OBJECTIVE:To investigate whether initiating prehabilitation during neoadjuvant chemotherapy (NAC) is associated with postoperative recovery of functional exercise capacity in patients with oesophageal cancer. METHODS:In this multicentre observational study, we classified patients with oesophageal cancer into two groups based on the timing of prehabilitation: the early prehab (initiated during NAC) and late prehab (initiated after NAC) groups. Prehabilitation consisted mainly of an exercise programme combining supervised sessions with prescribed self-exercise. Functional exercise capacity was assessed using the 6 min walk distance (6MWD) before surgery (T0) and at 3 (T1) and 6 weeks (T2) postoperatively. Secondary outcomes included muscle strength, body weight, fatigue and health-related quality of life. Between-group differences in changes in 6MWD were analysed using a linear mixed-effects model, and secondary outcomes were descriptively summarised. RESULTS:51 patients were analysed (early prehab group, n=17; late prehab group, n=34). Both groups showed a decline in 6MWD at T1 with partial recovery at T2. The early prehab group showed a smaller decrease in 6MWD at T2 (-13 m) compared with the late prehab group (-27 m), though the difference was not statistically significant (p=0.70). Trends favoured the early prehab group in muscle strength, fatigue and global health status scores. CONCLUSIONS:This study observed a modest trend towards better postoperative recovery in patients who initiated prehabilitation during NAC, although no statistically significant differences were detected between groups. Further prospective trials are needed to refine intervention quality and identify patient populations most likely to benefit. TRIAL REGISTRATION NUMBER:UMIN000047895.

Background The current state of respiratory physical therapy for adult pneumonia in Japan is insufficiently characterized. This study aimed to elucidate the current practices of respiratory physical therapy in Japan, including its implementation specifics, clinical frameworks, and medical reimbursement, with the aim of optimization respiratory physical therapy for adult pneumonia. Methods A cross-sectional questionnaire survey comprising 21 questions was administered to members of the Japanese Society of Respiratory Physical Therapy. The survey items encompassed basic institutional information, existence of protocols, timing of rehabilitation prescriptions, clinical and educational systems for respiratory physical therapy (such as training systems), and content of respiratory physical therapy. Results The timing of rehabilitation prescriptions for adult pneumonia “varies depending on clinical decision-making by attending physicians” in 35.4% of institutions, and only 8.3% of facilities had established rehabilitation protocols. Furthermore, the most pressing issue concerning respiratory physical therapy for adult pneumonia was identified as “the lack of guidelines for respiratory physical therapy (pulmonary rehabilitation) for pneumonia,” with 92 institutions citing this as the most significant problem. Conclusions The practice of respiratory physical therapy for adult pneumonia in Japan varies across institutions, with a lack of reference materials, including clinical practice guidelines, potentially contributing to this variability. These findings highlight the need for further research and the development of optimized clinical guidance.

BACKGROUND:Individual differences exist in the recovery of muscle strength in critically ill patients with intensive care unit (ICU)-acquired weakness, but the characteristics of patients who do not recover muscle strength are unclear. OBJECTIVE:To elucidate the factors associated with the nonrecovery of muscle strength in patients with ICU-acquired weakness. METHODS:This prospective cohort study involved critically ill patients with ICU-acquired weakness. The patients' outcomes were categorized as recovery (Medical Research Council Sum Score [MRC-SS] ≥48 until hospital discharge or the time of stroke, death, or ICU readmission) or nonrecovery (MRC-SS <48). Separate logistic regression analyses adjusted for age and sex were performed for each candidate factor to identify factors associated with nonrecovery of muscle strength. RESULTS:A total of 111 patients were included in the analysis. Thirty patients were classified as having nonrecovery. Analysis using a logistic regression model showed that septic shock, duration of deep sedation, corticosteroid use, total amount of corticosteroids used, duration of mechanical ventilation, duration of renal replacement therapy, day of first out-of-bed mobilization, initial evaluation of MRC-SS, and length of ICU stay were age- and sex-adjusted predictors of nonrecovery of muscle strength. CONCLUSIONS:Patients with ICU-acquired weakness with the predictors identified in this study may not recover muscle strength. Future multicenter interventional studies should assess not only the timing of rehabilitation but also its intensity and the muscle groups specifically targeted.

