OBJECTIVE:To identify empirical patterns of multimorbidity and quantify their associations with socioeconomic, behavioral characteristics, and health outcomes in the megacity of São Paulo. METHODS:This was a cross-sectional study conducted through household interviews with residents aged 20 years or older in urban areas (n = 3,184). Latent class analysis was used to identify patterns among the co-existence of 22 health conditions. Age-adjusted prevalence ratios were estimated using Poisson regression. RESULTS:The analysis of latent classes showed 4 patterns of multimorbidity, whereas 58.6% of individuals were classified in the low disease probability group, followed by participants presenting cardiovascular conditions (15.9%), respiratory conditions (12.8%), and rheumatic, musculoskeletal, and emotional conditions (12.8%). Older individuals, with lower schooling and lower household income, presented higher multimorbidity prevalence in cardiovascular, respiratory, rheumatic, musculoskeletal, and emotional conditions patterns compared with the low disease probability pattern. CONCLUSION:The results showed four distinct patterns of multimorbidity in the megacity population, and these patterns are clinically recognizable and theoretically plausible. The identification of trends between patterns would make it feasible to estimate the magnitude of the challenge for the organization of health care policies.

The primary objective of this study is the preparation of the certification of the Clynx® Platform, a physiotherapy software, as a Class IIa medical device software in accordance with the regulatory framework outlined in Medical Device Regulation 2017/745 (MDR). The methodology involves a comprehensive analysis of European Union medical device regulations and guidelines, with a specific focus on the certification process essential for obtaining a Conformité Européenne (CE) marking for Class IIa medical device software. This section explores the intricate aspects of the certification process, emphasizing the compilation of Technical Documentation, the nuances of Clinical Evaluation, and the establishment of a Quality Management System. The approach aligns closely with the stipulations of MDR 2017/745. The study includes an industry case study featuring the Clynx® Platform, developed by Clynx® Health. Insights derived from the MDR are applied to categorize an in-development version of the software as a Class IIa medical device. The preparation of certification of this product involves the meticulous creation of Intended Use, Classification, General and Safety Performance Requirements, and Clinical Evaluation files, the presentation of an experimental protocol to validate the software’s technical performance for inclusion in the Clinical Evaluation, and a description of an Internal Audit performed on the Quality Management System. The certification of Class IIa medical device software necessitates the compilation of thorough Technical Documentation, including an extensive Clinical Evaluation, and the implementation of a robust Quality Management System. The certification process is conducted in collaboration with Notified Bodies, ensuring adherence to the stringent requirements set forth by the regulatory framework.

Digital physiotherapy is emerging as a promising solution to enhance patient care and improve rehabilitation outcomes. This chapter explores the available solutions in digital physiotherapy, their benefits, and limitations. Best practices in implementing digital physiotherapy are discussed, emphasizing the need for personalized approaches and patient engagement. The importance of clinical and scientific validation in assessing the efficacy and safety of digital physiotherapy interventions is also addressed. The aspects of the future of digital physiotherapy, such as gamification tools, virtual reality-based therapies, wearable devices, and artificial intelligence powered platforms can impact on rehabilitation practices. With ongoing research and innovation, digital physiotherapy may have potential to optimize physiotherapy care.

Objetivo – Determinar e analisar o perfil comportamental dos estudantes do primeiro ciclo do ensino básico sobre o uso da mochila escolar. Método – Estudo observacional, analítico e transversal. A amostra foi constituída por 88 estudantes do 1º ciclo do ensino básico no concelho de Vila Nova de Famalicão (Portugal). Foi aplicado um questionário para avaliar o comportamento dos estudantes relativamente ao tipo, modo de transporte, organização do material escolar e peso da mochila. Resultados – Todas as mochilas apresentavam duas alças e eram reguláveis. A maioria dos estudantes de todos os anos letivos transportava a mochila de alças nos dois ombros. No geral, os estudantes do 1º ciclo distribuíam o material de forma desorganizada pelos compartimentos da mochila e colocavam o material mais pesado afastado da coluna vertebral, não se verificando diferenças significativas. O índice de proporção mostrou que os estudantes transportavam as mochilas com peso inferior a 10% do peso corporal, exceto os estudantes do 1º ano de escolaridade (p<0,05). O peso transportado nas mochilas era significativamente assimétrico durante os dias da semana e entre os níveis de escolaridade (p<0,05). Conclusões – A maioria dos estudantes do 1º ciclo transportava a mochila com as alças nos dois ombros; porém, desconheciam as características adequadas do tipo de mochila e da distribuição uniforme do material escolar. A variação da carga da mochila durante a semana entre os níveis de escolaridade era significativamente inconsistente, mostrando que o índice de proporção de carga era mais elevado no primeiro ano de escolaridade.

