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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">P6&#46; &#191;C&#243;mo prescribir actividad f&#237;sica y qu&#233; estrategias puedo utilizar para que el paciente con EPOC realice actividad f&#237;sica&#63;</span></p><p id="par0090" class="elsevierStylePara elsevierViewall">Puntos clave&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Las estrategias y recomendaciones de actividad f&#237;sica &#40;AF&#41; deben estar adaptadas a la vida cotidiana del paciente&#46; El paciente debe ser</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0020" class="elsevierStylePara elsevierViewall">parte activa en la decisi&#243;n de la prescripci&#243;n y de las estrategias para aumentar su AF&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">La prescripci&#243;n de AF debe ser individualizada&#44; y debe tener en cuenta la capacidad de ejercicio&#44; la morbilidad y&#47;o discapacidad&#44; el entorno familiar y social&#44; y los factores de comportamiento y culturales del paciente con EPOC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Usar recomendaciones de AF en intervalos cortos de tiempo &#40;m&#237;nimo 10 min&#41; repartidos durante el d&#237;a&#44; en lugar de la recomendaci&#243;n general de 30 min de AF moderada en los pacientes con EPOC m&#225;s grave&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Las intervenciones de AF que se centren en el aumento de esta y en combinaci&#243;n con programas de entrenamiento f&#237;sico m&#225;s largos &#40;&#62; 12 semanas&#41; pueden tener un mayor impacto en la AF del paciente con EPOC&#44; ya que podr&#237;an facilitar un cambio de comportamiento del paciente hacia una vida m&#225;s activa&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Las estrategias de AF con retroalimentaci&#243;n de un monitor de actividad o tecnolog&#237;a &#40;aplicaciones m&#243;viles&#41; son intervenciones prometedoras para incrementar los niveles de AF de los pacientes con EPOC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Las intervenciones conductuales pueden ser una estrategia efectiva para conseguir un aumento en la pr&#225;ctica de AF en pacientes con EPOC&#46;</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">La AF en el paciente con EPOC ha generado un creciente inter&#233;s cient&#237;fico en los &#250;ltimos a&#241;os<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; La importancia de la prescripci&#243;n de AF a los pacientes con EPOC viene determinada entre otros factores por&#58; <span class="elsevierStyleItalic">a&#41;</span> la alta morbimortalidad relacionada con la EPOC<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#59; <span class="elsevierStyleItalic">b&#41;</span> la evidencia de que la inactividad f&#237;sica se asocia a un incremento del riesgo de mortalidad y de presentar reagudizaciones<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#59; <span class="elsevierStyleItalic">c&#41;</span> si se comparan con individuos sanos de la misma edad&#44; los pacientes con EPOC tiene un nivel de AF m&#225;s bajo<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#59; <span class="elsevierStyleItalic">d&#41;</span> las comorbilidades que pueden presentar los pacientes con EPOC tambi&#233;n mejoran con la pr&#225;ctica regular de AF<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#59; <span class="elsevierStyleItalic">e&#41;</span> la inactividad f&#237;sica est&#225; asociada a una progresi&#243;n de la intolerancia al ejercicio y de la afectaci&#243;n muscular<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#59; <span class="elsevierStyleItalic">f&#41;</span> los niveles bajos de AF se dan incluso en pacientes con EPOC leve&#44; lo que hace pensar en la necesidad de intervenciones tempranas para reducir as&#237; el riesgo de presentar comorbilidades futuras en sujetos con EPOC y&#44; posiblemente&#44; la progresi&#243;n de la enfermedad<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#59; <span class="elsevierStyleItalic">g&#41;</span> la AF en pacientes con EPOC depende de factores psicol&#243;gicos y de comportamiento&#44; sociales&#44; ambientales y culturales<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#44; y <span class="elsevierStyleItalic">h&#41;</span> es fundamental que el profesional sanitario est&#233; convencido de que la prescripci&#243;n de AF debe formar parte del tratamiento de todo paciente con EPOC<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Hasta la fecha no se han establecido recomendaciones espec&#237;ficas sobre el grado de AF que deber&#237;an mantener los pacientes con EPOC&#46; Sin embargo&#44; en general son bien aceptadas las recomendaciones generales sobre los beneficios de realizar AF moderada un m&#237;nimo de 30 min al d&#237;a 5 d&#237;as por semana &#40;o el equivalente a 1&#46;000 kcal&#47;semana&#41;&#44; como las del American College of Sports Medicine<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46; Se considera AF moderada si el paciente reporta una sensaci&#243;n de disnea y&#47;o fatiga entre 4 y 6 seg&#250;n la escala de Borg modificada&#46; Recientemente&#44; Demeyer et al<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> han demostrado que la diferencia m&#237;nima cl&#237;nicamente importante tras un programa de rehabilitaci&#243;n pulmonar de 3 meses de duraci&#243;n oscila entre un incremento de 600 y 1&#46;100 pasos al d&#237;a&#46; Adem&#225;s&#44; en los pacientes que presentaron un aumento de m&#225;s de 600 pasos al d&#237;a disminuyeron los reingresos hospitalarios&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">No hay un claro consenso establecido en relaci&#243;n con los determinantes que influyen en la AF en pacientes con EPOC&#46; No obstante&#44; recientemente Miravitlles et al<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> observaron