Association Between Protocols of the Sit-to-Stand Test and Lower Limb Muscle Force Output in Patients on Hemodialysis and Subjects Without Chronic Kidney Disease.

OBJECTIVE: To evaluate the association of three protocols of the sit-to-stand (STS) test with muscle force output of knee extension (KE) and knee flexion (KF) in patients on hemodialysis and subjects without chronic kidney disease. METHODS: This cross-sectional study included a hemodialysis group [n = 60, 59.5 (16.8) years, 55% female] and a control group [n = 60, 43.0 (11.8) years, 50% female]. The assessments were performed in 2 days, and the participants were submitted to three protocols of STS test (5-repetition STS, 10-repetition STS and 30-s STS) or muscle force output of the KE and KF evaluation by handheld dynamometer based on randomization. RESULTS: The hemodialysis group presented reduced muscle force output of the KE and KF, a longer time to perform the 5 STS and 10 STS tests, and a lower number of repetitions in the 30-s STS test. The three STS tests were associated with muscle force output of the KE in the hemodialysis group, in which the 10-repetition STS test showed the best association (R2 = 0.47; adjusted R2 = 0.42). However, the only association between the STS test and muscle force output of the KE in the control group was found in the 10-repetition STS test (R2 = 0.20; adjusted R2 = 0.13). CONCLUSIONS: The three protocols of STS tests were associated with muscle force output of the KE in patients on hemodialysis. However, the 10-repetition STS test was the best protocol to estimate the quadriceps muscle torque in these patients.

Global research publications on cardiovascular and pulmonary rehabilitation and their alignment with population rehabilitation needs: An ecological study.

PURPOSE: Towards informing health research policy and planning, this article evaluates the relationship of the research publications in cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) with the rehabilitation needs arising from cardiovascular diseases (except stroke) and chronic respiratory diseases, over time (1990-2017). METHODS: Ecological study using a secondary analysis and linear regressions of public domain data to associate two datasets of population-level data: (1) research publications for CR and PR (data from the PubMed database); and (2) global need for CR and PR (data from the Global Burden of Disease study). RESULTS: The percentage of both CR and PR publications (among total rehabilitation research) significantly decreased from 1990 to 2017 (both: p < 0.01). PR needs and research publications were aligned: around 5% of total rehabilitation needs and rehabilitation research. For CR needs (around 2%, but significantly increasing since 1990), we found a greater portion of CR research publications (6.5% or over). Finally, we found an inverse association among the percentage of CR research publications and CR needs (b = -6.08; r2  = 0.37, p = 0.001). CONCLUSION: The portion of CR and PR research (among total rehabilitation research) is declining over time. Yearly percentage of CR publications were greater than those of PR but for lower level of rehabilitation need, but the disparate trend was significantly decreasing over time. Population rehabilitation needs and their alignment with research volume must be one factor in the design of population-centred, equitable health research priorities.

Exercise training during hemodialysis in Brazil: A national survey.

To evaluate the availability and characteristics of exercise training during hemodialysis in Brazil and to identify the reported barriers to exercise program implementation and maintenance. All dialysis units were assessed for eligibility using the database of the Brazilian Society of Nephrology. Each dialysis unit was contacted by telephone and the questions were administered. In dialysis units with exercise training, questions related to personnel involved, exercise components, and program delivery were included. Additionally, the barriers to exercise program implementation and maintenance were evaluated. This study included 261 dialysis units that responded to the survey. Forty-one dialysis units reported exercise training during hemodialysis in Brazil (prevalence of 15.7%). We identified 66 physiotherapists and 10 exercise physiologists in dialysis units with exercise training. Resistance training was the most common program component (92.7%). Hypotension (90.5%) and muscle cramps (85.7%) were the most common adverse events reported. In dialysis units with exercise training, poor patients' adherence to exercise was the most commonly reported barrier. The most prevalent barrier in dialysis units that tried or never tried to implement the exercise programs was a lack of resources. The number of dialysis units that have exercise training during hemodialysis in Brazil is low, and the most common program component is resistance training. A lack of resources was the most prevalent barrier in dialysis units that tried or never tried to implement the exercise programs.

Effect of low-level laser therapy on the inflammatory response in an experimental model of ventilator-induced lung injury.

