Getting to the Heart of the Matter: What is the Landscape of Exercise Rehabilitation for People With Heart Failure in Australia?

BACKGROUND: The benefits of exercise rehabilitation for people with heart failure (HF) are well established. In Australia, little is known about how the guidelines around exercise rehabilitation for people with HF are being implemented in clinical practice. Furthermore, it is unknown what organisational barriers are faced in providing exercise rehabilitation programs for this population. The aim of this study is to provide an updated review of exercise rehabilitation services for people with HF in Australia and to identify perceived organisational barriers to providing these services. METHODS: A cross-sectional survey of cardiac rehabilitation centres in Australia, investigating the number and characteristics of services providing exercise rehabilitation for people with HF. RESULTS: A total of 334 of 457 identified services responded to the survey. Of these, 251 reported providing a supervised group-based exercise rehabilitation program for people with HF. These services were mapped, showing their distribution across Australia. Services which were unable to provide group-based exercise training for HF patients reported organisational barriers including insufficient funding (60%), staffing (56%) and clinical resources (53%). Of the 78 services that reported patients in their local area were unable to access appropriate exercise guidance, 81% were located in regional or remote areas. We found that reported exercise practices align with current best-practice guidelines with 99% of group based exercise programs reportedly including endurance training and 89% including resistance training. CONCLUSIONS: In Australia, exercise practices for people with HF align with current best-practice guidelines for this condition. Limited resources, funding and geographic isolation are reported as the major organisational barriers to providing these programs. Future endeavours should include the development of alternative and flexible delivery models such as telerehabilitation and other home-based therapies to improve access for these individuals to such services.

Heart Failure and Thermoregulatory Control: Can Patients With Heart Failure Handle the Heat?

Upon heat exposure, the thermoregulatory system evokes reflex increases in sweating and skin blood flow responses to facilitate heat dissipation and maintain heat balance to prevent the continuing rise in core temperature. These heat dissipating responses are mediated primarily by autonomic and cardiovascular adjustments; which, if attenuated, may compromise thermoregulatory control. In patients with heart failure (HF), the neurohumoral and cardiovascular dysfunction that underpins this condition may potentially impair thermoregulatory responses and, consequently, place these patients at a greater risk of heat-related illness. The aim of this review is to describe thermoregulatory mechanisms and the factors that may increase the risk of heat-related illness in patients with HF. An understanding of the mechanisms responsible for impaired thermoregulatory control in HF patients is of particular importance, given the current and projected increase in frequency and intensity of heat waves, as well as the promotion of regular exercise as a therapeutic modality. Furthermore, novel therapeutic strategies that may improve thermoregulatory control in HF, and the clinical relevance of this work in this population will be discussed.

Aquatic Exercise Training is Effective in Maintaining Exercise Performance in Trained Heart Failure Patients: A Randomised Crossover Pilot Trial.

BACKGROUND: Providing flexible models and a variety of exercise options are fundamental to supporting long-term exercise participation for patients with heart failure (HF). The aim of this pilot study was to determine the feasibility and efficacy of aquatic exercise training during a maintenance phase for a clinical heart failure population. METHODS: In this 2 x 2 crossover design trial, individuals who had previously completed HF rehabilitation were randomised into either a land-based or aquatic training program once per week for six weeks, after which time they changed to the alternate exercise training protocol for an additional six weeks. Six-minute walk test (6MWT), grip strength, walk speed, and measures of balance were compared for the two training protocols. RESULTS: Fifty-one participants (43 males, mean age 69.2 yrs) contributed data for the analysis. Both groups maintained function during the follow-up period, however improvements in 6MWT were greater in the land-based training group (95% CI: 0.7, 22.5; p=0.038), by a mean difference of 10.8 metres. No significant difference was observed for other parameters when the two training protocols were compared. CONCLUSION: Attending an aquatic exercise program once per week is feasible for patients with stable HF and may provide a suitable option to maintain functional performance in select patients.

Timed Up and Go Test: A Reliable and Valid Test in Patients With Chronic Heart Failure.

