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OBJECTIVE: To investigate the feasibility of submaximal cardiopulmonary exercise testing (CPET) in patients with knee osteoarthritis (OA) scheduled for primary total knee arthroplasty (TKA) surgery. Secondly, to assess their preoperative aerobic capacity.METHODS: In this observational, single-center study, participants performed a submaximal CPET 3-6 weeks before surgery. To examine their experiences, participants completed a questionnaire and one week later they were contacted by telephone. CPET was deemed feasible when five feasibility criteria were met. Aerobic capacity was evaluated by determining the oxygen uptake (VO2) at the ventilatory anaerobic threshold (VAT) and oxygen uptake efficiency slope (OUES). OUES values were compared with two sets of normative values.RESULTS: All feasibility criteria were met as 14 representative participants were recruited (recruitment rate: 60.9%), and all participants were able to perform the test and reached the VAT. No adverse events occurred, and all participants were positive toward submaximal CPET. The median VO2 at the VAT was 12.8 mL/kg/min (IQR 11.3-13.6). The median OUES/kg was 23.1 (IQR 20.2-28.9), 106.4% and 109.4% of predicted.CONCLUSION: Submaximal CPET using cycle ergometry seems feasible in patients with knee OA scheduled for TKA surgery to evaluate preoperative aerobic capacity.

Suboptimal quality of feasibility assessments might partially explain inconsistencies observed in the effectiveness of exercise prehabilitation before colorectal cancer (CRC) surgery. This systematic review aimed to assess the reporting quality and clinical generalizability of feasibility outcomes in feasibility studies addressing exercise prehabilitation before CRC surgery. PubMed/Medline, Embase, Cochrane, and CINAHL were searched to identify all feasibility studies focussing on exercise prehabilitation in CRC surgery. Reporting quality was assessed using the Thabane et al. checklist and the Consolidated Standards of Reporting Trials extension for feasibility studies. Clinical generalizability was evaluated by appraising patient participation in all steps of the study and intervention. Twelve studies were included. The main feasibility outcome in all studies was adherence to the intervention by the study sample. Based on adherence, 10 studies (83%) concluded exercise prehabilitation to be feasible. Six studies (50%) reported all details to assess patient participation showing retention rates between 18.4% and 58.2%, which was caused by non-participation and drop-out. Three feasibility studies (25%) discussed patient-reported barriers to participation and five additional studies (41%) described potential selection bias. Four studies (33%) reported lessons learned to solve issues hampering feasibility and clinical generalizability. Results suggest that true feasibility of exercise prehabilitation before CRC surgery remains questionable due to poor reporting quality, insufficient clarity regarding the representativeness of the study sample for the target population, and limited attention for clinical generalizability. Feasibility of exercise prehabilitation might be improved by offering supervised community- or home-based interventions tailored to the physical and mental abilities of the patient.

Patients with Crohn’s disease (CD) are at a considerable risk for intestinal surgery. Approximately 25% of patients with CD will undergo an intestinal resection within 10 years of diagnosis. Postoperative complications after CD surgery have been reported in 20%-47% of the patients. Both general and CD-related risk factors are associated with postoperative complications, and comprise non-modifiable (e.g., age) and potentially modifiable risk factors (e.g., malnutrition). Prehabilitation focuses on the preoperative period with strategies designed to optimize modifiable risk factors concerning the physical and mental condition of the individual patient. The aim of prehabilitation is to enhance postoperative recovery and return to or even improve preoperative functional capacity. Preoperative improvement of nutritional status, physical fitness, cessation of smoking, psychological support, and critical revision of preoperative use of CD medication are important strategies. Studies of the effect on postoperative outcome in CD patients are scarce, and guidelines lack recommendations on tailored management. In this opinion review, we review the current evidence on the impact of screening and management of nutritional status, physical fitness, CD medication and laboratory values on the postoperative course following an intestinal resection in CD patients. In addition, we aim to provide guidance for individualized multimodal prehabilitation in clinical practice concerning these modifiable factors.

Background and Objectives: To assess the association of preoperative aerobic fitness and body composition variables with a patient's resilience to the development and impact of postoperative complications after elective colorectal cancer (CRC) surgery. Methods: Preoperative aerobic fitness was assessed by steep ramp test performance. Preoperative body composition was assessed by muscle mass and density determined from preoperative computed tomography scan analysis at the L3-level. Complication development and severity was graded according to Clavien-Dindo. Complication impact was assessed by the time to recovery of physical functioning after complications. Multivariable logistic regression analyses adjusted for age, sex, comorbidities and tumour location was performed. Results: Of 238 included patients, 96 (40.3%) developed postoperative complications. Better preoperative aerobic fitness decreased the likelihood to develop complications, independent of muscle mass (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.35−0.85) or muscle density (OR: 0.57, 95% CI: 0.36−0.89). A prolonged time to recovery following complications was associated with lower preoperative muscle density (OR: 4.14, 95% CI: 1.28−13.41), independent of aerobic fitness. Conclusions: Lower aerobic fitness increases the risk of complication development, while low muscle density seems associated with a prolonged recovery from complications. Aerobic fitness and muscle density could be valuable additives to preoperative risk assessment.

