Standardization use of the international classification of functioning, disability and health in the determination of health status in patients with post-acute COVID-19 syndrome.

PURPOSE: To propose a standardized method for the use of the International Classification of Functioning, Disability and Health (ICF) to describe the health status in Post-Acute COVID-19 Syndrome (PACS) and investigate interrater agreement in the linking process in instruments and clinical exams using the ICF categories. MATERIALS AND METHODS: Cross-sectional and interrater agreement study that followed the Guidelines for Reporting Reliability and Agreement Studies. Two raters performed the linking coding process in instruments of quality of life, anxiety and depression, fatigue and pulmonary function, inspiratory muscle strength and cardiopulmonary exercise testing. The codes were qualified by standards defined to each instrument and exams. RESULTS: The instrument with the lowest Cohen's Kappa coefficient was anxiety and depression (k = 0.57). Forty ICF codes were linked to clinical instruments and exams. The fatigue instrument presented a higher degree of disability by the qualification process, from severe to complete, in the linked codes. CONCLUSION: The study presents a standardized method for the assessment of the health status of patients with PACS through ICF. Restriction in work performance, socialization and family relationships as well as disabilities in physical endurance, fatigue and exercise tolerance were found in the sample. The agreement between the raters was moderate to perfect, demonstrating that the method can be reproducible.

The body structures and functions, environmental factors, activities and participation in a person's environment are determinant aspects of his health.Ways to measure these aspects are key to assessing health not only as absence of disease, so the International Classification of Disability and Functional Health demonstrates the ability to fully describe health.This study proposes a standardization in the use of the tool to facilitate usability in clinical practice.

Diaphragm thickness and mobility elicited by two different modalities of inspiratory muscle loading in heart failure participants: A randomized crossover study.

OBJECTIVES: To analyze diaphragmatic thickness, at end-inspiration and end-expiration, diaphragmatic thickening index and mobility via US under two different modalities of inspiratory muscle loading, in two different modalities of inspiratory muscle loading and different load intensities at full-vital capacity maneuvers and the relationship between diaphragmatic thickness with pulmonary function tests in participants with HF. METHODS: This randomized crossover trial, enrolled with 17 HF subjects, evaluated diaphragm thickness (Tdi, mm), fractional thickness (TFdi, %), and mobility (mm) US during low and high intensities (30% and 60% of maximal inspiratory pressure-MIP) with two modalities of inspiratory muscle loading mechanical threshold loading (MTL) and tapered flow-resistive loading (TFRL). RESULTS: Both MTL and TFRL produced a increase in Tdi, but only with high intensity loading compared to baseline-2.21 (0.26) vs. 2.68 (0.33) and 2.73 (0.44) mm; p = .01. TFdi was greater than baseline under all conditions, except during low intensity of TFRL. Diaphragm mobility was greater than baseline under all conditions, and high intensity of TFRL elicited greater mobility compared to all other conditions. Additionally, baseline Tdi was moderately correlated with pulmonary function tests. CONCLUSIONS: MTL and TFRL modalities elicit similar increases in diaphragm thickness at loads, but only during high intensity loading it was greater than baseline. Diaphragm mobility was significantly greater than baseline under both loads and devices, and at high intensity compared to low intensity, although TFRL produced greater mobility compared to modalities of inspiratory muscle loading. There is an association between diaphragm thickness and pulmonary function tests.

Inspiratory Muscle Training in Phase 1 and 2 Postoperative Cardiac Rehabilitation Following Coronary Artery Bypass Graft Surgery: Systematic Review with Meta-Analysis.

OBJECTIVE: This study aimed to determine the effects of inspiratory muscle training (IMT) on exercise capacity, respiratory muscle strength, length of hospital stay (LOS), and quality of life (QOL) following coronary artery bypass graft surgery. METHODS: The search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane Handbook and included the databases MEDLINE, EMBASE, CINAHL, Scopus, and CENTRAL. The review included randomized controlled trials utilizing IMT during phase 1 or 2 postoperative cardiac rehabilitation (PoCR) versus alternative treatment (active or passive control) in patients following coronary artery bypass graft surgery. RESULTS: Fifteen studies were included (11 phase 1 studies, 4 phase 2 studies) with no reported adverse events. In phase 1 PoCR, IMT reduced the LOS (-1.02 days; 95% CI = -2.00 to -0.03) and increased exercise capacity (6-minute walk distance [6MWD]).(+75.46 m; 95% CI = 52.34 to 98.57), and maximal inspiratory pressure (MIP) (10.46 cm H2O; 95% CI = 2.83 to 18.10), but had no effect on maximal expiratory pressure. In phase 2 PoCR, IMT increased 6MWD (45.84 m; 95% CI = 10.89 to 80.80), MIP (-23.19 cm H2O; 95% CI = -31.31 to -15), maximal expiratory pressure (20.18 cm H2O; 95% CI = 9.60 to 30.76), and QOL (-11.17; 95% CI = -17.98 to -4.36), with no effect on peak oxygen uptake. There was a high risk of bias for MIP (75% of the phase 1 studies) and 6MWT (1 of 4 phase 2 studies). The quality of the evidence ranged from very low to moderate. CONCLUSIONS: IMT significantly improves exercise capacity, respiratory muscle strength, LOS, and QOL in phase 1 and 2 PoCR. IMPACT: IMT may benefit patients during phase 1 and 2 of PoCR, considering the safety, low cost, and potential benefits.

Accurate Prediction Equations for Ventilatory Thresholds in Cardiometabolic Disease When Gas Exchange Analysis is Unavailable: Development and Validation.

