
==== Front
Sports Med Health Sci
Sports Med Health Sci
Sports Medicine and Health Science
2666-3376
Chengdu Sport University

S2666-3376(23)00022-7
10.1016/j.smhs.2023.03.002
Original Article
Effect of a cardiac telerehabilitation program during COVID-19 associated social isolation
Prado João Paulo
Galdino Giovane giovanegsouza@yahoo.com.br
∗
Institute of Motricity Sciences, Federal University of Alfenas, Alfenas, Minas Gerais, Brazil
∗ Corresponding author. Jovino Fernandes Sales Ave 2600, 37133-840, Alfenas, Brazil. giovanegsouza@yahoo.com.br
31 3 2023
9 2024
31 3 2023
6 3 273278
24 8 2022
13 3 2023
14 3 2023
© 2023 Chengdu Sport University. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd.
2023
Chengdu Sport University
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
This study aimed to compare the impact of a cardiac telerehabilitation (CTR) protocol aimed at patients with cardiovascular diseases (CVDs) during the period of coronavirus disease 2019 (COVID-19) associated with social isolation. This retrospective cohort study included 58 participants diagnosed with stable cardiovascular diseases (CVDs), which were divided into three groups: conventional cardiac rehabilitation (CCR) group (n ​= ​20), composed of patients undergoing conventional cardiac rehabilitation; cardiac telerehabilitation (CTR) group (n ​= ​18), composed of patients undergoing cardiac telerehabilitation and control group (n ​= ​20), composed of patients admitted for cardiac rehabilitation who had not started training programs. The results showed that body mass index was reduced (p ​= ​0.019) and quality of life was improved (e.g., limitations due to physical aspects [p ​= ​0.021), vitality [p ​= ​0.045] and limitations due to emotional aspects [p ​= ​0.024]) by CCR compared to baseline. These outcomes were not improved by CTR (p ​> ​0.05). However, this strategy prevented clinical deterioration in the investigated patients. Although CCR achieved a superior effect on clinical improvement and quality of life, CTR was relevant to stabilize the blood pressure and quality of life of patients with cardiovascular diseases during the period of COVID-19-associated social isolation.

Keywords

COVID-19
Cardiac telerehabilitation
Quality-of-life
==== Body
pmcList of abbreviations

CVDs cardiovascular diseases

CTR cardiac telerehabilitation

COVID-19 coronavirus disease 2019

ICTV International Committee on Taxonomy of Viruses

SARS-CoV severe acute respiratory syndrome

CR cardiac rehabilitation

CCR conventional cardiac rehabilitation

BMI body mass index

DBP diastolic blood pressure

SBP systolic blood pressure; min: minute; HR, heart rate

PA physical activity

BP blood pressure

kg kilograms

a.m. ante meridiem

kg/m2 kilograms per square meter

CO group control group

FC functional capacity

LPA limitation of physical aspects

GH general health

VIT vitality

SA social aspects

LEA limitation of emotional aspects

MH mental health

SD standard deviation

IQT interquartile range

SF-36 36-item short form health survey

kcal kilocalorie

CG control group

SARS severe acute respiratory syndrome

SARS-CoV-2 severe acute respiratory syndrome coronavirus 2

Introduction

Cardiovascular diseases (CVDs) are the leading causes of death worldwide. About 17.9 million people died from CVDs in 2019, accounting for 32% of all global deaths.1 In addition, sedentary behavior and physical inactivity are major modifiable CVDs risk factors.2

Since the beginning of December 2019, thousands of people have been affected by a new infectious disease, defined as coronavirus disease 2019 (COVID-19), an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus.3 The International Committee on Taxonomy of Viruses (ICTV) officialized this pathogenesis based on phylogeny, taxonomy, and established practice. Accordingly, a complete genomic analysis identified that the virus shares 88% sequence identity with two bat-derived severe acute respiratory syndrome (SARS)-like coronaviruses, although it exhibits less similarity to severe acute respiratory syndrome (SARS).4 Due to the high risk of infection and the rapid worldwide spread of COVID-19, several governments have imposed restrictions on outdoor social activities and even population quarantines.5 This isolation led to the suspension of group-based cardiac rehabilitation (CR) programs, which are frequently hosted in hospitals, community centers, and public gyms, with up to 72% of Phase IV (long-term, community-based) CR programs being suspended.6

