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PubMed1997

Interpreting small differences in functional status: the Six Minute Walk test in chronic lung disease patients.

Functional status measurements are often difficult to interpret because small differences may be statistically significant but not clinically significant. How much does the Six Minute Walk test (6MW) need to differ to signify a noticeable difference in walking ability for patients with chronic obstructive pulmonary disease (COPD)? We studied individuals with stable COPD (n = 112, mean age = 67 yr, mean FEV1 = 975 ml) and estimated the smallest difference in 6MW distances that was associated with a noticeable difference in patients' subjective comparison ratings of their walking ability. We found that the 6MW was significantly correlated with patients' ratings of their walking ability relative to other patients (r = 0.59, 95% confidence interval [CI]: 0.54 to 0.63). Distances needed to differ by 54 m for the average patient to stop rating themselves as "about the same" and start rating themselves as either "a little bit better" or "a little bit worse" (95% CI: 37 to 71 m). We suggest that differences in functional status can be statistically significant but below the threshold at which patients notice a difference in themselves relative to others; an awareness of the smallest difference in walking distance that is noticeable to patients may help clinicians interpret the effectiveness of symptomatic treatments for COPD.

Aged↗
PubMed2001

Reliability, validity, and responsiveness of the six-minute walk test in patients with heart failure.

BACKGROUND: Our purpose was to evaluate the reliability, validity, and responsiveness of the 6-minute walk test (6MWT) in patients with heart failure (HF) enrolled in the Randomized Evaluation of Strategies for Left Ventricular Dysfunction (RESOLVD) pilot study. METHODS: A total of 768 patients was enrolled in a multicenter randomized clinical trial evaluating the effect of candesartan, enalapril, and metoprolol on left ventricular ejection fraction (LVEF), 6MWT distance, neurohormones, and quality of life. The 6MWT was performed once at screening and twice at baseline, 18 weeks, and 43 weeks by a standardized method. RESULTS: Test-retest reliability at baseline (intraclass correlation coefficient [ICC] = 0.90), 18 weeks (ICC = 0.88), and 43 weeks (ICC = 0.91) was very good. Baseline 6MWT distance was weakly inversely correlated to the quality-of-life cumulative score (r = -0.26, P =.0001) and moderately inversely correlated to the New York Heart Association functional classification (NYHA-FC) (r = -0.43, P =.001). In the RESOLVD study, the 6MWT was not responsive to change when effect sizes and standardized response means were used. Disease-specific quality of life was responsive to change in patients treated with candesartan and enalapril and NYHA-FC was responsive to change in the candesartan and enalapril combination and for enalapril alone with small effect sizes. The 6MWT, NYHA-FC, and quality of life were not responsive to change during the metoprolol or placebo phase. CONCLUSIONS: The 6MWT is highly reproducible in patients with symptoms of HF. It is somewhat correlated to NYHA-FC and quality of life. Overall, quality of life was most responsive to change, whereas 6MWT and NYHA-FC were comparable but less responsive to change in the RESOLVD study.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2002

The incremental shuttle walking test in elderly people with chronic airflow limitation.

BACKGROUND: There is a concern that comorbidity or frailty in older people could limit the usefulness of currently available exercise tests for chronic lung disease. This study evaluated the feasibility and reproducibility of the incremental shuttle walking test (SWT) in people aged 70 years or over, compared exercise tolerance with other disability markers, and assessed whether the SWT is responsive to change after bronchodilators. METHODS: Fifty elderly patients with chronic airflow limitation (CAL) and 32 controls without airflow limitation attempted the SWT before and after combined nebulised salbutamol/ipratropium bromide. Subjects also completed the Nottingham Extended Activities of Daily Living index (NEADL) and the London Handicap score (LHS). RESULTS: Forty four subjects with CAL (88%) and 29 controls (84%) completed the SWT, including many with co-morbidities. Two week repeatability was good and the SWT was strongly associated with EADL (r=0.51, p<0.001) and LHS (r=0.43, p<0.004), but only weakly with forced expiratory volume in 1 second (FEV1) (r=0.31, p=0.05). Subjects with CAL walked a mean distance of 177.7 m compared with 243.3 m in controls (p<0.001); following bronchodilator therapy the distance walked increased in the CAL group by 13.2% (p=0.009). CONCLUSION: The SWT is a feasible and reproducible measure of exercise tolerance in elderly people with and without airflow obstruction and correlates with other markers of disability. It is sensitive to change following bronchodilation in subjects with CAL, although the change correlates less well with improvements in FEV1. Overall, these results suggest that the SWT might be an appropriate measure to assess interventions in elderly people.

