ABSTRACT Objective To compare the profiles of patients with chronic obstructive pulmonary disease (COPD) considered physically active or inactive according to different classifications of the level of physical activity in daily life (PADL). Method Pulmonary function, dyspnea, functional status, body composition, exercise capacity, respiratory and peripheral muscle strength, and presence of comorbidities were assessed in 104 patients with COPD. The level of PADL was quantified with a SenseWear Armband activity monitor. Three classifications were used to classify the patients as physically active or inactive: 30 minutes of activity/day with intensity >3.2 METs, if age ≥65 years, and >4 METs, if age <65 years; 30 minutes of activity/day with intensity >3.0 METs, regardless of patient age; and 80 minutes of activity/day with intensity >3.0 METs, regardless of patient age. Results In all classifications, when compared with the inactive group, the physically active group had better values of anthropometric variables (higher fat-free mass, lower body weight, body mass index and fat percentage), exercise capacity (6-minute walking distance), lung function (forced vital capacity) and functional status (personal care domain of the London Chest Activity of Daily Living). Furthermore, patients classified as physically active in two classifications also had better peripheral and expiratory muscle strength, airflow obstruction, functional status, and quality of life, as well as lower prevalence of heart disease and mortality risk. Conclusion In all classification methods, physically active patients with COPD have better exercise capacity, lung function, body composition, and functional status compared to physically inactive patients.

ABSTRACT Objective To investigate the acute effects of EPAP on the activity of sternocleidomastoid (SCM), parasternal muscles and ventilatory parameters in COPD patients. Method Twenty-four patients with COPD were studied using surface electromyography (sEMG) and a ventilometer. Patients were randomly assigned to EPAP 10 cmH2O-EPAP10 or 15 cmH2O-EPAP15 for 20 minutes. Results The parasternal muscle sEMG activity increased during EPAP10 and EPAP15; however, a greater and significant increase was observed with EPAP10 (mean between-group difference: 12.5% RMS, 95% CI: 9.5 to 15.4, p<0.001). In relation to the baseline, at 10 and 20 minutes and upon recovery, respectively parasternal activity increased by 23.9%, 28.9% and 19.1% during EPAP10 and by 10.7% at 10 and 20 minutes and upon recovery, respectively, 11.4% and 6.9% during EPAP15 at 10 and 20 minutes and upon recovery, respectively. The sEMG activity of SCM muscle showed an opposite pattern, increasing with EPAP15 and decreasing with EPAP10 (mean between-group difference: 15.5% RMS, 95% CI: 12.6 to 18.4, p<0.001). SCM muscle activity during EPAP15, increased by 4.8% and 6.1% at 10 and 20 minutes and decreased by -4.0% upon recovery compared to decreases of –5.6%, –20.6% and –21.3% during EPAP10 at 10, 20 minutes, and recovery. Ventilation at both EPAP intensities promoted significant reductions in respiratory rate (RR) and dyspnea, more pronounced in EPAP15: RR (mean between-group difference: –3,8bpm, 95%CI: –7,5 to –0,2, p=0,015) and dyspnea (mean between-group difference: –1.01, 95%CI: –1.4 to –0.53, p=0.028) . Conclusion In COPD patients, the use of EPAP10 was more effective in reducing accessory inspiratory activity and increasing parasternal activity, which was accompanied by an improvement in ventilation and a reduction in dyspnea.

ABSTRACT Background Longitudinal studies have shown that the symptoms of chronic low back pain (CLBP) will follow an episodic trajectory characterized by periods of high and low pain intensity that can persist for many years. There is a growing belief that the contemporary approach of limiting physical therapy to short, but intense courses of treatment for (CLBP) may be sub-optimal because these limited “windows” of clinical care are not congruent with the natural history of this condition. Recent research has suggested that people with CLBP undergo substantial, and individualized long-term variations in the neural processing of nociception over time. This has led to the concept of a “unique biosignature of pain” that may explain much of the variation in a person’s clinical picture. These and other findings have led to the reconceptualization of CLBP as an individualized, and continually evolving condition that may be more suitably managed by empowering the patient toward self-management strategies that can be modified as needed over time by the PT. Objectives The purpose of this Master Class Paper is to describe an emerging approach for the treatment of CLBP that emphasizes the formation of a long-term therapeutic alliance between the patient and the PT with an emphasis on individualized, patient-preferred approaches for activity-based self-management as an alternative to the contemporary approach of short, intense episodes of care directed toward pain reduction. Conclusion Longitudinal care using assisted self-management strategies is more congruent with the natural history of CLBP than are traditional approaches for PT intervention. This approach may empower patients to undergo lifestyle changes that will favorably influence long-term outcomes; however additional research is needed.

