The effect of the surgical mask on functional exercise capacity in children with cerebral palsy

The effect of the surgical mask on functional exercise capacity in children with cerebral palsy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The effect of the surgical mask on functional exercise capacity in children with cerebral palsy Turgay Altunalan, Burhan Sancakdar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4435970/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The current study focused on children with cerebral palsy (CP) and aimed to evaluate the effects of using a surgical mask during submaximal exercise on functional exercise capacity and physiological responses. This single-center observational study enrolled 20 children with CP (12 boys and eight girls) between the ages of 6 and 18 years. Participants performed 6-minute walk tests (6-MWT) with and without a surgical mask on different days. We recorded walking distance, oxygen saturation, heart rate, and respiratory rate before and immediately after the end of the 6-MWT with and without the mask. The mean walking distance was significantly (p=0.013, Cohen’s-d=0.345) shorter with the surgical mask, 254.77±77.83 and 293.57±81.27 without a mask. There were no significant differences in O2 saturation, heart rate, and respiratory rate after the 6-MWT with or without a mask. Using a surgical mask significantly reduced the walking distance by up to 13% in children with CP, with no significant changes in physiological responses. Clinical Trial Number: We did not apply for the clinical trial number. If it is mandatory, we can apply retrospectively. cerebral palsy masks physical endurance walk test heart rate oxygen saturation Figures Figure 1 Introduction Cerebral palsy (CP) is a permanent movement and postural disorder caused by nonprogressive damage to a child's developing brain before, during, and after birth [ 1 ]. Movement difficulties and postural misalignment are common in patients with cerebral palsy. These atypical alignments of the skeletal system adversely affect movement kinetics and cause more effort expenditure during movements [ 2 , 3 ]. Posture disorders also disturb respiratory muscle function and may cause more frequent and superficial breathing. Postural problems increase energy expenditure and reduce effective breathing [ 4 ]. Increased energy demand and decreased respiratory capacity in CP lead to decreased physical activity and endurance levels compared to their peers. In addition to the movement and postural difficulties of children with CP, the pandemic conditions also negatively affect their physical activity and endurance. When the coronavirus was first observed in China in late 2019, several rules were introduced, such as using masks and curfews. One of the rules affecting the daily routine is the obligation to wear masks in closed areas. Although the literature has shown that using masks can reduce the risk of respiratory viral infection by up to 80%, there may be a few adverse outcomes. The mask may cause temperature increase, irritation, breathing difficulty, and discomfort [ 5 , 6 ]. Masks increase inspiratory and expiratory resistance, and some exhaled carbon dioxide can be reinspired in the respiratory cycle, increasing respiratory frequency [ 7 ]. Furthermore, they may result in a fluctuation in oxygen saturation during physical exertion [ 8 ]. Masks that protect with an air filter are not suitable for use during sporting activities or exercise [ 9 ]. Using a mask during submaximal physical exertion has increased perceived exertion, dyspnea [ 10 ], and fatigue [ 11 ]. For this reason, examining the effects of masks in special populations, such as those with Cerebral Palsy, becomes even more critical. The literature has shown that using masks during rest or low-intensity physical activity has no adverse effect on respiration, gas exchange, endurance, perceived exertion, and dyspnea in healthy children and adults [ 12 – 14 ]. However, there is a need to examine the effect of mask use on children with different risk groups [ 15 ]. To the best of our knowledge, no studies have investigated the impact of mask use on functional exercise capacity and physiological responses in children with CP. The current study aims to investigate the effect of surgical masks while using submaximal exercises on functional exercise capacity, oxygen saturation, heart rate, and respiratory frequency in children with CP, highlighting their motor severity. The present study hypothesizes that physiological parameters will remain constant, whereas the 6-minute walking distance will be shortened because of the masked walk. Methods Study Design This is a single-center observational study of children with CP from Istanbul Beylikdüzü İlk Evin Special Education and Rehabilitation Center between January and February 2022. The study was applied by obtaining the ethics committee approval number 61351342/2268 from Üsküdar University and adhered to the Declaration of Helsinki. Participants We enrolled 20 children, 14 of whom were hemiplegic and six of whom were diplegic, aged between 6 and 18. The study included children who were able to follow and implement sequential commands. We excluded individuals with ataxia and dyskinesia subtypes to create a homogenous group. Children who could not follow instructions and had genetic and metabolic diagnoses were excluded from the study. Also, the study did not include children who described coughing, sore throats, or asthenia. The written consent of the children was obtained through face-to-face interviews with them and their parents. Since the guidelines recommend using masks for children aged six and above, we excluded participants younger than 6 and [ 15 ]. We enrolled children with the Gross Motor Classification Scale (GMFCS) I and II levels because walking tests are more feasible and accurate for high-motor-functioning children. Test Protocol We used the 6-MWT as a standard effort to investigate walking distance and physiological changes during walking with and without a mask. We used CE-certified latex-free L2 level and 3-ply surgical masks for children. Surgical masks at the L2 level had a particle filtration efficiency (PFE) of 94% [ 16 ]. Participants walked through a 10-meter-long corridor. First, the walk was performed without a mask and repeated with the mask at the same time for the next three days. The measurements were carried out on different days because the participants might get tired during the test. The test started with the ‘Start’ command and ended with the ‘Stop’ command. We instructed the participants to walk as fast as possible without running for six minutes. Walking distances were measured with a tape measure in meters, and walking time was measured with a stopwatch. The corridor length was multiplied by the number of laps, and the walking distances were determined in meters [ 17 ]. All children in the study adhered to the protocol for the 6-minute walk test and completed the test. Outcome Measures We measured participants’ O2 saturation, respiratory frequency, and heart rate before and after the 6-MWT was completed. The 6-MWT is a test published by the American Thoracic Society that is easy to administer, tolerable, and reflects daily activities. It is a self-controlled measure of functional exercise capacity. It is considered the gold standard submaximal exercise test to assess aerobic capacity and endurance [ 18 ]. This test measures the longest distance walked in 6 minutes at walking speed. It can be applied to children with the typical development and diagnosis of CP. Tabulations of expected walking distances by age for children between GMFCS I-III have been published [ 19 ]. Pulse oximetry is a