AIMS: To develop and validate equations predicting heart rate (HR) at the first and second ventilatory thresholds (VTs) and an optimized range-adjusted prescription for patients with cardiometabolic disease (CMD). To compare their performance against guideline-based exercise intensity domains. METHODS: Cross-sectional study involving 2,868 CMD patients from nine countries. HR predictive equations for first and second VTs (VT1, VT2) were developed using multivariate linear regression with 975 cycle-ergometer cardiopulmonary exercise tests (CPET). 'Adjusted' percentages of peak HR (%HRpeak) and HR reserve (%HRR) were derived from this group. External validation with 1,893 CPET (cycle-ergometer or treadmill) assessed accuracy, agreement, and reliability against guideline-based %HRpeak and %HRR prescriptions using mean absolute percentage error (MAPE), Bland-Altman analyses, intraclass correlation coefficients (ICC). RESULTS: HR predictive equations (R²: 0.77 VT1, 0.88 VT2) and adjusted %HRR (VT1: 42%, VT2: 77%) were developed. External validation demonstrated superiority over widely used guideline-directed intensity domains for %HRpeak and %HRR. The new methods showed consistent performance across both VTs with lower MAPE (VT1: 7.1%, VT2: 5.0%), 'good' ICC for VT1 (0.81, 0.82) and 'excellent' for VT2 (0.93). Guideline-based exercise intensity domains had higher MAPE (VT1: 6.8%-21.3%, VT2: 5.1%-16.7%), 'poor' to 'good' ICC for VT1, and 'poor' to 'excellent' for VT2, indicating inconsistencies related to specific VTs across guidelines. CONCLUSION: Developed and validated HR predictive equations and the optimized %HRR for CMD patients for determining VT1 and VT2 outperformed the guideline-based exercise intensity domains and showed ergometer interchangeability. They offer a superior alternative for prescribing moderate intensity exercise when CPET is unavailable.

Equations to predict heart rate at ventilatory thresholds were developed and externally validated, offering a new perspective when a cardiopulmonary exercise test is unavailable to accurately determine the aerobic exercise intensity domains. Additionally, an adjusted range for exercise intensity prescription based on the percentage of heart rate reserve (%HRR) was provided, utilizing a large sample from eight countries. The proposed equations and the range-adjusted %HRR significantly outperformed the guideline-directed methods for determining exercise intensity, exhibiting higher accuracy, agreement, and reliability. Exercise intensity prescription based on the percentage of heart rate peak showed higher errors, raising concerns about its clinical applicability. Our study may enhance the efficacy of exercise training and physical activity advice when gas exchange analysis is unavailable, potentially leading to improved clinical outcomes, even in low-resource settings. Employing these approaches in research could facilitate more tailored and consistent interventions, introducing a contemporary perspective for studies comparing exercise intensity prescriptions.

Effects of blood flow restriction therapy in patients with knee osteoarthritis: protocol for an overview of systematic reviews.

Background: Osteoarthritis (OA) is the most common and prevalent musculoskeletal disease associated with population aging, negatively impacting function and quality of life. A consequence of knee OA is quadriceps muscle weakness. Musculoskeletal rehabilitation using low load exercises, associated with Blood Flow Restriction (BFR) may be a useful alternative to high load exercises when those cannot be tolerated. Several systematic reviews have reported inconclusive results due to discrepancies in study findings, heterogeneity of results, evaluated time points, and research questions explored. Objective: To perform an overview of systematic reviews with meta-analyses, synthesizing the most recent evidence on the effects of muscle strength training with BFR for knee OA. Methodology: Systematic reviews that include primary controlled and randomized clinical trials will be considered for inclusion. Articles will be considered only if they present a clear and reproducible methodological structure, and when they clearly demonstrate that a critical analysis of the evidence was carried out using instrumented analysis. Narrative reviews, other types of review, overviews of systematic reviews, and diagnostic, prognostic and economic evaluation studies will be excluded. Studies must include adults aged 40 years and older with a diagnosis of knee OA. Two authors will perform an electronic search with guidance from an experienced librarian. The following databases will be searched: PubMed via MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), PEDro, Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host, Web of Science, and the gray literature. The search strategy used in the databases will follow the acronym PICOS (population, intervention, comparison, outcome, and study design). Screening (i.e., titles and abstracts) of studies identified by the search strategy will be selected using Rayyan (http://rayyan.qcri.org). The quality assessment will be performed using the "Assessment of Multiple Systematic Reviews" (AMSTAR-2) tool. Systematic Review Registration: PROSPERO, CRD42022367209.

Longitudinal strain and myocardial work in symptomatic patients having recovered from COVID-19 and possible associations with the severity of the disease.

COVID-19 may have residual consequences in multiple organs, including the cardiovascular system. The purpose of the present investigation is to quantify myocardial function in symptomatic individuals with long COVID and investigate the association between illness severity and myocardial function. A retrospective cross-sectional study was conducted in which symptomatic individuals with previous COVID-19 underwent echocardiographic analysis of left ventricle global longitudinal strain (LVGLS) and myocardial work (MW). Individuals also performed cardiopulmonary testing (CPX) to assess peak oxygen uptake (VO2peak). Differences between illness severity subgroups were analyzed by the Mann-Whitney test. Correlations were calculated using the Spearman correlation test. Multilinear regressions were performed to evaluate the influences of COVID-19 severity, body mass index, age, and sex on MW. Fifty-six individuals were included (critical subgroup: 17; moderate/severe subgroup: 39), 59% females; median age: 56 years (IQR: 43-63). CPX revealed a substantial reduction in VO2peak (median of 53% of predicted values). LVGLS were not statistically different between subgroups. Global wasted work (GWW) was higher in the critical subgroup [146 (104-212) versus 121 (74-163) mmHg%, p = 0.01], and global work efficiency (GWE) was lower in this subgroup [93 (91-95) versus 94 (93-96), p = 0.03]. Illness severity was the only independent predictor of GWW and GWE (GWW: r2 = 0.167; p = 0.009; GWE: r2 = 0.172; p = 0.005) in multilinear regressions. In our study with long COVID-19 individuals, despite having a similar LVGLS, patients had subclinical LV dysfunction, demonstrated only by an increase in GWW and a decrease in GWE.

Respiratory sarcopenia screening in dialysis patients: cross-sectional and multicentre study protocol.

