BACKGROUND:This study aims to evaluate and compare the effects of two neurorehabilitation methods-action observation therapy (AOT) and XBOX 360 Kinect™ (XBOX) on upper extremity body structure functions, activity, and functional participation levels in children with Unilateral Cerebral Palsy (UCP). METHODS:Forty-five children with UCP (aged 5-15 years) were randomly divided into three groups: AOT, XBOX, and Conventional (CNV). All groups received conventional physiotherapy (45 minutes, twice weekly for 3 weeks). The AOT group had additional 30-minute daily telerehabilitation sessions, while the XBOX group used XBOX 360 Kinect for the same duration. Evaluations included the Modified Ashworth Scale (MAS), Jamar Hand Dynamometer, Baseline Mechanical Grip Meter, Selective Control of the Upper Extremity Scale (SCUES), Jebsen Taylor Hand Function Test (JTHFT), Abilhand-Kids, and Pediatric Quality of Life Inventory (PedsQL). Statistical significance was set at p<0.017. RESULTS:Both AOT and XBOX groups showed greater improvements than CNV(p<0.017). AOT achieved clinically meaningful gains in all grasp types and selectivity, while XBOX mainly improved pinch, lateral grip, and forearm selectivity. Both groups improved in ABILHAND-Kids and PedsQL, with broader gains in AOT. CONCLUSION:AOT and XBOX are effective supplementary therapies for upper extremity rehabilitation in children with UCP, complementing conventional physiotherapy. CLINICAL TRIAL NUMBER:NCT05327179.
Background Knee osteoarthritis manifests as a myriad of signs and symptoms, driving people to seek rehabilitation. It is unclear which features of osteoarthritis patients view as most problematic and what their specific rehabilitation goals are. Objective To explore what individuals with painful osteoarthritis identify as the worst aspect of their knee problems, along with their 3-month rehabilitation goals. Methods Qualitative study with content analysis. Data from 387 participants in a randomized controlled trial, comparing in-person and telerehabilitation physiotherapy, were analyzed. All participants had chronic knee pain consistent with a clinical diagnosis of knee osteoarthritis. Pre-consultation surveys included open-text responses to two questions: 1) worst aspect of knee osteoarthritis and 2) 3-month functional rehabilitation goals. Responses were analyzed inductively, and knee problems were deductively mapped to the International Classification of Functioning, Disability, and Health framework. Results Participants identified wide-ranging knee osteoarthritis problems, including impairments (e.g., pain and sleep problems), activity limitations (e.g., walking and using stairs), and participation restrictions (e.g., running, spending time with family, and gardening). Three-month functional rehabilitation goals included: 1) walk more and with fewer restrictions, 2) become more physically active and/or return to physical activity, 3) improve performance of activities of daily living, 4) improve general health and well-being, and 5) increase participation in meaningful activities. Conclusions People with knee osteoarthritis vary widely in the knee problems they consider most problematic and the rehabilitation goals they prioritize, which may be centered on high-level physical activities. Based on our findings, clinicians and researchers should consider using outcome measures that capture individualized goals.
BACKGROUND:Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by progressive muscle weakness. Falls are common and may lead to dependence, reduced quality of life, higher healthcare costs, and death. Few studies have examined falls in ALS. OBJECTIVES:To investigate the frequency of falls in individuals with ALS with and without functional ambulation, and to identify predictors of falls at three and six months among those with functional ambulation. METHODS:A longitudinal prospective study included 66 individuals with ALS. Falls were assessed through interviews at three- and six-month follow-ups. Demographic and clinical characteristics, functional capacity, lower limb strength, fatigue, mobility, and balance were assessed. Descriptive, bivariate, and logistic regression analyses were performed. RESULTS:At baseline, 42 participants were ambulatory and 24 non ambulatory (wheelchair-dependent). Among ambulatory participants, 38 were assessed at three months (18 fallers, 47%) and 37 at six months (22 fallers, 59%). Among non-ambulatory participants, 22 were assessed at three months (4 fallers, 18%) and 20 at six months (2 fallers, 10%). Losses in both groups were due to death. Predictors of falls in the ambulatory group were lower limb strength (Odds Ratio [OR]: 0.844; p = 0.016) and fatigue (OR: 7.800; p = 0.037) at three months, and lower limb strength (OR: 0.856; p = 0.009) at six months. CONCLUSION:Falls can occur across functional profiles in ALS and are most frequent among ambulatory individuals. These findings highlight the importance of assessing fall risk and considering strategies. In ambulatory participants, interventions focusing on lower limb strength and fatigue may contribute to fall prevention.
