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PURPOSE Whether the modified shuttle test (MST) achieves maximal effort in children and adolescents with asthma is unclear. The aim was to compare the physiological responses of MST to the cardiopulmonary exercise test (CPET) in pediatric patients with asthma, to observe its convergent validity. PATIENTS AND METHODS A cross-sectional study with volunteers with asthma (6-17 years of age) under regular treatment. The MST is an external-paced test, and the participants were allowed to walk/run. CPET was performed on a cycle ergometer to compare with MST. Gas exchange (VO2 , VCO2 , and VE) and heart rate (HR) were the outcomes and were continuously assessed in both tests. RESULTS Forty-seven volunteers were included, normal lung function expiratory forced volume at 1st second/forced vital capacity (FEV1 /FVC) 88.6 (7.7). VO2peak was higher at MST (2.0 ± 0.6 L/min) compared to CPET (1.6 ± 0.5 L/min), p

Background Inflammation caused by chronic lung disease in childhood may lead to delayed heart rate recovery (HRR) however, there is lack of evidence on HRR in this population. The aim was to assess HRR after functional capacity testing in asthmatic children and adolescents and to compare with severity and disease control. Method This was a study secondary to a randomized control trial. The modified shuttle test (MST) was performed to assess functional capacity and HRR. This is an externally cadenced test in which the distance walked is the outcome. HRR was assessed after MST and was defined as HR at exercise peak minus HR in the second minute after the end of exercise. Asthma control was assessed by the Asthma Control Test (ACT). Data normality was tested by Shapiro Wilk and the comparison between groups was made by Student’s t test or Mann Whitney test for numerical variables, and by Chi-square test for categorical variables. Statistical significance was considered when p Results The sample included 77 patients diagnosed with asthma (asthma group - AG) who were regularly treated for asthma. Control group (CG) consisted of 44 volunteers considered healthy, matched in age and gender to AG. The median age of CG was 12 (10–14) years and in AG 11 (9–13 years) being classified as mild to moderate asthmatic, and 57% of the sample had controlled asthma by ACT. Distance walked in the CG was 952 ± 286 m and AG 799 ± 313 m, p = 0.001. HRR was more efficient in CG (79 ± 15 bpm) compared to AG (69 ± 12 bpm), p = 0.001. The mild (69 ± 12 beats) and severe (72 ± 15 beats) AG presented worse HRR compared to control group (79 ± 15 bpm), p Conclusions Asthmatic children and adolescents have delayed HRR after modified Shuttle test compared to their peers, suggesting that asthma leads to autonomic nervous system imbalance. Trial registration: Registered in Clinical Trials under number NCT02383069 and approved by the Universidade Nove de Julho - UNINOVE Research Ethics Committee, protocol number 738192/2014.

Six-min walking test (6MWT) has been widely in patients with symptomatic peripheral artery disease (PAD) to quantify the walking impairment and the efficacy of different therapeutic interventions. Despite the aforementioned usefulness of 6MWT for PAD, the information provided by this test goes beyond the meters walked. The aim of this study was to describe the relative values of 6MWT and body weight-walking distance product (DW) in patients with symptomatic PAD.Two hundred twenty-seven patients with symptomatic PAD participated in the study. The 6MWT was performed and absolute and claudication distances were obtained. The results of 6MWT were then relativized and expressed as a percentage of a healthy subject. DW was obtained by the product of 6MWT distance by weight. In both sexes, the relative 6MWT ranged from 57% to 64%.Absolute 6MWT total distance (P 0.001) was lower in women than in men, whereas the relative 6MWT total distance was similar between sexes (P = 0.398). The absolute and relative 6MWT total distance were similar among age categories (P 0.072). The DW was higher in men than in women (P 0.05). In addition, in women, DW was higher in younger group than in other age groups (P 0.05).Patients with symptomatic PAD achieve less than 70% of the distance achieved by an age-matched healthy subject. In patients with symptomatic PAD, the relative values of 6MWT total distance are similar between sexes and among different age groups, whereas DW are influenced by age and sex.

Background Pulmonary disease is a frequent acute and chronic manifestation in sickle cell disease (SCD), presenting high morbidity and mortality. Objectives To identify the prevalence and association of asthma, allergic sensitization and altered pulmonary function in patients with SCD (SS and Sβo). Methods A single-center, cross-sectional study was conducted, in which 70 patients with SCD and 44 controls, aged six to 18 years, responded to the questionnaire of the International Study of Asthma and Allergies in Childhood (ISAAC), complemented with an anamnesis regarding the associated clinical outcomes. All patients underwent immediate hypersensitivity skin tests with aeroallergens and a pulmonary function evaluation (spirometry). Regarding the statistical analysis, parametric and non-parametric methods were used, depending on the variables studied. Tests were considered significant when p Results There was no significant difference between the patients and controls regarding the prevalence of asthma and allergic sensitization (p > 0.05). The number of occurrences of acute chest syndrome per patient per year was significantly higher for asthmatic patients than for non-asthmatic patients (p = 0.04). Obstructive pulmonary function occurred in 30.9% of the patients and in 5.4% of the controls, and restrictive pulmonary function occurred in 5.5% of the patients and 5.4% of the controls. Asthma and wheezing in the last 12 months had significant associations with obstructive pulmonary function (p = 0.014 and p = 0.027, respectively). Conclusions The occurrence of asthma, allergic sensitization and alteration in lung function in patients with SCD reinforces the importance of routine monitoring of these diagnoses, which allows for early treatment and prevention of the evolution of pulmonary disease in adulthood.

Aim. To evaluate cardiovascular, autonomic, and oxidative stress markers in eutrophic and overweight offspring of hypertensive parents comparing them to eutrophic and overweight offspring of normotensive parents. Methods. We conducted a cross-sectional study. We selected 71 male and sedentary subjects, divided into 4 groups: eutrophic group with a negative family history of hypertension (EH-, n=18) or positive family history of hypertension (EH+, n=17), overweight group with a negative family history of hypertension (OH-, n=19) or a positive family history of hypertension (OH+, n=17), and aged between 18 and 35 years. Results. Blood glucose was higher in the OH+ group when compared to other groups. Diastolic blood pressure was increased in OH- and OH+ groups when compared to eutrophic groups. Regarding the HRV, the LF abs was higher in OH- and OH+ groups when compared to the EH- group. LF/HF values were higher in EH+ and OH+ groups when compared to the EH- and OH- groups. As to oxidative stress and the metabolism of nitric oxide, we observed an increase in hydrogen peroxide and nitrite levels in the OH+ group, and in the NADPH oxidase in OH- and OH+ groups when compared to the other groups. Conclusion. Our findings demonstrate that the overweight group with a family history of hypertension presented all the dysfunctions observed in isolation from these risk factors. We observed an exacerbation of cardiac sympathetic modulation and early prooxidants increase, which may be associated with target organ damage and cardiovascular risk in this population.

