Spaulding Hospital

Background: Heart rate variability (HRV) is a sensitive marker of autonomic dysfunction and an independent predictor of mortality in cardiovascular disease (CVD). While structured exercise training is widely used in cardiac rehabilitation, its impact on HRV, particularly with respect to training characteristics, remains unclear. This systematic review examined the effectiveness of structured exercise on HRV in individuals with CVD. Methods: PubMed, Embase, and CINAHL were screened through February 2025. Eligible studies included clinical trials assessing the effect of exercise training (≥6 weeks) on HRV in adults with CVD. Extracted data included demographics, training characteristics, and HRV acquisition methods. HRV outcomes were grouped as a) time-domain (RMSSD, SDNN) and b) frequency-domain measures (LF, HF). Three reviewers independently screened studies using Covidence and assessed risk of bias with RoB-2 and ROBINS-I tools. Meta-analyses were performed in R using a random effects model to calculate pooled standard mean differences (SMDs) and 95% confidence intervals (CIs). Results: Twenty studies (1,131 participants; mean age 58.7±2.5 yrs; 89.1% male) were included. Diagnoses included coronary artery disease (n=387), coronary artery bypass grafting (n=300), chronic heart failure (n=203), and acute myocardial infarction (n=241). Most protocols were aerobic (n=16), lasting 6–24 weeks, and included ≥3 sessions/week (n=15), of 20–120 minutes. Intensity ranged from moderate to vigorous (n=9) or low to moderate (n=11). Sixty-five percent of studies used ECG (n=13) with supine recordings (n=14), ≥ 5 minutes (n=18). A general trend toward improved HRV was observed, especially in higher-intensity and longer-duration programs. Meta-analysis of six studies showed a small but statistically significant improvement in SDNN (SMD=0.2, 95%CI=0.08-0.31), suggesting its utility as a marker of autonomic adaptation. Other HRV indices showed no significant change. Methodological heterogeneity was observed in LF and HF outcomes (I 2 > 50%), HRV acquisition, and training protocols. Conclusion: Structured exercise training may improve cardiac autonomic function in CVD, primarily through increases in SDNN. However, variability in exercise dosing and HRV methodology likely limits broader conclusions. Future research should use sex-stratified data, standardized exercise prescriptions, and uniform HRV protocols to improve understanding of its role as a prognostic marker.

Grip strength, a surrogate for quantifying strength, correlates with function and longevity. However, this relationship is less clear in women with breast cancer. 138 women undergoing oncologic treatment for breast cancer were enrolled across three institutional review board-approved protocols with three months of resistance training with pre and post assessment of body composition, phase angle, functional movement screen (FMS), balance, weight lifted (load), quality of life, activity levels, and hand grip strength. Significant increases in maximum, minimum, and mean grip strength were seen. Mean grip strength increased by 12.6% and 3.5 kg. Right/left (R/L) mismatch significantly decreased from baseline to post-intervention (13.3 to 8.7%). On univariable analysis, greater baseline mean grip strength was associated with younger age, greater baseline FMS, composite load lifted, activity levels, and decreased R/L balance mismatch. On multivariable analysis, greater mean grip strength was independently associated with greater baseline mobility and composite load lifted. Baseline mean grip strength was associated with baseline lower bodyfat percentage and greater muscle mass, whole body phase angle, and resting metabolic rate (all significant on multivariable analysis, R2 = 0.247). Grip strength may be a valuable surrogate biomarker within breast cancer survivorship care, particularly in resource-limited settings.

