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Background The exercise strategy that yields the greatest improvement in both cardiorespiratory fitness (V̇O2peak$$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$) and walking capacity poststroke has not been determined. This study aimed to determine whether conventional moderate‐intensity continuous training (MICT) or high‐intensity interval training (HIIT) have different effects on V̇O2peak$$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ and 6‐minute walk distance (6MWD). Methods and Results In this 24‐week superiority trial, people with poststroke gait dysfunction were randomized to MICT (5 days/week) or HIIT (3 days/week with 2 days/week of MICT). MICT trained to target intensity at the ventilatory anaerobic threshold. HIIT trained at the maximal tolerable treadmill speed/grade using a novel program of 2 work‐to‐recovery protocols: 30:60 and 120:180 seconds. V̇O2 and heart rate was measured during performance of the exercise that was prescribed at 8 and 24 weeks for treatment fidelity. Main outcomes were change in V̇O2peak$$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ and 6MWD. Assessors were blinded to the treatment group for V̇O2peak$$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ but not 6MWD. Secondary outcomes were change in ventilatory anaerobic threshold, cognition, gait‐economy, 10‐meter gait‐velocity, balance, stair‐climb performance, strength, and quality‐of‐life. Among 47 participants randomized to either MICT (n=23) or HIIT (n=24) (mean age, 62±11 years; 81% men), 96% completed training. In intention‐to‐treat analysis, change in V̇O2peak$$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ for MICT versus HIIT was 2.4±2.7 versus 5.7±3.1 mL·kg−1·min−1 (mean difference, 3.2 [95% CI, 1.5–4.8]; P

Objectives To adapt the content and functionalities of Brain Health PRO, a web-based multidomain program designed to increase dementia literacy, to the context and needs of users, providers and community organisations across Québec, Canada.Design Five consecutive qualitative co-creation focus group sessions 30–90 min in duration each, exploring potential barriers and facilitators to usability, accessibility, comprehensibility, participant recruitment and retention.Setting Virtual meetings.Participants A 15-member team based in Québec and Ontario, Canada, consisting of 9 researchers (including a graduate student and the project coordinator), representing occupational therapy, sensory rehabilitation, neuropsychology, psychology, health science and research methods, 3 informal caregivers of older adults living with cognitive decline and 3 members of the Federation of Quebec Alzheimer Societies.Data analysis Session recordings were summarised through both qualitative description and thematic analysis.Results The synthesised recommendations included adjustments around diversity, the complexity and presentation styles of the materials, suggestions on refining the web interface and the measurement approaches; it influenced aspects of participant recruitment, retention efforts and engagement with the content of Brain Health PRO.Conclusions Co-creation in dementia prevention research is important because it involves collaboration between researchers, community support and service providers, and persons with lived experience as care providers, in the design and implementation of clinical studies. This approach helps to ensure that the content and presentation of educational material is relevant and meaningful to the target population and those involved in its delivery, and it leads to a greater understanding of their needs and perspectives.

Abstract Background Increasing evidence implicates oxidative stress (OS) in Alzheimer disease (AD) and mild cognitive impairment (MCI). Depletion of the brain antioxidant glutathione (GSH) may be important in OS-mediated neurodegeneration, though studies of post-mortem brain GSH changes in AD have been inconclusive. Recent in vivo measurements of the brain and blood GSH may shed light on GSH changes earlier in the disease. Aim To quantitatively review in vivo GSH in AD and MCI compared to healthy controls (HC) using meta-analyses. Method Studies with in vivo brain or blood GSH levels in MCI or AD with a HC group were identified using MEDLINE, PsychInfo, and Embase (1947–June 2020). Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated for outcomes using random effects models. Outcome measures included brain GSH (Meshcher-Garwood Point Resolved Spectroscopy (MEGA-PRESS) versus non-MEGA-PRESS) and blood GSH (intracellular versus extracellular) in AD and MCI. The Q statistic and Egger’s test were used to assess heterogeneity and risk of publication bias, respectively. Results For brain GSH, 4 AD (AD=135, HC=223) and 4 MCI (MCI=213, HC=211) studies were included. For blood GSH, 26 AD (AD=1203, HC=1135) and 7 MCI (MCI=434, HC=408) studies were included. Brain GSH overall did not differ in AD or MCI compared to HC; however, the subgroup of studies using MEGA-PRESS reported lower brain GSH in AD (SMD [95%CI] −1.45 [−1.83, −1.06], p85%) and not fully accounted by subgroup analysis. Egger’s test indicated risk of publication bias. Conclusion Blood intracellular GSH decrease is seen in MCI, while both intra- and extracellular decreases were seen in AD. Brain GSH is decreased in AD and MCI in subgroup analysis. Potential bias and heterogeneity suggest the need for measurement standardization and additional studies to explore sources of heterogeneity.