Introduction: The purpose of this case study was to demonstrate the clinical decision-making process of healthcare professionals within a rehabilitation program during chemoradiotherapy (CHRT) for a high-risk patient diagnosed with stage III non-small cell lung cancer (NSCLC). The course of CHRT and patient's preferences, facilitators, and barriers were considered.Case-description: The patient was a 69-year-old man with a history of rheumatoid arthritis diagnosed with stage III NSCLC.Intervention: A home-based, personalized, and partly supervised rehabilitation program during CHRT, including aerobic, resistance, and breathing exercises, as well as nutritional counseling.Outcomes: The patient suffered from side effects of CHRT, which required adjustments in the context and intensity of the exercises. An important facilitator for the patient was encouraged by his wife in following the home-based rehabilitation program. During home visits, the patient and physiotherapists performed the exercises together to help him to overcome the burden and motivate the patient to adhere to the rehabilitation program.Conclusion: This case study demonstrates that physical exercise training could be performed by adjusting training intensity and the way in which the physical exercise training was delivered, while the patient experienced side effects from CHRT. In addition, the involvement and support of (in)formal caregivers seems essential for adherence to rehabilitation.

Objective Hospitals and healthcare providers should assess and compare their quality of care given to patients and based on this improve the care. In the Netherlands, hospitals provide data to national quality registries, which in return provide annual quality indicators. However, this process is time-consuming, resource intensive and risks patient privacy and confidentiality. In this paper, we presented a multicentric ‘Proof of Principle’ study for federated calculation of quality indicators in patients with colorectal cancer. Materials and Methods Two quality indicators are calculated in an efficient and privacy persevering federated manner, by i) applying the Findable Accessible Interoperable and Reusable (FAIR) data principles and ii) using the Personal Health Train (PHT) infrastructure. Instead of sharing data to a centralized registry, PHT enables analysis by sending algorithms and sharing only insights from the data. Results ETL process extracted data from the Electronic Health Record systems of the hospitals, converted them to FAIR data and hosted in RDF endpoints within each hospital. Finally, quality indicators from each center are calculated using PHT and the mean result along with the individual results plotted. Discussion and Conclusion PHT and FAIR data principles can efficiently calculate quality indicators in a privacy-preserving federated approach and the work can be scaled up both nationally and internationally. Despite this, application of the methodology was largely hampered by ELSI issues. However, the lessons learned from this study can provide other hospitals and researchers to adapt to the process easily and take effective measures in building quality of care infrastructures.

Introduction: Prehabilitation aims for an optimal physical functioning level before, during, and after hospitalization for major surgery. The purpose of this case report was to illustrate the care pathway of a high-risk patient who opted for pylorus-preserving pancreaticoduodenectomy, including preparation for this procedure by participating in a community-based exercise prehabilitation program. The report describes patient examination, evaluation in decision-making for surgery, the prehabilitation program, and outcomes within the context of the Hypothesis-Oriented Algorithm for Clinicians II. Case Description: The patient was a 75-year-old woman with a history of several comorbidities and a polypoid mass in the descending segment of the duodenum. Based on the preoperative assessment, the level of physical functioning was expected to be insufficient to cope adequately with the stress of hospitalization and surgery. Intervention: A 4-week prehabilitation program, including aerobic, resistance, and functional task training in a community-based physical therapy practice. Outcomes: Prehabilitation had a beneficial impact on improving functional mobility preoperatively (timed up-and-go test score improved from 19.4 to 10.0 s, five times sit-to-stand test score improved from 30.1 to 10.1 s, and two-minute walk test distance improved from 55.0 to 107.0 m). Surgery and postoperative recovery proceeded without complications. She achieved independent physical functioning on postoperative day 6 and was discharged home on postoperative day 12. Conclusion: Preoperative risk-assessment can support clinical decision-making in a high-risk patient opting for major abdominal surgery. Furthermore, a remarkable improvement in physical functioning can be achieved by community-based prehabilitation in a high-risk surgical patient.

Background: Morbidity rates in pancreatic surgery are high, and especially frail patients with low aerobic capacity are at risk of complications and require specialized prophylactic interventions. Previous studies of small patient cohorts receiving intra-abdominal surgery have shown that an exercise prehabilitation program increases aerobic capacity, leading to better treatment outcomes. In this study we aim to assess the feasibility of a home-based exercise prehabilitation program in unfit patients scheduled for pancreatic surgery on a larger scale. Methods: In this multicenter study adult patients scheduled for elective pancreatic surgery, with a preoperative oxygen uptake (VO2) at the ventilatory anaerobic threshold ≤13 mL/kg/min and/or a VO2 at peak exercise (VO2peak) ≤18 mL/kg/min will be recruited. The study will be conducted in a pretest-posttest design. A total of 30 patients will be included in the four-week home-based, partly supervised exercise prehabilitation program on an advanced cycle ergometer. The program comprises 30-minute high-intensity interval training three times a week. Training intensity will be based on a steep ramp test (i.e., an abbreviated maximum exercise test on the advanced ergometer) performance, aiming to improve aerobic fitness. Twice a week, patients will perform functional task exercises to improve muscle function and functional mobility. Every week, a steep ramp test will be repeated, and training intensity will be adjusted accordingly. Next to assessing feasibility (participation rate, reasons for non-participation, adherence, dropout rate, reasons for dropout, adverse events, and patient and therapist appreciation) of this exercise prehabilitation program, we will evaluate individual patient’s responses to prehabilitation on aerobic capacity, functional mobility, body composition, perceived fatigue, quality of life, muscle function, and immune system factors. Discussion: Results of this study will provide important clinical and scientific knowledge on the feasibility of a partly supervised home-based exercise prehabilitation program in a vulnerable patient population. This might ease the path to implementing prehabilitation programs in unfit patients undergoing complex abdominal surgery, such as pancreatic surgery. Trial registration: This study was approved by the Medical Research Ethics Committee of the Maastricht University Medical Center+ (METC azM/UM), the Netherlands (registration number METC20-090, NL75340.068.20, September 2021) and is registered in the Clinicaltrials.gov register (NCT05496777).

