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1.
BMC Pulm Med ; 21(1): 241, 2021 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-34273962

RESUMO

INTRODUCTION: The novel coronavirus SARS-Cov-2 can infect the respiratory tract causing a spectrum of disease varying from mild to fatal pneumonia, and known as COVID-19. Ongoing clinical research is assessing the potential for long-term respiratory sequelae in these patients. We assessed the respiratory function in a cohort of patients after recovering from SARS-Cov-2 infection, stratified according to PaO2/FiO2 (p/F) values. METHOD: Approximately one month after hospital discharge, 86 COVID-19 patients underwent physical examination, arterial blood gas (ABG) analysis, pulmonary function tests (PFTs), and six-minute walk test (6MWT). Patients were also asked to quantify the severity of dyspnoea and cough before, during, and after hospitalization using a visual analogic scale (VAS). Seventy-six subjects with ABG during hospitalization were stratified in three groups according to their worst p/F values: above 300 (n = 38), between 200 and 300 (n = 30) and below 200 (n = 20). RESULTS: On PFTs, lung volumes were overall preserved yet, mean percent predicted residual volume was slightly reduced (74.8 ± 18.1%). Percent predicted diffusing capacity for carbon monoxide (DLCO) was also mildly reduced (77.2 ± 16.5%). Patients reported residual breathlessness at the time of the visit (VAS 19.8, p < 0.001). Patients with p/F below 200 during hospitalization had lower percent predicted forced vital capacity (p = 0.005), lower percent predicted total lung capacity (p = 0.012), lower DLCO (p < 0.001) and shorter 6MWT distance (p = 0.004) than patients with higher p/F. CONCLUSION: Approximately one month after hospital discharge, patients with COVID-19 can have residual respiratory impairment, including lower exercise tolerance. The extent of this impairment seems to correlate with the severity of respiratory failure during hospitalization.


Assuntos
COVID-19/fisiopatologia , Pneumonia Viral/fisiopatologia , Idoso , Gasometria , COVID-19/complicações , Monóxido de Carbono , Dispneia/virologia , Tolerância ao Exercício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Pressão Parcial , Pneumonia Viral/complicações , Pneumonia Viral/virologia , Capacidade de Difusão Pulmonar , Volume Residual , SARS-CoV-2 , Índice de Gravidade de Doença , Teste de Caminhada
2.
Braz J Med Biol Res ; 54(10): e10514, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34287574

RESUMO

Exercise intolerance is the hallmark consequence of advanced chronic heart failure (HF). The six-minute step test (6MST) has been considered an option for the six-minute walk test because it is safe, inexpensive, and can be applied in small places. However, its reliability and concurrent validity has still not been investigated in participants with HF with reduced ejection fraction (HFrEF). Clinically stable HFrEF participants were included. Reliability and error measurement were calculated by comparing the first with the second 6MST result. Forty-eight hours after participants underwent the 6MST, they were invited to perform a cardiopulmonary exercise test (CPET) on a cycle ergometer. Concurrent validity was assessed by correlation between number of steps and peak oxygen uptake (V̇O2 peak) at CPET. Twenty-seven participants with HFrEF (60±8 years old and left ventricle ejection fraction of 41±6%) undertook a mean of 94±30 steps in the 6MST. Intra-rater reliability was excellent for 6MST (ICC=0.9), with mean error of 4.85 steps and superior and inferior limits of agreement of 30.6 and -20.9 steps, respectively. In addition, strong correlations between number of steps and CPET workload (r=0.76, P<0.01) and peak V̇O2 (r=0.71, P<0.01) were observed. From simple linear regression the following predictive equations were obtained with 6MST results: V̇O2 peak (mL/min) = 350.22 + (7.333 × number of steps), with R2=0.51, and peak workload (W) = 4.044 + (0.772 × number of steps), with R2=0.58. The 6MST was a reliable and valid tool to assess functional capacity in HFrEF participants and may moderately predict peak workload and oxygen uptake of a CPET.


Assuntos
Teste de Esforço , Insuficiência Cardíaca , Idoso , Tolerância ao Exercício , Insuficiência Cardíaca/diagnóstico , Humanos , Pessoa de Meia-Idade , Consumo de Oxigênio , Reprodutibilidade dos Testes , Volume Sistólico , Teste de Caminhada
3.
Spine (Phila Pa 1976) ; 46(15): E826-E831, 2021 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-34228693

RESUMO

STUDY DESIGN: A prospective cohort study. OBJECTIVE: To assess the relationship of fear avoidance and demoralization on gait and balance and determine a threshold score for the Tampa Scale for Kinesophobia (TSK) and the Demoralization Scale (DS) that identifies spine patients with gait and balance dysfunction amplified by underlying psychological factors. SUMMARY OF BACKGROUND DATA: Fear avoidance and demoralization are crucial components of mental health that impact the outcomes in spine surgery. However, interpreting their effect on patient function remains challenging. Further establishing this correlation and identifying a threshold of severity can aid in identifying patients in whom a portion of their altered gait and balance may be amplified by underlying psychologic distress. METHODS: Four hundred five symptomatic spine patients were given the TSK and DS questionnaires. Patient's gait and balance were tested with a human motion capture system. A TSK score of 41 and a DS score of 30 were chosen as thresholds to classify moderate versus severe dysfunction based on literature and statistical analysis. RESULTS: Higher TSK and DS scores were correlated with worse walking speed (P < 0.001), longer stride time (P = 0.001), decreased stride length (P < 0.048), and wider step width (<0.001) during gait as well as increased sway across planes (P = 0.001) during standing balance. When classified by TSK scores >41, patients with more severe fear avoidance had slower walking speed (P < 0.001), longer stride time (P = 0.001), shorter stride length (P = 0.004), increased step width (P < 0.001), and increased sway (P = 0.001) compared with their lower scoring counterparts. Similarly, patients with DS > 30 had slower walking speed (P = 0.012), longer stride time (P = 0.022), and increased sway (P = 0.003) compared with their lower scoring counterparts. CONCLUSION: This study demonstrates that fear avoidance and demoralization directly correlate with worsening gait and balance. Furthermore, patients with TSK > 41 and DS > 30 have more underlying psychological factors that contribute to significantly worse function compared with lower scoring peers. Understanding this relationship and using these guidelines can help identify and treat patients whose gait dysfunction may be amplified by psychologic distress.Level of Evidence: 3.


