Brazilian Journal of Physical Therapy

Transcrição

Brazilian Journal of Physical Therapy
ISSN 1413-3555
Rev Bras Fisioter, São Carlos, v. 14, n. 5, p. 361-445, Sept./Oct. 2010
© Revista Brasileira de Fisioterapia
Associação Brasileira
de Editores Científicos
Journal affiliated with the
A B E C
ISSN 1413-3555
Rev. Bras. Fisioter., São Carlos, v. 14 n. 5
INFORMAÇÕES BÁSICAS
A Revista Brasileira de Fisioterapia/ Brazilian Journal of Physical Therapy é o veículo da Associação Brasileira de Pesquisa e Pós-Graduação em
Fisioterapia (ABRAPG-Ft). Publicada a partir de 1996, a Revista adota o processo de revisão por especialistas (peer review), sendo que cada artigo
somente é publicado apenas após a aceitação dos revisores, mantidos no anonimato.
Os editores não assumem nenhuma responsabilidade por danos a pessoas ou propriedades que possam ser causados por uso das idéias, técnicas ou
procedimentos contidos no material publicado nesta revista.
A submissão de artigos pressupõe que estes artigos, com exceção dos resumos ampliados, não tenham sido publicados anteriormente, nem submetidos
a qualquer outra publicação.
O título abreviado da revista é Rev. Bras. Fisioter., forma que deve ser usada em bibliografias, notas de rodapé, referências e legendas bibliográficas.
Nenhuma parte desta publicação pode ser reproduzida ou transmitida, por qualquer meio, seja eletrônico, mecânico ou fotocópia sem expressa
autorização dos editores.
A Revista Brasileira de Fisioterapia/ Brazilian Journal of Physical Therapy encontra-se gratuitamente disponível na página da internet (http://scielo.br/
scielo.php?script=sci_serial&pid=1413-3555&Ing=en&nrm=iso). Os artigos estão disponíveis nos idiomas inglês e português.
MISSÃO: publicar artigos científicos relativos ao objeto básico de estudo e campo de atuação profissional da Fisioterapia e Ciências da Reabilitação,
veiculando estudos básicos e aplicados sobre a prevenção e tratamento das disfunções de movimento.
BASIC INFORMATION
The Revista Brasileira de Fisioterapia/ Brazilian Journal of Physical Therapy is published by the Brazilian Association for Research and Graduate studies
in Physical Therapy. Published since 1996, the Brazilian Journal of Physical Therapy adopts a peer review process. Each article is only published after it is
accepted by the reviewers, who are maintained anonymous during the process.
The editors accept no responsibility for damage to people or property, which may have been caused by the use of ideas, techniques or procedures
described in the material published by this journal.
The submission of articles presupposes that these articles, with the exception of extended summaries, have not been previously published elsewhere, nor
submitted to any other publication.
The abbreviated title of the journal is Rev. Bras. Fisioter. and this must be used in references, footnotes and bibliographic legends. No part of this
publication can be reproduced or transmitted by any media, be it electronic, mechanical or photocopy, without the express authorization of the editors.
The Revista Brasileira de Fisioterapia/ Brazilian Journal of Physical Therapy is freely accessible at the homepage on the web (http://scielo.br/scielo.
php?script=sci_serial&pid=1413-3555&Ing=en&nrm=iso).
All papers are available in full text in both English and Portuguese.
MISSION: to publish scientific articles related to the areas of study and professional activity in Physical Therapy and Rehabilitation Sciences, specially
basic and applied research on the prevention and treatment of movement disorders.
Indexada nos seguintes bancos de dados/ Indexed in the following databases: MEDLINE (National Library of Medicine), CINAHL, CSA, EMcare,
JCR (Journal Citation Reports), LILACS, LATINDEX, Periódica, SciELO, SciSearch (Science Citation Index Expanded), Scopus and SPORTDiscus
Endereço para contato/ Contact address: Revista Brasileira de Fisioterapia/ Brazilian Journal of Physical Therapy, UFSCar, Rod. Washington Luís, Km
235, Caixa Postal 676, CEP 13565-905, São Carlos, SP - Brasil
Tel/Fax: +55(16) 3351-8755; E-mail: [email protected]
Suporte Técnico - Administrativo/ Technical - Administrative Support: Ana Paula de Luca, Leonor A. Saidel Aizza and Lucilda P. Rosales
Produção Editorial/ Editorial Production: Zeppelini Editorial, Rua Dr. César, 530, Cj. 1308, Santana, São Paulo, SP
Tel/Fax: (11) 2978-6686; www.zeppelini.com.br
Printed in acid free paper
Assinatura: consulte o site/Subscription: see web site www.rbf-bjpt.org.br
Revista Brasileira de Fisioterapia (Brazilian Journal of Physical
Therapy)/Associação Brasileira de Pesquisa e Pós-Graduação
em Fisioterapia. v. 1, n. 1 (1996). – São Carlos: 1996.
v. 14, n. 5 (Sept/Oct 2010).
Bimonthly
Abstracts in English and Portuguese
ISSN 1413-3555
1. Physical Therapy/journals I. Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia.
Revisão/Review
Librarian: Dormélia Pereira Cazella
CRB 8/4334
ii
Summary / Sumário
ISSN 1413-3555
EDITORIAL
v
The COFFITO/BJPT partnership
A parceria COFFITO e RBF
Roberto Mattar Cepeda
vii
The reality of open access and the search for financial stability
A realidade do Acesso Livre (Open-Access) e a busca por estabilidade financeira
Marisa Cotta Mancini, Aparecida Maria Catai, Débora Bevilaqua Grossi
SYSTEMATIC REVIEW/REVISÃO SISTEMÁTICA
361
A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults
Revisão sistemática sobre os efeitos da reabilitação vestibular em adultos de meia-idade e idosos
Natalia A. Ricci, Mayra C. Aratani, Flávia Doná, Camila Macedo, Heloísa H. Caovilla, Fernando F. Ganança
ORIGINAL ARTICLES/ARTIGOS ORIGINAIS
372
Limitations of the Neurological Evolutional Exam (ENE) as a motor assessment for first graders
Limitações do Exame Neurológico Evolutivo (ENE) como um instrumento de avaliação motora para crianças da
primeira série
Priscila M. Caçola, Tatiana G. Bobbio, Amabile V. Arias, Vanda G. Gonçalves, Carl Gabbard
377
Psychometric properties of the Portuguese version of the Jebsen-Taylor test for adults with mild
hemiparesis
Avaliação das propriedades pscicométricas da versão em português do teste de Jebsen Taylor para adultos
com hemiparesia leve
Karina N. Ferreiro, Renata L. dos Santos, Adriana B. Conforto
383
Heart rate responses during isometric exercises in patients undergoing a phase III cardiac rehabilitation
program
Resposta da frequência cardíaca durante o exercício isométrico de pacientes submetidos à reabilitação
cardíaca fase III
Poliana H. Leite, Ruth C. Melo, Marcelo F. Mello, Ester da Silva, Audrey Borghi-Silva, Aparecida M. Catai
390
Effects of physical exercise in the perception of life satisfaction and immunological function in HIVinfected patients: Non-randomized clinical trial
Efeito do exercício físico na percepção de satisfação de vida e função imunológica em pacientes infectados
pelo HIV: Ensaio clínico não randomizado
Rodrigo D. Gomes, Juliana P. Borges, Dirce B. Lima, Paulo T. V. Farinatti
396
Pattern and rate of motor skill acquisition among preterm infants during the first four months corrected age
Padrão e ritmo de aquisição das habilidades motoras de lactentes pré-termo nos quatro primeiros meses de
idade corrigida
Elaine P. Raniero, Eloisa Tudella, Rosana S. Mattos
404
Analysis of partial body weight support during treadmill and overground walking of children with
cerebral palsy
Análise do uso de suporte parcial de peso corporal em esteira e em piso fixo durante o andar de crianças com
paralisia cerebral
Vânia M. Matsuno, Muriel R. Camargo, Gabriel C. Palma, Diego Alveno, Ana Maria F. Barela
411
Breathing pattern and thoracoabdominal motion in healthy individuals: influence of age and sex
Padrão respiratório e movimento toracoabdominal em indivíduos saudáveis: influência da idade e do sexo
Verônica F. Parreira, Carolina J. Bueno,Danielle C. França, Danielle S. R. Vieira, Dirceu R. Pereira, Raquel R. Britto
417
Caracterization of adults with cerebral palsy
Caracterização de adultos com paralisia cerebral
Anna L. M.Margre, Maria G. L. Reis, Rosane L. S. Morais
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426
Comparison between a national and a foreign manovacuometer for nasal inspiratory pressure measurement
Comparação entre o manovacuômetro nacional e o importado para medida da pressão inspiratória nasal
Fernanda G. Severino, Vanessa R. Resqueti, Selma S. Bruno, Ingrid G. Azevedo, Rudolfo H. G. Vieira,
Guilherme A. F. Fregonezi
432
Inter and intra-rater reliability of the scoliometer
Confiabilidade interavaliadores e intra-avaliador do escoliômetro
Guilherme H. Bonagamba, Daniel M. Coelho, Anamaria S. de Oliveira
METHODOLOGICAL ARTICLE/ARTIGO METODOLÓGICO
438
Pain Locus of control scale: adaptation and reliability for elderly
Escala de Locus de controle da dor: adaptação e confiabilidade para idosos
Louise G. Araújo, Débora M. F. Lima, Rosana F. Sampaio, Leani S. M. Pereira
INDEX/ÍNDICE
GENERAL INSTRUCTIONS TO AUTHORS/INSTRUÇÕES GERAIS AOS AUTORES
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ISSN 1413-3555
EDITORIAL
Rev Bras Fisioter, São Carlos, v. 14, n. 5, p. v-vi, Sept./Oct. 2010
©
Revista Brasileira de Fisioterapia
The COFFITO/BJPT partnership
A parceria COFFITO e RBF
Respected colleague,
In the world or in the era of knowledge, we will only expand our being as we expand our knowledge. Scientific
knowledge is infinite and it has no boundaries because, anywhere in the planet, we are constantly questioning, revisiting, and reassessing our truths, our learning, and our clinical practice in search of what is best for people’s lives.
Therefore, the signing of the cooperation agreement between the Federal Council of Physical Therapy and Occupational Therapy (Conselho Federal de Fisioterapia e Terapia Ocupacional - COFFITO) and the Brazilian Journal
of Physical Therapy (BJPT) brought us much pleasure and honor, as well as many emotions, including:
The feeling of gratitude and respect for the first editors of the BJPT – Profs. Carlos Eduardo dos Santos, Dirceu
Costa, Eloísa Tudella, José Rubens Rebellato, Nivaldo A. Parizotto, Rosana Mattioli, Vanessa M. Pedro – and for the
people who continued with the project and devoted themselves to this scientific journal – Prof. Helenice Jane Cote
Gil Coury, Prof. Gil Lúcio Almeida, Prof. Tania de Fátima Salvini, Prof. Sérgio T. Fonseca, and currently, Professors
Aparecida Maria Catai, Débora Bevilaqua Grossi, and Marisa Cotta Mancini.
The feeling of commitment and responsibility, given that COFFITO is a self-managed federal entity that must
have a zeal for ethics. According to Rubem Alves1, in his extended concept, ethics means compassion – a desire to
take care of and to love all living beings and everything around you. Thus, to make scientific knowledge available
for the care of life is undoubtedly the most relevant ethical justification for this project.
The feeling of solidarity for being able to extend top scientific knowledge to the 140,000 physical therapy and
occupational therapy professionals in this country with the intention of benefitting approximately 190 million
Brazilians with quality care based increasingly on scientific research.
The feeling of hope that, drawing on this and other examples, the government will give more careful thought to
the importance of research in the field of health. Research is not conducted merely on the basis of the teacher’s title
or legal requirements. Our researchers need basic standards of infrastructure and adequate funding to develop and
share their scientific knowledge, which will allow more people on the planet to live longer and better.
If health is a right of all Brazilians, I believe that the true value of scientific research is in its capacity to transform society’s present situation in the quest for human dignity and social justice.
Finally, the signing of this cooperation agreement also represents the COFFITO-CREFITO System’s recognition
of the services of physical therapists and occupational therapists on the upcoming day of our professions, October
1
Alves R. Meu coração fica junto ao coração dela... Sabor do saber. Folha de São Paulo (Sinapse), 09/27/2005
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Rev Bras Fisioter. 2010;14(5):v-vi.
13th, and, consequently, the fulfillment of our duty to the Brazilian population that, starting from today, as already mentioned, will
also directly benefit from this initiative.
Roberto Mattar Cepeda
President of COFFITO
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Rev Bras Fisioter. 2010;14(5):v-vi.
ISSN 1413-3555
EDITORIAL
Rev Bras Fisioter, São Carlos, v. 14, n. 5, p. vii-viii, Sept./Oct. 2010
©
The reality of open access and the search for
financial stability
A realidade do Acesso Livre (Open-Access) e a busca por estabilidade financeira
A
ll articles published in the Brazilian Journal of Physical Therapy (BJPT) have gained great visibility in the national
and international scene with the journal’s indexing in the SciELO database and, more recently, in MEDLINE. The
articles electronically published by the BJPT can also be accessed freely, without payment for access or subscription.
If, on one hand, the adoption of the open-access system is an important step toward the dissemination and citation of
the articles made available by the BJPT, on the other, it creates a distortion. How can a journal be financially viable if
it does not charge for access to its product? The solution to this problem is far from trivial, but necessary for a journal
of this magnitude.
The literature available through open access (OA) is digital, online, and free, in other words, exempt from certain
restrictions imposed by the charge of fees and/or permission barriers1 (i.e. copyright). Actually, this unpaid reality
extends in chain-like fashion. The authors of scientific articles donate their work and their intellectual production
to be available in OA. In the same way, the ad-hoc reviewers, who analyze and evaluate the articles submitted to
the scientific journal, work voluntarily, and the editors of these journals take on responsibilities and commitments,
also without pay. These voluntary workers are committed to science. Certainly, researchers and scientists receive a
very different treatment with regard to their production compared to that of other areas such as music or movies,
in which the authorship of the production is strongly anchored to copyright legislation.
In spite of OA, the available literature has production and dissemination costs. Most of the journals that offer
articles online and in print version rely on an administrative infrastructure that guarantees the procedures for
receiving, processing, and organization of the printed version and, in Brazil, the costs of translation are necessary
for the quality of the English version. Given this scenario, the question that arises is how to pay the bill.
The BJPT has been reaching significant levels of indexing, which increase the visibility of its publications. But, as the
journal grows, so do its operating costs. The BJPT now has financial support from the funding agencies CNPq-CAPES
and FAPESP and from the educational institutions UFSCar, UFMG, UNINOVE, and USP. Although indispensable, this
support is insufficient to cover the costs associated with technical and administrative personnel and translators, production, and dissemination of the journal. More recently, the Federal Council of Physical Therapy and Occupational Therapy (COFFITO) approved the request for financial support from the BJPT, which will be vital to fulfill the commitments
relating to the human resource expenses of the administrative infrastructure.
In the attempt to keep the journal in circulation, the editorial board of the BJPT convened at Universidade de
São Paulo in Ribeirão Preto on 6/18/2010 to approve the processing fee to be paid by the authors at the moment
of submission of the article, as well as the end of the subsidy of the publication/translation fee, which is currently
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Rev Bras Fisioter. 2010;14(5):vii-viii.
charged when the article is accepted for publication*. We reiterate that the increase in the publication/translation fee corresponds,
in reality, to the end of the subsidy that was given to the translation of the published manuscripts, transferring to the authors the
full responsibility for the translation costs.
The purpose of these fees is to allow the BJPT to continue investing in the upgrade of its infrastructure, ensuring the continuity
of the progress demonstrated by the journal in the last few years. In spite of the fees, the above-mentioned sources of funding are
still necessary to meet our expenses. We, the editors of the BJPT, will continue to dedicate ourselves voluntarily to the responsibilities that are attributed to us. We take this opportunity to reiterate our gratefulness to the researchers who submit their articles to
the BJPT, to the commitment of the editorial staff, to the efforts of the editorial board, and to the dedication of the reviewers who
also contribute for free so that the BJPT can be maintained in conformity with the high standards required by the community.
Marisa Cotta Mancini
Aparecida Maria Catai
Débora Bevilaqua Grossi
Editors
RBF/BJPT
Reference
1.
Suber, P [Internet]. Open Access Overview. C. 2004-2006 [updated on June 19, 2007; quoted on July 7, 2010]. Available at http://www.earlham.edu/~peters/fos/overview.htm
* Rates for processing and publication/translation are available at www.rbf.org.br.
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ISSN 1413-3555
SYSTEMATIC REVIEW
©
A systematic review about the effects of the
vestibular rehabilitation in middle-age and
older adults
Revisão sistemática sobre os efeitos da reabilitação vestibular em adultos de
meia-idade e idosos
Natalia A. Ricci1 , Mayra C. Aratani2, Flávia Doná3, Camila Macedo4, Heloísa H. Caovilla4, Fernando F. Ganança4
Abstract
Objective: To summarize the results of clinical trials on vestibular rehabilitation (VR) in middle-aged and elderly people with vestibular
disorders. Methods: A search for relevant trials was performed in the databases LILACS, EMBASE, MEDLINE, SciELO, Cochrane, ISI
Web of Knowledge and virtual libraries of theses and dissertations. Randomized controlled trials published in the last 10 years and
written in English, Portuguese or Spanish were included. The methodological quality of the studies was assessed by the PEDro scale.
Results from the included studies were analyzed through a critical review of content. Results: Nine studies were included in the review.
Four studies reported on participants aged over 40 years (middle-aged and elderly) and five studies consisted exclusively of elderly
subjects (over 60 years). Findings of vestibular dysfunction were diverse and the most common complaints were body imbalance or
postural instability (3 studies), and vertigo or dizziness (3 studies). The Visual Analogue Scale (VAS) was the most commonly used
instrument to assess subjective perception of symptoms of vestibular dysfunction (4 studies). According to the PEDro scale, four
studies were considered to be of good quality. The most common experimental intervention was the Cawthorne & Cooksey protocol (4
studies). For most outcome measures, the studies comparing VR with another type of intervention showed no differences between the
groups after the therapy. Conclusions: The studies included in this review provide evidence for the positive effects of VR in elderly and
middle-aged adults with vestibular disturbances.
