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Right heart catheterization (RHC) is the internationally standardized reference method for measuring pulmonary hemodynamics under resting conditions. In recent years, increasing efforts have been made to establish the reliable assessment of exercise hemodynamics as well, in order to obtain additional diagnostic and prognostic data. Furthermore, cardiopulmonary exercise testing (CPET), as the most comprehensive non-invasive exercise test, is increasingly performed in combination with RHC providing detailed pathophysiological insights into the exercise response, so-called invasive cardiopulmonary exercise testing (iCPET).In this review, the accumulated experience with iCPET is presented and methodological details are discussed. This complex examination is especially helpful in differentiating the underlying causes of unexplained dyspnea. In particular, early forms of cardiac or pulmonary vascular dysfunction can be detected by integrated analysis of hemodynamic as well as ventilatory and gas exchange data. It is expected that with increasing validation of iCPET parameters, a more reliable differentiation of normal from pathological stress reactions will be possible.Die Standardmethode zur Messung der pulmonalen Hämodynamik ist der Rechtsherzkatheter (RHK) unter Ruhebedingungen, welcher international standardisiert ist. In den letzten Jahren wurden Bemühungen unternommen, auch die methodischen Aspekte des RHK unter Belastung zu vereinheitlichen und die somit gewonnenen Daten hinsichtlich ihrer prognostischen Aussagekraft zu definieren. Die Spiroergometrie als eine nichtinvasive Methode kann zusätzliche Aspekte der Pathophysiologie unter Belastung darstellen, und beide Methoden werden zunehmend kombiniert (als sog. invasive Spiroergometrie, iCPET) und ermöglichen eine sehr differenzierte Analyse der Belastungsreaktion.In dieser Übersicht werden die bisherigen Erfahrungen mit der invasiven Spiroergometrie dargestellt und insbesondere methodische Details erläutert.Die bisherigen Daten zur invasiven Spiroergometrie zeigen, dass diese komplexe Untersuchung besonders bei der Differenzierung der zugrundeliegenden Ursachen einer unklaren Dyspnoe hilfreich ist. Es zeichnet sich ab, dass über die Kombination aus hämodynamischen sowie ventilatorischen und gasanalytischen Daten schon frühe Formen einer kardialen bzw. pulmonalvaskulären Störung zu detektieren sind. Durch die zunehmende Validierung gewonnener Parameter aus der iCPET sind zukünftig Grenzwerte zur Unterscheidung normaler vs. pathologischer Belastungsreaktionen zu erwarten, die genauer als durch die alleinige Anwendung der jeweiligen Methoden möglich werden.

In Germany, pulmonary rehabilitation (PR) traditionally takes place in rehabilitation clinics. According to the current German guideline "Diagnostics and assessment of asbestos-related occupational diseases", PR can also be offered as outpatient program with the essential elements of inpatient PR (compact rehabilitation [CR]). Our project investigated the effects of CR regarding acceptance, physical performance, and quality of life of patients with occupational lung diseases. CR included 24 units of 90 minutes each with physiotherapy and breathing therapy as well as device-supported strength and endurance training. The aim of our study was to investigate the effects of CR in subjects with occupational diseases of the respiratory system and a legally anchored right to PR. Randomization was therefore not planned. A total of 148 insured persons with a confirmed occupational disease of the respiratory system were invited to participate by the employers' liability insurance association; 126 patients (85 %) accepted the invitation, and 78 participants (mean age: 71 years) completed the entire program (53 %). Benign asbestos-related diseases (plaques, pleural thickening, asbestosis) dominated with around 80 %. Ailments, depression, and dementia were typical obstacles. No adverse events occurred with strict observance of the chosen inclusion and exclusion criteria and training conditions. The measurement results at enrolment were compared with those at completion of the CR. CR led to a significant (p 0.01) improvement in all parameters of physical performance: 6-minute walking test: + 36 m, ergometer test: + 9 watts, hand dynamometry: + 29 N, quadriceps strength test: + 84 MKI. The inspiratory capacity of the respiratory muscles (PiIn Deutschland findet die Lungenrehabilitation (PR) traditionell in Rehabilitationskliniken statt. Nach der aktuellen deutschen Richtlinie „Diagnostik und Beurteilung asbestbedingter Berufskrankheiten“ kann PR auch als ambulantes Programm mit den wesentlichen Elementen der stationären PR (Kompakt-Rehabilitation [KR]) angeboten werden. Unser Projekt untersuchte die Auswirkungen der KR auf Akzeptanz, körperliche Leistungsfähigkeit und Lebensqualität bei Patienten mit berufsbedingten Lungenerkrankungen. KR umfasste 24 Einheiten à 90 Minuten mit Physiotherapie und Atemtherapie sowie gerätegestütztes Kraft- und Ausdauertraining. Ziel unserer Studie war es, die Auswirkungen der KR bei Patienten mit Berufskrankheiten der Atemwege und einem gesetzlich verankerten Recht auf PR zu untersuchen. Eine Randomisierung war daher nicht geplant. 148 versicherte Personen mit einer bestätigten beruflichen Erkrankung der Lunge wurden von den Berufsgenossenschaften zur Teilnahme eingeladen. 126 Patienten (85 %) nahmen die Einladung an, und 78 Teilnehmer (Durchschnittsalter 71 Jahre) schlossen das gesamte Programm ab (53 %). Gutartige asbestbedingte Erkrankungen (Plaques, Pleuraverdickungen, Asbestose) dominierten mit rund 80 %. Gebrechlichkeit, Depression und Demenz sind typische Hindernisse. Unter strikter Einhaltung der gewählten Einschluss- und Ausschlusskriterien und Trainingsbedingungen traten keine unerwünschten Ereignisse auf. Die Messergebnisse am Beginn der KR wurden mit denen bei Beendigung verglichen. KR führte zu einer signifikanten (p 0,01) Verbesserung aller Parameter der körperlichen Leistung: 6-Minuten-Gehtest: + 36 m, Ergometertest: + 9 Watt, Handdynamometrie: + 29 N, Quadriceps-Krafttest: + 84 MKI. Die Inspirationskapazität der Atemmuskulatur (Pi

