Análisis comparativo de la coordinación motora gruesa en niños con sobrepeso / obesidad y eutróficas

fm Fisioterapia em Movimento Fisioter. mov. 1980-5918 Pontifícia Universidade Católica do Paraná Resumen Introducción: Niños con sobrepeso/obesidad pueden tener menores escores de coordinación motora, comparados a las eutróficas. Objetivo: Comparar la coordinación motora gruesa entre escolares con sobrepeso/obesidad y eutróficos, y analizar factores asociados a coordinación motora. Método: Este estudio transversal incluyó niños de 6-9 años, de ambos géneros. Se excluyeron: niños con malformaciones congénitas, deformidades osteomioarticulares, trastornos neurológicos o IMC < -2 escore-z. Se evaluó la coordinación motora gruesa por las pruebas Körperkoordinations test für Kinder (KTK). Factores asociados a los escores de coordinación motora fueron analizados por regresión lineal. Resultado: Las medias de los escores en la marcha hacia atrás (84,2 ± 13,2 vs. 91,0 ± 15,0), saltos monopedales (127,9 ± 10,1 vs. 132,3 ± 12,1, transferencia en plataformas (123,5 ± 23,4 vs. 129,8 ± 14,9) y escore global (112,5 ± 14,8 vs. 118,8 ± 11,6) fueron significativamente menores (p < 0,05) en niños con sobrepeso/obesidad, comparados a las eutróficas. El porcentaje de alumnos con escore motor deficiente (< 85) fue mayor en sobrepeso/obesidad en la marcha hacia atrás (60,4% vs. 36,4%, p = 0,004) y similares en los saltos laterales (18,8% vs. 9,9%, p = 0,116) y transferencia lateral (6,3% vs. 0,8%, p = 0,070). En el análisis de regresión lineal múltiple, las variables sobrepeso/obesidad y práctica de deporte < 2 veces/semana redujeron significantemente (p < 0,05) el puntaje motor global en 18,7 y 15,6 puntos, respectivamente. Conclusiones: Niños con sobrepeso/obesidad presentaron menores escores de coordinación motora que las eutróficas. Sobrepeso/obesidad y baja frecuencia de actividad física se asociaron a menores escores de coordinación motora gruesa. Introduction Global estimates show that the prevalence of overweight/obesity among children has increased from 4.2%, in 1990, to 6.7%, in 2010. Moreover, in 2010 there were approximately 43 million overweight/obese children worldwide, of whom 35 million resided in developing countries 1. Obese children and adolescents frequently show a higher frequency of physical and psychological comorbidities 2, such as arterial hypertension, diabetes, insulin resistance, dyslipidemias, coronary diseases, and sleep disorders 3), (4. Furthermore, Utesch et al. 5 pointed out that overweight/obese children had greater difficulty, both in motor skills and in the future, and were less prone to a physical activity routine. Another study conducted with 165 children showed worse scores for abdominal activities, balance, and 6-minute walk test among children with severe obesity when compared to their eutrophic pairs 6. According to Liang et al. 7, obese subjects have twice as many motor difficulties as their normal-weight counterparts. In childhood and adolescence obesity may also affect the neurocognitive functions, such as cognitive processing speed, speech, learning, memory, attention, and visual and spatial performance 7), (8. In this sense, the literature points out that poor motor coordination, not only negatively affects normal motor development, but may also influence the development of academic activities and peer interaction in social and physical activities 9), (10. Although the knowledge that motor disorders may interfere with the academic or daily life activities, there are few studies in gross and fine motor coordination, specially using the KTK test in obese schoolchildren 11. In this context, this study aimed to compare gross motor coordination between overweight/obese and normal-weight children, as well as to investigate associated factors with the gross motor coordination scores. Methods This is a cross-sectional study with a convenience sample of 6-9-year-old children, of both genders, enrolled at two public schools in Itabuna, BA, Brazil. Exclusion criteria were congenital malformations, bone, muscle, and