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if not all&#44; group exercise training sessions due to concerns over spreading SARS-CoV-2&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;4</span></a> Nevertheless&#44; resumption of CRP is warranted&#44; provided safety measures are adopted&#44; including the use of facemasks &#40;FM&#41; during exercise training sessions&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;5</span></a> This has been increasingly recognized and recommended as a mitigation strategy to overcome the potential aerosolization associated with the higher expiratory flows generated during submaximal and maximal exercise&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">6&#44;7</span></a> However&#44; the ability to exercise in these conditions raises some concerns&#46; Rebreathing of low-oxygen high-carbon dioxide expired air may interfere with alveolar gas diffusion and blood oxygen uptake&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> On the other hand&#44; increased resistance to air flow resulting from using FM can lead to increased respiratory effort and early respiratory muscle fatigue&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> This combination could potentially result in an impaired exercise performance&#44; although there are mixed results on this topic&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a> Our study aimed to assess the impact of using different FMs &#40;surgical mask &#40;SM&#41; and respirator &#40;R&#41;&#41;&#44; compared to not using a FM&#44; on the cardiorespiratory physiological response and rate of perceived exertion and dyspnea during treadmill aerobic training in healthy subjects&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Subjects</span><p id="par0010" class="elsevierStylePara elsevierViewall">We recruited a consecutive sample of healthy health professionals from our department&#46; A brief review of clinical data was obtained using a structured questionnaire regarding past medical history and medication&#46; Physical activity was assessed by the Portuguese version of the International Physical Activity Questionnaire &#40;IPAQ&#41;&#44; which classifies leisure time physical activity levels as low&#44; moderate or high&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">10&#44;11</span></a> None of the subjects had performed an exercise test on treadmill in the previous twelve months&#46; Sample size calculation with the power to detect differences between groups of 80&#37; with a level of significance of 0&#46;05&#44; was calculated assuming a mean difference in overall exercise discomfort score between not wearing a FM and using either SM or R of 2&#46;4 and a standard deviation &#40;SD&#41; of 2&#46;0&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> resulting in at least 12 observations for each time point&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Surgical masks and respirators</span><p id="par0015" class="elsevierStylePara elsevierViewall">Our study aimed to compare the physiological response and perceived exertion in an incremental exercise protocol in three testing conditions&#58; Not wearing a FM &#40;group 1&#58; without mask &#91;WM&#93;&#41; versus using two different types of FM with different filtration properties&#46; A disposable three-layer type 2 SM &#40;MASK-98 model&#44; manufactured by Razi Protect&#44; in Portugal&#41; &#40;group 2&#58; SM&#41;&#44; with a minimum filter capacity of 95&#37; of particles 3&#46;0 microns or larger in diameter&#44; and a R with a filtering facepiece score of 2 &#40;FFP2&#41; &#40;group 3&#58; R&#41; were used&#46; The R available at the time of the study as the Chinese KN95 &#40;GB2626-2006 model&#44; manufactured by Lianyungang Manai Protective Equipment Company&#44; in China&#41;&#44; which filtrates a minimum of 94&#37; of all particles &#62;0&#46;3 microns or larger in diameter &#8211; an equivalent safety specification to the European FFP2 respirators&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">13</span></a> The KN95 respirators were therefore considered adequate for this study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study protocol</span><p id="par0020" class="elsevierStylePara elsevierViewall">Each subject performed three tests&#58; One in regular conditions&#44; without a FM&#59; one with a SM&#59; and another one with a KN95 respirator&#46; Each test was performed with at least a 48 hour interval and preferably at the same time of day&#46; The subjects were asked not to perform vigorous exercise in the 24 hours prior to each test&#46; The sequence of tests was randomized to reduce bias&#44; using a computerized random number generator&#44; with allocation known to the examiner and patient only at the time of the test&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">For exercise testing &#40;ET&#41; we followed the Bruce treadmill protocol &#40;using the Mill &#38; Mill&#174; Track model&#44; manufactured by Lode B&#46;V&#46;&#44; in the Netherlands&#41;&#46; Handrail support was allowed only for balance&#46; At rest&#44; at the last minute of each of the three-minute stages of the Bruce protocol and at peak exercise&#44; we recorded heart rate &#40;HR&#41;&#44; blood pressure &#40;BP&#41; and arterial oxygen saturation &#40;SpO2&#41; and quantified level of fatigue and dyspnea using the Borg Scale of Perceived Exertion and the Borg Dyspnea Scale&#44; respectively&#46; BP was measured with an upper-arm manual BP cuff &#40;Big Ben Round model&#44; manufactured by Riester&#44; in Germany&#41;&#44; in the left arm&#44; and HR and SpO2 with a finger oximeter worn throughout the test &#40;GIMA PC-68B&#41;&#46; Subjects were allowed ET warm up period at 2&#46;7 km&#47;h with 0&#37; grade for three minutes and performed a cool down period of 5 minutes at the end&#46; BP&#44; HR and SpO2 were recorded again during the cool down period &#40;after three minutes for BP and after one and three minutes for HR and SpO2&#41;&#46; The investigators followed the American Heart Association criteria for ET termination&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">14</span></a> All data was registered during each test in a blinded form &#40;no identifiable information on the subject&#41;&#44; coded using a single randomly generated combination of digits and characters and inserted into the database by a different member of the investigator team not otherwise involved in any step of the study&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">All participants were informed of the procedures and potential risks before testing and a written informed consent was obtained as per institution protocol&#46; All safety measures regarding ET were adopted&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Standard descriptive measures&#44; namely mean and standard deviation &#40;SD&#41; for normally distributed continuous variables and proportion &#40;expressed as &#37;&#41; for categorical variables were used&#46; Normality assessment was done using the Kolmogorov-Smirnov test and visual inspection of the distribution histogram&#46; To account for the dependence of observations&#44; since the same subject was tested in three study conditions&#44; a repeated measure analysis of variance was used&#46; For within-subjects&#8217; differences in each timepoint F statistics were used considering a significance p&#60;0&#46;05&#46; Furthermore&#44; to allow for between-group comparisons &#40;WM&#44; SM&#44; R&#41;&#44; a Bonferroni adjustment analysis was performed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Each patient exercise test was categorized according to a percentage of the total time achieved &#40;25&#37;&#44; 50&#37;&#44; 75&#37; and 100&#37;&#41;&#44; independently of its duration&#44; and data was collected in each of these timepoints&#46; This approach was chosen since not all subjects completed the total protocol time&#44; leaving fewer observations in the last stages of the exercise test&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Population characteristics</span><p id="par0045" class="elsevierStylePara elsevierViewall">Twelve subjects were recruited&#46; Baseline characteristics are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The study sample consisted of young &#40;age range&#58; 25-45 years&#41;&#44; mostly male health professionals&#46; All subjects had normal body mass index&#44; ranging between 19&#46;9 kg&#47;m<span class="elsevierStyleSup">2</span> and 24&#46;7 kg&#47;m<span class="elsevierStyleSup">2</span>&#44; with the majority &#40;seven subjects &#40;58&#46;3&#37;&#41;&#41; being moderately to highly physically active&#46; Two subjects had previous respiratory disorders&#44; namely one subject with asthma &#40;medicated with a leukotriene receptor antagonist &#8211; montelukast&#44; 10 mg per day&#44; with no recent exacerbations&#41; and another one with allergic rhinitis&#46; Concerning musculoskeletal diseases&#44; one subject had a history of a healed peroneal fracture&#44; one subject had a history of previous surgical treatment for a lumbar disk herniation and one had a recent history of paratendinopathy of the Achilles tendon&#46; All subjects performed the three tests and there were no dropouts&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Exercise test duration</span><p id="par0050" class="elsevierStylePara elsevierViewall">Our study found that&#44; compared to not wearing a FM&#44; wearing a FM was associated with shorter ET duration&#44; independent of the type of mask worn &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; There was no significant difference in ET duration between wearing SM or R&#46; All patients completed the third stage of the Bruce protocol&#44; with dropouts beginning at stage four&#44; when using a FM&#44; and at stage five when not wearing a mask&#46; The Bruce protocol was completed by seven &#40;50&#46;3&#37;&#41; subjects when WM&#44; but only by four &#40;33&#46;3&#37;&#41; when wearing a SM or a R&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Level of perceived exertion</span><p id="par0055" class="elsevierStylePara elsevierViewall">At 25&#37; of total time achieved in ET&#44; only wearing a SM showed a significant higher level of exercise perception compared to not wearing a FM &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; At 50&#37; of total time achieved in ET&#44; both wearing a SM or a R showed a significantly higher level of perceived exertion compared to WM &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; At 75&#37; of test completion&#44; no differences between testing conditions &#40;p&#61;0&#46;14&#41; were found&#46; At the end of the ET&#44; wearing a R was associated with a significantly higher level of perceived exertion