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Renal Rehabilitation: Exercise Intervention and Nutritional Support in Dialysis Patients.
Hoshino, J
Nutrients. 2021;(5)
Abstract
With the growing number of dialysis patients with frailty, the concept of renal rehabilitation, including exercise intervention and nutrition programs for patients with chronic kidney disease (CKD), has become popular recently. Renal rehabilitation is a comprehensive multidisciplinary program for CKD patients that is led by doctors, rehabilitation therapists, diet nutritionists, nursing specialists, social workers, pharmacists, and therapists. Many observational studies have observed better outcomes in CKD patients with more physical activity. Furthermore, recent systematic reviews have shown the beneficial effects of exercise intervention on exercise tolerance, physical ability, and quality of life in dialysis patients, though the beneficial effect on overall mortality remains unclear. Nutritional support is also fundamental to renal rehabilitation. There are various causes of skeletal muscle loss in CKD patients. To prevent muscle protein catabolism, in addition to exercise, a sufficient supply of energy, including carbohydrates, protein, iron, and vitamins, is needed. Because of decreased digestive function and energy loss due to dialysis treatment, dialysis patients are recommended to ingest 1.2-fold more protein than the regular population. Motivating patients to join in activities is also an important part of renal rehabilitation. It is essential for us to recognize the importance of renal rehabilitation to maximize patient satisfaction.
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Optimal Protein Intake in Pre-Dialysis Chronic Kidney Disease Patients with Sarcopenia: An Overview.
Isaka, Y
Nutrients. 2021;(4)
Abstract
Multi-factors, such as anorexia, activation of renin-angiotensin system, inflammation, and metabolic acidosis, contribute to malnutrition in chronic kidney disease (CKD) patients. Most of these factors, contributing to the progression of malnutrition, worsen as CKD progresses. Protein restriction, used as a treatment for CKD, can reduce the risk of CKD progression, but may worsen the sarcopenia, a syndrome characterized by a progressive and systemic loss of muscle mass and strength. The concomitant rate of sarcopenia is higher in CKD patients than in the general population. Sarcopenia is also associated with mortality risk in CKD patients. Thus, it is important to determine whether protein restriction should be continued or loosened in CKD patients with sarcopenia. We may prioritize protein restriction in CKD patients with a high risk of end-stage kidney disease (ESKD), classified to stage G4 to G5, but may loosen protein restriction in ESKD-low risk CKD stage G3 patients with proteinuria <0.5 g/day, and rate of eGFR decline <3.0 mL/min/1.73 m2/year. However, the effect of increasing protein intake alone without exercise therapy may be limited in CKD patients with sarcopenia. The combination of exercise therapy and increased protein intake is effective in improving muscle mass and strength in CKD patients with sarcopenia. In the case of loosening protein restriction, it is safe to avoid protein intake of more than 1.5 g/kgBW/day. In CKD patients with high risk in ESKD, 0.8 g/kgBW/day may be a critical point of protein intake.
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Exercise modulation of tumour perfusion and hypoxia to improve radiotherapy response in prostate cancer.
Schumacher, O, Galvão, DA, Taaffe, DR, Chee, R, Spry, N, Newton, RU
Prostate cancer and prostatic diseases. 2021;(1):1-14
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Abstract
BACKGROUND An increasing number of studies indicate that exercise plays an important role in the overall care of prostate cancer (PCa) patients before, during and after treatment. Historically, research has focused on exercise as a modulator of physical function, psychosocial well-being as well as a countermeasure to cancer- and treatment-related adverse effects. However, recent studies reveal that exercise may also directly influence tumour physiology that could beneficially affect the response to radiotherapy. METHODS In this narrative review, we provide an overview of tumour vascular characteristics that limit the effect of radiation and establish a rationale for exercise as adjunct therapy during PCa radiotherapy. Further, we summarise the existing literature on exercise as a modulator of tumour perfusion and hypoxia and outline potential future research directions. RESULTS Preclinical research has shown that exercise can reduce intratumoral hypoxia-a major limiting factor in radiotherapy-by improving tumour perfusion and vascularisation. In addition, preliminary evidence suggests that exercise training can improve radiotherapy treatment outcomes by increasing natural killer cell infiltration in a murine PCa model. CONCLUSIONS Exercise is a potentially promising adjunct therapy for men with PCa undergoing radiotherapy that may increase its effectiveness. However, exercise-induced tumour radiosensitisation remains to be confirmed in preclinical and clinical trials, as does the optimal exercise prescription to elicit such effects.
