Physical therapy intervention during hospitalization in patients with acute exacerbation of chronic obstructive pulmonary disease and pneumonia: A randomized clinical trial

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Paz Moreno-Ramírez, Irene Cabrera-Martos, Marie Carmen Valenza" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Adelina" "apellidos" => "Martín-Salvador" ] 1 => array:2 [ "nombre" => "Gloria" "apellidos" => "Colodro-Amores" ] 2 => array:2 [ "nombre" => "Irene" "apellidos" => "Torres-Sánchez" ] 3 => array:2 [ "nombre" => "M. Paz" "apellidos" => "Moreno-Ramírez" ] 4 => array:2 [ "nombre" => "Irene" "apellidos" => "Cabrera-Martos" ] 5 => array:4 [ "nombre" => "Marie Carmen" "apellidos" => "Valenza" "email" => array:1 [ 0 => "cvalenza@ugr.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Fisioterapia, Universidad de Granada, Granada, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Intervención fisioterápica durante la hospitalización en pacientes con exacerbación aguda de la enfermedad pulmonar obstructiva crónica y neumonía: un ensayo clínico aleatorizado" ] ] "textoCompleto" => "IntroductionRespiratory diseases are the second leading cause of hospitalisation; they not only represent admission because of community-acquired pneumonia (CAP), but also the most acute exacerbations of chronic obstructive pulmonary disease (AECOPD), both generating mortality figures associated with hospitalisation >15%.<a class="elsevierStyleCrossRef" href="#bib0055">1</a>The impact of hospitalisation on patients with respiratory disease has been analysed,<a class="elsevierStyleCrossRef" href="#bib0060">2</a> relating it to rest and a long hospital stay, which implies, after hospitalisation, relocation to residencies, caregiver syndrome and increased health-related costs.<a class="elsevierStyleCrossRef" href="#bib0065">3</a>Interventions have been proposed<a class="elsevierStyleCrossRefs" href="#bib0070">4,5</a> to reduce the impact of hospitalisation, focusing on the deterioration of muscle strength as an indicator of loss of autonomy and functionality. Given the similarity of patients with COPD and CAP, and the similar duration of their hospitalisation, the purpose of this study was to evaluate the effectiveness of physiotherapy on muscle strength and functional capacity affected by respiratory symptoms, during the hospitalisation period of patients admitted for AECOPD and CAP.MethodologyDesign and patientsThis was a randomised clinical trial. Randomisation was performed by a team member who assigned patients to an experimental or control group according to a randomisation list generated by a computer program.Patients were selected upon admission to the Respiratory Units of Granada hospitals during October 2014 to May 2015; follow-ups were performed upon hospital discharge (8–9 days later). The collection process was terminated upon reaching the intended sample size.Inclusion criteria were: patients admitted because of AECOPD or CAP, included on the first day of admission, aged between 65 and 90 and a with predicted forced vital capacity (FVC) value of <60%.Patients were excluded because of: significant cognitive impairment, effusion, pneumothorax or haemoptysis, cancer, skin problems or venous insufficiency, having osteosynthesis material, not being able to perform the evaluation, or being in isolation (with tuberculosis and influenza A), or having been admitted in the last 2 weeks.Patients were informed of the study and signed a consent prior to inclusion. The study was approved by the hospital's Ethics Committee. The study was registered at clinicaltrials.gov <a id="intr0010" class="elsevierStyleInterRef" href="https://clinicaltrials.gov/NCT02515565">NCT02515565</a>, <a id="intr0015" class="elsevierStyleInterRef" href="https://clinicaltrials.gov/NCT01826682">NCT01826682</a>.EvaluationPatients were assessed when they were admitted and discharged from the hospital. The examiner was blinded to the intervention and the assessments. The sociodemographic and anthropometric data were taken at the start.Main variables. Muscle strength was assessed using a dynamometry, quadriceps with a dynamometer, the Lafayette Manual Muscle Testing System (Model 01163, Lafayette Instrument Company, Lafayette, IN, USA), according to protocol.<a class="elsevierStyleCrossRef" href="#bib0080">6</a> The functionality related to respiratory symptoms was assessed with the London Chest Activity of Daily Living Scale (LCADL).<a class="elsevierStyleCrossRef" href="#bib0085">7</a>Secondary variables. The patient's nutritional status (Mini Nutritional Assessment), levels of dependence (Barthel index) and quality of life (St. George Respiratory Questionnaire) were assessed. The respiratory function was assessed by spirometry with a portable spirometer Micro Spirometer™ (CareFusion, Basingstoke, UK) and according to the Spanish Society of Pneumology and Thoracic Surgery regulations; saturation, with Konica-Minolta Pulsox®-1 oximeter (Konica Minolta Sensing Inc., Osaka, Japan), and dyspnoea, with modified Borg Scale.InterventionThe control intervention consisted of standard medical treatment according to medical prescription (in most cases oxygen therapy, antibiotics and bronchodilators). The experimental intervention consisted of standard treatment and a physiotherapy programme of one hour per day during hospitalisation. The sessions included 10min ventalory re-education (relaxation exercises, breathing with pursed lips and active breathing), 30min electrostimulation in both quadriceps (asymmetric biphasic current, pulse 400ms, 50Hz frequency with cycles of 8s contraction and 20s of rest) 15min exercise with elastic band (2 sets of 10 repetitions of various exercise sets) and 5min relaxation. The programme was the same for all patients and adapted to their levels of dyspnoea and fatigue.Statistical analysisThe SPSS® program was used. Data were presented as mean±standard deviation. Initially, to compare the characteristics between groups, Student's t test or the Mann–Whitney test were used. The effect of the intervention on the strength and functional capacity was analysed with the difference between groups using the analysis of variance with the baseline as covariate. The sample size was calculated based on an assumed improvement in the variable “quadriceps muscle strength” of 20% for a strength of 80% and a significance of p<0.05 in bilateral contrast.Results66 patients were selected for inclusion in the study; 22 were excluded and 44 were eventually randomised into the intervention (n=24) and control (n=20) groups.