BACKGROUND: The timed up and go test (TUGT) is a short-duration functional test frequently used in rehabilitation settings as a measure of balance and mobility. Reliability and validity for patients with chronic heart failure (CHF) has yet to be determined. This prospective cohort study aimed to determine test-retest reliability of the TUGT in patients with CHF, relationships between the TUGT and other variables, including functional tests, and predictors of the TUGT. METHODS AND RESULTS: This was a secondary analysis of data collected in a multicenter randomized controlled trial of exercise training in recently hospitalized patients with heart failure (EJECTION-HF). The TUGT was conducted twice at baseline to determine reliability. Assessments were compared with 6-minute walk distance (6MWD), 10-m walk test time, and other clinical variables. Intraclass correlation coefficient (ICC) was used to determine test-retest reliability and correlations for relationships with other variables. A multiple regression was used to identify predictors of the TUGT. In 278 participants (mean age 62 years), the TUGT demonstrated excellent within-day test-retest reliability (ICC 0.93). A shorter (better) TUGT time was associated with longer 6MWD (r = -0.81; P < .001) and shorter 10-m walk test time (rs = 0.80; P < .001). Best predictors of the TUGT were 6MWD and age, which accounted for 66% of the variance. CONCLUSIONS: The TUGT appears to be a reliable and valid functional measurement in patients with CHF.

Effects of a pilot multidisciplinary clinic for frequent attending elderly patients on deprescribing.

OBJECTIVE: Multimorbidity and associated polypharmacy are risk factors for hospital re-admission. The Targeting Hospitalization Risks in Vulnerable Elders (THRIVE) clinic is a novel multidisciplinary out-patient clinic to improve transitions of care and decrease re-admission risk for older medical patients with frequent hospital admissions. This pilot study examined the effect of the THRIVE model on medication count, tablet load and potentially inappropriate medicines (PIMs). METHODS: Participants with frequent medical admissions were referred within 2 weeks of discharge from hospital and assessed at baseline and then at 4 and 12 weeks by the THRIVE team. A thorough reconciliation of all medications was performed collaboratively by a clinical pharmacist and a physician. Optimising medications, including deprescribing, was in collaboration with the participants' general practitioner. The complete medication history of each patient was compared retrospectively by an independent assessor at baseline and after the 12-week clinic, comparing total number of regular medications, tablet load and PIMs (measured using the Screening Tool of Older Persons Prescriptions (STOPP) tool). RESULTS: All 17 participants attending the pilot THRIVE clinic were included in the study. At 12 weeks, there was a significant reduction in mean medication count (from 14.3 to 11.2 medications; P < 0.001) and mean tablet load (from 20.5 to 16.9 tablets; P < 0.01). There was an absolute reduction in the total number of PIMs from 38 to 14. Common medications deprescribed included opioids, tricyclic antidepressants, benzodiazepines and diuretics. CONCLUSIONS: Patients who attended the THRIVE clinic had a significant reduction in medication count and tablet load. The pilot study demonstrates the potential benefits of a multidisciplinary out-patient clinic to improve prescribing and reduce unwarranted medications in an elderly population. An adequately powered comparative study would allow assessment of clinical outcomes and costs.

Interventions to Promote Physical Activity and Reduce Functional Decline in Medical Inpatients: An Umbrella Review.

OBJECTIVES: Physical inactivity in hospitals is common and is associated with poor patient and clinical outcomes. This review was undertaken to identify and describe the effectiveness of interventions implemented at the ward or system level for improving physical activity and reducing functional decline in general medical inpatients. The secondary aim was to describe the effects on length of stay, discharge destination, falls, and hospital costs. DESIGN: Umbrella review. SETTING AND PARTICIPANTS: Systematic reviews that evaluated ward- or system-level interventions aiming to improve physical activity or reduce functional decline in medical inpatients. METHODS: PubMed, EMBASE, Cochrane Database, CINAHL, JBI, and Web of Science databases were searched for English-language reviews published between 2000 and 2023. AMSTAR 2 was used to assess methodologic quality. Two reviewers independently assessed eligibility and methodologic quality and completed data abstraction, with results presented as a narrative synthesis. RESULTS: The search yielded 568 systematic reviews of which 12 met criteria, half of which were published since 2020. Reviews included 76 unique primary studies with 72,645 participants. Most reviews were of low quality. Interventions that focused on progressive mobilization likely increased physical activity participation, reduced functional decline, and improved discharge home. Multicomponent interventions that employed multiple strategies targeting a broader range of barriers likely improved functional decline and discharge home and may have been associated with shorter length of stay. No interventions were associated with increased frequency of falls. Few studies reported costs. CONCLUSIONS AND IMPLICATIONS: Progressive mobilization interventions and multicomponent interventions appear to be effective for improving physical activity participation and reducing functional decline in medical inpatients. Further high-quality studies may help to determine the most important aspects of multicomponent interventions. Standardized terminology related to inpatient physical activity may help promote a shared understanding and purpose across professions.

