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a significant relationship between steroid usage and both peripheral and respiratory muscle weakness has been reported in chronic pulmonary disease<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and cystic fibrosis&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> because&#44; in skeletal muscle&#44; corticosteroids decrease the rate of protein synthesis and increase the rate of protein breakdown contributing to atrophy&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;18</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The resulting weakness of peripheral and respiratory muscles may have major clinical implications&#44; such as loss of quality of life&#44; fatigue&#44; impaired wound healing&#44; compromised lung function&#44; and poor immune response&#46; However&#44; it is not known whether these patients suffer neurophysiological changes due to drug effect&#44; 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age between 40 and 60 years&#59; diagnosis of DCA&#59; history of daily symptoms &#40;cough&#44; dyspnea&#44; tightness in chest and wheezing&#41;&#59; nocturnal awakening&#59; continuous limitation of activities&#59; frequent exacerbation&#59; FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>80&#37; of best value exhibited by patient&#59; and symptoms controlled or partially controlled at time of evaluation&#46; The exclusion criteria were regular physical exercise &#40;three or more times a week&#41;&#59; smoking&#59; uncontrolled DCA&#59; and participation in lung rehabilitation program&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patients were divided into two groups&#58; those who used an oral corticosteroid &#40;DCA-C&#59; 12 individuals&#41; and those who used omalizumab &#40;DCA-O&#59; 6 individuals&#41;&#46; A third group made up of 11 healthy subjects paired for age served as the control group &#40;CG&#41;&#59; 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fast blow&#44; while the extension of the knee was observed&#46; For the Achilles reflex&#44; the patient remained in ventral decubitus&#44; with feet dangling off the table and the Achilles tendon slighted tensed by discreet passive dorsiflexion of the foot&#59; the tendon was struck&#44; inducing involuntary plantar flexion<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Assessment of muscle strength</span><p id="par0060" class="elsevierStylePara elsevierViewall">The seated patient performed extension of the knee under resistance at maximal strength capacity&#8211;peak strength of isometric contraction of the dominant quadriceps&#46; The data were collected using a load cell &#40;kg&#47;force&#41; coupled to the electromyographic signal conditioning module&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Assessment of static balance</span><p id="par0065" class="elsevierStylePara elsevierViewall">A force plate &#40;TekScan&#44; MatScan model&#41; measuring 0&#46;50<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;60<span class="elsevierStyleHsp" style=""></span>cm was used&#44; on which oscillations of the force points in relation to velocity and anteroposterior and laterolateral displacement were analyzed&#44; allowing the assessment of balance based on the oscillating center of force&#44; which is the result of these two variables&#46; This measurement system contains 2288 force sensors arranged in rows and columns on the platform and connected to a data acquisition system controlled by the Research Foot 5&#46;60 program &#40;TekScan&#41; for data storage and analysis by the computer&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The participant was instructed to remain in a static position on the platform with feet spaced at shoulder width&#46; After the calibration of the system based on body weight&#44; the participant remained in biped position for 60<span class="elsevierStyleHsp" style=""></span>s with head aligned&#44; concentrating on a fixed point on the wall at eye height without talking&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Sit-to-stand test</span><p id="par0075" class="elsevierStylePara elsevierViewall">For the sit-to-stand test&#44; a standard chair &#40;height&#58; 46<span class="elsevierStyleHsp" style=""></span>cm&#41; with no arms was used&#46; After a demonstration&#44; the participants were instructed to stand up from the chair and sit back down without using their hands&#44; repeating the procedure as many times as possible in one minute at a velocity in which the participants felt safe and comfortable&#46; The number of repetitions was recorded&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Six-minute walk test</span><p id="par0080" class="elsevierStylePara elsevierViewall">The six-minute walk test was performed in a corridor 30<span class="elsevierStyleHsp" style=""></span>m in length and free from pedestrian traffic&#46; The participants were instructed to walk as fast as possible in a six-minute period&#46; During the test&#44; standardized words of encouragement were given each minute&#46; The distance traveled was recorded&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0085" class="elsevierStylePara elsevierViewall">The Shapiro&#8211;Wilk test determined normal distribution for all data&#46; Thus&#44; one-way ANOVA was used for the comparison of mean values between the three groups and Tukey&#39;s DHS test was used for multiple means in the presence of significance&#46; The level of significance was set at 5&#37;&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">Forty individuals with DCA were recruited&#44; eleven were excluded as not meeting the inclusion criteria&#44; three were excluded because of associated respiratory diseases&#44; four were excluded because they were hospitalized and four were excluded as they did not show up for the evaluation&#46; Thus&#44; the total sample with DCA was made up of 18 individuals&#46; Twenty-nine individuals participated in the present study&#44; distributed among three different groups&#58; CG &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41;&#44; DCA-C &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#41; and DCA-O &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&#46; No