The purpose of this study was to determine potential adverse cardiac effects of chronic endurance training by comparing sympathovagal modulation via heart rate variability (HRV) and heart rate recovery (HRR) in middle-aged endurance athletes (EA) and physically-active individuals (PA) following maximal exercise. 36 (53±5 years) EA and 19 (56±5 years) PA were recruited to complete a two-week exercise diary and graded exercise to exhaustion. Time domain and power spectral HRV analyses were completed on recorded R-R intervals. EA had a greater HRR slope following exercise (95%CI, 0.0134-0.0138 vs. 0.0101-0.0104 beats/second;p<0.001). While EA had greater HRR 1-5 minutes post-exercise (all p<0.01), PA and EA did not differ when expressed as a percentage of baseline HR (130±19 vs. 139±19; p=0.2). Root mean square of successive differences in R-R intervals (rest and immediately post-exercise) were elevated in EA (p<0.05). Low frequency (LF) and high frequency (HF) spectral components were non-significantly elevated post-exercise (p=0.045-0.147) in EA while LF/HF was not different (p=0.529-0.986). This data suggests greater HRR in EA may arise in part due to a lower resting HR. While non-significant elevations in HF and LF in EA produces a LF/HF similar to PA, absolute spectral component modulation differed. These observations require further exploration. Novelty Bullets: • Acute effects of exercise on HRV in EA compared to a relevant control group, PA, are unknown. • EA had greater HRR, and non-significant elevations in LF and HF compared to PA, yet LF/HF was not different. • Future work should explore the implications of this observation.

OBJECTIVE:To investigate the efficacy of a short-term application of Transcutaneous Electric Nerve Stimulation to relieve rest pain in patients with chronic limb-threatening ischemia. METHODS:In patients ³18 years old, with chronic limb-threatening ischemia and rest pain ³3 in the Visual Analogue Scale, without diabetic neuropathy were randomly assigned to 1) Transcutaneous Electric Nerve Stimulation (100 Hz, 200 μs) or 2) sham intervention, both during one or two 20 min treatment sessions. The primary outcome was pain intensity, assessed by the visual analogue scale (0-10 cm) and described by the McGill Pain Questionnaire. We used a t-test for difference of means.RESULTS: A total of 169 patients were assessed, 23 met the study criteria and were randomized. Thirty-four applications were performed in two days: in the 17 Transcutaneous Nerve Stimulation and 17 sham. The within-group analysis indicated a pain decrease in both groups (Transcutaneous Electric Nerve Stimulation, from 7-3.9 cm, p<0.0001, and sham from 5.8-3.2 cm, p<0.0001). No statistically significant difference was verified between-groups (p=0.5). CONCLUSIONS:Both groups showed a decrease in rest pain of 54 and 55%, respectively. However, there was no difference between short-term high-frequency Transcutaneous Electric Nerve Stimulation and sham intervention to relieve ischemic rest pain in chronic limbthreatening ischemia patients.

RESUMO A isquemia crítica de membro inferior (ICMI) gera impacto nos sistemas de saúde, na qualidade de vida e funcionalidade dos indivíduos diagnosticados. Entretanto, há pouca evidência científica que permita fundamentar a intervenção fisioterapêutica para pacientes internados por ICMI. O objetivo desse estudo foi elaborar um consenso de especialistas sobre a fisioterapia intra-hospitalar para pacientes com ICMI. Para tal, foi utilizado o método Delphi. Um painel de especialistas foi formado por 18 fisioterapeutas que representavam 85,7% da equipe de um hospital de referência em cirurgia vascular. Foram consideradas, para o consenso, as respostas com valor mínimo de concordância de 70% e média ou mediana ≥3,1 na escala Likert. Os questionários abordaram itens da avaliação, objetivos e condutas fisioterapêuticas nas fases pré e pós-cirurgia de revascularização. Definiram-se como itens essenciais a avaliação de sintomas, função cognitiva, musculoesquelética e cardiorrespiratória. Controle da dor, redução de edemas, ganho de amplitude de movimento, deambulação e educação em saúde são objetivos no pré-operatório e o ganho de força muscular na fase pós-operatória. Exercícios passivo, assistido, ativo livre e circulatório, incluindo os membros superiores, estão indicados antes e após as cirurgias. Educação em saúde e deambulação com redução de peso em área de lesão plantar são essenciais em todo o período de internação. A eletroanalgesia foi preconizada no pré-operatório e a elevação do membro inferior e exercícios resistidos no pós-operatório.