Objective: The modified shuttle test is a field test that avoids the ceiling effect, and there are no reports of a multidimensional assessment concerning physical activity in asthmatic patients. Thus, the aim was to evaluate functional capacity by MST, additionally to perform a multidimensional assessment as physical activity in daily life, muscle strength, and cytokine levels in children and adolescents with asthma, and to correlate these variables. Method: This cross-sectional study included volunteers aged between 6 and 18 years who were divided into two groups: asthma group (n = 43) that received regular treatment and control group (n = 24). Functional capacity was evaluated by distance walked during the MST; physical activity in daily life was evaluated using an accelerometer by the number of steps. Quadriceps femoris strength was evaluated by load cell. Results: Distance walked was lower for the asthma group (790 m [222 m]) when compared with the control group (950 m [240 m]; p = 0.007); however, the number of steps was similar between the two groups (asthma group: 7743 [3075]; control group: 7181 [3040]; p = 0.41), and both groups were classified as sedentary behavior. There was no difference in muscle strength. Tumor necrosis factor-α differed, but interleukin levels were similar between groups. Quadriceps strength was correlated to distance walked (r = 0.62; p

Objectives: To develop reference equations of maximal voluntary ventilation (MVV) in children and adolescents, and to test the validity and reproducibility of MVV. Study Design: Cross-sectional study. Patient-Subject selection: A total of 348 healthy volunteers (6-17 years)—248 for the development of reference equations and 100 to test the validity— were selected. Methodology: Spirometry and MVV were performed. Volunteers were instructed to breathe quickly and strongly to estimate the MVV. Independent variables tested were age, sex, weight, height, and pulmonary function. Results: All volunteers (50% boys) had a normal pulmonary function. Mean MVV was 66.3 (17.8) L/minute for children and 118.8 (20.0) L/minute for adolescents. The equation developed for children was MVV = 4.865 + (forced expiratory volume in the first second [FEV1] × 16.257) + (peak expiratory flow [PEF] × 7.621); for adolescents was MVV = −25.450 + (FEV1 × 11.591) + (PEF × 6.672) + (sex × 12.179) + (age × 3.613). No significant differences were observed between measured and predicted MVV in children (64.6 [10.3] vs 64.6 [8.5] L/minute; P = .34) or adolescents (111.8 [23.4] vs 113.1 [22.8] L/minute, P = .12). The intraclass correlation coefficient between measured and predicted MVV was 0.95 (0.91-0.97) for children and 0.90 (0.82-0.94) for adolescents. The mean bias of Bland-Altman analysis was −0.8 L/minute for children and −2.7 L/minute for adolescents. Conclusions: Normative values for MVV were established for children and adolescents, additionally, these equations are reproducible and it can be used to determine the respiratory impairments in the pediatric population.

INTRODUCTION Mucopolysaccharidoses (MPSs) are a group of rare diseases caused by an intralysosomal accumulation of glycosaminoglycans, resulting in a multisystemic clinical condition characterized by variable degrees of physical-functional impairment. OBJECTIVE To evaluate the functional capacity (FC) of MPS patients and compare with a healthy control group. METHODS This is a cross-sectional study of 6- to 39-year-old patients followed at a medical reference center and compared with their control peers, matched by age and sex. FC was assessed using the Sit-to-Stand Test (SST) and Incremental Shuttle Walk Test (ISWT). Heart rate (HR) and Borg rating of perceived exertion were measured before and after ISWT. HR recovery (HRR) was defined as the HR at the end of the test minus the HR in the second minute after ISWT. RESULTS Nineteen (19) MPS patients, 69% with type II MPS and mean age 17 ± 11 years were evaluated. Every patient was under enzyme replacement therapy. The time to perform the SST was longer in the MPS group (10.6 ± 2.5 s vs. 6.7 ± 1.2 s; p

BACKGROUND: Single-step tests have been proposed as simple and inexpensive challenges todiagnose exercise-induced bronchoconstriction (EIB) in the pediatric population. Work performed and the resulting ventilation, however, might be substantially lower in stepping than running. This might decrease the diagnostic yield of step-based challenges. METHODS: In a cross-sectional study, 53 children with asthma with exercise-related symptoms (34 boys, age 6–18 y) underwent an incremental stepping test, a 6-min constant stepping test, and a treadmill running test on different days. RESULTS: Constant and incremental stepping tests presented with lower metabolic demands (V˙ O2 1.42 0.48 and 1.34 0.55 L/min, respectively), ventilatory demands (V˙ O2 45 14 and 43 16 L/min, respectively), and cardiovascular demands (160 20 and 161 19 beats/min, respectively) than the treadmill running test (1.65 0.60 L/min, 54 17 L/min, and 172 7 beats/min, respectively) (P < .05). Between-test agreement in diagnosing EIB was poor (kappa 0.217–0.361). Although EIB prevalence was higher after the treadmill running test (60%) compared to constant (53%) and incremental (47%) stepping tests, 7 subjects developed EIB only in stepping. Clinical and resting functional characteristics did not differ in iscordant subjects (ie, EIB negative in a given test but positive in another) versus concordant subjects (ie, EIB negative or positive in both tests). EIB was not related to individual test ability in eliciting high to very-high ventilation (> 40% or > 60% maximum voluntary ventilation, respectively). Moreover, a negative stepping test but a positive treadmill test (and vice versa) was not associated with greater ventilatory demands. CONCLUSIONS: Lower prevalence of EIB in stepping compared to treadmill running is not related to less ventilation demand in the former modality. Although stepping might be useful as a screening EIB test due its portability and low cost, a negative test should be confirmed with a running-based test in symptomatic children.