Assuntos
Medo/psicologia , Doenças da Coluna Vertebral , Desmoralização , Humanos , Equilíbrio Postural/fisiologia , Doenças da Coluna Vertebral/epidemiologia , Doenças da Coluna Vertebral/fisiopatologia , Doenças da Coluna Vertebral/psicologia , Inquéritos e Questionários , Teste de Caminhada , Caminhada/psicologia
4.
Medicine (Baltimore) ; 100(25): e26483, 2021 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-34160461

RESUMO

ABSTRACT: To investigate the importance of pulmonary vascular measurements on computed tomography (CT) in predicting pulmonary hypertension (PH) and worse outcomes in diffuse cystic lung diseases (DCLDs).We conducted a cross-sectional study of patients with DCLDs. Patients underwent pulmonary function tests, a six-minute walk test (6MWT), chest CT, transthoracic echocardiography, and right heart catheterization. Pulmonary artery (PA) diameter and PA-ascending aorta ratio (PA-Ao ratio) were obtained from CT. Mean pulmonary artery pressure (mPAP) from right heart catheterization was correlated with tomographic, functional, and echocardiographic variables. The association between the PA-Ao ratio with outcomes was determined by Kaplan-Meier curves.Thirty-four patients were included (18 with pulmonary Langerhans cell histiocytosis and 16 with lymphangioleiomyomatosis, mean age 46 ±â€Š9 years). Forced expiratory volume in the first second and lung diffusing capacity for carbon monoxide were 47 ±â€Š20% and 38 ±â€Š21% predicted, respectively. PA diameter and PA-Ao ratio were 29 ±â€Š6 mm and 0.95 ±â€Š0.24, respectively. PA-Ao ratio > 1 occurred in 38.2% of patients. PA-Ao ratio was a good predictor of PH. mPAP correlated best with PA-Ao ratio, PA diameter, oxygen desaturation during six-minute walk test, and echocardiographic variables. Patients with PA-Ao ratio > 1 had greater mPAP, and a higher risk of death or lung transplantation (log-rank, P < .001) than those with PA-Ao ratio ≤ 1.The PA-Ao ratio measured on CT scan has a potential role as a non-invasive tool to predict the presence of PH and as a prognostic parameter in patients with DCLDs.


Assuntos
Aorta/diagnóstico por imagem , Hipertensão Pulmonar/diagnóstico , Pneumopatias/complicações , Transplante de Pulmão/estatística & dados numéricos , Artéria Pulmonar/diagnóstico por imagem , Adulto , Aorta/patologia , Estudos Transversais , Ecocardiografia , Feminino , Humanos , Hipertensão Pulmonar/etiologia , Pulmão/irrigação sanguínea , Pulmão/diagnóstico por imagem , Pulmão/patologia , Pneumopatias/mortalidade , Pneumopatias/patologia , Pneumopatias/cirurgia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Artéria Pulmonar/patologia , Curva ROC , Medição de Risco/estatística & dados numéricos , Tomografia Computadorizada por Raios X , Teste de Caminhada
5.
JMIR Mhealth Uhealth ; 9(6): e22748, 2021 06 07.
Artigo em Inglês | MEDLINE | ID: mdl-34096876

RESUMO

BACKGROUND: Pulmonary arterial hypertension (PAH) is a chronic disease of the pulmonary vasculature that can lead to heart failure and premature death. Assessment of patients with PAH includes performing a 6-minute walk test (6MWT) in clinics. We developed a smartphone app to compute the walked distance (6MWD) indoors, by counting U-turns, and outdoors, by using satellite positioning. OBJECTIVE: The goal of the research was to assess (1) accuracy of the indoor 6MWTs in clinical settings, (2) validity and test-retest reliability of outdoor 6MWTs in the community, (3) compliance, usability, and acceptance of the app, and (4) feasibility of pulse oximetry during 6MWTs. METHODS: We tested the app on 30 PAH patients over 6 months. Patients were asked to perform 3 conventional 6MWTs in clinic while using the app in the indoor mode and one or more app-based 6MWTs in outdoor mode in the community per month. RESULTS: Bland-Altman analysis of 70 pairs of conventional versus app-based indoor 6MWDs suggests that the app is sometimes inaccurate (14.6 m mean difference, lower and upper limit of agreement: -133.35 m to 162.55 m). The comparison of 69 pairs of conventional 6MWDs and community-based outdoor 6MWDs within 7 days shows that community tests are strongly related to those performed in clinic (correlation 0.89), but the interpretation of the distance should consider that differences above the clinically significant threshold are not uncommon. Analysis of 89 pairs of outdoor tests performed by the same patient within 7 days shows that community-based tests are repeatable (intraclass correlation 0.91, standard error of measurement 36.97 m, mean coefficient of variation 12.45%). Questionnaires and semistructured interviews indicate that the app is usable and well accepted, but motivation to use it could be affected if the data are not used for clinical decision, which may explain low compliance in 52% of our cohort. Analysis of pulse oximetry data indicates that conventional pulse oximeters are unreliable if used during a walk. CONCLUSIONS: App-based outdoor 6MWTs in community settings are valid, repeatable, and well accepted by patients. More studies would be needed to assess the benefits of using the app in clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT04633538; https://clinicaltrials.gov/ct2/show/NCT04633538.


