Níveis plasmáticos de nitrito/nitrato, GMPc e cortisol em mulheres normotensas e hipertensas após a menopausa: efeito crônico do exercício físico e exposição aguda à L-arginina

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Início de ativação muscular de estabilizadores primários e a capacidade física para avaliar estabilização lombo-pélvica

Introduction: Due to the high incidence of low back pain without apparent cause, different approaches to evaluate the lumbar instability has been proposed, such as surface electromyography to determine pre-activation and the ability of lumbar stabilization through functional physical assessment. In this context, the objective of this study was to evaluate the early activation of the primary stabilizing muscles in subjects without low back pain, with different physical abilities function (CFF). Method: Study participants were 20 subjects with 19.8 ± 1.4 years, 55.7 ± 8.8 kilos, 1.66 ± 0.08 m, of both sexes. The subjects underwent six Tests Physical Function (TFF) and the Test of Fast Moving Flexion Arm (TMRFB) to capture the electromyographic activity of the lumbar multifidus muscles (LM) and internal oblique - lower fibers (HI). Were assigned weights for each functional test and the result of the physical capacity of the final functional subject ranged from 0 to 100%. In the analysis of TMRB was considered the onset time of activation between the ML and HI. Results: Regarding TFF 2 (10%) subjects were considered to have normal physical capacity, 6 (30%) with good physical ability and 12 (60%) with regular physical capacity or poor. As for TMRFB average values of initiation of muscle activation in 75% of subjects were within the limits to characterize the condition of pre-muscle activation. Conclusion:The results obtained in the TFF were low compared with the CFF of asymptomatic subjects evaluated. This fact does not mean that the condition of stabilization of the subject is appropriate. However, the results obtained in the electromyographic examination to suggest that 25% of asymptomatic subjects tested did not have a proper condition of lumbar stabilization.

Long-term multimodal exercise program enhances mobility of patients with Parkinson's disease

Objective. This study aimed to evaluate the effect of a long-period multimodal exercise program on balance, mobility and clinical status of patients with Parkinson’s disease (PD). Methods. Thirty-three PD patients were assigned into two groups: a training group (TG—n = 22; aged 67.23 ± 8.39 years) and a control group (CG—n = 9; aged 71.56 ± 8.50 years). The TG patients were enrolled in a 6-month multimodal exercise program. This program was designed to improve physical capacity components and to reduce PD impairments. Balance and mobility were assessed immediately before and after the training protocol using the Berg Balance Scale (BBS), the “Timed up and go” (TUG), and the Posture Locomotion Test (PLM). Also, clinical variables were assessed (disease stage and impairments). Results. The TG showed an improvement in the TUG (P = 0.006) while CG were not influenced by the 6-months period. Both groups showed no differences for BBS and PLM and for their disease impairments—assessed through the Unified Parkinson’s disease Scale. Conclusions. Long-term multimodal exercise programs are able to improve mobility of patients with Parkinson’s disease and therefore should be used on clinical day life.

Exercise training in juvenile dermatomyositis

Objective. To investigate the effects of a supervised exercise training program on health parameters, physical capacity, and health-related quality of life in patients with mild and chronic juvenile dermatomyositis (DM). Methods. This was a prospective longitudinal study following 10 children with mild and chronic juvenile DM (disease duration >1 year). The exercise program consisted of twice-a-week aerobic and resistance training. At baseline and after the 12-week intervention, we assessed muscle strength and function, aerobic conditioning, body composition, juvenile DM scores, and health-related quality of life. Results. Child self-report and parent proxy-report Pediatric Quality of Life Inventory scores were improved after the intervention (-40.3%; P = 0.001 and -48.2%; P = 0.049, respectively). Importantly, after exercise, the Disease Activity Score was reduced (-26.9%; P = 0.026) and the Childhood Muscle Assessment Scale was improved (+2.5%; P = 0.009), whereas the Manual Muscle Test presented a trend toward statistical significance (+2.2%; P = 0.081). The peak oxygen consumption and time-to-exhaustion were increased by 13.3% (P = 0.001) and 18.2% (P = 0.003), respectively, whereas resting heart rate was decreased by 14.7% (P = 0.006), indicating important cardiovascular adaptations to the exercise program. Upper and lower extremity muscle strength and muscle function were also significantly improved after the exercise training (P < 0.05). Both the whole-body and the lumbar spine bone mineral apparent density were significantly increased after training (1.44%; P = 0.044 and 2.85%; P = 0.008, respectively). Conclusion. We showed for the first time that a 12-week supervised exercise program is safe and can improve muscle strength and function, aerobic conditioning, bone mass, disease activity, and health-related quality of life in patients with active and nonactive mild and chronic juvenile DM with near normal physical function and quality of life.