Abstract Background High-intensity interval training (HIIT) has shown to confer cognitive benefits in healthy adults, via a mechanism purportedly driven by the exercise metabolite lactate. However, our understanding of the exercise parameters (e.g., work interval duration, session volume, work-to-rest ratio) that evoke a peak blood lactate response in healthy adults is limited. Moreover, evidence relating HIIT-induced blood lactate and cognitive performance has yet to be reviewed and analyzed. The primary objective of this systematic review is to use network meta-analyses to compare the relative impact of different HIIT work-interval durations, session volumes, and work-to-rest ratios on post-exercise blood lactate response in healthy adults. The secondary objective is to determine the relationship between HIIT-induced blood lactate and acute post-HIIT cognitive performance. Methods A systematic review is being conducted to identify studies measuring blood lactate response following one session of HIIT in healthy adults. The search was carried out in (1) MEDLINE, (2) EMBASE, (3) Cochrane Central Register of Controlled Trials, (4) Sport Discus, and (5) Cumulative Index to Nursing and Allied Health Literature Plus with Full Text (CINAHL+). After abstract and full-text screening, two reviewers will independently extract data on key outcomes variables and complete risk of bias assessment using the Cochrane Risk of Bias Tool and the Risk of Bias in Non-Randomized Studies of Interventions tool. Network meta-analyses will be used to generate estimates of the comparative effectiveness of blood lactate on cognitive outcomes using corresponding rankings for each work-interval duration, session volume, and work-to-rest ratio category. Where applicable, meta-regressions analyses will be performed to test the relationship between changes in the blood lactate and changes in cognitive performance. Analyses will be conducted using MetaInsight Software. Discussion This study will provide evidence on how to structure a HIIT protocol to elicit peak blood lactate response in healthy adults and will increase our understanding of the relationship between HIIT-induced blood lactate response and associated cognitive benefits. Systematic review registration PROSPERO CRD42020204400

Abstract Background Transcranial direct current stimulation (tDCS) is a non-invasive type of brain stimulation that uses electrical currents to modulate neuronal activity. A small number of studies have investigated the effects of tDCS on cognition in patients with Mild Cognitive Impairment (MCI) and Alzheimer’s disease (AD), and have demonstrated variable effects. Emerging evidence suggests that tDCS is most effective when applied to active brain circuits. Aerobic exercise is known to increase cortical excitability and improve brain network connectivity. Exercise may therefore be an effective, yet previously unexplored primer for tDCS to improve cognition in MCI and mild AD. Methods Participants with MCI or AD will be randomized to receive 10 sessions over 2 weeks of either exercise primed tDCS, exercise primed sham tDCS, or tDCS alone in a blinded, parallel-design trial. Those randomized to an exercise intervention will receive individualized 30-min aerobic exercise prescriptions to achieve a moderate-intensity dosage, equivalent to the ventilatory anaerobic threshold determined by cardiopulmonary assessment, to sufficiently increase cortical excitability. The tDCS protocol consists of 20 min sessions at 2 mA, 5 times per week for 2 weeks applied through 35 cm2 bitemporal electrodes. Our primary aim is to assess the efficacy of exercise primed tDCS for improving global cognition using the Montreal Cognitive Assessment (MoCA). Our secondary aims are to evaluate the efficacy of exercise primed tDCS for improving specific cognitive domains using various cognitive tests (n-back, Word Recall and Word Recognition Tasks from the Alzheimer’s Disease Assessment Scale-Cognitive subscale) and neuropsychiatric symptoms (Neuropsychiatric Inventory). We will also explore whether exercise primed tDCS is associated with an increase in markers of neurogenesis, oxidative stress and angiogenesis, and if changes in these markers are correlated with cognitive improvement. Discussion We describe a novel clinical trial to investigate the effects of exercise priming before tDCS in patients with MCI or mild AD. This proof-of-concept study may identify a previously unexplored, non-invasive, non-pharmacological combination intervention that improves cognitive symptoms in patients. Findings from this study may also identify potential mechanistic actions of tDCS in MCI and mild AD. Trial registration Clinicaltrials.gov, NCT03670615 . Registered on September 13, 2018.

