Reduced Body Flexibility Is Associated With Poor Survival in Middle-Aged Men and Women: A Prospective Cohort Study.

OBJECTIVES: Flexibility is recognized as one of the components of physical fitness and commonly included as part of exercise prescriptions for all ages. However, limited data exist regarding the relationship between flexibility and survival. We evaluated the sex-specific nature and magnitude of the associations between body flexibility and natural and non-COVID-19 mortality in a middle-aged cohort of men and women. DESIGN: Prospective cohort study. METHODS: Anthropometric, health and vital data from 3139 (66% men) individuals aged 46-65 years spanning from March 1994 to October 2022 were available. A body flexibility score, termed Flexindex, was derived from a combination of 20 movements (scored 0-4) involving seven different joints, resulting in a score range of 0-80. Kaplan-Meier survival curves were obtained, and unadjusted and adjusted hazard ratios (HRs) for mortality estimated. RESULTS: During a mean follow-up of 12.9 years, 302 individuals (9.6%) comprising 224 men/78 women died. Flexindex was 35% higher in women compared to men (mean ± SD: 41.1 ± 9.4 vs. 30.5 ± 8.7; p < 0.001) and exhibited an inverse relationship with mortality risk in both sexes (p < 0.001). Following adjustment for age, body mass index, and health status, the HR (95% CI) for mortality comparing upper and bottom of distributions of Flexindex were 1.87 (1.50-2.33; p < 0.001) for men and 4.78 (1.23-31.71; p = 0.047) for women. CONCLUSIONS: A component of physical fitness-body flexibility-as assessed by the Flexindex is strongly and inversely associated with natural and non-COVID-19 mortality risk in middle-aged men and women. Future studies should assess whether training-induced flexibility gains are related to longer survival.

Successful 10-second one-legged stance performance predicts survival in middle-aged and older individuals.

OBJECTIVES: Balance quickly diminishes after the mid-50s increasing the risk for falls and other adverse health outcomes. Our aim was to assess whether the ability to complete a 10- s one-legged stance (10-second OLS) is associated with all-cause mortality and whether it adds relevant prognostic information beyond ordinary demographic, anthropometric and clinical data. METHODS: Anthropometric, clinical and vital status and 10-s OLS data were assessed in 1702 individuals (68% men) aged 51-75 years between 2008 and 2020. Log-rank and Cox modelling were used to compare survival curves and risk of death according to ability (YES) or inability (NO) to complete the 10-s OLS test. RESULTS: Overall, 20.4% of the individuals were classified as NO. During a median follow-up of 7 years, 7.2% died, with 4.6% (YES) and 17.5% (NO) on the 10-s OLS. Survival curves were worse for NO 10-s OLS (log-rank test=85.6; p<0.001). In an adjusted model incorporating age, sex, body mass index and comorbidities, the HR of all-cause mortality was higher (1.84 (95% CI: 1.23 to 2.78) (p<0.001)) for NO individuals. Adding 10-s OLS to a model containing established risk factors was associated with significantly improved mortality risk prediction as measured by differences in -2 log likelihood and integrated discrimination improvement. CONCLUSIONS: Within the limitations of uncontrolled variables such as recent history of falls and physical activity, the ability to successfully complete the 10-s OLS is independently associated with all-cause mortality and adds relevant prognostic information beyond age, sex and several other anthropometric and clinical variables. There is potential benefit to including the 10-s OLS as part of routine physical examination in middle-aged and older adults.

Women Have Lower Mortality Than Men After Attending a Long-Term Medically Supervised Exercise Program.