joint deformities, neurological disorders that prevented test performance, and the body mass index (BMI) z-score for age below -2, classified by the World Health Organization (WHO) 12 as underweight or severe underweight. The motor coordination was assessed by the “Körperkoordinationstest für Kinder” (KTK) [Body Coordination Test for Kids] 13), (14. This test is composed by the following subtests: 1) balancing backwards over three progressively narrow boards (6 cm, 4.5 cm, and 3 cm wide) and walking up to 8 steps. Three valid trials were recorded. Participants were not allowed to touch the floor with their feet during the test. 2) Hoppingon one foot over rectangular foam rubber mats (50 cm x 20 cm x 5 cm each), placedon top of each other. The maximum height was 60 cm. The right and left legs were tested separately, and subjects were allowed three trials. 3) Jumping sideways as fast as possible with both feet together over a lath on the floor in two sets of 15 seconds. 4) Shifting platforms sidewise. The child had to stand on one platform and move the other identical platform to the opposite side, using both hands, then move sideways to the other platform and repeat this procedure as often as possible for two sets of 20 seconds 13), (14 (Figure 1). Figure 1 1A: balancing backwards; 1B: hopping over on one foot; 1C: jumping sideways; 1D/1E: shifting platforms. The overall objective of the KTK is to measure the degree of motor deficit for the activities of balance, rhythm, laterality, speed, and agility. The balancing backwards measures the child’s degree of stability in backward movement; hopping over on one foot assesses lower limb coordination and dynamic energy / strength; jumping sideways measures the velocity; and the shifting platforms sidewise measures laterality and spatiotemporal structuration 10. The KTS tests were applied for the participant children after the researcher had instructed and demonstrated the trial. The motor scores for each test, as well as that for the overall motor score, were calculated according to the test guidelines 14 and classified as normal if above 85 points, and as low motor performance when less than or equal to 85 14. The KTS test is widely used in Germany, and in other countries, by many healthcare professionals, being specially applied by physical educators 9), (15. In Brazil, the KTS test was validated by Gorla et al. 14 and has been used to assess gross motor coordination in 5-14-year-old children 16), (17. In this study, the children’s weight was measured wearing light clothes and no footwear, on a Welmy analog scale (model R-110, series 11953) with precise 100 g and variation of 2 to 150 Kg. Each child’s height was measured with a stadiometer (Nutri Vida, São Paulo, SP, Brazil), with intervals of 0.5 cm between the set values. Overweight was defined as a BMI z-score greater or equal to 1 and less than 2, and obesity was stated when BMI z-score was equal or greater than 2 12. At the baseline, the following information was collected: sociodemographic and anthropometric data, and frequency of physical activity outside of the school schedule per week. The Research Ethics Committee of the Federal University of São Paulo (#238.369) approved this study. At the start of the study, all parents or legal guardians were asked to give a written informed consent, as well as all children. Statistical Analysis Numerical variables were expressed as mean ± standard deviation or median (range). Normally distributed variables were compared by the t test, otherwise the Mann-Whitney U test was used. Categorical variables were expressed as number (percentage) and compared by the chi-square test or by the Fisher’s exact test. Factors that could potentially be associated with lower motor coordination score were examined with the univariate and the multiple linear regression analyses. First the researchers of this study performed a univariate analysis of the clinical variables that could possibly be associated with the motor scores. Variables with statistical significance below 0.20 upon univariate and regression