Key words: vestibular diseases; rehabilitation; older adults.
Resumo
Objetivo: Sistematizar os resultados de ensaios clínicos sobre reabilitação vestibular (RV) em indivíduos de meia-idade e idosos com
distúrbios vestibulares. Métodos: A busca de publicações sobre a RV em indivíduos com distúrbios vestibulares foi realizada nas
bases de dados LILACS, EMBASE, MEDLINE, SciELO, Cochrane, ISI Web of Knowledge e bibliotecas virtuais de teses e dissertações.
Foram selecionados ensaios clínicos aleatórios e controlados dos últimos 10 anos em língua inglesa, portuguesa e espanhola. A
qualidade metodológica dos estudos foi avaliada pela escala PEDro. A análise dos resultados dos estudos foi feita por meio de revisão
crítica dos conteúdos. Resultados: Nove estudos foram revisados na íntegra, sendo a faixa etária dos participantes acima de 40 anos
(n= 4) e composta exclusivamente por idosos (n=5). Os achados de disfunção vestibular foram diversificados, sendo os mais comuns
queixa de desequilíbrio corporal ou instabilidade postural (n=3) e queixa de vertigem ou tontura (n=3). A Escala Visual Analógica (EVA)
foi o instrumento mais utilizado para avaliar a percepção subjetiva da sintomatologia da disfunção vestibular (n=4). A escala PEDro
revelou que quatro dos artigos apresentaram delineamento de boa qualidade para a condução do estudo experimental. A proposta
de intervenção mais utilizada foi o protocolo de Cawthorne & Cooksey (n=4). Os estudos que compararam a RV com outro tipo de
intervenção não apresentaram, na maioria dos desfechos analisados, diferença entre os grupos após a terapia. Conclusão: Estudos
aleatorizados controlados disponibilizaram evidências de efeitos positivos da RV em idosos e adultos de meia-idade com distúrbios
vestibulares.
Palavras-chave: tontura; doenças vestibulares; reabilitação; idosos.
Received: 19/05/2009 – Revised: 13/10/2009 – Accepted: 12/12/2009
1
Department of Physical Therapy, Universidade Federal de São Carlos (UFSCar), São Carlos (SP), Brazil
2
Post-graduate Program in Otorhinolaringology and Surgery from the Neck and Head, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil
3
Post-graduate Program in Vestibular Rehabilitation and Social Inclusion, Universidade Bandeirante de São Paulo (UNIBAN), São Paulo (SP), Brazil
4
Department of Otorhinolaringology and Surgery from the Neck and Head, EPM, UNIFESP
Correspondence to: Natalia Aquaroni Ricci, Rua Pacaembu, 257 apto 602, Jardim Paulistano, CEP 18040-710, Sorocaba (SP), Brazil, e-mail: [email protected]
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Rev Bras Fisioter. 2010;14(5):361-71.
Natalia A. Ricci , Mayra C. Aratani, Flávia Doná, Camila Macedo, Heloísa H. Caovilla, Fernando F. Ganança
Introduction
The maintenance of body balance depends on the harmonious interaction among the information generated by the
sensory systems (visual, somatosensory and vestibular), the
central nervous system (CNS) processing, and the proper execution by the motor system (neuromuscular). The integration
of the sensory information by the CNS triggers reflexes such
as the vestibulo-ocular reflex (VOR) and the vestibulo-spinal
reflex, which act on visual field stabilization and maintenance
of the standing posture during body and cephalic movements.
In situations of sensory information conflict, specially due to
vestibular dysfunction, the signs and symptoms of body balance impairment become frequent1,2.
The complaining of vertigo or other types of dizziness in
subjects with vestibular dysfunction are generally expressed
as postural instability, increase in postural sway, reduction in
the limits of stability, gait impairments, falls, and reduction in
functional capacity2,3.
Dizziness is the sensation of impairment in body balance,
while vertigo is a sensation of rotary-type spatial disorientation.
Vertigo and other dizziness from vestibular origin are present in
5% to 10% of the world’s population, representing the most common symptoms after the age of 65 years-old, and affecting 80% of
the older adults attending geriatric outpatient settings4.
The dizziness in older adults is considered a multi-factorial
geriatric syndrome originated from changes inherent to the
aging process and/or from pathological conditions, that result
in instability and greater predisposition to falls4. After the age
of 40 years, it is possible to observe microscopic synaptic changes in the vestibular nerve; at the age of 50 years, there is an
increase in the degeneration of the vestibular receptors in the
ampullary crest of semicircular canals and macular region of
saccule and utricle; at the age of 60 years, among several alterations, there is an increase in friction among the fibers of the
vestibular nerve and a decrease in conduction velocity of the
electrical stimuli in the vestibular nerve4.
Vestibular rehabilitation (VR) is a therapeutic tool used in
patients with body balance disorders of vestibular origin. Its
proposed action is based on central mechanisms of neuroplasticity, known as adaptation, habituation and substitution, aiming a vestibular compensation5. The aim of VR exercises is to
improve the vestibule-visual interaction during cephalic movement and to increase static and dynamic postural stability in
conditions that produce conflicting sensory information.
VR has a positive effect in improving static and dynamic
balance, gait, self-confidence, quality of life, and in reducing
symptoms of dizziness, anxiety and depression4,5. VR can promote complete healing in 30% of patients and improvement of
different degrees in 85% of patients6. There are several protocols
362
of VR described in the literature, and the most frequently used
ones are those of Cawthorne & Cooksey, Herdman, Italian
Association of Neuro-Otology, and Norré39. However, there is
a paucity of information on the effectiveness of the various VR
protocols in middle-aged and elderly adults, given the peculiarities of vestibular disorders in this population.
This systematic review aims to provide a summary of the
evidence on the effects of VR in middle-aged and elderly people
with vestibular disorders.
Methods
A literature search was conducted on November 2008 in
the electronic databases LILACS, EMBASE, MEDLINE, SciELO,
Cochrane Library, ISI Web of Knowledge, and in three virtual
libraries of theses and dissertations (Universidade de São Paulo
(USP), Universidade Estadual de Campinas (UNICAMP) e Universidade Estadual Paulista (UNESP). Potentially relevant studies were identified by the following search strategy: (“aged” OR
“elderly” OR “middle aged” OR “older people”) AND (“vestibular
diseases” OR “vestibular disorder”) AND (“vestibular rehabilitation” OR “exercises” OR “balance training” OR “balance exercises” OR “virtual reality rehabilitation” OR “rehabilitation”).
The search was limited by language (English, Portuguese or
Spanish) and by date of publication ( from November 1998 to
November 2008).
The records retrieved from the search strategy had their
titles and abstracts screened for eligibility by two independent
reviewers, according to the following inclusion criteria: (1) sample aged over 40 years; (2) participants with vestibular dysfunction; (3) random sampling; (4) experimental group consisting
of VR and control group with no treatment/placebo or another
type of active intervention; and (5) experimental intervention
defined as stimulation exercises for restoration of vestibular
and body balance function, through vestibular neuroplasticity.
Studies not specifying the exact age range of the participants
were excluded, as were studies investigating pharmacological
interventions, or electrophysiological or repositioning maneuvers not associated with vestibular exercises.
After the screening of titles and abstracts, the full texts of
potentially eligible studies were screened, and those meeting
the inclusion criteria had the relevant data extracted using
a standardized form that included the following items: sample characteristics, primary and secondary outcomes, trial
design, characteristics of the interventions and effects of the
interventions.
The primary outcomes were selected according to the
practicality and clinical relevance in outpatient clinics and
rehabilitation centers; these included the subjective evaluation
Effects from vestibular rehabilitation in adults and older adults
of the intensity of dizziness and body imbalance, clinical tests
to assess balance and gait, and questionnaires and/or scales
for measuring the impact of vestibular disorders in activities of
daily living. The secondary measures chosen were laboratory
tests assessing body balance, gait and visual acuity, doppler
ultrasound and scales used to assess symptoms secondary to
vestibular disorders (e.g. depression and anxiety).
The PEDro scale was used to assess the methodological
quality of the included studies. The PEDro scale consists of
a list of 11 criteria on validity and interpretation of results of
controlled trials7. The rating of the methodological quality is
done by assigning one point for each criterion of quality that is
fulfilled; the first criterion, which refers to the sample eligibility
criteria, is not scored. The higher the score on the PEDro scale,
the most appropriate the study design, and the greater the possibility of reproducing the data presented. PEDro’s website lists
the quality ratings of the trials included in their database.
The disagreements between reviewers in the early stages
of selection and assessment of the studies were solved by
consensus, with divergent issues resolved by a third reviewer.
Results of the included studies were analyzed by critical review
of content and confrontation with those of other publications
on the subject.
Results
One hundred and five studies were retrieved from the initial
search strategy. After the title and abstract screening, 28 studies were identified as potentially eligible. However, after full
text screening, 19 studies were excluded due to the following
reasons: sample outside the pre-specified age range (n=14)8-21,
lack of randomization (n=4)22-25, and sample with no complaints or vestibular disorders (n=1)26. Thus, nine randomized
controlled trials were eligible for inclusion in this review and
had their content critically analyzed. A synopsis of the main
study characteristics and results of the included trials is shown
on Table 1.
topography of the vestibular dysfunction was rarely reported,
with the most common being vestibular hypofunction27,29. To
obtain the topographic diagnosis of the vestibular syndrome,
studies employed electronystagmography29,30,32 and other tests
such as tone threshold audiometry28,32, rotatory chair test27,29,33,
and the investigation of the brainstem electric response audiometry28. Diet was not controlled in any of the studies, and
only one study27 restricted the use of anti-vertigo drugs during
treatment with VR.
Outcomes
Primary outcomes: The subjective perception of vestibular
dysfunction symptoms was assessed in the majority of the
studies27,28,30-33,35, and the Visual Analogue Scale (VAS)27,31,32,35
was the instrument most commonly used for this purpose.
Other frequently used outcomes included static28,30-33,35 and
dynamic30,31,33,35 body balance. Functional scales that evaluate
the impact of dizziness in activities of daily living and in quality of life were applied in four studies30,32-34, with the Dizziness
Handicap Inventory (DHI) being the most commonly used30,33.
Secondary outcomes: The laboratory tests used in the studies were computerized posturography28,32,35 force platform for
the assessment of gait29, computerized test of visual acuity27,
and intracranial ultrasonography with doppler mapping28.
Trial design and methodological quality
All studies were clinical controlled trials, with random allocation of participants to study groups. The effectiveness of VR
was analyzed by the change in outcomes (pre- to post-treatment) between the VR group and the no treatment or placebo
groups27,28,30,31,33-35, or between the VR group and the other active
treatment group29,32. The studies from Vereecke et al.30 and from
Hansson, Mansson and Håkansson31 conducted a follow-up
analysis after the intervention period.
The assessment of the quality revealed that four studies
(44%)27,30,33,35 were of good quality, and consequently yielded
scientific evidence of higher level (Table 2).
Sample characteristics
Intervention protocol
The sample sizes ranged from 1427 to 21528 subjects randomized to either VR or the control intervention. In four studies,
participants aged over 40 years (middle-aged and elderly)27,29-31;
in five studies, samples consisted exclusively of elderly subjects
(over 60 years)28, 32-35. The samples were composed of participants
from both genders, but with a predominance of women28,29,31,33-35.
The data on vestibular dysfunction were variable among the studies, with the most common complaints being body imbalance
or postural instability28,32,35, and dizziness or vertigo31,33,35. The
The experimental intervention most commonly used was
the VR protocol from Cawthorne & Cooksey28,32-34. In most
studies, participants were instructed to perform home exercises, which were assisted by information leaflets27-30,33. In three
studies27,28,30, the exercises were performed exclusively at home,
from three30 to five27 times a day, and visits to guide the progression of treatment were made to the therapist weekly27, or
every three weeks30. In the other studies28,29,33, home exercises
363
364
McGibbon
et al.29
EG: n = 17
(56.9 ± 11.6 years-old)
CG: n = 19
(61.7 ± 11.3 years-old)
3) Limits of stability by dynamic posturography:
- latency for movement onset;
Groups: n = 39
- velocity of movement;
(sample lost to follow-up = 7)
- end point of the center of
mass displacement;
EG: n = 16
- maximum displacement of the center
CG: n = 16
of mass;
- directional control of movement.
Randomized controlled trial.
1) Gait analysis (force platform):
Age: 41 to 81 years-old.
- dynamic function of gait (gait velocity,
Diagnosis: unilateral and bilateral
step length, step width and posture
vestibular hypofunction.
Inclusion criteria: subjects with body im- duration);
balance without VR in the last 6 months. - neuromuscular function of lower limbs
(mechanical energy waste at ankle, knee,
hip and total);
Groups: n = 53
- trunk stability by the center of mass
(anteroposterior, lateral, angular sagital
n = 36 (20 women and 16 men)
and frontal velocity of the trunk).
59.5 ± 11.5 years-old
2) VAS of the imbalance symptom.
Schedule: group sessions, once aweek,
70 minutes duration (total: 10 weeks)
CG: Tai Chi Chuan Protocol.
- Warming up (stretching);
- Tai Chi positions (reduction of the base
of support, trunk extension and arms
rotation in challenging positions) and
meditation (diaphragmatic breathing).
- Discussion about the symptoms and
home-based exercises.
Schedule: group sessions, once a week,
70 minutes duration (total: 10 weeks)
EG: Protocol of VR.
- Ocular and cephalic exercises during
static and dynamic functional activities.
- Training of VOR.
- Training of vertical balance (base of
support, sensory information, addition of
cephalic and trunk movements).
- No difference between groups in
neuromuscular function measures and
trunk stability.
- Significant improvement in EG for
posture duration and step length.
- Significant improvement in CG for gait
velocity and step length.
- Significant reduction in mechanical
energy at hip and increase at ankle for
the CG.
- Significant increase in trunk velocity
during gait after the intervention in CG.
No significant difference in EG.
EG: VR (Cawthorne & Cooksey protocol). - EG and CG showed statistically
significant within-group reductions on
Schedule: 2 times/day (total = 60 days). Disability Index.
- VAS with 100% improvement in EG
CG: exercises for VOR adaptation (Tusa and 87.5% in CG.
- No between-group differences on the
and Herdman protocol).
limits of stability after intervention.
Schedule: 2 times/day (total = 60 days). - Significant improvement in CG regarding the center of mass displacement.
1) “Disability Index” Scale.
Age: above 65 years-old.
Diagnosis: body
imbalance.
Inclusion criteria: symptoms of body
imbalance for three months or more.
Simoceli, Bittar
and Sznifer32
Effects observed
Intervention
Trial Design
Outcomes
Sample
Study
Table 1. Characteristics and results of trials on vestibular rehabilitation in middle-age and older adults.
Herdman et al.27
Johansson
et al.33
EG: n = 8
63.6±9.4 years-old
CG: n = 5
63.6±10.8 years-old
Groups: n = 14
63.6 ± 9.4 years-old
Age: 46 to 73 years-old.
Diagnosis: bilateral vestibular hypofunction.
Inclusion criteria: subjects with bilateral
vestibular hypofunction and dynamic
visual acuity improper for the age.
GE: n = 9
GC: n = 10
Groups: n = 22 (16 women and 6 men)
Diagnosis: chronic dizziness.
Inclusion criteria: older adults (65 to 80
years-old) with recurrent vertigo for at
least 1 month.
Table 1. Continuation.
3) Vestibular function (Gain on the VOR)
through the caloric proof and the rotator
chair test.
2) VAS of the “grade” of oscillopsia and
intensity of body imbalance.
7) Beck Depression Inventory (BDI).
1) Evaluation of dynamic visual acuity by Randomized controlled trial.
computerized test.
6) Spielberger’s Trait Anxiety Inventory
(STAI-t).
5) Vertigo Symptom Scale, short version
(VSS).
4) DHI.
3) Time spent in cephalic rotation
exercises.
2) Romberg: tandem position.
1) Fast Gait in 10 meters (duration).
Schedule: weekly visits to learn the
exercises to be performd at home 4 to 5
times/day (total: 6 weeks)
CG: Protocol of placebo exercises.
- Ocular exercises without labirintic
stimulation (stationary head);
- Exercises for gait and body balance;
- Recommendation for home-based exercises according to patients’ symptoms.
Schedule: weekly sessions to learn the
exercises to be performed at home from
4 to 5 times/day (total: 6 weeks)
EG: Protocol of VR.
- Exercises for ocular and cephalic
adaptation.
- Exercises for gait and body balance.
- Recommendations for home-based exercises according to patients’ symptoms.
CG: waiting list without any type of
intervention.
- Significant improvement of the EG on
dynamic visual acuity after intervention.
- Absence of significant changes in
vestibular function by the VOR in both
groups after intervention.
- Absence of correlation between the
variables age, VAS of oscillopsia and
VAS of body imbalance with visual acuity
after intervention.
- Improvement in gait test in EG in relation to CG after treatment.
- No difference in Tandem position
between groups.
- Significant improvement in two movements provocative of dizziness (inclined
head with opened eyes and inclined head
with fixed eyes) in EG after treatment.
- Improvement in DHI scores in EG in
Schedule: 5 group sessions, 1-2 hours relation to CG.
- VSS, STAI-t, BDI: no difference
duration (total: 7 weeks with phone
contact in the middle of the intervention). between groups.
EG: VR protocol associated to behavioral
therapy.
- VR by the exercises of Yardley and of
Cawthorne & Cooksey.
- Behavioral therapy with relaxing
exercises.
365
366
Vereeck et al.30
CGElderly: n = 15
(60.0 ± 6.6 years-old)
CGYoung = 16
(41.6 ± 5.9 years-old)
EGElderly: n = 11
(58.5 ± 6.2 years-old)
EGyoung: n = 11
(40.8 ± 7.4 years-old)
Groups: n = 57
n = 53
EG: n = 110 (79 women and 31 men)
(67.2 ± 6.4 years-old)
CG: n = 105 (82 women and 23 men)
(67.6 ± 5.5 years-old)
Diagnosis: acoustic neuroma.
Inclusion criteria: indication for surgery
for acoustic neuroma removal.
Groups: n = 265
n =215 (161 women and 54 men)
Prasansuk et al.28 Age: above 60 years-old.
Diagnosis: vestibular or imbalance
symptoms.
Inclusion criteria: symptoms of body
imbalance, vertigo or dizziness in the last
6 months.
5) DGI.
4) Tandem Gait.
3) TUGT.
