Influence of mild pulmonary congestion on diaphragmatic mobility and activities of daily living in chronic kidney disease: An experimental and clinical study / Influencia de la congestión pulmonar leve en la movilidad diafragmática y las actividades de la vida diaria en la enfermedad renal crónica: un estudio experimental y clínico

Background: Pulmonary congestion is a strong predictor of mortality and cardiovascular events in chronic kidney disease (CKD); however, the effects of the mild form on functionality have not yet been investigated. The objective of this study was to assess the influence of mild pulmonary congestion on diaphragmatic mobility (DM) and activities of daily living (ADL) in hemodialysis (HD) subjects, as well as compare ADL behavior on dialysis and non-dialysis days. In parallel, experimentally induce CKD in mice and analyze the resulting pulmonary and functional repercussions. Methods: Thirty subjects in HD underwent thoracic and abdominal ultrasonography, anthropometric assessment, lung and kidney function, respiratory muscle strength assessment and symptoms analysis. To measure ADL a triaxial accelerometer was used over seven consecutive days. Twenty male mice were randomized in Control and CKD group. Thoracic ultrasonography, TNF-α analysis in kidney and lung tissue, exploratory behavior and functionality assessments were performed. Results: Mild pulmonary congestion caused a 26.1% decline in DM (R2=.261; P=.004) and 20% reduction in walking time (R2=.200; P=.01), indicating decreases of 2.23mm and 1.54min, respectively, for every unit increase in lung comet-tails. Regarding ADL, subjects exhibited statistically significant differences for standing (P=.002), walking (P=.034) and active time (P=.002), and number of steps taken (P=.01) on days with and without HD. In the experimental model, CKD resulted in increased levels of TNF-α on kidneys (P=.037) and lungs (P=.02), attenuation of exploratory behavior (P=.01) and significant decrease in traveled distance (P=.034). Thoracic ultrasonography of CKD mice showed presence of B-lines. (AU)

Antecedentes: La congestión pulmonar es un fuerte predictor de mortalidad y eventos cardiovasculares en la enfermedad renal crónica (ERC); sin embargo, aún no se han investigado los efectos de la forma leve sobre la funcionalidad. El objetivo de este estudio fue evaluar la influencia de la congestión pulmonar leve en la movilidad diafragmática (MD) y las actividades de la vida diaria (AVD) en sujetos en hemodiálisis (HD), así como comparar el comportamiento de las AVD en los días de diálisis y no diálisis. Paralelamente, inducir de forma experimental la ERC en ratones y analizar las repercusiones pulmonares y funcionales resultantes. Métodos: Treinta sujetos en HD fueron sometidos a ecografía torácica y abdominal, evaluación antropométrica, función pulmonar y renal, evaluación de la fuerza de los músculos respiratorios y análisis de síntomas. Para medir las AVD se utilizó un acelerómetro triaxial durante 7 días consecutivos. Se aleatorizaron 20 ratones machos en el grupo control y con ERC. Se realizó ecografía torácica, análisis de TNF-α en tejido renal y pulmonar, comportamiento exploratorio y evaluaciones de funcionalidad. Resultados: La congestión pulmonar leve provocó una disminución del 26,1% en la MD (R2=,261; P=,004) y una reducción del 20% en el tiempo de caminata (R2=0,200; P=,01), lo que indica disminuciones de 2,23mm y 1,54minutos, respectivamente, por cada unidad de aumento de las colas de cometa pulmonares. En cuanto a las AVD los sujetos mostraron diferencias estadísticamente significativas para estar de pie (P=,002), caminar (P=,034) y tiempo activo (P=,002) y número de pasos dados (P=,01) en los días con y sin HD. En el modelo experimental la ERC resultó en un aumento de los niveles de TNF-α en los riñones (P=,037) y los pulmones (P=,02), la atenuación del comportamiento exploratorio (P=,01) y una disminución significativa en la distancia recorrida (P=,034). La ecografía torácica de ratones con ERC mostró la presencia de líneas B. (AU)

Influence of mild pulmonary congestion on diaphragmatic mobility and activities of daily living in chronic kidney disease: An experimental and clinical study.

BACKGROUND: Pulmonary congestion is a strong predictor of mortality and cardiovascular events in chronic kidney disease (CKD); however, the effects of the mild form on functionality have not yet been investigated. The objective of this study was to assess the influence of mild pulmonary congestion on diaphragmatic mobility (DM) and activities of daily living (ADL) in hemodialysis (HD) subjects, as well as compare ADL behavior on dialysis and non-dialysis days. In parallel, experimentally induce CKD in mice and analyze the resulting pulmonary and functional repercussions. METHODS: Thirty subjects in HD underwent thoracic and abdominal ultrasonography, anthropometric assessment, lung and kidney function, respiratory muscle strength assessment and symptoms analysis. To measure ADL a triaxial accelerometer was used over seven consecutive days. Twenty male mice were randomized in Control and CKD group. Thoracic ultrasonography, TNF-α analysis in kidney and lung tissue, exploratory behavior and functionality assessments were performed. RESULTS: Mild pulmonary congestion caused a 26.1% decline in DM (R2=.261; P=.004) and 20% reduction in walking time (R2=.200; P=.01), indicating decreases of 2.23mm and 1.54min, respectively, for every unit increase in lung comet-tails. Regarding ADL, subjects exhibited statistically significant differences for standing (P=.002), walking (P=.034) and active time (P=.002), and number of steps taken (P=.01) on days with and without HD. In the experimental model, CKD resulted in increased levels of TNF-α on kidneys (P=.037) and lungs (P=.02), attenuation of exploratory behavior (P=.01) and significant decrease in traveled distance (P=.034). Thoracic ultrasonography of CKD mice showed presence of B-lines. CONCLUSION: The mild pulmonary congestion reduced DM and walking time in subjects undergoing HD. Individuals were less active on dialysis days. Furthermore, the experimental model implies that the presence of pulmonary congestion and inflammation may play a decisive role in the low physical and exploratory performance of CKD mice.

Dynamic hyperinflation induced by the 6-minute pegboard and ring test in hospitalized patients with exacerbated COPD.

BACKGROUND: The six-minute pegboard and ring test (6-PBRT) has been used to evaluate functional capacity of the upper limbs in stable chronic obstructive pulmonary disease (COPD) patients. To the best of our knowledge, no studies have evaluated dynamic hyperinflation (DH) during exercise with upper limbs in the hospital setting. The aim of this study was to evaluate physiological responses and DH induced by 6-PBRT in hospitalized patients with acute exacerbation of COPD (AECOPD). METHODS: A cross-sectional study was conducted in a tertiary hospital enrolling patients who were hospitalized due to AECOPD. All included participants underwent an evaluation of lung function and 6-PBRT when they reached minimum clinical criteria. Ventilatory and hemodynamics parameters were monitored during 6-PBRT and until 6 minutes of rest after the test. Symptoms of dyspnea and upper limb fatigue were also measured. RESULTS: Eighteen patients (71.3±5.1 years) with a mean FEV1 of 43.2±18.3% were included in the study (11 females). Prevalence of DH after 6-PBRT was 50% (considering the drop of 150 ml or 10% of inspiratory capacity, immediately after the end of the test). There was a significant increase in respiratory rate, minute volume, dyspnea, and upper limb fatigue after the end of 6-PBRT (p<0.05). Dyspnea recovered more precociously than the perception of fatigue, being reestablished within four minutes of rest. An increase in heart rate, systolic and diastolic blood pressures was also induced by 6-PBRT (p<0.05), requiring 6 minutes of recovery to return to baseline. No adverse events were observed during 6-PBRT. We concluded that 6-PBRT induces physiological changes during its execution, at safe levels, requiring a maximum of 6 minutes for recovery. Finally, the test proved to be safe and applicable for patients hospitalized due to AECOPD.