Background: Patients with locally advanced rectal cancer are often considered for neoadjuvant chemoradiotherapy before resection. This presurgical treatment can have negative effects on physical fitness, muscle mass, and treatment compliance, which can negatively influence clinical outcomes. Objective: The aim of this study was to evaluate physical fitness and skeletal muscle mass before and after neoadjuvant chemoradiotherapy in single subjects with locally advanced rectal cancer. Design: An observational longitudinal study of single subjects. Methods: Routine care data were retrospectively analyzed. Data consisted of tumor characteristics, clinical data (eg, side effects and toxicity of the neoadjuvant chemoradiotherapy, loss of body mass), data on performance-based physical fitness, and computed tomography-derived skeletal muscle mass. An independent-samples t test or its nonparametric equivalent was performed on outcome measures to test for significant differences between T-0 and T-1. For comparing several subgroups in this cohort, the Mann-Whitney U test was performed and correlations were studied using the Pearson or Spearman correlation coefficient, as appropriate. Results: Data from 25 single subjects were available. Aerobic capacity (n = 25, P = .033) and skeletal muscle mass (n = 16, P = .005) were significantly reduced after neoadjuvant chemoradiotherapy. Although not statistically significant, a large number of patients demonstrated a decrease in muscle strength and functional mobility after completing neoadjuvant chemoradiotherapy. In 14 patients (56%), adverse events, dose-limiting toxicity, or early termination of treatment occurred. Conclusions: Aerobic capacity and skeletal muscle mass decreased following neoadjuvant chemoradiotherapy, with large interindividual differences concerning the changes in physical fitness and muscle mass. This between-subject variability indicates the importance of a personalized treatment approach.

Aims Previous research has shown the possibility to use the pre-operative period to improve a patient’s tolerance for surgery. However, there is limited experience with prehabilitation in cardiac surgery. The aim of this study is to evaluate the effect of a comprehensive personalized teleprehabilitation programme on major adverse cardiac events (MACE) in patients scheduled for elective cardiac surgery. Secondary outcomes are post-operative complications, cardiovascular risk factors, quality of life, and cost-effectiveness. Methods and results In this single-centre randomized controlled trial, patients are eligible for inclusion when they are ≥18 years of age and cardiac surgery is scheduled at least 8 weeks from informed consent. Participants will be randomized to the teleprehabilitation group or the control group. After a digital baseline screening for perioperative risk factors, patients in the intervention arm can pre-operatively be referred to one or more of the prehabilitation modules (functional exercise training, inspiratory muscle training, psychological support, nutritional support, and/or smoking cessation). The programme is targeted at a duration of at least 6 weeks. It is executed by a multidisciplinary team using (video)calls and supported by a custom-made digital platform. During the pre-operative period, the platform is also used to inform patients about their upcoming surgery and for telemonitoring. Conclusion Reducing perioperative risk factors might result in a reduction of MACE, post-operative complications, length of stay, and cardiovascular risk factors, as well as improved quality of life. Cost-effectiveness will be evaluated.

Objective The aim of this study was to evaluate associations between pretreatment physical status parameters and tolerance of concurrent chemoradiation (cCHRT) and survival among patients with stage III non-small cell lung cancer (NSCLC).Methods A retrospective cohort study was conducted among patients with stage III NSCLC who had received cCHRT between 2006 and 2015. Multivariate independent associations were analysed between the pretreatment parameters age, Charlson comorbidity index, World Health Organization performance status (WHO performance status), body mass index (BMI), fat-free mass index (FFMI), maximal handgrip strength, forced expiratory volume in one second and carbon monoxide lung diffusion capacity on the one hand with tolerance of cCHRT (defined as a received radiation dose at least equal to the prescribed radiation dose) and survival on the other hand.Results 527 of 577 patients (91.3%) tolerated cCHRT. A WHO performance status >= 2 (odds ratio (OR) 0.43) and BMI < 18.5 kg/m(2) (OR 0.36) were associated with poorer tolerance of cCHRT. In the total group, a WHO performance status >= 2 (hazard ratio (HR) 1.73), low FFMI (HR 1.23) and intolerance of cCHRT (HR 1.55) were associated with poorer survival.Conclusion In patients with stage III NSCLC receiving cCHRT, poor WHO performance status and BMI< 18.5 kg/m(2) were independently associated with tolerance of cCHRT. Physical status parameters and intolerance of cCHRT were independently associated with poorer survival. Besides using this information for treatment decisions, optimizing physical status in patients at risk for intolerance of cCHRT might be a next step for improving treatment outcomes.[GRAPHICS].

Rehabilitation during chemoradiotherapy (CHRT) might (partly) prevent reduction in physical fitness and nutritional status and could improve treatment tolerance in patients with stage III non-small cell lung cancer (NSCLC). The aim of this proof-of-concept study was to investigate the feasibility of a multimodal program for rehabilitation during CHRT. A home-based multimodal rehabilitation program (partly supervised moderate-intensity physical exercise training and nutritional support) during CHRT was developed in collaboration with patients with stage III NSCLC and specialized healthcare professionals. A predetermined number of six patients with stage III NSCLC (aged > 50 years) who underwent CHRT and participated in this program were monitored in detail to assess its feasibility for further development and optimization of the program. The patient’s level of physical functioning (e.g., cardiopulmonary exercise test, six-minute walking test, handgrip strength, body mass index, fat free mass index, energy and protein intake) was evaluated in order to provide personalized advice regarding physical exercise training and nutrition. The program appeared feasible and well-tolerated. All six included patients managed to perform the assessments. Exercise session adherence was high in five patients and low in one patient. The performed exercise intensity was lower than prescribed for all patients. Patients were motivated to complete the home-based rehabilitation program during CHRT. Preliminary effects on physical and nutritional parameters revealed relatively stable values throughout CHRT, with inter-individual variation. Supervised and personalized rehabilitation in patients with stage III NSCLC undergoing CHRT seems feasible when the intensity of the physical exercise training was adjusted to the possibilities and preferences of the patients. Future research should investigate the feasibility of a supervised and personalized rehabilitation program during CHRT with a low-to-moderate exercise intensity with the aim to prevent physical decline during CHRT.

