Effects of high-definition transcranial direct current stimulation combined with inspiratory muscle training for treating respiratory sequelae of long COVID: A case series.

INTRODUCTION: Long COVID occurs when numerous symptoms begin 3 weeks after acute infection and last for 12 months or more. High-definition transcranial direct current stimulation (HD-tDCS) has been tested in patients with COVID-19; however, previous studies did not investigate the HD-tDCS use combined with inspiratory muscle training (IMT) for respiratory sequelae of long COVID. CASE PRESENTATION: Six individuals (four women and two men) aged between 29 and 71 years and presenting with respiratory sequelae of long COVID were included. They were submitted to an intervention that comprised HD-tDCS combined with IMT twice a week for 5 weeks. Lung function and respiratory muscle assessments were performed at baseline and after 5 weeks of intervention. IMPLICATIONS ON PHYSIOTHERAPY PRACTICE: HD-tDCS may enhance the IMT effects by increasing respiratory muscle strength, efficiency, and lung function of individuals with long COVID.

Respiratory Muscle Strength and Quality of Life in Patients With Heart Failure and Their Main Correlated Factors: A Cross-sectional Study.

BACKGROUND: Heart failure may cause peripheral and respiratory muscle alterations, dyspnea, fatigue, and exercise intolerance, worsening the quality of life of patients. OBJECTIVES: The aims of this study were to analyze respiratory muscle strength and quality of life of patients with heart failure and correlate them with clinical variables and functional classification. METHODS: This cross-sectional study involved patients with heart failure. A manovacuometer assessed maximum inspiratory and expiratory pressures, and quality of life was assessed using the Minnesota Living with Heart Failure Questionnaire. Functional classification was categorized according to the New York Heart Association (NYHA) class in I, II, III, or IV. RESULTS: We included 60 patients (66.7% male) with a mean age of 62.0 years and mean left ventricular ejection fraction of 42.0%. Maximum inspiratory pressure and maximum expiratory pressure were close to normal (>70% of predicted) in most patients; however, a subgroup composed mostly of patients with dilated heart failure and NYHA class III (n = 21) presented low maximum inspiratory pressure values (59.2%; 95% confidence interval, 55.7%-62.8%). The mean total score of the Minnesota Living with Heart Failure Questionnaire was 44.4 points, being negatively correlated with left ventricular ejection fraction (r = -0.29, P = .02). Patients with NYHA class III and disease duration longer than 120 months presented higher total (P < .01) and physical dimension scores. CONCLUSIONS: Most patients had respiratory muscle strength close to normal; however, those with dilated heart failure and NYHA class III presented low maximum inspiratory pressure values. Quality of life was moderately compromised, mainly because of long disease duration, NYHA class III, and low left ventricular ejection fraction.

Analysis of respiratory muscle strength and its relationship with functional capacity between different field tests in patients with heart failure.

OBJECTIVE: To analyze respiratory muscle strength of patients with heart failure (HF) and correlate with functional capacity. METHODS: This cross-sectional study involved patients with compensated HF of both sexes, aged above 18 years. Respiratory muscle strength was assessed by measuring maximum inspiratory (MIP) and expiratory pressures (MEP) using a manovacuometer. Patients were randomized into two groups to assess functional capacity: six-minute walk test (6MWT) and incremental shuttle walk test (ISWT). RESULTS: Forty-eight patients were evaluated (23 from 6MWT and 25 from ISWT group). Most were male (67.8%), with mean age of 62.3 years and left ventricular ejection fraction of 40.8%. Mean predicted values of MIP [81.2% (74.7-87.8%)] and MEP [95.6% (88.2-103.0%)] did not indicate respiratory muscle weakness. The higher the New York Heart Association (NYHA) functional class, the lower the MIP (p = .011) and MEP (p = .016) values. Physically active patients presented higher respiratory muscle strength than those sedentary (MIP: 104.5 vs. 71.9 cmH2O, p < .001; MEP: 120.0 vs. 91.1 cmH2O, p = .004). Functional capacity was impaired [6MWT: 416.0 m (372.8-459.3 m); ISWT: 304 m (263.4-344.9 m)], and distance covered in the ISWT was shorter than 6MWT group (p < .001). Distance covered in the ISWT group presented a moderate positive correlation with MIP (r = 0.45; p = .022) and MEP (r = 0.41; p = .041). CONCLUSION: Most patients with HF presented respiratory muscle strength close to predicted values; however, sedentary patients and those with high NYHA functional class, showed reduced MIP and MEP. Functional capacity was reduced, and MIP and MEP correlated with distance covered in the ISWT.