Administration, Inhalation↗
PubMed2004

The two-minute walk test as a measure of functional capacity in cardiac surgery patients.

OBJECTIVE: To examine construct validity and sensitivity of the two-minute walk test (2MWT) in cardiac surgery patients. DESIGN: Measurements were made in patients preoperatively, during the postoperative in-hospital stay, and 6 to 8 weeks after discharge from hospital. SETTING: Ambulatory and hospitalized care. PARTICIPANTS: Patients (N=122; mean age +/- standard deviation, 63+/-9 y) undergoing coronary artery bypass grafting. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The 2MWT, New York Heart Association (NYHA) functional classification for cardiac disease, the Nottingham Extended Activities of Daily Living scale, and the Medical Outcomes Survey 36-Item Short-Form Health Questionnaire (SF-36). RESULTS: Distance walked in 2 minutes decreased significantly postoperatively (from 138+/-26 m to 84+/-33 m, P<.001), but increased again at follow-up (151+/-31 m, P<.0001). Distance walked on the 2MWT correlated significantly to SF-36 (physical function subscale) preoperatively (r=.44) and at follow-up (r=.48) (P<.001). There was a significant difference in distance walked between those with NYHA class I and II compared with those classified as III or IV (P=.04). However, there was no significant difference in distance walked in 2 minutes between those who developed cardiac or pulmonary complications postoperatively (P> or =0.2). CONCLUSIONS: The 2MWT was sensitive to change after cardiac surgery and showed moderate correlation with measures of physical functioning in this population. However, the 2MWT could not identify those who developed complications in the postoperative period.

Activities of Daily Living↗
PubMed2005

Clinical determinants of poor six-minute walk test performance in patients with left ventricular systolic dysfunction and no major structural heart disease.

BACKGROUND: The clinical determinants of six-minute walk test (6-MWT) performance in patients with left ventricular systolic dysfunction (LVSD) have rarely been investigated, and it is not clear whether they differ from patients referred for the assessment of symptoms of heart failure who do not have major structural heart disease (MSHD). METHODS AND RESULTS: 571 patients with LVSD enrolled in a chronic disease management programme (79% male; mean age 71+/-10 years; BMI 28+/-5) completed a 6-MWT with a mean distance 337+/-103 m. 688 patients referred with suspected heart failure but in whom MSHD was excluded (49% male; mean age 70+/-11 years; BMI 28+/-6) had a mean 6-MWT distance of 391+/-106 m (P<0.001 compared to patients with LVSD). Relationships with walking distance were determined by calculating odds ratios (ORs) with 95% confidence intervals (CIs) for walking 300 m. In patients with LVSD, predictors of poor walking distance ( or=75 years (OR=4.0, 95% CI=2.4-6.4); low BMI (<20) (OR=3.4, 95% CI=1.6-7.3); anaemia (OR=2.8, 95% CI=1.8-4.2); resting heart rate>80 beats x min(-1) (OR=2.2, 95% CI=1.3-3.5); and being female (OR=2.0, 95% CI=1.3-3.0). Serum creatinine and NT-proBNP showed dose-response effects, as did self-perceived feelings of depression and anxiety. Determinants of 6-MWT in patients without MSHD were similar including age>or=75 years (OR=6.0, 95% CI=3.4-10.4), anaemia (OR=2.8, 95% CI=1.6-4.9), resting HR>80 beats x min(-1) (OR=2.5, 95% CI=1.4-4.4) and being female (OR=1.6, 95% CI=1.9-2.4). NT-proBNP and self-perceived feelings of depression and anxiety also showed dose-response effects. CONCLUSION: The determinants of poor 6-MWT performance depend on physical-cardiovascular and non-cardiovascular, and psychological factors. Clinical predictors for poor walking performance are similar for patients with LVSD and without MSHD.

Aged↗
PubMed2005

Six minute corridor walk test as an outcome measure for the assessment of treatment in randomized, blinded intervention trials of chronic heart failure: a systematic review.