statistically significant differences were detected between groups with regard to age&#44; weight&#44; height or body mass index &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; thereby demonstrating the homogeneity of the sample &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">No statistically significant differences were detected between groups with regard to neurophysiological aspects &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The CG differed significantly from the DCA groups with regard to functional capacity&#44; achieving a greater number of repetitions on the sit-to-stand test and a longer distance on the six-minute walk test&#46; Regarding muscle strength&#44; as measured by the analysis of the quadriceps muscle&#44; the CG only differed from the DCA-C &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The results revealed that the group that used the oral corticosteroid &#40;DCA-C&#41; had the lowest FEV<span class="elsevierStyleInf">1</span>&#44; achieved the shortest distance on the six-minute walk test and achieved the smallest number of repetitions in the sit-to-stand test&#44; thereby suggesting muscle weakness&#44; which was confirmed by the assessment of quadriceps muscle strength&#46; However&#44; despite exhibiting greater obstructive severity and lower functional capacity&#44; the DCA-C group was similar to the DCA-O and control groups with regard to neurophysiological aspects&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Supplemental oxygen was not needed during the evaluations&#44; as the patients did not exhibit a drop in SpO<span class="elsevierStyleInf">2</span> greater than 4&#37; of the baseline condition or clinical signs that indicated oxygen use&#44; thereby avoiding masking the results obtained&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">No statistically significant differences between groups were found regarding static balance&#44; as assessed by oscillations from the center of pressure on a force plate&#46; There were also no statistically significant differences between groups regarding latency time in the patellar and Achilles reflexes&#46; However&#44; patients with chronic obstructive pulmonary disease &#40;COPD&#41; were found to have motor impairment&#44; reduced reflex response&#44; muscle weakness and lower functional capacity in comparison to healthy subjects&#44; probably due to the sensory-motor impairment caused by hypoxemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;25&#44;26</span></a> Kayacan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> report neurophysiological alterations in 93&#46;8&#37; of patients with COPD and Jann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> report a slight reduction in nerve conduction velocity and a reduction in the amplitude of the action potential of motor units in cases of chronic respiratory failure&#44; suggesting the occurrence of peripheral neuropathy&#46; Although there is evidence that patients with DCA may exhibit physical limitations&#44; this was not true of this study&#44; where no alterations of neurophysiological in these individuals were found&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Ozalevli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> compared the sit-to-stand test with the six-minute walk test and found that the former can determine functional capacity equally well as the latter&#44; with less hemodynamic stress in patients with lung conditions&#46; According to the authors&#44; the sit-to-stand test was also correlated with dyspnea and peripheral muscle strength&#46; The present study corroborates these findings&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Muscle strength differed significantly between the DCA-C and control groups&#44; probably due to fact that the continual use of corticosteroids causes myopathy&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;18</span></a> This finding does not corroborate results reported in a study carried out by Bruin&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> which found that asthmatic patients &#40;mild and moderate&#41; demonstrated no alterations in cross-section area during peak muscle strength generated by the quadriceps in comparison to healthy subjects&#46; Nevertheless&#44; Lim<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> described that prolonged treatment with corticosteroids resulted in important muscle weakness of the quadriceps and respiratory muscle force in patients with asthma and COPD&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Although all patients with DCA demonstrated a reduction in functional capacity&#44; the group treated with omalizumab &#40;DCA-O&#41; did not exhibit a reduction in muscle strength in comparison to the control group&#46; It should be stressed that patients using omalizumab are not susceptible to the diverse side effects of corticosteroids&#44; including skin problems&#44; diabetes mellitus&#44; systemic arterial hypertension&#44; heart failure&#44; osteoporosis&#44; etc&#46;&#44; which leads one to infer that patients who make use of omalizumab appear to benefit more&#46; The disadvantage of omalizumab is its high cost &#40;approximately &#8364; 815&#47;month&#41;&#44; which means that even when offered by the Brazilian public healthcare system&#44; this medication is not freely released and is only distributed in specific centers&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">While no statistically significant differences were detected between groups with regard to neurophysiological aspects&#44; all patients with DCA exhibited a reduction in functional capacity in comparison to the control group &#40;reduction in muscle strength&#44; shorter distance traveled on six-minute walk test and fewer repetitions on sit-to-stand test&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0135" class="elsevierStylePara elsevierViewall">Individuals with DCA exhibited a reduction in functional capacity&#46; The DCA-C group also demonstrated a reduction in muscle strength when compared with the control group&#44; the likely cause being the continual use of corticosteroids&#46; However&#44; no neurophysiological alterations were found