: Nous avons étudié les intensivistes canadiens qui prennent soin de patients potentiellement donneurs d'organes afin de comprendre leurs attitudes et connaissances quant aux lois régissant le système de don d'organes de donneurs décédés. MéTHODE: Nous avons utilisé un sondage électronique auto-administré incluant des questions liées au consentement implicite avec option de retrait et à la législation de référence obligatoire. Les participants potentiels ont été identifiés grâce aux listes des sociétés professionnelles et par des recherches manuelles. Nous avons conçu notre sondage à l'aide de méthodes standardisées et l'avons administré en février et mars 2018. RéSULTATS: Cinquante pour cent (263/529) des participants potentiels ont complété le questionnaire. La majorité (61 %; 144/235) était en faveur d'un changement vers un modèle de consentement avec option de retrait, et 77 % (181/235) ont déclaré penser que cela augmenterait les taux de don. Lorsqu'il leur a été demandé si l'option de consentement avec option de retrait modifierait leur pratique, 71 % (166/235) ont affirmé qu'un modèle avec possibilité de retrait ne modifierait pas leur façon ou leur intention d'approcher les familles pour parler de don d'organes. Cinquante-six pour cent (139/249) étaient en faveur de lois concernant la référence obligatoire, alors que seulement 42 % (93/219) des intensivistes travaillant dans des provinces où la référence était obligatoire ont correctement déclaré que de telles lois existaient dans leur province. Les répondants ont donné des réponses variables quant à l'imputabilité lors de la non-référence des patient, et 16 % (40/249) étaient d'avis que personne ne devrait être tenu responsable. CONCLUSION: Alors que la majorité des intensivistes était en faveur du consentement avec option de retrait et de la référence obligatoire, bon nombre n'avaient pas d'avis sur la question ou étaient contre. De nombreux intensivistes ne connaissaient pas bien les lois existantes et avaient des opinions variables sur la façon de garantir l'imputabilité. Des efforts sont nécessaires pour augmenter la compréhension de la manière dont les modèles législatifs influencent la pratique afin qu'une loi, quelle qu'elle soit, ait l'effet désiré.

Effect of a 12-week mixed power training on physical function in dynapenic-obese older men: does severity of dynapenia matter?

INTRODUCTION: Mobility disability affects nearly 15% of people aged 65 or over worldwide. Excess weight or obesity (OB), along with an accentuated loss of muscle strength (dynapenia), is recognized to be one of the most common risk factors for mobility impairment among the elderly. OBJECTIVE: To investigate the effect of a 12-week mixed power training (MPT high-velocity resistance training mixed with functional exercises) on physical function in obese older men exhibiting different severities of dynapenia. METHODS: Community-dwelling older men (69 ± 6 years) were assigned to the study if they were considered obese (OB, fat mass ≥ 25% body weight, BW) and to one of the two groups according to severity of dynapenia [(handgrip strength-HS)/BW]: type 1(OB-DY1) or type 2(OB-DY2), < 1 or 2SD from a young reference group. Participants followed a 12-week MPT, three times/week, 75 min/session. Main outcomes included the performance on the 4-m and 6-min walking tests, Timed Up and Go, stair and balance tests. RESULTS AND DISCUSSION: At baseline, OB-DY1 performed better than OB-DY2 in all functional tests (p < 0.05). Following the intervention, medium-to-large training effect size (ES) were observed for fat (ES = 0.21) and lean (ES = 0.32, p < 0.001) masses, functional performance (ES 0.11-0.54, p < 0.05), HS (ES = 0.10, p < 0.05) and lower limb muscle strength (ES = 0.67, p < 0.001) and power (ES = 0.60, p < 0.05). Training-by-group interaction showed that OB-DY1 lost more FM (ES = 0.11, p = 0.03) and OB-DY2 improved more HS (ES = 0.19, p = 0.006) than their counterparts. CONCLUSIONS: Seniors with obesity and severe dynapenia have poorer physical function than those in the early stage of dynapenia. Both seem to benefit from a high-velocity resistance training mixed with functional exercises, although by slightly different pathways.