PURPOSE: Medically supervised exercise programs (MSEPs) are equally recommended for men and women with cardiovascular disease (CVD). Aware of the lower CVD mortality in women, we hypothesized that among patients attending a MSEP, women would also have better survival. METHODS: Data from men and women, who were enrolled in a MSEP between 1994 and 2018, were retrospectively analyzed. Sessions included aerobic, resistance, flexibility and balance exercises, and cardiopulmonary exercise test was performed. Date and underlying cause of death were obtained. Kaplan-Meier methods and Cox proportional hazards regression were used for survival analysis. RESULTS: A total of 2236 participants (66% men, age range 33-85 yr) attended a median of 52 (18, 172) exercise sessions, and 23% died during 11 (6, 16) yr of follow-up. In both sexes, CVD was the leading cause of death (39%). Overall, women had a more favorable clinical profile and a longer survival compared to men (HR = 0.71: 95% CI, 0.58-0.85; P < .01). When considering those with coronary artery disease and similar clinical profile, although women had a lower percentage of sex- and age-predicted maximal oxygen uptake at baseline than men (58 vs 78%; P < .01), after adjusting for age, women still had a better long-term survival (HR = 0.68: 95% CI, 0.49-0.93; P = .02). CONCLUSION: Survival after attendance to a long-term MSEP was better among women, despite lower baseline cardiorespiratory fitness. Future studies should address whether men and women would similarly benefit when participating in an MSEP.

4-Second Exercise Test: Reference Values for Ages 18-81 Years.

BACKGROUND: Physiological reflexes modulated primarily by the vagus nerve allow the heart to decelerate and accelerate rapidly after a deep inspiration followed by rapid movement of the limbs. This is the physiological and pharmacologically validated basis for the 4-s exercise test (4sET) used to assess the vagal modulation of cardiac chronotropism. OBJECTIVE: To present reference data for 4sET in healthy adults. METHODS: After applying strict clinical inclusion/exclusion criteria, 1,605 healthy adults (61% men) aged between 18 and 81 years subjected to 4sET were evaluated between 1994 and 2014. Using 4sET, the cardiac vagal index (CVI) was obtained by calculating the ratio between the duration of two RR intervals in the electrocardiogram: 1) after a 4-s rapid and deep breath and immediately before pedaling and 2) at the end of a rapid and resistance-free 4-s pedaling exercise. RESULTS: CVI varied inversely with age (r = -0.33, p < 0.01), and the intercepts and slopes of the linear regressions between CVI and age were similar for men and women (p > 0.05). Considering the heteroscedasticity and the asymmetry of the distribution of the CVI values according to age, we chose to express the reference values in percentiles for eight age groups (years): 18-30, 31-40, 41-45, 46-50, 51-55, 56-60, 61-65, and 66+, obtaining progressively lower median CVI values ranging from 1.63 to 1.24. CONCLUSION: The availability of CVI percentiles for different age groups should promote the clinical use of 4sET, which is a simple and safe procedure for the evaluation of vagal modulation of cardiac chronotropism.

CLINIMEX Aerobic Fitness Questionnaire: Proposal and Validation

Cardiorespiratory (aerobic) fitness is strongly and directly related to major health outcomes, including all-cause mortality. Maximum oxygen uptake (VO2max), directly measured by maximal cardiopulmonary exercise test (CPET), represents the subject's aerobic fitness. However, as CPET is not always available, aerobic fitness estimation tools are necessary. Objectives: a) to propose the CLINIMEX Aerobic Fitness Questionnaire (C-AFQ); b) to validate C-AFQ against measured VO2max; and c) to analyze the influence of some potentially relevant variables on the error of estimate. Methods: We prospectively studied 1,000 healthy and unhealthy subjects (68.6% men) aged from 14 to 96 years that underwent a CPET. The two-step C-AFQ describes physical activities with corresponding values in metabolic equivalents (METs) - ranging from 0.9 to 21 METs. Results: Application of C-AFQ took less than two minutes. Linear regression analysis indicated a very strong association between estimated (C-AFQ) and measured (CPET) maximal METs - r2 = 0.83 (Sy.x = 1.63; p < .001) - with median difference of only 0.2 METs between both values and interquartile range (percentiles 25 and 75) of 2 METs. The difference between estimated and measured METs was not influenced by age, sex, body mass index, clinical condition, ß-blocker use or sitting-rising test scores. Conclusion: C-AFQ is a simple and valid tool for estimating aerobic fitness when CPET is unavailable and it is also useful in planning individual ramp protocols. However, individual error of estimate is quite high, so C-AFQ should not be considered a perfect substitute for CPET's measured VO2max

