Effect of Physical Training on Nitric Oxide Levels in Patients with Arterial Hypertension: An Integrative Review

Abstract The regular practice of physical exercise as a non-pharmacological treatment of arterial hypertension (AH) has been encouraged due to causing a series of physiological responses in the cardiovascular system, such as the production of vasoactive substances, including nitric oxide (NO). NO is a relaxation factor released by the endothelium, and the decrease in its bioavailability is related to coronary and arterial diseases, such as AH. This study aimed to perform an integrative literature review to elucidate the effect of physical training on NO levels in patients with AH and to establish a relationship between these levels and blood pressure (BP) control. A literature review was was performed by searching PubMed / MEDLINE, Lilacs, Scielo, Cinahl and Embase databases. The search string used was ("arterial hypertension" OR hypertension) AND (exercise OR "physical exercise" OR "aerobic exercise" OR "exercise training" or "physical activity") AND ("nitric oxide"). We included fully available controlled and uncontrolled clinical trials published in English and Portuguese languages in the last 10 years. The review consisted of 16 articles, of which 13 reported an increase in NO production after the physical training intervention, and three studies found no change. In addition, 15 studies observed a reduction in BP after the intervention. In conclusion, regular practice of physical exercises, advocating moderate intensity, can improve NO bioavailability in pre-hypertensive and hypertensive individuals, which seems to be one of the mechanisms responsible for BP reduction.

Whole-body electrical stimulation as a strategy to improve functional capacity and preserver lean mass after bariatric surgery: a randomized triple-blind controlled trial.

BACKGROUND/OBJECTIVES: Bariatric surgery (BS) is a successful, long-lasting treatment option for obese. The early postoperative (PO) period is followed by dietary restriction and physical inactivity, leading to declines in muscle mass and functional capacity. Whole-body electromyostimulation (WB-EMS) may be a feasible and potential early rehabilitation strategy post BS. The aim was to evaluate the effects of WB-EMS with exercise training (Fe) on functional capacity, body composition, blood biomarkers, muscle strength, and endurance post BS. SUBJECTS/METHODS: This is a randomized, triple-blind, sham-controlled trial. Thirty-five volunteers underwent a Roux-en-Y gastric bypass and were randomized into a WB-EMS (WB-EMSG) or control group (ShamG). Preoperative evaluations consisted of maximal and submaximal exercise testing, body composition, blood biomarkers, quadriceps strength, and endurance. After discharge, functional capacity and body composition were obtained. Exercise training protocols in both groups consisted of 14 dynamic exercises, 5 days per week, completing 30 sessions. The WB-EMSG also underwent an electrical stimulation protocol (Endurance: 85 Hz, 350 ms, 6 s of strain, 4 f of rest; Strength: 30 Hz, 350 ms, 4 s of strain, 10 seconds of rest, with bipolar electrical pulse). After intervention, subjects were reevaluated. RESULTS: The protocol started on average 6.7 ± 3.7 days after discharge. Both groups presented with a decline in functional capacity after BS (p < 0.05) and a reduction in all body composition measurements (p < 0.05). The exercise training program led to significant improvements in functional capacity (ShamG - PO: 453.8 ± 66.1 m, Post: 519.2 ± 62.8 m; WB-EMSG- PO: 435.9 ± 74.5, Post: 562.5 ± 66.4 m, p < 0.05), however, only the WB-EMSG demonstrated significant changes of distance walked (interaction time vs group effect, p < 0.05). In addition, adiponectin significantly increased only in the WB-EMSG (p < 0.05). The WB-EMSG was also able to preserve muscle strength, endurance, and fatigue index, while the ShamG demonstrated significant decline (p < 0.05). CONCLUSION: WB-EMS + Fe can be an attractive and feasible method following BS to enhance functional capacity and prevent deterioration of muscle function in the early PO. CLINICAL TRIAL REGISTRATION: ReBEC, RBR-99qw5h, on 20 February 2015.

Acute Effects of the 6-Minute Pegboard and Ring Test in COPD.