In response to social restrictions, COVID-19-associated quarantine has been accompanied by marked behavioral and psychological changes, especially unhealthy eating habits, physical inactivity, anxiety, stress, and depression.7 A study developed in Lithuania evaluated the eating behavior of 2 447 adult individuals during the period of social confinement imposed by COVID-19.8 In this investigation, snacks and the habit of cooking at home were more frequent in almost half of the interviewees. In addition, 60.6% of the participants decreased the frequency of physical activities and 31.5% gained body mass.8 An important systematic review also identified 64 studies corroborating the increased frequency of sedentary behaviors during COVID-19-associated lockdown in different population groups, including children and patients with chronic diseases.9 Compared to the pre-pandemic physical activity profile, Ammar et al.10 found that time spent in vigorous (38.7 vs. 26.0 ​min/week) and moderate (32.1 vs. 21.4 ​min/week) activities, walking (37.2 vs. 24.6 ​min/week) and combined activities (108.0 vs. 71.8 ​min/week) was reduced during COVID-19-associated lockdown. Moreover, daily sitting time increased from 5.31 ​h/day before the confinement to 8.41 ​h/day during confinement.

Currently, the medical literature recommends that adults accumulate at least 150 ​min of moderate-intensity or at least 75 ​min of vigorous-intensity of activity divided into 5–7 sessions per week. Additionally, exercise protocols must be adapted to the participant's fitness level and a progressive model of intensity and volume should be utilized, which should preferably be monitored by phone applications and wearable sensors.11

The practice of physical activity is even more important in individuals with CVDs, mainly to control or reduce risk factors related to the disease. In addition, this practice contributes to maintaining good physical conditions and improving the quality of life in this population.12 Due to the risk of acquiring COVID-19, participation of patients with CVDs in a hospital or outpatient CR programs has been limited.13 Thus, telerehabilitation has become a viable strategy to continue treatment during the COVID-19 pandemic, especially considering the effectiveness of virtual home-based CR programs to improve physical fitness and quality of life.14,15 In addition, this CR strategy has some advantages such as privacy, no need for transportation, greater independence, low cost, and customization that can be combined with telemonitoring.14,15

A recent systematic review and meta-analysis compared a wearable sensors-assisted cardiac telerehabilitation home-based model of CR with conventional outpatient CR and found that cardiac telerehabilitation (CTR) was better in the cardiorespiratory fitness outcome. However, regarding physical activity, quality of life, depression levels, modification of cardiovascular risk factors/laboratory parameters, and adherence, no difference was found between both modalities.16 Furthermore, CTR was demonstrated to be similar in training intensities to conventional CR in CVD patients with low to moderate cardiovascular risk.17

Regarding safety, CTR is comparable with conventional CR.18 However, it is advisable that all patients undergoing a CTR program be previously evaluated remotely via video or phone conference by a multidisciplinary team and that they receive educational advice regarding risk factors, before starting the individualized physical training program.14 During CTR it is recommended to use remote technology and wearable sensors, which provide exercise variables such as intensity, time, distance, and patient's physical status indications (Heart rate, physical activity, and blood pressure) and many other pertinent aspects.14 Taken together, adherence to these recommendations is essential for patient safety in CTR programs.

Considering that treatment maintenance may determine better clinical outcomes, we used a clinical cohort framework to compare the impact of conventional cardiac rehabilitation with patients undergoing usual care and with a CTR protocol aimed at patients with CVDs during the period of COVID-19-associated social isolation.

Methods

Design

This retrospective cohort study included 58 participants diagnosed with stable cardiovascular diseases (CVDs), between February 2018 and September 2021. Data were obtained from the cardiovascular rehabilitation sector of the Physiotherapy Clinic at the Federal University of Alfenas, Brazil. All volunteers provided written consent. The institution's Human Research Ethics Committee approved this study (Protocol number: 40764014.8.0000.5414).

Clinical information (e.g., questions regarding present illnesses, complaints, and disorders and their course and details on current living conditions), systolic and diastolic blood pressure levels, as well as the quality of life data, were collected and recorded in medical records prepared for each participant. This information was collected in person or online, according to the group evaluated.

