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Importance: The 3-min step test is a simple option to monitor submaximal exercise capacity, although its use via remote video monitoring has not been investigated in children with cystic fibrosis (CF)., Objective: This study aimed to assess the feasibility and reproducibility of performing the 3-min step test with remote supervision., Methods: A cross-sectional study including CF patients (6-18 years) from two CF services were performed. Demographic, anthropometric, clinical, and lung function data were collected and two 3-min step tests were performed: (i) in-person supervision, and (ii) remotely supervised by video monitoring. Before and after the tests, heart rate (HR), oxygen saturation (SpO 2 ), and the Borg score for dyspnea and lower limb fatigue were monitored., Results: Twenty-three patients (10.7 ± 3.7 years) with a mean FEV 1 of 89.5% ± 23.2% were included. There were no significant differences between tests, with mean differences (95% confidence intervals) in final HR of -3.3 (-8.9, 2.4), change in HR of -1.9 (-6.1, 2.1), final SpO 2 of 0.3 (-0.4, 1.0), and final dyspnea of 0.1 (-0.8, 0.9). The intraclass correlation coefficient was 0.852 (final HR), 0.762 (final SpO 2 ), and 0.775 (final lower limb fatigue). Significant and moderate correlations were found between tests for final HR ( r = 0.75), change in HR ( r = 0.61), and final SpO 2 ( r = 0.61). The Bland-Altman analysis showed a mean difference in final SpO 2 between tests of 0.3% (limit of agreement -3.0%, 3.5%)., Interpretation: Physiological responses between tests were similar, indicating it was feasible to perform the 3-min step test with remote supervision in CF children., Competing Interests: The authors declare no conflict of interest., (© 2024 Chinese Medical Association. Pediatric Investigation published by John Wiley & Sons Australia, Ltd on behalf of Futang Research Center of Pediatric Development.)

Background: Despite the improvements in the completeness of reporting of randomized trial protocols after the publication of the Standard Protocol Items: Recommendations for Interventional Trial (SPIRIT) guidelines, many items remain poorly reported. This study aimed to assess the effectiveness of using SPIRIT-tailored templates for trial protocols to improve the completeness of reporting of the protocols that master's students write as part of their master's theses., Methods: Before and after experimental study performed at the University Master's Degree in Orthopaedic Manual Physiotherapy of the Universitat Internacional de Catalunya (Barcelona, Spain). While students in the post-intervention period were instructed to use a trial protocol template that was tailored to SPIRIT, students in the pre-intervention period did not use the template., Primary Outcome: Difference between the pre- and post-intervention periods in the mean number of adequately reported items (0-10 scale). The outcomes were evaluated independently and in duplicate by two blinded assessors. Students and their supervisors were not aware that they were part of a research project. For the statistical analysis, we used a generalized linear regression model (dependent variable: number of adequately reported items in the protocol; independent variables: intervention period, call, language)., Results: Thirty-four trial protocols were included (17, pre-intervention; 17, post-intervention). Protocols produced during the post-intervention period (mean: 8.24; SD: 1.52) were more completely reported than those produced during the pre-intervention period (mean: 6.35; SD: 1.80); adjusted difference: 1.79 (95% CI: 0.58 to 3.00)., Conclusions: SPIRIT-based templates could be used to improve the completeness of reporting of randomized trial protocols., (© 2024. The Author(s).)

Background: The International Study of Wheezing in Infants defines recurrent wheezing as the presence of three or more medically documented episodes of wheezing within one year. To date, there is no evidence on the use of hypertonic saline (HS) combined with airway clearance techniques (ACT) for children with recurrent wheezing treated in an outpatient setting. Therefore, this is the first study to explore the use of such interventions in infants with recurrent wheezing., Objectives: To evaluate the effects and safety of a three-month protocol including HS and ACT for non-hospitalized infants with recurrent wheezing., Methods: Randomized, double-blind, controlled trial, including outpatient infants with recurrent wheezing. Children were randomized to either 3% HS or 0.9% saline groups and were treated with bronchodilator and nebulized with the respective solutions before ACT. The primary outcome was the Wang score. Secondary outcomes included the number of hospitalizations and respiratory crisis, need for rescue medication, and school absences. All variables were measured during the three previous months from inclusion and during intervention period. The study protocol was registered at ClinicalTrials.gov (NCT04331496) on March, 31, 2020., Results: Forty children were included. Regarding immediate effects, significant differences ( p < 0 . 001 ) were found for time, but not for group or interaction (group × time), in all outcome variables (increase in SpO 2 , decrease in heart and respiratory rate, wheezing episodes, retraction, and Wang score). Comparing the previous three months with the study period, there were significant differences in both groups for the severity of crisis ( p < 0 . 001 ) and medication steps ( p = 0 . 002 )., Conclusion: A three-month protocol including HS and ACT for outpatient infants with recurrent wheezing was safe and reduced morbidity. No differences were found between the use of HS and 0.9% saline., Competing Interests: The authors have no conflicts of interest to disclose., (© 2023, Hong Kong Physiotherapy Association.)

Objective: To compare lung function between adolescents with and without substance use disorder (SUD)., Methods: This was an observational, cross-sectional exploratory study. The sample consisted of 16 adolescents with SUD and 24 age-matched healthy controls. The adolescents in the clinical group were recruited from a psychiatric inpatient unit for detoxification and rehabilitation; their primary diagnosis was SUD related to marijuana, cocaine, or polysubstance use. Questionnaires and pulmonary function tests were applied for clinical evaluation., Results: We found that FVC, FEV1, and their percentages of the predicted values were significantly lower in the adolescents with SUD than in those without. Those differences remained significant after adjustment for BMI and the effects of high levels of physical activity. The largest effect size (Cohen's d = 1.82) was found for FVC as a percentage of the predicted value (FVC%), which was, on average, 17.95% lower in the SUD group. In addition, the years of regular use of smoked substances (tobacco, marijuana, and crack cocaine) correlated negatively with the FVC%., Conclusions: This exploratory study is innovative in that it demonstrates the early consequences of smoked substance use for the lung health of adolescents with SUD.

