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Background: The desaturation–distance ratio (DDR), the ratio of the desaturation area to the distance walked, is a promising, reliable, and simple physiologic tool for functional evaluation in subjects with interstitial lung diseases. Lymphangioleiomyomatosis (LAM) is a rare neoplastic condition frequently associated with exercise impairment. However, DDR has rarely been evaluated in patients with LAM.Objectives: To assess DDR during maximal and submaximal exercises and evaluate whether DDR can be predicted using lung function parameters.Methods: A cross-sectional study was conducted in a cohort of women with LAM. The 6-min walking test (6MWT) and the incremental shuttle walking test (ISWT) were performed, and DDR was obtained from both tests. The functional parameters were assessed at rest using spirometry and body plethysmography. The pulmonary function variables predictive of DDR were also assessed.Results: Forty patients were included in this study. The mean age was 46 ± 10 years. Airway obstruction, reduced DLCO, and air trapping were found in 60, 57, and 15% of patients, respectively. The distance walked and the DDR for the 6MWT and ISWT were, respectively, 517 ± 65 and 443 ± 127 m; and 6.6 (3.8–10.9) and 8.3 (6.2–12.7). FEV1 (airway obstruction) and reduced DLCO and RV/TLC (air trapping) were independent variables predictive of DDR during exercises field tests [DDR6MWT = 18.66–(0.06 × FEV1%pred)–(0.10 × DLCO%pred) + (1.54 × air trapping), Radjust2 = 0.43] and maximal [DDRISWT = 18.84–(0.09 × FEV1%pred)–(0.05 × DLCO%pred) + (3.10 × air trapping), Radjust2 = 0.33].Conclusion: Our results demonstrated that DDR is a useful tool for functional evaluation during maximal and submaximal exercises in patients with LAM, and it can be predicted using airway obstruction, reduced DLCO, and air trapping.

PURPOSE This study evaluated the accuracy of the Mini-Balance Evaluation System Test (Mini-BESTest) for predicting falls in patients with chronic obstructive pulmonary disease (COPD) and investigated whether postural balance is a risk factor for falls. METHODS Postural balance was evaluated by the Mini-BESTest at baseline, and the incidence of falls over a 12-mo period was prospectively measured by a self-reported falls diary and confirmed by telephone calls. A discriminative power analysis was performed using receiver operating characteristic (ROC) curve and logistic regression analysis. RESULTS Sixty-seven outpatients with COPD (mean age ± SD = 67 ± 9.3 yr) were included. Twenty-five patients (37.3%) experienced ≥1 fall, and 28.2% of the falls resulted in injuries. The Mini-BESTest predicted falls in patients with COPD at the 6- and 12-mo follow-ups with a cut-off score of 22.5 (area under the curve = 0.85 and 0.87) with good sensitivity and specificity (85.7% and 66.7%; 84% and 73.8%, respectively). Higher scores on the Mini-BESTest were associated with a lower risk of falls at 12 mo (OR = 0.50; 95% CI, 0.36-0.70; P < .001). CONCLUSIONS Postural balance assessed by the Mini-BESTest is a good predictor of falls in patients with COPD. Our results imply that impaired balance contributes to the risk of falling and that balance training and fall prevention programs may be required for this population.

Determining the presence of thoracoabdominal asynchrony in chronic obstructive pulmonary disease (COPD) patients is clinically relevant, but there is no consensus on the optimal parameters for performing this analysis. We assessed 22 COPD patients (FEV1 40 ± 10% predicted) and 13 healthy controls during rest and exercise with optoelectronic plethysmography (70% maximum workload) on a cycle ergometer. Thoracoabdominal asynchrony was calculated by using phase angle and phase shift parameters following a three-compartment model involving the upper and lower rib cages and abdomen. Patients were classified as having thoracoabdominal asynchrony (TAA+) or not (TAA−) based on control values (mean ± 2 SDs). The chest wall volume and compartmental contribution were also measured. Thoracoabdominal asynchrony was observed in the lower rib cage. The phase angle detected more TAA+ patients at rest (15 vs. 7 patients) and during exercise (14 vs. 8 patients) compared with the phase shift. TAA+ patients also presented a lower chest wall volume, lower rib cage contribution, and higher abdominal contribution to chest wall volume compared with the control and TAA− patients. Thoracoabdominal asynchrony was more detectable during rest and exercise using the phase angle parameter, and it was observed in the lower rib cage compartment, reducing the chest wall volume during exercise in patients with COPD. NEW & NOTEWORTHY This study contributes to advance the knowledge over the previous lack of consensus on the assessment of thoracoabdominal asynchrony. We rigorously evaluated the related features that interfere in the measurement of the asynchrony (measurement tool, chest wall model and calculation parameter). Our results suggest that phase angle detects more suitably thoracoabdominal asynchrony that occurs on the lower ribcage and leads to a reduction in the chest wall volume during exercise in COPD patients.