Outcome measures

The primary outcomes evaluated were: (i) systolic and diastolic arterial blood pressure, and (ii) quality of life. The secondary outcome investigated was: (i) body mass index (BMI). Due to COVID-19-associated social isolation, the participants, family members, or caregivers evaluated the blood pressure of the CTR group.

Arterial blood pressure

Participants remained seated at rest for 10 ​min before measuring diastolic (DBP) and systolic (SBP) blood pressure. Mid-upper arm circumference was assessed using a calibrated aneroid sphygmomanometer coupled to an appropriately sized brachial blood pressure cuff. All measurements were taken on the left arm at heart level. The average of two readings was recorded as the blood pressure value for each volunteer. Recommended standard procedures were used for selecting the position and sizes of sphygmomanometers used.19

Quality of life

The 36-Item Short Form Health Survey (SF-36) questionnaire was used to assess the quality of life. This questionnaire consists of 36 items, which are mostly assigned to one of eight health domains covering various aspects of physical and mental health such as: (i) physical functioning (10 items), (ii) physical role functioning (4 items), (iii) bodily pain (2 items), (iv) general health perceptions (5 items), (v) vitality, (5 items), (vi) social role functioning (2 items), (vii) emotional role functioning (3 items), and (viii) mental health (5 items).20 Higher scores in each domain indicate better health status. Scores range from 0 to 100, so scores closer to 0 are less favorable to health status and scores closer to 100 are more favorable. As the questionnaire was administered, each question was read and clarified by the evaluator. Then, they were answered by the participants. The questionnaire was applied and the score was calculated using the SF36+ software. SF-36 data were collected online for the CTR group.

Body mass index

Body mass index (BMI) was evaluated according to the reference values previously described.21 Height and weight data provided by patients online were used to calculate the BMI in the CTR group.

All measurements previously described were taken between 7:30 a.m. and 10:00 a.m., and each participant was instructed to avoid coffee, alcohol, nicotine, and exercise for at least 2 ​h before the assessment. After baseline assessments, participants started the training. Two days after the last session, a new assessment was performed.

Cardiac rehabilitation programs

Data from the medical records of 58 patients admitted to the cardiac rehabilitation program were from the following groups: CTR group (n ​= ​18), composed of patients who underwent a real-time delivery of the CTR program via the Google meet platform, three 35-min sessions per week on alternate days (Monday, Wednesday and Friday), for 9 weeks in a total of 27 sessions. This program consisted of a 5-min warm-up period with stationary walking, followed by a 20-min conditioning period that included combined aerobic and resistance exercises (jumping jack, sit and stand, leg abduction and abduction, knee extension, and flexion, and strengthening for biceps, triceps, and deltoid muscles with 1–2 ​kg loads), and a cool-down period consisting of 10-min stretching and breathing exercises; conventional cardiac rehabilitation (CCR) group (n ​= ​20), composed of patients undergoing conventional cardiac rehabilitation in three 50-min sessions of treadmill aerobic exercise training per week, on alternate days (Monday, Wednesday, and Friday), for 12 weeks in a total of 36 sessions. In this protocol, the training intensity was kept between 60% and 70% of the heart rate (target zone), which was calculated according to the Karvonen formula.22 In addition, the modified Borg's perception of exertion scale was used in both training programs (CTR and CCR), in which the maximum score maintained was between 5 and 6,23 and this scale was the reference to intensity for the CTR group. Data from the CCR group were collected prior to the COVID-19 pandemic. All exercise programs were carried out between 7:00 a.m. and 10:00 a.m. and followed the American College of Sports Medicine Guidelines (2014).24 Data from 20 patients admitted for cardiac rehabilitation who had not started training programs were used as a control group (CG). This group was evaluated and re-evaluated before the COVID-19 pandemic in a similar period to the CCR group.

At the end of each intervention, energy expenditure was evaluated using the formula 0.0175 ​× ​weight (kg) ​× ​METs ​= ​kCal/min,25 in which the MET of each group (CTR and CCR) was defined according to the Compendium of Physical Activities.26,27 This value was then multiplied by the number of minutes in a day (35 for the CTR group and 50 for the CCR group) to give kCal/day, and by the number of sessions, 27 and 32, respectively.

