Impact of Long-Term Exercise-Based Cardiac Rehabilitation in Patients With Chronic Heart Failure　- A Systematic Review and Meta-Analysis.

BACKGROUND: This study aimed to clarify the effects of exercise-based cardiac rehabilitation (CR) on patients with heart failure.Methods and Results: Patients were divided into groups according to intervention duration (<6 and ≥6 months). We searched for studies published up to July 2023 in Embase, MEDLINE, PubMed, and the Cochrane Library, without limitations on data, language, or publication status. We included randomized controlled trials comparing the efficacy of CR and usual care on mortality, prehospitalization, peak oxygen uptake (V̇O2), and quality of life. Seventy-two studies involving 8,495 patients were included in this review. It was found that CR reduced the risk of rehospitalization for any cause (risk ratio [RR] 0.80; 95% confidence interval [CI] 0.70-0.92) and for heart failure (RR 0.88; 95% CI 0.78-1.00). Furthermore, CR was found to improve exercise tolerance (measured by peak V̇O2and the 6-min walk test) and quality of life. A subanalysis performed based on intervention duration (<6 and ≥6 months) revealed a similar trend. CONCLUSIONS: Our meta-analysis showed that although CR does not reduce mortality, it is effective in reducing rehospitalization rates and improving exercise tolerance and quality of life, regardless of the intervention duration.

Impact of raising the upper extremity siding cardiac implantable electrical devices on postoperative safety.

Background: The upper extremity siding cardiac implantable electrical device tends to have a limited range of motion during the perioperative period; however, the underlying reason lacks scientific evidence. This study aimed to investigate the safety of the two methods (stepwise or early) of postoperative early upper extremity rehabilitation. Methods: We retrospectively investigated 650 consecutive patients with a new implantable pacemaker (PM), implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), or generator exchange between March 2017 and December 2020.The limitation program was conducted from March 2017 to March 2018. The intervention program started as a stepwise protocol in April 2018 and was switched to an early protocol in December 2019. Results: This study analyzed 591 patients, excluding 59 who met the exclusion criteria. The mean age was 76.0 (69.0-82.0) years; 412 (69.7%) patients had a PM, 79 (13.4%) had an ICD, and 100 (16.9%) utilized CRT. There were 155 patients in the limitation protocol, 251 in the stepwise protocol, and 185 patients in the early protocol groups. Postoperative complications occurred in 53 (9.0%) patients. There was no significant difference in the incidence of all complications between the three groups (16 patients [10.3%] vs. 26 patients [10.4%] vs. 11 patients [5.9%]). Shoulder exercise-related complications were defined as hematoma (p = .94), lead dislodgement (p = .16), and increased pacing threshold (p = .23). General complications included wound infection (p = .51), pneumothorax (p = .27), tamponade (p = .07), and deep venous thrombosis (p = .26). Conclusion: Raising of the upper extremity siding cardiac implantable electrical devices above the head did not compromise postoperative safety.

Predictive factors for walking in acute stroke patients: a multicenter study using classification and regression tree analysis.

[Purpose] Walking ability should be predicted as early as possible in acute stroke patients. The purpose is to construct a prediction model for independent walking from bedside assessments using classification and regression tree analysis. [Participants and Methods] We conducted a multicenter case-control study with 240 stroke patients. Survey items included age, gender, injured hemisphere, the National Institute of Health Stroke Scale, the Brunnstrom Recovery Stage for lower extremities, and "turn over from a supine position" from the Ability for Basic Movement Scale. The National Institute of Health Stroke Scale items, such as language, extinction, and inattention, were grouped under higher brain dysfunction. We used the Functional Ambulation Categories to classify patients into independent (four or more the Functional Ambulation Categories; n=120) and dependent (three or fewer the Functional Ambulation Categories; n=120) walking groups. A classification and regression tree analysis was used to create a model to predict independent walking. [Results] The Brunnstrom Recovery Stage for lower extremities, "turn over from a supine position" from the Ability for Basic Movement Scale, and higher brain dysfunction were the splitting criteria for classifying patients into four categories: Category 1 (0%), severe motor paresis; Category 2 (10.0%), mild motor paresis and could not turn over; Category 3 (52.5%), with mild motor paresis, could turn over, and had higher brain dysfunction; and Category 4 (82.5%), with mild motor paresis, could turn over, and no higher brain dysfunction. [Conclusion] We constructed a useful prediction model for independent walking based on the three criteria.