The effect of low-level laser therapy (LLLT) on an experimental model of ventilator-induced lung injury (VILI) was evaluated in this study. 24 adult Wistar rats were randomized into four groups: protective mechanical ventilation (PMV), PMV + laser, VILI and VILI + laser. The animals of the PMV and VILI groups were ventilated with tidal volumes of 6 and 35 ml kg-1, respectively, for 90 minutes. After the first 60 minutes of ventilation, the animals in the laser groups were irradiated (808 nm, 100 mW power density, 20 J cm-2 energy density, continuous emission mode, and exposure time of 5 s) and after 30 minutes of irradiation, the animals were euthanized. Lung samples were removed for morphological analysis, bronchoalveolar lavage (BAL) and real time quantitative polynucleotide chain reaction (RT-qPCR). The VILI group showed a greater acute lung injury (ALI) score with an increase in neutrophil infiltration, higher neutrophil count in the BAL fluid and greater cytokine mRNA expression compared to the PMV groups (p < 0.05). The VILI + laser group when compared to the VILI group showed a lower ALI score (0.35 ± 0.08 vs. 0.54 ± 0.13, p < 0.05), alveolar neutrophil infiltration (7.00 ± 5.73 vs. 21.50 ± 9.52, p < 0.05), total cell count (1.90 ± 0.71 vs. 4.09 ± 0.96 × 105, p < 0.05) and neutrophil count in the BAL fluid (0.60 ± 0.37 vs. 2.28 ± 0.48 × 105, p < 0.05). Moreover, LLLT induced a decrease in pro-inflammatory and an increase of anti-inflammatory mRNA levels compared to the VILI group (p < 0.05). In conclusion, LLLT was found to reduce the inflammatory response in an experimental model of VILI.

Objectively measured daily-life physical activity of moderate-to-severe Brazilian asthmatic women in comparison to healthy controls: A cross-sectional study.

Considering the complex relationship between asthma symptoms and exercise, asthmatics are usually believed to be less active in daily life than healthy subjects. However, few studies have objectively assessed daily-life physical activity (DLPA) of asthmatic adults. OBJECTIVE: To objectively assess DLPA of a sample of Brazilian asthmatic women in comparison to healthy controls, and to investigate the associations between DLPA and asthma control, health-related quality of life, anxiety and depression levels, and the Six-minute walk test (6MWT) in this population. METHODS: Sixty-six women were included, 36 in the asthma group (AG) and 30 in the control group (CG). The AG was composed by clinically stable moderate-to-severe asthmatics. The CG was composed by apparently healthy volunteers. All subjects underwent DLPA assessment (considered as the average of steps taken during six consecutive days measured by a pedometer) and performed the 6MWT. Additionally, participants in the AG were assessed using the Asthma Control Questionnaire, the Asthma Quality of Life Questionnaire (AQLQ), and the Hospital Anxiety and Depression Scale. RESULTS: There was no difference between the AG and the CG regarding DLPA (7490.3 ± 3330.2 vs 6876.4 ± 3242.1 steps respectively, p = 0.45), even after adjustment for covariates. DLPA was significantly correlated to the activity limitation domain of the AQLQ among asthmatics (r = 0.43, p < 0.01). CONCLUSION: Despite the association between self-perceived activity limitation and DLPA among asthmatics, there were no differences regarding DLPA between a sample of moderate-to-severe Brazilian asthmatic women and apparently healthy controls.

Effects of an unsupervised pedometer-based physical activity program on daily steps of adults with moderate to severe asthma: a randomized controlled trial.

Supervised exercise has shown benefits for subjects with asthma, but little is known about the effectiveness of unsupervised physical activity on this population. We investigated the effects of a 12-week unsupervised pedometer-based physical activity program on daily steps and on clinical and psychological parameters of adults with asthma. Clinically stable adults with moderate to severe asthma were encouraged to take daily 30-minute walks and were randomized to pedometer and control groups. The pedometer group received pedometers and individualized daily step targets. Changes in daily steps (average of steps taken during six consecutive days), six-minute walk test (6MWT), health-related quality of life, asthma control and anxiety and depression levels were assessed 12 weeks after intervention and 24-28 weeks after randomization. Thirty-seven participants were recruited and 30 completed the intervention. At 12 weeks, the groups differed significantly in daily steps (adjusted average difference, 2488 steps; 95% confidence interval [CI], 803 to 4172; p = 0.005) and in the 6MWT (adjusted average difference, 21.9 m; 95% CI, 6.6 to 37.3; p = 0.006). These differences were not significant 24-28 weeks after randomization. The program was effective in increasing daily steps of adults with moderate to severe asthma 12 weeks after intervention.

