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The goal of rehabilitation after hip fracture is to improve mobility and physical function while reversing or preventing deconditioning (functional loss following a period of inactivity). The primary method by which this goal is achieved is immediate postoperative mobilization, when feasible. Rehabilitation also includes close monitoring of pain control, nutrition, and mental health.

Oral communication and activities of daily living require efficient respiratory function to couple with downstream subsystems of phonation and resonance/articulation. Respiratory function also helps maintain a clear airway. Deficits in respiration may arise from disease states, posture changes, or deconditioning following a medical event. Optimum management is essential to provide the patient with healthy oxygen exchange necessary for other body organs (circulation, renal, hepatic, and hematological systems) and to set up necessary aerodynamics to protect the airway and permit phonation.

Physical activity plays a fundamental role in contrasting physiological deconditioning during ageing. Considering the complexity of the modifications that can occur in the physical activity domain, international guidelines recommend that older adults engage in a combination of aerobic, strength, flexibility, and balance training to promote active ageing and maintain adequate health status. For this reason, virtual coaches must be designed to prescribe appropriate physical activity plans in each of the specific target sub-domain. Technological solutions based on wearable devices and digital games are promising can be the key to a successful system. This chapter describes the physiological bases and the technological approaches implemented by the NESTORE system to evaluate users’ functional abilities and to propose a comprehensive and individualised coaching plan in the physical activity domain according to the internationally recognised guidelines. The main technological NESTORE components, co-designed together with users to monitor their status and behaviour and coach them to perform effective physical activity, are (i) the NESTORE wristband that will assess the users’ performances and monitor the main physiological parameters during aerobic activity and (ii) the NESTORE Pocket Odyssey mobile game that will engage the users during physical activities in the strength, flexibility and balance domains.

The effects of long-term reduced (lunar) gravity are very much unknown. The Apollo Program represents our only experience with humans in extended lunar gravity. Those exposures were brief, but few if any major medical issues were encountered that cannot be ascribed to issues other than reduced gravity. Animal experiments will be of great value in elucidating partial-g effects, but they have uncertain transfer to human responses; the best of these experiments are being performed now (2021) with rodents on an ISS centrifuge. We might expect that some of the main physiological issues that occur in extended weightlessness (e.g., ISS) will manifest also in extended lunar gravity, but this is far from certain. The reduced but non-zero gravity level on the moon may well be sufficient to halt or dramatically reduce the main aspects of physiological deconditioning seen in weightlessness. Those aspects that are not sufficiently alleviated in this way might benefit from additional exercise and intermittent exposures to higher gravity levels.

Epidemiologic studies report varying estimates of prevalence of orthostatic hypotension. These are mostly due to differences in age, gender, and ethnicity of study samples as well as different methods used to measure and determine orthostatic hypotension. Even as orthostatic hypotension is largely asymptomatic or only followed by minimal symptoms, studies have named orthostatic hypotension as an independent factor associated with cerebro- and cardiovascular morbidity and mortality. Orthostatic hypotension is a result of a dysfunction in the normal adaptive mechanisms of blood pressure regulation. Although the exact etiology is still unclear, different risk factors have been proposed including age, hydration status, use of medication, deconditioning as well as a number of cardiovascular and neurologic illnesses. As orthostatic hypotension remains the second most common cause of syncope and its high prevalence among older adults influencing in terms of the incidence of falls, injury, institutionalization, and hospitalization, it presents an important public health issue. The following chapter outlines studies investigating prevalence, risk factors, and the role of orthostatic hypotension in the etiological pathways of other chronic illnesses and mortality.

Exercise is an important component of the management of PoTS especially where deconditioning is present. In particular the long term effects of increased physical fitness such as increased blood volume, stroke volume and cardiac output, enhanced vascular pressure by enlarged muscle tissue and possible changes to the baroreflex are all thought to counteract orthostatic intolerance. Exercise needs to be carefully prescribed through careful clinically reasoning, gradation and monitoring, alongside other non pharmacological and pharmacological treatments. In particular people with overlapping pathologies such as Hypermobility Spectrum Disorder, Ehlers Danlos Syndromes, fibromyalgia, chronic fatigue syndrome or overtraining scenarios need to be carefully managed to avoid exacerbation of symptoms and to enable steady progress.