Introduction Patients with a low cardiorespiratory fitness (CRF) undergoing colorectal cancer surgery have a high risk for postoperative complications. Cardiopulmonary exercise testing (CPET) to assess CRF is the gold standard for preoperative risk assessment. To aid interpretation of raw breath-by-breath data, different methods of data-averaging can be applied. This study aimed to investigate the influence of different data-averaging intervals on CPET variables used for preoperative risk assessment, as well as to evaluate whether different data-averaging intervals influence preoperative risk assessment. Methods A total of 21 preoperative CPETs were interpreted by two exercise physiologists using stationary time-based data-averaging intervals of 10, 20, and 30 seconds and rolling average intervals of 3 and 7 breaths. Mean values of CPET variables between different data averaging intervals were compared using repeated measures ANOVA. The variables of interest were oxygen uptake at peak exercise (VO2peak), oxygen uptake at the ventilatory anaerobic threshold (VO2VAT), oxygen uptake efficiency slope (OUES), the ventilatory equivalent for carbon dioxide at the ventilatory anaerobic threshold (VE/VCO2VAT), and the slope of the relationship between the minute ventilation and carbon dioxide production (VE/VCO2-slope). Results Between data-averaging intervals, no statistically significant differences were found in the mean values of CPET variables except for the ventilatory equivalent for carbon dioxide at the ventilatory anaerobic threshold (P = 0.001). No statistically significant differences were found in the proportion of patients classified as high or low risk regardless of the used data-averaging interval. Conclusion There appears to be no significant or clinically relevant influence of the evaluated data-averaging intervals on the mean values of CPET outcomes used for preoperative risk assessment. Clinicians may choose a data-averaging interval that is appropriate for optimal interpretation and data visualization of the preoperative CPET. Nevertheless, caution should be taken as the chosen data-averaging interval might lead to substantial within-patient variation for individual patients. Clinical trial registration Prospectively registered at ClinicalTrials.gov (NCT05353127).

OBJECTIVE: To assess the effects of a 3-week community-based exercise program on 30-day postoperative complications in high-risk patients scheduled for elective colorectal resection for (pre)malignancy.SUMMARY BACKGROUND DATA: Patients with a low preoperative aerobic fitness undergoing colorectal surgery have an increased risk of postoperative complications. It remains, however, to be demonstrated whether prehabilitation in these patients reduces postoperative complications.METHODS: This 2-center, prospective, single-blinded randomized clinical trial was carried out in 2 large teaching hospitals in the Netherlands. Patients (≥60 years) with colorectal (pre)malignancy scheduled for elective colorectal resection and with a score ≤7 metabolic equivalents on the veterans-specific activity questionnaire were randomly assigned to the prehabilitation group or the usual care group by using block-stratified randomization. An oxygen uptake at the ventilatory anaerobic threshold RESULTS: Between February 2014 and December 2018, 57 patients [30 males and 27 females; mean age 73.6 years (standard deviation 6.1), range 61-88 years] were randomized to either prehabilitation (n = 28) or usual care (n = 29). The rate of postoperative complications was lower in the prehabilitation group (n = 12, 42.9%) than in the usual care group (n = 21, 72.4%, relative risk 0.59, 95% confidence interval 0.37-0.96, P = 0.024).CONCLUSIONS: Exercise prehabilitation reduced postoperative complications in high-risk patients scheduled to undergo elective colon resection for (pre)malignancy. Prehabilitation should be considered as usual care in high-risk patients scheduled for elective colon, and probably also rectal, surgery.

Steep ramp test (SRT) performance provides an estimation of preoperative aerobic fitness that is associated with postoperative outcomes. Patients with a better SRT-estimated aerobic fitness are less likely to develop postoperative complications and more likely to experience a shorter time to recovery. The SRT might be a useful and clinically accessible tool in preoperative risk assessment to identify patients at risk of postoperative morbidity and who might benefit from preoperative exercise interventions.

Aim Although cardiopulmonary exercise testing (CPET) is considered the gold standard, a preoperative abdominal CT scan might also provide information concerning preoperative aerobic fitness for risk assessment. This study aimed to investigate the association between preoperative CT-scan-derived body composition variables and preoperative CPET variables of aerobic fitness in colorectal surgery. Method In this retrospective cohort study, CT images at level L3 were analysed for skeletal muscle mass, skeletal muscle radiation attenuation, visceral adipose tissue (VAT) mass and subcutaneous adipose tissue mass. Regression analyses were performed to investigate the relation between CT-scan-derived body composition variables, CPET-derived aerobic fitness and other preoperative patient-related variables. Logistic regression analysis was performed to predict a preoperative anaerobic threshold (AT) ≤ 11.1 ml/kg/min as cut-off for having a high risk for postoperative complications. Results Data from 78 patients (45 men; mean [SD] age 74.5 [6.4 years]) were analysed. A correlation coefficient of 0.55 was observed between absolute AT and skeletal muscle mass index. Absolute AT (R2 of 51.1%) was lower in patients with a lower skeletal muscle mass index, together with higher age, lower body mass and higher American Society of Anesthesiologists (ASA) score. Higher ASA score (odds ratio 5.64; P = 0.033) and higher VAT mass (odds ratio 1.02; P = 0.036) were associated with an increased risk of an AT ≤ 11.1 ml/kg/min. Conclusion Body composition variables from the preoperative CT scan were moderately associated with preoperative CPET-derived aerobic fitness. Higher ASA score and higher VAT mass were associated with an increased risk of an AT ≤ 11.1 ml/kg/min.