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Exercise Interventions Targeting Obesity in Persons With Spinal Cord Injury.
McMillan, DW, Maher, JL, Jacobs, KA, Nash, MS, Gater, DR
Topics in spinal cord injury rehabilitation. 2021;(1):109-120
Abstract
Spinal cord injury (SCI) results in an array of cardiometabolic complications, with obesity being the most common component risk of cardiometabolic disease (CMD) in this population. Recent Consortium for Spinal Cord Medicine Clinical Practice Guidelines for CMD in SCI recommend physical exercise as a primary treatment strategy for the management of CMD in SCI. However, the high prevalence of obesity in SCI and the pleiotropic nature of this body habitus warrant strategies for tailoring exercise to specifically target obesity. In general, exercise for obesity management should aim primarily to induce a negative energy balance and secondarily to increase the use of fat as a fuel source. In persons with SCI, reductions in the muscle mass that can be recruited during activity limit the capacity for exercise to induce a calorie deficit. Furthermore, the available musculature exhibits a decreased oxidative capacity, limiting the utilization of fat during exercise. These constraints must be considered when designing exercise interventions for obesity management in SCI. Certain forms of exercise have a greater therapeutic potential in this population partly due to impacts on metabolism during recovery from exercise and at rest. In this article, we propose that exercise for obesity in SCI should target large muscle groups and aim to induce hypertrophy to increase total energy expenditure response to training. Furthermore, although carbohydrate reliance will be high during activity, certain forms of exercise might induce meaningful postexercise shifts in the use of fat as a fuel. General activity in this population is important for many components of health, but low energy cost of daily activities and limitations in upper body volitional exercise mean that exercise interventions targeting utilization and hypertrophy of large muscle groups will likely be required for obesity management.
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Inflammatory Depression-Mechanisms and Non-Pharmacological Interventions.
Suneson, K, Lindahl, J, Chamli Hårsmar, S, Söderberg, G, Lindqvist, D
International journal of molecular sciences. 2021;(4)
Abstract
Treatment of depression is hampered by the failure to identify distinct symptom profiles with distinct pathophysiologies that differentially respond to distinct treatments. We posit that inflammatory depression is a meaningful depression subtype associated with specific symptoms and biological abnormalities. We review several upstream, potentially causative, mechanisms driving low-grade inflammation in this subtype of depression. We also discuss downstream mechanisms mediating the link between inflammation and symptoms of depression, including alterations in dopaminergic neurotransmission and tryptophan metabolism. Finally, we review evidence for several non-pharmacological interventions for inflammatory depression, including probiotics, omega-3 fatty acids, and physical exercise interventions. While some evidence suggests that these interventions may be efficacious in inflammatory depression, future clinical trials should consider enriching patient populations for inflammatory markers, or stratify patients by inflammatory status, to confirm or refute this hypothesis.
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Look Before You Leap: Interventions Supervised via Telehealth Involving Activities in Weight-Bearing or Standing Positions for People After Stroke-A Scoping Review.