<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patients’ characteristics at the start, per group. No variable between groups showed significant differences at the start.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the comparison between groups and changes during hospitalisation in each.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The fundamental variables showed no significant differences between groups at the start. After surgery, patients experienced a significant improvement in dyspnoea (p<0.001). Functional capacity improved significantly in the subscales “physical activity” (p=0.043) and “leisure” (p=0.007). There was a non-significant improvement of strength.The control group improved dyspnoea (p<0.001) and worsened in quadriceps strength (p<0.05).Differences in dyspnoea (p=0.041) and quadriceps strength (p<0.05) were found when comparing the groups. The subscale “domestic activities” in the LCADL questionnaire showed differences (p=0.036).DiscussionThe aim of the study was to evaluate the effectiveness of physiotherapy during the hospital period in patients with AECOPD and CAP. Our results show that this intervention improves strength and function impairment.The physical impact of the hospitalisation in patients with respiratory disease<a class="elsevierStyleCrossRef" href="#bib0060">2</a> is detrimental to recovery and supposes a high risk of disability and mortality.<a class="elsevierStyleCrossRef" href="#bib0065">3</a> Various interventions have been proposed to combat this degradation<a class="elsevierStyleCrossRefs" href="#bib0070">4,5</a>; however, no programmes have been developed to reduce the impact of hospitalisation on muscle strength and functional capacity that include patients with AECOPD and CAP.The proposed intervention did not generate any adverse effects during treatment.Schultz et al.<a class="elsevierStyleCrossRef" href="#bib0090">8</a> demonstrated the benefits of rehabilitation after a period of acute illness, but they also carried out interventions during hospitalisation<a class="elsevierStyleCrossRef" href="#bib0070">4</a> or during the hospital period, continuing until after discharge.<a class="elsevierStyleCrossRef" href="#bib0095">9</a> Previous studies<a class="elsevierStyleCrossRef" href="#bib0070">4</a>.<a class="elsevierStyleCrossRef" href="#bib0075">5</a> have demonstrated the feasibility, safety and tolerability of electrostimulation in patients with AECOPD. Additionally, Giavedoni et al.<a class="elsevierStyleCrossRef" href="#bib0070">4</a> found that preventing deterioration of strength is effective, and Vivodtzev et al.<a class="elsevierStyleCrossRef" href="#bib0075">5</a> showed that improvements can be achieved without increasing dyspnoea during the training session.Nyberg et al.<a class="elsevierStyleCrossRef" href="#bib0100">10</a> did not obtain any significant improvements in quality of life, fatigue and dyspnoea using elastic bands in stable COPD. Our results quantify improvement in dyspnoea, strength and function by carrying out a short-term intervention. Patients tolerated the programme, without encountering adverse effects during implementation.A limitation of this research is the lack of patient monitoring after discharge to assess the long-term impact.Its main strength is that, to our knowledge, it is the first time a procedure to reduce deterioration caused by prolonged bed rest in patients with AECOPD and CAP has been performed during hospitalisation, with successful results from the short-term intervention.In conclusion, physiotherapy during the hospitalisation period for patients with AECOPD and CAP generates improvements at a musculoskeletal level that counteract the deterioration caused by immobilisation during hospitalisation.FinancingThis project has been developed without funding.Conflict of interestThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres690118" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec696163" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres690119" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Fundamento y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec696162" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methodology" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Design and patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Evaluation" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Intervention" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Financing" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-07-12" "fechaAceptado" => "2015-11-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec696163" "palabras" => array:4 [ 0 => "Pneumonia" 1 => "Chronic obstructive pulmonary disease" 2 => "Hospitalization" 3 => "Physical therapy modalities" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec696162" "palabras" => array:4 [ 0 => "Neumonía" 1 => "Enfermedad pulmonar obstructiva crónica" 2 => "Hospitalización" 3 => "Modalidades de fisioterapia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Background and objectiveRespiratory infections involve not only hospitalization due to pneumonia, but also acute exacerbations of COPD (AECOPD). The objective of the present study was to evaluate the effectiveness of a physical therapy intervention during hospitalization in patients admitted due to community-acquired pneumonia (CAP) and AECOPD. Material and methodRandomized clinical trial, 44 patients were randomized into 2 groups: a control group which received standard medical therapy (oxygen therapy and pharmacotherapy) and an experimental group that received standard treatment and a physical therapy intervention (breathing exercises, electrostimulation, exercises with elastic bands and relaxation). ResultsBetween-groups analysis showed that after the intervention (experimental vs. control) significant differences were found in perceived dyspnoea (p=0.041), and right and left quadriceps muscle strength (p=0.008 and p=0.010, respectively). In addition, the subscale of “domestic activities” of the functional ability related to respiratory symptoms questionnaire showed significant differences (p=0.036). ConclusionA physical therapy intervention during hospitalization in patients with AECOPD and CAP can generate skeletal muscle level gains that exceed the deterioration caused by immobilisation during hospitalization." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Fundamento y objetivoLas infecciones respiratorias suponen no solo los ingresos por neumonía, sino también la mayoría de las exacerbaciones agudas de EPOC (EAEPOC). El objetivo de este trabajo fue evaluar la efectividad de una intervención fisioterápica durante el período hospitalario en pacientes ingresados por EAEPOC y neumonía adquirida en la comunidad (NAC). Material y métodoEnsayo clínico aleatorizado, con 44 pacientes distribuidos en 2 grupos: un grupo control que recibió el tratamiento médico estándar (oxigenoterapia y farmacoterapia) y un grupo experimental que recibió el tratamiento estándar y una intervención fisioterápica (reeducación ventilatoria, electroestimulación, ejercicios con bandas elásticas y relajación). ResultadosAl comparar ambos grupos tras las intervenciones (experimental frente a control) se encontraron diferencias significativas en la disnea percibida (p=0,041), así como en la fuerza muscular de los cuádriceps derecho e izquierdo (p=0,008 y p=0,010, respectivamente). Adicionalmente, la subescala «actividades domésticas» del cuestionario de capacidad funcional relacionada con sintomatología respiratoria mostró diferencias significativas (p=0,036). ConclusiónUna intervención fisioterápica durante el período hospitalario en pacientes con EAEPOC y NAC puede generar mejoras a nivel musculoesquelético que superen el deterioro causado por la inmovilización durante la hospitalización." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Fundamento y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Martín-Salvador A, Colodro-Amores G, Torres-Sánchez I, Moreno-Ramírez MP, Cabrera-Martos I, Valenza MC. Intervención fisioterápica durante la hospitalización en pacientes con exacerbación aguda de la enfermedad pulmonar obstructiva crónica y neumonía: un ensayo clínico aleatorizado. Med Clin (Barc). 2016;146:301–304." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "FEV1: forced expiratory volume in one second; FVC: forced vital capacity; BMI: body mass index; SGRQ: St. George's Respiratory Questionnaire." "tablatextoimagen" => array:1 [ 0 => array:2 [ "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="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group (n=20) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Experimental group (n=24) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex (% male) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.726 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI (kg/m2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.86 (5.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.60 (3.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.318 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.40 (5.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78.82 (6.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.345 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Days hospitalised \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.49 (4.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.39 (3.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.437 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FVC, % predicted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.29 (23.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.95 (25.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.688 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FEV1, % predicted \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.84 (25.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.41 (20.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.947 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SGRQ symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.66 (20.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.09 (20.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.296 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SGRQ activity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.36 (28.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.44 (22.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.536 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SGRQ impact \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50.97 (16.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.31 (12.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.769 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SGRQ total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.61 (17.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58.75 (13.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.976 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1122957.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of subjects included in the study." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "T1: admission; T2: discharge." "tablatextoimagen" => array:1 [ 0 => array:2 [ "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="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Control group</th><th class="td" title="table-head " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Experimental group</th><th class="td" title="table-head " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">T1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">T2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95% CI \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">T1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">T2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95% CI \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyspnoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.68 (3.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.66 (2.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.87–2.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.96 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.29 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.42–5.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.041<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="10" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="10" align="left" valign="top">Muscle strength</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dynamometry right (No.) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">102.83 (49.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87.94 (33.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.45–28.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.005<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">108.83 (30.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">115.59 (40.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−23.42–9.91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.408 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.008<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dynamometry left (No.) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.95 (55.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85.48 (26.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.25–32.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.047<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">102.68 (37.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">112.37 (49.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−30.49–11.10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.342 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.010<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="10" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="10" align="left" valign="top">Functional capacity related respiratory symptoms</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Subscale selfcare \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.96 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.61 (5.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.14–3.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.301 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.18 (5.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.10 (6.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−3.37–3.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.950 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.843 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Domestic activities subscale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.35 (10.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.79 (11.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−6.19–3.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.489 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.55 (11.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.05 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−4.07–5.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.776 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.036<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Physical activity subscale \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.65 (2.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.67 (2.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.35–0.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.679 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.05 (5.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.90 (2.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.05–2.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.043<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.318 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; 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Physical therapy intervention during hospitalization in patients with acute exacerbation of chronic obstructive pulmonary disease and pneumonia: A randomized clinical trial

Intervención fisioterápica durante la hospitalización en pacientes con exacerbación aguda de la enfermedad pulmonar obstructiva crónica y neumonía: un ensayo clínico aleatorizado

Adelina Martín-Salvador, Gloria Colodro-Amores, Irene Torres-Sánchez, M. Paz Moreno-Ramírez, Irene Cabrera-Martos, Marie Carmen Valenza

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cvalenza@ugr.es

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Departamento de Fisioterapia, Universidad de Granada, Granada, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Respiratory diseases are the second leading cause of hospitalisation&#59; they not only represent admission because of community-acquired pneumonia &#40;CAP&#41;&#44; but also the most acute exacerbations of chronic obstructive pulmonary disease &#40;AECOPD&#41;&#44; both generating mortality figures associated with hospitalisation &#62;15&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The impact of hospitalisation on patients with respiratory disease has been analysed&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> relating it to rest and a long hospital stay&#44; which implies&#44; after hospitalisation&#44; relocation to residencies&#44; caregiver syndrome and increased health-related costs&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Interventions have been proposed<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a> to reduce the impact of hospitalisation&#44; focusing on the deterioration of muscle strength as an indicator of loss of autonomy and functionality&#46; Given the similarity of patients with COPD and CAP&#44; and the similar duration of their hospitalisation&#44; the purpose of this study was to evaluate the effectiveness of physiotherapy on muscle strength and functional capacity affected by respiratory symptoms&#44; during the hospitalisation period of patients admitted for AECOPD and CAP&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methodology</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design and patients</span><p id="par0020" class="elsevierStylePara elsevierViewall">This was a randomised clinical trial&#46; Randomisation was performed by a team member who assigned patients to an experimental or control group according to a randomisation list generated by a computer program&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients were selected upon admission to the Respiratory Units of Granada hospitals during October 2014 to May 2015&#59; follow-ups were performed upon hospital discharge &#40;8&#8211;9 days later&#41;&#46; The collection process was terminated upon reaching the intended sample size&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Inclusion criteria were&#58; patients admitted because of AECOPD or CAP&#44; included on the first day of admission&#44; aged between 65 and 90 