Objective: To evaluate the criterion validity and responsiveness of the steep ramp test (SRT) compared with the cardiopulmonary exercise test (CPET) in evaluating aerobic capacity in survivors of cancer participating in a rehabilitation program.Design: A prospective cohort study in which survivors of cancer performed an SRT and CPET before (T=0) and after (T=1) a 10-week exercise rehabilitation program. Peak work rate achieved during the SRT (SRT-WRpeak) was compared with peak oxygen consumption measured during the CPET (CPET-VO(2)peak), which is the criterion standard for aerobic capacity. Correlation coefficients were calculated between SRT-WRpeak and CPET-VO(2)peak at T=0 to examine criterion validity and between changes in SRT-WRpeak and CPET-VO(2)peak from T=0 to T=1 to determine responsiveness. Receiver operating characteristic analysis was performed to examine the ability of the SRT to detect a true improvement (6%) in CPET-VO(2)peak.Setting: University medical center.Participants: Survivors of cancer (N=106).Interventions: Exercise rehabilitation.Main Outcome Measures: Correlation coefficients between CPET-VO2peak and SRT-WRpeak and between changes in CPET-VO2peak and SRTWRpeak.Results: An r of 0.86 (N=106) was found for the relation between SRT-WRpeak and CPET-VO(2)peak at T=0. An r of 0.51 was observed for the relation between changes in SRT-WRpeak and CPET-VO(2)peak (n=59). Receiver operating characteristic analysis showed an area under the curve of 0.74 for the SRT to detect a true improvement in CPET-VO(2)peak, with an optimal cutoff value of +0.26 W/kg (sensitivity 70.7%, specificity 66.7%).Conclusions: Because SRT-WRpeak and CPET-VO(2)peak were strongly correlated, the SRT seems a valid tool to estimate aerobic capacity in survivors of cancer. The responsiveness to measure changes in aerobic capacity appears moderate. Nevertheless, the SRT seems able to detect improvement in aerobic capacity, with a cutoff value of 0.26 W/kg. (C) 2021 The Authors. Published by Elsevier Inc. on behalf of The American Congress of Rehabilitation Medicine.

BACKGROUND: Although prehabilitation programmes for patients undergoing major intra-abdominal cancer surgery have been shown to improve pre-operative physical fitness, the conclusions regarding any postoperative benefits are inconsistent. OBJECTIVES: The aim of this study was to evaluate the content of and the outcome measures used in studies of prehabilitation programmes for these patients. It was hypothesised that the content of prehabilitation programmes is often therapeutically invalid, and that the postoperative outcomes assessed are inadequate to evaluate the impact of complications. DESIGN: A systematic review of randomised controlled trials. DATA SOURCES: Studies published between January 2009 and January 2019 were retrieved from PubMed, Embase and PEDro. ELIGIBILITY CRITERIA: Studies were included when they investigated the effects of prehabilitation in patients undergoing intra-abdominal surgery for cancer, reported pre-operative and/or postoperative outcome measures and were conducted as a randomised controlled trial. Studies for which the full text was not available were excluded, as were studies of patients undergoing nonabdominal cancer surgery. RESULTS: Eight studies (565 patients) were included. Therapeutic validity was low in five studies. Most studies included low-risk surgical patients and considerable variation was observed between prehabilitation programmes in terms of supervision, training context, frequency, intensity, duration and training type. Objective monitoring of training progression was typically not performed, and most trials did not include nutritional or psychological support. Postoperative complications were reported in seven studies, but no study reported the impact of postoperative complications, nor on long-term postoperative outcomes. CONCLUSION: The content of prehabilitation programmes was heterogeneous. Studies with a high therapeutic validity found unequivocal evidence that prehabilitation had beneficial effects on postoperative outcomes. Future research should focus on adequate selection and inclusion of high-risk surgical patients and provide personalised and probably multimodal (partly) supervised prehabilitation, with objective monitoring of progress. Measuring the incidence and impact of postoperative complications may contribute to demonstrating the clinical value of prehabilitation.

Background: This study evaluated the association between practical performance-based indices of preoperative physical functioning and short-term postoperative outcomes in patients undergoing hepatic resection.Method: Preoperative characteristics and results of practical performance-based tests of physical functioning were analyzed concerning the effect on postoperative outcomes (recovery of physical functioning, non-surgical complications, and length of hospital stay) using univariable and multivariable logistic regression.Results: Perioperative data of 96 patients showed that besides the conventional risk-factors (American Society of Anesthesiologists grade III and BMI), lower absolute steep ramp test performance (in watts; OR 0.992), and lower perceived level of functional capacity to perform activities of daily living (ADL) on Duke activity status index (in metabolic equivalent of task (MET); OR 0.806) and lower score on the veterans-specific activity questionnaire (in MET, OR 0.875) were associated with delayed recovery of physical functioning. Furthermore, more comorbidities, worse functional mobility, and lower levels of perceived functional capacity to perform ADL were associated with non-surgical complications and length of hospital stay.Conclusion: Adequate preoperative performance and perceived level of functional capacity to perform ADL appear to be of importance to identify individual patients that are at risk of a complicated postoperative course.

The use of cardiopulmonary exercise testing in pediatrics provides critical insights into potential physiological causes of unexplained exercise-related complaints or symptoms, as well as specific pathophysiological patterns based on physiological responses or abnormalities. Clinical interpretation of the results of a cardiopulmonary exercise test in pediatrics requires specific knowledge with regard to pathophysiological responses and interpretative strategies that can be adapted to address concerns specific to the child's medical condition or disability. In this review, the authors outline the 7-step interpretative approach that they apply in their outpatient clinic for diagnostic, prognostic, and evaluative purposes. This approach allows the pediatric clinician to interpret cardiopulmonary exercise testing results in a systematic order to support their physiological reasoning and clinical decision making.