Efficacy of a rehabilitation protocol on pulmonary and respiratory muscle function and ultrasound evaluation of diaphragm and quadriceps femoris in patients with post-COVID-19 syndrome: a series of cases.

This study assessed the efficacy of a pulmonary rehabilitation (PR) on pulmonary and respiratory muscle function and thickness of quadriceps femoris and diaphragm of patients with post-COVID-19 syndrome. This series of cases followed nine patients who performed PR twice a week for six weeks. Patients received the following PR program: lung expansion therapy; respiratory muscle training; upper limb strength exercises; aerobic exercises on a treadmill. After the program, we observed increased peak expiratory flow (26.03%), forced vital capacity (FVC) (7.14%), forced expiratory volume in the first second (FEV1) (9.55%), and ratio between FEV1/FVC (6.19%). All parameters of respiratory muscle strength and endurance were improved. Diaphragmatic thickening fraction and thickness of quadriceps femoris also improved, whereas echo intensity of quadriceps reduced. Thus, RP protocol improved pulmonary function, respiratory muscle strength and endurance, and thickness of diaphragm and quadriceps femoris, and reduced echo intensity of quadriceps in patients with post-COVID-19 syndrome.

Assessment of Cardiorespiratory and Metabolic Responses in Women with Obesity After Surgically Induced Weight Loss: Results from a Pilot Study.

PURPOSE: Bariatric surgery is effective in controlling severe obesity. However, studies investigating the impact of surgically induced weight loss on cardiorespiratory and metabolic responses during maximal effort are controversial. The aim of this study was to assess cardiorespiratory and metabolic responses in women with obesity after bariatric surgery. MATERIALS AND METHODS: We performed a secondary analysis on data from a pilot study with women with obesity submitted to bariatric surgery and who did not participate in a controlled physical training program. Anthropometry, pulmonary function (spirometry), and cardiorespiratory fitness (cardiopulmonary exercise testing [CPX]) were assessed before and after bariatric surgery. RESULTS: Thirty-four women were included (38.7 ± 9.6 years, body mass index = 44.1 ± 6.3 kg/m2). Postoperative assessment was conducted 9.4 ± 2.7 months after surgery. After surgery, we observed a reduction in all anthropometric measurements (mean loss of 28.6 kg, p < 0.001), and improvement in spirometry values (p < 0.001). Relative VO2peak (mL/kg/min) increased slightly (Δ = 1.7; p = 0.06); however, absolute VO2peak (L/min) reduced significantly (Δ = - 0.398; p < 0.001). We also observed an increase of 1.3 min (p < 0.001) in CPX duration, a reduction of 11.3 bpm (p < 0.001) in resting heart rate, and a decrease of systolic (p = 0.02) and diastolic (p < 0.001) blood pressures at peak effort. CONCLUSION: Surgically induced weight loss without exercise training improved cardiac reserve, ventilatory response, blood pressure, and resting heart rate. Cardiorespiratory fitness reflected by relative VO2peak increased slightly, despite increased tolerance to CPX.

Ventilation Dispersion Index as an Objective Evaluation Tool of Exercise Oscillatory Ventilation in Patients With Heart Failure.

BACKGROUND: Exercise oscillatory ventilation (EOV) is related to worse prognosis in patients with heart failure (HF). However, its determination is subjective and there is no standard measure to identify it. The aim of the study was to evaluate and characterize the EOV of patients with HF using the ventilation dispersion index (VDI). METHODS AND RESULTS: Patients underwent cardiopulmonary exercise testing (CPX), EOV was assessed by 2 reviewers and the VDI was calculated. The receiver operator curve analysis was used to assess the ability of the VDI to predict EOV. Pearson's correlation test was performed to determine the relationship between VDI and CPX variables. Forty-three patients with HF underwent CPX and were divided into 2 groups: with a VDI of less than 0.601 and a VDI of 0.601 or greater. An area under the curve of 0.759 was observed in the receiver operator curve analysis between VDI and EOV (P = .008). The VDI showed a significant correlation with the ventilatory CPX variables. According to the cut-off point obtained on the receiver operator curve, patients with a VDI of 0.601 or greater had lower left ventricular ejection fraction and higher values of resting minute ventilation and peak minute ventilation. CONCLUSIONS: The VDI proved to be a good predictor of EOV in patients with HF.