OBJECTIVE Lung expansion techniques (LETs) are widely used to prevent postoperative pulmonary complications (PPCs). However, the effects of each of these techniques on thoracoabdominal mechanics and PPC incidence after abdominal surgery remain unclear. The objective of this study was to compare the effects of LET on pulmonary volumes, respiratory muscle activation, and PPC incidence after major, elective upper abdominal surgery. METHODS This randomized controlled trial enrolled 137 patients who were randomly assigned into four groups: control (n = 35), flow incentive spirometry (n = 33), deep breathing (n = 35), and volume incentive spirometry (n = 34). Each intervention was performed tid during 5 consecutive days. Subsequently, PPCs (pneumonia, atelectasis, or severe hypoxemia) were analyzed by a blinded assessor until hospital discharge. Lung volumes (optoelectronic plethysmography) and inspiratory muscular activation (surface electromyography) were assessed before and 3 days after surgery. Intention-to-treat analysis was performed. RESULTS Before surgery, all groups were homogenous for age, sex, BMI, lung function, and thoracoabdominal mechanics. After surgery, no difference was observed in the lung volumes and inspiratory muscular activation during the lung expansion technique (P ≥ .05). The PPC incidence was higher in the deep breathing group (P CONCLUSIONS LETs do not modify the changes on thoracoabdominal mechanics or prevent PPCs after abdominal surgery. The indiscriminate use of LETs should not be routinely prescribed to prevent PPCs; however, more studies are required to confirm our results and to change the standard practice. TRIAL REGISTRY ClinicalTrials.gov ; No.: NCT01993602; URL: www.clinicaltrials.gov

Background Thoracoabdominal asynchrony is the nonparallel motion of the ribcage and abdomen. It is estimated by using respiratory inductive plethysmography and, recently, using optoelectronic plethysmography; however the agreement of measurements between these 2 techniques is unknown. Therefore, the present study compared respiratory inductive plethysmography with optoelectronic plethysmography for measuring thoracoabdominal asynchrony to see if the measurements were similar or different. Methods 27 individuals (9 healthy subjects, 9 patients with interstitial lung disease, and 9 with chronic obstructive pulmonary disease performed 2 cycle ergometer tests with respiratory inductive plethysmography or optoelectronic plethysmography in a random order. Thoracoabdominal asynchrony was evaluated at rest, and at 50% and 75% of maximal workload between the superior ribcage and abdomen using a phase angle. Results Thoracoabdominal asynchrony values were very similar in both approaches not only at rest but also with exercise, with no statistical difference. There was a good correlation between the methods and the Phase angle values were within the limits of agreement in the Bland-Altman analysis. Conclusion Thoracoabdominal asynchrony measured by optoelectronic plethysmography and respiratory inductive plethysmography results in similar values and has a satisfactory agreement at rest and even for different exercise intensities in these groups.

Background: Incentive spirometers (IS) are widely used in clinical practice and classified as flow-oriented (FIS) and volumetric (VIS). Until recently, the respiratory inductive plethysmography used to evaluate the effects of IS on chest wall mechanics presented limitations, which may explain why the impact of VIS and FIS remains poorly known. Objective: We compared the effects of the VIS and FIS on thoracoabdominal mechanics and respiratory muscular activity in healthy volunteers. Methods: This cross-sectional trial assessed 20 subjects, 60% female, aged between 20 and 40 years and with a body mass index (BMI) between 20 and 30 kg/m2. All participants performed 8 quiet and 8 deep breaths using both FIS and VIS in a randomized order. The outcomes measured were the thoracoabdominal kinematics (i.e., chest wall, upper and lower ribcage and abdominal volumes), assessed using Optoelectronic Plethysmography, and the muscular activity of the sternocleidomastoid and superior and inferior intercostal muscles, assessed using electromyography. The statistical analysis was performed with one-way repeated measures ANOVA, and the significance level was set to 5%. Results: VIS increased 17 the chest wall volume to a greater extent than the FIS (p=0.007) and induced a larger increase in the upper and lower ribcages and abdomen (respectively, 156%, 91% and 151% p

