Exercise is beneficial in pulmonary arterial hypertension (PAH), although studies to date indicate little effect on the elevated pulmonary pressures or maladaptive right ventricle (RV) hypertrophy associated with the disease. For chronic left ventricle failure, high-intensity interval training (HIIT) promotes greater endothelial stimulation and superior benefit than customary continuous exercise training (CExT); however, HIIT has not been tested for PAH. Therefore, here we investigated acute and chronic responses to HIIT vs. CExT in a rat model of monocrotaline (MCT)-induced mild PAH. Six weeks of treadmill training (5 times/wk) were performed, as either 30 min HIIT or 60 min low-intensity CExT. To characterize acute hemodynamic responses to the two approaches, novel recordings of simultaneous pulmonary and systemic pressures during running were obtained at pre- and 2, 4, 6, and 8 wk post-MCT using long-term implantable telemetry. MCT-induced decrement in maximal aerobic capacity was ameliorated by both HIIT and CExT, with less pronounced pulmonary vascular remodeling and no increase in RV inflammation or apoptosis observed. Most importantly, only HIIT lowered RV systolic pressure, RV hypertrophy, and total pulmonary resistance, and prompted higher cardiac index that was complemented by a RV increase in the positive inotrope apelin and reduced fibrosis. HIIT prompted a markedly pulsatile pulmonary pressure during running and was associated with greater lung endothelial nitric oxide synthase after 6 wk. We conclude that HIIT may be superior to CExT for improving hemodynamics and maladaptive RV hypertrophy in PAH. HIIT's superior outcomes may be explained by more favorable pulmonary vascular endothelial adaptation to the pulsatile HIIT stimulus.
Purpose of Review As rehabilitation patient volume across the age spectrum increases and reimbursement rates decrease, clinicians are forced to produce favorable outcomes with limited resources and time. The purpose of this review is to highlight new technologies being utilized to improve standardization and outcomes for patients rehabilitating orthopedic injuries ranging from sports medicine to trauma to joint arthroplasty. Recent Findings A proliferation of new technologies in rehabilitation has recently occurred with the hope of improved outcomes, better patient compliance and safety, and return to athletic performance. These include technologies applied directly to the patient such as exoskeletons and instrumented insoles to extrinsic applications such as biofeedback and personalized reference charts. Well-structured randomized trials are ongoing centered around the efficacy and safety of these new technologies to help guide clinical necessity and appropriate application. Summary We present a range of new technologies that may assist a diverse population of orthopedic conditions. Many of these interventions are already supported by level 1 evidence and appear safe and feasible for most clinical settings.
Objective: Total knee arthroplasty (TKA) rehabilitation trials use exclusion criteria, which may limit their generalizability in practice. We investigated whether patients seen in routine practice who meet common exclusion criteria recover differently from TKA compared to research-eligible patients. We hypothesized that research-ineligible patients would demonstrate poorer average postoperative function and slower rate of functional recovery compared to research-eligible patients.Methods: Patient characteristics and exclusion criteria were extracted and summarized from trials included in the three most recent systematic reviews of TKA rehabilitation. Trial participant characteristics were compared to a clinical dataset of patient outcomes collected in routine TKA rehabilitation. Where possible, individual exclusion criterion from the trials were applied to the clinical dataset to determine "eligible" and "ineligible" groups for research participation. Postoperative functional outcomes including the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Timed Up and Go (TUG) were compared between "eligible" and "ineligible" groups using mixed effects models.Results: 2,528 participants from 27 trials were compared to 474 patients from the clinical dataset. Research participants were older, with lower Body Mass Index than patients in the clinical dataset. Many patients in the clinical dataset would be "ineligible" for research participation based upon common exclusion criteria from the trials. Differences were observed in average postoperative functioning between some "eligible" and "ineligible" groups in the clinical dataset. However, no differences were observed in functional recovery rate between groups, except for patients with diabetes whose TUG recovered more slowly than their "eligible" counterparts.Conclusions: Many patients in the clinical dataset were "ineligible" for research participation based upon common TKA rehabilitation trial exclusion criteria. However, the postoperative recovery rate did not differ between "eligible" and "ineligible" groups based on individual exclusion criterion-except for individuals with diabetes.
Purpose: To understand patients' and physical therapists' perspectives related to decision making during outpatient rehabilitation after total knee arthroplasty (TKA), and to describe potential barriers and opportunities for shared decision making (SDM) in this setting.Methods: A qualitative study examined the beliefs, thoughts, and experiences of patients and physical therapists regarding decision making in outpatient rehabilitation after TKA. Semi-structured interviews were conducted and analysed using directed content analysis.Results: Thirty-five participants were interviewed (20 patients, 15 physical therapists). Three main themes emerged from the data: (1) there is variability among physical therapists in how patients are involved in care decisions, (2) several features of the outpatient care paradigm are not supportive of SDM, and (3) preoperative patient-clinician interactions may facilitate SDM in postoperative rehabilitation, but these interactions are not typically utilized. Conclusion: Physical therapists described using decision-making strategies with varying levels of patient involvement. Both patients and physical therapists described barriers to routine use of SDM in the outpatient setting. Several actionable strategies for overcoming these barriers were identified for providers and organizations seeking to consistently use SDM in outpatient TKA rehabilitation.
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