STUDY DESIGN: Descriptive cross-sectional study. SETTING: The study was conducted in the Spinal Cord Injury Unit of the University Vall d'Hebron Hospital and in the Physical Education and Sports Department of the University of Valencia. OBJECTIVES: The aim of this study was to quantify the presence of comorbidities in spinal cord injury (SCI) subjects who did or did not perform regular physical activity (PA) and to identify the relationship between PA and the level of comorbidity. METHODS: The sample consisted of patients with complete motor SCI (T2-T12), who were fitted with an accelerometer attached to the non-dominant wrist for a period of 1 week. The clinical and blood analytic variables were selected by an expert panel. RESULTS: In the exploratory analysis, we have found differences in the total number of pathologies between active and inactive patients, with fewer total pathologies in the active patient group. An association was found between the PA level and diabetes mellitus (; P=0.047; φ=0.25). We also observed an association between the cardioprotector level of high-density lipoprotein (HDL)-cholesterol and PA level (; P=0.057; Φ0.24). CONCLUSIONS: Our results suggest that patients considered active showed lower total comorbidity than inactive patients and higher protection levels against developing cardiovascular comorbidity.
Exercise/physiology , Paraplegia/epidemiology , Paraplegia/physiopathology , Spinal Cord Injuries/epidemiology , Adult , Aged , Comorbidity , Cross-Sectional Studies , Female , Humans , Male , Middle Aged , Motor Activity/physiology , Spinal Cord Injuries/physiopathology
Objetivo: En el contexto universitario resulta necesaria la elaboración y validación de cuestionarios para ser aplicados en la valoración de nuevos modelos formativos que garanticen la adquisición de la competencia ética. El objetivo de este estudio es presentar la elaboración, evaluación de la fiabilidad y unidimensionalidad del «Cuestionario de actitudes hacia la ética profesional en Fisioterapia» (CAEPFIS). Material y método: Se procedió a la elaboración de un cuestionario que analizara las actitudes hacia la ética profesional en estudiantes de Fisioterapia (CAEPFIS) mediante un estudio piloto con estudiantes de Fisioterapia de último curso (n=100). Se llevó a cabo un análisis de consistencia interna (alfa de Cronbach) y se detectaron y eliminaron los ítems indiferenciadores. Posteriormente, se analizó la unidimensionalidad del cuestionario (análisis factorial de componentes principales, prueba de esfericidad de Barlett y medida de adecuación muestral de Kaiser-Meyer-OIkin [KMO]). Finalmente, el cuestionario constó de 33 ítems. Se empleó Predictive Analytics Software (PASW) 18.0 (SPSS Inc., Chicago, IL, EE. UU.). Resultados: El CAEPFIS presenta una elevada consistencia interna (coeficiente alfa de Cronbach=0,898). Los ítems del CAEPFIS se acercan a la unidimensionalidad deseada (análisis factorial de componentes principales: KMO=0,762; χ2=1.871,874; df=528; p<0,001). El primer factor muestra una buena proporción de la varianza total, explica el 25,8% de la misma y todos los ítems presentan pesos por encima de 0,3. Conclusiones: El CAEPFIS muestra fiabilidad y unidimensionalidad para ser empleado como instrumento de recogida de datos para analizar las actitudes hacia la ética profesional en estudiantes de Fisioterapia
Purpose: In the university context the creation and validation of questionnaires to be applied in assessment of new teaching models that guarantee the acquisition of ethical competence is necessary. This study aims at presenting the creation, assessment of internal consistence and unidimensionality of the Attitudes questionnaire towards professional ethics in Physiotherapy (CAEPFIS). Material and method: A questionnaire analyzing attitudes towards professional ethics in Physiotherapy students (CAEPFIS) was created by means of a study carried out with physiotherapy students in the last year of their degree (n=100). An analysis of internal consistency (Cronbach's Alpha) was carried out, whilst differentiator elements were detected and deleted. Afterwards, unidimensionality of the questionnaire was analyzed (factorial analysis of principal components, Barlett's test of sphericity