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Hornig L, Szmola B, Pätzold W, Vox JP, Wolf KI. Evaluation of Lateral Radar Positioning for Vital Sign Monitoring: An Empirical Study. SENSORS (BASEL, SWITZERLAND) 2024; 24:3548. [PMID: 38894339 PMCID: PMC11175299 DOI: 10.3390/s24113548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024]
Abstract
Vital sign monitoring is dominated by precise but costly contact-based sensors. Contactless devices such as radars provide a promising alternative. In this article, the effects of lateral radar positions on breathing and heartbeat extraction are evaluated based on a sleep study. A lateral radar position is a radar placement from which multiple human body zones are mapped onto different radar range sections. These body zones can be used to extract breathing and heartbeat motions independently from one another via these different range sections. Radars were positioned above the bed as a conventional approach and on a bedside table as well as at the foot end of the bed as lateral positions. These positions were evaluated based on six nights of sleep collected from healthy volunteers with polysomnography (PSG) as a reference system. For breathing extraction, comparable results were observed for all three radar positions. For heartbeat extraction, a higher level of agreement between the radar foot end position and the PSG was found. An example of the distinction between thoracic and abdominal breathing using a lateral radar position is shown. Lateral radar positions could lead to a more detailed analysis of movements along the body, with the potential for diagnostic applications.
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Affiliation(s)
- Lars Hornig
- Fraunhofer Institute for Digital Media Technology IDMT, Oldenburg Branch for Hearing, Speech and Audio Technology HSA, Marie-Curie-Straße 2, 26129 Oldenburg, Germany; (B.S.); (W.P.); (J.P.V.); (K.I.W.)
| | - Benedek Szmola
- Fraunhofer Institute for Digital Media Technology IDMT, Oldenburg Branch for Hearing, Speech and Audio Technology HSA, Marie-Curie-Straße 2, 26129 Oldenburg, Germany; (B.S.); (W.P.); (J.P.V.); (K.I.W.)
- Medizinische Physik, Carl von Ossietzky University of Oldenburg, 26046 Oldenburg, Germany
- Department of Neurology, School of Medicine and Health Science, Carl von Ossietzky University of Oldenburg, 26046 Oldenburg, Germany
| | - Wiebke Pätzold
- Fraunhofer Institute for Digital Media Technology IDMT, Oldenburg Branch for Hearing, Speech and Audio Technology HSA, Marie-Curie-Straße 2, 26129 Oldenburg, Germany; (B.S.); (W.P.); (J.P.V.); (K.I.W.)
| | - Jan Paul Vox
- Fraunhofer Institute for Digital Media Technology IDMT, Oldenburg Branch for Hearing, Speech and Audio Technology HSA, Marie-Curie-Straße 2, 26129 Oldenburg, Germany; (B.S.); (W.P.); (J.P.V.); (K.I.W.)
| | - Karen Insa Wolf
- Fraunhofer Institute for Digital Media Technology IDMT, Oldenburg Branch for Hearing, Speech and Audio Technology HSA, Marie-Curie-Straße 2, 26129 Oldenburg, Germany; (B.S.); (W.P.); (J.P.V.); (K.I.W.)
