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      Concentric and Eccentric Pedaling-Type Interval Exercise on a Soft Robot for Stable Coronary Artery Disease Patients: Toward a Personalized Protocol


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          Cardiovascular diseases are the leading causes of death worldwide, and coronary artery disease (CAD) is one of the most common causes of death in Europe. Leading cardiac societies recommend exercise as an integral part of cardiovascular rehabilitation because it reduces the morbidity and mortality of patients with CAD. Continuous low-intensity exercise using shortening muscle actions (concentric, CON) is a common training modality during cardiovascular rehabilitation. However, a growing clinical interest has been recently developed in high-intensity interval training (HIIT) for stable patients with CAD. Exercise performed with lengthening muscle actions (eccentric, ECC) could be tolerated better by patients with CAD as they can be performed with higher loads and lower metabolic cost than CON exercise.


          We developed a clinical protocol on a soft robot to compare cardiovascular and muscle effects of repeated and work-matched CON versus ECC pedaling-type interval exercise between patients with CAD during cardiovascular rehabilitation. This study aims to ascertain whether the developed training protocols affect peak oxygen uptake (VO 2peak), peak aerobic power output (P peak), and parameters of muscle oxygen saturation (SmO 2) during exercise, and anaerobic muscle power.


          We will randomize 20-30 subjects to either the CON or ECC group. Both groups will perform a ramp test to exhaustion before and after the training period to measure cardiovascular parameters and SmO 2. Moreover, the aerobic skeletal muscle power (P peak) is measured weekly during the 8-week training period using a simulated squat jump and a counter movement jump on the soft robot and used to adjust the training load. The pedaling-type interval exercise on the soft robot is performed involving either CON or ECC muscle actions. The soft robotic device being used is a closed kinetic chain, force-controlled interactive training, and testing device for the lower extremities, which consists of two independent pedals and free footplates that are operated by pneumatic artificial muscles.


          The first patients with CAD, who completed the training, showed protocol-specific improvements, reflecting, in part, the lower aerobic training status of the patient completing the CON protocol. Rehabilitation under the CON protocol, more than under the ECC protocol, improved cardiovascular parameters, that is, VO 2peak (+26% vs −6%), and P peak (+20% vs 0%), and exaggerated muscle deoxygenation during the ramp test (248% vs 49%). Conversely, markers of metabolic stress and recovery from the exhaustive ramp test improved more after the ECC than the CON protocol, that is, peak blood lactate (−9% vs +20%) and peak SmO 2 (+7% vs −7%). Anaerobic muscle power only improved after the CON protocol (+18% vs −15%).


          This study indicates the potential of the implemented CON and ECC protocols of pedaling-type interval exercise to improve oxygen metabolism of exercised muscle groups while maintaining or even increasing the P peak. The ECC training protocol seemingly provided a lower cardiovascular stimulus in patients with CAD while specifically enhancing the reoxygenation and blood lactate clearance in recruited muscle groups during recovery from exercise.

          Trial Registration

          ClinicalTrials.gov NCT02845063; https://clinicaltrials.gov/ct2/show/NCT02845063

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          Most cited references31

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          Skeletal muscle power: a critical determinant of physical functioning in older adults.

          Muscle power declines earlier and more precipitously with advancing age compared with muscle strength. Peak muscle power also has emerged as an important predictor of functional limitations in older adults. Our current working hypothesis is focused on examining lower extremity muscle power as a more discriminant variable for understanding the relationships between impairments, functional limitations, and resultant disability with aging.
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            Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women.

            To quantify the relation of cardiorespiratory fitness to cardiovascular disease (CVD) mortality and to all-cause mortality within strata of other personal characteristics that predispose to early mortality. DESIGN--Observational cohort study. We calculated CVD and all-cause death rates for low (least fit 20%), moderate (next 40%), and high (most fit 40%) fitness categories by strata of smoking habit, cholesterol level, blood pressure, and health status. Preventive medicine clinic. Participants were 25341 men and 7080 women who completed preventive medical examinations, including a maximal exercise test. Cardiovascular disease and all-cause mortality. There were 601 deaths during 211996 man-years of follow-up, and 89 deaths during 52982 woman-years of follow-up. Independent predictors of mortality among men, with adjusted relative risks (RRs) and 95% confidence intervals (CIs), were low fitness (RR, 1.52;95% CI, 1.28-1.82), smoking (RR, 1.65; 95% CI, 1.39-1.97), abnormal electrocardiogram (RR, 1.64;95% CI, 1.34-2.01), chronic illness (RR, 1.63;95% CI, 1.37-1.95), increased cholesterol level (RR, 1.34; 95% CI, 1.13-1.59), and elevated systolic blood pressure (RR, 1.34; 95% CI, 1.13-1.59). The only statistically significant independent predictors of mortality in women were low fitness (RR, 2.10; 95% Cl, 1.36-3.21) and smoking (RR, 1.99; 95% Cl, 1.25-3.17). Inverse gradients were seen for mortality across fitness categories within strata of other mortality predictors for both sexes. Fit persons with any combination of smoking, elevated blood pressure, or elevated cholesterol level had lower adjusted death rates than low-fit persons with none of these characteristics. Low fitness is an important precursor of mortality. The protective effect of fitness held for smokers and nonsmokers, those with and without elevated cholesterol levels or elevated blood pressure, and unhealthy and healthy persons. Moderate fitness seems to protect against the influence of these other predictors on mortality. Physicians should encourage sedentary patients to become physically active and thereby reduce the risk of premature mortality.
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              2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR).


                Author and article information

                JMIR Res Protoc
                JMIR Res Protoc
                JMIR Research Protocols
                JMIR Publications (Toronto, Canada )
                March 2019
                27 March 2019
                : 8
                : 3
                : e10970
                [1 ] Laboratory for Muscle Plasticity Department of Orthopaedics, Balgrist University Hospital University of Zurich Zurich Switzerland
                [2 ] Balgrist Move>Med Swiss Olympic Medical Center Balgrist University Hospital Zurich Switzerland
                [3 ] Spinal Cord Injury Center Balgrist University Hospital Zurich Switzerland
                [4 ] Rehabilitation Engineering Laboratory Department of Health Sciences and Technology ETH Zurich Zurich Switzerland
                [5 ] University Heart Center Zurich, Sports Cardiology Section, Department of Cardiology University Hospital Zurich University of Zurich Zurich Switzerland
                Author notes
                Corresponding Author: Martin Flück mflueck@ 123456research.balgrist.ch
                Author information
                ©Daniel P Fitze, Martino Franchi, Werner L Popp, Severin Ruoss, Silvio Catuogno, Karin Camenisch, Debora Lehmann, Christian M Schmied, David Niederseer, Walter O Frey, Martin Flück. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 27.03.2019.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org.as well as this copyright and license information must be included.

                : 7 May 2018
                : 20 September 2018
                : 18 October 2018
                : 20 October 2018
                Early Report
                Early Report

                cardiovascular rehabilitation,concentric and eccentric exercise,high-intensity interval training,muscle oxygen saturation,near-infrared spectroscopy,peak oxygen uptake,ramp test,skeletal muscle power,soft robot


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