noninvasive, painless, and reliable method to measure arterial blood's transcutaneous oxygen saturation (tcSO2). We measured HR and tcSO2 using a handheld pulse oximeter (Slyfox C03 model) placed on the index finger of the patient's right hand. Transcutaneous oxygen saturation and heart rate (HR) were measured before (baseline) and after 6-MWT. Respiratory rate is defined as the number of breaths per minute. We measured respiratory rate by recording chest oscillation in 1 minute based on visual observation and palpation of the chest wall along the upper abdominal region. We used a digital clock to determine the 1-minute breathing interval [ 20 , 21 ]. We calculated the effect size based on previous studies showing 60 m mean differences for 6-MWT [ 22 ]. We calculated that 18 individuals should be included with an effect size of 1.1, 95% confidence interval, and 80% power. Considering the possibility of participants dropping out, we included 20 participants. Statistical analysis Statistical analyses were performed using SPSS version 25.0 (IBM SPSS Statistics for Windows, IBM Corp, Armonk, NY, USA). We used the frequency, percentage, arithmetic mean, standard deviation, and distribution width to analyze the demographics. Walking distances of masked and unmasked participants were analyzed using a paired t-test as they fit the normal distribution. Oxygen saturation, heart rate, and respiratory frequency were calculated by paired t-test and reported by trend figure to show their differences before and after walking. The significance level was set at p < 0.05. Cohen-d was used in the effect size analysis. The effect size calculation was considered 0.2 ≥ small effect, 0.5 ≥ medium effect, 0.8 ≥ large effect. Results Twenty participants completed the 6-minute walk test, both masked and unmasked. Only over half of the participants were male. Table 1 shows the participants' age, gender, severity of motor impairments, and motor impairment types. All the participants' movement disorders were spasticity. Table 1 Demographic information of the participants Parameters GMFCS I (n:12) GMFCS II (n:8) Total Age 6–11 (n:6) 8.33 ± 1.75 (n:1) 7.00 (n:7) 8.14 ± 1.67 12–18 (n:6) 15.33 ± 2.65 (n:7) 16.00 ± 2.76 (n:13) 15.69 ± 2.62 BMI Kg/m 2 18.06 ± 2.45 19.54 ± 3.42 18.65 ± 2.89 n (%) n (%) n (%) Gender Male 8 (66.7) 4 (33.3) 12 Female 4 (50) 4 (50) 8 Motor Disorder Spasticity 12 (60) 8 (40) 17 Topographic Classification Hemiplegia 11 (78) 3 (22) 14 Diplegia 1 (16.7) 5 (83.3) 6 BMI: Body Made Index, GMFCS: Gross motor function classification system. We analyzed walking distances in two subgroups according to age: 6–11 and 12–18. In both age groups, the average distance of masked walking was 10 and 8% lower than that of unmasked walkers, with medium and small effect sizes, respectively. However, this difference was statistically significant only in the 6–11 age and total sample groups. Mean walking distances according to the severity of motor impairment in both age groups are shown in Table 2 . Table 2 Walking Distance with and without Mask 6-MWT distance (meter) Masked M (SD) Unmasked M (SD) Difference M - % P Cohen d 6–11 ages, n:7 GMFCS I (n:6) 235.75 ± 50.19 258.00 ± 63.99 22.25–8% 0.090 0.386 GMFCS II (n:1) 195.00 ± NA 257.91 ± NA NA NA Total (n:7) 229.92 ± 48.34 257.85 ± 58.43 27.92–10% 0.039* 0.520 12–18 ages, n:13 GMFCS I (n:6) 335.81 ± 82.74 351.75 ± 66.76 15.93–4% 0.600 0.212 GMFCS II (n:7) 210.14 ± 42.03 243.71 ± 56.67 33.56–13% 0.050 0.672 Total (n:13) 268.14 ± 88.71 293.57 ± 81.27 25.42–8% 0.091 0.298 Total (n:20) 254.77 ± 77.83 281.07 ± 74.53 26.30–9% 0.013* 0.345 GMFCS: Gross motor function classification system, M: Mean, 6-MWT: Six minute walking test, *P 0.05) different (Fig. 1 ). Discussion To the best of our knowledge, this is the first study to examine the effects of surgical mask use during submaximal exercise on walking distance and physiological responses in children with CP. Our study showed that the walking distance decreased significantly with a surgical mask in children with CP. However, physiological responses were similar when masked and unmasked walking were compared. Due to reduced physical activity opportunities as a result of the pandemic, children with cerebral palsy are likely to have reduced walking endurance. In our study, unmasked 6-MWT distances were approximately 100 meters shorter than the pre-pandemic literature [ 23 , 24 ]. The current study was carried out during the pandemic period. Closing schools and rehabilitation centers and restricting leisure activities [ 25 ] during this period may have negatively affected their physical activity level and endurance [ 26 ]. It can be posited that the functional cardiorespiratory capacity of children with cerebral palsy decreased during the pandemic period. It can be considered that children with cerebral palsy may be more sensitive to physical activity with a mask. The masked walking distance was significantly shorter than the unmasked walking distance in our study. This difference may be explained by increased perceived effort or discomfort during masked walking [ 27 , 28 ]. Furthermore, using a surgical mask increases the resistance encountered during inspiration and expiration [ 29 ]. The increased perceived exertion and inspiratory and expiratory resistance may have contributed to reduced walking distance with masks in children with CP. In contrast, the existing literature indicates no significant reduction in submaximal exercise capacity with wearing a surgical mask in typically developing children [ 27 ]. The divergent outcomes observed between typical children and those with CP may be attributed to the reduced cardiorespiratory and musculoskeletal fitness in children with CP. Children with CP exhibit a reduced cardiorespiratory capacity and a higher respiratory rate and surface ventilation when compared to typically developing children [ 30 ]. Children with CP are at an increased risk of developing musculoskeletal disorders, including contractures, atypical postures, balance problems, and misalignments. These findings have been well documented to be associated with low gait performance and require high energy expenditure [ 31 , 32 ]. The decreased performance of children with CP during submaximal masked exercise can be attributed to these specific characteristics of these children. Our study found no significant differences in oxygen saturation, heart rate, and respiratory frequency between masked and unmasked walking. Consistent with our research, the literature shows that physiological responses do not change significantly during submaximal masked exercise. The use of face masks during moderate to vigorous physical activity in healthy children has a small and physiologically tolerable effect on respiratory and hemodynamic parameters [ 33 , 34 ]. The ventilation was physiologically managed using feedback loops. A decrease in partial oxygen pressure increases heart rate and minute ventilation [ 35 ]. This theoretical information suggests that using a mask may increase the volume of carbon dioxide, which in turn may increase hemodynamic indicators. However, the existing literature on typically developing children and our study indicated that the physiological responses during submaximal physical exertion with a mask did not change significantly or in a clinically meaningful way [ 36 ]. It is important to note that there is evidence from some studies indicating that the use of N95 and surgical masks at increased exertion can result in changes to cardiac and respiratory parameters. However, these changes are within the safety range of [ 37 , 38 ]. Our study has some limitations. The nature of our research makes it challenging to objectively assess oxygen consumption when wearing a mask, as