Assuntos
Hipertensão Pulmonar , Aplicativos Móveis , Humanos , Hipertensão Pulmonar/diagnóstico , Reprodutibilidade dos Testes , Teste de Caminhada , Caminhada
6.
Am J Phys Med Rehabil ; 100(8): 737-741, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-34091469

RESUMO

ABSTRACT: The long-term exercise capacity of coronavirus disease 2019 patients with acute respiratory distress syndrome is not clear. The 6-min walking distance of four patients with coronavirus disease 2019-associated acute respiratory distress syndrome was followed for 6 mos after admission to the hospital. These four patients were admitted to the intensive care unit of our hospital and received mechanical ventilation. Rehabilitation therapy (positioning, postural drainage, and passive range-of-motion exercises) was started after intensive care unit admission. Mobilization therapy, including muscle power training, sitting on the edge of the bed, and endurance training, was performed after the end of sedation. The Medical Research Council sum scores and Barthel Indexes for the patients improved after intensive care unit discharge and completely recovered 6 mos after admission to the hospital. However, the 6-min walking distance of the four patients remained shorter than those of healthy persons of the same age at 6 mos after admission to the hospital. Furthermore, the minimum Spo2 during the 6-min walking test remained less than 96%. It is possible that patients who receive mechanical ventilation due to coronavirus disease 2019-associated acute respiratory distress syndrome have decreased long-term exercise capacity, despite muscle power and activities of daily living recovering completely.


Assuntos
COVID-19/complicações , COVID-19/terapia , Tolerância ao Exercício , Respiração Artificial , Síndrome do Desconforto Respiratório/terapia , Síndrome do Desconforto Respiratório/virologia , Adulto , Idoso , Terapia por Exercício , Humanos , Unidades de Terapia Intensiva , Japão , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/terapia , Pneumonia Viral/virologia , Recuperação de Função Fisiológica , SARS-CoV-2 , Teste de Caminhada
7.
BMJ Open ; 11(6): e048808, 2021 06 02.
Artigo em Inglês | MEDLINE | ID: mdl-34083348

RESUMO

OBJECTIVES: To assess the acceptability of neuromuscular electrical stimulation (NMES) of the quadriceps muscles in people with idiopathic pulmonary fibrosis (IPF) and to identify whether a future definitive trial is feasible. DESIGN: A randomised, parallel, two-group, participant and assessor-blinded, placebo-controlled feasibility trial with embedded qualitative interviews. SETTING: Outpatient department, Royal Brompton and Harefield Hospitals. PARTICIPANTS: Twenty-two people with IPF: median (25th, 75th centiles) age 76 (74, 82) years, forced vital capacity 62 (50, 75) % predicted, 6 min walk test distance 289 (149, 360) m. INTERVENTIONS: Usual care (home-based exercise, weekly telephone support, breathlessness management leaflet) with either placebo or active NMES for 6 weeks, with follow-up at 6 and 12 weeks. PRIMARY OUTCOME MEASURES: Feasibility of recruitment and retention, treatment uptake and adherence, outcome assessments, participant and outcome assessor blinding and adverse events related to interventions. SECONDARY OUTCOME MEASURES: Outcome measures with potential to be primary or secondary outcomes in a definitive clinical trial. In addition, purposively sampled participants were interviewed to capture their experiences and acceptability of the trial. RESULTS: Out of 364 people screened, 23 were recruited: 11 were allocated to each group and one was withdrawn prior to randomisation. Compared with the control group, a greater proportion of the intervention group completed the intervention, remained in the trial blinded to group allocation and experienced intervention-related adverse events. Assessor blinding was maintained. The secondary outcome measures were feasible with most missing data associated with the accelerometer. Small participant numbers precluded identification of an outcome measure suitable for a definitive trial. Qualitative findings demonstrated that trial process and active NMES were acceptable but there were concerns about the credibility of placebo NMES. CONCLUSIONS: Primarily owing to recruitment difficulties, a definitive trial using the current protocol to evaluate NMES in people with IPF is not feasible. TRIAL REGISTRATION NUMBER: NCT03499275.


Assuntos
Fibrose Pulmonar Idiopática , Músculo Quadríceps , Idoso , Método Duplo-Cego , Estudos de Viabilidade , Humanos , Fibrose Pulmonar Idiopática/terapia , Teste de Caminhada
8.
J Cardiovasc Magn Reson ; 23(1): 77, 2021 06 10.
Artigo em Inglês | MEDLINE | ID: mdl-34112195

RESUMO

BACKGROUND: Although coronavirus disease 2019 (COVID-19) is primarily a respiratory illness, myocardial injury is increasingly reported and associated with adverse outcomes. However, the pathophysiology, extent of myocardial injury and clinical significance remains unclear. METHODS: COVID-HEART is a UK, multicentre, prospective, observational, longitudinal cohort study of patients with confirmed COVID-19 and elevated troponin (sex-specific > 99th centile). Baseline assessment will be whilst recovering in-hospital or recently discharged, and include cardiovascular magnetic resonance (CMR) imaging, quality of life (QoL) assessments, electrocardiogram (ECG), serum biomarkers and genetics. Assessment at 6-months includes repeat CMR, QoL assessments and 6-min walk test (6MWT). The CMR protocol includes cine imaging, T1/T2 mapping, aortic distensibility, late gadolinium enhancement (LGE), and adenosine stress myocardial perfusion imaging in selected patients. The main objectives of the study are to: (1) characterise the extent and nature of myocardial involvement in COVID-19 patients with an elevated troponin, (2) assess how cardiac involvement and clinical outcome associate with recognised risk factors for mortality (age, sex, ethnicity and comorbidities) and genetic factors, (3) evaluate if differences in myocardial recovery at 6 months are dependent on demographics, genetics and comorbidities, (4) understand the impact of recovery status at 6 months on patient-reported QoL and functional capacity. DISCUSSION: COVID-HEART will provide detailed characterisation of cardiac involvement, and its repair and recovery in relation to comorbidity, genetics, patient-reported QoL measures and functional capacity. CLINICAL TRIAL REGISTRATION: ISRCTN 58667920. Registered 04 August 2020.