Background:This study aimed to: (1) assess changes in peripheral skeletal muscle oxygenation during exercise after transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis (AS); and (2) identify characteristics of patients who exhibited improved exercise tolerance. Methods and Results:In this single-center prospective study, 20 patients with severe symptomatic AS underwent evaluation before and 1 week after TAVI. Exercise tolerance was assessed using the incremental shuttle walk test (ISWT), and the incremental shuttle walk distance (ISWD) was recorded. Calf muscle oxygenation during the ISWT was continuously measured using near-infrared spectroscopy (NIRS). ISWD increased significantly after TAVI (P<0.01). During the ISWT, the change in oxygenated hemoglobin (∆O2Hb) was greater after TAVI than before TAVI. Compared with non-responders, responders demonstrated lower ∆O2Hb and greater increases in deoxygenated hemoglobin (∆HHb) from rest to peak exercise before TAVI (all P<0.05). Conclusions:Peripheral skeletal muscle oxygenation during exercise improved early after TAVI. Moreover, a pre-TAVI pattern characterized by reduced oxygen delivery (lower ∆O2Hb) and enhanced oxygen extraction/utilization (higher ∆HHb) during exercise was associated with greater improvement in exercise tolerance after TAVI.

Background:Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disease characterized by airflow limitation and exertional dyspnea, leading to reduced exercise tolerance and physical inactivity. Nasal high-flow (NHF) therapy delivers heated and humidified gas at a high flow rate through a nasal cannula, washing out anatomical dead space, providing a small degree of positive airway pressure, improving ventilation efficiency, and reducing the work of breathing. In addition, adequate humidification may enhance ciliary clearance. The AIRVO3TM (Fisher & Paykel Healthcare, Auckland, New Zealand) is a novel portable NHF device that incorporates these features and can be used during ambulation. Using AIRVO3TM during exertion may improve exercise tolerance in patients with COPD; however, its safety and effectiveness in ambulatory patients have not yet been established. Methods:This is a single-center, early-phase, open-label, randomized, two-period crossover pilot trial conducted at Nagasaki University Hospital, designed to evaluate the acute, within-day effects of AIRVO3TM on exercise tolerance during a single visit. Twenty patients with moderate to severe COPD will perform two 6-minute walk tests (6MWT) in a randomized order: one with AIRVO3TM and one without the device. The primary outcome is the 6-minute walk distance (6MWD). Secondary outcomes include percutaneous oxygen saturation (SpO2), transcutaneous partial pressure of carbon dioxide (PtcCO2), respiratory rate, pulse rate, Borg dyspnea scale score, time to desaturation (SpO2 ≤90%), time to PtcCO2 ≥45 mmHg, time to respiratory rate ≥22/min, walking distance to the first rest, patient-reported comfort, and subjective symptoms. Safety outcomes include the incidence of SpO2 <90%, adverse events (AEs), device-related discomfort, and withdrawal or dropout. Data will be analyzed primarily using paired t-tests and mixed-effects models that are appropriate for a crossover design. Discussion:This trial will evaluate whether a portable NHF device increases exercise tolerance and is safe during ambulation in patients with COPD who do not require long-term oxygen therapy. By using room air [finspiratory oxygen fraction (FiO2) 21%] and focusing on high flow rather than high oxygen concentration, this study will clarify the pure effects of high-flow nasal therapy on exertional capacity. If the AIRVO3TM device is shown to be effective and acceptable, it may expand the options for pulmonary rehabilitation and daily physical activity in patients with COPD. Because all assessments are performed during a single study visit, this trial specifically evaluates short-term, acute responses to AIRVO3TM rather than long-term training effects of repeated use. Trial Registration:The study is registered in the Japan Registry of Clinical Trials (jRCT; trial ID jRCTs072240116; registered on February 20, 2025; https://jrct.mhlw.go.jp/latest-detail/jRCTs072240116). This article describes the protocol version 1.1 (March 11, 2025).