Physiotherapist perspectives of airway clearance techniques in bronchiectasis.

INTRODUCTION: Our understanding regarding the personalization of airway clearance techniques (ACTs) in bronchiectasis is limited. OBJECTIVE: This study aimed to determine physiotherapist perceptions regarding the prescription of ACTs in inpatients and outpatients with bronchiectasis. METHODS: A single-center qualitative study using semi-structured interviews of physiotherapists who treated individuals with bronchiectasis was undertaken. All interviews were audio recorded and transcribed verbatim. Data was analyzed using the thematic framework approach described by Braun and Clark. NVivo 12 software assisted with coding and thematic analysis of the interview transcripts. Findings were summarized into major conceptual themes. Participant demographic data was also obtained. RESULTS: Eleven physiotherapists participated in the interviews. Central to all themes was the complexity of physiotherapy clinical decision-making regarding ACT prescription. Main themes included: organizational factors (i.e. workload, scope of service, access to resources/ACTs); patient-related factors (i.e. symptom severity, finances, disease-specific knowledge, social commitments, clinical setting, and perceived benefit); and physiotherapist/profession-related factors (i.e. clinical experience, access to professional support and education, awareness of evidence of ACTs, and evaluating ACT effectiveness). CONCLUSION: Physiotherapists regularly and routinely prescribe ACTs for individuals with bronchiectasis allowing for a multitude of competing factors. These factors should be considered by physiotherapists to enhance the personalized prescription of ACTs and may help promote patient adherence to ACTs to improve outcomes.

A Study of the Reliability, Validity, and Physiological Changes of Sit-to-Stand Tests in People With Heart Failure.

PURPOSE: The objective of this study was to describe the psychometric properties and physiological response of the five times sit-to-stand (STST-5) and 60-sec sit-to-stand test (STST-60) in adults with heart failure (HF). METHODS: People with HF enrolled in a 12-wk exercise rehabilitation program completed two STST-5 and two STST-60 as part of their usual baseline and follow-up assessments. Test-retest reliability, validity, and responsiveness of the two STSTs were described. Results were correlated with the 6-min walk test (6MWT) and timed up and go test (TUGT), and rating of perceived exertion and physiological responses were compared between all tests. Feasibility was also reported according to the presence of adverse events and adherence to the protocol. RESULTS: Forty-nine adults with HF participated in this study. Intraclass correlation coefficients of the STST-5 and STST-60 were 0.91 (95% CI, 0.78-0.96) and 0.96 (95% CI, 0.93-0.98), respectively. The STST-60 was strongly associated with both the 6MWT ( r = 0.76) and the TUGT ( rs =-0.77). The STST-5 was strongly associated with the TUGT ( rs = 0.79) and moderately associated with the 6MWT ( rs =-0.70). Rating of perceived exertion and lower limb fatigue were greater in the STST-60 than in the 6MWT ( P < .001) or STST-5 ( P < .001). Adverse events occurred in five participants undertaking the STST-60 and one participant undertaking the STST-5. CONCLUSIONS: The STST-5 and STST-60 are reliable and valid measures of functional exercise capacity in people with HF.

Physical Activity Levels in Hospitalized Adults With Burn Injuries.

