Effect of a Pulmonary Rehabilitation Program on the levels of anxiety and depression and on the quality of life of patients with chronic obstructive pulmonary disease

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Silveira Martins, 655 ap. 905, Novo Hamburgo, RS, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Universidade Federal do Rio Grande do Sul, Center for Health Sciences, Universidade Feevale, Rua Caeté, 200 ap. 34, Novo Hamburgo, RS, Brazil" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Universidade do Vale do Sinos, Center for Health Sciences, Universidade Feevale, Rua Adolfo Jaeger, 44 ap. 201, Novo Hamburgo, RS, Brazil" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Universidade Federal do Rio Grande do Sul, Center for Health Sciences, Universidade Feevale, RS, Brazil" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Department of Physiotherapy, Universidade Federal de Ciências da Saúde de Porto Alegre, Av. Itajaí, 368 ap. 301, Porto Alegre, RS, Brazil" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Department of Medical Clinic, Pulmonology, Universidade Federal de Ciências da Saúde de Porto Alegre, ERS 239, 2755, Novo Hamburgo, RS, Brazil" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Efeito de um Programa de Reabilitação Pulmonar nos níveis de ansiedade e depressão e na qualidade de vida de pacientes com doença pulmonar obstrutiva crônica" ] ] "textoCompleto" => "IntroductionIn the past few years, interest in assessing quality of life of patients with chronic illnesses has increased. This is especially true of health matters supported by the understanding of fundamental needs, material and spiritual, and referring to the ability of living without illness or overcoming difficulties due to morbid conditions. Quality of life related to health is defined, therefore, as the value given to life span, when modified by the perception of physical, psychological, and social limitations and limited opportunities, which are influenced by illness or health problems.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Patients with chronic obstructive pulmonary disease (COPD) show changes in pulmonary function, dyspnea, and peripheral muscle dysfunction. These factors lead to intolerance to exercise and progressive worsening of physical conditioning, even limiting daily activities. This can lead to social isolation, anxiety, depression, and dependence. Physical disability, loss of productivity, and decrease in quality of life are substantially aggravated by the progression of COPD.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Anxiety and depression are important psychiatric disorders in patients with COPD, showing percentages that vary, respectively, from 21% to 96% and from 27% to 79%.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> The depressive symptoms have been associated with reduced quality of life, longer hospital stay, more frequent readmissions, and even higher mortality rates.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Documents in the literature show that Pulmonary Rehabilitation Programs (PRP) promote improvements in functional exercise capacity and quality of life, and reduce the sensation of breathlessness, frequency and duration of hospitalizations, apart from reducing the frequency of exacerbations.<a class="elsevierStyleCrossRefs" href="#bib0015">3,5–9</a> The goal of this study was to evaluate the effect of a Pulmonary Rehabilitation Program (PRP) on the levels of anxiety and depression and the quality of life of patients with chronic obstructive pulmonary disease.MethodsIn a prospective, study, which included 147 patients with COPD, 22 patients were not considered for research purposes, as they did not conclude the program. The remaining 125 patients with the diagnosis of COPD who completed the PRP at Universidade Feevale in Novo Hamburgo – RS in the period between May 2007 and December 2011 were analyzed. The diagnosis of COPD was made according to GOLD (Global Initiative for Chronic Obstructive Lung Disease) using clinical history, physical examinations, and the confirmation of airflow obstruction through the ratio of forced expiratory volume in the first second (FEV1) to forced vital capacity (FVC) as less than 70% of predicted. All patients presented moderate to severe COPD defined by a FEV1<60% of the predicted value after using a bronchodilator.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>The PRP lasted 12 weeks, and was held on Mondays, Wednesdays, and Fridays, in the morning. The sessions lasted 2h on average, divided into physical activities and educational lectures. They consisted of a warm-up, aerobic physical exercise using a treadmill, upper and lower body strengthening exercises, and stretching. All assessments were made when the patients entered the program, before beginning treatment, and after finishing it.Apart from the activities above, the patients took part in weekly educational lectures with an interdisciplinary team on the following topics: anatomy and pulmonary physiology, COPD physiopathology, recognizing exacerbation symptoms, purpose and proper use of medications, airway management, energy conservation techniques, oxygen therapy, benefits of the exercises, nutrition, as well as a support group coordinated by the psychologist. Relatives were also invited to participate in these activities. The Beck Scales for Anxiety and Depression (BDI and BAI), each having 21 items with four options each, were used to measure levels of anxiety and depression in these patients. The options referred to are minimum depression levels (score from 0 to 11), mild (from 12 to 19), moderate (from 20 to 35), and severe (from 36 to 63); minimum anxiety levels (score from 0 to 10), mild (from 11 to 19), moderate (from 20 to 30), and severe (from 31 to 63).<a class="elsevierStyleCrossRef" href="#bib0055">11</a>Saint George's Respiratory Questionnaire (SGRQ), previously translated and validated in Brazil in patients with COPD,<a class="elsevierStyleCrossRef" href="#bib0060">12</a> was used to assess quality of life. The questionnaire consists of 3 domains – symptoms, activities, and impact – with scores from 0 to 100, the highest score representing poor quality of life in any one of the domains in the total calculation. A decrease of 4% in any domain was considered a clinically significant difference.All patients signed the term of informed consent. The study began after approval by the ethics committee of Universidade Feevale, process number 4.08.03.08.1239.All variables studied are presented through descriptive statistics with means and standard deviation. For variables with normal distribution, comparing pre- and post-PRP values, the Student t test and the Pearson test were used for correlation with the other variables. The value of statistical significance was considered to be p≤0.05.ResultsA total of 125 patients with COPD of both genders were analyzed, of which 61.6% were male. The age average of patients was 63.89±8.8 years and, in relation to the severity of the illness, all patients could be assigned to moderate or severe COPD stages, with average FEV1 of 1.16±0.6L (43.29±18.6% predicted). In relation to smoking index, according to number of packs/year, most of the patients were stratified in the range of >50≤100. The body mass index (BMI) remained similar in pre- and post-PRP, but the distance covered in the six-minute walk test (6MWT) was significantly greater post-PRP, as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Regarding the results of the anxiety and depression variables, we obtained (10.15±6.32 vs. 7.67±7.21; Δ=2.48 p=0.0041) and (12.60±7.99 vs. 8.96±7.29; Δ=3.64 p=0.00016) as averages of BAI and BDI before and after PRP, respectively, demonstrating improvement in anxiety and depression after PRP. When analyzing <a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>, we observed that participation in the PRP led to a decrease in the levels of anxiety and depression of the patients (57.6% before PRP and 73.6% after PRP). Only one patient reported an increase in anxiety levels considered severe after PRP. It was the same in patients with depression: before PRP there were 55.2% with a minimum level and after PRP, 80.0%. In this particular variable analyzed in this study, we were able to see more specifically that there was a decrease in the moderate level, where before PRP we had 12.8% and after it was 3.3%. This pattern of behavior in patients was similar in relation to decrease in anxiety and depression levels.