Age- and sex-stratified normal values for circulatory and ventilatory power during ramp exercise derived from a healthy Japanese population.

Circulatory power (CP) and ventilatory power (VP), obtained by cardiopulmonary exercise testing (CPX), have been suggested to be excellent prognostic markers for heart failure. However, the normal values of these parameters in healthy Japanese populations remain unknown; thus, we aimed to investigate these values in such a population. A total of 391 healthy Japanese participants, 20-78 years of age, underwent CPX with a cycle ergometer with ramp protocols. Systolic blood pressure (SBP), heart rate, oxygen uptake ([Formula: see text]O2) at peak exercise, and the slope of minute ventilation ([Formula: see text]E) versus carbon dioxide ([Formula: see text]CO2) ([Formula: see text]E vs. [Formula: see text]CO2 slope) were measured. CP was calculated by multiplying the peak [Formula: see text]O2 and SBP values, and VP was calculated by dividing the peak SBP value by the [Formula: see text]E versus [Formula: see text]CO2 slope. For males and females, the average CP values were 6119 ± 1280 (mean ± standard deviation) and 4775 ± 914 mmHg·mL/min/kg, respectively (p < 0.001). The average VP values for males and females were 8.0 ± 1.3 and 6.9 ± 1.3 mmHg (p < 0.001). CP decreased with age in both sexes. VP increased with age in females, with no significant change in males. We calculated the normal values for CP and VP in a healthy Japanese population. The results can contribute to the evaluation of patients' CPX results as a reference.

Study Protocol of Cardiac Rehabilitation for Acute Myocardial Infarction From the JROAD/JROAD-DPC Database　- JROAD-CR.

Background: Although cardiac rehabilitation (CR) has been reported to be effective for improving the prognosis of acute myocardial infarction (AMI), more patients must participate in CR during admission and as outpatients. Factors contributing to, and countermeasures against, the low CR participation rate need to be identified. Here we describe the protocol for a study designed to evaluate the effectiveness and problems of CR for AMI from the Japanese Registry of All Cardiac and Vascular Diseases (JROAD) and the JROAD-Japanese Diagnosis Procedure Combination system (JROAD-DPC) database. Methods and Results: This is a multicenter retrospective cohort study that will use the JROAD/JROAD-DPC database to evaluate the effectiveness of CR for AMI (JROAD-CR). Five thousand patients with AMI who were admitted to hospitals registered in the JROAD database in 2014 will be investigated with regard to their baseline characteristics, AMI severity and treatment, examination results, history of CR, and prognosis up to 5 years. We will also investigate the presence, quantity, and quality of CR, and evaluate the effectiveness of CR with respect to cost, exercise tolerance, and prognosis during admission and follow-up. Conclusions: The JROAD-CR study will seek to reveal the effectiveness of CR for AMI in the era of early reperfusion therapy and shortened hospitalization.

Analyses of weight-bearing asymmetry pattern for standing in the early phase after stroke: a cross-sectional study.

BACKGROUND: How the weight-bearing asymmetry pattern and related maximum lateral weight-bearing capacity, physical functions, balance, and mobility involved in weight-bearing asymmetry and lesions are related to weight-bearing asymmetry in patients with early-onset stroke remains unclear. OBJECTIVE: To investigate the difference between weight-bearing in the early phase after stroke categorized as symmetrical or nonsymmetrical regarding impairments, balance, walking, and independence, and any lesion location difference. METHODS: This cross-sectional study included 46 persons with hemiparetic stroke within 3 weeks from onset undergoing inpatient rehabilitation and classified into symmetrical, paretic, and non-paretic groups. We performed posturographic, functional, mobility, and lesion location assessments on participants once the evaluation was possible. RESULTS: The symmetrical, paretic, and non-paretic groups included 14, 11, and 21 patients, respectively. The non-paretic group had lesser mean % body weight in maximum lateral weight-bearing to the paretic direction (79% versus 55%, p < .001), motor function of the hip lower limb (64 versus 58, p = .003) per the Stroke Impairment Assessment Set, Trunk Impairment Scale (18 versus 15, p = .020), and Berg Balance Scale (42 versus 32, p = .047) than the paretic group with more lesions in the insula (55% versus 0%, p < .001) and parietal cortex (36% versus 0%, p = .009) than the non-paretic group. CONCLUSION: The non-paretic group had low dynamic balance, severe motor paresis, and trunk dysfunction. The paretic group had lesions in the insula or parietal cortex.