Background Work-related spinal pain is highly prevalent among office workers and contributes to disability and reduced productivity. Active breaks have shown benefits, but their integration into daily routines remains challenging. Objective To explore office workers’ beliefs, expectations, and perceived barriers regarding a digital intervention designed to support active breaks at work for the management of work-related spinal pain. Methods Seventeen office workers from the University of Lleida, all experiencing work-related spinal pain, participated in semi-structured interviews between June 2023 and February 2024. Data were analysed using Malterud’s systematic text condensation framework. Results Three main themes emerged: work-related spinal pain, implementation of active breaks at work, and feasibility of a digital intervention in the workplace. Participants reported persistent spinal pain due to static postures and job stress, often leading to passive coping strategies. Although they perceived stretching and mobility exercises at work as beneficial, integrating them into daily routines was challenging due to heavy workloads and concerns about managerial perceptions. Employees preferred shorter, flexible breaks over longer interruptions. Digital interventions were viewed favourably for their convenience and accessibility, but personalised guidance from health professionals was considered crucial for adherence. Conclusion Office workers expressed confidence in adopting a digital intervention for active breaks, supported by self-management strategies and physiotherapist guidance, to alleviate spinal pain. These findings highlight the importance of involving workers in designing workplace health programs tailored to their needs and preferences.
OBJECTIVE:The aim of this study was to assess the feasibility and inter-rater reliability of a set of 22 quality indicators and to identify quality problems in the clinical practice of hospital-based physical therapy units. METHODS:An observational, descriptive, cross-sectional, multicentre study with a mixed approach was conducted in three hospitals in Spain. Twenty-two indicators (nine management and thirteen clinical) were evaluated and refined according to the feasibility of the available data, and interobserver agreement (inter-rater reliability) was measured. The analysis combined qualitative and quantitative methods. RESULTS:Of the 22 quality indicators, 13 were feasible and showed concordance between evaluators across all hospitals included in the study. The main difficulties the evaluators observed were: inadequate identification of the pathologies of interest, limited identification of the initial diagnosis or index episode in patients with chronic conditions, and failure to record essential evaluation information. Opportunities for improvement include enhancing the detailed assessment of therapeutic objectives, providing early care for stroke patients, and clearly prescribing exercise treatment. CONCLUSION:A total of 13 quality indicators (9 clinical and 4 management indicators) were feasible and reliable. The remaining 9 were refined to assess those units that so request. The quality levels, along with analyses of feasibility and inter-rater reliability, provided relevant information on the performance of the physical therapy service across three hospitals. Implementing this set of indicators provides hospitals with a systematic evaluation tool that promotes improvements in care quality and organizational learning.
OBJECTIVE:To assess equity in telehealth interventions in physiotherapy research using the PROGRESS plus framework. METHODS:We searched the PEDro, CENTRAL, and PubMed databases from January 2020 to December 2023 for randomized controlled trials evaluating the effectiveness of telehealth in physiotherapy. We selected, extracted, and assessed the characteristics and the PROGRESS factors. The PROGRESS Plus is a framework of factors that influence health outcomes. Telehealth studies were classified as equity-focused and oriented. Data were analyzed descriptively for the characteristics and the PROGRESS factors. We provided a hypothesis-testing approach to describe the three social gradient hypotheses. RESULTS:We included 94 telehealth equity trials (n = 45 telehealth equity-focused; n = 49 telehealth equity-oriented). Telehealth equity-focused trials demonstrated favorable outcomes in 28 studies (62%), primarily addressing factors such as place of residence, race/ethnicity, and vulnerable populations. Telehealth equity-oriented showed favorable benefits in 15 cases (30%), while 33 trials (67%) incorporated more than one PROGRESS-Plus factor. Most trials showed no social gradients (86%), while few (12%) demonstrated a reduction in health inequities. CONCLUSION:Robust evidence for equity-focused telehealth interventions in physiotherapy is uncertain; reported benefits vary, with some studies reporting similar outcomes and others favoring telehealth. Most telehealth equity-oriented trials no differential effects, although they provided some evidence of benefits specifically for disadvantaged populations. Telehealth equity studies often fail to systematically integrate PROGRESS factors throughout the entire research lifecycle.