Assuntos
COVID-19/complicações , Cardiopatias/virologia , Projetos de Pesquisa , Biomarcadores/sangue , Comorbidade , Meios de Contraste , Eletrocardiografia , Feminino , Cardiopatias/fisiopatologia , Humanos , Estudos Longitudinais , Imagem Cinética por Ressonância Magnética , Masculino , Estudos Multicêntricos como Assunto , Imagem de Perfusão do Miocárdio , Observação , Pneumonia Viral/virologia , Estudos Prospectivos , Qualidade de Vida , Fatores de Risco , SARS-CoV-2 , Troponina/sangue , Reino Unido , Teste de Caminhada
9.
NeuroRehabilitation ; 48(4): 413-439, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33967070

RESUMO

BACKGROUND: Improving walking capacity is a key objective of post-stroke rehabilitation. Evidence describing the quality and protocols of standardized tools for assessing walking capacity can facilitate their implementation. OBJECTIVE: To synthesize existing literature describing test protocols and measurement properties of distance-limited walk tests in people post-stroke. METHODS: Electronic database searches were completed in 2017. Records were screened and appraised for quality. RESULTS: Data were extracted from 43 eligible articles. Among the 12 walk tests identified, the 10-metre walk test (10mWT) at a comfortable pace was most commonly evaluated. Sixty-three unique protocols at comfortable and fast paces were identified. Walking pace and walkway surface, but not walkway length, influenced walking speed. Intraclass correlation coefficients for test-retest reliability ranged from 0.80-0.99 across walk tests. Measurement error values ranged from 0.04-0.40 and 0.06 to 0.20 for the 10mWT at comfortable and fast and paces, respectively. Across walk tests, performance was most frequently correlated with measures of strength, balance, and physical activity (r = 0.26-0.8, p < 0.05). CONCLUSIONS: The 10mWT has the most evidence of reliability and validity. Findings indicate that studies that include people with severe walking deficits, in acute and subacute phases of recovery, with improved quality of reporting, are needed.


Assuntos
Reabilitação do Acidente Vascular Cerebral/métodos , Teste de Caminhada/métodos , Humanos , Reprodutibilidade dos Testes , Teste de Caminhada/normas , Velocidade de Caminhada
10.
Am J Cardiol ; 150: 55-59, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34006373

RESUMO

Coronary artery bypass grafting (CABG) often causes physiological changes in patients. Although functional changes, such as lung function and exercise capacity changes, are observed in patients, there are no detailed studies examining this. The aim was to compare preoperative and postoperative pulmonary function and exercise capacity in patients undergoing on-pump CABG with a multidimensional index (BODE index). Demographic and surgical characteristics of patients were recorded. Pulmonary function test, six-minute walk test (6MWT), and modified Medical Research Council (mMRC) dyspnea score were assessed and BODE index were calculated in preoperative and at six months postoperatively. A total of 75 patients were included with a mean ± standard deviation age of 59.8±10.0 years. The male to female ratio was 57/18. There was a statistically significant decrease in the forced expiratory flow at 25-75% (FEF25-75%) value after CABG. Other pulmonary function test values were also lower in the postoperative period compared to the preoperative period, but these changes were not significant. The mean distance achieved in the 6MWT (p=0.02) and the mMRC dyspnea score (p=0.001) were significantly better postoperatively. The BODE index, which combines these parameters, had increased in the postoperative period. Age (OR 1.09; 95% CI: 1.008-1.181) and postoperative FEF25-75% (OR -0.96; 95% CI: 0.938-0.988) were the independent predictors of BODE score ≥3 in multivariate analysis. Despite the decrease in pulmonary function in patients undergoing CABG, there was an improvement in exercise capacity and dyspnea score.


Assuntos
Ponte de Artéria Coronária/métodos , Doença das Coronárias/fisiopatologia , Doença das Coronárias/cirurgia , Tolerância ao Exercício/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Dispneia/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Testes de Função Respiratória , Índice de Gravidade de Doença , Teste de Caminhada
11.
J Orthop Sports Phys Ther ; 51(6): 298-304, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33971732

RESUMO

OBJECTIVE: To examine the associations of knee injury, radiographic osteoarthritis severity, and quadriceps strength with knee pain exacerbation during walking. DESIGN: Within-person knee-matched case-control study. METHODS: Participants from the Osteoarthritis Initiative who completed a 20-m walking test at the 24-month visit were included. Pain exacerbation was defined as an increase in pain intensity of 1 or more on a numeric rating scale (0 as no pain and 10 as the worst imaginable pain) while completing the 20-m walking test. We used conditional logistic regression to assess the relation of recent knee injury, Kellgren-Lawrence (KL) grade, and quadriceps strength to unilateral knee pain exacerbation during walking. RESULTS: We included 277 people who experienced unilateral knee pain exacerbation during the walking test. Recent knee injury was associated with pain exacerbation during walking, with an odds ratio of 3.4 (95% confidence interval [CI]: 1.3, 9.2). Compared with knees with a KL grade of 0, the odds ratios of pain exacerbation during walking were 1.3 (95% CI: 0.7, 2.7), 3.3 (95% CI: 1.5, 7.1), and 8.1 (95% CI: 3.1, 21.1) for knees with KL grades of 2, 3, and 4, respectively. Painful knees with a deficit in quadriceps strength of greater than or equal to 4% had a 1.4-fold (95% CI: 1.0, 1.9) higher risk of pain exacerbation during walking than their pain-free counterparts. CONCLUSION: Recent knee injury, more severe radiographic osteoarthritis, and lower quadriceps strength were associated with an increased risk of knee pain exacerbation during walking. J Orthop Sports Phys Ther 2021;51(6):298-304. Epub 10 May 2021. doi:10.2519/jospt.2021.9735.


Assuntos
Artralgia/fisiopatologia , Traumatismos do Joelho/fisiopatologia , Força Muscular/fisiologia , Osteoartrite do Joelho/fisiopatologia , Músculo Quadríceps/fisiopatologia , Caminhada/fisiologia , Idoso , Idoso de 80 Anos ou mais , Artralgia/diagnóstico por imagem , Estudos de Casos e Controles , Feminino , Humanos , Traumatismos do Joelho/diagnóstico por imagem , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico por imagem , Radiografia , Teste de Caminhada
12.
Respir Med ; 184: 106470, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34022502

