Strength capacity in young patients who are receiving maintenance therapy for acute lymphoblastic leukemia: a case-control study

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"Faculdade de Medicina da Universidade de Sao Paulo/SP, Brazil." "etiqueta" => "I" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "School of Physical Education and Sport, University of Sao Paulo, Sao Paulo – Brazil." "etiqueta" => "II" "identificador" => "aff2" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Tel.: 55 11 3091-3096" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig2" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 493 "Ancho" => 532 "Tamanyo" => 29287 ] ] "descripcion" => array:1 [ "en" => "Elbow flexor and extensor isokinetic strength measurements for the right (panels A and C) and left (panels B and D) limbs. PT, peak torque; PT/BW, peak torque normalized to body weight; Flex/Ext, balance between flexors and extensors; TW, total work; Wmax, maximum work performed during a single repetition. *, p<0.05 for between-group comparisons." ] ] ] "textoCompleto" => "INTRODUCTIONThe treatment for children and adolescents with acute lymphoblastic leukemia (ALL) can lead to multiple adverse effects, including a poor physical capacity. Accordingly, several studies have reported that survivors of ALL may experience muscle weakness, even years following their remission.<a class="elsevierStyleCrossRefs" href="#bib1">1,2</a> However, it has not yet been determined whether patients who are currently receiving treatment for ALL present with impaired strength.To date, only a single pilot study compared muscle strength in ALL with healthy controls.<a class="elsevierStyleCrossRef" href="#bib3">3</a> Using an isometric strength assessment, the authors found that the ALL patients were weaker than their healthy peers. Importantly, the children with ALL demonstrated a progressive weakening from the initiation of delayed intensification phase through the next 28 days, suggesting that muscle strength may fluctuate during ALL treatment. Understanding the time course of treatment-induced muscle strength impairments can help to determine the timing of exercise training intervention,<a class="elsevierStyleCrossRef" href="#bib3">3</a> which is known to benefit ALL patients.<a class="elsevierStyleCrossRefs" href="#bib4">4–6</a>The present case-control study aimed to characterize muscle strength in children who were receiving maintenance therapy for ALL and to compare this strength to that of age-, gender-, and BMI-matched healthy controls.METHODSSubjectsTen patients with ALL (ALL group) were recruited from the Children's Institute of the School of Medicine, University of São Paulo (São Paulo, Brazil). The inclusion criteria were the following: 1) children and adolescents (12-16 years of age) who were receiving maintenance therapy for high-risk ALL; 2) patients who had undergone more than six months of treatment; 3) patients with a preserved cardiac structure and function as assessed by an echocardiogram; and 4) patients with an absence of musculoskeletal disturbances that may preclude their participation in the strength assessment. The patients' characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>. A group of ten age-, gender-, and BMI-matched healthy children were recruited using an advertisement and served as the control group (CTRL group). None of the patients were involved in a structured physical activity program for at least six months prior to testing, whereas the healthy children were only engaged in regular physical education classes (twice a week, 50 min per class). None of the participants had previous experience with the isokinetic strength test. The present study was approved by the institution's Ethics and Committee Review Board. The subjects' parents provided written informed consent after receiving a complete verbal and written explanation of the study's objectives and the associated risks and benefits.<elsevierMultimedia ident="tbl1"></elsevierMultimedia>One, one and eight of the patients in the ALL group were entered into the GBTLI–99, GBTLI–2009 and PROP-II-97 protocols, respectively. The GBTLI-99 protocol (Brazilian Group of Childhood Leukemia Treatment) included the administration of mercaptopurine (50 mg/m2/day-1) and methotrexate (25 mg/m2/week-1). The patients also received vincristine (1.5 mg/m2) and dexamethasone (4 mg/m2) for seven days. The GBTLI–2009 protocol included the administration of methotrexate (200 mg/m2) every 21 days, leucovorin plus mercaptopurine pulses (100 mg/m2/day-1) for ten days, vincristine (1.5 mg/m2) and predinisone (40 mg/m2/day-1) every four weeks for seven days. GBTLI–99 and GBTLI–2009 also included intrathecal chemotherapy with methotrexate, citarabine and dexamethasone every eight weeks until the 106th week. The PROP-II-97 protocol (Institutional Protocol of the University of São Paulo) included the administration of the following medications for 80 weeks: methotrexate (2 g/m2/week-1) plus mercaptopurine (75 mg/m2/day-1) for three weeks; cyclophosphamide (250 mg/m2/day-1) for four consecutive days followed by etoposide (250 mg/m2/day-1) for three consecutive days; teniposide and citarabine (300 mg/m2/week-1 and 250 mg/m2/dose/week-1, respectively) for three weeks; citarabine (15 g/m2/day-1) for two consecutive days and methotrexate (40 mg/m2/week-1) with mercaptopurine for six weeks. After the 80th week, the patients were given methotrexate (40 mg/m2/week-1) with continuous daily mercaptopurine and vincristine (1.5 mg/m2) pulses every six weeks and dexamethasone (3 mg/m2/day-1) for seven days until the 120th week.Isokinetic strength assessmentTo assess the lower- and upper-limb isokinetic strengths, we measured the concentric knee and elbow flexion and the extension strength using a calibrated isokinetic dynamometer (Biodex System 3, Biodex Medical Systems, NY, USA). Before testing, the patients were familiarized with the procedures. The testing sessions were comprised of a standardized procedure that included a 2-min warm-up period on a cycle ergometer at moderate intensity. The patients were seated in the dynamometer's chair with 90° of hip flexion. The