Objective: To evaluate the impact of COVID-19 social distancing recommendations on nutritional status, pulmonary function, and morbidity in patients with cystic fibrosis (CF)., Methods: A retrospective cohort study including patients older than six years with a diagnosis of CF was performed. Demographic and clinical data, anthropometric measurements, pulmonary function, days of antibiotic use, and length of hospital stay were recorded. Variables were recorded at three time points relative to the baseline for implementation of social distancing measures: T-1 (14 months before implementation), T0 (baseline), and T1 (14 months after implementation). Delta (Δ) was calculated for each period: Δ1 (pre-pandemic T0-T-1) and Δ2 (pandemic T1-T0)., Results: The study included 25 patients, with a mean age of 11.7±4.3 years. The mean forced expiratory volume in the first second (FEV1) was 85.6±23.6%, and body mass index (BMI) was 17.5±3.0 kg/m2. When comparing the two periods (Δ1 and Δ2), there was a significant increase in the FEV1/forced vital capacity (FVC) ratio (p=0.013) and in the forced expiratory flow between 25 and 75% of vital capacity (FEF25-75%) (p=0.037) in the pandemic period. There was also a significant reduction (p=0.005) in the use of antibiotics in the pandemic period compared with the pre-pandemic period. The Δ1 and Δ2 values did not differ significantly for BMI, FEV1, or length of hospital stay., Conclusions: COVID-19 social distancing recommendations had a positive impact (decrease) on morbidity (use of antibiotics) and small airway obstruction (FEF25-75%) in patients with CF.

Background: Whereas pulmonary exacerbations and aerobic fitness play a key role in the prognosis of cystic fibrosis (CF), the use of ventilatory threshold data as markers of exacerbation risk has been scarcely addressed. This study sought to examine the association between aerobic fitness, assessed through ventilatory threshold variables recorded during cardiopulmonary exercise testing (CPET), and the risk of exacerbations in individuals with CF., Methods: Participants of this retrospective cohort study were subjects from 6 y of age. Over a 4-y period, the following data were recorded: lung function indicators, CPET variables, time to first exacerbation and antibiotic use, along with demographic, clinical, and anthropometric data., Results: The mean age of 20 subjects included was 16 ± 5.4 y. Univariate regression analysis revealed that lung function (FEV 1 : Cox hazard ratio [HR] 0.97, P = .03; and forced expiratory flow between 25-75% of vital capacity [FEF 25-75 ]: Cox HR 0.98, P = .036) and aerobic fitness (oxygen consumption [V̇ O 2 ] at ventilatory threshold: Cox HR 0.94, P = .01; and ventilatory equivalent for carbon dioxide [V̇ E /V̇ CO 2 ] at ventilatory threshold: Cox HR 1.13, P = .049) were associated with exacerbation risk, whereas in the multivariate model, only V̇ O 2 at the ventilatory threshold (%max) (Cox HR 0.92, P = .01) had a significant impact on this risk. Consistently, individuals experiencing exacerbation had significantly lower V̇ O 2 values (%max) at the ventilatory threshold ( P = .050) and higher ventilatory equivalent for oxygen consumption (V̇ E /V̇ O 2 ) ( P = .040) and V̇ E /V̇ O 2 ( P = .037) values at the ventilatory threshold. Time to exacerbation was significantly correlated with V̇ O 2 at the ventilatory threshold (r = 0.50, P = .02), V̇ E /V̇ O 2 (r = -0.48, P = .02), and V̇ E /V̇ CO 2 (r = -0.50, P = .02)., Conclusions: Our results suggest an association between CPET variables at the ventilatory threshold and exacerbations. Percentage V̇ O 2 at the ventilatory threshold could serve as a complementary variable to monitor exacerbations in people with CF., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2023 by Daedalus Enterprises.)

Objective: To analyze the lipid profile and cardiovascular risk of overweight and obese adolescents and correlate the findings with anthropometric measurements., Methods: This is a cross-sectional study on overweight and obese adolescents of both sexes (aged 14 to 18 years old). The collected variables were sex, weight, height, age, total cholesterol, triglycerides, High-density lipoprotein (HDL) and low-density lipoprotein (LDL). The Atherogenic Index of Plasma and Castelli Risk Indices I and II were calculated. These indices were classified into cutoff points to stratify cardiovascular risk. The anthropometric profile was evaluated by Z score according to Body Mass Index for age. Significance level was considered as p≤0.05., Results: A total of 146 adolescents participated in the study; the mean age was 16.4±1.1 years and most of them were girls (74.7%) and obese (52.7%). The prevalent dyslipidemias were high triglycerides (47.9%), LDL (26.7%), total cholesterol (37.7%), and low HDL (46.6%). Most adolescents presented increased atherogenic risk according to the Atherogenic Index of Plasma (55.5%); 15.1% presented high cardiovascular risk according to Castelli Risk Index I; and 13.7%, according to Castelli Risk Index II. Boys presented higher values of anthropometric measurements and Castelli Risk Indices I and II in relation to girls - who, conversely, presented higher values of HDL. There was a positive correlation of the Z score with Atherogenic Index of Plasma and a negative correlation with HDL., Conclusions: The adolescents of the study presented high prevalence of cardiovascular and atherogenic risk according to the evaluated indices. In addition, the increased cardiovascular risk was correlated with higher Body Mass Index.

The purpose of the study was to evaluate the association of field test outcomes with peak oxygen uptake (VO 2 peak) in patients with cystic fibrosis (CF) and to describe the main prediction equations available. Data searches were performed in five databases (Pubmed, Embase, LILACs, Scopus and Web of Science) and also in the reference lists of articles included. The following inclusion criteria were used: studies including individuals with CF, presenting both a field test and a cardiopulmonary exercise testing (CPET), and describing a predictive equation or coefficient of correlation/determination. Case studies, abstracts, letters of reply, editorials and duplicate publications were excluded. The methodological quality analysis was performed using the JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies scale. Protocol registration number: CRD42020148363. Ten studies were eligible. Five equations were found to predict VO 2 peak. Equations derived from the shuttle tests (ST) showed strong correlations with VO 2 peak ( r = 0.79 to 0.95). The six-minute walk test (6MWT) showed moderate associations with VO 2 peak in participants with moderate disease severity ( r = 0.53 to 0.65). Furthermore, patients with lower maximum heart rate on the three-minute step test tended to have a higher percent predicted VO 2 peak ( r = -0.40), and the one-minute sit-to-stand test demonstrated moderate correlations between VO 2 peak and the number of repetitions ( r = 0.52 to 0.66). In conclusion, field test outcomes correlate with oxygen consumption assessed through CPET, although only the ST seems to be valid as a predictor of VO 2 peak in patients with CF.

