Kim M; University College of Medicine, Seoul,  Korea.
Lee J; Yang T; Oh J; Kang SM; Lee CJ

International Journal of Obesity. 50(2):338-345, 2026 Feb.

BACKGROUND: High-grade glioma (HGG) patients experience enormous disease
burden both from tumor- and treatment-related symptoms. Exercise can
improve physical fitness and quality of life (QoL); yet experience in
neuro-oncology, especially with high-intensity exercise, remains limited.
This study evaluated feasibility, safety, and efficacy of the intensive,
structured 16-week strength and endurance program, “Active in
Neuro-Oncology” (ActiNO) for HGG patients undergoing chemotherapy.

METHODS: In this prospective, oligocentric, single-arm proof-of-concept
trial, 54 HGG patients participated in ActiNO, with twice-weekly
supervised exercise sessions. The primary endpoint was cardiorespiratory
fitness, assessed via physical working capacity (PWC75%)-the workload
(W/kg body weight) achieved at 75% of age-adjusted maximum heart rate
during a maximal cardiopulmonary exercise test. Secondary endpoints
included peak oxygen uptake (VO2peak), peak power output (Ppeak), and QoL
(EORTC QLQ-C30). Analyses focused on within-subject changes from pre- to
post-intervention. Additionally, comparisons to normative data were
performed. Feasibility was assessed via accrual, adherence, and attrition;
safety via adverse event monitoring (CTCAE).

RESULTS: Program tolerance was high, with few exercise-related adverse
events (all CTCAE grade 1-2). Over 16 weeks, significant improvements were
observed in PWC75% (1.023-1.256 W/kg BW, +23%), VO2peak (23.04-26.09
ml/min/kg BW, +13%), and Ppeak (1.771-2.104 W/kg BW, +19%). QoL, including
global health and physical functioning, improved, reaching normative
values. Adherence was high (85%), though attrition was 48%, mainly due to
disease progression or physical constraints.

CONCLUSIONS: High-intensity exercise is feasible and safe in HGG patients
undergoing chemotherapy. The observed improvements in physical fitness and
QoL support incorporating structured exercise into neuro-oncology care.

Cabuk R; Ondokuz Mayis University, Samsun, Turkiye
Alp E; Murias JM; Karsten B

Scandinavian Journal of Medicine & Science in Sports. 36(2):e70226,
2026 Feb.

This study examined whether constant-workload verification trials
performed at intensities below, at, and above the ramp-incremental peak
power output (PPO) contribute to confirming maximal oxygen uptake
(VO2max). Fifteen trained to well-trained male cyclists (VO2max: 63.6 +/-
5.6 mL.kg-1.min-1) completed maximal ramp testing followed by seven
randomized verification trials (80%-110% PPO at 5% intervals) on separate
days. Differences in VO2 responses were analyzed using linear
mixed-effects models. Effect size was calculated using Hedges’ g. The peak
VO2 attained during the verification trials was expressed relative to the
ramp-derived VO2max and classified as lower (< 95%), within normal
variability (95%-105%), or higher (> 105%). The peak VO2 values at 80%,
105%, and 110% PPO were significantly lower than ramp-derived VO2max (p <
0.05), whereas no significant differences were observed at 85%, 90%, and
95% PPO. Effect sizes were small at 85%-95% PPO (Hedges’ g = 0.29-0.32),
medium at 100%-105% PPO (Hedges’ g = 0.63-0.66), and large at 80% and 110%
PPO (Hedges’ g = 1.21-1.34). Of 105 verification trials, 81 were within
+/-5% of ramp VO2max, 22 were lower (mainly at 80% and 110% PPO), and two
exceeded ramp VO2max (at 85% and 95% PPO). Although verification trials
did not meaningfully contribute to the verification of VO2max, trials
performed at 85%-95% PPO provided the best chances of confirming VO2max in
trained individuals. Interpretation of verification trials relative to
ramp-derived PPO is protocol dependent, which may limit generalizability
across different ramp designs.

Vitturi N; University Hospital of Padova, Padova, Italy.
Gugelmo G; Gasperetti A; Duregon F; Dalmonico A; Lenzini L;
Sponchiado S; Carraro G; Marchi G; Cominacini M; Momente C; Baciga F;
Baschirotto C; Caccia F; Girelli D; Ermolao A; Fadini GP; Battaglia Y

Journal of Cachexia, Sarcopenia and Muscle. 17(1):e70233, 2026 Feb.