European journal of surgical oncology 47(3 Pt A), 551-559 (2021). doi:10.1016/j.ejso.2020.03.211, Published by Harcourt, Burlington, Mass.

Allostatic load reflects the cumulative strain on organic functions that may gradually evolve into overt disease. Our aim was to evaluate the allostatic parameters in the context of aging, and identify the parameters that may be suitable for an allostatic load index for elderly people (&gt, 60 years). From previously published studies, 11 allostatic (bio)markers could be identified that sustain sufficient variability with aging to capture meaningful changes in health status. Based on reported statistics (prevalence of a biomarker and its associated outcome, and/or an odds/risk ratio relating these two), seven of these could be adopted in a Bayesian Belief Network (BBN), providing the probability of “disturbed” allostasis in any given elder. Additional statistical analyses showed that changes in IL-6 and BMI contributed the most to a “disturbed” allostasis, indicating their prognostic potential in relation to deteriorating health in otherwise generally healthy elderly. In this way, and despite the natural decline in variance that irrevocably alters the prognostic relevance of most allostatic (bio)markers with aging, it appeared possible to outline an allostatic load index specifically for the elderly. The allostatic parameters here identified might consequently be considered a useful basis for future quantitative modelling in the context of (healthy) aging.

Low preoperative aerobic fitness is associated with an increased risk of postoperative complications and delayed recovery in patients with abdominal cancer. Surgical prehabilitation aims to increase aerobic fitness preoperatively to improve patient- and treatment-related outcomes. However, an optimal physical exercise training program that is effective within the short time period available for prehabilitation (

HPB : official journal of The International Hepato-Pancreato-Biliary Association 23(9), 1299-1310 (2021). doi:10.1016/j.hpb.2021.04.021, Published by Elsevier, [London]

This systematic review evaluated which outcome variables and cut-off values of pretreatment exercise tests are associated with treatment complications in patients with stage I-III non-small cell lung cancer (NSCLC). PRISMA and Cochrane guidelines were followed. A total of 38 studies with adult patients undergoing treatment for stage I-III NSCLC who completed pretreatment exercise tests, and of whom treatment-related complications were recorded were included. A lower oxygen uptake at peak exercise amongst several other variables on the cardiopulmonary exercise test and a lower performance on field tests, such as the incremental shuttle walk test, stair-climb test, and 6-minute walk test, were associated with a higher risk for postoperative complications and/ or postoperative mortality. Cut-off values were reported in a limited number of studies and were inconsistent. Due to the variety in outcomes, further research is needed to evaluate which outcomes and cut-off values of physical exercise tests are most clinically relevant.

Background: Preoperative cardiorespiratory fitness, as measured by cardiopulmonary testing or estimated using the less sophisticated incremental shuttle walk test, timed up-and-go test or stair climb test is known to be associated with postoperative outcome. This study aimed to evaluate whether parameters of physical fitness are associated with postoperative outcome in patients with colorectal cancer scheduled for elective resection.Patients-and Methods: Perioperative data of patients who underwent colorectal resection at Maastricht University Medical Center were retrospectively analyzed. Preoperative variables (e.g., age, body mass index, comorbidities, physical fitness, tumour characteristics, neoadjuvant treatment, American Society of Anesthesiologists score, level of perceived fatigue and nutritional status) were compared with postoperative outcomes.Results: Out of 80 consecutive cases, 75 (93.8%) were available for analysis (57.3% male, median +/- interquartile range age 69.2 +/- 11.7 years). A higher Charlson comorbidity index (odds ratio (OR) of 1.604, 95% confidence interval (CI) 1.120-2.296), worse functional exercise capacity (in meters, OR of 0.995, 95% CI 0.991-1.000), a lower physical activity level (in min/day, OR of 0.994, 95% CI 0.988-1.000), and a higher level of perceived fatigue (OR of 1.047, 95% CI 1.016-1.078), were associated with a slower time to recovery of physical functioning. A better functional exercise capacity was associated with a lower OR (OR of 0.995, 95% CI 0.991-1.000) for nonsurgical complications.Conclusion: There is an association between preoperative parameters and postoperative outcomes in patients with colorectal cancer scheduled for resection. Patients benefit from an optimal preoperative physical fitness level. Specific interventions can target this physical fitness level. (C) 2017 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Article, Aerobic fitness is an important determinant of overall health. Higher aerobic fitness has been associated with many health benefits. Because myocardial ischemia is rare in children, indications for exercise testing differ in children compared to adults. Pediatric exercise testing is imperative to unravel the physiological mechanisms of a reduced aerobic fitness and to evaluate intervention effects in children and adolescents with a chronic disease or disability. Cardiopulmonary exercise testing includes the measurement of respiratory gas exchange and is the gold standard for determining aerobic fitness, as well as for examining the integrated physiological responses to exercise in pediatric medicine. As the physiological responses to exercise change during growth and development, appropriate pediatric reference values are essential for an adequate interpretation of the cardiopulmonary exercise test., final draft, peerReviewed