Fresh air for weakened lungs - pulmonary rehabilitation in Switzerland 2019

Cardiorespiratory fitness has been established as an independent overall predictor of morbidity and mortality. However, patients' symptoms or stated levels of exercise intolerance correlate only poorly with resting functional and imaging tests. Cardiopulmonary exercise testing (CPET) is the gold standard for the integrative assessment of the cardiocirculatory, pulmonary and metabolic response to exercise and can help identify the source of exercise limitation, monitor disease progression, evaluate treatment responsiveness and inform about prognosis. Though CPET offers more valuable and pertinent information with slightly more expenditure of time compared to other methods even at submaximal exercise levels, it remains underutilized for various reasons such as costs, reimbursement and expertise. CPET can be seen as a complex, but not necessarily difficult tool. The objective of this review was to provide a description of the underlying principles of physiology, and an easy-to-follow guidance to indications, methodology, and interpretative strategies of CPET.Die kardiorespiratorische Fitness gilt als unabhängiger Prognosefaktor für Morbidität und Mortalität unterschiedlicher Genese. Patientenrelevante Symptome wie latente Belastungsdyspnoe, körperliche Leistungsdefizite und Erschöpfung korrelieren oft schlecht mit der kardiopulmonalen und bildgebenden „Ruhediagnostik“. Die Spiroergometrie als Goldstandard der Belastungsanalyse dient der Früherkennung, Differenzialdiagnostik, Verlaufs- und Therapiekontrolle von kardiopulmonalen Erkrankungen und deren Prognose. Als integrative Untersuchungsmethode des Lungen-Herz-Kreislauf-Muskel-Systems ist sie bei geringem zeitlichem Mehraufwand deutlich aussagekräftiger und informativer als alternative Messmethoden und ermöglicht auch Aussagen im submaximalen Belastungsbereich. Trotz dieser enormen Bedeutung wird die Spiroergometrie aus verschiedenen Gründen (z. B. Aufwand, Budget, Expertise) auch hierzulande zu selten durchgeführt. Die Methode ist komplex, aber nicht unbedingt kompliziert. Ziel dieser Übersicht ist es daher, allen Interessierten diesen häufig wegweisenden Globaltest leichter zugänglich zu machen. Inhaltlich werden sowohl die physiologischen Grundlagen, die Indikationen und praktischen Aspekte der Messung als auch die strukturierte Auswertung spiroergometrischer Befunde übersichtlich vorgestellt. Damit soll auch das Interesse und der eigene Anspruch geweckt werden, diese fachspezifische Referenzuntersuchung in indizierten Fällen selbst häufiger durchzuführen.