Locomotor training using an overground robotic exoskeleton in long-term manual wheelchair users with a chronic spinal cord injury living in the community: Lessons learned from a feasibility study in terms of recruitment, attendance, learnability, performance and safety.

BACKGROUND: For individuals who sustain a complete motor spinal cord injury (SCI) and rely on a wheelchair as their primary mode of locomotion, overground robotic exoskeletons represent a promising solution to stand and walk again. Although overground robotic exoskeletons have gained tremendous attention over the past decade and are now being transferred from laboratories to clinical settings, their effects remain unclear given the paucity of scientific evidence and the absence of large-scale clinical trials. This study aims to examine the feasibility of a locomotor training program with an overground robotic exoskeleton in terms of recruitment, attendance, and drop-out rates as well as walking performance, learnability, and safety. METHODS: Individuals with a SCI were invited to participate in a 6 to 8-week locomotor training program with a robotic exoskeleton encompassing 18 sessions. Selected participants underwent a comprehensive screening process and completed two familiarization sessions with the robotic exoskeleton. The outcome measures were the rate of recruitment of potential participants, the rate of attendance at training sessions, the rate of drop-outs, the ability to walk with the exoskeleton, and its progression over the program as well as the adverse events. RESULTS: Out of 49 individuals who expressed their interest in participating in the study, only 14 initiated the program (recruitment rate = 28.6%). Of these, 13 individuals completed the program (drop-out rate = 7.1%) and attended 17.6 ± 1.1 sessions (attendance rate = 97.9%). Their greatest standing time, walking time, and number of steps taken during a session were 64.5 ± 10.2 min, 47.2 ± 11.3 min, and 1843 ± 577 steps, respectively. During the training program, these last three parameters increased by 45.3%, 102.1%, and 248.7%, respectively. At the end of the program, when walking with the exoskeleton, most participants required one therapist (85.7%), needed stand-by or contact-guard assistance (57.1%), used forearm crutches (71.4%), and reached a walking speed of 0.25 ± 0.05 m/s. Five participants reported training-related pain or stiffness in the upper extremities during the program. One participant sustained bilateral calcaneal fractures and stopped the program. CONCLUSIONS: This study confirms that larger clinical trials investigating the effects of a locomotor training program with an overground robotic exoskeleton are feasible and relatively safe in individuals with complete motor SCI. Moreover, to optimize the recruitment rate and safety in future trials, this study now highlights the need of developing pre-training rehabilitation programs to increase passive lower extremity range of motion and standing tolerance. This study also calls for the development of clinical practice guidelines targeting fragility fracture risk assessment linked to the use of overground robotic exoskeletons.

Inpatient Physical Therapy in Moderate to Severe Traumatic Brain Injury in in Older Adults: A Scoping Review.

BACKGROUND: Around 500/100,000 Canadians experience a traumatic brain injury (TBI) resulting in long-term disabilities and premature death. Physiotherapy is known to positively impact the prognosis of young adults following a TBI. OBJECTIVE: This is a scoping review that aimed to identify research topics in physiotherapy interventions for seniors after a TBI, describe potential knowledge gaps, and uncover needs for future research. METHODOLOGY: Ten databases were interrogated (January-March 2022). We included texts published after 2010, in English or French, scientific papers, guidelines, and gray literature sources targeting in-hospital, acute-to-subacute interventions for people aged ≥55 years old with a moderate-to-severe TBI. The outcomes sought were physical/functional capacities, injury severity, and quality of life. RESULTS: From 1296 articles, 16 were selected. The number of participants from the studies altogether was 248,794. We identified eight retrospectives studies, three clinical trials, and five articles from the gray literature. Articles were classified according to the nature of their analysis and outcomes: (1) interventional studies including physiotherapy (at least 10 types of rehabilitative or preventive interventions were identified); (2) studies evaluating prognostic factors (five factors identified); and (3) recommendations from clinical practical guidelines and other sources (gray literature). Our results provide evidence that physiotherapy is effective in TBI acute rehabilitation for the elderly to prevent complications arising from the primary injury and to improve functional capacities. CONCLUSION: The heterogeneity of our results does not allow us to infer the effectiveness of one intervention over another. However, we found that the elderly population benefits from physiotherapy interventions as much as adults, but the gap must be filled with higher-quality studies to make definite recommendations.