BACKGROUND: Fabry disease (FD) is a rare, X-linked lysosomal storage
disorder affecting multiple organs, including the musculoskeletal system.
The physical status of FD patients remains poorly characterized. This
multicentre cross-sectional study aimed to evaluate physical fitness and
function in FD patients and investigate associations with sex, FD
phenotype and treatment status.

METHODS: Adults (aged >= 18 years) with genetically confirmed FD were
recruited. Demographic and laboratory data were collected. Physical
fitness was assessed using cardiopulmonary exercise testing (VO2 peak) and
body composition parameters (fat-free mass index [FFMI], fat mass index
[FM] and phase angle [PA]) via bioelectrical impedance analysis. Physical
function was evaluated with performance tests (6-min walk test, handgrip
strength test, 30-s chair-stand test, short physical performance battery),
muscle strength tests (isometric and isokinetic knee strength) and
self-report fatigue questionnaires. Statistical analyses were stratified
by sex, phenotype (classic vs. late-onset/Variants of Uncertain
Significance [VUS]) and treatment status (enzyme replacement therapy
[ERT]/chaperone-treated versus untreated).

RESULTS: Forty-two FD patients (13 males; mean age 46 +/- 13.9 years)
were enrolled. VO2 < 85% of predicted was more frequent in classic
phenotype patients (53.8%) than in late-onset/VUS (11.5%; p < 0.01). FFMI
was lower in classic than late-onset/VUS (16.8 +/- 1.0 vs. 18.6 +/- 2.1
kg/m2; p = 0.01). Treated males had lower PA than untreated males
(4.8degree +/- 1.0degree vs. 7.6degree +/- 0.9degree; p = 0.04), and PA
correlated with VO2 peak (r = 0.879; p = 0.01). Among classic phenotype
males, 74.3% scored below the 50th percentile in handgrip strength (26.1
+/- 7.8 kg), and 60.9% performed below predicted values in the 30-s
chair-stand test (12.4 +/- 4.3 repetitions). Self-reported fatigue scores
were higher in classic versus late-onset/VUS patients (p = 0.05) and in
treated patients compared to untreated patients (p = 0.02).

CONCLUSIONS: Classic FD phenotype, particularly in males, was associated
with reduced exercise capacity, muscle mass and physical performance.
These findings support the integration of cardiopulmonary exercise
testing, physical functional assessments and body composition analysis
into the routine evaluation of FD patients.

Guerreiro I; Division of Pneumology, Geneva, Switzerland.
Bringard A; Weber P; Leverington V; Kharat A; Genecand L;
Taboni A; Lador F

Respiratory Physiology & Neurobiology. 341:104543, 2026 Apr.

INTRODUCTION: Dysfunctional breathing (DB) can be defined as a change in
breathing pattern associated with respiratory and/or systemic symptoms,
after ruling out underlying respiratory or cardiac disease. Recent
evidence suggests that DB contributes to dyspnea in post-COVID-19 syndrome
(PCS), as demonstrated by ventilation analysis during cardiopulmonary
exercise testing (CPET). Nevertheless, the lack of a standardized
classification for the different subtypes of DB poses challenges for
accurate diagnosis and effective management. We hypothesized that
analyzing the evolution of breathing parameters during CPET may help
classify DB into three patterns.

METHODS: We analyzed 79 CPETs performed between July 2020 and May 2022 on
patients with persistent respiratory symptoms at least three months after
COVID-19 infection. We classified patients into three different categories
based on abnormal breathing patterns: hyperventilation (HYPV), erratic
breathing (ERBR), and flattening (FLAT).

RESULTS: Age, BMI, gender and peak O2 uptake (VO2) were similar between
patterns. Compared to normal pattern (N), we found higher VE – VCO2 slope
in HYPV and FLAT, and a lower VT/ VE slope in FLAT and ERBR. The FLAT
pattern was also characterized by a higher breathing frequency at peak
exercise compared to the other patterns. ERBR and FLAT were associated
with higher symptom scores (Nijmegen Questionnaire and Dyspnea-12)
compared to N.