Background Evidence about the role of physical therapy in perioperative care pathways to improve postoperative outcomes is growing. However, it is unclear whether research findings have been translated into daily practice. Objective The objectives of this study were to describe the current content and between-hospital variability of perioperative physical therapist management for patients undergoing colorectal, hepatic, or pancreatic resection in the Netherlands and to compare currently recommended state-of-the-art physical therapy with self-reported daily clinical physical therapist management. Design This was a cross-sectional survey study. Methods Hospital physical therapists were asked to complete an online survey about pre- and postoperative physical therapy at their hospital. To explore the variability of perioperative physical therapist management between hospitals, frequency variables were clustered to determine the level of uniformity. Latent class analysis was performed to identify clusters of hospitals with certain homogeneous characteristics on a 19-item dichotomous scale. Results Of 82 eligible Dutch hospitals, 65 filled out the survey (79.3%). Preoperative physical therapy was performed in 34 hospitals (54.0%; 2/65 responding hospitals were excluded from the data analysis). Postoperative physical therapy was performed in all responding hospitals, focusing mainly on regaining independent physical functioning. Latent class analysis identified a 3-class model. Hospitals in classes I and II were more likely to provide preoperative physical therapist interventions than hospitals in class III. Limitations The use of self-reported answers can lead to bias. Conclusions There was a wide degree of variability between hospitals regarding pre- and postoperative clinical physical therapist practice for patients opting for major abdominal surgery. Three different classes of daily practice were identified. Further translation of key research findings into clinical physical therapist practice is advised, especially for hospitals in which the physical therapist is not involved preoperatively. Moreover, improving uniformity by developing up-to-date clinical guidelines is recommended.

Introduction: Reference values for cardiopulmonary exercise testing (CPET) parameters provide the comparative basis for answering important questions concerning the normalcy of exercise responses in patients, and significantly impacts the clinical decision-making process. Areas covered: The aim of this study was to provide an updated systematic review of the literature on reference values for CPET parameters in healthy subjects across the life span. A systematic search in MEDLINE, Embase, and PEDro databases were performed for articles describing reference values for CPET published between March 2014 and February 2019. Expert opinion: Compared to the review published in 2014, more data have been published in the last five years compared to the 35 years before. However, there is still a lot of progress to be made. Quality can be further improved by performing a power analysis, a good quality assurance of equipment and methodologies, and by validating the developed reference equation in an independent (sub)sample. Methodological quality of future studies can be further improved by measuring and reporting the level of physical activity, by reporting values for different racial groups within a cohort as well as by the exclusion of smokers in the sample studied. Normal reference ranges should be well defined in consensus statements.

BACKGROUND: This study aimed to evaluate the association between preoperative level of physical functioning and time to recovery of physical functioning, postoperative complications, and the impact of postoperative major complications in patients undergoing elective pancreatic resection. Additionally, prediction models to identify high-risk patients for developing a major complication were externally validated.METHODS: Perioperative data of patients who underwent pancreatic resection were analysed. Primary outcomes were time to recovery of physical functioning and postoperative major complications. Impact of a major complication was explored by evaluating its effect on time to recovery of physical functioning. Risk-prediction models were retrieved following a systematic review.RESULTS: Multivariable analysis (n = 63) showed that ASA grade III (OR 3.498) and preoperative platelet count (OR 1.005) were associated with major complications, whereas aerobic capacity (OR 0.347) was associated with time to recovery of physical functioning. Age, preoperative aerobic capacity, functional mobility, and perceived level of functional capacity were associated with the impact of a major complication. The AUC of two risk prediction models were 0.556 and 0.701.CONCLUSION: Preoperative parameters of physical function were associated with postoperative outcomes and may be useful in outcome prediction, although future approaches should not only register the incidence of major complications but also take the impact of a complication on a patient's physical functioning into account.

Background Recent research has shown that the Fitkids Treadmill Test (FTT) is a valid and reproducible exercise test for the assessment of aerobic exercise capacity in children and adolescents who are healthy. Objective The study objective was to provide sex- and age-related normative values for FTT performance in children and adolescents who were healthy, developing typically, and 6 to 18 years of age. Design This was a cross-sectional, observational study. Methods Three hundred fifty-six children and adolescents who were healthy (174 boys and 182 girls; mean age=12.9 years, SD=3.7) performed the FTT to their maximal effort to assess time to exhaustion (TTE). The least-mean-square method was used to generate sex- and age-related centile charts (P3, P10, P25, P50, P75, P90, and P97) for TTE on the FTT. Results In boys, the reference curve (P50) showed an almost linear increase in TTE with age, from 8.8 minutes at 6 years of age to 16.1 minutes at 18 years of age. In girls, the P50 values for TTE increased from 8.8 minutes at 6 years of age to 12.5 minutes at 18 years of age, with a plateau in TTE starting at approximately 10 years of age. Limitations Youth who were not white were underrepresented in this study. Conclusions This study describes sex- and age-related normative values for FTT performance in children and adolescents who were healthy, developing typically, and 6 to 18 years of age. These age- and sex-related normative values will increase the usefulness of the FTT in clinical practice.

Background Physical fitness levels in youth with osteogenesis imperfecta (OI) who use wheelchairs are unknown. The 10-m Shuttle Ride Test (SRiT) has recently been introduced as a field test to determine cardiorespiratory fitness in children with cerebral palsy who self-propel a wheelchair. Objective The purpose of this study was to investigate the feasibility and reproducibility of the SRiT, as well as the physiological responses to the SRiT, in youth with moderate-to-severe OI between 8 and 25 years of age who self-propel a wheelchair at least for long distances. Design A test-retest design was used. Methods Thirteen patients with OI (8 boys, 5 girls; mean±SD values for age=15.5±6.4 years) using a manual wheelchair performed 2 SRiTs within 2 weeks. Adverse events, reached stage, peak heart rate (HRpeak), peak respiratory exchange ratio (RERpeak), peak oxygen uptake (V̇o2peak), and peak minute ventilation (V̇epeak) were the main outcome parameters. Results and Discussion All participants performed a maximal effort at both SRiTs (mean±SD values for HRpeak of 195±9 beats per minute [bpm], RERpeak of 1.32±0.16, V̇o2peak of 25.4±5.6 mL·kg−1·min−1, and V̇epeak of 47.9±18.6 L·min−1), without adverse events. The intraclass correlation coefficient of the reached stage showed excellent reliability (.95). Limits of agreement (LoA) analysis revealed acceptable LoA for reached stage (mean bias=−0.58, range=−2.50 to +1.35). There was a low correlation between reached stage and V̇o2peak (r=.61 and r=.45 for the first and second SRiTs, respectively). Limitations The influence of wheelchair properties and individually adjusted wheelchair designs was not examined. Conclusions The SRiT appears to be a feasible, safe, and reproducible maximal field test in youth with OI using wheelchairs at least for long distances. This field test might be useful to provide an indication of physical fitness and to assess the efficacy of interventions on physical fitness in these patients.