RESUMO

Patients recovering from coronavirus disease 2019 (COVID-19) may not return to a pre-COVID functional status and baseline levels of healthcare needs after discharge from acute care hospitals. Since the long-term outcomes of COVID-19 can be more severe in patients with underlying cardiorespiratory diseases, we aimed at verifying the impact of a preexisting cardiorespiratory comorbidity on multidisciplinary rehabilitation in post-COVID-19 patients. We enrolled 95 consecutive patients referring to the Pulmonary Rehabilitation Unit of Istituti Clinici Scientifici Maugeri Spa SB, IRCCS of Telese Terme, Benevento, Italy after being discharged from the COVID-19 acute care ward and after recovering from acute COVID-19 pneumonia. Forty-nine of them were not suffering from underlying comorbidities, while 46 had a preexisting cardiorespiratory disease. Rehabilitation induced statistically significant improvements in respiratory function, blood gases and the ability to exercise both in patients without any preexisting comorbidities and in those with an underlying cardiorespiratory disease. Response to the rehabilitation cycle tended to be greater in those without preexisting comorbidities, but DLco%-predicted was the only parameter that showed a significant greater improvement when compared to the response in the group of patients with underlying cardiorespiratory comorbidity. This study suggests that multidisciplinary rehabilitation may be useful in post-COVID-19 patients regardless of the presence of preexisting cardiorespiratory comorbidities.


Assuntos
COVID-19/reabilitação , Comunicação Interdisciplinar , Equipe de Assistência ao Paciente , Reabilitação/métodos , COVID-19/epidemiologia , COVID-19/fisiopatologia , Monóxido de Carbono/sangue , Doenças Cardiovasculares/epidemiologia , Comorbidade , Feminino , Volume Expiratório Forçado , Humanos , Itália/epidemiologia , Pulmão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Doenças Respiratórias/epidemiologia , Resultado do Tratamento , Capacidade Vital , Teste de Caminhada
14.
Medicine (Baltimore) ; 100(21): e26010, 2021 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-34032718

RESUMO

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common respiratory disease that is associated with significant morbidity and mortality. Exercise training confers health benefits to people with COPD. The purpose of this study was to compare differences in the rehabilitation of COPD between Qigong exercise (QE) and aerobic exercise using a cycle ergometer (CE). METHODS: This study was a randomized single-blind controlled trial. Twenty six participants were recruited and randomized to either the Qigong group or the cycle ergometer group. Both interventions lasted 12 weeks and comprised a 30 minutes supervised training session performed twice a week, that is, 24 sessions in total. The primary outcome measure was the endurance capacity measured by the six-minute walk test (6MWT). The secondary outcome measures were the results of the St. George's Hospital Respiratory Questionnaire (SGRQ) and the COPD assessment test (CAT). RESULTS: Participants in the group that performed aerobic exercise using a cycle ergometer had significantly improved 6MWT (P = .005), SGRQ (P = .029), and CAT (P = .018) results. Participants in the Qigong exercise group had significant changes in 6MWT (P = .033). However, the differences in 6MWT and SGRQ were not statistically significant between the 2 groups. The changes in CAT scores before and after the intervention were significantly different between the 2 groups (P = .020). There were no reports of adverse events during the course of the trial. CONCLUSIONS: There was no difference in the primary outcome between groups. In particular, QE and cycle ergometer exercise had similar rehabilitation effects on the improvement of the cardiopulmonary endurance and quality of life of chronic obstructive pulmonary disease patients. In addition, cycle ergometer exercise may lead to a better trend of improvement in the quality of life and can improve the severity of the clinical symptoms of chronic obstructive pulmonary disease. TRIAL REGISTRATION: ChiCTR-TRC-14004404.


Assuntos
Terapia por Exercício/métodos , Doença Pulmonar Obstrutiva Crônica/reabilitação , Qigong/métodos , Qualidade de Vida , Adulto , Idoso , Terapia por Exercício/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/psicologia , Autorrelato/estatística & dados numéricos , Índice de Gravidade de Doença , Método Simples-Cego , Resultado do Tratamento , Teste de Caminhada
15.
JAMA ; 325(13): 1266-1276, 2021 04 06.
Artigo em Inglês | MEDLINE | ID: mdl-33821898

RESUMO

Importance: Supervised high-intensity walking exercise that induces ischemic leg symptoms is the first-line therapy for people with lower-extremity peripheral artery disease (PAD), but adherence is poor. Objective: To determine whether low-intensity home-based walking exercise at a comfortable pace significantly improves walking ability in people with PAD vs high-intensity home-based walking exercise that induces ischemic leg symptoms and vs a nonexercise control. Design, Setting, and Participants: Multicenter randomized clinical trial conducted at 4 US centers and including 305 participants. Enrollment occurred between September 25, 2015, and December 11, 2019; final follow-up was October 7, 2020. Interventions: Participants with PAD were randomized to low-intensity walking exercise (n = 116), high-intensity walking exercise (n = 124), or nonexercise control (n = 65) for 12 months. Both exercise groups were asked to walk for exercise in an unsupervised setting 5 times per week for up to 50 minutes per session wearing an accelerometer to document exercise intensity and time. The low-intensity group walked at a pace without ischemic leg symptoms. The high-intensity group walked at a pace eliciting moderate to severe ischemic leg symptoms. Accelerometer data were viewable to a coach who telephoned participants weekly for 12 months and helped them adhere to their prescribed exercise. The nonexercise control group received weekly educational telephone calls for 12 months. Main Outcomes and Measures: The primary outcome was mean change in 6-minute walk distance at 12 months (minimum clinically important difference, 8-20 m). Results: Among 305 randomized patients (mean age, 69.3 [SD, 9.5] years, 146 [47.9%] women, 181 [59.3%] Black patients), 250 (82%) completed 12-month follow-up. The 6-minute walk distance changed from 332.1 m at baseline to 327.5 m at 12-month follow-up in the low-intensity exercise group (within-group mean change, -6.4 m [95% CI, -21.5 to 8.8 m]; P = .34) and from 338.1 m to 371.2 m in the high-intensity exercise group (within-group mean change, 34.5 m [95% CI, 20.1 to 48.9 m]; P < .001) and the mean change for the between-group comparison was -40.9 m (97.5% CI, -61.7 to -20.0 m; P < .001). The 6-minute walk distance changed from 328.1 m at baseline to 317.5 m at 12-month follow-up in the nonexercise control group (within-group mean change, -15.1 m [95% CI, -35.8 to 5.7 m]; P = .10), which was not significantly different from the change in the low-intensity exercise group (between-group mean change, 8.7 m [97.5% CI, -17.0 to 34.4 m]; P = .44). Of 184 serious adverse events, the event rate per participant was 0.64 in the low-intensity group, 0.65 in the high-intensity group, and 0.46 in the nonexercise control group. One serious adverse event in each exercise group was related to study participation. Conclusions and Relevance: Among patients with PAD, low-intensity home-based exercise was significantly less effective than high-intensity home-based exercise and was not significantly different from the nonexercise control for improving 6-minute walk distance. These results do not support the use of low-intensity home-based walking exercise for improving objectively measured walking performance in patients with PAD. Trial Registration: ClinicalTrials.gov Identifier: NCT02538900.