Physical activity behavior has not been previously described in hospitalized adults with burn injuries. This prospective, cross-sectional study used a standardized behavioral mapping protocol to observe patient behavior related to physical activity over a 12-hour period on one weekday in a quaternary referral specialist burn center. Structured observations were recorded for each of four domains: 1) patient location, 2) position, 3) activity performed, and 4) the presence of others. Observations were summarized across all participants as median (interquartile range [IQR]) proportion of time. Participants (n = 17) were predominantly male (82%) with a mean age of 44.3 (SD 15.2) years, a mean burn size of 34.9% (SD 26.7) TBSA, and a median hospital length of stay of 18 (IQR 6-49) days at time of observation. Participants spent a median of 83% (IQR 73-93) of time in their bedroom, 92% (IQR 68-97) of time in or on their bed and a median of 5% (IQR 3-13) of time mobilizing. Exercise accounted for 10% (IQR 8-17) of activity-related observations. A median of 68% (IQR 39-83) of time was spent alone. Results suggest time spent engaging in physical activity is low. Further studies are required to investigate motivators and barriers to performing physical activity in this population. This will consequently inform the development and implementation of appropriate strategies to improve physical activity behavior in this cohort.

Home-based and remote functional exercise testing in cardiac conditions, during the covid-19 pandemic and beyond: a systematic review.

BACKGROUND: With the change in healthcare to one that adopts a greater reliance on remote delivery, guidance regarding functional exercise testing, either in-person in the home or performed remotely, is urgently needed for people with cardiac conditions. OBJECTIVES: To identify functional exercise tests that have been conducted in the home or remotely in patients with cardiac conditions. DATA SOURCES: A search was undertaken across four electronic databases and grey literature for English language publications without time restrictions. STUDY ELIGIBILITY CRITERIA: Studies of any designs were selected if they reported an exercise test conducted at home or remotely in patients with cardiac conditions. STUDY APPRAISAL AND SYNTHESIS: Studies were independently screened and graded by two reviewers according to the Downs and Black checklist. A narrative synthesis of the included studies was undertaken. RESULTS: Five studies (six articles) were included, with a total of 438 patients with cardiac conditions. Tests used at home or remotely were the 6-minute walk test (6MWT, five studies) and the timed up and go test (one study). No studies reported the use of step tests in the home or remotely. The 6MWTs were administered via a smartphone application, rope, videoconferencing and accelerometer and proved to be feasible, valid and reliable. CONCLUSIONS: Despite a marked demand for home-based exercise programs, the 6MWT remains the most commonly administered functional exercise test for people with cardiac conditions. Surprisingly few studies have explored alternative tests for this patient population that may be more suitable for home or remote performance. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO: CRD42020219512.

Patient perspectives of airway clearance techniques in bronchiectasis.

INTRODUCTION: While airway clearance techniques (ACTs) are recommended for individuals with bronchiectasis, data suggests the use of and adherence to ACTs is poor. OBJECTIVE: This study aimed to identify patient perceptions regarding ACTs, the barriers and facilitators to ACTs, and factors affecting adherence. METHODS: A multi-center qualitative study using in-depth semi-structured interviews of individuals with bronchiectasis was undertaken. All interviews were audio recorded and transcribed verbatim. Data was analyzed using the thematic framework approach described by Braun and Clark. NVIVO™ 12 software assisted with coding and thematic analysis of the interview transcripts. Data saturation was achieved when no new common themes were identified. Findings were summarized into major conceptual themes. Participant demographic data was also obtained. RESULTS: Twenty-four participants participated in semi-structured interviews. The main facilitators to using ACTs included a perceived health and quality of life benefit, a tailored approach to ACTs and the use of self-management strategies. Main barriers included lack of time and motivation, lack of access to resources, and a lack of perceived health benefit. A number of factors were identified by participants that may help promote adherence including combining and trialing different ACTs, receiving regular ACT reviews and education from physiotherapists, and having good social support. CONCLUSION: To assist the personalized prescription of ACTs, these facilitators and barriers should be considered by clinicians to help promote adherence and improve patient outcomes.

Repeat six-minute walk tests in patients with chronic heart failure: are they clinically necessary?