knee of the dominant leg was positioned near the apparatus' lever arm, and the anatomical axis of rotation of this joint was aligned with the dynamometer's rotation axis. The contact pad was placed approximately 3 cm superior to the medial malleolus with the foot in a plantigrade position. The range of motion was set from 90° of knee flexion to 10° of knee extension. For the elbow flexion/extension assessments, the dynamometer's power head was rotated to 30°. The limb rest-device was used to support the patient's arm with the elbow slightly beyond the end of the pad to allow for full extension. The elbow's axis of rotation was aligned to that of the dynamometer. The subject then gripped the handle bar in a neutral forearm position. The length of the attachment shaft was adjusted while moving through the range of motion so that the wrist was neither compressed nor stretched when gripped firmly to the handle bar. The range of motion for the elbow test was set at 100° from the fully extended position (with full extension = 0°).During both of the tests (i.e., concentric knee and elbow flexion/extension), the patients were asked to perform five maximal repetitions to determine the peak torque (PT), normalized peak torque (PT/BW), total work (TW) and maximum work performed in a single repetition (Wmax). These values were recorded at 30 and 60°/sec for the elbow and knee, respectively. During the tests, the verbal encouragement was consistent and standardized.The dynamometer was calibrated according to the manufacturer's calibration procedure. At the start of each test, a passive determination of the effects of gravity on the limb and lever arm was performed. Additionally, straps were used to minimize unwanted body movements. When lower-limb was tested, patients were instructed to keep their arms crossed at their chest.Statistical analysisBetween-group comparisons of all of the strength parameters were performed using an unpaired Student's t-test. The data are expressed as mean ± standard deviation. Differences with p≤0.05 were considered to be statistically significant.RESULTSThe children in the ALL group exhibited a decreased knee extension peak torque (PT) for the right (29.8%; p = 0.05) and left limbs (30.8%; p = 0.02), and a lower normalized peak torque (i.e., peak torque to body weight, PT/BW) than the CTRL group for the right (24.3%; p = 0.05) and left limbs (21.1%; p = 0.06) (<a class="elsevierStyleCrossRef" href="#fig1">Figure 1A and B</a>). Additionally, the ALL group exhibited a higher degree of unbalance between the flexors and extensors than the CTRL group (for the right limb: p = 0.05; <a class="elsevierStyleCrossRef" href="#fig1">Figure 1A</a>). The children in the ALL group also expended less total work during knee extension than their healthy peers (right limb: 25.1%, p = 0.03; left limb: 23.9%, p = 0.02). Additionally, the maximum amount of work that was performed during a single knee extension repetition was lower for the ALL group when compared to the CTRL group for the right (22.6%, p = 0.04) and left limbs (22.3%, p = 0.008) (<a class="elsevierStyleCrossRef" href="#fig1">Figure 1C and D</a>). Moreover, the time-to-peak torque during the concentric knee flexion was significantly greater for the ALL group when compared to the CTRL group in the right (868±299 vs. 594±234 ms, respectively; p = 0.03) and left limbs (696±256 vs. 542±203 ms, respectively; p = 0.05). No differences were observed with regard to the time-to-peak torque during the concentric knee extension.<elsevierMultimedia ident="fig1"></elsevierMultimedia>Our evaluation of the upper limbs revealed that the children in the ALL group exhibited a greater disparity in their left limb balance between the flexors and extensors when compared to the CTRL group (left limb: p = 0.002 <a class="elsevierStyleCrossRef" href="#fig2">Figure 2B</a>). The total work expended by the elbow extensor was also less for the ALL group when compared to the CTRL group for the right (9.5%, p = 0.04, <a class="elsevierStyleCrossRef" href="#fig2">Figure 2C</a>) and left limbs (9.4%, p = 0.002, <a class="elsevierStyleCrossRef" href="#fig2">Figure 2D</a>). The time-to-peak torque during the concentric elbow flexion was significantly greater for the ALL group when compared to the CTRL group for the right (1627±670 vs. 1164±543 ms, respectively; p = 0.02) and left limbs (1723±453 vs. 1157±563 ms, respectively; p = 0.02). No differences were observed with regard to the concentric elbow extension values.<elsevierMultimedia ident="fig2"></elsevierMultimedia>DISCUSSIONThe aim of the present study was to characterize the muscle strength in children who were receiving maintenance treatment for high-risk ALL. We observed that these patients generally presented with decreased muscle strength relative to their healthy control peers.Although several studies have reported muscle weakness in long-term survivors of ALL,<a class="elsevierStyleCrossRefs" href="#bib1">1,2</a> there is a paucity of data regarding the time course of the strength impairment in this disease. Marchese et al<a class="elsevierStyleCrossRef" href="#bib3">3</a> reported a decreased isometric strength and function in children with ALL early in their course of treatment, with the weakest muscle strength occurring on the 28th day of the delayed intensification phase. Our present data are consistent with the idea that muscle weakness is a relevant clinical manifestation in patients with ALL and further extend this notion to patients who are in the maintenance phase of ALL therapy.It has been suggested that muscle weakness in patients with ALL is the result of several combined factors, such as impaired neuropsychological functioning, gross and fine motor disturbances, alterations in growth, cardiac and endocrine function, vincristine- and corticosteroid-induced muscle wasting, and hypoactivity, with the latter-most factor playing a key role in the decline in strength.