BACKGROUND: There are few reports in the literature supporting the understanding of the physiological mechanisms of intolerance in patients with COPD to perform unsupported upper limb activities. The aims of this study were to quantify the electrical activity and oxygenation of inspiratory and upper limb muscles, and to investigate whether electromyographic manifestations of muscle fatigue are related to upper limb function as assessed by the 6-min pegboard and ring test (6PBRT) in subjects with COPD and in healthy subjects. METHODS: Thirty subjects with COPD (FEV1 42.1 ± 16.4% predicted; 68.0 ± 7.6 y old) comprised the COPD group, and 34 healthy subjects (66.8 ± 8.0 y old) comprised the control group. Both groups were assessed for body composition with dual-energy radiograph absorptiometry and spirometry. The 6PBRT was performed with simultaneous assessment of electromyography, near-infrared spectroscopy, and gas analyses (expiratory minute volume). RESULTS: Differences were observed between groups for performance (number of rings) in the 6PBRT, with the COPD group achieving lower values than the control group (P < .001). The ventilatory demand (expiratory minute volume/maximum voluntary ventilation) and root mean square amplitude of the sternocleidomastoid muscle were higher in the COPD group than in the control group (P < .04). Lower values for oxyhemoglobin and total hemoglobin were found in intercostal muscles of the COPD group compared to the control group. The root mean square amplitude of the intercostal muscles was lower in the COPD group, while it was similar between groups for anterior deltoid and trapezius muscles. Median frequency of anterior deltoid muscles presented a decreased in both groups. CONCLUSIONS: Our results indicate that the 6PBRT was performed at a higher electrical activity in the accessory inspiratory muscles, such as the sternocleidomastoid muscle, and a lower oxygenation profile in the intercostal muscles in subjects with COPD compared with healthy controls, but without muscle fatigue signs. These findings suggest that the higher ventilatory demand presented in subjects with COPD could have contributed to the worse performance in this group without signals of peripheral muscle limitation.

Can a physical activity similar to activities of daily living cause dynamic hyperinflation and change the thoracoabdominal configuration in patients with chronic obstructive pulmonary disease?

Introduction: COPD is characterized by the ventilatory limitation, with reduction of the inspiratory reserve volume and dynamic hyperinflation (DH), which changes the configuration of the thoracic compartment, resulting in a disadvantage in respiratory muscle kinetics, and reduced functional capacity. The optoelectronic plethysmography (OEP) has been used to monitor changes in thoracoabdominal mobility. The Glittre-ADL test is a short battery of functional tests that simulate activities of daily living. In mild and moderate COPD, the effect of Glittre-ADL on thoracoabdominal kinetics and DH is understudied. Objective: The aim of our study was to evaluate the acute effects of the Glittre-ADL test on lung function and thoracoabdominal mobility using OEP in patients with mild and moderate COPD. Materials and methods: Twenty-five male and female patients between 45 and 80 years of age with COPD were submitted to the exercises that simulated Glittre-ADL test. Spirometry and OEP were performed before and after the test. Results: After the Glittre test, increases were found in EV (p=0.005), percentage of contribution of the abdominal compartment (p=0.054) and expiratory reserve volume (ERV) (p=0.006) and reductions were found in the contribution of the upper thoracic compartment (p=0.008) and inspiratory capacity (IC) (p=0.040). Conclusion: The acute effect of ADL was a change in thoracoabdominal kinetics, especially the percentage of contribution of the abdominal compartment, as demonstrated by OEP. These findings, together with the reduction in IC and increase in ERV, after the Glittre-ADL test suggest the occurrence of DH, even in patients with mild to moderate COPD according to the GOLD classification.

Effects of inspiratory muscle training on respiratory muscle strength, lung function, functional capacity and cardiac autonomic function in Parkinson's disease: Randomized controlled clinical trial protocol.

BACKGROUND: Individuals with Parkinson's disease (PD), in addition to motor impairment, may evolve with respiratory and autonomic nervous system disorders. Currently, there are few studies with emphasis on muscle and pulmonary dysfunction and that verify the benefits of inspiratory muscle training (IMT) in this population. AIM: The aim of this study was to evaluate whether IMT is effective for the improvement of respiratory muscle strength, lung function, thoracic mobility, functional capacity and cardiac autonomic function in PD. METHODS: A randomized and controlled trial will be conducted with 26 participants with idiopathic PD, with aged between 50 and 65 years, in the Stages I to III by the Modified Hoehn and Yahr Scale. Respiratory muscle strength will be performed by manovacuometry and lung function by spirometry. Functional capacity will be evaluated by the 6-min walk test and autonomic cardiac function by heart rate variability. In addition, thoracic mobility measurement will also be performed. After the evaluations, these participants will be randomly assigned to two groups: the IMT group with Powerbreathe® , which will perform the eight series of 2 min each, with 1 min of rest between them, totaling 30 min, at 60% of the maximum inspiratory pressure and the control group, who will perform the same training protocol but with the load maintained at 9 cmH2 O. All participants will be submitted to the same motor training protocol. CONCLUSION: It is expected that IMT increases the inspiratory muscle strength, contributing to the improved expiratory muscle strength, lung function, thoracic mobility, functional capacity and cardiac autonomic function in individuals with mild to moderate PD.

Reproducibility and Validity of the 6-Minute Stationary Walk Test Associated With Virtual Reality in Subjects With COPD.