analysis (except for the collinear variables with the same clinical significance) were included in the multivariate analysis. All analyses were conducted using the SPSS for Win/v.17.0 (IBM SPSS Statistics, Somers, NY). The level of significance was set at 5%. Results At the time of the study, 225 children aged 6-9 years were enrolled in the two biggest schools of Itabuna that agreed to participate in the study. Thirty-two (82.1%) of 45 enrolled students in school A and 137 (81.1%) of 180 enrolled students in school B were included in the sample. Of 225 children, 17 (7.6%) fulfilled the exclusion criteria, and 208 (92.4%) children met the inclusion criteria. Of these, 39 (18.8%) students did not agree to participate; thus, the final study sample was composed of 169 (81.3%) students. The mean age of the sample was 8.1 ± 1.2 years old (range = 6.0 - 9.9) and 85 of the studied sample (50.3%) were male. One hundred and twenty-one children (71.6%; 95%CI: 64.4 - 77.9%) were normal-weight, 29 of them (17.2%; 95%CI: 12.2 - 23.6%) were overweight, and 19 of them (11.2%; 95%CI: 7.3 - 16.9%) were obese. For comparison purposes, the children were divided into two groups: normal-weight (n = 121) and overweight/obese (n = 48). Both groups had similar age (8.2 ± 1.3 vs. 8.0 ± 1.2, p = 0.770) and male gender participation (52.1 vs. 49.6%, p = 0.182). But the two groups had different weight (36.6 ± 8.4 vs. 25.8 ± 4.5kg, p < 0.001) and BMI z-score (1.9 ± 0.7 vs. -0.3 ± 0.8, p < 0.001). Practice of physical activity for at least twice a week was similar for both the overweight/obese and the normal-weight groups (87.5% vs. 80.2%, p = 0.260). The mean motor quotient for hopping over on one foot (127.9 ± 10.1 vs. 132.3 ± 121.1 ± 12.1, p = 0.027), balancing backwards (84.2 ± 13.2 vs. 91.0 ± 15.0, p = 0.027), and shifting platforms sidewise (123.5 ± 23.4 vs. 129.8 ± 14.9, p = 0.038) subtests, as well as for the overall test scores (112.5 ± 14.8 vs. 118.8 ± 11.6, p = 0.04) were significantly lower for the overweight/obese compared to the eutrophic group. There were no significant differences in the jumping sideways subtest or in the maximum height of obstacles in the hopping over on one foot subtest (Table 1). Table 1 Means and standard deviations of the motor quotients of the performed tests according to the nutritional status Overweight/obese (n = 48) Eutrophic (n = 121) p MQ jumping sideways 103.5 ± 16.4 105.8 ± 16.1 0.399 MQ hopping over on one foot 127.9 ± 10.1 132.3 ± 12.1 0.027 MQ balancing backwards 84.2 ± 13.2 91.0 ± 15.0 0.007 MQ shifting platforms 123.5 ± 23.4 129.8 ± 14.9 0.038 MQ overall score 112.5 ± 14.8 118.8 ± 11.6 0.004 Note: MQ: motor quociente score; p value: t test. The percentage of children with altered overall motor coordination (score < 85) was higher in the overweight/obese group than in the eutrophic group (4.2% vs. 0%, p = 0.005). When compared to their normal-weight counterparts, the overweight/obese students showed a higher frequency of altered gross motor coordination (MQ < 85) during the balancing backwards subtest (60.4% vs. 36.4%, p = 0.004), and greater likelihood of deficits on the shifting platforms sidewise subtest (6.3% vs. 0.8%, p = 0.070). Both groups had similar scores on the jumping sideways subtest (18.8% vs. 9.9%, p = 0.116). None of the students had altered motor function on the hopping over on one foot subtest. Sports practice for less than two times per week, compared to more than two times per week, scored less in jumping sideways (140.0 ± 15.6 vs. 110.5 ± 17.7, p = 0.045), and in the overall score (116.0 ± 12.8 vs. 121.8 ± 12.6, p = 0.025), respectively (Table 2). Table 2 Mean and standard deviations of the motor quotients of the performed tests according to the level of physical activities Sports < 2 times/week (n = 139) Sports > 2 times/week (n = 30) p QM jumping sideways 104.0 ± 15.6 110.5 ± 17.7 0.045 QM hopping over on one foot 130.5 ± 11.8 133.3 ± 1 2.0 0.226 QM balancing backwards 88.3 ± 14.6 92.8 ± 15.7 0.232 QM shifting platforms 127.4 ± 18.6 131.0 ± 14.0 0.307 QM overall score 116.0 ± 12.8 121.8 ± 12.6 