que &#8212;tras ajustar por la edad y la gravedad de los s&#237;ntomas&#8212; la mala percepci&#243;n de la salud&#44; la gravedad de la EPOC y la depresi&#243;n fueron los principales factores asociados con un menor tiempo de marcha en pacientes con EPOC<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46; En relaci&#243;n con lo anterior&#44; en los pacientes de la cohorte PAC-COPD &#40;Phenotype and Course of Chronic Obstructive Pulmonary Disease&#41; se observ&#243; que los sujetos con EPOC grave y muy grave realizaban sus actividades diarias en per&#237;odos m&#225;s cortos y en menor n&#250;mero que los pacientes en fases leves y moderadas de la enfermedad<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46; Este patr&#243;n<a name="p2"></a> deber&#237;a tenerse en cuenta en el momento de recomendar y prescribir AF a los pacientes m&#225;s graves&#44; ya que la AF deber&#237;a realizarse en varios intervalos cortos de tiempo &#40;m&#237;nimo 10 minutos&#41; a lo largo del d&#237;a&#44; en lugar de recomendar intervalos m&#225;s largos de 20-30 min seguidos&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Por lo tanto&#44; la prescripci&#243;n de AF es un acto complejo porque interviene una combinaci&#243;n de factores individuales&#44; socioculturales y ambientales que habr&#225; que tener en cuenta<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; En consecuencia&#44; y ante la falta de evidencia y consenso en la prescripci&#243;n y en las estrategias para aumentar la AF en los pacientes con EPOC&#44; se deben plantear estrategias adaptadas a la vida cotidiana pactadas con el propio paciente&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Hasta la fecha se han descrito m&#250;ltiples estrategias para incrementar o consolidar la AF en pacientes con EPOC &#40;p&#46; ej&#46;&#44; consejos sobre la propia AF&#44; suplementos nutricionales&#44; oxigenoterapia&#44; utilizaci&#243;n de broncodilatadores&#44; electroestimulaci&#243;n muscular&#44; ventilaci&#243;n no invasiva nocturna o programas de rehabilitaci&#243;n&#44; etc&#46;&#41;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se describen ECA en los que se realiz&#243; una intervenci&#243;n de AF y la variable de medida utilizada para valorar la AF en pacientes con EPOC&#46; En una revisi&#243;n sistem&#225;tica reciente realizada por Mantoani et al<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> se concluye que&#44; a pesar de la heterogeneidad de las variables y de la baja calidad de los trabajos&#44; las intervenciones con programas de rehabilitaci&#243;n pulmonar superior a 12 semanas tienen un impacto positivo en el incremento de la AF&#46; Este resultado coincide con las conclusiones obtenidas por Ng et al<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> que confirmaron que los programas de rehabilitaci&#243;n pulmonar incrementan los niveles de AF en un grado equivalente a 5 min m&#225;s de actividad al d&#237;a<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; La retroalimentaci&#243;n que obtiene el paciente al llevar un pod&#243;metro o un monitor de actividad &#40;incluyendo la m&#225;s reciente tecnolog&#237;a de las aplicaciones m&#243;viles&#41; constituye una herramienta muy &#250;til para incrementar la pr&#225;ctica de AF y optimizar la tasa de &#233;xito de los programas de asesoramiento de AF en pacientes con EPOC<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Otras alternativas m&#225;s espec&#237;ficas recogidas en la revisi&#243;n de Mantoani et al<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> &#8212;como la intervenci&#243;n diet&#233;tica en pacientes con caquexia y la ventilaci&#243;n no invasiva nocturna asociada a ejercicio en<a name="p3"></a> sujetos con hipercapnia&#8212; parecen mejorar los niveles de AF en estos grupos de pacientes&#46; La oxigenoterapia a largo plazo &#40;&#8805; 8 semanas&#41; y la electroestimulaci&#243;n muscular no presentan un impacto significativo en los niveles de AF&#44; pero podr&#237;an utilizarse como coadyuvantes de otras intervenciones&#46; Por &#250;ltimo&#44; los autores encontraron que los broncodilatadores podr&#237;an incrementar los niveles de actividad de la vida diaria en sujetos EPOC<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Es importante recordar que la AF supone un comportamiento complejo&#44; y como tal&#44; dif&#237;cil de modificar&#46; Cambiar la actitud del paciente con EPOC frente la AF requiere una aproximaci&#243;n interdisciplinar en la que se incluyan las ciencias m&#233;dicas&#44; las ciencias sociales y las ciencias del comportamiento&#44; y las intervenciones deben estar basadas en modelos te&#243;ricos de cambio de conducta<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; La &#250;ltima gu&#237;a sobre AF en EPOC de la ERS destaca que el papel del soporte social y el uso de t&#233;cnicas espec&#237;ficas para la modificaci&#243;n de la conducta proporcionan mejor contacto y mayor motivaci&#243;n para el cambio&#44; por lo que constituyen componentes centrales para lograr una mayor efectividad de las intervenciones conductuales<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">En la pr&#225;ctica se deber&#237;a motivar a los pacientes con EPOC para que incrementen su nivel de AF y transmitirles de forma clara los beneficios que aporta a la enfermedad<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; Las estrategias dirigidas a incrementar la motivaci&#243;n para la realizaci&#243;n de AF&#44; y por lo tanto la adherencia a la pr&#225;ctica de AF&#44; deber&#237;an contemplar unos objetivos espec&#237;ficos&#44; 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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Faager &#40;2004&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSup">2</span>Cuestionario &#8220;Standford Health