<a class="elsevierStyleCrossRef" href="#bib7">7</a> Accordingly, it seems reasonable to speculate that any reduction in daily-living activities would compromise the muscles of the lower limb, a notion that is supported by our observation of an impaired peak torque (both absolute and normalized) in the muscles of the lower but not upper limbs. In practical terms, it seems reasonable to recommend that lower-limb strengthening exercises must be incorporated in a training program for patients with ALL during the maintenance phase of their treatment.Another noteworthy finding is the reduced time-to-peak torque that we observed in the upper and lower limb flexors. The ability to produce torque rapidly has been positively associated with balance and functionality in the elderly.<a class="elsevierStyleCrossRef" href="#bib8">8</a> In children, there is evidence suggesting that knee-flexor peak torque is an important contributor to retaining balance following an induced forward sway, thereby reducing the time needed to stabilize the center of gravity.<a class="elsevierStyleCrossRef" href="#bib9">9</a> Taken together, these data allow us to speculate that the higher time-to-peak torque for the knee flexors may be implicated in the function and balance deficits that were previously observed in children with ALL.<a class="elsevierStyleCrossRefs" href="#bib3">3,10</a> Moreover, the total and maximal work that was produced during a single repetition were reduced in the upper and lower limbs, which partially explains why children with ALL are more prone to fatigue and weakness.<a class="elsevierStyleCrossRefs" href="#bib3">3,10</a>It is important to note that the strength impairment was more evident for the extensor muscles than for the flexor muscles of the lower limb. Although these findings are difficult to reconcile, one may intuitively speculate that daily-living activities primarily involve the activation of the lower-limb extensor muscle groups. However, this idea cannot be extrapolated to the upper limbs, thus warranting further investigation into the causes of the impaired upper-limb extensor strength in ALL patients.In conclusion, we report that children who are receiving maintenance treatment for ALL generally present with weaker isokinetic strength than their healthy counterparts. This finding further supports the prescription of exercise training programs that include strengthening exercises for patients with ALL, particularly during the maintenance phase of their therapy." 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PT, peak torque; PT/BW, peak torque normalized to body weight; Flex/Ext, balance between flexors and extensors; TW, total work; Wmax, maximum work performed during a single repetition. *, p≤0.05 for between-group comparisons. #, p = 0.06 for between-group comparisons." ] ] 1 => array:7 [ "identificador" => "fig2" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 493 "Ancho" => 532 "Tamanyo" => 29287 ] ] "descripcion" => array:1 [ "en" => "Elbow flexor and extensor isokinetic strength measurements for the right (panels A and C) and left (panels B and D) limbs. 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"tablatextoimagen" => array:1 [ 0 => array:1 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="top" scope="col">Patient \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col">Gender \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col">Age (years) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col">Weeks elapsed since start of treatment \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col">Risk factor \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col">Treatment Protocol \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="top" scope="col">BMI (kg/m2) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">116 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">PROP-II-97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">19.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">115 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">PROP-II-97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">GBTLI-2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">19.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">117 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">PROP-II-97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">22.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">GBTLI-99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">21.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">PROP-II-97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">21.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">PROP-II-97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">20.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">PROP-II-97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">22.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">PROP-II-97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">24.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">112 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">PROP-II-97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">26.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="top">Mean</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">13.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">78.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top">21.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="top" style="border-bottom: 2px solid black">SD</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top" style="border-bottom: 2px solid black">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top" style="border-bottom: 2px solid black">37.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top" style="border-bottom: 2px solid black">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="center" valign="top" style="border-bottom: 2px solid black">- \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="top" style="border-bottom: 2px solid black">2.65 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Physical characteristics and treatment protocols for the patients in the ALL group." ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "cebibsec10" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impaired muscle strength in female adolescents and young adults surviving leukemia in childhood" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => """ L Hovi \n \t\t\t\t\t\t\t\t """ 1 => """ P Era \n \t\t\t\t\t\t\t\t """ 2 => """ M Rautonen \n \t\t\t\t\t\t\t\t """ 3 => """ MA Siimes \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1002/1097-0142(19930701)72:1<276::aid-cncr2820720148>3.0.co;2-2" "Revista" => array:6 [ "tituloSerie" => "Cancer" "fecha" => "1993" "volumen" => "72" "paginaInicial" => "276" "paginaFinal" => "281" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8508418" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1002/1097-0142(19930701)72:1<276::aid-cncr2820720148>3.0.co;2-2" "WWW" => array:1 [ "link" => "10.1002/1097-0142(19930701)72:1<276::AID-CNCR2820720148>3.0.CO;2-2" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lanning. Decreased isokinetic trunk muscle strength and performance in long-term survivors of childhood malignancies: correlation with hormonal defects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ KK Talvensaari \n \t\t\t\t\t\t\t\t """ 1 => """ A Jämsen \n \t\t\t\t\t\t\t\t """ 2 => """ H Vanharanta \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1016/s0003-9993(95)81033-1" "Revista" => array:6 [ "tituloSerie" => "Arch Phys Med Rehabil" "fecha" => "1995" "volumen" => "76" "paginaInicial" => "983" "paginaFinal" => "988" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7487450" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1016/s0003-9993(95)81033-1" "WWW" => array:1 [ "link" => "10.1016/S0003-9993(95)81033-1" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Strength and functional mobility in children with acute lymphoblastic leukemia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => """ VG Marchese \n \t\t\t\t\t\t\t\t """ 1 => """ LA Chiarello \n \t\t\t\t\t\t\t\t """ 2 => """ BG Lange \n \t\t\t\t\t\t\t\t """ ] ] ] ] ] "host" => array:2 [ 0 => array:2 [ "doi" => "10.1002/mpo.10266" "Revista" => array:6 [ "tituloSerie" => "Med Pediatr Oncol" "fecha" => "2003" "volumen" => "40" "paginaInicial" => "230" "paginaFinal" => "232" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12555250" "web" => "Medline" ] ] ] ] 1 => array:2 [ "doi" => "10.1002/mpo.10266" "WWW" => array:1 [ "link" => "10.1002/mpo.10266" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effects of physical therapy intervention for children with acute lymphoblastic leukemia" "autores" => array:1 [ 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Mavi Diehl MurattI, Maria Beatriz PerondiI, Julia Maria D'Andréa GreveI, Hamilton RoschelI,II, Ana Lúcia de Sá PintoI, Bruno GualanoI,II,

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gualano@usp.br

Tel.: 55 11 3091-3096

I Faculdade de Medicina da Universidade de Sao Paulo/SP, Brazil.

II School of Physical Education and Sport, University of Sao Paulo, Sao Paulo – Brazil.

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">The treatment for children and adolescents with acute lymphoblastic leukemia &#40;ALL&#41; can lead to multiple adverse effects&#44; including a poor physical capacity&#46; Accordingly&#44; several studies have reported that survivors of ALL may experience muscle weakness&#44; even years following their remission&#46;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;2</a> However&#44; it has not yet been determined whether patients who are currently receiving treatment for ALL present with impaired strength&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">To date&#44; only a single pilot study compared muscle strength in ALL with healthy controls&#46;<a class="elsevierStyleCrossRef" href="#bib3">3</a> Using an isometric strength assessment&#44; the authors found that the ALL patients were weaker than their healthy peers&#46; Importantly&#44; the children with ALL demonstrated a progressive weakening from the initiation of delayed intensification phase through the next 28 days&#44; suggesting that muscle strength may fluctuate during ALL treatment&#46; Understanding the time course of treatment-induced muscle strength impairments can help to determine the timing of exercise training intervention&#44;<a class="elsevierStyleCrossRef" href="#bib3">3</a> which is known to benefit ALL patients&#46;<a class="elsevierStyleCrossRefs" href="#bib4">4&#8211;6</a></p><p id="para30" class="elsevierStylePara elsevierViewall">The present case-control study aimed to characterize muscle strength in children who were receiving maintenance therapy for ALL and to compare this strength to that of age-&#44; gender-&#44; and BMI-matched healthy controls&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">METHODS</span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">Subjects</span><p id="para40" class="elsevierStylePara elsevierViewall">Ten patients with ALL &#40;ALL group&#41; were recruited from the Children&#39;s Institute of the School of Medicine&#44; University of S&#227;o Paulo &#40;S&#227;o Paulo&#44; Brazil&#41;&#46; The inclusion criteria were the following&#58; 1&#41; children and adolescents &#40;12-16 years of age&#41; who were receiving maintenance therapy for high-risk ALL&#59; 2&#41; patients who had undergone more than six months of treatment&#59; 3&#41; patients with a preserved cardiac structure and function as assessed by an echocardiogram&#59; and 4&#41; patients with an absence of musculoskeletal disturbances that may preclude their participation in the strength assessment&#46; The patients&#39; characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#46; A group of ten age-&#44; gender-&#44; and BMI-matched healthy children were recruited using an advertisement and served as the control group &#40;CTRL group&#41;&#46; None of the patients were involved in a structured physical activity program for at least six months prior to testing&#44; whereas the healthy children were only engaged in regular physical education classes &#40;twice a week&#44; 50&#160;min per class&#41;&#46; None of the participants had previous experience with the isokinetic strength test&#46; The present study was approved by the institution&#39;s Ethics and Committee Review Board&#46; The subjects&#39; parents provided written informed consent after receiving a complete verbal and written explanation of the study&#39;s