CONCLUSION: Analyzing the evolution of ventilatory parameters during
incremental exercise enables the classification of dysfunctional breathing
into three distinct breathing patterns: hyperventilation, erratic
breathing, and flattening.

Harris EA; Center for Pulmonary Heart Disease, Boston,  United States.
Waxman AB

Respiratory Physiology & Neurobiology. 341:104550, 2026 Apr.

Unexplained dyspnea and exertional intolerance are common, burdensome
clinical problems that may persist despite routine resting cardiopulmonary
testing. Invasive cardiopulmonary exercise testing (iCPET) integrates
breath-by-breath gas exchange with invasive hemodynamic and blood gas
assessment during incremental exercise, enabling evaluation of physiologic
abnormalities that may be unapparent at rest. This review summarizes
practical considerations for iCPET performance (including upright cycle
ergometry, catheter-based pressure measurements, direct Fick cardiac
output, and symptom assessment using separate visual analog Modified Borg
ratings for dyspnea and leg fatigue at peak exercise), and presents a
structured approach to interpretation using pressure-flow relationships
and age-related reference ranges. Emphasis is placed on how characteristic
iCPET patterns inform mechanistic contributors to exertional dyspnea by
identifying upstream physiologic triggers-such as abnormal rises in
pulmonary arterial wedge pressure (exercise-HFpEF), abnormal pulmonary
vascular pressure-flow responses (exercise-PAH), impaired preload
augmentation associated with autonomic dysfunction, and impaired
peripheral oxygen extraction consistent with mitochondrial myopathy. The
review also highlights evolving applications in post-pulmonary embolism
syndromes and acknowledges that exercise hemodynamic thresholds and
protocols vary across centers, underscoring the need for broader
standardization.

Ordine L; School of Medicine, Naples, Italy.
Canciello G; Di Napoli S; Polizzi R; Pacella D; Lombardi R;
Esposito G; Losi MA

ESC heart failure. 13(1), 2026 Feb 03.

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) is a heterogeneous
myocardial disorder characterized by left ventricular hypertrophy. The
role of cardiopulmonary exercise testing (CPET) in predicting major
adverse cardiac events (MACE) remains incompletely understood,
particularly over long-term follow-up and independently of baseline
symptoms.

METHODS: We longitudinally studied 154 HCM patients (age 43 +/- 16 years;
27% female), who underwent symptom-limited CPET. At baseline, 98 patients
were in New York Heart Association (NYHA) Class I, 48 in Class II, and 8
in Class III. Septal reduction therapies (SRT), progression to end-stage
HCM (ES-HCM), sudden cardiac death (SCD), heart failure-related death
(HF), and heart transplantation (HT) represented a composite MACE
endpoint.

RESULTS: Over a mean follow-up of 12 +/- 9 years, 38 patients experienced
MACE (SRT = 9; ES-HCM = 11; SCD = 10; HF/HT = 8). In multivariable
analysis, independent predictors of MACE were percentage predicted peak
VO2 (PVO2%) < 60 [hazard ratio (HR) 4.16, 95% confidence interval (CI)
1.89-9.14; P < .001], and NYHA Class >I (HR 2.27, 95% CI 1.06-4.89; P =
.036). By using SRT as a competing risk, the only predictor of MACE became
PVO2% < 60 (HR 3.966, 95% CI 1.626-9.670; P = .002). Among asymptomatic
patients (i.e. NYHA Class I), only PVO2% < 60 remained a significant
predictor of MACE (HR 5.611, 95% CI 1.635-19.253; P = .006), with risk
divergence evident after nearly 15 years of follow-up. The result was also
confirmed in the competing risk analysis.

CONCLUSION: In this long follow-up study, CPET is a powerful prognostic
tool in HCM. A reduced peak VO2 identifies those at higher risk,
highlighting the potential for CPET to improve risk stratification, even
among patients classified as NYHA Class I.

Del Vecchio L; Southern Cross University, Lismore, Australia
Climstein M

Journal of Sports Medicine & Physical Fitness. 66(2):223-231, 2026 Feb

BACKGROUND: The oxygen uptake efficiency slope (OUES) is a submaximal,
effort-independent index derived from cardiopulmonary exercise testing
that reflects aerobic fitness. Although OUES has shown strong correlations
with maximal oxygen uptake (VO2max) in clinical populations, its validity
and relationship with habitual physical activity in healthy middle-aged
adults remain underexplored. This study aimed to evaluate OUES as a marker
of aerobic fitness and examine its association with self-reported physical
activity in this demographic.