Correlação da força muscular respiratória com medidas antropométricas e nível de atividade física em adultos da atenção primária / Correlación de la fuerza muscular respiratoria con las medidas antropométricas y el nivel de actividad física en adultos en la atención primaria / Correlation of respiratory muscle strength with anthropometric measures and physical activity level in adults in primary care

RESUMO O objetivo deste estudo foi correlacionar a força muscular respiratória com as medidas antropométricas e o nível de atividade física de indivíduos adultos da atenção primária. Trata-se de um estudo transversal, realizado em uma unidade básica de saúde, onde foram incluídos indivíduos de ambos os sexos e com idade superior a 18 anos. A força muscular respiratória foi analisada pela pressão inspiratória máxima (PImáx) e pressão expiratória máxima (PEmáx), por meio do manovacuômetro, onde valores pressóricos acima de 80% em relação ao predito foram considerados normais. Utilizou-se balança mecânica, estadiômetro e fita métrica para mensuração das principais medidas antropométricas: índice de massa corporal (IMC), circunferência de pescoço (CP), circunferência abdominal (CA), circunferência de quadril (CQ), relação cintura-quadril (RCQ) e o índice de adiposidade corporal (IAC). O nível de atividade física foi determinado pelo questionário internacional de atividade física (IPAQ), onde os indivíduos foram categorizados como sedentário, irregularmente ativo A, irregularmente ativo B, ativo ou muito ativo, sendo realizada também a estimativa dos equivalentes metabólicos (MET) alcançados. Foram avaliados 110 indivíduos adultos (78,1% do sexo feminino; 51,9±12,3 anos), e com porcentagem em relação ao predito (%) de PImáx de 96,3±32,4% e 98,9±27,3% de PEmáx. A %PImáx apresentou fraca correlação com o IAC (r=0,23; p=0,01) e com a CQ (r=0,20; p=0,03), e a %PEmáx com o IMC (r=0,26; p<0,01) e IAC (r=0,30; p<0,01). Não houve diferença dos valores médios de %PImáx (p=0,61) e %PEmáx (p=0,54) entre as categorias do IPAQ, além de não existirem correlações (p>0,05) com os MET estimados. Em adultos da atenção primária, a força muscular respiratória apresentou fraca correlação com IMC, CQ e IAC, porém sem correlação com o nível de atividade física.

RESUMEN El objetivo de este estudio fue correlacionar la fuerza muscular respiratoria con las medidas antropométricas y el nivel de actividad física de individuos adultos en atención primaria. Este es un estudio transversal, realizado con personas de ambos los sexos y mayores de 18 años en una unidad básica de salud. Se evaluó la presión inspiratoria máxima (PImáx.) y la presión espiratoria máxima (PEmáx.) de la fuerza muscular respiratoria mediante un manovacuómetro, en el que se consideraron normales los valores de presión superiores al 80% en relación al valor predicho. Se utilizó una balanza mecánica, estadiómetro y cinta métrica para obtener las principales medidas antropométricas: índice de masa corporal (IMC), circunferencia del cuello (CC), circunferencia abdominal (CA), circunferencia de la cadera (CCA), relación cintura-cadera (RCCA) y el índice de adiposidad corporal (IAC). El nivel de actividad física fue determinado por el Cuestionario internacional de actividad física (IPAQ), que clasifica a los individuos como sedentarios, irregularmente activos A, irregularmente activos B, activos o muy activos, y también se estimó los equivalentes metabólicos alcanzados (MET). Se evaluaron 110 individuos adultos (78,1% mujeres; 51,9±12,3 años), y con un porcentaje en relación al predicho (%) de PImáx. de 96,3±32,4% y de PEmáx de 98,9±27,3%. El %PImáx. mostró una correlación débil con el IAC (r=0,23; p=0,01) y con el CCA (r=0,20; p=0,03), y el %PEmáx. con el IMC (r=0,26; p<0,01) e IAC (r=0,30; p<0,01). No hubo diferencia en los valores medios de %PImáx. (p=0,61) y %PEmáx. (p=0,54) entre las categorías de IPAQ, además de que no existen correlaciones (p>0,05) con los MET estimados. En los adultos en la atención primaria, la fuerza muscular respiratoria mostró una correlación débil con el IMC, CCA e IAC, pero sin correlación con el nivel de actividad física.