Efficacy of graded activity versus supervised exercises in patients with chronic non-specific low back pain: protocol of a randomised controlled trial

Abstract Background Low back pain is a relevant public health problem, being an important cause of work absenteeism worldwide, as well as affecting the quality of life of sufferers and their individual functional performances. Supervised active physical routines and of cognitive-behavioral therapies are recommended for the treatment of chronic Low back pain, although evidence to support the effectiveness of different techniques is missing. Accordingly, the aim of this study is to contrast the effectiveness of two types of exercises, graded activity or supervised, in decreasing symptoms of chronic low back pain. Methods/design Sample will consist of 66 patients, blindly allocated into one of two groups: 1) Graded activity which, based on an operant approach, will use time-contingent methods aiming to increase participants’ activity levels; 2) Supervised exercise, where participants will be trained for strengthening, stretching, and motor control targeting different muscle groups. Interventions will last one hour, and will happen twice a week for 6 weeks. Outcomes (pain, disability, quality of life, global perceived effect, return to work, physical activity, physical capacity, and kinesiophobia) will be assessed at baseline, at treatment end, and three and six months after treatment end. Data collection will be conducted by an investigator blinded to treatment allocation. Discussion This project describes the randomisation method that will be used to compare the effectiveness of two different treatments for chronic low back pain: graded activity and supervised exercises. Since optimal approach for patients with chronic back pain have yet not been defined based on evidence, good quality studies on the subject are necessary. Trial registration NCT01719276

Adaptations of the aging animal to exercise: role of daily supplementation with melatonin

The pineal gland, through melatonin, seems to be of fundamental importance in determining the metabolic adaptations of adipose and muscle tissues to physical training. Evidence shows that pinealectomized animals fail to develop adaptive metabolic changes in response to aerobic exercise and therefore do not exhibit the same performance as control-trained animals. The known prominent reduction in melatonin synthesis in aging animals led us to investigate the metabolic adaptations to physical training in aged animals with and without daily melatonin replacement. Male Wistar rats were assigned to four groups: sedentary control (SC), trained control (TC), sedentary treated with melatonin (SM), and trained treated with melatonin (TM). Melatonin supplementation lasted 16 wk, and the animals were subjected to exercise during the last 8 wk of the experiment. After euthanasia, samples of liver, muscle, and adipose tissues were collected for analysis. Trained animals treated with melatonin presented better results in the following parameters: glucose tolerance, physical capacity, citrate synthase activity, hepatic and muscular glycogen content, body weight, protein expression of phosphatidylinositol 3-kinase (PI3K), mitogen-activated protein kinase (MAPK), and protein kinase activated by adenosine monophosphate (AMPK) in the liver, as well as the protein expression of the glucose transporter type 4 (GLUT4) and AMPK in the muscle. In conclusion, these results demonstrate that melatonin supplementation in aging animals is of great importance for the required metabolic adaptations induced by aerobic exercise. Adequate levels of circulating melatonin are, therefore, necessary to improve energetic metabolism efficiency, reducing body weight and increasing insulin sensitivity.

Effect of comprehensive cardiac rehabilitation after heart valve surgery (CopenHeartVR): study protocol for a randomised clinical trial