BACKGROUND: Respiratory sarcopenia is characterized by the weakness of respiratory muscles associated with sarcopenia due to aging or systemic diseases such as chronic kidney disease (CKD). Patients with CKD undergoing dialysis are particularly susceptible to respiratory muscle weakness caused by factors such as fluid overload and electrolyte imbalance. This weakness not only affects ventilation but also impairs oxygen uptake and delivery to muscle tissue, potentially leading to severe sarcopenia. Thus, the objective of this study is to conduct a respiratory sarcopenia screening in patients with CKD undergoing haemodialysis (HD) and peritoneal dialysis (PD). METHODS: This is an observational, cross-sectional and multicentre study conducted between March 2023 and March 2025. The study was approved by the Research Ethics Committee at two centres. Sarcopenia diagnosis is determined based on low handgrip strength and amount of appendicular skeletal muscle mass, assessed through bioelectrical impedance analysis. Respiratory sarcopenia is diagnosed in patients with sarcopenia who have low inspiratory muscle strength, evaluated through a manovacuometry test. The severity of sarcopenia and respiratory sarcopenia is defined, respectively, by low physical performance (measured using the Short Physical Performance Battery and Timed-Up and Go test) and pulmonary performance (measured through spirometry). Thus, this study will include 81 patients undergoing dialysis (41 on HD and 40 on PD) from three participating centres. DISCUSSION: The literature has been focused on respiratory function in CKD; however, the relationship with sarcopenia remains understudied. We believe that, similar to appendicular skeleton muscles, the axial skeleton muscles are also likely to weaken with the presence of chronic disease, such as CKD.

Exercise intensity domains determined by heart rate at the ventilatory thresholds in patients with cardiovascular disease: new insights and comparisons to cardiovascular rehabilitation prescription recommendations.

Objectives: To compare the elicited exercise responses at ventilatory thresholds (VTs: VT1 and VT2) identified by cardiopulmonary exercise testing (CPET) in patients with cardiovascular disease (CVD) with the guideline-directed exercise intensity domains; to propose equations to predict heart rate (HR) at VTs; and to compare the accuracy of prescription methods. Methods: A cross-sectional study was performed with 972 maximal treadmill CPET on patients with CVD. First, VTs were identified and compared with guideline-directed exercise intensity domains. Second, multivariate linear regression analyses were performed to generate prediction equations for HR at VTs. Finally, the accuracy of prescription methods was assessed by the mean absolute percentage error (MAPE). Results: Significant dispersions of individual responses were found for VTs, with the same relative intensity of exercise corresponding to different guideline-directed exercise intensity domains. A mathematical error inherent to methods based on percentages of peak effort was identified, which may help to explain the dispersions. Tailored multivariable equations yielded r2 of 0.726 for VT1 and 0.901 for VT2. MAPE for the novel VT1 equation was 6.0%, lower than that for guideline-based prescription methods (9.5 to 23.8%). MAPE for the novel VT2 equation was 4.3%, lower than guideline-based methods (5.8%-19.3%). Conclusion: The guideline-based exercise intensity domains for cardiovascular rehabilitation revealed inconsistencies and heterogeneity, which limits the currently used methods. New multivariable equations for patients with CVD were developed and demonstrated better accuracy, indicating that this methodology may be a valid alternative when CPET is unavailable.

Inspiratory muscle training on quality of life in individuals with spinal cord injury: A systematic review and meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: The objective was to summarize the effectiveness of Inspiratory Muscle Training (IMT) on the quality of life in individuals with Spinal Cord Injury (SCI). METHODS: An online systematic literature search was conducted in the following databases: PubMed/MEDLINE, PubMed CENTRAL, EMBASE, ISI Web of Science, SciELO, CINAHL/SPORTDiscus, and PsycINFO. Randomized and non-randomized clinical studies investigating the effectiveness of IMT in quality of life were included in the present study. The results used the mean difference and 95% confidence interval for maximal inspiratory pressure (MIP), forced expiratory volume in 1 s (FEV1), maximal expiratory pressure (MEP), and the standardized mean differences for the quality of life and maximum ventilation volume. RESULTS: The search found 232 papers, and after the screening, four studies met the inclusion criteria and were included in the meta-analytical procedures (n = 150 participants). No changes were demonstrated in the quality of life domains (general health, physical function, mental health, vitality, social function, emotional problem, and pain) after IMT. The IMT provided a considerable effect over the MIP but not on FEV1 and MEP. Conversely, it was not able to provide changes in any of the quality of life domains. None of the included studies evaluated the IMT effects on the expiratory muscle maximal expiratory pressure. CONCLUSION: Evidence from studies shows that inspiratory muscle training improves the MIP; however, this effect does not seem to translate to any change in the quality of life or respiratory function outcomes in individuals with SCI.

Cardiopulmonary Exercise Testing in Post-COVID-19 Patients: Where Does Exercise Intolerance Come From? / Teste Cardiopulmonar em Pacientes Pós-COVID-19: De Onde vem a Intolerância ao Exercício?

BACKGROUND: Post-COVID-19 exercise intolerance is poorly understood. Cardiopulmonary exercise testing (CPET) can identify the underlying exercise limitations. OBJECTIVES: To evaluate the source and magnitude of exercise intolerance in post-COVID-19 subjects. METHODS: Cohort study assessing subjects with different COVID-19 illness severities and a control group selected by propensity score matching. In a selected sample with CPET prior to viral infection, before and after comparisons were performed. Level of significance was 5% in the entire analysis. RESULTS: One hundred forty-four subjects with COVID-19 were assessed (median age: 43.0 years, 57% male), with different illness severities (60% mild, 21% moderate, 19% severe). CPET was performed 11.5 (7.0, 21.2) weeks after disease onset, with exercise limitations being attributed to the peripheral muscle (92%), and the pulmonary (6%), and cardiovascular (2%) systems. Lower median percent-predicted peak oxygen uptake was observed in the severe subgroup (72.2%) as compared to the controls (91.6%). Oxygen uptake differed among illness severities and controls at peak and ventilatory thresholds. Conversely, ventilatory equivalents, oxygen uptake efficiency slope, and peak oxygen pulse were similar. Subgroup analysis of 42 subjects with prior CPET revealed significant reduction in only peak treadmill speed in the mild subgroup and in oxygen uptake at peak and ventilatory thresholds in the moderate/severe subgroup. By contrast, ventilatory equivalents, oxygen uptake efficiency slope, and peak oxygen pulse did not change significantly. CONCLUSIONS: Peripheral muscle fatigue was the most common exercise limitation etiology in post-COVID-19 patients regardless of the illness severity. Data suggest that treatment should emphasize comprehensive rehabilitation programs, including aerobic and muscle strengthening components.