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>In the quality of life assessed by the SGRQ, we observed a decrease in all domains, including the total, which demonstrates a significant clinical improvement in these patients, before and after PRP. The results of the domains of the SGRQ before and after PRP were, respectively: Symptoms (48.53±20.41 vs. 32.58±18.95; Δ=15.9), Activity (69.15±20.79 vs. 52.42±23.70; Δ=16.7), Impact (32.92±18.29 vs. 20.27±16.70; Δ=12.6), Total (46.69±16.90 vs. 32.07±16.96; Δ=14.6). The activities domain, above all, showed greater variation (Δ 16.7); this domain was closely connected to physical performance, developed during PRP.When correlating the variations of the domains of the SGRQ to the variations of the BDI and BAI, the symptoms and activities domains showed weak, although statistically significant, correlations, (r=0.22; p=0.01 r=0.28; p=0.001), and (r=0.2; p=0.0009 r=0.32; p=0.0005), respectively. The impact domain and the total score showed moderate correlations, although with no statistical significance, as shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionOne of the main goals in treating COPD patients is maintaining the quality of life that is determined by several factors, such as gender, rates of illness severity, parameters of pulmonary function, exercise capacity, and performing daily life activities, among others.<a class="elsevierStyleCrossRefs" href="#bib0065">13–15</a>Many of these variables have been assessed in Pulmonary Rehabilitation Programs, demonstrating an increase in quality of life after this type of intervention.<a class="elsevierStyleCrossRefs" href="#bib0080">16–18</a> However, a recent systematic review demonstrated that the factors that correlated the most to the health status of these individuals were dyspnea, depression, anxiety, and exercise tolerance.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> The data analyzed in this study demonstrated that depression and anxiety in patients with COPD decreased after participating in a PRP and this reflected, consequently, improvement in their quality of life. However, the correlations of symptoms and activities domains of the SGRQ with the variables assessed by the Beck inventories were weak, but statistically significant (p<0.01).In this way, we were able to see that the reduction of symptoms caused by the illness and improvement in activities had a positive influence on anxiety and depression, reducing the percentage of patients classified as having mild, moderate, and severe disorders, to minimum level disorders (Anxiety before PRP 57.5% and after PRP 73.5%; Depression before PRP 55.1% and after PRP 80.4%), even though no specific and individualized interventions were carried out with members of the group. This improvement was obtained exclusively by multidisciplinary treatment that included physical training, educational sessions about the illness, and a psychological support team. Godoy and Godoy (2003) in a randomized study demonstrated that individualized psychotherapy permitted more significant improvement in anxiety and depression scores, unlike that in the control group, which only had physical training.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>One study analyzed patients with COPD who spent 64% of their time sitting or lying down, and compared them to healthy individuals of the same age group who spent more than half of their time standing or walking.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> Due to this situation, many patients become heavily dependent on their families, which results in reinforcing their feeling of helplessness and contributes to a decrease in self esteem, consequently generating more anxious and depressive patients.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> This fits in with the variables in our study, where the vast majority of the patients who entered the PRP had high levels of anxiety and depression, which were reduced after the intervention. Patients with COPD have reactive depression that can precede or be triggered by a variety of changes in lifestyle; the intensity and duration will depend on the value each individual gives to this change, mainly in daily life activities.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>When we analyze quality of life in relation to the SGQR domains in our study, we can observe that, the activities domain showed a greater variation compared to the others (Δ 16.7). However in a study where two questionnaires were used to assess quality of life, among them the SGQR, the domain with the greatest variation was impact (Δ 28.64), which also correlated significantly to the BDI (p<0.01). This was not observed with the data collected in this study, although there was moderate correlation (p=7.33).<a class="elsevierStyleCrossRef" href="#bib0120">24</a> However, in a study developed with 81 patients with COPD the conclusion reached was that changes in the BAI were not significantly associated with changes in the domains of SGQR.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>In another study, exercise capability, quality of life, and psychic suffering were assessed in 134 patients with COPD after 4 weeks of training in a Pulmonary Rehabilitation Program, confirming that this intervention improved quality of life, exercise capability, and reduced depression in these patients.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> A further study confirmed that depressed patients with COPD have an almost three times greater risk of exacerbation of the respiratory illness, in comparison with non-depressed patients.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> In two other studies a strong association between the presence of depressive symptoms and the increase of exacerbation rates was identified.<a class="elsevierStyleCrossRefs" href="#bib0135">27,28</a> In this way, the symptoms of anxiety and depression can have even more negative consequences on patients with COPD.The quality of life, as well as recognition of all the factors that influence it, is extremely important for elaborating medical and non-medical interventions. As pulmonary rehabilitation is a multidisciplinary approach, which includes physical training as a strategy for recovering independence and execution of daily life activities, the extended duration of this intervention potentially offers greater benefits, but is not economically feasible.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> Godoy et al. (2009) analyzed the effects after 24 months of a PRP on levels of anxiety, depression, quality of life, and physical performance in 30 patients with COPD. They concluded that the benefits obtained from PRP at these levels lasted throughout the 24 months, even with lower values.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>A major limitation of this study was not using a specific instrument for assessing the daily life activities of patients before and after the PRP. However, the SGQR questionnaire gives the information as perceived by the patients themselves regarding their illness in its domains, and the fact that the activities domain was the one with the greatest variation indicates improvement in their execution of these activities.We can conclude that the PRP was able to improve rates of anxiety and depression and quality of life in patients with COPD, and also made it possible to observe a weak, but significant, correlation between anxiety and depression rates and the symptoms and activities domains, highlighting dyspnea as a cardinal symptom in COPD and loss of capacity in performing daily life activities as a fundamental component of the illness.Ethical disclosuresProtection of human and animal subjectsThe authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.Right to privacy and informed consentThe authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres549680" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec567274" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres549679" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec567275" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-12-10" "fechaAceptado" => "2014-03-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec567274" "palabras" => array:5 [ 0 => "COPD" 1 => "Pulmonary rehabilitation" 2 => "Anxiety" 3 => "Depression" 4 => "Quality of life" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec567275" "palabras" => array:5 [ 0 => "DPOC" 1 => "Reabilitação pulmonar" 2 => "Ansiedade" 3 => "Depressão" 4 => "Qualidade de vida" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo analyze the effect of a Pulmonary Rehabilitation Program (PRP) on the levels of anxiety and depression and the quality of life of patients with chronic obstructive pulmonary disease. MethodPatients with chronic obstructive pulmonary disease (COPD) who completed the PRP of 3 weekly sessions of 60min duration for 12 weeks, a total of 36 sessions, were assessed using Beck Inventory (BAI and BDI) and Saint George's Respiratory Questionnaire (SGRQ). ResultsA total of 125 individuals, with an average age of 63.7±8.8 years, FEV1: 1.17±0.57L (43.18±18.79% predicted), 61.6% male and 38.4% female, were analyzed. The BAI and BDI before and after PRP were, respectively, 10.15±6.32 vs. 7.67±7.21; p=0.0041 and 12.60±7.99 vs. 8.96±7.29; p=0.00016. The results of the SGRQ domains were, respectively, Before and After symptoms (48.53±20.41 vs. 32.58±18.95), Activity (69.15±20.79 vs. 52.42±23.70), Impact (32.92±18.29 vs. 20.27±16.70), Total (46.69±16.90 vs. 32.07±16.96). When correlating the BDI to the domains of the SGRQ, weak correlations were observed (Symptoms r=0.22; p=0.01; Activity r=0.28; p=0.001; Impact r=0.52; p=2.72; Total r=0.44; p=0.17). In the same way, weak correlations were observed when correlating the BAI to the SGRQ (Symptoms r=0.28; p=0.0009; Activity r=0.32; p=0.0005; Impact r=0.42; p=7.33; Total r=0.43; p=0.74). ConclusionAlthough the PRP improves levels of depression and anxiety as well as the quality of life in patients with COPD, no significant correlation of these analyzed variables was observed." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "ObjetivoAnalisar o efeito de um programa de reabilitação pulmonar (PRP) nos níveis de ansiedade e depressão e na qualidade de vida de doentes com doença pulmonar obstrutiva crónica (DPOC). MétodoOs doentes com DPOC que completaram o PRP de 3 sessões semanais de 60 minutos de duração, durante 12 semanas, num total de 36 sessões, foram avaliados usando o Inventário de Beck (BAI e BDI) e o Questionário Saint George na Doença Respiratória (SGRQ). ResultadosForam analisados 125 doentes com uma idade média de 63,7±8,8, FEV1: 1,17±0,57L (43,18±18,79% previsto), 61,6% homens e 38,4% mulheres. O BAI e o BDI antes e depois do PRP foram, respectivamente, 10,15±6,32 vs. 7,67±7,21; p=0,0041 e 12,60±7,99 vs. 8,96±7,29; p=0,00016. Os resultados dos domínios do SGRQ foram, respectivamente, antes e depois dos sintomas (48,53±20,41 vs. 32,58±18,95), Atividade (69,15±20,79 vs. 52,42±23,70), Impacto (32,92±18,29 vs. 20,27±16,70), Total (46,69±16,90 vs. 32,07±16,96). Quando correlacionámos o BDI aos domínios do SGRQ, foram observadas ligeiras correlações (Sintomas r=0,22; p=0,01; Atividade r=0,28; p=0,001; Impacto r=0,52; p=2,72; Total r=0,44; p=0,17). Também foram observadas correlações ligeiras quando correlacionamos o BAI com o SGRQ (Sintomas r=0,28; p=0,0009; Atividade r=0,32; p=0,0005; Impacto r=0,42; p=7,33; Total r=0,43; p=0,74). ConclusãoApesar de o PRP melhorar os níveis de depressão e ansiedade, bem como os níveis de qualidade de vida dos doentes com DPOC, não foram observadas correlações significativas destas variáveis analisadas." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusão" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "PRP, Pulmonary Rehabilitation Program; FVC, forced vital capacity; FEV1, forced expiratory volume in the first second; BMI, Body Mass Index, m, meters, kg/m2, kilograms per square meter; 6MWT, six-minute walk test, n, number." "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">Before PRP \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">After PRP \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Age \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">63.89±8.88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Sex</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">FVC (L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.25±0.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">FVC (% of the predict) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65.6±21.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">FEV1(L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.16±0.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">FEV1(% of the predict) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43.29±18.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Pack/years (n)</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">0 (32) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">≤30 (29) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.9±9.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">>30≤50 (20) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.2±5.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">>50≤100 (33) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76.1±14.92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">>100≤150 (7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">126.9±17.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">>150≤360 (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">217.6±95.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " 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">26.09±5.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.94±4.79 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">6MWT (m) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">397.13±95.89 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">452.11±94.28<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab887994.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "p≤0.001 (test T de Student)." ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of 125 patients with COPD treated in the pulmonary rehabilitation program." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "BAI, beck anxiety inventory; BDI, beck depression inventory." "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 " colspan="2" align="center" valign="top" scope="col">BAI</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col">BDI</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Before \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">After \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Before \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">After \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">10.15±6.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.67±7.21<a class="elsevierStyleCrossRef" href="#tblfn0015">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.60±7.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.96±7.29<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab887995.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "*" "nota" => "p<0.0041." ] 1 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "**" "nota" => "p<0.00016 (Student T Test matched)." ] ] ] "descripcion" => array:1 [ "en" => "Comparison of results of 125 patients analyzed with BAI and BDI before and after PRP." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "BAI, beck anxiety inventory; BDI, beck depression inventory." "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="left" valign="top" scope="col">Degrees \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">BAI n (%)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">BDI n (%)</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">Before \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">After \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">Before \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">After \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Minimum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72 (57.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92 (73.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 (55.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (80.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mild \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 (28.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (14.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (29.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (16.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (13.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (11.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (12.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (3.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Severe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab887997.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Distribution of 125 patients with COPD according to levels of anxiety and depression before and after the PRP." ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "BAI, beck anxiety inventory; BDI, beck depression inventory." "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="left" valign="top" scope="col" style="border-bottom: 2px solid black">Domains \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">Δ \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">BAI (Δ) \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">r \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">BDI (Δ) \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">r \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" title="table-entry " align="left" valign="top">Symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0009<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Activity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.0005<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.28 \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="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Impact \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.72 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab887996.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "*" "nota" => "p<0.05." ] ] ] "descripcion" => 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Original article