in the population studied&#46; These data contribute toward a better understanding of the physical condition of such patients and can be used to improve lung rehabilitation programs for individuals with difficult-to-control asthma&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Electromyographic evaluation"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Due to the inadequate response to inhaled corticosteroids&#44; patients with difficult-to-control asthma &#40;DCA&#41; are submitted to oral corticosteroids or use of omalizumab&#46; Although it is necessary to treat these patients&#44; a significant relationship between steroid usage and both peripheral and respiratory weakness muscle&#44; results in implications&#44; such as loss of quality of life and compromised lung function&#46; Nonetheless&#44; it is not known whether these patients suffer neurophysiological changes due to drug effect&#46;</p> <span class="elsevierStyleSectionTitle">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To investigate the neurophysiological and functional characteristics of patients with DCA in order to gain a better understanding of the condition&#46;</p> <span class="elsevierStyleSectionTitle">Method</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A cross-sectional study was carried out involving three groups of patients&#58; DCA-C &#40;use of oral corticosteroids&#41;&#44; DCA-O &#40;use of omalizumab&#41; and CG &#40;healthy controls matched for age&#41;&#46; The assessment involved the six-minute walk test&#44; sit-to-stand test&#44; static balance on a pressure platform&#44; patellar and Achilles reflexes and quadriceps strength in the dominant leg&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The results revealed no statistically significant differences between the control group and DCA groups in relation to neurophysiological aspects&#46; However&#44; the DCA groups exhibited a significant reduction in functional capacity &#91;decreased muscle strength &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; shorter distance covered on walk test &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and lesser number of repetitions on sit-to-stand test &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#93; in comparison to the control group&#46;</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Individuals with DCA exhibited a reduction in functional capacity&#46; The DCA-C group also demonstrated a reduction in muscle strength when compared with control group&#44; likely caused by the continual use of corticosteroids&#46; However&#44; no neurophysiological alterations were found in the studied population&#46;</p>"
      ]
      "pt" => array:2 [
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        "resumen" => "<span class="elsevierStyleSectionTitle">Introdu&#231;&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Devido &#224; inadequada resposta aos cortic&#243;ides inalat&#243;rios&#44; os pacientes com asma de dif&#237;cil controlo &#40;ADC&#41; s&#227;o submetidos a cortic&#243;ides orais ou uso de omalizumabe&#46; Embora sejam necess&#225;rios para o tratamento desses pacientes&#44; h&#225; uma rela&#231;&#227;o significativa entre o uso de ester&#243;ides e fraqueza muscular perif&#233;rica e respirat&#243;ria&#44; resultando em implica&#231;&#245;es como a perda da qualidade de vida e fun&#231;&#227;o pulmonar comprometida&#46; No entanto&#44; n&#227;o se sabe se estes pacientes sofrem altera&#231;&#245;es neurofisiol&#243;gicas devido ao efeito da droga&#46;</p> <span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Investigar as caracter&#237;sticas neurofisiol&#243;gicas e funcionais de pacientes com ADC&#44; para melhor compreens&#227;o da doen&#231;a&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Foi realizado um estudo transversal em 3 grupos de pacientes&#58; ADCC &#40;que fazem uso de cortic&#243;ide por via oral&#41;&#59; ADCO &#40;que fazem uso do Omalizumab&#41; e GC &#40;controlo saud&#225;vel da mesma idade&#41;&#46; A avalia&#231;&#227;o foi composta pela prova da marcha dos 6 minutos&#44; teste senta-levanta&#44; equil&#237;brio est&#225;tico com a plataforma de press&#227;o&#44; reflexos monossimp&#225;ticos &#40;patelar e aquileu&#41; e a for&#231;a do quadr&#237;ceps do membro inferior dominante&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Embora os resultados em rela&#231;&#227;o aos aspetos neurofisiol&#243;gicos mostrem n&#227;o haver diferen&#231;a estatisticamente significativa entre os grupos controlo e com ADC&#44; deve ser observado que o grupo com ADC&#44; apresentou importante redu&#231;&#227;o da capacidade funcional&#44; quando comparado ao grupo controlo &#40;diminui&#231;&#227;o da for&#231;a muscular &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; diminui&#231;&#227;o da dist&#226;ncia percorrida no teste da caminhada &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; e diminui&#231;&#227;o do n&#250;mero de repeti&#231;&#245;es no teste senta&#47;levanta &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclus&#227;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Indiv&#237;duos com ADC apresentaram redu&#231;&#227;o da capacidade funcional&#46; O grupo ADCC tamb&#233;m demonstrou redu&#231;&#227;o na for&#231;a muscular quando comparado ao grupo controlo&#44; provavelmente causado pelo uso cont&#237;nuo de cortic&#243;ides&#46; No entanto&#44; nenhuma altera&#231;&#227;o neurofisiol&#243;gica foi encontrada na popula&#231;&#227;o estudada&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Ferrari Corr&#234;a JC&#44; et al&#46; Avalia&#231;&#227;o neurofisiol&#243;gica e funcional em pacientes com asma de dificil controle&#46; Rev Port Pneumol&#46; 2012&#46; <span class="elsevierStyleInterRef" href="doi:10.1016/j.rppneu.2012.02.008">http&#58;&#47;&#47;dx&#46;doi&#46;org&#47;10&#46;1016&#47;j&#46;rppneu&#46;2012&#46;02&#46;008</span></p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CG&#58; control group&#59; DCA-O&#58; difficult-to-control asthma with use of omalizumab&#59; DCA-C&#58; difficult-to-control asthma with use of oral corticosteroid&#59; BMI&#58; body mass index&#59; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume in first second&#59; ACQ&#58; asthma control questionnaire&#46; One-way ANOVA and Tukey&#39;s post hoc test&#58; &#42;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&#46;36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Weight &#40;kg&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">62&#46;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>32&#46;79&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#46;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>18&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#46;27<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">29&#46;89<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;62&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">48&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">71&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">97&#46;0<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#46;33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">96&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;83&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Medication time &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">12<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">ACQ&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;1&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">2 &#40;0&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  """
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">CG&#58; control group&#59; DCA-O&#58; difficult-to-control asthma with use of omalizumab&#59; DCA-C&#58; difficult-to-control asthma with use of oral corticosteroid&#59; L-L&#58; laterolateral&#59; A-P&#58; anteroposterior&#59; Strength mm&#58; muscle strength of quadriceps&#59; 6&#8242;WT &#40;m&#41;&#58; six-minute walk test in meters&#59; SST&#58; sit-to-stand test &#40;number of repetitions&#41;&#46; One-way ANOVA and Tukey&#39;s post hoc test&#58; &#42;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>difference between CG and DCA-C &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; <span class="elsevierStyleSup">&#8800;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>difference between CG and DCA-O &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">DCA-C <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">1&#46;37 &#40;&#177;0&#46;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;24 &#40;&#177;1&#46;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;1 &#40;&#177;0&#46;93&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">A-P deviation &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;75 &#40;&#177;1&#46;02&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;46 &#40;&#177;4&#46;57&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;98 &#40;&#177;1&#46;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Patellar reflex &#40;ms&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">34&#46;64 &#40;&#177;5&#46;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">38&#46;67 &#40;&#177;4&#46;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;41 &#40;&#177;2&#46;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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Original article
Neurophysiological and functional assessment of patients with difficult-to-control asthma
Avaliação neurofisiológica e funcional em pacientes com asma de difícil controlo
F. Freitas Canutoa, S.M. Silvab,
Corresponding author
soraia.micaela@uninove.edu.br

Corresponding author.
, L.M. Malosá Sampaioc, R. Stirbulovd, J.C. Ferrari Corrêae
a Unidade de Ciências da Reabilitação, Programa de Pós-Graduação em Ciências da Reabilitação, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
b Unidade de Ciências da Reabilitação, Programa de Pós-Graduação em Ciências da Reabilitação, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
c Programa de Pós-Graduação em Ciências da Reabilitação, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
d Unidade de Disciplina de Pneumologia, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP, Brazil
e Programa de Pós-Graduação em Ciências da Reabilitação, Universidade Nove de Julho (UNINOVE), São Paulo, SP, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Asthma is a chronic inflammatory disease characterized by hyper-sensitivity of the lower airways and a variable degree of airflow limitation&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> Patients generally respond to treatment with inhaled corticosteroids &#40;with or without the addition of long-acting beta agonists or other medications&#41;&#44; with a reduction in inflammation&#44; obstruction and hyper-sensitivity of the airways&#46; However&#44; complete reversibility of the symptoms does not occur in 5&#8211;10&#37; of patients&#46; Severe asthma or difficult-to-control asthma &#40;DCA&#41; is the term employed when asthma is insufficiently controlled for more than six months despite adequate treatment tailored to the level of clinical severity&#44; as indicated by a specialist&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Due to the inadequate response to inhaled corticosteroids&#44; patients with DCA are submitted to oral &#40;systemic&#41; corticosteroids&#44; where the main action is the inhibition of recruitment of inflammatory cells and inhibition of release of pro-inflammatory mediators and cytokines from activated inflammatory and airway epithelial cells&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Another option is the use of omalizumab&#44; an anti-IgE antibody&#44; which works by preventing the attachment of IgE to high affinity receptor thereby avoiding activation of mast cells and basophils&#44; from the initial phase of the allergic response&#44; and blocks the attachment of immunoglobulin to the existing low-affinity receptor in B lymphocytes and in several types celulares&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;12</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although it is necessary for treatment of these patients&#44; a significant relationship between steroid usage and both peripheral and respiratory muscle weakness has been reported in chronic pulmonary disease<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and cystic