BACKGROUND: Owing to a reported learning effect in patients with chronic cardiopulmonary disease, performance of at least two six-minute walk tests (6MWT) are recommended as standard practice. Patients with chronic heart failure (CHF) are typically elderly and frail and it is unknown whether current guidelines are practical in a clinical setting. AIMS: The aim of this study was to determine whether repeat performance of 6MWTs in patients with CHF is related to between-test interval or baseline performance. METHODS: This was a multisite observational study enrolling participants entering into heart failure rehabilitation programmes. Participants performed two 6MWTs with randomly allocated inter-test intervals between 15 and 90 minutes. Distance walked in the second test was compared with the first test using a paired t test. RESULTS: Eighty-eight participants (45 females, age 65 ± 14 years) with stable CHF were enrolled. Mean distance walked increased from 301 metres in test 1 to 313 metres in test 2 (p < 0.001). No significant change was recorded between test 1 and test 2 for those whose baseline distance was <300 metres. The interval between tests had no significant effect on the distance walked. CONCLUSION: The change in 6MWT distance was significantly associated with better baseline performance but not with the interval between tests.

Frailty implications for exercise participation and outcomes in patients with heart failure.

BACKGROUND/OBJECTIVES: Frailty is common in people with heart failure (HF) and associated with poorer outcomes. The aim of this study was to describe the characteristics, exercise participation, and outcomes of frail and not-frail participants enrolled in a randomized trial of exercise training (ET) within a cardiac rehabilitation (CR) program. DESIGN: Secondary analysis of EJECTION-HF randomized trial (ACTRN12608000263392). SETTING: Five HF-specific CR programs in Queensland, Australia. PARTICIPANTS: Adults recently hospitalized with HF. INTERVENTION: All participated in CR including home exercise prescription and monitoring; half were randomized to center-based ET. MEASUREMENTS: A frailty index (FI) was constructed at randomization and 6-month follow-up. Outcomes included ET attendance, change in 6-min walk distance (6MWD), improved FI (>0.09 units) at 6 months, achieving physical activity (PA) guidelines at 6 months, and 12 month all-cause death or readmission. RESULTS: The FI was measured in 256 participants at randomization: 110 (43%) were not-frail (FI 0.2 or less), 119 (46%) were frail (FI >0.2 to 0.39), and 27 (11%) were very frail (FI ≥0.4). Frailty was more common with older age, female gender, decompensated HF, worse HF symptoms, and preserved ejection fraction. ET attendance did not differ by frailty group. Participants who were more frail had lower 6WMD at enrollment, but similar improvement over 6 months. Mean FI improved by 0.03 units at 6 months (95% CI 0.02-0.04, p < 0.001). Participants who were more frail had significantly greater improvements in FI compared with not-frail participants and were often able to achieve PA guidelines, both in intervention and control groups. Neither baseline frailty nor intervention was significantly associated with 12-month death or readmission. CONCLUSION: Frail people with HF participating in CR that includes home and/or center-based ET often achieve PA guidelines, and some may have meaningful reductions in frailty.

Impact of exercise training program attendance and physical activity participation on six minute walk distance in patients with heart failure.

Background: Exercise training is recommended for all people with stable heart failure (HF) however adherence is poor. This study sought to describe exercise participation in recently hospitalized HF patients who participated in a 12-week exercise training program. The association between exercise training variables and improvement in 6-min walk distance (6MWD) was also investigated.Methods: This study is a secondary analysis of results from the intervention arm of the EJECTION-HF trial (ACTRN12608000263392), (n = 140). Exercise program attendance was defined according to session frequency (< 12 sessions vs ≥ 12 sessions) and attendance duration (< 6 weeks attendance vs ≥ 6 weeks) over the 12 weeks. Physical activity at baseline and follow up were reported according to self-report of 150 min of moderate intensity exercise per week. Primary outcome was change in 6MWD at 12 weeks.Results: Being physically active (OR 3.8, CI 1.3-11.5) and frequent program attendance (OR 2.7, CI 1.2-5.9) were associated with significant improvements in 6MWD. Program duration and baseline physical activity were not significantly associated with the outcome.Conclusions: Attainment of 150 min of moderate intensity exercise per week and at least weekly attendance at the program, were associated with significant improvements in 6MWD at follow up. Efforts should be made to assist patients with HF to achieve these targets.

The Effectiveness of Exercise Interventions Supported by Telerehabilitation For Recently Hospitalized Adult Medical Patients: A Systematic Review.