BACKGROUND:Lumbopelvic pain (LPP) is common during pregnancy. However, there is a lack of strong systematic reviews summarizing the evidence on conservative care. AIMS:To evaluate the effectiveness of physiotherapy interventions compared to standard obstetric care (SOC) or other treatments for physical function, pain intensity, and quality of life in pregnant women with LPP. METHODS:Medline, Emcare, Embase, Emcare, Physiotherapy Evidence Database (PEDro), Web of Science, and Cochrane Central Register were searched for randomized controlled trials evaluating physiotherapy interventions for pregnancy-related LPP. Risk of bias was assessed using Cochrane Risk of Bias 2, and evidence was summarized using the GRADE framework. When appropriate, a meta-analysis was conducted to synthesize the available evidence. RESULTS:Thirty-one trials were included (n = 3279 screened): 23 investigated exercise, 7 manual therapy, 3 electrophysical modalities, and 2 education. Exercise was not better than SOC for the short-term pain (low certainty evidence, MD = -18.80, 95 % CI -45.97 to 8.33), but was superior at 6-12 weeks (moderate certainty evidence, MD = -25.84, 95 % CI -35.04 to -16.64). After a sensitivity analysis, exercise significantly improved physical function compared to SOC at 0-5 weeks (low certainty evidence, SMD= -0.65 95 % CI -1.25 to -0.04). Exercise was superior to SOC at 6-12 weeks (very-low certainty evidence, SMD -2.79 95 % CI -4.64 to -0.95). CONCLUSION:Exercise interventions show low certainty evidence for improving pain and physical function in pregnancy-related LPP over medium-term periods. Higher quality research is necessary, and future studies should adhere to standardized reporting guidelines and include larger sample sizes.
INTRODUCTION:Unsupported upper limb exercise (UULEX) is an incremental test that assesses upper limb (UL) exercise capacity. Individuals with post-COVID-19 syndrome commonly present UL fatigue and reduced functional capacity, needing a valid assessment tool. OBJECTIVE:To verify the concurrent validity of the UULEX-modified version (UULEX-M) to assess the UL exercise capacity in individuals with post-COVID-19 syndrome. METHODS:This was a cross-sectional validation study conducted at post COVID-19 ambulatory (UFMG), between 07/2020 and 11/2020. Individuals selected underwent UULEX and UULEX-M tests in random order on a single day, with a 30-minute interval between tests. UULEX-M proposed a fixed load without warm-up and fewer incremental levels. Pearson and Spearman correlation tests assessed concurrent validity. Comparison between tests was performed with the t-independent and the Wilcoxon tests. RESULTS:Sixty-four individuals aged 61±14 years were included. Test time, heart rate at the test peak, and female sex were strongly correlated between tests (r = 0.872; 95%CI: 3.4 to 4.55 min; p < 0.001; r = 0.774; 95%CI: 1-7 bpm; p < 0.001; r = 0.887; 95%CI: 2.35 to 3.92 min; p < 0.001, respectively). Moderate correlation was found for dyspnea (r = 0.566; 95%CI: -2.8 to -1.8; p < 0.001), fatigue (r = 0.605; 95%CI: -0.5 to 0.3; p < 0.001) and male sex (r = 0.744; 95%CI:3.9 to 5.5 min; p < 0.001). The mean testing time was 36% shorter for women than for men. CONCLUSION:The UULEX-M test was valid and reliable for assessing UL exercise capacity in individuals with post-COVID-19 syndrome. The UULEX-M test time was shorter and induced the same symptoms and physiological responses in both sexes. Moreover, this test is low-cost and may be an alternative in clinical practice.
Background Patient and Public Involvement (PPI) in research is defined as “research being carried out ‘with’ or ‘by’ members of the public rather than ‘to’, ‘about’ or ‘for’ them”. This importance of PPI has significantly grown with worldwide advances in access to information, changes in the models of care provided toward patient-centered care, and the urge to hear their voices. Objective This masterclass aims to provide a critical overview of patient and public involvement in research, examining current international practices and reflecting on future directions and challenges for strengthening PPI in Brazil. Discussion This masterclass explores the definitions of PPI used worldwide and how the patient and public can be involved in all stages of the research cycle. The uptake of PPI in research around the world has grown in the last 20 years, but with little expression in low- and middle-income countries (LMIC). Strategies to enhance the use of PPI in countries like Brazil must be provided with knowledge translation, funding, training, and awareness of the importance of patient and public involvement.