Capacidade pulmonar e funcional no pós-operatório de mulheres submetidas à mastectomia: série de casos / Pulmonary and functional capacity in the post-surgery of women submitted to mastectomy: preliminary results

Mulheres submetidas à cirurgia de mastectomia podem apresentar algumas complicações, dentre elas, alterações respiratórias e prejuízo funcional. O objetivo deste estudo foi avaliar a cinemática da parede torácica e a capacidade funcional no pós-operatório de pacientes mastectomizadas sem tratamento neoadjuvante e adjuvante associados. Foram avaliadas 4 mulheres no grupo mastectomia (GM) e 4 mulheres no grupo controle (GC). Todas as participantes foram submetidas aos procedimentos de avaliação antropométrica, função pulmonar, força muscular respiratória, cinemática da parede torácica e capacidade funcional. O GM também foi submetido à avaliação de inspeção e palpação torácica. Os dados foram analisados por meio de estatística descritiva. Foi observado que o GM apresentou menor variação de volume corrente da parede torácica, com delta de variação de 22,03% a menos que o GC, sendo a maior redução de volume corrente evidenciada no compartimento de caixa torácica pulmonar, com redução de 41,57% em relação ao GC. O GM não apresentou alterações de função pulmonar, força muscular respiratória e capacidade funcional, apresentando valores de normalidade nessas avaliações. Portanto, mulheres submetidas ao procedimento cirúrgico de mastectomia, sem tratamento neoadjuvante e adjuvante associados, não apresentaram comprometimento da função pulmonar, da força muscular respiratória e da capacidade funcional, contudo foi verificado redução do volume pulmonar na região do procedimento cirúrgico.

Women submitted to a mastectomy surgery may present some complications, among them, respiratory changes and functional impairment. The purpose of this study was to evaluate the chest wall kinematics and functional capacity in the postoperative period of mastectomized patients without associated adjuvant and neoadjuvant treatment. A total of four (4) women in the mastectomy group (MG) and four (4) in the control group (CG) were evaluated. All participants were submitted to the procedures of anthropometric evaluation, pulmonary function, respiratory muscle strength, chest wall kinematics and functional capacity. Patients in MG were also submitted to an inspection and palpation evaluation of the chest and breasts. Database was analyzed using descriptive statistics. It was observed that the MG presented a smaller variation of tidal volume of the chest wall, with a variation delta of 22.03% less than CG, with the largest reduction in tidal volume evidenced in the pulmonary chest cavity compartment, with a reduction of 41.57% when compared to CG. The MG did not present alterations of pulmonary function, respiratory muscle strength and functional capacity, presenting values of normality in these evaluations. Therefore, women submitted to the surgical procedure of mastectomy without associated neoadjuvant and adjuvant treatment did not present any impairment of pulmonary function, respiratory muscle strength and functional capacity. However, a reduction could be observed in the pulmonary volume in the region of the surgical procedure.

Is the peripheral muscle weakness a limitation to exercise on chronic kidney disease? / A fraqueza muscular periférica é uma limitação ao exercício na doença renal crônica?

Abstract Introduction: Chronic kidney disease (CKD) is a global public health problem with systemic repercussions, compromising muscle function and making patients less exercise tolerant. Objective: To verify the contribution of peripheral muscle strength in the exercise capacity of patients in hemodialysis (HD), as well as to compare peripheral muscle strength and exercise capacity between renal patients and healthy individuals. Method: 50 patients with chronic kidney disease (CKD) who performed HD and 13 healthy subjects underwent anthropometric evaluation, evaluation of peripheral muscle strength, pulmonary function test and exercise capacity assessment. Results: Simple linear regression indicated that the peripheral muscle strength contributed 41.4% to the distance walked in the six-minute walk test (R2 0.414; p < 0.001), showing that for every 1 Kgf reduced in the right lower limb the patient it stops walking 0.5m while for every 1 Kgf reduced in the lower left limb the patient stops walking 0.8m. In addition, it was observed that patients with CKD had a reduction in right lower limb muscle strength (129.44 ± 48.05 vs. 169.36 ± 44.30, p = 0.002), left (136.12 ± 52, 08 vs 168.40 ± 43.35, p = 0.01) and exercise capacity (421.20 ± 98.07 vs. 611.28 ± 80.91, p < 0.001) when compared to healthy pairs. Conclusion: Peripheral muscle weakness is an important limiting factor for exercise in CKD and patients on HD experience a decline in peripheral muscle strength and exercise capacity when compared to healthy individuals.

Resumo Introdução: A doença renal crônica (DRC) é um problema de saúde pública global com repercussões sistêmicas, comprometendo a função muscular e tornando os pacientes menos tolerantes ao exercício. Objetivo: Verificar a contribuição da força muscular periférica na capacidade de exercício de pacientes em hemodiálise (HD), bem como, comparar a força muscular periférica e a capacidade de exercício entre pacientes renais e indivíduos saudáveis. Método: 50 pacientes com DRC que realizavam HD e 13 indivíduos saudáveis foram submetidos à avaliação antropométrica, avaliação da força muscular periférica, prova de função pulmonar e avaliação da capacidade de exercício. Resultados: A regressão linear simples indicou que a força muscular periférica contribuiu em 41,4% a distância percorrida no teste de caminhada de seis minutos (R2 0,414; p < 0,001), mostrando que para cada 1 Kgf reduzido no membro inferior direito o paciente deixa de caminhar 0,5m enquanto que para cada 1 Kgf reduzido no membro inferior esquerdo, o paciente deixa de caminhar 0,8m. Além disso, observou-se que pacientes com DRC apresentam redução da força muscular de membro inferior direito (129,44 ± 48,05 vs. 169,36 ± 44,30; p = 0,002), esquerdo (136,12 ± 52,08 vs. 168,40 ± 43,35; p = 0,01) e da capacidade de exercício (421,20 ± 98,07 vs. 611,28 ± 80,91; p < 0,001) quando comparados aos pares saudáveis. Conclusão: A fraqueza muscular periférica é um importante fator de limitação ao exercício na DRC. Além disso, pacientes em HD apresentam redução da força muscular periférica e da capacidade de exercício quando comparados a indivíduos saudáveis.

Relationship between handgrip strength and pulmonary capacity in patients on hemodialysis / Relação entre a força de preensão manual e a capacidade pulmonar de pacientes em hemodiálise

Abstract Introduction: Chronic kidney disease (CKD) is defined as loss of kidney function, but its progression leads to systemic changes that compromise the quality of life of patients on dialysis. As such, the decline in lung capacity in this population may be one of the factors related to reduced peripheral muscle strength. Objective: Assess the relationship between handgrip strength (HGS), pulmonary function and respiratory muscle strength in patients with CKD on hemodialysis. Method: Thirty patients with CKD were assessed in terms of anthropometric data, pulmonary function, respiratory muscle strength and HGS. Results: A moderate association was observed between HGS and the variables forced vital capacity (r=0.54; p=0.002), maximum voluntary ventilation (r=0.51; p=0.004) and maximum expiratory pressure (r=0.59; p=0.001), and a weak association with forced expiratory volume in 1 second (FEV1) (r=0.46; p=0.009) and maximum inspiratory pressure (r=0.38; p=0.03). Additionally, about 67% of the sample (n=20) exhibited some degree of restrictive ventilatory defect in the pulmonary function test. With respect to muscle strength, 40% of the sample (n=12) displayed below-normal handgrip strength, as well as low mean MIP and MEP. Conclusion: Decreased lung capacity may be related to a decline in HGS in patients with chronic kidney disease on hemodialysis. Thus, therapeutic strategies aimed at lung expansion and respiratory muscle training may contribute to facilitating and favoring rehabilitation in this population.