Purpose: High impact exercise is known to induce osteogenic effects in the skeleton. However, less is known about the systemic effect of exercise practice in a potential adaptive mechanism of the skeletal accrual. This research aimed to assess the effect of impact exercise on bone mineral density (BMD) in the radius throughout adolescence. Methods: This study evaluated 1137 adolescents, at 13 and 17 years old, as part of the population-based cohort EPITeen. BMD (g/cm(2)) was measured at the ultradistal and proximal radius of the non-dominant forearm by dual-energy X-ray absorptiometry (DXA) using a Lunar (R) Peripheral Instantaneous X-ray Image device. The practice of (extra-curricular) exercise was categorized as: no exercise, exercise with high impact and exercise with low impact. Regression coefficients (beta) and respective 95% confidence intervals (CI95%) were used to estimate the association between exercise practice categories at 13 years old and BMD at 13 and 17 years old and BMD gain between evaluations. Results: In boys, at 13 years, BMD was similar between the ones not practicing exercise and those practicing exercise with low impact, and the gain of BMD was also similar in both groups. Still in boys, at 13 years, those who practiced exercise with high impact presented higher mean (standard-deviation) of BMD, comparing to the other two groups (no exercise and low impact exercise), and also significantly increased the BMD gain between 13 and 17 years (beta = 0.013; CI(95%)0.003;0.023). In girls, no statistically significant differences on BMD were found between the categories of exercise at 13 years and BMD at 17 years of age. Conclusion: This research shows that the practice of high impact exercise could help to increase BMD more than low impact exercise even in a nonweight-bearing bone during adolescence.

Few studies have explored the impacts of COVID-19 and lockdown on the mental health of undergraduate nursing students. This study aimed: a) to explore perceived stress among undergraduate nursing students in Portugal and Spain during the COVID-19 pandemic outbreak; and b) to analyze several COVID-19 related factors and psychological issues that may be associated with perceived stress. A cross-sectional study was conducted with a convenience sample of Portuguese and Spanish undergraduate nursing students (n=1075). The data gathered included demographic information, questions about COVID-19 related factors, and psychological issues. Data were analyzed using multiple logistic regression with a degree of significance at p<0.05. High perceived stress scores were found in 558 participants (51.9%). Students with high perceived stress most likely had a COVID-19 diagnosis in their household; their household income had been affected by the COVID-19 pandemic; experienced difficulty falling asleep or sleeping all night; consumed junk food in excess; neglected their appearance; felt headaches, stomach aches, and back pain; and lacked the patience or desire to exercise. Additionally, high perceived stress was negatively associated with life satisfaction. The results provide evidence that infectious diseases, such as COVID-19, may significantly influence mental health. Further research should explore the long-term psychological effects of the COVID-19 pandemic among nursing students.

Objetivos: avaliar o impacto das atividades de um programa de estimulação cognitiva na saúde mental de idosos no âmbito do estado cognitivo e depressivo. Método: Estudo longitudinal, tipo pré e pós intervenção, desenvolvido com 33 idosos, na cidade de Porto, Portugal, no contexto do no programa VintAGEING+Felizes, aplicado por equipe multiprofissional, em duas edições, de 2019 a 2020. Resultados: A melhora no estado cognitivo evidenciou-se através do aumento da variação das médias dos escores do Montreal Cognitive Assessment em 6,5% (p=0,044) e melhora do estado depressivo, obtido pela Escala de Depressão Geriátrica, na redução da variação das médias dos escores em 22,5% (p=0,153), além de 100% de redução da depressão severa. Conclusão: os ganhos em saúde mental na amostra de idosos pós intervenção com estimulação cognitiva demonstra que o programa VintAGEING+Felizes possui componentes necessários e factíveis para seguir como uma intervenção positiva para o bem-estar de idosos.