Assuntos
Terapia por Exercício/métodos , Doença Arterial Periférica/terapia , Caminhada , Idoso , Biópsia , Feminino , Humanos , Isquemia/terapia , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/patologia , Masculino , Músculo Esquelético/patologia , Doença Arterial Periférica/patologia , Doença Arterial Periférica/fisiopatologia , Teste de Caminhada
16.
Sensors (Basel) ; 21(9)2021 Apr 28.
Artigo em Inglês | MEDLINE | ID: mdl-33925075

RESUMO

BACKGROUND: Walking disorders represent the most disabling condition in persons with Multiple Sclerosis (PwMS). Several studies showed good reliability of the 6-min walk test (6MWT) (i.e., especially distance traveled), but little is known about the reliability of the Spatio-temporal (ST) variables in the 6MWT. OBJECTIVE: To evaluate the test-retest reliability of ST variables and perceived exertion during the 6MWT in PwMS and comparable healthy persons. METHODS: We explored three 1-min intervals (initial: 0'-1', middle: 2'30″-3'30″, end: 5'-6') of the 6MWT. Six ST variables and perceived exertion were measured (respectively, using the GAITRite system and the Borg Scale). These measurements were performed twice, 1 week apart. The test-retest effects were assessed using the intraclass correlation coefficient (ICC) or the weighted kappa. RESULTS: Forty-five PwMS and 24 healthy persons were included. The test-retest reliability of ST variables values was good-to-excellent for PwMS (ICC range: 0.858-0.919) and moderate-to-excellent for healthy persons (ICC range: 0.569-0.946). The test-retest reliability values of perceived exertion were fair for PwMS (weighted kappa range: 0.279-0.376) and substantial for healthy persons (weighted kappa range: 0.734-0.788). CONCLUSION: The measurement of ST variables during these 6MWT intervals is reliable and applicable in clinical practice and research to adapt rehabilitation care in PwMS.


Assuntos
Pessoas com Deficiência , Esclerose Múltipla , Teste de Esforço , Humanos , Esclerose Múltipla/diagnóstico , Reprodutibilidade dos Testes , Teste de Caminhada , Caminhada
17.
Respiration ; 100(7): 594-599, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33878758

RESUMO

BACKGROUND AND OBJECTIVES: The 6-minute walk test (6MWT), as a clinical assessment tool for functional exercise capacity, is an integral component of lung allocation scores (LASs). In times of the coronavirus disease (COVID-19) pandemic, patients underwent 6MWTs wearing a surgical mask in ambulatory care. We investigated the impact of wearing a mask on 6-minute walk distances (6MWDs). METHOD: 6MWDs of 64 patients with end-stage lung diseases wearing an oronasal surgical mask were retrospectively compared to previously investigated 6MWDs of the same cohort, in a pre-COVID-19 pandemic era, without wearing a mask. Four patients were excluded due to a primary vascular disease, 29 patients due to clinically unstable pulmonary functions, and 1 patient due to a psychiatric disorder. RESULTS: The median age of the patients included was 55 (46-58) years; 15 (48%) were male. Ten (32.2%) were on the Eurotransplant lung transplant waiting list with a median LAS of 34.3 (31.9-36.2). Twenty (64.5%) patients had chronic obstructive pulmonary diseases, 7 (22.6%) had interstitial lung diseases, and 4 (12.9%) had other end-stage lung diseases. The mean 6MWD without versus with wearing a mask was 306.9 (101.9) versus 305.7 (103.8) m, with a mean difference of -1.19 m (95% confidence interval -13.4 to 11.03). The observed difference is statistically equivalent to zero (p < 0.001). No significant differences in 6MWDs were observed between the clinical groups. CONCLUSION: Wearing an oronasal surgical mask did not affect the 6MWDs of patients with advanced lung diseases. Therefore, a masked 6MWT appears to provide a reliable examination of functional exercise capacity in this cohort.


Assuntos
COVID-19/prevenção & controle , Doenças Pulmonares Intersticiais/fisiopatologia , Máscaras , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Insuficiência Respiratória/fisiopatologia , Teste de Caminhada/métodos , Gasometria , Doença Crônica , Tolerância ao Exercício , Feminino , Volume Expiratório Forçado , Humanos , Pneumopatias/fisiopatologia , Pneumopatias/cirurgia , Doenças Pulmonares Intersticiais/cirurgia , Transplante de Pulmão , Masculino , Pessoa de Meia-Idade , Diferença Mínima Clinicamente Importante , Pletismografia Total , Doença Pulmonar Obstrutiva Crônica/cirurgia , Reprodutibilidade dos Testes , Insuficiência Respiratória/cirurgia , Estudos Retrospectivos , SARS-CoV-2 , Capacidade Vital
18.
NeuroRehabilitation ; 48(3): 375-383, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33814473

RESUMO

BACKGROUND: Impaired motor control, balance, muscle strength, and respiratory function may affect the exercise capacity related to motor performance and activities in individuals with stroke. OBJECTIVE: To identify a physical parameter that the exercise capacity has the most significant relationship among physical parameters related to motor function, trunk control, balance, and motor performance and activities in individuals with ischemic stroke. METHODS: In total, 241 ischemic stroke patients were recruited in this retrospective study. The clinical measurements included the 6-minute walk test (6 MWT), Montreal cognitive assessment (MoCA), Fugl-Meyer assessment-lower extremity motor function (FMA-LE), trunk impairment scale (TIS), Berg balance scale (BBS), timed up and go test (TUG), 10-meter walk test (10 MWT), functional ambulation category (FAC), and functional independence measure (FIM). RESULTS: The 6 MWT was significantly correlated with the FMA-LE, BBS, TUG, 10 MWT, FAC, and FIM, indicating negative or positive moderate correlations. Additionally, the FMA-LE, TIS, BBS, TUG, 10 MWT, FAC, and FIM, excluding the 6 MWT, showed moderate to strong correlations with all of the other outcome measures, whereas the MoCA showed significant correlations only with the BBS and FIM. CONCLUSIONS: In this study, the exercise capacity has the most significant relationship with the TUG parameter in stroke patients. Additionally, we suggest that significant relationships between 6 MWT and other comprehensive physical functions measurements are closely related to walking ability in individuals with stroke.