BACKGROUND: The importance of evaluating the functional capacity of patients with COPD is well known, and there is a wide range of tests described in the literature. The 6-min stationary walk test associated with virtual reality (STVR-6) was created in light of the current limitations of evaluation tests. It does not require a large physical space or sophisticated equipment, and it is not costly; furthermore, it can be performed by a single rater. The objective of this study was to evaluate intra- and inter-rater reproducibility and to verify the criterion validity of the STVR-6. METHODS: 50 subjects with COPD were evaluated over the course of 3 d. The execution order of the tests was randomized; the STVR-6 was performed over 2 d, and the 6-min walk test was performed in 1 d. The 6-min walk distance variables and number of steps in the STVR-6 were obtained with a gas analysis performed for both tests. RESULTS: Relative reproducibility was found for intraclass correlation coefficient values (0.57-0.94, P < .001) between the number of steps and the highest value of oxygen consumption during the test (V̇O2 peak), intra- and inter-rater. In terms of absolute reproducibility, the standard error of measurement and minimum detectable difference values were verified. In the Bland-Altman analysis, the intra- and inter-rater mean difference values were 21 and 17 steps and 0.002 and 0.242 mL/min/kg, respectively. Pearson correlation values were 0.57-0.75 (P < .001) between the number of steps and V̇O2 peak. CONCLUSIONS: STVR-6 had excellent intra-rater reproducibility and excellent to good inter-rater reproducibility, but the high values of error measures demonstrated that there is a learning effect and a need to perform at least 2 tests. In addition, there was high to moderate correlation between the STVR-6 and the 6-min walk test. Therefore, the STVR-6 proved to be reproducible and valid for evaluating the functional capacity of subjects with COPD.

Surface electromyography in inspiratory muscles in adults and elderly individuals: A systematic review.

INTRODUCTION: Electromyography (EMG) helps to evaluate disorders and pulmonary behavior, as impairments in respiratory muscle function are associated with the development of diseases. There is a wide range of methods and protocols used to record and analyze EMG obtained from respiratory muscles, demonstrating a lack of standardization. OBJECTIVE: To identify the most common procedures used to record surface EMG (sEMG) of inspiratory muscles in adults and elderly individuals through a systematic review (primary), and to evaluate the quality of the report presented by the studies (secondary). METHOD: Studies published from January 1995 until June 2018 were searched for in the Web of Science, PubMed, LILACS, EBSCO and Embase databases. Only studies evaluating sEMG of inspiratory muscles were included. RESULTS: The electronic search retrieved a total of 6697 titles and 92 of them were included. A great variability on the methods applied to both recording and processing/analyzing data was found. Therefore, the synthesis of practical/clinical evidence to support immediate recommendations was impaired. In general, the descriptions presented by the studies are poor. CONCLUSION: The most common procedures used for sEMG were identified. Methodological studies with objective comparisons were fundamental for improving standardization, given the impossibility of recommendations from this review.

Functional and systemic effects of whole body electrical stimulation post bariatric surgery: study protocol for a randomized controlled trial.

BACKGROUND: Obesity represents a major public health problem and is the fifth leading risk factor for mortality. Morbid obesity is associated with chronic systemic inflammation which increases the risk of comorbidities. Bariatric surgery (BS) is considered an effective intervention for obese patients. However, BS is associated with dietary restriction, potentially limiting physical activity. Whole-body neuromuscular electrical stimulation (WBS) could represent an innovative option for the rehabilitation of BS patients, especially during the early postoperative phase when other conventional techniques are contraindicated. WBS is a safe and effective tool to combat sarcopenia and metabolic risk as well as increasing muscle mass, producing greater glucose uptake, and reducing the proinflammatory state. Therefore, the objective of this study is to evaluate the effects of WBS on body composition, functional capacity, muscle strength and endurance, insulin resistance, and pro- and anti-inflammatory circulating markers in obese patients undergoing BS. METHODS/DESIGN: The present study is a randomized, double-blind, placebo-controlled, parallel groups clinical trial approved by the Ethics Committee of our Institution. Thirty-six volunteers (body mass index (BMI) > 35 kg/m2) between 18 and 45 years of age will be randomized to the WBS group (WBSG) or control (Sham) group (ShamG) after being submitted to BS. Preoperative assessments will include maximal and submaximal exercise testing, body composition, blood inflammatory markers, and quadriceps strength and endurance. The second day after discharge, body composition will be evaluated and a 6-min walk test (6MWT) will be performed. The WBS or Sham protocol will consist of 30 daily sessions for 6 consecutive weeks. Afterwards, the same assessments that were performed in the preoperative period will be repeated. DISCUSSION: Considering the important role of WBS in skeletal muscle conditioning and its value as an aid in exercise performance, the proposed study will investigate this technique as a tool to promote early rehabilitation in these patients, and as a strategy to enhance exercise capacity, weight loss, and peripheral muscle strength with positive systemic effects. The present study is still ongoing, and data will be published after its conclusion. TRIAL REGISTRATION: REBEC, RBR-99qw5h . Registered on 20 February 2015.