Non-communicable diseases (NCDs) frequently aggregate due to shared pathophysiological mechanisms, either as sequential steps in the same causal pathway or as common results of the same exposures, leading to a high prevalence of disease co-occurrence, a phenomenon known as multimorbidity. Multimorbidity is a patient-centered concept where all morbidities are regarded of equal importance irrespective of whether they started before or after any other disease in question. Rheumatic and musculoskeletal diseases (RMDs) are among the most prevalent groups of NCDs, and probably due to their high incidence and low case fatality, they are highly susceptible to multimorbidity. Complex patients, such as some of those with multimorbidity, are nowadays the norm, implying a growing concern that clinical practice guidelines fail to adequately address the care of complex patients. The ramifications of suffering from multimorbidity unfold for each patient, within their social, educational, cultural, behavioral, economic, and environmental contexts, which in turn affect disease management.

Non-communicable diseases (NCDs) frequently aggregate due to shared pathophysiological mechanisms, either as sequential steps in the same causal pathway or as common results of the same exposures, leading to a high prevalence of disease co-occurrence, a phenomenon known as multimorbidity. Multimorbidity is a patient-centered concept where all morbidities are regarded of equal importance irrespective of whether they started before or after any other disease in question. Rheumatic and musculoskeletal diseases (RMDs) are among the most prevalent groups of NCDs, and probably due to their high incidence and low case fatality, they are highly susceptible to multimorbidity. Complex patients, such as some of those with multimorbidity, are nowadays the norm, implying a growing concern that clinical practice guidelines fail to adequately address the care of complex patients. The ramifications of suffering from multimorbidity unfold for each patient, within their social, educational, cultural, behavioral, economic, and environmental contexts, which in turn affect disease management.

CONTEXT:Deep friction massage (DFM) is often used in the treatment of tendinopathies; however, the pressure applied may vary and interfere with the obtained results. OBJECTIVE:To assess whether the immediate effects of DFM on pain (pain intensity and time to onset of analgesia) and muscle strength are dependent on the pressure applied during the DFM application in athletes with patellar tendinopathy. DESIGN:Randomized, controlled, cross-over trial. SETTING:University research laboratory (institutional). PARTICIPANTS:Ten athletes with diagnosis of unilateral patellar tendinopathy (age 27.90 [5.24] y). INTERVENTIONS:All participants attended 4 sessions, 3 treatment sessions with DFM applied with different pressures (the mean pressure-previously determined for each participant-and the mean pressure ± 25%) and a control session, each of which was separated by 48 hours. MAIN OUTCOME MEASURES:Pain (intensity upon palpation and time to onset of analgesia), and muscle strength of knee extensors were assessed before and immediately after each session. RESULTS:Pain intensity changed significantly over time (F1,9 = 52.364; P < .001; ηp2=.853) and among sessions (F3,27 = 82.588; P < .001; ηp2=.902), with a significant interaction for group × time (F3,27 = 19.841; P < .001; ηp2=.688). The knee extensors strength did not change significantly over time (F1,9 = 2.240; P = .17; ηp2=.199), nor a significant interaction for session × time was observed (F3,27 = 3.276; P = .07; ηp2=.267). Regardless of the pressure applied, the time to onset of analgesia was not significantly different (F2,18 = 1.026; P > .05; ηp2=.102). CONCLUSION:It was shown that DFM induces an immediate reduction in pain intensity upon palpation, regardless of the pressure performed. Notwithstanding, the reader should take into account the small sample size and the caution needed in the results' interpretation.