COPD patients are susceptible to falls due to balance deficits; however, the sensory impairments due to age or disease remain poorly known. Aim: To investigate the effect of aging and pulmonary disease on the balance in COPD patients in sensory impairment conditions. Methods: 30 COPD patients (64±8 yrs; FEV 1 39±14 %predicted), 30 healthy adults matched for gender and age (64±8 yrs) and 30 young controls (25±5 yrs) were submitted to a computerized dynamic posturography. The assessment of balance control was conducted in four distinct sensory conditions: open eyes-fixed surface, closed eyes-fixed surface, open eyes-sway surface and closed eyes-sway surface. The variables evaluated were: maximal amplitude from the centre of pressure (COPamp), mean velocity of the path of the centre of pressure (COPvm) and COP asymmetry, all in the anteroposterior direction. ANOVA 3-way test was used for comparison among groups. Results: COPD patients had a worse balance compared to the healthy adult and young controls in sway surface in COPamp (8.7±3.8cm, 8.0±4cm and 6.2±3cm, respectively; p Conclusion: COPD patients have more instability in the anteroposterior direction in sensory impairment conditions as a result of age and disease, which implies a greater possibility of falling and suggests the need to therapeutic changes.

COPD patients have impaired balance and pulmonary hyperinflation could contribute to balance deficits in this population. Aim: To evaluate the relationship between postural balance and pulmonary hyperinflation in COPD patients. Methods: 67 patients were included (12% mild, 44% moderate and 44% severe COPD). Postural balance was evaluated by centre of pressure displacement analysis using a portable force platform in 3 different sensory conditions: standing with eyes open, eyes closed and on a foam surface with open eyes. The variables analysed included total path length, path velocity and amplitude, in both anteroposterior (AP) and mediolateral (ML) directions. Pulmonary hyperinflation was evaluated using body plethysmography. Participants were classified into 2 groups: hyperinflated (Total lung capacity >120% predicted) and non-hyperinflated. The Mann-Whitney-U-test was used for group comparison. Results: The hyperinflated patients (N=23; 64.8±9.7 yrs; FEV 1 35.1±12.0% predicted) presented a smaller postural balance variation compared to non-hyperinflated patients (N=44; 67.5±8.8 yrs; FEV 1 46.7±13.8% predicted) in the total path length (28.7±10.7cm vs. 32.8±8.3cm, p=0.02), in the amplitude (1.95±0.95cm vs. 2.26±0.87cm, p=0.016) and path velocity (0.74±0.26cm/s vs. 0.88±0.24cm/s, p=0.01), respectively, in the AP direction in the condition standing with eyes open. No significant difference between groups were observed in the ML direction or for the more difficult tests (p>0.05). Conclusion: Hyperinflated COPD patients present less displacement in the anteroposterior direction possibly due to change in the centre of pressure. This lower displacement may have implications for falls.

