Selma S. Bruno

The First Physical Therapy Summit on Global Health: Implications and Recommendations for the 21st century

The First Physical Therapy Summit on Global Health was convened at the 2007 World Confederation for Physical Therapy (WCPT) Congress to vision practice in the 21st century and, in turn, entry-level education and research, as informed by epidemiological indicators, and consistent with evidence-based noninvasive interventions, the hallmark of physical therapy. The Summit and its findings were informed by WHO data and validated through national databases of the countries of the five WCPT regions. The health priorities based on mortality were examined in relation to proportions of physical therapists practicing in the areas of regional priorities and of the curricula in entry-level programs. As a validation check and to contextualize the findings, input from members of the 800 Summit participants was integrated and international consultants refined the recommendations. Lifestyle-related conditions (ischemic heart disease, smoking-related conditions, hypertension, stroke, cancer, and diabetes) were leading causes of premature death across regions. Contemporary definitions of physical therapy support that the profession has a leading role in preventing, reversing, as well as managing lifestyle-related conditions. The proportions of practitioners practicing primarily in these priority areas and of the entry-level curricula based on these priorities were low. The proportions of practitioners in priority areas and entry-level curricula devoted to lifestyle-related conditions warrant being better aligned with the prevalence of these conditions across regions in the 21st century. A focus on clinical competencies associated with effective health education and health behavior change formulates the basis for The Second Physical Therapy Summit on Global Health.

The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases

Abstract Based on indicators that emerged from The First Physical Therapy Summit on Global Health (2007), the Second Summit (2011) identified themes to inform a global physical therapy action plan to integrate health promotion into practice across the World Confederation for Physical Therapy (WCPT) regions. Working questions were: (1) how well is health promotion implemented within physical therapy practice; and (2) how might this be improved across five target audiences (i.e. physical therapist practitioners, educators, researchers, professional body representatives, and government liaisons/consultants). In structured facilitated sessions, Summit representatives (n = 32) discussed: (1) within WCPT regions, what is working and the challenges; and (2) across WCPT regions, what are potential directions using World CaféTM methodology. Commonalities outweighed differences with respect to strategies to advance health-focused physical therapy as a clinical competency across regions and within target audiences. Participants agreed that health-focused practice is a professional priority, and a strategic action plan was needed to develop it as a clinical competency. The action plan and recommendations largely paralleled the principles and objectives of the World Health Organization’s non-communicable diseases action plan. A third Summit planned for 2015 will provide a mechanism for follow-up to evaluate progress in integrating health-focused physical therapy within the profession.

Influence of Neck Circumference on Respiratory Endurance and Muscle Strength in the Morbidly Obese

BACKGROUND Respiratory function decline has been reported mainly in the morbidly obese. Little is known about the influence of adiposity pattern on the ability to generate strength in respiratory muscles. This study evaluated strength and respiratory endurance in the morbidly obese in preoperative bariatric surgery to determine if such variables were affected by different anthropometric markers (body mass index (BMI), waist-hip ratio (WHR), and neck circumference (NC)). METHODS We evaluated 39 adult and young obese patients of both sexes, with no respiratory or heart diseases. Standard pulmonary function tests and static respiratory muscle strength (maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP)) and endurance (maximum voluntary ventilation (MVV)) were measured in relation to sex and groups (WHR > 0.95 and WHR < 0.95; NC > 43 and NC < 43). RESULTS Thirty-nine obese patients (28 women), aged 36.9 + 11.9 years, BMI 49.3 + 5.1 kg/m², WHR 0.96 + 0.07, and NC 44.1 + 4.2 cm, took part in the study Standard pulmonary function tests and respiratory muscle strength were within normal parameters, except MVV (<80%). Obese with NC ≥ 43 cm (n = 22) have greater respiratory muscle strength and less endurance, MEP (p = 0.031) and MVV (p = 0.018). Abdominal adiposity (n = 19) does not seem to affect respiratory muscle strength. A positive correlation was observed only between NC and PEF (r = 0.392, p = 0.014) and marginally between NC and MVV (r = 0.308, p = 0.056). CONCLUSION Although adiposity patterns did not affect inspiratory muscle strength, neck adiposity was associated lower respiratory muscle endurance.