Ponto Ótimo Cardiorrespiratório em Futebolistas Profissionais: Uma Nova Variável Submáxima do Exercício / Cardiorespiratory Optimal Point in Professional Soccer Players: A Novel Submaximal Variable During Exercise

O consumo máximo de oxigênio (VO2max) e o limiar anaeróbico (LA) obtidos no teste cardiopulmonar de exercício (TCPE) são utilizados na avaliação de atletas. Todavia, dificuldades na identificação e mensuração dessas variáveis dificultam sua utilização prática. O ponto ótimo cardiorrespiratório (POC) é uma variável submáxima do TCPE de mensuração objetiva e com significado clínico prognóstico. Contudo, é desconhecido o seu comportamento em atletas. Objetivo: Descrever o comportamento do POC em jogadores profissionais de futebol e sua associação com VO2max e LA. Materiais e Método: Análise retrospectiva de 198 futebolistas submetidos a TCPE máximo em esteira rolante com protocolo em rampa, divididos pela posição em campo: goleiro, zagueiro, lateral, meio-campo e atacante. Foram determinados VO2max, LA e POC. O POC correspondeu ao menor valor de ventilação/consumo de oxigênio em um dado minuto do TCPE. Variáveis contínuas foram comparadas pelo teste t de Student não emparelhado ou ANOVA, ou teste de Mann-Whitney ou de Kruskal-Wallis dependendo na distribuição das mesmas, e variáveis categóricas foram comparadas pelo teste do qui-quadrado. A correlação de Pearson foi utilizada para testar a associação entre POC e outras variáveis ventilatórias. Adotou-se um nível de 5% para significância estatística. Resultados: O POC (média ± desvio-padrão) foi de 18,2 ± 2,1 a uma velocidade 4,3 ± 1,4 km.h-1 menor do que a do LA. Enquanto o VO2max (62,1 ± 6,2 mL.kg-1.min-1) tendeu a ser menor nos goleiros (p < 0,05), o POC não variou conforme a posição em campo (p = 0,41). Não houve associação significativa entre POC e VO2max (r = 0,032, p = 0,65) nem com LA (r = -0,003, p = 0,96). Conclusão: O POC pode ser facilmente determinado em exercício submáximo realizado com velocidades incrementais em futebolistas e não varia pela posição em campo. A ausência de associação com VO2max e LA indica que o POC traz uma informação distinta e complementar a essas variáveis. Estudos futuros são necessários para determinar implicações práticas do POC na avaliação de atletas

Maximal oxygen consumption (VO2max) and ventilatory threshold (VT) obtained during a cardiopulmonary exercise test (CPX) are used in the evaluation of athletes. However, the identification of these variables may sometimes be unreliable, which limits their use. In contrast, the cardiorespiratory optimal point (COP) is a submaximal variable derived from CPX with objective measurement and prognostic significance. However, its behavior in athletes is unknown. Objective: To describe the behavior of COP in professional soccer players and its association with VO2max and VT. Methods: VO2max, VT and COP were obtained retrospectively from 198 soccer players undergoing maximal treadmill CPX using ramp protocol. COP was defined as the lowest value of the ventilation/oxygen consumption ratio in a given minute of the CPX. The soccer players were stratified according to their field position: goalkeeper, center-defender, left/right-back, midfielder and forwarder. Continuous variables were compared using unpaired Student t test or ANOVA, or Mann-Whitney test or Kruskal-Wallis test depending on their distribution, and categorical variables were compared using chi-square test. Pearson correlation was used to test the association between COP and other ventilatory variables. A level of 5% was used for statistical significance. Results: COP (mean ± SD) was 18.2 ± 2.1 and was achieved at a speed 4.3 ± 1.4 km.h-1 lower than that achieved at the VT. While VO2max (62.1 ± 6.2 mL.kg-1.min-1) tended to be lower in goalkeepers (p < 0.05), the COP did not vary according to field position (p = 0.41). No significant association was observed between COP and VO2max (r = 0.032, p = 0.65) or between COP and VT (r = -0.003, p = 0.96). Conclusion: COP can be easily determined during submaximal exercise performed with incremental speed in soccer players and does not vary according to the athlete's field position. The absence of association with VO2max and VT indicates that COP provides distinct and complementary information to these variables. Future studies are needed to determine the practical implications of COP in assessing athletes