Factors Associated With Functional Capacity in Hemodialysis Patients.

Hemodialysis patients have a marked decrease in functional capacity when compared to healthy individuals. We evaluated the factors associated with functional capacity in hemodialysis patients. A total of 102 hemodialysis patients were evaluated. The patients were submitted to a 6-min walk test, peripheral muscle strength tests, and an evaluation of quality of life, anxiety, and depression. The laboratory data were measured. The 6-min walk test distance correlated significantly with age, educational level, hemoglobin, creatinine, number of comorbidities, peripheral muscle strength, and some domains of SF-36 quality of life questionnaire and depression (P < 0.05). Multiple linear regression showed that educational level, hemoglobin, peripheral muscle strength, and depression significantly affected the 6-min walk test distance (P < 0.05). The multiple correlation coefficient was 0.74, and the squared multiple correlation coefficient adjusted was 0.52. In conclusion, functional capacity was significantly associated with educational level, hemoglobin, peripheral muscle strength, and depression in hemodialysis patients.

Emphysema induced by elastase enhances acute inflammatory pulmonary response to intraperitoneal LPS in rats.

Abnormalities in lungs caused by emphysema might alter their response to sepsis and the occurrence of acute lung injury (ALI). This study compared the extension of ALI in response to intraperitoneal lipopolysaccharide (LPS) injection in Wistar rats with and without emphysema induced by elastase. Adult male Wistar rats were randomized into four groups: control, emphysema without sepsis, normal lung with sepsis and emphysema with sepsis. Sepsis was induced, and 24 h later the rats were euthanised. The following analysis was performed: blood gas measurements, bronchoalveolar lavage (BAL), lung permeability and histology. Animals that received LPS showed significant increase in a lung injury scoring system, inflammatory cells in bronchoalveolar lavage (BAL) and IL-6, TNF-α and CXCL2 mRNA expression in lung tissue. Animals with emphysema and sepsis showed increased alveolocapillary membrane permeability, demonstrated by higher BAL/serum albumin ratio. In conclusion, the presence of emphysema induced by elastase increases the inflammatory response in the lungs to a systemic stimulus, represented in this model by the intraperitoneal injection of LPS.

The Effects of Prone Position Ventilation on Experimental Mild Acute Lung Injury Induced by Intraperitoneal Lipopolysaccharide Injection in Rats.

INTRODUCTION: The benefits of prone position ventilation are well demonstrated in the severe forms of acute respiratory distress syndrome, but not in the milder forms. We investigated the effects of prone position on arterial blood gases, lung inflammation, and histology in an experimental mild acute lung injury (ALI) model. METHODS: ALI was induced in Wistar rats by intraperitoneal Escherichia coli lipopolysaccharide (LPS, 5 mg/kg). After 24 h, the animals with PaO2/FIO2 between 200 and 300 mmHg were randomized into 2 groups: prone position (n = 6) and supine position (n = 6). Both groups were compared with a control group (n = 5) that was ventilated in the supine position. All of the groups were ventilated for 1 h with volume-controlled ventilation mode (tidal volume = 6 ml/kg, respiratory rate = 80 breaths/min, positive end-expiratory pressure = 5 cmH2O, inspired oxygen fraction = 1) RESULTS: Significantly higher lung injury scores were observed in the LPS-supine group compared to the LPS-prone and control groups (0.32 ± 0.03; 0.17 ± 0.03 and 0.13 ± 0.04, respectively) (p < 0.001), mainly due to a higher neutrophil infiltration level in the interstitial space and more proteinaceous debris that filled the airspaces. Similar differences were observed when the gravity-dependent lung regions and non-dependent lung regions were analyzed separately (p < 0.05). The BAL neutrophil content was also higher in the LPS-supine group compared to the LPS-prone and control groups (p < 0.05). There were no significant differences in the wet/dry ratio and gas exchange levels. CONCLUSIONS: In this experimental extrapulmonary mild ALI model, prone position ventilation for 1 h, when compared with supine position ventilation, was associated with lower lung inflammation and injury.