Statistical analysis

Clinical and qualitative data were expressed as relative and absolute values. The Kolmogorov-Smirnov test was used to assess data normality. Parametric data were reported as means and standard deviation. Non-parametric data were expressed as median and interquartile range, and compared using the Wilcoxon or Mann-Whitney tests. ANOVA or t-test was used to analyze differences within the cohort. Results with p ​≤ ​0.05 indicated statistical differences. All data were analyzed using the statistical program GraphPad Prism v8 (San Diego, CA, USA).

Results

Anthropometric and clinical variables

Our sample consisted of 58 participants of both sexes (71.9% women and 28.1% men) with (69.42 ​± ​6.23) years. Most volunteers (72%) presented systemic arterial hypertension, followed by myocardial infarction (8%) and coronary artery bypass graft surgery (5%). The mean BMI indicated overweight in all groups (CCR: [29.27 ​± ​3.47] kg/m2; CTR: [29.12 ​± ​5.4] kg/m2 and CG: [29.87 ​± ​6.3] kg/m2).28 According to baseline blood pressure values, participants in the CCR and CTR groups had stage 1 hypertension, while the volunteers in the CG group had stage 2 hypertension.29

Effect of cardiac telerehabilitation on blood pressure, BMI, energy expended, and quality of life

As shown in Table 1, systolic and diastolic blood pressure levels remained unchanged upon completion of both cardiovascular rehabilitation protocols. In contrast, BMI was significantly (p ​= ​0.019) reduced in the CCR group compared to baseline levels (Table 1). When evaluating the energy expended by physical activity between the CCR and CTR groups after interventions, we found that this outcome was significantly higher in the CCR group ([6 692.07 ​± ​1 015.13] kCal/32days for CCR vs. [3 960.29 ​± ​567.66] kCal/27days for CTR, p ​< ​0.001).Table 1 Clinical variables and quality of life of study participants.

Table 1	CCR group Median (IQT) or Mean (SD) (n ​= ​20)		CTR group Median (IQT) or Mean (SD) (n ​= ​18)		CG Median (IQT) or Mean (SD) (n ​= ​20)	Between groups comparison Post	
Clinical variables	Baseline	Post	p value or 95% CI	Baseline	Post	p value or 95% CI	Baseline	Post	p value or 95% CI	p value or 95% CI	
SBP (mmHg)	130 (120–140)	130 (100–137.5)	0.074	130 (120–140)	130 (120–145.5)	0.909	130 (130–140)	130 (120–140)	0.273	0.560	
DBP (mmHg)	80 (80–90)	80 (70–80)	0.058	80 (68–85)	80 (70–90)	0.656	80 (80–90)	85 (79–90)	0.517	0.077	
BMI (kg/m2)	29.60 (25.71–31.73)	28.35 (27.23–28.35)	0.019∗	28.95 (25.78–32.48)	29.15 (25.85–32.73)	0.771	28.62 (25.46–31.97)	28.99 (24.17–33.38)	0.860	0.507	
SF-36 domains	
FC	71.25 ​± ​22.35	77.75 ​± ​26.38	−11.31 to 24.31	62.50 ​± ​23.70	67.22 ​± ​26.02	- 0.06 to 9.50	73.00 ​± ​21.29	76.25 ​± ​18.55	−11.40 to 17.90	0.352	
LPA	50 (31.25–93.75)	100.0 (75–100.0)	0.021∗	75 (18.75–100.0)	84 (23.75–100.0)	0.632	50 (0–75)	80 (50–80)	0.086	0.087	
Pain	47 (41–72)	73 (61–100)	0.075	41.5 (28.75–72.50)	51 (31.0–70.50)	0.938	41.50 (24.0–52.0)	51.0 (24.50–67.75)	0.602	0.352	
GH	66.40 ​± ​17.68	77.25 ​± ​18.64	−2.75 to 24.45	64.33 ​± ​23.41	56.38 ​± ​18.06	−18.42 to 2.52	58.35 ​± ​19.80	56.60 ​± ​20.20	−14.40 to 10.90	0.001b,c	
Vit	60.0 (36.25–80.0)	75.0 (66.25–85.0)	0.045∗	75.0 (68.75–86.35)	75.0 (30.0–85.0)	0.439	50.0 (45.0–80.0)	52.50 (41.25–72.50)	0.967	0.066	
SA	56 (28.25–100.0)	81.50 (75.0–100.0)	0.059	75.0 (50.0–100.0)	75.0 (37.50–87.50)	0.511	75.0 (62.0–97.50)	94.0 (50.0–100.0)	0.857	0.207	
LEA	33.0 (0–100.0)	100.0 (67.0–100.0)	0.024∗	77.0 (0–100.0)	83.35 (33.23–100.0)	0.203	0 (0–45.75)	50.0 (30.75–100.0)	0.010∗	0.109	
MH	73.0 (53.0–87.0)	80.0 (72.0–99.0)	0.199	72.0 (67.0–81.0)	78.0 (46.0–92.0)	0.840	68.0 (54.0–83.0)	68.0 (56.0–78.0)	0.940	0.040c	
CO group ​= ​control group. CCR group ​= ​conventional cardiac rehabilitation group. CTR group ​= ​cardiac telerehabilitation group. SBP ​= ​systolic blood pressure. DBP ​= ​diastolic blood pressure. BMI ​= ​body mass index. FC ​= ​functional capacity. LPA ​= ​Limitation of physical aspects. GH ​= ​general health. VIT ​= ​vitality. SA ​= ​social aspects. LEA ​= ​limitation of emotional aspects. MH ​= ​mental health. Data are presented as mean ​± ​standard deviation (SD, for parametric data) or median and interquartile range (IQT, for non-parametric data).∗Significant intra-groups differences (p ​< ​0.05, Wolcoxon test); b and c Significant between-groups diferences post intervention compared to CCR group (p ​< ​0.05, Kruskal-Wallis test, b for CTR group and c for CO group).