AIMS: The 6 min walk test (6MWT) is commonly used in clinical trials to assess treatments for heart failure, but its ability to distinguish between effective and ineffective treatments is questionable. The aim of this study is to investigate, using a systematic literature review, the utility of the 6MWT as a measure of the effectiveness of treatment in randomized controlled trials of heart failure. METHODS AND RESULTS: A literature search was performed using Medline, EMBASE, CINAHL, and Biological abstracts for randomized controlled trials that measured 6MWT between 1988 and 31 May 2004. A significant increase in 6MWT distance was observed in only 9 of 47 randomized controlled trials of pharmacological therapy; 2 of 6 trials of ACE-inhibitors; 3 of 17 trials of beta-blockers; 1 of 4 trials of digoxin; one trial of ibopamine; one trial of l-arginine; one trial of beriberine; and one trial showed superiority of captopril over flosequinan. A significant increase in 6MWT was observed in four out of six placebo-controlled trials of cardiac resynchronization. Smaller pharmacological trials with fewer centres were more likely to be positive; six out of nine positive pharmacological trials had four or less participating centres, raising the possibility of publication bias. Pharmacological trials including patients with more severe heart failure were more likely to show a significant improvement with therapy than trials of milder heart failure. Five out of seven pharmacological trials that reported an improvement in symptoms also reported an improvement in 6MWT distance. Of 30 pharmacological trials, 29 that reported no improvement in symptoms also reported no improvement in 6MWT. Using mean values in these trials, the age of patients appeared a more important determinant of 6MWT distance than New York Heart Association classification. CONCLUSION: The 6MWT has not yet been proven to be a robust test for the identification of effective pharmacological interventions although it appears useful for the assessment of cardiac resynchronization therapy. The results of the 6MWT were concordant with changes in symptoms, suggesting that it may be used as supportive evidence for symptom benefit. The test may be of greater value in patients with more advanced heart failure, where it may function as a maximal exercise test.

Cardiotonic Agents↗
PubMed2006

The 6-minute walk test predicts clinical outcome in Asian patients with chronic congestive heart failure on contemporary medical therapy: a study of the multiracial population in Singapore.

BACKGROUND: We sought the value of the 6-min walk test (6MWT) in predicting morbidity and mortality in Asian patients with congestive heart failure (CHF). METHODS: 668 patients (Age 66+/-12 years, Ejection fraction 29+/-13%, NYHA I to IV) were prospectively followed up for 36+/-12 months. 386 patients (58%) took the 6MWT. Cardiac events, defined as the composite end-point of death or CHF readmission were documented. RESULTS: 188 patients (28%) reached the composite end-point (63 deaths, 125 readmissions). 6MWT distance was an independent predictor of cardiac events (quartile 1 vs quartile 4)(p=0.041), as were beta-blocker or spironolactone use (p=0.008 for both), diabetes (p=0.042), monthly income less than SGD$1000 (p=0.030), and NYHA class (class III vs class I)(p=0.003). A 6MWT distance <340 m predicted occurrence of cardiac events with a sensitivity of 69% and specificity of 48%. CONCLUSIONS: The 6MWT is a safe and simple clinical tool, which could predict both morbidity and mortality in a large population of Asian patients with CHF of differing etiology and severity (169 words).

Age Factors↗
PubMed1986

Twelve-minute walking test in a group of Dutch patients with chronic obstructive pulmonary diseases; relationship with functional capacity.

Limitations in exercise tolerance are characteristic for patients with chronic obstructive pulmonary disease. The twelve-minute walking test has been proposed as a simple, reproducible test to assess exercise tolerance in these patients. We investigated factors, that predicted the twelve-minute walking distance in a group of fifty patients with COPD, who had a maximal reversibility in the FEV1 of 20% after inhaled salbutamol. There was a strong correlation between walking distance and IVC (%pred) (p less than 0.001), RV% TLC (%pred) (p less than 0.001), FEV1 (ml) (p less than 0.001), FEV1 (%pred) (p less than 0.001) and PaO2 (mm Hg) (p less than 0.01). It is concluded that pathophysiological factors are the main determinants of the twelve-minute walking distance.

Adult↗
PubMed2001

Oxygen desaturation on the six-minute walk test and mortality in untreated primary pulmonary hypertension.