Comparação entre o manovacuômetro nacional e o importado para medida da pressão inspiratória nasal

BACKGROUND the measurement of nasal inspiratory pressure, known as the sniff test, was developed as a new test of inspiratory muscle strength, mainly used in neuromuscular conditions. The test is easy to be performed and noninvasive. Despite the clinical importance of assessment of nasal inspiratory pressure a national equipment is not available to assess it. OBJECTIVES to compare a national with a foreign manovacuometer in assessing the nasal inspiratory pressure (sniff test) in healthy subjects. METHODS 18 subjects were evaluated (age 21.44 ± 2.8 years, BMI 23.4 ± 2.5 kg/m² , FVC 102.1 ±1 0.3% pred, FEV1 98.4 ± 1% pred). We performed two measures of nasal inspiratory pressure using two different manovacuometer: a national and a foreign. All subjects performed the tests at the same time of day, in different days being the order of the testes established randomly. It was used the paired t test, Pearson correlation and the Bland-Altman plots for statistical analysis considering a 5% significance level. RESULTS The averages observed for the two measures of nasal pressures were 125 ± 42.4 cmH2O for the foreign equipment, and 131.7 ± 2 8.7 cmH2O for the national equipment. The Pearson correlation showed significant correlation between the means with a coefficient of r=0.63. The t test showed no significant differences between both measurements (p>0,05). The BIAS ± SD found in Bland-Altman plot analysis was 7 cmH2O with limits of agreement between -57.5 cmH2O and 71.5 cmH2O. CONCLUSION the results suggest that the national electronic device is feasible and safe to the sniff test measurement in healthy subjects.

Addressing the Common Pathway Underlying Hypertension and Diabetes in People Who Are Obese by Maximizing Health: The Ultimate Knowledge Translation Gap

In accordance with the WHO definition of health, this article examines the alarming discord between the epidemiology of hypertension, type 2 diabetes mellitus (T2DM), and obesity and the low profile of noninvasive (nondrug) compared with invasive (drug) interventions with respect to their prevention, reversal and management. Herein lies the ultimate knowledge translation gap and challenge in 21st century health care. Although lifestyle modification has long appeared in guidelines for medically managing these conditions, this evidence-based strategy is seldom implemented as rigorously as drug prescription. Biomedicine focuses largely on reducing signs and symptoms; the effects of the problem rather than the problem. This article highlights the evidence-based rationale supporting prioritizing the underlying causes and contributing factors for hypertension and T2DM, and, in turn, obesity. We argue that a primary focus on maximizing health could eliminate all three conditions, at best, or, at worst, minimize their severity, complications, and medication needs. To enable such knowledge translation and maximizing health outcome, the health care community needs to practice as an integrated team, and address barriers to effecting maximal health in all patients. Addressing the ultimate knowledge translation gap, by aligning the health care paradigm to 21st century needs, would constitute a major advance.

Sexual dysfunction in obese women is more affected by psychological domains than that of non-obese

PURPOSE To compare differences in the occurrence and changed domains of sexual dysfunction in obese and non-obese Brazilian women. METHODS Female Sexual Function Index, based on six domains, to investigate 31 sexual dysfunction incidence for obese compared to 32 non-obese women, was used. Statistical analysis using ANOVA and MANOVA were performed to compare total scores of Female Sexual Function Index among groups and to identify the differences among domains, Student t -test was used. Statistical significant level was established for all tests for p<0.05. RESULTS No difference in female sexual dysfunction frequency between obese (25.8%) and non-obese women (22.5%) was found. However, an important distinction in which aspects of sexual life were affected was found. While the obese group was impaired in three domains of sexual life (desire, orgasm, and arousal), in the control group five aspects were dysfunctional (desire, orgasm, arousal, pain and lubrication). Future research exploring psychological outcomes in obese females, such as body image and measures of positive and negative effect, might better characterize the female sexual dysfunction in this group. CONCLUSIONS Obesity does not appear to be an independent factor for allow quality of female sexual life. However, disturbance associated to obesity indicates a low frequency of disorder in physical domains, suggesting that psychological factors seem to be mainly involved in the sexual dysfunction in obese women.

Força muscular respiratória e qualidade de vida em pacientes com distrofia miotónica

Introduction Studies on quality of life in myotonic dystrophy (MD) are scarce and the relationship between respiratory muscle strength and health-related quality of life (HRQoL) has yet to be determined. The present study aims to investigate respiratory muscle strength and HRQoL and their relationship in MD patients.

Respiratory muscle strength and quality of life in myotonic dystrophy patients.