0.025 Note: MQ: motor quociente score; p value: t-test Male and female children showed similar mean motor quotient for hopping over on one foot (130.7 ± 11.5 vs. 131.3 ± 12.0, p = 0.743), balancing backwards (88.5 ± 13.1 ± 89.6 ± 16.5, p = 0.649), and shifting platforms sidewise (129.1 ± 18.4 vs. 126.9 ± 17.3, p = 0.427) subtests, as well as for the overall test scores (72.3 ± 22.1 vs. 83.4 ± 19.5, p = 0.112). However, for jumping sideways (110.5 ± 14.5 vs. 99.8 ± 16.0, p < 0.001), boys presented higher mean score than girls. By linear univariate analysis, the associated factors with lower overall motor coordination scores were from the overweight/obese group, BMI, BMI-z-score, and practice of sports for less than two times a week (Table 3). Table 3 Univariate linear regression analysis for associated factors with the overall motor scores Beta CI 95% p Female −11.264 −23.338 to 0.810 0.067 Overweight/obesity −19.843 −33.021 to -6.664 0.003 BMI (kg/cm2) −3.510 −5.481 to -1.540 0.001 BMI z-score −5.196 −9.869 to -0.524 0.030 Sports for < 2 times/week −17.489 −33.223 to -1.756 0.030 After excluding collinear variables and adjusting them for gender, overweight/obesity, and sports for < 2 times/week, the associated factors with overall motor coordination scores were overweight/obesity and practice of sports for less than twice a week (Table 4). Table 4 Multiple linear regression analysis for associated factors with the overall motor scores Beta 95%CI p Overweight/obesity −18.700 −31.813 to -5.587 0.005 Sports for < 2 times/week −15.579 −31.055 to -0.103 0.049 Note: Adjusted for gender. Overweight/obesity and Sports for < 2 times/week. Conclusion This study showed a high frequency of overweight/obese children and also low level of physical activity outside the school, compared to the 6.7%worldwide prevalence of childhood overweight and obesity (95%CI: 5.6%, 7.7%) in 2010 1. The overweight/obese children presented lower overall motor coordination scores and lower scores than the eutrophic scholars in the followings sub-tests: hopping over on one foot, balancing backwards, and shifting platform sidewise. The motor coordination lowest score was found in the overweight/obese children with physical activity for less than twice a week. This study showed that except the jumping sideways subtest, the overweight/obese children presented lower motor coordination scores in all KTK subtests. In addition, there were higher percentage of overweight/obese children with altered scores of overall gross motor coordination and balancing backwards subtest compared to the normal-weight students. This performance of overweight/obese children on the KTS test may suggests that they have, compared to eutrophic children, lower motor coordination and dynamic energy, lower stability during movement, and lower degree of laterality and spatiotemporality. These results agree to other studies referring that overweight/obesity is associated with the delayed motor development in children 18), (19, and when compared to normal-weight children, obese children have significantly lower motor performance and tend to be less skilled in related tasks involving support, propulsion, and movement 20. Likewise, a study with 6-9-year-olds and 13-year-olds showed that overweight/obese children had, respectively, 5.2 and 5.4 greater chance to present lower motor development scores than normal-weight children 21. This reinforces the finding that the BMI increase affects normal motor patterns and flexibility 21. Furthermore, a study with 1,276 children showed significantly lower scores on all KTK subtests in the overweight/obese children compared to their normal-weight counterparts 22. In this study, multiple linear regression analysis showed that the overall motor coordination score was negatively associated with overweight/obesity and practice of sports for less than twice a week. As well as Henrique et al. 23) showed, motor coordination in children assessed by the KTK test was negatively associated with subcutaneous fat, higher BMI, and lower scores in physical fitness tests. Also, Freitas