Background: Autonomic nervous system balance is altered in cystic fibrosis (CF), although its influence on physical fitness has been poorly explored., Objective: This study aimed to evaluate the association of heart rate variability (HRV) with exercise capacity and levels of daily physical activity in children and adolescents with mild-to-moderate CF., Methods: A cross-sectional study including individuals with CF aged 6-18 years, not under CFTR modulator therapy, was performed. Sociodemographic (age, sex) and clinical information (airway colonization, pancreatic insufficiency, and genotyping) were collected. In addition, exercise capacity (modified shuttle test - MST), lung function (spirometry), body composition (bioimpedance), levels of daily physical activity (5-day accelerometer), and HRV (both at rest and during the MST) were evaluated., Results: 30 individuals (20 females) aged 11 . 2 ± 3 . 7 years, mean FEV 1 62 . 8 ± 27 . 6 %, were included. A sympathovagal balance (LF/HF) increase ( p < 0 . 001 ) during the MST was shown, indicating a predominance of sympathetic modulation. The standard deviation of all RR intervals (SDNN) and the high frequency (HF) index during exercise correlated significantly with FEV 1 ( r = 0 . 45 , p = 0 . 01 and r = 0 . 46 , p = 0 . 01 ; respectively). MST distance also correlated positively and significantly with SDNN ( r = 0 . 43 , p = 0 . 01 ), square root of the mean of the sums of squares of frequencies between RR intervals greater than 50 ms - RMSSD ( r = 0 . 53 , p < 0 . 01 ), low frequency - LF ( r = 0 . 48 , p < 0 . 01 ), HF ( r = 0 . 64 , p < 0 . 01 ), dispersion of points perpendicular to the short-term identity line - SD1 ( r = 0 . 40 , p = 0 . 02 ) and negatively with LF/HF ( r =- 0 . 57 , p < 0 . 01 ). Regarding daily physical activity, SDNN at rest ( r = 0 . 37 , p = 0 . 04 ) and exercise ( r = 0 . 41 , p = 0 . 02 ) showed positive correlations with time in moderate-to-vigorous activities. When normalizing the SDNN and classifying individuals as normal or altered, those presenting altered SDNN showed poorest FEV 1 ( p = 0 . 001 ) and lower exercise capacity ( p = 0 . 027 )., Conclusion: HRV correlates with lung function, exercise capacity and levels of daily physical activity in children and adolescents with CF. The study highlights the influence of CF on autonomic function and suggests HRV measurement as an easy tool to be used in clinical settings as an alternative marker to monitor CF individuals., Competing Interests: The authors have no conflict of interests to declare., (© 2021, Hong Kong Physiotherapy Association.)

Background: Evidence on resistance-training programs for cystic fibrosis (CF) is limited and the possible benefits of the addition of neuromuscular electrical stimulation (NMES) are unknown. This study aimed to evaluate the effects of a supervised resistance-training program, associated or not with NMES, on muscle strength, aerobic fitness, lung function and quality of life in children with CF presenting mild-to-moderate pulmonary impairment., Methods: This is a randomized controlled trial including CF patients aged between 6 and 17years. Subjects were randomly allocated to control (CON); exercise (EX); or exercise and NMES (EX + NMES) groups, and evaluated at baseline and at the end of an 8-week individualized exercise-program (3 days/week, 60min/session). NMES was applied in the quadriceps and the interscapular region, simultaneously to the exercises. CON group followed the CF team recommendations. The main outcome measures were lung function, cardiorespiratory fitness, functional capacity, quality of life and muscle strength., Results: Twenty-seven patients, aged 12.6 ± 3.0 years, were analyzed. No significant interactions were found for cardiorespiratory fitness. Functional capacity presented significant differences, indicating a better performance in both EX and EX + NMES. No significant changes between groups were seen for quality of life and lung function. As for muscle strength, EX and EX + NMES presented large effect sizes and significant differences, compared to CON, for quadriceps (p = 0.004, η 2 p  = 0.401), pectoral (p = 0.001, η 2 p  = 0.487), dorsal (p = 0.009, η 2 p  = 0.333) and handgrip (p = 0.028, η 2 p  = 0.278)., Conclusion: A resistance exercise-training program led to improvements in muscle strength and functional capacity in CF patients with mild-to-moderate pulmonary impairment. The addition of NMES to the training program resulted in no extra favorable effects., (Copyright © 2022. Published by Elsevier Ltd.)

Objective: Chronic neurological disorders (CNDs) generally produce deleterious effects on the musculoskeletal system and can affect physical activity and increase sedentary behavior in children, hindering the execution of training programs and the attainment of a correct dose of exercise. The purpose of this systematic review was to analyze the effect of neuromuscular electrical stimulation (NMES) on skeletal muscle and then on biomechanics of movement, functional mobility, strength, spasticity, muscle architecture, and body composition of children and adolescents with CNDs and chronic diseases., Methods: The search was conducted in April 2020 in PubMed, MEDLINE, Scopus, the Cochrane Library, and Web of Science, without publication period restriction. Publications investigating the effect of NMES on children and adolescents with CNDs and other chronic diseases were independently selected by 2 researchers. One author independently extracted data from the studies selected, and a second author cross-checked., Results: Eighteen studies with 595 participants aged between 3 and 14 years were included. Quality assessment showed that 50% of the studies presented a low risk of bias. The pooled effect of NMES on gross motor functional measure, calculated as a standardized mean difference using a random effects model, was 0.41 (95% CI = 0.19-0.64)., Conclusion: The use of NMES programs for children diagnosed with cerebral palsy, spinal muscular atrophy, and obstetric injury of the brachial plexus was effective in improving muscle strength, biomechanics of movement, and functional mobility., Impact: NMES can be a useful tool to prevent the reduction of mobility that results from CNDs., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To assess the association of sleep disorders with the findings of heart rate variability (HRV) in children and adolescents with cystic fibrosis (CF)., Methods: Cross-sectional study including children and adolescents aged six to 18 years with a clinical diagnosis of CF. Sociodemographic and clinical data were collected. Sleep disorders were evaluated using baseline nocturnal polysomnography. The autonomic nervous system (ANS) was evaluated through resting HRV., Results: A total of 30 individuals (11.2 years) with a mean forced expiratory volume in the first second (FEV1) of 62.7% were included. The respiratory disturbance index presented a median of 2.6 and obstructive sleep apnea syndrome (OSAS) was identified in 30%. In the HRV analysis, a mean standard deviation of all inter-beat (RR) intervals (SDNN) of 60.8±45.9ms was found. There was a significant correlation between the HRV low-frequency/high-frequency (LF/HF) global modulation index and the minimum SpO2 during sleep in patients with FEV1<60% (r=0.71; p=0.02). The prevalence of sleep disorders and HRV abnormalities was higher in individuals with lesser pulmonary function (FEV1<60%)., Conclusions: The results indicate a weak correlation of sleep disorders (minimum SpO2) with HRV parameters (LH/HF) in children and adolescents with CF. When pulmonary function was reduced, a stronger correlation was found, highlighting the influence of disease severity. A high prevalence of ANS disorders, nocturnal hypoxemia, and presence of OSAS was also found.