In addition, the CCR group presented improvements in quality of life domains compared to baseline scores, especially in components related to limitations in physical aspects (p ​= ​0.021), vitality (p ​= ​0.045), and limitations in emotional aspects (p ​= ​0.024) (Table 1). Although no difference was found in general health after both interventions, the CCR group scores for this domain were higher (p ​= ​0.001) than the control and CTR groups. A similar result was found comparing the CCR and control group (p ​= ​0.040) in the mental health domain (Table 1). Interestingly, the control group showed improvement (p ​= ​0.010) in mental health scores compared to the baseline.

Discussion

The present study showed that a cardiac telerehabilitation program administered during the COVID-19 pandemic was efficient in preventing the worsening of systolic and diastolic blood pressure, BMI, and quality of life in patients with CVDs. Although this treatment strategy did not achieve a superior result than conventional cardiac rehabilitation, our data suggest that telerehabilitation was effective to stabilize clinical conditions, such as blood pressure, and in all the evaluated domains of quality of life in response to the social restrictions associated with COVID-19.

Several deleterious effects have been reported during the COVID-19 pandemic isolation period. Among them, many studies have identified a relevant increase in blood pressure. A study conducted with US adults found an increase of 2.50 ​mmHg for SBP and 0.53 ​mmHg for DBP during April to December 2020 compared to 2019.30 Small population increases in blood pressure levels are associated with increased long-term incidence of major adverse cardiovascular events. A meta-analysis showed that a 2-mmHg higher SBP is associated with significant increases in mortality from stroke and ischemic heart disease among middle-aged adults.31 In addition, worsening dyspnea, a higher percentage of lower limb edema, higher incidence of heart attack, and deaths from heart failure were also identified during 60 days of COVID-19-associated lockdown.32

Although there was no reduction in blood pressure values, both interventions were efficient in preventing an increase in this parameter, which did not occur for DBP in the control group. Thus, these data demonstrate the importance of cardiac telerehabilitation during the COVID-19 pandemic, suggesting a potential to control the risk of cardiovascular events in this population with CVDs.

Body mass index was another important parameter evaluated in the present study. Evidence has demonstrated that the period of COVID-19-associated social isolation was responsible for body mass gain in the general population. Daniel et al.33 evaluated the eating behavior of 1 334 participants during five months of the COVID-19 pandemic. In this study, the authors found a 58.8% increase in body mass (approximately 3 ​kg), which was mainly associated with increased consumption of snacking, fast food, canned products, and sedentary behavior. Another longitudinal study conducted in Saudi Arabia found that 10% of participants reached the overweight or obese BMI classes. In addition, 4.8% of participants with normal BMI switched to overweight or obese classes, while 5.1% of overweight individuals reached the obese class, compared to the pre-pandemic period (years 2018 and 2019) and post-2020 (the year 2021).34 Considering these findings, we suggest that the cardiac telerehabilitation program developed in the present study may be effective in preventing body mass gain in the participants, although it did not promote a significant reduction in this parameter.