Resumo Introdução: A doença renal crônica (DRC) é definida pela perda da função renal, contudo a sua progressão leva ao surgimento de alterações sistêmicas que comprometem a qualidade de vida dos pacientes em hemodiálise. Consequentemente, a redução da capacidade pulmonar nessa população pode ser um dos fatores que esteja relacionado ao declínio da força muscular periférica. Objetivo: Avaliar a relação entre a força de preensão manual (FPM) com a função pulmonar e a força muscular respiratória de pacientes com DRC em hemodiálise. Método: 30 pacientes com DRC foram avaliados quanto aos dados antropométricos, função pulmonar, força muscular respiratória e FPM. Resultados: Observou-se uma relação moderada da FPM com as variáveis capacidade vital forçada (r=0,54; p=0,002), ventilação voluntária máxima (r=0,51; p=0,004) e pressão expiratória máxima (r=0,59; p=0,001). Já as correlações entre a FPM com o volume expiratório forçado no primeiro segundo (r=0,46; p=0,009) e a pressão inspiratória máxima (r=0,38; p=0,03) foram fracas. Além disso, aproximadamente 67% da amostra (n=20) apresentou algum grau de restrição ventilatória na prova de função pulmonar. Em relação à força muscular, 40% da amostra (n=12) apresentou FPM abaixo do previsto de normalidade, e as médias da pressão inspiratória máxima e da pressão expiratória máxima em porcentagem também se encontraram reduzidas. Conclusão: A redução da capacidade pulmonar pode estar relacionada com o declínio da FPM nos pacientes com DRC em hemodiálise. Sendo assim, recursos terapêuticos visando à expansão pulmonar e o treinamento muscular respiratório podem ser estratégias para facilitar e favorecer a reabilitação dessa população.

Capacidade pulmonar, muscular e funcional de pacientes com doença renal crônica / Pulmonary, muscular and functional capacity of patients with chronic kidney disease

Objetivo: Conhecer o perfil pulmonar, muscular e funcional de pacientes com doença renal crônica (DRC) e verificar a relação entre a força muscular periférica e a capacidade funcional desses pacientes. Métodos: 21 pacientes com DRC e 17 saudáveis foram avaliados quanto à antropometria, função pulmonar, força muscular periférica e capacidade funcional. Para comparação entres os grupos foi utilizado o teste t de Student ou U de Mann Whitney. Para correlacionar a força muscular periférica com a capacidade funcional do grupo DRC utilizou-se o coeficiente de Pearson ou Spearman. Resultados: Houve diferença estatisticamente significativa entre os grupos DRC e saudável, respectivamente, nas variáveis da função pulmonar: volume expiratório forçado no primeiro segundo (77,62 ± 18,05% vs. 99,71 ± 16,43%; p = 0,001) e capacidade vital forçada (78,86 ± 17,16% vs. 98,48 ± 16,99%; p = 0,001); e na força muscular periférica de quadríceps direito (127,76 ± 49,77 Nm vs. 170,90 ± 55,38 Nm; p = 0,006) e esquerdo (134,10 ± 55,19 Nm vs. 171,05 ± 57,86 Nm; p = 0,04). O teste de caminhada de 6 minutos foi menor no grupo DRC comparado ao saudável em valor absoluto (419,95 ± 98,51m vs. 616,90 ± 90,01m; p < 0,0001) e em % do predito (66,07 ± 15,04% vs. 94,80 ± 9,35%; p < 0,0001). Observou-se correlação moderada entre a capacidade funcional e a força muscular periférica de quadríceps direito (rho = 0,52; p = 0,01) e quadríceps esquerdo (r = 0,63; p = 0,002) no grupo DRC. Conclusão: Pacientes com DRC apresentam alteração na função pulmonar, redução da força muscular periférica e da capacidade funcional. (AU)

Objective: To study the pulmonary, muscular and functional profile of patients with chronic kidney disease (CKD) and verify the correlation between peripheral muscle strength and functional capacity of these patients. Methods: 21 patients with CKD and 17 healthy individuals were evaluated for anthropometry, pulmonary function, peripheral muscle strength and functional capacity. In the comparison between the groups, the Student t test or the Mann Whitney U test were used. Correlation of peripheral muscle strength with the functional capacity of the CKD group was tested by the Pearson or Spearman coefficient. Results: There was a statistically significant difference between the CKD and healthy groups, respectively, in the pulmonary function variables: forced expiratory volume in the first second (77.62 ± 18.05% vs. 99.71 ± 16.43%, p = 0.001) and forced vital capacity (78.86 ± 17.16% vs. 98.48 ± 16.99%, p=0.001); and right quadriceps muscle strength (127.76 ± 49.77 Nm vs. 170.90 ± 55.38 Nm, p = 0.006) and left quadriceps (134.10 ± 55.19 Nm vs. 171.05 ± 57.86 Nm; p = 0.04). The 6-minute walk test was lower in the CKD group compared to healthy in absolute values (419.95 ± 98.51 m vs. 616.90 ± 90.01 m, p < 0.0001) and in % predicted (66,07 ± 15.04% vs. 94.80 ± 9.35%, p<0.0001). There was a moderate correlation between functional capacity and muscle strength of right quadriceps (rho = 0.52, p = 0.01) and left quadriceps (r = 0.63, p = 0.002) in the CKD group. Conclusion: Patients with CKD have altered pulmonary function, reduced peripheral muscle strength and functional capacity. (AU)

The Benefits of Neuromuscular Electrical Stimulation in the Muscular and Functional Capacity of Patients With Liver Cirrhosis: Protocol for a Randomized Clinical Trial.

Cirrhosis causes systemic and metabolic changes that culminate in various complications, such as compromised pulmonary function, ascites, hepatic encephalopathy, weight loss, and muscle weakness with significant physical function limitations. Our aim is to evaluate the effects of training with neuromuscular electrical stimulation (NMES) on the muscular and functional capacity of patients with cirrhosis classified as Child-Pugh B and C. A total of 72 patients diagnosed with cirrhosis will be recruited and randomized to perform an NMES protocol for 50 minutes, 3 times a week, for 4 weeks. The evaluations will be performed at the beginning and after 12 sessions, and patients will be submitted to a pulmonary function test, an ultrasound evaluation of the rectus femoris, an evaluation of peripheral muscle strength, a submaximal exercise capacity test associated with an evaluation of peripheral tissue oxygenation, a quality of life evaluation, and orientation about monitoring daily physical activities. The evaluators and patients will be blinded to the allocation of the groups. Training Group will be treated with the following parameters: frequency of 50 Hz, pulse width of 400 µs, rise and fall times of 2 s, and on:off 1:1; Sham Group: 5 Hz, 100 µs, on:off 1:3. The data will be analyzed using the principles of the intention to treat. This study provides health professionals with information on the benefits of this intervention. In this way, we believe that the results of this study could stimulate the use of NMES as a way of rehabilitating patients with more severe cirrhosis, with the objective of improving these patients' functional independence.