FUNDAMENTO: A intolerância ao exercício pós-COVID-19 não é bem entendida. O teste de esforço cardiopulmonar (TECP) pode identificar as limitações ao exercício subjacentes. OBJETIVOS: Avaliar a etiologia e a magnitude da intolerância ao exercício em sujeitos pós-COVID-19. MÉTODOS: Estudo de coorte que avaliou sujeitos com níveis de gravidades diferentes da doença COVID-19 e um grupo de controle selecionado por pareamento por escores de propensão. Em uma amostra seleta com TECP anterior à infecção viral disponível, foram realizadas comparações antes e depois. O nível de significância foi de 5% em toda a análise. RESULTADOS: Foram avaliados cento e quarenta e dois sujeitos com COVID-19 (idade mediana: 43 anos, 57% do sexo masculino), com níveis de gravidade de doença diferentes (60% leve, 21% moderada, 19% grave). O TECP foi realizado 11,5 (7,0, 21,2) semanas após o aparecimento da doença, com as limitações ao exercício sendo atribuídas aos sistemas muscular periférico (92%), pulmonar (6%), e cardiovascular (2%). Menor valor mediano do consumo de oxigênio pico percentual foi observado no subgrupo com níveis graves de doença (72,2%) em comparação com os controles (91,6%). O consumo de oxigênio foi diferente entre os grupos com diferentes níveis de gravidade de doença e o controle no pico e nos limiares ventilatórios. Inversamente, os equivalentes ventilatórios, a inclinação da eficiência do consumo de oxigênio, e o pico do pulso de oxigênio foram semelhantes. A análise do subgrupo de 42 sujeitos com TECP prévio revelou uma redução significativa no pico de velocidade da esteira no subgrupo com nível leve de doença, e no consumo de oxigênio no pico e nos limiares ventilatórios nos subgrupos com níveis moderado/grave. Por outro lado, os equivalentes ventilatórios, a inclinação da eficiência do consumo de oxigênio e o pico do pulso de oxigênio não apresentaram alterações significativas. CONCLUSÕES: A fadiga do músculo periférico foi a etiologia de limitação de exercício mais comum em pacientes pós-COVID-19 independentemente da gravidade da doença. Os dados sugerem que o tratamento deve enfatizar programas de reabilitação abrangentes, incluindo componentes aeróbicos e de fortalecimento muscular.

Oxygen Uptake Efficiency Slope in South American Healthy Adults: COMPREHENSIVE REFERENCE VALUES AND INTERNATIONAL COMPARISONS.

PURPOSE: The purpose of this study is to provide comprehensive reference values for oxygen uptake efficiency slope (OUES) in healthy adults. International heterogeneity was also explored through published databases. METHODS: A cross-sectional study was conducted with treadmill cardiopulmonary exercise testing (CPX) from a Brazilian healthy adult sample, in which absolute OUES and values normalized by weight and body surface area (BSA) were calculated. Data were stratified by sex and age group. Prediction equations were calculated using age and anthropometric variables. International data were pooled and differences were explored using factorial analysis of variance or the t test, as appropriate. The OUES age-related patterns were calculated using regression analysis. RESULTS: A total of 3544 CPX were included (1970 males and 1574 females) and the age ranged from 20-80 yr. Males had higher values than females for OUES, OUES/kg, and OUES/BSA. Lower values were found with aging and the data followed a quadratic regression curve. Reference value tables and predictive equations were provided for absolute and normalized OUES in both sexes. International comparisons of absolute OUES values among Brazilian, European, and Japanese data revealed substantial heterogeneity. The OUES/BSA measure minimized the discrepancies between Brazilian and European data. CONCLUSIONS: Our study provided comprehensive OUES reference values in a large healthy adult sample from South America with a wide age range and included absolute and normalized values. Differences observed between Brazilian and European data were reduced in the BSA-normalized OUES.

Impact of COVID-19's on Cardiovascular Rehabilitation Programs in Brazil: An Online Survey-Based Cross-Sectional Study. / Impacto da COVID-19 nos Programas de Reabilitação Cardiovascular no Brasil: Um Estudo Transversal Baseado em uma Pesquisa Online.

BACKGROUND: The COVID-19 pandemic had an impact on cardiovascular rehabilitation (CR) programs in Brazil. OBJECTIVES: To describe the characteristics of CR programs in Brazil, the impacts of the first epidemiological wave of COVID-19 (first 60 days) on the programs and present the initiatives used to overcome the impacts. METHOD: This cross-sectional and retrospective study utilized a specific online survey. Participants were coordinators of CR programs. Variables were presented by Brazilian geographic region and as the following categories: demographic, clinical and operational characteristics. The significance level for statistical analysis was set at 5%. RESULTS: Fifty-nine CR programs were responsible for 5,349 patients, of which only 1,817 were post-acute cardiovascular events, which corresponded to 1.99% of hospitalized patients in the month prior to the survey (n=91,231). The greatest impact was the suspension of on-site activities, which occurred similarly in areas with the highest and the lowest rates of COVID-19 in the period. Forty-five programs (75%) were shortly interrupted, while three (5%) were ended. All 42 programs that already used remote rehabilitation strategies noticed a substantial increase in activities, based primarily on the use of media and video calling. Only three (5%) considered safe to see patients during the first 60 days. CONCLUSIONS: There was a reduction in the number of CR programs with the COVID-19 pandemic. Telerehabilitation activities increased during the first two months of the COVID-19 pandemic, but this was not enough to overcome the reduction in CR program activities across Brazil.