when compared to WM &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; No differences were found in any stage of ET between wearing SM and R&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Level of dyspnea</span><p id="par0060" class="elsevierStylePara elsevierViewall">A significant difference in level of dyspnea between testing conditions at 25&#37;&#44; 50&#37; and at ET completion was found &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#44; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Using a R resulted in higher levels of dyspnea&#44; compared to not wearing a mask&#44; at 25&#37;&#44; 50&#37; and at ET completion&#44; while compared to WM&#44; SM showed higher dyspnea levels only at 50&#37; of total time achieved in ET&#46; No differences were found in any stage of ET between wearing SM and R&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Arterial oxygen saturation</span><p id="par0065" class="elsevierStylePara elsevierViewall">Regarding SpO2&#44; significant desaturation was only observed at ET completion when comparing R versus WM &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#44; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; During cool down&#44; at one and three minutes after ET completion&#44; there were no significant differences between testing conditions &#40;&#40;mean&#40;SD&#41; at one minute&#58; 96&#46;0&#37; &#40;1&#46;6&#41; for those WM&#59; 95&#46;4&#37; &#40;1&#46;6&#41; for SM and 95&#46;6&#37; &#40;2&#46;0&#41; for those wearing R&#59; p&#61;0&#46;45&#41;&#59; at 3 minutes&#58; 96&#46;4&#37; &#40;1&#46;2&#41; for those WM&#59; 96&#46;0&#37; &#40;1&#46;2&#41; for SM and 96&#46;2&#37; &#40;1&#46;0&#41; for those wearing R&#59; p&#61;0&#46;36&#41;&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Hemodynamic response &#8211; heart rate and blood pressure</span><p id="par0070" class="elsevierStylePara elsevierViewall">Heart rate increased proportionally during each test&#44; for each subject&#44; according to the intensity of the exercise&#46; When comparing HR at the end of the ET and chronotropic reserve&#44; there were no significant differences between groups at any stage of ET &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The percentage of maximal age-predicted HR achieved at ET completion did not differ between groups with 90&#46;0&#37; &#40;7&#46;9&#41; for WM&#44; 90&#46;9&#37; &#40;6&#46;4&#41; when wearing a SM and 89&#46;8&#37; &#40;7&#46;1&#41; when wearing a R&#59; there were no significant differences between these values&#46; There were no statistically significant differences in mean systolic and diastolic end blood pressure according to testing conditions &#40;p&#61;0&#46;30 and p&#61;0&#46;93&#44; respectively&#41;&#46; During cool down&#44; at one and three minutes after ET completion&#44; there were no significant differences in HR according to testing conditions &#40;&#40;mean&#40;SD&#41; at 1 minute&#58; 147&#46;3 &#40;17&#46;7&#41; bpm for those WM&#59; 144&#46;1 &#40;18&#46;3&#41; bpm for SM and 142&#46;3 &#40;20&#46;9&#41; bpm for those wearing R&#59; p&#61;0&#46;56&#41;&#59; at 3 minutes&#58; 117&#46;5 &#40;19&#46;6&#41; bpm for those WM&#59; 122&#46;6 &#40;19&#46;2&#41; bpm for SM and 120&#46;0 &#40;19&#46;5&#41; bpm for those wearing R&#59; p&#61;0&#46;27&#41;&#41;&#46; No significant differences between test conditions for systolic BP at three minutes of recovery were found &#40;p&#61;0&#46;31&#41;&#46; Diastolic BP showed significant differences only between the test WM and with SM &#40;p&#61;0&#46;04&#41; &#8211; the mean &#40;SD&#41; values were 60&#46;2 &#40;5&#46;9&#41; mmHg&#44; 69&#46;0 &#40;9&#46;2&#41; mmHg&#44; and 66&#46;0 &#40;6&#46;0&#41; mmHg&#44; respectively&#44; for WM&#44; SM and R&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">The main findings of our study were as follows&#58; &#40;1&#41; regardless of type of mask worn&#44; using a FM resulted in shorter duration of maximal symptom-limited ET and higher levels of dyspnea and perceived exertion&#59; &#40;2&#41; a significant drop in SpO2 was present at the end of ET only when using a R&#59; &#40;3&#41; there were no differences in either chronotropic response or BP between testing conditions&#59; &#40;4&#41; there were no significant differences in response to ET between wearing SM or R&#46; In the light of the restrictions imposed on cardiac rehabilitation by COVID-19&#44; including regarding safety in group exercise sessions&#44; there have been a few recent studies on the impact of wearing different types of FM on cardiorespiratory parameters and subjective levels of dyspnea and exertion during exercise&#44;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">9&#44;15&#8211;17</span></a> albeit showing mixed results&#46; Fikenzer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">15</span></a> found that cardiopulmonary exercise capacity is reduced by SM and highly impaired by R during a progressive cycle ergometer test&#46; In contrast&#44; Epstein et al&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">17</span></a> found only minor changes in physiological parameters during a progressive cycle ergometer test when wearing a SM or a R&#44; and Shaw et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a> did not report any discernable detrimental effect on exercise performance while using a FM during a cycle ergometer test onexhaustion&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Our study showed a shorter duration of ET when using a FM&#44; regardless of its type&#44; reflecting limitations at higher levels of exercise intensity&#46; SM and R might exert these detrimental effects on exercise capacity through different mechanisms&#58; Resistance to airflow and heightened respiratory pressures&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> increased dead space ventilation&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">19</span></a> alveolar hypoventilation<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">20&#44;21</span></a> and interference with tidal volume&#44; thermal regulation&#44; vision&#44; communication and task performance&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">19</span></a> It is known that FM restrict airflow and require generation of higher inspiratory and expiratory pressures when breathing&#44;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">20&#44;22</span></a> changing the inspiration and expiration process from passive to active<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> and leading to increased breathing work&#44; respiratory muscle fatigue<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">22&#44;23</span></a> and reduced exercise performance&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">24</span></a> Considering that perceived breathing effort is positively correlated with ventilation effort&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">25</span></a> the increased respiratory load may itself be associated with physical and psychological discomfort&#46; On the other hand&#44; higher resistance to airflow results in alveolar hypoventilation&#44;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">20&#44;21</span></a> leading to an earlier onset of the first and second ventilatory thresholds and a shorter time to exhaustion and achievement of lower peak VO<span class="elsevierStyleInf">2&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">8&#44;26</span></a> There is also a substantial variability in the individual tolerance<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">19</span></a> of higher respiratory resistance and to the hot and humid conditions created inside the FM&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">27</span></a> The increase in temperature of inhaled air associated with wearing a FM might also result in bronchoconstriction and higher pulmonary resistance&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">28</span></a> contributing further to dyspnea and respiratory discomfort&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">29</span></a> This tolerance is also greatly influenced by the anxiety levels of the wearer&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">30</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Granados et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">31</span></a> in a pilot study to assess the impact of FM on exercise performance and ventilatory responses&#44; postulated that&#44; for effort levels above 60&#37; VO<span class="elsevierStyleInf">2</span>peak&#44; wearing a FM was associated with inadequate hyperventilation and arterial hypoxemia due to reduced breathing frequency and dead space carbon dioxide rebreathing&#46; Accordingly&#44; our study shows a reduction in SpO2 measured during ET when using a SM or a R&#44; although the difference was only significant during maximal exercise intensities using a R&#44; comparing to not wearing a FM&#46; In contrast&#44; other studies found no significant impact on SpO<span class="elsevierStyleInf">2</span> when wearing a SM during a submaximal exertion measured during the six-minute walk test&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a> a SM or a R during a cycle ergometry test of time to exhaustion<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">9&#44;17</span></a> or when wearing a R during a low to moderate intensity walk &#40;5&#46;6 km&#47;h&#41; on a treadmill for an hour&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> We believe that respiratory function &#40;gas exchange&#41; may not represent a limiting factor for peripheral oxygen carrying capacity during mild to moderate intensity exercise in healthy adults&#44; despite the loaded breathing&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Perceived exertion has an array of possible determinants&#44; ranging from physiological&#44; volitional&#44; motivational and psychological&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">33</span></a> In the present study&#44; compared to not using any FM&#44; perceived exertion was higher when using either a SM or a R&#59; notably&#44; it was most significant at the first stages of ET&#44; when using a SM&#44; and most significant toward the end of it when using a R&#46; On the other hand&#44; perceived breathing effort was significantly higher when using a R throughout the ET&#44; compared to not wearing a FM&#46; Perceived breathing effort with the SM was only significantly higher than WM at half of the ET duration&#46; Both hypoxemia and respiratory muscle fatigue&#44; resulting from increased work of breathing because of increased airflow resistance&#44; possibly contribute to increased perceived exertion at maximal exercise intensity&#46; This trend is supported by Johnson