Validity and reliability of assessing diaphragmatic mobility by area on X-rays of healthy subjects.

OBJECTIVE: To investigate the concurrent validity, as well as the intra- and inter-rater reliability, of assessing diaphragmatic mobility by area (DMarea) on chest X-rays of healthy adults. METHODS: We evaluated anthropometric parameters, pulmonary function, and diaphragmatic mobility in 43 participants. Two observers (rater A and rater B) determined diaphragmatic mobility at two time points. We used Pearson's correlation coefficient to evaluate the correlation between DMarea and the assessment of diaphragmatic mobility by distance (DMdist). To evaluate intra- and inter-rater reliability, we used the intraclass correlation coefficient (ICC [2,1]), 95% CI, and Bland-Altman analysis. RESULTS: A significant correlation was found between the DMarea and DMdist methods (r = 0.743; p < 0.0001). For DMarea, the intra-rater reliability was found to be quite high for the right hemidiaphragm (RHD)-ICC (2,1) = 0.92 (95% CI: 0.86-0.95) for rater A and ICC (2,1) = 0.90 (95% CI: 0.84-0.94) for rater B-and the left hemidiaphragm (LHD)-ICC (2,1) = 0.96 (95% CI: 0.93-0.97) for rater A and ICC (2,1) = 0.91 (95% CI: 0.81-0.95) for rater B-(p < 0.0001 for all). Also for DMarea, the inter-rater reliability was found to be quite high for the first and second evaluations of the RHD-ICC (2,1) = 0.99 (95% CI: 0.98-0.99) and ICC (2,1) = 0.95 (95% CI: 0.86-0.97), respectively-and the LHD-ICC (2,1) = 0.99 (95% CI: 0.98-0.99) and ICC (2,1) = 0.94 (95% CI: 0.87-0.97)-(p < 0.0001 for both). The Bland-Altman analysis showed good agreement between the mobility of the RHD and that of the LHD. CONCLUSIONS: The DMarea method proved to be a valid, reliable measure of diaphragmatic mobility.

Is the 6-minute pegboard and ring test valid to evaluate upper limb function in hospitalized patients with acute exacerbation of COPD?

Background: The 6-minute pegboard and ring test (6-PBRT) is a useful test for assessing the functional capacity of upper limbs in patients with stable COPD. Although 6-PBRT has been validated in stable patients, the possibility of a high floor effect could compromise the validity of the test in the hospital setting. The aim of this study was to verify the convergent validity of 6-PBRT in hospitalized patients with acute exacerbation of COPD (AECOPD). Methods: A cross-sectional study was conducted in a tertiary hospital. Patients who were hospitalized due to AECOPD and healthy elderly participants, voluntarily recruited from the community, were considered for inclusion. All participants underwent a 6-PBRT. Isokinetic evaluation to measure the strength and endurance of elbow flexors and extensors, handgrip strength (HGS), spirometry testing, the modified Pulmonary Functional Status Dyspnea Questionnaire (PFSDQ-M), the COPD assessment test (CAT), and symptoms of dyspnea and fatigue were all measured as comparisons for convergent validity. Good convergent validity was considered if >75% of these hypotheses could be confirmed (correlation coefficient>0.50). Results: A total of 17 patients with AECOPD (70.9±5.1 years and forced expiratory volume in 1 second [FEV1] of 41.8%±17.9% of predicted) and 11 healthy elderly subjects were included. The HGS showed a significant strong correlation with 6-PBRT performance (r=0.70; p=0.002). The performance in 6-PBRT presented a significant moderate correlation with elbow flexor torque peak (r=0.52; p=0.03) and elbow extensor torque peak (r=0.61; p=0.01). The total muscular work of the 15 isokinetic contractions of the elbow flexor and extensor muscles showed a significant moderate correlation with the performance in 6-PBRT (r=0.59; p=0.01 and r=0.57; p=0.02, respectively). Concerning the endurance of elbow flexors and extensors, there was a significant moderate correlation with 6-PBRT performance (r=-0.50; p=0.04 and r=-0.51; p=0.03, respectively). In relation to the upper-extremity physical activities of daily living (ADLs) assessed by means of PFSDQ-M, there was a significant moderate correlation of 6-PBRT with three domains: influence of dyspnea on ADLs (r=-0.66; p<0.001), influence of fatigue on ADLs (r=-0.60; p=0.01), and change in ADLs in relation to the period before the disease onset (r=-0.51; p=0.03). The CAT was also correlated with 6-PBRT (r=-0.51; p=0.03). Finally, the performance in 6-PBRT showed a significant moderate correlation with the increase in dyspnea (r=-0.63; p=0.01) and a strong correlation with the increase in fatigue of upper limbs (r=-0.76; p<0.001) in patients with AECOPD. Convergent validity was considered adequate, since 81% from 16 predefined hypotheses were confirmed. There was no correlation between 6-PBRT and patients' height. The performance in 6-PBRT was worse in patients with AECOPD compared to healthy elderly individuals (248.7±63.0 vs 361.6±49.9 number of moved rings; p<0.001). Conclusion: The 6-PBRT is valid for the evaluation of functional capacity of upper limbs in hospitalized patients with AECOPD.

Mobilidade diafragmática direita e esquerda em indivíduos saudáveis e na doença pulmonar obstrutiva crônica / Movilidad diafragmática derecha e izquierda en individuos saludables y en la enfermedad pulmonar obstructiva crónica / Mobility of right and left hemidiaphragms in healthy individuals and in individuals with chronic obstructive pulmonary disease

RESUMO Avaliar o músculo diafragma é importante para verificar suas possíveis alterações ou disfunções. Existem várias formas de avaliar a mobilidade diafragmática, mas poucos estudos que comparam a mobilidade do hemidiafragma direito com o esquerdo. O objetivo deste estudo é avaliar se existem diferenças entre a mobilidade diafragmática das hemicúpulas direita e esquerda em indivíduos saudáveis e em indivíduos com Doença Pulmonar Obstrutiva Crônica (DOCP), bem como comparar a mobilidade diafragmática entre homens e mulheres, e entre pacientes saudáveis e com DPOC. Foram avaliados 40 indivíduos saudáveis e 40 indivíduos com diagnóstico clínico de DPOC. Utilizaram-se os parâmetros antropométricos, cardiopulmonares e avaliação da mobilidade diafragmática pelo método radiográfico. Os dados foram analisados estatisticamente e tratados com análise descritiva (média e desvio-padrão) e análise inferencial. Para comparar a mobilidade das hemicúpulas diafragmáticas direita e esquerda, utilizou-se o teste t pareado. O nível de significância adotado para o tratamento estatístico foi de 5% (p<0,05). Não houve diferença da mobilidade diafragmática tanto do lado direito quanto do lado esquerdo nos indivíduos saudáveis (p=0,45) e nos indivíduos com DPOC (p=0,77), assim como não houve diferenças quando os grupos foram separados por sexo. Foi encontrada uma diferença importante comparando tanto a mobilidade diafragmática do lado direito quanto do lado esquerdo entre indivíduos saudáveis e DPOC (p<0,001). Concluiu-se que a mobilidade diafragmática das hemicúpulas direita e esquerda em indivíduos saudáveis e em indivíduos com DPOC é a mesma. Não há diferença da mobilidade entre homens e mulheres. A mobilidade diafragmática é reduzida em paciente com DPOC.