et al. 24 found that the BMI increase had a negative impact on the acquisition of coordination and essential motor skills, assessed by the KTK tests. Regarding physical activity, as in this study, Morrison et al. 25) reported that children with high body fat percentages and low levels of physical activity showed worse motor performance. Another study evaluated 794 children and concluded that low levels of physical activity were negatively associated with motor ability between the overweight/obese groups 26. Despite the well-recognized benefits of physical activity on motor development, adherence to it was extremely low in this study. Over 80% of the children performed physical activity at least twice a week at school, but only 20% performed physical activity outside the school environment. As for the influence of physical activity on motor development, it is widely known that overweight children may experience motor difficulties that limit their participation in physical activity 27. This may cause children to prefer a sedentary life to an active life and is directly associated with impaired development of motor skills 19. This suggests that an early intervention program to control weight would benefit these children. Pona et al. 28 reported that after a program to control weight a significant interaction between child age and time of intervention revealed that younger children exhibited greater decreases in z-score body mass index over the treatment compared to older children. In this study, the linear regression analysis showed that females and males presented similar overall KTK performance, only with a higher mean score in jumping sideways for boys than for girls. The literature is controversial regarding children’s gender-related motor performance. A study with 2,470 children from 26 German schools showed that girls had better performance than boys on the balancing backwards and on the hopping over on one foot subtests, and no statistically significant differences on the jumping sideways and on the shifting platforms sidewise subtests 9. A previous study that used the KTK on 627 children aged from 5 to 6 years found no differences in motor skills between males and females 29. However, another study showed that boys had 1.72 more chance of motor discoordination than girls when walking in the cross bars 30. Lopes et al. 31 evaluated 7175 overweight/obese and eutrophic children aged from 6 to 14 years with the KTK and concluded that regardless of gender, overweight/obese children had lower motor development scores when compared to the eutrophic group. The motor development of the sample was positively associated with the children’s level of physical activity, while the opposite was associated with the concomitant BMI increase, especially observed in 11-year-old children, regardless of gender. It may suggest that the influence of overweight/obesity on motor coordination may overlap the influence of gender 32 as this study observed. The gender variable has lost its statistical significance in the final model of the linear regression, remaining only the nutritional status variables and the physical activity level. One strong point of this study is the fact that the KTK tests were performed by the same examiner, which ensured the administration uniformity. In addition, the fact that more than 80% of the students of both schools were included may have contributed to its internal validity. The limitations of this study are its cross-sectional design, which preclude the case-effect nature of associated factors with gross motor coordination; and the inclusion of only two schools that may have compromised the external validity of this study. In addition, the authors point out the likelihood selection bias, since the students were included by spontaneous demand and both groups may not represent the real population in terms of nutritional status and motor coordination, which could have interfered in the results. In conclusion, overweight/obese children had lower gross motor coordination scores than their normal-weight counterparts when