et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">21</span></a> who demonstrated that the impact of inspiratory resistance on performance is mostly felt at higher exercise intensities&#46; Fikenzer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">15</span></a> also demonstrated higher perceived exertion when wearing a SM or a R during a maximal symptom-limited cycle ergometer test&#44; findings that contradict a study by Roberge et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a> on the effects of wearing a surgical mask during a treadmill exercise test for one hour&#46; In this study&#44; there was no significant impact on perceived exertion&#46; Shaw et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a> also did not report any detrimental effect of FM on perceived exertion&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">There is an alternative view on the beneficial effects of wearing a FM&#44; especially R&#44; during exercise training programs&#46; Davis and Tsen<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> postulate that the increased work of breathing derived from using this type of FM during exercise might be used for conditioning purposes&#44; increasing respiratory muscle strength and respiratory muscle endurance&#44; improving ventilatory efficiency&#44; oxygen delivery and overall exercise performance&#46; This is of particular importance in the context of CRP&#44; considering the overall objectives of this intervention&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Loading in breathing effort during exercise may reduce respiratory frequency and implies an additional muscle recruitment and potentially slow oxygen consumption kinetics&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a> a myriad of factors that may possibly change the signaling in the central CV center and increase HR and BP&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">35</span></a> Based on that&#44; the authors hypothesized that exercising while wearing a FM would greatly influence hemodynamics when comparing to not wearing a FM&#44; as demonstrated on healthy volunteers performing a low to moderate intensity walk &#40;5&#46;6 km&#47;h&#41; on a treadmill for an hour&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">16</span></a> However&#44; our study did not demonstrate a significant difference in BP and HR response during and after ET in the different testing conditions besides a shorter time to reach maximal HR values&#46; Jung et al&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a> reported similar results in their study on the effect of an elevation training mask during cycling &#8211; although they reported a significant autonomic-mediated blunted HR decrease during recovery when wearing the mask&#46; Data from multiple studies have also shown that the use of a FM has no significant effect on HR&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">12&#44;24&#44;37</span></a> Nevertheless&#44; the authors believe that further studies are necessary to draw more definite conclusions on the CV response to wearing a FM during exercise&#44; especially in those patients with previous CV and pulmonary disorders&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Based on other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">36&#44;37</span></a> our findings may be related to the combination of duration and intensity of the exercise performed&#46; Interestingly&#44; after an initial period of subjective destabilization during the first half of the ET when using a FM&#44; there seems to be a leveling of the perceived discomfort at mid-stage of the ET &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; This potential compensation mechanism appears to become ineffective as the subject reaches their maximal exercise capacity&#44; possibly due to the breathing difficulty resulting from an increase minute-ventilation against an increased inspiratory and expiratory resistance from wearing the FM&#46; In type 2 SM&#44; this resistance is usually expressed as a differential pressure of 40 Pa&#47;cm<span class="elsevierStyleSup">2</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">38&#44;39</span></a> On the other hand&#44; KN95 Rs show a maximal differential pressure of approximately 70 Pa&#47;cm<span class="elsevierStyleSup">2</span> for inhalation flow and 50 Pa&#47;cm<span class="elsevierStyleSup">2</span> for exhalation flow&#44; considering a flow rate of 85L&#47;min&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">13&#44;38</span></a> These values increase in proportion to the flow rate&#44; which depends on the ventilation per minute&#46; For this reason&#44; it is reasonable that perceived exertion and dyspnea are significantly higher with either FM throughout the ET&#44; when compared to not wearing a FM&#46; At lower intensities&#44; the air resistance offered by SM and R is low and probably similar&#44; as flow rates are still increasing&#46; However&#44; at maximal intensity&#44; when flow rates and air resistance from using FM are at their highest&#44; there is a steep increase in work of breathing resulting in fatigue of respiratory muscles&#44; higher perceived exertion and dyspnea&#44; especially when wearing a R&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In the setting of CRP&#44; professionals should be aware of the physical and psychological discomfort caused by FM&#44; as well as be advised of a possible influence on CV response&#46; Relative oxygen desaturation is a major concern in this patient population&#44; especially when there is concomitant respiratory pathology&#46; Patient familiarity with the physiological adjustments that occur when using a FM can lead to enhanced effectiveness of therapeutic exercise in this context&#46; Nevertheless&#44; the authors believe that implementation of monitored home-based CRP may replace in-hospital sessions in some cases&#44; particularly in low CV risk patients&#44; as has already been suggested&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a> It seems reasonable to start with remote low-intensity exercise training in combination with resistance and flexibility exercises after a safety assessment&#46; These home-based programs may be monitored through tele-rehabilitation and circumvent the need of using a FM during exercise&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Limitations</span><p id="par0115" class="elsevierStylePara elsevierViewall">Some limitations must be considered&#46; This is a preliminary single-center study of a limited number of overall healthy&#44; relatively young health workers&#44; who agreed to participate&#46; Caution is recommended when extrapolating results to clinical settings and different populations&#44; namely older patients&#44; those with high comorbidity burden and patients attending CV or pulmonary rehabilitation exercise programs&#46; On the other hand&#44; we must consider that the subjects in this study are healthcare workers who routinely use a FM for long periods of time &#8211; this can impact on their tolerance of the equipment compared with other subjects&#46; Additionally&#44; the lack of multivariable analysis according to age&#44; gender and physical activity habits also limits the generalization of these results&#46; Although the investigators followed a strict protocol of ET&#44; randomization of ET sequence&#44; blinding of researchers involved in data abstraction and database completion&#44; difficulties from nonblinding of patient and researcher performing the ET could not be overcome&#46; Moreover&#44; no information was collected regarding other ventilatory parameters&#44; including direct measurement of dead space with different FM&#44; minute-ventilation and&#47;or respiratory frequency&#44; baseline cardiorespiratory performance &#40;cardiopulmonary ET&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">Our study found that wearing a FM may be associated with reduced exercise capacity and higher levels of dyspnea and effort perception&#44; especially at maximal intensity&#44; independent of the type of FM worn&#46; There is no evidence that wearing a FM during high intensity aerobic exercise significantly changes chronotropic and BP responses&#46; On the other hand&#44; wearing a R in these conditions induces arterial hypoxemia in healthy adults&#46; In the setting of CRP&#44; these findings may represent a major concern during the COVID-19 pandemic and may warrant a readjustment of the exercise intensities used in this context&#46; To further assess and in order to make exercise prescription recommendations&#44; further trials are needed&#44; including with larger and more representative samples and with more extensive indicators of cardiopulmonary responses to wearing different types of FM&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Introduction and objectives"
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              "titulo" => "Introdu&#231;&#227;o e objetivos"
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          "titulo" => "Results"
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            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Population characteristics"
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            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Exercise test duration"
            ]
            2 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Level of perceived exertion"
            ]
            3 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Level of dyspnea"
            ]
            4 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Arterial oxygen saturation"
            ]
            5 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Hemodynamic response &#8211; heart rate and blood pressure"
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          "identificador" => "sec0070"
          "titulo" => "Discussion"
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          "titulo" => "Limitations"
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          "titulo" => "Conclusions"
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          "identificador" => "sec0085"
          "titulo" => "Conflicts of interest"
        ]
        11 => array:2 [
          "identificador" => "xack575150"
          "titulo" => "Acknowledgments"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2020-09-17"
    "fechaAceptado" => "2021-01-10"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1454434"
          "palabras" => array:6 [
            0 => "Facemask"
            1 => "Respirator"
            2 => "Exercise"
            3 => "Cardiac rehabilitation"
            4 => "Covid-19"