Effect of a Pulmonary Rehabilitation Program on the levels of anxiety and depression and on the quality of life of patients with chronic obstructive pulmonary disease

Efeito de um Programa de Reabilitação Pulmonar nos níveis de ansiedade e depressão e na qualidade de vida de pacientes com doença pulmonar obstrutiva crônica

C.C. da Costaa,

Corresponding author

cassiac@feevale.br
cassiabusch@ig.com.br

Corresponding author.

, C. de Azeredo Lermenb, C. Colomboc, D.B. Canterled, M.L.L. Machadoe, A. Kesslerf,g, P.J.Z. Teixeiraf,h

a Universidade Federal do Rio Grande do Sul, Center for Health Sciences and Coordinator of the Pulmonary Rehabilitation Project, Universidade Feevale, Flores da Cunha, 111 ap. 504, CEP: 93410-110, Novo Hamburgo, RS, Brazil

b Universidade Feevale, Maurício Cardoso, 980 ap. 206, Novo Hamburgo, RS, Brazil

c Universidade Feevale, R. Silveira Martins, 655 ap. 905, Novo Hamburgo, RS, Brazil

d Universidade Federal do Rio Grande do Sul, Center for Health Sciences, Universidade Feevale, Rua Caeté, 200 ap. 34, Novo Hamburgo, RS, Brazil

e Universidade do Vale do Sinos, Center for Health Sciences, Universidade Feevale, Rua Adolfo Jaeger, 44 ap. 201, Novo Hamburgo, RS, Brazil

f Universidade Federal do Rio Grande do Sul, Center for Health Sciences, Universidade Feevale, RS, Brazil

g Department of Physiotherapy, Universidade Federal de Ciências da Saúde de Porto Alegre, Av. Itajaí, 368 ap. 301, Porto Alegre, RS, Brazil

h Department of Medical Clinic, Pulmonology, Universidade Federal de Ciências da Saúde de Porto Alegre, ERS 239, 2755, Novo Hamburgo, RS, Brazil