Objective To examine the effectiveness of the FIFA 11+ in reducing injury in futsal players. Methods Ninety-one male futsal players from six amateur futsal clubs were recruited and assessed for eligibility, and 71 were randomized to the 11+ group (n = 37, age: 27.0 +/- 5.1 years) and a control group (n = 34, age: 26.0 +/- 5.1 years). The 11+ program was executed twice a week for 20 weeks, separated by a 10-week period where both groups executed their regular warm-up. Data on match, training exposure, and injuries were recorded during the regular season. Results The players sustained a total of 58 injuries during the futsal regular season, with 24 injuries in the 11+ group and 34 injuries in the control group; the overall incidence of injuries per 1000 player-hours was significantly higher in the control group (11.6 vs 6.5; mean difference (95% CI) -5.1 (-9.1 to -1.1), P = .014). The 11+ group had a significantly lower incidence of acute (11.2 vs 5.7; -5.5 (-9.4 to -1.6), P = .007) and lower limb (8.7 vs 4.4; -4.2 (-8.1 to -0.4), P = .032) injuries per 1000 player-hours. Players from the control group had a higher number of days injured (20.4 +/- 17.3 vs 10.5 +/- 9.1, P = .036). Conclusion The FIFA 11+ is an injury prevention program suited for injury reduction in amateur futsal players, as it reduces the incidence of overall, acute, and lower limb injuries during the season.

This study aims to determine if a dose–response relationship exists between the pressure applied during deep friction massage (DFM) and the time to the onset of analgesia in an asymptomatic patellar tendon. For this purpose, pressures applied by physiotherapists during DFM (study 1) were characterized and then, based on these pressures, the effects of different DFM pressures on the time to the onset of analgesia were assessed (study 2). First, the mean pressure applied by 40 physiotherapists during a DFM session was assessed with a pressure sensor through an observational, cross-sectional and analytical study. Next, the effects of different pressure intensities (the median, the percentile 25 (P25), and the percentile 75 (P75) of the mean pressure obtained in study 1) were studied in a crossover trial enrolling 30 participants with an asymptomatic patellar tendon. A pressure sensor was used to register the pressures applied during DFM. Our main results indicated that the physiotherapists applied pressures with a wide variation ((mean pressure: 2.317 kg/cm2 (P25: 1.022 kg/cm2; P75: 4.161 kg/cm2)). It was also shown that higher pressures had shorter times to the onset of analgesia (pressure: 1 kg/m2, time to the onset of analgesia: 67.0 s (P25: 84.5 s; P75: 113.5 s); pressure: 2.3 kg/m2, time to the onset of analgesia: 59.0 s (P25: 73.5 s; P75: 87.3 s); pressure: 4.2 kg/m2, time to the onset of analgesia: 37.8 s (P25: 54.0 s; P75: 62.0 s)) (p ≤ 0.001). In conclusion, the mean DFM pressure obtained by the physiotherapists was 2.3 kg/cm2 (P25: 1.02 kg/cm2; P75: 4.16 kg/cm2). Higher pressures of DFM resulted in shorter times to the onset of analgesia.

Introduction: The purpose of this article was to develop and validate a scale to assess common knowledge about temporomandibular disorders (TMDs) in the general population, evaluate the status of TMDs knowledge in the Portuguese population, quantify the severity and prevalence of TMDs-related symptoms in the general population, and assess the association between TMDs-related symptoms’ severity and demographic, medical and oral associated factors. Materials and Methods: This study was an analytical cross-sectional survey design. The sample consisted of 2165 participants selected through a snowball sampling method. The participants completed an online questionnaire regarding social and demographic characteristics, medical history, oral habits, Fonseca’s Anamnestic Index, a scale about difficulties on impulsiveness control and also the TMDs knowledge scale developed. The psychometric properties of the scale developed was tested on a small number of participants (n = 210). The P value set was 0.05. Results: Concerning psychometric properties all items showed a moderate-to-strong positive association with the loading factor. The Cronbach’s alpha was 0.956, showing good reliability. TMDs knowledge was positive in 1295 participants (59.8%). Multivariate-adjusted odds showed that female gender, diagnosis of tension-type headache, migraine, anxiety, impulsiveness, facial trauma, and parafunctional habits increased the risk of developing TMDs (adjusted odds ratios from 1.84 to 49.38). Conclusion: The scale developed is psychometrically valid and reliable and the participants had an overall positive knowledge about TMDs. A high prevalence of TMDs-related symptoms among the Portuguese population was found and the associated factors were female gender, impulsiveness, tension-type headache, migraine, anxiety, facial trauma, and parafunctional habits.