ABSTRACT This study aimed to correlate respiratory muscle strength with anthropometric measures and physical activity level in adults in primary care. This cross-sectional study was conducted in a basic health unit with individuals of both genders aged 18 years or older. Respiratory muscle strength was analyzed by maximal inspiratory (MIP) and expiratory (MEP) pressures using a manovacuometer. Values above 80% of the predicted were considered normal. Anthropometric data was obtained using a mechanical scale, stadiometer, and measuring tape, namely: body mass index (BMI); neck (NC), waist (WC), and hip (HC) circumference; waist-to-hip ratio (WHR), and body adiposity index (BAI). Physical activity level was determined by the international physical activity questionnaire (IPAQ), where individuals were categorized into sedentary, irregularly active A, irregularly active B, active, or very active. The instrument also estimated the achieved metabolic equivalents (MET). Our study sample comprised 110 adults (78.1% female; 51.9±12.3 years) with 96.3 ± 32.4% MIP and 98.9 ± 27.3 % MEP in relation to the predicted. The %MIP showed a weak correlation with BAI (r=0.23; p=0.01) and HC (r=0.20; p=0.03), and %MEP with BMI (r=0.26; p<0, 01) and BAI (r=0.30; p<0.01). We verified no difference between the average %MIP (p=0.61) and %MEP (p=0.54) within the IPAQ categories and no correlations (p> 0.05) with the estimated MET. Respiratory muscle strength of adults in primary care showed a weak correlation with BMI, HC, and BAI, and no correlation with physical activity level.

Impact of an early physiotherapy program after kidney transplant during hospital stay: a randomized controlled trial / Impacto de um programa precoce de fisioterapia após transplante renal durante a internação: um estudo clínico randomizado controlado

Abstract Introduction: Cardiorespiratory and musculoskeletal dysfunctions are common in the postoperative period of kidney transplant patients and are often accompanied by low exercise tolerance. Objective: The purpose of this study was to evaluate the impact of an early physiotherapy program during hospital stay on functional capacity and peripheral and respiratory muscle strength after kidney transplant. Methods: An open, randomized clinical trial was conducted in patients undergoing living donor kidney transplant. Sixty-three patients were included (intervention group-IG: n = 30; control group-CG: n = 33). IG received an early physiotherapy program from first postoperative day until hospital discharge and CG received standard care. The variables of interest were measured preoperatively and at discharge except for respiratory muscle strength and vital capacity (VC), which were also measured on the first postoperative day. Functional capacity was evaluated through six-minute walk test (6MWT); peripheral and respiratory muscle strength using a dynamometer and manovacuometer, respectively; and VC through spirometer. Results: After surgery, there was a reduction in functional walking capacity and peripheral muscle strength without different between groups (p > 0.05); however, respiratory muscle strength was significantly higher in IG (p < 0.001) at hospital discharge, when comparing with CG. Conclusions: An early physiotherapy program during hospitalization for patients undergoing living donor kidney transplant caused a lower reduction in respiratory muscle strength and without additional benefits in the functional capacity, when compared to a control group, although the clinical relevance of this finding is uncertain.