Previous studies have reported that visceral disturbances can lead to increased musculoskeletal tension and pain in structures innervated from the corresponding spinal level through viscerosomatic reflexes. We designed a pilot randomised placebo-controlled study using placebo visceral manipulation as the control to evaluate the effect of osteopathic visceral manipulation (OVM) of the stomach and liver on pain, cervical mobility, and electromyographic activity of the upper trapezius (UT) muscle in individuals with nonspecific neck pain (NS-NP) and functional dyspepsia. Twenty-eight NS-NP patients were randomly assigned into two groups: treated with OVM (OVMG; n = 14) and treated with placebo visceral manipulation (PVMG; n = 14). The effects were evaluated immediately and 7 days after treatment through pain, cervical range, and electromyographic activity of the UT muscle. Significant effects were confirmed immediately after treatment (OVMG and PVMG) for numeric rating scale scores (p < 0.001) and pain area (p < 0.001). Significant increases in EMG amplitude were identified immediately and 7 days after treatment for the OVMG (p < 0.001). No differences were identified between the OVMG and the PVMG for cervical range of motion (p > 0.05). This study demonstrated that a single visceral mobilisation session for the stomach and liver reduces cervical pain and increases the amplitude of the EMG signal of the UT muscle immediately and 7 days after treatment in patients with nonspecific neck pain and functional dyspepsia.

This study compared maximum oxygen consumption (VO2max) on a 20-meter multistage shuttle run test (20-Srt) with a cardiopulmonary exercise test (CPET) to determine a VO2max prediction equation for a 20-Srt in children aged 6–10 years. Eighty healthy children performed the CPET on a treadmill, while the 20-Srt took place on a sports court. Heart rate (HR) was measured and the expired gases were continuously measured breath-by-breath using a portable gas analyzer. The VO2max was lower (p

To investigate the cardiorespiratory responses to the 6-min pegboard and ring test (6PBRT) and to assess its reproducibility in healthy adolescents.It was a cross-sectional study with 52 healthy adolescents (11-18 years old of both genders). The 6PBRT was performed twice on two different days by the same examiner. Intra-rater reliability, percentage of the minimal difference chance (MDC%) and agreement of the number of moving rings were analyzed. Also, cardiopulmonary parameters were collected before and after tests.Intraclass correlation coefficient (ICC) for the number of rings moved was 0.87 (95%CI 0.69-0.93). The mean number of moved rings during the second test was higher. The MDC% with a 95 % confidence interval was greater than acceptable values. Bland-Altman analysis did not show agreement between measurements (bias = 30.1); with upper and lower limits of agreement of -67.8 to 127.9, respectively. There was a significant increase in dyspnea, fatigue and HR values at the end of the tests (p 0.0001). In both tests, participants reached HR equivalent to 48 % of the maximum predicted.Together, the results suggest that the 6PBRT is not a reliable measure for a population of healthy adolescents, which indicates the necessity to perform more than one test. The 6PBRT is suggested to be a submaximal test for this population.

BackgroundPatients with severe refractory asthma (SRA), even when using high doses of multiple controller medications in a regular and appropriate way, can have persistent complaints of exercise limitation.MethodsThis was a cross-sectional study involving patients with SRA (treated with ≥ 800 μg of budesonide or equivalent, with ≥ 80% adherence, appropriate inhaler technique, and comorbidities treated), who presented no signs of a lack of asthma control other than exercise limitation. We also evaluated healthy controls, matched to the patients for sex, age, and body mass index. All participants underwent cardiopulmonary exercise testing (CPET) on a cycle ergometer, maximum exertion being defined as ≥ 85% of the predicted heart rate, with a respiratory exchange ratio ≥ 1.0 for children and ≥ 1.1 for adolescents. Physical deconditioning was defined as oxygen uptake (VO2) < 80% of predicted at peak exercise, without cardiac impairment or ventilatory limitation. Exercise-induced bronchoconstriction (EIB) was defined as a forced expiratory volume in one second ≥ 10% lower than the baseline value at 5, 10, 20, and 30 minutes after CPET.ResultsWe evaluated 20 patients with SRA and 19 controls. In the sample as a whole, the mean age was 12.9 ± 0.4 years. The CPET was considered maximal in all participants. In terms of the peak VO2 (VO2peak), there was no significant difference between the patients and controls, (P = 0.10). Among the patients, we observed isolated EIB in 30%, isolated physical deconditioning in 25%, physical deconditioning accompanied by EIB in 25%, and exercise-induced symptoms not supported by the CPET data in 15%.Conclusion and Clinical RelevancePhysical deconditioning, alone or accompanied by EIB, was the determining factor in reducing exercise tolerance in patients with SRA and was not therefore found to be associated with a lack of asthma control.

Background COVID-19 has quickly become a worldwide threat to health, travel, and commerce. Studies adressing the clinical-functional presentation of viral infection and physiotherapy management in children are scarce. The purpose statement was to provide current perspectives on the physiotherapy interventions for managing children based on COVID-19 evidences. Methods In this review, databases were searched between 1th January and 26 th March 2020. The following descriptors were considered: (novel coronavirus); (novel corona virus); Coronavirus; (corona virus); 2019-nCoV; nCovor; COVID-19; SARSCoV-2; in the electronic databases National Library of Medicine (PubMed/Medline), Scientific Electronic Library Online (SciELO) and Physiotherapy Evidence Database (PEDro). The results were described through the International Classification of Functioning, Disability and Health. Results 16 papers were included in this review. COVID-19 seems to lead to restriction of participation and interfere in tasks, such as recreation and leisure activities, respiratory muscle function and exercise tolerance. Personal protective equipments and contact precautions are important part of treatment. Effective oxygen therapy should be given immediately in presence of hypoxia. Nasal high-flow oxygen therapy, non-invasive ventilation, lung-protective ventilation strategies and prone position, should be undertaken when necessary under appropriate conditions. Airway clearance techniques should be administered only strictly needed and early activities must be encouraged. Conclusions Potential physiotherapy interventions for children with COVID-19/SARS-CoV-2 consist on ventilatory management, airway clearance techniques and early activities and mobilization.

