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INTRODUCTION: Impaired physical fitness may contribute to functional limitations and disability after stroke. Physical fitness (including cardiorespiratory fitness and muscle strength/power) can be improved by appropriate fitness training; this is of benefit to healthy people and patient groups but whether it is of benefit for people after stroke is unclear. The aim of this thesis was to determine whether physical fitness training is beneficial after stroke. OBJECTIVES: (1) Develop a rationale for fitness training by determining whether physical fitness after stroke is a) impaired, and b) associated with functional limitations and disability. (2) Develop and evaluate randomized controlled trial (RCT) evidence by a) determining the feasibility of a definitive RCT, and b) evaluating the benefits of fitness training after stroke. METHODS: (1) Systematic review of observational data and multiple linear regression of exploratory RCT baseline data determined the nature of fitness impairments and any associations with functional limitation and disability. (2) Systematic review and meta-analysis of RCTs established the effects of fitness training on disability, death and dependence. An exploratory RCT (‘STARTER’) compared the effects of a fitness training programme (cardiorespiratory plus strength training 3 days/week for 12 weeks) with an attention control (relaxation) on fitness, function, disability, mood and quality of life in 66 ambulatory people with stroke. RESULTS: (1) Systematic review of observational data showed cardiorespiratory fitness (peak oxygen uptake and economy of walking) and muscle strength were low after stroke; the impairments predicted functional limitation but links to disability were unclear. STARTER baseline data showed little impairment in economy of walking but lower limb extensor power was impaired (42-54% of values expected in healthy age and gender matched people) and this predicted functional limitation and disability. (2) The systematic review identified 12 RCTs (n=289) in 2003, and 24 RCTs (n=1147) when updated in 2007. The systematic reviews showed death was uncommon, and effects on dependence and disability were unclear. However training did improve fitness and cardiorespiratory training during rehabilitation improved ambulation. Most benefits resulted from task-related training. The STARTER fitness training intervention was feasible, with good attendance (>90%) and good compliance with intervention content (94-99%). At the end of the fitness training intervention there were small improvements in some cardiorespiratory fitness, physical function and quality of life outcomes compared with the control group, but these differences had diminished four months later. CONCLUSIONS: (1) Cardiorespiratory fitness, muscle strength and power are impaired after stroke, so there is scope to increase fitness, and there are plausible benefits. (2) Physical fitness training after stroke is feasible, it improves fitness and has some functional benefits, in particular for walking ability. Effects on disability, death and dependence are not known. Further research is required to determine the timing, mode, duration, frequency and intensity of fitness training for optimum benefits, and investigate how benefits can be retained in the long-term.

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The aim of these experiments was to investigate the influence that dietary manipulation has upon acid-base balance and substrate availability at rest and during high intensity exercise. It was hoped to identify some of the mechanisms that may control the utilisation of energy substrate and influence the onset of fatigue during high intensity exercise. A pattern of dietary and exercise manipulation intended to alter carbohydrate (CHO) and fat availability was undertaken during the first two experiments. In addition to influencing energy substrate availability, the diet and exercise regimen also significantly influenced resting acid-base balance and high intensity exercise capacity. The reduction in exercise performance afer administration of a low CHO, high fat, high protein diet may have been due to the diet-induced acidosis produced by this diet. However, it is also probable that glycogen availability was influencing exercise performance in this situation. A fixed period of exercise under the same experimental conditions indicates that a higher than normal muscle glycogen content may dictate the pattern of substrate utilisation during high intensity exercise. In a second series of experiments it was demonstrated that dietary manipulation alone will influence acid-base balance and exercise capacity. A high fat, high protein diet will produce a metabolic acidosis but will not influence total muscle glycogen content. In this situation, it is unlikely that a reduction in high intensity exercise performance can be attributed to the availability of muscle glycogen. It is possible that a change in fat availability, rather than muscle glycogen content, will influence the pattern of substrate utilisation during high intensity exercise. However, it is unlikely that a change in fat availability will be responsible for the reduction in exercise capacity recorded after a high fat, high protein diet. The reduction in exercise capacity may be the result of a diet-induced acidosis. Although it is unlikely that dietary acidosis will influence H+ efflux from muscle it may influence pre-exercise muscle buffering capacity. The resulting greater decline in muscle pH during exercise after a high fat, high protein diet may influence muscle function: firstly, by inhibiting the activation of muscle contraction which is due possibly to a reduction in the release of Ca2+ from the sarcoplasmic reticulum and a reduction in the affinity of the myofilaments to Ca2+. Secondly, by inhibiting muscle relaxation which is thought to result from a disruption in actin-myosin corss-bridge separation and a reduction in the rate of Ca2+ removal from the myofibril cytoplasm. Thirdly, by inhibiting muscle glycolysis at the point of PFK. Finally, there is some evidence to suggest that the rate of muscle lactate efflux and/or the metabolic fate of lactate produced during high intensity exercise are different from normal after a period of dietary manipulation.

Patients with pulmonary arterial hypertension (PAH) often require parenteral prostanoids to improve symptoms and signs of PAH. Complications of parenteral prostanoids-such as catheter-related infections and intolerable adverse effects-may develop, prompting transition to inhaled prostanoids. We report a prospective, protocol-driven transition from parenteral prostanoids to inhaled prostanoids with monitoring of exercise gas exchange and acute hemodynamics. Three PAH centers recruited patients transitioning from parenteral prostanoids to inhaled trepostinil. Rigid inclusion criteria were used, including parenteral prostanoid dose < 30 ng/kg/min, New York Heart Association functional class (FC) < 3, and pulmonary vascular resistance (PVR) < 6 Wood units. Of the 9 patients meeting initial inclusion criteria, 3 were excluded. In the remaining patients, the parenteral prostanoid was reduced and the inhaled prostanoid was increased over 24-36 hours with continuous hemodynamic monitoring. Exercise capacity and FC were measured at baseline and weeks 1, 4, and 12. All patients were successfully weaned from parenteral prostanoids. An acute PVR decrease was seen with most inhaled prostanoid doses, but PVR varied throughout the transition. Patients tolerated inhaled prostanoids for 9-12 breaths 4 times a day with no treatment-limiting adverse events. At week 12, FC was unchanged, and all patients continued to receive inhaled prostanoids without serious adverse events or additional PAH therapy. In 5 of 6 patients, 6-minute walk distance and peak VO2 were within 10% of baseline. Using a strict transition protocol and rigid patient selection criteria, the parenteral prostanoid to inhaled prostanoid transition appeared safe and well tolerated and did not result in clinical deterioration over 12 weeks. Hemodynamic variability noted acutely during transition in our study did not adversely affect successful transition.

The problem of this study was to investigate through experimentation whether or not there would be any significant improvement of one hundred and fifty girls enrolled in the seventh and eighth grades of Azle Junior High School of Azle, TX, in their performance of the volleyball volley and serve upon the completion of prescribed programs.

The purposes of this study are 1) to investigate the development of physical fitness through the medium of fifteen-minute exercise routines in junior college physical education classes; 2) to determine the relationship between each of four exercise routines and the improvement of physical development in a specific body area; and 3) to compare the results of intensive, isometric, calisthenic, and continuous exercise routines to determine if any one routine was of greater value to three alternate routines in assisting the individual to attain a higher degree of physical fitness development.