fibrosis&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> because&#44; in skeletal muscle&#44; corticosteroids decrease the rate of protein synthesis and increase the rate of protein breakdown contributing to atrophy&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;18</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The resulting weakness of peripheral and respiratory muscles may have major clinical implications&#44; such as loss of quality of life&#44; fatigue&#44; impaired wound healing&#44; compromised lung function&#44; and poor immune response&#46; However&#44; it is not known whether these patients suffer neurophysiological changes due to drug effect&#44; but to understand this&#44; it is important to investigate the neurological and functional alterations in individuals with DCA with use of the corticosteroids or omalizumab in order to establish a better directed therapeutic intervention&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of the present study&#44; therefore&#44; was to investigate the neurophysiological and functional characteristics of patients with DCA in order to get a better understanding of the condition and monitoring processes in the pulmonary rehabilitation of such individuals&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">A cross-sectional study was carried out at the Biodynamics of Human Movement Laboratory&#46; The patients were recruited from the Difficult-to-Control Asthma Clinic&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The inclusion criteria were as follows&#58; age between 40 and 60 years&#59; diagnosis of DCA&#59; history of daily symptoms &#40;cough&#44; dyspnea&#44; tightness in chest and wheezing&#41;&#59; nocturnal awakening&#59; continuous limitation of activities&#59; frequent exacerbation&#59; FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>80&#37; of best value exhibited by patient&#59; and symptoms controlled or partially controlled at time of evaluation&#46; The exclusion criteria were regular physical exercise &#40;three or more times a week&#41;&#59; smoking&#59; uncontrolled DCA&#59; and participation in lung rehabilitation program&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patients were divided into two groups&#58; those who used an oral corticosteroid &#40;DCA-C&#59; 12 individuals&#41; and those who used omalizumab &#40;DCA-O&#59; 6 individuals&#41;&#46; A third group made up of 11 healthy subjects paired for age served as the control group &#40;CG&#41;&#59; the inclusion criteria for the CG were the absence of pulmonary disease&#44; no current or past smoking habits and no regular physical exercise that were assessed with the use of the International Physical Activity Questionnaire-short form &#40;IPAQ&#41;&#44; and subjects recruited were classified as insufficiently active &#40;does not perform any physical activity&#44; or performs physical activity but not enough to be classified as of moderate or high intensity&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">All participants signed a term of informed consent and were told they could withdraw from the study at any stage without being penalized in any way&#46; The study was approved by the Human Research Ethics Committee of the &#40;process no&#46; 334&#47;09&#41;&#46; At the end of the informative phase &#40;term of informed consent&#41;&#44; guidance was given about the activities that would take place during the data acquisition phase and the objectives of the study&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Procedures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Electromyographic evaluation</span><p id="par0050" class="elsevierStylePara elsevierViewall">The components of the signal acquisition system &#40;electrodes and load cell&#41; were connected to a signal conditioning module&#44; in which the analog signals amplified tenfold were amplified a second time with a 100-fold gain&#44; totaling a final gain of 1000&#44; and filtered with a 10&#8211;500<span class="elsevierStyleHsp" style=""></span>Hz bandpass filter&#46; Two pairs of bipolar&#44; differential&#44; active surface electrodes with an 80<span class="elsevierStyleHsp" style=""></span>dB common mode rejection ratio were placed on the motor point of the rectus femoris &#40;RF&#41; and soleus &#40;SO&#41; muscles&#44; according to the guidelines of the SENIAM Project&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The electromyographic signal was captured during the reflex test performed with a neurological exam hammer adapted with a switch on the area of percussion&#46; For the patellar reflex&#44; the patient remained seated with legs dangling and the patellar tendon was struck with a short&#44; fast blow&#44; while the extension of the knee was observed&#46; For the Achilles reflex&#44; the patient remained in ventral decubitus&#44; with feet dangling off the table and the Achilles tendon slighted tensed by discreet passive dorsiflexion of the foot&#59; the tendon was struck&#44; inducing involuntary plantar flexion<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Assessment of muscle strength</span><p id="par0060" class="elsevierStylePara elsevierViewall">The seated patient performed extension of the knee under resistance at maximal strength capacity&#8211;peak strength of isometric contraction of the dominant quadriceps&#46; The data were collected using a load cell &#40;kg&#47;force&#41; coupled to the electromyographic signal conditioning module&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Assessment of static balance</span><p id="par0065" class="elsevierStylePara elsevierViewall">A force plate &#40;TekScan&#44; MatScan model&#41; measuring 0&#46;50<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>0&#46;60<span class="elsevierStyleHsp" style=""></span>cm was used&#44; on which oscillations of the force points in relation to velocity and anteroposterior and laterolateral displacement were analyzed&#44; allowing the assessment of balance based on the oscillating center of force&#44; which is the result of these two variables&#46; This measurement system contains 2288 force sensors arranged in rows and columns on the platform and connected to a data acquisition system controlled by the Research Foot 5&#46;60 program &#40;TekScan&#41; for data storage and analysis by the computer&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The participant was instructed to remain in a static position on the platform with feet spaced at shoulder width&#46; After the calibration of the system based on body weight&#44; the participant remained in biped position for 60<span class="elsevierStyleHsp" style=""></span>s with head aligned&#44; concentrating on a fixed point on the wall at eye height without talking&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Sit-to-stand test</span><p id="par0075" class="elsevierStylePara elsevierViewall">For the sit-to-stand test&#44; a standard chair &#40;height&#58; 46<span class="elsevierStyleHsp" style=""></span>cm&#41; with no arms was used&#46; After a demonstration&#44; the participants were instructed to stand up from the chair and sit back down without using their hands&#44; repeating the procedure as many times as possible in one minute at a velocity in which the participants felt safe and comfortable&#46; The number of repetitions was recorded&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Six-minute walk test</span><p id="par0080" class="elsevierStylePara elsevierViewall">The six-minute walk test was performed in a corridor 30<span class="elsevierStyleHsp" style=""></span>m in length and free from pedestrian traffic&#46; The participants were instructed to walk as fast as possible in a six-minute period&#46; During the test&#44; standardized words of encouragement were given each minute&#46; The distance traveled was recorded&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0085" class="elsevierStylePara elsevierViewall">The Shapiro&#8211;Wilk test determined normal distribution for all data&#46; Thus&#44; one-way ANOVA was used for the comparison of mean values between the three groups and Tukey&#39;s DHS test was used for multiple means in the presence of significance&#46; The level of significance was set at 5&#37;&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">Forty individuals with DCA were recruited&#44; eleven were excluded as not meeting the inclusion criteria&#44; three were excluded because of associated respiratory diseases&#44; four were excluded because they were hospitalized and four were excluded as they did not show up for the evaluation&#46; Thus&#44; the total sample with DCA was made up of 18 individuals&#46; Twenty-nine individuals participated in the present study&#44; distributed among three different groups&#58; CG &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41;&#44; DCA-C &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#41; and DCA-O &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&#46; No statistically significant differences were detected between groups with regard to age&#44; weight&#44; height or body mass index &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; thereby demonstrating the homogeneity of the sample &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">No statistically significant differences were detected between groups with regard to neurophysiological aspects &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The CG differed significantly from the DCA groups with regard to functional capacity&#44; achieving a greater number of repetitions on the sit-to-stand test and a longer distance on the six-minute walk test&#46; Regarding muscle strength&#44; as measured by the analysis of the quadriceps muscle&#44; the CG only differed from the DCA-C &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The results revealed that the group that used the oral corticosteroid &#40;DCA-C&#41; had the lowest FEV<span class="elsevierStyleInf">1</span>&#44; achieved the shortest distance on the six-minute walk test and achieved the smallest number of repetitions in the sit-to-stand test&#44; thereby suggesting muscle weakness&#44; which was confirmed by the assessment of quadriceps muscle strength&#46; However&#44; despite exhibiting greater obstructive severity and lower functional capacity&#44; the DCA-C group was similar to the DCA-O and control groups with regard to neurophysiological aspects&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Supplemental oxygen was not needed during the evaluations&#44; as the patients did not exhibit a drop in SpO<span class="elsevierStyleInf">2</span> greater than 4&#37; of the baseline condition or clinical signs that indicated oxygen use&#44; thereby avoiding masking the results obtained&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">No statistically significant differences between groups were found regarding static balance&#44; as assessed by oscillations from the center of pressure on a force plate&#46; There were also no statistically significant differences between groups regarding latency time in the patellar and Achilles reflexes&#46; However&#44; patients with chronic obstructive pulmonary disease &#40;COPD&#41; were found to have motor impairment&#44; reduced reflex response&#44; muscle weakness and lower functional capacity in comparison to healthy subjects&#44; probably due to the sensory-motor impairment caused by hypoxemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;25&#44;26</span></a> Kayacan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> report neurophysiological alterations in 93&#46;8&#37; of patients with COPD and Jann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> report a slight reduction in nerve conduction velocity and a reduction in the amplitude of the action potential of motor units in cases of chronic respiratory failure&#44; suggesting the occurrence of peripheral neuropathy&#46; Although there is evidence that patients with DCA may exhibit physical limitations&#44; this was not true of this study&#44; where no alterations of neurophysiological in these individuals were found&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Ozalevli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> compared the sit-to-stand test with the six-minute walk test and found that the former can determine functional capacity equally well as the latter&#44; with less hemodynamic stress in patients with lung conditions&#46; According to the authors&#44; the sit-to-stand test was