the mask must be worn over the mask itself. If we had also measured perceived exertion and dyspnea in our study, we could have more comprehensively discussed the decrease in the 6-MWT distance. Although the post-power test indicated that our sample group was sufficient, our case number was limited for the complete representation of the sub-dimensions of CP. We measured oxygen saturation, respiratory frequency, and heart rate before and after submaximal activity. Further studies suggest that these data be measured during activity as well. Since we did not know the participants' physical activity levels, it was impossible to discuss the effect of mask use on submaximal activity in active and sedentary children with CP. We recommend evaluating children's physical activity levels in future studies. Conclusion In conclusion, masked submaximal walking distances can be significantly reduced by up to 13% in children with CP at GMFCS levels I and II. However, wearing a mask during submaximal activity did not significantly change physiological parameters such as oxygen saturation, respiratory frequency, and heart rate. Our study's findings indicate that using surgical masks during submaximal physical activity in children with CP is safe in physiological parameters. However, a reduction in physical performance may be observed. The results of the current study may support clinicians in the decision about submaximal exercise effort level with a surgical mask in children with CP in situations such as pandemics, air pollution, and respiratory infections. In future studies, we recommend investigating the effects of mask use in more severely affected children, such as those with GMFCS III, IV, and V. Declarations Author contributions statement T.A. and B.S. conducted the research design, participated in collecting data, and drafted the manuscript. B.S. conceived the experiment. T.A. and B.S. analysed the results interpretation of the data and drafted the manuscript. All authors reviewed the manuscript. Ethics approval and consent to participate The study was applied by obtaining the ethics committee approval number 61351342/2268 from Üsküdar University and adhered to the Declaration of Helsinki. All participants provided a signed informed consent form before enrolled the study. All methods were performed in accordance with the relevant guidelines and regulations. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector. Author Contribution T.A. and B.S. conducted the research design, participated in collecting data, and drafted the manuscript. B.S. conceived the experiment. T.A. and B.S. analysed the results interpretation of the data and drafted the manuscript. All authors reviewed the manuscript. Acknowledgement The authors would like to thank the children and their parents who volunteered to participate in the study. Data availability statement The data that support the findings of this study are available from the corresponding author, [T. A.], upon reasonable request. References Rosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007;109:8–14. Kwon YH, Lee HY. Differences of respiratory function according to level of the gross motor function classification system in children with cerebral palsy. J Phys Ther Sci. 2014;26:389–91. Shin H-K, Byeon E-J, Kim SH. Effects of seat surface inclination on respiration and speech production in children with spastic cerebral palsy. J Physiol Anthropol. 2015;34:17. Saxena S, Kumaran S, Rao BK. Energy expenditure during standing in children with cerebral palsy: A brief report1. J Pediatr Rehabil Med. 2016;9:241–5. Ünal ZB, Gökçen Ö, Yazar S, Ünal ZB. Research Surgial Masks and Use of Masks in Children. TJFDM. 2021;3:11–24. Tate E, Wylie K, Moss JD. The effects of face masks on emotional appraisal ability of students with autism spectrum disorder. IJDD. 2023;1–9. Lazzarino AI, Steptoe A, Hamer M, Michie S. Covid-19: Important potential side effects of wearing face masks that we should bear in mind. BMJ. 2020;369:m2003. Georgi C, Haase-Fielitz A, Meretz D, Gäsert L, Butter C. The Impact of Commonly-Worn Face Masks on Physiological Parameters and on Discomfort During Standard Work-Related Physical Effort. Dtsch Arztebl Int. 2020;117:674–5. Swiatek KM, Lester C, Ng N, Golia S, Pinson J, Grinnan D. Impact of Face Masks on 6-Minute Walk Test in Healthy Volunteers. Pulm Circ. 2021;11:2045894020988437. Shaw KA, Zello GA, Butcher SJ, Ko JB, Bertrand L, Chilibeck PD. The impact of face masks on performance and physiological outcomes during exercise: a systematic review and meta-analysis. Appl Physiol Nutr Metab. 2021;46:693–703. Dressler T, Stoff J, Di Pietro T, Cavadini GB, Büsser G, Büsser X et al. Masks For Sports: Development project of protective respiratory masks for ice hockey teams during the COVID-19 pandemic [Internet]. ETH Zurich; 2020 Aug p. 14 p. http://hdl.handle.net/20.500.11850/432255 . Epstein D, Korytny A, Isenberg Y, Marcusohn E, Zukermann R, Bishop B, et al. Return to training in the COVID-19 era: The physiological effects of face masks during exercise. Scand J Med Sci Sports. 2021;31:70–5. Lubrano R, Bloise S, Marcellino A, Ciolli CP, Testa A, De Luca E, et al. Effects of N95 Mask Use on Pulmonary Function in Children. J Pediatr. 2021;237:143–7. Majek P, Kaleta-Pilarska A, Barański K. The use of protective masks and the level of arterial oxygen saturation at rest and after exercise. Med Pr. 2022;73:363–8. Eberhart M, Orthaber S, Kerbl R. The impact of face masks on children-A mini review. Acta Paediatr. 2021;110:1778–83. LaRue RJ, Morkus P, Laengert S, Rassenberg S, Halali MA, Colenbrander JW, et al. Navigating Performance Standards for Face Mask Materials: A Custom-Built Apparatus for Measuring Particle Filtration Efficiency. Glob Chall. 2021;5:2100052. Boucault R, Fernandes M, Oliveira Carvalho V. Six-minute walking test in children. Disabil Rehabil. 2013;35:1586–7. Enright PL. The six-minute walk test. Respir Care. 2003;48:783–5. Fitzgerald D, Hickey C, Delahunt E, Walsh M, O’Brien T. Six-Minute Walk Test in Children With Spastic Cerebral Palsy and Children Developing Typically. Pediatr Phys Ther. 2016;28:192–9. LaPier TK, Cook A, Droege K, Oliverson R, Rulon R, Stuhr E, et al. Intertester and Intratester Reliability of Chest Excursion Measurements in Subjects Without Impairment. CPTJ. 2000;11:94. Takken T, Bongers BC, van Brussel M, Haapala EA, Hulzebos EHJ. Cardiopulmonary Exercise Testing in Pediatrics. Ann Am Thorac Soc. 2017;14:S123–8. Keles MN, Elbasan B, Apaydin U, Aribas Z, Bakirtas A, Kokturk N. Effects of inspiratory muscle training in children with cerebral palsy: a randomized controlled trial. Braz J Phys Ther. 2018;22:493–501. Fiss AL, Jeffries L, Bjornson K, Avery L, Hanna S, Westcott McCoy S. Developmental Trajectories and Reference Percentiles for the 6-Minute Walk Test for Children With Cerebral Palsy. Pediatr Phys Ther. 2019;31:51–9. Martakis K, Stark C, Rehberg M, Semler O, Duran I, Schoenau E. Reference Centiles to Monitor the 6-minute-walk Test in Ambulant Children with Cerebral Palsy and Identification of Effects after Rehabilitation Utilizing Whole-body Vibration. Dev Neurorehabil. 2021;24:45–55. Sedaghati P, Balayi E, Ahmadabadi S. Effects of COVID-19 related physical inactivity on motor skills in children with intellectual disability. BMC Public Health. 2022;22:2381. Bhaskar AR, Gad MV, Rathod CM. Impact of COVID Pandemic on the Children with Cerebral Palsy. Indian J Orthop. 2022;56:927–32. Reychler G, Standaert M, Audag N, Caty G, Robert A, Poncin W. Effects of surgical facemasks on perceived exertion during submaximal exercise test in healthy children. Eur J Pediatr. 2022;181:2311–7. Smart NR, Horwell CJ, Smart TS, Galea KS. Assessment of the Wearability of Facemasks against Air Pollution in Primary School-Aged Children in London. Int J Environ Res Public Health. 