            5 => "Coronavirus"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "<span class="elsevierStyleBold">Palavras-chave</span>"
          "identificador" => "xpalclavsec1454433"
          "palabras" => array:6 [
            0 => "M&#225;scara facial"
            1 => "Respirador"
            2 => "Exerc&#237;cio"
            3 => "Reabilita&#231;&#227;o card&#237;aca"
            4 => "Covid-19"
            5 => "Coronavirus"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">During the COVID-19 pandemic&#44; among the safety measures adopted&#44; use of facemasks during exercise training sessions in cardiac rehabilitation programs raised concerns regarding possible detrimental effects on exercise capacity&#46; Our study examined the cardiorespiratory impact of wearing two types of the most common facemasks during treadmill aerobic training&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Twelve healthy health professionals completed three trials of a symptom-limited Bruce treadmill protocol&#58; Without a mask&#44; with a surgical mask and with a respirator&#46; Perceived exertion and dyspnea were evaluated with the Borg Scale of Perceived Exertion and the Borg Dyspnea Scale&#44; respectively&#46; Blood pressure&#44; heart rate and arterial oxygen saturation &#40;SpO2&#41; were measured at each 3-minute stage&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Using a surgical mask or a respirator resulted in a shorter duration of exercise testing&#46; At peak capacity&#44; using a respirator resulted in higher levels of dyspnea and perceived exertion compared to not wearing a facemask&#46; A significant drop in SpO2 was present at the end of exercise testing only when using a respirator&#46; There were no differences in either chronotropic or blood pressure responses between testing conditions&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Professionals involved in cardiac rehabilitation should be aware of the cardiorespiratory impact of facemasks&#46; Future studies should assess whether exposure to these conditions may impact on the overall results of contemporary cardiac rehabilitation programs&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Durante a pandemia Covid-19 a utiliza&#231;&#227;o de m&#225;scaras faciais&#44; incluindo durante o exerc&#237;cio terap&#234;utico&#44; faz parte das medidas de seguran&#231;a adotadas&#46; Este facto originou preocupa&#231;&#227;o a n&#237;vel das unidades de reabilita&#231;&#227;o card&#237;aca&#44; uma vez que as m&#225;scaras faciais podem promover efeitos delet&#233;rios na capacidade de exerc&#237;cio&#46; Este estudo avaliou o impacto da utiliza&#231;&#227;o das m&#225;scaras faciais durante o treino aer&#243;bio em passadeira&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Doze profissionais de sa&#250;de saud&#225;veis completaram tr&#234;s provas em passadeira de acordo com o protocolo de Bruce&#58; sem m&#225;scara&#44; com m&#225;scara cir&#250;rgica e com um respirador&#46; A perce&#231;&#227;o de esfor&#231;o e dispneia foi avaliada com a Escala de Perce&#231;&#227;o de Esfor&#231;o de Borg e com a Escala de Dispneia de Borg&#44; respetivamente&#46; A press&#227;o arterial&#44; frequ&#234;ncia card&#237;aca e satura&#231;&#227;o arterial de oxig&#233;nio &#40;SpO2&#41; foram registadas em cada estadio do protocolo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A utiliza&#231;&#227;o de m&#225;scara facial resultou numa menor dura&#231;&#227;o da prova e&#44; em determinados momentos&#44; n&#237;veis de perce&#231;&#227;o de dispneia e de esfor&#231;o mais elevados&#46; Verificou-se uma descida significativa da SpO2 no final da prova com respirador&#46; N&#227;o se verificaram diferen&#231;as na resposta cronotr&#243;pica ou da press&#227;o arterial entre as diferentes condi&#231;&#245;es de prova&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Os profissionais envolvidos na reabilita&#231;&#227;o card&#237;aca devem reconhecer os impactos cardiorrespirat&#243;rios provocados pela utiliza&#231;&#227;o da m&#225;scara facial&#46; S&#227;o necess&#225;rios mais estudos para determinar se a exposi&#231;&#227;o a estas condi&#231;&#245;es de treino pode ter impacto nos resultados dos programas de reabilita&#231;&#227;o card&#237;aca&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Introdu&#231;&#227;o e objetivos"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#245;es"
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        "etiqueta" => "Figure 1"
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        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Progression of mean values of SpO2&#44; level of perceived exertion &#40;Borg Scale of Perceived Exertion&#41; and level of dyspnea &#40;Borg Dyspnea Scale&#41; at different stages of the exercise test &#40;at rest&#44; at 25&#37;&#44; 50&#37; and 75&#37; of the duration of the test and at the end of the test&#41;&#46; &#91;SpO2&#58; arterial oxygen saturation&#59; &#9632;&#58; without mask&#59; &#9679;&#58; surgical mask&#59; <elsevierMultimedia ident="202112160943504841"></elsevierMultimedia>&#58; respirator&#59; &#42;&#58; signals p&#60;0&#46;05 on comparison of test conditions&#93;&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Abbreviations</span>&#58; IPAQ&#58; International Physical Activity Questionnaire&#59; METS&#58; metabolic equivalents&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Abbreviations</span>&#58; bpm&#58; beats per minute&#59; ET&#58; exercise testing&#59; HR&#58; heart rate&#59; R&#58; respirator&#59; SM&#58; surgical mask&#59; SpO2&#58; arterial oxygen saturation&#59; WM&#58; without mask&#46;</p>"
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                  \t\t\t\t">8&#58;25 &#40;3&#58;20&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#58;23 &#40;3&#58;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#58;21 &#40;03&#58;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;2 &#40;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Borg scale of perceived exertion&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;3 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;4 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;1 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;1 &#40;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Borg dyspnea scale&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;7 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;8 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;6 &#40;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;5 &#40;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SpO2 &#40;&#37;&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94&#46;5 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#46;5 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&#46;3 &#40;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;3 &#40;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Maximal HR in bpm&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">170&#46;1 &#40;14&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">173&#46;0 &#40;14&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">170&#46;8 &#40;13&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;6 &#40;p&#61;0&#46;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronotropic reserve in bpm&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">101&#46;8 &#40;14&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#46;6 &#40;14&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#46;8 &#40;16&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;8 &#40;p&#61;0&#46;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Abbreviations</span>&#58; CI&#58; confidence interval&#59; ET&#58; exercise testing&#59; MD&#58; mean difference&#59; PE&#58; perceived exertion&#59; R&#58; respirator&#59; SM&#58; surgical mask&#59; SpO2&#58; arterial oxygen saturation&#59; WM&#58; without mask&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">25&#37; of ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">50&#37; of ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">75&#37; of ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">100&#37; of ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">WM <span class="elsevierStyleItalic">vs&#46;</span> SM</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Borg Scale of PE&#44;MD &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;1&#40;0&#46;3-1&#46;9&#59;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;1&#40;1&#46;2-3&#46;0&#59;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;9&#40;&#8722;0&#46;9-2&#46;8&#59;p&#61;0&#46;57&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;1&#40;&#8722;0&#46;3-2&#46;5&#59;p&#61;0&#46;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Borg Dyspnea Scale&#44;MD &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;3&#40;&#8722;0&#46;1-0&#46;8&#59;p&#61;0&#46;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;0&#40;0&#46;0-2&#46;1&#59;p&#61;0&#46;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;7&#40;&#8722;1&#46;4-2&#46;7&#59;p&#61;1&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;2&#40;&#8722;0&#46;5-2&#46;8&#59;p&#61;0&#46;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>SpO2 &#40;&#37;&#41;&#44;MD &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;5&#40;&#8722;1&#46;3-0&#46;3&#59;p&#61;0&#46;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;3&#40;&#8722;1&#46;5-0&#46;8&#59;p&#61;1&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;0&#46;3&#40;&#8722;1&#46;8-1&#46;2&#59;p&#61;1&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8722;2&#46;0&#40;&#8722;4&#46;1-0&#46;1&#59;p&#61;0&#46;07&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">WM <span class="elsevierStyleItalic">vs&#46;</span> R</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Borg Scale of PE&#44;MD &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;3&#40;&#8722;0&#46;3-0&#46;8&#59;p&#61;0&#46;57&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5&#40;0&#46;4-2&#46;6&#44;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;8&#40;&#8722;1&#46;2-2&#46;7&#59;p&#61;0&#46;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;8&#40;0&#46;1-3&#46;4&#59;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Borg Dyspnea Scale&#44;MD &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;4&#40;0&#46;0-0&#46;7&#59;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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Original Article
Facemasks during aerobic exercise: Implications for cardiac rehabilitation programs during the Covid-19 pandemic
Máscaras faciais durante o exercício aeróbio: implicações para os programas de reabilitação cardíaca durante a pandemia COVID-19
Tiago Pimenta
Corresponding author
tiago.pmt@gmail.com

Corresponding author.