Assuntos
Tolerância ao Exercício , AVC Isquêmico/reabilitação , Reabilitação do Acidente Vascular Cerebral/métodos , Idoso , Feminino , Humanos , Extremidade Inferior/fisiopatologia , Masculino , Pessoa de Meia-Idade , Força Muscular , Equilíbrio Postural , Teste de Caminhada , Caminhada
19.
Cochrane Database Syst Rev ; 4: CD013110, 2021 04 06.
Artigo em Inglês | MEDLINE | ID: mdl-33822364

RESUMO

BACKGROUND: Bronchiectasis is characterised by excessive sputum production, chronic cough, and acute exacerbations and is associated with symptoms of dyspnoea and fatigue, which reduce exercise tolerance and impair quality of life. Exercise training in isolation or in conjunction with other interventions is beneficial for people with other respiratory diseases, but its effects in bronchiectasis have not been well established. OBJECTIVES: To determine effects of exercise training compared to usual care on exercise tolerance (primary outcome), quality of life (primary outcome), incidence of acute exacerbation and hospitalisation, respiratory and mental health symptoms, physical function, mortality, and adverse events in people with stable or acute exacerbation of bronchiectasis. SEARCH METHODS: We identified trials from the Cochrane Airways Specialised Register, ClinicalTrials.gov, and the World Health Organization trials portal, from their inception to October 2020. We reviewed respiratory conference abstracts and reference lists of all primary studies and review articles for additional references. SELECTION CRITERIA: We included randomised controlled trials in which exercise training of at least four weeks' duration (or eight sessions) was compared to usual care for people with stable bronchiectasis or experiencing an acute exacerbation. Co-interventions with exercise training including education, respiratory muscle training, and airway clearance therapy were permitted if also applied as part of usual care. DATA COLLECTION AND ANALYSIS: Two review authors independently screened and selected trials for inclusion, extracted outcome data, and assessed risk of bias. We contacted study authors for missing data. We calculated mean differences (MDs) using a random-effects model. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We included six studies, two of which were published as abstracts, with a total of 275 participants. Five studies were undertaken with people with clinically stable bronchiectasis, and one pilot study was undertaken post acute exacerbation. All studies included co-interventions such as instructions for airway clearance therapy and/or breathing strategies, provision of an educational booklet, and delivery of educational sessions. The duration of training ranged from six to eight weeks, with a mix of supervised and unsupervised sessions conducted in the outpatient or home setting. No studies of children were included in the review; however we identified two studies as currently ongoing. No data were available regarding physical activity levels or adverse events. For people with stable bronchiectasis, evidence suggests that exercise training compared to usual care improves functional exercise tolerance as measured by the incremental shuttle walk distance, with a mean difference (MD) between groups of 87 metres (95% confidence interval (CI) 43 to 132 metres; 4 studies, 161 participants; low-certainty evidence). Evidence also suggests that exercise training improves six-minute walk distance (6MWD) (MD between groups of 42 metres, 95% CI 22 to 62; 1 study, 76 participants; low-certainty evidence). The magnitude of these observed mean changes appears clinically relevant as they exceed minimal clinically important difference (MCID) thresholds for people with chronic lung disease. Evidence suggests that quality of life improves following exercise training according to St George's Respiratory Questionnaire (SGRQ) total score (MD -9.62 points, 95% CI -15.67 to -3.56 points; 3 studies, 160 participants; low-certainty evidence), which exceeds the MCID of 4 points for this outcome. A reduction in dyspnoea (MD 1.0 points, 95% CI 0.47 to 1.53; 1 study, 76 participants) and fatigue (MD 1.51 points, 95% CI 0.80 to 2.22 points; 1 study, 76 participants) was observed following exercise training according to these domains of the Chronic Respiratory Disease Questionnaire. However, there was no change in cough-related quality of life as measured by the Leicester Cough Questionnaire (LCQ) (MD -0.09 points, 95% CI -0.98 to 0.80 points; 2 studies, 103 participants; moderate-certainty evidence), nor in anxiety or depression. Two studies reported longer-term outcomes up to 12 months after intervention completion; however exercise training did not appear to improve exercise capacity or quality of life more than usual care. Exercise training reduced the number of acute exacerbations of bronchiectasis over 12 months in people with stable bronchiectasis (odds ratio 0.26, 95% CI 0.08 to 0.81; 1 study, 55 participants). After an acute exacerbation of bronchiectasis, data from a single study (N = 27) suggest that exercise training compared to usual care confers little to no effect on exercise capacity (MD 11 metres, 95% CI -27 to 49 metres; low-certainty evidence), SGRQ total score (MD 6.34 points, 95%CI -17.08 to 29.76 points), or LCQ score (MD -0.08 points, 95% CI -0.94 to 0.78 points; low-certainty evidence) and does not reduce the time to first exacerbation (hazard ratio 0.83, 95% CI 0.31 to 2.22). AUTHORS' CONCLUSIONS: This review provides low-certainty evidence suggesting improvement in functional exercise capacity and quality of life immediately following exercise training in people with stable bronchiectasis; however the effects of exercise training on cough-related quality of life and psychological symptoms appear to be minimal. Due to inadequate reporting of methods, small study numbers, and variation between study findings, evidence is of very low to moderate certainty. Limited evidence is available to show longer-term effects of exercise training on these outcomes.


