Benefits of Physical Training in Sarcoidosis.

BACKGROUND: Sarcoidosis patients suffer from fatigue and exercise limitation. The aim of this study was to establish whether a physical training program improves these and other outcomes important to sarcoidosis patients. METHODS: From 11/2012 to 9/2014, 201 sarcoidosis patients were referred to the ild care expertise team, Ede, the Netherlands. In our center, all patients are routinely recommended to undergo testing at baseline to determine their physical functioning and encouraged to complete a 12-week, supervised physical training program. Ninety patients underwent baseline testing and returned for repeat testing at 3 months in the interim, 49 completed the training program (Group I) and 41 chose not to participate (Group II). Change over time (from baseline to 3 months) in fatigue, exercise capacity, and skeletal muscle strength were assessed between the two groups. RESULTS: At baseline, there were no between-group differences for fatigue, DLCO%, FVC%, or exercise capacity [assessed by percent predicted six-minute walk distance (6MWD%) and Steep Ramp Test (SRT)]. The 6MWD for Group I improved between baseline and 3 months, while the 6MWD remained the same in Group II (F = 72.2, p < 0.001). Group I showed a significantly larger decrease of fatigue compared with Group II (F = 6.27, p = 0.014). Lung function tests did not change in either group. CONCLUSION: A supervised physical training program improves exercise capacity and fatigue among sarcoidosis patients and should be included in their management regimen.

The effect of an intervention of porcine protein versus maltodextrin supplement on CONvalescence of FUnCtional outcomes after IcU Stay (CONFUCIUS): Study protocol for a randomized controlled, single-center, double-blind trial.

BACKGROUND: Patients discharged from the Intensive Care Unit (ICU) frequently suffer from ICU-acquired weakness because of immobilization and massive inflammation-induced muscle mass loss. Consequently, rehospitalization, reduced quality of life (QoL), increased disabilities, and higher post-ICU mortality is observed. Exercise rehabilitation and optimal nutrition, particularly protein intake, are pivotal to regaining muscle mass and function. Studies have shown that protein requirements in the post-ICU phase are often unmet. Furthermore, protein supplementation in other patient groups has shown beneficial effects. However, a study on protein supplementation during the post-ICU period is lacking. This study aims to investigate the effect of a six-week intervention of daily porcine protein supplementation versus an isocaloric control (maltodextrin) on functional outcomes in the post-ICU period in patients with moderately severe ICU-acquired weakness. METHODS: 72 post-ICU patients with moderately severe ICU-acquired weakness of Hospital Gelderse Vallei will be randomly assigned to either the intervention or the control group (36 per arm). The intervention group receives a porcine protein supplement twice a day. The control group receives a maltodextrin supplement twice a day. The intervention starts on the first day in the general ward and lasts 42 days (6 weeks). The primary outcome is the between-group difference in physical function at hospital discharge (t;=2), the end of the intervention (t;=3, day 42), and the 3-month follow-up (t;=4) expressed as a composite score consisting of handgrip strength, muscle strength leg, muscle strength arm and exercise capacity. Secondary outcomes encompass physical function, QoL, Activity of daily living (ADL), and plasma amino acids concentrations. Lastly, ICU readmission after ICU discharge, hospital readmission after hospital discharge, and overall survival status will be considered. Linear mixed models will be used to test the treatment effect for the primary and secondary outcome measures. DISCUSSION: This trial will be the first to investigate porcine protein supplementation compared with carbohydrate supplementation in the post-ICU period aiming to improve functional outcomes of ICU survivors with moderately severe ICU-acquired weakness. TRIAL REGISTRATION: The study has been registered at ClinicalTrials.gov. Number: NCT05405764.

Physical recovery of COVID-19 pneumosepsis intensive care survivors compared with non-COVID pneumosepsis intensive care survivors during post-intensive care hospitalization: The RECOVID retrospective cohort study.