Immediate effect of standing and sit-to-stand training on postural vertical for backward disequilibrium following stroke: a case report.

BACKGROUND: Effects of therapeutic interventions backward disequilibrium following stroke are scarcely reported. OBJECTIVE: To clarify the effects of standing and sit-to-stand/stand-to-sit training aimed at postural deviation in the anterior direction for backward disequilibrium and posterior deviation of subjective postural vertical. CASE DESCRIPTION: The participant presented with backward disequilibrium and pontine hemorrhage-associated sensory impairment of the extremities. Physical therapy included standing and sit-to-stand/stand-to-sit training, expected to bias the center of gravity in the anterior direction. We measured subjective postural vertical on the sagittal plane to assess vertical perception. Backward disequilibrium was evaluated using the Backward Disequilibrium Scale. Walking ability was assessed using the functional ambulation category. These outcomes were assessed before and at 3 days post-intervention. OUTCOMES: Neurological findings were unchanged between pre- and post-intervention. Post-intervention, in subjective postural vertical, tilt direction modulated from -6.1° to 1.3°, variability changed from 5.9° to 3.3°, and Backward Disequilibrium Scale score improved from 7 to 1 point. Functional ambulation category changed from 2 to 3. CONCLUSION: Standing and sit-to-stand/stand-to-sit training aimed at shifting center of gravity and subjective postural vertical in the anterior direction appeared to improve backward disequilibrium and correct tilt to the anterior direction for this participant. Long-term effects of the training for this participant were not determined.

The Effect of Trunk Position on Attentional Disengagement in Unilateral Spatial Neglect.

Unilateral spatial neglect (USN) causes difficulties in disengaging attention from the right side to unexpected targets on the left. However, the relationship between egocentric spatial position and attentional disengagement remains unclear. Therefore, this study aimed to clarify the relationship between trunk position and attentional disengagement. Thirty-eight patients with early stroke onset were classified as follows: USN (n = 18), right brain damage without USN (n = 10), and left brain damage (n = 10). The primary outcome was reaction time (RT) in the modified Posner task (MPT). The MPT comprised a condition in which the preceding cue and target direction were the same (valid condition) and a condition in which the directions were opposite (invalid condition). RT to the target was calculated. The MPT was performed in three different trunk positions (trunk midline, left, and right). In each group, the RT was compared on the basis of the stimulus conditions and trunk position. The RT was delayed in the valid and invalid left conditions, especially in the invalid left condition. The RT of the trunk right condition was significantly reduced compared with that of trunk midline and left conditions in the invalid left condition. Thus, trunk position influences attentional disengagement. This study contributes to the rehabilitation of patients with neglect symptoms.

Study Design of the Japanese Association of Cardiac Rehabilitation Registry (J-CARRY)　- Protocol for a Prospective, Multicenter, Open Registry.

Background: Guidelines for the prevention and management of cardiovascular disease (CVD) highly recommend cardiac rehabilitation (CR) on the basis of abundant evidence of its effectiveness. However, the current understanding and dissemination of CR in Japan are far from sufficient. Methods and Results: The Japanese Association of Cardiac Rehabilitation Registry (J-CARRY) is an academic society-led prospective multicenter observational registry conducted by the Registration and Facility Accreditation System Committee of the Japanese Association of Cardiac Rehabilitation. Data are collected prospectively using an electronic data capture system. Items related to patients' clinical background and CR, as well as mortality and major adverse cardiac and cerebrovascular events, will be collected in all cases. This Registry started in May 2014, and the number of participating medical institutions is expected to increase to >30; the targeted number of cases exceeded 3,000 per year as of April 30, 2022. Focusing on late Phase II data collection is a novel and significantly different approach compared with previous studies. The results of this study are currently under investigation. Conclusions: J-CARRY will provide real-world data regarding the current status and prognosis of CVD in patients who undergo Phase II CR in Japan.