Driving pressure, as opposed to tidal volume based on predicted body weight, is associated with mortality: results from a prospective cohort of COVID-19 acute respiratory distress syndrome patients.

OBJECTIVE: To evaluate the association between driving pressure and tidal volume based on predicted body weight and mortality in a cohort of patients with acute respiratory distress syndrome caused by COVID-19. METHODS: This was a prospective, observational study that included patients with acute respiratory distress syndrome due to COVID-19 admitted to two intensive care units. We performed multivariable analyses to determine whether driving pressure and tidal volume/kg predicted body weight on the first day of mechanical ventilation, as independent variables, are associated with hospital mortality. RESULTS: We included 231 patients. The mean age was 64 (53 - 74) years, and the mean Simplified Acute and Physiology Score 3 score was 45 (39 - 54). The hospital mortality rate was 51.9%. Driving pressure was independently associated with hospital mortality (odds ratio 1.21, 95%CI 1.04 - 1.41 for each cm H2O increase in driving pressure, p = 0.01). Based on a double stratification analysis, we found that for the same level of tidal volume/kg predicted body weight, the risk of hospital death increased with increasing driving pressure. However, changes in tidal volume/kg predicted body weight were not associated with mortality when they did not lead to an increase in driving pressure. CONCLUSION: In patients with acute respiratory distress syndrome caused by COVID-19, exposure to higher driving pressure, as opposed to higher tidal volume/kg predicted body weight, is associated with greater mortality. These results suggest that driving pressure might be a primary target for lung-protective mechanical ventilation in these patients.

Effect of a structured early mobilization protocol on the level of mobilization and muscle strength in critical care patients: A randomized clinical trial.

BACKGROUND: Few studies have evaluated the effects of structured early mobilization (EM) protocols on the level of mobilization in critical care patients. OBJECTIVE: To evaluate the impact of a structured EM protocol on the level of mobilization, muscle strength, and the level of activities of daily living (LADL) after intensive care unit (ICU) and hospital discharge. METHODS: This randomized clinical trial (U1111-1245-4840) included adults patients who were randomized into two groups: intervention (n = 40) and control (n = 45). The intervention group underwent conventional physiotherapy and structured EM protocols, and the control group underwent conventional physiotherapy. The level of mobilization from 0 (no mobilization) to 5 (walking), muscle strength (Medical Research Council scale), LADL (Katz Index), and incidence of complications were evaluated. RESULTS: The level of mobilization from day 1 to day 7 increased in the intervention group compared with the control group (p < .05). Muscle strength did not change during the protocol in the intervention and control groups {day 1 [effect size (r) = 0.15, p = .161], at ICU discharge [r = 0.16, p = .145], and after ICU discharge [r = 0.16, p = .191]}. The LADL did not differ between the intervention and control groups after ICU discharge [4 (1-6) vs. 3 (1-5), p = .702] or 30 days after hospital discharge [6 (5-6) vs. 6 (5-6), p = .945]. The structured EM protocol was safe, and no severe complications were observed during the protocol. CONCLUSION: A structured EM protocol increased the level of mobilization without improving muscle strength and the LADL compared with conventional physiotherapy.

Association between fear of falling and a history of falls in patients with end-stage renal disease on hemodialysis.

INTRODUCTION: Hemodialysis patients have complications that increase fear of falling (FOF). This study evaluated the association between FOF and a retrospective history of falls in hemodialysis patients and investigated the ability of the Fall Efficacy Scale-International (FES-I) to discriminate fallers from nonfallers. METHODS: A retrospective study was conducted with 183 patients to investigate the history of falls in the last 12 months and to evaluate FOF by the FES-I. RESULTS: The univariate linear regression model showed that the FES-I score was significantly associated with a history of falls (p = 0.01). After adjustment for potential confounders, this association remained significant (R2  = 0.19, p < 0.001). The FES-I score showed an area under the curve of 0.660 with a cutoff point of 25 (sensitivity-61.8%; specificity-62.2%). CONCLUSION: FOF was associated with a history of falls in the 12-month period in hemodialysis patients, and FOF assessed by the FES-I was able to discriminate fallers from nonfallers.