INTRODUCTION Studies on quality of life in myotonic dystrophy (MD) are scarce and the relationship between respiratory muscle strength and health-related quality of life (HRQoL) has yet to be determined. The present study aims to investigate respiratory muscle strength and HRQoL and their relationship in MD patients. METHODS Twenty-three patients (13 men, aged 40 ± 16 years) with MD were evaluated for pulmonary function, maximal inspiratory and expiratory pressure (MIP and MEP, respectively), sniff nasal inspiratory pressure (SNIP) and HRQoL using the Short Form (SF-36) quality of life questionnaire. RESULTS Respiratory muscle strength values were 71 ± 20 cmH₂O (64 % predicted), 76 ± 32 cmH₂O (70 % predicted), and 79 ± 28 cmH₂O (80 % predicted) for MEP, MIP, and SNIP respectively. Significant differences were found in the SF-36 domains of physical functioning 58.7 ± 31.4 vs. 84.5 ± 23 (p < 0.01, 95 % CI = 1.6-39.9) and physical problems 43.4 ± 35.2 vs. 81.2 ± 34 (p < 0.001, 95 % CI = 19.4-6.1) when compared with the reference values. According to single linear regression analysis, MIP explains 29 % of the variance in physical functioning, 18 % of physical problems and 20 % of vitality. CONCLUSIONS Individuals with MD have reduced expiratory muscle strength. HRQoL may be more impaired in some physical domains, which might be influenced by variations in inspiratory muscle strength.

Modulação pela progesterona da sensibilidade dolorosa a estímulos mecânicos e isquêmicos em mulheres saudáveis e jovens

PURPOSE: to investigate the relationship between pain perception (experimental pain threshold and tolerance, in response to ischemia and pressure) in young and healthy young women and female sexual hormone seric levels (estradiol and progesterone). METHODS: 18 volunteers have participated of this study, during three consecutive menstrual cycles. A pressure algometer and a manual dynamometer have been used to measure painful responses to pressure and ischemia algesic stimuli. Blood has been collected for assessment of both hormonal and painful variables, during three menstrual cycles, whose characterization was based on daily oral temperature record, a diary of the menstrual cycles with the onset and end of each cycle, and on estradiol and progesterone plasmatic levels. The average for the algesic variables measured has been compared by analysis of variance (ANOVA) and the Tukey-Kramers post-test, among the menstrual cycle phases (follicular, periovulatory, early luteal, late luteal and menstrual). The Pearsons test has been used for correlation analysis between algesic and hormonal variables. Statistical significance has been defined as p<0.05. RESULTS: no significant change in pain parameters among the menstrual cycle phases has been observed. Nevertheless, there have been significant negative correlations between progesterone and ischemic threshold (r=-0.23; p<0.01), and pressure tolerance (r=-0.23; p<0.01) at the early luteal phase. CONCLUSIONS: these results indicate that the increase in progesterone levels correlates with a decrease of ischemic threshold and pressure tolerance, suggesting that progesterone plays a role in the pain modulation during the early luteal phase.

Oxygen uptake efficiency slope as a useful measure of cardiorespiratory fitness in morbidly obese women

Cardiopulmonary assessment through oxygen uptake efficiency slope (OUES) data has shown encouraging results, revealing that we can obtain important clinical information about functional status. Until now, the use of OUES has not been established as a measure of cardiorespiratory capacity in an obese adult population, only in cardiac and pulmonary diseases or pediatric patients. The aim of this study was to characterize submaximal and maximal levels of OUES in a sample of morbidly obese women and analyze its relationship with traditional measures of cardiorespiratory fitness, anthropometry and pulmonary function. Thirty-three morbidly obese women (age 39.1 ± 9.2 years) performed Cardiopulmonary Exercise Testing (CPX) on a treadmill using the ramp protocol. In addition, anthropometric measurements and pulmonary function were also evaluated. Maximal and submaximal OUES were measured, being calculated from data obtained in the first 50% (OUES50%) and 75% (OUES75%) of total CPX duration. In one-way ANOVA analysis, OUES did not significantly differ between the three different exercise intensities, as observed through a Bland-Altman concordance of 58.9 mL/min/log(L/min) between OUES75% and OUES100%, and 0.49 mL/kg/min/log(l/min) between OUES/kg75% and OUES/kg100%. A strong positive correlation between the maximal (r = 0.79) and submaximal (r = 0.81) OUES/kg with oxygen consumption at peak exercise (VO2peak) and ventilatory anaerobic threshold (VO2VAT) was observed, and a moderate negative correlation with hip circumference (r = -0.46) and body adiposity index (r = -0.50) was also verified. There was no significant difference between maximal and submaximal OUES, showing strong correlations with each other and oxygen consumption (peak and VAT). These results indicate that OUES can be a useful parameter which could be used as a cardiopulmonary fitness index in subjects with severe limitations to perform CPX, as for morbidly obese women.