ABSTRACT Background Different ultrasound parameters have been frequently used to assess changes associated with training, aging, immobilization, and neuromuscular diseases. However, an exploratory reliability analysis of the echo intensity (EI) and muscle thickness (MT) of the forearm flexors is scarce, especially in women. Objective The purpose of the present study was to determine the intra-rater reliability of MT and EI assessed by ultrasound in young women. Method Ultrasonographic MT and EI were acquired in the forearm flexors of 41 young women (22±2 yrs). Reliability was calculated using intraclass correlation coefficient (ICC2,1), standard error of measurement (SEM), coefficient of variation (CV), smallest detectable change (SDC), and Bland and Altman plot analysis. Results ICC values for MT and EI were 0.88 (95% CI: 0.78-0.93). The SEM and CV values were lower than 10%. Bland and Altman analysis revealed that ultrasound mean differences were 0.27 mm (Limits of Agreement - LOA 95%: - 2.6 to 3.2 mm) and -0.09 a.u. (LOA 95%: - 10.9 to 10.7 a.u.). Conclusion MT and EI assessed by ultrasonography in young women appear to be reliable and may be used to monitor changes in muscle mass induced by strength training when these changes exceed the precision of ultrasound.

ABSTRACT Objective To evaluate the effectiveness of prophylactic, non-invasive ventilation (NIV) on respiratory function in seven- to 16-year-old children in the post-operative phase of cardiac surgery. Method A randomized, controlled trial with 50 children who had undergone cardiac surgery with median sternotomy. After extubation, patients were randomly assigned to one of two groups: control group (n=26), which received instructions regarding posture, early ambulation, and cough stimulation, and CPAP group (continuous positive airway pressure; n=24), which received the same instructions as the control group and CPAP=10 cmH20 twice daily for 30 minutes from the 1st to the 5th post-operative day (POD). As a primary outcome, lung function was evaluated before and on the 1st, 3rd, and 5th PODs with measures of respiratory rate (RR), tidal volume (TV), slow vital capacity (SVC), inspiratory capacity (IC), minute volume (MV), peak expiratory flow (PEF), and maximal inspiratory pressure (MIP). As secondary outcomes, the time of hospitalization and intensive care were recorded. A mixed, linear regression model and z-test were used to analyze respiratory function, considering p<0.05. Results All variables, except RR and MV, showed a significant drop on the 1st POD, with gradual recovery; however, only MIP had returned to pre-operative values on the 5th POD in both groups. The RR showed a significant increase on the 1st POD, with a gradual reduction but without returning to baseline. In the intergroup analysis, significant improvement (p=0.04) was observed only in PEF in the CPAP group on the 1st DPO. The length of hospitalization and intensive care showed no significant differences. Conclusion NIV was safe and well accepted in this group of patients, and the protocol used was effective in improving PEF on the 1st DPO in the CPAP group.