, Helena Tavares, João Ramos, Mafalda Oliveira, David Reis, Hugo Amorim, Afonso Rocha
Department of Physical Medicine & Rehabilitation, Centro Hospitalar e Universitário de São João, Porto, Portugal
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        "titulo" => "M&#225;scaras faciais durante o exerc&#237;cio aer&#243;bio&#58; implica&#231;&#245;es para os programas de reabilita&#231;&#227;o card&#237;aca durante a pandemia COVID-19"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Progression of mean values of SpO2&#44; level of perceived exertion &#40;Borg Scale of Perceived Exertion&#41; and level of dyspnea &#40;Borg Dyspnea Scale&#41; at different stages of the exercise test &#40;at rest&#44; at 25&#37;&#44; 50&#37; and 75&#37; of the duration of the test and at the end of the test&#41;&#46; &#91;SpO2&#58; arterial oxygen saturation&#59; &#9632;&#58; without mask&#59; &#9679;&#58; surgical mask&#59; <elsevierMultimedia ident="202112160943504841"></elsevierMultimedia>&#58; respirator&#59; &#42;&#58; signals p&#60;0&#46;05 on comparison of test conditions&#93;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiac rehabilitation programs &#40;CRP&#41; are widely recommended as part of the optimal treatment of patients with cardiovascular &#40;CV&#41; disease&#44; particularly after an acute coronary syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> These patients often have a lower exercise tolerance and require a higher exertion to perform the same level of activity compared to a healthy individual&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">2</span></a> and these limitations can be effectively overturned by participation in exercise-based CRP&#46; The COVID-19 &#40;SARS-CoV-2 associated disease&#41; pandemic has forced the suspension of most&#44; if not all&#44; group exercise training sessions due to concerns over spreading SARS-CoV-2&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;4</span></a> Nevertheless&#44; resumption of CRP is warranted&#44; provided safety measures are adopted&#44; including the use of facemasks &#40;FM&#41; during exercise training sessions&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;5</span></a> This has been increasingly recognized and recommended as a mitigation strategy to overcome the potential aerosolization associated with the higher expiratory flows generated during submaximal and maximal exercise&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">6&#44;7</span></a> However&#44; the ability to exercise in these conditions raises some concerns&#46; Rebreathing of low-oxygen high-carbon dioxide expired air may interfere with alveolar gas diffusion and blood oxygen uptake&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> On the other hand&#44; increased resistance to air flow resulting from using FM can lead to increased respiratory effort and early respiratory muscle fatigue&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> This combination could potentially result in an impaired exercise performance&#44; although there are mixed results on this topic&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a> Our study aimed to assess the impact of using different FMs &#40;surgical mask &#40;SM&#41; and respirator &#40;R&#41;&#41;&#44; compared to not using a FM&#44; on the cardiorespiratory physiological response and rate of perceived exertion and dyspnea during treadmill aerobic training in healthy subjects&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Subjects</span><p id="par0010" class="elsevierStylePara elsevierViewall">We recruited a consecutive sample of healthy health professionals from our department&#46; A brief review of clinical data was obtained using a structured questionnaire regarding past medical history and medication&#46; Physical activity was assessed by the Portuguese version of the International Physical Activity Questionnaire &#40;IPAQ&#41;&#44; which classifies leisure time physical activity levels as low&#44; moderate or high&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">10&#44;11</span></a> None of the subjects had performed an exercise test on treadmill in the previous twelve months&#46; Sample size calculation with the power to detect differences between groups of 80&#37; with a level of significance of 0&#46;05&#44; was calculated assuming a mean difference in overall exercise discomfort score between not wearing a FM and using either SM or R of 2&#46;4 and a standard deviation &#40;SD&#41; of 2&#46;0&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> resulting in at least 12 observations for each time point&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Surgical masks and respirators</span><p id="par0015" class="elsevierStylePara elsevierViewall">Our study aimed to compare the physiological response and perceived exertion in an incremental exercise protocol in three testing conditions&#58; Not wearing a FM &#40;group 1&#58; without mask &#91;WM&#93;&#41; versus using two different types of FM with different filtration properties&#46; A disposable three-layer type 2 SM &#40;MASK-98 model&#44; manufactured by Razi Protect&#44; in Portugal&#41; &#40;group 2&#58; SM&#41;&#44; with a minimum filter capacity of 95&#37; of particles 3&#46;0 microns or larger in diameter&#44; and a R with a filtering facepiece score of 2 &#40;FFP2&#41; &#40;group 3&#58; R&#41; were used&#46; The R available at the time of the study as the Chinese KN95 &#40;GB2626-2006 model&#44; manufactured by Lianyungang Manai Protective Equipment Company&#44; in China&#41;&#44; which filtrates a minimum of 94&#37; of all particles &#62;0&#46;3 microns or larger in diameter &#8211; an equivalent safety specification to the European FFP2 respirators&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">13</span></a> The KN95 respirators were therefore considered adequate for this study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study protocol</span><p id="par0020" class="elsevierStylePara elsevierViewall">Each subject performed three tests&#58; One in regular conditions&#44; without a FM&#59; one with a SM&#59; and another one with a KN95 respirator&#46; Each test was performed with at least a 48 hour interval and preferably at the same time of day&#46; The subjects were asked not to perform vigorous exercise in the 24 hours prior to each test&#46; The sequence of tests was randomized to reduce bias&#44; using a computerized random number generator&#44; with allocation known to the examiner and patient only at the time of the test&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">For exercise testing &#40;ET&#41; we followed the Bruce treadmill protocol &#40;using the Mill &#38; Mill&#174; Track model&#44; manufactured by Lode B&#46;V&#46;&#44; in the Netherlands&#41;&#46; Handrail support was allowed only for balance&#46; At rest&#44; at the last minute of each of the three-minute stages of the Bruce protocol and at peak exercise&#44; we recorded heart rate &#40;HR&#41;&#44; blood pressure &#40;BP&#41; and arterial oxygen saturation &#40;SpO2&#41; and quantified level of fatigue and dyspnea using the Borg Scale of Perceived Exertion and the Borg Dyspnea Scale&#44; respectively&#46; BP was measured with an upper-arm manual BP cuff &#40;Big Ben Round model&#44; manufactured by Riester&#44; in Germany&#41;&#44; in the left arm&#44; and HR and SpO2 with a finger oximeter worn throughout the test &#40;GIMA PC-68B&#41;&#46; Subjects were allowed ET warm up period at 2&#46;7 km&#47;h with 0&#37; grade for three minutes and performed a cool down period of 5 minutes at the end&#46; BP&#44; HR and SpO2 were recorded again during the cool down period &#40;after three minutes for BP and after one and three minutes for HR and SpO2&#41;&#46; The investigators followed the American Heart Association criteria for ET termination&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">14</span></a> All data was registered during each test in a blinded form &#40;no identifiable information on the subject&#41;&#44; coded using a single randomly generated combination of digits and characters and inserted into the database by a different member of the investigator team not otherwise involved in any step of the study&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">All participants were informed of the procedures and potential risks before testing and a written informed consent was obtained as per institution protocol&#46; All safety measures regarding ET were adopted&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Standard descriptive measures&#44; namely mean and standard deviation &#40;SD&#41; for normally distributed continuous variables and proportion &#40;expressed as &#37;&#41; for categorical variables were used&#46; Normality assessment was done using the Kolmogorov-Smirnov test and visual inspection of the distribution histogram&#46; To account for the dependence of observations&#44; since the same subject was tested in three study conditions&#44; a repeated measure analysis of variance was used&#46; For within-subjects&#8217; differences in each timepoint F statistics were used considering a significance p&#60;0&#46;05&#46; Furthermore&#44; to allow for between-group comparisons &#40;WM&#44; SM&#44; R&#41;&#44; a Bonferroni adjustment analysis was performed&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Each patient exercise test was categorized according to a percentage of the total time achieved &#40;25&#37;&#44; 50&#37;&#44; 75&#37; and 100&#37;&#41;&#44; independently of its duration&#44; and data was collected in each of these timepoints&#46; This approach was chosen since not all subjects completed the total protocol time&#44; leaving fewer observations in the last stages of the exercise test&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Population characteristics</span><p id="par0045" class="elsevierStylePara elsevierViewall">Twelve subjects were recruited&#46; Baseline characteristics are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The study sample consisted of young &#40;age range&#58; 25-45 years&#41;&#44; mostly male health professionals&#46; All subjects had normal body mass index&#44; ranging between 19&#46;9 kg&#47;m<span class="elsevierStyleSup">2</span> and 24&#46;7 kg&#47;m<span class="elsevierStyleSup">2</span>&#44; with the majority &#40;seven subjects &#40;58&#46;3&#37;&#41;&#41; being moderately to highly physically active&#46; Two subjects had previous respiratory disorders&#44; namely one subject with asthma &#40;medicated with a leukotriene receptor antagonist &#8211; montelukast&#44; 10 mg per day&#44; with no recent exacerbations&#41; and another one with allergic rhinitis&#46; Concerning musculoskeletal diseases&#44; one subject had a history of a healed peroneal fracture&#44; one subject had a history of previous surgical treatment for a lumbar disk herniation and one had a recent history of paratendinopathy of the Achilles tendon&#46; All subjects performed the three tests and there were no dropouts&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Exercise test duration</span><p id="par0050" class="elsevierStylePara elsevierViewall">Our study found that&#44; compared to not wearing a FM&#44; wearing a FM was associated with shorter ET duration&#44; independent of the type of mask worn &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; There was no significant difference in ET duration between wearing SM or R&#46; All patients completed the third stage of the Bruce protocol&#44; with dropouts