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show changes in pulmonary function&#44; dyspnea&#44; and peripheral muscle dysfunction&#46; These factors lead to intolerance to exercise and progressive worsening of physical conditioning&#44; even limiting daily activities&#46; This can lead to social isolation&#44; anxiety&#44; depression&#44; and dependence&#46; Physical disability&#44; loss of productivity&#44; and decrease in quality of life are substantially aggravated by the progression of COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Anxiety and depression are important psychiatric disorders in patients with COPD&#44; showing percentages that vary&#44; respectively&#44; from 21&#37; to 96&#37; and from 27&#37; to 79&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The depressive symptoms have been associated with reduced quality of life&#44; longer hospital stay&#44; more frequent readmissions&#44; and even higher mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Documents in the literature show that Pulmonary Rehabilitation Programs &#40;PRP&#41; promote improvements in functional exercise capacity and quality of life&#44; and reduce the sensation of breathlessness&#44; frequency and duration of hospitalizations&#44; apart from reducing the frequency of exacerbations&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#8211;9</span></a> The goal of this study was to evaluate the effect of a Pulmonary Rehabilitation Program &#40;PRP&#41; on the levels of anxiety and depression and the quality of life of patients with chronic obstructive pulmonary disease&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">In a prospective&#44; study&#44; which included 147 patients with COPD&#44; 22 patients were not considered for research purposes&#44; as they did not conclude the program&#46; The remaining 125 patients with the diagnosis of COPD who completed the PRP at Universidade Feevale in Novo Hamburgo &#8211; RS in the period between May 2007 and December 2011 were analyzed&#46; The diagnosis of COPD was made according to GOLD &#40;Global Initiative for Chronic Obstructive Lung Disease&#41; using clinical history&#44; physical examinations&#44; and the confirmation of airflow obstruction through the ratio of forced expiratory volume in the first second &#40;FEV<span class="elsevierStyleInf">1</span>&#41; to forced vital capacity &#40;FVC&#41; as less than 70&#37; of predicted&#46; All patients presented moderate to severe COPD defined by a FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>60&#37; of the predicted value after using a bronchodilator&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The PRP lasted 12 weeks&#44; and was held on Mondays&#44; Wednesdays&#44; and Fridays&#44; in the morning&#46; The sessions lasted 2<span class="elsevierStyleHsp" style=""></span>h on average&#44; divided into physical activities and educational lectures&#46; They consisted of a warm-up&#44; aerobic physical exercise using a treadmill&#44; upper and lower body strengthening exercises&#44; and stretching&#46; All assessments were made when the patients entered the program&#44; before beginning treatment&#44; and after finishing it&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Apart from the activities above&#44; the patients took part in weekly educational lectures with an interdisciplinary team on the following topics&#58; anatomy and pulmonary physiology&#44; COPD physiopathology&#44; recognizing exacerbation symptoms&#44; purpose and proper use of medications&#44; airway management&#44; energy conservation techniques&#44; oxygen therapy&#44; benefits of the exercises&#44; nutrition&#44; as well as a support group coordinated by the psychologist&#46; Relatives were also invited to participate in these activities&#46; 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symptoms&#44; activities&#44; and impact &#8211; with scores from 0 to 100&#44; the highest score representing poor quality of life in any one of the domains in the total calculation&#46; A decrease of 4&#37; in any domain was considered a clinically significant difference&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">All patients signed the term of informed consent&#46; The study began after approval by the ethics committee of Universidade Feevale&#44; process number 4&#46;08&#46;03&#46;08&#46;1239&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">All variables studied are presented through descriptive statistics with means and standard deviation&#46; For variables with normal distribution&#44; comparing pre- and post-PRP values&#44; the Student t test and the Pearson test were used for correlation with the other variables&#46; The value of statistical significance was considered to be <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 125 patients with COPD of both genders were analyzed&#44; of which 61&#46;6&#37; were male&#46; The age average of patients was 63&#46;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;8 years and&#44; in relation to the severity of the illness&#44; all patients could be assigned to moderate or severe COPD stages&#44; with average FEV<span class="elsevierStyleInf">1</span> of 1&#46;16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;6<span class="elsevierStyleHsp" style=""></span>L &#40;43&#46;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;6&#37; predicted&#41;&#46; In relation to smoking index&#44; according to number of packs&#47;year&#44; most of the patients were stratified in the range of &#62;50<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>100&#46; The body mass index &#40;BMI&#41; remained similar in pre- and post-PRP&#44; but the distance covered in the six-minute walk test &#40;6MWT&#41; was significantly greater post-PRP&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Regarding the results of the anxiety and depression variables&#44; we obtained &#40;10&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;32 vs&#46; 7&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;21&#59; <span class="elsevierStyleItalic">&#916;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;48 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0041&#41; and &#40;12&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;99 vs&#46; 8&#46;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;29&#59; <span class="elsevierStyleItalic">&#916;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;64 <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;00016&#41; as averages of BAI and BDI before and after PRP&#44; respectively&#44; demonstrating improvement in anxiety and depression after PRP&#46; When analyzing <a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a>&#44; we observed that participation in the PRP led to a decrease in the levels of anxiety and depression of the patients &#40;57&#46;6&#37; before PRP and 73&#46;6&#37; after PRP&#41;&#46; Only one patient reported an increase in anxiety levels considered severe after PRP&#46; It was the same in patients with depression&#58; before PRP there were 55&#46;2&#37; with a minimum level and after PRP&#44; 80&#46;0&#37;&#46; In this particular variable analyzed in this study&#44; we were able to see more specifically that there was a decrease in the moderate level&#44; where before PRP we had 12&#46;8&#37; and after it was 3&#46;3&#37;&#46; This pattern of behavior in patients was similar in relation to decrease in anxiety and depression levels&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">In the quality of life assessed by the SGRQ&#44; we observed a decrease in all domains&#44; including the total&#44; which demonstrates a significant clinical improvement in these patients&#44; before and after PRP&#46; The results of the domains of the SGRQ before and after PRP were&#44; respectively&#58; Symptoms &#40;48&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;41 vs&#46; 32&#46;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;95&#59; <span class="elsevierStyleItalic">&#916;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#46;9&#41;&#44; Activity &#40;69&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;79 vs&#46; 52&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#46;70&#59; <span class="elsevierStyleItalic">&#916;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#46;7&#41;&#44; Impact &#40;32&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;29 vs&#46; 20&#46;27<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;70&#59; <span class="elsevierStyleItalic">&#916;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#46;6&#41;&#44; Total &#40;46&#46;69<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;90 vs&#46; 32&#46;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;96&#59; <span class="elsevierStyleItalic">&#916;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#46;6&#41;&#46; The activities domain&#44; above all&#44; showed greater variation &#40;<span class="elsevierStyleItalic">&#916;</span> 16&#46;7&#41;&#59; this domain was closely connected to physical performance&#44; developed during PRP&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">When correlating the variations of the domains of the SGRQ to the variations of the BDI and BAI&#44; the symptoms and activities domains showed weak&#44; although statistically significant&#44; correlations&#44; &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;22&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01 <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;28&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; and &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;2&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0009 <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;32&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0005&#41;&#44; respectively&#46; The impact domain and the total score showed moderate correlations&#44; although with no statistical significance&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">One