Familial history of hypertension is associated with autonomic dysfunction and increase in blood pressure (BP). However, an active lifestyle has been found to improve a number of health outcomes and reduce all-cause mortality. The aim of the present study was to investigate the effects of an active lifestyle on hemodynamics, heart rate variability (HRV) and oxidative stress markers in offspring of hypertensive parents. One hundred twenty-seven subjects were assigned into four groups: sedentary offspring of normotensives (S-ON) or hypertensives (S-OH); and physically active offspring of normotensives (A-ON) or hypertensives (A-OH). Diastolic BP and heart rate were reduced in the physically active groups when compared to S-OH group. A-ON and A-OH groups presented increased values of RR total variance when compared to the sedentary ones (A-ON: 4,912 ± 538 vs. S-ON: 2,354 ± 159; A-OH: 3,112 ± 236 vs. S-OH: 2,232 ± 241 ms2). Cardiac sympato-vagal balance (LF/HF), systemic hydrogen peroxide and superoxide anion were markedly increased in S-OH group when compared to all other studied groups. Additionally, important correlations were observed between LF/HF with diastolic BP (r = 0.30) and hydrogen peroxide (r = 0.41). Thus, our findings seem to confirm an early autonomic dysfunction in offspring of hypertensive parents, which was associated with a systemic increase in reactive oxygen species and blood pressure. However, our most important finding lies in the attenuation of such disorders in offspring of physically active hypertensives, thus emphasizing the importance of a physically active lifestyle in the prevention of early disorders that may be associated with onset of hypertension.

PURPOSE To compare the performances of patients with chronic obstructive pulmonary disease (COPD) and healthy individuals on the Continuous Scale Physical Functional Performance 10 (PFP10) test and, second, to test the reproducibility of the PFP10 test in these participants. METHODS In a prospective, cross-sectional study, 28 patients with COPD (67 ± 9 y, FEV1: 44.3 ± 16.9% pred) and 12 healthy volunteers (healthy group) matched by age, body mass index, and sex were included. The participants performed 2 PFP10 tests 5 d apart. Main outcome measure was performance on the PFP10 test and included total score, score for specific domains, and total time to perform the PFP10 test. RESULTS The functional performance of patients with COPD was worse than that of the healthy group on PFP10 total scores (43.9 ± 12.6 vs 63.5 ± 9.4, respectively; P < .001; effect size: 1.78) and time to complete the tasks (207.9 ± 36.1 sec vs 153.2 ± 12.1 sec, respectively; P < .001, effect size: 2.27). In addition, the COPD group had significantly worse performance in the domains of upper-body strength, lower-body strength, balance and coordination, and endurance. The test was highly reproducible (ICC: 0.98; 95% CI, 0.96-0.99 for both groups), and the mean difference (upper and lower limits of agreement) of the total scores was -3 (-9 to 3). CONCLUSIONS The PFP10 test is a suitable and reproducible test for determining decreases in the functional performance of patients with COPD compared with healthy individuals.

Objetivo: Realizar levantamento da literatura cientí­fi ca sobre provas de função pulmonar (PFP) em lactentes, suas aplicações e perspectivas. Métodos: Foi realizada busca de artigos cientí­fi cos (lí­ngua inglesa, portuguesa e espanhola) nas bases de dados: PubMed, Embase, Scielo e Lilacs. Palavras de busca utilizadas: lactente, prova de função pulmonar, volume corrente, fl uxos expiratórios forçados, pletismografi a e mecânica respiratória; de forma combinada ou isolada, entre os anos de 1940 a 2008 incluindo artigos de revisão, ensaios clí­nicos, consensos e livros. Resultados: Nos últimos anos houve grande avanço no aperfeiçoamento e padronização das PFP em lactentes. As técnicas mais empregadas são: análise dos parâmetros do volume corrente; mecânica passiva do sistema respiratório; análise dos volumes pulmonares por pletismografi a ou por métodos de difusão; compressão toracoabdominal para obtenção de fl uxos expiratórios forçados seja em volume corrente ou em volume pulmonar aumentado. Na maioria dos casos sedação é necessária para a realização desses testes e os derivados do Cloral são os sedativos mais empregados. As principais contraindicações das PFP em lactentes são decorrentes da sedação: obstrução de via aérea, cardiopatias arrí­tmicas e neuropatias. Complicações decorrentes desses exames são extremamente raras, mas equipe experiente e suporte para reanimação cardiorrespiratória são recomendados. Apesar de utilizadas principalmente em pesquisas, as PFP em lactentes já apresentam indicações clí­nicas defi nidas. Conclusão: PFP pode ser considerada como ferramenta útil e viável no manejo e pesquisa de pneumopatias de lactentes. O conhecimento desses exames pode auxiliar diversos profi ssionais envolvidos nos cuidados desses pacientes aprimorando a terapêutica e trazendo novas perspectivas na avaliação de terapias respiratórias.Palavras-chave: prova de função pulmonar, lactente, pletismografi a, fl uxos expiratórios forçado.

Objective: To describe the efficacy and safety of chloral hydrate sedation in infants for pulmonary function tests. Methods: All sedation attempts for pulmonary function tests in infants carried out between June 2007 and August 2014 were evaluated. Obstructive sleep apnea and heart disease were contraindications to the exams. Anthropometric data, exam indication, used dose, outcomes of sedation and clinical events were recorded and described. Results: The sedation attempts in 277 infants (165 boys) with a median age of 51.5 weeks of life (14-182 weeks) were evaluated. The main indication for the tests was recurrent wheezing (56%) and the chloral hydrate dose ranged from 50 to 80mg/kg (orally). Eighteen (6.5%) infants had some type of clinical complication, with the most frequent being cough and/or airway secretion (1.8%); respiratory distress (1.4%) and vomiting (1.1%). A preterm infant had bradycardia for approximately 15 minutes, which was responsive to tactile stimulation. All observed adverse effects were transient and there was no need for resuscitation or use of injectable medications. Conclusions: The data demonstrated that chloral hydrate at the employed doses is a safe and effective medicament for sedation during short procedures in infants, such as pulmonary function tests. Because of the possibility of severe adverse events, recommendations on doses and contraindications should be strictly followed and infants should be monitored by trained staff. Resumo Objetivo: Descrever a eficácia e a segurança do hidrato de cloral na sedação de lactentes para testes de função pulmonar. Métodos: Foram avaliadas retrospectivamente todas as tentativas de sedação para exames de função pulmonar em lactentes feitas entre junho 2007 e agosto 2014. Apneia obstrutiva do sono e cardiopatia foram contraindicações para os exames. Dados antropométricos, indicação do exame, dose empregada, desfechos da sedação e intercorrências clínicas foram registrados e descritos. Resultados: Avaliaram-se as tentativas de sedação de 277 lactentes (165 meninos) com mediana de 51,5 semanas de vida (14-182). A principal indicação para os testes foi sibilância recorrente (56%) e a dose de hidrato de cloral usada variou entre 50-80mg/kg (via oral). Dezoito (6,5%) lactentes apresentaram algum tipo de intercorrência clínica e foram as mais frequentes: tosse e/ou secreção na via aérea (1,8%); desconforto respiratório alto (1,4%) e vômitos (1,1%). Um lactente prematuro apresentou bradicardia por cerca de 15 minutos, responsiva a estimulação tátil. Todos os efeitos adversos observados foram transitórios e não houve necessidade de manobras de reanimação e uso de medicações injetáveis. Conclusões: Os dados demonstraram que o hidrato de cloral, nas doses empregadas, é um medicamento seguro e eficaz para a sedação de lactentes em procedimentos de curta duração, como os testes de função pulmonar. Devido à possibilidade de eventos adversos graves, as recomendações referentes à dosagem e contraindicações devem ser seguidas de forma rígida e os lactentes devem ser monitorados por equipe treinada.