beginning at stage four&#44; when using a FM&#44; and at stage five when not wearing a mask&#46; The Bruce protocol was completed by seven &#40;50&#46;3&#37;&#41; subjects when WM&#44; but only by four &#40;33&#46;3&#37;&#41; when wearing a SM or a R&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Level of perceived exertion</span><p id="par0055" class="elsevierStylePara elsevierViewall">At 25&#37; of total time achieved in ET&#44; only wearing a SM showed a significant higher level of exercise perception compared to not wearing a FM &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; At 50&#37; of total time achieved in ET&#44; both wearing a SM or a R showed a significantly higher level of perceived exertion compared to WM &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; At 75&#37; of test completion&#44; no differences between testing conditions &#40;p&#61;0&#46;14&#41; were found&#46; At the end of the ET&#44; wearing a R was associated with a significantly higher level of perceived exertion when compared to WM &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; No differences were found in any stage of ET between wearing SM and R&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Level of dyspnea</span><p id="par0060" class="elsevierStylePara elsevierViewall">A significant difference in level of dyspnea between testing conditions at 25&#37;&#44; 50&#37; and at ET completion was found &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#44; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Using a R resulted in higher levels of dyspnea&#44; compared to not wearing a mask&#44; at 25&#37;&#44; 50&#37; and at ET completion&#44; while compared to WM&#44; SM showed higher dyspnea levels only at 50&#37; of total time achieved in ET&#46; No differences were found in any stage of ET between wearing SM and R&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Arterial oxygen saturation</span><p id="par0065" class="elsevierStylePara elsevierViewall">Regarding SpO2&#44; significant desaturation was only observed at ET completion when comparing R versus WM &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#44; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; During cool down&#44; at one and three minutes after ET completion&#44; there were no significant differences between testing conditions &#40;&#40;mean&#40;SD&#41; at one minute&#58; 96&#46;0&#37; &#40;1&#46;6&#41; for those WM&#59; 95&#46;4&#37; &#40;1&#46;6&#41; for SM and 95&#46;6&#37; &#40;2&#46;0&#41; for those wearing R&#59; p&#61;0&#46;45&#41;&#59; at 3 minutes&#58; 96&#46;4&#37; &#40;1&#46;2&#41; for those WM&#59; 96&#46;0&#37; &#40;1&#46;2&#41; for SM and 96&#46;2&#37; &#40;1&#46;0&#41; for those wearing R&#59; p&#61;0&#46;36&#41;&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Hemodynamic response &#8211; heart rate and blood pressure</span><p id="par0070" class="elsevierStylePara elsevierViewall">Heart rate increased proportionally during each test&#44; for each subject&#44; according to the intensity of the exercise&#46; When comparing HR at the end of the ET and chronotropic reserve&#44; there were no significant differences between groups at any stage of ET &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The percentage of maximal age-predicted HR achieved at ET completion did not differ between groups with 90&#46;0&#37; &#40;7&#46;9&#41; for WM&#44; 90&#46;9&#37; &#40;6&#46;4&#41; when wearing a SM and 89&#46;8&#37; &#40;7&#46;1&#41; when wearing a R&#59; there were no significant differences between these values&#46; There were no statistically significant differences in mean systolic and diastolic end blood pressure according to testing conditions &#40;p&#61;0&#46;30 and p&#61;0&#46;93&#44; respectively&#41;&#46; During cool down&#44; at one and three minutes after ET completion&#44; there were no significant differences in HR according to testing conditions &#40;&#40;mean&#40;SD&#41; at 1 minute&#58; 147&#46;3 &#40;17&#46;7&#41; bpm for those WM&#59; 144&#46;1 &#40;18&#46;3&#41; bpm for SM and 142&#46;3 &#40;20&#46;9&#41; bpm for those wearing R&#59; p&#61;0&#46;56&#41;&#59; at 3 minutes&#58; 117&#46;5 &#40;19&#46;6&#41; bpm for those WM&#59; 122&#46;6 &#40;19&#46;2&#41; bpm for SM and 120&#46;0 &#40;19&#46;5&#41; bpm for those wearing R&#59; p&#61;0&#46;27&#41;&#41;&#46; No significant differences between test conditions for systolic BP at three minutes of recovery were found &#40;p&#61;0&#46;31&#41;&#46; Diastolic BP showed significant differences only between the test WM and with SM &#40;p&#61;0&#46;04&#41; &#8211; the mean &#40;SD&#41; values were 60&#46;2 &#40;5&#46;9&#41; mmHg&#44; 69&#46;0 &#40;9&#46;2&#41; mmHg&#44; and 66&#46;0 &#40;6&#46;0&#41; mmHg&#44; respectively&#44; for WM&#44; SM and R&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">The main findings of our study were as follows&#58; &#40;1&#41; regardless of type of mask worn&#44; using a FM resulted in shorter duration of maximal symptom-limited ET and higher levels of dyspnea and perceived exertion&#59; &#40;2&#41; a significant drop in SpO2 was present at the end of ET only when using a R&#59; &#40;3&#41; there were no differences in either chronotropic response or BP between testing conditions&#59; &#40;4&#41; there were no significant differences in response to ET between wearing SM or R&#46; In the light of the restrictions imposed on cardiac rehabilitation by COVID-19&#44; including regarding safety in group exercise sessions&#44; there have been a few recent studies on the impact of wearing different types of FM on cardiorespiratory parameters and subjective levels of dyspnea and exertion during exercise&#44;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">9&#44;15&#8211;17</span></a> albeit showing mixed results&#46; Fikenzer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">15</span></a> found that cardiopulmonary exercise capacity is reduced by SM and highly impaired by R during a progressive cycle ergometer test&#46; In contrast&#44; Epstein et al&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">17</span></a> found only minor changes in physiological parameters during a progressive cycle ergometer test when wearing a SM or a R&#44; and Shaw et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a> did not report any discernable detrimental effect on exercise performance while using a FM during a cycle ergometer test onexhaustion&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Our study showed a shorter duration of ET when using a FM&#44; regardless of its type&#44; reflecting limitations at higher levels of exercise intensity&#46; SM and R might exert these detrimental effects on exercise capacity through different mechanisms&#58; Resistance to airflow and heightened respiratory pressures&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> increased dead space ventilation&#44;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">19</span></a> alveolar hypoventilation<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">20&#44;21</span></a> and interference with tidal volume&#44; thermal regulation&#44; vision&#44; communication and task performance&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">19</span></a> It is known that FM restrict airflow and require generation of higher inspiratory and expiratory pressures when breathing&#44;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">20&#44;22</span></a> changing the inspiration and expiration process from passive to active<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a> and leading to increased breathing work&#44; respiratory muscle fatigue<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">22&#44;23</span></a> and reduced exercise performance&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">24</span></a> Considering that perceived breathing effort is positively correlated with ventilation effort&#44;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">25</span></a> the increased respiratory load may itself be associated with physical and psychological discomfort&#46; On the other hand&#44; higher resistance to airflow results in alveolar hypoventilation&#44;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">20&#44;21</span></a> leading to an earlier onset of the first and second ventilatory thresholds and a shorter time to exhaustion and achievement of lower peak VO<span class="elsevierStyleInf">2&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">8&#44;26</span></a> There is also a substantial variability in the individual tolerance<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">19</span></a> of higher respiratory resistance and to the hot and humid conditions created inside the FM&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">27</span></a> The increase in temperature of inhaled air associated with wearing a FM might also result in bronchoconstriction and higher pulmonary resistance&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">28</span></a> contributing further to dyspnea and respiratory discomfort&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">29</span></a> This tolerance is also greatly influenced by the anxiety levels of the wearer&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">30</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Granados et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">31</span></a> in a pilot study to assess the impact of FM on exercise performance and ventilatory responses&#44; postulated that&#44; for effort levels above 60&#37; VO<span class="elsevierStyleInf">2</span>peak&#44; wearing a FM was associated with inadequate hyperventilation and arterial hypoxemia due to reduced breathing frequency and dead space carbon dioxide rebreathing&#46; Accordingly&#44; our study shows a reduction in SpO2 measured during ET when using a SM or a R&#44; although the difference was only significant during maximal exercise intensities using a R&#44; comparing to not wearing a FM&#46; In contrast&#44; other studies found no significant impact on SpO<span class="elsevierStyleInf">2</span> when wearing a SM during a submaximal exertion measured during the six-minute walk test&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a> a SM or a R during a cycle ergometry test of time to exhaustion<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">9&#44;17</span></a> or when wearing a R during a low to moderate intensity walk &#40;5&#46;6 km&#47;h&#41; on a treadmill for an hour&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a> We believe that respiratory function &#40;gas exchange&#41; may not represent a limiting factor for peripheral oxygen carrying capacity during mild to moderate intensity exercise in healthy adults&#44; despite the loaded breathing&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Perceived exertion has an array of possible determinants&#44; ranging from physiological&#44; volitional&#44; motivational and psychological&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">33</span></a> In the present study&#44; compared to not using any FM&#44; perceived exertion was higher when using either a SM or a R&#59; notably&#44; it was most significant at the first stages of ET&#44; when using a SM&#44; and most significant toward the end of it when using a R&#46; On the other hand&#44; perceived breathing effort was significantly higher when using a R throughout the ET&#44; compared to not wearing a FM&#46; Perceived breathing effort with the SM was only significantly higher than