FUNDAMENTO: A pandemia da COVID-19 teve um impacto sobre os programas de reabilitação cardiovasculares (RC) no Brasil. OBJETIVOS: Descrever características dos programas de RC no Brasil, os impactos da primeira onda epidemiológica da COVID-19 (primeiros 60 dias) sobre os programas, e apresentar as iniciativas usadas para superar esses impactos. MÉTODOS: Este estudo transversal e retrospectivo usou um questionário online específico. Os participantes eram coordenadores de programas de RC. As variáveis foram apresentadas por região geográfica do Brasil, como as seguintes categorias: característica demográficas, clínicas e operacionais. O nível de significância estatística foi definido em 5%. RESULTADOS: Cinquenta e nove programas de RC atendiam 5349 pacientes, dos quais somente 1817 eram pacientes após eventos cardiovasculares agudos, o que correspondia a 1,99% dos pacientes internados no mês anterior à pesquisa (n=91.231). O maior impacto foi a suspensão das atividades presenciais, o que ocorreu de maneira similar em áreas com as taxas mais altas e áreas com as taxas mais baixas de COVID-19 no período. Quarenta e quatro (75%) programas foram interrompidos de forma breve, e três (5%) foram encerrados. Todos os 42 programas que já utilizavam estratégias de reabilitação remota notaram aumento substancial nas atividades, baseadas principalmente no uso da mídia e chamadas por vídeo. Somente três (5%) consideraram seguro atender pacientes durante os primeiros 60 dias. CONCLUSÕES: Houve redução no número de programas de RC devido a pandemia da COVID-19. Atividades de telerreabilitação aumentaram durante os primeiros dois meses da pandemia da COVID-19, mas que não foi suficiente para superar a redução nas atividades dos programas de RC no Brasil.

Analysis of physical function, muscle strength, and pulmonary function in surgical cancer patients: a prospective cohort study.

The aim of this study was to investigate mobility, physical functioning, peripheral muscle strength, inspiratory muscle strength and pulmonary function in surgical cancer patients admitted to an intensive care unit (ICU). We conducted a prospective cohort study with 85 patients. Mobility, physical functioning, peripheral muscle strength, inspiratory muscle strength, and pulmonary function were assessed using the following tests: ICU Mobility Scale (IMS); Chelsea Critical Care Physical Assessment (CPAx); handgrip strength and Medical Research Council Sum-Score (MRC-SS); maximal inspiratory pressure (MIP) and S-Index; and peak inspiratory flow, respectively. The assessments were undertaken at ICU admission and discharge. The data were analyzed using the Shapiro-Wilk and Wilcoxon tests and Spearman's correlation coefficient. Significant differences in inspiratory muscle strength, CPAx, grip strength, MRC-SS, MIP, S-Index, and peak inspiratory flow scores were observed between ICU admission and discharge. Grip strength showed a moderate correlation with MIP at admission and discharge. The findings also show a moderate correlation between S-Index scores and both MIP and peak inspiratory flow scores at admission and a strong correlation at discharge. Patients showed a gradual improvement in mobility, physical functioning, peripheral and inspiratory muscle strength, and inspiratory flow during their stay in the ICU.

Translation, transcultural adaptation, and validation of the Brazilian Portuguese version of the Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA) questionnaire.

PURPOSE: To analyse the psychometric properties of the translated and cross-culturally adapted version of the OSAKA (Obstructive Sleep Apnea Knowledge and Attitudes) questionnaire in the Brazilian Portuguese language. METHODS: The OSAKA instrument was translated by two independent translators, and the back-translated conciliated version was presented and approved by Washington University, which holds the intellectual property for the OSAKA questionnaire. Physicians from different specialties electronically completed the OSAKA instrument and the ASKME (Assessment of Sleep Knowledge in Medical Education) questionnaire, which was used as an auxiliary instrument to analyse the construct validity. RESULTS: The questionnaire was tested with 176 physicians. The items from the knowledge and attitudes domains presented acceptable internal consistency values, with McDonald's omega coefficients (Ω) of 0.70 and 0.73, respectively. The OSAKA questionnaire showed a moderate correlation with the ASKME instrument (r = 0.60, p < 0.001) and excellent retest reliability, with an intraclass correlation coefficient of 0.81. There were differences in knowledge between the medical specialties (p < 0.001). Regarding attitudes, most respondents considered obstructive sleep apnoea and its diagnosis to be important and felt confident in identifying it, but the same majority did not feel confident in treating the disease. CONCLUSION: The OSAKA instrument, as a translated and cross-culturally adapted Brazilian Portuguese version, presented psychometric properties with adequate reliability and validity.

Teste Cardiopulmonar em Pacientes Pós-COVID-19: De Onde vem a Intolerância ao Exercício? / Cardiopulmonary Exercise Testing in Post-COVID-19 Patients: Where Does Exercise Intolerance Come From?