Assessment&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ries &#40;1995&#41;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSup">3</span>Adaptaci&#243;n del cuestionario de autoeficacia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Berry &#40;2010&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP &#43; automanejo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;CHAMPS Physical Activity Questionnaire for Older Adults&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Duiverman &#40;2011&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP &#43; CPAP nocturna&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Groningen Activity and Restriction Scale&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Engstrom &#40;1999&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP &#43; programa de marcha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Sickness Impact Profile&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Faulkner&#40;2010&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP &#43; consejos de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Stanford 7-day physical activity recall questionnaire&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Kesten &#40;2008&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broncodilatador&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom"><span class="elsevierStyleSup">1</span>Cuestionario no validado<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Shioya &#40;2008&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom"><span class="elsevierStyleSup">2</span>Cuestionario &#8220;London Chest Activities of Daily Living Scale&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Mohammadi &#40;2013&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP domiciliaria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Barthel index&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Nield &#40;2007&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Ejercicios respiratorios&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Human Activity Profile&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Pleguezuelos &#40;2013&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Consejos de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Diario de marcha diaria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Steele &#40;2008&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de marcha &#43; consejos de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Wlaking Self-Efficacy&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Vergeret &#40;1989&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Oxigenoterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario no validado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Weekes &#40;2009&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Suplementaci&#243;n nutricional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Townsed score&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Yohannes&#40;2003&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de marcha &#43; oxigenoterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Barthel index&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " colspan="3" align="left" valign="bottom"><span class="elsevierStyleItalic">Monitores de AF&#58; aceler&#243;metros</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Borges &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Larson &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Entrenamiento de resistencia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom"><span class="elsevierStyleSup">1</span>Aceler&#243;metro DynaPort<br><span class="elsevierStyleSup">2</span>Aceler&#243;metro Actigraph 7164&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Breyer &#40;2010&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Pomidori &#40;2012&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Programa de marcha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom"><span class="elsevierStyleSup">1</span>Aceler&#243;metro DynaPort<br><span class="elsevierStyleSup">2</span>Aceler&#243;metro SenseWear Armband PRO3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Casaburi &#40;2012&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Sandland &#40;2008&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Oxigenoterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom"><span class="elsevierStyleSup">1</span>Aceler&#243;metro RT3<br><span class="elsevierStyleSup">2</span>Aceler&#243;metro Gaehwiler Z80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Dal Negro &#40;2010&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Dal Negro &#40;2012&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Goris &#40;2003&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Suplementaci&#243;n nutricional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSup">1</span>Aceler&#243;metro SenseWear Armband PRO3<br><span class="elsevierStyleSup">2</span>Aceler&#243;metro Tracmor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Nguyen &#40;2009&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Consejos de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Aceler&#243;metro Sptepwatch 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Probst &#40;2011&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Sewell &#40;2005&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><br>Sewell &#40;2010&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Programa de RP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSup">1</span>Aceler&#243;metro Dynaport y SenseWear Armband PRO3<br><span class="elsevierStyleSup">2</span>Aceler&#243;metro Gaehwiler Z80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Steele &#40;2008&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de marcha &#43; consejos