Tomoyuki Ikeuchi,1,2 Kazuaki Suyama,1,3 Miyako Yagita,4 Shunichiro Mori,1,2 Daichi Mori,5 Tetsuya Kawano,6 Hideaki Takahata,7 Terumitsu Sawai,8 Toru Tsuda,6 Ryo Kozu11Department of Physical Therapy Science, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; 2Department of Pulmonary Rehabilitation Center, Kirigaoka Tsuda Hospital, Fukuoka, Japan; 3Faculty of Rehabilitation, Reiwa Health Sciences University, Fukuoka, Japan; 4Department of Nutrition, Kirigaoka Tsuda Hospital, Fukuoka, Japan; 5NAORU Technology, Nagasaki, Japan; 6Department of Respiratory Medicine, Kirigaoka Tsuda Hospital, Fukuoka, Japan; 7Department of Rehabilitation Medicine, Nagasaki University Hospital, Nagasaki, Japan; 8Department of Nursing, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, JapanCorrespondence: Ryo Kozu, Department of Physical Therapy Science, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8520, Japan, Tel/Fax +81-95-819-7963, Email ryokozu@nagasaki-u.ac.jpPurpose: Chronic obstructive pulmonary disease (COPD) is frequently complicated by nutritional disorders, and low body weight is an independent prognostic factor. High-intensity exercise training may affect leptin, an appetite-regulating hormone, and dietary intake. However, longitudinal evidence regarding these associations in COPD is limited. This study aimed to examine changes in dietary intake and leptin levels during pulmonary rehabilitation in patients with COPD, with exploratory analyses according to attainment of high-intensity exercise training.Patients and Methods: In this prospective observational study, patients with COPD participated in a 6-week pulmonary rehabilitation program. High-intensity exercise training (≥ 80% prescribed intensity) was performed whenever feasible. Dietary intake (primary outcome) and leptin were assessed before and after the program. In exploratory subgroup analyses, participants were classified as high-intensity "attainers” (Attainment group) or "nonattainers” (Nonattainment group), and within-group before and after changes as well as between-group differences in change scores were compared. Furthermore, multivariate linear regression analysis was performed to examine whether exercise intensity was independently associated with changes in dietary intake and leptin.Results: Of the 69 participants, 55 completed the study and were included in the analysis. Dietary intake increased significantly from 1367 to 1484 kcal/day (p = 0.01), whereas leptin did not change significantly in the overall cohort. Between-group comparisons of change scores revealed a significant difference in leptin (p < 0.01) but not in dietary intake (p = 0.16). Multivariable regression analysis showed that exercise intensity attainment was associated with changes in leptin (B = − 4.47, p < 0.01) but not dietary intake (p = 0.12).Conclusion: Dietary intake increased following pulmonary rehabilitation in patients with COPD. Although exploratory analyses suggested an association between attainment of high-intensity exercise training and changes in leptin levels, the relationship with dietary intake remains unclear.Keywords: exercise training, dietary intake, leptin, chronic obstructive pulmonary disease

To investigate whether adding early upper-limb aerobic exercise to usual postoperative rehabilitation reduces the incidence of chronic postsurgical pain (CPSP) at 6 months after total knee arthroplasty (TKA). Eighty patients undergoing primary unilateral TKA were randomized to the intervention or control groups. Both groups received usual postoperative rehabilitation, and the intervention group additionally performed upper-limb ergometer exercise on postoperative days 2–14. The primary outcome, CPSP at 6 months, occurred at very low rates in both the intervention (2.6