Efficacy of Early Cardiac Rehabilitation After Cardiac Surgery　- Verification Using Japanese Diagnosis Procedure Combination Data.

Background: The current status of cardiac rehabilitation (CR) after cardiac surgery and the introduction of early CR (E-CR) in Japan are not fully understood. In this study, the current status of E-CR and its efficacy were investigated by the Academic Committee of the Japanese Association of Cardiac Rehabilitation. Methods and Results: We examined the rate of introduction of E-CR and its effects among 220,122 patients who underwent major cardiac and thoracic vascular surgery, as registered in the Diagnosis Procedure Combination (DPC) classification system, between April 2012 and March 2018. In this study, E-CR was defined as CR starting within 1 day after surgery. Patients with and without E-CR were propensity score matched and analyzed for clinical outcomes. Of all patients participating in CR after surgery, E-CR was initiated in 52.1%, 56.9%, 47.4%, and 54.1% of patients undergoing coronary artery bypass grafting, valve surgery, aortic surgery, and other cardiovascular surgery, respectively. After propensity score matching, outcomes for E-CR were significantly superior to non-E-CR in terms of in-hospital deaths, Barthel Index score at discharge, length of hospital stay, and hospitalization costs. Conclusions: E-CR after cardiac surgery was effective in terms of prognosis, hospital stay, and medical costs. This study is the first report using big data in Japan. The results indicate that further introduction of E-CR needs to be recommended in the future.

The impacts of preoperative frailty on readmission after cardiac implantable electrical device implantation.

Cardiac implantable electrical devices (CIED) such as pacemakers, implantable cardioverter defibrillators, and cardiac resynchronization therapies are generally recommended for older patients and those with severe heart failure (HF). However, there is currently a lack of evidence on the relationship between frailty and readmission rates among patients with CIED. This study investigated whether preoperative frailty influenced readmission rates among patients with CIED over a one-year period following implantation. The study retrospectively analyzed 101 patients who underwent CIED implantations. To compare frailty-based differences in their characteristics and readmission rates, these participants were categorized into frailty and non-frailty groups via the modified frailty index (mFI). The frailty group had a significantly higher readmission rate than the non-frailty group (non-frailty group vs. frailty group = 1 vs. 8 patients: P < 0.05). Further, a multivariate analysis showed that frailty was a significant readmission factor. Based on individual analyses with/without histories of HF, the readmission rate also tended to be higher among individuals considered frail via the mFI (readmission rate in HF patients: non-frailty group vs. frailty group = 1 vs. 5 patients: P = 0.65; non-HF patients: non-frailty group vs. frailty group = 0 vs. 3 patients: P = 0.01). Participants with preoperative frailty showed higher readmission rates within a one-year period following implantation compared to those without preoperative frailty. This tendency was consistent regardless of HF history. The mFI may thus help predict readmission among patients with CIED.

Second Nationwide Survey of Japanese Cardiac Rehabilitation Training Facilities During the Coronavirus Disease 2019 (COVID-19) Outbreak.

Background: We previously reported the results of a questionnaire survey of 37 cardiac rehabilitation (CR) training facilities conducted during April 2020, in Japan. Methods and Results: We conducted a second questionnaire survey in 38 CR training facilities to explore the preventive measures against Coronavirus Disease 2019 (COVID-19) after a nationwide state of emergency was declared and to investigate differences between the 2 surveys. No significant differences were observed, except for the requirement for patients to wear surgical masks during CR (P=0.01) in the second survey. Thirty-four facilities (89%) continued CR with innovations, 61% revised their instruction manuals (vs. 46% in the first survey), and, in 39%, patients requested resumption of ambulatory CR and training videos. Conclusions: In the second survey, 74% of facilities were unable to continue conventional group ambulatory CR; however, patients maintained their physical activity and exercise regimens and managed their illnesses with the aid of telephones and mobile devices.

Effects of Dynamic Sitting Exercise with Delayed Visual Feedback in the Early Post-Stroke Phase: A Pilot Double-Blinded Randomized Controlled Trial.