2020;17:3935. Lee HP, Wang DY. Objective assessment of increase in breathing resistance of N95 respirators on human subjects. Ann Occup Hyg. 2011;55:917–21. Kwon YH, Lee HY. Differences in respiratory pressure and pulmonary function among children with spastic diplegic and hemiplegic cerebral palsy in comparison with normal controls. J Phys Ther Sci. 2015;27:401–3. Kepenek-Varol B, Gürses HN, İçağasıoğlu DF. Effects of Inspiratory Muscle and Balance Training in Children with Hemiplegic Cerebral Palsy: A Randomized Controlled Trial. Dev Neurorehabil. 2022;25:1–9. Nardon M, Ruzzante F, O’Donnell L, Adami A, Dayanidhi S, Bertucco M. Energetics of walking in individuals with cerebral palsy and typical development, across severity and age: A systematic review and meta-analysis. Gait Posture. 2021;90:388–407. Marticorena FM, Barreto GC, Guardieiro NM, Esteves GP, Oliveira TN, De Oliveira LF et al. Performing moderate to severe activity is safe and tolerable for healthy youth while wearing a cloth facemask. Boullosa D, editor. PLoS ONE. 2023;18:e0282475. Fikenzer S, Uhe T, Lavall D, Rudolph U, Falz R, Busse M, et al. Effects of surgical and FFP2/N95 face masks on cardiopulmonary exercise capacity. Clin Res Cardiol. 2020;109:1522–30. Pape H-C, Kurtz A, Silbernagl S, editors. Physiologie [Internet]. 9th ed. Stuttgart: Georg Thieme Verlag; 2019 [cited 2023 May 8]. p. b-006-163285. https://eref.thieme.de/ 10.1055/b-006-163285 . Zheng C, Poon ET-C, Wan K, Dai Z, Wong SH-S. Effects of Wearing a Mask During Exercise on Physiological and Psychological Outcomes in Healthy Individuals: A Systematic Review and Meta-Analysis. Sports Med. 2023;53:125–50. Vishwanath V, Favo CL, Tu TH, Anderson B, Erickson C, Scarpulla M, et al. Effects of face masks on oxygen saturation at graded exercise intensities. J Osteopath Med. 2023;123:167–76. Umutlu G, Acar NE, Sinar DS, Akarsu G, Güven E, Yildirim I. COVID-19 and physical activity in sedentary individuals: differences in metabolic, cardiovascular, and respiratory responses during aerobic exercise performed with and without a surgical face masks. J Sports Med Phys Fit. 2022;62:851–8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4435970","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":314403352,"identity":"1cfa45b7-4c72-494a-a93a-9c9fc3e52bd2","order_by":0,"name":"Turgay Altunalan","email":"data:image/png;base64,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","orcid":"","institution":"Karadeniz Technical University","correspondingAuthor":true,"prefix":"","firstName":"Turgay","middleName":"","lastName":"Altunalan","suffix":""},{"id":314403353,"identity":"56c42766-1d2e-42bf-ad45-5b410164a89b","order_by":1,"name":"Burhan Sancakdar","email":"","orcid":"","institution":"Uskudar University","correspondingAuthor":false,"prefix":"","firstName":"Burhan","middleName":"","lastName":"Sancakdar","suffix":""}],"badges":[],"createdAt":"2024-05-17 10:12:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4435970/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4435970/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59436759,"identity":"cbeae7d3-33ab-4eb4-8bd0-18da6c11b85b","added_by":"auto","created_at":"2024-07-01 19:16:26","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":170044,"visible":true,"origin":"","legend":"Physiological responses of 6-MWT with and without a surgical mask","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4435970/v1/4f48763072258f7849005f77.jpeg"},{"id":77194650,"identity":"5fe7a9d8-b09f-4ca9-8e80-8e98eba3161e","added_by":"auto","created_at":"2025-02-26 06:03:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":708766,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4435970/v1/fe25f57d-c2cd-42ba-8198-d585312833b5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effect of the surgical mask on functional exercise capacity in children with cerebral palsy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCerebral palsy (CP) is a permanent movement and postural disorder caused by nonprogressive damage to a child's developing brain before, during, and after birth [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Movement difficulties and postural misalignment are common in patients with cerebral palsy. These atypical alignments of the skeletal system adversely affect movement kinetics and cause more effort expenditure during movements [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Posture disorders also disturb respiratory muscle function and may cause more frequent and superficial breathing. Postural problems increase energy expenditure and reduce effective breathing [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Increased energy demand and decreased respiratory capacity in CP lead to decreased physical activity and endurance levels compared to their peers.\u003c/p\u003e \u003cp\u003eIn addition to the movement and postural difficulties of children with CP, the pandemic conditions also negatively affect their physical activity and endurance. When the coronavirus was first observed in China in late 2019, several rules were introduced, such as using masks and curfews. One of the rules affecting the daily routine is the obligation to wear masks in closed areas. Although the literature has shown that using masks can reduce the risk of respiratory viral infection by up to 80%, there may be a few adverse outcomes. The mask may cause temperature increase, irritation, breathing difficulty, and discomfort [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Masks increase inspiratory and expiratory resistance, and some exhaled carbon dioxide can be reinspired in the respiratory cycle, increasing respiratory frequency [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Furthermore, they may result in a fluctuation in oxygen saturation during physical exertion [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Masks that protect with an air filter are not suitable for use during sporting activities or exercise [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Using a mask during submaximal physical exertion has increased perceived exertion, dyspnea [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and fatigue [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. For this reason, examining the effects of masks in special populations, such as those with Cerebral Palsy, becomes even more critical.\u003c/p\u003e \u003cp\u003eThe literature has shown that using masks during rest or low-intensity physical activity has no adverse effect on respiration, gas exchange, endurance, perceived exertion, and dyspnea in healthy children and adults [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. However, there is a need to examine the effect of mask use on children with different risk groups [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. To the best of our knowledge, no studies have investigated the impact of mask use on functional exercise capacity and physiological responses in children with CP. The current study aims to investigate the effect of surgical masks while using submaximal exercises on functional exercise capacity, oxygen saturation, heart rate, and respiratory frequency in children with CP, highlighting their motor severity. The present study hypothesizes that physiological parameters will remain constant, whereas the 6-minute walking distance will be shortened because of the masked walk.