Introduction The Fremantle Back Awareness Questionnaire (FreBAQ) is one of the most translated questionnaires that assesses the individual’s back awareness. However, the questionnaire is not available in Brazilian Portuguese. This study aimed to cross-culturally translate the original English version of the FreBAQ into Brazilian Portuguese (Br) and evaluate its measurement properties in individuals with chronic low back pain (CLBP). Methods The sample consisted of two hundred and seventy-nine participants, 178 with CLBP and 101 asymptomatic controls. Cross-cultural adaptation was performed, and the measurement properties were analyzed. Intraclass Correlation Coefficient (ICC2.1), Cronbach's α, and Smallest Detectable Change (SDC) were used to assess test-retest reliability, internal consistency, and measurement error, respectively. In addition, Pearson's correlation and Confirmatory Factor Analysis (CFA) were used to test hypotheses about construct validity and structural validity, respectively. Results Sufficient structural validity indices were obtained for the 9-item unidimensional model. Internal consistency (α=0.84) and reliability (ICC=0.81) of the FreBAQ-Br were both considered adequate. The FreBAQ-Br showed SDC = 3.33 as a parameter of measurement error. The hypothesis testing for construct validity confirmed 94.11% of the hypotheses raised a priori, and FreBAQ score showed sufficient discriminative capability to distinguish CLBP controls from asymptomatic participants. Conclusion The FreBAQ-Br demonstrated adequate reliability, internal consistency, structural validity, construct validity, and discriminant validity. As a result, we recommend its use to assess back awareness in Brazilian speakers.
Background Accurate interpretation of hip radiographic imaging is critical for the early detection of hip displacement, the second most common impairment observed in children with cerebral palsy (CP). We aimed to evaluate the measurement properties of the HipScreen for assessing hip migration percentage (MP) in Brazilian children/adolescents with CP. Method MP was measured on pelvis radiographs of children and adolescents with CP by eight independent raters using the HipScreen app and traditional Reimer’s measurement method. Concurrent validity (Spearman correlation), sensitivity, specificity, and accuracy were established by the correlation between the MP values obtained from the HipScreen and the traditional Reimers method. Intra and inter-rater reliability were evaluated using the intraclass correlation coefficient (ICC). All raters assessed the clinical utility of the HipScreen app with a standardized questionnaire. Results Sixty-eight children (136 hips) were included, with a mean age of 8.09 years and 67.5% were classified in the Gross Motor Function Classification System IV or V levels. Notably, 49.3% of hips had an MP > 30%. Intra and inter-rater reliability were excellent (0.89 < ICC < 0.95). The HipScreen app presented strong to very strong correlations (0.82 < r < 0.91) with the traditional Reimers method with 80% sensitivity, 75% specificity, and 77% accuracy. All examiners considered the Hipscreen app easy and very useful for clinical practice. Conclusion The HipScreen provides reliable and valid measurements of MP in Brazilian children with CP, facilitating the implementation of hip surveillance programs in the Brazilian context.
Background Patients with neck pain (NP) commonly display impairments in cervical movement control. Improvements in technology used to assess movement control allow extraction of various parameters that could enable more precise classification, but this has not yet been investigated. Objective This study aimed to assess validity (classification performance of different machine learning models) of different parameters and difficulty levels of the Butterfly cervical movement control test. Methods Sixty-five patients with NP and fifty asymptomatic controls performed the Butterfly test. Random forest, support vector machines and logistic regression classification methods were used to build models based on individual or multiple parameters across different difficulty levels. The area under the curve (AUC), classification accuracy, F1 score, precision, recall, specificity, information gain and Gini index were reported. Results Models using amplitude accuracy, time-on-target or undershoot achieved the highest classification performance. However, models combining directional accuracy or all parameters of the Butterfly test at all difficulty levels yielded the most balanced probability of classification. Conclusion Results of our study suggest that either directional accuracy or all parameters of the Butterfly test (calculated for all difficulty levels) should be used for classifying patients with NP to provide the most clinically valid tool.