and a with predicted <span class="elsevierStyleItalic">forced vital capacity</span> &#40;FVC&#41; value of <span class="elsevierStyleMonospace">&#60;</span>60&#37;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Patients were excluded because of&#58; significant cognitive impairment&#44; effusion&#44; pneumothorax or haemoptysis&#44; cancer&#44; skin problems or venous insufficiency&#44; having osteosynthesis material&#44; not being able to perform the evaluation&#44; or being in isolation &#40;with tuberculosis and influenza A&#41;&#44; or having been admitted in the last 2 weeks&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Patients were informed of the study and signed a consent prior to inclusion&#46; The study was approved by the hospital&#39;s Ethics Committee&#46; The study was registered at clinicaltrials&#46;gov <a id="intr0010" class="elsevierStyleInterRef" href="https://clinicaltrials.gov/NCT02515565">NCT02515565</a>&#44; <a id="intr0015" class="elsevierStyleInterRef" href="https://clinicaltrials.gov/NCT01826682">NCT01826682</a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Evaluation</span><p id="par0045" class="elsevierStylePara elsevierViewall">Patients were assessed when they were admitted and discharged from the hospital&#46; The examiner was blinded to the intervention and the assessments&#46; The sociodemographic and anthropometric data were taken at the start&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Main variables&#46;</span> Muscle strength was assessed using a dynamometry&#44; quadriceps with a dynamometer&#44; the Lafayette Manual Muscle Testing System &#40;Model 01163&#44; Lafayette Instrument Company&#44; Lafayette&#44; IN&#44; USA&#41;&#44; according to protocol&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> The functionality related to respiratory symptoms was assessed with the London Chest Activity of Daily Living Scale &#40;LCADL&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Secondary variables&#46;</span> The patient&#39;s nutritional status <span class="elsevierStyleItalic">&#40;Mini Nutritional Assessment&#41;</span>&#44; levels of dependence &#40;Barthel index&#41; and quality of life <span class="elsevierStyleItalic">&#40;St&#46; George Respiratory Questionnaire&#41;</span> were assessed&#46; The respiratory function was assessed by spirometry with a portable spirometer Micro Spirometer&#8482; &#40;CareFusion&#44; Basingstoke&#44; UK&#41; and according to the Spanish Society of Pneumology and Thoracic Surgery regulations&#59; saturation&#44; with Konica-Minolta Pulsox<span class="elsevierStyleSup">&#174;</span>-1 oximeter &#40;Konica Minolta Sensing Inc&#46;&#44; Osaka&#44; Japan&#41;&#44; and dyspnoea&#44; with modified Borg Scale&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Intervention</span><p id="par0060" class="elsevierStylePara elsevierViewall">The control intervention consisted of standard medical treatment according to medical prescription &#40;in most cases oxygen therapy&#44; antibiotics and bronchodilators&#41;&#46; The experimental intervention consisted of standard treatment and a physiotherapy programme of one hour per day during hospitalisation&#46; The sessions included 10<span class="elsevierStyleHsp" style=""></span>min ventalory re-education &#40;relaxation exercises&#44; breathing with pursed lips and active breathing&#41;&#44; 30<span class="elsevierStyleHsp" style=""></span>min electrostimulation in both quadriceps &#40;asymmetric biphasic current&#44; pulse 400<span class="elsevierStyleHsp" style=""></span>ms&#44; 50<span class="elsevierStyleHsp" style=""></span>Hz frequency with cycles of 8<span class="elsevierStyleHsp" style=""></span>s contraction and 20<span class="elsevierStyleHsp" style=""></span>s of rest&#41; 15<span class="elsevierStyleHsp" style=""></span>min exercise with elastic band &#40;2 sets of 10 repetitions of various exercise sets&#41; and 5<span class="elsevierStyleHsp" style=""></span>min relaxation&#46; The programme was the same for all patients and adapted to their levels of dyspnoea and fatigue&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">The SPSS<span class="elsevierStyleSup">&#174;</span> program was used&#46; Data were presented as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46; Initially&#44; to compare the characteristics between groups&#44; Student&#39;s <span class="elsevierStyleItalic">t</span> test or the Mann&#8211;Whitney test were used&#46; The effect of the intervention on the strength and functional capacity was analysed with the difference between groups using the analysis of variance with the baseline as covariate&#46; The sample size was calculated based on an assumed improvement in the variable &#8220;quadriceps muscle strength&#8221; of 20&#37; for a strength of 80&#37; and a significance of <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#46;05 in bilateral contrast&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">66 patients were selected for inclusion in the study&#59; 22 were excluded and 44 were eventually randomised into the intervention &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#41; and control &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&#41; groups&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patients&#8217; characteristics at the start&#44; per group&#46; No variable between groups showed significant differences at the start&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the comparison between groups and changes during hospitalisation in each&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The fundamental variables showed no significant differences between groups at the start&#46; After surgery&#44; patients experienced a significant improvement in dyspnoea &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Functional capacity improved significantly in the subscales &#8220;physical activity&#8221; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;043&#41; and &#8220;leisure&#8221; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;007&#41;&#46; There was a non-significant improvement of strength&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The control group improved dyspnoea &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and worsened in quadriceps strength &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Differences in