Abstract Aims: To describe food consumption in Portuguese primary school children, to analyze the influence of food consumption on the body mass index (BMI), and to analyze the relationship between physical exercise and the child's food consumption. Method: A quantitative, descriptive, exploratory, and cross-sectional study was conducted in 2 primary schools of the north of Portugal (n = 109 child). The use of a food register for 5 consecutive days and anthropometric evaluation of the children were used. Results: The vast majority of children had a normal weight (65.10%). However, 34.90% of the children presented significant changes in their BMI (14.70% with low weight, 11.90% overweight, and 8.30% with obesity). Children who engage in physical activity drink more water and consume less sugary products. However, they also consume less meat, fish, and eggs than those who do not perform regular physical activity. Conclusions: The study highlights the emergence of new problems, such as the increasing prevalence of underweight children. The prevention of these problems, overweight, or underweight children, should be addressed among healthcare providers, local authorities, families, and teachers.

BACKGROUND:The ability of the FIFA 11+ to enhance performance has demonstrated controversial results. Hence, we examined the short and long-term effects of the FIFA 11+ on performance in male amateur futsal players.METHODS:Seventy-one male futsal players from six amateur clubs were recruited and randomized to an intervention (N.=37, age: 27.0±5.1 years) or a control group (N.=34, age: 26.0±5.1 years). The intervention group was submitted to 10 weeks of FIFA 11+ injury prevention program, 2 sessions/week, followed by a 10-week follow-up period, while the control group performed regular futsal warm-ups during the training sessions. During the follow-up period both groups performed only regular warm-ups during their training sessions. Physical performance was assessed by measuring agility (T-test), sprint (30 m sprint), flexibility (sit-and-reach test) and vertical jump performance (squat jump).RESULTS:Differences between groups were found at baseline for training exposure, body mass index, body weight, flexibility, and sprint. The results of the effect of the FIFA 11+ on the sit-and-reach test, speed and agility did not show differences pre-post intervention, as well as for the 10-week follow-up. Jump performance, showed a significant difference in favor of the control group for the intervention period and the follow-up (crude β: -0.04 [95% CI: -0.06; -0.01]; -0.03 [95% CI: -0.06; -0.00], respectively), however after adjustment for the baseline differences the confidence interval fell out of the range of significance for the intervention and follow-up period (adjusted β, -0.05 [95% CI: -0.10; 0.00]; -0.05 [95% CI: -0.10; 0.04]).CONCLUSIONS:The present study has shown no short and long-term performance enhancement in sprint, flexibility, agility and jump performance after the FIFA 11+ in male amateur futsal players.

Background: Anthropometry and body composition are plausible influences on pediatric sagittal standing posture. Despite that, the relationship of anthropometrics since birth and body composition with individual postural parameters in children has never been assessed. Research question: To assess the associations between anthropometrics since birth and body composition parameters, and angles of sagittal standing posture in children. Methods: The sample included 1021 girls and 1096 boys, evaluated in the population-based birth cohort Generation XXI, Portugal. Weight and height were obtained at birth, 4 and 7 years of age. At age 7, total body less head fat/fat-free mass and bone properties were estimated from whole body dual energy X-ray absorptiometry scans and posture was assessed through right-side photographs during habitual standing with retro-reflective markers placed on body landmarks. Results: Girls showed increased values of lumbar angle, head and neck flexion, and craniocervical angle with the largest mean (standard deviation) difference in lumbar angle [281.7 degrees (7.4) vs. 276.8 degrees (7.1) in boys, p < 0.001]. In both genders, weight and body mass index were weakly associated with lumbar angle: 0.24 >= r <= 0.31 in girls and 0.16 >= r <= 0.26 in boys, all p < 0.001. Fat and fat-free mass and bone mineral density were weakly associated with lumbar angle in both genders. Significance: Our study showed clear postural heterogeneity between girls and boys in early ages. Lumbar angle is likely to be the single most relevant proxy of overall posture based on the associations with the exposures reported in this study.

Ações de prevenção e de manutenção da saúde do idoso, na sua comunidade e no seu domicílio, devem ser resultado de um esforço de parcerias públicas e/ou privadas, academia e serviço. O programa intitulado, VintANGEING+Felizes, tem como finalidade realizar um trabalho multidisciplinar de intervenção comunitária, disponibilizando o conhecimento científico e contribuindo para o cumprimento das diretrizes e das políticas de atenção pública à saúde do idoso, na direção do envelhecimento ativo e saudável.