Background Clinical functional tests for patellofemoral pain (PFP), such as step-up, step-down and squat, are commonly used in clinic practice, although the extent to which changes in these tests reflect changes in patient-reported outcome measures (PROMs) remains unclear. Objective Investigate how changes in step-up, step-down, and squat tests are associated with changes in PROMs in individuals with PFP. Methods This secondary analysis used data from a randomized controlled trial (N = 218) comparing 12-week outcomes following either foot orthoses or 4-week hip exercise program. The number of pain-free repetitions in the functional tests of step-up, step-down and squat was assessed. PROMs included the Kujala, the Knee Injury and Osteoarthritis Outcome Scale (KOOS) subscales (Symptoms, Pain, Activities of Daily Living, Sporting and Recreation and Quality of Life (QoL), and the Global Rating of Change (GROC). Associations between change scores (differences between follow-up and baseline) in pain-free repetitions in the clinical functional tests and PROMs were analyzed using multivariate regression and binary logistic regression for dichotomized GROC (p < 0.05). Results Data was available for 157 participants. There was a positive association between change scores in functional tests and PROMs, with explained variances ranging from 11 to 30%. The step-up test was weakly to moderately associated with KOOS Symptoms, Pain, QoL and Sport/Recreation. Step-down was associated with Kujala and KOOS Sport/Recreation. The squat test was not associated with any PROM. Conclusions Improvement in step-up test is associated with better PROMs. Clinicians might use the step-up test to monitor progress in individuals with PFP.
Background Long-COVID is a heterogenous, episodic, and multisystemic condition which can result following infection with a novel pathogen, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Whilst a precise pathophysiological cause is unknown, several mechanisms are hypothesised, each with plausible scientific rationale. Most people experiencing persistent symptoms following COVID-19 infection recover, yet some experience severe and debilitating illness for years after infection. Strategies to manage the sequelae of Long-COVID can improve the lives of sufferers. Objective To describe the physiotherapy management of Long-COVID based on current evidence. Content Those with ‘invisible illness’ (illness without outwardly visible signs), such as Long-COVID, often report stigmatisation and scepticism from healthcare systems. Validation of the experience of those with Long-COVID is therefore crucial to ensure patient-centred care. Thorough patient assessment is required to provide tailored management approaches given the diversity of Long-COVID presentations. Red flags that may contraindicate certain rehabilitation approaches (particularly exercise-based interventions) or that warrant further investigation should be considered. Assessments of fatigue, post-exertional malaise, respiratory symptoms, neurocognitive symptoms (i.e., brain fog), physical function, and orthostatic intolerance are strongly recommended. Management strategies may involve pacing and energy conservation techniques, pulmonary rehabilitation, inspiratory muscle training, dysfunctional breathing retraining, lifestyle and dietary strategies to manage orthostatic intolerance, and return-to-work planning. Conclusion Physiotherapists are well positioned to deliver individualised, patient-centred, and validating care based on best available evidence.
Background Persistent pain is a complex condition that places substantial demands on physical therapists and healthcare systems. Understanding how clinicians experience and navigate these complexities is essential for improving care. Objective To investigate the challenges, priorities, and opportunities from the perspective physical therapists who work with people experiencing persistent pain. Methods We conducted focus groups with physical therapists working in pain management settings. Participants responded to four open-ended discussion questions in written and verbal formats. Data were analyzed using systematic text condensation to identify themes. Results Sixty-six physical therapists across eight focus groups participated. An overarching theme of "complexity of pain" emerged, reflecting its influence across all aspects of care. Eleven interrelated subthemes were identified: clinical skills and education; funding models; professional networking and referral pathways; health professional awareness of evidence-based pain management; community awareness of evidence-based pain management; access to care; physical therapy advocacy and leadership; patient engagement and expectations; clinical time; clinician and patient emotional wellbeing; and clinical and social complexity. Conclusion From the perspectives of Australian physical therapists, the complexities of managing persistent pain are deeply interrelated and extend across the healthcare system. These challenges are not attributable to pain complexity alone but reflect systemic issues spanning education, funding, access, and advocacy. Addressing these challenges requires coordinated action at individual, organizational, and societal levels.