Background: Pulmonary rehabilitation, primarily with exercise training, is well-established for patients with chronic obstructive pulmonary disease (COPD); however, rehabilitative intervention specifically targeting physical frailty in patients with chronic respiratory disease (CRD) remains unexplored. This study evaluates a rehabilitative intervention for frailty in older patients with CRDs (REINFORCE), including various lung diseases. Methods: This multicentre, prospective, randomised, controlled trial will enrol 184 patients with CRD. Patients will undergo a 4-week programme focused on addressing declined physical functions, as measured by the Short Physical Performance Battery (SPPB) items such as balance, walking, and/or sit-to-stand chair test. The primary outcome is the change in daily step count as a physical activity measure before and after the programme between the two groups. Secondary outcomes include changes in the SPPB score, peripheral muscle strength (handgrip and quadriceps), 6-minute walk distance (6MWD), and health-related quality of life (HRQL) scores at 4 weeks and 1 year. Discussion: The REINFORCE study is designed to be one of the first randomised trials targeting frailty in CRD and aims to explore the feasibility and potential benefit of a novel intervention to improve physical activity levels. Trial Registration: This randomised controlled trial was prospectively registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) under the registration number UMIN000053979 on June 1, 2024.

Background: Critically ill patients often have long-lasting limitations in activities of daily living, particularly in walking ability. Although early mobilization increases the likelihood of independent ambulation at hospital discharge, the timing at which different mobilization levels become associated with ambulatory recovery is unclear. This study describes the timing for achieving several mobilization levels and its associations with ambulatory recovery at hospital discharge.Methods: In this single-center retrospective cohort study, patients were divided into a regained group, composed of patients whose ambulation recovered to pre–intensive care unit (ICU) admission levels by hospital discharge, and a non-regained group. Multivariable logistic regression analyses and receiver operating characteristic curve analyses were performed to examine the association between the timing of mobilization (standing, marching in place, and assisted walking) and regained ambulation at hospital discharge.Results: In total, 295 patients were included, and 223 (76%) of them had regained ambulation at hospital discharge. The adjusted odds ratio for standing peaked on day 10 after ICU admission (odds ratio, 5.61; 95% CI, 2.21–17.76) and declined thereafter. The optimal cutoff time linking marching in place and walking with assistance to regained ambulation was also day 10 after ICU admission (marching in place: area under the curve [AUC], 0.78; sensitivity, 0.83; specificity, 0.64; and walking with assistance: AUC, 0.79; sensitivity, 0.77; specificity, 0.68).Conclusions: The findings suggest that mobility status on day 10 after ICU admission can serve as a pragmatic marker for identifying patients at risk of poor ambulatory recovery.

Objective To investigate the association between individualised rehabilitation dose levels and functional outcomes across age- and frailty-specific cohorts of critically ill patients. Design Multicentre prospective observational cohort study Setting Intensive care units at 22 hospitals in Japan. Participants Overall, 422 adult patients receiving mechanical ventilation for ≥48 h were categorised into old non-frail (age ≥65 years, clinical frailty scale: 1–4), old frail (age ≥65 years, clinical frailty scale: > 4) and middle-aged/young (age <65 years) cohorts. Main measures The primary outcome was independence in activity of daily living at hospital discharge, defined by a Barthel Index score of ≥90. Rehabilitation parameters dose, intensity, duration, frequency and timing were assessed. Multivariable logistic regression analysis was performed for each cohort. Results In the old non-frail cohort, activity of daily living independence was associate with higher dose (odds ratio: 1.10, 95% confidence interval: [1.04–1.17]), higher intensity (odds ratio: 1.18 [1.02–1.37]) and shorter time to first mobilisation (odds ratio: 0.92 [0.86–0.98]), whereas, in the old frail cohort, it was higher dose (odds ratio: 1.07 [1.02–1.18]), longer duration (odds ratio: 1.05 [1.01–1.12]) and higher frequency (odds ratio: 1.82 [1.07–4.62]). In the middle-aged/young cohort, activity of daily living independence was associated with higher dose (odds ratio: 1.14 [1.05–1.28]) and higher intensity (1.30 [1.06–1.62]). Conclusions The impact of rehabilitation dose on functional recovery varies across age- and frailty-specific cohorts. These findings highlight the importance of tailoring rehabilitation dose to patient characteristics to optimise functional outcomes in critical illness. Trial registration: UMIN000036503.