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Santos EAD, Pinto TF, Xavier RF, Stelmach R, Carvalho-Pinto RM, Carvalho CRFD. Elastic tape reduces dyspnea and improves health status in the short term in nonobese COPD males: A randomized controlled trial. Respir Med 2024; 221:107459. [PMID: 37944827 DOI: 10.1016/j.rmed.2023.107459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 10/12/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION AND OBJECTIVES The elastic tape (ET) is a novel intervention that acutely improves exercise capacity in laboratory tests; however, its effect on a patient's daily life remains unknown. This randomized controlled trial evaluated the effects of ET on daily life physical activity (DLPA), dyspnea symptoms, health status, and health-related quality of life (HRQoL) in individuals with COPD. METHODS Fifty males with moderate to very severe COPD were randomly assigned to an intervention group (ETG, n = 25), receiving ET on the chest wall and abdomen, or a control group (CG, n = 25). The intervention was for 14 days. DLPA (accelerometry; steps per day, and sedentary time), dyspnea symptoms (transition dyspnea index, TDI; and modified Medical Research Council, mMRC), health status (COPD assessment test, CAT), and health-related quality of life (HRQoL, CRQ) were evaluated at baseline and on Day 21 after the intervention. RESULTS No change in the DLPA was observed in between-group comparison. CG presented a reduction in step counts after 21days (-707,p <0.05) while ETG. maintained (-114,p > 0.94). However, ET reduced dyspnea symptoms in all TDI domains (functional, task, and effort) and on the mMRC scale after 14 days compared with CG (p < 0.01). Also, the ETG improved CAT score compared to the CG, reaching minimal clinical important difference (MCID) (-4.4 score, p <0.01). The ETG also improved in most CRQ domains reaching MCID after 21 days. CONCLUSIONS ET does not modify DLPA but reduces dyspnea and improves health status and HRQoL in nonobese males with moderate to very severe COPD in the short term. This novel and low-cost intervention improves COPD symptoms.
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Affiliation(s)
| | - Thiago Fernandes Pinto
- Department of Physical Therapy, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Rafael Stelmach
- Pulmonary Division, Heart Institute (InCor), Clinics Hospital, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
| | - Regina Maria Carvalho-Pinto
- Pulmonary Division, Heart Institute (InCor), Clinics Hospital, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil
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Cheng JC, Buduhan G, Venkataraman S, Tan L, Sasaki D, Bashir B, Ahmed N, Kidane B, Sivananthan G, Koul R, Leylek A, Butler J, McCurdy B, Wong R, Kim JO. Endobronchially Implanted Real-Time Electromagnetic Transponder Beacon-Guided, Respiratory-Gated SABR for Moving Lung Tumors: A Prospective Phase 1/2 Cohort Study. Adv Radiat Oncol 2023; 8:101243. [PMID: 37408673 PMCID: PMC10318214 DOI: 10.1016/j.adro.2023.101243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/03/2023] [Indexed: 07/07/2023] Open
Abstract
Purpose Endobronchial electromagnetic transponder beacons (EMT) provide real-time, precise positional data of moving lung tumors. We report results of a phase 1/2, prospective, single-arm cohort study evaluating the treatment planning effects of EMT-guided SABR for moving lung tumors. Methods and Materials Eligible patients were adults, Eastern Cooperative Oncology Group 0 to 2, with T1-T2N0 non-small cell lung cancer or pulmonary metastasis ≤4 cm with motion amplitude ≥5 mm. Three EMTs were endobronchially implanted using navigational bronchoscopy. Four-dimensional free-breathing computed tomography simulation scans were obtained, and end-exhalation phases were used to define the gating window internal target volume. A 3-mm expansion of gating window internal target volume defined the planning target volume (PTV). EMT-guided, respiratory-gated (RG) SABR was delivered (54 Gy/3 fractions or 48 Gy/4 fractions) using volumetric modulated arc therapy. For each RG-SABR plan, a 10-phase image-guided SABR plan was generated for dosimetric comparison. PTV/organ-at-risk (OAR) metrics were tabulated and analyzed using the Wilcoxon signed-rank pair test. Treatment outcomes were evaluated using RECIST (Response Evaluation Criteria in Solid Tumours; version 1.1). Results Of 41 patients screened, 17 were enrolled and 2 withdrew from the study. Median age was 73 years, with 7 women. Sixty percent had T1/T2 non-small cell lung cancer and 40% had M1 disease. Median tumor diameter was 1.9 cm with 73% of targets located peripherally. Mean respiratory tumor motion was 1.25 cm (range, 0.53-4.04 cm). Thirteen tumors were treated with EMT-guided SABR and 47% of patients received 48 Gy in 4 fractions while 53% received 54 Gy in 3 fractions. RG-SABR yielded an average PTV reduction of 46.9% (P < .005). Lung V5, V10, V20, and mean lung dose had mean relative reductions of 11.3%, 20.3%, 31.1%, and 20.3%, respectively (P < .005). Dose to OARs was significantly reduced (P < .05) except for spinal cord. At 6 months, mean radiographic tumor volume reduction was 53.5% (P < .005). Conclusions EMT-guided RG-SABR significantly reduced PTVs of moving lung tumors compared with image-guided SABR. EMT-guided RG-SABR should be considered for tumors with large respiratory motion amplitudes or those located in close proximity to OARs.