Background Childbirth is a complex, subjective phenomenon, the significance of which is influenced by sociocultural and individual factors. Anxieties surrounding childbirth, often stemming from gaps in knowledge about the physiological process, can negatively affect maternal expectations. Prenatal health education has been proposed as a key intervention to mitigate these anxieties by enhancing self-efficacy, promoting patient autonomy, and encouraging active participation. Objective This study aimed to investigate women's perceptions of their labor and childbirth experience following participation in a patient-centered prenatal education program, the 'Oficina do Parto'. Methods This qualitative study used thematic analysis. Participants included nine women and their companions who attended the 'Oficina do Parto' program. Data were collected through semi-structured interviews conducted during the postpartum period. Results The analysis yielded two main themes: 1) the perceived impact of the educational program on labor and delivery experiences; and 2) the role and influence of the companion's participation during childbirth. Participants reported that the program effectively increased their knowledge, which contributed to a more positive childbirth experience and a greater appreciation for the companion's role. Conclusion The 'Oficina do Parto' program successfully enhanced women's knowledge, fostering positive perceptions of childbirth and the involvement of companions. The alignment between the educational content and the practices of the attending obstetric team, together with the women's prior childbirth knowledge, emerged as factors that positively influenced the overall childbirth experience.
Background Endometriosis is a benign and chronic disease characterized by inflammation of the endometrial tissue outside the uterus. Numerous physical therapy interventions have been studied to alleviate the related symptoms. Objective To evaluate the effectiveness of different physical therapy methods and techniques in improving the symptoms triggered by endometriosis. Methods Systematic review of articles exclusively including women with endometriosis, quantitative studies, and interventions that included some form of physical therapy techniques. Difference in mean differences and their 95% confidence interval were calculated. The I² statistic was used to determine the degree of heterogeneity, and the GRADE approach was used to assess the certainty of the evidence. Results The interventions analyzed included manual therapy, education, electrotherapy, exercise, relaxation techniques, and acupuncture. Dyspareunia (p = 0.001; I2 = 95.6%) and pelvic pain (p = 0.012; I2 = 90.1%) were significantly reduced. Quality of life was significantly increased (p < 0.001; I2 = 94.9%). The certainty of the evidence obtained was moderate. Conclusion Massage therapy combined with perineal stretching, electrotherapy, acupuncture, exercise, and patient education are effective in improving chronic pelvic pain, dyspareunia, dysmenorrhea, non-menstrual pain, the basic and modular domains of quality of life, mental and physical health, and functional well-being in endometriosis. Healthcare professionals must recognize the importance of evaluating each case individually and tailoring treatments to the specific needs of each patient.
Background: Although cognitive impairment is associated with adverse outcomes, evidence on its relationship with gait speed across specific cognitive domains remains limited, particularly in middle-income countries. Objective: To investigate the association between global and domain-specific cognitive function and gait speed in Brazilian older adults. Methods: This cross-sectional study included 6940 participants from the Brazilian Longitudinal Study of Aging (ELSI-Brazil). Gait speed was assessed with standardized z-scores and classified as "normal" or "slower". Global cognitive function and specific domains (immediate and delayed memory, verbal fluency, and temporal orientation) were similarly standardized and categorized as "normal" or "impaired". Associations between cognition and gait speed were estimated using crude and adjusted Poisson regression models. Interaction analyses with sociodemographic, behavioral, and health-related variables were performed. Results: Participants were mostly female (52.8%) aged 50-59 years (51.0%). Slower gait speed was observed in 10.1% (95% CI: 8.3, 12.1), while impaired global cognition occurred in 12.5% (95% CI: 11.1, 14.0). In the adjusted models, global cognitive impairment was associated with a higher prevalence of slower gait speed (PR: 1.63; 95% CI: 1.30, 2.04). Verbal fluency (PR: 1.80; 95% CI: 1.45, 2.24) and delayed memory (PR: 1.46; 95% CI: 1.16, 1.83) showed the strongest domain-specific associations. Educational level moderated this relationship, with higher education attenuating the association between cognitive impairment and gait speed. Conclusion: Global and domain-specific cognitive impairments, particularly in executive function and memory, were associated with slower gait speed. Education moderated this relationship, underscoring the role of cognitive and social factors in mobility outcomes among Brazilian older adults.