objectives and the associated risks and benefits&#46;</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="para50" class="elsevierStylePara elsevierViewall">One&#44; one and eight of the patients in the ALL group were entered into the GBTLI&#8211;99&#44; GBTLI&#8211;2009 and PROP-II-97 protocols&#44; respectively&#46; The GBTLI-99 protocol &#40;Brazilian Group of Childhood Leukemia Treatment&#41; included the administration of mercaptopurine &#40;50&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#47;day<span class="elsevierStyleSup">-1</span>&#41; and methotrexate &#40;25&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#47;week<span class="elsevierStyleSup">-1</span>&#41;&#46; The patients also received vincristine &#40;1&#46;5&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#41; and dexamethasone &#40;4&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#41; for seven days&#46; The GBTLI&#8211;2009 protocol included the administration of methotrexate &#40;200 mg&#47;m<span class="elsevierStyleSup">2</span>&#41; every 21 days&#44; leucovorin plus mercaptopurine pulses &#40;100 mg&#47;m<span class="elsevierStyleSup">2</span>&#47;day<span class="elsevierStyleSup">-1</span>&#41; for ten days&#44; vincristine &#40;1&#46;5 mg&#47;m<span class="elsevierStyleSup">2</span>&#41; and predinisone &#40;40 mg&#47;m<span class="elsevierStyleSup">2</span>&#47;day<span class="elsevierStyleSup">-1</span>&#41; every four weeks for seven days&#46; GBTLI&#8211;99 and GBTLI&#8211;2009 also included intrathecal chemotherapy with methotrexate&#44; citarabine and dexamethasone every eight weeks until the 106<span class="elsevierStyleSup">th</span> week&#46; The PROP-II-97 protocol &#40;Institutional Protocol of the University of S&#227;o Paulo&#41; included the administration of the following medications for 80 weeks&#58; methotrexate &#40;2&#160;g&#47;m<span class="elsevierStyleSup">2</span>&#47;week<span class="elsevierStyleSup">-1</span>&#41; plus mercaptopurine &#40;75&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#47;day<span class="elsevierStyleSup">-1</span>&#41; for three weeks&#59; cyclophosphamide &#40;250&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#47;day<span class="elsevierStyleSup">-1</span>&#41; for four consecutive days followed by etoposide &#40;250&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#47;day<span class="elsevierStyleSup">-1</span>&#41; for three consecutive days&#59; teniposide and citarabine &#40;300&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#47;week<span class="elsevierStyleSup">-1</span> and 250&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#47;dose&#47;week<span class="elsevierStyleSup">-1</span>&#44; respectively&#41; for three weeks&#59; citarabine &#40;15&#160;g&#47;m<span class="elsevierStyleSup">2</span>&#47;day<span class="elsevierStyleSup">-1</span>&#41; for two consecutive days and methotrexate &#40;40&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#47;week<span class="elsevierStyleSup">-1</span>&#41; with mercaptopurine for six weeks&#46; After the 80<span class="elsevierStyleSup">th</span> week&#44; the patients were given methotrexate &#40;40&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#47;week<span class="elsevierStyleSup">-1</span>&#41; with continuous daily mercaptopurine and vincristine &#40;1&#46;5&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#41; pulses every six weeks and dexamethasone &#40;3&#160;mg&#47;m<span class="elsevierStyleSup">2</span>&#47;day<span class="elsevierStyleSup">-1</span>&#41; for seven days until the 120<span class="elsevierStyleSup">th</span> week&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">Isokinetic strength assessment</span><p id="para60" class="elsevierStylePara elsevierViewall">To assess the lower- and upper-limb isokinetic strengths&#44; we measured the concentric knee and elbow flexion and the extension strength using a calibrated isokinetic dynamometer &#40;Biodex System 3&#44; Biodex Medical Systems&#44; NY&#44; USA&#41;&#46; Before testing&#44; the patients were familiarized with the procedures&#46; The testing sessions were comprised of a standardized procedure that included a 2-min warm-up period on a cycle ergometer at moderate intensity&#46; The patients were seated in the dynamometer&#39;s chair with 90&#176; of hip flexion&#46; The knee of the dominant leg was positioned near the apparatus&#39; lever arm&#44; and the anatomical axis of rotation of this joint was aligned with the dynamometer&#39;s rotation axis&#46; The contact pad was placed approximately 3&#160;cm superior to the medial malleolus with the foot in a plantigrade position&#46; The range of motion was set from 90&#176; of knee flexion to 10&#176; of knee extension&#46; For the elbow flexion&#47;extension assessments&#44; the dynamometer&#39;s power head was rotated to 30&#176;&#46; The limb rest-device was used to support the patient&#39;s arm with the elbow slightly beyond the end of the pad to allow for full extension&#46; The elbow&#39;s axis of rotation was aligned to that of the dynamometer&#46; The subject then gripped the handle bar in a neutral forearm position&#46; The length of the attachment shaft was adjusted while moving through the range of motion so that the wrist was neither compressed nor stretched when gripped firmly to the handle bar&#46; The range of motion for the elbow test was set at 100&#176; from the fully extended position &#40;with full extension &#61; 0&#176;&#41;&#46;</p><p id="para70" class="elsevierStylePara elsevierViewall">During both of the tests &#40;i&#46;e&#46;&#44; concentric knee and elbow flexion&#47;extension&#41;&#44; the patients were asked to perform five maximal repetitions to determine the peak torque &#40;PT&#41;&#44; normalized peak torque &#40;PT&#47;BW&#41;&#44; total work &#40;TW&#41; and maximum work performed in a single repetition &#40;Wmax&#41;&#46; These values were recorded at 30 and 60&#176;&#47;sec for the elbow and knee&#44; respectively&#46; During the tests&#44; the verbal encouragement was consistent and standardized&#46;</p><p id="para80" class="elsevierStylePara elsevierViewall">The dynamometer was calibrated