2) Static Balance (Romberg, Romberg
in unstable surface, Romberg in Tandem
position and Single Leg Stance).
1) DHI.
4) Doppler Ultrasound.
3) Posturography.
2) Questionnaire regarding the protocol
of exercises (easiness of execution,
benefits and severity of the symptoms).
1) Numeric scale of vestibular imbalance symptoms (0-10 points).
Assessment done before and after
surgery (1st acute, 3rd, 6th, 9th and 12th
weekcompensation) and follow-up (6
months and 1 year after surgery).
Assessments done at the 8th and 20th
weeks of treatment.
CGYoung and CGElderly: General
instructions before and after surgery.
-Increasing daily activities gradually.
- No home-based exercises after
discharge.
EGYoung and EGElderly:
- Genneral instructions before and after
surgery.
- Increasing daily activities gradually.
- Hospital exercises after surgery (3 to
5 days).
- Individualized handbook of VR after
discharge. Exercises (ocular stability,
gait, sensibilization to movement and
static balance) performed 3 times/day
for at least 30 minutes. Progression was
done at each visit to rehabilitation center
(every 3 weeks, for a total of 12 weeks).
Schedule: individualized treatment,
home-based nature, no therapist
supervision.
CG:
- 8 weeks without exercise practice.
- Last 12 weeks, same protocol
of EG.
Schedule: 12 weeks.
EG: Protocol of VR.
- Exercises (Cawthorne & Cooksey
protocol with emphasis on cephalic
movements).
- Handbook with the protocol of homebased exercises.
Schedule: 20 weeks.
- General comparison between CGElderly/CGYoung with EGElderly/CGYoung
showed statistical difference on tandem
gait in the acute and compensation
phases.
- No differences between the young
groups in any recovery phase.
- Improvements in EGElderly present in
all measures and phases, except on DHI
in the acute phase, and in tandem gait
and static balance in the follow-up in
relation to the CGElderly.
- Improvements in all 4 groups after the
acute and compensatory phases.
- No differences between groups at
follow-up.
- 6 weeks after surgery, only EGElderly
reached the initial results in all tests.
- After 12 weeks, all groups reached their
previous levels of function.
- The beneficial effects remained after 1
year from surgery in all groups.
- No difference between groups after 8
weeks on intracanial doppler ultrasound
and BERA.
- EG had significant improvement in
blood flow at internal carotid artery.
- Number of abnormal cases on posturography statistically higher in CG in
relation to EG at the 8th week.
- No difference in the numerical scale of
symptoms after the 20th week.
- 19.3% of the sample reported total cure
after the exercises.
EG: n = 23
CG: n = 19
Groups: n = 57
n = 42 (30 women and 12 men)
Average age of 77 years-old
CG: n = 12 (7 women and 5 men)
(71.8 ± 3.5 years-old)
Diagnosis: Dizziness from central origin
and dizziness related to aging.
Inclusion criteria: subjects (50 years-old
or more) with dizziness from central
origin caused by the aging process.
EG: n = 11 (6 women and 5 men)
(71.5 ± 4.3 years-old)
Groups: n = 67
n=23
Groups: n = 16
(16 women)
EG: n = 8
Average age of 70.5 years-old
CG: n = 8
Average age of 69.3 years-old
Diagnosis: vertigo of non-peripheral
origin and postural instability.
Inclusion criteria: Older adults with
vertigo of non-peripheral origin, and/
or instability, whom did not take part in
balance training.
3)VAS of the dizziness complaint
2) Dynamic balance:
- Stop walking when talking;
- Gait tandem;
- Gait in eigth.
- Rigth one leg stance with closed eyes
significantly improved in EG in relation
to CG after 6 weeks of intervention.
- After 3 months, single leg stance tests
Schedule:group sessions, 2 times/week significantly improved in EG in relation
to CG.
for 45 minutes (total: 6 weeks)
- No between-group differences in other
CG: Did not receive any type of interven- tests.
- EG improved in 80% of the tests and
tion.
worsened in 5%;CG improved in 30% of
the tests and worsened in 55%.
- EG with significant improvement in
the 3 dimensions of the scale after
intervention.
Schedule: group sessions, 2 times/week - CG without significant differences in
the dimensions of the scale during the
(total = 5 weeks).
- 40mg of Gingko-Biloba every12h for30 study period.
- Scale of activities of daily living
days.
significantly improved inEG in relation to
CG after intervention.
CG: did not perform exercises.
- 40mg of Gingko-Biloba every 12h for
30 days.
- EG with significant improvement in
EG: Protocol of VR:
single leg stance with opened eyes,
- Warming up.
forward, backward and fast gait.
- Training of balance in different situa- One leg stance with opened eyes
tions.
significantly improved in EG in relation
- Flexibility, strengthening and balance
to CG.
exercise in stable surface.
- Vertigo symptoms and instability
- Relaxing.
assessed by VAS significant improved
Schedule: group sessions, 2 times/week in EG (within-group and between-group
with 60 minutes duration (total: 8 weeks) analyses).
- Conditions 3, 4 and 6 of posturograCG: Did not perform any type of exercise. phy significantly improved in EG.
- Conditions 1, 3, 4 and 6 of posturography significantly improved in EG in
relation to CG.
EG: VR (protocol of Cawthorne &
Cooksey).
1) Static balance with opened and closed Randomized controlled trial (3 months of EG: Protocol of VR with exercises of
eyes (Romberg, Romberg in tandem
follow-up).
body balance, eyes and cephalic moveposition and one leg stance).
ments in unstable surface.
4) Dynamic posturography: sensory
organization test.
3) Gait analysis (forward, backyard and
fast).
2) Static balance with opened and closed
eyes (Romberg, Romberg in tandem
position and one leg stance).
1) VAS of the vertigo and instability
levels.
1) Vestibular Disorders Activities of Daily Randomized controlled trial.
Living Scale (Dimensions: physical,
Diagnosis: BPPV
Inclusion criteria: older adults (60 years- locomotion and instrumental).
old or more) with BPPV.
BDI = Beck Depression Inventory; BERA = Brainstem Electric Response Audiometry; BPPV = Benign Paroxismal Positional Vertigo ; CG = Control Group; DGI = Dinamic Gait Index; DHI = Dizziness Handicap Inventory; EG = Experimental Group;
STAI-t = Spielberger’s Trait Anxiety Inventory; TUGT = Time Up and Go Test; VAS = Visual Analogue Scale ; VOR = Vestibulo-Ocular Reflex; VR = Vestibular Rehabilitation; VSS = Vertigo Symptom Scale, short version.
Hånsson,
Mansson and
Håkansson31
Kammerlind,
Håkansson e
Skogsberg35
Resende et al.34
367
Table 2. Analysis of the methodological quality of the randomized studies on vestibular rehabilitation in middle-age and older adults, according to
the Pedro Scale.
1 - Inclusion criteria
2 - Random allocation
3 - Concealled allocation
4 - Group similarity at
baseline
5 - Blinding of participants
6 - Blinding of therapists
7 - Blinding of assessors
8 - Outcome measures in
85% of sample
9 - Intention-to-treat
analysis
10 - Comparison between
groups
11 - Measures of central
tendency and dispersion
Total score
Simoceli,
Bittar e
Sznifer32*
-
YES
YES
NO
YES
YES
YES
NO
YES
YES
YES
NO
YES
YES
YES
NO
YES
NO
YES
NO
YES
YES
YES
NO
YES
Kammerlind,
Håkansson e
Skogsberg35
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
YES
YES
YES
NO
YES
YES
NO
NO
NO
NO
NO
NO
YES
YES
NO
NO
NO
NO
NO
NO
NO
YES
NO
NO
NO
YES
NO
NO
NO
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
04
06
07
04
06
04
06
02
McGibbon Johansson
et al.29
et al.33
Herdman
et al.27
Prasansuk Vereeck et
et al.28
al.30
Resende
et al.34
Hånsson,
Mansson e
Håkansson31
YES
YES
NO
NO
*Study not yet rated by PEDro.
complemented the therapy performed in the rehabilitation center. In most studies, exercises were performed in groups29,31,33-35
and were administered weekly29,33 or twice a week31,34,35. The
total treatment duration varied between the minimum of five34
to the maximum of 20 weeks28,30.
Most studies compared the VR protocol with a control
group formed by participants who did not perform any type of
exercise28,30,31,33-35, or who performed placebo exercises27. In the
study of McGibbon et al.29, the control group performed Tai Chi
Chuan, and in the study of Simoceli, Bittar and Sznifer32, the
protocol of Tusa and Herdman was used for comparison with
traditional VR.
Effects of Intervention
The studies that compared VR with other type of active
intervention29,32 showed no difference between groups in most
outcome measures after therapy. In the study of Simoceli,
Bittar and Sznifer32, the group that performed the protocol
of Cawthorne & Cooksey (experimental) and the group that
performed the protocol of Tusa and Herdman (control) for
adaptation of the VOR showed improvements in VAS and in
the functional scale, but no difference was found in the limits
of stability measured by dynamic posturography after the interventions. In the study comparing VR exercises with Tai Chi
Chuan29, there was also no evidence of significant betweengroup differences in the parameters of neuromuscular function and trunk stability after the interventions.
368
Considering the control group, the proposed intervention
through home exercises27,30 showed higher gains in dynamic
visual acuity27, Timed-Up-and-Go Test (TUGT)30 and Dynamic
Gait Index (DGI)30, but no significant difference was found for
the stabilization of VOR27, tandem gait30, static balance30 and
DHI30.
In the study by Hansson, Mansson, and Håkansson31, in
the follow-up period of three months, the intervention group
remained with a significant improvement in the one leg stance
test in comparison to the control group. Another study30 that
examined the effects of VR six months and one year after the
intervention found that both groups (experimental and control) reached their previous functional levels and maintained
the gains obtained in the period. In the same study, the control
group, which did not perform any exercise, showed functional
values similar to those of the VR group after surgery for removal
of acoustic neuroma. However, in the early stages, the recovery
of elderly participants in the VR group was superior to that of
participants in the control group.
Among the studies that used the protocol of Cawtorne &
Cooksey, there was a significant improvement in the experimental group in DHI33, gait speed33, in the number of abnormal
cases in posturography28, and in the scale of activities of daily
living and vestibular disorders34. However, after the intervention, no between-group differences were found in the limits of
stability32, functional scale32, VAS32, doppler ultrasound of the
internal carotid arteries28, tandem position33, or in the psychocognitive scales Vertigo Symptom Scale (VSS), Spielberger’s
Trait Anxiety Inventory (STAI- t) and Beck Depression Inventory (BDI)33.
Of the four studies27,31,32,35 that evaluated the symptoms of
dizziness through the VAS, two32,35 found a significant improvement after intervention. Regarding static balance, there was an
improvement in two31, 35 of the six studies28, 30-33,35 that examined
this outcome; similarly, only two studies33,35 showed results favoring the experimental intervention in terms of gait29-31,33,35.
None of the studies included in this review reported adverse
effects related to VR.
Discussion
Randomized controlled trials evaluating the effects of VR
are scarce in the literature, particularly in the middle-aged and
elderly population. However, despite the shortage in numbers,
the studies included in this review showed positive results in
favor of VR regarding the outcomes postural control, functional capacity and quality of life in elderly and middle-aged
adults with complaints or diagnosis of vestibular syndrome.
However, the methodological differences among the included
studies made it difficult to establish what is the best protocol,
time of intervention, or other ideal parameters.
While four studies were found to be of adequate quality
according to the PEDro scale, they did not present allocation
concealment or blinding of participants, therapists and assessors. This can sometimes lead to biased results and thus the
strength of the evidence coming from these studies is decreased. The study of Simoceli, Bittar and Sznifer32 had not been
rated for quality at PEDro’s website by the time this review
was conducted, but the study shows methodological problems
similar to those of the other included studies. Moreover, the
sample size of some studies27,32,33,35 may have been insufficient
to ensure the external validity of the results found. Due to the
variability in assessments and interventions, it was not possible to perform a meta-analysis of the results.
The included studies generally reported on both middleaged and elderly adults in order to enable a broader discussion
on the effects of VR, since the structural and physiological
changes in the vestibular system begin to emerge at the age of
40 years4. Several studies were excluded from this review because their samples consisted of a combination of youth, adult
and senior participants. This fact reinforces the necessity of future studies with homogeneous samples, involving exclusively
the elderly population, because this is a group with peculiar
physical and functional characteristics.
The diversity of the inclusion criteria among the studies had
limited their comparison. Grouping subjects by the topography of the vestibular syndrome can be uncertain, since elderly
subjects may present normal caloric test, even in the presence
of vestibular symptoms6. Additional tests, such as those assessing the brainstem electric response audiometry and tone
threshold audiometry, do not characterize the vestibular disorders according to the functional aspects of body balance.
Thus, these tests have little significance for clinical monitoring
in the elderly population. In the other hand, the computerized
posturography is used to quantify the postural control in upright stance in either static or dynamic. Thus, grouping elderly
subjects according to a single cause of vestibular dysfunction
can be challenging, since many of them may present multiple
conditions leading to the manifestation of dizziness6. Despite
these difficulties, working with homogeneous samples allows
greater control of confounding factors that interfere with the
evaluation of VR effectiveness. The proper identification of vestibular dysfunction and its causes is essential to implement the
best type of treatment6.
It is estimated that in 20% of the elderly patients the vestibular dysfunction is due to vascular problems36. The main
circulatory disorders that can cause impairment of the peripheral or central auditory and vestibular systems are hyper- or
hypotension, heart failure, myocardial infarction, arrhythmia,
hypersensitivity of the carotid sinus reflex, aortic stenosis and
atherosclerosis36. One of the included studies28 used intracranial doppler ultrasound mapping and found a reduction in the
blood flow of the internal carotid, ophthalmic and basilar arteries in elderly patients with complaints of chronic dizziness and
body imbalance. The authors observed a significant increase in
blood flow in the carotid artery after eight weeks of VR.
Among the outcomes investigated, the VAS was the instrument most commonly used to assess the subjective perception
of patients regarding the intensity of dizziness31,35, oscillopsia27,
postural instability35 and/or body imbalance27,28,32. Other subjective instruments used to measure the impact of dizziness
on quality of life and on activities of daily living in elderly people were the DHI30,33, Disability Index32, VSS33 and the Vestibular Disorders Activities of Daily Living Scale34. The objective
measures, such as balance tests, can reveal major limitations
in performance. However, subjective measures consider the
perception of the individual regarding the impact of symptoms
that are difficult to quantify objectively, such as the impact of
dizziness on everyday life.
The postural control was assessed through tests of
static30,31,33,35 and dynamic30,31 balance, functional scales30, and
computerized posturography28,32-35. The static balance tests
(Romberg and its higher sensibility versions) are practical
and can be easily applied, but they do not evaluate the functional aspects of body balance and mobility. The dynamic and
functional tests, such as DGI and TUGT, were used in one of
the studies30 and they evaluate the individual performance in
369
tasks based on the basic and instrumental activities of daily
living, as well as on characteristics of balance, gait and mobility. Although functional tests are useful for the delineation of
functional prognosis, they have a limited role in determining
muscle shortening or weakness, or lack of motor coordination,
which are important signs for the planning of a personalized
treatment. On the other hand, these signs can be assessed by
computerized posturography performed during the laboratory
evaluation of body balance. Among the outcomes evaluated in
three studies28,32,35 using computerized posturography, stood
out the limits of stability32, the latency until the beginning of
movement32, the displacement of the center of pressure28,35
and the influence of sensory interaction on body balance28,35.
The computerized posturography complements the conventional tests for the diagnosis of vestibular disorders, and it is
important for an adequate clinical management, documentation and monitoring of treatments concerning body balance
disorders30.
The literature is consistent in stating that individualized or
group VR exercises, performed at the clinic and daily at home,
minimize the sensory conflict in elderly patients with dizziness
and body imbalance27-35. Age is not considered a limiting factor for the final response to treatment. A retrospective study
observed a similarity in the effectiveness of individualized VR
performed in young and elderly participants on the symptoms
and quality of life37.
In the included studies, there was no comparison of effectiveness between individualized and group VR, or between
home-based and clinic-based exercises. However, the most
commonly used form of VR was the group VR28,29,31,33-35 and
home exercises27-30,33. These strategies appear to be appropriate
given the high demand and costs of providing health care to
the elderly population. In a systematic review on the effects of
VR in adults with unilateral peripheral vestibular dysfunction,
rehabilitation protocols focusing on education and home-based exercises showed satisfactory results38. However, according
to Herdman39, individualized VR exercises lead to the remission
of symptoms in 85% of patients with vestibular disorders, while
generic exercises lead to the complete resolution of symptoms
in 64% of the cases.
The interventions used in most studies were the protocol
of Cawthorne & Cooksey28,32-34, the adaptation exercises of Herdman39 and static and dynamic body balance exercises27,29-31,35.
These interventions aim to promote visual stabilization during
cephalic movements, to improve postural stability in situations
where sensory conflicts arise, to minimize sensory sensitivity
370
to cephalic movements, and to improve static and dynamic
body balance. Among the studies that used the protocol of Cawthorne & Cooksey28,32 -34, there was a significant improvement
in dynamic balance in relation to the control group, as observed in the posturography and in the scale of activities of daily
living. No between-group differences were found in the outcomes limits of stability, tandem position, and psycho-cognitive
scales or VAS. These results may be due to the fact that the
Cawthorne & Cooksey protocol does not include exercises that
address the proprioceptive information together with visual information, or the modification of the base of support and other
sensorimotor components.
The duration and frequency of the exercise protocols were
largely variable among the studies, precluding the elucidation
of the optimal procedures for an effective VR protocol. However, after VR, most authors showed a reduction or remission of
the symptoms of dizziness, oscillopsia or postural instability,
and a gradual disappearance of the static and dynamic body
imbalance.
The Tai Chi exercises used in McGibbon’s study29 were
effective according to the laboratory evaluation of gait in elderly people with vestibular hypofunction, when compared to
VR. Tai Chi is a form of Chinese gymnastic of high adherence
among the elderly, which is capable of increasing the gains in
fitness, strength and balance, and of preventing falls in this
population40, 41.
The somato-psychic consequences of dizziness caused by
vestibular disorders may include anguish, anxiety and panic
attacks, fear of going out alone, interference with daily life activities and feelings of being out of reality, depersonalization and
depressive humor42. One of the included studies showed that
cognitive-behavioral therapy associated with VR significantly
reduced the dizziness and improved quality of life in elderly
participants with vestibular diseases, when compared to participants managed with VR only33.