Abstract Background Despite women’s greater need for cardiac rehabilitation (CR), they are less likely to utilize it. Innovative CR models have been developed to better meet women’s needs, yet there is little controlled, comparative data assessing the effects of these models for women. This study compared outcomes in women electing to participate in mixed-sex, women-only, or home-based CR, and a matched sample of men. Methods In this retrospective study, electronic records of CR participants in Toronto who were offered the choice of program model between January 2017 and July 2019 were analyzed; clinical outcomes comprised cardiorespiratory fitness, risk factors and psychosocial well-being. These were assessed at intake and post-6-month program and analyzed using general linear mixed models. Results There were 1181 patients (727 women [74.7% mixed, 22.0% women-only, 3.3% home-based]; 454 age and diagnosis-matched men) who initiated CR; Cardiorespiratory fitness among women was higher at initiation of mixed-sex than women-only (METs 5.1 ± 1.5 vs 4.6 ± 1.3; P = .007), but no other outcome differences were observed. 428 (58.9%) women completed the programs, with few women retained in the home-based model limiting comparisons. There were significant improvements in high-density lipoprotein cholesterol (P = .001) and quality of life (P = .001), and lower depressive symptoms (P = .030) as well as waist circumference (P = .001) with mixed-sex only. VO2peak was significantly higher at discharge in mixed-sex than women-only (estimate = 1.67, standard error = 0.63, 95% confidence interval = 0.43–2.91). Conclusion Participation in non-gender-tailored women-only CR was not advantageous as expected. More research is needed, particularly including women participating in home-based programs.

Background: Cardiac rehabilitation programs (CRPs) had to change quickly in response to a shift in clinical priorities related to to the coronavirus disease 2019 (COVID-19). Yet, no study has examined the effect of COVID-19 on CRPs and if there has been an adequate transition to alternative programming. Methods: To examine the status of CRPs during the COVID-19 pandemic, a web-based questionnaire was completed by CRP managers from April 23rd to May 14th, 2020. Results: Overall, 114 representatives of 144 CRPs (79.1% of Canadian programs) responded. Of respondents, 41.2% (n = 47) reported CRP closure; primary reasons were staff redeployment and facility closure (41% of 51 responses, for both). Redeployment occurred in open CRPs and closed CRPs (30% ± 34% and 47% ± 38% of employees, respectively; P = 0.05) and reduced hours in 17.8% ± 31% and 22.5% ± 33% for remaining employees; P = 0.56. Of open CRPs, 84.8% accepted referrals for medically high-risk patients pre-COVID-19; this level fell to only 43.5% during the COVID-19 pandemic, P < 0.001. There was a significant reduction in patients with cognitive/communication/mobility deficits who were eligible to participate during the COVID-19 pandemic. Of respondents, 57%-82.6% reported safety concerns related to prescribing exercise to medically high-risk and vulnerable populations. CRPs transitioned from group-based to one-to-one delivery models—>80% by phone and/or e-mail. Any tele-rehabilitation (one-to-one/group) was also used by 32.7% and 43.5% of CRPs to deliver exercise and education, respectively (mostly one-to-one). Resource barriers cited by open and closed CRPs were related to technology—no tele-rehabilitation, lack of equipment and patient access (35% of all barriers)—and 25.3% of barriers were owing to greater demands on staff time. Conclusions: Within 2-months of COVID-19 being declared a pandemic, 41.2% of CRPs were closed and almost half of employees redeployed. Less time-efficient one-to-one models of remote care, mostly by phone/e-mail, were adopted. Vulnerable populations were disproportionately affected, becoming ineligible owing to safety concerns. Strategies to open closed CRPs, admission of high-risk/vulnerable populations, and offering of group-based tele-rehabilitation should be a national priority. Résumé: Contexte: Les programmes de réadaptation cardiaques (PRC) ont dû s'adapter rapidement en réponse à un changement des priorités cliniques liées à la maladie à coronavirus 2019 (COVID-19). Pourtant, aucune étude n'a examiné l'effet du COVID-19 sur les PRC et s'il y a eu une transition adéquate vers une programmation alternative. Méthodes: Pour examiner l'état des PRC durant la pandémie de COVID-19, un questionnaire en ligne a été rempli par les responsables des PRC du 23 avril au 14 mai 2020. Résultats: Au total, 114 représentants de 144 PRC (79,1 % des programmes canadiens) y ont répondu. Parmi les répondants, 41,2 % (n = 47) ont signalé une fermeture du PRC; les principales raisons résidaient en un redéploiement du personnel ou une fermeture des installations (41 % des 51 réponses, avec une combinaison des deux). Le redéploiement a eu lieu pour les PRC ouverts et les PRC fermés (concernant 30 % ± 34 % et 47 % ± 38 % des employés, respectivement; P = 0,05) et les heures réduites pour 17,8 % ± 31 % et 22,5 % ± 33 % des employés restants; P = 0,56. Concernant les PRC restés ouverts, 84,8 % acceptaient de guider les patients à haut risque médical avant la COVID-19; ce niveau est tombé à seulement 43,5 % pendant la pandémie de COVID-19, P < 0,001. Parmi les patients dont la participation était éligible durant la pandémie de COVID-19, il y a eu une réduction significative du nombre de patients présentant des déficits cognitifs/communicationnels/de mobilité. Parmi les responsables interrogés, 57 % à 82,6 % ont fait état de problèmes de sécurité lorsqu’il était question de prescription d'exercice physique à des populations vulnérables et médicalement à haut risque. Les PRC sont passées d'un modèle de groupe à un modèle de prestation individuelle—>80 % par téléphone et/ou par courriel. La réadaptation à distance (individuelle/en groupe) a également été utilisée par, respectivement, 32,7 % et 43,5 % des PRC pour dispenser des exercices et des formations (principalement en séance individuelle). Les obstacles en matière de ressources identifiés par les PRC ouverts et fermés étaient liés à la technologie - pas de réadaptation à distance, manque d'équipement et de moyen d'accès par les patients (35 % de tous les obstacles) - et 25,3 % des obstacles étaient dus à des exigences plus importantes en matière de temps de travail du personnel. Conclusions: Dans les deux mois suivant la déclaration de la COVID-19 en tant que pandémie, 41,2 % des PRC ont été fermés et près de la moitié des employés ont été redéployés. Des modèles de soins individuels à distance, moins efficaces en termes de temps, principalement par téléphone/courriel, ont été adoptés. Les populations vulnérables ont été touchées de manière disproportionnée, devenant inéligibles pour des raisons de sécurité. Des stratégies d'ouverture des PRC fermés, d'admission des populations à haut risque ou vulnérables et d'offre de réadaptation à distance, en groupe, devraient constituer une priorité nationale.