Repercussão da oxigenoterapia domiciliar na qualidade de vida de pacientes com doença pulmonar obstrutiva crônica / Repercussion of home oxygen therapy on the quality of life of patients with chronic obstructive pulmonary disease

A hipoxemia encontrada na Doença Pulmonar Obstrutiva Crônica (DPOC) deve-se a alterações de ventilação/perfusão, então oferecer uma fração inspiratória de oxigênio maior é a solução encontrada. Entretanto, embora aumente a sobrevida, o uso prolongado do oxigênio diminui a independência do indiví­duo, e estudar o impacto dessa intervenção na qualidade de vida (QV) desses pacientes é muito importante para a indicação na prática clí­nica. Objetivo: Identificar as implicações do uso da oxigenoterapia domiciliar na QV do DPOC. Material e métodos: Realizado o levantamento de artigos cientí­ficos nas bases de dados Pubmed, Lilacs e Scielo, com a string: "(COPD) AND (Oxygen therapy) AND (quality of life)", sendo incluí­dos ensaios clí­nicos randomizados, quasi randomizados, e observacionais, nos idiomas inglês e português, publicados de 2000 a 2017. Resultados: Nove estudos foram inseridos, sendo três ensaios clí­nicos randomizados e controlados. Apenas um estudo identificou melhora na QV, dois não encontraram diferença entre os grupos e quatro apresentaram piores escores com a oxigenoterapia. Dois estudos avaliaram a influência do tipo de dispositivo na QV. Conclusão: A oxigenoterapia parece piorar a qualidade de vida dos pacientes com DPOC. Porém, poucos foram os estudos encontrados e nem todos com o melhor desenho experimental, o que prejudica a confirmação dos resultados. (AU)

The hypoxemia observed in Chronic Obstructive Pulmonary Disease (COPD) is due to ventilation/perfusion changes, so a greater inspiratory fraction of oxygen could be the solution. However, while increasing survival, prolonged use of oxygen decreases the independence, and studying the impact of this intervention on the quality of life (QoL) of these patients is very important for indication in clinical practice. Objective: To identify the implications of the use of home oxygen therapy in COPD QoL. Methods: The search for scientific articles in the Pubmed, Lilacs and Scielo databases was performed with the string: "(COPD) AND (Oxygen therapy) AND (quality of life)", including randomized, quasi-randomized, and observational studies, published in English and Portuguese, from 2000 to 2017. Results: Nine studies were included, three of which were randomized and controlled clinical trials. Only one study identified improvement in QoL, two found no difference between groups, and four had worse scores with oxygen therapy. Two studies evaluated the influence of device type on QoL. Conclusion: Oxygen therapy seems to worsen the quality of life of patients with COPD. However, few studies have been found and not all with the best experimental design, which impairs the confirmation of the results. (AU)

Metabolic syndrome impact on cardiac autonomic modulation and exercise capacity in obese adults.

Obesity is often associated with increased risk of cardiometabolic morbidities and mortality. However, evidence shows that some obese individuals are more likely to develop such risk factors early in life, including those with Metabolic Syndrome (MetS). Whether the presence of MetS in obese people impairs cardiac autonomic modulation (CAM) remains to be investigated. METHODS: Cross-sectional study. Sixty-six subjects were classified as normal-weight (NW, n = 24) or obese (BMI ≥ 30 kg·m-2): metabolically healthy (MHO, n = 19) vs unhealthy (MUHO, n = 23: NCEP/ATPIII-MetS criteria). Body composition (bioimpedance), metabolic (glucose-insulin/lipid) and inflammatory profiles were determined. Linear and nonlinear heart rate variability (HRV) indices were computed at rest and during the submaximal six-minute step test (6MST). Blood pressure (BP) and metabolic and ventilatory variables were assessed (oxygen uptake, VO2; carbon dioxide production, VCO2; minute ventilation, VE) during the 6MST and the maximal cardiopulmonary exercise testing (CPX). RESULTS: All groups reached the same 6MST intensity (VO2 ~ 80% and HR ~ 87% of CPX peak values). Both obese groups, independently of MetS, presented higher BP and lower maximal VO2 than NW. However, HRV differed between groups according to MetS at rest and during exercise: MUHO had lower meanRRi and SD1 than NW and lower RMSSD and pNN50 than MHO at rest; during exercise, the lowest SDNN, TINN, SD1 and Shannon entropy were observed for MUHO. Significant correlations were found between MetS, insulin resistance and HRV indices; and between insulin resistance and aerobic capacity (VO2peak). CONCLUSION: Obesity per se impairs aerobic-hemodynamic responses to exercise. However, MetS in obese young adults negatively impacts overall HRV, parasympathetic activity and HRV complexity.

Improvement in lung function and functional capacity in morbidly obese women subjected to bariatric surgery.