de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Aceler&#243;metro RT3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Troosters &#40;2014&#41;<br>Watz &#40;2014&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broncodilatador&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aceler&#243;metro SenseWear Armband PRO3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " colspan="3" align="left" valign="bottom"><span class="elsevierStyleItalic">Monitores de AF&#58; pod&#243;metros</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Altenburg &#40;2015&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Hospes &#40;2009&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Mendoza &#40;2015&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><br>Tabak &#40;2013&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consejos de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSup">1</span>Pod&#243;metro Yamax Digi Walker SW-200<br><span class="elsevierStyleSup">2</span>Pod&#243;metro Tanita PD724&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Bauldoff &#40;2002&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de marcha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Pod&#243;metro Sportline 342 &#43; diario de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">De Blok &#40;2006&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP &#43; consejos AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Pod&#243;metro Yamax Digi Walker SW-200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Duiverman &#40;2008&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP &#43; CPAP nocturna&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Pod&#243;metro Yamax Digi Walker SW-200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Effing &#40;2011&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RP m&#225;s automanejo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pod&#243;metro Yamax Digi Walker SW-200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ensayos cl&#237;nicos controlados aleatorizados en relaci&#243;n con diferentes estrategias para incrementar el nivel de actividad f&#237;sica&#44; clasificados por instrumento de evaluaci&#243;n &#40;cuestionario y&#47;o diario&#44; aceler&#243;metros y pod&#243;metros&#41; y ordenados por autor&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "Bibliograf&#237;a"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:19 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease&#58; a population based cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46; Garcia-Aymerich"
                            1 => "P&#46; Lange"
                            2 => "M&#46; Benet"
                            3 => "P&#46; Schnohr"
                            4 => "J&#46;M&#46; Ant&#243;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2006.060145"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax&#46;"
                        "fecha" => "2006"
                        "volumen" => "61"
                        "paginaInicial" => "772"
                        "paginaFinal" => "778"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16738033"
                            "web" => "Medline"
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                      ]
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                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Disease and Injury Incidence and Prevalence Collaborators Global&#44; regional&#44; and national incidence&#44; prevalence&#44; and years lived with disability for 310 diseases and injuries&#44; 1990-2015&#58; a systematic analysis for the Global Burden of Disease Study 2015"
                      "autores" => array:1 [
                        0 => array:2 [
                          "colaboracion" => "G&#46;B&#46;D&#46;"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(16)31678-6"
                      "Revista" => array:7 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2016"
                        "volumen" => "388"
                        "numero" => "10053"
                        "paginaInicial" => "1545"
                        "paginaFinal" => "1602"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27733282"
                            "web" => "Medline"
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              "identificador" => "bib0015"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Changes in physical activity and all-cause mortality in COPD"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;W&#46; Vaes"
                            1 => "J&#46; Garcia-Aymerich"
                            2 => "J&#46;L&#46; Marott"
                            3 => "M&#46; Benet"
                            4 => "M&#46;T&#46; Groenen"
                            5 => "P&#46; Schnohr"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00023214"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J&#46;"
                        "fecha" => "2014"
                        "volumen" => "44"
                        "paginaInicial" => "1199"
                        "paginaFinal" => "1209"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25063247"