RESUMEN Evaluar el músculo diafragma es importante para certificar sus posibles alteraciones o disfunciones. Hay varias maneras de evaluar la movilidad diafragmática, sin embargo, pocos estudios que comparan la movilidad del hemidiafragma derecho con el izquierdo. El objetivo de este estudio es evaluar si hay diferencias entre la movilidad diafragmática de las hemicúpulas derecha e izquierda en individuos saludables y en individuos con Enfermedad Pulmonar Obstructiva Crónica (EPOC), así como comparar la movilidad diafragmática entre hombres y mujeres, y entre pacientes saludables y con EPOC. Fueron evaluados 40 individuos saludables y 40 individuos con diagnóstico clínico de EPOC. Se utilizaron los parámetros antropométricos, los cardiopulmonares y la evaluación de la movilidad diafragmática por el método radiográfico. Los datos fueron analizados estadísticamente y tratados con el análisis descriptivo (promedio y desviación estándar) y el análisis inferencial. Para comparar la movilidad de las hemicúpulas diafragmáticas derecha e izquierda, se utilizó la prueba t pareada. El nivel de significancia adoptado para el tratamiento estadístico fue del 5% (p<0,05). No hubo diferencia de la movilidad diafragmática tanto del lado derecho cuanto del lado izquierdo en los individuos saludables (p=0,45) y en los individuos con EPOC (p=0,77), así como no hubo diferencias cuando los grupos fueron separados por sexo. Fue encontrada una diferencia importante comparando tanto la movilidad diafragmática del lado derecho cuanto del lado izquierdo entre individuos saludables y EPOC (p<0,001). Se concluyó que la movilidad diafragmática de las hemicúpulas derecha e izquierda en individuos saludables y en individuos con EPOC es la misma. No hay diferencia de la movilidad entre hombres y mujeres. La movilidad diafragmática es reducida en paciente con EPOC.

ABSTRACT To evaluate the diaphragm muscle is important for verifying its possible changes or malfunctions. There are several ways to evaluate the diaphragmatic mobility, but only a few compare the mobility of the right hemidiaphragm with the left one. The aim of this study was to evaluate whether there are differences between the mobility of right and left hemidiaphragms in healthy individuals and individuals with chronic obstructive pulmonary disease (COPD), as well as to evaluate the diaphragmatic mobility between men and women, and between healthy and COPD patients. We evaluated 40 healthy individuals and 40 individuals with clinical diagnosis of COPD. Anthropometric and cardiopulmonary parameters were used. The diaphragmatic mobility was evaluated by radiography. Data were statistically analyzed and processed with descriptive analysis (mean and standard deviation) and inferential analysis. To compare the mobilities of the right and left hemidiaphragms, the paired t-test was used. The significance level adopted for statistical treatment was 5% (p<0.05). There was no difference of the diaphragmatic mobility for both left and right sides in healthy individuals (p=0.45) and individuals with COPD (p=0.77). Also, no differences were found when groups were separated according to sex. An important difference was found comparing both diaphragmatic mobilities of the right and left sides between healthy and COPD individuals (p<0.001). We concluded that mobility of left and right hemidiaphragms in healthy and COPD individuals is the same. There is no difference for mobility between men and women. Diaphragmatic mobility is reduced in COPD patients.

Validity and reliability of assessing diaphragmatic mobility by area on X-rays of healthy subjects / Validade e confiabilidade da avaliação da mobilidade diafragmática pelo método da área radiográfica em sujeitos saudáveis

ABSTRACT Objective: To investigate the concurrent validity, as well as the intra- and inter-rater reliability, of assessing diaphragmatic mobility by area (DMarea) on chest X-rays of healthy adults. Methods: We evaluated anthropometric parameters, pulmonary function, and diaphragmatic mobility in 43 participants. Two observers (rater A and rater B) determined diaphragmatic mobility at two time points. We used Pearson's correlation coefficient to evaluate the correlation between DMarea and the assessment of diaphragmatic mobility by distance (DMdist). To evaluate intra- and inter-rater reliability, we used the intraclass correlation coefficient (ICC [2,1]), 95% CI, and Bland-Altman analysis. Results: A significant correlation was found between the DMarea and DMdist methods (r = 0.743; p < 0.0001). For DMarea, the intra-rater reliability was found to be quite high for the right hemidiaphragm (RHD)-ICC (2,1) = 0.92 (95% CI: 0.86-0.95) for rater A and ICC (2,1) = 0.90 (95% CI: 0.84-0.94) for rater B-and the left hemidiaphragm (LHD)-ICC (2,1) = 0.96 (95% CI: 0.93-0.97) for rater A and ICC (2,1) = 0.91 (95% CI: 0.81-0.95) for rater B-(p < 0.0001 for all). Also for DMarea, the inter-rater reliability was found to be quite high for the first and second evaluations of the RHD-ICC (2,1) = 0.99 (95% CI: 0.98-0.99) and ICC (2,1) = 0.95 (95% CI: 0.86-0.97), respectively-and the LHD-ICC (2,1) = 0.99 (95% CI: 0.98-0.99) and ICC (2,1) = 0.94 (95% CI: 0.87-0.97)-(p < 0.0001 for both). The Bland-Altman analysis showed good agreement between the mobility of the RHD and that of the LHD. Conclusions: The DMarea method proved to be a valid, reliable measure of diaphragmatic mobility.

RESUMO Objetivo: Avaliar a validade concorrente, assim como a confiabilidade intra e interobservador, da avaliação da mobilidade diafragmática pelo método da área radiográfica (MDárea) em adultos saudáveis. Métodos: Foram avaliados os parâmetros antropométricos, a função pulmonar e a mobilidade diafragmática de 43 participantes. A mobilidade diafragmática foi determinada por dois observadores (A e B) em dois momentos distintos. O coeficiente de correlação de Pearson foi utilizado para avaliar a correlação entre o método da MDárea e o método por distância (MDdist). Para avaliar a confiabilidade intra e interobservador, foi utilizado o coeficiente de correlação intraclasse (CCI [2,1]), IC95% e a disposição gráfica de Bland & Altman. Resultados: Houve uma correlação significativa entre MDárea e MDdist (r = 0,743; p < 0,0001). Para MDárea, a confiabilidade intraobservador foi alta para a avaliação radiográfica do hemidiafragma direito (HDD) - CCI (2,1) = 0,92 (IC95%: 0,86-0,95) para o observador A e CCI (2,1) = 0,90 (IC95%: 0,84-0,94) para o observador B - e do hemidiafragma esquerdo (HDE) - CCI (2,1) = 0,96 (IC95%: 0,93-0,97) para o observador A e CCI (2,1) = 0,91 (IC95%: 0,81-0,95 para o observador B (p < 0,0001 para todos). Também para MDárea, a confiabilidade interobservador foi alta para a primeira e segunda avaliações do HDD - CCI (2,1) = 0,99 (IC95%: 0,98-0,99) e CCI (2,1) = 0,95 (IC95%: 0,86-0,97), respectivamente - e HDE - CCI (2,1) = 0,94 (IC95%: 0,87-0,97) e CCI (2,1) = 0,94 (IC95%: 0,87-0,97), respectivamente - (p < 0,0001 para ambos). A disposição gráfica de Bland & Altman mostrou uma boa concordância entre as medidas de mobilidade de HDD e HDE. Conclusões: O método de MDárea demonstrou ser válido e reprodutível para medir a mobilidade diafragmática.

Comparison of diaphragmatic mobility between COPD patients with and without thoracic hyperkyphosis: a cross-sectional study.