WM at half of the ET duration&#46; Both hypoxemia and respiratory muscle fatigue&#44; resulting from increased work of breathing because of increased airflow resistance&#44; possibly contribute to increased perceived exertion at maximal exercise intensity&#46; This trend is supported by Johnson et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">21</span></a> who demonstrated that the impact of inspiratory resistance on performance is mostly felt at higher exercise intensities&#46; Fikenzer et al&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">15</span></a> also demonstrated higher perceived exertion when wearing a SM or a R during a maximal symptom-limited cycle ergometer test&#44; findings that contradict a study by Roberge et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a> on the effects of wearing a surgical mask during a treadmill exercise test for one hour&#46; In this study&#44; there was no significant impact on perceived exertion&#46; Shaw et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a> also did not report any detrimental effect of FM on perceived exertion&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">There is an alternative view on the beneficial effects of wearing a FM&#44; especially R&#44; during exercise training programs&#46; Davis and Tsen<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> postulate that the increased work of breathing derived from using this type of FM during exercise might be used for conditioning purposes&#44; increasing respiratory muscle strength and respiratory muscle endurance&#44; improving ventilatory efficiency&#44; oxygen delivery and overall exercise performance&#46; This is of particular importance in the context of CRP&#44; considering the overall objectives of this intervention&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Loading in breathing effort during exercise may reduce respiratory frequency and implies an additional muscle recruitment and potentially slow oxygen consumption kinetics&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a> a myriad of factors that may possibly change the signaling in the central CV center and increase HR and BP&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">35</span></a> Based on that&#44; the authors hypothesized that exercising while wearing a FM would greatly influence hemodynamics when comparing to not wearing a FM&#44; as demonstrated on healthy volunteers performing a low to moderate intensity walk &#40;5&#46;6 km&#47;h&#41; on a treadmill for an hour&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">16</span></a> However&#44; our study did not demonstrate a significant difference in BP and HR response during and after ET in the different testing conditions besides a shorter time to reach maximal HR values&#46; Jung et al&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">36</span></a> reported similar results in their study on the effect of an elevation training mask during cycling &#8211; although they reported a significant autonomic-mediated blunted HR decrease during recovery when wearing the mask&#46; Data from multiple studies have also shown that the use of a FM has no significant effect on HR&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">12&#44;24&#44;37</span></a> Nevertheless&#44; the authors believe that further studies are necessary to draw more definite conclusions on the CV response to wearing a FM during exercise&#44; especially in those patients with previous CV and pulmonary disorders&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Based on other studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">36&#44;37</span></a> our findings may be related to the combination of duration and intensity of the exercise performed&#46; Interestingly&#44; after an initial period of subjective destabilization during the first half of the ET when using a FM&#44; there seems to be a leveling of the perceived discomfort at mid-stage of the ET &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; This potential compensation mechanism appears to become ineffective as the subject reaches their maximal exercise capacity&#44; possibly due to the breathing difficulty resulting from an increase minute-ventilation against an increased inspiratory and expiratory resistance from wearing the FM&#46; In type 2 SM&#44; this resistance is usually expressed as a differential pressure of 40 Pa&#47;cm<span class="elsevierStyleSup">2</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">38&#44;39</span></a> On the other hand&#44; KN95 Rs show a maximal differential pressure of approximately 70 Pa&#47;cm<span class="elsevierStyleSup">2</span> for inhalation flow and 50 Pa&#47;cm<span class="elsevierStyleSup">2</span> for exhalation flow&#44; considering a flow rate of 85L&#47;min&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">13&#44;38</span></a> These values increase in proportion to the flow rate&#44; which depends on the ventilation per minute&#46; For this reason&#44; it is reasonable that perceived exertion and dyspnea are significantly higher with either FM throughout the ET&#44; when compared to not wearing a FM&#46; At lower intensities&#44; the air resistance offered by SM and R is low and probably similar&#44; as flow rates are still increasing&#46; However&#44; at maximal intensity&#44; when flow rates and air resistance from using FM are at their highest&#44; there is a steep increase in work of breathing resulting in fatigue of respiratory muscles&#44; higher perceived exertion and dyspnea&#44; especially when wearing a R&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In the setting of CRP&#44; professionals should be aware of the physical and psychological discomfort caused by FM&#44; as well as be advised of a possible influence on CV response&#46; Relative oxygen desaturation is a major concern in this patient population&#44; especially when there is concomitant respiratory pathology&#46; Patient familiarity with the physiological adjustments that occur when using a FM can lead to enhanced effectiveness of therapeutic exercise in this context&#46; Nevertheless&#44; the authors believe that implementation of monitored home-based CRP may replace in-hospital sessions in some cases&#44; particularly in low CV risk patients&#44; as has already been suggested&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a> It seems reasonable to start with remote low-intensity exercise training in combination with resistance and flexibility exercises after a safety assessment&#46; These home-based programs may be monitored through tele-rehabilitation and circumvent the need of using a FM during exercise&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Limitations</span><p id="par0115" class="elsevierStylePara elsevierViewall">Some limitations must be considered&#46; This is a preliminary single-center study of a limited number of overall healthy&#44; relatively young health workers&#44; who agreed to participate&#46; Caution is recommended when extrapolating results to clinical settings and different populations&#44; namely older patients&#44; those with high comorbidity burden and patients attending CV or pulmonary rehabilitation exercise programs&#46; On the other hand&#44; we must consider that the subjects in this study are healthcare workers who routinely use a FM for long periods of time &#8211; this can impact on their tolerance of the equipment compared with other subjects&#46; Additionally&#44; the lack of multivariable analysis according to age&#44; gender and physical activity habits also limits the generalization of these results&#46; Although the investigators followed a strict protocol of ET&#44; randomization of ET sequence&#44; blinding of researchers involved in data abstraction and database completion&#44; difficulties from nonblinding of patient and researcher performing the ET could not be overcome&#46; Moreover&#44; no information was collected regarding other ventilatory parameters&#44; including direct measurement of dead space with different FM&#44; minute-ventilation and&#47;or respiratory frequency&#44; baseline cardiorespiratory performance &#40;cardiopulmonary ET&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">Our study found that wearing a FM may be associated with reduced exercise capacity and higher levels of dyspnea and effort perception&#44; especially at maximal intensity&#44; independent of the type of FM worn&#46; There is no evidence that wearing a FM during high intensity aerobic exercise significantly changes chronotropic and BP responses&#46; On the other hand&#44; wearing a R in these conditions induces arterial hypoxemia in healthy adults&#46; In the setting of CRP&#44; these findings may represent a major concern during the COVID-19 pandemic and may warrant a readjustment of the exercise intensities used in this context&#46; To further assess and in order to make exercise prescription recommendations&#44; further trials are needed&#44; including with larger and more representative samples and with more extensive indicators of cardiopulmonary responses to wearing different types of FM&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "xres1629627"
          "titulo" => "Abstract"
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            0 => array:2 [
              "identificador" => "abst0005"
              "titulo" => "Introduction and objectives"
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          "titulo" => "Keywords"
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          "titulo" => "Resumo"
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              "titulo" => "Introdu&#231;&#227;o e objetivos"
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              "titulo" => "M&#233;todos"
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            2 => array:2 [
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              "titulo" => "Resultados"
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          "identificador" => "xpalclavsec1454433"
          "titulo" => "<span class="elsevierStyleBold">Palavras-chave</span>"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Materials and methods"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Subjects"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Surgical masks and respirators"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Study protocol"
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              "identificador" => "sec0030"
              "titulo" => "Statistical analysis"
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          "titulo" => "Results"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Population characteristics"
            ]
            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Exercise test duration"
            ]
            2 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Level of perceived exertion"
            ]
            3 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Level of dyspnea"
            ]
            4 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Arterial oxygen saturation"
            ]
            5 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Hemodynamic response &#8211; heart rate and blood pressure"
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          "titulo" => "Discussion"
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          "titulo" => "Limitations"
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          "titulo" => "Conclusions"