Pulmonary hypertension (PH) is defined as an elevation of mean pulmonary-arterial pressure by 20 mmHg at rest, which may lead to right heart failure. Physical exercise has not been regularly recommended for PH patients for fear of symptom deterioration or occurrence of exercise-induced adverse events. Three electronic databases were searched for randomized, controlled trials investigating exercise training in PH patients using the following keywords: "pulmonary hypertension" OR "pulmonary arterial hypertension" AND "exercise" OR "pulmonary rehabilitation" AND "randomized". Five studies involving 187 PH patients were included in this systematic review. Exercise programs lasted for 3 - 12 weeks (e. g. endurance training for 10 - 45 minutes; 60 - 80 % of the peak heart rate). PH patients significantly improved exercise capacity compared to controls in 6-minute walk distance (+ 45 m; 95 % CI: 26 m - 64 m) or peak oxygen consumption (+ 2.3 ml/kg/min; 95 % CI: 1.8 - 2.9 ml/kg/min), both p 0.001. Also, physical and mental quality of life improved significantly by exercise training. No exercise-induced adverse events were observed. Supervised exercise training can safely and significantly improve physical performance and quality of life in clinically stable PH patients with optimal drug treatment. However, larger studies including a wider range of PH are mandatory. Pulmonale Hypertonie (PH) ist definiert als ein Anstieg des mittleren pulmonal-arteriellen Drucks auf 20 mmHg in Ruhe, der auf Dauer zu einer Rechtsherzinsuffizienz führen kann. Bis vor einigen Jahren wurde PH-Patienten wegen der Befürchtung einer möglichen Symptomverschlechterung und dem Auftreten unerwünschter, belastungsassoziierter klinischer Ereignisse von körperlichem Training abgeraten. Drei elektronische Datenbanken wurden mit folgenden Suchbegriffen nach randomisiert, kontrollierten Studien durchsucht, in denen eine Trainingsintervention bei PH-Patienten untersucht wurde: „pulmonary hypertension ODER „pulmonary arterial hypertension“ UND „exercise“ ODER „pulmonary rehabilitation“ UND „randomized“. In dieser Metaanalyse konnten Daten von 5 Studien mit insgesamt 187 PH-Patienten eingeschlossen werden, welche 3- bis 12-wöchige Trainingsprogramme (z. B. 10 – 45 Minuten Ergometertraining; 60 – 80 % der maximalen Herzfrequenz) absolvierten. Patienten in den Trainingsgruppen wiesen im Vergleich zur Kontrollgruppe signifikante (p 0,001) Verbesserungen ihrer körperlichen Belastbarkeit auf: 6-Minuten-Gehtest: + 45 m [95 % KI: 26 m – 64 m] oder maximale Sauerstoffaufnahme VO Ein individuell angepasstes Trainingsprogramm bei stabilen PH-Patienten kann nach zuvor optimierter medikamentöser Therapie die körperliche Belastbarkeit und Lebensqualität ohne nachweisbare klinische Gefährdung verbessern. Diese Einschätzungen basieren bisher nur auf kleinen Fallzahlen und größere, randomisierte Studien mit unterschiedlichen PH-Schweregraden sind dringend notwendig.

Cardiopulmonary Exercise Testing (CPET) is a non-invasive simultaneous measurement of the cardiovascular and respiratory system during exercise to assess a patient's exercise capacity.It is used in a wide spectrum of clinical applications for the objective determination of functional capacity and impairment. Cardiopulmonary exercise testing involves measurements of respiratory oxygen uptake (VO2), carbon dioxide production (VCO2), and other cardiopulmonary and metabolic measures during a symptom-limited exercise test.This article gives an overview of indications and contraindications and explains step by step how cardiopulmonary exercise testing is being performed.

As the number of HIITs is increasing in competitive and non-competitive sports, the risk of injuries and overload is increasing. There are no scientific data to support specific recommendations in regard to intensity, duration, number of intervals and gradient for HIIT that result in improved muscular parameters in athletes. Therefore the aim of this study was to compare HIIT in plain and uphill exercise, with respect to exercise tolerance and improvements in performance (VO17 well-trained sport students (10 females, 7 males; Ø VOIn GE, three subjects dropped out of the study because of overtraining. In GB, two subjects did not complete the study because of time constraints. The evaluation of the perceived exertion of the training in flat terrain showed a trend (p = 0.08; t = - 1.96) towards being perceived as more exhausting then in hilly terrain. A four week HIIT showed significant improvements in VOIn this study, the application of HIIT leads to significant improvements in the performance of well-trained athletes. There is no evidence that the mode of training influenced the running improvements. However, uphill training tends to be better tolerated by the athletes.Mit Zunahme hochintensiven Intervalltrainings (HIIT) im Breiten- und Leistungssport steigt das Verletzungs- und Überlastungsrisiko. Für die Effektivität eines HIITs in ansteigendem Gelände (bergauf) fehlen wissenschaftliche Evidenz und verlässliche Angaben für Intensität, Dauer und Steigungsgrad. Das Ziel dieser Untersuchung war es, die Belastungsverträglichkeit und Leistungsveränderungen (VOAn der Untersuchung nahmen insgesamt 17 gut trainierte SportstudentInnen (Ø VOIn der GE konnten 3 Probanden ihr Training aufgrund von Überlastungssymptomen nicht zu Ende bringen, in der GB 2 Probanden aus zeitlichen Gründen. Bei der Auswertung des Belastungsempfindens war eine Tendenz (p = 0,08; t = – 1,96) erkennbar, dass das Training in der Ebene als anstrengender empfunden wurde. Durch ein vierwöchiges HIIT hat sich die VODiese Untersuchung ist ein weiteres Beispiel dafür, dass sich die sportartspezifische Leistungsfähigkeit gut trainierter Athleten nach einem HIIT signifikant verbessert. Die Verbesserung der Laufleistungen unterscheidet sich nicht zwischen den Trainingsgruppen (Bergauf vs. Ebene). Bedeutsam ist die Beobachtung, dass Bergauf-HIITs tendenziell besser verträglich waren als HIITs in der Ebene.

Daily activity is essential for children's development. Especially children with congenital heart disease do not burden adequate, even physical activity is beneficial for them. They should get used to activity and individual athletic performance. Once risks are defined or excluded in a cardiological examination, a detailed sports medical examination is recommended to give advice on individual intensity for leisure and school sports activities. By participation in sporting activities with their peers, they will benefit both physically as well as psychologically. Furthermore, children with congenital heart disease are able to experience their performance limitations.