OBJECTIVE: To compare diaphragmatic mobility, lung function, and respiratory muscle strength between COPD patients with and without thoracic hyperkyphosis; to determine the relationship of thoracic kyphosis angle with diaphragmatic mobility, lung function, and respiratory muscle strength in COPD patients; and to compare diaphragmatic mobility and thoracic kyphosis between male and female patients with COPD. METHODS: Participants underwent anthropometry, spirometry, thoracic kyphosis measurement, and evaluation of diaphragmatic mobility. RESULTS: A total of 34 patients with COPD participated in the study. Diaphragmatic mobility was significantly lower in the group of COPD patients with thoracic hyperkyphosis than in that of those without it (p = 0.002). There were no statistically significant differences between the two groups of COPD patients regarding lung function or respiratory muscle strength variables. There was a significant negative correlation between thoracic kyphosis angle and diaphragmatic mobility (r = -0.47; p = 0.005). In the sample as a whole, there were statistically significant differences between males and females regarding body weight (p = 0.011), height (p < 0.001), and thoracic kyphosis angle (p = 0.036); however, there were no significant differences in diaphragmatic mobility between males and females (p = 0.210). CONCLUSIONS: Diaphragmatic mobility is lower in COPD patients with thoracic hyperkyphosis than in those without it. There is a negative correlation between thoracic kyphosis angle and diaphragmatic mobility. In comparison with male patients with COPD, female patients with COPD have a significantly increased thoracic kyphosis angle.

Comparison of diaphragmatic mobility between COPD patients with and without thoracic hyperkyphosis: a cross-sectional study / Comparação da mobilidade diafragmática em pacientes com DPOC com e sem hipercifose torácica: um estudo transversal

ABSTRACT Objective: To compare diaphragmatic mobility, lung function, and respiratory muscle strength between COPD patients with and without thoracic hyperkyphosis; to determine the relationship of thoracic kyphosis angle with diaphragmatic mobility, lung function, and respiratory muscle strength in COPD patients; and to compare diaphragmatic mobility and thoracic kyphosis between male and female patients with COPD. Methods: Participants underwent anthropometry, spirometry, thoracic kyphosis measurement, and evaluation of diaphragmatic mobility. Results: A total of 34 patients with COPD participated in the study. Diaphragmatic mobility was significantly lower in the group of COPD patients with thoracic hyperkyphosis than in that of those without it (p = 0.002). There were no statistically significant differences between the two groups of COPD patients regarding lung function or respiratory muscle strength variables. There was a significant negative correlation between thoracic kyphosis angle and diaphragmatic mobility (r = −0.47; p = 0.005). In the sample as a whole, there were statistically significant differences between males and females regarding body weight (p = 0.011), height (p < 0.001), and thoracic kyphosis angle (p = 0.036); however, there were no significant differences in diaphragmatic mobility between males and females (p = 0.210). Conclusions: Diaphragmatic mobility is lower in COPD patients with thoracic hyperkyphosis than in those without it. There is a negative correlation between thoracic kyphosis angle and diaphragmatic mobility. In comparison with male patients with COPD, female patients with COPD have a significantly increased thoracic kyphosis angle.

RESUMO Objetivo: Comparar a mobilidade diafragmática, a função pulmonar e a força muscular respiratória em pacientes que apresentam DPOC com e sem hipercifose torácica; verificar a relação do ângulo da curvatura torácica com a mobilidade diafragmática, variáveis da função pulmonar e de força muscular respiratória dos pacientes com DPOC; e comparar a mobilidade diafragmática e a cifose torácica entre os gêneros nesses pacientes. Métodos: Foram realizadas as seguintes avaliações: antropometria, espirometria, mensuração do ângulo da curvatura torácica e mobilidade diafragmática. Resultados: Participaram do estudo 34 pacientes com DPOC. No grupo de pacientes com DPOC e hipercifose torácica, a mobilidade diafragmática foi estatisticamente menor quando comparada à do grupo DPOC sem hipercifose torácica (p = 0,002). Não houve diferenças estatisticamente significantes entre esses grupos em relação a variáveis de função pulmonar e de força muscular respiratória. Houve uma correlação negativa significante entre o ângulo da curvatura torácica e a mobilidade diafragmática (r = −0,47; p = 0,005). Quando comparados homens e mulheres da amostra geral, houve diferenças estatisticamente significantes em relação à massa corpórea (p = 0,011), estatura (p < 0,001) e ângulo da curvatura da cifose torácica (p = 0,036), mas não em relação à mobilidade diafragmática (p = 0,210). Conclusões: Os pacientes com DPOC e hipercifose torácica apresentaram menor mobilidade diafragmática quando comparados com os pacientes com DPOC sem hipercifose torácica. O ângulo da curvatura torácica se correlacionou negativamente com a mobilidade diafragmática. O grupo feminino apresentou um aumento significante no ângulo da curvatura torácica quando comparado ao grupo masculino.

Postural alignment of patients with Chronic Obstructive Pulmonary Disease / Alinhamento postural de pacientes com Doença Pulmonar Obstrutiva Crônica

Abstract Introduction: In chronic obstructive pulmonary disease (COPD), airflow resistance impairs respiratory mechanics that may compromise postural alignment. There is a lack of studies that have investigated compromised postures and their possible associations with pulmonary function. Objectives: To compare the postural alignment of COPD patients with apparently healthy individuals; To correlate pulmonary function with postural alignment in the COPD group. Methods: 20 COPD patients and 20 apparently healthy individuals performed: anthropometry, spirometry and postural evaluation. The following postural changes were assessed: lateral head tilt (LHT), shoulder asymmetry (SA1), anterior pelvic asymmetry (APA), lateral trunk tilt (LTT), scapular asymmetry (SA2), posterior pelvic asymmetry (PPA), head protrusion (HP), shoulder protrusion (SP), anterior pelvic tilt (APT) and thoracic kyphosis (TK). Results: There was a statistically significant difference between COPD patients and apparently healthy individuals in the following variables: PPT (p= 0.021), APT (p=0.014) and TK (p=0.011). There was a correlation between pulmonary variables and postural alignment in the COPD group: Forced Volume in one second (FEV1% pred) and HP (°) (r=0.488, p=0.029), FEV1 (% pred) and APT (°) (r= -0.472, p= 0.036); Forced Vital Capacity (FVC % pred) and HP (°) (r=0.568, p=0.009); FVC (% pred) and APT (°) (r=-0.461, p=0.041). Conclusion: Postural alignment of the anterior tilt of the right and left pelvis and thoracic kyphosis is different when compared with COPD patients and healthy individuals. There is a relationship between pulmonary function and postural alignment in COPD patients.

