Long-Term Benefits of Tailored Exercise in Severe Sarcoidosis: A Case Report.

BACKGROUND: We studied the effects of a supervised, structured exercise program in a severe sarcoidosis patient. METHODS: After being clinically stable for two years, a 52-year-old woman (stage IV, American Thoracic Society) who originally had irreversible lung fibrosis, pulmonary arterial hypertension (PAH), mild mitral insufficiency, and atrial dilatation, and was candidate for lung transplant, performed a combined high-intensity interval, high load resistance, and inspiratory muscle training for 4.5 years, and was tested (cardiopulmonary exercise testing and dual X-ray absorptiometry) every six months. RESULTS: Cardiorespiratory fitness (CRF) and maximal pulmonary ventilation increased by 44% and 60%, respectively. Ventilatory efficiency also improved (decrease in the ventilatory equivalent for oxygen by 32% and 14% at the ventilatory threshold and respiratory compensation point, respectively). She improved New York Heart Association (NYHA) class (from III to II), and cardiac alterations as well as PAH reversed so that she was not in need of lung transplantation anymore. Likewise, she suffered no more episodes of hemoptysis. Bone health was overall maintained despite the post-menopausal status and the corticoid treatment. CONCLUSIONS: A long-term combined exercise intervention safely contributed-at least partly-to improve CRF and NYHA class in a patient with severe sarcoidosis, suggesting a potential coadjuvant effect to attenuate clinical manifestations.

Reply: Letter to the Editor: Exercise Interventions and Cardiovascular Health in Childhood Cancer: A Meta-Analysis.

Dear EditorWe sincerely appreciate the nice comments by Drs. P.V. da Costa Ghignatti and R. Pereira de Lima 1 concerning our recent meta-analysis assessing the effects of physical exercise interventions on cardiovascular endpoints in childhood cancer survivors 2. They are quite right to remain that even non-significant improvements in cardiorespiratory fitness (CRF) might be clinically relevant. Indeed, we still do not know if CRF increments of a theoretically low magnitude (i. e., <1 metabolic equivalent) might have a prognostic value in the context of pediatric cancer and treatment-associated cardiotoxicity. We also agree that unsupervised exercise interventions are unlikely to be as effective as tailored programs, especially because the latter allow for intensity to being adequately controlled and thus gradually increased. It is indeed our opinion, after long years of experience working with children with cancer as well as with other debilitated clinical populations, that there is always room for physiological improvement and ideally loads should be gradually improved instead of remaining stable.

What are the effects of exercise training in childhood cancer survivors? A systematic review.

This systematic review aimed to summarize evidence on the effects of physical exercise interventions in childhood cancer survivors (CCS) who had finished anticancer therapy ≥ 1 year before the study. Relevant articles were identified in the electronic databases PubMed, Web of Science, and SPORTDiscus (from inception to June 27, 2019). The PEDro scale was used to assess methodological quality. Twelve studies including 109 CCS met all inclusion criteria and were included in the systematic review. The quality of the included studies was overall low. Physical exercise improved endothelial function, reduced waist circumference, and waist-to-hip ratio and increased physical activity levels. Preliminary evidence was found regarding benefits on brain volume and structure after exercise interventions in childhood brain tumor survivors. Only two studies reported exercise-related adverse events. Physical exercise seems to be safe and effective for improving several health markers in CCS, but further high-quality research and especially randomized controlled trials are needed to confirm these results.

Exercise Interventions and Cardiovascular Health in Childhood Cancer: A Meta-analysis.

This study analyzed the effects of physical exercise interventions on cardiovascular endpoints in childhood cancer survivors. Relevant articles were systematically searched in PubMed, CINAHL, and Web of Science databases (since inception to 11th September 2019). We performed a meta-analysis (random effects) to determine the mean difference (expressed together with 95% confidence intervals) between pre- and post-intervention values for those cardiovascular endpoints reported in more than three studies. Twenty-seven studies (of which 16 were controlled studies) comprising 697 participants were included. Only three studies reported adverse events related to exercise interventions. Exercise resulted in an increased performance on the 6-minute walk distance test (mean difference=111 m, 95% confidence interval=39-183, p=0.003) and a non-significant trend (mean difference=1.97 ml∙kg-1∙min-1, 95% confidence interval=-0.12-4.06, p=0.065) for improvement in peak oxygen uptake. Furthermore, left ventricular ejection fraction was preserved after exercise interventions (mean difference=0.29%, 95% confidence interval=-1.41-1.99, p=0.738). In summary, exercise interventions might exert a cardioprotective effect in childhood cancer survivors by improving - or attenuating the decline of - physical capacity and cardiovascular function. Further studies, particularly randomized controlled trials, are needed to confirm these benefits.