There are hardly any publications about the outcome of cardiac rehabilitation considering patients with an increased need for medical, nursing and therapeutic care. The aim of this study, which consecutively included n=387 statutory health insurance inpatients over a period of 2 years, was to find out differences in outcome in self-care patients (Barthel index70) as compared to patients with a need for complex care (Barthel index≤70).Rehabilitation outcomes concerning physical capacity, emotional status and activities of daily living as measured by Barthel index, FIM index, HADS, clinical complications, exercise test, duration of rehabilitation and form of dismission were analyzed and compared between both groups.The inpatients with a Barthel index ≤70 at admission were older, had a longer stay in hospital and in rehabilitation, developed more complications and more often suffered from concomitant diseases. They were readmitted to hospital more often. They showed a comparatively higher increase in indices of self-care and a significant increase in physical performance tests.Higher medical care expenses of multimorbid cardiac inpatients are no contraindication against rehabilitation, because even in this group the specific rehabilitation aims of the healthcare payers can be reached.

The objective of this study was assess robot-assisted gait therapy with the Lokomat® system in heart failure patients.Patients (n = 5) with stable heart failure and a left ventricular ejection fraction of less than 45% completed a four-week aerobic training period with three trainings per week and an integrated dynamic resistance training of the lower limbs. Patients underwent testing of cardiac and inflammatory biomarkers. A cardiopulmonary exercise test, a quality of life score and an evaluation of the muscular strength by measuring the peak quadriceps force was performed.No adverse events occurred. The combined training resulted in an improvement in peak work rate (range: 6% to 36%) and peak quadriceps force (range: 3% to 80%) in all participants. Peak oxygen consumption (range: –3% to + 61%) increased in three, and oxygen pulse (range: –7% to + 44%) in four of five patients. The quality of life assessment indicated better well-being in all participants. NT-ProBNP (+233 to –733 ng/ml) and the inflammatory biomarkers (hsCRP and IL6) decreased in four of five patients (IL 6: +0.5 to –2 mg/l, hsCRP: +0.2 to –6.5 mg/l).Robot-assisted gait therapy with the Lokomat® System is feasible in heart failure patients and was safe in this trial. The combined aerobic and resistance training intervention with augmented feedback resulted in benefits in exercise capacity, muscle strength and quality of life, as well as an improvement of cardiac (NT-ProBNP) and inflammatory (IL6, hsCRP) biomarkers. Results can only be considered as preliminary and need further validation in larger studies. (ClinicalTrials.gov number, NCT 02146196)

In the course of time implantation of left ventricular assist devices (LVAD) has become an alternative to heart transplantation due to the enormous technical developments and miniaturization of these systems. Following implantation most patients show a significant improvement in their clinical condition and exercise capacity as measured by the New York Heart Association (NYHA) classification; nevertheless, exercise tolerance remains clearly limited even after LVAD implantation. The complex physiological and hemodynamic changes in LVAD patients both at rest and during exercise are ultimately not completely understood. The aim of this article is to describe the current state of scientific knowledge with respect to the physical capacity of patients with terminal heart failure after LVAD implantation at rest and during exercise. The influence of increasing the pump speed and continuous physical exercise training on the physical capacity in the long-term course is reviewed. The significance of new diagnostic tools, such as the non-invasive inert gas rebreathing method for measurement of cardiac output and arteriovenous oxygen difference (AVDO2) in assessment of the performance of LVAD patients is discussed.

COPD is a heterogeneous disease with a wide range of clinical phenotypes and breath-functional dysfunctions. Cardiopulmonary exercise testing (CPET) allows describing all component parts of breathing and determining exercise capacity and the mechanisms of exercise limitation. From these aspects 64 COPD patient stages II, III and IV according to the conventional GOLD classification were examined by means of CPET to evaluate whether CPET can provide a better functional characterization of COPD than the standard investigation procedures in pulmonary practice.We could show that in pulmonary practice CPET is safely and effectively practicable in stable COPD patients of all GOLD stages. This method allowed a clinical and prognostic disease severity assessment of all patients, proving important differences of peak oxygen uptake in each GOLD stage, so that patients in spite of identical GOLD disease severity were to be assigned to different prognostic groups according CPET criteria. Furthermore, we found relevant differences of individual breath-functional patterns in exercise, which can neither be objectified nor be prognosticated by standard investigation procedures at rest.Therefore CPET allows, aside from an objective clinical and prognostic disease severity assessment, also a breath-functional evaluation in a subtly way in COPD patients reflecting the multidimensional background of the disease with variable dysfunctions in pulmonary ventilation, gas exchange, circulation and muscular function as well as associated cardio vascular comorbidities. The breath-functional phenotyping of the COPD patient seems to be meaningful in particular for an individualised therapy management.