Effects of atelectatic areas on the surrounding lung tissue during mechanical ventilation in an experimental model of acute lung injury induced by lipopolysaccharide.

OBJECTIVE: To assess the effect of atelectasis during mechanical ventilation on the periatelectatic and normal lung regions in a model of atelectasis in rats with acute lung injury induced by lipopolysaccharide. METHODS: Twenty-four rats were randomized into the following four groups, each with 6 animals: the Saline-Control Group, Lipopolysaccharide Control Group, Saline-Atelectasis Group, and Lipopolysaccharide Atelectasis Group. Acute lung injury was induced by intraperitoneal injection of lipopolysaccharide. After 24 hours, atelectasis was induced by bronchial blocking. The animals underwent mechanical ventilation for two hours with protective parameters, and respiratory mechanics were monitored during this period. Thereafter, histologic analyses of two regions of interest, periatelectatic areas and the normally-aerated lung contralateral to the atelectatic areas, were performed. RESULTS: The lung injury score was significantly higher in the Lipopolysaccharide Control Group (0.41 ± 0.13) than in the Saline Control Group (0.15 ± 0.51), p < 0.05. Periatelectatic regions showed higher lung injury scores than normally-aerated regions in both the Saline-Atelectasis (0.44 ± 0.06 x 0.27 ± 0.74 p < 0.05) and Lipopolysaccharide Atelectasis (0.56 ± 0.09 x 0.35 ± 0.04 p < 0.05) Groups. The lung injury score in the periatelectatic regions was higher in the Lipopolysaccharide Atelectasis Group (0.56 ± 0.09) than in the periatelectatic region of the Saline-Atelectasis Group (0.44 ± 0.06), p < 0.05. CONCLUSION: Atelectasis may cause injury to the surrounding tissue after a period of mechanical ventilation with protective parameters. Its effect was more significant in previously injured lungs.

Factors associated with postural balance in patients with end-stage renal disease on hemodialysis.

BACKGROUND: Patients with end-stage renal disease on hemodialysis have postural balance impairments due to uremic syndrome and hemodialysis complications. This study evaluated the factors associated with postural balance in patients on hemodialysis. METHODS: This cross-sectional study included patients on hemodialysis [n = 93, 62.0 (16.0) years]. Postural balance was evaluated using a force plate in a static position with eyes opened and eyes closed on a firm surface and with eyes opened on a foam surface to register the center of pressure path length. Physical function was assessed by isometric handgrip force, the 5-repetition sit-to-stand test, and gait speed. The level of physical activity and quality of life were evaluated by accelerometry and the 36-Item Short Form Health Survey, respectively. FINDINGS: After adjustment for potential confounders, the multiple linear regression analysis showed that the presence of diabetes mellitus and neurological disease and gait speed were significantly associated with the center of pressure path length in the eyes opened test (R2 = 0.263; p < 0.001). The center of pressure path length in the eyes closed test was significantly associated with the presence of neurological disease (R2 = 0.177; p = 0.002). The center of pressure path length in the eyes opened on a foam surface test was significantly associated with the presence of diabetes mellitus (R2 = 0.223; p < 0.001). INTERPRETATION: Poor postural balance was associated with the presence of diabetes mellitus and neurological disease and a slower gait speed in patients on hemodialysis.

Profile of professionals working in intradialytic exercise programs in Brazil: a national survey.

OBJECTIVE: This survey was designed to assess the profile of professionals working in intradialytic exercise programs (IEPs) in Brazil and reveal the motivators and barriers they face. METHODS: The survey was sent to physiotherapists and exercise physiologists working in IEPs in Brazil. Phone interviews and electronic forms were used to collect the answers to the survey questionnaire. RESULTS: Forty-one of the 261 included dialysis centers had IEPs; 44 professionals answered the questionnaire over the phone and 26 used the electronic form to do it. A total of 70 professionals (mean age 33.4±7.4 years; 84.3% physiotherapists) answered the questionnaire. Resistance training was the preferred mode of therapy. Most of the IEPs were connected to research and were paid for by private health insurance. The desire to work in a different field (30.0%) and lack of resources (31.4%) were the most prevalent motivator and barrier cited by IEP professionals working in dialysis centers, respectively. CONCLUSION: The majority of the few professionals that work in IEPs in Brazil are physiotherapists. Lack of resources was the most commonly reported barrier faced by survey respondents.