and Kaiser-Meyer-OIkin KMO). Finally, the questionnaire comprised 33 items. Predictive Analytics Software (PASW) 18.0 (SPSS Inc., Chicago, IL, USA) was used. Results: CAEPFIS shows a high internal consistency (Cronbach's Alfa=0.898). Items of CAEPFIS are close to the desired unidimensionality (Factorial Analysis of Principal Components: KMO=0.762; χ2=1,871.874; df=528; p<0.001). The first factor shows a good proportion of total variance, explains the 25.8% of it and all items present weights higher than 0.3. Conclusions: CAEPFIS shows internal consistency and unidimensionality to be used as a tool of data collection to analyze attitudes towards professional ethics in physiotherapy students
Humans , Physical Therapy Specialty/ethics , Ethics, Professional/education , Psychometrics/instrumentation , Educational Measurement , Attitude of Health Personnel , Students, Health Occupations/statistics & numerical data
Objectives. The main goal of our study is to compare the hamstring/quadriceps (H/Q) ratio at different knee angles between level-matched male and female soccer players and to determine whether differences in the H/Q ratio exist between the dominant and the non-dominant leg. Methods. A cross-sectional study design was used to compare an isometric H/Q ratio and functional isokinetic ratio (between hamstring in eccentric contraction and quadriceps in concentric contraction) between males (n=14) and females (n=14). These ratios were studied at two different speeds of movement (60°s−1 and 180°s−1) and in five different positions (40°, 50°, 60°, 70° and 80° degrees of knee flexion). Results. Our results showed no differences in the H/Q ratio between genders. The ratio in the dominant leg showed an average of 9% higher values. The ratios were an average of 53.4% lower in positions near flexion than in positions near extension. Conclusions. For both men and women, the results showed lower ratios in the non-dominant leg compared to the dominant leg. At higher velocities, the force ratios were higher, while in more knee-flexed positions, the ratios were lower. Finally, we did not find differences in ratios between men and women (AU)
Objetivos. El objetivo principal del estudio es comparar el ratio de fuerza isquiotibial/cuádriceps (ratio H/Q) en diferentes ángulos de rodilla entre jugadores de fútbol de niveles similares y determinar si existen diferencias en dicho ratio entre la pierna dominante y la no dominante. Métodos. Se utilizó un diseño transversal para comparar el ratio isométrico H/Q y el ratio funcional isocinético (ratio entre la fuerza durante una contracción excéntrica de isquiotibial y la fuerza durante una contracción concéntrica de cuádriceps) entre hombres (n=14) y mujeres (n=14). Estos ratios se estudiaron en dos velocidades (60° s−1 y 180° s−1) y en 5 posiciones diferentes (40, 50, 60, 70 y 80 grados de flexión de rodilla). Resultados. Nuestros resultados no mostraron diferencias significativas en el ratio H/Q entre sexos. El ratio en la pierna dominante mostró valores un 9% más altos que en la pierna no dominante. Los ratios fueron de media un 53.4% más bajos en posiciones cercanas a la flexión que en posiciones cercanas a la extensión. Conclusiones. Para ambos sexos los resultados mostraron ratios más bajos en la pierna no dominante comparado con la pierna dominante. A velocidades superiores, los ratios de fuerza fueron mayores, mientras que en posiciones de mayor flexión de rodilla los ratios fueron menores. Por último, no se encontraron diferencias significativas en los ratios entre hombres y mujeres (AU)
Objetivos. O principal objetivo do nosso estudo é comparar a relação de força entre Isquiotibiais/Quadríceps (H/Q) em diferentes ângulos do joelho entre jogadores de futebol (masculino e feminino) de níveis semelhantes para determinar se existem diferenças na relação entre H/Q entre o membro dominante e a não-dominante. Método. U estudo de delineamento transversal foi utilizado para comparar a relação isométrica entre H/Q e isocinética funcional (razão entre a força dos isquiotibiais em contração excêntrica e do quadríceps em contração concêntrica, durante a extensão do joelho) entre homens (n=14) e mulheres (n=14). Estas razões foram estudadas em duas velocidades diferentes