Objective Patients who suffered from an acute coronary syndrome (ACS) boast a low exercise capacity (EC). To enhance EC is a core component of cardiac rehabilitation (CR). The aim of the study was to investigate predictors of exercise capacity to optimize the rehabilitation process in untrained subgroups.47 286 patients (mean age 64±11.62, 74.5% male) were enclosed in the TROL registry. All patients underwent a bicycle stress test at admission and discharge. The dependent variable for the univariate analysis and multivariate logistic regression was the increase of EC during CR, with a cutoff of 15 Watts (pre/post design). Furthermore comorbidities and physical activity before the index event were analyzed.Exercise capacity enhancement differs between active and inactive patients significantly (21.84 Watt vs. 16.35 Watt; p0.001). While a male gender (OR 1.62 [95% CI: 1.51-1.74]) and physical activity before rehabilitation (OR 1.85 [95% CI: 1.75-1.97]) were positive, comorbidities and age (OR 0.82 [95% CI: 0.74-0.90]) were negative predictors.In cardiac rehabilitation settings special exercise training programs for elderly and comorbid patients are needed, to enhance their exercise capacity sufficiently.

Physical exercise has been recognized as a standard therapy in the guidelines for secondary prevention of chronic heart failure. This is mostly due to the overwhelming scientific evidence, including meta-analyses that have illustrated the positive effect of physical exercise on quality of life, hospitalisation and exercise capacity. However, it is crucial that patients undergo thorough clinical screening, including exercise testing, before starting an exercise regimen. Once a patient is eligible to exercise, it is also important that only approved exercise regimens are prescribed and that the exercise itself is monitored appropriately. Both, traditional moderate continuous endurance training and recently developed interval training have been shown to be safe and effective in chronic heart failure. Ideally, moderate intensity training should be started and later combined with interval training that is added by moderate resistance training in order to improve quality of life and prognosis.

Anaemia and iron deficiency are frequent co-morbidities in patients with chronic heart failure. Both are bound to worsen an already reduced exercise capacity in these patients. Recent data have demonstrated that iron deficiency alone, i.e. without concomitant anaemia, reduces quality of life, exercise capacity and likely also survival. Two clinical entities should be differentiated in this context: absolute and functional iron deficiency, the first being an absolute deficiency of iron, the second representing a disturbed mobilisation capacity. The FAIR-HF study has shown that intravenous iron administration can improve quality of life and exercise capacity in affected patients. A correct diagnosis can easily be arrived at using parameters such as serum ferritin and transferrin saturation. Replenishing iron stores is most useful using the intravenous route, and administered doses need to be adjusted to individual needs.

The dynamic decrease in inspiratory capacity (IC) during exercise with restriction of tidal volume (VT) is known as dynamic hyperinflation (DH) and is described mostly in patients with COPD differentiating between a "hyperinflator" and a "non-hyperinflator". Recent studies have revealed DH in patients with idiopathic pulmonary arterial hypertension (iPAH), but the influence of the DH on the reduced exercise capacity with exertional dyspnoae is still being debated.We analysed flow-volume curves during cardiopulmonary exercise testing (CPET) in idiopathic PAH (n = 19), in COPD (n = 17), in idiopathic pulmonary fibrosis (IPF) (n = 19) and a control group (n = 30). We measured IC at rest and during maximal exercise and furthermore ventilation, VT and oxygen uptake (VO2 peak). In iPAH a right heart catheter test and a 6-minute walk test (6MWT) were performed, also the B-type naturetic peptide (BNP) and the NYHA/WHO functional class were determined.The IC decreased significantly in 11 PAH "hyperinflators" (PAH-H) (Δ IC: - 0.34 ± 0.14 L, p0.001) compared to 8 PAH "non-hyperinflators" (PAH-NH) (Δ IC: 0.08 ± 0.2 L). COPD patients exhibited a characteristic hyperinflation pattern with a decrease in IC throughout exercise (Δ IC: - 0.61 ± 0.3 L, p0.001), while patients with IPF (Δ IC: 0.03 ± 0.15 L) and the control group responsed to exercise with a non-hyperinflator pattern (Δ IC: 0.1 ± 0.2 L). Both PAH collectives showed a reduced IC/TLC, while VT/IC was elevated with a decreased peak VO2 and max. performance compared to the control group. Correlations of the IC rest/max (L) were shown in PAH-H and PAH-NH with the VO2 peak, max. performance and VT.The analysis of flow-volume curves during CPET can indentify DH in a subgroup of patients with iPAH. The DH contributes significantly but slightly to the development of exertional limitations and dyspnoe in a subgroup of iPAH. Further studies with a larger sample size will be required to definitively measure the impact of the DH seen in these patients.

The interpretation of gas exchange measured by cardiopulmonary exercise testing (CPET) depends on reliable reference values. Within the population based Study of Health in Pomerania (SHIP) CPET was assessed in 1706 volunteers. The assessment based on symptom limited exercise tests on a bicycle in a sitting position according to a modified Jones protocol. CPET was embedded in an extensive examination program. After the exclusion of active smokers and volunteers with evidence of cardiopulmonary and musculoskeletal disorders the reference population comprised 616 healthy subjects (333 women) aged 25 to 85 years. Reference equations including upper and/or lower limits based on quantile regression were assessed. All values were corrected for the most important influencing factors.This study provides reference equations for gas exchange and exercise capacity assessed within a population in Germany.