Background: Controversial evidence currently exists regarding the feasibility and effectiveness to improve preoperative aerobic fitness during home-based prehabilitation in patients scheduled for liver or pancreatic resection, whereas morbidity rates are high following these resections. The primary aim of this study is to evaluate the preoperative oxygen uptake (VO2) at the ventilatory anaerobic threshold before and after a four-week home-based preoperative training program with nutritional supplementation in high-risk patients scheduled for elective liver or pancreatic resection. Secondary aims are to evaluate program feasibility, immune system function, cardiopulmonary exercise test responses, individual progression profiles on training responses, quality of life, and postoperative course.Methods: In this multicenter study with a pretest-posttest design, patients with a liver or pancreatic tumor scheduled for elective resection will be recruited. To select the high-risk fraction of this surgical population, their VO2 at the ventilatory anaerobic threshold should be Discussion: Effects of a partly supervised home-based bimodal prehabilitation regimen are unknown in high-risk patients opting for liver or pancreatic resection. Improved preoperative aerobic fitness might translate into improved postoperative outcomes and a reduced demand on care resources.Trial Registration: The study is registered in the Netherlands Trial Registry (NL6151) and was approved by the Institutional Ethics Committee, Twente, Enschede, the Netherlands (P17-08).

Background: Measurement of respiratory muscle function is important in the diagnosis of respiratory muscle disease, respiratory failure, to assess the impact of chronic diseases, and/or to evaluate respiratory muscle function after treatment. Objectives: To establish reference values for maximal inspiratory and expiratory pressure, and the tension-time index at rest in healthy children and adolescents aged 8–19 years, as well as to present sex- and age-related reference centiles normalized for demographic and anthropometric determinants. Methods: In this cross-sectional observational study, demographic, anthropometric, and spirometric data were assessed, as well as data on respiratory muscle strength (PImax and PEmax) and work of breathing at rest (TT0.1), in a total of 251 children (117 boys and 134 girls; mean age 13.4 ± 2.9 years). Reference values are presented as reference centiles developed by use of the lambda, mu, sigma method. Results: Boys had significantly higher PImax and PEmax values. Next to sex and age, fat-free mass appeared to be an important predictor of respiratory muscle strength. Reference centiles demonstrated a slight, almost linear increase in PImax with age in boys, and a less steep increase with age in girls. TT0.1 values did not differ between boys and girls and decreased linearly with age. Conclusion: This study provides reference values for respiratory muscle strength and work of breathing at rest. In addition to sex and age, fat-free mass was found to be an important predictor of respiratory muscle strength in boys and girls.

Background/Aims: To systematically assess contemporary knowledge regarding the effectiveness and safety of bisphosphonates (BPs) in children with osteogenesis imperfecta (OI). Methods: PubMed/MEDLINE, Embase, and Cochrane were searched for eligible articles up to June 2014. Studies eligible for inclusion were (randomized) controlled trials assessing the effects of BPs in children with OI. Methodological quality was assessed independently by 4 reviewers using the Cochrane Collaboration's tool for risk of bias. Results: Ten studies (519 children) were included. Four studies (40%) showed a low risk of bias. All studies investigating lumbar spine areal bone mineral density indicated a significant increase as a result of BP treatment. Most studies observed a significant decrease in fracture incidence. The most frequently reported adverse events were gastrointestinal complaints, fever, and muscle soreness. A significant decrease in (bone) pain due to BP treatment was observed in more than half of the studies. Most studies measuring urinary markers of bone resorption reported a significant decrease. The majority of studies with intravenous treatment showed a significant increase in lumbar projection area, whereas studies with oral treatment did not. Conclusions: Treatment with oral or intravenous BPs in children with OI results in an increase in bone mineral density and seems to be safe and well tolerated.

Purpose: The steep ramp test (SRT) can be used to provide an indication of exercise capacity when gas exchange measurements are not possible. This study evaluated the clinical usefulness of the SRT in adolescents with cystic fibrosis (CF) and compared the physiological responses of the SRT with the standard cardiopulmonary exercise test (CPET). Methods: Forty patients with CF (17 boys and 23 girls; mean +/- SD age, 14.7 +/- 1.7 years; forced expiratory volume in 1 s, 86% +/- 18% of predicted) performed an SRT and a CPET with respiratory gas analysis in a randomized balanced design. Peak work rate (WRpeak), HRpeak, peak minute ventilation ((v) over dot(Epeak)), and peak oxygen uptake ((v) over dotO(2peak)) were the main outcome measures. Results: Patients with CF attained values for absolute and relative WRpeak during the SRT of 82% T 14% and 92% +/- 14% of predicted. Nutritional status and degree of airway obstruction did not influence SRT performance. Significantly higher values were attained for WRpeak during the SRT compared with those during the CPET (252 +/- 60 vs 174 +/- 46 W; P