There are no reliable predictors of mortality in primary pulmonary hypertension (PPH). This study assessed whether exercise oxygen desaturation and distance achieved during a six-minute walk are associated with mortality in moderately symptomatic patients with PPH. Thirty-four patients with PPH underwent a pretreatment six-minute walk test, and an invasive haemodynamic assessment of pulmonary vasodilator reserve, to select the best treatment option (epoprostenol in 27 and nifedipine in 7). Median follow-up was 26 months (12 months for the nonsurvivors was 26%), and median survival, >46 months by Kaplan-Maier estimate. The mean+/-SD distance walked was 275+/-155 m and reduction in arterial oxygen saturation (Sa,O2) at maximal distance (deltaSa,O2) was 8.4+/-4.5%). A distance < or =300 m increased mortality risk by 2.4, and a deltaSa,O2 of > or = 10% increased mortality risk by 2.9. Only Sa,O2 at peak distance, deltaSa,O2 and pulmonary vascular resistance (PVR) were related to mortality. After adjusting for PVR, there remained a 27% increase in risk of death for each per cent decrease in Sa,O2. The six-minute walk distance and exercise oxygen saturation may be helpful in selecting patients with primary pulmonary hypertension for whom transplant listing is appropriate.

Adult↗
PubMed2002

The reliability of the Shuttle Walking Test, the Swiss Spinal Stenosis Questionnaire, the Oxford Spinal Stenosis Score, and the Oswestry Disability Index in the assessment of patients with lumbar spinal stenosis.

STUDY DESIGN: The Shuttle Walking Test (SWT), the Swiss Spinal Stenosis (SSS) Questionnaire, the Oxford Claudication Score (OCS), and the Oswestry Disability Index (ODI) were administered to patients with lumbar spinal stenosis and neurogenic claudication. OBJECTIVE: To determine reliability of the SWT, the SSS (Q1-12), the OCS, and the ODI in lumbar spinal stenosis assessment. SUMMARY OF BACKGROUND DATA: Reliability data for exercise tests in lumbar spinal stenosis are lacking. METHODS: To determine reliability, 32 clinic patients with lumbar spinal stenosis were assessed twice, with 1 week between assessments. Retrospective data from 17 patients assessed before surgery and 18 months after surgery for lumbar spinal stenosis were used to investigate the use of reliability in a clinical setting. RESULTS: Test-retest reliability in terms of the intraclass correlation coefficient (ICC) was 0.92 for the SWT, 0.92 for the SSS, 0.83 for the OCS and 0.89 for the ODI. The mean percentage scores were 51 for the SSS, 45 for the OCS, and 40 for the ODI. To achieve 95% certainty of change between assessments for a single patient, the SSS would need to change by 15, the OCS by 20, and the ODI by 16. The mean SWT was 150 m, with a change of 76 m required for 95% confidence. Cronbach's alpha was 0.91 for the SSS, 0.90 for the OCS, and 0.89 for the ODI. The change in ODI correlated most strongly with patient satisfaction after surgery (rho = 0.80; P < 0.001). CONCLUSIONS: Fluctuations in a patient's symptoms result in wide individual confidence intervals. Performance on the SSS, OCS, and ODI questionnaires are broadly similar, the most precise being the condition-specific SSS. The SWT gives a snapshot of physical function, which is acceptable for group analysis. Use of the SWT for individual assessment after surgery is feasible.

Aged↗
PubMed1998

Development of a 12-min treadmill walk test at a self-selected pace for the evaluation of cardiorespiratory fitness in adult men.