Background Heart valve diseases are common with an estimated prevalence of 2.5% in the Western world. The number is rising due to an ageing population. Once symptomatic, heart valve diseases are potentially lethal, and heavily influence daily living and quality of life. Surgical treatment, either valve replacement or repair, remains the treatment of choice. However, post surgery, the transition to daily living may become a physical, mental and social challenge. We hypothesise that a comprehensive cardiac rehabilitation programme can improve physical capacity and self-assessed mental health and reduce hospitalisation and healthcare costs after heart valve surgery. Methods A randomised clinical trial, CopenHeartVR, aims to investigate whether cardiac rehabilitation in addition to usual care is superior to treatment as usual after heart valve surgery. The trial will randomly allocate 210 patients, 1:1 intervention to control group, using central randomisation, and blinded outcome assessment and statistical analyses. The intervention consists of 12 weeks of physical exercise, and a psycho-educational intervention comprising five consultations. Primary outcome is peak oxygen uptake (VO2 peak) measured by cardiopulmonary exercise testing with ventilatory gas analysis. Secondary outcome is self-assessed mental health measured by the standardised questionnaire Short Form 36. Also, long-term healthcare utilisation and mortality as well as biochemistry, echocardiography and cost-benefit will be assessed. A mixed-method design is used to evaluate qualitative and quantitative findings encompassing a survey-based study before the trial and a qualitative pre- and post-intervention study. Discussion The study is approved by the local regional Research Ethics Committee (H-1-2011-157), and the Danish Data Protection Agency (j.nr. 2007-58-0015).

[Klinik und Diagnose von Hypogonadismus und Andropause]

Diagnosis and therapy of male hypogonadism is still a challenge because of the unspecific clinical signs and symptoms. The clinical presentation of a androgen deficiency is age-related. In the adult men, one can often observe fatigue, decrease in physical capacity, loss of libido and erectile dysfunction. At the physical examination, genitalia have always to be assessed in search of a testes/penis atrophy. Two fasting measurements of total testosterone concentrations by a reliable assay are needed to confirm the diagnosis. By assessing gonadotropines the origin of hypogonadism can be determined (central/secondary or peripheral/primary). Exogenous administration of androgens should be considered in young, sportive, healthy and muscular males. Patients with metabolic syndrome should only be screened for hypogonadism in the presence of suggestive symptoms. Prostate disease, hematocrit higher than 50 %, uncontrolled heart failure and severe obstructive sleep apnea are contraindications of a testosterone replacement therapy. Patients with metabolic-syndrome-associated low testosterone levels should firstly benefit from a lifestyle intervention that can normalize clinical and biochemical hypogonadism. So far, there is no clear evidence for a possible benefit of testosterone therapy in patients with the metabolic syndrome. Similarly, in patients with PADAM (partial androgen deficiency of the aging male) testosterone therapy is not established or recommended.

La resistencia especial en el fútbol

La finalidad de esta tesis es establecer un análisis de la metodología de entrenamiento de la resistencia especial en el futbolista. Su objetivo no está vinculado a realizar propuestas prácticas de entrenamiento, sino más bien, se tratará de abordar una posible justificación fisiológico - metabólica, a partir de la relevancia bioenergética de la creatina, en función de la creciente especialización que debe ir adquiriendo el proceso del entrenamiento deportivo a largo plazo, enfocado al logro de altos rendimientos deportivos. A partir del análisis de conceptos terminológicos de referencia, se asienta la idea general de este trabajo, es decir, la estructuración y desarrollo de la resistencia en los deportes de conjunto, como el fútbol. Los pilares de una adecuada planificación son el conocimiento y la aplicación de distintas leyes y principios del entrenamiento deportivo y su relación con los distintos medios y métodos de entrenamiento, como así también, los efectos de adaptación que provocan. Por lo tanto, a partir del análisis de los requerimientos morfológicos - funcionales de las competiciones de elite en fútbol, se pueden elaborar modelos que servirán de base y como objetivo final al cual debe ser orientado el proceso de entrenamiento. Es decir, que un entrenamiento multianual con miras a la formación de futbolistas de elite, debe respetar la especialización creciente de las cargas de entrenamiento, estableciendo una sucesión metodológica adecuada en función de los objetivos de cada etapa. En función de lo expuesto, se realiza un análisis que va desde la resistencia como capacidad física y su metodología de entrenamiento, recorriendo distintos conceptos y manifestaciones, pasando por el análisis de distintas zonas de intensidad o áreas funcionales, y desembocando en la metodología de entrenamiento intermitente de la resistencia o resistencia especial -en los deportes de conjunto-. Y es a partir de todo el análisis precedente que estamos en condiciones de abordar el entrenamiento específico en el fútbol, y más detalladamente la resistencia específica o intermitente que requiere este deporte. El entrenamiento intermitente puede ser considerado como una metodología cuyo énfasis es puesto en modificaciones que se producen a nivel muscular, por sobre factores centrales de rendimiento, presentándose como una variante óptima para el entrenamiento de la resistencia muscular local y específica del futbolista. Básicamente, el entrenamiento intermitente actuaría sobre dos puntos centrales: la mejora del sistema shuttle de la CrP, y sobre la rapidez de entrega de oxígeno al inicio del ejercicio. Aquí aparece la importancia de la suplementación con Cr: que al aumentar las concentraciones del sustrato, y junto con el entrenamiento, que mejora las reacciones enzimáticas implicadas, potenciaría las mejoras buscadas con este tipo de metodología. Queda por determinar cual es el preciso mecanismo de acción por el cual la recuperación de los fosfatos altamente energéticos se produce: si por biogénesis mitocondrial en las fibras reclutadas - generalmente FT -; o mediante el sistema de proteínas transportadoras de Cr - destacando la importancia de las ST - o por algún otro mecanismo no conocido. Su descubrimiento permitiría direccionar más precisamente el entrenamiento deportivo.