dyspnoea &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;041&#41; and quadriceps strength &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#60;</span><span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; were found when comparing the groups&#46; The subscale &#8220;domestic activities&#8221; in the LCADL questionnaire showed differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;036&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The aim of the study was to evaluate the effectiveness of physiotherapy during the hospital period in patients with AECOPD and CAP&#46; Our results show that this intervention improves strength and function impairment&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The physical impact of the hospitalisation in patients with respiratory disease<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> is detrimental to recovery and supposes a high risk of disability and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Various interventions have been proposed to combat this degradation<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;5</span></a>&#59; however&#44; no programmes have been developed to reduce the impact of hospitalisation on muscle strength and functional capacity that include patients with AECOPD and CAP&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The proposed intervention did not generate any adverse effects during treatment&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Schultz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> demonstrated the benefits of rehabilitation after a period of acute illness&#44; but they also carried out interventions during hospitalisation<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> or during the hospital period&#44; continuing until after discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Previous studies<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> have demonstrated the feasibility&#44; safety and tolerability of electrostimulation in patients with AECOPD&#46; Additionally&#44; Giavedoni et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> found that preventing deterioration of strength is effective&#44; and Vivodtzev et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> showed that improvements can be achieved without increasing dyspnoea during the training session&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Nyberg et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> did not obtain any significant improvements in quality of life&#44; fatigue and dyspnoea using elastic bands in stable COPD&#46; Our results quantify improvement in dyspnoea&#44; strength and function by carrying out a short-term intervention&#46; Patients tolerated the programme&#44; without encountering adverse effects during implementation&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">A limitation of this research is the lack of patient monitoring after discharge to assess the long-term impact&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Its main strength is that&#44; to our knowledge&#44; it is the first time a procedure to reduce deterioration caused by prolonged bed rest in patients with AECOPD and CAP has been performed during hospitalisation&#44; with successful results from the short-term intervention&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In conclusion&#44; physiotherapy during the hospitalisation period for patients with AECOPD and CAP generates improvements at a musculoskeletal level that counteract the deterioration caused by immobilisation during hospitalisation&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Financing</span><p id="par0140" class="elsevierStylePara elsevierViewall">This project has been developed without funding&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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          ]
        ]
      ]
    ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Respiratory infections involve not only hospitalization due to pneumonia&#44; but also acute exacerbations of COPD &#40;AECOPD&#41;&#46; The objective of the present study was to evaluate the effectiveness of a physical therapy intervention during hospitalization in patients admitted due to community-acquired pneumonia &#40;CAP&#41; and AECOPD&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Randomized clinical trial&#44; 44 patients were randomized into 2 groups&#58; a control group which received standard medical therapy &#40;oxygen therapy and pharmacotherapy&#41; and an experimental group that received standard treatment and a physical therapy intervention &#40;breathing exercises&#44; electrostimulation&#44; exercises with elastic bands and relaxation&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Between-groups analysis showed that after the intervention &#40;experimental vs&#46; control&#41; significant differences were found in perceived dyspnoea &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;041&#41;&#44; and right and left quadriceps muscle strength &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;008 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;010&#44; respectively&#41;&#46; In addition&#44; the subscale of &#8220;domestic activities&#8221; of the functional ability related to respiratory symptoms questionnaire showed significant differences &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;036&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A physical therapy intervention during hospitalization in patients with AECOPD and CAP can generate skeletal muscle level gains that exceed the deterioration caused by immobilisation during hospitalization&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and method"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