The direct measurement of true maximal oxygen uptake (VO2max) and oxygen uptake corresponding to anaerobic threshold (VO2AT) is not always practical, especially in middle age and older populations. Therefore, the purpose of this study was to develop a simple test that could accurately estimate cardiorespiratory fitness using a submaximal treadmill walking protocol for middle age, older, sedentary individuals and patients with chronic disease. Subjects for this study were 42 men (44.9 +/- 15.7 years), which included 17 patients with coronary heart disease (57.0 +/- 9.6 years). VO2peak and VO2AT were measured using a treadmill protocol (VO2peak; 38.4 +/- 11.6 ml/kg/min, VO2AT; 22.9 +/- 7.4 ml/kg/min). This simple test assessed the total distance covered in 12 minutes on the treadmill at an intensity corresponding to either 1) 11 on the Borg scale of ratings of perceived exertion (RPE11), 2) 13 on the Borg scale of ratings of perceived exertion (RPE13), or 3) "Optimal" by subjective judgment. The correlation coefficients between VO2peak or VO2AT and total distance at the three intensities (RPE11; 950 +/- 100 m, RPE13; 1080 +/- 140 m Optimal; 1050 +/- 110 m) were statistically significant, ranging from 0.72 to 0.85. The test-retest reliability coefficient on 12 subjects was 0.98. The oxygen uptake (VO2) was measured during the three walk tests on 15 subjects. There were no significant changes in submaximal VO2 values from min 4 to min 12 (RPE11; 19.8 +/- 4.7 ml/kg/min, RPE13; 24.1 +/- 4.9 ml/kg/min, Optimal; 23.1 +/- 4.8 ml/kg/min) in any of the three tests. Similarly, the three submaximal VO2 values did not differ from the VO2AT value (21.2 +/- 8.3 ml/kg/min) obtained in the initial maximal test. These results suggest that the 12-min submaximal treadmill walk test (STWT) is a valid method for the assessment of VO2peak and VO2AT. Therefore, the STWT could be a useful performance test for evaluating cardiorespiratory fitness in middle age, older, sedentary individuals and patients with chronic disease.

Adult↗
PubMed1985

A self paced treadmill walking test for breathless patients.

A treadmill exercise test is described that retains the advantages of self paced walking but allows the measurement of cardiorespiratory variables. A horizontal treadmill was modified to allow patients to control their own speed. During exercise continuous measurements of speed, distance, heart rate, arterial oxygen saturation, and stride length were made and subjective assessments of breathlessness were recorded on a visual analogue scale. Ten men with severe chronic obstructive lung disease performed a 12 minute corridor walk and a self paced 12 minute treadmill walk on the same day and repeat treadmill walks on different days. Six of them performed three walks or more. Six patients had ventilatory measurements during treadmill exercise. There was no significant difference (p greater than 0.1) in the distance covered during corridor and treadmill walks, and distances on the treadmill were repeatable after the first walk. Use of a mouthpiece significantly reduced the distance covered on the treadmill. The self paced treadmill walk is a simple repeatable test and has advantages over both a corridor walking test and standard progressive tests for assessment of breathless patients.

Aged↗
PubMed2001

Relationship between six-minute walking test and pulmonary function and ventilatory drive in patients with airflow limitation.

BACKGROUND: We studied the correlation between exercise tolerance and pulmonary function, arterial blood gases, and ventilatory drive in patients with airflow limitation (AFL). METHODS: Forty-one patients (36 men, 5 women, mean age 63.6 +/- 10.3 years) with forced expiratory volume in one second (FEV1) < 75% and FEV1/forced vital capacity (FVC) < 75% were enrolled. All patients were clinically stable with no impairment of the lower extremities. On the first day of the study, pulmonary function test (PF), including FVC, FEV1, diffusion capacity (DLCO), and residual volume (RV)/total lung capacity (TLC) was measured by plethysmography. On the next day, ventilatory drive P0.1 were measured before drawing blood gases. Then, a 6-minute walking test with pulse-oxymetry and end tidal CO2 monitoring was performed. Ventilation efficiency (O2SATp & ETCO2) was recorded every 6 seconds during exercise. RESULTS: The walking distance (WD) was significantly correlated to PF: FVC%, FEV1%, DLCO%, and RV/TLC. There was also a significant correlation between resting arterial blood gases (PaO2, PaCO2, SatO2) and PF (FVC%, FEV1%, DLCO% and RV/TLC). The SatO2 at the end of exercise was highly correlated to PF (FVC%, FEV1%, DLCO% and RV/TLC). Gas exchange parameters: PaO2, PaCO2, O2SATa, O2SATp at rest, and O2SATp at the end of exercise were also significantly related to WD. CONCLUSION: The magnitude of exercise intolerance in patients with AFL was not only significantly correlated to the impairment of pulmonary function, but also closely related to gas exchange during exercise. Therefore, limitation of ventilation could be identified earlier using an exercise test.

Aged↗
PubMed2001

Inspiratory capacity, dynamic hyperinflation, breathlessness, and exercise performance during the 6-minute-walk test in chronic obstructive pulmonary disease.