                            "web" => "Medline"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">P6&#46; &#191;C&#243;mo prescribir actividad f&#237;sica y qu&#233; estrategias puedo utilizar para que el paciente con EPOC realice actividad f&#237;sica&#63;</span></p><p id="par0090" class="elsevierStylePara elsevierViewall">Puntos clave&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Las estrategias y recomendaciones de actividad f&#237;sica &#40;AF&#41; deben estar adaptadas a la vida cotidiana del paciente&#46; El paciente debe ser</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0020" class="elsevierStylePara elsevierViewall">parte activa en la decisi&#243;n de la prescripci&#243;n y de las estrategias para aumentar su AF&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0025" class="elsevierStylePara elsevierViewall">La prescripci&#243;n de AF debe ser individualizada&#44; y debe tener en cuenta la capacidad de ejercicio&#44; la morbilidad y&#47;o discapacidad&#44; el entorno familiar y social&#44; y los factores de comportamiento y culturales del paciente con EPOC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Usar recomendaciones de AF en intervalos cortos de tiempo &#40;m&#237;nimo 10 min&#41; repartidos durante el d&#237;a&#44; en lugar de la recomendaci&#243;n general de 30 min de AF moderada en los pacientes con EPOC m&#225;s grave&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0035" class="elsevierStylePara elsevierViewall">Las intervenciones de AF que se centren en el aumento de esta y en combinaci&#243;n con programas de entrenamiento f&#237;sico m&#225;s largos &#40;&#62; 12 semanas&#41; pueden tener un mayor impacto en la AF del paciente con EPOC&#44; ya que podr&#237;an facilitar un cambio de comportamiento del paciente hacia una vida m&#225;s activa&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Las estrategias de AF con retroalimentaci&#243;n de un monitor de actividad o tecnolog&#237;a &#40;aplicaciones m&#243;viles&#41; son intervenciones prometedoras para incrementar los niveles de AF de los pacientes con EPOC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Las intervenciones conductuales pueden ser una estrategia efectiva para conseguir un aumento en la pr&#225;ctica de AF en pacientes con EPOC&#46;</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">La AF en el paciente con EPOC ha generado un creciente inter&#233;s cient&#237;fico en los &#250;ltimos a&#241;os<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; La importancia de la prescripci&#243;n de AF a los pacientes con EPOC viene determinada entre otros factores por&#58; <span class="elsevierStyleItalic">a&#41;</span> la alta morbimortalidad relacionada con la EPOC<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#59; <span class="elsevierStyleItalic">b&#41;</span> la evidencia de que la inactividad f&#237;sica se asocia a un incremento del riesgo de mortalidad y de presentar reagudizaciones<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#59; <span class="elsevierStyleItalic">c&#41;</span> si se comparan con individuos sanos de la misma edad&#44; los pacientes con EPOC tiene un nivel de AF m&#225;s bajo<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#59; <span class="elsevierStyleItalic">d&#41;</span> las comorbilidades que pueden presentar los pacientes con EPOC tambi&#233;n mejoran con la pr&#225;ctica regular de AF<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#59; <span class="elsevierStyleItalic">e&#41;</span> la inactividad f&#237;sica est&#225; asociada a una progresi&#243;n de la intolerancia al ejercicio y de la afectaci&#243;n muscular<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#59; <span class="elsevierStyleItalic">f&#41;</span> los niveles bajos de AF se dan incluso en pacientes con EPOC leve&#44; lo que hace pensar en la necesidad de intervenciones tempranas para reducir as&#237; el riesgo de presentar comorbilidades futuras en sujetos con EPOC y&#44; posiblemente&#44; la progresi&#243;n de la enfermedad<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#59; <span class="elsevierStyleItalic">g&#41;</span> la AF en pacientes con EPOC depende de factores psicol&#243;gicos y de comportamiento&#44; sociales&#44; ambientales y culturales<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#44; y <span class="elsevierStyleItalic">h&#41;</span> es fundamental que el profesional sanitario est&#233; convencido de que la prescripci&#243;n de AF debe formar parte del tratamiento de todo paciente con EPOC<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Hasta la fecha no se han establecido recomendaciones espec&#237;ficas sobre el grado de AF que deber&#237;an mantener los pacientes con EPOC&#46; Sin embargo&#44; en general son bien aceptadas las recomendaciones generales sobre los beneficios de realizar AF moderada un m&#237;nimo de 30 min al d&#237;a 5 d&#237;as por semana &#40;o el equivalente a 1&#46;000 kcal&#47;semana&#41;&#44; como las del American College of Sports Medicine<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46; Se considera AF moderada si el paciente reporta una sensaci&#243;n de disnea y&#47;o fatiga entre 4 y 6 seg&#250;n la escala de Borg modificada&#46; Recientemente&#44; Demeyer et al<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> han demostrado que la diferencia m&#237;nima cl&#237;nicamente importante tras un programa de rehabilitaci&#243;n pulmonar de 3 meses de duraci&#243;n oscila entre un incremento de 600 y 1&#46;100 pasos al d&#237;a&#46; Adem&#225;s&#44; en los pacientes que presentaron un aumento de m&#225;s de 600 pasos al d&#237;a disminuyeron los reingresos hospitalarios&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">No hay un claro consenso establecido en relaci&#243;n con los determinantes que influyen en la AF en pacientes con EPOC&#46; No obstante&#44; recientemente Miravitlles et al<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> observaron que &#8212;tras ajustar por la edad y la gravedad de los s&#237;ntomas&#8212; la mala percepci&#243;n de la salud&#44; la gravedad de la EPOC y la depresi&#243;n fueron los principales factores asociados con un menor tiempo de marcha en pacientes con EPOC<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#46; En relaci&#243;n con lo anterior&#44; en los pacientes de la cohorte PAC-COPD &#40;Phenotype and Course of Chronic Obstructive Pulmonary Disease&#41; se observ&#243; que los sujetos con EPOC grave y muy grave realizaban sus actividades diarias en per&#237;odos m&#225;s