OBJECTIVE: To determine whether weight loss in women with morbid obesity subjected to bariatric surgery alters lung function, respiratory muscle strength, functional capacity and the level of habitual physical activity and to investigate the relationship between these variables and changes in both body composition and anthropometrics. METHODS: Twenty-four women with morbid obesity were evaluated with regard to lung function, respiratory muscle strength, functional capacity, body composition, anthropometrics and the level of habitual physical activity two weeks prior to and six months after bariatric surgery. RESULTS: Regarding lung function, mean increases of 160 mL in slow vital capacity, 550 mL in expiratory reserve volume, 290 mL in forced vital capacity and 250 mL in forced expiratory volume in the first second as well as a mean reduction of 490 mL in inspiratory capacity were found. Respiratory muscle strength increased by a mean of 10 cmH2O of maximum inspiratory pressure, and a 72-meter longer distance on the Incremental Shuttle Walk Test demonstrated that functional capacity also improved. Significant changes also occurred in anthropometric variables and body composition but not in the level of physical activity detected using the Baecke questionnaire, indicating that the participants remained sedentary. Moreover, correlations were found between the percentages of lean and fat mass and both inspiratory and expiratory reserve volumes. CONCLUSION: The present data suggest that changes in body composition and anthropometric variables exerted a direct influence on functional capacity and lung function in the women analyzed but exerted no influence on sedentarism, even after accentuated weight loss following bariatric surgery.

Myostatin and adipokines: The role of the metabolically unhealthy obese phenotype in muscle function and aerobic capacity in young adults.

Obesity is often associated with metabolic disorders. However, some obese people can present a metabolically healthy phenotype, despite having excessive body fat. Obesity-related cytokines, such as myostatin (MSTN), leptin (LP) and adiponectin (ADP) appear to be key factors for the regulation of muscle and energy metabolism. Our aim was to compare lipid, glucose-insulin and inflammatory (tumor necrosis factor alpha; TNF-α) profiles, muscle function, energy expenditure and aerobic capacity between healthy normal-weight (NW) adults, metabolically healthy obese (MHO) and metabolically unhealthy obese (MUHO) adults; to study the associations between these outcomes and the cytokines MSTN, ADP, LP; and to establish cutoffs for MSTN and LP/ADP to identify the MUHO phenotype. Sixty-one young adults (NW, n = 24; MHO, n = 16; MUHO, n = 21) underwent body composition (body fat -BF and muscle mass - MM), energy expenditure at rest (RER) and aerobic capacity (VO2peak) evaluation, muscle strength and endurance tests and blood profile characterization (glucose-insulin homeostasis and serum MSTN, ADP, LP and TNF-α). MHO and MUHO had a BMI ≥ 30 kg m-2. MUHO was defined as presenting ≥3 criteria for metabolic syndrome (NCEP/ATPIII) in association with insulin resistance (HOMA-IR ≥3.46). MSTN and LP/ADP were associated with MM, MetS and glucose-insulin profile; MSTN was associated with TNF-α and only LP/ADP was associated with parameters of obesity and VO2peak. Neither MSTN nor LP/ADP was associated with muscle functions (p < .05 for adjusted correlations). Both of them were able to discriminate the MUHO phenotype: MSTN [AUC(95%CI) = 0.71(0.55-0.86), MSTN > 517.3 pg/mL] and LP/ADP [AUC(95%CI) = 0.89(0.81-0.97), LP/ADP > 2.14 pg/ng]. In conclusion, high MSTN and LP/ADP are associated with MetS, glucose-insulin homeostasis impairment and low muscle mass. Myostatin is associated with TNF-α and leptin-to-adiponectin ratio is associated with body fatness and aerobic capacity. Neither MSTN nor LP/ADP is associated with energy expenditure, muscle strength and endurance. Myostatin and adipokines cutoffs can identify the metabolically unhealthy obese phenotype in young adults with acceptable accuracy.

Reproducibility of inspiratory muscle endurance testing using PowerBreathe for COPD patients.

BACKGROUND: Assessing the strength and endurance of respiratory muscles is fundamental for characterizing respiratory muscle dysfunction. Although a variety of tests are used to evaluate respiratory muscle endurance, not all of them are applicable in clinical practice. Assessments can be made using a practical device called PowerBreathe®, but its reproducibility has not been tested in chronic obstructive pulmonary disease (COPD) patients. AIM: To verify the reproducibility of the inspiratory muscle endurance test using a manometer and PowerBreathe® in COPD patients. METHODS: A cross-sectional study was used. In total, 19 moderate-severe COPD patients, male and female, aged 50 to 80 years took part in the research. This evaluation consisted of 2 tests: an incremental test and a constant one held on the same day and repeated after 48 hr. The incremental test started with 10-cm H2 O, adding 10-cm H2 O every 2 min and taking 1 min of rest before increasing the load. The highest load that could be sustained for at least 1 min was considered the sustained maximum inspiratory pressure (SMIP) value. The constant test was performed at an intensity of 80% of the SMIP and the maximum time limit was 30 min. RESULTS: In the incremental test, there was a significant increase in the SMIP compared to the test-retest (61 ± 24/64.7 ± 23.8; p = .015); the value of the relative reproducibility was 0.96, the standard error of the absolute measurement was 4.7 (95% confidence interval 9.2), and the minimum detectable difference was 10.9. In the Bland-Altman analysis, the mean error was 4.2 (confidence interval -7.6 to 16.1). The constant test was not reproducible. CONCLUSION: It was observed that the incremental test was reproducible to evaluate inspiratory muscle endurance in COPD patients. Furthermore, 2 tests needed to be carried out due to the learning effect.