Introduction: For adolescents, activities of daily living (ADL) is evaluated by tests developed for adults in which the activities are not suitable for them. Objective: to describe a feasibility study for ADL tasks in adolescents. Method:6 healthy volunteers (12-17 years old) were evaluated. Ten ADLs were performed in randomized order (four minutes each): raising ramp, shelving, jump star, climbing steps, running, jump rope, kick ball (feet), throwing a ball (hands), cycling, and playing basketball. The VO2peak, minute ventilation(VE), and heart rate(HR) assessed at the peak of each task were the outcomes. The cardiopulmonary exercise test (CPET) was also performed. Results: the most difficult activity reported was jump star, the easiest was raising ramp. Activities with higher outcomes were jump star VE:45(41–56L/min), VO2:1.6(1.4–1.9L/min), HR:161(147–187bpm) and jump rope VE:41(33–51L/min), VO2:1.7(1.2–1.9L/min), HR:163(141–185bpm). Activities with lower outcomeswere the rise ramp VE:14(12–15L/min),VO2:0.6(0.5–0.8L/min), HR:123(112–141bpm) and throwing ball VE:17(14–20L/min),VO2:0.7(0.6–0.8L/min), HR:105(102–120bpm). Interestingly, the VE of shelving (29(23-45L/min)) seems to be higher than running(23(18–42L/min)), but not statically(p=0.4), with a similar VO2(1.2(1.0–1.5L/min) vs.1.2(0.8–1.7L/min), respectively. The range of VO2 for all ADLs was from 40 to 113% of the CPET. Conclusion: the tasks are feasible, easily to understand, and the ADLs provide consistent physiological responses.

Obstructive sleep apnea (OSA) results in mechanical stress induced by pharyngeal collapse during sleep, with increase of inflammatory mediators, can be evaluated through Infrared Thermography (IT) (Jarnalo, 2018). Therapies such as isokinetic inspiratory muscle training (Herkenrath, 2018) have been applied as an effective method to minimize respiratory deficit resulting from chronic diseases, impacting on the improvement of the quality of life. The aime of study was to evaluate the influence of isokinetic inspiratory muscle training on airway thermal imaging in subjects with OSA. The study was composed of 20 participants with OSA (polysomnography-diagnosed), approved by the research ethics committee, of a sample for convenience, divided into two groups: Group Training (TG) (n = 10) and control group (CG) (n = 10). Both patients was acclimation in a room with temperature of 23 degrees, and the images were performed (FlirONE Pro camera) in a standard way, with a distance of one meter to the participant, who remained seated in a chair with a cervical hyperextension. The TG was submitted to isokinetic inspiratory muscle training (IMT) with load adjusted automatically (30% of the Sindex), for 30 repetitions with POWERbreathe K5. The thermal images recording in two moments (M1= initial) and (M2=10 minutes after M1) and the CG they were at rest and thermal image recording in M1 and M2. Acute responses in the temperature reduction after the stimulation of IMT in the TG were demonstrated (p=0,087) and satble on CG. The isokinetic inspiratory muscle training could impact on the reduction of antero-cervical region temperature in individuals with OSA.

INTRODUCTION In view of the difficulties and risks of performing lung function tests in infants and the hypothesis that children with abnormal pulmonary test may exhibit thoracic musculoskeletal alterations. OBJECTIVES This study aimed to determine the frequency of abnormal lung function and their relationship. MATERIALS AND METHODS This was a cross-sectional study with children from 6 to 12 months of corrected age, born at a gestational age of

FAPESP - Fundação de Amparo à Pesquisa do Estado de São Paulo The COPD assessment test (CAT) is a short questionnaire developed to help patients and clinicians to assess the impact of symptoms in routine clinical practice. We aimed to validate and to test the reproducibility of CAT in patients with bronchiectasis and correlate with the severity of dyspnea, aerobic and functional capacity, and physical activity in daily life. This is a cross-sectional study, patients with bronchiectasis underwent spirometry, cardiopulmonary exercise test (CPET), incremental shuttle walk test (ISWT), Saint George`s Respiratory Questionnaire (SGRQ), and received pedometer. CAT was applied twice (CAT-1 and CAT-2, 7 to 10 days apart). The severity of bronchiectasis was assessed by E-FACED and bronchiectasis severity index (BSI). A total of 100 patients were evaluated (48 ± 14 years, 59 women, FVC: 67 ± 22% pred, FEV1: 52 ± 25% pred). According to CAT, 14% patients presented low, 40% medium, 32% high, and 14% very high impact. The higher the CAT, the worse the severity of bronchiectasis, dyspnea, quality of life, performance on the CPET, and smaller the distance walked (DW) on the ISWT and number of steps (NS) per day. There was significant correlation between CAT and SGRQ, E-FACED, BSI, NS, ISWT, oxygen uptake, and workload at CPET. CAT-1 and CAT-2 presented similar values: 21 (13–26) and 19 (13–26), respectively. The CAT is a valid and reproducible instrument in patients with bronchiectasis presenting good correlation with clinical, functional, and quality of life measurements. This easy-to-use, easy-to-understand, quick, and useful tool may play an important role to assess the impact of bronchiectasis on both daily medical practice and clinical trial settings.