according to the manufacturer&#39;s calibration procedure&#46; At the start of each test&#44; a passive determination of the effects of gravity on the limb and lever arm was performed&#46; Additionally&#44; straps were used to minimize unwanted body movements&#46; When lower-limb was tested&#44; patients were instructed to keep their arms crossed at their chest&#46;</p></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle50">Statistical analysis</span><p id="para90" class="elsevierStylePara elsevierViewall">Between-group comparisons of all of the strength parameters were performed using an unpaired Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#46; The data are expressed as mean &#177; standard deviation&#46; Differences with <span class="elsevierStyleItalic">p</span>&#8804;0&#46;05 were considered to be statistically significant&#46;</p></span></span><span id="cesec60" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">RESULTS</span><p id="para100" class="elsevierStylePara elsevierViewall">The children in the ALL group exhibited a decreased knee extension peak torque &#40;PT&#41; for the right &#40;29&#46;8&#37;&#59; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;05&#41; and left limbs &#40;30&#46;8&#37;&#59; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;02&#41;&#44; and a lower normalized peak torque &#40;i&#46;e&#46;&#44; peak torque to body weight&#44; PT&#47;BW&#41; than the CTRL group for the right &#40;24&#46;3&#37;&#59; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;05&#41; and left limbs &#40;21&#46;1&#37;&#59; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;06&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1A and B</a>&#41;&#46; Additionally&#44; the ALL group exhibited a higher degree of unbalance between the flexors and extensors than the CTRL group &#40;for the right limb&#58; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;05&#59; <a class="elsevierStyleCrossRef" href="#fig1">Figure 1A</a>&#41;&#46; The children in the ALL group also expended less total work during knee extension than their healthy peers &#40;right limb&#58; 25&#46;1&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;03&#59; left limb&#58; 23&#46;9&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;02&#41;&#46; Additionally&#44; the maximum amount of work that was performed during a single knee extension repetition was lower for the ALL group when compared to the CTRL group for the right &#40;22&#46;6&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;04&#41; and left limbs &#40;22&#46;3&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;008&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1C and D</a>&#41;&#46; Moreover&#44; the time-to-peak torque during the concentric knee flexion was significantly greater for the ALL group when compared to the CTRL group in the right &#40;868&#177;299 <span class="elsevierStyleItalic">vs&#46;</span> 594&#177;234&#160;ms&#44; respectively&#59; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;03&#41; and left limbs &#40;696&#177;256 <span class="elsevierStyleItalic">vs&#46;</span> 542&#177;203&#160;ms&#44; respectively&#59; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;05&#41;&#46; No differences were observed with regard to the time-to-peak torque during the concentric knee extension&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia><p id="para110" class="elsevierStylePara elsevierViewall">Our evaluation of the upper limbs revealed that the children in the ALL group exhibited a greater disparity in their left limb balance between the flexors and extensors when compared to the CTRL group &#40;left limb&#58; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;002 <a class="elsevierStyleCrossRef" href="#fig2">Figure 2B</a>&#41;&#46; The total work expended by the elbow extensor was also less for the ALL group when compared to the CTRL group for the right &#40;9&#46;5&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;04&#44; <a class="elsevierStyleCrossRef" href="#fig2">Figure 2C</a>&#41; and left limbs &#40;9&#46;4&#37;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;002&#44; <a class="elsevierStyleCrossRef" href="#fig2">Figure 2D</a>&#41;&#46; The time-to-peak torque during the concentric elbow flexion was significantly greater for the ALL group when compared to the CTRL group for the right &#40;1627&#177;670 <span class="elsevierStyleItalic">vs&#46;</span> 1164&#177;543&#160;ms&#44; respectively&#59; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;02&#41; and left limbs &#40;1723&#177;453 <span class="elsevierStyleItalic">vs&#46;</span> 1157&#177;563&#160;ms&#44; respectively&#59; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;02&#41;&#46; No differences were observed with regard to the concentric elbow extension values&#46;</p><elsevierMultimedia ident="fig2"></elsevierMultimedia></span><span id="cesec70" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">DISCUSSION</span><p id="para120" class="elsevierStylePara elsevierViewall">The aim of the present study was to characterize the muscle strength in children who were receiving maintenance treatment for high-risk ALL&#46; We observed that these patients generally presented with decreased muscle strength relative to their healthy control peers&#46;</p><p id="para130" class="elsevierStylePara elsevierViewall">Although several studies have reported muscle weakness in long-term survivors of ALL&#44;<a class="elsevierStyleCrossRefs" href="#bib1">1&#44;2</a> there is a paucity of data regarding the time course of the strength impairment in this disease&#46; Marchese et al<a class="elsevierStyleCrossRef" href="#bib3">3</a> reported a decreased isometric strength and function in children with ALL early in their course of treatment&#44; with the weakest muscle strength occurring on the 28<span class="elsevierStyleSup">th</span> day of the delayed intensification phase&#46; Our present data are consistent with the idea that muscle weakness is a relevant clinical manifestation in patients with ALL and further extend this notion to patients who are in the maintenance phase of ALL therapy&#46;</p><p id="para140" class="elsevierStylePara