Background: Evidence supports establishing a continuum of care from stroke rehabilitation (SR) to cardiac rehabilitation programs (CRPs). It is not known to what extent people poststroke are being integrated. This study aimed to determine the proportion of CRPs that accept referrals poststroke, barriers/facilitators, and eligibility criteria. Methods: A web-based questionnaire was sent to CRPs across Canada. Results: Of 160 questionnaires sent, 114 representatives (71%) of 130 CRPs responded. Of respondents, 65% (n = 74) reported accepting people with a diagnosis of stroke and doing so for a median of 11 years, 11 offering stroke-specific classes and an additional 6 planning inclusion. However, 62.5% of CRPs reported that < 11 patients participated in the last calendar year despite 88.5% reporting no limit to the number they could enroll. Among CRPs, 25% accepted only patients with concurrent cardiac diagnoses, living in the community (47.8%), and without severe mobility (70.1%), communication (80.6%), or cognitive (85.1%) deficits. The 2 most influential barriers and facilitators among all CRPs were funding and staffing. The fourth greatest barrier was lack of poststroke referrals, and third to sixth facilitators were SR/CRP collaboration to ensure appropriate referrals (third) and to increase referrals (sixth), toolkits for prescribing resistance (fourth), and aerobic training (fifth). CRP characteristics associated with accepting stroke were a hybrid program model, a medium program size, and having a falls prevention component. Conclusions: Most CRPs accept patients poststroke, but few participate. Therefore, establishing SR/CRP partnerships to increase appropriate referrals, using a toolkit to help operationalize exercise components, and allocating funding/resources to CRPs may significantly increase access to secondary prevention strategies. Résumé: Contexte: Les données recueillies appuient la continuité des soins entre les programmes de réadaptation après un accident vasculaire cérébral (PR-AVC) et les programmes de réadaptation cardiaque (PRC). On ne sait toutefois pas dans quelle mesure les patients qui ont subi un accident vasculaire cérébral (AVC) sont intégrés à un PRC. L’étude visait donc à déterminer la proportion de PRC admettant les patients ayant subi un AVC, les obstacles à l’intégration de ces derniers et les éléments qui la facilitent, ainsi que les critères d’admissibilité. Méthodologie: Des responsables de PRC de partout au Canada ont été invités à répondre à un questionnaire en ligne. Résultats: Au total, 160 invitations ont été envoyées et 114 (71 %) responsables rattachés à 130 PRC y ont répondu. Parmi ces répondants, 65 % (n = 74) ont dit que leur programme admettait depuis un nombre médian de 11 ans les patients ayant reçu un diagnostic d’AVC; 11 programmes offraient des cours spécialement destinés aux patients ayant subi un AVC et 6 autres prévoyaient de le faire. Toutefois, 62,5 % des répondants ont souligné que moins de 11 patients avaient participé à leur programme au cours de l’année qui précédait, malgré le fait que dans 88,5 % des cas, il n’y avait pas de limite au nombre de participants admis. Parmi les PRC, 25 % n’admettaient que des patients ayant aussi reçu un diagnostic d’atteinte cardiaque, vivant dans la collectivité (47,8 %) et n’ayant pas de déficit sévère sur les plans de la mobilité (70,1 %), de la communication (80,6 %) ou de la fonction cognitive (85,1 %). Dans tous les cas, les deux facteurs influant le plus (positivement ou négativement, selon le cas) sur l’intégration des patients ayant subi un AVC étaient les ressources financières et les ressources humaines. Le quatrième obstacle en importance était le faible nombre de patients ayant subi un AVC orientés vers les programmes; les autres éléments facilitateurs également recensés étaient la collaboration entre les PR-AVC et les PRC afin d’assurer l’orientation des patients concernés (3e place), l’augmentation du nombre de ces orientations (6e place), ainsi que les outils permettant de prescrire un programme d’entraînement musculaire (4e place) et un programme d’entraînement aérobique (5e place). Les PRC admettant des patients ayant subi un AVC avaient en commun les caractéristiques suivantes : ils reposaient sur un modèle hybride, ils étaient de taille moyenne et ils comprenaient un volet sur la prévention des chutes. Conclusions: Si la plupart des PRC admettent les patients qui ont subi un AVC, ces derniers sont peu nombreux à y participer. L’établissement de partenariats entre les PR-AVC et les PRC afin d’augmenter le nombre de patients orientés, la mise en place d’outils facilitant l’exécution de programmes d’exercice physique et l’affectation de fonds et de ressources aux PRC pourraient donc augmenter considérablement l’accès aux stratégies de prévention secondaire.