Improvement in lung function and functional capacity in morbidly obese women subjected to bariatric surgery

OBJECTIVE: To determine whether weight loss in women with morbid obesity subjected to bariatric surgery alters lung function, respiratory muscle strength, functional capacity and the level of habitual physical activity and to investigate the relationship between these variables and changes in both body composition and anthropometrics. METHODS: Twenty-four women with morbid obesity were evaluated with regard to lung function, respiratory muscle strength, functional capacity, body composition, anthropometrics and the level of habitual physical activity two weeks prior to and six months after bariatric surgery. RESULTS: Regarding lung function, mean increases of 160 mL in slow vital capacity, 550 mL in expiratory reserve volume, 290 mL in forced vital capacity and 250 mL in forced expiratory volume in the first second as well as a mean reduction of 490 mL in inspiratory capacity were found. Respiratory muscle strength increased by a mean of 10 cmH2O of maximum inspiratory pressure, and a 72-meter longer distance on the Incremental Shuttle Walk Test demonstrated that functional capacity also improved. Significant changes also occurred in anthropometric variables and body composition but not in the level of physical activity detected using the Baecke questionnaire, indicating that the participants remained sedentary. Moreover, correlations were found between the percentages of lean and fat mass and both inspiratory and expiratory reserve volumes. CONCLUSION: The present data suggest that changes in body composition and anthropometric variables exerted a direct influence on functional capacity and lung function in the women analyzed but exerted no influence on sedentarism, even after accentuated weight loss following bariatric surgery.

Teste de caminhada de seis minutos em pediatria: discutindo evidências em situações específicas / Six minutes walk test in pediatrics: discussing evidence in specific situations

Teste de caminhada de seis minutos (TC6) tem se mostrado uma ferramenta bem tolerada, confiá- vel e de baixo custo para monitorar a capacidade funcional de crianças e adolescentes saudáveis e em diferentes situações clínicas. Objetivo: Verificar e discutir as evidências científicas do TC6 utilizado em 4 situações específicas da criança com: 1) asma; 2) fibrose cística 3) obesidade e 4) higidez. Método: A busca nas bases de dados foi conduzida utilizando-se as palavras-chaves: teste de caminhada de seis minutos, crianças, adolescentes, obesos, fibrose cística e asma. Consultou-se as bases Pubmed (Medline), Lilacs e PEDro. Foram considerados os ensaios clínicos em português, inglês e espanhol, publicados no período de 2005 a 2016 e incluídos os estudos que abordam o TC6como método de avaliação, monitorização e prognóstico de crianças e adolescentes saudáveis, com diagnósticos de asma, fibrose cística e obesidade. Resultados: Identificou-se 97 artigos, sendo 48 duplicados. Conduziu-se a pré-seleção de 43 estudos dos quais 6foram excluídos, pelo título ou resumo, por não atenderem aos critérios de inclusão. A seleção final totalizou 39 manuscritos para a apreciação na íntegra e discussão na presente revisão. Conclusão: TC6 é reprodutível e validado para a população pediátrica, sendo considerado um instrumento importante para avaliar as implicações das doenças crônicas na capacidade funcional. 1) TC6 tem se mostrado útil pra identificação do prejuízo das atividades de vida diária durante a crise de asma e fora dela, assim como do comprometimento da capacidade funcional diante do hábito de vida sedentário. 2) É adequado para avaliação de programas de reeducação alimentar na obesidade. 3) Na fibrose cística é uma boa ferramenta para avaliação de programas de reabilitação pulmonar e acompanhamento da progressão da doença. 4) Entre os saudáveis observa-se a busca por valores de referência e falta de um consenso sobre a forma de aplicabilidade do teste

The six-minute walk test (6MWT) is regarded as a well-tolerated, reliable and cost-effective tool to monitor the functional capacity of healthy children and adolescents and in different clinical situations. Objective: To verify and discuss the scientific evidence of the 6MWT in four specific situations of children with: 1) asthma; 2) cystic fibrosis 3) obesity and 4) healthy controls. Method: A search was conducted in Pubmed (Medline), Lilacs and PEDro databases with the key words: sixminute walk test, children, adolescents, obesity, cystic fibrosis and asthma. The selected articles were those that reported clinical trials in Portuguese, English or Spanish, published between 2005- 2016 that included studies that assessed the 6MWT as a method of evaluation for monitoring and prognosis of healthy or diseased children and adolescents. Results: We identified 97 articles, 48 of them were duplicate. A pre-selection of 43 remaining studies based on title or summary excluded 6 articles for not meeting the inclusion criteria. Finally, 39 manuscripts were included in this review. Conclusion: 6MWT is reproducible and validated for the pediatric population and is considered an important instrument to assess the implications of chronic diseases on functional status. 1) 6MWT has proven useful to identify function losses to the activities of daily living during or in-between asthma attacks, as well as the functional jeopardy of sedentary habit; 2) It is suitable for assessing nutritional education programs in obesity; 3) In cystic fibrosis, it is a good tool for evaluating pulmonary rehabilitation programs and monitoring of the disease progression; and 4) Among healthy subjects, however, there is still lack of consensus of a reference as well as the most suitable applicability of this test