Resumo Introdução: Distúrbios cardiorrespiratórios e musculoesqueléticos são comuns no período pós-operatório de pacientes de transplante renal, e são frequentemente acompanhados por baixa tolerância a exercícios. Objetivo: O presente estudo pretendeu avaliar o impacto de um programa precoce de fisioterapia durante a internação sobre a capacidade funcional e força muscular periférica e respiratória após transplante renal. Métodos: Foi realizado um estudo clínico randomizado aberto com pacientes submetidos a transplantes renais com doadores vivos. Sessenta e três pacientes foram incluídos (grupo de intervenção GI: n = 30; grupo de controle - GC: n = 33). O GI recebeu o programa precoce de fisioterapia a partir do primeiro dia de pós-operatório até a alta hospitalar e o GC recebeu tratamento padrão. As variáveis de interesse foram medidas no pré-operatório e na alta, exceto por força muscular respiratória e capacidade vital (CV), que foram medidas no primeiro dia de pós-operatório. A capacidade funcional foi avaliada através do teste da caminhada dos seis minutos (TC6); força muscular periférica e respiratória com o uso de um dinamômetro e um manovacuômetro, respectivamente; e a CV por meio de um espirômetro. Resultados: Após a cirurgia houve reduções na capacidade funcional de caminhar e na força muscular respiratória sem diferenças entre os grupos (p > 0,05); contudo, a força muscular respiratória foi significativamente mais elevada no GI (p < 0,001) no momento da alta hospitalar em comparação ao GC. Conclusões: O programa precoce de fisioterapia oferecido durante a internação dos pacientes submetidos a transplantes renais com doadores vivos produziu uma menor redução da força muscular respiratória e não resultou em benefícios adicionais na capacidade funcional, apesar da relevância clínica desse achado ser incerta.

Effects of a Physical Activity Program on Cardiorespiratory Fitness and Pulmonary Function in Obese Women after Bariatric Surgery: a Pilot Study.

BACKGROUND: In severely obese individuals, reducing body weight induced by bariatric surgery is able to promote a reduction in comorbidities and improve respiratory symptoms. However, cardiorespiratory fitness (CRF) reflected by peak oxygen uptake (VO2peak) may not improve in individuals who remain sedentary post-surgery. The objective of this study was to evaluate the effects of a physical training program on CRF and pulmonary function in obese women after bariatric surgery, and to compare them to a control group. METHODS: Twelve obese female candidates for bariatric surgery were evaluated in the preoperative, 3 months postoperative (3MPO), and 6 months postoperative (6MPO) periods through anthropometry, spirometry, and cardiopulmonary exercise testing (CPX). In the 3MPO period, patients were divided into control group (CG, n = 6) and intervention group (IG, n = 6). CG received only general guidelines while IG underwent a structured and supervised physical training program involving aerobic and resistance exercises, lasting 12 weeks. RESULTS: All patients had a significant reduction in anthropometric measurements and an increase in lung function after surgery, with no difference between groups. However, only IG presented a significant increase (p < 0.05) in VO2peak and total CPX duration of 5.9 mL/kg/min (23.8%) and 4.9 min (42.9%), respectively. CONCLUSIONS: Applying a physical training program to a group of obese women after 3 months of bariatric surgery could promote a significant increase in CRF only in the trained group, yet also showing that bariatric surgery alone caused an improvement in the lung function of both groups.

Oxygen uptake efficiency slope as a useful measure of cardiorespiratory fitness in morbidly obese women.

Cardiopulmonary assessment through oxygen uptake efficiency slope (OUES) data has shown encouraging results, revealing that we can obtain important clinical information about functional status. Until now, the use of OUES has not been established as a measure of cardiorespiratory capacity in an obese adult population, only in cardiac and pulmonary diseases or pediatric patients. The aim of this study was to characterize submaximal and maximal levels of OUES in a sample of morbidly obese women and analyze its relationship with traditional measures of cardiorespiratory fitness, anthropometry and pulmonary function. Thirty-three morbidly obese women (age 39.1 ± 9.2 years) performed Cardiopulmonary Exercise Testing (CPX) on a treadmill using the ramp protocol. In addition, anthropometric measurements and pulmonary function were also evaluated. Maximal and submaximal OUES were measured, being calculated from data obtained in the first 50% (OUES50%) and 75% (OUES75%) of total CPX duration. In one-way ANOVA analysis, OUES did not significantly differ between the three different exercise intensities, as observed through a Bland-Altman concordance of 58.9 mL/min/log(L/min) between OUES75% and OUES100%, and 0.49 mL/kg/min/log(l/min) between OUES/kg75% and OUES/kg100%. A strong positive correlation between the maximal (r = 0.79) and submaximal (r = 0.81) OUES/kg with oxygen consumption at peak exercise (VO2peak) and ventilatory anaerobic threshold (VO2VAT) was observed, and a moderate negative correlation with hip circumference (r = -0.46) and body adiposity index (r = -0.50) was also verified. There was no significant difference between maximal and submaximal OUES, showing strong correlations with each other and oxygen consumption (peak and VAT). These results indicate that OUES can be a useful parameter which could be used as a cardiopulmonary fitness index in subjects with severe limitations to perform CPX, as for morbidly obese women.