Ponto ótimo cardiorrespiratório em futebolistas profissionais: uma nova variável submáxima do exercício / Cardiorespiratory optimal point in professional soccer players: a novel submaximal variable during exercise

O consumo máximo de oxigênio (VO2 max) e o limiar anaeróbico (LA) obtidos no teste cardiopulmonar de exercício (TCPE) são utilizados na avaliação de atletas. Todavia, dificuldades na identificação e mensuração dessas variáveis dificultam sua utilização prática. O ponto ótimo cardiorrespiratório (POC) é uma variável submáxima do TCPE de mensuração objetiva e com significado clínico prognóstico. Contudo, é desconhecido o seu comportamento em atletas.Descrever o comportamento do POC em jogadores profissionais de futebol e sua associação com VO2 max e LA. Análise retrospectiva de 198 futebolistas submetidos a TCPE máximo em esteira rolante com protocolo em rampa, divididos pela posição em campo: goleiro, zagueiro, lateral, meio-campo e atacante. Foram determinados VO2max, LA e POC. O POC correspondeu ao menor valor de ventilação/consumo de oxigênio em um dado minuto do TCPE. Variáveis contínuas foram comparadas pelo teste t de Student não emparelhado ou ANOVA, ou teste de Mann-Whitney ou de Kruskal-Wallis dependendo na distribuição das mesmas, e variáveis categóricas foram comparadas pelo teste do qui-quadrado. A correlação de Pearson foi utilizada para testar a associação entre POC e outras variáveis ventilatórias. Adotou-se um nível de 5% para significância estatística. O POC (média ± desvio-padrão) foi de 18,2 ± 2,1 a uma velocidade 4,3 ± 1,4 km.h-1 menor do que a do LA. Enquanto o VO2 max (62,1 ± 6,2 mL.kg-1.min-1) tendeu a ser menor nos goleiros (p < 0,05), o POC não variou conforme a posição em campo (p = 0,41). Não houve associação significativa entre POC e VO2max (r = 0,032,p = 0,65) nem com LA (r = -0,003, p = 0,96).O POC pode ser facilmente determinado em exercício submáximo realizado com velocidades incrementais em futebolistas e não varia pela posição em campo. A ausência de associação com VO2max e LA indica que o POC traz uma informação distinta e complementar a essas variáveis. Estudos futuros são necessários para determinar implicações práticas do POC na avaliação de atletas