Effects of Inspiratory Muscle Training and Calisthenics-and-Breathing Exercises in COPD With and Without Respiratory Muscle Weakness.

BACKGROUND: Patients with COPD may experience respiratory muscle weakness. Two therapeutic approaches to the respiratory muscles are inspiratory muscle training and calisthenics-and-breathing exercises. The aims of the study are to compare the effects of inspiratory muscle training and calisthenics-and-breathing exercises associated with physical training in subjects with COPD as an additional benefit of strength and endurance of the inspiratory muscles, thoracoabdominal mobility, physical exercise capacity, and reduction in dyspnea on exertion. In addition, these gains were compared between subjects with and without respiratory muscle weakness. METHODS: 25 subjects completed the study: 13 composed the inspiratory muscle training group, and 12 composed the calisthenics-and-breathing exercises group. Subjects were assessed before and after training by spirometry, measurements of respiratory muscle strength and test of inspiratory muscle endurance, thoracoabdominal excursion measurements, and the 6-min walk test. Moreover, scores for the Modified Medical Research Council dyspnea scale were reported. RESULTS: After intervention, there was a significant improvement in both groups of respiratory muscle strength and endurance, thoracoabdominal mobility, and walking distance in the 6-min walk test. Additionally, there was a decrease of dyspnea in the 6-min walk test peak. A difference was found between groups, with higher values of respiratory muscle strength and thoracoabdominal mobility and lower values of dyspnea in the 6-min walk test peak and the Modified Medical Research Council dyspnea scale in the inspiratory muscle training group. In the inspiratory muscle training group, subjects with respiratory muscle weakness had greater gains in inspiratory muscle strength and endurance. CONCLUSIONS: Both interventions increased exercise capacity and decreased dyspnea during physical effort. However, inspiratory muscle training was more effective in increasing inspiratory muscle strength and endurance, which could result in a decreased sensation of dyspnea. In addition, subjects with respiratory muscle weakness that performed inspiratory muscle training had higher gains in inspiratory muscle strength and endurance but not of dyspnea and submaximal exercise capacity. (ClinicalTrials.gov registration NCT01510041.).

Limitation of Activities of Daily Living and Quality of Life Based on COPD Combined Classification.

BACKGROUND: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 update recommends that the management and treatment of COPD be made to combine the impact of disease and future risk of exacerbation. These patients have worsening quality of life and limitation of activities of daily living (ADLs), which can be manifested as a decrease in S(pO2) and progressive dyspnea. The aim of this study was to determine whether the COPD combined classification proposed by GOLD 2011 is able to differentiate patients with ADL limitation, such as oxygen desaturation or dyspnea, and impaired quality of life. METHODS: This was an observational, cross-sectional study. Forty-four subjects were categorized in 4 GOLD groups (A-D). The mean age was 69 ± 8.8 y, with FEV1 of 1.33 ± 0.53 L (49 ± 15.7% of predicted). The Modified Medical Research Council dyspnea and London Chest Activity of Daily Living (LCADL) scales and the St George Respiratory Questionnaire (SGRQ) were applied. The 6-min walk test and ADL simulation in an appropriate laboratory were also conducted. RESULTS: There was no association between the COPD combined evaluation groups and the presence of oxygen desaturation and dyspnea (chi-square test), although a higher prevalence of oxygen desaturation was noticed in group D subjects. With regard to dyspnea, there were subjects with dyspnea in all groups when ADLs were performed. No correlation between dyspnea and oxygen desaturation variation was found. Group B and D subjects showed higher ADL dyspnea (total LCADL scores of 28% and 30%) compared with group A subjects. Group D subjects showed poorer quality of life (total SGRQ score of 49.3%) compared with less symptomatic groups. CONCLUSIONS: The COPD combined classification was not efficient in determining oxygen desaturation and dyspnea while subjects were performing ADLs. The subjects in the symptomatic groups with increased risk of exacerbation showed poorer quality of life and higher dyspnea levels. (ClinicalTrials.gov registration NCT01977469).