Aims: The purpose of this study was to assess functional capacity in leprosy patients by using the Glittre-ADL test, comparing it with the performance of healthy subjects, and correlating with the Screening of Activity Limitation and Safety Awareness (SALSA) scale and quality of life (QoL). Methods: A controlled transversal study was conducted with 27 participants, 16 patients with leprosy (Leprosy Group, LG) and 11 healthy participants (Control Group, CG). Eligible participants performed the Glittre ADL-test and answered the QoL Questionnaire (WHOQOL-BREF). Additionally, the participants in the LG answered the SALSA and the WHO's Participation Scale. Results: Time to complete the Glittre-ADL test was higher in LG compared with CG (5.06 ± 0.96 min versus 3.76 ± 0.78 min, p lessthan 0.05). The activity limitations according to the SALSA scale total scores revealed moderate limitations. A significant correlation was observed between the Glittre-ADL test and the SALSA score (r = 0.74) but no with QoL. Patients with leprosy showed a worse quality of life compared with their healthy pairs. Conclusion: The Glittre test is a valid test to assess functional performance in patients with leprosy, differentiating them from their healthy pairs. This is a suitable option to questionnaires and scales when an objective assessment of the functional performance is required in patients with leprosy.

Esse documento tem por objetivo apresentar recomendações para uso adequado e seguro de filtros de umidificação, aquecimento e/ou proteção nos ventiladores mecânicos em pacientes com COVID-19 suspeita ou confirmada. Utilizar adequadamente recursos para proteção das vias aéreas do paciente e minimizar a contaminação dos profissionais devem ser preocupações constantes em pacientes em uso de ventilação mecânica invasiva ou não invasiva. Para tanto é necessária a correta utilização de filtros de umidificação, aquecimento e/ou proteção. Os filtros trocadores de calor e umidade (HMEFs) são os preferencialmente utilizados, mas ressalta-se que na população neonatal há restrições devido a resistência e espaço morto impostos. Na indisponibilidade deste, a opção é utilizar o umidificador passivo, associado ao filtro barreira de alta eficiência (HEPA). A umidificação ativa/aquecida deve ser a de última escolha em adultos, mas é viável em neonatos, sendo necessário um HEPA no ramo expiratório.

Este documento tem por objetivo trazer informações sobre a COVID-19 na populac?a?o infantil, bem como a adequada atuação do fisioterapeuta na prevenção e tratamento desses pacientes no ambiente hospitalar. Em meio a pandemia do COVID-19 há necessidade de indicar, baseado no melhor nível de evidência, o tratamento às crianças e adolescentes com suspeita ou confirmação de COVID-19. O acometimento na população infantil é menor, e uma das hipóteses é a menor quantidade de receptores da enzima conversora de angiotensina no pulmão das crianças, comparado aos adultos. A transmissão se dá pelo contato direto com gotículas com presença do vírus SAR-CoV-2 nas mucosas do indivíduo, e o diagnóstico é baseado no quadro clínico que tem febre, dispneia, tosse, e por vezes diarreia, além de história de ter estado próximo a pessoas com diagnóstico do COVID-19. Nos pacientes com infecção leve e moderada o tratamento será domiciliar, mas nos pacientes graves, devido a hipoxemia e desconforto respiratório será necessário internação hospitalar. Quando a SpO2 for menor que 94% há necessidade de instalar oxigenoterapia, e se houver desconforto respiratório importante, a intubação orotraqueal será necessária.

Este documento tem por objetivo abordar os principais dados de suporte ventilatório, da ventilação mecânica em pacientes pediátricos com COVID-19. As manifestações clínicas da doença grave de COVID-19 em crianças ainda não foram completamente elucidadas, mas não se pode descartar que uma proporção de pacientes possa apresentar características clínicas muito parecidas com a bronquiolite, broncopneumonia, asma, pneumonite que são observadas em outras doenças respiratórias virais da infância. As informações dos casos que necessitam de cuidados intensivos e uso de ventilação mecânica são muito escassos e limitados, de maneira geral, os dados são compatíveis com uma infecção viral respiratória semelhante a outras. O consenso de especialistas Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) e Pediatric Acute Lung Injury Consensus Conference (PALICC), apontam a adesão às recomendações sobre ventilação mecânica em crianças publicadas anteriormente e às recomendações práticas nas questões específicas relacionadas à doença de COVID-19 em crianças.

Esse documento tem por objetivo apresentar recomendações para mobilização precoce e exercícios terapêuticos em pacientes pediátricos acometidos pela COVID-19, ou em suspeita da doença, no ambiente hospitalar, bem como para reabilitação pós alta. Independente da fase de tratamento, ressalta-se a extrema necessidade do uso de equipamentos de proteção individual pelo fisioterapeuta. Com o objetivo de prevenir/minimizar a fraqueza muscular adquirida na UTI, recomenda-se a utilização de protocolo de mobilização precoce baseado na mobilização funcional segura e progressiva, apropriando atividades ao nível de desenvolvimento neuropsicomotor. A reabilitação hospitalar está indicada aos pacientes na unidade de internação e a avaliação da capacidade funcional poderá ser utilizada nos pacientes mais estáveis, para conduzir a intervenção. Como a reabilitação ambulatorial presencial deve ser evitada durante a pandemia de COVID-19, recomenda-se a Telereabilitação. No entanto, ressalta-se a necessidade da primeira avaliação ser presencial para correta prescrição de treinamento e especial atenção para dispneia e dessaturação durante o telemonitoramento.

Objective: To generate reference values for spirometry in Brazilian children 3-12 years of age and to compare those values with the values employed in the equations currently in use in Brazil. Methods: This study involved healthy children, 3-12 years of age, recruited from 14 centers (primary data) and spirometry results from children with the same characteristics in six databases (secondary data). Reference equations by quantile regressions were generated after log transformation of the spirometric and anthropometric data. Skin color was classified as self-reported by the participants. To determine the suitability of the results obtained, they were compared with those predicted by the equations currently in use in Brazil. Results: We included 1,990 individuals from a total of 21 primary and secondary data sources. Of those, 1,059 (53%) were female. Equations for FEV1, FVC, the FEV1/FVC ratio, FEF between 25% and 75% of the FVC (FEF25-75%) and the FEF25-75%/FVC ratio were generated for white-, black-, and brown-skinned children. The logarithms for height and age, together with skin color, were the best predictors of FEV1 and FVC. The reference values obtained were significantly higher than those employed in the equations currently in use in Brazil, for predicted values, as well as for the lower limit of normality, particularly in children with self-reported black or brown skin. Conclusions: New spirometric equations were generated for Brazilian children 3-12 years of age, in the three skin-color categories defined. The equations currently in use in Brazil seem to underestimate the lung function of Brazilian children 3-12 years of age and should be replaced by the equations proposed in this study.