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Affiliation(s)
- Jui Chih Cheng
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gordon Buduhan
- Thoracic Surgery, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Lawrence Tan
- Thoracic Surgery, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Sasaki
- Medical Physics, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Bashir Bashir
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Naseer Ahmed
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Biniam Kidane
- Thoracic Surgery, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gokulan Sivananthan
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rashmi Koul
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ahmet Leylek
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James Butler
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Boyd McCurdy
- Medical Physics, CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Ralph Wong
- Medical Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Julian O. Kim
- Radiation Oncology, Max Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- CancerCare Manitoba Research Institute, Winnipeg, Manitoba, Canada
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Molinaro N, Schena E, Silvestri S, Massaroni C. Breathing Chest Wall Kinematics Assessment through a Single Digital Camera: A Feasibility Study. SENSORS (BASEL, SWITZERLAND) 2023; 23:6960. [PMID: 37571742 PMCID: PMC10422340 DOI: 10.3390/s23156960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/13/2023]
Abstract
The identification of respiratory patterns based on the movement of the chest wall can assist in monitoring an individual's health status, particularly those with neuromuscular disorders, such as hemiplegia and Duchenne muscular dystrophy. Thoraco-abdominal asynchrony (TAA) refers to the lack of coordination between the rib cage and abdominal movements, characterized by a time delay in their expansion. Motion capture systems, like optoelectronic plethysmography (OEP), are commonly employed to assess these asynchronous movements. However, alternative technologies able to capture chest wall movements without physical contact, such as RGB digital cameras and time-of-flight digital cameras, can also be utilized due to their accessibility, affordability, and non-invasive nature. This study explores the possibility of using a single RGB digital camera to record the kinematics of the thoracic and abdominal regions by placing four non-reflective markers on the torso. In order to choose the positions of these markers, we previously investigated the movements of 89 chest wall landmarks using OEP. Laboratory tests and volunteer experiments were conducted to assess the viability of the proposed system in capturing the kinematics of the chest wall and estimating various time-related respiratory parameters (i.e., fR, Ti, Te, and Ttot) as well as TAA indexes. The results demonstrate a high level of agreement between the detected chest wall kinematics and the reference data. Furthermore, the system shows promising potential in estimating time-related respiratory parameters and identifying phase shifts indicative of TAA, thus suggesting its feasibility in detecting abnormal chest wall movements without physical contact with a single RGB camera.
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Affiliation(s)
| | | | - Sergio Silvestri
- Unit of Measurements and Biomedical Instrumentation, Università Campus Bio-Medico di Roma, 00128 Rome, Italy; (N.M.); (E.S.); (C.M.)
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Higashino M, Miyata K, Kudo K. Coordination dynamics of thoracic and abdominal movements during voluntary breathing. Sci Rep 2022; 12:13266. [PMID: 35918415 PMCID: PMC9345990 DOI: 10.1038/s41598-022-17473-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 07/26/2022] [Indexed: 11/15/2022] Open
Abstract
Thoracic and abdominal movements can be tightly coupled during voluntary breathing, such as when singing and playing wind instruments. The present study investigated the coordination of thoracic and abdominal movements during voluntary breathing using a dynamical systems approach. We examined whether there are two stable coordination patterns, and if the coordination pattern would abruptly change when the breathing frequency increased, which is known as phase transition. The participants inhaled and exhaled repeatedly at 7.5, 15, 30, 60, or 120 breaths per minute. At the beginning and end of the experiment, the participants performed breathing at their preferred frequency. As a result, the coordination pattern at the lower and preferred frequencies exhibited an in-phase pattern. When breathing frequency increased, participants showed deviated coordination patterns from the in-phase pattern to either a thoracic-leading pattern, an abdominal-leading pattern, or an anti-phase pattern depending on the individual. These deviations occurred gradually; thus, phase transition was not observed. Our findings suggest that thoracic and abdominal movements are tightly coupled at lower frequencies, but their patterns vary depending on the breathing frequency and individuals. Therefore, the present study suggests the importance of viewing breath control in terms of coordination of thoracic and abdominal movements.