Purpose National Collegiate Athletic Association (NCAA) artistic sports, including gymnastics and diving, require inversion, somersaulting, and rotational movements where concussions account for 8.4% and 10.38% of injuries, respectively.This study describes the epidemiology and common characteristics of sport-related concussion (SRC) in men's and women's collegiate gymnastics and diving from 2013/14 to 2023/24.Methods Clinical SRC incidence (concussions/100-athletes, 95% confidence intervals [95%CI] by sport and ratios (CIR; 95%CI) were calculated based on Ivy League-Big Ten Epidemiology of Concussion Study surveillance.Mechanisms of injury (MOI) patterns were classified via proportions: activity at time of injury, head impact object (e.g., apparatus, water), and descriptive narratives.Results Of 183 total SRC, clinical incidence was higher in women's gymnastics (CIR: 2.91 [95%CI: 1.37-7.40];women: 8.98/100-athletes [95%CI: 7.52-10.6];men: 3.08/100-athletes [95%CI: 1.25-6.25]).There was no significant difference in diving clinical incidence (CIR: 1.41 [95%CI 0.76-2.77];women: 6.12/100-athletes [95%CI: 4.34-8.33];men: 4.34/ 100-athletes [95%CI: 2.45-7.05]).80.8% (n=105/130) gymnastics SRC and 81.1% (n=43/53) diving SRC occurred during practice activities.In gymnastics floor contact was the most common MOI (n=78/130, 60.0%).Similarly, water impact was the most common diving MOI (n=43/53, 81.1%).Approximately 67.7% of gymnastics SRC (n=88/130) and 52.8% of diving SRC (n=28/53) had symptom resolution within two weeks.Conclusion Clinical incidence of SRC was comparable to football (approximately 7.60/100-athletes [95%CI: 7.17-8.04]),yet artistic sports are underrepresented in the research.Clinical incidence was higher in women than men in gymnastics.Most SRC occurred due to contact with the floor or water during practice activities motivating targeted prevention interventions.

In 2011, the Centers for Medicare & Medicaid Services (CMS) implemented the Hospital Outpatient Quality Reporting Program to assess the quality of outpatient imaging efficiency (OIE). In this study, trends in hospital performance on these national hospital OIE measures a year after inception and public reporting were described. An observational trend analysis was conducted using 2013-2019 data from CMS 6 OIE measures. The trend analysis of metric scores indicates year-to-year variability in all 6 OIE variables. The reporting of these measures appears to have effectively improved the efficiency of most of the measures since the inception of the program.

This video presents assessment and management of hallux limitus using intrinsic foot strengthening and joint mobilization techniques with combination of extracorporeal shockwave therapy (ESWT). Clinical history includes pain with walking, running, jumping, or loaded plantarflexion localized to the first metatarsophalangeal (MTP) joint. Indications for our treatment approach of hallux limitus include pain localized to the first MTP joint, corresponding lack of active range of motion/passive range of motion, and reduced foot/ankle strength often with joint space narrowing on imaging. Our program uses the principle of foot core exercises that enhance intrinsic muscles of the foot to assist in medial longitudinal arch stabilization and hallux strengthening. Progression of these exercises can be done in weight-bearing and impact activities specific to patient goals. In addition to these foot intrinsic exercises, calf raises should be incorporated to strengthen the gastroc-soleus complex to both improve plantar foot strength and facilitate extension of the first MTP joint. Manual therapy techniques reduce the rigidity of the first MTP joint and restore appropriate medial-lateral and plantar-dorsal balance. With severe limitations in mobility or pain limitations, ESWT can be incorporated to treat the joint and surrounding soft tissue restrictions. Increased first MTP extension is observed. Reduced symptoms of first MTP joint pain with activity allow patients to return to walking and other physical activities with improved comfort. Complications are rare. Pain over the first MTP joint is expected during ESWT. Rarely, irritation of the plantar components of the first MTP joint, including the tibial and fibular sesamoid bones, may occur. Non-surgical management of hallux limitus may improve using the described technique of intrinsic foot strengthening with focus on stabilization of the medial longitudinal arch and strategies of improved mobility of the first MTP joint. Adding ESWT may address joint limitations and facilitate gains in exercise and mobility.

Context/Objectives Cardiometabolic disease (CMD) is increased after spinal cord injury (SCI), with an increased number of CMD risk factors that relate to higher mortality. The study objective was to characterize the relationship of age and injury duration with CMD. Design Retrospective cohort assessment of CMD risks using unbiased recursive partitioning to divide for group comparison: (1) Lowest Risk, (2) Moderate Risk, and (3) Highest Risk based on classification and regression trees predicting CMD diagnosis by age and injury duration. Setting Academic rehabilitation center laboratory. Participants Adults (N = 103; aged 18–75) with traumatic SCI (C4-L2) of 3 months to 42 years duration. Interventions NA. Outcome measures CMD risk factors (obesity, insulin resistance, dyslipidemia, and hypertension) using Paralyzed Veterans of America SCI-specific guidelines. Results Obesity was prevalent (82%) and co-occurred with most other risk factors present. Age increased odds for CMD diagnosis by 1.05 per year (P = 0.02) and was directly related to elevated body mass index (BMI, β = 0.42, P < 0.05), fasting glucose (β = 0.58, P < 0.01), and higher systolic blood pressure (β = 0.31, P < 0.10). In contrast, time since injury contributed to lower risk factor count (β = −0.29, P < 0.10) and higher HDL-C (β = 0.50, P < 0.01), and was not related to odds of CMD diagnosis. Conclusion While SCI is linked to an increased risk of CMD, age is associated with higher CMD risk. Increased SCI duration related to improvement in individual CMD risk factors but did not decrease overall risk for CMD diagnosis. SCI may not uniformly increase CMD risks and highlight a necessary focus on weight management for risk prevention.