Objective: To determine and compare haemodynamic responses at maximal arm-crank (ACE) and wheelchair exercise (WCE) in individuals with cervical spinal cord injury and pair-matched able-bodied individuals. Methods: Nine male, motor-complete cervical spinal cord injured and 9 able-bodied individuals performed graded, maximal ACE and WCE. Cardiac output, heart rate, and stroke volume were determined at rest and at maximal exercise in cervical spinal cord injured individuals. In able-bodied individuals, measurements were performed at rest and at the maximal workload of the matched cervical spinal cord injured individuals. Results: In cervical spinal cord injured, maximal cardiac output (ACE 7.4 (standard deviation (SD) 1.6); WCE 7.3 (SD 2.1) l/min) and heart rate (ACE 101 (SD 22); WCE 103 (SD 27) bpm) increased significantly compared with rest (4.6 (SD 1.0) l/min; 65 (SD 12) bpm), while stroke volume (ACE 77 (SD 22); WCE 73 (SD 21) ml) did not differ from rest (73 (SD 20) ml). In able-bodied individuals, cardiac output (rest 4.8 (SD 1.4); ACE 10.7 (SD 1.8); WCE 10.3 (SD 2.2) l/min), heart rate (rest 68 (SD 10); ACE 103 (SD 27); WCE 109 (SD 27) bpm), and stroke volume (rest 70 (SD 10); ACE 105 (SD 20); WCE 96 (SD 17) ml) increased significantly compared with rest. Cardiac output and stroke volume were significantly lower in cervical spinal cord injured compared with able-bodied individuals at the same workloads. Conclusion: Haemodynamic responses to maximal exercise were similar for both exercise modes in individuals with cervical spinal cord injury. The lower cardiac output in individuals with cervical spinal cord injury compared with able-bodied individuals at equivalent workloads reflects the inability of the circulatory system to increase stroke volume.

After bronchoscopic lung-volume reduction (LVR) improvement in pulmonary function and exercising tolerance can be achieved in patients with severe heterogeneous lung emphysema. Feasibility and safety for one-way valve placement in homogeneous emphysema were evaluated.Ten patients entered this prospective study. In all cases a homogeneous distribution was confirmed by computer analysis of the CT-scans. We performed unilateral LVR and occluded the lobe with the lowest perfusion, measured by nuclear scintigraphy. Endpoints of the study were changes in lung function test, quality of life and 6-minutes-walk-test (6-MWT) at day 30 and 90 and the safety of the procedure.Preoperative mean forced expiratory volume in 1 second (FEV1) was 0.93 l (range 0.55 - 1.35 l), mean residual volume was 5.23 l (3.55 - 8.24 l) and 6-MWT was 325 m ( 150 - 480 m). Improvement of dyspnoe and exercising tolerance was reported in 7 cases. No major changes in lung function were evident at days 30 and 90. A trend towards improvement was observed in 6-MWT (DeltaMW + 10.4 +/- 9.8 %). One pneumothorax was noticed, in one case the valves were removed after 90 days because of recurrent infections.This study shows that bronchoscopic LVR in patients with severe homogeneous emphysema is feasible and seems to be safe. In contrast to surgical LVR patients may have a cinical benefit by bronchoscopic treatment. Longtime follow -up and patient selection criteria have to be examined in larger trials.

The value of pulmonary rehabilitation in the treatment of chronic obstructive pulmonary disease (COPD) is well accepted. However, there are no data on the efficacy of in-patient rehabilitation instituted within 14 days after an acute disease episode, as practised in Germany. It was the purpose of this multi-centre prospective study to assess changes in lung function, exercise capacity, symptoms and disease-related quality of life (QoL) in patients discharged from hospital for an episode of worsening COPD or asthma, pulmonary embolism, pneumonia or treatment of lung cancer.207 patients (mean age 60 13 years) with COPD (n=86), pneumonia (n=42), lung cancer (n=24), asthma (n=14), pulmonary embolism (n=7) or other pulmonary disease (n=34) were included. Measurements of lung function, exercise capacity and disease-related QoL were carried out at the beginning and end of rehabilitation. Socio-economic data and disease-related QoL measurements were recorded again after 2 months.Rehabilitation led to a significant improvement of lung function, exercise capacity and QoL. Patients felt rehabilitation was efficacious (95%), to be recommended (99%) and important (100%). Improvement of QoL was maintained at two 2 months and only 16% of previously working patients had applied for retirement.The data demonstrate the clinically relevant benefit of in-patient pulmonary rehabilitation immediately after a period of acute illness. In view of these result and the known morbidity and mortality of patients with COPD after hospitalization for a period of acute illness, this form of pulmonary rehabilitation should be considered as standard treatment for these patients.

This review article summarizes the effect of cardiac resynchronization therapy (CRT) on exercise tolerance, functional capacity and quality of life, as it has been shown in previous randomized controlled trials. Based on these data we carefully have to reconsider the initial goals of this therapy. An early prophylactic implantation is not justified today. Especially patient selection has to be performed with more care in the future using new methods for detection of cardiac asynchrony to avoid a mismatch between implant numbers and real functional benefit.