of the main goals in treating COPD patients is maintaining the quality of life that is determined by several factors&#44; such as gender&#44; rates of illness severity&#44; parameters of pulmonary function&#44; exercise capacity&#44; and performing daily life activities&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#8211;15</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Many of these variables have been assessed in Pulmonary Rehabilitation Programs&#44; demonstrating an increase in quality of life after this type of intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#8211;18</span></a> However&#44; a recent systematic review demonstrated that the factors that correlated the most to the health status of these individuals were dyspnea&#44; depression&#44; anxiety&#44; and exercise tolerance&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The data analyzed in this study demonstrated that depression and anxiety in patients with COPD decreased after participating in a PRP and this reflected&#44; consequently&#44; improvement in their quality of life&#46; However&#44; the correlations of symptoms and activities domains of the SGRQ with the variables assessed by the Beck inventories were weak&#44; but statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In this way&#44; we were able to see that the reduction of symptoms caused by the illness and improvement in activities had a positive influence on anxiety and depression&#44; reducing the percentage of patients classified as having mild&#44; moderate&#44; and severe disorders&#44; to minimum level disorders &#40;Anxiety before PRP 57&#46;5&#37; and after PRP 73&#46;5&#37;&#59; Depression before PRP 55&#46;1&#37; and after PRP 80&#46;4&#37;&#41;&#44; even though no specific and individualized interventions were carried out with members of the group&#46; This improvement was obtained exclusively by multidisciplinary treatment that included physical training&#44; educational sessions about the illness&#44; and a psychological support team&#46; Godoy and Godoy &#40;2003&#41; in a randomized study demonstrated that individualized psychotherapy permitted more significant improvement in anxiety and depression scores&#44; unlike that in the control group&#44; which only had physical training&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">One study analyzed patients with COPD who spent 64&#37; of their time sitting or lying down&#44; and compared them to healthy individuals of the same age group who spent more than half of their time standing or walking&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Due to this situation&#44; many patients become heavily dependent on their families&#44; which results in reinforcing their feeling of helplessness and contributes to a decrease in self esteem&#44; consequently generating more anxious and depressive patients&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> This fits in with the variables in our study&#44; where the vast majority of the patients who entered the PRP had high levels of anxiety and depression&#44; which were reduced after the intervention&#46; Patients with COPD have reactive depression that can precede or be triggered by a variety of changes in lifestyle&#59; the intensity and duration will depend on the value each individual gives to this change&#44; mainly in daily life activities&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">When we analyze quality of life in relation to the SGQR domains in our study&#44; we can observe that&#44; the activities domain showed a greater variation compared to the others &#40;<span class="elsevierStyleItalic">&#916;</span> 16&#46;7&#41;&#46; However in a study where two questionnaires were used to assess quality of life&#44; among them the SGQR&#44; the domain with the greatest variation was impact &#40;<span class="elsevierStyleItalic">&#916;</span> 28&#46;64&#41;&#44; which also correlated significantly to the BDI &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; This was not observed with the data collected in this study&#44; although there was moderate correlation &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#46;33&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> However&#44; in a study developed with 81 patients with COPD the conclusion reached was that changes in the BAI were not significantly associated with changes in the domains of SGQR&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In another study&#44; exercise capability&#44; quality of life&#44; and psychic suffering were assessed in 134 patients with COPD after 4 weeks of training in a Pulmonary Rehabilitation Program&#44; confirming that this intervention improved quality of life&#44; exercise capability&#44; and reduced depression in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> A further study confirmed that depressed patients with COPD have an almost three times greater risk of exacerbation of the respiratory illness&#44; in comparison with non-depressed patients&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In two other studies a strong association between the presence of depressive symptoms and the increase of exacerbation rates was identified&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;28</span></a> In this way&#44; the symptoms of anxiety and depression can have even more negative consequences on patients with COPD&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The quality of life&#44; as well as recognition of all the factors that influence it&#44; is extremely important for elaborating medical and non-medical interventions&#46; As pulmonary rehabilitation is a multidisciplinary approach&#44; which includes physical training as a strategy for recovering independence and execution of daily life activities&#44; the extended duration of this intervention potentially offers greater benefits&#44; but is not economically feasible&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Godoy et al&#46; &#40;2009&#41; analyzed the effects after 24 months of a PRP on levels of anxiety&#44; depression&#44; quality of life&#44; and physical performance in 30 patients with COPD&#46; They concluded that the benefits obtained from PRP at these levels lasted throughout the 24 months&#44; even with lower values&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">A major limitation of this study was not using a specific instrument for assessing the daily life activities of patients before and after the PRP&#46; However&#44; the SGQR questionnaire gives the information as perceived by the patients themselves regarding their illness in its domains&#44; and the fact that the activities domain was the one with the greatest variation indicates improvement in their execution of these activities&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">We can conclude that the PRP was able to improve rates of anxiety and depression and quality of life in patients with COPD&#44; and also made it possible to observe a weak&#44; but significant&#44; correlation between anxiety and depression rates and the symptoms and activities domains&#44; highlighting dyspnea as a cardinal symptom in COPD and loss of capacity in performing daily life activities as a fundamental component of the illness&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of human and animal subjects</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association &#40;Declaration of Helsinki&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article&#46; The corresponding author is in possession of this document&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the effect of a Pulmonary Rehabilitation Program &#40;PRP&#41; on the levels of anxiety and depression and the quality of life of patients with chronic obstructive pulmonary disease&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients with chronic obstructive pulmonary disease &#40;COPD&#41; who completed the PRP of 3 weekly sessions of 60<span class="elsevierStyleHsp" style=""></span>min duration for 12 weeks&#44; a total of 36 sessions&#44; were assessed using Beck Inventory &#40;BAI and BDI&#41; and <span class="elsevierStyleItalic">Saint George&#39;s Respiratory Questionnaire</span> &#40;SGRQ&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 125 individuals&#44; with an average age of 63&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;8 years&#44; FEV<span class="elsevierStyleInf">1</span>&#58; 1&#46;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;57<span class="elsevierStyleHsp" style=""></span>L &#40;43&#46;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;79&#37; predicted&#41;&#44; 61&#46;6&#37; male and 38&#46;4&#37; female&#44; were analyzed&#46; The BAI and BDI before and after PRP were&#44; respectively&#44; 10&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;32 vs&#46; 7&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;21&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0041 and 12&#46;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;99 vs&#46; 8&#46;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;29&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;00016&#46; The results of the SGRQ domains were&#44; respectively&#44; Before and After symptoms &#40;48&#46;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;41 vs&#46; 32&#46;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;95&#41;&#44; Activity &#40;69&#46;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;79 vs&#46; 52&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#46;70&#41;&#44; Impact &#40;32&#46;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;29 vs&#46; 20&#46;27<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;70&#41;&#44; Total &#40;46&#46;69<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;90 vs&#46; 32&#46;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;96&#41;&#46; When correlating the BDI to the domains of the SGRQ&#44; weak correlations were observed &#40;Symptoms <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;22&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#59; Activity <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;28&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; Impact <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;52&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;72&#59; Total <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;44&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;17&#41;&#46; In the same way&#44; weak correlations were observed when correlating the BAI to the SGRQ &#40;Symptoms <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;28&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0009&#59; Activity <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;32&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0005&#59; Impact <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;42&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#46;33&#59; Total <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;43&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;74&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Although the PRP improves levels of depression and anxiety as well as the quality of life in patients with COPD&#44; no significant correlation of these analyzed variables was observed&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Method"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