assessed by the KTK tests. The associated factors with the lower motor coordination scores were overweight/obesity and sports practice for < 2 times/week. References 1 1. Onis M, Blössner M, Borghi E. Global prevalence and trends overweight and obesity among preschool children. Am J Clin Nutr. 2010;92(5):1257-64. Onis M Blössner M Borghi E Global prevalence and trends overweight and obesity among preschool children Am J Clin Nutr 2010 92 5 1257 1264 2 2. O'Malley G, Clarke M, Burls A, Murphy S, Murphy N, Perry IJ. A smartphone intervention for adolescent obesity: study protocol for a randomized controlled non-inferiority trial. Trials. 2014;15:15-43. O'Malley G Clarke M Burls A Murphy S Murphy N Perry IJ A smartphone intervention for adolescent obesity study protocol for a randomized controlled non-inferiority trial Trials 2014 15 15 43 3 3. Moore SM, Borawski EA, Cuttler L, Ievers-Landis CE, Love TE. IMPACT: a multi-level family and school intervention targeting obesity in urban youth. Contemp Clin Trials. 2013;36(2):574-86. Moore SM Borawski EA Cuttler L Ievers-Landis CE Love TE IMPACT a multi-level family and school intervention targeting obesity in urban youth Contemp Clin Trials 2013 36 2 574 586 4 4. Händel MN, Larsen SC, Rohde JF, Stougaard M, Olsen NJ, Heitmann BL. Effects of the Healthy Start randomized intervention trial on physical activity among normal weight preschool children predisposed to overweight and obesity. PloS One. 2017;12(10):e0185266. Händel MN Larsen SC Rohde JF Stougaard M Olsen NJ Heitmann BL Effects of the Healthy Start randomized intervention trial on physical activity among normal weight preschool children predisposed to overweight and obesity PloS One 2017 12 10 e0185266 5 5. Utesch T, Dreiskämper D, Naul R, Geukes K. Understanding physical (in) activity, overweight and obesity childhood: effects of congruence between physical self-concept and motor competence. Sci Rep. 2018;8(1):5908. Utesch T Dreiskämper D Naul R Geukes K Understanding physical (in) activity, overweight and obesity childhood effects of congruence between physical self-concept and motor competence Sci Rep 2018 8 1 5908 5908 6 6. Häcker AL, Bigras JL, Henderson M, Barnett TA, Mathieu ME. Motor skills of obese and severely obese children and adolescents - a CIRCUIT study. J Strength Cond Res. 2017. doi: 10.1519/JSC.0000000000002213. Häcker AL Bigras JL Henderson M Barnett TA Mathieu ME Motor skills of obese and severely obese children and adolescents - a CIRCUIT study J Strength Cond Res 2017 10.1519/JSC.0000000000002213 7 7. Liang J, Matheson BE, Kaye WH, Boutelle KN. Neurocognitive correlates of obesity and obesity-related behaviors in children and adolescents. Int J Obes. 2014;38(4):494-506. Liang J Matheson BE Kaye WH Boutelle KN Neurocognitive correlates of obesity and obesity-related behaviors in children and adolescents Int J Obes 2014 38 4 494 506 8 8. Sweat V, Yates KF, Migliaccio R, Convit A. Obese adolescents show reduced cognitive processing speed compared with healthy weight peers. Child Obes. 2017;13(3):190-6. Sweat V Yates KF Migliaccio R Convit A Obese adolescents show reduced cognitive processing speed compared with healthy weight peers Child Obes 2017 13 3 190 196 9 9. Vandorpe B, Vandendriessche J, Lefevre J, Pion J, Vaeyens R, Matthys S, et al. The Körperkoordinations Test für Kinder: reference values and suitability for 6-12-year-old children in Flanders. Scand J Med Sci Sports. 2011;21(3):378-88. Vandorpe B Vandendriessche J Lefevre J Pion J Vaeyens R Matthys S The Körperkoordinations Test für Kinder reference values and suitability for 6-12-year-old children in Flanders Scand J Med Sci Sports 2011 21 3 378 388 10 10. Glazebrook C, Baty MJ, Mullan N, Macdonald I, Nathan D, Sayal K, et al. Evaluating the effectiveness of a schools-based programme to promote exercise self-efficacy in children and young people with risk factors for obesity: step to active kids (STAK). BMC Public Health. 