Patients with severe chronic obstructive pulmonary disease (COPD) develop dynamic lung hyperinflation (DH) during symptom-limited incremental and constant work exercise with cycle ergometer and treadmill. The increase in end-expiratory lung volume seems to be the best predictor of dyspnea. Quantification of DH is based on the relatively complex use of on-line measurement of inspiratory capacity (IC) from flow volume loops. We reasoned that DH could occur during daily activities such as walking, and that it could be simply measured using the spirometrically determined IC. We studied 72 men with COPD (FEV(1) = 45 +/- 13.3% predicted). IC was measured at rest and after a 6-min walk test. Exertional dyspnea was evaluated using the Borg scale and dyspnea during daily activities with the modified Medical Research Council (MRC) scale. IC decreased significantly from 28.9 +/- 6.7% TLC at rest to 24.1 +/- 6.8% TLC after exercise (p < 0.001). Exertional dyspnea correlated with DeltaIC (r = -0.49, p < 0.00001) and baseline MRC (r = 0.59, p < 0.00001). In many patients with COPD, walking leads to DH that can be easily determined with simple spirometric testing. DH helps explain exercise capacity limitation and breathlessness during simple daily activities.

Activities of Daily Living↗
PubMed1997

[6 minute walking test as stress test for patients treated by intermittent self-ventilation].

BACKGROUND: Until now there are no data about the exercise capacity of patients with chronic ventilatory pump failure before and during IPPV. PATIENTS AND METHODS: 55 patients with chronic ventilatory failure-20 patients before IPPV, 35 patients during mechanical ventilation with a mean of 16.5 months-were studied by the six-minute walking test. Eight patients were sampled in a follow-up study before and during IPPV with a mean of 2 months. RESULTS: The median walking distance was reduced to 273 in. The exercise capacity of the follow-up patients was not improved. The arterial pO2 during exercise fell markedly, arterial pCO2 increased only moderate. CONCLUSION: The exercise capacity of patients with chronic ventilatory failure is markedly reduced. Because of the significant oxygen desaturation on exercise we may frequently indicate ambulatory oxygen therapy.

Adult↗
PubMed2003

[Distance covered in walking test after heart surgery in patients over 70 years of age: outcome indicator for the assessment of quality of care in intensive rehabilitation].

UNLABELLED: For quality-of-care assessment of rehabilitation programs after cardiac surgery, measures of functional recovery have been proposed as outcome indicators. Aim of this study was to evaluate the feasibility, the safety and the informative content of the 6-min walking test (6 WT) performed in elderly patients soon after admission in an intensive rehabilitation program after cardiac surgery. METHODS: Population consists of 115 consecutive over-70 patients admitted to an in-hospital rehabilitation program after cardiac surgery. Within 7 days of admission, in 107 patients (93%) clinical conditions allowed the execution of a 6 WT, on ECG telemetry monitoring. Resting and exertional heart rate, score of fatigue (Borg Scale 1 divided by 20), symptoms, ECG alterations and arrhythmias were recorded. Other considered variables were: comorbidity (Charlson index), length of stay and complications occurring during the whole surgical and rehabilitation in-hospitalisation stay, disability (nursing needs: Maslow and nursing chart), functional status at discharge, left ventricular ejection fraction, number of exercise treatment sessions, self-perceived health-status at admission and at discharge (EuroQoL questionnaire). RESULTS: The mean walked distance was 194 +/- 93 m. No complication neither ECG alteration occurred during the 6 WT; only isolated premature ventricular beats were recorded in 26 pts. Heart rate increased from 86 +/- 13 at rest to 95 +/- 17 bpm at the end of the 6 WT (p < .0001). The perceived fatigue score was 12.9 +/- 1.2 Borg. Complications, length of stay, nursing needs, self-perceived health-status and functional capacity at discharge differed between patients who performed the 6 WT within 4 days compared with those who did it later, and between patients who walked < or = 120 m (lower quartile) compared with those who walked more. CONCLUSIONS: In elderly patients after cardiac surgery the 6 WT performed within the first week of admission in rehabilitation unit is feasible and safe. Simple cut-offs like timing of the 6 WT and walking performance identify more severe patients with lower susceptibility to recovery.

Age Factors↗