Background: Exposure to thousands of head and body impacts during a career in contact and collision sports may contribute to current or later life issues related to brain health. Wearable technology enables the measurement of impact exposure. The validation of impact detection is required for accurate exposure monitoring. In this study, we present a method of automatic identification (classification) of head and body impacts using an instrumented mouthguard, video-verified impacts, and machine-learning algorithms.Methods: Time series data were collected via the Nexus A9 mouthguard from 60 elite level men (mean age = 26.33; SD = 3.79) and four women (mean age = 25.50; SD = 5.91) from the Australian Rules Football players from eight clubs, participating in 119 games during the 2020 season. Ground truth data labeling on the captures used in this machine learning study was performed through the analysis of game footage by two expert video reviewers using SportCode and Catapult Vision. The visual labeling process occurred independently of the mouthguard time series data. True positive captures (captures where the reviewer directly observed contact between the mouthguard wearer and another player, the ball, or the ground) were defined as hits. Spectral and convolutional kernel based features were extracted from time series data. Performances of untuned classification algorithms from scikit-learn in addition to XGBoost were assessed to select the best performing baseline method for tuning.Results: Based on performance, XGBoost was selected as the classifier algorithm for tuning. A total of 13,712 video verified captures were collected and used to train and validate the classifier. True positive detection ranged from 94.67% in the Test set to 100% in the hold out set. True negatives ranged from 95.65 to 96.83% in the test and rest sets, respectively.Discussion and conclusion: This study suggests the potential for high performing impact classification models to be used for Australian Rules Football and highlights the importance of frequencies <150 Hz for the identification of these impacts.

Objective: Rugby league is an international full-contact sport, with frequent concussive injuries. Participation in other full-contact sports such as American football has been considered to be a risk factor for neuropsychiatric sequelae later-in-life, but little research has addressed the mental and cognitive health of retired professional rugby league players. We examined predictors and correlates of perceived (self-reported) cognitive decline in retired National Rugby League (NRL) players.Methods: Participants were 133 retired male elite level rugby league players in Australia. Participants completed clinical interviews, neuropsychological testing, and self-report measures. The Informant Questionnaire on Cognitive Decline in the Elderly, self-report (IQCODE-Self), measured perceived cognitive decline.Results: The median age of the sample was 55.0 (M = 53.1, SD = 13.9, range = 30–89) and the median years of education completed was 12.0 (M = 11.9, SD = 2.6, range = 7–18). The retired players reported a median of 15.0 total lifetime concussions (M = 28.0, SD = 36.6, range = 0–200). The mean IQCODE-Self score was 3.2 (SD = 0.5; Range = 1.3–5.0); 10/133 (7.5%) and 38/133 (28.6%) scored above conservative and liberal cutoffs for cognitive decline on the IQCODE-Self, respectively. Perceived cognitive decline was positively correlated with current depressive symptoms, negatively correlated with years of professional sport exposure and resilience, and unrelated to objective cognition and number of self-reported concussions. A multiple regression model with perceived cognitive decline regressed on age, concussion history, professional rugby league exposure, depression, resilience, objective cognitive functioning, daytime sleepiness, and pain severity showed depression as the only significant predictor.Conclusion: This is the first large study examining subjectively experienced cognitive decline in retired professional rugby league players. Similar to studies from the general population and specialty clinics, no relationship was found between objective cognitive test performance and perceived cognitive decline. Depressive symptoms emerged as the strongest predictor of perceived cognitive decline, suggesting that subjective reports of worsening cognition in retired elite rugby league players might reflect psychological distress rather than current cognitive impairment.