This systematic review summarizes the evidence on the
effects of VR for balance disorders and on the assessment tools
that can contribute to support the clinical actions of health
professionals working in this area. The studies presented here
support the use of simple and costless protocols for the management of vestibular disorders in middle-aged and elderly
people. However, further high-quality studies are still needed
to clarify some doubts regarding the effects of VR for certain
diseases, the optimal treatment duration necessary to avoid
recurrence of symptoms, and the comparison with protocols
of multi-components of postural control.
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371
ISSN 1413-3555
©
ORIGINAL ARTICLE
Limitations of the Neurological Evolutional
Exam (ENE) as a motor assessment for first
graders
Limitações do Exame Neurológico Evolutivo (ENE) como um instrumento de
avaliação motora para crianças da primeira série
Priscila M. Caçola1, Tatiana G. Bobbio2, Amabile V. Arias2, Vanda G. Gonçalves2, Carl Gabbard1
Abstract
Background: Many clinicians and researchers in Brazil consider the Neurological Developmental Exam (NDE), a valid and reliable
assessment for Brazilian school-aged children. However, since its inception, several tests have emerged that, according to some
researchers, provide more in-depth evaluation of motor ability and go beyond the detection of general motor status (soft neurological
signs). Objectives: To highlight the limitations of the NDE as a motor skill assessment for first graders. Methods: Thirty-five children were
compared on seven selected items of the NDE, seven of the Bruininks-Oseretsky Test (BOT), and seven of the Visual-Motor Integration
test (VMI). Participants received a “pass” or “fail” score for each item, as prescribed by the respective test manual. Results: Chi-square
and ANOVA results indicated that the vast majority of children (74%) passed the NDE items, whereas values for the other tests were
29% (BOT) and 20% (VMI). Analysis of specific categories (e.g. visual, fine, and gross motor coordination) revealed a similar outcome.
Conclusions: Our data suggest that while the NDE may be a valid and reliable test for the detection of general motor status, its use as a
diagnostic/remedial tool for identifying motor ability is questionable. One of our recommendations is the consideration of a revised NDE
in light of the current needs of clinicians and researchers.
Key words: motor skills; psychomotor performance; child development.
Resumo
Contextualização: Muitos clínicos e pesquisadores brasileiros consideram o Exame Neurológico Evolutivo (ENE), um instrumento válido
e confiável para crianças brasileiras em idade escolar. Entretanto, desde a sua criação, surgiram outros testes para uma avaliação mais
profunda de habilidade motora, os quais vão além de detectar status motor geral em forma de sinais neurológicos leves. Objetivos:
Demonstrar os pontos fracos do ENE como teste de avaliação de habilidade motora para crianças de primeira série. Métodos: Trinta
e cinco crianças realizaram 7 itens selecionados do ENE, 7 do teste Bruininks-Oseretsky (BOT) e 7 do Visual-Motor Integration Test
(VMI), numa sessão única de 30 minutos. Para cada item, os participantes receberam a classificação “êxito” ou “fracasso”, como
prescrito por cada manual. Resultados: Os testes chi-quadrado e ANOVA indicaram que a vasta maioria das crianças (74%) passaram
nos itens do ENE, enquanto os valores para os outros testes foram 29% (BOT) e 20% (VMI). Análises das categorias específicas
(fino, visual e motor grosso) revelaram um resultado similar. Conclusões: Estes dados sugerem que, enquanto o ENE pode ser um
teste válido e confiável para detecção de status motor geral, a sua atuação como instrumento diagnóstico e de encaminhamento
para identificação de habilidade motora é questionável. Uma das nossas recomendações é a consideração de uma versão do ENE
revisada, baseada nas necessidades atuais de profissionais clínicos e pesquisadores.
Palavras-chave: habilidades motoras; performance psicomotora; desenvolvimento da criança.
1
Department of Health and Kinesiology, Texas A&M University, College Station, TX, USA
2
Center for Investigation in Pediatrics (CIPED), Universidade de Campinas (UNICAMP), Campinas (SP), Brazil
Correspondence to: Priscila Caçola, Texas A&M University, Department of Health and Kinesiology, 276A Read Building, TAMU 4243 - College Station, TX, USA 77843-4243,
e-mail: [email protected]
372
Limitations of the NDE
Introduction
Motor function assessments are useful to determine whether the child is developing normally or if there are delays
requiring therapy and special assistance. Standards for motor
assessments are often used as indicators for identifying developmental status and prescribing rehabilitative activities.
Although there is a variety of acceptable motor performance
assessments for use with infants and preschoolers, there are
only a few assessments for school-age children (six years and
older). The importance of this fact was underscored by Bessa
and Ferreira1 when they suggested that an adequate motor
coordination assessment is essential for school-age children,
as any alteration in this capacity may interfere with school learning and general behavior.
Among the most common tests used internationally are (a)
the Bruininks-Oseretsky Test (BOT)2 for ages five to 14 years,
(b) the Visual-Motor Integration Test (VMI)3 for ages three
to seven years, (c) the Peabody Developmental Motor Scales
(PDMS-2)4 for ages zero to seven years, (d) the Test of Gross
Motor Development (TGMD-2)5 for ages three to ten years, and
(e) the Movement ABC (M-ABC)6 for ages three to 16 years. In
our search for a motor assessment for school-age children in
Brazil, one of the most widely used and highly recommended
was the Neurological Developmental Exam7 (NDE), designed
for children aged three to seven years. The instrument has been
recognized for its ease of administration and strong set of standards for Brazilian children.
The NDE was developed to facilitate the administration of
neurological assessment in clinical examinations. The exam
consists of 124 test items that assess the functional development of the nervous system. The test items are divided into
blocks to assess speech, static balance, dynamic balance, fine
motor coordination, upper-body coordination, motor persistence, muscle tonus and sensibility. The test is administered
individually, and the scoring system is relatively simple: each
item is scored as “pass” when the child is able to perform the
task or “fail” when the child is unable to execute the task appropriately. The NDE has been reported as a valid and reliable
assessment with Brazilian children8-12.
Bobbio et al.13 recently evaluated 402 first graders using the
NDE and found an unusually high passing rate for virtually all
test items. In addition, a ‘ceiling effect’ was observed. With the
exception of a few gross motor items identified as interlimb coordination skills, 85% or more passed in the categories of visual,
fine, and gross motor coordination at the end of the school year.
In essence, the test items were too easy for the vast majority
of children. When designing the present study, the researchers
asked four international experts in motor assessment for their
opinion on task item classification. Interestingly, their evaluation
concluded that, in general, the NDE was an assessment of “soft
neurological signs” (SNS), i.e. the test can be used to detect
“general motor [neurological] status and minor abnormalities”,
which is in accordance with the NDE’s purpose.
Nevertheless, and relevant to the aim of this paper, it has
been suggested that SNS tests such as the NDE are not sensitive
enough to assess motor ability or detect specific motor development delays, especially the ones related to daily life skills. It is
important to note that it is not uncommon for researchers and
clinicians to use the NDE to identify motor ability, motor delay,
and prescribe remediation, which arguably is not the purpose
of the NDE. In fact, Vohr14 pointed out that assessments that
are basically neurological are poor predictors of motor delays.
Furthermore, the NDE was created in 1979, and since then it
has not been revised.
In order to demonstrate the limitations of the NDE, compared
to more contemporary assessments of wide use, we compared
motor scores of children evaluated with selected items of the NDE
with selected items from two internationally used motor assessment batteries that have reputable psychometric properties, namely the VMI15 and the BOT16. Test selection was based primarily
on test availability and appropriateness for the age group tested.
We hypothesized that significantly more children would achieve
passing scores with the NDE. This result would add to our initial
expectation that, compared to more contemporary tests, the NDE
is less sensitive in detecting motor skill delays.
Methods
Participants
The study involved a convenience sample of 35 first graders (20 males, 15 females) from Campinas, a large city in
southeast Brazil. Participants were recruited from a single
public school. At this particular school, class size was approximately 40 students, physical education was provided twice
a week, and art classes once a week. Children were excluded
from the study if they had previously failed the first grade,
did not attend school regularly, required special care, did
not wish to be evaluated, and had physical, mental or neurological disorders. The mean age was 6.8 years (±0.37; range
6.7-7.3 years). Considering the gender division, the mean age
for females was 6.7 (±0.9) and for males, 6.7 (±0.6), showing
no statistical difference for gender and age (p=0.11). All participants were volunteers via agreement with the children
and parent or guardian. This research project was approved
by the Research Ethics Committee of the School of Medical
Sciences, Universidade Estadual de Campinas (UNICAMP),
Campinas (SP), Brazil, under protocol number 818/2008.
373
Priscila M. Caçola, Tatiana G. Bobbio, Amabile V. Arias, Vanda G. Gonçalves, and Carl Gabbard
Assessment of motor function
All 35 children were submitted to selected test items of the
NDE, VMI and BOT. It is important to mention that, to the best
of our knowledge, the VMI and BOT have not been validated
for use with the Brazilian population. However, our goal was
to use them only as comparative measures for the NDE. Hence,
two Brazilian researchers translated the two test items into
Portuguese. The selected items for each test used are shown
in Table 1.
We used seven items from the original “upper body (appendicular) coordination” section of the NDE. Within that section,
we identified tasks that could be grouped as visual-motor integration (2), fine motor control (1), and gross motor coordination (4). More specifically, these items were evaluated as tasks
requiring interlimb coordination. It is important to note that
classifications were based on the expert opinion of four motor
assessment specialists from the USA.
For the VMI, we chose seven items that assess integration
between visual and motor abilities. For the BOT, we chose seven items representing interlimb coordination (6) and visualmotor control (1). It is worth noting that although the items
were obviously not identical across tests, the group of tasks
represented the specific test’s assessment of motor ability for
that category.
The instructions for each item, as defined in the manuals,
were rigorously followed. A single examiner trained to administer and report on all tests conducted the assessments
in an isolated room. All children performed the three tests
in a single session (lasting approximately 30 minutes) in the
following order: NDE, VMI, and BOT. The BOT and NDE tasks
were first demonstrated by the examiner, and the child then
had two chances to perform each task. For the VMI, geometric
figures were shown, and the child was asked to copy them,
as instructed in the manual. The item was scored as “fail” if
the child was unable to achieve the objective of the task or as
“pass” if the child performed the task correctly, as prescribed
by the respective test manual. For the few items that belonged
to two tests simultaneously (i.e. NDE and BOT), we used the
respective scoring system for that test to define the score. In
addition, BOT items 2 and 7 presented a “point score” instead
of “pass” or “fail”, therefore we simply assigned a passing score
to the child who achieved 50% or more of the point score and a
failing score otherwise.
Table 1. Selected items from the NDE, BOT, VMI and categories.
Category
Gross Motor (Interlimb)
Coordination
Fine Motor Control
Visual-Motor
Control
Selected Items
NDE
1. Moving hands back and forth simultaneously with
palms facing out
2. Making circular motions with index fingers, arms
extended to the side
3. Pivoting thumb and index finger
4. Tapping – foot and finger on opposite sides
synchronized
5. Replicating rhythmic taps with pencil
6. Winding thread onto a reel while walking
7. Copying a vertical diamond with preferred hand
BOT
1. Jumping up and touching heels with hands
VMI
2. Drawing lines and crosses simultaneously
3. Pivoting thumb and index finger
4. Tapping – foot and finger on opposite sides
synchronized
5. Jumping in place – leg and arm on same side
synchronized
6. Jumping in place – leg and arm on opposite
sides synchronized
7. Copying a horizontal diamond with preferred hand
1.
2.
3.
4.
5.
6.
7.
* For all VMI items, the task was simply to copy the geometric figures with the preferred hand (figures are not displayed in real size).
374
Limitations of the NDE
Treatment of the data
Data (scores) were analyzed using frequency analyses and
chi-square procedures to compare participants classified as
“pass” or “fail”. Analyses were performed with Epi-Info 6.0 and
SPSS 15.0. Statistical significance was set at p<0.05.
Results
The percentages of participants who passed each test (composite score for all sections) were 29% for the BOT test, 74%
for the NDE test and 20% for the VMI test. Chi-square analysis
revealed significant differences between the tests (X2(2)=24.6;
p<0.0001). As shown in Table 2, scores were lowest on the BOT
and VMI tests, and highest on the NDE test. According to these
results, 71% of participants failed when evaluated with the BOT
items, and 80% with the VMI.
Discussion
The purpose of the present study was to highlight the limitations of the NDE. In order to do that, we compared the participants’ scores for selected items of the NDE with their scores
for two other motor assessment batteries that are recognized
for providing more in-depth evaluation of motor ability, i.e. the
VMI15 and BOT16. As hypothesized, significantly more children
obtained passing scores for the NDE than for the BOT and VMI
assessments, and data for the BOT and VMI were similar. In
both tests, more than 70% of the participants were classified
as “fail”.
The present findings address interesting observations. First,
we found that the NDE assessment is indeed a less sensitive
test of motor skills compared to the VMI and BOT. The vast
majority of children in our sample passed almost all of the NDE
items, confirming the unusually high passing rate found by Bobbio et al.13. This is in contrast to having failed the majority of
items from the other tests we selected. This result means that
in a clinical assessment, for instance, more than 50% of the children in our study would be identified as “typically developing”
when evaluated with the NDE. Arguably, this finding supports
the suggested fragility of the NDE for specific motor functions,
especially those items related to daily life skills. This is not a
surprising fact, as the intended purpose of the NDE was not to
test motor skills. Nevertheless, this test has been widely used
to determine levels of motor behavior for clinical assessment
and research purposes ( for examples, see references 9 and 10).
We wish to note that our purpose was not to compare domains between tests but rather compare age-related test items
in general. However, interesting points are worthy of note. For
example, out of seven selected items of the NDE, two represented visual-motor integration, one represented fine motor coordination, and four were defined as interlimb coordination (with
the gross motor section). For the VMI, we chose seven items
that assessed integration between visual and motor abilities,
and for the BOT, six items were selected from the sections of
interlimb coordination and one from visual-motor control. In
our sample, the visual-motor component of the VMI was the
section in which the participants had the poorest performance,
with a 20% passing rate. The VMI assessment requires the child
to copy a series of geometric designs. According to Goyen and
Duff17, visual-motor integration may be more important when
children are learning to form letters, when speed is not important, and reliance on visual feedback may be greater. Our
sample of children was finishing the first grade of elementary
school when they were administered the tests, and it is quite
puzzling that only a small portion of them (20%) were able to
pass the skills required by the VMI. We would have expected at
least 50% of the group would pass the visual-motor integration
items; the literature supports the notion that this characteristic
plays an influential role in the primary stages of learning letter
formation17. However, for such a generalization, we admit that
our relatively small sample size may have been a factor.
Only the NDE and the BOT assessments provide specific
tasks of interlimb coordination, and as expected, scores for
the latter were lower than those for the former. It is important
to note that the interlimb coordination items from the NDE
were actually listed in the gross motor section. Interlimb coordination involves the timing of locomotor cycles of the limbs
in relation to one another18. In the context used here, that
meant alternating opening and closing hands, alternating tapping finger/foot of one side with the other side, turning hands
simultaneously with arms extended, and matching a rhythm
with alternating feet tapping. Although basic characteristics of
interlimb coordination are displayed by the end of the first year,
it appears considerable improvement occurs from about age
six to ten years18-21.
In regard to the implications of the present study, our findings have local as well as possibly far-reaching implications.
First, however, we feel the need to mention the strengths of the
NDE. In Brazil, the NDE is recognized by many as a relatively
Table 2. Percentage of children identified as “pass” and “fail”.
Tests
BOT
NDE
VMI
Fail
N (%)
25 (71.4)
9 (25.7)
28 (80.0)
Pass
N (%)
10 (28.6)
26 (74.3)
7 (20.0)
χ²
24.6*
*P<0.001
375
Priscila M. Caçola, Tatiana G. Bobbio, Amabile V. Arias, Vanda G. Gonçalves, and Carl Gabbard
easy-to-administer, valid, and reliable test of SNS in children,
even though it was created three decades ago. In addition, it
has a large set of standards based on Brazilian children.
However, the NDE could have limitations as a research tool,
and according to our findings, it was less sensitive in detecting
motor ability. If we were to re-evaluate the NDE, we would suggest that researchers and clinicians take a close look at the
potential considerations addressed by the present study. First
of all, NDE scores presented a “ceiling effect” for 7-year-old
children. Bobbio et al.22 found that 85% of children in a large
sample obtained passing scores with the NDE. In addition, the
age range for NDE is limited: three to seven years. Moreover, if
the aim is to gather specific information regarding the developmental status of the child, perhaps other motor tasks should be
added to the NDE assessment. Also, gross motor and interlimb
coordination as well as fine motor coordination and visual motor integration sections should be separated.
Some points warrant mention when it comes to the limitations of the present study. Once again, the sample was relatively
small and restricted to one city, which obviously limits the generalization of results. In addition, the VMI and BOT test items
were translated into Portuguese for the purposes of this study;
however, they were not submitted to transcultural adaptation.
Our goal was to use those tests for comparative purposes only.
Obviously the tests in their entirety are not comparable, but we
feel that their role as illustrative measures was fulfilled. Given
that these international tests have not yet been validated for
Brazilian children does not, in our opinion, take away from the
suggestion to revise the NDE and perhaps reconsider its use.
One of the merits of our findings is that they could be used to
revise and amplify the scope of the NDE. Tests such as the VMI
and BOT present items that could be included in a revision of
the NDE and/or the creation of another instrument that taps
more characteristics of motor skill development for Brazilian
children.
And finally, we wish to point out that we acknowledge
that no single assessment instrument tests all facets of motor
function. Therefore, researchers and practitioners need to determine what their goals are (testing specific motor delays or
general neurological status) and select the appropriate test or
combination of tests. Here, we demonstrated some possible
limitations of the NDE as an assessment of motor skills and
provided suggestions for strengthening the instrument. And,
finally, it is our strong belief that the NDE, with adequate revision, could continue to be an effective tool for assessing schoolage Brazilian children.
References
1.