METHODS: Twenty-one middle-aged adults (14 women, seven men; mean age
63.3+/-3.8 years) without known cardiopulmonary disease were recruited.
Participants completed the Sports Medicine Australia pre-exercise
screening questionnaire, including weekly physical activity reporting.
Each participant underwent a graded treadmill test (Bruce protocol) to
submaximal effort, with oxygen uptake (VO2) and ventilation (VE) measured
continuously using a validated portable metabolic system. OUES was
calculated from the linear regression of VO2 against the log10VE). VO2max
was estimated via a resting seismocardiography device (VentriJect
Seismofit R). Pearson’s correlations and one-way ANOVA were used to
evaluate relationships between variables and tertile-based fitness groups.
An independent-samples t-test compared OUES values by sex.

RESULTS: Mean peak VO2 was 25.2+/-4.1 mL/kg/min; mean OUES was
1629.6+/-522.0 mL/min per log L/min. OUES showed a moderate but
non-significant correlation with estimated VO2max (r=0.415, P=0.069) and
no meaningful association with self-reported physical activity (r=-0.012,
P=0.960). One-way ANOVA showed significant differences in VO2max across
VentriJect VO2 tertiles (P<0.001, eta2=0.65), but not in OUES (P=0.162).
Males had significantly higher OUES values than females (2171+/-391 vs.
1366+/-282; P<0.001), with a large effect size (Cohen’s d=2.50).

CONCLUSIONS: OUES can be reliably obtained using a brief treadmill
protocol and portable metabolic equipment in middle-aged adults. While not
associated with self-reported activity, OUES showed moderate correlations
with VO2max and differentiated higher-fitness individuals, especially by
sex. These findings support OUES as a valid submaximal marker of
cardiorespiratory fitness and underscore the importance of objective
fitness measures alongside self-report tools in health and exercise
settings.

Vecchiato M; University Hospital of Padova,  Padova, Italy
Neunhaeuserer D; Zanardo E; Quinto G; Battista F; Aghi A;
Palermi S; Babuin L; Tessari C; Guazzi M; Gasperetti A; Ermolao A

Clinical Research in Cardiology. 115(3):412-423, 2026 Mar.

BACKGROUND AND AIMS: Transient increases (overshoot) in respiratory gas
analyses have been observed during exercise recovery, but their clinical
significance is not clearly understood. An overshoot phenomenon of the
respiratory exchange ratio (RER) is commonly observed during recovery from
maximal cardiopulmonary exercise testing (CPET), but it has been found
reduced in patients with heart failure with reduced ejection fraction
(HFrEF). The aim of the study was to analyze the clinical significance of
these RER recovery parameters and to understand if these may improve the
risk stratification of patients with HFrEF.

METHODS: This cross-sectional study includes HFrEF patients who underwent
functional evaluation with maximal CPET for the heart transplant checklist
at our Sports and Exercise Medicine Division. RER recovery parameters,
including RER overshoot as the percentual increase of RER during recovery
(RER mag), have been evaluated after CPET with assessment of hard clinical
long-term endpoints (MACEs/deaths and transplant/LVAD-free survival).

RESULTS: A total of 190 patients with HFrEF and 103 controls were
included (54.6 +/- 11.9 years; 73% male). RER recovery parameters were
significantly lower in patients with HFrEF compared to healthy subjects
(RER mag 24.8 +/- 14.5% vs 31.4 +/- 13.0%), and they showed significant
correlations with prognostically relevant CPET parameters. Thirty-three
patients with HFrEF did not present a RER overshoot, showing worse
cardiorespiratory fitness and efficiency when compared with those patients
who showed a detectable overshoot (VO2 peak: 11.0 +/- 3.1 vs 15.9 +/- 5.1
ml/kg/min; VE/VCO2 slope: 41.5 +/- 8.7 vs 32.9 +/- 7.9; DELTAPETCO2: 2.75
+/- 1.83 vs 4.45 +/- 2.69 mmHg, respectively). The presence of RER
overshoot was associated with a lower risk of cardiovascular events and
longer transplant-free survival.