ABSTRACT Background The Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT), developed with innovative measurement methodologies, evaluates functioning of children and youth, from 0 to 21 years, with different health conditions. It is a revision of an earlier instrument (PEDI) that has been used in national and international clinical practice and research. It was felt to be necessary to make this new version (PEDI-CAT) available in Brazil. Objectives Translate and culturally adapt the PEDI-CAT to the Brazilian-Portuguese language and test its psychometric properties. Method This methodological study was developed through the following stages: (1) translation, (2) synthesis, (3) back-translation, (4) revision by an expert committee, (5) testing of the pre-final version, and (6) evaluation of the psychometric properties. The 276 translated PEDI-CAT items were divided into three age groups (0-7, 8-14, and 15-21 years). Results The PEDI-CAT translation followed all six stages. The adaptations incorporated cultural and socioeconomic class specificities. The PEDI-CAT/Brazil showed good indices of inter-examiner (intraclass correlation coefficient-ICC=0.83-0.89) and test-retest (ICC=0.96-0.97) reliability, good internal consistency (0.99) and small standard error of measurement in all three age groups (0.12-0.17). Factor analyses grouped the items from the three functional skills domains into one factor, and items from the responsibility scale into three factors, supporting the adequacy of these factor solutions to the conceptual structure of the instrument and the developmental model. Conclusion The PEDI-CAT/Brazil is a theoretically consistent, culturally appropriate, and reliable instrument. Its availability in Brazil will contribute to the evaluation and measurement of functional outcomes from clinical interventions, longitudinal follow-up, and rehabilitation research.

ABSTRACT Background Cardiovascular Disease (CVD) is the leading burden of disease worldwide. Moreover, CVD-related death rates are considered an epidemic in low- and middle-income countries (LMICs). Research shows that cardiac rehabilitation (CR) participation reduces death and improves disability and quality of life. Given the growing epidemic of CVD in LMICs and the insufficient evidence about CR programs in these countries, a Randomized Control Trial (RCT) in Latin America is warranted. Objective To investigate the effects of comprehensive CR on functional capacity and cardiovascular risk factors. Method The design is a single-blinded RCT with three parallel arms: comprehensive CR (exercise + education) versus exercise-based CR versus wait-list control (no CR). The primary outcome will be measured by the Incremental Shuttle Walk Test. Secondary outcomes are risk factors (blood pressure, dyslipidemia, dysglycemia, body mass index and waist circumference); tertiary outcomes are heart health behaviors (exercise, medication adherence, diet, and smoking), knowledge, and depressive symptoms. The CR program is six months in duration. Participants randomized to exercise-based CR will receive 24 weeks of exercise classes. The comprehensive CR group will also receive 24 educational sessions, including a workbook. Every outcome will be assessed at baseline and 6-months later, and mortality will be ascertained at six months and one year. Conclusion This will be the first RCT to establish the effects of CR in Latin America. If positive, results will be used to promote broader implementation of comprehensive CR and patient access in the region and to inform a larger-scale trial powered for mortality.

ABSTRACT Objective To investigate whether handgrip strength normalized to body weight could be a useful clinical tool to identify dynapenia and assess functional capacity in post-menopausal women. Method A total of 136 postmenopausal women were recruited. Body composition (Dual Energy X-ray Absorptiometry [DEXA], Bio-electrical Impedence Analysis [BIA]), grip strength (dynamometer) and functional capacity (senior fitness tests) were evaluated. Dynapenia was established according to a handgrip strength index (handgrip strength divided by body weight (BW) in Kg/KgBW) obtained from a reference population of young women: Type I dynapenic (<0.44 kg/KgBW) and type II dynapenic (<0.35 kg/KgBW). Results The results show a positive correlation between handgrip strength index (in kg/KgBW) and alternate-step test (r=0.30, p<0.001), chair-stand test (r=0.25, p<0.005) and one-leg stance test (r=0.335, p<0.001). The results also showed a significant difference in non-dynapenic compared to type I dynapenic and type II dynapenic for the chair-stand test (Non-dynapenic: 12.0±3.0; Type I: 11.7±2.5; Type II: 10.3±3.0) (p=0.037 and p=0.005, respectively) and the one-leg stance test (Non-dynapenic: 54.2±14.2; Type I: 43.8±21.4; Type II: 35.0±21.8) (p=0.030 and p=0.004, respectively). Finally, a significant difference was observed between type II dynapenic and non-dynapenic for the chair-stand test (p=0.032), but not with type I dynapenic. Conclusion The results showed that handgrip strength was positively correlated with functional capacity. In addition, non-dynapenic women displayed a better functional status when compared to type I and type II dynapenic women. Thus, the determination of the handgrip strength thresholds could be an accessible and affordable clinical tool to identify people at risk of autonomy loss.