Objective: To evaluate the effectiveness of exercise interventions delivered via telerehabilitation (via videoconference) for recently hospitalized adult medical patients. Data sources: A search was undertaken across six databases for English language publications from inception to May 2020. Methods: Studies were selected if they included an exercise intervention for recently hospitalized adults, delivered by a physiotherapist via videoconference. Two reviewers independently screened 1,122 articles (21 full text screening) and assessed methodological quality using the Downs and Black Checklist. A narrative synthesis of the included studies was undertaken. Results: Three studies met eligibility criteria involving 201 participants with chronic heart failure or chronic obstructive pulmonary disease. Findings demonstrated limited evidence supporting the effectiveness of exercise delivered via telerehabilitation in improving physical function and patient reported quality of life outcomes in recently hospitalized medical patients. Telerehabilitation in this setting was also associated with high attendance rates and patient satisfaction. Conclusions: Findings provide preliminary support for the benefits of exercise interventions delivered via telerehabilitation for recently hospitalized medical patients. Results do need to be interpreted with caution as further high-quality studies specific to this method of exercise intervention delivery are needed.

Predictors of Exercise Training and Physical Activity Adherence in People Recently Hospitalized With Heart Failure: A BRIEF REPORT.

PURPOSE: For individuals with heart failure (HF), frequent attendance at exercise training programs and meeting physical activity (PA) guidelines are significantly associated with improvements in 6-min walk distance. Despite the evidence, adherence to exercise interventions remains poor. The aim of this study was to identify predictors of these 2 variables in patients recently hospitalized with HF. METHODS: In this substudy of the Exercise Joins Education: Combined Therapy to Improve Outcomes in Newly-discharged Heart Failure (EJECTION-HF) trial, all participants were enrolled in a HF disease management program, including weekly review of a home exercise program for 12 wk. Intervention group participants additionally undertook twice weekly supervised exercise training. Primary outcomes were frequent exercise training program attendance (≥12 sessions) and attainment of PA guidelines (150 min/wk of moderate intensity exercise) at 12 wk. Participant and clinical characteristics were analyzed using a logistic regression model to identify significant predictors of each outcome. RESULTS: A total of 278 participants provided PA data and 140 contributed attendance data. New diagnosis of HF was a significant predictor of frequent program attendance (OR = 2.3; 95% CI, 1.1-4.7; P = .03). Predictors of meeting PA guidelines at follow-up included new HF diagnosis (OR = 2.4; 95% CI, 1.2-4.8, P = .013), and being physically active at baseline (OR = 2.7; 95% CI, 1.3-5.6; P = .007). Gender, symptom severity, multimorbidity, and disability were not significantly associated with either outcome in multivariate analysis. CONCLUSION: To improve adherence, specific strategies may be required for patients with decompensated HF and those physically inactive at time of referral.

Motivators and barriers for participation in aquatic and land-based exercise training programs for people with stable heart failure: A mixed methods approach.

BACKGROUND: Aquatic exercise training may be suitable for people with stable heart failure (HF) to engage in physical activity. OBJECTIVES: Acceptability, experiences and preferences regarding aquatic and traditional land-based exercise training, were explored in people with HF. METHODS: As part of a comparative intervention study, participants completed a questionnaire assessing acceptability, benefits and challenges of aquatic compared to land-based programs. Semi-structured interviews explored participant experiences in greater depth. RESULTS: Forty-eight participants, (mean age 70 + /- 11 years), completed the questionnaire and 14 participated in semi structured interviews. Aquatic exercise was regarded as acceptable and beneficial. Motivators were similar for both programs and included: a skilled and compassionate workforce, tailored care, perceived health benefit, sense of safety and an inclusive and enjoyable environment. Few barriers were identified for either program. CONCLUSIONS: Aquatic and land-based exercise training are equally acceptable for people with stable HF and motivators are similar for both programs.

Addition of Supervised Exercise Training to a Post-Hospital Disease Management Program for Patients Recently Hospitalized With Acute Heart Failure: The EJECTION-HF Randomized Phase 4 Trial.