La resistencia especial en el fútbol

La finalidad de esta tesis es establecer un análisis de la metodología de entrenamiento de la resistencia especial en el futbolista. Su objetivo no está vinculado a realizar propuestas prácticas de entrenamiento, sino más bien, se tratará de abordar una posible justificación fisiológico - metabólica, a partir de la relevancia bioenergética de la creatina, en función de la creciente especialización que debe ir adquiriendo el proceso del entrenamiento deportivo a largo plazo, enfocado al logro de altos rendimientos deportivos. A partir del análisis de conceptos terminológicos de referencia, se asienta la idea general de este trabajo, es decir, la estructuración y desarrollo de la resistencia en los deportes de conjunto, como el fútbol. Los pilares de una adecuada planificación son el conocimiento y la aplicación de distintas leyes y principios del entrenamiento deportivo y su relación con los distintos medios y métodos de entrenamiento, como así también, los efectos de adaptación que provocan. Por lo tanto, a partir del análisis de los requerimientos morfológicos - funcionales de las competiciones de elite en fútbol, se pueden elaborar modelos que servirán de base y como objetivo final al cual debe ser orientado el proceso de entrenamiento. Es decir, que un entrenamiento multianual con miras a la formación de futbolistas de elite, debe respetar la especialización creciente de las cargas de entrenamiento, estableciendo una sucesión metodológica adecuada en función de los objetivos de cada etapa. En función de lo expuesto, se realiza un análisis que va desde la resistencia como capacidad física y su metodología de entrenamiento, recorriendo distintos conceptos y manifestaciones, pasando por el análisis de distintas zonas de intensidad o áreas funcionales, y desembocando en la metodología de entrenamiento intermitente de la resistencia o resistencia especial -en los deportes de conjunto-. Y es a partir de todo el análisis precedente que estamos en condiciones de abordar el entrenamiento específico en el fútbol, y más detalladamente la resistencia específica o intermitente que requiere este deporte. El entrenamiento intermitente puede ser considerado como una metodología cuyo énfasis es puesto en modificaciones que se producen a nivel muscular, por sobre factores centrales de rendimiento, presentándose como una variante óptima para el entrenamiento de la resistencia muscular local y específica del futbolista. Básicamente, el entrenamiento intermitente actuaría sobre dos puntos centrales: la mejora del sistema shuttle de la CrP, y sobre la rapidez de entrega de oxígeno al inicio del ejercicio. Aquí aparece la importancia de la suplementación con Cr: que al aumentar las concentraciones del sustrato, y junto con el entrenamiento, que mejora las reacciones enzimáticas implicadas, potenciaría las mejoras buscadas con este tipo de metodología. Queda por determinar cual es el preciso mecanismo de acción por el cual la recuperación de los fosfatos altamente energéticos se produce: si por biogénesis mitocondrial en las fibras reclutadas - generalmente FT -; o mediante el sistema de proteínas transportadoras de Cr - destacando la importancia de las ST - o por algún otro mecanismo no conocido. Su descubrimiento permitiría direccionar más precisamente el entrenamiento deportivo.