Background: Patients with cystic fibrosis (CF) present exercise intolerance and episodes of pulmonary exacerbations. This study aimed to evaluate the association of the distance covered on the modified shuttle test (MST), as well as other clinical variables (anthropometry, chronic colonization by Pseudomonas aeruginosa, lung function), with the risk of hospitalization for pulmonary exacerbation., Methods: Cohort study including CF patients older than 6 years, from two specialized CF centers. All patients underwent a MST and a lung function test at the time of inclusion. Demographic, anthropometric and clinical data were collected. Free time until the first hospitalization, total days of hospitalization and use of antibiotics during the two years of follow-up were recorded., Results: Sixty-seven patients with a mean (SD) age of 12.4 (5.2) years and forced expiratory volume in the first second (FEV 1 ) of 78.7% (22.4) were included. The mean distance covered (m) in the MST was 775.6 (255.7) (73.4 ± 19.5% of predicted). The distance achieved (MST) was considered as the main independent variable to predict the risk of hospitalization (Cox HR 0.97, p = 0.029). Patients who walked a distance of less than 80% of predicted in the MST showed an increase of 3.9 (95%CI 1.0-15.3) in the relative risk for hospitalization and significantly higher total number of days of hospitalization (p = 0.022)., Conclusion: There is an association between the distance covered in the MST and the risk of hospitalization in youths with CF. Patients with reduced exercise capacity presented a 3.9 times increase in the relative risk for hospitalization due to pulmonary exacerbation., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors have no conflict of interests to declare., (Copyright © 2020. Published by Elsevier B.V.)

Introduction: The aim of the study was to evaluate the diagnostic performance of the item concerning physical activity of the Global Initiative for Asthma (GINA) asthma control questionnaire for detection of exercise-induced bronchoconstriction (EIB) in children and adolescents., Material and Methods: We divided participants (aged 6-18 years) with a diagnosis of asthma into two groups according to the GINA severity classification: mild/moderate asthma (MMA) and severe therapy-resistant asthma (STRA). We collected anthropometric, clinical and functional data (spirometry) and performed an EIB test. We used item 4 of the GINA questionnaire regarding exercise-induced symptoms to assess the diagnostic power of this instrument., Results: We included 40 patients (17 with MMA and 23 with STRA) with a mean age of 11.3 years and a mean FEV 1 z-score of -0.33, of who 13 (32.5%) were classified as having uncontrolled asthma. Of the patients with uncontrolled asthma, 7 (53.8%) exhibited a decrease in the FEV 1 after the EIB test. We found a higher frequency of EIB in participants with FEV 1 z-score values of less than -1.0 compared to those with a z-score of -1.0 or greater (P = .05). There were no significant differences in the frequency of EIB based on disease severity and control. We also found no association of item 4 (GINA) with EIB. The area under the ROC curve demonstrated that the discriminative power of the GINA questionnaire for the detection of EIB is inadequate (P = .41), with sensitivity of 42.1% and specificity of 57.1%., Conclusions: The item concerning physical activity in the GINA questionnaire has insufficient diagnostic power to detect EIB in children and adolescents with asthma., (Copyright © 2021 Asociación Española de Pediatría. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Cystic fibrosis (CF) affects the autonomic nervous system (ANS) and exercise in healthy children modulates the interaction between sympathetic and parasympathetic activity. This study aimed to evaluate the effects of a short-term resistance exercise program on heart rate variability (HRV) in children and adolescents with CF. Methods: A randomized controlled trial was carried out in children diagnosed with CF aged 6-18 years. Individuals were divided into two groups: control (CON) and resistance-training (EX). Individuals in the EX group completed an individualized guided resistance program (5-RM-60-80%) for 8 weeks (3 sessions of 60 min/week). Upper and lower limbs exercises (seated bench press, seated lateral row, and leg press) were used. HRV was measured using a Suunto watch with subjects in lying position. Results: Nineteen subjects (13 boys) were included (CON = 11; and EX = 8). Mean age was 12.2 ± 3.3, FEV 1 (forced expiratory volume in the first second) z-score was 1.72 ± 1.54 and peak oxygen consumption (VO 2 peak) 42.7 ± 7.4 mL.Kg -1 .min -1 . Exercise induced significant changes in the frequency-domain variables, including a decrease in LF power ( p = 0.001, d = 0.98) and LF/HF ratio ( p = 0.020, d = 0.92), and an increase in HF power ( p = 0.001, d = -0.97), compared to the CON group. No significant changes were found for time-domain variables, although increases with a moderate effect size were seen for SDNN ( p = 0.152, d = -0.41) and RMSSD ( p = 0.059, d = -0.49) compared to the CON group. Conclusion: A short-term resistance exercise-training program was able to modulate HRV in children and adolescents with CF presenting mild to moderate lung function impairment and good physical condition. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT04293926., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Estévez-González, Donadio, Cobo-Vicente, Fernández-Luna, Sanz-Santiago, Villa Asensi, Iturriaga Ramirez, Fernández-del-Valle, Diez-Vega, Larumbe-Zabala and Pérez-Ruiz.)