Chronic obstructive pulmonary disease Assessment Test na avaliação de pacientes com doença pulmonar obstrutiva crônica em reabilitação pulmonar: há relação com nível de dispneia nas atividades de vida diária e com índice preditor de mortalidade? Estudo transversal / Chronic obstructive pulmonary disease Assessment Test in assessing of patients with chronic obstructive pulmonary disease: there is a relationship with activities of daily living and mortality predictor index? A cross-sectional study / Chronic obstructive pulmonary disease Assessment Test en la evaluación de pacientes con enfermedad pulmonar obstructiva crónica en rehabilitación pulmonar: ¿Hay relación con el nivel de disnea en las actividades de la vida diaria y con el índice predictor de mortalidad? Estudio transversal

O objetivo do estudo foi investigar se há relação entre o impacto da Doença Pulmonar Obstrutiva Crônica (DPOC) no estado de saúde com o nível de dispneia nas atividades de vida diária (AVD) e o índice preditor de mortalidade em pacientes em reabilitação pulmonar (RP). Trata-se de um estudo transversal, em que foram avaliados 32 pacientes com DPOC moderada a muito grave (23 homens; 66,6±12,0 anos; VEF1: 40,6±15,6% previsto) por meio do COPD Assessment Test (CAT), Índice de Massa Corpórea (IMC), Teste de Caminhada de Seis Minutos (TC6), London Chest Activity of Daily Living Scale (LCADL), modified Medical Research Council (mMRC) e Índice BODE (Body mass index, airflow Obstruction, Dyspnea and Exercise capacity). Observaram-se correlações positivas moderadas do CAT com o questionário mMRC (r=0,35; p=0,048), a pontuação total da LCADL (r=0,60; p<0,001) e com a porcentagem da pontuação total da LCADL (r=0,57; p=0,001). Apenas a pontuação total da LCADL é capaz de predizer independentemente a pontuação do questionário CAT (p<0,05; r²=0,61). Não foram constatadas correlações significativas entre o CAT e o Índice BODE, IMC, TC6 e VEF1. Dessa forma, quanto maior o nível de dispneia nas AVD, maior o impacto da DPOC no estado de saúde do paciente, entretanto, o mesmo não ocorre em relação ao prognóstico de mortalidade nos pacientes com DPOC em RP...

The aim of this study was to investigate if there is a relationship between the impact of Chronic Obstructive Pulmonary Disease (COPD) on health status and the level of dyspnea in Activities of Daily Living (ADL) and the mortality predictor index in patients undergoing Pulmonary Rehabilitation (PR). It is a cross-sectional study in which 32 patients with moderate to very severe COPD (23 men; 66.6±12.0 years; FEV1: 40.6±15.6% predicted) were assessed by: COPD Assessment Test (CAT), Body Mass Index (BMI), six-Minute Walking Test (6MWT), London Chest Activity of Daily Living Scale (LCADL), modified Medical Research Council (mMRC) and BODE Index (Body mass index, airflow Obstruction, Dyspnea and Exercise capacity). The CAT score presented moderate correlation with the mMRC questionnaire (r=0.35; p=0.048), total score of LCADL (r=0.60; p<0.001) and total score LCADL percentage (r=0.57; p=0.001). Only the total score of LCADL is able to predict the CAT questionnaire scores (p<0.05; r²=0.61). There were no significant correlations between CAT and BODE index, BMI, FEV1 and 6MWT. Thus, the higher the level of dyspnea in ADL, the greater the impact of COPD on the patient's health status. However, this is not true in relation to mortality prognosis in patients with COPD in PR...

El objetivo del estudio fue investigar si hay relación entre el impacto de la Enfermedad Pulmonar Obstructiva Crónica (EPOC) en el estado de salud con el nivel de disnea en las actividades de la vida diaria (AVD) y el índice predictor de mortalidad en pacientes en rehabilitación pulmonar (RP). Se trata de un estudio transversal, en el que fueron evaluados 32 pacientes con EPOC moderada a muy grave (23 hombres; 66,6±12,0 años; VEF1: 40,6±15,6% previsto) por medio del COPD Assessment Test (CAT), Índice de Masa Corpórea (IMC), Test de Caminata de Seis Minutos (TC6), London Chest Activity of Daily Living Scale (LCADL), mo dified Medical Research Council (mMRC) e Índice BODE (Body mass index, airflow Obstruction, Dyspnea and Exercise capacity). Se observaron correlaciones positivas moderadas del CAT con el cuestionario mMRC (r=0,35; p=0,048), la puntuación total de la LCADL (r=0,60; p<0,001) y con el porcentaje de la puntuación total de la LCADL (r=0,57; p=0,001). Apenas la puntuación total de la LCADL es capaz de predecir independientemente la puntuación del cuestionario CAT (p<0,05; r²=0,61). No fueron constatadas correlaciones significativas entre el CAT y el Índice BODE, IMC, TC6 e VEF1. De esa forma, cuanto mayor es el nivel de disnea en las AVD, mayor es el impacto de la EPOC en el estado de salud del paciente, entre tanto, lo mismo no ocurre en relación al pronóstico de mortalidad en los pacientes con EPOC en RP...