While the beneficial effects of exercise in coronary artery disease and heart failure are established as an evidence-based therapeutic strategy, valvular heart disease (VHD) shows a more complex relationship with physical activity. Evidence on beneficial effects of exercise as a conservative medical management in VHD patients is scarce, and patients with moderate to severe VHD are often discouraged from exercise. Preclinical and clinical studies support a potential beneficial role of limited exercise training programs in counteracting deconditioning and frailty and in delaying the natural history in selected cases. Following cardiac surgery, cardiac rehabilitation is effective in increasing cardiorespiratory fitness alongside an improved circulatory response to exercise, particularly after years of physical activity restriction. It further reduces cardiovascular mortality and hospital readmissions and improves quality of life. In contrast, hemodynamic improvements after valve surgery are impaired by the type of valve lesion, the degree of preoperative ventricular impairment, the extent of frailty and the presence of surgical complications. Therefore, exercise training should be part of a multidisciplinary rehabilitation approach. Prior to inclusion, patients should undergo cardiopulmonary exercise testing and echocardiography. More recently, minimally invasive cardiac surgery and percutaneous approaches facilitate an early initiation of exercise training, reducing muscular atrophy, anxiety and fatigue. Most studies focused on cardiovascular rehabilitation after transcatheter aortic valve implantation and demonstrated improvements in quality of life, 6-min walking distance and perceived physical function, whereas only few studies evaluated cardiorespiratory fitness by assessing peak oxygen uptake. The increasing significance of cardiac rehabilitation thus requires support from randomized trials to establish evidence-based exercise regimens in the growing population of surgically or interventionally treated VHD patients.

This chapter describes investigations that explored the genomic correlates of fibromyalgia. Significance and prevalence rates are reviewed and definitions are discussed within the context of the need to develop case definitions and phenotypes to advance the science and management of fibromyalgia. Underlying mechanisms and several clinical practice guidelines are presented. A summary of recommendations regarding assessment and management of fibromyalgia, drawn from the guidelines, is listed with particular emphasis on the co-management of co-occurring symptoms and conditions such as deconditioning and muscle weakness, lack of energy, pain, emotional distress, cognitive impairment, sleep disturbance/insomnia, and nutrition-related issues. The chapter concludes with a brief discussion about the significance of these genomic correlates of fibromyalgia recommending potential research topics to pursue in order to fill the existing gaps in knowledge.

It is increasingly recognized that factors beyond traditional measures of liver severity like the Model for End-Stage Liver Disease such as disability, frailty, and sarcopenia are important predictors of meaningful outcomes for patients with cirrhosis. Although each concept is measured in different ways with clinical utility that is context dependent, they share a common biology. Understanding the overlap between these measures informs practice in important ways. Underlying each factor is malnutrition, deconditioning, and hepatic encephalopathy. Interventions to forestall or rehabilitate markers such as disability, frailty, and sarcopenia will require a deliberate, multimodal approach geared toward their specific drivers.

The progress of intensive care medicine has dramatically improved survival of critically ill patients, especially in patients with acute respiratory distress syndrome (ARDS) and sepsis [1, 2]. However, this improved survival is often associated with general deconditioning, muscle weakness, prolonged mechanical ventilation, dyspnoea, depression, anxiety, and reduced health-related quality of life after intensive care unit (ICU) discharge [3, 4]. Deconditioning and specifically muscle weakness have a key role in impaired functional status after ICU stay [5, 6]. Bed rest and limited mobility during critical illness result in profound physical deconditioning and dysfunction of the respiratory, cardiovascular, musculoskeletal, neurological, renal, and endocrine systems [7]. These effects can be exacerbated by inflammation and pharmacological agents, such as corticosteroids, neuromuscular blockers, and antibiotics associated with critical illness and its treatment. The prevalence of skeletal muscle weakness in the intensive care unit (ICU-acquired weakness) varies up to 50%. Skeletal muscle wasting appears to be the highest during the first 2–3 weeks of ICU stay [8–11] and is associated with weaning failure, ICU and hospital length of stay, and increased 1-year mortality [5, 12].

Heart transplantation is an established therapy in children with end-stage heart failure. Ninety percent of pediatric heart transplant recipients have congenital heart disease or cardiomyopathy as the underlying disease. Exercise performance in the early posttransplant period is affected by factors that precede transplant, such as malnutrition and deconditioning from heart failure, as well as associated medical conditions (e.g., neuromuscular disease). Improvement in exercise performance in the months following transplant may be aided by referral to a formal rehabilitation program. Performance on long-term follow-up remains subnormal due to transplant-specific factors such as cardiac autonomic denervation with resulting chronotropic incompetence and persistent left ventricular diastolic dysfunction. Exercise testing with stress echocardiography has potential utility in noninvasive surveillance for posttransplant coronary artery disease.

