Efeitos da reabilitação física intra-hospitalar com versus sem treinamento muscular inspiratório em pacientes submetidos ao transplante de células-tronco hematopoiéticas

Abstract

Hospitalized patients for hematopoietic stem cell transplantation (HSCT), also known as bone marrow transplantation, present significant alterations in global health, especially due to prolonged immobility and high-dose chemotherapy. Therefore, alterations in functional capacity and autonomic control are observed in these patients. Functional capacity is a predictor of mortality in this population, but the association between this variable and the self-perceived quality of life in patients undergoing HSCT is not known. Furthermore, it is known that autonomic control in patients undergoing HSCT is impaired when evaluated in the intermediate and late post-HSCT phases, but it is not known the time course of autonomic control profile in the acute phase, more precisely during hospitalization for HSCT. Finally, several studies have discussed the effects of different types of physical rehabilitation. However, the effects of inspiratory muscle training (IMT) in hospitalized patients undergoing HSCT are not yet known, nor whether this training modality is feasible and safe for this population. The objectives were: 1) to evaluate the association between changes in functional capacity and quality of life during hospitalization for HSCT; 2) to verify the time course of autonomic control during hospitalization for HSCT; 3) to systematically review the effects of IMT on autonomic control; 4) to assess the feasibility and safety of performing IMT in hospitalized patients undergoing HSCT; 5) to evaluate the effects of IMT on the global health of hospitalized patients undergoing HSCT. For this thesis, four original studies and a systematic review study were developed: 1) the first article assessed the functional capacity (6-Minute Step test) and the quality of life (EORTC-QLQ-C30) of hospitalized patients for HSCT in the admission and hospital discharge. Then, patients were allocated into a group that improved functional capacity and another group that maintained or worsened functional capacity. Thus, the quality of life of patients in different groups was assessed; 2) in the second article, hospitalized patients for HSCT were followed from admission to hospital discharge and had their autonomic control evaluated through heart rate variability (HRV). Patients were evaluated consecutively on the day of hospital admission, on the day following the end of chemotherapy, on the first day of neutropenia, on the day of grafting bone marrow, and on the day of hospital discharge; 3) for the third article, it was searched the literature for published articles with a study design of a controlled and randomized clinical trial that had evaluated the effect of IMT on autonomic control of any type of population. Thus, the quality of the included studies was evaluated, as well as the effect of IMT on variables related to the autonomic nervous system; 4) the fourth article evaluated the feasibility and safety of IMT in patients undergoing HSCT, which was applied based on clinical and laboratory criteria. Measures of recruitment, attrition, adherence and number of adverse events that occurred due to IMT were evaluated; 5) in the fifth article the effects of IMT, which was applied during hospitalization for HSCT, on respiratory, cardiovascular, musculoskeletal, functional, quality of life, and fatigue variables were assessed. For this study, the IMT group was compared to a control group, which performed a conventional rehabilitation protocol, without IMT. Patients were evaluated on admission and hospital discharge, being rehabilitated with IMT throughout the hospitalization. As results, the article 1 showed that the increase of at least one step in hospital discharge compared to admission, reflecting the increase in functional capacity, is associated with the better overall quality of life and better quality of life-related to the symptoms. Article 2 showed that, early, during hospitalization for HSCT, patients have reduced cardiac autonomic control, suggesting worse cardiovascular health. These results were supported by the reduction in HRV measurements that reflects the parasympathetic nervous system and the increase in HRV measurements that reflects the sympathetic nervous system. Additionally, it was possible to verify that this worsening of cardiac autonomic control occurs, mainly, after chemotherapy and at the beginning of neutropenia. The results of article 3 showed that four articles with an adequate study design evaluated the effects of IMT on autonomic control, especially in cardiovascular patients. Among those articles, three indicated that IMT improved autonomic control assessed by HRV and plasma norepinephrine levels. Article 4 demonstrated that the application of IMT based on clinical and laboratory criteria is feasible and safe, showing high recruitment and adherence values, as well as low attrition and number of adverse events related to IMT. Article 5 showed that IMT, when performed during hospitalization for HSCT, has beneficial effects on inspiratory muscle strength, on systolic and diastolic blood pressure, on fatigue, and, apparently, on functional capacity. In conclusion., initially, it is important to note that the improvement in functional capacity during hospitalization for HSCT has an impact on patients’ perception of their quality of life. In addition, the assessment of cardiac autonomic control during hospitalization for HSCT showed that patients had worsening of cardiovascular health, especially after chemotherapy and at the beginning of neutropenia. Regarding the effects of IMT, it is important to note that although most of the reviewed studies point to an improvement in autonomic control with this training modality, hospitalized patients for HSCT did not show benefits in relation to this measure. However, IMT is considered safe and feasible for this population, promoting beneficial effects in relation to inspiratory muscle strength, blood pressure, and fatigue.