Resumo Fundamento A intolerância ao exercício pós-COVID-19 não é bem entendida. O teste de esforço cardiopulmonar (TECP) pode identificar as limitações ao exercício subjacentes. Objetivos Avaliar a etiologia e a magnitude da intolerância ao exercício em sujeitos pós-COVID-19. Métodos Estudo de coorte que avaliou sujeitos com níveis de gravidades diferentes da doença COVID-19 e um grupo de controle selecionado por pareamento por escores de propensão. Em uma amostra seleta com TECP anterior à infecção viral disponível, foram realizadas comparações antes e depois. O nível de significância foi de 5% em toda a análise. Resultados Foram avaliados cento e quarenta e dois sujeitos com COVID-19 (idade mediana: 43 anos, 57% do sexo masculino), com níveis de gravidade de doença diferentes (60% leve, 21% moderada, 19% grave). O TECP foi realizado 11,5 (7,0, 21,2) semanas após o aparecimento da doença, com as limitações ao exercício sendo atribuídas aos sistemas muscular periférico (92%), pulmonar (6%), e cardiovascular (2%). Menor valor mediano do consumo de oxigênio pico percentual foi observado no subgrupo com níveis graves de doença (72,2%) em comparação com os controles (91,6%). O consumo de oxigênio foi diferente entre os grupos com diferentes níveis de gravidade de doença e o controle no pico e nos limiares ventilatórios. Inversamente, os equivalentes ventilatórios, a inclinação da eficiência do consumo de oxigênio, e o pico do pulso de oxigênio foram semelhantes. A análise do subgrupo de 42 sujeitos com TECP prévio revelou uma redução significativa no pico de velocidade da esteira no subgrupo com nível leve de doença, e no consumo de oxigênio no pico e nos limiares ventilatórios nos subgrupos com níveis moderado/grave. Por outro lado, os equivalentes ventilatórios, a inclinação da eficiência do consumo de oxigênio e o pico do pulso de oxigênio não apresentaram alterações significativas. Conclusões A fadiga do músculo periférico foi a etiologia de limitação de exercício mais comum em pacientes pós-COVID-19 independentemente da gravidade da doença. Os dados sugerem que o tratamento deve enfatizar programas de reabilitação abrangentes, incluindo componentes aeróbicos e de fortalecimento muscular.

Abstract Background Post-COVID-19 exercise intolerance is poorly understood. Cardiopulmonary exercise testing (CPET) can identify the underlying exercise limitations. Objectives To evaluate the source and magnitude of exercise intolerance in post-COVID-19 subjects. Methods Cohort study assessing subjects with different COVID-19 illness severities and a control group selected by propensity score matching. In a selected sample with CPET prior to viral infection, before and after comparisons were performed. Level of significance was 5% in the entire analysis. Results One hundred forty-four subjects with COVID-19 were assessed (median age: 43.0 years, 57% male), with different illness severities (60% mild, 21% moderate, 19% severe). CPET was performed 11.5 (7.0, 21.2) weeks after disease onset, with exercise limitations being attributed to the peripheral muscle (92%), and the pulmonary (6%), and cardiovascular (2%) systems. Lower median percent-predicted peak oxygen uptake was observed in the severe subgroup (72.2%) as compared to the controls (91.6%). Oxygen uptake differed among illness severities and controls at peak and ventilatory thresholds. Conversely, ventilatory equivalents, oxygen uptake efficiency slope, and peak oxygen pulse were similar. Subgroup analysis of 42 subjects with prior CPET revealed significant reduction in only peak treadmill speed in the mild subgroup and in oxygen uptake at peak and ventilatory thresholds in the moderate/severe subgroup. By contrast, ventilatory equivalents, oxygen uptake efficiency slope, and peak oxygen pulse did not change significantly. Conclusions Peripheral muscle fatigue was the most common exercise limitation etiology in post-COVID-19 patients regardless of the illness severity. Data suggest that treatment should emphasize comprehensive rehabilitation programs, including aerobic and muscle strengthening components.

Impacto da COVID-19 nos Programas de Reabilitação Cardiovascular no Brasil: Um Estudo Transversal Baseado em uma Pesquisa Online / Impact of COVID-19's on Cardiovascular Rehabilitation Programs in Brazil: An Online Survey-Based Cross-Sectional Study

Resumo Fundamento A pandemia da COVID-19 teve um impacto sobre os programas de reabilitação cardiovasculares (RC) no Brasil. Objetivos Descrever características dos programas de RC no Brasil, os impactos da primeira onda epidemiológica da COVID-19 (primeiros 60 dias) sobre os programas, e apresentar as iniciativas usadas para superar esses impactos. Métodos Este estudo transversal e retrospectivo usou um questionário online específico. Os participantes eram coordenadores de programas de RC. As variáveis foram apresentadas por região geográfica do Brasil, como as seguintes categorias: característica demográficas, clínicas e operacionais. O nível de significância estatística foi definido em 5%. Resultados Cinquenta e nove programas de RC atendiam 5349 pacientes, dos quais somente 1817 eram pacientes após eventos cardiovasculares agudos, o que correspondia a 1,99% dos pacientes internados no mês anterior à pesquisa (n=91.231). O maior impacto foi a suspensão das atividades presenciais, o que ocorreu de maneira similar em áreas com as taxas mais altas e áreas com as taxas mais baixas de COVID-19 no período. Quarenta e quatro (75%) programas foram interrompidos de forma breve, e três (5%) foram encerrados. Todos os 42 programas que já utilizavam estratégias de reabilitação remota notaram aumento substancial nas atividades, baseadas principalmente no uso da mídia e chamadas por vídeo. Somente três (5%) consideraram seguro atender pacientes durante os primeiros 60 dias. Conclusões Houve redução no número de programas de RC devido a pandemia da COVID-19. Atividades de telerreabilitação aumentaram durante os primeiros dois meses da pandemia da COVID-19, mas que não foi suficiente para superar a redução nas atividades dos programas de RC no Brasil.