elsevierViewall">It has been suggested that muscle weakness in patients with ALL is the result of several combined factors&#44; such as impaired neuropsychological functioning&#44; gross and fine motor disturbances&#44; alterations in growth&#44; cardiac and endocrine function&#44; vincristine- and corticosteroid-induced muscle wasting&#44; and hypoactivity&#44; with the latter-most factor playing a key role in the decline in strength&#46;<a class="elsevierStyleCrossRef" href="#bib7">7</a> Accordingly&#44; it seems reasonable to speculate that any reduction in daily-living activities would compromise the muscles of the lower limb&#44; a notion that is supported by our observation of an impaired peak torque &#40;both absolute and normalized&#41; in the muscles of the lower but not upper limbs&#46; In practical terms&#44; it seems reasonable to recommend that lower-limb strengthening exercises must be incorporated in a training program for patients with ALL during the maintenance phase of their treatment&#46;</p><p id="para150" class="elsevierStylePara elsevierViewall">Another noteworthy finding is the reduced time-to-peak torque that we observed in the upper and lower limb flexors&#46; The ability to produce torque rapidly has been positively associated with balance and functionality in the elderly&#46;<a class="elsevierStyleCrossRef" href="#bib8">8</a> In children&#44; there is evidence suggesting that knee-flexor peak torque is an important contributor to retaining balance following an induced forward sway&#44; thereby reducing the time needed to stabilize the center of gravity&#46;<a class="elsevierStyleCrossRef" href="#bib9">9</a> Taken together&#44; these data allow us to speculate that the higher time-to-peak torque for the knee flexors may be implicated in the function and balance deficits that were previously observed in children with ALL&#46;<a class="elsevierStyleCrossRefs" href="#bib3">3&#44;10</a> Moreover&#44; the total and maximal work that was produced during a single repetition were reduced in the upper and lower limbs&#44; which partially explains why children with ALL are more prone to fatigue and weakness&#46;<a class="elsevierStyleCrossRefs" href="#bib3">3&#44;10</a></p><p id="para160" class="elsevierStylePara elsevierViewall">It is important to note that the strength impairment was more evident for the extensor muscles than for the flexor muscles of the lower limb&#46; Although these findings are difficult to reconcile&#44; one may intuitively speculate that daily-living activities primarily involve the activation of the lower-limb extensor muscle groups&#46; However&#44; this idea cannot be extrapolated to the upper limbs&#44; thus warranting further investigation into the causes of the impaired upper-limb extensor strength in ALL patients&#46;</p><p id="para170" class="elsevierStylePara elsevierViewall">In conclusion&#44; we report that children who are receiving maintenance treatment for ALL generally present with weaker isokinetic strength than their healthy counterparts&#46; This finding further supports the prescription of exercise training programs that include strengthening exercises for patients with ALL&#44; particularly during the maintenance phase of their therapy&#46;</p></span></span>"
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Knee flexor and extensor isokinetic strength measurements for the right &#40;panels A and C&#41; and left &#40;panels B and D&#41; limbs&#46; PT&#44; peak torque&#59; PT&#47;BW&#44; peak torque normalized to body weight&#59; Flex&#47;Ext&#44; balance between flexors and extensors&#59; TW&#44; total work&#59; Wmax&#44; maximum work performed during a single repetition&#46; &#42;&#44; <span class="elsevierStyleItalic">p</span>&#8804;0&#46;05 for between-group comparisons&#46; &#35;&#44; <span class="elsevierStyleItalic">p</span> &#61; 0&#46;06 for between-group comparisons&#46;</p>"
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          "en" => "<p id="spara20" class="elsevierStyleSimplePara elsevierViewall">Elbow flexor and extensor isokinetic strength measurements for the right &#40;panels A and C&#41; and left &#40;panels B and D&#41; limbs&#46; PT&#44; peak torque&#59; PT&#47;BW&#44; peak torque normalized to body weight&#59; Flex&#47;Ext&#44; balance between flexors and extensors&#59; TW&#44; total work&#59; Wmax&#44; maximum work performed during a single repetition&#46; &#42;&#44; <span class="elsevierStyleItalic">p</span>&#60;0&#46;05 for between-group comparisons&#46;</p>"
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          "leyenda" => "<p id="spara40" class="elsevierStyleSimplePara elsevierViewall">All patients were at high risk&#46;</p>"
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="top" scope="col">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Gender&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top" scope="col">Weeks elapsed since start of treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top" scope="col">Treatment Protocol&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top" scope="col">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="center" valign="top">PROP-II-97&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">115&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">PROP-II-97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">GBTLI-2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">19&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">117&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">PROP-II-97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">22&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">GBTLI-99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">21&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">PROP-II-97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">21&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">PROP-II-97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">20&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">PROP-II-97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">22&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">PROP-II-97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">24&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">112&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">High&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">PROP-II-97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">26&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="top">Mean</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">13&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">78&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top">21&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="top" style="border-bottom: 