Combined HIIT and Resistance Training in Very Long-Chain Acyl-CoA Dehydrogenase Deficiency: A Case Report.

Very long-chain acyl-CoA dehydrogenase deficiency (VLCADD) is a rare disorder of mitochondrial fatty acid ß-oxidation characterized by a spectrum of clinical manifestations. Patients with the adult-onset form can present with muscle pain, rhabdomyolysis and myoglobinuria after physiological stress, such as fasting and exercise. We report on a 23-year-old female patient with a history of recurrent rhabdomyolysis. The patient completed a 6-month supervised combined (high-intensity interval training [HIIT] + resistance training) program, with the addition of a medium chain triglyceride + carbohydrate supplement provided 60 min before each session. The HIIT consisted of 6 sets of 70-80 s performed at maximum intensity with a minimum cadence of 100 rpm. Resistance training consisted of a circuit of basic exercises with dumbbells and elastic bands, with sets of 4-7 repetitions. The patient was evaluated at months 0, 3 and 6 using an incremental discontinuous step protocol, with steps of 1 min of exercise/1 min of passive recovery, at a high pedal cadence. The test started at 10 W, with a load increase of 10 W/step. Blood creatine kinase (CK) concentration was measured before each evaluation. There was a training-induced increment of 90.2% in peak oxygen uptake (VO2peak), 71.4% in peak power output and 24.7% in peak heart rate. The patient reported no muscle pain, contractures, rhabdomyolysis (basal CK concentration was always <200 U/L) or hospital admissions during the training period. After completion of 6-month program, the patient remained active, doing similar but non-supervised training for 1.5 years (to date). During this period, the patient has not reported myalgias, contractures, rhabdomyolysis or hospital admissions. Our preliminary data suggest that it is possible to carry out a combined (HIIT + strength) training program in patients with VLCADD, safely (without muscle contractures or rhabdomyolysis) and obtaining high values of VO2peak and cycling power output.

Inhospital Exercise Training in Children With Cancer: Does It Work for All?

Purpose: Physical exercise training might counteract the weakening effects of both pediatric cancer and anti-cancer treatment. We aimed to analyze the prevalence of "responders" and "non-responders" to inhospital exercise training in children with cancer and to identify the factors that could influence responsiveness, which might help personalize exercise interventions for this patient population. Methods: We performed an ancillary analysis of the randomized controlled trial "Physical activity in Pediatric Cancer" (NCT01645436), in which 49 children with solid tumors were allocated to an inhospital exercise intervention or control group. The present study focused on the children in the former group (n = 24, 10 ± 4 years), who performed 3 weekly training sessions (aerobic + strength exercises). The intervention lasted 19 ± 8 weeks (i.e., from the start to the end of neoadjuvant chemotherapy treatment). A responder-vs-non-responder analysis was performed for physical capacity-related endpoints (five-repetition maximum strength, functional mobility tests, and cardiorespiratory fitness [CRF]). Only those participants showing improvements in a given test of a magnitude greater than both the random error and the threshold for clinically meaningful changes were considered responders. Results: Most participants improved their performance in the strength tests, with 80, 88, and 93% of total showing a positive response for seated bench press, lateral row, and leg press, respectively (p < 0.001). No significant improvements were observed for the functional mobility tests or CRF (p > 0.05, rate of responsiveness ≤ 50%). No differences between responders and non-responders were observed for sex, age, type of cancer, or treatment (i.e., including or not anthracyclines/radiotherapy). However, significant differences (p < 0.05) were observed between responders and non-responders for baseline performance in all the tests, and a significant (p < 0.05) inverse relationship was found between baseline performance and relative improvement for most endpoints. Conclusions: Although most children improved their muscle strength after the exercise intervention, a considerable individual variability was observed for the training responsiveness of functional mobility and CRF. A lower baseline performance was associated with a higher responsiveness for all the study endpoints, with the fittest children at the start of treatment showing the lowest responses. Efforts to individualize exercise prescription are needed to maximize responsiveness in pediatric cancer patients.