Maximal oxygen consumption (VO2max) and ventilatory threshold (VT) obtained during a cardiopulmonary exercise test (CPX) are used in the evaluation of athletes. However, the identification of these variables may sometimes be unreliable, which limits their use. In contrast, the cardiorespiratory optimal point (COP) is a submaximal variable derived from CPX with objective measurement and prognostic significance. However, its behavior in athletes is unknown. To describe the behavior of COP in professional soccer players and its association with VO2max and VT. VO2max, VT and COP were obtained retrospectively from 198 soccer players undergoing maximal treadmill CPX using ramp protocol. COP was defined as the lowest value of the ventilation/oxygen consumption ratio in a given minute of the CPX. The soccer players were stratified according to their field position: goalkeeper, center-defender, left/right-back, midfielder and forwarder. Continuous variables were compared using unpaired Student t test or ANOVA, or Mann-Whitney test or Kruskal-Wallis test depending on their distribution, and categorical variables were compared using chi-square test. Pearson correlation was used to test the association between COP and other ventilatory variables. A level of 5% was used for statistical significance. COP (mean ± SD) was 18.2 ± 2.1 and was achieved at a speed 4.3 ± 1.4 km.h-1 lower than that achieved at the VT. While VO2max (62.1 ± 6.2 mL.kg-1.min-1) tended to be lower in goalkeepers (p < 0.05), the COP did not vary according to field position (p = 0.41). No significant association was observed between COP and VO2max (r = 0.032, p = 0.65) or between COP and VT (r = -0.003, p = 0.96). COP can be easily determined during submaximal exercise performed with incremental speed in soccer players and does not vary according to the athlete's field position. The absence of association with VO2max and VT indicates that COP provides distinct and complementary information to these variables. Future studies are needed to determine the practical implications of COP in assessing athletes

4-Second Exercise Test: Reference Values for Ages 18–81 Years / Teste de Exercício de 4 Segundos: Valores de Referência dos 18 aos 81 Anos de Idade

Background: Physiological reflexes modulated primarily by the vagus nerve allow the heart to decelerate and accelerate rapidly after a deep inspiration followed by rapid movement of the limbs. This is the physiological and pharmacologically validated basis for the 4-s exercise test (4sET) used to assess the vagal modulation of cardiac chronotropism. Objective: To present reference data for 4sET in healthy adults. Methods: After applying strict clinical inclusion/exclusion criteria, 1,605 healthy adults (61% men) aged between 18 and 81 years subjected to 4sET were evaluated between 1994 and 2014. Using 4sET, the cardiac vagal index (CVI) was obtained by calculating the ratio between the duration of two RR intervals in the electrocardiogram: 1) after a 4-s rapid and deep breath and immediately before pedaling and 2) at the end of a rapid and resistance-free 4-s pedaling exercise. Results: CVI varied inversely with age (r = -0.33, p < 0.01), and the intercepts and slopes of the linear regressions between CVI and age were similar for men and women (p > 0.05). Considering the heteroscedasticity and the asymmetry of the distribution of the CVI values according to age, we chose to express the reference values in percentiles for eight age groups (years): 18–30, 31–40, 41–45, 46–50, 51–55, 56–60, 61–65, and 66+, obtaining progressively lower median CVI values ranging from 1.63 to 1.24. Conclusion: The availability of CVI percentiles for different age groups should promote the clinical use of 4sET, which is a simple and safe procedure for the evaluation of vagal modulation of cardiac chronotropism. .

Fundamento: Reflexos fisiológicos modulados primariamente pelo vago permitem que a frequência cardíaca diminua e aumente rapidamente, após uma inspiração profunda seguida da movimentação rápida dos membros. Essa é a base fisiológica e farmacologicamente validada do teste de exercício de 4 segundos (T4s) para a avaliação da modulação vagal sobre o cronotropismo cardíaco. Objetivo: Apresentar os dados de referência do T4s em adultos saudáveis. Métodos: Após aplicação de rígidos critérios clínicos de inclusão/exclusão foram estudados 1.605 adultos saudáveis (61% homens), entre 18 e 81 anos de idade, submetidos ao T4s, entre 1994 e 2014. No T4s, o Índice Vagal Cardíaco (IVC) foi obtido pela razão entre as durações de dois intervalos RR no traçado eletrocardiográfico: 1) após 4 segundos de inspiração rápida e profunda e imediatamente antes da pedalada; e 2) ao final da pedalada livre e rápida de 4 segundos. Resultados: IVC varia inversamente com a idade (r = - 0,33; p < 0,01) e os interceptos e as inclinações das regressões lineares entre IVC e idade são similares para homens e mulheres (p > 0,05). Considerando a heterocedasticidade e a assimetria da distribuição de IVC em função da idade, optou-se por expressar os valores de referência em percentis para oito faixas etárias (anos): 18-30, 31-40, 41-45, 46-50, 51-55, 56-60, 61-65 e 66+, obtendo-se medianas de IVC progressivamente menores de 1,63 a 1,24. Conclusão: A disponibilização dos percentis de IVC por diferentes faixas etárias deverá facilitar a maior utilização clínica do T4s, um procedimento simples e seguro, para a avaliação da modulação vagal do cronotropismo cardíaco. .