The conventional cardiac rehabilitation program promoted a significant reduction in BMI compared to baseline. However, no differences were found in relation to the telerehabilitation protocol or the control group. One hypothesis for this finding is that greater load intensity and training volume are allowed during this program compared to telerehabilitation, whose remote monitoring of training intensity (e.g., heart rate) is limited.

The quality of life of patients undergoing the cardiac telerehabilitation program was also unchanged. Ferreira et al.35 demonstrated that individuals presented lower levels of quality of life during the COVID-19 pandemic, which was associated with increased anxiety levels, especially in elderly populations. In addition, a recent review carried out between March and September 2020 indicated that social isolation and the quarantine period exerted a negative impact on the population's quality of life and long-term mental health.36 These data help us to recognize the importance of cardiac telerehabilitation in helping to maintain and prevent a worsening in the quality of life of patients with CVDs. Exercise by telerehabilitation is a viable alternative to treat pain, improving physical function and quality of life in adults with physical disabilities when compared with other interventions (i.e., traditional rehabilitation at home or in healthcare facilities).37 Probably the shorter training period (9 weeks) of the CTR group may have interfered with our results; since the CCR group showed better results in the quality of life and the participants' training period was 12 weeks. In addition, another study also demonstrated an improvement in this outcome after 12 weeks of a CTR program.38

Although conventional cardiac rehabilitation achieved better effects, patients who underwent cardiac telerehabilitation did not present a worsening in quality of life evaluated by physical and mental aspects. In addition to the beneficial effects identified, some limitations should be considered in the present study, especially the lack of a control group evaluated during the pandemic for ethical reasons. The number of patients in the cardiac telerehabilitation group was also limited, an aspect mainly related to the fact that they were patients treated at the rehabilitation service and not previously recruited for this study. In addition, another limitation was the CTR training period (9 weeks), which was much shorter than the CCR (12 weeks). This reduced period was made difficult by adapting to the restrictive measures of the pandemic and learning to use the online platform by both researchers and patients. Thus, we suggest that cardiac telerehabilitation protocols performed in periods longer than 9 weeks may bring more positive results both in relation to the improvement of physical capacity and quality of life. Thus, we suggest that cardiac telerehabilitation protocols performed in periods longer than 9 weeks may bring more positive results both in relation to the improvement of physical capacity and quality of life. As previously discussed, a recent study demonstrated improvement in these outcomes after a 12-week cardiac telerehabilitation program.38

This hypothesis is supported by the energy expenditure in each group. The CCR group burned approximately 209 kCal in each session, while the CTR group burned 146 kCal/per session. A study had already shown that 83% of cardiac rehabilitation programs exercise below 300 kCal per session, and this level favors cardiovascular improvements.39 Although the exercise protocols used in both groups are important, this outcome supports the positive results found in the CCR group compared to the CTR group, which presented a greater volume of work and, consequently, a greater energy expenditure.

In conclusion, although the results may take longer to experience, our data demonstrated that cardiac telerehabilitation might be an effective treatment strategy to maintain controlled blood pressure levels, BMI, and good quality of life in patients with cardiovascular diseases undergoing social isolation. Although these restrictions have been linked to the COVID-19 pandemic, cardiac telerehabilitation is potentially applicable in other situations of social isolation, whose impact deserves further investigation in different contexts and populations with cardiovascular diseases.

Submission statement

We declare that the work described has not been published previously, that it is not under consideration for publication else-where, that its publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published elsewhere including electronically in the same form, in English or in any other language, without the written consent of the copyright-holder.

Authors’ contributions

GG: recruitment, data curation, the draft of the manuscript, conceptualization and project administration. JPP: recruitment, data curation, and formal analysis. All authors interpreted the data and participated in the critical revision and final approval.

Ethical approval statement

This research was approved by Federal University of Alfenas, Brazil and the institution's Human Research Ethics Committee approved this study (Protocol number: 40764014.8.0000.5414). All participants gave their consent and agreed to participate in the study.

Conflict of interest

The authors report no conflict of interest.

Acknowledgements

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brazil (CAPES) [Finance Code 001].
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