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O. Chialà et al
involved only the upper limbs (shoulder abduction, and
right and left shoulder flexion). Interestingly, the DASI
score loaded in the lower limb factor. This can be ex-
plained by the fact that the items ask about the ability to
walk, climb stairs, walk up a hill, run, work around the
house and play sports (18). This should be taken into
account in research or clinical practice when assessing
patients with impairment of the lower limbs. In such ca-
ses, clinicians and researchers should choose alternative
methods proposed in the literature for assessing physical
fitness (2, 5), especially in patients with HF, to avoid, for
example, an inadequate evaluation of exercise capacity.
Such strategy reduces the possible effect of movement
impairment on physical fitness assessment.
A strength of the current study is the inclusion of pa-
tients with movement impairments, not compromising
the inclusion criteria. Patients correctly recruited might
have shoulder or knee pain that limits their real exercise
capacity or muscle function, but still be able to perform
exercise, according to the HF-Wii protocol (21). This
allowed for exploration of the effects of movement
impairment on the tests used to assess the patients’ phy-
sical fitness. Among the limitations of this study are the
in-hospital recruitment of patients; thus, generalizability
is reduced because the results cannot be extrapolated to
outpatients. Another limitation on the generalizability of
the results is the preponderance of male patients in the
sample. In fact, previous studies showed that incidence
in patients with HF is equally distributed between men
and women (44). Finally, the DASI questionnaire used
for this study was not cross-cultural validated in Italian.
In conclusion, this study confirmed that physical
fitness in patients with HF is multidimensional (2);
therefore, the 3 measures used here can help clinicians
to assess physical fitness in patients with HF more
comprehensively. Exercise capacity, muscle function
and functional capacity had a low-to-moderate rela-
tionship; thus, they are good methods for assessing
patients’ physical fitness even if the focus is different.
These measures can be applied to the evaluation of
patients with movement impairments because using
only one instrument for physical assessment would
be inadequate. As was reported in the literature, some
instruments, such as the 6MWT, have strong predictive
power for patients with HF, but are not appropriate for
measuring the exercise capacity of patients who are
unable to walk. In such cases, the MFT and the DASI
could provide better information. Researchers and
clinicians must be alert to the need to tailor an optimal
test for each patient.
ACKNOWLEDGEMENTS
The authors thank Roberto Corsi, Health Director of Casa di
Cura Villa delle Querce in Nemi (Rome), Italy for allowing
www.medicaljournals.se/jrm
this research to be conducted and providing logistical support.
They also give special thanks to physical therapist Manlio
Bitocchi and nurse Pamela Basei for their assistance during
the recruitment phase.
Funding. This work was supported by the Swedish National
Science Council (K2013-69X-22302-01-3 and 2016-01390),
The Swedish Heart and Lung Association (E085/12 and
E120/15), The Swedish Heart-Lung Foundation (20130340 and
20160439), the Vårdal Foundation (2014–0018), the Medical
Research Council of Southeast Sweden (FORSS 474681), and
the Swedish Research Council for Health, Working Life, and
Welfare (VR-FORTE) 2014–4100.
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