2px solid black">SD</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top" style="border-bottom: 2px solid black">37&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top" style="border-bottom: 2px solid black">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="top" style="border-bottom: 2px solid black">2&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">Physical characteristics and treatment protocols for the patients in the ALL group&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "REFERENCES"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "cebibsec10"
          "bibliografiaReferencia" => array:10 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impaired muscle strength in female adolescents and young adults surviving leukemia in childhood"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => """
                              L Hovi \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              P Era \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              M Rautonen \n
                              \t\t\t\t\t\t\t\t
                              """
                            3 => """
                              MA Siimes \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1002/1097-0142(19930701)72:1<276::aid-cncr2820720148>3.0.co;2-2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Cancer"
                        "fecha" => "1993"
                        "volumen" => "72"
                        "paginaInicial" => "276"
                        "paginaFinal" => "281"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8508418"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                    1 => array:2 [
                      "doi" => "10.1002/1097-0142(19930701)72:1<276::aid-cncr2820720148>3.0.co;2-2"
                      "WWW" => array:1 [
                        "link" => "10&#46;1002&#47;1097-0142&#40;19930701&#41;72&#58;1&#60;276&#58;&#58;AID-CNCR2820720148&#62;3&#46;0&#46;CO&#59;2-2"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lanning&#46; Decreased isokinetic trunk muscle strength and performance in long-term survivors of childhood malignancies&#58; correlation with hormonal defects"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              KK Talvensaari \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              A J&#228;msen \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              H Vanharanta \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1016/s0003-9993(95)81033-1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Phys Med Rehabil"
                        "fecha" => "1995"
                        "volumen" => "76"
                        "paginaInicial" => "983"
                        "paginaFinal" => "988"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7487450"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                    1 => array:2 [
                      "doi" => "10.1016/s0003-9993(95)81033-1"
                      "WWW" => array:1 [
                        "link" => "10&#46;1016&#47;S0003-9993&#40;95&#41;81033-1"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Strength and functional mobility in children with acute lymphoblastic leukemia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              VG Marchese \n
                              \t\t\t\t\t\t\t\t
                              """
                            1 => """
                              LA Chiarello \n
                              \t\t\t\t\t\t\t\t
                              """
                            2 => """
                              BG Lange \n
                              \t\t\t\t\t\t\t\t
                              """
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:2 [
                    0 => array:2 [
                      "doi" => "10.1002/mpo.10266"
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Pediatr Oncol"
                        "fecha" => "2003"
                        "volumen" => "40"
                        "paginaInicial" => "230"
                        "paginaFinal" => "232"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12555250"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                    1 => array:2 [
                      "doi" => "10.1002/mpo.10266"
                      "WWW" => array:1 [
                        "link" => "10&#46;1002&#47;mpo&#46;10266"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effects of physical therapy intervention for children with acute lymphoblastic leukemia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => """
                              VG Marchese \n
                              \t\t\t\t\t\t\t\t
                              """
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                              LA Chiarello \n
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Article information

ISSN: 18075932
Original language: English

DOI:10.1590/S1807-59322011000700026

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Year/Month	Html	Pdf	Total

2024 November	5	1	6
2024 October	23	18	41
2024 September	21	18	39
2024 August	41	17	58
2024 July	18	26	44
2024 June	28	8	36
2024 May	43	12	55
2024 April	30	12	42
2024 March	52	14	66
2024 February	36	16	52
2024 January	20	13	33
2023 December	9	19	28
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2023 October	17	22	39
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2023 August	7	12	19
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2023 June	18	10	28
2023 May	6	0	6
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