Introduction: Evaluation of limb hemodynamics using the ankle–brachial index (ABI) may be difficult due to skin lesions, extensive necrosis, and obesity, such as commonly present in patients with diabetes with chronic limb-threatening ischemia (CLTI). We hypothesized that the pedal acceleration time (PAT) correlates with ABI and Wound, Ischemia, and foot Infection (WIfI) scores in patients with diabetes to serve as a new modality to accurately stage CLTI. Methods: A single-center, cross-sectional study included patients with and without diabetes > 18 years with CLTI. Limbs were categorized in three grades of ischemia based on the ABI (ABI < 0.8, < 0.6, and < 0.4) and in two classes based on WIfI stages of amputation risk. Receiver operator characteristic (ROC) curves were used to determine PAT sensitivity, specificity, and accuracy to predict lower-limb ischemia. Results: A total of 141 patients (67 nondiabetic and 74 diabetic) and 198 lower limbs (94 nondiabetic and 104 diabetic) met the inclusion criteria. In patients without diabetes, the accuracy of PAT for detecting an ABI < 0.8 was 85%; for detecting an ABI < 0.6 was 85%; and for detecting an ABI < 0.4 was 87%. In patients with diabetes, the accuracy of PAT in detecting an ABI < 0.8 was 91%; for detecting an ABI < 0.6 was 79%; and for detecting an ABI < 0.4 was 88%. In patients without diabetes, the accuracy for detecting WIfI stages of moderate and high amputation risk was 77% and for patients with diabetes was also 77%. Conclusions: PAT shows high correlation with the ABI as well as with the WIfI stages of amputation risk and the grades of ischemia, with high accuracy.

Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Natural Sciences and Engineering Research Council of Canada and B.C. Sports & Exercise Medicine Research Foundation. Background The epidemiologic evidence suggests that the health benefits of exercise in healthy adults outweigh the adverse effects of air pollution in all but the most extreme concentrations. However, no studies have examined the acute response to exercise in air pollution in individuals with hypertension, a subgroup particularly susceptible to the cardiovascular effects of air population. Purpose The purpose of this study was to determine the impact of traffic-related air pollution on the acute cardiovascular response to exercise in patients with hypertension. We hypothesized that exposure to higher levels of traffic-related air pollution during exercise would attenuate, but not eliminate, acute post-exercise reductions in blood pressure and arterial stiffness. Methods Fourteen patients with hypertension (62.4±6.8 years; 81% male) completed a real-world, randomized, crossover study. Two 30-minute exercise bouts at 40-59% heart rate reserve were performed: once along a commercial street (high traffic) and once in an urban plaza (low traffic). Blood pressure (BP) and arterial stiffness (i.e., carotid-femoral pulse wave velocity [cfPWV]) were examined prior to, 30 minutes after, and 2 hours following exercise. 24-hour ambulatory BP monitoring was immediately completed following each visit. Black carbon, noise, relative humidity, and temperature were measured during each exercise bout (Figure 1). Results No differences were found for baseline cardiovascular measures between high and low traffic visits. At 30 minutes and 2 hours post-exercise, systolic BP was significantly reduced relative to baseline in the low-traffic condition only; diastolic BP was not significantly reduced at any timepoint. Based on linear mixed-effects analyses, exercising at the low traffic site was associated, relative to the high traffic site, with a significant (p = 0.04) reduction in systolic BP (-4.30 mm Hg [95% CI -8.09 to -0.54]) up to 2 hours following exercise after adjusting for exercise intensity, temperature, and noise; no differences were found for diastolic BP (-1.56 mm Hg [95% CI -4.87 to 1.83], p = 0.39). Each interquartile increase in black carbon (1168 ng/m³) was significantly associated with a 2.33 mm Hg (95% CI 0.37 to 4.17) increase in systolic BP up to 2 hours following exercise. No associations were observed between traffic site and BP for any ambulatory periods (i.e., 24-hour average, daytime, nighttime, or evening). The acute cfPWV response to exercise was also similar between traffic sites (p &gt; 0.05). Conclusion Our findings suggest that exposure to traffic-related air pollution during exercise may adversely impact the beneficial short-term BP response to exercise in patients with hypertension. While the long-term implications of these changes to the acute BP response to exercise must be further explored, patients with hypertension can employ the prudent strategy of maximizing their distance from major roadways when exercising.

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