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          "identificador" => "sec0085"
          "titulo" => "Conflicts of interest"
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          "identificador" => "xack575150"
          "titulo" => "Acknowledgments"
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          "titulo" => "References"
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      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2020-09-17"
    "fechaAceptado" => "2021-01-10"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1454434"
          "palabras" => array:6 [
            0 => "Facemask"
            1 => "Respirator"
            2 => "Exercise"
            3 => "Cardiac rehabilitation"
            4 => "Covid-19"
            5 => "Coronavirus"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "<span class="elsevierStyleBold">Palavras-chave</span>"
          "identificador" => "xpalclavsec1454433"
          "palabras" => array:6 [
            0 => "M&#225;scara facial"
            1 => "Respirador"
            2 => "Exerc&#237;cio"
            3 => "Reabilita&#231;&#227;o card&#237;aca"
            4 => "Covid-19"
            5 => "Coronavirus"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">During the COVID-19 pandemic&#44; among the safety measures adopted&#44; use of facemasks during exercise training sessions in cardiac rehabilitation programs raised concerns regarding possible detrimental effects on exercise capacity&#46; Our study examined the cardiorespiratory impact of wearing two types of the most common facemasks during treadmill aerobic training&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Twelve healthy health professionals completed three trials of a symptom-limited Bruce treadmill protocol&#58; Without a mask&#44; with a surgical mask and with a respirator&#46; Perceived exertion and dyspnea were evaluated with the Borg Scale of Perceived Exertion and the Borg Dyspnea Scale&#44; respectively&#46; Blood pressure&#44; heart rate and arterial oxygen saturation &#40;SpO2&#41; were measured at each 3-minute stage&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Using a surgical mask or a respirator resulted in a shorter duration of exercise testing&#46; At peak capacity&#44; using a respirator resulted in higher levels of dyspnea and perceived exertion compared to not wearing a facemask&#46; A significant drop in SpO2 was present at the end of exercise testing only when using a respirator&#46; There were no differences in either chronotropic or blood pressure responses between testing conditions&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Professionals involved in cardiac rehabilitation should be aware of the cardiorespiratory impact of facemasks&#46; Future studies should assess whether exposure to these conditions may impact on the overall results of contemporary cardiac rehabilitation programs&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Durante a pandemia Covid-19 a utiliza&#231;&#227;o de m&#225;scaras faciais&#44; incluindo durante o exerc&#237;cio terap&#234;utico&#44; faz parte das medidas de seguran&#231;a adotadas&#46; Este facto originou preocupa&#231;&#227;o a n&#237;vel das unidades de reabilita&#231;&#227;o card&#237;aca&#44; uma vez que as m&#225;scaras faciais podem promover efeitos delet&#233;rios na capacidade de exerc&#237;cio&#46; Este estudo avaliou o impacto da utiliza&#231;&#227;o das m&#225;scaras faciais durante o treino aer&#243;bio em passadeira&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Doze profissionais de sa&#250;de saud&#225;veis completaram tr&#234;s provas em passadeira de acordo com o protocolo de Bruce&#58; sem m&#225;scara&#44; com m&#225;scara cir&#250;rgica e com um respirador&#46; A perce&#231;&#227;o de esfor&#231;o e dispneia foi avaliada com a Escala de Perce&#231;&#227;o de Esfor&#231;o de Borg e com a Escala de Dispneia de Borg&#44; respetivamente&#46; A press&#227;o arterial&#44; frequ&#234;ncia card&#237;aca e satura&#231;&#227;o arterial de oxig&#233;nio &#40;SpO2&#41; foram registadas em cada estadio do protocolo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A utiliza&#231;&#227;o de m&#225;scara facial resultou numa menor dura&#231;&#227;o da prova e&#44; em determinados momentos&#44; n&#237;veis de perce&#231;&#227;o de dispneia e de esfor&#231;o mais elevados&#46; Verificou-se uma descida significativa da SpO2 no final da prova com respirador&#46; N&#227;o se verificaram diferen&#231;as na resposta cronotr&#243;pica ou da press&#227;o arterial entre as diferentes condi&#231;&#245;es de prova&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Os profissionais envolvidos na reabilita&#231;&#227;o card&#237;aca devem reconhecer os impactos cardiorrespirat&#243;rios provocados pela utiliza&#231;&#227;o da m&#225;scara facial&#46; S&#227;o necess&#225;rios mais estudos para determinar se a exposi&#231;&#227;o a estas condi&#231;&#245;es de treino pode ter impacto nos resultados dos programas de reabilita&#231;&#227;o card&#237;aca&#46;</p></span>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Progression of mean values of SpO2&#44; level of perceived exertion &#40;Borg Scale of Perceived Exertion&#41; and level of dyspnea &#40;Borg Dyspnea Scale&#41; at different stages of the exercise test &#40;at rest&#44; at 25&#37;&#44; 50&#37; and 75&#37; of the duration of the test and at the end of the test&#41;&#46; &#91;SpO2&#58; arterial oxygen saturation&#59; &#9632;&#58; without mask&#59; &#9679;&#58; surgical mask&#59; <elsevierMultimedia ident="202112160943504841"></elsevierMultimedia>&#58; respirator&#59; &#42;&#58; signals p&#60;0&#46;05 on comparison of test conditions&#93;&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Abbreviations</span>&#58; IPAQ&#58; International Physical Activity Questionnaire&#59; METS&#58; metabolic equivalents&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age in yr&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">172&#46;9 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Body mass index in kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#44; mean &#40;SD&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#46;1 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Leisure time physical activity</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IPAQ score in METS-min&#47;week&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2113&#46;2 &#40;1474&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>High level of physical activity on IPAQ&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;41&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low level of physical activity on IPAQ&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;41&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Comorbidities</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Respiratory pathology &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;25&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Musculoskeletal pathology&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;25&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Active smokers&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Baseline characteristics of study sample&#46;</p>"
        ]
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Abbreviations</span>&#58; bpm&#58; beats per minute&#59; ET&#58; exercise testing&#59; HR&#58; heart rate&#59; R&#58; respirator&#59; SM&#58; surgical mask&#59; SpO2&#58; arterial oxygen saturation&#59; WM&#58; without mask&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">WM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">F statistics&#40;p value&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ET duration in m&#58;sec&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#58;25 &#40;3&#58;20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#58;23 &#40;3&#58;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#58;21 &#40;03&#58;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;2 &#40;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Borg scale of perceived exertion&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;3 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;4 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;1 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;1 &#40;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Borg dyspnea scale&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;7 &#40;1&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;8 &#40;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;6 &#40;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;5 &#40;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SpO2 &#40;&#37;&#41;&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94&#46;5 &#40;2&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#46;5 &#40;3&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&#46;3 &#40;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;3 &#40;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Maximal HR in bpm&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">170&#46;1 &#40;14&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">173&#46;0 &#40;14&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">170&#46;8 &#40;13&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;6 &#40;p&#61;0&#46;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronotropic reserve in bpm&#44; mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">101&#46;8 &#40;14&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#46;6 &#40;14&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#46;8 &#40;16&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;8 &#40;p&#61;0&#46;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Comparison of variables measured at the end of the exercise testing protocol between each of the test conditions&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">Abbreviations</span>&#58; CI&#58; confidence interval&#59; ET&#58; exercise testing&#59; MD&#58; mean difference&#59; PE&#58; perceived exertion&#59; R&#58; respirator&#59; SM&#58; surgical mask&#59; SpO2&#58; arterial oxygen saturation&#59; WM&#58; without mask&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">25&#37; of ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">50&#37; of ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">75&#37; of ET&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">100&#37; of ET&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Borg Scale of PE&#44;MD &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;1&#40;0&#46;3-1&#46;9&#59;p&#60;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;1&#40;&#8722;0&#46;3-2&#46;5&#59;p&#61;0&#46;14&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Borg Dyspnea Scale&#44;MD &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>SpO2 &#40;&#37;&#41;&#44;MD &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
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        "texto" => "<p id="par0130" class="elsevierStylePara elsevierViewall">The authors wish to thank to Jo&#227;o Barroso Monteiro&#44; MD&#44; Department Director of Physical Medicine &#38; Rehabilitation at Centro Hospitalar e Universit&#225;rio de S&#227;o Jo&#227;o&#44; for his scientific guidance and manuscript revision&#46;</p>"
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Idiomas
Revista Portuguesa de Cardiologia (English edition)
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