Pulmonary impairment is common in sickle cell anemia (SCA) and is one of the leading causes of morbidity and mortality.1 The origins of lung alterations in SCA are still poorly known. Studies in adults and children of school age and older frequently reveal impaired lung function in patients with SCA with different patterns of ventilatory dysfunction.2 Studies involving young children and infants are scarce. The present study aimed to evaluate the pulmonary function of infants with SCA and compare the findings with a control group.

Background: Oxygen uptake (VO2) evaluations by cardiopulmonary exercise test is expensive and time-consuming. Estimating VO2 based on a field test would be an alternative. Objective: To develop and validate an equation to predict VO2peak based on the modified shuttle test (MST). Methods: Cross sectional study, with 97 children and adolescents with asthma. Participants were divided in two groups: the equation group (EG), to construct the equation model of VO2peak, and the cross-validation group (VG). Each subject performed the MST twice using a portable gas analyzer. The peak VO2peak during MST was used in the equation model. The patients' height, weight, gender, and distance walked (DW) during MST were tested as independent variables. Results: The final model [-0.457 + (gender × 0.139) + (weight × 0.025) + (DW × 0.002)] explained 87% of VO2peak variation. The VO2peak predicted was similar to VO2peak measured by gas analyzer (1.9 ± 0.5 L/min and 2.0 ± 0.5 L/min, respectively) (p = 0.67), and presented significant ICC 0.91 (IC95% 0.77 to 0.96); p < 0.001. The Bland-Altman analysis showed low bias (-0.15 L/min) and limits of agreement (-0.65 to 0.35 L/min). There was no difference in DW between EG (760 ± 209 m) and VG (731 ± 180 m), p = 0.51. Conclusion: The developed equation adequately predicts VO2peak in pediatric patients with asthma.

Background Prolonged slow expiration (PSE) is a manual chest physical therapy technique routinely performed in clinical practice. However, the reliability and agreement of the technique have not been tested. Objective The objective of this study was to assess reliability and agreement between physical therapists during the application of PSE in infants with wheezing. Design This was a cross-sectional study. Methods Infants with a mean age of 59 weeks (SD = 26 weeks) were included in this study. Two physical therapists (physical therapist 1 and physical therapist 2) randomly performed 3 PSE sequences (A, B, and C). The expiratory reserve volume (ERV) was measured with a pneumotachograph connected to a face mask. ERV was used to evaluate the reproducibility of the technique between sequences and between physical therapist 1 and physical therapist 2. Results The mean ERV of the infants was 63 mL (SD = 21 mL). There was no statistically significant difference between the ERV values in the 3 sequences for physical therapist 1 (A: mean = 46.6 mL [SD = 17.8 mL]; B: mean = 45.7 mL [SD = 19.9 mL]; C: mean = 53.3 mL [SD = 26.3 mL]) and physical therapist 2 (A: mean = 43.5 mL [SD = 15.4 mL]; B: mean = 43.2 mL [SD = 18.3 mL]; C: mean = 44.8 mL [SD = 25.0 mL]). There was excellent reliability between the sequences for physical therapist 1 (ICC = 0.88 [95% CI = 0.63–0.95]) and physical therapist 2 (ICC = 0.82 [95% CI = 0.48–0.93]). Moderate agreement was observed between physical therapist 1 and physical therapist 2 (ICC = 0.67 [95% CI = 0.01–0.88]). According to Bland-Altman analysis, the mean difference between physical therapist 1 and physical therapist 2 was 4.1 mL (95% CI = −38.5 to 46.5 mL). Limitations The data were collected in infants with wheezing who were not in crisis. This decreased lung mucus; however, it also reduced evaluation risks. Conclusions PSE was a reproducible chest physical therapy technique between physical therapists.

Background The aim of the proposed study is to analyze the effect of a six-week osteopathic visceral manipulation (OVM) program on the flexion-relaxation phenomenon in individuals with non-specific chronic low back pain (LBP) and functional constipation. Methods/Design An assessor-blinded, two-arm, randomized, placebo-controlled trial will be conducted. The sample will comprise 76 individuals with non-specific chronic LBP who have functional intestinal constipation, aged 18–65 years. The participants will be randomly allocated to two groups: (1) OVM and (2) sham OVM (SOVM). Evaluations will involve an interview, the Oswestry Disability Index, Fear-Avoidance Beliefs Questionnaire, functional constipation according to Rome III criteria, Biering-Sorensen test to normalize electromyographic (EMG) data, T12–L1 paraspinal level of the EMG signal during the flexion-relaxation phenomenon, 11-point numeric pain rating scale and fingertip-to-floor test. OVM and SOVM will be performed once per week for six weeks. Group 1 will receive OVM for 15 min and Group 2 will receive a sham visceral technique. Evaluations will be performed before and after the first session, after six weeks of treatment, and three months after randomization (follow-up). The findings will be analyzed statistically considering a 5% significance level (p ≤ 0.05). The limitation of the study is that the therapist will not be blinded. Discussion This will be the first trial to analyze the clinical response and electromyographic signals during the flexion-relaxation phenomenon after OVM. Trial registration Brazilian Clinical Trial Registry, RBR-7sx8j3. Registered on 26 October 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2532-8) contains supplementary material, which is available to authorized users.

A low heart rate variability (HRV) has been associated with cardiovascular risk factors in adolescents. However, no cut-off points are known for HRV parameters in this age group, making it difficult to use in clinical practice. Thus, the aims of the current study were to establish cutoffs of HRV parameters and to examine their association with cardiovascular risk in Brazilian adolescents male. For this reason, this cross-sectional study included 1152 adolescent boys (16.6 ± 1.2 years old). HRV measures of time (SD of all RR intervals, root mean square of the squared differences between adjacent normal RR intervals, and the percentage of adjacent intervals over 50 ms), frequency domains [low (LF) and high (HF) frequency], and Poincare plot (SD1, SD2 and SD1/SD2 ratio) were assessed. Cardiovascular risk was assessed by sum of abdominal obesity, high blood pressure, overweight, and low physical activity level. The proposed cutoffs showed moderate to high sensitivity, specificity, and area under curve values (p