Patients with life-threatening conditions that present with syncope can be recognized promptly and appropriately with history, physical electrocardiogram (EKG), and echocardiography. Once diseases are recognized, exercise testing may be part of disease characterization and management. Exercise testing has a critical role in patients with high-risk histories of syncope, to evaluate for catecholaminergic polymorphic ventricular tachycardia (CPVT) and other unusual arrhythmia syndromes. Most patients with low severity, typical syncope will not benefit from exercise testing (or any substantial testing). For patients with more problematic symptoms, exercise testing represents a relatively low barrier test that can identify multiple contributors to symptoms. This includes deconditioning, abnormal or potentially abnormal blood pressure responses, and incidental or potentially important arrhythmias. The differences between normal and abnormal exercise responses in those with potential orthostatic syndrome overlap with normal physiology. Testing always needs to be interpreted in context.

Dyspnoea and exercise limitation are among the most common symptoms experienced by patients with chronic obstructive pulmonary disease (COPD) and are linked to poor perceived health status and increased mortality. Cardiopulmonary exercise testing (CPET) provides a unique opportunity to objectively evaluate the ability of the respiratory system to respond to measured physiological stress across the spectrum of disease severity. In symptomatic mild COPD, the combined abnormalities of increased wasted ventilation leading to increased ventilatory demand and critical erosion of the dynamic inspiratory reserve volume lead to intolerable respiratory discomfort and early exercise limitation. In moderate-to-severe COPD, these major physiological abnormalities that culminate in pronounced demand-capacity imbalance of the respiratory system and dyspnoea become further amplified and are evident at relatively low exercise intensities. In this group, exercise intolerance is often further compounded by the effects of generalized skeletal muscle deconditioning and worsening cardio-circulatory dysfunction. Last but not least, significant dynamic lung hyperinflation on exertion has recently been demonstrated in asymptomatic subjects with mild airway obstruction. It goes without saying that identification of specific physiological derangements exposed by CPET facilitates an individualized approach to management in COPD.

Cancer-related fatigue is a common and troubling symptom for cancer patients. Its physiologic mechanisms are complex and interplay with other symptoms, hormonal changes, deconditioning, and a pro-inflammatory state. While further studies are needed, current evidence suggests exercise results in reduced cancer-related fatigue compared to other existing treatments. A combination of resistive and aerobic exercises reduces fatigue. Unfortunately, the wide variation in exercise programs studied means that the most effective types of exercise and optimal doses of exercise are unclear. Despite a growing amount of evidence to support the beneficial effects of exercise on fatigue and other cancer symptoms; it is under-addressed by cancer healthcare professionals.

Physical activity (PA) has benefits in optimising function and decreasing the impact of secondary chronic conditions due to deconditioning in older people with neurological conditions. However, PA is poorly recommended, prescribed, and delivered in this population despite the growing body of existing evidence-based research. This chapter reviews the major determinants of physical inactivity and sedentary behaviour for key neurological conditions that affect older people including stroke, Parkinson’s disease, and neuromuscular diseases and summarises the evidence on the implementation of PA programmes.

Critical care poses significant challenges for all patients. However, the elderly population requires extra vigilance owing to age-related changes in physiology, multiple medical comorbidities, polypharmacy, and deconditioning. The elderly, defined here as persons 65 years or older, account for 14.5% of the population and account for 42–52% of ICU admissions. The impact of the elderly will dramatically increase as their population will double to 70 million in 2030. Given increasing life expectancy (78.8 years in the United States), and the fact that this segment of the population accounts for 42–52% of ICU admissions [1, 2], the impact on health care and critical care is immense. Mortality is increased in the elderly, and studies demonstrate an 18.7% mortality for surgical patients, up to 26.5% ICU mortality for medical cause, and up to 50% mortality 1 year after discharge [1–3]. Aging affects every system in the body, and combined with comorbidities, multiple medications, and frequent end-of-life ethical issues, caring for these patients poses significant challenges in today’s health-care environment [4–13]. Knowing how to care for this special population with age-related physiologic changes and a lack of physiologic reserve compared to the general population is of paramount importance.