Bessa MFS, Ferreira JS. Balance and motor coordination in preschool: A comparative study. Rev
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ISSN 1413-3555
ORIGINAL ARTICLE
Rev Bras Fisioter, São Carlos, v. 14, n. n. 5, p. 377-81, Sept./Oct. 2010
©
Psychometric properties of the Portuguese
version of the Jebsen-Taylor test for adults
with mild hemiparesis
Avaliação das propriedades pscicométricas da versão em português do teste de
Jebsen Taylor para adultos com hemiparesia leve
Karina N. Ferreiro1, Renata L. dos Santos1, Adriana B. Conforto1,2
Abstract
Objectives: To evaluate the psychometric properties of the Portuguese version of the Jebsen-Taylor Test (JTT) in patients with stroke.
Methods: Forty participants who suffered a stroke in the cerebral hemisphere were videotaped while performing the JTT. Scores were
defined by the time taken to perform the tasks, and two physical therapists evaluated the performance of the participants. Intra- and
inter-rater reliability was defined by intraclass correlation coefficients (ICC) through videotape analysis. Cronbach’s alpha and Pearson’s
correlation coefficient (r) were used to measure the internal consistency of the scale. Confidence intervals (CI) were calculated, and
the influence of handedness and educational level on the JTT scores was evaluated. Results: Inter-rater (ICC = 1.0; CI, 1.0-1.0) and
intra-rater reliabilities (ICC=0.997; CI, 0.995-0.998) were excellent. Regarding internal consistency, Cronbach’s α was 0.924. The item
“writing a sentence” was less consistent than the other items (Cronbach’s alpha=0.884). Pearson’s r (item score - total score) was
lower for the item “small objects” (r=0.657). There was no significant influence of handedness or educational level on the JTT scores.
Conclusions: Videotaping test performances can be a useful tool in multicenter studies if inter-rater reliability is appropriate. The interand intra-rater reliabilities of the Portuguese version of the JTT were excellent in patients with stroke. The JTT can be a valuable tool for
evaluating dexterity in research protocols aiming at efficacy of rehabilitation interventions.
Key words: Stroke; reproducibility of results; disability evaluation; motor skills; rehabilitation; activities of daily living.
Resumo
Objetivos: Avaliar as propriedades psicométricas da versão em Português do teste de Jebsen-Taylor (TJT) em pacientes com acidente
vascular encefálico (AVE). Métodos: Quarenta pacientes com AVEs em hemisférios cerebrais foram filmados enquanto realizaram o
TJT. A pontuação no teste é definida pelo tempo de execução de tarefas motoras. Duas fisioterapeutas avaliaram o desempenho dos
pacientes. Por meio das análises dos vídeos, foram determinadas as confiabilidades intra e interexaminador, pelos coeficientes de
correlação intraclasse (CCI). O alfa de Crobach e o coeficiente de correlação de Pearson (r) foram utilizados para medir a consistência
interna da escala. Foram avaliados os efeitos de dominância manual e escolaridade sobre a pontuação no TJT. Resultados: Houve
excelentes correlações interexaminador (CCI=1,0; intervalo de confiança, 1,0-1,0) e intraexaminador (CCI=0,997; intervalo de
confiança, 0,995-0,998). Na avaliação da consistência interna, o alfa de Cronbach total foi 0,924. O item “escrever uma frase” teve
consistência menor que os demais itens (Cronbach’s alpha=0,884). O coeficiente de correlação de Pearson (item - total da escala) foi
mais baixo para o item “objetos pequenos” (r=0,657). Não houve efeitos significativos de dominância manual ou escolaridade, sobre
a pontuação no TJT. Conclusões: As confiabilidades interexaminador e intraexaminador foram excelentes, assim como a consistência
interna da versão em Português do TJT em pacientes com AVE, avaliada por meio de vídeos. Essas são informações importantes para
o planejamento de protocolos de reabilitação voltados para a melhora da função do membro superior em pacientes com AVE.
Palavras-chave: acidente vascular encefálico; reprodutibilidade dos resultados; avaliação da deficiência; destreza motora; reabilitação; atividades cotidianas.
1
Laboratório de Neuroestimulação, Divisão de Clínica Neurológica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brazil
2
Instituto Israelita de Ensino e Pesquisa, Hospital Israelita Albert Einstein, São Paulo (SP), Brazil
Correspondence to: Karina Nocelo Ferreiro, Laboratório de Neuroestimulação, Divisão de Clínica Neurológica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, Av
Dr. Enéas de Carvalho Aguiar, ICHC, 255/ 5084, CEP 05403-000, Cerqueira César, São Paulo (SP), Brazil, e-mail: knfi[email protected]
377
Introduction
Stroke is a leading cause of death in Brazil1, and the most
frequent neurological impairment is hemiparesis2, which can
lead to a decrease in function and ability in activities of daily
living (ADLs). In general, the functional recovery of the upper
limbs is slower and less efficient than lower limb recovery3.
It has been estimated that 45% of stroke patients do not recover upper limb function2. Hand function has a significant
impact on disability in patients with stroke2,4, therefore tools
to evaluate upper limb function are highly relevant to stroke
rehabilitation.
Grasping, holding and manipulating objects are ADLs that
may be affected after stroke5. The Jebsen Taylor Test6 (JTT)
(Figure 1), described in 1969, evaluates these activities and consists of seven tasks: writing a sentence, card turning, small common objects, simulated feeding, stacking checkers, moving large
light objects and large heavy objects. The JTT has good test-retest
reliability6, good concurrent validity with other tests of upper limb
dexterity7, and it has been used in many studies on the effects of
somatosensory or cortical stimulation on upper extremity function in patients with stroke and spinal cord injury8-12.
The aim of the present study was to evaluate the following
psychometric properties: inter-rater reliability, intra-rater reliability and internal consistency of the videotaped Portuguese
1. Writing a sentence; 2. Card Turning; 3. Small common objects; 4. Simulated
Feeding; 5. Checkers; 6. Large light and large heavy objects.
Figure 1. Tasks of the Jebsen-Taylor test.
378
version of the JTT in patients with hemiparesis following stroke.
In addition, we investigated the influence of handedness and
educational level on test performance.
Methods
Patients were recruited from the Cerebrovascular Diseases
Clinic and the Neurology Emergency Department of our institution. The inclusion criteria were: hemiparesis following a
single, ischemic stroke confirmed by computed tomography
or magnetic resonance imaging; a minimum of 30 days since
stroke; age between 18 and 80 years; ability to understand
instructions and perform all JTT tasks. The exclusion criteria
were: multiple brain lesions; severe joint deformity; severe heart
or lung disease, advanced cancer. Forty-eight patients fulfilled
the inclusion criteria, and eight patients were excluded due to
inability to perform all JTT tasks. Therefore, forty patients were
included in the study. Age, gender, years of education (<5 years
or ≥5 years), time since stroke and handedness (according to
the Oldfield Inventory13) were recorded.
The JTT instructions were translated and adapted to the
Portuguese language. Back-translation was performed by an
expert in English14. We manufactured a board with the characteristics described by Jebsen et al.6: 105.4 cm long, 28.6 cm wide
and 1.1 cm thick. The front edge (1.1 cm thick) of the board was
marked at 10.1 cm intervals. A vertical barrier (50.8 cm long, 5.08
cm wide and 1.3 cm thick) was glued to the board 11.7 cm from
the right end and 15.2 cm from the front of the board. The front
of the vertical barrier was marked at 5.1 cm intervals beginning
2.5 cm from each end for referencing in object placement.
Cards were placed 5.1 cm apart and 12.7 cm from the front
edge of the desk. For the “small objects” task, a can was placed
12.7 cm from the front edge of the desk. Six small objects were
placed in a horizontal row to the left of the can: two paper clips
positioned vertically, two regular-size bottle caps with the inside of the cap facing up and two US one-cent coins. The paper
clips were placed at the far left and the coins next to the can.
The distance between objects was 5.1 cm.
For the “simulated feeding” task, five beans were placed on
the board in front of the participant, 12.7 cm from the front
edge of the desk, positioned to the left of the center, parallel
to and touching the vertical barrier, and 5.1 cm apart. A can
was placed in front of the board. For the “stacking checkers”
task, four checkers (3.2 cm diameter) were placed on the table
in contact with the front of the board, at a distance of 12.7 cm
from the front edge of the desk. For the “moving objects” task,
five light cans (height, 9.5 cm; diameter, 7.5 cm) were placed
in front of the board, 5.1 cm apart. In addition, five heavy cans
(weighing 1 pound) were positioned as described above.
Jebsen-Taylor test: psychometric properties
The commands given to the patients to complete the tasks
were the same as those described in the original article, and
all tests were videotaped. Rater 1 (R.L.S.) evaluated the participants and reevaluated the tapes on separate occasions,
blinded to the performance time measured in the first evaluation. Rater 2 (K.N.F) evaluated the videos and was blind to the
performance time measured by Rater 1. Intra- and inter-rater
reliabilities were evaluated by intraclass correlation coefficients
(ICC)15. The internal consistency15 of the scale was checked with
Pearson’s16 r (total score versus each item and total score versus
total score minus each item), and Cronbach’s α17 (total score
versus total score minus each item). The raters also recorded
the number of mistakes performed during the JTT: misspelled
words; changes in the strategy to turn the cards; dropped small
objects, beans, checkers, or cans.
The JTT scores for the paretic, dominant hand were compared to the scores for the paretic, non-dominant hand using
the Mann-Whitney test. This test was also used to compare
scores between participants with higher (>4 years) and lower
levels (≤4 years) of education. The Wilcoxon test was used to
compare the number of mistakes recorded by Raters 1 and 2.
The Mann-Whitney test was used to evaluate differences in
JTT scores between participants with lesions on the right and
left hemispheres. A p-value of 0.05 was considered statistically
significant. The experimental protocol was approved by the
Ethics Committee of Hospital das Clínicas/ Universidade de
São Paulo, São Paulo (SP), Brazil (protocol numbers 1049/04
and 279/05). All patients gave their written informed consent.
Results
The mean age (±SD) was 52.5±16.1 years, and 42.5% of the
participants were male. Fifty percent had 5 to 16 years of education. The mean interval between stroke onset and testing was
214 (±141.9) days; 57.2% of the participants had hemiparesis on
the dominant side, and 92.5% were right-handed according to
the Oldfield Inventory13.
The ICC was 0.997 (0.995-0.998) for intra-rater reliability
and 1.0 (1.0-1.0) for inter-rater reliability. Inter-rater reliability
for each of the tasks is shown in Table 1. Pearson’s correlation
coefficients and Cronbach’s alpha were used to assess internal
consistency and are shown in Table 2. The internal consistency
of the test was good (Cronbach’s α=0.924). Regarding each item,
“writing a sentence” was less consistent than the other tasks
(Cronbach’s α=0.884, total versus total minus item). Pearson’s r
was lower for the task “picking up small objects” (r=0.657).
There were no significant differences in JTT scores between the participants with different levels of education
(p=0.291). In addition, there were no significant differences
Table 1. Interrater reliability for each task.
Rater 1
mean (SD)
Writing (s)
56.8 (39.1)
Card turning (s)
16.5 (9.3)
Small common object (s) 16.1 (10.2)
Simulated feeding (s)
16.6 (7.7)
Checkers (s)
12.0 (9.4)
Large light objects (s)
8.0 (3.9)
Large heavy objects (s) 7.6 (3.0)
Rater 2
mean (SD)
56.6 (38.9)
15.6 (8.9)
16.1 (10.1)
16.2 (7.5)
11.8 (9.3)
7.9 (3.9)
7.5 (3.1)
ICC (95% CI)
interrater
0.999 (0.998-0.999)
0.977 (0.957-0.987)
0.998 (0.996-0.999)
0.991 (0.984-0.995)
0.995 (0.991-0.997)
0.988 (0.977-0.993)
0.991 (0.983-0.995)
p value
<0.01
<0.01
<0.01
<0.01
<0.01
<0.01
<0.01
Table 2. Internal consistency of the Jebsen-Taylor test, evaluated with
Pearson correlation coefficients (r) and Cronbach’s alpha.
Internal Consistency
Writing
Card turning
Small common objects
Simulated feeding
Checkers
Large light objects
Large heavy objects
R
r
Cronbach’s alpha
Total x Total x Total
Total x Total
Each item minus item
minus item
0.812
0.886
0.844
0.857
0.998
0.632
0.657
0.982
0.651
0.813
0.998
0.646
0.712
0.985
0.633
0.849
1.000
0.681
0.898
1.000
0.687
Table 3. Individual scores for each task performed with the dominant
(dom) or non-dominant (non-dom) limb.
Writing (s)
Card turning (s)
Small common objects (s)
Simulated feeding (s)
Checkers (s)
Large light objects (s)
Large heavy objects (s)
Mean (SD)
dom
52.6 (45.5)
14.9 (10.3)
17.3 (12.7)
14.8 (7.5)
12.9 (11.8)
8.2 (4.6)
7.8 (3.8)
Mean (SD)
non-dom
62.0 (28.1)
16.6 (6.6)
14.4 (4.6)
18.2 (7.2)
10.4 (4.0)
7.6 (2.7)
7.1 (1.9)
p
0.82
0.17
0.80
0.07
0.72
0.91
0.99
SD=standard deviation.
(p=0.277) in the JTT scores measured in the paretic, dominant hand (128.6±80.5 seconds) and those measured in the
paretic, non-dominant hand (139.3±41.1 seconds). Table 3
shows individual scores for each task. The median number
of mistakes in the JTT was 1 (range, 0-10). There were no significant differences (p=0.531) in the number of mistakes, as
evaluated by each of the raters (Rater 1: median 1, range 0-8;
Rater 2: median 1, range 0-10).
Discussion
Our results showed excellent intra- and inter-rater reliabilities of the JTT scale in stroke patients by videotape
analysis. The psychometric properties of the scale were similar to those reported by the videotape analysis of the Wolf
379
Motor Function (WMFT)18 and the Action Research Arm
Test (ARAT)19. The WMFT is a detailed, validated laboratory-based scale for evaluation of upper-limb performance
that has been widely used, particularly in clinical trials of
constraint-induced therapy9,20-23. The test can be videotaped
for off-line scoring. Concerns have been raised regarding the
limitations of the WMFT in functional evaluation23,24. The
tasks in this test are not directly related to ADLs, and the
scores are based on the time taken to complete predefined
tasks and on the evaluation of coordination and fluidity, as
well as clinically relevant characteristics of movement18.
The ARAT is composed of 19 tasks that include grasping,
gripping, pinching and gross movement subscales. Rating is
based on the ability to properly perform the tasks. The test
can be administered relatively quickly, can be videotaped
and is sensitive to clinically meaningful changes in upper
limb ability19,25. Standardized instructions for administration have been published26. The ARAT tasks are less related
to ADLs than the JTT tasks.
The Arm Motor Ability Test (AMAT)27 is composed of ten
tasks for the upper limb that resemble ADLs, and the interrater reliability has been shown to be appropriate. The test
is time consuming, which may be an obstacle to widespread
use. The original version of the Test d’Évaluation des Membres Supérieurs de Personnes Âgées (TEMPA)28 is comprised
of nine tasks (5 bimanual and 4 unimanual) and evaluates
quantitative and qualitative aspects of motor performance.
The ICC for inter-rater reliability of the translated version of
the TEMPA (with 8 tasks) was 0.94. This is lower than the coefficient obtained in the present study. AMAT and TEMPA assess
many bimanual activities, whereas JTT evaluates unimanual
tasks. Although the number of tasks in the adapted version of
TEMPA and the JTT is quite similar, the TEMPA can be more
time-consuming because it includes more complex tasks and
because the functional rating and the quality of the performed
tasks are also analyzed.
The intra-rater reliability of the JTT was excellent, and
the inter-rater reliability was higher than the inter-rater
reliability reported by the videotape analysis of the Wolf
Motor Function 18 (WMFT; ICC=0.97) and the Action Research Arm Test19 (ARAT; ICC=0.98). The internal consistency of the JTT scale was similar to that of the WMFT
scale (α=0.92). However, the items “writing” and “picking
up small objects” were slightly less consistent than the
others. The relatively low level of education and the fact
that most patients had lesions in the left hemisphere ( frequently associated with language disorders) might explain
the results obtained in the item “writing a sentence”. The
likely explanation for this finding is that this item reflects
380
not only dexterity but also language abilities. With regard
to the item “picking up small objects”, the performance of
more precise pinch movements, requiring higher levels of
dexterity, may have contributed to the lower consistency
of this item, compared to the others.
There were no significant differences between the scores
obtained in the item “writing a sentence” for the participants
with lower and higher levels of education or in the participants performing the task with the paretic, dominant hand
compared to those performing the test with the paretic,
non-dominant hand. The sample size may have limited the
statistical power to make these comparisons. Alternatively,
the effect of impairment due to stroke on performance in
this item may have had a greater magnitude than the effects
of handedness or education.
A limitation of this study is that the inter- and intra-rater
reliability was based on the evaluation of videotapes by the
raters. Rater 1 evaluated the participants in person and, for
intra-rater reliability, watched the videotapes blinded to the
previously scored results. Rater 2 evaluated only the videotapes. It is theoretically possible that reliability would be
lower if the participants were not instructed in a standard
manner, or if the scores were based on a less objective evaluation than on time to complete the tasks. The need to provide the same written instructions to patients and to follow
the recommendations to position the participant and the
objects cannot be overemphasized. Still, our results show
that, if patients are taped while performing the JTT, reliable
scores can be given by different raters and by the same rater
on separate occasions. This information is important to
plan rehabilitation trials.
In other scales that are widely used in neurology studies,
videotapes are often employed to train raters, as well as to
check intra- and inter-rater reliability, and the results are
sometimes not as good as those reported here. For instance,
videotapes have been used in the certification of a widely
used scale of neurological impairment in patients with stroke,
the NIH stroke scale29 (NIHSS). The NIHSS is often used in research protocols and in clinical practice because the score in
this scale is part of the criteria to perform intravenous thrombolysis in acute stroke patients30. Nevertheless, NIHSS overall
scoring by analysis of videotapes by a large diverse sample of
physicians has been shown to be inconsistent31. In contrast,
inter-rater reliability based on the videotape analysis of the
WMFT18 has been reported to be as high as that reported in
the present study.
The objects used in the test can be easily purchased, and
the implementation of the JTT is inexpensive. The instructions
are simple, straightforward, and expertise on administering
Jebsen-Taylor test: psychometric properties
the test is not time-consuming. Another important advantage of the JTT scale is the evaluation of movements related
to ADLs, even though the WMFT includes some tasks that
are commonly performed in daily living (such as turning a
key in the lock, lifting a basket), other tasks (such as elbow
extension, moving the hand to a box) are more laboratorybased23,24. In addition, the WMFT is more time-consuming
than the JTT.