          ]
        ]
      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analisar o efeito de um programa de reabilita&#231;&#227;o pulmonar &#40;PRP&#41; nos n&#237;veis de ansiedade e depress&#227;o e na qualidade de vida de doentes com doen&#231;a pulmonar obstrutiva cr&#243;nica &#40;DPOC&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Os doentes com DPOC que completaram o PRP de 3 sess&#245;es semanais de 60 minutos de dura&#231;&#227;o&#44; durante 12 semanas&#44; num total de 36 sess&#245;es&#44; foram avaliados usando o Invent&#225;rio de Beck &#40;BAI e BDI&#41; e o <span class="elsevierStyleItalic">Question&#225;rio Saint George na Doen&#231;a Respirat&#243;ri</span>a &#40;SGRQ&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Foram analisados 125 doentes com uma idade m&#233;dia de 63&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;8&#44; FEV<span class="elsevierStyleInf">1</span>&#58; 1&#44;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#44;57<span class="elsevierStyleHsp" style=""></span>L &#40;43&#44;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;79&#37; previsto&#41;&#44; 61&#44;6&#37; homens e 38&#44;4&#37; mulheres&#46; O BAI e o BDI antes e depois do PRP foram&#44; respectivamente&#44; 10&#44;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;32 vs&#46; 7&#44;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;21&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0041 e 12&#44;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;99 vs&#46; 8&#44;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#44;29&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00016&#46; Os resultados dos dom&#237;nios do SGRQ foram&#44; respectivamente&#44; antes e depois dos sintomas &#40;48&#44;53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#44;41 vs&#46; 32&#44;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;95&#41;&#44; Atividade &#40;69&#44;15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#44;79 vs&#46; 52&#44;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>23&#44;70&#41;&#44; Impacto &#40;32&#44;92<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#44;29 vs&#46; 20&#44;27<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;70&#41;&#44; Total &#40;46&#44;69<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;90 vs&#46; 32&#44;07<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#44;96&#41;&#46; Quando correlacion&#225;mos o BDI aos dom&#237;nios do SGRQ&#44; foram observadas ligeiras correla&#231;&#245;es &#40;Sintomas r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;22&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#59; Atividade r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;28&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#59; Impacto r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;52&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#44;72&#59; Total r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;44&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;17&#41;&#46; Tamb&#233;m foram observadas correla&#231;&#245;es ligeiras quando correlacionamos o BAI com o SGRQ &#40;Sintomas r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;28&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0009&#59; Atividade r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;32&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;0005&#59; Impacto r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;42&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#44;33&#59; Total r<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;43&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;74&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#227;o</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Apesar de o PRP melhorar os n&#237;veis de depress&#227;o e ansiedade&#44; bem como os n&#237;veis de qualidade de vida dos doentes com DPOC&#44; n&#227;o foram observadas correla&#231;&#245;es significativas destas vari&#225;veis analisadas&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#227;o"
          ]
        ]
      ]
    ]
    "multimedia" => array:4 [
      0 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">PRP&#44; Pulmonary Rehabilitation Program&#59; FVC&#44; forced vital capacity&#59; FEV<span class="elsevierStyleInf">1</span>&#44; forced expiratory volume in the first second&#59; BMI&#44; Body Mass Index&#44; m&#44; meters&#44; kg&#47;m<span class="elsevierStyleSup">2</span>&#44; kilograms per square meter&#59; 6MWT&#44; six-minute walk test&#44; <span class="elsevierStyleItalic">n</span>&#44; number&#46;</p>"
          "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">&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">Before PRP&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">After PRP&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" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Age</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">63&#46;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;88&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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="3" align="left" valign="top"><span class="elsevierStyleItalic">Sex</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">61&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">FVC &#40;L&#41;</span>&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;25<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">FVC &#40;&#37; of the predict&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">65&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">FEV</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleItalic">&#40;L&#41;</span>&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;16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">FEV</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleItalic">&#40;&#37; of the predict&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&#46;29<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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="3" 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="3" align="left" valign="top"><span class="elsevierStyleItalic">Pack&#47;years &#40;n&#41;</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0 &#40;32&#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&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8804;30 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;30<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>50 &#40;20&#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;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;50<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>100 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;100<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>150 &#40;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">126&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#62;150<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>360 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&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">Before&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92 &#40;73&#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">69 &#40;55&#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">100 &#40;80&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;14&#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">37 &#40;29&#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">20 &#40;16&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;22&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;01<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;28&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;48&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;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;64&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;48&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;64&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;44&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;17&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
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        0 => array:2 [
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            0 => array:3 [
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Correlation between clinical parameters and quality of life related to health in women with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "N&#46;M&#46; Mangueira"
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Article information