Background Knowledge gaps exist regarding the effect of time elapsed after stroke on the effectiveness of exercise training interventions, offering incomplete guidance to clinicians. Methods and Results To determine the associations between time after stroke and 6‐minute walk distance, 10‐meter walk time, cardiorespiratory fitness and balance (Berg Balance Scale score [BBS]) in exercise training interventions, relevant studies in post‐stroke populations were identified by systematic review. Time after stroke as continuous or dichotomized (≤3 months versus >3 months, and ≤6 months versus >6 months) variables and weighted mean differences in postintervention outcomes were examined in meta‐regression analyses adjusted for study baseline mean values (pre‐post comparisons) or baseline mean values and baseline control‐intervention differences (controlled comparisons). Secondary models were adjusted additionally for mean age, sex, and aerobic exercise intensity, dose, and modality. We included 148 studies. Earlier exercise training initiation was associated with larger pre‐post differences in mobility; studies initiated ≤3 months versus >3 months after stroke were associated with larger differences (weighted mean differences [95% confidence interval]) in 6‐minute walk distance (36.3 meters; 95% CI, 14.2–58.5), comfortable 10‐meter walk time (0.13 m/s; 95% CI, 0.06–0.19) and fast 10‐meter walk time (0.16 m/s; 95% CI, 0.03–0.3), in fully adjusted models. Initiation ≤3 months versus >3 months was not associated with cardiorespiratory fitness but was associated with a higher but not clinically important Berg Balance Scale score difference (2.9 points; 95% CI, 0.41–5.5). In exercise training versus control studies, initiation ≤3 months was associated with a greater difference in only postintervention 6‐minute walk distance (baseline‐adjusted 27.3 meters; 95% CI, 6.1–48.5; fully adjusted, 24.9 meters; 95% CI, 0.82–49.1; a similar association was seen for ≤6 months versus >6 months after stroke (fully adjusted, 26.6 meters; 95% CI, 2.6–50.6). Conclusions There may be a clinically meaningful benefit to mobility outcomes when exercise is initiated within 3 months and up to 6 months after stroke.