de movimento (60°/s e 180°/s) e em cinco posições diferentes (por exemplo 40, 50, 60, 70, e 80 graus de flexão do joelho). Resultados. Os resultados não mostraram diferenças significativas na relação H/Q entre os sexos. A relação da perna dominante mostrou valores médios de 9% mais elevados em relação a perna não dominante. As proporções foram, em média, 53,4% menor em posições próximas a flexão do que em posições perto da extensão. Conclusões. Para ambos os sexos, os resultados mostram razões mais baixas no membro não dominante em comparação com a dominante. À velocidade mais elevadas, as relações de força foram superiores, enquanto que em maiores flexões de joelho as relações foram menores. Finalmente, não foram encontradas diferenças significativas nas proporções entre homens e mulheres (AU)
Humans , Male , Female , Soccer/physiology , Soccer/statistics & numerical data , Muscle Strength/physiology , Exercise/physiology , Isometric Contraction/physiology , Isotonic Contraction/physiology , Risk Factors , Quadriceps Muscle/physiology , Cross-Sectional Studies/methods , Cross-Sectional Studies/trends , 28599 , Analysis of Variance
STUDY DESIGN: Cross-sectional study. OBJECTIVES: The main goal of this study was to examine the influence of regular physical activity (PA) on lung volumes and flows. SETTING: The study was conducted in the Vall d'Hebrón Hospital, Barcelona (Spain), and La Fe Hospital, Valencia (Spain). METHODS: Spirometric tests were performed to 67 paraplegics, and differences were established between the active group (AG) (n=37) that performed >60 min per week of moderate-to-vigorous PA (MVPA) and 30 non-AG (NAG). Further, we established the relationship between the spirometric and PA variables and between being active and reaching the lower limit of normal (LLN) of the spirometric variables. RESULTS: AG had greater values than the NAG: FVC (P<0.01), FEV1 (P<0.01) and PEF (P<0.01). Moderate correlations between the MVPA and FVC (r=0.41, P<0.01) and the MVPA and FEV1 (r=0.39, P<0.01) were obtained. The relationship between being physically active and reaching the LLN was statistically significant for FEV1 (χ2=6.184, P<0.05) but not for FVC (P>0.05). CONCLUSIONS: The performance of MVPA for a minimum of 60 min per week can have a beneficial effect, both on lung volumes and on expiratory flow, and led to an achievement of the LLN in FEV1.
Exercise/physiology , Lung Diseases/etiology , Paraplegia/complications , Adult , Chi-Square Distribution , Cross-Sectional Studies , Female , Forced Expiratory Volume/physiology , Humans , Lung Diseases/diagnosis , Male , Middle Aged , Spain , Spirometry , Vital Capacity
STUDY DESIGN: Experimental study. OBJECTIVES: Exercise improves functional capacity in spinal cord injury (SCI). However, exhaustive exercise, especially when sporadic, is linked to the production of reactive oxygen species that may have a detrimental effect on SCI. We aimed to study the effect of a single bout of exhaustive exercise on systemic oxidative stress parameters and on the expression of antioxidant enzymes in individuals with paraplegia. SETTING: The study was conducted in the Physical Therapy department and the Physical Education and Sports department of the University of Valencia. METHODS: Sixteen paraplegic subjects were submitted to a graded exercise test (GET) until volitional exhaustion. They were divided into active or non-active groups. Blood samples were drawn immediately, 1 and 2 h after the GET. We determined plasma malondialdehyde (MDA) and protein carbonylation as markers of oxidative damage. Antioxidant gene expression (catalase and glutathione peroxidase-GPx) was determined in peripheral blood mononuclear cells. RESULTS: We found a significant increase in plasma MDA and protein carbonyls immediately after the GET (P<0.05). This increment correlated significantly with the lactate levels. Active paraplegics showed lower levels of exercise-induced oxidative damage (P<0.05) and higher exercise-induced catalase (P<0.01) and GPx (P<0.05) gene expression after the GET. CONCLUSIONS: These results suggest that exercise training may be useful in SCI patients to develop systemic antioxidant defenses that may protect them against exercise-induced oxidative damage.