Ramage, ER, Fini, N, Lynch, EA, Marsden, DL, Patterson, AJ, Said, CM, English, C
Physical therapy. 2021;(6)
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OBJECTIVE The COVID-19 pandemic has seen a rapid shift to telehealth-delivered physical therapy services. Common impairments after stroke create unique challenges when providing rehabilitation via telehealth, particularly when it involves activities undertaken in weight-bearing or standing positions, including walking training. Our scoping review maps the evidence regarding safety, efficacy, and feasibility of remotely supervised telehealth interventions involving activities undertaken in weight-bearing or standing positions for people after stroke. METHODS Searches of relevant databases for primary research studies were conducted using keywords relating to exercise and telehealth. Studies of stroke survivors undertaking interventions involving activities in weight-bearing or standing positions, supervised in real-time via telehealth were included. Two reviewers independently appraised all studies. Data were charted by one reviewer, checked by another, and results synthesized narratively. RESULTS Seven studies (2 randomized trials, 1 mixed-methods, and 4 pre-post studies) were included, involving 179 participants. Some studies included stroke survivors with cognitive impairment, and 2 (29%) studies included only participants who walked independently. Adherence (reported in 3 studies) and satisfaction (reported in 4 studies) were good, and no serious adverse events (data from 4 studies) related to interventions were reported. Strategies to overcome technological barriers were used to optimize intervention safety and feasibility, along with physiological monitoring, caregiver assistance, and in-person exercise prescription. However, there is limited high-quality evidence of efficacy. CONCLUSIONS We identified strategies used in research to date that can support current practice. However, urgent research is needed to ensure that stroke survivors are receiving evidence-based, effective services. IMPACT The COVID-19 pandemic has necessitated a rapid shift to telerehabilitation services for people with stroke, but there is little evidence to guide best practice. Our review provides practical guidance and strategies to overcome barriers and optimize safety and adherence for telehealth interventions involving activities in weight-bearing or standing positions.
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Pathophysiology of Exercise Intolerance and Its Treatment With Exercise-Based Cardiac Rehabilitation in Heart Failure With Preserved Ejection Fraction.
Tucker, WJ, Angadi, SS, Haykowsky, MJ, Nelson, MD, Sarma, S, Tomczak, CR
Journal of cardiopulmonary rehabilitation and prevention. 2020;(1):9-16
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Heart failure with preserved ejection fraction (HFpEF) is the fastest growing form of heart failure in the United States. The cardinal feature of HFpEF is reduced exercise tolerance (peak oxygen uptake, (Equation is included in full-text article.)O2peak) secondary to impaired cardiac, vascular, and skeletal muscle function. There are currently no evidence-based drug therapies to improve clinical outcomes in patients with HFpEF. In contrast, exercise training is a proven effective intervention for improving (Equation is included in full-text article.)O2peak, aerobic endurance, and quality of life in HFpEF patients. This brief review discusses the pathophysiology of exercise intolerance and the role of exercise training to improve (Equation is included in full-text article.)O2peak in clinically stable HFpEF patients. It also discusses the mechanisms responsible for the exercise training-mediated improvements in (Equation is included in full-text article.)O2peak in HFpEF. Finally, it provides evidence-based exercise prescription guidelines for cardiac rehabilitation specialists to assist them with safely implementing exercise-based cardiac rehabilitation programs for HFpEF patients.
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Which specific modes of exercise training are most effective for treating low back pain? Network meta-analysis.