also correlated with dyspnea and peripheral muscle strength&#46; The present study corroborates these findings&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Muscle strength differed significantly between the DCA-C and control groups&#44; probably due to fact that the continual use of corticosteroids causes myopathy&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#8211;18</span></a> This finding does not corroborate results reported in a study carried out by Bruin&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> which found that asthmatic patients &#40;mild and moderate&#41; demonstrated no alterations in cross-section area during peak muscle strength generated by the quadriceps in comparison to healthy subjects&#46; Nevertheless&#44; Lim<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> described that prolonged treatment with corticosteroids resulted in important muscle weakness of the quadriceps and respiratory muscle force in patients with asthma and COPD&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Although all patients with DCA demonstrated a reduction in functional capacity&#44; the group treated with omalizumab &#40;DCA-O&#41; did not exhibit a reduction in muscle strength in comparison to the control group&#46; It should be stressed that patients using omalizumab are not susceptible to the diverse side effects of corticosteroids&#44; including skin problems&#44; diabetes mellitus&#44; systemic arterial hypertension&#44; heart failure&#44; osteoporosis&#44; etc&#46;&#44; which leads one to infer that patients who make use of omalizumab appear to benefit more&#46; The disadvantage of omalizumab is its high cost &#40;approximately &#8364; 815&#47;month&#41;&#44; which means that even when offered by the Brazilian public healthcare system&#44; this medication is not freely released and is only distributed in specific centers&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">While no statistically significant differences were detected between groups with regard to neurophysiological aspects&#44; all patients with DCA exhibited a reduction in functional capacity in comparison to the control group &#40;reduction in muscle strength&#44; shorter distance traveled on six-minute walk test and fewer repetitions on sit-to-stand test&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0135" class="elsevierStylePara elsevierViewall">Individuals with DCA exhibited a reduction in functional capacity&#46; The DCA-C group also demonstrated a reduction in muscle strength when compared with the control group&#44; the likely cause being the continual use of corticosteroids&#46; However&#44; no neurophysiological alterations were found in the population studied&#46; These data contribute toward a better understanding of the physical condition of such patients and can be used to improve lung rehabilitation programs for individuals with difficult-to-control asthma&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Electromyographic evaluation"
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              "titulo" => "Assessment of muscle strength"
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              "titulo" => "Assessment of static balance"
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              "titulo" => "Sit-to-stand test"
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              "titulo" => "Six-minute walk test"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2011-05-18"
    "fechaAceptado" => "2012-02-14"
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          "clase" => "keyword"
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          "identificador" => "xpalclavsec162038"
          "palabras" => array:3 [
            0 => "Asthma"
            1 => "Neurophysiology"
            2 => "Functional capacity"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec162037"
          "palabras" => array:3 [
            0 => "Asma"
            1 => "Neurofisiologia"
            2 => "Capacidade funcional"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Due to the inadequate response to inhaled corticosteroids&#44; patients with difficult-to-control asthma &#40;DCA&#41; are submitted to oral corticosteroids or use of omalizumab&#46; Although it is necessary to treat these patients&#44; a significant relationship between steroid usage and both peripheral and respiratory weakness muscle&#44; results in implications&#44; such as loss of quality of life and compromised lung function&#46; Nonetheless&#44; it is not known whether these patients suffer neurophysiological changes due to drug effect&#46;</p> <span class="elsevierStyleSectionTitle">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To investigate the neurophysiological and functional characteristics of patients with DCA in order to gain a better understanding of the condition&#46;</p> <span class="elsevierStyleSectionTitle">Method</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A cross-sectional study was carried out involving three groups of patients&#58; DCA-C &#40;use of oral corticosteroids&#41;&#44; DCA-O &#40;use of omalizumab&#41; and CG &#40;healthy controls matched for age&#41;&#46; The assessment involved the six-minute walk test&#44; sit-to-stand test&#44; static balance on a pressure platform&#44; patellar and Achilles reflexes and quadriceps strength in the dominant leg&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The results revealed no statistically significant differences between the control group and DCA groups in relation to neurophysiological aspects&#46; However&#44; the DCA groups exhibited a significant reduction in functional capacity &#91;decreased muscle strength &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; shorter distance covered on walk test &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and lesser number of repetitions on sit-to-stand test &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#93; in comparison to the control group&#46;</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Individuals with DCA exhibited a reduction in functional capacity&#46; The DCA-C group also demonstrated a reduction in muscle strength when compared with control group&#44; likely