Antioxidants/metabolism , Exercise/physiology , Gene Expression Regulation/physiology , Paraplegia/enzymology , Paraplegia/rehabilitation , Accelerometry , Adult , Aged , Catalase/genetics , Catalase/metabolism , Exercise Test , Female , Glutathione Peroxidase/genetics , Glutathione Peroxidase/metabolism , Humans , Leukocytes, Mononuclear/metabolism , Lipid Peroxidation/physiology , Male , Malondialdehyde , Middle Aged , Paraplegia/blood , Protein Carbonylation/physiology , RNA, Messenger/metabolism , Superoxide Dismutase/blood
STUDY DESIGN: This was a cross-sectional study. OBJECTIVES: The main objective of this study was to develop and test classification algorithms based on machine learning using accelerometers to identify the activity type performed by manual wheelchair users with spinal cord injury (SCI). SETTING: The study was conducted in the Physical Therapy department and the Physical Education and Sports department of the University of Valencia. METHODS: A total of 20 volunteers were asked to perform 10 physical activities, lying down, body transfers, moving items, mopping, working on a computer, watching TV, arm-ergometer exercises, passive propulsion, slow propulsion and fast propulsion, while fitted with four accelerometers placed on both wrists, chest and waist. The activities were grouped into five categories: sedentary, locomotion, housework, body transfers and moderate physical activity. Different machine learning algorithms were used to develop individual and group activity classifiers from the acceleration data for different combinations of number and position of the accelerometers. RESULTS: We found that although the accuracy of the classifiers for individual activities was moderate (55-72%), with higher values for a greater number of accelerometers, grouped activities were correctly classified in a high percentage of cases (83.2-93.6%). CONCLUSIONS: With only two accelerometers and the quadratic discriminant analysis algorithm we achieved a reasonably accurate group activity recognition system (>90%). Such a system with the minimum of intervention would be a valuable tool for studying physical activity in individuals with SCI.
Accelerometry/methods , Motor Activity , Spinal Cord Injuries/classification , Spinal Cord Injuries/rehabilitation , Wheelchairs , Accelerometry/instrumentation , Aged , Cross-Sectional Studies , Discriminant Analysis , Functional Laterality , Humans , Motor Activity/physiology , Reproducibility of Results , Spinal Cord Injuries/physiopathology , Support Vector Machine , Wrist/physiopathology
STUDY DESIGN: Cross-sectional study. OBJECTIVES: The main goal of our study was to explore the differences in heart rate variability (HRV) while sitting between able-bodied (AB) participants and paraplegic (P) individuals. SETTING: The study was conducted in the Physical Therapy department and the Physical Education and Sports department of the University of Valencia and Vall d'Hebrón Hospital. METHODS: To record the HRV, a 1000-Hz Suunto Oy t6 heart rate monitor was used. The data were analyzed in the temporal and frequency domains, and nonlinear analysis was performed as well. RESULTS: We found significant differences between P and AB participants in SDNN: t(76)=2.81, P<0.01; root mean squared of the difference of successive RR intervals: t(76)=2.35, P<0.05; very low frequency: t(76)=2.97, P<0.01; low frequency: t(41.06)=2.33, P<0.05; total power of the spectrum: t(45.74)=2.57, P<0.05; SD1: t(76)=2.35, P<0.05; SD2: t(76)=2.82, P<0.01. Furthermore, there is a reduced variability in the P participants who adopted a sedentary lifestyle as could be observed in detrended fluctuation1 t(40)=-2.10; P<0.05. CONCLUSION: Although individuals in the P group were more active in sports than the AB group, they had an altered HRV when compared with AB individuals. It could be important to develop more intense sports programs to improve cardiac vagal tone, which in turn produces a decrease in work and oxygen consumption of the heart.
Heart Rate/physiology , Spinal Cord Injuries/physiopathology , Adult , Cross-Sectional Studies , Female , Fourier Analysis , Humans , Male , Middle Aged , Paraplegia/etiology , Spinal Cord Injuries/rehabilitation , Thoracic Vertebrae
The aim of the present study is to obtain models for estimating energy expenditure based on the heart rates of people with spinal cord injury without requiring individual calibration. A cohort of 20 persons with spinal cord injury performed a routine of 10 activities while their breath-by-breath oxygen consumption and heart rates were monitored. The minute-by-minute oxygen consumption collected from minute 4 to minute 7 was used as the dependent variable. A total of 7 features extracted from the heart rate signals were used as independent variables. 2 mathematical models were used to estimate the oxygen consumption using the heart rate: a multiple linear model and artificial neural networks. We determined that the artificial neural network model provided a better estimation (r=0.88, MSE=4.4 ml · kg(-1) · min(-1)) than the multiple linear model (r=0.78; MSE=7.63 ml · kg(-1) · min(-1)).The goodness of fit with the artificial neural network was similar to previous reported linear models involving individual calibration. In conclusion, we have validated the use of the heart rate to estimate oxygen consumption in paraplegic persons without individual calibration and, under this constraint, we have shown that the artificial neural network is the mathematical tool that provides the better estimation.