OBJECTIVES: This study sought to measure the impact on all-cause death or readmission of adding center-based exercise training (ET) to disease management programs for patients with a recent acute heart failure (HF) hospitalization. BACKGROUND: ET is recommended for patients with HF, but evidence is based mainly on ET as a single intervention in stable outpatients. METHODS: A randomized, controlled trial with blinded outcome assessor, enrolling adult participants with HF discharged from 5 hospitals in Queensland, Australia. All participants received HF-disease management program plus supported home exercise program; intervention participants were offered 24 weeks of supervised center-based ET. Primary outcome was all-cause 12-month death or readmission. Pre-planned subgroups included age (<70 years vs. older), sex, left ventricular ejection fraction (≤40% vs. >40%), and exercise adherence. RESULTS: Between May 2008 and July 2013, 278 participants (140 intervention, 138 control) were enrolled: 98 (35.3%) age ≥70 years, 71 (25.5%) females, and 62 (23.3%) with a left ventricular ejection fraction of >40%. There were no adverse events associated with ET. There was no difference in primary outcome between groups (84 of 140 [60.0%] intervention vs. 90 of 138 [65.2%] control; p = 0.37), but a trend toward greater benefit in participants age <70 years (OR: 0.56 [95% CI: 0.30 to 1.02] vs. OR: 1.56 [95% CI: 0.67 to 3.64]; p for interaction = 0.05). Participants who exercised to guidelines (72 of 101 control and 92 of 117 intervention at 3 months) had a significantly lower rate of death and readmission (91 of 164 [55.5%] vs. 41 of 54 [75.9%]; p = 0.008). CONCLUSIONS: Supervised center-based ET was a safe, feasible addition to disease management programs with supported home exercise in patients recently hospitalized with acute HF, but did not reduce combined end-point of death or readmission. (A supervised exercise programme following hospitalisation for heart failure: does it add to disease management?; ACTRN12608000263392).

Physiotherapy in intensive care is safe: an observational study.

QUESTION: How often do adverse events (including adverse physiological changes) occur during physiotherapy intervention in intensive care? DESIGN: A multi-centre prospective observational study. PARTICIPANTS: Five tertiary level university-affiliated intensive care units. OUTCOME MEASURES: All physiotherapy intervention in five intensive care units over a three month period. When certain specified changes occurred during physiotherapy intervention, details were noted including diagnosis of patient, intervention, vital signs, radiological changes, co-morbidities, chemical pathology, and fluid balance. RESULTS: 12 281 physiotherapy interventions were completed with 27 interventions resulting in adverse physiological changes (0.2%). This incidence was significantly lower than a previous study of adverse physiological changes (663 events in 247 patients over a 24-hour period); the incidence during physiotherapy intervention was lower than during general intensive care. Common factors in the patients who had an adverse physiological change were a deterioration in cardiovascular status (ie, decrease in blood pressure or arrhythmia) in patients on medium to high doses of inotropes/vasopressors, unstable baseline hemodynamic values, previous cardiac co-morbidities and intervention consisting of positive pressure or right side lying. CONCLUSION: The incidence of adverse events during physiotherapy intervention in these five tertiary hospitals was low, demonstrating that physiotherapy intervention in intensive care is safe.

Re-admission to intensive care: identification of risk factors.

BACKGROUND AND PURPOSE: The re-admission of patients to intensive care is associated with increased morbidity, mortality, loss of morale for patients and family, and increased health costs. The aim of the present study was to identify factors which place patients at a higher risk of re-admission to intensive care. METHOD: A prospective study of patients who were re-admitted to a 22-bed tertiary level intensive care facility within a 12 month period. Data were kept on every patient re-admitted to intensive care, including standard demographic data, initial admission diagnosis, co-morbidities, re-admission diagnosis, mobility on discharge, secretions, airway, chest X-ray, PaCO2, PaO2, PaO2/FiO2 and time of discharge. Subjects included 74 patients who had been re-admitted to intensive care in 12-month period and a comparison group of patients who were not re-admitted to intensive care. A cross-tabs procedure was initially used to estimate maximum likelihood. Significant factors with an alpha value of <0.10 were entered into a backward conditional binary logistic regression to determine independent factors. RESULTS: The overall percentage of patients who were re-admitted to intensive care compared with total admissions was 7.7%. Significant independent factors for re-admission were found to be age >65 years (p<0.05), colonization (p<0.001), weakness (p<0.001), co-morbidities of cardiac and/or respiratory disease (p<0.001) and depression (p<0.001). CONCLUSIONS: A certain profile of patients has been established who are at increased risk of re-admission to intensive care. These patients could be provided with increased intervention and surveillance on discharge from intensive care.