Sitting ability in the early post-stroke phase affects functional balance ability and other prognoses. We investigated whether dynamic sitting exercise with delayed visual feedback in the mediolateral and anteroposterior directions affected postural control in the early post-stroke phase. In this pilot randomized controlled trial, 27 hemiparetic stroke patients were randomized to experimental (n = 13) and control (n = 14) groups. Dynamic sitting exercise (30 times/day, 5 days/week) in the mediolateral and anteroposterior directions, with 500-ms-delayed (experimental group) or real-time (control group) visual feedback on a computer, was added to usual physical therapy. We evaluated the postural assessment scale for stroke (PASS), static and dynamic sitting balance tasks, the five-times sit-to-stand test, trunk impairment scale, functional ambulation category, and functional independence measure−motor items. In intention-to-treat analysis, the experimental group demonstrated a significant intervention effect on the PASS score (p < 0.05). The mean percentage of body weight on the moving side in the lateral sitting task and the number of successes in the five-times sit-to-stand test were significantly higher in the experimental group than those in the control group (p < 0.05). Thus, the proposed exercise improves postural control, dynamic sitting balance, and sit-to-stand ability in early post-stroke patients.

Effects of standing and walking training using a laser pointer based on stimulus-driven attention for behavioural outcome in spatial neglect: A single-case study.

The therapy for unilateral spatial neglect (USN) is unclear. This case report investigated the effect of standing and walking training using a laser pointer based on stimulus-driven attention for USN. The patient was a right-handed 79-year-old man with cardiogenic cerebral embolism in the right middle and posterior cerebral arteries. Initially, we evaluated the absence of hemiparalysis in the lower limb and sensory disorder; almost all daily activities were performed independently. Intervention effects were verified using the BABA method. The course of the four phases (B1, A1, B2, A2) was conducted for 5 days. In the B1 and B2 phases, standing and walking training using a laser pointer was performed additionally to conventional physical therapy. Outcomes were measured using the Behavioural Inattention Test conventional subtest (BIT-c), Catherine Bergego Scale (CBS), and modified Posner task (MPT). The BIT-c remained unchanged in each phase. CBS scores improved after B1 and B2. In the MPT, the reaction time in the left space reduced after B1 and B2 compared with those in the A1 and A2 control phases. In this case, training may have contributed to the improvement in the response to the neglected space and behavioural assessment of USN.

Effects of dynamic supported standing training in a patient with pusher behavior: a case report.

BACKGROUND: The effects of task-specific and voluntary exercise in upright positions for pusher behavior remain unclear. In this report, we aimed to describe the effects of dynamic supported standing training using a modified standing frame to correct the alignment in a patient with severe pusher behavior. CASE DESCRIPTION: A 76-year-old man with cardioembolic ischemic stroke demonstrated pusher behavior. The patient underwent 3 days of dynamic supported standing training using a modified standing frame. The Scale for Contraversive Pushing, the Burke Lateropulsion Scale, and the Trunk Control Test were used to assess changes. OUTCOMES: Immediate improvements in sitting balance were observed after the intervention, and the effects persisted to 8 days later. CONCLUSION: Dynamic supported standing training using a modified standing frame may improve pusher behavior with short-term training. The collapsed posture of the patient in the present case was corrected using the modified standing frame. This neutral standing position could have a positive effect on motor learning with respect to holding one's posture.

Cardiac Telerehabilitation　- A Solution for Cardiovascular Care in Japan.

Cardiac rehabilitation (CR) is a well-known intervention for the secondary prevention of cardiovascular diseases. However, in Japan, the outpatient CR participation rate is estimated to be very low. Cardiac telerehabilitation (CTR) can be defined as a remote CR program using digital health technology to support it. Evidence regarding the use of CTR has been accumulated, and the COVID-19 pandemic has accelerated the need for CTR. Japan has sufficient potential to benefit from CTR because, nationally, digital literacy is high and the infrastructure for telemedicine is developed. To overcome several barriers, evidence of CTR in Japan, well-educated multidisciplinary CTR teams, a good combination of center-based CR and CTR, and sophisticated systems including social insurance and adequate legislation need to be developed immediately. CTR has the potential to increase the low CR participation rate in Japan. CTR also has many different effects that not only cardiologists, but also paramedics who engage in CTR, have to be aware of.