Energy Metabolism/physiology , Heart Rate/physiology , Neural Networks, Computer , Paraplegia/physiopathology , Adult , Humans , Linear Models , Oxygen Consumption/physiology
STUDY DESIGN: Cross-sectional validation study. OBJECTIVES: The goals of this study were to validate the use of accelerometers by means of multiple linear models (MLMs) to estimate the O2 consumption (VO2) in paraplegic persons and to determine the best placement for accelerometers on the human body. SETTING: Non-hospitalized paraplegics' community. METHODS: Twenty participants (age=40.03 years, weight=75.8 kg and height=1.76 m) completed sedentary, propulsion and housework activities for 10 min each. A portable gas analyzer was used to record VO2. Additionally, four accelerometers (placed on the non-dominant chest, non-dominant waist and both wrists) were used to collect second-by-second acceleration signals. Minute-by-minute VO2 (ml kg(-1) min(-1)) collected from minutes 4 to 7 was used as the dependent variable. Thirty-six features extracted from the acceleration signals were used as independent variables. These variables were, for each axis including the resultant vector, the percentiles 10th, 25th, 50th, 75th and 90th; the autocorrelation with lag of 1 s and three variables extracted from wavelet analysis. The independent variables that were determined to be statistically significant using the forward stepwise method were subsequently analyzed using MLMs. RESULTS: The model obtained for the non-dominant wrist was the most accurate (VO2=4.0558-0.0318Y25+0.0107Y90+0.0051YND2-0.0061ZND2+0.0357VR50) with an r-value of 0.86 and a root mean square error of 2.23 ml kg(-1) min(-1). CONCLUSIONS: The use of MLMs is appropriate to estimate VO2 by accelerometer data in paraplegic persons. The model obtained to the non-dominant wrist accelerometer (best placement) data improves the previous models for this population.
Accelerometry/instrumentation , Accelerometry/standards , Energy Metabolism/physiology , Monitoring, Ambulatory/instrumentation , Paraplegia/etiology , Spinal Cord Injuries/complications , Wheelchairs , Adult , Cross-Sectional Studies , Female , Humans , Male , Middle Aged , Models, Biological , Oxygen Consumption/physiology , Paraplegia/metabolism , Paraplegia/rehabilitation , Spinal Cord Injuries/rehabilitation
STUDY DESIGN: Cross-sectional, observational study of paraplegic and able-bodied persons. OBJECTIVES: The aim of the study was to analyse the temporal and frequency domains of seated balance to better understand nervous system control in equilibrium in persons with spinal cord injury (SCI) and to explore their centre of pressure (CoP) limits before experiencing a fall. SETTING: University of Valencia, Spain. METHODS: Static and dynamic seated balance were assessed in 24 paraplegic persons divided into two groups: low paraplegia group (LP) and high paraplegia group (HP), and 24 healthy volunteers with an extensiometric force plate. Two types of tests were performed: a static test (ST), where data signal was analysed by temporal and frequency domains, and a stability limit test (SLT), where different stability limits were calculated. RESULTS: The paraplegic group revealed lower static postural control in both domains in most of the parameters analysed compared with the control group (CG). Similar results were obtained with regard to the SLT, showing differences in the three parameters analysed between the CG and SCI groups. CONCLUSION: Posturographic assessment in ST was useful to explore nervous system control in equilibrium in this population, presenting a decreased balance in paraplegic groups and an altered pattern in the sensorial and cerebellum bands compared with able-bodied individuals. Furthermore, SLT indicated less movement control of the CoP in paraplegic groups, which may influence the performance of their daily activities.