BACKGROUND: Coronavirusdisease 2019 (COVID-19) pneumosepsis survivors are at a high risk of developing intensive care unit (ICU)-acquired weakness (ICUAW) because of high incidence of acute respiratory distress syndrome and the common need for prolonged invasive ventilation. It remains unknown whether regular postpneumosepsis physical rehabilitation strategies are suitable for this extraordinary patient category. METHODS: We retrospectively compared the physical recovery of COVID-19 and non-COVID pneumosepsis ICU survivors during post-ICU hospitalization, defined as the difference in performance on the Medical Research Council Sum-Score (MRC-SS), Chelsea Critical Care Physical Assessment tool (CPAx), and percentage of predicted handgrip strength (POP-HGS). An analysis of covariance model was built using age, sex, Barthel index, body mass index, admission Acute Physiology And Chronic Health Evaluation II score, adequacy of protein delivery during ICU stay, and ward length of stay as covariates. RESULTS: Thirty-five COVID-19 ICU patients could be compared with 21 non-COVID pneumosepsis ICU survivors. All patients scored ≤48 on the MRC-SS at ICU discharge, indicating ICUAW. When controlling for covariates, COVID-19 patients performed worse on all physical assessments upon ICU discharge, but had improved more at hospital discharge on the MRC-SS (ɳ2 = 0.214, P =.002) and CPAx (ɳ2 = 0.153, P =.011). POP-HGS remained lower in COVID-19 patients throughout hospital stay. CONCLUSION: COVID-19 ICU survivors are vulnerable to ICUAW, but they show better tendency towards physical rehabilitation than non-COVID pneumosepsis ICU survivors during the post-ICU hospitalization period regarding MRC-SS and CPAx. COVID-19 ICU patients might benefit from early, more intensive physical therapy.

Health-Related Quality of Life (HRQoL) in Sarcoidosis: Diagnosis, Management, and Health Outcomes.

Health-related quality of life (HRQoL), though rarely considered as a primary endpoint in clinical trials, may be the single outcome reflective of patient priorities when living with a health condition. HRQoL is a multi-dimensional concept that reflects the degree to which a health condition interferes with participation in and fulfillment of important life areas. HRQoL is intended to capture the composite degree of physical, physiologic, psychological, and social impairment resulting from symptom burden, patient-perceived disease severity, and treatment side effects. Diminished HRQoL expectedly correlates to worsening disability and death; but interventions addressing HRQoL are linked to increased survival. Sarcoidosis, being a multi-organ system disease, is associated with a diffuse array of manifestations resulting in multiple symptoms, complications, and medication-related side effects that are linked to reduced HRQoL. Diminished HRQoL in sarcoidosis is related to decreased physical function, pain, significant loss of income, absence from work, and strain on personal relationships. Symptom distress can result clearly from a sarcoidosis manifestation (e.g., ocular pain, breathlessness, cough) but may also be non-specific, such as pain or fatigue. More complex, a single non-specific symptom, e.g., fatigue may be directly sarcoidosis-derived (e.g., inflammatory state, neurologic, hormonal, cardiopulmonary), medication-related (e.g., anemia, sleeplessness, weight gain, sub-clinical infection), or an indirect complication (e.g., sleep apnea, physical deconditioning, depression). Identifying and distinguishing underlying causes of impaired HRQoL provides opportunity for treatment strategies that can greatly impact a patient's function, well-being, and disease outcomes. Herein, we present a reference manual that describes the current state of knowledge in sarcoidosis-related HRQoL and distinguish between diverse causes of symptom distress and other influences on sarcoidosis-related HRQoL. We provide tools to assess, investigate, and diagnose compromised HRQoL and its influencers. Strategies to address modifiable HRQoL factors through palliation of symptoms and methods to improve the sarcoidosis health profile are outlined; as well as a proposed research agenda in sarcoidosis-related HRQoL.

Benefit of Wearing an Activity Tracker in Sarcoidosis.