The JTT has some limitations. The test rates speed, but
does not rate different strategies of task performance. Different compensation mechanisms to position the upper limb
during the JTT will not be reflected on the scores. Hence, it is
important to provide appropriate instructions before starting
the test and to ask patients not to change their strategy while
being tested or, in clinical trials that use the JTT score as an
endpoint, not to change strategies in follow-up evaluations.
Furthermore, patients with moderate to severe functional
impairment are often not testable with the JTT. Therefore, the
test is appropriate to evaluate dexterity in patients with slight
to moderate hand disability.
The main advantage of the JTT is to provide an objective
measure of hand function, employing functionally relevant tasks,
with good intra- and inter-rater reliability. We conclude that the
Brazilian Portuguese version of the JTT is an important scale in
protocols that investigate the efficacy of rehabilitation interventions on upper extremity function in hemiparetic stroke patients.
Acknowledgments
Researchers received funding from the Fogarty International
Center, the National Institutes of Health (1R21 TW006706)
and Fundação de Amparo à Pesquisa do Estado de São Paulo
(FAPESP) (07/53123-1).
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ISSN 1413-3555
ORIGINAL ARTICLE
©
Heart rate responses during isometric
exercises in patients undergoing a phase III
cardiac rehabilitation program
Resposta da frequência cardíaca durante o exercício isométrico de pacientes
submetidos à reabilitação cardíaca fase III
Poliana H. Leite1, Ruth C. Melo2, Marcelo F. Mello1, Ester da Silva3, Audrey Borghi-Silva1, Aparecida M. Catai1
Abstract
Background: The magnitude of cardiovascular responses is dependent on the static and dynamic components as well as the duration
and intensity of the contraction performed. Objective: To evaluate the heart rate responses to different percentages of isometric
contractions in 12 patients (63±11.6 years) with coronary artery disease and/or risk factors for coronary artery disease that were
participating in a phase III cardiac rehabilitation program. Methods: Heart rate variation (ΔHR) was evaluated during maximum (MVC,
five and ten seconds in duration) and submaximal (SMVC, 30 and 60% of MVC-5, until muscle exhaustion) voluntary contraction,
using a handgrip dynamometer. Additionally, the representative index of cardiac vagal modulation (RMSSD index) was calculated at
rest (pre-contraction), at the final 30 seconds of SMVC and during recovery (post-contraction). Results: ΔHR showed higher values
in MVC-10 versus MVC-5 (17±5.5 vs 12±4.2 bpm, p<0.05) and the SMVC-60 vs SMVC-30 (19±5.8 vs 15±5.1 bpm, p<0.05). However,
results for CVM-10 showed similar ΔHR compared to results for CVSM (p> 0.05). RICVM at rest decreased (p<0.05) during SMVC-30
(30% = 27.9±17.1 vs 12.9±8.5 ms) and SMVC-60 (60% =25.8±18.2 vs 9.96±4.2 ms), but returned to the baseline values when the
contraction was interrupted. Conclusions: In patients with coronary artery disease and/or risk factors for coronary heart disease, low
intensity isometric contraction, maintained over long periods of time, presents the same effect on the responses of HR, compared to a
high intensity or maximal isometric contraction of briefly duration.
Key words: isometric contraction; heart rate; autonomic nervous system; cardiovascular diseases.
Resumo
Contextualização: A magnitude das respostas cardiovasculares depende dos componentes estático e dinâmico bem como da duração
e intensidade da contração realizada. Objetivo: Avaliar as respostas da frequência cardíaca (FC) frente a diferentes percentuais de
contração isométrica em 12 pacientes (63±11,6 anos; média±dp) com doença da artéria coronária e/ou fatores de risco para ela,
participantes de um programa de reabilitação cardíaca fase III. Métodos: A variação da frequência cardíaca (ΔFC) foi avaliada durante
as contrações voluntárias máximas (CVM; 5” e 10” de duração) e submáximas (CVSM; 30 e 60% da CVM-5, até exaustão muscular)
de preensão palmar, utilizando-se um dinamômetro (hand grip). Adicionalmente, o RMSSD dos iR-R em ms (índice representante da
modulação vagal cardíaca) foi calculado em repouso (pré-contração) nos últimos 30 segundos da CVSM e na recuperação (póscontração). Resultados: A ΔFC apresentou maiores valores em CVM-10 vs CVM-5 (17±5,5 vs 12±4,2 bpm, p<0,05) e no CVSM-60 vs
CVSM-30 (19±5,8 vs 15±5,1 bpm, p<0,05). No entanto, os resultados para CVM-10 mostraram ΔFC similar quando comparados aos
resultados obtidos para CVSM (p>0,05). RMSSD de repouso reduziu-se (p<0,05) durante a CVSM-30 (30%=29,9±17,1 vs 12,9±8,5ms)
e CVSM-60 (60%=25,8±18,2 vs 9,96±4,2 ms), mas retornou aos valores basais quando a contração foi interrompida. Conclusões: Em
pacientes com doença da artéria coronária e/ou fatores de risco para ela, a contração isométrica de baixa intensidade mantida por
longos períodos de tempo apresenta os mesmos efeitos sobre as respostas da FC, quando comparada à contração isométrica de alta
ou máxima intensidade, porém de breve duração.
Palavras-chave: contração isométrica; frequência cardíaca; sistema nervoso autonômico; doenças cardiovasculares.
1
Physical Therapy Department, Laboratory of Cardiovascular Physical Therapy, Nucleus of Research in Physical Exercise (NUPEF), Universidade Federal de São Carlos (UFSCar), São Carlos
(SP), Brazil
2
School of Arts, Sciences and Humanities (EACH), Universidade de São Paulo (USP), São Paulo (SP), Brazil
3
Faculty of Health Sciences, Universidade Metodista de Piracicaba (UNIMEP), Piracicaba (SP), Brazil
Correspondence to: Aparecida Maria Catai, Departamento de Fisioterapia, Universidade Federal de São Carlos (UFSCar), Rodovia Washington Luís, Km 235, Bairro Monjolinho, CEP 13565905, São Carlos (SP), Brasil, e-mail: [email protected]
383
Introduction
Every physical activity requires quick adjustments on cardiovascular system (CVS) to maintain circulatory homeostasis1,2.
Heart rate (HR) regulation and the modulation of its oscillations are very dependent on the autonomic nervous system
(ANS), through the stimulation or inhibition of its efferent, the
parasympathetic nervous system (PNS), through the vagus
nerve, and the sympathetic nervous system (SNS)2.
It is well documented that isometric contractions increase
HR. It is characterized by a quick initial response, attributed
to the inhibition of vagus modulation on sinus node (SN). This
occurs in the first 10 seconds of exercise2. Depending on the
intensity and duration of the isometric contraction performed,
the HR increases gradually, especially due to the sympathetic
modulation of the ANS2-7.
Some studies have reported that the improvements on
muscle strength and the resistance training are safe for lowrisk patients8-10. However, it is important to note that this type
of training mentioned includes both isotonic and isometric
exercises, and the magnitude of cardiovascular responses depends on the static and dynamic components as well as the
duration and intensity of the exercise10.
Based on the fact that isometric contraction causes a high
overload and increases sympathetic activity7,11, the prescription
of the isometric exercises alone must be avoided in programs of
cardiovascular rehabilitation9. However, some current studies
have reported that the isometric training with handgrip modifies some cardiovascular risk factors (that is, reduces blood
pressure (BP), improves endothelial function and increases HR
variability) in patients with arterial hypertension12,13.
Therefore, studies considering the cardiovascular responses
during isometric contractions in different intensities and durations are needed to generate evidences regarding the adequate
prescription of this modality of exercise for patients enrolled in
programs of cardiovascular rehabilitation.
The hypothesis of the this study is that the isometric contraction in 100% of the maximal voluntary contraction (MVC)
(5” and 10”) would lead to lower responses of the HR than the
sub-maximal percentage of the MVC with longer duration.
The objective of the this study was to evaluate the responses
of HR during three isometric contractions of different intensities in patients with coronary artery disease and/or risk factor
for coronary artery disease.
Methods
Twelve men (63±11.6 years) with coronary artery disease and/or risk factors for coronary artery disease (Table 1)
384
participated in this study. All this patients were enrolled, for at
least six months, in a phase III cardiovascular rehabilitation program. This rehabilitation program (60’/session, 3 sessions/week)
was predominantly aerobic, including exercises in treadmill and
cycloergometer, at an intensity of 70 to 75% of the HR observed
during the clinical ergometric test. Patient were submitted to
clinical exams (general examination, conventional electrocardiogram (ECG), physical exams (maximal ergometric test and/or
limited by symptom, performed by a cardiologist) and laboratory
tests (total cholesterol and fractions, triglycerides, fasting blood
glucose, complete blood count, type 1 urine and urea).
Smokers and patients with musculo skeletal diseases were
excluded. All patients were informed about the experimental proceedings and, after agreeing with it, they signed the
informed consent, which had been approved by the Ethics
Committee of Research in Humans from the Universidade Federal de São Carlos (UFSCar), São Carlos (SP), Brazil (protocol
071/2005). All participants were evaluated at the same time of
the day considering the influence of circadian cicle.
The data collection was performed in an acclimatized
room. The temperature and relative humidity were maintained
at 22-23°C and 50-60%, respectively. The tests were performed
in non-consecutive days, separated by a five-day interval. Patients were previously familiarized with the proceedings and
equipments to be used in the study. They were oriented to
avoid caffeine, alcohol and physical exercise and to maintain
the usual medication in the day before and in the experiment
day. Before the starting of the test, the participants were asked
about the occurrence of a regular sleep at night. They were also
examined to certificate that the basal conditions were within
the normality limits (BP≤130/85mmHg; HR: 60-80bpm)14.
During the experiments, the HR and the intervals between
two waves R of the ECG (R-R interval) were collected at each
heart beat from the CM5 derivation by a cardiac monitor of one
channel (TC–500, ECAFIX, São Paulo, SP, Brazil) coupled to an
analogue-digital converter Lab – PC + (National Instruments,
Co, Austin, TX, USA), which is an interface between the cardiac
monitor and the computer. Then, the analogical sign of the ECG
was converted in binary values to a computer input at a sampling rate of 500Hz which, through a specific software15, allowed
the data processing and analysis to be performed later.
Prior to the measure of the HR subjects remained at rest
(20’) to obtain its stabilization. Then, HR and R-R interval
were obtained during the rest pre-contraction (60”); the
isometric contractions (5” and 10” to the maximal and until
muscle exhaustion to sub-maximal) and recovery post-contraction (120”) were performed with the patient seated. Furthermore, blood pressure (BP) was measured with a mercury
sphygmomanometer before and immediately after muscle
contraction.
Heart rate response during isometric exercise
The isometric contractions were performed using an analogue hand grip dynamometer (Jamar® - Sammons Preston,
INC Bolingbrook, IL, USA) with the patient sitting in a chair
with back support and adjustable arm support, so that the flexion forearm angle was maintained at 90°.
On the first day of the study, the participants performed two
sets of three MVC, which were randomly sustained for 5 (MVC-5)
and 10 (MVC-10) seconds. On the second day, patients were
instructed to maintain a 30% (SMVC-30) and 60% (SMVC-60)
contraction of the MVC-5, in a randomized order by draw, until
muscle exhaustion. On both test days, patients rested for a three
minutes period or until the return of HR to the basal levels. In addition, they were instructed to maintain normal breathing and
to avoid the Valsalva maneuver during exercise.
The cardiovascular responses to isometric contraction were
evaluated by the difference between HR peak (highest value
observed before the end of contraction) and HR rest (pre-contraction). The duration of voluntary sub-maximal contraction
(SMVC) was not predetermined that is, the subjects maintained
the muscle contraction until exhaustion. The RMSSD index
(square root of the sum of the square of the differences between
the R-R interval in ms in the record divided by the number of R-R
interval in ms at a given time minus one) was also calculated during the SMVC-30 being the period of analysis was chosen based
in the individual time to exhaustion observed for the SMVC-60.
Moreover the autonomic modulation of HR was assessed at rest
(pre-contraction), in the 30 seconds preceding the end of the
contraction and in the first seconds of the recovery period.
For data analysis, the SMVC at 30% (30% of MVC, considering 5”) was divided in SMVC-30%A=value calculated based in
time to exhaustion at 60% SMVC and SMVC-30%B= value calculated based in time to exhaustion at SMCV at 30% of SMCV.
Statistical analysis
Data are presented as mean ± SD. The differences of HR and
RICVM among all contractions were compared through one-way
analysis of variance for repeated measures (one-way ANOVA).
Blood pressure values pre and post contraction were compared
by Student’s t test. The level of significance was set at p<0.05.
Table 1. Patients’ characteristics.
Characteristics
Age (years)
Weight (kg)
Height (m)
BMI (Kg/m2)
Clinical diagnosis
Arterial hypertension
CAD
CAD + CABG
Myocardial infarction
Dyslipidemia
Medications
β-blockers
Diuretics
Diuretics
Calcium channel blockers
Hipolipidemic
Hipolipidemic
Antiarrythmic
n=12
63±11.6
82.2±14.6
1.70±0.1
25.4±9.9
7 (58%)
1 (8%)
4 (33%)
2 (17%)
6 (50%)
3 (25%)
8 (66%)
4 (33%)
1 (8%)
6 (50%)
6 (50%)
1 (8%)
BMI= body mass index; CAD= coronary artery disease; CABG= coronary artery bypass graft.
Table 2. Isometric contractions.
MVC
Time (sec)
Intensity (%)
HRrest (bpm)
HRpeak (bpm)
ΔHR (bpm)
RICVM (ms)
Rest
Exercise
Recovery
Strength (Kgf)
SBP (mmHg)
Rest
Recovery
DBP (mmHg)
Rest
Recovery
5
5
100
61±9.1
73±10.2
12±4.2
10
10
100
60±9.7
77±12.7
17±5.5†
30%A
69±13.8
30
61±8.7
67±10.6*
6±3.9*
SMVC
30%B
198±58.0
30
61±9.0
76±11.1
15±5.1
60%
69±13.8
60
61±8.7
79±12.4†
19±5.8†§
37.9±7.1
35.4±5.3
27.9±17.1
16.8±11.5
27.6±19.1
12.7±2.3
27.9±17.1
12.9±8.5+
27.6±19.1
12.7±2.3
25.8±18.2
9.96±4.2+‡
28.9±10.6
23.2±4.1
120.4±6.3
129.2±11.3+
120.4±6.3
128.3±12.9+
120.0±12.9
-
120.0±12.9
127.9±12.3+
120.0±12.9
129.2±10.6+
80.4±4.8
85.0±6.8+
80.4±4.8
86.7±7.2+
79.6±9.3
-
79.6±9.3
80.8±9.3
79.6±9.3
82.1±10.0
Values shown as mean±SD. HR=heart rate; SBP=systolic blood pressure; DBP=dyastolic blood pressure; MVC=maximal voluntary contraction; SMVC=submaximal voluntary contraction;
30=intensity at 30% of MVC (5”); A=value calculated based on time to exhaustion of SMVC at 60%; B= value calculated based on time to exhaustion of SMVC at 30%; 60=intensity at 60% of
MVC (5”); *p<0.05 vs. all the contractions studied; †p<0.05 vs. MVC-5; §p<0.05 vs. SMVC-30%B; +p<0.05 vs. rest and recovery conditions (when applied); ‡p<0.05 vs. SMVC-30%A.
385
A=value calculated based on time to exhaustion of SMVC at 60%; B= value calculated based on time to exhaustion of SMVC at 30%; *p<0.05 vs. MVC-5 †p<0.05 vs.
all the contractions studied; §p<0.05 vs. SMVC-30%B.
Figure 1. Variation of heart rate during maximal (MVC) and submaximal (SMVC) voluntary contractions.
considering muscle exhaustion; it was observed a ΔHR similar
to the MVC-5 and MVC-10 (Table 2 and Figure 1).
At rest, there were no statistical differences for the RMSSD
index of the SMVC-30 and SMVC-60. As expected, the RMSSD
index reduced during isometric contraction, reaching statistical significance (p<0.05), except for SMVC-30%A. Moreover,
when this index was calculated considering time to exhaustion of SMVC-60, a lower value of RMSSD index was observed
for CVSM-60 when compared to SMVC-30%A (p<0.05). In the
recovery period after contraction, the values of RMSSD index
were similar for both intensities tested (p>0.05) (Table 2 and
Figure 2).The values of systolic blood pressure (SBP) and diastolic blood pressure (DBP), measured in the first seconds of the
recovery period were higher in comparison to the resting values
(p<0.05), except the SMVC, which presented similar values of
DBP (p>0.05) between the rest and recovery periods (Table 2).
Discussion
A=value calculated based on time to exhaustion of SMVC at 60%; B= value calculated based on time to exhaustion of SMVC at 30%; *p<0.05 vs. rest and recovery
conditions; †p<0.05 vs. SMVC-30%A.
Figure 2. Autonomic modulation of heart rate through the RMSSD
index of the R-R intervals in ms, assessed at rest, during sub-maximal
voluntary contractions (SMVC) and recovery.
Results
Table 1 presents the patients’ characteristics, the clinical diagnosis and the medications in use. No differences were found
for resting HR for all contractions analyzed (Table 2). For the HR
peak, the SMVC-30%A, determined based on time to exhaustion
of SMVC-60, showed the lowest value compared to the other
contractions (p<0.05) (Table 2). Moreover, the MVC-5 had HR
peak significantly lower than the SMVC-60 (p<0.05) (Table 2).
Considering the ΔHR, the SMVC-30%A produced the lowest cardiovascular response (p<0.05) in comparison with to
the remaining contractions, while the SMVC-60 presented the
highest ΔHR among the contractions measured (except for
MVC-10). For the SMVC-30%B, in which ΔHR was calculated
386
This study investigated the response of the HR during isometric contractions, with different intensities and durations,
in patients with cardiovascular disease and/or risk factors
for cardiovascular disease. The magnitude of cardiovascular
responses, evaluated through ΔHR and index RMSSD of R-R
interval in ms, showed to be dependent of the intensity and
duration of the isometric contractions. Thus, for an isometric
contraction of low intensity, maintained for long period of time,
there were observed effects on HR responses similar to those of
a high or maximal intensity contraction, maintained for a short
period of time.