Resumo Introdução: Na doença pulmonar obstrutiva crônica (DPOC), a resistência ao fluxo aéreo prejudica a mecânica respiratória que pode comprometer o alinhamento postural. Existe uma escassez de estudos que tenham investigado os comprometimentos posturais e suas possíveis relações com a função pulmonar. Objetivos: Comparar o alinhamento postural entre pacientes com DPOC e indivíduos aparentemente saudáveis; correlacionar a função pulmonar com o alinhamento postural no grupo DPOC. Métodos: 20 pacientes com DPOC e 20 indivíduos aparentemente saudáveis realizaram: antropometria, espirometria e avaliação postural. Foram analisadas as alterações posturais: inclinação lateral da cabeça (ILC), desnivelamento dos ombros (DO), desnivelamento pélvico anterior (DPA), inclinação lateral do tronco (ILT), desnivelamento das escápulas (DE), desnivelamento pélvico posterior (DPP), protrusão da cabeça (PC), protrusão de ombro (PO), báscula anterior da pelve (BAP) e cifose torácica (CT). Resultados: Houve diferença estatisticamente significante entre os pacientes com DPOC e os indivíduos aparentemente saudáveis nas variáveis: DPP (0,021), BAP (p=0,014) e CT (p=0,011). Houve correlação entre as variáveis pulmonares e o alinhamento postural no grupo DPOC: volume forçado no primeiro segundo (VEF1 %prev) e PC (°) (r= 0,488, p=0,029), VEF1 (%prev) e BAP (°) (r= -0,472; p= 0,036); Capacidade Vital Forçada (CVF %prev) e PC (°) (r= 0,568; p= 0,009); CVF %prev) e BAP (°) (r= -0,461; p=0,041). Conclusão: O alinhamento postural da báscula anterior da pelve direita e esquerda e da cifose torácica é diferente quando comparados pacientes com DPOC e saudáveis. Existe relação entre a função pulmonar e o alinhamento postural no paciente com DPOC.

Relação entre a mobilidade diafragmática e as curvaturas da coluna vertebral em pacientes com doença pulmonar obstrutiva crônica / Relación entre la movilidad diafragmática y las curvaturas de la columna vertebral en los pacientes con la enfermedad pulmonar obstructiva crónica / The relation between diaphragmatic mobility and spinal curvatures in patients with chronic obstructive pulmonary disease

RESUMO Na doença pulmonar obstrutiva crônica (DPOC), os pacientes podem apresentar redução da mobilidade diafragmática e uma série de compensações na coluna torácica, nas cinturas escapular e pélvica. No entanto, não está clara a relação da mobilidade diafragmática com alterações posturais na coluna vertebral e na pelve desses indivíduos. Objetivou-se verificar se existe relação entre a mobilidade diafragmática com as curvaturas da coluna vertebral de pacientes com DPOC e em indivíduos aparentemente saudáveis. Foram avaliados 22 pacientes com DPOC e 22 indivíduos aparentemente saudáveis. As avaliações foram: antropometria, espirometria, mobilidade diafragmática e avaliação postural. Foram analisadas quatro alterações posturais: lordose cervical, cifose torácica, lordose lombar, posição pélvica. Não houve diferença estatisticamente significativa entre os grupos, em relação às variáveis idade, massa corporal, estatura e IMC, confirmando que os grupos foram pareados. Não houve diferença estatisticamente significante em nenhuma das variáveis referentes às curvaturas da coluna vertebral e à posição da pelve entre os grupos estudados. No grupo DPOC houve correlação da mobilidade diafragmática com a cifose torácica (r=-0,543; p=0,009). Já em relação ao grupo de indivíduos aparentemente saudáveis, não houve correlação da mobilidade quanto os indivíduos aparentemente saudáveis apresentaram os mesmos ângulos de curvatura da coluna vertebral e a mesma posição da pelve. Contudo, os pacientes com DPOC apresentaram relação entre a mobilidade diafragmática e o ângulo da curvatura torácica.

RESUMEN En la enfermedad pulmonar obstructiva crónica (EPOC), los pacientes pueden presentar reducción de la movilidad diafragmática y muchas compensaciones en la columna torácica, en las cinturas escapular y pélvica. No obstante, no está clara la relación de la movilidad diafragmática con las alteraciones posturales en la columna vertebral y en la pelvis de esos individuos. Se tuvo el objetivo de ver si hay relación entre la movilidad diafragmática con las curvaturas de la columna vertebral de los pacientes con la EPOC y en los individuos aparentemente saludables. Fueron evaluados 22 pacientes con la EPOC y 22 individuos aparentemente saludables. Las evaluaciones fueron: la antropometría, la espirometría, la movilidad diafragmática y la evaluación postural. Fueron analizadas cuatro alteraciones posturales: la lordosis cervical, la cifosis torácica, la lordosis lumbar, la posición pélvica. No hubo diferencia estadísticamente significativa entre los grupos, en relación a las variables edad, la masa corporal, la estatura y el IMC, confirmando que los grupos fueron pareados. No hubo diferencia estadísticamente significante en ninguna de las variables referentes a las curvaturas de la columna vertebral y a la posición de la pelvis entre los grupos estudiados. En el grupo EPOC hubo correlación de la movilidad diafragmática con la cifosis torácica (r = -0,543; p = 0,009). Ya en relación al grupo de los individuos aparentemente saludables, no hubo correlación de la movilidad cuanto a los individuos aparentemente saludables que presentaron los mismos ángulos de curvatura de la columna vertebral y la misma posición de la pelvis. No obstante, los pacientes con la EPOC presentaron relación entre la movilidad diafragmática y el ángulo de la curvatura torácica.

ABSTRACT In the chronic obstructive pulmonary disease (COPD), patients may have reduced diaphragmatic mobility and a series of compensations in the thoracic spine, the scapular and pelvic girdles. However, the relation between diaphragmatic mobility and postural changes in these individuals' vertebral column and pelvis is not clear. The aim of this study was to verify if there is a relation between diaphragmatic mobility and spinal curvatures in patients with COPD and in apparently healthy individuals. Were evaluated 22 patients with COPD and 22 apparently healthy individuals. The evaluations consisted of: anthropometry, spirometry, diaphragmatic mobility and postural evaluation. Four postural alterations were analyzed: cervical lordosis, thoracic kyphosis, lumbar lordosis, pelvic position. There was no statistically significant difference between the groups, in relation to the variables age, body mass, stature and BMI, confirming that the groups were paired. There was no statistically significant difference in any of the variables related to spinal curvatures and pelvic position between the studied groups. In the COPD group, there was a correlation between diaphragmatic mobility and thoracic kyphosis (r=-0.543; p=0.009). Regarding the group of apparently healthy individuals, there was no correlation of mobility as the apparently healthy individuals presented the same angles of curvature of the vertebral column and the same position of the pelvis. However, there was a relation between diaphragmatic mobility and the angle of the thoracic curvature in patients with COPD.

Validity and reliability of fluoroscopy for digital radiography: a new way to evaluate diaphragmatic mobility.

BACKGROUND: Fluoroscopy is considered the most accurate method to evaluate the diaphragm, yet most existing methods for measuring diaphragmatic mobility using fluoroscopy are complex. To assess the validity and reliability of a new evaluation method of diaphragmatic motion using fluoroscopy by digital radiography of healthy adults. METHODS: Twenty-six adults were evaluated, according to the parameters: anthropometry and pulmonary function test. The evaluation of diaphragm mobility by means of fluoroscopy by digital radiography method was randomly conducted by two raters (A and B). The Pearson correlation coefficient and the intraclass correlation coefficient (ICC) were used to assess the concurrent validity. The inter-rater and intra-rater reliability of the measurement of diaphragmatic motion was determined using ICC and a confidence interval of 95%. RESULTS: There was a relationship in the assessment of the concurrent validity. There was good inter-rater reliability for right hemidiaphragm mobility and moderate reliability for left hemidiaphragm in the first assessment. In the second assessment, there was good reliability for the mobility of both hemidiaphragms. There was good intra-rater reliability in the mobility of both hemidiaphragms for raters A and B. CONCLUSION: The evaluation of diaphragmatic motion using fluoroscopy by digital radiography proved to be a valid and reliable method of healthy adults.

Diaphragmatic mobility: relationship with lung function, respiratory muscle strength, dyspnea, and physical activity in daily life in patients with COPD.