Paraplegia/physiopathology , Postural Balance/physiology , Posture/physiology , Adolescent , Adult , Cross-Sectional Studies , Female , Humans , Male , Middle Aged , Observation , Physical Examination , Spain , Young Adult
STUDY DESIGN: Time series design. OBJECTIVES: To determine the effects of a shoulder resistance training programme on isokinetic and isometric strength, body composition, pain and functionality in paraplegic subjects. SETTING: University of Valencia, Valencia, Spain. METHODS: A total of 15 subjects with thoracic spinal cord injury (SCI) performed three testing sessions with an 8-week period between the sessions. Subjects were not disturbed between the first and the second testing sessions. Subjects performed an 8-week resistance training programme after the second testing session. Variations in isometric and isokinetic shoulder muscle strength, body composition, reported pain and shoulder functionality were evaluated. RESULTS: The training programme produced a significant increase (P<0.05) in the isometric and isokinetic strength of several shoulder movements as well as an increase (P<0.05) in arm fat-free mass and a decrease in arm fat mass (FM). Furthermore, reported pain was decreased, (P<0.05) and upper-limb functionality was increased (P<0.05). CONCLUSION: Implementing resistance training programmes as physical therapy in SCI subjects effectively increases strength, muscle mass and upper-limb functionality, whereas decreasing FM and pain perception.
Muscle Strength/physiology , Paraplegia/rehabilitation , Recovery of Function/physiology , Resistance Training , Spinal Cord Injuries/rehabilitation , Adult , Female , Humans , Male , Middle Aged , Pain/etiology , Pain/rehabilitation , Paraplegia/etiology , Shoulder , Spinal Cord Injuries/complications
The principal aim of our study was the determination of the effectiveness of a standardized ratio, allometric scaling model and a gamma function model in normalizing the isometric torque data of spinal cord patients and healthy subjects. For this purpose we studied a sample of 21 healthy males and 23 spinal cord injury males. The experiment consisted of the measurement of the force of the upper limb movement executed by all the subjects. We also determined anthropometric variables with dual-energy x-ray absorptiometry. The experimental data were analyzed with 3 force normalization methods. Our results indicate that the most important confounding variable was the fat free mass of the dominant upper limb (r>0.36, p<0.05). With the standardization by body mass and allometric scaling model, the normalized torque was influenced by body size variables. However, the normalized torque by the gamma function model was independent of body size measures. Paraplegics were weaker (p<0.05) in extension movements when the data were normalized by the gamma function model. In summary, this study shows that the gamma function model with fat free mass of the dominant upper limb was more effective than the standardized ratio in removing the influence of body size variables.
Muscle Strength/physiology , Muscle, Skeletal/physiopathology , Paraplegia/physiopathology , Spinal Cord Injuries/physiopathology , Upper Extremity/physiopathology , Absorptiometry, Photon , Adult , Anthropometry , Body Composition , Body Size , Humans , Male , Models, Biological , Torque
Introducción. La esperanza de vida en España esde 76,4 años en los hombres y de 83 años en lasmujeres. Es necesario facilitar que estas personas,cada día más mayores, sean a la vez autónomasy puedan vivir de manera satisfactoria.Material y métodos. Lo que se pretende en estetrabajo es demostrar la efectividad del ejerciciofísico en el aumento de la capacidad funcional ala hora de mantener el equilibrio, tanto dinámicocomo estático; para ello, estudiamos un primergrupo, o grupo A, compuesto por 8 personas(5 hombres y 3 mujeres) que practican habitualmente ejercicio físico aeróbico, y un grupo B, formado por 8 personas (2 hombres y 6 mujeres) que llevan una vida sedentaria.Resultados. Encontramos diferencias estadísticamente significativas, al comparar ambos grupos, en el mantenimiento del equilibrio en determinadas posiciones mediante biofeedback (p 0,05), que es mayor en el grupo A. En el resto de los parámetros, sólo encontramos una tendencia al aumento, en el grupo que realiza ejercicio físico, sin alcanzar significación estadística
Introduction. Life expectancy in Spain is 76.4 years old for men and 83 years old forwomen. It is necessary to make life easier and facilitate autonomy to these increasingly older people. Material and methods. This study aims to demonstrate the effectiveness of physical exercise to increase functional capacity for the maintenance of dynamic and state balance. Following these guidelines, we have studied group A, made up of 8 people, 5 men and 3 women who usually practice aerobic physical exercise, and group B, made up of 8 people, 2 men and 6 women, who lead a sedentary life. Results. We have found statistically significant differences in maintenance of balance in certain positions by biofeedback (p 0.05) when comparing both groups, this being greater in group A. Regarding the remaining parameters, we have only found an increasing tendency in the group practicing physical exercise, which is not statistically significance
Humans , Male , Female , Aged , Motor Activity/physiology , Motor Skills/physiology , Exercise/physiology , Aging/physiology , Life Expectancy/trends , Exercise Therapy