Abstract Background The COVID-19 pandemic had an impact on cardiovascular rehabilitation (CR) programs in Brazil. Objectives To describe the characteristics of CR programs in Brazil, the impacts of the first epidemiological wave of COVID-19 (first 60 days) on the programs and present the initiatives used to overcome the impacts. Method This cross-sectional and retrospective study utilized a specific online survey. Participants were coordinators of CR programs. Variables were presented by Brazilian geographic region and as the following categories: demographic, clinical and operational characteristics. The significance level for statistical analysis was set at 5%. Results Fifty-nine CR programs were responsible for 5,349 patients, of which only 1,817 were post-acute cardiovascular events, which corresponded to 1.99% of hospitalized patients in the month prior to the survey (n=91,231). The greatest impact was the suspension of on-site activities, which occurred similarly in areas with the highest and the lowest rates of COVID-19 in the period. Forty-five programs (75%) were shortly interrupted, while three (5%) were ended. All 42 programs that already used remote rehabilitation strategies noticed a substantial increase in activities, based primarily on the use of media and video calling. Only three (5%) considered safe to see patients during the first 60 days. Conclusions There was a reduction in the number of CR programs with the COVID-19 pandemic. Telerehabilitation activities increased during the first two months of the COVID-19 pandemic, but this was not enough to overcome the reduction in CR program activities across Brazil.

Reference Standards for Cardiorespiratory Fitness in Brazil: A POOLED ANALYSIS AND OVERVIEW OF HETEROGENEITY IN NATIONAL AND INTERNATIONAL STUDIES.

PURPOSE: This study aimed to propose reference standards for cardiorespiratory fitness (CRF) for Brazil from a pooled analysis and to compare peak oxygen uptake (V˙ o2peak ) in Brazilian, United States (US), and Norwegian samples, exploring possible national and international differences. METHODS: Reference values for treadmill V˙ o2peak in three different Brazilian regions were assessed from previous publications. We analyzed available samples to assess possible differences, generate weighted average data for Brazil, and compared them with US and Norwegian data. RESULTS: Brazilian reference values had a lower V˙ o2peak value for the Northeast region and a higher V˙ o2peak value for the Southeast region for all sex and age groups. International comparisons with the Brazilian pooled data (n = 26661) revealed higher values for the Norwegian sample (n = 3810) and lower values for the US sample (n = 16278). The observed heterogeneity in CRF is possibly related to differences in anthropometric (weight, height) and socioeconomic factors, which differed among the samples. Also, Brazilian data showed a curvilinear V˙ o2peak age reduction trend rather than the linear characteristic commonly utilized, and the regression curves were different from those for US and Norwegian data. CONCLUSION: This study provides new CRF reference standards for Brazil. After pooling data from three Brazilian regions, a comparison revealed notable differences between regions, evidencing a negative gradient from Southern to Northern regions. Similarly, the international comparisons between Brazil, US, and Norway data revealed CRF heterogeneity, with differences in the V˙ o2peak values and in the age relationship patterns. These findings reinforce the importance of using national- or regional-specific V˙ o2peak reference values, ensuring proper CRF evaluation.

Relação da Função Pulmonar e da Força Inspiratória com Capacidade Aeróbica e com Prognóstico na Insuficiência Cardíaca / Relationship of Lung Function and Inspiratory Strength with Exercise Capacity and Prognosis in Heart Failure

Resumo Fundamento A espirometria é subutilizada na insuficiência cardíaca (IC) e não está claro o grau de associação de cada defeito com a capacidade de exercício e com o prognóstico desses pacientes. Objetivo Determinar a relação da %CVF prevista (ppCVF) e do VEF1/CVF contínuos com: 1) pressão inspiratória máxima (PImáx), fração de ejeção do ventrículo esquerdo (FEVE) e desempenho ao exercício; e 2) prognóstico, para o desfecho composto de morte cardiovascular, transplante cardíaco ou implante de dispositivo de assistência ventricular. Métodos Coorte de 111 participantes com IC (estágios AHA C/D) sem pneumopatia; foram submetidos a espirometria, manovacuometria e teste cardiopulmonar máximo. As magnitudes de associação foram verificadas por regressões lineares e de Cox (HR; IC 95%), ajustadas para idade/sexo, e p <0,05 foi considerado significativo. Resultados Com idade média 57±12 anos, 60% eram homens, 64% em NYHAIII. A cada aumento de 10% no VEF1/CVF [β 7% (IC 95%: 3-10)] e no ppCVF [4% (2-6)], foi associado à reserva ventilatória (VRes); no entanto, apenas o ppCVF associado à PImáx [3,8cmH2O (0,3-7,3)], à fração de ejeção do ventrículo esquerdo (FEVE) [2,1% (0,5-3,8)] e ao VO2 pico [0,5mL/kg/min (0,1-1,0)], considerando idade/sexo. Em 2,2 anos (média), ocorreram 22 eventos; tanto FEV1/FVC (HR 1,44; IC 95%: 0,97-2,13) quanto ppCVF (HR 1,13; 0,89-1,43) não foram associados ao desfecho. Apenas no subgrupo FEVE ≤50% (n=87, 20 eventos), VEF1/CVF (HR 1,50; 1,01-2,23), mas não ppCVF, foi associado a risco. Conclusão Na IC crônica, ppCVF reduzido associou-se a menor PImáx, FEVE, VRes e VO2 pico, mas não distinguiu pior prognóstico em 2,2 anos de acompanhamento. Entretanto, VEF1/CVF associou-se apenas com VRes, e, em participantes com FEVE ≤50%, o VEF1/CVF reduzido mostrou pior prognóstico proporcional. Portanto, VEF1/CVF e ppFVC contribuem para melhor fenotipagem de pacientes com IC.