Heart transplantation has the potential to change a patient with a life-threatening illness into an active healthy person with a potentially excellent quality of life. Survival with excellent allograft function for 10 years is now common for the majority of patients. However, exercise performance remains impaired when compared to healthy subjects. Reasons include a decrease of maximal heart rate, cardiac output and oxygen uptake, which are present after heart transplantation. The role of these abnormalities may differ as a function of time after surgery. Possible reasons like cardiac denervation, diastolic dysfunction, and endothelial dysfunction are discussed in this article. Furthermore, exercise capacity may be diminished because of peripheral limitations associated with physical deconditioning, abnormal muscle structure and function or pharmacological side effects. Endurance and strength training may greatly improve muscle function and maximal aerobic performance as well as reduce side effects of immunosuppressive therapy. Exercise should be considered a valuable tool in the long-term treatment after heart transplantation.

In order to tolerate the exertion in fitness exercise in the long term a sufficiently strong trunk musculature should be aimed at. In order to stabilize and balance the trunk and the pelvis there should be an optimal interaction of the muscles of the abdomen, the lateral trunk, the back and the flexors and extensors of the hip. If that balance is disrupted, muscular imbalance and a weakening or shortening of the muscles involved can occur. That imbalance leads to inadequate and excessive strain of the functional system of spine and pelvis. The functional anatomy of the trunk is described with clinical references in order to elucidate this context. A program of strength and stretching exercises for the trunk is presented suited to the needs of those practicing fitness exercise.

There are many different aspects that should be taken into account when exercise counselling of trained and untrained persons is required. Factors to be considered include the endurance capacity (EC), the general sport skills and the goals of the individual willing to start a training program. First the advisor should try to characterize the EC of the person by estimating or measuring EC. Based on this information, advice for an individual training programme can be given. As a principle for cardio-respiratory fitness training, a person should at least practise three times per week 20-30 minutes in a moderate exercise intensity to achieve a sufficient training effect. When training more than three times/week people should vary the mode of exercise and training intensity to improve the quality of training and to avoid overcharge symptoms. After a certain duration of the training cycle, the plans should be adapted to new or changed conditions. A distinct improvement of EC can be expected after 8-12 weeks of regular training. The article gives an overview of the possibilities for testing and the planning of training, should help the reader either to start his own training program or to give appropriate advice to an athlete requiring training counselling.

Specific difficulties in the assessment of reduced performance capacity in patients with gastroenterologic illness led to the development of a standardized and unified assessment method. The following five steps--exemplified for chronic liver-disease--were designed: (1) determination of disease features (and their graduations), leading to reduced performance capacity; (2) construction of a detailed performance capacity model using more concrete factors (e.g. motivation, cognition, cardiovascular-pulmonary system, etc.); (3) deduction of rules between disease features and the concrete factors of performance capacity, describing the expected (unfavourable) limitations; (4) consideration of individual limitations on the level of the concrete factors, and (5) conversion into a computer-aided expert system. The benefit of the method developed lies in prompt and practicable assistance by the expert system and in transparency of the decision processes. Therefore, performance capacity assessment will certainly gain in reliability and objectivity.

Physical exercise leads to an elevated coagulation activity with a possibly disturbed hemostatic balance. Therefore patients with coronary heart disease have a potentially increased risk of thromboembolic events after a bicycle exercise tolerance test, that is frequently performed for diagnostic reasons.Patients with angiographically known coronary heart disease (Group I: n = 49; age 59 years; male = 42, female = 7) were investigated in comparison to a healthy cohort (Group 2: n = 51; age 53 years; male = 44, female = 7) to study the influence of a standardized exercise tolerance test on hemostatic variables. Blood samples were taken before and after exercise.No significant changes were found for any investigated parameter between both groups. However, 3 parameters did change significantly within the groups: factor VIII rose in Group 1 from 132 to 156% and in Group 2 from 106 to 136% and the von Willebrand factor rose in Group 1 from 230 to 249% and in Group 2 from 228 to 247%. An elevated fibrinolytic potential was found with an increase of plasminogen-alpha 2-antiplasmin in Group 1 from 251 to 401 micrograms/l and in Group 2 from 247 to 350 micrograms/l.The findings underline the clinical presumption that exercise tolerance test does not increase the risk for thromboembolic complications in patients with coronary heart disease in comparison to patients without coronary heart disease, as long as the exercise tolerance test is performed in a standardized way and under aerobe conditions.