IMPORTANCE:Although survival rates in ICUs have improved, ICU length of stay is increasing, particularly among critically ill patients requiring prolonged mechanical ventilation. These patients often face challenges in early rehabilitation. Despite the importance of early mobilization, its implementation is often hindered by the severity of patient conditions. The details of rehabilitation interventions, particularly the element of intervention time, have not been fully examined. OBJECTIVES:This study evaluated the time, content, and effects of rehabilitation during ICU stays. DESIGN, SETTING, AND PARTICIPANTS:This study is a secondary analysis of data from the Japanese Rehabilitation and Risk Factors on the Post-Intensive Care Syndrome (J-RELIFE) prospective multicenter registry, which enrolled critically ill patients across 22 institutions in Japan. From this registry, we identified 423 patients who underwent mechanical ventilation in the ICU for greater than 48 hours. Patients were categorized into three groups based on ICU stay length: short-, medium-, and long-term (199, 157, and 67 patients, respectively). MAIN OUTCOMES AND MEASURES:The primary variable was rehabilitation intervention time in the ICU, analyzed relative to ICU stay length. Secondary measures included the association between rehabilitation time and the highest Sequential Organ Failure Assessment (SOFA) score, as well as functional outcomes at ICU and hospital discharge. RESULTS:The long-term group had significantly greater rehabilitation time (p < 0.05). A significant correlation was observed between rehabilitation time and highest SOFA score (r = 0.354; p < 0.001). In the long-term ICU group, even with high illness severity and delayed mobilization, patients' activities of daily living were restored by discharge. CONCLUSIONS AND RELEVANCE:Our registry-based analysis shows that severely ill ICU patients require extended rehabilitation interventions. This highlights the need for staffing and implementation systems that can ensure sufficient rehabilitation time for severely ill patients.

Purpose Predicting walking recovery in critically ill patients, including the timing of early rehabilitation, remains unclear. This study aimed to identify clinical factors, particularly the timing of first sitting on the edge of the bed, that are associated with walking recovery in critically ill patients. Methods We retrospectively analyzed data from mechanically ventilated patients (≥48 hours) admitted to the intensive care unit (ICU) of a tertiary-care hospital. Only patients who survived until hospital discharge were included. Walking recovery was defined as achieving a Functional Ambulation Categories (FAC) score ≥ 3, indicating independent walking on level ground with supervision for safety. Results A total of 121 patients were included. The median age was 73 years, 83 (68.6%) were male, the mean Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 18.9 ± 6.5, and the median duration of mechanical ventilation was seven days. Cox proportional-hazards regression identified three independent predictors of walking recovery: younger age (hazard ratio (HR) 0.98; 95% CI 0.97-1.00; p = 0.016), shorter duration of mechanical ventilation (HR 0.97; 95% CI: 0.95-1.00; p = 0.049), and sitting on the edge of the bed within 13 days (HR 0.11; 95% CI 0.52-0.91; p < 0.001). Receiver operating characteristic (ROC) analysis identified day 13 as the optimal cutoff for sitting, with an area under the curve (AUC) of 0.76, sensitivity of 81.6%, and specificity of 67.4% for predicting walking recovery. Gray's test further demonstrated that initiating sitting after 13 days significantly reduced the probability of walking recovery compared to earlier initiation (p < 0.001). Conclusion Achieving a sitting position at the edge of the bed by day 13 may serve as a clinically relevant marker for timely rehabilitation initiation and improved walking recovery in critically ill patients. However, the timing for initiating sitting on the edge of the bed should be validated through future prospective multicenter studies.