Background: No studies have investigated the use and safety of high-frequency chest wall compression (HFCWC) for non-hospitalized infants with acute viral bronchiolitis (AVB). The aim of the present study was to evaluate the immediate effects and safety of HFCWC as compared to airway clearance techniques in children with AVB., Methods: In this randomized clinical trial in non-hospitalized infants (0-12 months old) with mild to moderate AVB, children were randomized into 2 groups: airway clearance techniques (20 min of prolonged slow expiration and provoked cough) or HFCWC (15 min). A single session was performed and children were evaluated at baseline and at 10 min and 20 min after treatments. Outcomes measures were the Wang severity score, [Formula: see text], sputum wet-weight, and the presence of adverse events., Results: A total of 91 infant subjects, mean age 7.9 ± 2.6 months, were included. Significant ( P = .004) between-group differences were found in the Wang score, which was 0.28 points lower in the airway clearance techniques group. There was a greater increase of infants classified as normal and a greater decrease of those classified as mild according to the Wang score when airway clearance techniques were used compared to the use of HFCWC ( P = .009). The sputum wet-weight was lower in subjects treated with the airway clearance techniques ( P < .001). Although [Formula: see text]improved in both groups, no differences were found between them. There was also no difference for adverse events, and the majority of children did not present any adverse events after 20 min., Conclusions: The use of HFCWC induced similar clinical effects as airway clearance techniques and was safe for non-hospitalized infants with AVB. Both techniques reduced respiratory symptoms and acutely improved [Formula: see text]. (ClinicalTrials.gov: NCT03835936.)., Competing Interests: Dr Donadio is supported in part by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior and Conselho Nacional de Desenvolvimento Científico e Tecnológico. The other authors have disclosed no conflicts of interests., (Copyright © 2021 by Daedalus Enterprises.)

Objective: To evaluate factors associated with the performance of children and adolescents with cystic fibrosis (CF) in the Modified Shuttle Test (MST) and compare it with healthy children and adolescents., Methods: This is a cross-sectional study, with children and adolescents divided into two groups: cystic fibrosis (CFG) and control (CG). Variables evaluated in the MST: walking distance, test level, heart rate variation (∆Hr), post-test mean arterial pressure (MAP Pt) and peripheral oxygen saturation variation (∆SPO2). Statistical analysis included Mann Whitney and Spearman coefficient tests, being significant p<0.05., Results: Sixty individuals aged 6-16 years old were evaluated. Anthropometric data was similar between groups. Differences between groups were shown for: baseline heart rate (BHr), peak heart rate (PHr), ∆Hr, recovery heart rate (RHr), post-test respiratory rate (PtBr), saturation variables, peripheral oxygen level (SpO2B) and level test. The ∆Hr and MAP Pt had a moderate positive correlation with distance and level test for both groups (respectively: r=0.6 / p<0.001; r=0.6 / p<0.001). In CFG, the level test had a significant association (r=0.4 - p=0.02) with %FEV1., Conclusions: Children with cystic fibrosis presented functional limitation in the Modified Shuttle Test, which was influenced by lung function.

Background: Respiratory therapy is a part of the treatment of patients with cystic fibrosis (CF). However, there is no information about the main factors influencing the recommendation of the use of different techniques or devices by physical therapists from different specialized centers., Objective: To determine the respiratory therapy techniques recommended for the treatment of patients with CF seen in specialized treatment centers in Brazil., Methods: This is a descriptive study including a sample of Brazilian CF specialized treatment centers. Data on demographics, spirometric variables, and recommended respiratory therapy treatment techniques were collected., Results: Twelve specialized treatment centers with a total of 974 patients were included (13.5±11.3 years old and FEV 1 (%) 75.7±27.9). The most recommended techniques were huffing (61.1% of patients), high frequency oral oscillation (HFOO) (52.0%), and positive expiratory pressure (PEP) (45.3%). Most often, recommendation was to perform treatment once (54.8% of patients) or twice (34%) a day. There was great variability in the recommendation among the different states. When data were separated by age, there was a predominance of performing conventional and manual techniques in infants and preschool children. There were no significant variations according to pulmonary function. Based on the literature, techniques based on volume, huffing, and PEP were most prevalently performed in international centers., Conclusion: The most recommended treatment techniques for patients with CF in Brazil are huffing, HFOO, and PEP, followed by volume-based techniques. There were geographical variations in the preferred treatment techniques, as well as based on patient age, but not based on the level of pulmonary function., (Copyright © 2019 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Background: Elevated extracellular DNA levels are found in the sputum of patients with cystic fibrosis (CF). However, studies investigating the association of extracellular DNA with CF severity are scarce., Objective: To evaluate the association of extracellular DNA levels with pulmonary function, antibiotic use, and hospitalization in CF patients., Methods: This cross-sectional study included CF patients aged ≥5 years who were clinically stable and produced spontaneously expectorated sputum. Extracellular DNA in sputum was quantified, and extracellular DNA networks were seen with immunofluorescence microscopy. Also, cell death profile was assessed. Data on pulmonary function, airway colonization, antibiotic use, and hospitalization in the previous year were collected. Patients were divided into two groups based on median DNA level., Results: Thirty-three patients were included. Their mean age was 16.3 ± 6.2 years, mean forced expiratory volume in the first second (FEV 1 ) was 67.0 ± 26.7 (% of the predicted), and mean DNA level was 241.9 ± 147.2 μg/mL. There were significant correlations of DNA level with FEV 1 (r = -0.60; p < 0.001) and forced vital capacity (r = -0.59; p < 0.001). Moreover, patients with higher DNA level (>243.0 μg/mL) had lower FEV 1 (52.1 ± 27.8% vs. 81.1 ± 16.2%; p = 0.001) and required more hospitalizations (68.8% vs. 35.3%; p = 0.05). Additional findings were the presence of extracellular DNA networks and low rates of necrosis and apoptosis., Conclusion: Elevated extracellular DNA levels in CF sputum are associated with reduced pulmonary function and increased hospitalizations., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Octyl gallate (OG) is an antioxidant commonly used in food, although there is no definition of its acceptable daily intake. There are reports in vitro and in vivo showing that food additives and drugs can alter lipid metabolism. Lipid droplet accumulation in hepatic cells is one of the main findings in the unregulated lipid metabolism and is strongly related to the development of nonalcoholic fatty liver disease (NAFLD). In this study, we investigated the effects of OG on lipid metabolism in the hepatocellular carcinoma cell line (HepG2). The results have shown, for the first time, that treatment with OG increased the overall amount of lipids, the triglyceride concentration, the lipid droplet area, and SREBP-1c and PPAR-γ gene expression. Taken together, the findings indicate that OG induces lipid droplet accumulation in HepG2 cells through the regulation of SREBP-1c and PPAR-γ gene expression without involving mTOR/S6K1 and may contribute to NAFLD when used as a food additive., (Copyright © 2020 Lima et al.)