2011;11:830. Glazebrook C Baty MJ Mullan N Macdonald I Nathan D Sayal K Evaluating the effectiveness of a schools-based programme to promote exercise self-efficacy in children and young people with risk factors for obesity step to active kids (STAK) BMC Public Health 2011 11 830 830 11 11. Cairney J, Hay JA, Faught BE, Hawes R. Developmental coordination disorder and overweight and obesity in children aged 9-14y. Int J Obes. 2005;29(4):369-72. Cairney J Hay JA Faught BE Hawes R Developmental coordination disorder and overweight and obesity in children aged 9-14y Int J Obes 2005 29 4 369 372 12 12. WHO. World Health Organization. Multicentre Growth Reference Study Group. WHO Child Growth Standards based on length/height, weight and age. Acta Paediatr Supl. 2006;450:76-85. WHO. World Health Organization Multicentre Growth Reference Study Group. WHO Child Growth Standards based on length/height, weight and age Acta Paediatr Supl 2006 450 76 85 13 13. Kiphard EJ, Schilling VF. Köoperkoordination test für kinder KTK: manual Von Fridhelm Schilling. Weinhein: Beltz Test GmBH; 1974. Kiphard EJ Schilling VF Köoperkoordination test für kinder KTK: manual Von Fridhelm Schilling 1974 Weinhein Beltz Test GmBH 14 14. Gorla JI, Araújo PF, Rodrigues JL. O teste de coordenação motora KTK. In: Avaliação motora em Educação Física Adaptada. 2a ed. São Paulo: Phorte; 2009, p. 104-15. Gorla JI Araújo PF Rodrigues JL Avaliação motora em Educação Física Adaptada O teste de coordenação motora KTK 2009 2 São Paulo Phorte 104 115 15 15. Lopes VP, Maia JAR, Silva RG, Seabra A, Morais FP. Estudo do nível de desenvolvimento da coordenação motora da população escolar (6 a 10 anos de idade) da Região Autónoma dos Açores. Rev Port de Cienc Desp. 2003;3(1):47-60. Lopes VP Maia JAR Silva RG Seabra A Morais FP Estudo do nível de desenvolvimento da coordenação motora da população escolar (6 a 10 anos de idade) da Região Autónoma dos Açores Rev Port de Cienc Desp 2003 3 1 47 60 16 16. Ribeiro AS, Formiga CK, David AC. Healthy preterm infants: global motor coordination and early intervention. Fisioter Mov. 2015;28(1):85-95. Ribeiro AS Formiga CK David AC Healthy preterm infants: global motor coordination and early intervention Fisioter Mov 2015 28 1 85 95 17 17. Costa VS, Silva HM, Azevêdo M, Silva AR, Cabral LL, Barros JF. Efeito da equoterapia na coordenação motora global em sujeitos com Síndrome de Down. Fisioter Mov. 2017;30(Suppl 1):229-40. Costa VS Silva HM Azevêdo M Silva AR Cabral LL Barros JF Efeito da equoterapia na coordenação motora global em sujeitos com Síndrome de Down Fisioter Mov 2017 30 Suppl 1 229 240 18 18. Alievi PT, Carvalho PR, Trotta EA, Mombelli Filho R. The impact of admission to a pediatric intensive care unit assessed by means of global and cognitive performance scales. J Pediatr. 2007;83(6):505-11. Alievi PT Carvalho PR Trotta EA Mombelli R Filho The impact of admission to a pediatric intensive care unit assessed by means of global and cognitive performance scales J Pediatr 2007 83 6 505 511 19 19. D'Hondt E, Deforche B, Gentier I, De Bourdeaudhuij I, Vaeyens R, Philippaerts R, et al. A longitudinal analysis of gross motor coordination in overweight and obese children versus normal-weight peers. Int J Obes. 2013;37(1):61-7. D'Hondt E Deforche B Gentier I De Bourdeaudhuij I Vaeyens R Philippaerts R A longitudinal analysis of gross motor coordination in overweight and obese children versus normal-weight peers Int J Obes 2013 37 1 61 67 20 20. Lopes L, Santos R, Moreira C, Pereira B, Lopes VP. Sensitivity and specificity of different measures of adiposity to distinguish between low/high motor coordination. J Pediatr. 2015;91(1):44-51. Lopes L Santos R Moreira C Pereira B Lopes VP Sensitivity and specificity of different measures of adiposity to distinguish between low/high motor coordination J Pediatr 2015 91 1 44 51 21 21. Lopes L, Póvoas S, Mota J, Okely AD, Coelho-E-Silva MJ, Cliff DP, et al. Flexibility is associated with motor competence in schoolchildren. Scand J Med Sci Sports. 2017;27(21):1806-13. Lopes L Póvoas S Mota J Okely AD Coelho-E-Silva MJ Cliff DP Flexibility is associated with motor competence in schoolchildren Scand J Med Sci Sports 2017 27 21 1806 1813 22 22. Lima RA, Bugge A, Pfeiffer KA, Andersen LB. Tracking of gross motor coordination from childhood into adolescence. Res Q Exerc Sport. 