Background The importance of cardiorespiratory fitness for stratifying risk and guiding clinical decisions in patients with cardiovascular disease is well‐established. To optimize the clinical value of cardiorespiratory fitness, normative reference standards are essential. The purpose of this report is to extend previous cardiorespiratory fitness normative standards by providing updated cardiorespiratory fitness reference standards according to cardiovascular disease category and testing modality. Methods and Results The analysis included 15 045 tests (8079 treadmill, 6966 cycle) from FRIEND (Fitness Registry and the Importance of Exercise National Database). Using data from tests conducted January 1, 1974, through March 1, 2021, percentiles of directly measured peak oxygen consumption (VO2peak) were determined for each decade from 30 through 89 years of age for men and women with a diagnosis of coronary artery bypass surgery, myocardial infarction, percutaneous coronary intervention, or heart failure. There were significant differences between sex and age groups for VO2peak (P

Background: (1) Sleep disorders are prevalent in coronary artery disease (CAD) patients and predict cardiac events and prognosis. While increased oxidative stress (OS) has been associated with sleep disorders, less is known about its relationship with sleep quality. Similarly, little is known of how this relationship might change with exercise, which can improve sleep quality. Factors of sleep quality, such as sleep duration and disturbances, are also important as they predict cardiovascular diseases better than a global score alone. This study investigated whether OS was associated with self-rated sleep quality and its factors before and after completing a 24-week exercise intervention. (2) Methods: CAD patients undergoing an exercise program were recruited. OS was measured at baseline by the concentrations of early- (lipid hydroperoxides, LPH) and late-stage (8-isoprostane, 8-ISO) lipid peroxidation products and their ratio. Sleep quality was measured by the self-reported Pittsburgh Sleep Quality Index (PSQI) instrument at baseline and termination. Three sleep factors—perceived sleep quality, sleep efficiency, and daily disturbances—were derived from the PSQI. (3) Results: Among CAD patients (n = 113, 85.0% male, age = 63.7 ± 6.4 years, global PSQI = 5.8 ± 4.0), those with poor sleep (PSQI ≥ 5) had higher baseline 8-ISO levels (F(1, 111) = 6.212, p = 0.014, ηp2 = 0.053) compared to those with normal sleep. Concentrations of LPH (F(1, 105) = 0.569, p = 0.453, ηp2 = 0.005) and 8-ISO/LPH ratios (F(1, 105) = 2.173, p = 0.143, ηp2 = 0.020) did not differ between those with poor sleep and normal sleep. Among factors, perceived sleep quality was associated with 8-ISO and 8-ISO/LPH, and daily disturbances were associated with 8-ISO. (4) Conclusions: A marker of late-stage lipid peroxidation is elevated in CAD patients with poor sleep and associated with daily disturbances, but not with other factors or with sleep quality and its factors after exercise intervention.