Protective mechanical ventilation in patients with risk factors for ARDS: prospective cohort study.

OBJECTIVE: To evaluate the association that protective mechanical ventilation (MV), based on VT and maximum distending pressure (MDP), has with mortality in patients at risk for ARDS. METHODS: This was a prospective cohort study conducted in an ICU and including 116 patients on MV who had at least one risk factor for the development of ARDS. Ventilatory parameters were collected twice a day for seven days, and patients were divided into two groups (protective MV and nonprotective MV) based on the MDP (difference between maximum airway pressure and PEEP) or VT. The outcome measures were 28-day mortality, ICU mortality, and in-hospital mortality. The risk factors associated with the adoption of nonprotective MV were also assessed. RESULTS: Nonprotective MV based on VT and MDP was applied in 49 (42.2%) and 38 (32.8%) of the patients, respectively. Multivariate Cox regression showed that protective MV based on MDP was associated with lower in-hospital mortality (hazard ratio = 0.37; 95% CI: 0.19-0.73) and lower ICU mortality (hazard ratio = 0.40; 95% CI: 0.19-0.85), after adjustment for age, Simplified Acute Physiology Score 3, and vasopressor use, as well as the baseline values for PaO2/FiO2 ratio, PEEP, pH, and PaCO2. These associations were not observed when nonprotective MV was based on the VT. CONCLUSIONS: The MDP seems to be a useful tool, better than VT, for adjusting MV in patients at risk for ARDS.

Factors Associated with Functional Capacity in CKD Patients.

To evaluate the factors associated with functional capacity in patients with chronic kidney disease (CKD). All patients were submitted to six-minute walk test (6MWT), 10-repetition sit-to-stand test (STS-10) and SF-36 health-related quality of life questionnaire (HRQoL). Patients with functional capacity ≥80% exhibited higher education level, family income, body mass index, estimated glomerular filtration rate, and lower age and STS-10 time. Multiple linear regression showed that gender, age, family income, chronic kidney disease stage, STS-10 time, and physical component summary of HRQoL were significantly associated with the 6MWT distance. Functional capacity was significantly associated with gender, age, family income, CKD stage, STS-10 time, and physical component of HRQoL. The progression of CKD has an impact on the decrease in functional capacity in these patients.

Factors associated with fear of falling in hemodialysis patients.

PURPOSE: Fear of falling (FOF) has important clinical and psychological consequences. This study evaluated the factors associated with FOF in hemodialysis patients and compared with the FOF reported by age-gender matched individuals without chronic kidney disease. METHODS: This cross sectional study included hemodialysis group (n = 60, 55.4 ± 7.6 years, 55.0% male) and control group (n = 40, 55.1 ± 7.5 years, 52.5% male). FOF was assessed by the Falls Efficacy Scale International (FES-I). Physical function was evaluated using the Mini-Balance Evaluation Systems Test (Mini-BESTest), Timed Up and Go test, 4-m gait speed, isometric handgrip force and 10-repetition sit-to-stand test. The physical and mental components of quality of life was evaluated by 36-Item Short Form Health Survey. RESULTS: The FES-I score was higher in the hemodialysis group compared to the control group (28.2 ± 9.7 vs. 23.3 ± 5.1, p = 0.020). In addition, the prevalence of individuals with a higher concern about falling was greater in the hemodialysis group (41.7 vs. 17.5%, p = 0.033). Multiple linear regression showed that the FES-I score was associated with the Mini-BESTest score and the physical component summary of quality of life (coefficient of determination of 0.51 and an adjusted coefficient of determination of 0.46). CONCLUSION: FOF was associated with poor postural balance and reduced physical component of quality of life in patients on hemodialysis and these patients showed higher FOF compared to individuals without chronic kidney disease.