BACKGROUND: The Objective Structured Clinical Evaluation (OSCE) has been considered a reliable method for the evaluation of students' clinical skills in health sciences, but it has been rarely applied in the teaching of physical therapy. OBJECTIVE: To assess the use of the OSCE as a tool to evaluate the abilities of undergraduate chest physical therapy students and to verify the internal consistency of the OSCE exam. METHODS: Forty-seven students were evaluated using two types of exams: the traditional exam and the OSCE. Independent educators elaborated the exams. Each question (traditional) or station (OSCE) was given a score ranging from 0.0 to 2.0; being 10.0 the highest possible score of both exams. The relationship between the total score that were obtained from both exams was analyzed using Bland-Altman analysis and Pearson's correlation coefficient. The internal consistency of the OSCE stations was evaluated by four experienced chest physical therapists and it was tested using Cronbach's alpha. RESULTS: The students' average score on the OSCE ranged from 4.4 to 9.6. The internal consistency of the OSCE stations was considered good (0.7). The agreement between exams was analyzed, and it was determined that the exams are not comparable. Examiners also observed a low agreement between the two exams (r=-0.1; p=0.9). CONCLUSION: Our results showed that OSCE and traditional exams are not interchangeable. The OSCE exam had good internal consistency and is able to evaluate aspects that the traditional exam fails to evaluate. CONTEXTUALIZAÇÃO: A avaliação clínica objetiva e estruturada (OSCE) é considerada um método confiável para avaliar as competências clínicas de estudantes na área de saúde, entretanto tem sido pouco aplicada no ensino de fisioterapia. OBJETIVO: Analisar o uso da OSCE como uma ferramenta para avaliar as habilidades dos alunos de graduação em fisioterapia respiratória e verificar sua consistência interna. MÉTODOS: Quarenta e sete alunos foram avaliados por meio de dois exames: tradicional e OSCE. As provas foram elaboradas por educadores independentes. Para cada questão (tradicional) ou estação (OSCE), atribuiu-se uma pontuação de 0 a 2. A pontuação máxima possível em ambos os exames foi de 10. As relações entre as pontuações obtidas nos dois exames foram analisadas por meio de Bland-Altman e Correlação de Pearson. A consistência interna das estações da OSCE foi avaliada por quatro fisioterapeutas experientes e foi testada pelo Alfa de Cronbach. RESULTADOS: A pontuação média dos estudantes na OSCE oscilou entre 4,4 e 9,6. A consistência interna das estações da OSCE foi considerada boa (0,7). A concordância entre os exames foi analisada, e determinou-se que os exames não são comparáveis. Os examinadores também observaram uma baixa concordância entre os dois exames (r=-0,1, p=0,9). CONCLUSÃO: Nossos resultados mostraram que a OSCE e o exame tradicional não são intercambiáveis. O exame da OSCE teve uma boa consistência interna, sendo capaz de avaliar aspectos que o exame tradicional não avalia.

The mechanical alterations related to the overload of respiratory muscles observed in adults with persistent asthma might lead to the development of chronic alterations in posture, musculoskeletal dysfunction and pain; however, these changes remain poorly understood.This study aimed to assess postural alignment, muscle shortening and chronic pain in adults with persistent asthma.This cross-sectional and controlled study enrolled 30 patients with mild (n = 17) and severe (n = 13) persistent asthma. Fifteen non-asthmatic volunteers were also assessed. Asthma was classified by the Global Initiative for Asthma (GINA) guidelines. Postural alignment and muscle shortening were evaluated by head and shoulder positions, chest wall mobility, and posterior (trunk and lower limb) muscle flexibility. In addition, the measures used were previously tested for their reproducibility. Pain complaints were also assessed.In comparison with non-asthmatic subjects, patients with mild or severe persistent asthma held their head and shoulders more forward and had lower chest wall expansion, decreased shoulder internal rotation, and decreased thoracic spine flexibility. Chronic lower thoracic, cervical, and shoulder pain was significantly increased in patients with mild or severe asthma compared with non-asthmatic subjects (p0.05).Adults with persistent asthma have musculoskeletal dysfunction and chronic pain that is independent of the severity of their disease but that might be related to their age at the onset of disease symptoms.

COPD patients usually present thoracoabdominal asynchrony (TAA) that occurs due to an opposite motion among chest wall compartments decreasing tidal volume; however, the proper effect of TAA on chest wall volume remains unclear. Aim: to compare chest wall volume and respiratory kinematics among healthy and COPD patients with and without TAA. Methods: In this cross-sectional study 22 COPD (FEV 1 40±10%pred) and 13 healthy controls (FEV 1 98±14%pred) were assessed during rest and exercise (70% maximum workload) in a cycle ergometer. TAA was evaluated via optoelectronic plethysmography by calculating the phase angle (Lissajous approach) among upper and lower ribcage and abdomen. COPD patients were classified in two groups: those presenting asynchrony (TAA+) or not (TAA-) based on reference values of phase angle (mean ± 2*standard-deviation from controls). Chest wall volume and compartmental contribution were estimated. ANOVA was used for comparison. Results: Controls and COPD were homogenous for age, gender and BMI. Asynchrony occurred during rest and exercise in the lower ribcage. At rest, lower ribcage contribution was decreased in TAA+ compared to controls (9±10.7 vs. 18±9.2, p Conclusion: Thoracoabdominal asynchrony decreases chest wall volume in COPD and changes respiratory kinematics, decreasing lower ribcage and increasing abdominal contributions during exercise.