Impact of an early physiotherapy program after kidney transplant during hospital stay: a randomized controlled trial.

INTRODUCTION: Cardiorespiratory and musculoskeletal dysfunctions are common in the postoperative period of kidney transplant patients and are often accompanied by low exercise tolerance. OBJECTIVE: The purpose of this study was to evaluate the impact of an early physiotherapy program during hospital stay on functional capacity and peripheral and respiratory muscle strength after kidney transplant. METHODS: An open, randomized clinical trial was conducted in patients undergoing living donor kidney transplant. Sixty-three patients were included (intervention group-IG: n = 30; control group-CG: n = 33). IG received an early physiotherapy program from first postoperative day until hospital discharge and CG received standard care. The variables of interest were measured preoperatively and at discharge except for respiratory muscle strength and vital capacity (VC), which were also measured on the first postoperative day. Functional capacity was evaluated through six-minute walk test (6MWT); peripheral and respiratory muscle strength using a dynamometer and manovacuometer, respectively; and VC through spirometer. RESULTS: After surgery, there was a reduction in functional walking capacity and peripheral muscle strength without different between groups (p > 0.05); however, respiratory muscle strength was significantly higher in IG (p < 0.001) at hospital discharge, when comparing with CG. CONCLUSIONS: An early physiotherapy program during hospitalization for patients undergoing living donor kidney transplant caused a lower reduction in respiratory muscle strength and without additional benefits in the functional capacity, when compared to a control group, although the clinical relevance of this finding is uncertain.

Ventilatory and Metabolic Response in the Incremental Shuttle and 6-Min Walking Tests Measured by Telemetry in Obese Patients Prior to Bariatric Surgery.

BACKGROUND: Low cardiopulmonary fitness, measured by oxygen uptake peak (VO 2pk), is associated with postoperative complications and mortality. Obese people have difficulty in performing the cardiopulmonary exercise test, which requires maximal exertion. The incremental shuttle walking test (ISWT) and 6-min walking test (6MWT) have been used to assess cardiorespiratory capacity, mortality, and complications in the postoperative phase. However, the physiological response elicited by these tests in obese people is unknown. This study analyzed and compared cardiopulmonary fitness (oxygen uptake [VO2] and CO2 output [VCO2]) in the ISWT and 6MWT in obese adults using a telemetry system. METHODS: Fifteen obese patients (10 women; mean age 39.4 ± 10.1 years; mean body mass index 43.5 ± 6.8 kg/m(2)) with normal forced vital capacity (% FVC 93.7) performed the 6MWT and ISWT in the field in this cross-sectional study. Metabolic (VO 2pk, VCO2) and respiratory (minute ventilation; VE) variables were recorded using telemetry. RESULTS: Obese patients performed the ISWT with an incremental and exponential cardiopulmonary response, with higher VO 2pk (15.4 ± 2.9 ml/kg/min), VCO2 (1.7 ± 0.7 l/min), and VE (51.4 ± 21.3 l/min) than the 6MWT (VO 2pk = 13.2 ± 2.59 ml/kg/min, VCO2 = 1.4 ± 0.6 l/min; VE = 41.2 ± 16.6 l/min (all p < 0.01). They also demonstrated more effort intensity, assessed by VO2, (p = 0.006) and heart rate (p = 0.04) in the ISWT than the 6MWT. In the 6MWT, patients showed a fast rise in ventilatory and metabolic response, reaching a plateau. CONCLUSION: The ISWT test generated superior metabolic and ventilatory stress than the 6MWT and may be more suitable for assessing cardiopulmonary fitness than self-paced tests.