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      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Fundamento y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las infecciones respiratorias suponen no solo los ingresos por neumon&#237;a&#44; sino tambi&#233;n la mayor&#237;a de las exacerbaciones agudas de EPOC &#40;EAEPOC&#41;&#46; El objetivo de este trabajo fue evaluar la efectividad de una intervenci&#243;n fisioter&#225;pica durante el per&#237;odo hospitalario en pacientes ingresados por EAEPOC y neumon&#237;a adquirida en la comunidad &#40;NAC&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Ensayo cl&#237;nico aleatorizado&#44; con 44 pacientes distribuidos en 2 grupos&#58; un grupo control que recibi&#243; el tratamiento m&#233;dico est&#225;ndar &#40;oxigenoterapia y farmacoterapia&#41; y un grupo experimental que recibi&#243; el tratamiento est&#225;ndar y una intervenci&#243;n fisioter&#225;pica &#40;reeducaci&#243;n ventilatoria&#44; electroestimulaci&#243;n&#44; ejercicios con bandas el&#225;sticas y relajaci&#243;n&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Al comparar ambos grupos tras las intervenciones &#40;experimental frente a control&#41; se encontraron diferencias significativas en la disnea percibida &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;041&#41;&#44; as&#237; como en la fuerza muscular de los cu&#225;driceps derecho e izquierdo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;008 y p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;010&#44; respectivamente&#41;&#46; Adicionalmente&#44; la subescala &#171;actividades dom&#233;sticas&#187; del cuestionario de capacidad funcional relacionada con sintomatolog&#237;a respiratoria mostr&#243; diferencias significativas &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;036&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Una intervenci&#243;n fisioter&#225;pica durante el per&#237;odo hospitalario en pacientes con EAEPOC y NAC puede generar mejoras a nivel musculoesquel&#233;tico que superen el deterioro causado por la inmovilizaci&#243;n durante la hospitalizaci&#243;n&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Fundamento y objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Mart&#237;n-Salvador A&#44; Colodro-Amores G&#44; Torres-S&#225;nchez I&#44; Moreno-Ram&#237;rez MP&#44; Cabrera-Martos I&#44; Valenza MC&#46; Intervenci&#243;n fisioter&#225;pica durante la hospitalizaci&#243;n en pacientes con exacerbaci&#243;n aguda de la enfermedad pulmonar obstructiva cr&#243;nica y neumon&#237;a&#58; un ensayo cl&#237;nico aleatorizado&#46; Med Clin &#40;Barc&#41;&#46; 2016&#59;146&#58;301&#8211;304&#46;</p>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume in one second&#59; FVC&#58; forced vital capacity&#59; BMI&#58; body mass index&#59; SGRQ&#58; St&#46; George&#39;s Respiratory Questionnaire&#46;</p>"
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                  <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="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Control group &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Experimental group &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex &#40;&#37; male&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">83&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;726&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;86 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;60 &#40;3&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;318&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&#46;40 &#40;5&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78&#46;82 &#40;6&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;345&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Days hospitalised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;49 &#40;4&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;39 &#40;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FVC&#44; &#37; predicted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#46;29 &#40;23&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&#46;95 &#40;25&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;688&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FEV<span class="elsevierStyleInf">1</span>&#44; &#37; predicted&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;84 &#40;25&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;41 &#40;20&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;947&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SGRQ symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;66 &#40;20&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&#46;09 &#40;20&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;296&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SGRQ activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">74&#46;36 &#40;28&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#46;44 &#40;22&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;536&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SGRQ impact&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#46;97 &#40;16&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&#46;31 &#40;12&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;769&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SGRQ total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#46;61 &#40;17&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58&#46;75 &#40;13&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;976&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Characteristics of subjects included in the study&#46;</p>"
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                  <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="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Control group</th><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Experimental group</th><th class="td" title="table-head  " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span></th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Dyspnoea</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;68 &#40;3&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;66 &#40;2&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;87&#8211;2&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;96 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;29 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;42&#8211;5&#46;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;041<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="10" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="10" align="left" valign="top"><span class="elsevierStyleItalic">Muscle strength</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Dynamometry right &#40;No&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">102&#46;83 &#40;49&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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