Owen, PJ, Miller, CT, Mundell, NL, Verswijveren, SJJM, Tagliaferri, SD, Brisby, H, Bowe, SJ, Belavy, DL
British journal of sports medicine. 2020;(21):1279-1287
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OBJECTIVE Examine the effectiveness of specific modes of exercise training in non-specific chronic low back pain (NSCLBP). DESIGN Network meta-analysis (NMA). DATA SOURCES MEDLINE, CINAHL, SPORTDiscus, EMBASE, CENTRAL. ELIGIBILITY CRITERIA Exercise training randomised controlled/clinical trials in adults with NSCLBP. RESULTS Among 9543 records, 89 studies (patients=5578) were eligible for qualitative synthesis and 70 (pain), 63 (physical function), 16 (mental health) and 4 (trunk muscle strength) for NMA. The NMA consistency model revealed that the following exercise training modalities had the highest probability (surface under the cumulative ranking (SUCRA)) of being best when compared with true control: Pilates for pain (SUCRA=100%; pooled standardised mean difference (95% CI): -1.86 (-2.54 to -1.19)), resistance (SUCRA=80%; -1.14 (-1.71 to -0.56)) and stabilisation/motor control (SUCRA=80%; -1.13 (-1.53 to -0.74)) for physical function and resistance (SUCRA=80%; -1.26 (-2.10 to -0.41)) and aerobic (SUCRA=80%; -1.18 (-2.20 to -0.15)) for mental health. True control was most likely (SUCRA≤10%) to be the worst treatment for all outcomes, followed by therapist hands-off control for pain (SUCRA=10%; 0.09 (-0.71 to 0.89)) and physical function (SUCRA=20%; -0.31 (-0.94 to 0.32)) and therapist hands-on control for mental health (SUCRA=20%; -0.31 (-1.31 to 0.70)). Stretching and McKenzie exercise effect sizes did not differ to true control for pain or function (p>0.095; SUCRA<40%). NMA was not possible for trunk muscle endurance or analgesic medication. The quality of the synthesised evidence was low according to Grading of Recommendations Assessment, Development and Evaluation criteria. SUMMARY/CONCLUSION There is low quality evidence that Pilates, stabilisation/motor control, resistance training and aerobic exercise training are the most effective treatments, pending outcome of interest, for adults with NSCLBP. Exercise training may also be more effective than therapist hands-on treatment. Heterogeneity among studies and the fact that there are few studies with low risk of bias are both limitations.
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Diet in neurogenic bowel management: A viewpoint on spinal cord injury.
Bernardi, M, Fedullo, AL, Bernardi, E, Munzi, D, Peluso, I, Myers, J, Lista, FR, Sciarra, T
World journal of gastroenterology. 2020;(20):2479-2497
Abstract
The aim of this review is to offer dietary advice for individuals with spinal cord injury (SCI) and neurogenic bowel dysfunction. With this in mind, we consider health conditions that are dependent on the level of lesion including skeletal muscle atrophy, autonomic dysreflexia and neurogenic bladder. In addition, SCI is often associated with a sedentary lifestyle, which increases risk for osteoporosis and diseases associated with chronic low-grade inflammation, including cardiovascular and chronic kidney diseases. The Mediterranean diet, along with exercise and dietary supplements, has been suggested as an anti-inflammatory intervention in individuals with SCI. However, individuals with chronic SCI have a daily intake of whole fruit, vegetables and whole grains lower than the recommended dietary allowance for the general population. Some studies have reported an increase in neurogenic bowel dysfunction symptoms after high fiber intake; therefore, this finding could explain the low consumption of plant foods. Low consumption of fibre induces dysbiosis, which is associated with both endotoxemia and inflammation. Dysbiosis can be reduced by exercise and diet in individuals with SCI. Therefore, to summarize our viewpoint, we developed a Mediterranean diet-based diet and exercise pyramid to integrate nutritional recommendations and exercise guidelines. Nutritional guidelines come from previously suggested recommendations for military veterans with disabilities and individuals with SCI, chronic kidney diseases, chronic pain and irritable bowel syndrome. We also considered the recent exercise guidelines and position stands for adults with SCI to improve muscle strength, flexibility and cardiorespiratory fitness and to obtain cardiometabolic benefits. Finally, dietary advice for Paralympic athletes is suggested.
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Consistent Morning Exercise May Be Beneficial for Individuals With Obesity.
Schumacher, LM, Thomas, JG, Raynor, HA, Rhodes, RE, Bond, DS
Exercise and sport sciences reviews. 2020;(4):201-208
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This review explores the hypothesis that a consistent exercise time, especially consistent morning exercise, improves exercise adherence and weight management for individuals with overweight or obesity. We discuss data supporting this premise, identify limitations of current research, and outline directions for future research on exercise timing to more robustly evaluate our thesis.