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis is a single-center observational study of children with CP from Istanbul Beylikd\u0026uuml;z\u0026uuml; İlk Evin Special Education and Rehabilitation Center between January and February 2022. The study was applied by obtaining the ethics committee approval number 61351342/2268 from \u0026Uuml;sk\u0026uuml;dar University and adhered to the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eWe enrolled 20 children, 14 of whom were hemiplegic and six of whom were diplegic, aged between 6 and 18. The study included children who were able to follow and implement sequential commands. We excluded individuals with ataxia and dyskinesia subtypes to create a homogenous group. Children who could not follow instructions and had genetic and metabolic diagnoses were excluded from the study. Also, the study did not include children who described coughing, sore throats, or asthenia.\u003c/p\u003e \u003cp\u003e The written consent of the children was obtained through face-to-face interviews with them and their parents. Since the guidelines recommend using masks for children aged six and above, we excluded participants younger than 6 and [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. We enrolled children with the Gross Motor Classification Scale (GMFCS) I and II levels because walking tests are more feasible and accurate for high-motor-functioning children.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTest Protocol\u003c/h2\u003e \u003cp\u003eWe used the 6-MWT as a standard effort to investigate walking distance and physiological changes during walking with and without a mask. We used CE-certified latex-free L2 level and 3-ply surgical masks for children. Surgical masks at the L2 level had a particle filtration efficiency (PFE) of 94% [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eParticipants walked through a 10-meter-long corridor. First, the walk was performed without a mask and repeated with the mask at the same time for the next three days. The measurements were carried out on different days because the participants might get tired during the test. The test started with the \u0026lsquo;Start\u0026rsquo; command and ended with the \u0026lsquo;Stop\u0026rsquo; command. We instructed the participants to walk as fast as possible without running for six minutes. Walking distances were measured with a tape measure in meters, and walking time was measured with a stopwatch. The corridor length was multiplied by the number of laps, and the walking distances were determined in meters [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. All children in the study adhered to the protocol for the 6-minute walk test and completed the test.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcome Measures\u003c/h2\u003e \u003cp\u003eWe measured participants\u0026rsquo; O2 saturation, respiratory frequency, and heart rate before and after the 6-MWT was completed.\u003c/p\u003e \u003cp\u003eThe 6-MWT is a test published by the American Thoracic Society that is easy to administer, tolerable, and reflects daily activities. It is a self-controlled measure of functional exercise capacity. It is considered the gold standard submaximal exercise test to assess aerobic capacity and endurance [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This test measures the longest distance walked in 6 minutes at walking speed. It can be applied to children with the typical development and diagnosis of CP. Tabulations of expected walking distances by age for children between GMFCS I-III have been published [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePulse oximetry is a noninvasive, painless, and reliable method to measure arterial blood's transcutaneous oxygen saturation (tcSO2). We measured HR and tcSO2 using a handheld pulse oximeter (Slyfox C03 model) placed on the index finger of the patient's right hand. Transcutaneous oxygen saturation and heart rate (HR) were measured before (baseline) and after 6-MWT.\u003c/p\u003e \u003cp\u003eRespiratory rate is defined as the number of breaths per minute. We measured respiratory rate by recording chest oscillation in 1 minute based on visual observation and palpation of the chest wall along the upper abdominal region. We used a digital clock to determine the 1-minute breathing interval [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe calculated the effect size based on previous studies showing 60 m mean differences for 6-MWT [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. We calculated that 18 individuals should be included with an effect size of 1.1, 95% confidence interval, and 80% power. Considering the possibility of participants dropping out, we included 20 participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using SPSS version 25.0 (IBM SPSS Statistics for Windows, IBM Corp, Armonk, NY, USA). We used the frequency, percentage, arithmetic mean, standard deviation, and distribution width to analyze the demographics. Walking distances of masked and unmasked participants were analyzed using a paired t-test as they fit the normal distribution. Oxygen saturation, heart rate, and respiratory frequency were calculated by paired t-test and reported by trend figure to show their differences before and after walking. The significance level was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Cohen-d was used in the effect size analysis. The effect size calculation was considered 0.2\u0026thinsp;\u0026ge;\u0026thinsp;small effect, 0.5\u0026thinsp;\u0026ge;\u0026thinsp;medium effect, 0.8\u0026thinsp;\u0026ge;\u0026thinsp;large effect.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTwenty participants completed the 6-minute walk test, both masked and unmasked. Only over half of the participants were male. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the participants' age, gender, severity of motor impairments, and motor impairment types. All the participants' movement disorders were spasticity.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic information of the participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGMFCS I\u003c/p\u003e \u003cp\u003e(n:12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGMFCS II\u003c/p\u003e \u003cp\u003e(n:8)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u0026ndash;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n:6)\u003c/p\u003e \u003cp\u003e8.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(n:1)\u003c/p\u003e \u003cp\u003e7.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(n:7)\u003c/p\u003e \u003cp\u003e8.14\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n:6)\u003c/p\u003e \u003cp\u003e15.33\u0026thinsp;\u0026plusmn;\u0026thinsp;2.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(n:7)\u003c/p\u003e \u003cp\u003e16.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(n:13)\u003c/p\u003e \u003cp\u003e15.69\u0026thinsp;\u0026plusmn;\u0026thinsp;2.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18.06\u0026thinsp;\u0026plusmn;\u0026thinsp;2.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.54\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.65\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMotor Disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpasticity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTopographic Classification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHemiplegia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiplegia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (83.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eBMI: Body Made Index, GMFCS: Gross motor function classification system.