Assuntos
Bronquiectasia/reabilitação , Tolerância ao Exercício , Exercício Físico , Qualidade de Vida , Adulto , Viés , Exercícios Respiratórios , Bronquiectasia/mortalidade , Tosse/terapia , Progressão da Doença , Dispneia/reabilitação , Hospitalização , Humanos , Saúde Mental , Resistência Física , Desempenho Físico Funcional , Transtornos Respiratórios/reabilitação , Teste de Caminhada
20.
Cochrane Database Syst Rev ; 4: CD013246, 2021 04 19.
Artigo em Inglês | MEDLINE | ID: mdl-33871065

RESUMO

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with dyspnoea, cough or sputum production (or both) and affects quality of life and functional status. More efficient approaches to alternative management that may include patients themselves managing their condition need further exploration in order to reduce the impact on both patients and healthcare services. Digital interventions may potentially impact on health behaviours and encourage patient engagement. OBJECTIVES: To assess benefits and harms of digital interventions for managing COPD and apply Behaviour Change Technique (BCT) taxonomy to describe and explore intervention content. SEARCH METHODS: We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register (date of last search 28 April 2020). We found other trials at web-based clinical trials registers. SELECTION CRITERIA: We included RCTs comparing digital technology interventions with or without routine supported self-management to usual care, or control treatment for self-management. Multi-component interventions (of which one component was digital self-management) compared with usual care, standard care or control treatment were included. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias. Discrepancies were resolved with a third review author. We assessed certainty of the evidence using the GRADE approach. Primary outcomes were impact on health behaviours, self-efficacy, exacerbations and quality of life, including the St George's Respiratory Questionnaire (SGRQ). The minimally important difference (MID) for the SGRQ is 4 points. Two review authors independently applied BCT taxonomy to identify mechanisms in the digital interventions that influence behaviours. MAIN RESULTS: Fourteen studies were included in the meta-analyses (1518 participants) ranging from 13 to 52 weeks duration. Participants had mild to very severe COPD. Risk of bias was high due to lack of blinding. GRADE ratings were low to very low certainty due to lack of blinding and imprecision. Common BCT clusters identified as behaviour change mechanisms in interventions were goals and planning, feedback and monitoring, social support, shaping knowledge and antecedents. Digital technology intervention with or without routine supported self-management Interventions included mobile phone (three studies), smartphone applications (one study), and web or Internet-based (five studies). Evidence is very uncertain about effects on impact on health behaviours as measured by six-minute walk distance (6MWD) at 13 weeks (mean difference (MD) 26.20, 95% confidence interval (CI) -21.70 to 74.10; participants = 122; studies = 2) or 23 to 26 weeks (MD 14.31, 95% CI -19.41 to 48.03; participants = 164; studies = 3). There may be improvement in 6MWD at 52 weeks (MD 54.33 95% CI -35.47 to 144.12; participants = 204; studies = 2) but studies were varied (very low certainty). There may be no difference in self-efficacy on managing Chronic Disease Scale (SEMCD) or pulmonary rehabilitation adapted index of self-efficacy tool (PRAISE). Evidence is very uncertain. Quality of life may be slightly improved on the chronic respiratory disease questionnaire (CRQ) at 13 weeks (MD 0.45, 95% CI 0.01 to 0.90; participants = 123; studies = 2; low certainty), but is not clinically important (MID 0.5). There may be little or no difference at 23 or 52 weeks (low to very low certainty). There may be a clinical improvement on SGRQ total at 52 weeks (MD -26.57, 95% CI -34.09 to -19.05; participants = 120; studies = 1; low certainty). Evidence for COPD assessment test (CAT) and Clinical COPD Questionnaire (CCQ) is very uncertain. There may be little or no difference in dyspnoea symptoms (CRQ dyspnoea) at 13, 23 weeks or 52 weeks (low to very low certainty evidence) or mean number of exacerbations at 26 weeks (low-certainty evidence). There was no evidence for the number of people experiencing adverse events. Multi-component interventions Digital components included mobile phone (one study), and web or internet-based (four studies). Evidence is very uncertain about effects on impact on health behaviour (6MWD) at 13 weeks (MD 99.60, 95% CI -15.23 to 214.43; participants = 20; studies = 1). No evidence was found for self-efficacy. Four studies reported effects on quality of life (SGRQ and CCQ scales). The evidence is very uncertain. There may be no difference in the number of people experiencing exacerbations or mean days to first exacerbation at 52 weeks with a multi-component intervention compared to standard care. Evidence is very uncertain about effects on the number of people experiencing adverse events at 52 weeks. AUTHORS' CONCLUSIONS: There is insufficient evidence to demonstrate a clear benefit or harm of digital technology interventions with or without supported self-management, or multi-component interventions compared to usual care in improving the 6MWD or self-efficacy. We found there may be some short-term improvement in quality of life with digital interventions, but there is no evidence about whether the effect is sustained long term. Dyspnoea symptoms may improve over a longer duration of digital intervention use. The evidence for multi-component interventions is very uncertain and as there is little or no evidence for adverse events, we cannot determine the benefit or harm of these interventions. The evidence base is predominantly of very low certainty with concerns around high risk of bias due to lack of blinding. Given that variation of interventions and blinding is likely to be a concern, future, larger studies are needed taking these limitations in consideration. Future studies are needed to determine whether the small improvements observed in this review can be applied to the general COPD population. A clear understanding of behaviour change through the BCT classification is important to gauge uptake of digital interventions and health outcomes in people with varying severity of COPD. Currently there is no guidance for interpreting BCT components of a digital intervention for changes to health outcomes. We could not interpret the BCT findings to the health outcomes we were investigating due to limited evidence that was of very low certainty. In future research, standardised approaches need to be considered when designing protocols to investigate effectiveness of digital interventions by including a standardised approach to BCT classification in addition to validated behavioural outcome measures that may reflect changes in behaviour.


Assuntos
Telefone Celular , Intervenção Baseada em Internet , Doença Pulmonar Obstrutiva Crônica/terapia , Autogestão/métodos , Viés , Doença Crônica , Humanos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Smartphone , Teste de Caminhada
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