Background: Patients with cystic fibrosis develop decreased exercise capacity. However, the main factors responsible for this decline are still unclear. Thus, the objective of this study was to evaluate the factors influencing exercise capacity assessed with the modified shuttle test (MST) in individuals with cystic fibrosis., Methods: A cross-sectional study was carried out in subjects with a diagnosis of cystic fibrosis who were 6-26 y old and were regularly monitored at 2 cystic fibrosis reference centers in Brazil. Individuals who were unable to perform the tests or who exhibited hemodynamic instability and exacerbation of respiratory symptoms were excluded. Anthropometric, clinical, and genotype data were collected. In addition, lung function and exercise capacity were evaluated with the MST., Results: 73 subjects (mean age 12.2 ± 4.9 y and FEV 1 76.8 ± 23.3%) were included. The mean distance achieved in the MST was 765 ± 258 m (71.6% of predicted). The distance achieved on the MST correlated significantly with age (r = 0.49, P < .001), body mass index (r = 0.41, P < .001), resting heart rate (r = -0.51, P < .001), and FEV 1 (r = 0.24, P = .042). Subjects with FEV 1 > 67% of predicted ( P = .02) and those with resting heart rate < 100 beats/min ( P = .01) had a greater exercise capacity. Resting heart rate, age, and FEV 1 (%) were found as significant variables to explain the distance achieved on the MST (R 2 = 0.48, standard error = 191.0 m)., Conclusions: The main determinants of exercise capacity assessed with the MST in individuals with cystic fibrosis were resting heart rate, age, and lung function., (Copyright © 2020 by Daedalus Enterprises.)

Background: Adherence of patients with cystic fibrosis (CF) to exercise is challenging. Here we compared the physiological responses during the use of interactive video games (VG) with the cardiopulmonary exercise test (CPET) in healthy and CF subjects., Methods: Cross-sectional study including CF and healthy (CON) subjects older than 6 years. Individuals were evaluated in two visits. At visit one, anthropometric measures, spirometry and CPET were performed. In the second visit, a physical activity questionnaire was applied and gas analyses performed during the use (10 min) of both Nintendo Wii (Wii Fit Plus: (1) Obstacle Course, (2) Rhythm Boxing and (3) Free Run) and Xbox One (Just Dance 2015: (1) Love Me Again, (2) Summer and (3) Happy)., Results: Twenty-five CON and 30 CF patients were included. The mean FEV 1 (%) was significantly lower in the CF group compared to CON. There were no differences between groups at peak exercise (CPET) for heart rate (HR), oxygen consumption (VO 2 ) and minute ventilation (V E ). In the CON group, games 2 and 3 (Xbox) and game 3 (Nintendo) increased HR to values similar to the anaerobic threshold (AT), while for the CF group this occurred for games 2 (Xbox) and 3 (Nintendo). As for VO 2 and V E , both groups obtained similar responses as compared to AT values in games 2 (Xbox) and 3 (Nintendo)., Conclusion: The use of VG generated a cardiorespiratory response similar to AT levels found during CPET, indicating that it may be an alternative for exercise training of CF individuals., Competing Interests: Declaration of Competing Interest The authors have no conflict of interests to disclose., (Copyright © 2020. Published by Elsevier B.V.)

Objective: To validate the upper limb assessments tool, Shriners Hospital Upper Extremity Evaluation (SHUEE), for individuals with hemiplegic cerebral palsy in the Brazilian population., Methods: Validation study to translate and culturally adapt the Manual and the instrument. The psychometric properties evaluated were reliability and convergent validity. Reliability was determined by internal consistency (Cronbach's α coefficient), ceiling and floor effect, sensitivity to changes, and intra- and interobserver agreement. Convergent validity was performed using the Pediatric Motor Activity Log, the self-care scale of the Pediatric Evaluation of Disability Inventory, and the Manual Ability Classification System., Results: We evaluated 21 individuals with hemiplegic cerebral palsy, with a mean age of 8.7±4.0 years. After the instrument was translated, there was no need for cultural adaptation. The total Cronbach's α coefficient was 0.887 (95% confidence interval [95%CI] 0.745-0.970). We calculated sensitivity to changes in five subjects who underwent treatment with Botulinum Toxin Type A and physical therapy, with a significant difference between pre- and post-treatment evaluations in the Spontaneous Functional Analysis and Dynamic Positional Analysis. Convergent validity showed a significant correlation of the Spontaneous Functional Analysis and Dynamic Positional Analysis with the scales evaluated. All items of SHUEE presented high intra- and interobserver agreement., Conclusions: The results revealed that the Brazilian version of the SHUEE demonstrated good reliability and convergent validity, suggesting that it is an adequate and reliable tool for individuals with hemiplegic cerebral palsy in the Brazilian population.

Objective To evaluate the effect of an interdisciplinary intervention with a motivational approach on exercise capacity and usual physical activity levels in overweight and obese adolescents. Methods This is a randomized, controlled clinical trial with single blinding of subjects. Adolescents aged 15 to 18 years with overweight and obesity (body mass index ≥ 85 percentile) were included. The adolescents were randomized into two groups: interdisciplinary intervention or control - traditional approach aiming at lifestyle modifications. The initial evaluations were carried out, including the cardiopulmonary exercise test and the physical activity level measurement by using the International Physical Activity Questionnaire and a pedometer. The evaluations were performed in two moments: time zero (time of inclusion in the study) and after 3 months (end of intervention). There were 12 sessions with weekly meetings. Results A total of 37 participants were included, 19 in the Intervention Group. There were no significant differences in the baseline demographic, anthropometric and physical activity characteristics between groups, with mean age of 17.3±1.0 years in the Control Group, and 16.8±0.9 years in the Intervention Group (p=0.14). The motivational intervention did not cause significant differences (p>0.05) in the comparison of the variables of exercise capacity and usual physical activity (questionnaire and pedometer) between groups. Conclusion The intervention with a motivational approach did not alter exercise capacity and levels of usual physical activity in overweight and obese adolescents. Clinical Trial Registry: NCT02455973 and REBEC: RBR-234nb5.