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Affiliation(s)
- Mimu Higashino
- Graduate School of Interdisciplinary Information Studies, The University of Tokyo, 3-8-1, Komaba, Meguro, Tokyo, 153-8902, Japan
| | - Kohei Miyata
- Graduate School of Arts and Sciences, The University of Tokyo, 3-8-1, Komaba, Meguro, Tokyo, 153-8902, Japan.
| | - Kazutoshi Kudo
- Graduate School of Interdisciplinary Information Studies, The University of Tokyo, 3-8-1, Komaba, Meguro, Tokyo, 153-8902, Japan. .,Graduate School of Arts and Sciences, The University of Tokyo, 3-8-1, Komaba, Meguro, Tokyo, 153-8902, Japan.
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Measurement of chest wall motion using a motion capture system with the one-pitch phase analysis method. Sci Rep 2021; 11:21497. [PMID: 34728740 PMCID: PMC8563798 DOI: 10.1038/s41598-021-01033-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 09/24/2021] [Indexed: 11/26/2022] Open
Abstract
Spirometry is a standard method for assessing lung function. However, its use is challenging in some patients, and it has limitations such as risk of infection and inability to assess regional chest wall motion. A three-dimensional motion capture system using the one-pitch phase analysis (MCO) method can facilitate high precision measurement of moving objects in real-time in a non-contacting manner. In this study, the MCO method was applied to examine thoraco-abdominal (TA) wall motion for assessing pulmonary function. We recruited 48 male participants, and all underwent spirometry and chest wall motion measurement with the MCO method. A significant positive correlation was observed between the vital capacity (Spearman’s ρ = 0.68, p < 0.0001), forced vital capacity (Spearman’s ρ = 0.62, p < 0.0001), and tidal volume (Spearman’s ρ = 0.61, p < 0.0001) of spirometry and the counterpart parameters of MCO method. Moreover, the MCO method could detect regional rib cage and abdomen compartment contributions and could assess TA asynchrony, indicating almost complete synchronous movement (phase angle for each compartment: − 5.05° to 3.86°). These findings suggest that this technique could examine chest wall motion, and may be effective in analyzing chest wall volume changes and pulmonary function.