Cardiovascular system has an important role on homeostasis maintenance. During physical exercise, hemodynamic
adjustments occur to allow the appropriate distribution of
blood to supply the demands of muscles in activity. Moreover,
the magnitude of these adjustments seems to depend on the
exercise’s characteristics2,16.
The isometric exercise promotes a significant increase
on HR, BP and peripheral vascular resistance11 being the
mechanisms responsible for these responses are central and
peripheral1,11,16,17. The central mechanism activates neuronal
pathways from central nervous system to modify the activities
of sympathetic and parasympathetic systems, consequently
determining some cardiovascular responses1. In addition,
evidences from electromyography records show that the activation of more motor units of muscle fibers recruited during
a contraction is related to the neural mechanism of central
command, which determines immediate changes in the level
of efferent activity from SNS and PNS, acting on heart, and of
SNS, acting on blood vessels17,18.
Moreover, the reflex neural mechanism, related to mechanical and metabolic activities from the muscle in contraction,
also determines the level of autonomic activity on cardiovascular system. Neural impulses related to the mechanical activity
are transmitted initially by muscle receptors through afferent
fibers from groups III and IV and reach areas of cardiovascular
control almost simultaneously to the neural impulses from
central command4,19,20. The neural impulses related to muscle
metabolic activity are transmitted primarily by afferent muscle
fibers from group IV and reach the area of vascular control
with a delay of some seconds17,21,22. The afferent muscle receptors from groups III and IV are divided in ergoreceptors (group
III), which are activated by muscle contraction, and nociceptors (group IV), activated by stimuli responsible for muscle
pain sensation20,23.
Thus, the reduction on oxygen supply of active muscles,
which is caused by a mechanical obstruction of blood vessels
during isometric contraction of high intensity, causes an increase on metabolites on the muscle and, consequently, stimulates pressor reflex of exercise19.
The elevation of HR occurs suddenly in the beggining
of the isometric exercise, being its magnitude seems to
be directly related to the levels of muscle tension2,24. This
initial elevation of HR that occurs within the first seconds
of contraction (5” to 30”) is also associated to the intensity
of the exercise and is attributed to the withdrawal of vagal
modulation on sinus node. However, if the exercise is maintained until exhaustion, HR will increase gradually due to
the increased sympathetic modulation acting on heart2,7,21.
In this study, it was possible to observe that the fast increase of HR, evaluated through ΔHR, for the same tension
(MVC), is dependent on the period in which the contraction
is maintained. Therefore, our results are in agreement with
the authors mentioned above, since MVC maintained for 5
seconds may not have been long enough to generate maximal vagal withdrawal.
Iellamo et al.7 evaluated the autonomic control of HR
in young subjects through the analysis of rate domain during 4 minutes of isometric contraction of knee extension
(30% of MVC). The authors observed a reduction on vagal
modulation and an increase on cardiac sympathetic modulation, which suggests the participation of the sympathetic
component on HR regulation during low intensity and long
duration exercises. Although Stewart et al.25 had shown a
reduction on vagal modulation during hand grip exercises
(35% MVC) in young subjects, they were not able to reproduce the same results of Iellamo et al.7. However, the authors
observed a reduction on sympathetic modulation in the
first minute of exercise and its return for pre-exercise basal
levels. Since Stewart et al.25 used only periods of 1 minute
to analyze HR variability, it is possible that sympathetic
modulation has been underestimated, which could explain
partially the divergence between the results found on the
two studies discussed above.
In this study, patients were unable to maintain, at SMVC,
the time required to perform the analysis of ΔHR in the rate
domain (30%=3 minutes and 60%=1 minute, approximately)
since it requires, at least, 4-5 minutes of data recording and,
also, with the ECG signal remaining stable26. In this context,
the autonomic control of HR was assessed only through the
RMSSD index of R-R interval in ms (time domain), which
represents the fast oscillatory component, that is, the vagal
modulation responsible by the variation between the cardiac cycles. Since the RMSSD index reduced during isometric contraction for both sub-maximal intensities studied,
our results agree partially with those of Iellamo et al.7 and
Stewart et al.25. However, nothing can be asserted on the
sympathetic modulation during isometric contraction from
these results.
The literature has reported that the magnitude of HR response during isometric exercise is related to muscle mass,
duration and tension developed during contraction17,27. In
this study, we sought to study the effect of different intensities and times of contraction on HR response. Thus, the
protocol used tested only one muscle group (palmar flexors) at a specific angle, that is, at the same muscle length
since the wrist was in a neutral position. Under these conditions, HR has shown to be influenced by duration and
intensity of isometric contraction, since maximal efforts
of short duration produced similar responses to sustained
sub-maximal efforts. Furthermore, the effect of time was
shown when the ΔHR was compared at the same intensity
(SMVC-30% A versus SMVC-30% B) but with a different
duration (69” versus 198”).
In this study, patients had adequate cardiovascular responses to isometric exercise and none had signs or symptoms that required exercise interruption. It is noteworthy
that, prior to the start of the experiment, all patients underwent a clinical ergometric test and, besides this, they already
participated of an aerobic physical training for at least six
months, so they presented adequate aerobic capacity and,
also, were using specific medication. Thus, the prescription
of isometric exercises seems to be promising and safe for low
risk patients. Low risk patients are those with good functional capacity, controlled hypertension, with no evidence
of myocardial ischemia at rest or induced by effort, without
severe left ventricular dysfunction or complex ventricular arrhythmia, which are common characteristics of the patients
from the this study, whom are enrolled in programs of cardiac rehabilitation (phase III). For this, they shall be correctly
387
examined and guided during the performance of this type of
exercise.
The responses of the BP are also directly related to the
duration of isometric contraction. However, the assessment
of BP during MVC could not be performed due to the limitation in contraction duration and the absence of a non-invasive
equipment for checking the BP during exercise continuously;
with regards to the SMVC, the variability of the duration of
contraction of the subjects did not allow a standardized data
collection, reason for why they are not presented in this manuscript. Considering this, we decided to assess BP responses
immediately after the interruption of the contractions (MVC
and SMVC), and the values of SBP showed to be higher in relation to rest values. For future studies, it would be interesting to
examine BP during isometric contractions that could lead to
additional contributions.
Overall, in patients with cardiovascular diseases and/or
risk factors for cardiovascular diseases, HR response and its
autonomic control seem to be dependent on the intensity
and duration of isometric contractions. In addition, all patients had adequate HR responses during exercise, suggesting its prescription in cardiovascular rehabilitation for low
risk patients, since they have characteristics similar of those
from this study, and the exercises are carefully selected and
guided.
It is also noteworthy that some participants (n=3) were
using drugs that directly affect the responses of HR (e.g. beta
blockers). As beta blockers are often used in the treatment
of patients with stable coronary artery disease, hypertension
and congestive heart failure28,29 mainly due to its positive effect on their prognosis, in clinical practice is very common to
find patients in Phase III of the cardiovascular rehabilitation
using beta blockers in combination to other drugs. Therefore,
the results of this study should be interpreted with caution
and should not be transferred to all types of people and / or
patients.
In conclusion, in the patients studied, the results showed
that isometric contraction of low intensity sustained for long
periods of time has the same effects on HR responses than an
isometric contraction of high or maximal intensity with short
duration.
Considering that the response of PA is directly related to
the isometric exercise, its evaluation would bring relevant and
complementary data to this study. For future studies it would
be interesting: a) to assess BP continuously during isometric
contraction, with a non invasive method; b) to evaluate the
chronic effects of isometric training in low risk patients and c)
to work with a control group.
Acknowledgments
Research supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq - 309312/2009-4)
and Fundação de Amparo à Pesquisa do Estado de São Paulo
(FAPESP - 05/54838-9).
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ISSN 1413-3555
ORIGINAL ARTICLE
©
Effects of physical exercise in the perception of
life satisfaction and immunological function in HIVinfected patients: Non-randomized clinical trial
Efeito do exercício físico na percepção de satisfação de vida e função imunológica
em pacientes infectados pelo HIV: Ensaio clínico não randomizado
Rodrigo D. Gomes1, Juliana P. Borges1, Dirce B. Lima2, Paulo T. V. Farinatti1,3
Abstract
Background: There is a lack of research about the relationship between exercise and the psychological well-being of HIV-infected
(Human Immunodeficiency Virus) patients. Objective: The objective of this study was to investigate the influence of a physical training
program on life satisfaction and on the immunological function in HIV-patients. Methods: A total of 29 HIV-seropositive patients [age:
45±2 yrs; Body Mass Index (BMI): 22.8±1.0 kg/m2; TCD4: 20.5±2.0%] were allocated to the control (CG, n=10) and to the experimental
groups (EG, n=19). The EG participated in an exercise program combining aerobic, strength, and flexibility exercises for a period of
12 weeks [3 times/week of 30 min of aerobic exercise (workload corresponding to 150 bpm-PWC150); 50 min of strength exercises (3
sets of 12 repetitions in 5 exercises at 60-80% 12 RM); and 10 min of flexibility exercises (2 sets of 30 seconds at maximal range of
motion of 8 exercises)]. The immunological function was assessed by flow citometry [absolute and relative TCD4 cells counting] and
the life satisfaction was assessed by the Life Satisfaction Index (LSI). Results: The analysis of variance (ANOVA) showed no significant
differences for relative and absolute CD4 T counts for both groups, however, a slight enhancement trend in the EG [16%, p=0.19] was
observed. There was a significant improvement of LSI [approximately 15%; P<0.05] in EG, but not for CG. Conclusion: A physical activity
program of moderate intensity improved life satisfaction perception in HIV-infected patients with no immunological function impairment.
Article registered in the Australian New Zealand Clinical Trials Registry under the number ACTRN12610000683033.
Key words: physical activity; AIDS; physical fitness; health; HIV.
Resumo
Contextualização: Os estudos sobre a relação entre prática de exercícios e bem-estar psicológico de pacientes com vírus da
imunodeficiência humana (HIV) são raros. Objetivo: Investigar a influência de programa de condicionamento físico sobre a satisfação
com a própria vida e sobre a função imunológica. Métodos: Para tal análise, 29 pacientes soropositivos (idade: 45±2 anos; índice de
massa corporal (IMC): 22,8±1,0 kg/m2; TCD4: 20,5±2,0%), foram divididos em grupo controle (GC, n=10) e grupo experimental (GE,
n=19). O GE participou durante 12 semanas de programa de exercícios que combinavam exercícios aeróbios, força e flexibilidade (três
vezes/semana; aeróbio-30min: carga em watts equivalente a 150bpm-PWC150; força-50min: três séries de 12 repetições em cinco
exercícios a 60-80% 12 RM; flexibilidade-10min: duas séries de 30s na máxima amplitude em oito exercícios). A função imunológica
foi avaliada por contagem absoluta e relativa das células TCD4 (citometria de fluxo),e a satisfação de vida, por meio do Índice de
Satisfação de Vida (ISV). Resultados: A análise de variância (ANOVA) não identificou alteração significativa para os linfócitos TCD4
em ambos os grupos, apesar da tendência à elevação no GE (16%, p=0,19). Houve melhora significativa no ISV (≈15%, P<0,05) para
o GE, mas não para o GC. Conclusão: Um programa de condicionamento físico de intensidade moderada melhorou a percepção de
satisfação de vida dos pacientes com HIV observados, sem acarretar prejuízos imunológicos.
Artigo registrado no Australian New Zealand Clinical Trials Registry sob o número ACTRN12610000683033
Palavras-chave: atividade física; AIDS; aptidão física; saúde; HIV.
1
Institute of Physical Education and Sports, Laboratory of Physical Activity and Health Promotion, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro (RJ), Brazil
2
Departament of Internal Medicine, UERJ.
3
Postgraduate Program in Physical Activity Sciences, Universidade Salgado de Oliveira (UNIVERSO), Rio de Janeiro (RJ), Brazil
Correspondence to: Paulo de Tarso Veras Farinatti, Laboratório de Atividade Física e Promoção da Saúde, Instituto de Educação Física e Desportos, Universidade do Estado do Rio de
Janeiro (UERJ), Rua São Francisco Xavier, 524, sala 8133, Bloco F, Maracanã, CEP 20550-013, Rio de Janeiro (RJ), Brasil, e-mail: [email protected] ou [email protected]
390
Exercise, life satisfaction and immune function in HIV-seropositives
Introduction
The current use of the highly active antiretroviral therapy
(HAART) has provided an increase of life expectancy in patients infected with human immunodeficiency virus (HIV)1,2;
therefore a new prognosis has been established. Since then,
the Acquired Immunodeficiency Syndrome (AIDS) has
become a chronic disease, enabling the use of non-pharmacological approaches such as physical exercises3,4 which
maintains functionality and quality of life for several years.
Therefore, maintaining the physical and functional fitness of
patients with HIV/AIDS has become one of the most important therapeutic targets, particularly in the case of “wasting
syndrome”, which is an important loss of muscle mass5.
On the other hand, HIV-infected patients suffer with multiple social stressors that may accelerate the progression of
this disease. These conditions may be related to the diagnosis, to the presence of events of uncontrolled nature related
to the disease6, and also to the reduced functional capacity
related to the overall physical losses7. Therefore, although life
expectancy has increased, psychological problems seem to
affect seropositives subjects and their quality of life8.
There is evidence that mental health may improve by
the regular practice of physical activities. Thus, the regular
practice of exercises may be an interesting approach to deal
with the psychological problems related to the HIV infection. Some studies have shown that subjects enrolled in
programs of aerobic or strength training may present improved well-being9 and reduction of depressive symptoms10.
However, the psychological aspects have been neglected by
the investigations with regards to the practice of physical
activity and the HIV-infection.
In fact, there are few studies considering this matter,
especially after the introduction of the HAART. Studies regarding this topic would be important since the side effects
of these drugs may also result in psychological disturbances.
Therefore, it would be important to understand better about
the impact that programs of regular physical exercises have
on the general condition of the HIV-infected subjects. Ideally, physical activity would led to favorable adaptations on
functionality and well-being perception, without causing
negative impact on clinical and immunological conditions
of patients.
Therefore, this study tested the influence of a program of
physical fitness in the psychological well-being of seropositive
subjects. It was hypothesized that HIV – infected subjects enrolled in a supervised program of exercises would exhibit more
favorable modifications in their quality of life perception in
relation to sedentary subjects, even receiving the HAART. In
addition, the immunologycal function was compared in both
groups of active and sedentary participants through the counting of CD4+T cells.
Methods
Sample
The sample was composed by 29 HIV-infected patients,
with a mean age of 45±2 years, body mass index (BMI):
22.8±1,0 kg/ m2; CD4+T: 20.5±2,0%, all assisted by doctors. Subjects were allocated in to two groups: experimental (EG, n=19;
12 men and 7 women), which participated on the exercises
program, and control (CG, n=10; 5 men and 5 women), which
remained with their normal activities. All the participants from
this study signed a consent form and the research protocol was
approved by the Ethics Committee of Research from the Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro
(RJ), Brazil (Process nº 1942-CEP).
Due to ethical reasons, the allocation of the groups was
not randomly: The EG was composed by those willing to join
the training sessions. The CG was composed by the subjects
who dropped out from the program, that where those selected
among the subjects whom attended less than 25% of the total
sessions and those subjects who were on the waiting list to join
the program. To be included in the study, subjects could not
have had opportunistic diseases until, at least, three months
before the training start and should be taking antiretroviral
drugs. In addition, they should not have been regularly exercising for at least 6 months prior to the begging of the training
program. There were no drops out in both groups during the
training program.
Training program
The exercises program included aerobic, strengthening
and flexibility activities, 3 times a week (in alternate days)
over 12 weeks. The training sessions consisted in 30 min of
aerobics (treadmill or cycloergometer), with intensity that
could not exceed the heart rate of 150 beats per minutes
(bpm) (physical work capacity-PWC 150), in order to avoid an
immune depression induced by high intensity exercises11,12.
Then, a set of strengthening exercises were performed: leg
press, horizontal supine, knee extension on an leg extension
machine, low rowing (supinated grip) and partial abdominal
flexion. For all exercises, three sets of 12 repetitions were
performed using workloads of 60% to 80% derived from 12
maximal repetitions (12MR). The workloads used were estimated based upon tests of 12MR performed at each two
weeks, to guarantee a progressive increase of loads. In these
391
tests, subjects performed 12 repetitions of the exercises with
the highest load possible until the performance become impossible without an external support. At the end of each session, eight flexibility exercises for trunk, hip, knee, shoulder
and elbow were performed, maintaining the maximal range
of motion. These exercises were performed in three sets of 30
seconds for each position.
CD4 T-cell counting
In order to verify the presence of immunological impairment due to the exercise, the lymphocyte CD4 T-cell were
quantified, since they are the most important marker of disease progression. To determine the absolute and relative CD4
T-cells counting, a small sample of blood (450μL) was obtained
from a peripheral vein of the arm (EDTA vacutainer tubes,
Becton-DickinsonTM, San Jose, CA, USA) and was immediately
analyzed through flow citometry (BD FACSArrayTM, Franklin
Lakes, NJ, USA), which is considered gold standard for CD4 Tcell counting13.
Cell counting was performed with a specific monoclonal
antibodies (CD3+ CD4+ T-cells), fluorescein isothiocyanate
(FITC) and fluorescein conjugated monoclonal antibodies
(PE) (Becton DickinsonTM Immunocytometry Systems, San
Jose, CA, USA). The antibodies were fixed, and the specific
structures of CD4 T-cells surface were identified through
fluorescence detection. All measures were performed in a
hospital environment, at the same time of day. The blood
samples were collected after, at least, 48h from the last
training session, in order to avoid acute effects from the
exercises. Patients were instructed not to ingest alcohol
and caffeine 24 hours prior to the exams. The exams were
performed according to the double-blind proceedings, in
which the examiners were unaware of the treatment allocation (CG or EG).
Life satisfaction index
The level of life satisfaction was evaluated through the
Life Satisfaction Index (LSI)14,15, an instrument previously validated for this purpose. This is a self-report questionnaire to
measure psychological well-being. The score ranges from 0 to
40, being higher scores representing better perception of life
satisfaction. Both validity and reliability of the LSI type A (Life
Satisfaction Index A – LSI-A) were tested in different situations
and populations16-18. The questionnaire aim to identify five
components (willingness, resolution, relationship between intended goals and achievements, positive self-concept and state
of mind) of what is understood as factors that contribute to
the subject’s satisfaction with his/her present existence. Just as
392
flow cytometry, the measurement of LSI was also performed in
double-blind design by examiners with experience in applying
the questionnaire.