Background: We investigated impacts of COVID-19 on cardiac rehabilitation (CR) delivery around the globe, including virtual delivery, as well as effects on providers and patients. Methods: In this cross-sectional study, a piloted survey was administered to CR programs globally via REDCap from April to June 2020. The 50 members of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) and personal contacts facilitated program identification. Results: Overall, 1062 (18.3% program response rate) responses were received from 70/111 (63.1% country response rate) countries in the world with existent CR programs. Of these, 367 (49.1%) programs reported they had stopped CR delivery, and 203 (27.1%) stopped temporarily (mean = 8.3 ± 2.8 weeks). Alternative models were delivered in 322 (39.7%) programs, primarily through low-tech modes (n = 226,19.3%). Furthermore, 353 (30.2%) respondents were re-deployed, and 276 (37.3%) felt the need to work due to fear of losing their job, despite the perceived risk of contracting COVID-19 (mean = 30.0% ± 27.4/100). Also, 266 (22.5%) reported anxiety, 241(20.4%) were concerned about exposing their family, 113 (9.7%) reported increased workload to transition to remote delivery, and 105 (9.0%) were juggling caregiving responsibilities during business hours. Patients were often contacting staff regarding grocery shopping for heart-healthy foods (n = 333, 28.4%), how to use technology to interact with the program (n = 329, 27.9%), having to stop their exercise because they have no place to exercise (n = 303, 25.7%), and their risk of death from COVID-19 due to pre-existing cardiovascular disease (n = 249, 21.2%). Respondents perceived staff (n = 488, 41.3%) and patient (n = 453, 38.6%) personal protective equipment, as well as COVID-19 screening (n = 414, 35.2%), and testing (n = 411, 35.0%) as paramount to in-person service resumption. Conclusion: Given the estimated number of CR programs globally, these results suggest approximately 4400 CR programs globally have ceased or temporarily stopped service delivery. Those that remain open are implementing new technologies to ensure their patients receive CR safely, despite the challenges. Highlights: COVID-19 has impacted cardiac rehabilitation (CR) delivery around the globe. In this cross-sectional study, a survey was completed by 1062 (18.3%) CR programs from 70 (63.1%) countries. The pandemic has resulted in at least temporary cessation of ~75% of CR programs, with others ceasing initiation of new patients, reducing components delivered, and/or changing of mode delivery with little opportunity for planning and training. There is also significant psychosocial and economic impact on CR providers. Alternative CR model (e.g., home-based, virtual) reimbursement advocacy is needed, to ensure safe, accessible secondary prevention delivery.

Introduction Breakdown of gut barrier integrity has been associated with inflammatory activation and is implicated in the etiology of several chronic medical conditions. Acute exercise is known to increase gut barrier permeability but the impact of chronic exercise is not clear. Most studies to date have examined how acute exercise impacts gut barrier integrity in healthy adults, while few studies have examined the impact of chronic exercise in older adults with comorbidities. We aim to investigate the impact of a 12-week program of aerobic and resistance training on biomarkers of gut barrier integrity in a sample of older adults with coronary artery disease. Methods Participants were adults with coronary artery disease undergoing a moderate-intensity 12-week cardiac rehabilitation exercise program. Fasting blood samples were taken at baseline and study termination. Serum levels of biomarkers of gut barrier integrity (zonulin and fatty acid-binding protein 2 (FABP2)) were measured by ELISA. Cardiorespiratory fitness was assessed by peak oxygen uptake (VO2peak) at study start & completion. Data analyses were performed using SPSS software version 24.0. Results Among study participants (n = 41, 70% male, age = 62.7± 9.35) we found a significant negative association between baseline FABP2 levels and baseline VO2peak in a multiple linear regression model adjusting for covariates (B = -0.3, p = 0.009). Over the course of the exercise program an increase in VO2peak (≥ 5 mL/kg/min) was independently associated with a relative decrease in FABP2 (B = -0.45, p = 0.018) after controlling for medical covariates. Conclusion Our findings indicate that an increase in cardiorespiratory fitness during a 12-week exercise program resulted in a relative improvement in a biomarker of gut barrier integrity. This indicates a potential mechanism by which longer term exercise may improve gut barrier integrity.

Knowledge gaps exist in how we implement aerobic exercise programs during the early phases post-stroke. Therefore, the objective of this review was to provide evidence-based guidelines for pre-participation screening, mobilization, and aerobic exercise training in the hyper-acute and acute phases post-stroke. In reviewing the literature to determine safe timelines of when to initiate exercise and mobilization we considered the following factors: arterial blood pressure dysregulation, cardiac complications, blood-brain barrier disruption, hemorrhagic stroke transformation, and ischemic penumbra viability. These stroke-related impairments could intensify with inappropriate mobilization/aerobic exercise, hence we deemed the integrity of cerebral autoregulation to be an essential physiological consideration to protect the brain when progressing exercise intensity. Pre-participation screening criteria are proposed and countermeasures to protect the brain from potentially adverse circulatory effects before, during, and following mobilization/exercise sessions are introduced. For example, prolonged periods of standing and static postures before and after mobilization/aerobic exercise may elicit blood pooling and/or trigger coagulation cascades and/or cerebral hypoperfusion. Countermeasures such as avoiding prolonged standing or incorporating periodic lower limb movement to activate the venous muscle pump could counteract blood pooling after an exercise session, minimize activation of the coagulation cascade, and mitigate potential cerebral hypoperfusion. We discuss patient safety in light of the complex nature of stroke presentations (i.e., type, severity, and etiology), medical history, comorbidities such as diabetes, cardiac manifestations, medications, and complications such as anemia and dehydration. The guidelines are easily incorporated into the care model, are low-risk, and use minimal resources. These and other strategies represent opportunities for improving the safety of the activity regimen offered to those in the early phases post-stroke. The timeline for initiating and progressing exercise/mobilization parameters are contingent on recovery stages both from neurobiological and cardiovascular perspectives, which to this point have not been specifically considered in practice. This review includes tailored exercise and mobilization prescription strategies and precautions that are not resource intensive and prioritize safety in stroke recovery.