ABSTRACT Background Low back pain (LBP) is a common musculoskeletal condition among elders and is associated with falls. However, the underlying biological risk factors for falling among elders with LBP has been poorly investigated. The Physiological Profile Assessment (PPA) is a validated fall-risk assessment tool that involves the direct assessment of sensorimotor abilities and may contribute to the understanding of risk factors for falls among elders with LBP. Objective To assess fall risk using the PPA in elders with and without LBP. Method This is an observational, comparative, cross-sectional study with elders aged ≥65 years. The present study was conducted with a subsample of participants from the Back Complaints in the Elders (BACE) - Brazil study. Fall risk was assessed using the PPA, which contains five tests: visual contrast sensitivity, hand reaction time, quadriceps strength, lower limb proprioception, and postural sway. Results Study participants included 104 individuals with average age of 72.3 (SD=4.0) years, divided into two groups: GI) 52 participants with LBP; GII) 52 participants without LBP. The participants with LBP had a significantly higher fall risk (1.10 95% CI 0.72 to 1.48), greater postural sway (49.78 95% CI 13.54 to 86.01), longer reaction time (58.95 95% CI 33.24 to 84.65), and lower quadriceps strength (–4.42 95% CI –8.24 to –0.59) compared to asymptomatic participants. There was no significant difference for vision and proprioception tests between LBP and non-LBP participants. Conclusion Elders with LBP have greater risk for falls than those without LBP. Our results suggest fall-risk screening may be sensible in elders with LBP.

ABSTRACT Background Reducing rearfoot eversion is a commonly desired effect in clinical practice to prevent or treat musculoskeletal dysfunction. Interventions that pull the lower limb into external rotation may reduce rearfoot eversion. Objective This study investigated whether the use of external rotation elastic bands, of different levels of stiffness, will decrease rearfoot eversion during walking. We hypothesized that the use of elastic bands would decrease rearfoot eversion and that the greater the band stiffness, the greater the eversion reduction. Method Seventeen healthy participants underwent three-dimensional kinematic analysis of the rearfoot and shank. The participants walked on a treadmill with and without high- and low-stiffness bands. Frontal-plane kinematics of the rearfoot-shank joint complex was obtained during the stance phase of walking. Repeated-measures ANOVAs were used to compare discrete variables that described rearfoot eversion-inversion: mean eversion-inversion; eversion peak; and eversion-inversion range of motion. Results The low-stiffness and high-stiffness bands significantly decreased eversion and increased mean eversion-inversion (p≤0.037) and eversion peak (p≤0.006) compared with the control condition. Both bands also decreased eversion-inversion range of motion (p≤0.047) compared with control by reducing eversion. The high-stiffness band condition was not significantly different from the low-stiffness band condition for any variables (p≥0.479). Conclusion The results indicated that the external rotation bands decreased rearfoot eversion during walking. This constitutes preliminary experimental evidence suggesting that increasing external rotation moments at the lower limb may reduce rearfoot eversion, which needs further testing.

ABSTRACT Background The attitudes and beliefs that older people have about acute low back pain (LBP) may influence the coping mechanisms and the adoption of treatment strategies in this population. Objective The aim of this study was to identify the factors associated with the attitudes and beliefs of elderly patients with acute low back pain using the Back Beliefs Questionnaire. Method This is a cross-sectional study with a subsample of the study “Back Complaints in the Elders” (BACE), composed of 532 older Brazilians of both genders with acute LBP. We investigated sociodemographic and clinical aspects, self-perceived health, psychosocial and emotional state, falls, and functional capacity. Multiple regression models were constructed to measure possible associations. Results The percentage of female participants was 85.7% and the mean age was 69.04 (SD=6.2). Disability, symptoms of depression, and expectation of return to activities were independently associated with attitudes and beliefs concerning LBP. Conclusion Screening of psychosocial factors is essential to the prevention of persistent and recurrent LBP. Early signs of these factors can help identify symptoms and behaviors for effective interventions.