The aim of this study was to quantify the population impact of rheumatic and musculoskeletal diseases (RMDs) with other non-communicable diseases (NCDs), using two complementary strategies: standard multivariate models based on global burden of disease (GBD)-defined groups vs. empirical mutually exclusive patterns of NCDs. We used cross-sectional data from the Portuguese Fourth National Health Survey ( n = 23,752). Six GBD-defined groups were included: RMDs, chronic obstructive pulmonary disease or asthma, cancer, depression, diabetes or renal failure, and stroke or myocardial infarction. The empirical approach comprised the patterns “low disease probability”, “cardiometabolic conditions”, “respiratory conditions” and “RMDs and depression”. As recommended by the outcome measures in rheumatology (OMERACT) initiative, health outcomes included life impact, pathophysiological manifestations, and resource use indicators. Population attributable fractions (PAF) were computed for each outcome and bootstrap confidence intervals (95% CI) were estimated. Among GBD-defined groups, RMDs had the highest impact across all the adverse health outcomes, from frequent healthcare utilization (PAF 7.8%, 95% CI 6.2–9.3) to negative self-rated health (PAF 18.1%, 95% CI 15.4–20.6). In the empirical approach, patterns “cardiometabolic conditions” and “RMDs and depression” had similar PAF estimates across all adverse health outcomes, but “RMDs and depression” showed significantly higher impact on chronic pain (PAF 8.9%, 95% CI 7.6–10.3) than the remaining multimorbidity patterns. RMDs revealed the greatest population impact across all adverse health outcomes tested, using both approaches. Empirical patterns are particularly interesting to evaluate the impact of RMDs in the context of their co-occurrence with other NCDs.

Objective: The purpose of this study was to determine the skin pressure needed to promote the macroscopic deformation of the asymptomatic patellar tendon and to verify if the pressure is associated with the individual's characteristics. Methods: A descriptive laboratory study was performed with a convenience sample of 18 young, voluntary, and asymptomatic individuals of both sexes. A progressively increasing pressure was applied on the skin over the patellar tendon, through an instrument designed to perform and control the pressure upon an ultrasound probe; data were recorded and analyzed by 2 blind investigators. All statistical analyses were conducted considering alpha = 0.05. Results: The average pressure needed to promote a macroscopic deformation of the patellar tendon was 1.12 +/- 0.37 kg/cm(2). Female sex and age were inversely but not significantly associated with the pressure performed. Sports practice, weight, height, body mass index, muscle mass, and subcutaneous thickness were positively but not significantly associated with the pressure executed. Conclusion: The average pressure needed to promote the macroscopic deformation of the patellar tendon was 1.12 +/- 0.37 kg/cm(2), which was not influenced by the characteristics of the participants.

Background: Deep friction massage is one of several physiotherapy interventions suggested for the management of tendinopathy. Objectives: To determine the prevalence of deep friction massage use in clinical practice, to characterize the application parameters used by physiotherapists, and to identify empirical model-based patterns of deep friction massage application in degenerative tendinopathy. Design: observational, analytical, cross-sectional and national web-based survey. Methods: 478 physiotherapists were selected through snow-ball sampling method. The participants completed an online questionnaire about personal and professional characteristics as well as specific questions regarding the use of deep friction massage. Characterization of deep friction massage parameters used by physiotherapists were presented as counts and proportions. Latent class analysis was used to identify the empirical model-based patterns. Crude and adjusted odds ratios and 95% confidence intervals were computed. Results: The use of deep friction massage was reported by 88.1% of the participants; tendinopathy was the clinical condition where it was most frequently used (84.9%) and, from these, 55.9% reported its use in degenerative tendinopathy. The "duration of application" parameters in chronic phase and " frequency of application" in acute and chronic phases are those that diverge most from those recommended by the author of deep friction massage. Conclusion: We found a high prevalence of deep friction massage use, namely in degenerative tendinopathy. Our results have shown that the application parameters are heterogeneous and diverse. This is reflected by the identification of two application patterns, although none is in complete agreement with Cyriax's description. (C) 2017 Elsevier Ltd. All rights reserved.