Exercise is increasingly recommended as an essential component of stroke rehabilitation, yet uncertainty remains with respect to its direct effect on the cerebral vasculature. The current study first demonstrated the repeatability of pseudo-continuous arterial spin labeling (ASL) magnetic resonance imaging (MRI) in older adults with stroke, and then investigated the change in cerebrovascular function following a 6-month cardiovascular rehabilitation program. In the repeatability study, 12 participants at least 3 months post-stroke underwent two ASL imaging scans 1 month apart. In the prospective observational study, eight individuals underwent ASL imaging and aerobic fitness testing before and after a 6-month cardiovascular rehabilitation program. Cerebral blood flow (CBF) and the spatial coefficient of variation of CBF (sCoV) were quantified to characterize tissue-level perfusion and large cerebral artery transit time properties, respectively. In repeat scanning, intraclass correlation (ICC) indicated moderate test-retest reliability for global gray matter CBF (ICC = 0.73) and excellent reliability for sCoV (ICC = 0.94). In the observational study, gray matter CBF increased after training (baseline: 40 ± 13 vs. 6-month: 46 ± 12 ml·100 g−1·min−1, P = 0.036). The greatest change occurred in the parietal lobe (+18 ± 12%). Gray matter sCoV, however, did not change following training (P = 0.31). This study provides preliminary evidence that exercise-based rehabilitation in chronic stroke enhances tissue-level perfusion, without changing the relative hemodynamic properties of the large cerebral arteries.

Although currently major contributors to morbidity and mortality, cardiovascular disease (CVD) and chronic respiratory diseases, such as chronic obstructive pulmonary disease, are projected to rank among the top three in global disease burden by 2020. Multimorbidity is a common feature in CVD and chronic respiratory disease, and patients often share the same pathological characteristics including anatomical location of disease, dyspnea and fatigue, among several others. However, patients entering rehabilitation programs for either condition are functionally diverse; therefore, individuals with respiratory comorbidities may not fare as well in cardiac rehabilitation programs. This retrospective cohort study investigated several relevant functional parameters and outcomes.

Objective: To describe the prevalence and impact of respiratory comorbidities on patients undergoing cardiac rehabilitation (CR)., Methods: A retrospective review of a CR database (1999 to 2004) of patients with ischemic heart disease with ≥10 pack per year (ppy) smoking history and respiratory comorbidities (RC), non-respiratory comorbidities (NRC) and no comorbidities (NC) was performed. Primary outcomes at zero, six and 12 months included peak oxygen uptake (VO2peak), maximum workload, resting heart rate, ventilatory anaerobic threshold and anthropometrics. Analyses were performed on individuals who completed the program, adjusting for age, sex and baseline VO2peak., Results: Of 5922 patients, 1247 had ≥10 ppy smoking history: 77 (6.2%) had RC; 957 (76.7%) had NRC; and 213 (17.1%) had NC. The program completion rate for each group was similar for the RC (46.8%), NRC (55.8%) and NC groups (57.3%) (P=0.26). The RC group had the lowest baseline fitness levels (P<0.002). For VO2peak, there were significant differences among groups (P=0.02) and improvements over program duration (P<0.0001). There were no significant differences in other outcomes., Conclusions: There was a low prevalence of patients with comorbid chronic obstructive pulmonary disease in CR when based on physician referral documentation. This is likely underestimated and/or reflects a referral bias. Diagnostic testing at CR entry would provide a more accurate measure of the prevalence and severity of disease. CR participation resulted in significant and similar improvements in most key CR outcomes in all groups including similar completion rate. A CR model was effective for patients with coexisting RCs. Strategies to improve access and diagnosis should be explored.