Abstract Background Spirometry is underused in heart failure (HF) and the extent to which each defect associates with exercise capacity and prognosis is unclear. Objective To determine the distinct relationship of continuous %predicted FVC (ppFVC) and FEV1/FVC with: 1) maximal inspiratory pressure (MIP), left ventricular ejection fraction (LVEF), exercise performance; and 2) prognosis for the composite of cardiovascular death, heart transplantation or left ventricular assist device implant. Methods A cohort of 111 HF participants (AHA stages C/D) without diagnosed pneumopathy, spirometry, manovacuometry and maximum cardiopulmonary test. The association magnitudes were verified by linear and Cox (HR; 95% CI) regressions, age/sex adjusted. A p<0.05 was considered significant. Results Age was 57±12 years, 60% men, 64% in NYHA III. Every 10%-point increase in FEV1/FVC [β 7% (95% CI: 3-10)] and ppFVC [4% (2-6)] associated with ventilatory reserve (VRes), however only ppFVC associated with MIP [3.8 cmH2O (0.3-7.3)], LVEF [2.1% (0.5-3.8)] and VO2peak [0.5 mL/kg/min (0.1-1.0)], accounting for age/sex. In 2.2 years (mean), 22 events occurred, and neither FEV1/FVC (HR 1.44; 95% CI: 0.97-2.13) nor ppFVC (HR 1.13; 0.89-1.43) was significantly associated with the outcome. Only in the LVEF ≤50% subgroup (n=87, 20 events), FEV1/FVC (HR 1.50; 1.01-2.23), but not ppFVC, was associated with greater risk. Conclusions In chronic HF, reduced ppFVC associated with lower MIP, LVEF, VRes and VO2peak, but no distinct poorer prognosis over 2.2 years of follow-up. Distinctively, FEV1/FVC was associated only with VRes, and, in participants with LVEF ≤50%, FEV1/FVC reduction proportionally worsened prognosis. Therefore, FEV1/FVC and ppFVC add supplementary information regarding HF phenotyping.

Relationship of Lung Function and Inspiratory Strength with Exercise Capacity and Prognosis in Heart Failure. / Relação da Função Pulmonar e da Força Inspiratória com Capacidade Aeróbica e com Prognóstico na Insuficiência Cardíaca.

BACKGROUND: Spirometry is underused in heart failure (HF) and the extent to which each defect associates with exercise capacity and prognosis is unclear. OBJECTIVE: To determine the distinct relationship of continuous %predicted FVC (ppFVC) and FEV1/FVC with: 1) maximal inspiratory pressure (MIP), left ventricular ejection fraction (LVEF), exercise performance; and 2) prognosis for the composite of cardiovascular death, heart transplantation or left ventricular assist device implant. METHODS: A cohort of 111 HF participants (AHA stages C/D) without diagnosed pneumopathy, spirometry, manovacuometry and maximum cardiopulmonary test. The association magnitudes were verified by linear and Cox (HR; 95% CI) regressions, age/sex adjusted. A p<0.05 was considered significant. RESULTS: Age was 57±12 years, 60% men, 64% in NYHA III. Every 10%-point increase in FEV1/FVC [ß 7% (95% CI: 3-10)] and ppFVC [4% (2-6)] associated with ventilatory reserve (VRes), however only ppFVC associated with MIP [3.8 cmH2O (0.3-7.3)], LVEF [2.1% (0.5-3.8)] and VO2peak [0.5 mL/kg/min (0.1-1.0)], accounting for age/sex. In 2.2 years (mean), 22 events occurred, and neither FEV1/FVC (HR 1.44; 95% CI: 0.97-2.13) nor ppFVC (HR 1.13; 0.89-1.43) was significantly associated with the outcome. Only in the LVEF ≤50% subgroup (n=87, 20 events), FEV1/FVC (HR 1.50; 1.01-2.23), but not ppFVC, was associated with greater risk. CONCLUSIONS: In chronic HF, reduced ppFVC associated with lower MIP, LVEF, VRes and VO2peak, but no distinct poorer prognosis over 2.2 years of follow-up. Distinctively, FEV1/FVC was associated only with VRes, and, in participants with LVEF ≤50%, FEV1/FVC reduction proportionally worsened prognosis. Therefore, FEV1/FVC and ppFVC add supplementary information regarding HF phenotyping.

FUNDAMENTO: A espirometria é subutilizada na insuficiência cardíaca (IC) e não está claro o grau de associação de cada defeito com a capacidade de exercício e com o prognóstico desses pacientes. OBJETIVO: Determinar a relação da %CVF prevista (ppCVF) e do VEF1/CVF contínuos com: 1) pressão inspiratória máxima (PImáx), fração de ejeção do ventrículo esquerdo (FEVE) e desempenho ao exercício; e 2) prognóstico, para o desfecho composto de morte cardiovascular, transplante cardíaco ou implante de dispositivo de assistência ventricular. MÉTODOS: Coorte de 111 participantes com IC (estágios AHA C/D) sem pneumopatia; foram submetidos a espirometria, manovacuometria e teste cardiopulmonar máximo. As magnitudes de associação foram verificadas por regressões lineares e de Cox (HR; IC 95%), ajustadas para idade/sexo, e p <0,05 foi considerado significativo. RESULTADOS: Com idade média 57±12 anos, 60% eram homens, 64% em NYHAIII. A cada aumento de 10% no VEF1/CVF [ß 7% (IC 95%: 3-10)] e no ppCVF [4% (2-6)], foi associado à reserva ventilatória (VRes); no entanto, apenas o ppCVF associado à PImáx [3,8cmH2O (0,3-7,3)], à fração de ejeção do ventrículo esquerdo (FEVE) [2,1% (0,5-3,8)] e ao VO2 pico [0,5mL/kg/min (0,1-1,0)], considerando idade/sexo. Em 2,2 anos (média), ocorreram 22 eventos; tanto FEV1/FVC (HR 1,44; IC 95%: 0,97-2,13) quanto ppCVF (HR 1,13; 0,89-1,43) não foram associados ao desfecho. Apenas no subgrupo FEVE ≤50% (n=87, 20 eventos), VEF1/CVF (HR 1,50; 1,01-2,23), mas não ppCVF, foi associado a risco. CONCLUSÃO: Na IC crônica, ppCVF reduzido associou-se a menor PImáx, FEVE, VRes e VO2 pico, mas não distinguiu pior prognóstico em 2,2 anos de acompanhamento. Entretanto, VEF1/CVF associou-se apenas com VRes, e, em participantes com FEVE ≤50%, o VEF1/CVF reduzido mostrou pior prognóstico proporcional. Portanto, VEF1/CVF e ppFVC contribuem para melhor fenotipagem de pacientes com IC.