CONCLUSION: RER overshoot represents a meaningful cardiorespiratory index
to monitor during exercise gas exchange evaluation; it is an easily
detectable parameter that could support clinicians to comprehensively
interpreting patients’ functional impairment and prognosis. CPET recovery
analyses should be implemented in the clinical decision-making of advanced
HF.

Kouroukli E; Aristotle University of Thessaloniki, Thessaloniki, Greece.
Sarafidis K; Tsanakas J; Hatziagorou E

Pediatric Pulmonology. 61(2):e71492, 2026 Feb.

BACKGROUND: Bronchopulmonary dysplasia is one of the most common
complications of preterm birth and has lifelong repercussions in
respiratory health.

OBJECTIVE: To examine lung function and exercise capacity and assess
potential differences in exertional respiratory pattern and ventilatory
and gas exchange responses in school-aged children with a history of
prematurity and/or BPD.

METHODS: Prospective observational study including children and
adolescents born preterm, with and without BPD, and healthy term-born
controls without a known history of asthma. Participants performed
spirometry and cardiopulmonary exercise testing.

RESULTS: Eighty-two children aged 6-18 years (mean: 11.9 years, SD: 3.1)
were enrolled and examined in three groups: preterm-born with BPD
(gestational age < 32 weeks), preterm-born without BPD (GA < 37 weeks),
and term-born controls (GA >= 37 weeks). FVC, FEV1, FEF25% -75%, and
FEV1/FVC were normal and comparable among the three groups. VO2peak% was
reduced in the BPD group and was significantly lower than the control
group (mean difference: -14.4, CI: -28 to -0.7, adjusted p = 0.04), but
the difference was not significant when adjusting for height. The BPD
group had the highest mean VE/VCO2 adjusted for height (32.7), followed by
the preterm (30.3) and the control group (29.5), and the difference
between the BPD and control group was statistically significant (p =
0.015). Moreover, BPD status was significantly associated with increased
VE/VCO2 (beta = +3.2, CI: 1-5.4, p = 0.005). The rest of the CPET
parameters were within normal limits and comparable among groups.

CONCLUSIONS: Children with BPD have normal lung function but reduced
exercise capacity and decreased ventilatory efficiency during exercise.

Ekstrom M;  Respiratory Medicine, Lund University, Lund, Sweden.
Li PZ; Bourbeau J; Tan WC; Jensen D

Chest. 169(2):449-461, 2026 Feb.

BACKGROUND: Breathlessness on exertion is a common, distressing, and
limiting symptom that can be quantified on incremental cardiopulmonary
exercise testing (CPET) using normative reference equations.

RESEARCH QUESTION: Is the breathlessness abnormality best uncovered and
assessed at symptom limitation (peak exercise) compared with submaximal
exercise intensities?

STUDY DESIGN AND METHODS: This was an analysis of people >= 40 years of
age undergoing symptom-limited incremental cycle CPET in the Canadian
Cohort Obstructive Lung Disease (CanCOLD) study. Each Borg 0-10 category
ratio scale breathlessness intensity rating during CPET was converted to
its probability of being normal, in relation to power output, rate of
oxygen uptake, and minute ventilation using normative reference equations.
Abnormally high exertional breathlessness (abnormal breathlessness) was
defined as a probability of being normal < 0.05.

RESULTS: Of 1,161 participants (42% female), abnormally high
breathlessness was present in 22%, 23%, and 16% in relation to rate of
oxygen uptake and minute ventilation at peak exercise. Among those with
abnormal breathlessness at peak exercise, 55% to 60% had normal
breathlessness across all submaximal exercise intensities. Among those
with normal breathlessness at peak exercise, 93% to 97% were normal across
all serial breathlessness ratings throughout the CPET (interclass
correlation coefficients, 0.93-0.95). Findings were similar in people with
or without chronic airflow limitation, and in people who did or did not
reach maximal exertion at the end (symptom limitation) of the CPET.

INTERPRETATION: The results of this study suggest that abnormal
breathlessness is uncovered and should be assessed at peak exercise during
symptom-limited incremental CPET. These findings inform symptom assessment
in research and clinical practice.