La resistencia especial en el fútbol

La finalidad de esta tesis es establecer un análisis de la metodología de entrenamiento de la resistencia especial en el futbolista. Su objetivo no está vinculado a realizar propuestas prácticas de entrenamiento, sino más bien, se tratará de abordar una posible justificación fisiológico - metabólica, a partir de la relevancia bioenergética de la creatina, en función de la creciente especialización que debe ir adquiriendo el proceso del entrenamiento deportivo a largo plazo, enfocado al logro de altos rendimientos deportivos. A partir del análisis de conceptos terminológicos de referencia, se asienta la idea general de este trabajo, es decir, la estructuración y desarrollo de la resistencia en los deportes de conjunto, como el fútbol. Los pilares de una adecuada planificación son el conocimiento y la aplicación de distintas leyes y principios del entrenamiento deportivo y su relación con los distintos medios y métodos de entrenamiento, como así también, los efectos de adaptación que provocan. Por lo tanto, a partir del análisis de los requerimientos morfológicos - funcionales de las competiciones de elite en fútbol, se pueden elaborar modelos que servirán de base y como objetivo final al cual debe ser orientado el proceso de entrenamiento. Es decir, que un entrenamiento multianual con miras a la formación de futbolistas de elite, debe respetar la especialización creciente de las cargas de entrenamiento, estableciendo una sucesión metodológica adecuada en función de los objetivos de cada etapa. En función de lo expuesto, se realiza un análisis que va desde la resistencia como capacidad física y su metodología de entrenamiento, recorriendo distintos conceptos y manifestaciones, pasando por el análisis de distintas zonas de intensidad o áreas funcionales, y desembocando en la metodología de entrenamiento intermitente de la resistencia o resistencia especial -en los deportes de conjunto-. Y es a partir de todo el análisis precedente que estamos en condiciones de abordar el entrenamiento específico en el fútbol, y más detalladamente la resistencia específica o intermitente que requiere este deporte. El entrenamiento intermitente puede ser considerado como una metodología cuyo énfasis es puesto en modificaciones que se producen a nivel muscular, por sobre factores centrales de rendimiento, presentándose como una variante óptima para el entrenamiento de la resistencia muscular local y específica del futbolista. Básicamente, el entrenamiento intermitente actuaría sobre dos puntos centrales: la mejora del sistema shuttle de la CrP, y sobre la rapidez de entrega de oxígeno al inicio del ejercicio. Aquí aparece la importancia de la suplementación con Cr: que al aumentar las concentraciones del sustrato, y junto con el entrenamiento, que mejora las reacciones enzimáticas implicadas, potenciaría las mejoras buscadas con este tipo de metodología. Queda por determinar cual es el preciso mecanismo de acción por el cual la recuperación de los fosfatos altamente energéticos se produce: si por biogénesis mitocondrial en las fibras reclutadas - generalmente FT -; o mediante el sistema de proteínas transportadoras de Cr - destacando la importancia de las ST - o por algún otro mecanismo no conocido. Su descubrimiento permitiría direccionar más precisamente el entrenamiento deportivo.

Immunophilins, Refsum disease, and lupus nephritis: The peroxisomal enzyme phytanoyl-COA α-hydroxylase is a new FKBP-associated protein

FKBP52 (FKBP59, FKBP4) is a “macro” immunophilin that, although sharing high structural and functional homologies in its amino-terminal domain with FKBP12 (FKBP1), does not have immunosuppressant activity when complexed with FK506, unlike FKBP12. To investigate the physiological function of FKBP52, we used the yeast two-hybrid system as an approach to find its potential protein partners and, from that, its cellular role. This methodology, which already has allowed us to find the FK506-binding protein (FKBP)-associated protein FAP48, also led to the detection of another FKBP-associated protein. Determination of the sequence of this protein permitted its identification as phytanoyl-CoA α-hydroxylase (PAHX), a peroxisomal enzyme that so far was unknown as an FKBP-associated protein. Inactivation of this enzyme is responsible for Refsum disease in humans. The protein also corresponds to the mouse protein LN1, which could be involved in the progress of lupus nephritis. We show here that PAHX has the physical capacity to interact with the FKBP12-like domain of FKBP52, but not with FKBP12, suggesting that it is a particular and specific target of FKBP52. Whereas the binding of calcineurin to FKBP12 is potentiated by FK506, the specific association of PAHX and FKBP52 is maintained in the presence of FK506. This observation suggests that PAHX is a serious candidate for studying the cellular signaling pathway(s) involving FKBP52 in the presence of immunosuppressant drugs.