cortos y en menor n&#250;mero que los pacientes en fases leves y moderadas de la enfermedad<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#46; Este patr&#243;n<a name="p2"></a> deber&#237;a tenerse en cuenta en el momento de recomendar y prescribir AF a los pacientes m&#225;s graves&#44; ya que la AF deber&#237;a realizarse en varios intervalos cortos de tiempo &#40;m&#237;nimo 10 minutos&#41; a lo largo del d&#237;a&#44; en lugar de recomendar intervalos m&#225;s largos de 20-30 min seguidos&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Por lo tanto&#44; la prescripci&#243;n de AF es un acto complejo porque interviene una combinaci&#243;n de factores individuales&#44; socioculturales y ambientales que habr&#225; que tener en cuenta<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; En consecuencia&#44; y ante la falta de evidencia y consenso en la prescripci&#243;n y en las estrategias para aumentar la AF en los pacientes con EPOC&#44; se deben plantear estrategias adaptadas a la vida cotidiana pactadas con el propio paciente&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Hasta la fecha se han descrito m&#250;ltiples estrategias para incrementar o consolidar la AF en pacientes con EPOC &#40;p&#46; ej&#46;&#44; consejos sobre la propia AF&#44; suplementos nutricionales&#44; oxigenoterapia&#44; utilizaci&#243;n de broncodilatadores&#44; electroestimulaci&#243;n muscular&#44; ventilaci&#243;n no invasiva nocturna o programas de rehabilitaci&#243;n&#44; etc&#46;&#41;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se describen ECA en los que se realiz&#243; una intervenci&#243;n de AF y la variable de medida utilizada para valorar la AF en pacientes con EPOC&#46; En una revisi&#243;n sistem&#225;tica reciente realizada por Mantoani et al<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> se concluye que&#44; a pesar de la heterogeneidad de las variables y de la baja calidad de los trabajos&#44; las intervenciones con programas de rehabilitaci&#243;n pulmonar superior a 12 semanas tienen un impacto positivo en el incremento de la AF&#46; Este resultado coincide con las conclusiones obtenidas por Ng et al<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> que confirmaron que los programas de rehabilitaci&#243;n pulmonar incrementan los niveles de AF en un grado equivalente a 5 min m&#225;s de actividad al d&#237;a<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#46; La retroalimentaci&#243;n que obtiene el paciente al llevar un pod&#243;metro o un monitor de actividad &#40;incluyendo la m&#225;s reciente tecnolog&#237;a de las aplicaciones m&#243;viles&#41; constituye una herramienta muy &#250;til para incrementar la pr&#225;ctica de AF y optimizar la tasa de &#233;xito de los programas de asesoramiento de AF en pacientes con EPOC<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Otras alternativas m&#225;s espec&#237;ficas recogidas en la revisi&#243;n de Mantoani et al<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> &#8212;como la intervenci&#243;n diet&#233;tica en pacientes con caquexia y la ventilaci&#243;n no invasiva nocturna asociada a ejercicio en<a name="p3"></a> sujetos con hipercapnia&#8212; parecen mejorar los niveles de AF en estos grupos de pacientes&#46; La oxigenoterapia a largo plazo &#40;&#8805; 8 semanas&#41; y la electroestimulaci&#243;n muscular no presentan un impacto significativo en los niveles de AF&#44; pero podr&#237;an utilizarse como coadyuvantes de otras intervenciones&#46; Por &#250;ltimo&#44; los autores encontraron que los broncodilatadores podr&#237;an incrementar los niveles de actividad de la vida diaria en sujetos EPOC<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Es importante recordar que la AF supone un comportamiento complejo&#44; y como tal&#44; dif&#237;cil de modificar&#46; Cambiar la actitud del paciente con EPOC frente la AF requiere una aproximaci&#243;n interdisciplinar en la que se incluyan las ciencias m&#233;dicas&#44; las ciencias sociales y las ciencias del comportamiento&#44; y las intervenciones deben estar basadas en modelos te&#243;ricos de cambio de conducta<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; La &#250;ltima gu&#237;a sobre AF en EPOC de la ERS destaca que el papel del soporte social y el uso de t&#233;cnicas espec&#237;ficas para la modificaci&#243;n de la conducta proporcionan mejor contacto y mayor motivaci&#243;n para el cambio&#44; por lo que constituyen componentes centrales para lograr una mayor efectividad de las intervenciones conductuales<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">En la pr&#225;ctica se deber&#237;a motivar a los pacientes con EPOC para que incrementen su nivel de AF y transmitirles de forma clara los beneficios que aporta a la enfermedad<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; Las estrategias dirigidas a incrementar la motivaci&#243;n para la realizaci&#243;n de AF&#44; y por lo tanto la adherencia a la pr&#225;ctica de AF&#44; deber&#237;an contemplar unos objetivos espec&#237;ficos&#44; medibles&#44; alcanzables&#44; realistas y por escrito&#44; por lo que se debe conseguir que el paciente desempe&#241;e un papel activo en el control de su enfermedad<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46;</p></span>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Programa de RP&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSup">3</span>Adaptaci&#243;n del cuestionario de autoeficacia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Berry &#40;2010&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP &#43; automanejo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;CHAMPS Physical Activity Questionnaire for Older Adults&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Duiverman &#40;2011&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP &#43; CPAP