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe analyzed walking distances in two subgroups according to age: 6\u0026ndash;11 and 12\u0026ndash;18. In both age groups, the average distance of masked walking was 10 and 8% lower than that of unmasked walkers, with medium and small effect sizes, respectively. However, this difference was statistically significant only in the 6\u0026ndash;11 age and total sample groups. Mean walking distances according to the severity of motor impairment in both age groups are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWalking Distance with and without Mask\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6-MWT distance\u003c/p\u003e \u003cp\u003e(meter)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMasked\u003c/p\u003e \u003cp\u003eM (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnmasked\u003c/p\u003e \u003cp\u003eM (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDifference\u003c/p\u003e \u003cp\u003eM - %\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCohen d\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;11 ages, n:7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGMFCS I (n:6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e235.75\u0026thinsp;\u0026plusmn;\u0026thinsp;50.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e258.00\u0026thinsp;\u0026plusmn;\u0026thinsp;63.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.25\u0026ndash;8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.386\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGMFCS II (n:1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e195.00\u0026thinsp;\u0026plusmn;\u0026thinsp;NA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e257.91\u0026thinsp;\u0026plusmn;\u0026thinsp;NA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal (n:7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e229.92\u0026thinsp;\u0026plusmn;\u0026thinsp;48.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e257.85\u0026thinsp;\u0026plusmn;\u0026thinsp;58.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.92\u0026ndash;10%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.039*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.520\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u0026ndash;18 ages, n:13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGMFCS I (n:6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e335.81\u0026thinsp;\u0026plusmn;\u0026thinsp;82.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e351.75\u0026thinsp;\u0026plusmn;\u0026thinsp;66.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.93\u0026ndash;4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.212\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGMFCS II (n:7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e210.14\u0026thinsp;\u0026plusmn;\u0026thinsp;42.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e243.71\u0026thinsp;\u0026plusmn;\u0026thinsp;56.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.56\u0026ndash;13%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.672\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal (n:13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e268.14\u0026thinsp;\u0026plusmn;\u0026thinsp;88.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e293.57\u0026thinsp;\u0026plusmn;\u0026thinsp;81.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.42\u0026ndash;8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.298\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal (n:20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e254.77\u0026thinsp;\u0026plusmn;\u0026thinsp;77.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e281.07\u0026thinsp;\u0026plusmn;\u0026thinsp;74.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.30\u0026ndash;9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.013*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.345\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eGMFCS: Gross motor function classification system, M: Mean, 6-MWT: Six minute walking test, *P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe trend changes in participants' saturation, heart rate, and respiratory frequency during masked and unmasked walking were parallel and not significantly (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) different (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first study to examine the effects of surgical mask use during submaximal exercise on walking distance and physiological responses in children with CP. Our study showed that the walking distance decreased significantly with a surgical mask in children with CP. However, physiological responses were similar when masked and unmasked walking were compared.\u003c/p\u003e \u003cp\u003eDue to reduced physical activity opportunities as a result of the pandemic, children with cerebral palsy are likely to have reduced walking endurance. In our study, unmasked 6-MWT distances were approximately 100 meters shorter than the pre-pandemic literature [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The current study was carried out during the pandemic period. Closing schools and rehabilitation centers and restricting leisure activities [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] during this period may have negatively affected their physical activity level and endurance [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. It can be posited that the functional cardiorespiratory capacity of children with cerebral palsy decreased during the pandemic period. It can be considered that children with cerebral palsy may be more sensitive to physical activity with a mask.\u003c/p\u003e \u003cp\u003eThe masked walking distance was significantly shorter than the unmasked walking distance in our study. This difference may be explained by increased perceived effort or discomfort during masked walking [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Furthermore, using a surgical mask increases the resistance encountered during inspiration and expiration [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The increased perceived exertion and inspiratory and expiratory resistance may have contributed to reduced walking distance with masks in children with CP. In contrast, the existing literature indicates no significant reduction in submaximal exercise capacity with wearing a surgical mask in typically developing children [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The divergent outcomes observed between typical children and those with CP may be attributed to the reduced cardiorespiratory and musculoskeletal fitness in children with CP. Children with CP exhibit a reduced cardiorespiratory capacity and a higher respiratory rate and surface ventilation when compared to typically developing children [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Children with CP are at an increased risk of developing musculoskeletal disorders, including contractures, atypical postures, balance problems, and misalignments. These findings have been well documented to be associated with low gait performance and require high energy expenditure [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The decreased performance of children with CP during submaximal masked exercise can be attributed to these specific characteristics of these children.