There are only a few papers concerning with exercise tolerance of patients under nasal intermittent positive pressure ventilation (nIPPV).Therefore since 1996 we routinely checked exercise tolerance of our nIPPV-patients when admitted to the hospital. Till March 1997 we had carried out 1386-minute walking tests (6-min WT) in 111 patients.Is there an improvement of exercise tolerance in the course of nIPPV-therapy? Are hypoxemia or hypercapnia occurring during exercise-test?The 6-min WT was performed after one practice walk. The patients got oxygen in case of a preexisting oxygen therapy or in case of an oxygen saturation below 85% before starting. Blood gas analyses were carried out before and after stopping the test. Oxygen saturation and heart rate were registered continuously. The distance walked was measured. Twenty-one patients were tested before introducing nIPPV therapy and 3 months after home mechanical ventilation (HMV).The average distance walked amounted only 283 +/- 82 m (norm in healthy persons: 800 m). pO2 decreased from 69 +/- 11 to 58 +/- 12 mm Hg, pCO2 increased from 47 +/- 8 to 49 +/- 8 mm Hg. Oxygen saturation (SaO2) fell from 92 +/- 5 to 80 +/- 10%, heart rate increased from 104 +/- 18 to 130 +/- 23 beats/min. The distance walked changed not significantly from 282 +/- 109 to 308 +/- 71 m. Six patients could be tested a 3rd time after 6 months HMV. The distance walked was 315 +/- 103 m (also no significant difference).Everyday activity can cause severe hypoxemia in nIPPV patients. Ambulatory oxygen therapy should be considered in each case. A significant improvement of exercise tolerance under nIPPV therapy is not yet proven. Our data only show a tendency towards an increase.

Lung volume reduction (LVR) is a new surgical approach designed to relieve shortness of breath and improve exercise tolerance in patients with severe lung emphysema. The aim of this study was to analyse surgical results and changes in the lung function, gas exchange, exercise tolerance and degree of dyspnoea until two years after LVR. From June 1994 to September 1997 ninety-four patients (31 women and 63 men, mean age 64 [35-79] years) with severe emphysema (12 with alpha 1-Pi-deficiency) underwent unilateral (n = 24) or bilateral (n = 70) LVR. 92 from 94 patients were extubated immediately after surgery. 30 days mortality was 2.2% (2/94), 90 days 3.3% (3/94) respectively. Most common postoperative complications were pneumonia (n = 15, 16%) and air leakage longer than 7 days (n = 22, 23.4%). One month after surgery there was a significant increase in forced expiratory vital capacity after one second (FEV1 59%) and significant decrease in total lung capacity (TLC 19%) and residual volume (RV 28%). Also significant changes were observed in paO2, paCO2, 6-minute walking distance, dyspnoea score and respiratory muscle function. Two years after LVR lung function tests in patients with smokers emphysema showed the benefit to be maintained (high responders). Patients with alpha 1-Pi-deficiency showed 6 to 12 months after surgery a remarkable deterioration of functional data (low responders). In selected patients with severe emphysema surgical LVR shows significant improved pulmonary function, gas exchange, dyspnoea and walking distance. The results are better after bilateral operation. Patients selection, rehabilitation program and interdisciplinary care resulted in a low operative morbidity and mortality.

Lung volume reduction (LVR) is a new surgical approach designed to relieve shortness of breath and improve exercise tolerance in patients with severe lung emphysema. The aim of this study was to analyse changes of lung function, gas exchange, exercise tolerance and degree of dyspnoea one and 3 months after LVR.Seventeen patients (15 men and two women; mean age 53 [38-68] years) with severe emphysema (six with alpha 1-PI deficiency) underwent unilateral (n = 14) or bilateral (n = 3) LVR surgery. One week before and one and 3 months after surgery pulmonary function tests, arterial blood gas analysis at rest breathing room air, 6-minute walking distance and dyspnoea score (Medical Research Council Scale) were determined.There was a significant increase in forced expiratory vital capacity after one second (FEV1, P0.001), and a significant decrease in total lung capacity (TLC, P0.0001) and residual volume (RV, P0.0001). The mean increase in FEV1 was 39% and in PaO2 9%. The mean decrease in TLC was 20%, in RV 26% (P0.001; both comparisons), and in paCO2 4% (not significant). The mean 6-minute walking distance increased by 96% from 229 to 405 meters (P0.0001). The mean dyspnoea score on a five point scale (0-4 points) decreased by 52% from 3.4 to 1.6. With the exception of the improved inspiratory vital capacity the postoperative results at one and 3 months after LVR did not differ significantly. All patients were alive 3 months postoperatively.In patients with severe emphysema surgical LVR shows significantly improved pulmonary function, gas exchange, dyspnoea and walking distance as assessed one and three months postoperatively. The early mortality seems to be low.

A 21-year-old woman suffering from increasing dyspnoea on intense physical exercise, was found to have a congenital right-sided arteriovenous pulmonary fistula. This was successfully and without complication embolized using a percutaneously introduced Gianturco wire coil. All symptoms disappeared after this procedure. Definite improvement in physical performance, in comparison with pre-embolization values, was documented by spiroergometry as early as two days later (oxygen uptake 1855 vs. 1459 ml/min; anaerobic threshold 920 vs. 790 ml/min; oxygen-pulse 10.6 vs. 8.0 ml/beat; oxygen partial pressure 77.5 vs. 67.6 mmHg; alveolar arterial oxygen difference 33 vs. 44 mm Hg). Further constant subjective and objective improvement in physical performance was demonstrated 3 months after embolization. This case confirms that embolization of a pulmonary arteriovenous fistula can rapidly achieve lasting improvement in exercise performance.