ABSTRACT Objective To investigate the effects of functional strengthening (using functional movements) and analytical strengthening (using repetitive movements) on level of activity and muscular strength gain in patients with chronic hemiparesis after stroke. Method A randomized, assessor-blinded trial was conducted in a therapist-supervised home rehabilitation program. Twenty-seven patients with chronic stroke were randomly allocated one of two groups: functional strengthening (FS) (n=13) and analytical strengthening (AS) (n=14). Each group received a five-week muscle strengthening protocol (30 minutes per day, three times per week) including functional movements or analytical movements, respectively. Pre-, post-, and ten-month follow-up outcomes included the Upper-Extremity Performance Test (primary outcome), Shoulder and Grip Strength, Active Shoulder Range of Motion (ROM), the Fugl-Meyer Assessment, and the Modified Ashworth Scale (MAS) (secondary outcomes). Results There was significant improvement in the Upper-Extremity Performance Test for the combined unilateral and bilateral task scores in the FS Group (mean difference 2.4; 95% CI=0.14 to 4.6) in the 10-month follow-up. No significant difference was observed between groups in the other outcomes (p>0.05). Conclusion A five-week home-based functional muscle strengthening induced positive results for the upper-extremity level of activity of patients with moderate impairment after chronic stroke.

ABSTRACT Background Airflow limitation frequently leads to the interruption of activities of daily living (ADL) in patients with Chronic Obstructive Pulmonary Disease (COPD). These patients commonly show absence of ventilatory reserve, reduced inspiratory reserve volume, and dynamic hyperinflation (DH). Objective To investigate ventilatory response and DH induced by three ADL-based protocols in COPD patients and compare them to healthy subjects. Method Cross-sectional study. COPD group: 23 patients (65±6 years, FEV1 37.2±15.4%pred); control group: 14 healthy subjects (64±4 years) matched for age, sex, and body mass index. Both groups performed all three tests: Glittre-ADL test; an activity test that involved moving objects on a shelf (TSHELF); and a modified shelf protocol isolating activity with upper limbs (TSHELF-M). Ventilatory response and inspiratory capacity were evaluated. Results Baseline ventilatory variables were similar between groups (p>0.05). The ventilatory demand increased and the inspiratory capacity decreased significantly at the end of the tests in the COPD group. Ventilatory demand and DH were higher (p<0.05) in the TSHELF than in the TSHELF–M in the COPD group (p<0.05). There were no differences in DH between the three tests in the control group (p>0.05) and ventilatory demand increased at the end of the tests (p<0.05) but to a lower extent than the COPD group. Conclusion The TSHELF induces similar ventilatory responses to the Glittre-ADL test in COPD patients with higher ventilatory demand and DH. In contrast, the ventilatory response was attenuated in the TSHELF-M, suggesting that squatting and bending down during the Glittre-ADL test could trigger significant ventilatory overload.

ABSTRACT Background These trials are the first randomised controlled trials of telephone-based weight management and healthy lifestyle interventions for low back pain and knee osteoarthritis. This article describes the protocol and statistical analysis plan. Method These trials are parallel randomised controlled trials that investigate and compare the effect of a telephone-based weight management and healthy lifestyle intervention for improving pain intensity in overweight or obese patients with low back pain or knee osteoarthritis. The analysis plan was finalised prior to initiation of analyses. All data collected as part of the trial were reviewed, without stratification by group, and classified by baseline characteristics, process of care and trial outcomes. Trial outcomes were classified as primary and secondary outcomes. Appropriate descriptive statistics and statistical testing of between-group differences, where relevant, have been planned and described. Conclusions A protocol for standard analyses was developed for the results of two randomised controlled trials. This protocol describes the data, and the pre-determined statistical tests of relevant outcome measures. The plan demonstrates transparent and verifiable use of the data collected. This a priori protocol will be followed to ensure rigorous standards of data analysis are strictly adhered to.