Efeito do treinamento físico associado a um programa de perda de peso no controle clínico e nos fatores de saúde relacionados à qualidade de vida em asmáticos obesos

Introdução: O fenótipo asma-obeso caracteriza-se por uma asma mais grave, no qual o controle clínico é mais difícil de ser alcançado, mesmo sob terapia medicamentosa otimizada. A cirurgia bariátrica tem sido recomendada para perda de peso e melhora dos sintomas, porém os benefícios de intervenções não-cirúrgicas têm sido pouco estudados. Objetivo: Avaliar o efeito do treinamento físico associado a um programa de perda de peso no controle clínico da asma, qualidade de vida e sintomas psicossociais em asmáticos obesos. Métodos: 55 pacientes com asma moderada a grave e obesidade grau II (IMC >= 35 e < 39.9 kg/m2) foram alocados em 2 grupos: programa de perda de peso + placebo (PP+P) ou programa de perda de peso + exercícios (PP+E), sendo que o programa de perda de peso incluiu terapia nutricional e psicológica (12 sessões semanais de 60 minutos cada). O grupo PP+E associou exercícios aeróbios e resistidos programa de perda de peso, enquanto o grupo PP+P associou exercícios placebo (respiratórios e alongamentos), 2xvezes/semana, 60 minutos/sessão durante 3 meses. Antes e após as intervenções, foram avaliados o controle clínico da asma, os fatores de saúde relacionados a qualidade de vida (FSRQV), a capacidade física, a composição corporal, os sintomas de ansiedade e depressão, a qualidade do sono, a função pulmonar e as inflamações das vias aéreas e sistêmica. A comparação dos dados contínuos entre os grupos foi realizada por ANOVA de dois fatores com medidas repetidas e das variáveis categóricas pelo teste qui-quadrado. A correlação linear e a regressão linear múltipla foram utilizadas para avaliar associações entre as variáveis avaliadas. Resultados: Foram analisados os resultados de 51 pacientes que foram reavaliados. Comparado com o grupo PP+P, os pacientes que realizaram exercício apresentaram melhora no controle clínico da asma (- 0,7 [-1,3 - -0,3] vs. -0,3 [-0,9 - 0,4] escore ACQ; p=0,01) e nos FSRQV (0,8 [0,3 -2,0] vs. 0,4 [-0,3 - 0,9] escore AQLQ; p=0,02), respectivamente. Essa melhora parece ter sido consequência do aumento do condicionamento físico (3,0 [2,4-4,0] vs. 0,9 [-0,3-1,3] mL.O2/Kg/min; p < 0,001) e da perda de peso (6,8±3,5% vs. 3,1±2,6% do peso corpóreo; p < 0,001) nos pacientes do grupo PP+E, que também apresentaram uma melhora dos sintomas de depressão, da qualidade do sono (ronco, latência e eficiência) e dos níveis séricos de vitamina D. Houve também melhora da função pulmonar (capacidade vital forçada e volume de reserva expiratório) e das inflamações das vias aéreas (FeNO) e sistêmica (CCL2, CXCL9, IL-4, IL-6, TNF-alfa, IL-10 e leptina/adiponectina), que parecem ser possíveis mecanismos associados à melhora do controle clinico da asma nos pacientes do grupo PP+E (p < 0,05 para todas variáveis apresentadas). Conclusão: A inclusão do treinamento físico em um programa de perda de peso a curto prazo deve ser considerada como uma intervenção eficiente para associar à terapia medicamentosa da asma na melhora do controle clínico em asmáticos obesos

Motherhood on ice? A media framing analysis of older mothers in the UK news

Changing gender roles and increased sexual and economic freedom have created opportunities for women to give birth relatively late in life. However, stigma and misplaced fears about physical capacity are often reported as sources of anxiety among older, and in vitro fertilisation-induced mothers. In this study, we apply a specially adapted method for analysing news media content to a week's selection of material in the British media following the dissemination of research at an international medical conference. Our findings suggest, despite some positive commentaries, that much negative discourse is circulated by the media about older mothers, from implied claims of selfishness (older mothers as 'delaying' conception) to violations of the 'natural order'. These latter claims reflect the long-standing ambivalence by the media generally towards scientific advancement, but they also reveal continuing resistance towards unorthodox lifestyles.

Older Adult Injury Risk Assessment in the Driving and Occupational Environments

Thesis (Ph.D.)--University of Washington, 2016-08