Prevalência de marcador de risco tardio no eletrocardiograma de repouso de futebolistas brasileiros e africanos / Prevalence of late-risk marker in alt-rest elctrocardiograms of brazilian and african soccer players

Fundamentos: A morte de atletas durante um treino ou evento desportivo, ainda que bastante raro, tem atraído a atenção dos médicos, da mídia e da população leiga. Objetivo: Identificar a prevalência do marcador eletrocardiográfico de risco relativo tardio em atletas, proposto por Pelliccia et al., em futebolistas adultos e profissionais de duas populações geograficamente distintas. Métodos: Utilizando registros eletrocardiográficos (ECG) digitais em repouso, três médicos experientes na interpretação de ECG de atletas identificaram a presença ou ausência do marcador – três ou mais derivações, exceto aVR e DIII, com onda T negativa de 2mm ou mais de amplitude - em 83 futebolistas que completaram todo o protocolo de avaliação médica e funcional pré-participação desportiva, entre junho de 2007 e fevereiro de 2008, sendo 46 deles de um clube do Rio de Janeiro e 37 de equipes africanas. A avaliação médico-funcional incluía a obtenção de dados cineantropométricos e a medida direta do consumo máximo de oxigênio. Resultados: As características cineantropométricas e funcionais dos atletas testados foram compatíveis com o desempenho de excelência em futebol (ex. VO2 máximo médio de 63mL/kg.min). Em 6 (7,2%) – 2 brasileiros e 4 africanos - dos 83 jogadores, houve concordância absoluta entre os três avaliadores médicos em identificar a presença do marcador de Pelliccia. Conclusões: Sugere-se que esses atletas sejam acompanhados com uma maior atenção, incluindo a obtenção de ECG de repouso e de outros exames, visando a reduzir a probabilidade de eventos fatais durante a prática desportiva, que parece ser mais comum nos atletas com presença desse marcador.

Background: Although quite rare, deaths of athletes during sports events or training sessions attract the attention of physicians, the media and lay persons. Objective: To identify the prevalence of a relative late-risk electrocardiographic marker for athletes, proposed by Pelliccia et al., among adult professional soccer players in two geographically distinct populations. Methods: Using at-rest digital electrocardiographic (ECG) records, three physicians experienced in interpreting the ECGs of athletes, identified the presence or absence of the marker − three or more derivations except aVR and DIII, with negative T wave of 2mm or more − among 83 soccer players who completed the entire protocol of medical and functional sport pre-participation evaluation, between June 2007 and February 2008, with 46 of them from a club in Rio de Janeiro and 37 from African teams. The medical and functional evaluations included kinanthropometric data and direct measurements of maximum oxygen consumption. Results: The kinanthropometric and functional characteristics of the athletes tested were compatible with excellent soccer performance (eg. VO2 maximum average of 63mL/kg.min). In 6 (7,2%) - 2 Brazilians and 4 Africans - of the 83 players there was absolute concordance between the three evaluators in identifying the presence of Pelliccia’s marker. Conclusions: It is suggested that these athletes should be accompanied with greater attention, including periodic at-rest ECGs and other tests, in order to lessen the likelihood of fatal events during sports activities, which seem to be more common among athletes in the presence of this marker.