Impact of high-intensity interval training with or without l-citrulline on physical performance, skeletal muscle, and adipose tissue in obese older adults.

BACKGROUND: Aging is associated with a progressive decline in skeletal muscle mass and strength as well as an increase in adiposity. These changes may have devastating impact on the quality of life of older adults. Mitochondrial dysfunctions have been implicated in aging-related and obesity-related deterioration of muscle function. Impairments in mitochondrial quality control processes (biogenesis, fusion, fission, and mitophagy) may underlie this accumulation of mitochondrial dysfunction. High-intensity interval training (HIIT) was shown to improve muscle and mitochondrial function in healthy young and old adults and to improve body composition in obese older adults. Recent studies also positioned citrulline (CIT) supplementation as a promising intervention to counter obesity-related and aging-related muscle dysfunction. In the present study, our objectives were to assess whether HIIT, alone or with CIT, improves muscle function, functional capacities, adipose tissue gene expression, and mitochondrial quality control processes in obese older adults. METHODS: Eighty-one-old and obese participants underwent a 12 week HIIT with or without CIT on an elliptical trainer [HIIT-CIT: 20 men/25 women, 67.2 ± 5.0 years; HIIT-placebo (PLA): 18 men/18 women, 68.1 ± 4.1 years]. Handgrip and quadriceps strength, lower limb muscle power, body composition, waist circumference, and functional capacities were assessed pre and post intervention. Vastus lateralis muscle biopsies were performed in a subset of participants to quantify markers of mitochondrial content (TOM20 and OXPHOS subunits), biogenesis (TFAM), fusion (MFN1&2, OPA1), fission (DRP1), and mitophagy (Parkin). Subcutaneous abdominal adipose tissue biopsies were also performed to assess the expression of genes involved in lipid metabolism. RESULTS: HIIT-PLA and HIIT-CIT displayed improvements in functional capacities (P < 0.05), total (mean ± SD: HIIT-PLA: +1.27 ± 3.19%, HIIT-CIT: +1.05 ± 2.91%, P < 0.05) and leg lean mass (HIIT-PLA: +1.62 ± 3.85%, HIIT-CIT: +1.28 ± 4.82%, P < 0.05), waist circumference (HIIT-PLA: -2.2 ± 2.9 cm, HIIT-CIT: -2.6 ± 2.5 cm, P < 0.05), and muscle power (HIIT-PLA: +15.81 ± 18.02%, HIIT-CIT: +14.62 ± 20.02%, P < 0.05). Only HIIT-CIT decreased fat mass (-1.04 ± 2.42%, P < 0.05) and increased handgrip and quadriceps strength (+4.28 ± 9.36% and +10.32 ± 14.38%, respectively, P < 0.05). Both groups increased markers of muscle mitochondrial content, mitochondrial fusion, and mitophagy (P < 0.05). Only HIIT-CIT decreased the expression of the lipid droplet-associated protein CIDEA (P < 0.001). CONCLUSIONS: High-intensity interval training is effective in improving functional capacities, lean mass, muscle power, and waist circumference in obese older adults. HIIT also increases markers of mitochondrial biogenesis, mitochondrial fusion, and mitophagy. Importantly, adding CIT to HIIT results in a greater increase in muscle strength and a significant decrease in fat mass. The present study therefore positions HIIT combined with CIT as an effective intervention to improve the health status of obese older adults.

Baduanjin Qigong Intervention by Telerehabilitation (TeleParkinson): A Proof-of-Concept Study in Parkinson's Disease.

