Exercise Tolerance

Based on consensus between the authors, physical therapy interventions for the rehabilitation of patients with stroke were divided into: (1) interventions related to gait and mobility-related functions and activities, including novel methods focusing on efficient resource use, such as circuit class training and caregiver-mediated exercises; (2) interventions related to arm-hand activities; (3) interventions related to activities of daily living; (4) interventions related to physical fitness; and (5) other interventions which could not be classified into one of the other categories. In addition, attention was paid to (6) intensity of practice and (7) neurological treatment approaches.
The ICF [15] , [23] was used to classify the outcome measures into the following domains: muscle and movement functions (e.g. muscle power functions [b730], control of voluntary movement functions [b760], muscle tone functions [b735]), joint and bone functions (e.g. mobility of joint functions [b710]), sensory functions (e.g. proprioceptive function [b260], touch function [b365], sensory functions related to temperature and other stimuli [b720]), gait pattern functions [b770] (e.g. gait speed, stride length), functions of the cardiovascular and respiratory systems (e.g. heart functions [b410], blood pressure functions [b420], respiration functions [b440], respiratory muscle functions [b445], exercise tolerance functions [b455]), mental functions (e.g. quality of life, depression), balance (e.g. changing basic body position [d410], maintaining a body position [d415]), walking [d450] (e.g. distance, independence, falls), arm-hand activities (e.g. fine hand use [d440], hand and arm use [d445]), basic ADL (e.g. washing oneself [d510], toileting [d520], dressing [d540], eating [d550], urination functions [d620]), extended ADL (e.g. acquisition of goods and services [d620], preparing meals [d630], doing housework [d640], recreation and leisure [d920]), and attitudes (e.g. individual attitudes of immediate or extended family members, like caregiver strain [e410 and e425 respectively]). The primary outcomes were at the body functions and activities and participation levels, while secondary outcomes included contextual factors.

After obtaining IRB approval, this single-center study was completed. Surgical scheduling software was queried for all patients >/= 65 years of age undergoing elective total hip or total knee replacements with surgical dates between 01 Jan 2015 and 31 Dec 2016 at a contemporary military treatment facility (MTF). A total of 303 patients were screened in the specified time period. These records were reviewed to eliminate emergent cases as well as to ensure that the patients had visited both the internal medicine preoperative clinic and the preoperative anesthetic unit (PAU). The resulting 177 records were reviewed of which 101 records were assigned an ASA-PS classification by both the medicine preoperative clinic and the PAU clinic (Table 2). These were included in the data analysis (Fig. 1).Table 2

ASA-PS classification distribution by clinic

	Medicine	Anesthesia PAU	Anesthesia DOS
1	0	0	1
2	66	51	49
3	32	49	50
4	3	1	1

Fig. 1

Consort diagram

At our institution, surgeons and anesthesia providers can make referrals to the internal medicine preoperative clinic based on clinical judgment. There is no algorithm that establishes which patients would benefit from additional resources in the form of an internal medicine preoperative visit. There is a stratification process in which the surgeons can determine who completes a PAU clinic visit versus who can bypass the PAU. Bypass is reserved for ASA-PS 1 and 2 patients. These patients are contacted telephonically by the PAU to determine if there are any outstanding issues that may need to be addressed by a PAU visit. The surgeons can refer ASA-PS 1 and ASA-PS 2 to the PAU based on their preference or if the surgeon believes they would benefit from seeing an anesthesia provider prior to the day of surgery. The order in which these visits occur is variable as the appointments are booked by the patient. The ASA-PS classification used in this study was the ASA-PS classification assigned following the initial encounter by both the PAU and the internal medicine clinic (Table 3).Table 3

ASA-PS class by PAU provider

Provider	Number	Percent
NP	27	27
PA	23	23
SRNA	4	4
Staff CRNA	39	39
Anes resident	5	5
Staff physician	2	2

For these records, the ASA classification from each visit as well as the day of surgery (DOS) ASA-PS class recorded by the anesthesia provider completing the case were collected. Supplemental data including age, BMI, gender, tobacco use, alcohol use, drug use, cardiac risk score, exercise tolerance (measured in metabolic equivalents), identified medical comorbidities, current medications, preoperative EKGs, additional preoperative cardiac study results, and preoperative pulmonary function test results were also collected (Table 4).Table 4

ASA-PS class by DOS provider

Provider	Number	Percent
SRNA	11	11.1
Staff CRNA	26	26.3
Anes resident	40	40.4
Staff physician	22	22.2

The outcome measures noted were the ASA-PS classification assigned by the internal medicine clinic provider, the ASA-PS classification assigned by the PAU clinic provider, and the ASA-PS classification assigned on the DOS by the anesthesia provider. There is no formal training in assigning an ASA-PS classification in our internal medicine department. Training is provided to PAU providers that are not anesthesia trained, specifically the Nurse Practioners and the Physician Assistants that see patients in the clinic.
Data analysis software was used to perform the following analyses [SPSS v22.0 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp)]. To assess the overall disagreement between the data sets, a McNemar test was completed with the following pairings: medicine and PAU, medicine and DOS, and PAU and DOS. To assess the overall agreement between the data sets, kappa statistics along with 95% confidence intervals were calculated for the aforementioned pairings (Table 5).Table 5

McNemar and Kappa statistic

	Medicine versus PAU	Medicine versus DOS	DOS versus PAU
Kappa CI: (LB, UB)	0.170 (− 0.001, 0.340)p = 0.057	0.156 (− 0.015, 0.327)p = 0.079	0.863 (0.696, 1.030)p = 0.000
McNemar	6.769 (p = 0.034)	7.400 (p = 0.025)	0.143 (p = 0.705)

Exercise tolerance will also be assessed through the number of repetitions during the one-minute sit-to-stand test (1MSTST). This test is focused in lower limb function, especially quadriceps force [38 (link)].
The secondary outcome measurements will include physical activity level (accelerometry, International Physical Activity Questionnaire -IPAQ, and patient’s diary), asthma-related symptoms and asthma control (Control of Allergic Rhinitis and Asthma Test -CARAT and patient’s diary), dyspnea (modified Medical Research Council -mMRC, and Borg scale), lung function (spirometry), handgrip strength (hand dynamometry), HRQoL (European Quality of Life Questionnaire– 5 dimensions– 5 levels -EQ-5D-5L, mini Asthma Quality of Life Questionnaire -miniAQLQ), quality of sleep (Pittsburgh Quality of Sleep Index -PQSI), treatment adherence (Test of Adhesion to Inhalers -TAI, and patient’s diary), and healthcare resources use (patient’s diary).

Respiratory muscle strength (maximum inspiratory -MIP and expiratory pressure -MEP) will be assessed to characterize sample, since no change with NW program is expected. Correlation with other outcomes such as exercise tolerance and physical activity will be explored [39 (link)].
Adverse effects reported by the participants will be registered.
Qualitative data will be collected through focus groups to a better understanding of participants’ experience with NW, namely: experience and satisfaction with the intervention received, facilitators and barriers to their participation perceived improvement in asthma management and the way of afront their disease.

The primary outcome will be exercise tolerance, measured by the distance walked during the 6MWT, a reliable and validated test in patients with asthma [37 ], which is strongly related with important clinical outcomes as dyspnea and fatigue perceived [32 (link)].