BACKGROUND AND OBJECTIVE:Although demand oxygen delivery system (DODS) prolongs ambulatory oxygen supply, the efficacy of preventing hypoxemia is likely to be lower than continuous oxygen flow (CF). We developed a new oxygen delivery method combining CF and DODS (CF + DODS). This study aimed in comparing the efficacy between conventional oxygen delivery methods and a new method during walking in patients with COPD. METHODS:We conducted three-treatment crossover study. Stable COPD patients performed three 6-min walk tests (6MWT) with different oxygen delivery methods in random order with CF, DODS, and CF + DODS. RESULTS:Twenty-six COPD patients were included in the study. The linear mixed model on SpO2 revealed significant main effects of oxygen conditions (P < 0.001) and exercise time (P < 0.001), however no significant interaction (P = 0.537). In the post-hoc analysis, SpO2 in DODS was significantly lower than in CF and CF + DODS throughout the 6MWT. CF and CF + DODS showed no significant differences in SpO2 at any exercise timepoint. There were no significant differences among each oxygen delivery method in walking distance and dyspnea before and after 6MWT. DODS utilized significantly less oxygen than CF and CF + DODS, and CF + DODS consumed significantly less oxygen than CF during 6MWT. CONCLUSION:CF + DODS enables a longer duration of oxygen supply, while preventing hypoxemia to the same degree as CF. These findings suggest that CF + DODS promotes outdoor activities in daily living while preventing hypoxemia in patients with COPD. TRIAL REGISTRATION:This study was registered in the UMIN Clinical Trials Registry (UMIN00005299).

Esophageal cancer surgery is highly invasive, often resulting in prolonged declines in health-related quality of life (HRQOL) and physical function. This review aims to evaluate the effectiveness and feasibility of postoperative rehabilitation after discharge for survivors of esophageal and gastroesophageal junction cancers. A systematic search of six databases (CENTRAL, MEDLINE, CINAHL, Web of Science, Scopus, and PEDro) identified eligible studies. Meta-analyses assessed the effects of postoperative rehabilitation after discharge on HRQOL, exercise capacity, muscle strength, skeletal muscle mass, physical activity, physical symptoms. Feasibility was evaluated based on adherence rates, dropout rates, and adverse events. From 9801 records, 12 studies involving 717 participants were included. A meta-analysis of four randomized controlled trials (RCTs) showed significant improvements in HRQOL (SMD [95

Background The high prevalence of poor sleep quality in patients with chronic respiratory diseases makes it an important clinical topic. However, the prevalence and characteristics of poor sleep quality in those with nontuberculous mycobacterial pulmonary disease and its association with clinical variables remain unclear. Methods This retrospective study involved patients with nontuberculous mycobacterial pulmonary disease between June 2017 and May 2022. The prevalence of poor sleep quality was measured by the Pittsburgh Sleep Quality Index was used to and its association with clinical variables including age, sex, laboratory data, pulmonary function, respiratory symptoms, mental health, health-related quality of life, and physical function was assessed. Results The median age of 233 participants was 65 years, with poor sleep quality present in 123 patients (52.8%) who were older, female, and unemployed with dyspnea, anxiety symptoms, low health-related quality of life, and low exercise capacity. Many reported that they "cannot get to sleep within 30 min," "wake up in the middle of the night or early morning," "have to get up to use the bathroom," "cannot breathe comfortably," or "cough or snore loudly." Multivariate logistic regression analysis indicated a significant association between poor sleep quality, female sex, and low health-related quality of life. Conclusion Our results suggested that for the patients in this study, a multidisciplinary management that considers poor sleep quality is required and assessment of sleep quality as a screening is needed.

Since the concept of post-intensive care syndrome (PICS) was proposed, numerous studies have assessed patients and their family members. However, a wide range of assessment timings has been employed across previous studies. This study aimed to clarify how assessment timings have been implemented in existing PICS research through a scoping review, and to explore expert opinions on optimal assessment timing via an online survey. We conducted a scoping review of studies assessing PICS-related outcomes, including physical, cognitive, and psychological impairments, as well as PICS in family members. Studies were retrieved from MEDLINE, CENTRAL, and CINAHL, and screened by two independent pairs of reviewers. Eligible studies were published between January 2014 and December 2022. Studies lacking a clear description of assessment timing were excluded. We analyzed the reference point used to determine assessment schedules, the assessment time points, and their frequency. Additionally, an online questionnaire was administered to 23 members of the Japanese Society of Intensive Care Medicine PICS committee and working group members to collect expert opinions on these three aspects for clinical research. A total of 657 studies were included. In prior studies, hospital discharge was the most commonly used reference point for determining assessment schedule (240 studies, 40