Introduction: Several tests may be used to assess exercise intolerance in severe therapy-resistant asthma (STRA), including the gold standard cardiopulmonary exercise test (CPET) and the modified shuttle test (MST)., Objective: To correlate the distance achieved in the MST with peak oxygen uptake (VO 2 peak) and to compare the maximal heart rate (HRmax) obtained in both tests in children and adolescents with STRA., Methods: This is a cross-sectional study, with 19 children and adolescents with STRA. Demographic, anthropometric, clinical data, and spirometric values were collected. CPET and the MST were performed in two consecutive visits. HRmax, pulse oxygen saturation, and dyspnea were compared between tests. The distance achieved in the MST was correlated with VO 2 peak., Results: Nineteen patients with a mean age of 11.5 ± 2.5 years were included. The mean HRmax (bpm) achieved was 180.8 ± 12.10 for the MST and 187.6 ± 9.35 for CPET, whereas the mean HRmax as a percentage of predicted (HRmax%) was 90.7 ± 6.5 for the MST and 93.8 ± 4.5 for CPET. A difference of only 6 bpm was found for HRmax ( p = 0.10) and of 3% for HRmax% ( p = 0.06) between tests. A strong correlation was found between the MST ( r = 0.79; p = 0.001) and VO 2 peak measured through CPET. However, there were no correlations between the MST and both body mass index ( r = -0.14; p = 0.564) and forced expiratory volume in the first second - FEV 1 ( r = -0.02; p = 0.917)., Conclusion: The results demonstrate that the MST distance strongly correlates with VO 2 peak, measured through CPET, and the main physiological variable responses were similar between both tests. Our results provide additional data for the use of the MST to assess exercise capacity in children and adolescents with STRA., (Copyright © 2019 Schiwe, Heinzmann-Filho, Schindel, Gheller, Campos, Pitrez and Donadio.)

Pulmonary fibrosis (PF) is the result of chronic injury where fibroblasts become activated and secrete large amounts of extracellular matrix (ECM), leading to impaired fibroblasts degradation followed by stiffness and loss of lung function. Fructose-1,6-bisphosphate (FBP), an intermediate of glycolytic pathway, decreases PF development, but the underlying mechanism is unknown. To address this issue, PF was induced in vivo using a mouse model, and pulmonary fibroblasts were isolated from healthy and fibrotic animals. In PF model mice, lung function was improved by FBP as revealed by reduced collagen deposition and downregulation of ECM gene expression such as collagens and fibronectin. Fibrotic lung fibroblasts (FLF) treated with FBP for 3 days in vitro showed decreased proliferation, contraction, and migration, which are characteristic of myofibroblast to fibroblast phenotype reversal. ECM-related genes and proteins such as collagens, fibronectin and α-smooth muscle actin, were also downregulated in FBP-treated FLF. Moreover, matrix metalloproteinase (MMP) 1, responsible for ECM degradation, was produced only in fibroblasts obtained from healthy lungs (HLF) and FBP did not alter its expression. On the other hand, tissue inhibitor of metalloproteinase (TIMP)-1, a MMP1 inhibitor, and MMP2, related to fibroblast tissue-invasion, were predominantly produced by FLF and FBP was able to downregulate its expression. These results demonstrate that FBP may prevent bleomycin-induced PF development through reduced expression of collagen and other ECM components mediated by a reduced TIMP-1 and MMP2 expression., Competing Interests: The authors have declared that no competing interests exist.

The incidence of hepatocellular carcinoma (HCC) keeps rising year by year, and became the second leading cause of cancer-related death. Some studies have found that liraglutide, a GLP-1 analog, may decrease the tumor cells proliferation. Due to this, the aim of this work is to investigate the antiproliferative potential of exenatide, another GLP-1 analog. Cell proliferation was assessed by direct count with Trypan blue dye exclusion. Flow cytometry was used to determinate autophagy and nuclear staining. Morphometric analysis was used to verify senescence and apoptosis. The mechanism that induced cell growth inhibition was analyzed by Western Blot. Treatment with exenatide significantly decreases cell proliferation and increases autophagy, both in relation to control and liraglutide. In addition, mTOR inhibition was greater in cells treated with exenatide. In relation to chronic treatment, exenatide does not allow cellular regrowth by preventing some resistance mechanism that the cells can acquire. These results suggest that exenatide has a potent anti-proliferative activity via mTOR modulation and, among the GLP-1 analogs tested, could be in the future an alternative for HCC treatment., (Copyright © 2019 Krause et al.)

Background: Aerobic fitness, as measured by peak oxygen uptake (V̇ O 2 peak), correlates with survival in children and adults with cystic fibrosis (CF). We sought to evaluate the effects of V̇ O 2 peak on mortality rates in subjects with CF., Methods: An online search in PubMed, Embase, LILACS, and SciELO databases was conducted, and cohort studies that assessed mortality rates after oxygen absorption measurements during a maximal exercise test were included. Data were extracted independently by 2 reviewers. The quality analysis of the selected articles was performed using the Newcastle-Ottawa scale. The main outcome evaluated was the mortality of subjects with CF. Whenever possible, and if appropriate, a random effect meta-analysis was performed., Results: Six cohort studies were included in this systematic review including 551 subjects. Five studies were classified with high methodological quality. Two analyses were carried out to evaluate the influence of V̇ O 2 peak on mortality. Total difference standardized mean between V̇ O 2 peak averages in the survival or non-survival groups was -0.606 (95% CI = -0.993 to -0.219, P = .002). In addition, subjects with a lower V̇ O 2 peak had a significantly higher mortality risk (relative risk 4.896, 95% CI = 1.086 to 22.072, P = .039) in an 8-y follow-up period., Conclusion: Low levels of peak oxygen uptake are associated with an increase of 4.9 in the risk of mortality in subjects with CF. This indicates that V̇ O 2 could be an important follow-up variable to measure, in addition to FEV 1 ., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2019 by Daedalus Enterprises.)