caused by the continual use of corticosteroids&#46; However&#44; no neurophysiological alterations were found in the studied population&#46;</p>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span class="elsevierStyleSectionTitle">Introdu&#231;&#227;o</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Devido &#224; inadequada resposta aos cortic&#243;ides inalat&#243;rios&#44; os pacientes com asma de dif&#237;cil controlo &#40;ADC&#41; s&#227;o submetidos a cortic&#243;ides orais ou uso de omalizumabe&#46; Embora sejam necess&#225;rios para o tratamento desses pacientes&#44; h&#225; uma rela&#231;&#227;o significativa entre o uso de ester&#243;ides e fraqueza muscular perif&#233;rica e respirat&#243;ria&#44; resultando em implica&#231;&#245;es como a perda da qualidade de vida e fun&#231;&#227;o pulmonar comprometida&#46; No entanto&#44; n&#227;o se sabe se estes pacientes sofrem altera&#231;&#245;es neurofisiol&#243;gicas devido ao efeito da droga&#46;</p> <span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Investigar as caracter&#237;sticas neurofisiol&#243;gicas e funcionais de pacientes com ADC&#44; para melhor compreens&#227;o da doen&#231;a&#46;</p> <span class="elsevierStyleSectionTitle">M&#233;todo</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Foi realizado um estudo transversal em 3 grupos de pacientes&#58; ADCC &#40;que fazem uso de cortic&#243;ide por via oral&#41;&#59; ADCO &#40;que fazem uso do Omalizumab&#41; e GC &#40;controlo saud&#225;vel da mesma idade&#41;&#46; A avalia&#231;&#227;o foi composta pela prova da marcha dos 6 minutos&#44; teste senta-levanta&#44; equil&#237;brio est&#225;tico com a plataforma de press&#227;o&#44; reflexos monossimp&#225;ticos &#40;patelar e aquileu&#41; e a for&#231;a do quadr&#237;ceps do membro inferior dominante&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Embora os resultados em rela&#231;&#227;o aos aspetos neurofisiol&#243;gicos mostrem n&#227;o haver diferen&#231;a estatisticamente significativa entre os grupos controlo e com ADC&#44; deve ser observado que o grupo com ADC&#44; apresentou importante redu&#231;&#227;o da capacidade funcional&#44; quando comparado ao grupo controlo &#40;diminui&#231;&#227;o da for&#231;a muscular &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; diminui&#231;&#227;o da dist&#226;ncia percorrida no teste da caminhada &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; e diminui&#231;&#227;o do n&#250;mero de repeti&#231;&#245;es no teste senta&#47;levanta &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclus&#227;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Indiv&#237;duos com ADC apresentaram redu&#231;&#227;o da capacidade funcional&#46; O grupo ADCC tamb&#233;m demonstrou redu&#231;&#227;o na for&#231;a muscular quando comparado ao grupo controlo&#44; provavelmente causado pelo uso cont&#237;nuo de cortic&#243;ides&#46; No entanto&#44; nenhuma altera&#231;&#227;o neurofisiol&#243;gica foi encontrada na popula&#231;&#227;o estudada&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Ferrari Corr&#234;a JC&#44; et al&#46; Avalia&#231;&#227;o neurofisiol&#243;gica e funcional em pacientes com asma de dificil controle&#46; Rev Port Pneumol&#46; 2012&#46; <span class="elsevierStyleInterRef" href="doi:10.1016/j.rppneu.2012.02.008">http&#58;&#47;&#47;dx&#46;doi&#46;org&#47;10&#46;1016&#47;j&#46;rppneu&#46;2012&#46;02&#46;008</span></p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CG&#58; control group&#59; DCA-O&#58; difficult-to-control asthma with use of omalizumab&#59; DCA-C&#58; difficult-to-control asthma with use of oral corticosteroid&#59; BMI&#58; body mass index&#59; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume in first second&#59; ACQ&#58; asthma control questionnaire&#46; One-way ANOVA and Tukey&#39;s post hoc test&#58; &#42;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p>"
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                  \t\t\t\t">49&#46;83<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;13&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;0&#8211;4&#41;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">CG&#58; control group&#59; DCA-O&#58; difficult-to-control asthma with use of omalizumab&#59; DCA-C&#58; difficult-to-control asthma with use of oral corticosteroid&#59; L-L&#58; laterolateral&#59; A-P&#58; anteroposterior&#59; Strength mm&#58; muscle strength of quadriceps&#59; 6&#8242;WT &#40;m&#41;&#58; six-minute walk test in meters&#59; SST&#58; sit-to-stand test &#40;number of repetitions&#41;&#46; One-way ANOVA and Tukey&#39;s post hoc test&#58; &#42;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>difference between CG and DCA-C &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; <span class="elsevierStyleSup">&#8800;</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>difference between CG and DCA-O &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;37 &#40;&#177;0&#46;62&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&#46;1 &#40;&#177;0&#46;93&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&#46;46 &#40;&#177;4&#46;57&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#46;98 &#40;&#177;1&#46;20&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Patellar reflex &#40;ms&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">34&#46;64 &#40;&#177;5&#46;46&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">38&#46;67 &#40;&#177;4&#46;56&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">35&#46;41 &#40;&#177;2&#46;36&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">43&#46;45 &#40;&#177;6&#46;73&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">43&#46;42 &#40;&#177;2&#46;87&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">27&#46;19 &#40;&#177;13&#46;65&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">19&#46;67 &#40;&#177;8&#46;29&#41;<span class="elsevierStyleSup">&#42;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6&#8242;WT &#40;m&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">618&#46;86 &#40;&#177;37&#46;26&#41;<span class="elsevierStyleSup">&#42;&#44;&#8800;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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