Pulmonary function in former preterm infants may be compromised during childhood.To assess pulmonary function in very-low-birth-weight preterm infants at 6-12 months of corrected age and analyze the factors associated with abnormal pulmonary function.Cross-sectional study with preterm infants at 6-12 months of corrected age with birth weight1500 g. Children with malformations or affected by neuromuscular and respiratory diseases were excluded. Forced expiratory flows were assessed using the chest compression technique, and volumes were measured by total body plethysmography. Pulmonary function parameters in preterm infants were compared to a control group of same-aged children born at term.We studied 51 preterm and 37 infants born at term. Preterm infants had: gestational age at birth (30.0 ± 2.5 weeks), birth weight (1179 ± 247 g), 27.5% had bronchopulmonary dysplasia, and 45% received mechanical ventilation. Preterm infants had lower median z-scores in comparison to term infants for the following parameters (p 0.05): FVC (-0.3 vs. 0.7), FEVPreterms had a high prevalence of abnormal pulmonary function and lower pulmonary function in comparison to term infants. Prematurity, intrauterine growth restriction, respiratory support and recurrent wheezing were associated with abnormal pulmonary function.

There has not been a detailed description of expiratory reserve volume (ERV) during slow expiration with glottis open in infralateral decubitus position (ELTGOL, for Expiration Lente Totale Glotte Ouverte en infraLatéral) and its reproducibility. The aim of this study was to determine ERV during ELTGOL and to evaluate ERV intra-observer and inter-observer reliability.In this prospective study, subjects were 30-70 y of age with chronic lung disease. ELTGOL (an active-passive or active physiotherapy technique) was applied in random order by 3 observers: 2 trained physiotherapists (PT 1 and PT 2) and the subject him/herself. Two ELTGOL compressions (A and B) were applied by PT 1, PT 2, and the subject.Thirty-two subjects were evaluated with moderate lung obstruction, FEV1: 47.7 ± 15.4, and ERV: 61.7 ± 29.4. The mean value of ERV for PT 1 was 51.4 ± 24.8%; for PT 2, it was 54.3 ± 31.8%; and for the subject, it was 53.5 ± 26.2% (P = .49). Considering the mean value of ERV, the ELTGOL mobilized more than 80% of ERV. There was good reliability intra-PT: PT 1, intraclass correlation coefficient (ICC) 0.85 (0.70-0.93), P.0001; PT 2, ICC 0.90 (0.80-0.95), P.0001, and inter-PT (ICC 0.86 [95% CI 0.71-0.93], P.001). The Bland-Altman plot with mean bias and limits of agreement for ERV of PT 1 and PT 2 was -3.3 (-42.7 to 35.9).ELTGOL mobilized more than 80% of ERV in subjects with moderate airway obstruction; there is no difference in ERV exhaled during the technique applied by a physiotherapist or by the subject. ELTGOL is a reproducible technique, determined by inter- and intra-observer testing.

Background: Maximum voluntary ventilation (MVV) estimates ventilatory capacity. Reference equation for MVV is helpful for interpretation of cardiopulmonary exercise testing, because it can identify ventilatory reserves. However, there is no established normal MVV value for Brazil’s pediatric population. Objectives: to determine reference equation for MVV and to test its reliability in Brazilian children and adolescents. Methods: cross-sectional study, 101 healthy volunteers (ages 6-17 yrs. old); 81 volunteers were evaluated to determine reference equation, and 20 were evaluated to test reproducibility. Volunteers who had abnormal lung function ( Results: the mean age was 9±3 yrs, 49% volunteers were male, the mean MVV was 74.5±29.7L/min. The equation was MMV= −13.024 + (PEF * 6.954) + (FEF25-75 * 7.516) + (age * 2.547) + (weight * 0.363); R2= 0.88, p Conclusion: it was established a predictive MVV equation for Brazilian pediatric population. The equation has excellent predictive reliability.

Background Bronchiectasis is characterized by a progressive structural lung damage, recurrent infections and chronic inflammation which compromise the exertion tolerance, and may have an impact on skeletal muscle function and physical function. Objective The purpose of this study was to compare peripheral muscle strength, exercise capacity, and physical activity in daily life between participants with bronchiectasis and controls and to investigate the determinants of the peripheral muscle strength and physical activity in daily life in bronchiectasis. Design This study used a cross-sectional design. Methods The participants’ quadriceps femoris and biceps brachii muscle strength was measured. They performed the incremental shuttle walk test (ISWT) and cardiopulmonary exercise testing, and the number of steps/day was measured by a pedometer. Results Participants had reduced quadriceps femoris muscle strength (mean difference to control group = 7 kg, 95% CI = 3.8–10.1 kg), biceps brachii muscle strength (2.1 kg, 95% CI = 0.7–3.4 kg), ISWT (227 m, 95% CI = 174–281 m), peak VO2 (6.4 ml/Kg/min, 95% CI = 4.0–8.7 ml/Kg/min), and number of steps/day (3,332 steps/day, 95% CI = 1,758–4,890 steps/day). A lower quadriceps femoris strength is independently associated to an older age, female sex, lower body mass index (BMI), higher score on the modified Medical Research Council scale, and shorter distance on the ISWT (R2 = 0.449). Biceps brachii strength is independently associated with sex, BMI, and dyspnea (R2 = 0.447). The determinants of number of daily steps were dyspnea and distance walked in ISWT, explaining only 27.7% of its variance. Limitations Number of steps per day was evaluated by a pedometer. Conclusions People with bronchiectasis have reduced peripheral muscle strength, and reduced aerobic and functional capacities, and they also are less active in daily life. Modifiable variables such as BMI, dyspnea, and distance walked on the ISWT are associated with peripheral muscle strength and physical activity in daily life.

OBJECTIVE: The aim of the study was to analyze the relationship between gait speed and measurements of physical function in patients with symptomatic peripheral artery disease (PAD).\ud \ud METHODS: One hundred sixty-nine patients (age 66.6±9.4 years) with symptomatic PAD were recruited. Usual and fast gait speeds were assessed with a 4-meter walk test. Objective (balance, sit-to-stand, handrip strength, and six-minute walk test) and subjective (WIQ - Walking Impairment Questionnaire and WELCH - Walking Estimated-Limitation Calculated by History) measurements of physical function were obtained. Crude and adjusted linear regression analyses were used to confirm significant associations.\ud \ud RESULTS: Usual and fast gait speeds were significantly correlated with all objective and subjective physical function variables examined (r