Certain medical conditions can compromise many aspects of human thermoregulatory adaptations, leading to heat intolerance. There are varying disorders of skin and perspiration, and depending on extent of the disease or injury, it can significantly impair heat dissipation. Common examples include sunburn and type 1 diabetes (i.e., impaired vasomotor and sudomotor control). Conditions affecting central thermoregulation (e.g., febrile illness, sleep deprivation) and metabolism (e.g., malignant hyperthermia susceptibility [MHS], hyperthyroidism) may also increase the risk of heat illness. The similarities between malignant hyperthermia and exertional heat stroke (EHS) have long been speculated, and many cases of EHS in individuals with MHS have been reported. Cardiovascular disorders contribute to heat intolerance via blunted cardiac output response to exercise, impaired blood shunting to the skin, and side effects of medications used to treat heart disease. This is especially relevant with today’s increasing numbers of “masters” runners and athletes. Other medical conditions or intrinsic factors may impair thermoregulation through a variety of mechanisms, including obesity, dehydration, poor physical fitness (or deconditioning), lack of acclimatization, increasing age, and sickle cell trait. The pre-participation physical exam is a critical opportunity to identify these medical conditions and implement risk-mitigation strategies (e.g., ensuring good hydration practices are followed, and coaches are notified of any athletes with increased risk). In individuals with medical conditions that contribute to heat intolerance, risk can generally be mitigated by optimizing every other factor possible, such as hydration, nutrition, sleep, acclimatization, and proper cycles of exercise and rest.

The perioperative management of mechanical support patients can be challenging. These patients are plagued by decompensated heart failure resulting in a low output state and, consequently, end organ dysfunction. They are additionaly challenged by immobility and deconditioning and very often require emergent temporary support or elective durable support. This can create for a lengthy, arduous convalescence. A standardized approach to critical care management can help optimize both the short and long term outcomes.

Despite improved survival rates during the past 25 years, older breast cancer survivors have a significantly higher cardiovascular disease (CVD) risk compared to age- and sex-matched noncancer controls, a finding attributed, in part, to sedentary (cardiovascular) deconditioning during and following cancer treatment. As a result, breast cancer survivors’ peak exercise oxygen uptake (peak VO2) is ~20% lower than age-matched noncancer controls. The objective of this chapter is to highlight the mechanisms responsible for impaired peak VO2 in older breast cancer survivors and discuss the role of exercise rehabilitation training to improve peak VO2, muscle strength and functional outcomes, fatigue resistance, and quality of life. Evidence to date suggests that the reduced peak VO2 in older breast cancer survivors is the result of both central and peripheral abnormalities that result in decreased oxygen delivery and/or utilization by exercising muscle. Exercise rehabilitation training improves peak VO2 by ~11% in older breast cancer survivors; however, the relative contributions of central (cardiac) and peripheral (skeletal muscle and vascular) adaptations to this improvement remain unclear and warrant further investigation. Breast cancer patients who perform exercise training during chemotherapy experience fewer changes in therapy regimens, better treatment effectiveness, and improved survival. Exercise training also increases muscle strength and preserves bone mineral density with subsequent improvements in functional outcomes (timed up and go and 6-min walk distance). Finally, older breast cancer survivors also report improvements in fatigue resistance and quality of life following exercise training.

The evolution of surgical technique and immunosuppression medications during the last half-century resulted in heart and lung transplantation becoming increasingly more common. While these life-saving procedures offer improved survival and quality of life, there are many challenges that need to be mitigated in order to realize these potential benefits. Advanced stage of primary disease, co-morbid conditions, and deconditioning are several factors that may place the recipient at risk of primary graft dysfunction, perioperative complications, and prolonged hospital course. In this chapter, we will review the underlying principles of anesthetic management that can contribute to successful outcomes for these complex operations. Tables 4.4 and 4.5 provide a summary of the considerations during heart and lung transplantation.