ISSN: 08732159
Original language: English

DOI:10.1016/j.rppneu.2014.03.007

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Year/Month	Html	Pdf	Total

2024 November	5	4	9
2024 October	31	28	59
2024 September	32	15	47
2024 August	68	28	96
2024 July	49	33	82
2024 June	44	33	77
2024 May	45	29	74
2024 April	47	30	77
2024 March	43	27	70
2024 February	48	28	76
2024 January	37	27	64
2023 December	26	19	45
2023 November	35	29	64
2023 October	39	30	69
2023 September	38	37	75
2023 August	37	15	52
2023 July	31	30	61
2023 June	25	15	40
2023 May	46	28	74
2023 April	51	18	69
2023 March	124	23	147
2023 February	56	19	75
2023 January	26	15	41
2022 December	63	21	84
2022 November	69	44	113
2022 October	73	33	106
2022 September	31	24	55
2022 August	41	43	84
2022 July	37	36	73
2022 June	23	28	51
2022 May	35	37	72
2022 April	33	29	62
2022 March	36	47	83
2022 February	31	26	57
2022 January	29	27	56
2021 December	26	33	59
2021 November	33	32	65
2021 October	26	38	64
2021 September	21	36	57
2021 August	25	43	68
2021 July	26	21	47
2021 June	21	29	50
2021 May	23	23	46
2021 April	56	68	124
2021 March	41	18	59
2021 February	47	18	65
2021 January	35	18	53
2020 December	37	5	42
2020 November	36	16	52
2020 October	49	28	77
2020 September	82	19	101
2020 August	91	31	122
2020 July	130	32	162
2020 June	123	28	151
2020 May	120	31	151
2020 April	86	11	97
2020 March	86	22	108
2020 February	96	19	115
2020 January	96	22	118
2019 December	92	25	117
2019 November	111	15	126
2019 October	119	33	152
2019 September	106	32	138
2019 August	281	19	300
2019 July	266	26	292
2019 June	284	26	310
2019 May	318	17	335
2019 April	279	28	307
2019 March	365	33	398
2019 February	285	17	302
2019 January	403	25	428
2018 December	238	9	247
2018 November	80	2	82
2018 October	97	6	103
2018 September	48	6	54
2018 August	47	21	68
2018 July	54	17	71
2018 June	66	14	80
2018 May	94	20	114
2018 April	106	26	132
2018 March	64	18	82
2018 February	24	14	38
2018 January	18	9	27
2017 December	38	17	55
2017 November	31	13	44
2017 October	32	15	47
2017 September	19	16	35
2017 August	18	10	28
2017 July	16	10	26
2017 June	30	19	49
2017 May	33	20	53
2017 April	18	13	31
2017 March	6	8	14
2017 February	9	2	11
2017 January	10	5	15
2016 December	6	5	11
2016 November	5	10	15
2016 October	6	6	12
2016 September	8	9	17
2016 August	8	3	11
2016 July	9	11	20
2016 April	27	8	35
2016 March	50	16	66
2016 February	41	20	61
2016 January	32	16	48
2015 December	34	17	51
2015 November	26	17	43
2015 October	25	14	39
2015 September	30	17	47
2015 August	37	21	58
2015 July	25	7	32
2015 June	22	10	32
2015 May	37	13	50
2015 April	31	12	43
2015 March	31	19	50
2015 February	65	30	95
2015 January	94	50	144
2014 December	81	73	154

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