nocturna&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Groningen Activity and Restriction Scale&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Engstrom &#40;1999&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP &#43; programa de marcha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Sickness Impact Profile&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Faulkner&#40;2010&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP &#43; consejos de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Stanford 7-day physical activity recall questionnaire&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Kesten &#40;2008&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broncodilatador&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom"><span class="elsevierStyleSup">1</span>Cuestionario no validado<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Shioya &#40;2008&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom"><span class="elsevierStyleSup">2</span>Cuestionario &#8220;London Chest Activities of Daily Living Scale&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Mohammadi &#40;2013&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP domiciliaria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Barthel index&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Nield &#40;2007&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Ejercicios respiratorios&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Human Activity Profile&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Pleguezuelos &#40;2013&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Consejos de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Diario de marcha diaria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Steele &#40;2008&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de marcha &#43; consejos de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Wlaking Self-Efficacy&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Vergeret &#40;1989&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Oxigenoterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario no validado&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Weekes &#40;2009&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Suplementaci&#243;n nutricional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Townsed score&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Yohannes&#40;2003&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de marcha &#43; oxigenoterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Cuestionario &#8220;Barthel index&#8221;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " colspan="3" align="left" valign="bottom"><span class="elsevierStyleItalic">Monitores de AF&#58; aceler&#243;metros</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Borges &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Larson &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Entrenamiento de resistencia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom"><span class="elsevierStyleSup">1</span>Aceler&#243;metro DynaPort<br><span class="elsevierStyleSup">2</span>Aceler&#243;metro Actigraph 7164&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Breyer &#40;2010&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Pomidori &#40;2012&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Programa de marcha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom"><span class="elsevierStyleSup">1</span>Aceler&#243;metro DynaPort<br><span class="elsevierStyleSup">2</span>Aceler&#243;metro SenseWear Armband PRO3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Casaburi &#40;2012&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Sandland &#40;2008&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Oxigenoterapia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom"><span class="elsevierStyleSup">1</span>Aceler&#243;metro RT3<br><span class="elsevierStyleSup">2</span>Aceler&#243;metro Gaehwiler Z80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Dal Negro &#40;2010&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Dal Negro &#40;2012&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Goris &#40;2003&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Suplementaci&#243;n nutricional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSup">1</span>Aceler&#243;metro SenseWear Armband PRO3<br><span class="elsevierStyleSup">2</span>Aceler&#243;metro Tracmor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Nguyen &#40;2009&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Consejos de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Aceler&#243;metro Sptepwatch 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Probst &#40;2011&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Sewell &#40;2005&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><br>Sewell &#40;2010&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Programa de RP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSup">1</span>Aceler&#243;metro Dynaport y SenseWear Armband PRO3<br><span class="elsevierStyleSup">2</span>Aceler&#243;metro Gaehwiler Z80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Steele &#40;2008&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de marcha &#43; consejos de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Aceler&#243;metro RT3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Troosters &#40;2014&#41;<br>Watz &#40;2014&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Broncodilatador&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Aceler&#243;metro SenseWear Armband PRO3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " colspan="3" align="left" valign="bottom"><span class="elsevierStyleItalic">Monitores de AF&#58; pod&#243;metros</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Altenburg &#40;2015&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Hospes &#40;2009&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><br>Mendoza &#40;2015&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><br>Tabak &#40;2013&#41;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consejos de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSup">1</span>Pod&#243;metro Yamax Digi Walker SW-200<br><span class="elsevierStyleSup">2</span>Pod&#243;metro Tanita PD724&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Bauldoff &#40;2002&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de marcha&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Pod&#243;metro Sportline 342 &#43; diario de AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">De Blok &#40;2006&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP &#43; consejos AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Pod&#243;metro Yamax Digi Walker SW-200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="bottom">Duiverman &#40;2008&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Programa de RP &#43; CPAP nocturna&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="bottom">Pod&#243;metro Yamax Digi Walker SW-200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Effing &#40;2011&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RP m&#225;s automanejo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pod&#243;metro Yamax Digi Walker SW-200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ensayos cl&#237;nicos controlados aleatorizados en relaci&#243;n con diferentes estrategias para incrementar el nivel de actividad f&#237;sica&#44; clasificados por instrumento de evaluaci&#243;n &#40;cuestionario y&#47;o diario&#44; aceler&#243;metros y pod&#243;metros&#41; y ordenados por autor&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "Bibliograf&#237;a"
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          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:19 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease&#58; a population based cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46; Garcia-Aymerich"
                            1 => "P&#46; Lange"
                            2 => "M&#46; Benet"
                            3 => "P&#46; Schnohr"
                            4 => "J&#46;M&#46; Ant&#243;"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2006.060145"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax&#46;"
                        "fecha" => "2006"
                        "volumen" => "61"
                        "paginaInicial" => "772"
                        "paginaFinal" => "778"
                        "link" => array:1 [
                          0 => array:2 [
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                            "web" => "Medline"
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                ]
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            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2&#46;"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Disease and Injury Incidence and Prevalence Collaborators Global&#44; regional&#44; and national incidence&#44; prevalence&#44; and years lived with disability for 310 diseases and injuries&#44; 1990-2015&#58; a systematic analysis for the Global Burden of Disease Study 2015"
                      "autores" => array:1 [
                        0 => array:2 [
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                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(16)31678-6"
                      "Revista" => array:7 [
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              "identificador" => "bib0015"
              "etiqueta" => "3&#46;"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Changes in physical activity and all-cause mortality in COPD"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;W&#46; Vaes"
                            1 => "J&#46; Garcia-Aymerich"
                            2 => "J&#46;L&#46; Marott"
                            3 => "M&#46; Benet"
                            4 => "M&#46;T&#46; Groenen"
                            5 => "P&#46; Schnohr"
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                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00023214"
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                        "fecha" => "2014"
                        "volumen" => "44"
                        "paginaInicial" => "1199"
                        "paginaFinal" => "1209"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25063247"
                            "web" => "Medline"
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              "identificador" => "bib0020"
              "etiqueta" => "4&#46;"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Characteristics of physical activities in daily life in chronic obstructive pulmonary disease"
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                            0 => "F&#46; Pitta"
                            1 => "T&#46; Troosters"
                            2 => "M&#46;A&#46; Spruit"
                            3 => "V&#46;S&#46; Probst"
                            4 => "M&#46; Decramer"
                            5 => "R&#46; Gosselink"
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                    0 => array:2 [
                      "doi" => "10.1164/rccm.200407-855OC"
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                        "tituloSerie" => "Am J Respir Crit Care Med&#46;"
                        "fecha" => "2005"
                        "volumen" => "171"
                        "paginaInicial" => "972"
                        "paginaFinal" => "977"
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ISSN: 03002896
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