Perioperative care is a complex intervention provided by multiple clinicians in the preoperative, intraoperative, and postoperative phases, aimed toward decreasing the perioperative stress response and limiting any functional decline due to a surgery and hospitalization. Strategies to minimize this deconditioning and accelerate the return to presurgical functionality have focused on the postoperative period in the form of rehabilitation programs. However, postoperative interventions such as an exercise program may not be helpful as patients are tired, in pain, and afraid of disturbing the surgical sites. Providing elderly patients with a structured program prior to surgery has the potential to increase their reserve and allow them to tolerate the surgical stress better. Such a program has been termed prehabilitation, as it is preemptive rather than reactive. Studies done in a colorectal cancer population highlight that 4 weeks of preoperative program involving aerobic and resistance exercises, protein supplementation and nutritional counseling, and relaxation techniques is the best strategy to improve recovery after surgery. Great care must be taken in tailoring the prehabilitation program to each individual to ensure optimal results. Although most studies included patients over 60 years of age, none of the studies have addressed specifically the elderly and frail. Nonetheless, it has been observed that at 8 weeks after surgery, 80% of patients who had received prehabilitation had recovered baseline functional capacity versus 40% of patients who did not receive such an intervention. Further research is needed in the field of prehabilitation, notably on different modalities of intervention, effect on postoperative complications and outcomes, and long-term effect.

The management of hip fracture in older people in the post-operative setting requires a multidisciplinary approach and geriatric competencies. The main goals of the post-operative stage are early mobilisation and prevention of complications. To achieve the goal of early mobilisation a stable surgical repair is essential, allowing the patient to bear weight as tolerated, as well as effective pain control and fluid management protocols, ensuring an adequate volume and avoiding orthostatic hypotension. Due to the age-related decline of the physiological reserve and function across multi-organ systems, patients with hip fracture are at risk of multiple complications. Almost every organ is vulnerable, although cognitive dysfunction, cardiac complications and infections are the most frequent and clinically significant. In most common conditions a systematic approach in the management of hip fracture, through a checklist for each professional and shared protocols, is an established method to improve the quality of the intervention and reduce post-operative complications. The vulnerability to complications of older patients with hip fractures may last for several days after surgical repair. However, this group of patients is at high risk of deconditioning in hospital and thus early discharge-planning based on discharge needs is a crucial component in the management of the acute episode.

The physiological response to exercise changes tremendously when children become adults. This chapter describes how exercise capacity, as well as anaerobic metabolism, develops throughout puberty and ventilatory pattern changes. In addition it presents an overview of the large variety of exercise limitations in adolescents with CHD that could be either congenital, like structural limitations resulting into impaired stroke volume or chronotropic impairment, or acquired deconditioning or detraining, enhanced thru parental overprotection and missing or insufficient counseling of medical doctors. Finally, it outlines the beneficial effects and importance of exercise and lifelong physical activity for all ages of CHD as prevention of cardiovascular disease starts already in childhood.

Spaceflight is known to include the risk for physiological deconditioning as well as mental impairments, endangering mission safety and success. While Space science primarily focussed on physical health in the past, mental health (i.e. cognitive performance and affective state) was widely neglected. Today, not only in Space but also exercise science, the promotion of exercise for mental health is on the rise. This chapter is dedicated to review the known cognitive and affective deficits in relation to spaceflight. It aims to provide information about the underlying neurophysiological mechanisms, thus discussing the effect and application of exercise as a countermeasure, and to illustrate the contribution of Space science to mental health for our society.

The lung is directly affected by weightlessness: the disappearance of weight forces on the lung tissue itself and surrounding tissues, and hydrostatic pressure gradient changes lung shape and the distribution of gas-filled space. However, inhomogeneous ventilation and aeration of alveolar volumes can also be detected in weightlessness. In the transient phase immediately after the onset of weightlessness, the lung as an interface between the environment and the cardiovascular system also compensates for temporary misbalances between right and left cardiac stroke volume. Long-term effects directly associated with weightlessness can also be attributed to deconditioning of respiratory muscles.

‘Awake’ extracorporeal membrane oxygenation (ECMO) is being used increasingly as a bridge to lung transplant (LuTx) to support refractory respiratory failure as an alternative to invasive mechanical ventilation and associated immobilisation and deconditioning which are associated with poor outcome. the ideal combination of ECMO cannulation and muscle training has yet to be determined and depends largely on patient-specific needs and procedural limitations.

Those undergoing hematopoietic stem cell transplant and related treatment are at risk for significant deconditioning and loss of overall functional abilities. The use of physical activity, in the form of both aerobic and strengthening, has been shown to be effective in the prevention and remediation of loss of strength, cancer-related fatigue, loss of cognitive functioning, and decreased quality of life. Rehabilitation services, primarily occupational and physical therapies, are beneficial members of the treatment team and are able to assist with return of function using a variety of techniques including engagement in physical activity.