\u003c/p\u003e \u003cp\u003eOur study found no significant differences in oxygen saturation, heart rate, and respiratory frequency between masked and unmasked walking. Consistent with our research, the literature shows that physiological responses do not change significantly during submaximal masked exercise. The use of face masks during moderate to vigorous physical activity in healthy children has a small and physiologically tolerable effect on respiratory and hemodynamic parameters [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The ventilation was physiologically managed using feedback loops. A decrease in partial oxygen pressure increases heart rate and minute ventilation [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. This theoretical information suggests that using a mask may increase the volume of carbon dioxide, which in turn may increase hemodynamic indicators. However, the existing literature on typically developing children and our study indicated that the physiological responses during submaximal physical exertion with a mask did not change significantly or in a clinically meaningful way [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. It is important to note that there is evidence from some studies indicating that the use of N95 and surgical masks at increased exertion can result in changes to cardiac and respiratory parameters. However, these changes are within the safety range of [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study has some limitations. The nature of our research makes it challenging to objectively assess oxygen consumption when wearing a mask, as the mask must be worn over the mask itself. If we had also measured perceived exertion and dyspnea in our study, we could have more comprehensively discussed the decrease in the 6-MWT distance. Although the post-power test indicated that our sample group was sufficient, our case number was limited for the complete representation of the sub-dimensions of CP. We measured oxygen saturation, respiratory frequency, and heart rate before and after submaximal activity. Further studies suggest that these data be measured during activity as well. Since we did not know the participants' physical activity levels, it was impossible to discuss the effect of mask use on submaximal activity in active and sedentary children with CP. We recommend evaluating children's physical activity levels in future studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, masked submaximal walking distances can be significantly reduced by up to 13% in children with CP at GMFCS levels I and II. However, wearing a mask during submaximal activity did not significantly change physiological parameters such as oxygen saturation, respiratory frequency, and heart rate. Our study's findings indicate that using surgical masks during submaximal physical activity in children with CP is safe in physiological parameters. However, a reduction in physical performance may be observed. The results of the current study may support clinicians in the decision about submaximal exercise effort level with a surgical mask in children with CP in situations such as pandemics, air pollution, and respiratory infections. In future studies, we recommend investigating the effects of mask use in more severely affected children, such as those with GMFCS III, IV, and V.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eAuthor contributions statement\u003c/h2\u003e \u003cp\u003eT.A. and B.S. conducted the research design, participated in collecting data, and drafted the manuscript. B.S. conceived the experiment. T.A. and B.S. analysed the results interpretation of the data and drafted the manuscript. All authors reviewed the manuscript.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThe study was applied by obtaining the ethics committee approval number 61351342/2268 from \u0026Uuml;sk\u0026uuml;dar University and adhered to the Declaration of Helsinki. All participants provided a signed informed consent form before enrolled the study. All methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eT.A. and B.S. conducted the research design, participated in collecting data, and drafted the manuscript. B.S. conceived the experiment. T.A. and B.S. analysed the results interpretation of the data and drafted the manuscript. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank the children and their parents who volunteered to participate in the study.\u003c/p\u003e\u003ch2\u003eData availability statement\u003c/h2\u003e \u003cp\u003eThe data that support the findings of this study are available from the corresponding author, [T. A.], upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRosenbaum P, Paneth N, Leviton A, Goldstein M, Bax M, Damiano D, et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol Suppl. 2007;109:8\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwon YH, Lee HY. Differences of respiratory function according to level of the gross motor function classification system in children with cerebral palsy. J Phys Ther Sci. 2014;26:389\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShin H-K, Byeon E-J, Kim SH. Effects of seat surface inclination on respiration and speech production in children with spastic cerebral palsy. J Physiol Anthropol. 2015;34:17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaxena S, Kumaran S, Rao BK. Energy expenditure during standing in children with cerebral palsy: A brief report1. J Pediatr Rehabil Med. 2016;9:241\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Uuml;nal ZB, G\u0026ouml;k\u0026ccedil;en \u0026Ouml;, Yazar S, \u0026Uuml;nal ZB. Research Surgial Masks and Use of Masks in Children. TJFDM. 2021;3:11\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTate E, Wylie K, Moss JD. The effects of face masks on emotional appraisal ability of students with autism spectrum disorder. IJDD. 2023;1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLazzarino AI, Steptoe A, Hamer M, Michie S. Covid-19: Important potential side effects of wearing face masks that we should bear in mind. BMJ. 2020;369:m2003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorgi C, Haase-Fielitz A, Meretz D, G\u0026auml;sert L, Butter C. The Impact of Commonly-Worn Face Masks on Physiological Parameters and on Discomfort During Standard Work-Related Physical Effort. Dtsch Arztebl Int. 2020;117:674\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSwiatek KM, Lester C, Ng N, Golia S, Pinson J, Grinnan D. Impact of Face Masks on 6-Minute Walk Test in Healthy Volunteers. Pulm Circ. 2021;11:2045894020988437.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShaw KA, Zello GA, Butcher SJ, Ko JB, Bertrand L, Chilibeck PD. The impact of face masks on performance and physiological outcomes during exercise: a systematic review and meta-analysis. Appl Physiol Nutr Metab. 2021;46:693\u0026ndash;703.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDressler T, Stoff J, Di Pietro T, Cavadini GB, B\u0026uuml;sser G, B\u0026uuml;sser X et al. Masks For Sports: Development project of protective respiratory masks for ice hockey teams during the COVID-19 pandemic [Internet]. ETH Zurich; 2020 Aug p. 14 p. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://hdl.handle.net/20.500.11850/432255\u003c/span\u003e\u003cspan address=\"http://hdl.handle.net/20.500.11850/432255\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEpstein D, Korytny A, Isenberg Y, Marcusohn E, Zukermann R, Bishop B, et al. Return to training in the COVID-19 era: The physiological effects of face masks during exercise. Scand J Med Sci Sports. 2021;31:70\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLubrano R, Bloise S, Marcellino A, Ciolli CP, Testa A, De Luca E, et al. Effects of N95 Mask Use on Pulmonary Function in Children. J Pediatr. 2021;237:143\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMajek P, Kaleta-Pilarska A, Barański K. The use of protective masks and the level of arterial oxygen saturation at rest and after exercise. Med Pr. 2022;73:363\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEberhart M, Orthaber S, Kerbl R. The impact of face masks on children-A mini review. Acta Paediatr. 2021;110:1778\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaRue RJ, Morkus P, Laengert S, Rassenberg S, Halali MA, Colenbrander JW, et al. Navigating Performance Standards for Face Mask Materials: A Custom-Built Apparatus for Measuring Particle Filtration Efficiency. Glob Chall. 2021;5:2100052.