Many people living with Parkinson's Disease (PD) face issues with healthcare services, including delays in diagnosis and treatment, as well as limited access to specialized care, including rehabilitation programs. Non-motor and motor signs and symptoms typically observed in people with PD, such as tremor, rigidity, postural instability, bradykinesia, and freezing are particularly disabling and have been associated with falls, fractures, hospitalizations, and a worse quality of life. Baduanjin Qigong (BDJ) programs have been proven potentially effective in improving physical outcomes and reducing the incidence of falls in PD. The aim of this case report, proof-of-concept, study was to explore the adherence, feasibility, acceptability, and potential efficacy of a BDJ program offered via telerehabilitation in people with PD living in the community. Two participants performed semi-supervised exercise sessions at home, twice a week (over eight weeks) using the TeraPlus platform. Adherence, adverse events, and feasibility (technical implementability), acceptability (patient satisfaction), patient-reported, self-reported, and performance outcomes were measured. Results were based on single-subject descriptive data, minimal detectable change, and anchor-based minimally important difference. Our findings suggest that the intervention seems feasible with no major technical issues or adverse events, and high adherence; acceptable (patient satisfaction); and potentially effective to improve markers of walking performance (gait speed, balance), and quality of life (activities of daily living, mobility).

A new approach toward gait training in patients with Parkinson's Disease.

BACKGROUND: Typically, people with Parkinson's Disease (PD) progress to develop a gait pattern that is characterized by quick, short and shuffling steps. Gait cycle is altered and lacks definition and fluidity. Gait training combined with a variety of feedback modalities for PD are usually based on non-immediate and externally-based cues but none of these provide real-time feedback on gait quality and acquired gains tend to abate shortly after rehabilitation. Based on principals of motor learning, our team has developed the Heel2Toe sensor to provide real-time auditory feedback during gait training. RESEARCH QUESTION: Is a short-term training using the Heel2Toe sensor feasible and efficient to improve gait in people with PD? Our objectives are to identify the extent of the immediate response to the feedback within the same session and the carry-over response to training and; 2) to identify patients' perceived effects, pleasures and challenges of using the Heel2Toe. METHODS: Single-arm, proof-of-concept study. Six people received five sessions of gait training over a 2-3-week period using the Heel2Toe augmented with mobility exercises as an adjunct to gait training. The main outcomes were technically assessed gait parameters collected over a 2-minute walk test, without and with feedback. Heel2Toe signals were analyzed to extract angular velocity(AV), percentage of good steps, average cadence, and AV coefficient of variation(CV). RESULTS: An immediate response to the Heel2Toe use and a carry-over response to the short-term training with the sensor were observed: an increase in AV with a reduction in CV (better heel strike and gait regularity); an increase in %good steps; and a near-optimal and homogeneous cadence (∼100 steps/min), which is equivalent to a moderate-intensity walking. SIGNIFICANCE: Gait training using the Heel2Toe sensor is feasible and potentially effective for improving gait quality in people with PD. A definitive trial is a logical next step.

A Systematic Approach for Prescribing Posthospitalization Home-Based Physical Activity for Mobility in Older Adults: The PATH Study.

BACKGROUND: Older patients experience increased loss of mobility after hospitalization, largely because of physical disabilities and inactivity. There are, however, no current recommendations for prescribing physical activity (PA) at hospital discharge. OBJECTIVES: Develop a decisional tree for the systematic prescription of an individualized, adapted, nonsupervised home-based PA program for older adults after hospital discharge; investigate its feasibility, acceptability, and safety; and estimate its efficacy at improving physical function and mobility. DESIGN: Pragmatic prospective single-arm pilot study. SETTING AND PARTICIPANTS: Geriatric assessment unit (GAU). PARTICIPANTS: Age ≥65 years, Mini-Mental State Examination score ≥18, hospitalization >7 days, discharge to home, no PA contraindications, understand French or English. METHODS: Development of a decisional tree for prescription of home-based exercise programs (Preventing loss of Autonomy by Treatment Post-Hospitalization: PATH tool) through meetings with a group of experts. The PATH tool was implemented in a short-term geriatric hospital. Feasibility, acceptability, and safety outcomes were measured and potential efficacy estimated after a 12-week period. RESULTS: The decisional tree has 3 main components (cognitive, cardio strength, and balance) and comprises 27 different mobility profiles and PA programs. Fifty-six of the first 100 successively admitted GAU patients were found eligible, of whom 29 agreed to participate and 17 completed the protocol. Most were satisfied (14/17) and enjoyed (13/17) the program, and most health professionals found it relevant to patients (7/8) without extra burden (6/8) to patient care. Adherence to the PA program was 5 sessions/wk, and a medium to large effect size on walking speed (P < .01, d = 1.04), chair stand performance (P = .04, d = 0.75), and PA level (P = .07, d = 0.56) was observed after a 12-week period. CONCLUSIONS AND IMPLICATIONS: This study suggests that implementing the PATH tool might be feasible across GAUs, as well as safe and acceptable for patients and health care professionals. If this intervention proves beneficial after conducting a randomized controlled trial, this hospital-initiated care transition strategy should be implemented in short-term geriatric hospitals to prevent long-term mobility disability.