Sarcoidosis causes many disabling symptoms, including fatigue and exercise limitations, which have been shown to improve by physical activity programs. The aim of this study was to estimate the effect of continuous activity monitoring using an electronic activity tracker (AT) on exercise performance and fatigue of sarcoidosis patients, compared to controls (cohort study), and the effect of additional personal coaching (randomized trial) over a period of 3 months. Fifty-four sarcoidosis patients received an AT (Group Ia: 27 with coaching and Group Ib: 27 without). A historical group of sarcoidosis patients (Group II; n = 41) who did not follow a physical activity program served as controls. Exercise performance of patients wearing an AT (Group I) improved compared with controls (Group II), including the 6MWD, % predicted (∆4.4 ± 9.1 versus ∆0.7 ± 5.0, respectively), and fatigue levels decreased (∆-3.9 ± 5.7 versus ∆-1.8 ± 5.3). Patients with coaching (Group Ia) showed greater improvement of exercise capacity over time than patients without coaching (Group Ib) as shown by the Steep Ramp Test results (watts: ∆20.2 ± 33.8 versus ∆5.7 ± 26.4; and SRT, VO2max, % predicted: ∆1.6 ± 2.6 versus ∆0.7 ± 2.3). Sarcoidosis patients wearing an AT achieved improvement of exercise performance and reduction of fatigue. We therefore recommend encouraging sarcoidosis patients to wear an AT to stimulate physical activity and reduce fatigue. The additional benefit of coaching needs to be explored in future studies.

Predictors of fatigue in sarcoidosis: The value of exercise testing.

BACKGROUND: Sarcoidosis patients often are troubled by dyspnea, exercise limitation, and fatigue. Many patients (up to 50-81%) suffer from sarcoidosis-associated fatigue. The etiology of fatigue in sarcoidosis is still unclear. OBJECTIVE: The aim of this study was to assess the relationship between fatigue and both exercise capacity and clinical characteristics in sarcoidosis patients. Additionally, we studied the predictive value of exercise test results and other relevant clinical characteristics for the independent variable of fatigue. METHODS: From November 2012 to September 2014, 201 sarcoidosis outpatients were referred to the Dutch ILD care foundation expertise team, 146 of whom were included in this retrospective cohort study. All patients completed the Fatigue Assessment Scale (FAS). Exercise capacity was assessed by the 6-min walking distance (6MWD) and steep ramp test (SRT) result. Clinical data were gathered from the medical records. RESULTS: Exercise capacity only showed a weak correlation with fatigue (r = 0.25, p = 0.002 for 6MWD % of predicted; r = 0.24, p = 0.003 for SRT). Fatigue was not correlated with the demographic variables of age, body mass index, or time since diagnosis. Inflammatory markers, lung function tests, and hand grip strength showed no significant correlations with fatigue. Backward multiple regression analysis showed that only female sex (t = -2,614, p = 0.01) and 6MWD % of predicted (t = -2.773, p = 0.006) were independent predictors of fatigue. However, the r(2) indicated that these two variables together explained only 11% of the FAS score. CONCLUSIONS: These results show that exercise capacity partly predicts patients' fatigue scores. Fatigue was not explained by lung function test results, inflammatory markers, or other clinical parameters.

Physical activity and training in sarcoidosis: review and experience-based recommendations.

INTRODUCTION: Sarcoidosis is a multisystemic inflammatory disorder with a great variety of symptoms, including fatigue, dyspnea, pain, reduced exercise tolerance and muscle strength. Physical training has the potential to improve exercise capacity and muscle strength, and reduce fatigue. The aim of this review and survey was to present information about the role of physical training in sarcoidosis and offer practical guidelines. AREAS COVERED: A systematic literature review guided an international consensus effort among sarcoidosis experts to establish practice-basic recommendations for the implementation of exercise as treatment for patients with various manifestations of sarcoidosis. International sarcoidosis experts suggested considering physical training in symptomatic patients with sarcoidosis. Expert commentary: There is promising evidence of a positive effect of physical training. Recommendations were based on available data and expert consensus. However, the heterogeneity of these patients will require modification and program adjustment of the standard rehabilitation format for e.g. COPD or interstitial lung diseases. An optimal training program (types of exercise, intensities, frequency, duration) still needs to be defined to optimize training adjustments, especially reduction of fatigue. Further randomized controlled trials are needed to consolidate these findings and optimize the comprehensive care of sarcoidosis patients.