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Mohning MP. An uncoordinated effort: A new mechanism of exercise intolerance in fibrotic interstitial lung disease. Respirology 2021; 26:634-635. [PMID: 34002423 DOI: 10.1111/resp.14087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/10/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Michael P Mohning
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, USA
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Santana PV, Cardenas LZ, Ferreira JG, de Carvalho CRR, de Albuquerque ALP, Caruso P. Thoracoabdominal asynchrony associates with exercise intolerance in fibrotic interstitial lung diseases. Respirology 2021; 26:673-682. [PMID: 33860975 DOI: 10.1111/resp.14064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/07/2021] [Accepted: 03/31/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVE The precise coordination of respiratory muscles during exercise minimizes work of breathing and avoids exercise intolerance. Fibrotic interstitial lung disease (f-ILD) patients are exercise-intolerant. We assessed whether respiratory muscle incoordination and thoracoabdominal asynchrony (TAA) occur in f-ILD during exercise, and their relationship with pulmonary function and exercise performance. METHODS We compared breathing pattern, respiratory mechanics, TAA and respiratory muscle recruitment in 31 f-ILD patients and 31 healthy subjects at rest and during incremental cycle exercise. TAA was defined as phase angle (PhAng) >20°. RESULTS During exercise, when compared with controls, f-ILD patients presented increased and early recruitment of inspiratory rib cage muscle (p < 0.05), and an increase in PhAng, indicating TAA. TAA was more frequent in f-ILD patients than in controls, both at 50% of the maximum workload (42.3% vs. 10.7%, p = 0.01) and at the peak (53.8% vs. 23%, p = 0.02). Compared with f-ILD patients without TAA, f-ILD patients with TAA had lower lung volumes (forced vital capacity, p < 0.01), greater dyspnoea (Medical Research Council > 2 in 64.3%, p = 0.02), worse exercise performance (lower maximal work rate % predicted, p = 0.03; lower tidal volume, p = 0.03; greater desaturation and dyspnoea, p < 0.01) and presented higher oesophageal inspiratory pressures with lower gastric inspiratory pressures and higher recruitment of scalene (p < 0.05). CONCLUSION Exercise induces TAA and higher recruitment of inspiratory accessory muscle in ILD patients. TAA during exercise occurred in more severely restricted ILD patients and was associated with exertional dyspnoea, desaturation and limited exercise performance.
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Affiliation(s)
- Pauliane Vieira Santana
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
| | - Leticia Zumpano Cardenas
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
| | - Jeferson George Ferreira
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
| | - Carlos Roberto Ribeiro de Carvalho
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - André Luis Pereira de Albuquerque
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Sírio-Libanês Teaching and Research Institute, Hospital Sírio Libanês, São Paulo, SP, Brazil
| | - Pedro Caruso
- Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
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Pinto TF, Fagundes Xavier R, Lunardi AC, Marques da Silva CCB, Moriya HT, Lima Vitorasso R, Torsani V, Amato MBP, Stelmach R, Salge JM, Carvalho-Pinto RM, Carvalho CR. Effects of elastic tape on thoracoabdominal mechanics, dyspnea, exercise capacity, and physical activity level in nonobese male subjects with COPD. J Appl Physiol (1985) 2020; 129:492-499. [DOI: 10.1152/japplphysiol.00690.2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Elastic tape can be used as a new and low-cost intervention to reduce thoracoabdominal asynchrony and sedentary behavior as well as improve exercise capacity and physical activity level in nonobese male subjects with severe-to-very severe chronic obstructive pulmonary disease.
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Affiliation(s)
- Thiago Fernandes Pinto
- Department of Physical Therapy, Medical School, University of São Paulo, São Paulo, Brazil
| | | | | | | | - Henrique Takachi Moriya
- Biomedical Engineering Laboratory, Escola Politécnica, University of São Paulo, São Paulo, Brazil
| | - Renato Lima Vitorasso
- Biomedical Engineering Laboratory, Escola Politécnica, University of São Paulo, São Paulo, Brazil
| | - Vinicius Torsani
- Pulmonary Division, Heart Institute (InCor), Clinics Hospital, Medical School, University of São Paulo, São Paulo, Brazil
| | - Marcelo Brito Passos Amato
- Pulmonary Division, Heart Institute (InCor), Clinics Hospital, Medical School, University of São Paulo, São Paulo, Brazil
| | - Rafael Stelmach
- Pulmonary Division, Heart Institute (InCor), Clinics Hospital, Medical School, University of São Paulo, São Paulo, Brazil
| | - João Marcos Salge
- Pulmonary Division, Heart Institute (InCor), Clinics Hospital, Medical School, University of São Paulo, São Paulo, Brazil
| | - Regina Maria Carvalho-Pinto
- Pulmonary Division, Heart Institute (InCor), Clinics Hospital, Medical School, University of São Paulo, São Paulo, Brazil
| | - Celso R.F. Carvalho
- Department of Physical Therapy, Medical School, University of São Paulo, São Paulo, Brazil
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