Effect of High-Intensity Interval Training Combined with L-Citrulline Supplementation on Functional Capacities and Muscle Function in Dynapenic-Obese Older Adults.

BACKGROUND: To compare the effects of high-intensity interval training (HIIT) alone vs. HIIT combined with L-citrulline (CIT) supplementation on functional capacity and muscle function in dynapenic-obese elderly. METHODS: A total of 56 obese (fat mass: men > 25%, women > 35%) and dynapenic (grip strength/body weight: women < 0.44, men < 0.61) subjects were recruited and divided in two groups: HIIT+CIT (n = 26; age: 6 5 ± four years) vs. HIIT+Placebo (PLA, n = 30; age: 68 ± four years). Participants followed a 12-week HIIT using an elliptical trainer. Participants took a single and isocaloric 10 g-dose of CIT or PLA every day. Body composition; functional and aerobic capacities; absolute or relative upper and lower limbs muscle strength, muscle power; and energy balance were measured pre and post intervention. RESULTS: Both groups significantly improved functional capacity and muscle function. However, HIIT+CIT demonstrated greater improvements in fast-paced Timed Up & Go (p = 0.04) and upper limbs muscle strength (absolute and relative) (p = 0.05) than HIIT+Placebo. CONCLUSION: CIT supplementation when combined with HIIT seems to induce greater improvements in upper limbs muscle strength and walking speed in dynapenic-obese elderly. Further studies are needed to confirm our results, to elucidate the mechanisms underlying the beneficial effects of CIT and to define the long-term impact of CIT/HIIT.

Metabolic syndrome impact on cardiac autonomic modulation and exercise capacity in obese adults.

Obesity is often associated with increased risk of cardiometabolic morbidities and mortality. However, evidence shows that some obese individuals are more likely to develop such risk factors early in life, including those with Metabolic Syndrome (MetS). Whether the presence of MetS in obese people impairs cardiac autonomic modulation (CAM) remains to be investigated. METHODS: Cross-sectional study. Sixty-six subjects were classified as normal-weight (NW, n = 24) or obese (BMI ≥ 30 kg·m-2): metabolically healthy (MHO, n = 19) vs unhealthy (MUHO, n = 23: NCEP/ATPIII-MetS criteria). Body composition (bioimpedance), metabolic (glucose-insulin/lipid) and inflammatory profiles were determined. Linear and nonlinear heart rate variability (HRV) indices were computed at rest and during the submaximal six-minute step test (6MST). Blood pressure (BP) and metabolic and ventilatory variables were assessed (oxygen uptake, VO2; carbon dioxide production, VCO2; minute ventilation, VE) during the 6MST and the maximal cardiopulmonary exercise testing (CPX). RESULTS: All groups reached the same 6MST intensity (VO2 ~ 80% and HR ~ 87% of CPX peak values). Both obese groups, independently of MetS, presented higher BP and lower maximal VO2 than NW. However, HRV differed between groups according to MetS at rest and during exercise: MUHO had lower meanRRi and SD1 than NW and lower RMSSD and pNN50 than MHO at rest; during exercise, the lowest SDNN, TINN, SD1 and Shannon entropy were observed for MUHO. Significant correlations were found between MetS, insulin resistance and HRV indices; and between insulin resistance and aerobic capacity (VO2peak). CONCLUSION: Obesity per se impairs aerobic-hemodynamic responses to exercise. However, MetS in obese young adults negatively impacts overall HRV, parasympathetic activity and HRV complexity.