OBJECTIVE:: To evaluate diaphragmatic mobility in relation to lung function, respiratory muscle strength, dyspnea, and physical activity in daily life (PADL) in patients with COPD. METHODS:: We included 25 patients with COPD, classified according to the Global Initiative for Chronic Obstructive Lung Disease criteria, and 25 healthy individuals. For all of the participants, the following were evaluated: anthropometric variables, spirometric parameters, respiratory muscle strength, diaphragmatic mobility (by X-ray), PADL, and the perception of dyspnea. RESULTS:: In the COPD group, diaphragmatic mobility was found to correlate with lung function variables, inspiratory muscle strength, and the perception of dyspnea, whereas it did not correlate with expiratory muscle strength or PADL. CONCLUSIONS:: In patients with COPD, diaphragmatic mobility seems to be associated with airway obstruction and lung hyperinflation, as well as with ventilatory capacity and the perception of dyspnea, although not with PADL. OBJETIVO:: Avaliar a relação da mobilidade diafragmática com a função pulmonar, força muscular respiratória, dispneia e atividade física de vida diária (AFVD) em pacientes com DPOC. MÉTODOS:: Foram avaliados 25 pacientes com diagnóstico de DPOC, classificados de acordo com critérios da Global Initiative for Chronic Obstructive Lung Disease, e 25 indivíduos saudáveis. Todos foram submetidos às seguintes avaliações: mensuração antropométrica, espirometria, força muscular respiratória, mobilidade diafragmática (por radiografia), AFVD e percepção de dispneia. RESULTADOS:: No grupo DPOC, houve correlações da mobilidade diafragmática com variáveis de função pulmonar, força muscular inspiratória e percepção de dispneia. Não houve correlações da mobilidade diafragmática com força muscular expiratória e AFVD. CONCLUSÕES:: A mobilidade diafragmática parece estar associada tanto com a obstrução das vias aéreas quanto com a hiperinsuflação pulmonar em pacientes com DPOC, assim como com a capacidade ventilatória e percepção de dispneia, mas não com AFVD.

Diaphragmatic mobility: relationship with lung function, respiratory muscle strength, dyspnea, and physical activity in daily life in patients with COPD / Relação da mobilidade diafragmática com função pulmonar, força muscular respiratória, dispneia e atividade física de vida diária em pacientes com DPOC

ABSTRACT Objective: To evaluate diaphragmatic mobility in relation to lung function, respiratory muscle strength, dyspnea, and physical activity in daily life (PADL) in patients with COPD. Methods: We included 25 patients with COPD, classified according to the Global Initiative for Chronic Obstructive Lung Disease criteria, and 25 healthy individuals. For all of the participants, the following were evaluated: anthropometric variables, spirometric parameters, respiratory muscle strength, diaphragmatic mobility (by X-ray), PADL, and the perception of dyspnea. Results: In the COPD group, diaphragmatic mobility was found to correlate with lung function variables, inspiratory muscle strength, and the perception of dyspnea, whereas it did not correlate with expiratory muscle strength or PADL. Conclusions: In patients with COPD, diaphragmatic mobility seems to be associated with airway obstruction and lung hyperinflation, as well as with ventilatory capacity and the perception of dyspnea, although not with PADL.

RESUMO Objetivo: Avaliar a relação da mobilidade diafragmática com a função pulmonar, força muscular respiratória, dispneia e atividade física de vida diária (AFVD) em pacientes com DPOC. Métodos: Foram avaliados 25 pacientes com diagnóstico de DPOC, classificados de acordo com critérios da Global Initiative for Chronic Obstructive Lung Disease, e 25 indivíduos saudáveis. Todos foram submetidos às seguintes avaliações: mensuração antropométrica, espirometria, força muscular respiratória, mobilidade diafragmática (por radiografia), AFVD e percepção de dispneia. Resultados: No grupo DPOC, houve correlações da mobilidade diafragmática com variáveis de função pulmonar, força muscular inspiratória e percepção de dispneia. Não houve correlações da mobilidade diafragmática com força muscular expiratória e AFVD. Conclusões: A mobilidade diafragmática parece estar associada tanto com a obstrução das vias aéreas quanto com a hiperinsuflação pulmonar em pacientes com DPOC, assim como com a capacidade ventilatória e percepção de dispneia, mas não com AFVD.

Effects of Neuromuscular Electrical Stimulation During Hemodialysis on Peripheral Muscle Strength and Exercise Capacity: A Randomized Clinical Trial.

OBJECTIVE: To evaluate the effects of neuromuscular electrical stimulation of high and low frequency and intensity, performed during hemodialysis, on physical function and inflammation markers in patients with chronic kidney disease (CKD). DESIGN: Randomized clinical trial. SETTING: Hemodialysis clinic. PARTICIPANTS: Patients with CKD (N=51) were randomized into blocks of 4 using opaque sealed envelopes. They were divided into a group of high frequency and intensity neuromuscular electrical stimulation and a group of low frequency and intensity neuromuscular electrical stimulation. INTERVENTIONS: The high frequency and intensity neuromuscular electrical stimulation group was submitted to neuromuscular electrical stimulation at a frequency of 50Hz and a medium intensity of 72.90mA, and the low frequency and intensity neuromuscular electrical stimulation group used a frequency of 5Hz and a medium intensity of 13.85mA, 3 times per week for 1 hour, during 12 sessions. MAIN OUTCOME MEASURES: Peripheral muscle strength, exercise capacity, levels of muscle trophism marker (insulin growth factor 1) and levels of proinflammatory (tumor necrosis factor α) and anti-inflammatory (interleukin 10) cytokines. RESULTS: The high frequency and intensity neuromuscular electrical stimulation group showed a significant increase in right peripheral muscle strength (155.35±65.32Nm initial vs 161.60±68.73Nm final; P=.01) and left peripheral muscle strength (156.60±66.51Nm initial vs 164.10±69.76Nm final; P=.02) after the training, which did not occur in the low frequency and intensity neuromuscular electrical stimulation group for both right muscle strength (109.40±32.08Nm initial vs 112.65±38.44Nm final; P=.50) and left muscle strength (113.65±37.79Nm initial vs 116.15±43.01Nm final; P=.61). The 6-minute walk test distance (6MWTD) increased in both groups: high frequency and intensity neuromuscular electrical stimulation group (435.55±95.81m initial vs 457.25±90.64m final; P=.02) and low frequency and intensity neuromuscular electrical stimulation group (403.80±90.56m initial vs 428.90±87.42m final; P=.007). The groups did not differ in peripheral muscle strength and 6MWTD after the training protocol. In the high frequency and intensity neuromuscular electrical stimulation group, a correlation was observed between the initial and final values of 6MWTD and muscle strength. In the low frequency and intensity neuromuscular electrical stimulation group, correlations occurred only between the 6MWTD and the initial muscle strength. Only the low frequency and intensity neuromuscular electrical stimulation group increased levels of insulin growth factor 1 (252.38±156.35pg/mL initial vs 336.97±207.34pg/mL final; P=.03), and only the high frequency and intensity neuromuscular electrical stimulation group reduced levels of interleukin 10 (7.26±1.81pg/mL vs 6.32±1.54pg/mL; P=.03). The groups showed no differences in tumor necrosis factor α levels. CONCLUSIONS: Patients with CKD on hemodialysis improve exercise capacity after peripheral neuromuscular electrical stimulation of high and low frequency and intensity. However, the benefits on muscle and inflammatory outcomes seem to be specific for the adopted electrical stimulation strategy.