New Findings: What is the central question of this study? Early-life adversity is associated with increased risk for obesity and metabolic dysfunction. However, it is unclear whether obesity and metabolic dysfunction result from coping strategies to deal with adversity-related emotional dysregulation, a direct programming of systems regulating metabolic function, or a combination of both. What is the main finding and its importance? Early-life adversity increases vulnerability to later-life obesity and metabolic dysfunction, indicating that genetics and adult lifestyle are not the only determinants of obesity and related metabolic dysfunction. Moreover, consumption of cafeteria diet exacerbated metabolic dysfunction associated with early-life adversity, suggesting that poor dietary choices might have a bigger impact in the context of early-life adversity., Abstract: Early-life adversity has become recognized as an important factor contributing to adult obesity and associated metabolic dysfunction. However, it is unclear whether obesity and metabolic dysfunction associated with early-life adversity result from coping strategies to deal with adversity-related emotional dysregulation, a direct programming of systems regulating metabolic function, or a combination. Interestingly, both early-life adversity and later-life dietary choices affect immune function, favouring pro-inflammatory mechanisms that are associated with obesity-related metabolic dysfunction. To investigate the unique and/or interactive effects of early-life adversity and later-life dietary choices for increased vulnerability to obesity and metabolic dysfunction, and specifically the role of the immune system in this vulnerability, we combined a naturalistic rat model of early-life scarcity-adversity with a rat model of obesity, the cafeteria diet. Our results indicate that early-life adversity alone induces insulin resistance, reduces pancreatic insulin secretion, plasma concentrations of triglycerides and cholesterol, and increases fasting glucose and tumour necrosis factor-α plasma concentrations. Importantly, animals exposed to adverse rearing were more vulnerable to metabolic dysregulation associated with the cafeteria diet, given that they consumed more energy, showed more severe hepatic steatosis and increased concentrations of the pro-inflammatory cytokine interleukin-1β than normally reared animals fed the cafeteria diet. Together, our results suggest that early-life adversity negatively programmes physiological systems that regulate metabolic function and increases vulnerability to obesity and metabolic dysfunction in adulthood. These results highlight the intrinsic relationship between the quality of the early postnatal environment and later-life dietary choices on adult health outcomes., (© 2018 The Authors. Experimental Physiology © 2018 The Physiological Society.)

Objective: To compare muscle thickness and subcutaneous fat in cystic fibrosis (CF) patients and healthy controls using ultrasonography (US), and to correlate US findings with nutritional, clinical and functional variables., Methods: Patients aged 6 to 18 years old with a diagnosis of CF and healthy controls were included. Participants underwent anthropometric measurements, an ultrasonographic evaluation of muscle thickness and subcutaneous fat in the triceps, quadriceps, and gastrocnemius regions, and skinfold thickness measurements. Body fat percentage was estimated using skinfold measurement. Subjects with CF also underwent a pulmonary function assessment using spirometry., Results: We studied 39 CF patients and 45 controls. Alower body mass index was observed in CF patients (p=0.011). Body composition and muscle thickness were similar between the groups. Only calf (p=0.023) circumference and femur diameter (p<0.001) were lower in CF patients. Although there were no significant between-group differences in the comparison of US measurements of subcutaneous fat, CF patients exhibited decreased skinfold thickness in the triceps (p=0.031) and quadriceps (p=0.019). Moreover, there were weak and moderate correlations of US quadricep thickness with forced vital capacity (FVC) and lean mass, respectively. Moderate correlations of the triceps, quadriceps and gastrocnemius between US subcutaneous fat and skinfold measurements were found., Conclusions: Patients with CF presented a reduction in subcutaneous fat content. Muscle thickness correlated with FVC and nutritional parameters. In addition, US findings correlated positively with skinfold measurements.

Objective: To compare the values of measured maximum heart rate (HRmax) and maximum heart rate estimated by different equations during the cardiopulmonary exercise test (CPET) in obese adolescents., Methods: This is a cross-sectional study. Adolescents aged between 15 and 18 years old, with obesity (BMI Z-score>2.0) were included. Demographic and anthropometric data were collected, followed by CPET, recording HRmax. The highest heart rate reached at peak exercise was considered as HRmax. The comparison between measured and estimated HRmax values was performed using four previous equations. Descriptive statistics and the ANOVA test (Bonferroni post-test) were used., Results: Fifty-nine obese adolescents were included, 44% of them male. The mean age was 16.8±1.2 years old and the BMI (Z-score) was 3.0±0.7. At peak exercise, the mean HRmax (bpm) was 190.0±9.2, the respiratory coefficient was 1.2±0.1, and the VO2max (mL/kg/min) was 26.9±4.5. When comparing the measured values of HRmax with those estimated by the different formulas, the equations "220-age", "208-0.7 x age" and "207-0.7 x age" were shown to overestimate (p<0.001) the measured HRmax results in obese adolescents. Only the "200-0.48 x age" equation presented similar results (p=0.103) with the values measured in the CPET., Conclusions: The findings of the present study demonstrate that the equation "200-0.48 x age" seems to be more adequate to estimate HRmax in obese adolescents.

Objective: To identify selection criteria for selective dorsal rhizotomy (SDR) in cerebral palsy, to analyze the instruments used for evaluation, and to describe the characteristics of physical therapy in postoperative protocols., Data Sources: Integrative review performed in the following databases: SciELO, PEDro, Cochrane Library, and PubMed. The terms in both Portuguese and English for "cerebral palsy", "selective dorsal rhizotomy", and "physical therapy" were used in the search. Studies whose samples enrolled individuals with cerebral palsy who had attended physical therapy sessions for selective dorsal rhizotomy according to protocols and describing such protocols' characteristics were included. Literature reviews were excluded and there was no restriction as to period of publication., Data Synthesis: Eighteen papers were selected, most of them being prospective cohort studies with eight-month to ten-year follow-ups. In most studies, the instruments of assessment encompassed the domains of functions, body structure, and activity. The percentage of posterior root sections was close to 50%. Primary indications for SDR included ambulatory spastic diplegia, presence of spasticity that interfered with mobility, good strength of lower limbs and trunk muscles, no musculoskeletal deformities, dystonia, ataxia or athetosis, and good cognitive function. Postoperative physical therapy is part of SDR treatment protocols and should be intensive and specific, being given special emphasis in the first year., Conclusions: The studies underline the importance of appropriate patient selection to obatin success in the SDR. Postoperative physical therapy should be intensive and long-term, and must necessarily include strategies to modify the patient's former motor pattern.