2017;88(1):52-9. Lima RA Bugge A Pfeiffer KA Andersen LB Tracking of gross motor coordination from childhood into adolescence Res Q Exerc Sport 2017 88 1 52 59 23 23. Henrique RS, Bustamante AV, Freitas DL, Tani G, Katzmarzyk PT, Maia JA. Tracking of gross motor coordination in Portuguese children. J Sport Sci. 2018;36(2):220-8. Henrique RS Bustamante AV Freitas DL Tani G Katzmarzyk PT Maia JA Tracking of gross motor coordination in Portuguese children J Sport Sci 2018 36 2 220 228 24 24. Freitas DL, Lausen B, Maia JA, Lefevre J, Gouveia ÉR, Thomis M, et al. Skeletal maturation, fundamental motor skills and motor coordination in children 7-10 years. J Sports Sci. 2015;33(9):924-34. Freitas DL Lausen B Maia JA Lefevre J Gouveia ÉR Thomis M Skeletal maturation, fundamental motor skills and motor coordination in children 7-10 years J Sports Sci 2015 33 9 924 934 25 25. Morrison K, Bugge A, El-Naaman B, Eisenmann JC, Froberg K, Pfeiffer KA, et al. Inter-relationships among physical activity, body fat, and motor performance in 6- to 8-year-old Danish children. Pediatr Exerc Sci. 2012;24(2):199-209. Morrison K Bugge A El-Naaman B Eisenmann JC Froberg K Pfeiffer KA Inter-relationships among physical activity, body fat, and motor performance in 6- to 8-year-old Danish children Pediatr Exerc Sci 2012 24 2 199 209 26 26. Melo MM, Lopes VP. Associação entre o índice de massa corporal e a coordenação motora em crianças. Rev Bras Educ Fis Esporte. 2013;27(1):7-13. Melo MM Lopes VP Associação entre o índice de massa corporal e a coordenação motora em crianças Rev Bras Educ Fis Esporte 2013 27 1 7 13 27 27. Lloyd J, Creanor C, Price L, Abraham C, Dean S, Green C, et al. Trial baseline characteristics of a cluster randomized controlled trail of a school-located obesity prevention programme; the Healthy Lifestyles Programme (HeLP) Trail. Pols One. 2017;17:91. Lloyd J Creanor C Price L Abraham C Dean S Green C Trial baseline characteristics of a cluster randomized controlled trail of a school-located obesity prevention programme; the Healthy Lifestyles Programme (HeLP) Trail Pols One 2017 17 91 91 28 28. Pona AA, Dreyer Gillette ML, Odar Stough C, Gerling JK, Sweeney BR. Long-Term outcomes of a multidisciplinary weight management intervention for youth with disabilities. Child Obes. 2017;13(6):455-61. Pona AA Dreyer Gillette ML Odar Stough C Gerling JK Sweeney BR Long-Term outcomes of a multidisciplinary weight management intervention for youth with disabilities Child Obes 2017 13 6 455 461 29 29. Olesen LG, Kristensen PL, Ried-Larsen M, Grøntved A, Froberg K. Physical activity and motor skills in children attending 43 preschools: a cross-sectional study. BMC Pediatrics. 2014;14:229. Olesen LG Kristensen PL Ried-Larsen M Grøntved A Froberg K Physical activity and motor skills in children attending 43 preschools: a cross-sectional study BMC Pediatrics 2014 14 229 229 30 30. Reis MS, Lisboa T, Alexandre JM, Capristano R, Santos JOL, Beltrame TS. Associação entre fatores antropométricos e desempenho de escolares em tarefas de equilíbrio. Fisioter Bras. 2017;18(5):580-8. Reis MS Lisboa T Alexandre JM Capristano R Santos JOL Beltrame TS Associação entre fatores antropométricos e desempenho de escolares em tarefas de equilíbrio Fisioter Bras 2017 18 5 580 588 31 31. Lopes LO, Lopes VP, Santos R, Pereira BO. Associações entre atividade física, habilidades e coordenação motora em crianças portuguesas. Rev Bras Cineantropom Desempenho Hum. 2011;13(1):15-21. Lopes LO Lopes VP Santos R Pereira BO Associações entre atividade física, habilidades e coordenação motora em crianças portuguesas Rev Bras Cineantropom Desempenho Hum 2011 13 1 15 21 32 32. Slining M, Adair LS, Goldman BD, Borja JB, Bentley M. Infant overweight is associated with delayed motor development. J Pediatr. 2010;157(1):20-5. Slining M Adair LS Goldman BD Borja JB Bentley M Infant overweight is associated with delayed motor development J Pediatr 2010 157 1 20 25