Validation of the King's Sarcoidosis Questionnaire (KSQ) in a Dutch sarcoidosis population.

BACKGROUND: The King's Sarcoidosis Questionnaire (KSQ) is a brief questionnaire assessing health status using five modules (General Health Status, Lung, Eyes, Skin, Medication) in patients with sarcoidosis. The KSQ was only validated in one English sarcoidosis cohort. OBJECTIVE: The aim of this study was to validate the KSQ in a Dutch sarcoidosis population. METHODS: The KSQ was translated according to international guidelines and tested in interviews with patients. Consecutive outpatients completed multiple questionnaires twice, two weeks apart. Construct validity, internal consistency and repeatability were determined. RESULTS: Of the 98 patients included 85 had lung, 22 skin and 24 eye disease. There was good construct validity of the KSQ General Health Status module against the World Health Organization Quality of Life-BREF questionnaire. The Medication module correlated weak to moderate with most questionnaires. The correlations with organ-specific questionnaires varied from strong for Eyes (r=0.75), Skin (r=-0.62) to moderate for Lung (r=-0.45 with MRC breathlessness scale). Internal consistency was good for all KSQ modules (Cronbach's α 0.72-0.93). Intraclass correlation coefficients (0.70-0.90) and Bland-Altman plots showed good repeatability of the KSQ. CONCLUSION: The Dutch KSQ is the first translation of the English KSQ, validated in a Dutch sarcoidosis population.

Consequences of Sarcoidosis.

Sarcoidosis is a multisystem disorder of unknown cause(s). Less specific disabling symptoms, including fatigue and physical impairments, may have a major influence on the daily activities and the social and professional lives of the patients, resulting in a reduced quality of life. A multidisciplinary approach focusing on somatic and psychosocial aspects is recommended. Patients self-perceived knowledge about the importance of exercise and lifestyle should be improved. Developing the most appropriate therapeutic approach for sarcoidosis requires careful consideration of the possible impact of fatigue, small fiber neuropathy related symptoms, pain, cognitive functioning, and coping strategies. Personalized medicine and appropriate communication are beneficial.

Benefits of physical training in patients with idiopathic or end-stage sarcoidosis-related pulmonary fibrosis: a pilot study.

BACKGROUND: The natural history of disease in patients with stage IV (fibrotic) sarcoidosis may mirror that of patients with idiopathic pulmonary fibrosis (IPF). Both are bothered by progressive dyspnea, exercise limitation and fatigue. OBJECTIVE: To establish whether patients suffering from pulmonary fibrosis might benefit from a physical training program. STUDY DESIGN: Twenty-four eligible patients referred to the out-patient clinic of the ild care expertise team of Hospital Gelderse Vallei, Ede, The Netherlands between November 2012 and November 2013 were included in this observational pilot study of a 12-week physical training program. Outcomes, including exercise capacity, skeletal muscle strength, lung function and fatigue were assessed at two time points: 1) baseline; and 2) after completion of a 12-week physical training program. RESULTS: At baseline, the percentage predicted DLCO, FVC, FEV1 and exercise capacity (assessed by six-minute walking distance (6MWD) or maximal oxygen uptake) was reduced in both groups. After program completion, exercise capacity improved (>10% improvement 6MWD) in 13 subjects (54.2%): 7 with IPF and 6 with sarcoidosis subjects. Other secondary endpoints, including pulmonary function tests and patient-reported outcome measures improved in some subjects. CONCLUSION: A 12-week physical training program improved or maintained exercise capacity in patients with IPF (despite disease progression) or fibrotic sarcoidosis. The results from this pilot study could be used to design prospective studies aimed at answering lingering questions about exercise training in patients with these progressive, incurable conditions.