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoucault R, Fernandes M, Oliveira Carvalho V. Six-minute walking test in children. Disabil Rehabil. 2013;35:1586\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnright PL. The six-minute walk test. Respir Care. 2003;48:783\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFitzgerald D, Hickey C, Delahunt E, Walsh M, O\u0026rsquo;Brien T. Six-Minute Walk Test in Children With Spastic Cerebral Palsy and Children Developing Typically. Pediatr Phys Ther. 2016;28:192\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaPier TK, Cook A, Droege K, Oliverson R, Rulon R, Stuhr E, et al. Intertester and Intratester Reliability of Chest Excursion Measurements in Subjects Without Impairment. CPTJ. 2000;11:94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakken T, Bongers BC, van Brussel M, Haapala EA, Hulzebos EHJ. Cardiopulmonary Exercise Testing in Pediatrics. Ann Am Thorac Soc. 2017;14:S123\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeles MN, Elbasan B, Apaydin U, Aribas Z, Bakirtas A, Kokturk N. Effects of inspiratory muscle training in children with cerebral palsy: a randomized controlled trial. Braz J Phys Ther. 2018;22:493\u0026ndash;501.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFiss AL, Jeffries L, Bjornson K, Avery L, Hanna S, Westcott McCoy S. Developmental Trajectories and Reference Percentiles for the 6-Minute Walk Test for Children With Cerebral Palsy. Pediatr Phys Ther. 2019;31:51\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartakis K, Stark C, Rehberg M, Semler O, Duran I, Schoenau E. Reference Centiles to Monitor the 6-minute-walk Test in Ambulant Children with Cerebral Palsy and Identification of Effects after Rehabilitation Utilizing Whole-body Vibration. Dev Neurorehabil. 2021;24:45\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSedaghati P, Balayi E, Ahmadabadi S. Effects of COVID-19 related physical inactivity on motor skills in children with intellectual disability. BMC Public Health. 2022;22:2381.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhaskar AR, Gad MV, Rathod CM. Impact of COVID Pandemic on the Children with Cerebral Palsy. Indian J Orthop. 2022;56:927\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReychler G, Standaert M, Audag N, Caty G, Robert A, Poncin W. Effects of surgical facemasks on perceived exertion during submaximal exercise test in healthy children. Eur J Pediatr. 2022;181:2311\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmart NR, Horwell CJ, Smart TS, Galea KS. Assessment of the Wearability of Facemasks against Air Pollution in Primary School-Aged Children in London. Int J Environ Res Public Health. 2020;17:3935.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee HP, Wang DY. Objective assessment of increase in breathing resistance of N95 respirators on human subjects. Ann Occup Hyg. 2011;55:917\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwon YH, Lee HY. Differences in respiratory pressure and pulmonary function among children with spastic diplegic and hemiplegic cerebral palsy in comparison with normal controls. J Phys Ther Sci. 2015;27:401\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKepenek-Varol B, G\u0026uuml;rses HN, İ\u0026ccedil;ağasıoğlu DF. Effects of Inspiratory Muscle and Balance Training in Children with Hemiplegic Cerebral Palsy: A Randomized Controlled Trial. Dev Neurorehabil. 2022;25:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNardon M, Ruzzante F, O\u0026rsquo;Donnell L, Adami A, Dayanidhi S, Bertucco M. Energetics of walking in individuals with cerebral palsy and typical development, across severity and age: A systematic review and meta-analysis. Gait Posture. 2021;90:388\u0026ndash;407.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarticorena FM, Barreto GC, Guardieiro NM, Esteves GP, Oliveira TN, De Oliveira LF et al. Performing moderate to severe activity is safe and tolerable for healthy youth while wearing a cloth facemask. Boullosa D, editor. PLoS ONE. 2023;18:e0282475.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFikenzer S, Uhe T, Lavall D, Rudolph U, Falz R, Busse M, et al. Effects of surgical and FFP2/N95 face masks on cardiopulmonary exercise capacity. Clin Res Cardiol. 2020;109:1522\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePape H-C, Kurtz A, Silbernagl S, editors. Physiologie [Internet]. 9th ed. Stuttgart: Georg Thieme Verlag; 2019 [cited 2023 May 8]. p. b-006-163285. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://eref.thieme.de/\u003c/span\u003e\u003cspan address=\"https://eref.thieme.de/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/b-006-163285\u003c/span\u003e\u003cspan address=\"10.1055/b-006-163285\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng C, Poon ET-C, Wan K, Dai Z, Wong SH-S. Effects of Wearing a Mask During Exercise on Physiological and Psychological Outcomes in Healthy Individuals: A Systematic Review and Meta-Analysis. Sports Med. 2023;53:125\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVishwanath V, Favo CL, Tu TH, Anderson B, Erickson C, Scarpulla M, et al. Effects of face masks on oxygen saturation at graded exercise intensities. J Osteopath Med. 2023;123:167\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUmutlu G, Acar NE, Sinar DS, Akarsu G, G\u0026uuml;ven E, Yildirim I. COVID-19 and physical activity in sedentary individuals: differences in metabolic, cardiovascular, and respiratory responses during aerobic exercise performed with and without a surgical face masks. J Sports Med Phys Fit. 2022;62:851\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cerebral palsy, masks, physical endurance, walk test, heart rate, oxygen saturation","lastPublishedDoi":"10.21203/rs.3.rs-4435970/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4435970/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe current study focused on children with cerebral palsy (CP) and aimed to evaluate the effects of using a surgical mask during submaximal exercise on functional exercise capacity and physiological responses. This single-center observational study enrolled 20 children with CP (12 boys and eight girls) between the ages of 6 and 18 years. Participants performed 6-minute walk tests (6-MWT) with and without a surgical mask on different days. We recorded walking distance, oxygen saturation, heart rate, and respiratory rate before and immediately after the end of the 6-MWT with and without the mask. The mean walking distance was significantly (p=0.013, Cohen’s-d=0.345) shorter with the surgical mask, 254.77±77.83 and 293.57±81.27 without a mask. There were no significant differences in O2 saturation, heart rate, and respiratory rate after the 6-MWT with or without a mask. Using a surgical mask significantly reduced the walking distance by up to 13% in children with CP, with no significant changes in physiological responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number: \u003c/strong\u003eWe did not apply for the clinical trial number. If it is mandatory, we can apply retrospectively.\u003c/p\u003e","manuscriptTitle":"The effect of the surgical mask on functional exercise capacity in children with cerebral palsy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-01 19:16:21","doi":"10.21203/rs.3.rs-4435970/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3d6527ff-0cdf-4b2e-9c85-81da083ed7ad","owner":[],"postedDate":"July 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-26T05:53:41+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-01 19:16:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4435970","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4435970","identity":"rs-4435970","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}