After verifying the assumptions of normality and homoscedasticity, a two-way analysis of variance (ANOVA) was used
to test significant differences between groups for CD4 T-cells,
followed by post-hoc Fisher test whenever necessary. Differences of LSI obtained by the questionnaire were assessed using
the Friedman test with subsequent post-hoc verification using
Wilcoxon test. In all situations, the level of significance was set
at p<0.05. The software STATISTICA 6.0 was used for all analysis (StatsoftTM, OK, USA).
Results
The effect-sizes associated with the differences between
the measurements pre and post exercise training, for CG and
EG, ranged from 2.13 to 2.94 (95% CI: 1.2 to 3.25). A post-hoc
sample size calculation analysis for both within and between
groups repeated measures was performed (GPower 3.0.10, Kiel,
Germany) considering a P≤0.05 and the effect-sizes obtained
revealed that the statistical power (1-beta) ranged between
0.80 and 0.85, which was considered as satisfactory.
Table 1 presents the descriptive analysis and the results of
ANOVA for the CD4 T- cells and for the LSI. There was no significant differences for the levels of lymphocytes CD4 T-cells in
both groups, although the clear trend of increase in cells count
in the EG, with a positive percentage variation for absolute
counting exceeding 12% (P=0.39). The counting decreased
about 14% for the CG (P=0.49). With regards to the relative
counting, the EG had an increase of 16% (P=0.19) compared to
the CG that had an increase of only 2% (P=0.67). Considering
the LSI, statistically significant improvements were observed
in the EG (aproximately15%; P=0.002), while no differences
Table 1. T CD4 cell count (total and relative) and Life Satisfaction
Index (LSI) pre and post exercise training in experimental and control
groups.
Experimental Group
Control Group
46±3 (n=19)
43±5 (n=10)
Pre
Post Δ%
Pre
Post
Δ%
T CD4. cells/mm³ 503.9±55.0 565.6±72.1 12.3 462.2±39.7 398.1±69.4 -13.9
T CD4. %
20.3±2.1 23.5±2.0 15.8 20.8±4.0 21.7±3.5 4.3
LSI
25±7
28±4 ¥ 15.1 28±5*
28±5
1.8
Age, Years
¥ significant difference in relation to baseline (p=0,002); * significant difference in
relation to experimental group (P=0,03). CD4 T (total and relative) [Mean±SD]. LSI
[Median±interquartile range].
were observed for the CG (P=0.39). In fact, the perception of
life satisfaction in the EG, initially lower for the CG (P=0.03),
improved in such a way that, at the end of the study, both
groups presented similar scores (P=0.56).
Discussion
This study aimed to investigate the effect of a physical
training program on immunological function and psychological well-being of seropositive individuals. The results indicated
that, at least, the exercise program did not cause harm with
regards to the immunological function. On the other hand, a
significant improvement in perception of life satisfaction was
observed for the participants allocated to the experimental
group (physical exercises).
Two limitations of the methods used should be pointed
out. Firstly, it must be recognized that the allocation of the
participants into the EG and CG was not random. Therefore,
the baseline values were not similar in relation to the observed
variables, mainly the results of the questionnaire for LSI. However, there was no reason, at an ethical level, to exclude of the
exercise’s program the patients who were interested and able
to follow it, thus benefiting from its effects.
There was no previous sample calculation according to
the characteristics of the HIV-infected patients. It is known
that it is difficult to compose large groups with this type of
patient, because of the likelihood of dropouts due to clinical
problems. Moreover, these patients do not always want to
have disclosed their condition. For this reason, most of the
available studies on the relationship between AIDS and exercise were performed with small samples, such as de Souza
et al.5 (14 patients in the experimental group, without CG),
Dolan et al.19 (40 patients in the experimental group, homebased program, without GC), Driscoll et al.20 (11 patients
in the experimental group and 14 controls), and Roubenoff
and Wilson21 (6 patients in the experimental group and 19
controls), MacArthur, Levine and Birk22 (3 patients in the experimental group and 3 controls), Rigsby et al.23 (19 patients
in the experimental group, without GC) or Spence et al.24 (24
patients in the experimental group and 12 controls). This
study, therefore, has a sample consistent with those other
similar studies in which the CG has a smaller number of
participants in relation to the EG, and many did not even
have a CG. Moreover, this difference did not affect the assumptions of homoscedasticity and sphericity required for
the application of ANOVA. Note that, even with this limitation, the confirmatory sample size calculation showed a
satisfactory statistical power (>0.80).
The second limitation concerns the establishment of the
intensity of aerobic workload on the basis of the absolute
load corresponding to the heart rate of 150 bpm (PWC150)
instead of using percentages of maximum heart rate as a
reference. Furthermore, it should be noted that the training program should be performed at an intensity that could
not acutely compromise the immunological function. The
establishment of the intensity based on Karvonen’s formula
would be problematic in this population because of the
level of sarcopenia and predisposition for peripheral fatigue
in some patients. Due to the impossibility to observe the
actual maximal heart rate or maximal oxygen consumption
( for operational reasons and the desire to avoid exercises of
that intensity), the commonly approach of PWC was chosen. Classically, there are two options for this method, the
PWC150 and the PWC170. At the age range of our patients,
the PWC150 would probably lead them to a intensity below
the point of respiratory compensation, which was consistent
with the goals of this study. Moreover, this method greatly
facilitated the control of the intensity during the sessions
since the patients could themselves contribute, keeping
in mind that they could not exceed the limit of 150 bpm25.
This approach was used in the same perspective by previous
studies with different sedentary, obese children, pregnant
women or elderly populations26-28.
Depression and anxiety seem to be the main psychological
symptoms assessed in seropositive subjects undergoing an
exercise program. It was impossible to find studies that had
examined the psychological condition from a more positive
view, such as the evaluation of well-being instead of negative
psychological traits. To determine the individual quality of life
is complex and always subjective, since this is a concept that
refers to a huge amount of constructs such as psychological
well-being, social adjustment, personal fulfillment, physical
independence or social support. However, life satisfaction
seems to have an evident relationship with general well-being,
and with quality of life, whatever the construct chosen.
Some studies have been conducted to verify the effects of
exercise on psychological parameters of several special populations, demonstrating positive results and improvement in the
levels of depression and anxiety. Singh et al.16 demonstrated
that high intensity strength training, 3 times a week over eight
weeks would be a safe, feasible and effective treatment method
of treatment for depressive older adults. Brochu et al. 29 studied
elderly women with coronary disease, observing that those
enrolled in strength training for six months presented lower
levels of depression compared to the inactive group. In general,
it is accepted that the preservation of physical and functional
fitness contributes to a better perception of quality of life30.
393
The improvement of life satisfaction of seropositive individuals observed in this study, is consistent with previous
researches and confirm their results. The study of LaPerriere
et al.31 may have been the first to examine this relationship.
However, the objective of this group was different since the
participants were still unaware of their infection. Those who
performed aerobic exercises and were seropositive for HIV had
lower levels of depression in relation to individuals with the
same results but that did not exercise.
Other studies presented similar results with subjects already
aware of their seropositivity. MacArthur, Levine e Birk22 administered the General Health Questionnaire to patients infected
by HIV, before and after 12 weeks of general physical training.
The score of the 28 items of this questionnaire is related to
symptoms of anxiety and depression. The patients whom participated in more that 80% of the training sessions presented a
non-significant trend to improve their scores, while the group
with lower participation deteriorated significant. Neidig, Smith
and Brashers10 also demonstrated that seropositive subjects
enrolled in a 12-week aerobic training (60-80% of VO2max)
presented significantly less depressive symptoms than subjects
allocated in CG.
The majority of studies that evaluated the influence of
physical training in psychological aspects focused exclusively
in aerobic modalities. It differs from our training protocol that
involved aerobic, strengthening and flexibility exercises performed together. Lox, McAuley and Tucker9 had also administered strengthening exercises for training, but worked with
different groups (strengthening, aerobic, and control). As in
our study, positive results were obtained with the groups that
trained, improving the subjective well-being sensation. Finally,
Roubenoff and Wilson21 reported that seropositive subjects
benefited from strength training, showing improvement on
self-reported physical function, which is also related to psychological function. Some factors could be cited as responsible by
the improvement observed on EG. LaPerriere et al.6 proposed
a theoretical model to describe the relations between exercises
and the psychological, endocrine and immunological aspects.
According to this model, physical training might contribute to
the improvement of emotional status, increase the release of
endogenous opioids and reduce the activity of the adrenocortical, pituitary and hypothalamic systems (ACPH). Considering
this model, physical activity could moderate the psychological
and physiological sequels from chronic diseases, including
HIV/AIDS. It is relevant to mention yet, that the performance
of these exercises in group, gathering people with same problems and anxieties, may have been a contribution to the results
obtained. Additional studies should be developed to confirm
this hypothesis.
394
The immunological function is a central concern of the exercises programs developed for HIV-infected patients. Thus,
the CD4 T-cells counting is often used as a marker19,32. The
absolute count measures the number of cells in each mm3 of
blood. The normal count in non-infected subjects ranges from
500 to 1500 cells/mm3. The relative count (%) is related to
the rate of CD4 T-cells in comparison to all the lymphocytes,
being normally around 40% and may decrease below 20% in
HIV-infected patients, reflecting a high risk of opportunistic
infections33.
Despite a possible relationship of exercises with a general
clinical improvement34, the available researches do not allow us to say with certainty that there is a significant direct
impact on indicators of immunological function (eg, CD4 Tcells count or viral load). A systematic review, including ten
randomized studies with aerobic training three times a week
for at least four weeks35 showed small improvements, but
not significant in CD4 T-cells count weighted average difference: 14 cells mm-3; 95% CI: -26 to 54 and viral load (weighted
mean difference: 0.40 log10 copies, 95% CI: -0.28 to 1.07). More
recently, a meta-analysis of the same group36 assessed the
impact of resistance exercises (alone or combined with aerobic exercises) in patients with HIV or AIDS. They observed a
non-significant increase in CD4 T-cell count [95% CI: -6.60 to
103.23, n=68] compared with CGs who did not exercise. The
confidence intervals reported, however, suggest a possible
trend toward higher cell counts in the EGs, which may be
clinically relevant.
In this study, no significant differences between experimental and control groups were observed for both the absolute and
the relative counts in response to the training program. However, the absolute values in EG rose 62 cells / mm 3 [~ 12%], and
has declined to 55 cells /mm3 in CG [~ 14%]. The relative count
was critically low in both groups at baseline (approximately
20%), indicating risk for opportunistic infections. After the intervention, there was an increase of almost 16% in the EG and
of only 2% in CG. Thus, although the differences did not have
statistical significance, these changes represent a clinically
important outcome, supporting the idea that physical exercise
can positively affect the CD4 T-cell count. Additional investigative effort should be performed for a better understanding of
the relationship between exercise and CD4 T-cells, and other
immunological markers.
In conclusion, a physical training program of moderate
intensity, combining aerobic, strengthening and flexibility
exercises was able to significantly improve the perception of
life satisfaction of seropositive subjects without causing immunological impairment, at least in the characteristics observed
in the present study. Therefore, supervised physical activity
programs can be effective tools for improving psychological
well-being of patients with HIV infection and may, potentially,
have a positive influence on CD4 T-cells. This information is relevant in the context of interventions conducted by health professionals, such as physical therapists and physical trainers.
Acknowledgments
To the National Council of Scientific and Technological Development (CNPq) and to the Foundation for Research of the
State of Rio de Janeiro (FAPERJ).
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ISSN 1413-3555
ORIGINAL ARTICLE
©
Pattern and rate of motor skill acquisition
among preterm infants during the first four
months corrected age
Padrão e ritmo de aquisição das habilidades motoras de lactentes pré-termo nos
quatro primeiros meses de idade corrigida
Elaine P. Raniero1, Eloisa Tudella2, Rosana S. Mattos1,3
Abstract
Objectives: This study aimed to characterize the pattern and rate of motor skill acquisition among preterm infants from newborn to
four months corrected age, in comparison with a group of full-term infants. Methods: Twelve healthy preterm infants (mean gestational
age=33.6 weeks ± 1.25) and 10 healthy full-term infants (mean gestational age=39.1 weeks ± 0.73) participated in the study. These
infants were assessed monthly (0-4 months of age) using the Test of Infant Motor Performance (TIMP). Results: The motor performance
pattern increased over the months in both groups, with variability in the total scores at all ages. The preterm group presented a higher
mean score than shown by the full-term group between one and four months of age. In the full-term group, the motor acquisition rate
was higher from age newborn to one month than from age three to four months. It was also found that the caregivers of the preterm
infants began toy stimulation earlier than did the caregivers of the full-term infants. Both groups presented mean scores below the TIMP
values. Conclusions: The preterm infants presented a pattern of motor development similar to the typical pattern regarding the sequence
of abilities achieved. The preterm infants also presented a faster rate during the neonate period at one month of age. This suggests
that correction for prematurity is unnecessary for preterm infants with these characteristics and that follow-up programs should instruct
parents and caregivers to begin stimulation with toys at one month of age, thereby providing early exploration of various motor skills.
Keywords: premature birth; infant development; performance test.
Resumo
Objetivos: Este estudo objetivou caracterizar o padrão e o ritmo de aquisição das habilidades motoras de lactentes nascidos pré-termo
nos quatro primeiros meses de idade corrigida, comparando-os com um grupo de lactentes a termo. Métodos: Participaram do estudo 12
lactentes pré-termo saudáveis, (MD=33,6 semanas de idade gestacional, ± 1,25) e 10 lactentes a termo saudáveis (MD=39,1 semanas de
idade gestacional, ± 0,73). Eles foram avaliados mensalmente (zero a quatro meses de idade) com o Test of Infant Motor Performance (TIM).
Resultados: O padrão de desempenho motor aumentou ao longo dos meses em ambos os grupos, constatando variabilidade nos escores
totais em todas as idades. O grupo pré-termo apresentou escore médio mais elevado do que o a termo entre um e quatro meses de idade.
Nesse grupo, o ritmo de aquisição motora foi maior de zero a um do que de três a quatro meses. Verificou-se também que os cuidadores
desses lactentes iniciaram a estimulação com brinquedos anteriormente aos cuidadores do grupo a termo. Ambos os grupos apresentaram
escores médios inferiores aos do TIMP. Conclusões: Os lactentes pré-termo apresentaram padrão de desenvolvimento motor semelhante
aos típicos quanto à sequência de habilidades adquiridas e ritmo acelerado no período de recém-nascido (RN) a um mês de idade.
Sugere-se que lactentes pré-termo com essas características não necessitam de correção do grau de prematuridade e que programas de
acompanhamento orientem os pais e cuidadores a estimulá-los, desde o primeiro mês, com brinquedos, propiciando a exploração precoce
de diversos padrões motores.
Palavras-chave: nascimento prematuro; desenvolvimento infantil; avaliação de desempenho.
1
Early Diagnosis and Intervention Program, Araraquara City Hall, Araraquara (SP), Brazil
2
Department of Physical Therapy, Universidade Federal de São Carlos (UFSCar), São Carlos (SP), Brazil
3
Intensive Care Unit, Santa Casa de Misericórdia de Araraquara, Araraquara (SP), Brazil
Correspondence to: Elaine Pereira Raniero, Avenida João Soares de Arruda, 1004, apto 112, Bl. IV, Jardim Universal, CEP 14801-525, Araraquara (SP), Brazil, e-mail: [email protected]
396
Introduction
Motor skill acquisition during the first year of life is extremely important for future overall development, given that
this period is marked by constant and rapid changes in the
rate and pattern of motor development. The first year of life
can also be influenced by various risk factors, such as premature birth and low birth weight1. Preterm infants show more
evident impairments in overall motor performance during
their first year of life, possibly due to the transient dystonia associated with prematurity2, and several studies have indicated
that preterm birth carries a significant risk of delayed motor
development3-5.
It is still a challenge for researchers to evaluate the acquisition and refinement of movement quality, postural control
and alignment, balance, coordination, and functional skills
over the first months of life in order to classify the development of preterm infants6-8. Thus, studies have sought to
establish the profile of the pattern and rate of motor skill
acquisition in typical infants in an attempt to set standards
to assess the normality of performance9. Studies along these
lines remain scarce, both among typical infants10 and among
infants with specific diagnoses such as cerebral palsy11,
Down syndrome12, and preterm infants13. The hypotheses
proposed have been that preterm infants present a nonlinear pattern and slower rate of motor skill acquisition than
the full-term group.
The present study aimed to characterize the pattern and
rate of motor skill acquisition among healthy preterm infants
during newborn to four months corrected age, in comparison
with a group of full-term newborns, using the Test of Infant
Motor Performance (TIMP)14. Such knowledge might contribute to accurately identifying infants who need early intervention. It may also facilitate the differentiation between
preterm infants with real motor deficit and preterm infants
whose particular acquisition rate would not involve future
motor impairment.
all of the preterm infants participated in a follow-up program
provided by the City Hall of Araraquara (SP), Brazil, in which
monthly guidance was given by a multidisciplinary team.
Inclusion criteria
The infants were selected in accordance with the following inclusion criteria. The preterm group was composed of
healthy infants with gestational age at birth between 31 and 36
weeks and six days, adequate weight for gestational age, and
five-minute Apgar score above seven. The full-term group was
composed of healthy infants with gestational age between 37
and 41 weeks, adequate weight for gestational age, and fiveminute Apgar score above seven.
Exclusion criteria
In both groups, infants were excluded if they presented
congenital abnormalities in the nervous and musculoskeletal
systems; diagnoses of genetic syndrome; symptoms of withdrawal syndrome associated with reports of maternal alcohol
and drug abuse; positive serological tests for gestational infections; and sensory (hearing and visual) deficits detected during
the neonatal period.
Participants
Methods
Twenty-nine infants who were born at Santa Casa de
Misericórdia de Araraquara (SP), Brazil were selected. Their
parents were living in the urban area of this municipality and
agreed to participate in this study. However, seven infants
were subsequently excluded ( five full-term and two preterm
infants) because of change of address or because the mother
decided not to continue in the study. The 22 remaining infants
were divided into two groups: a) preterm group composed of
12 newborns ( four females and eight males) ranging from 32 to
36 weeks gestational age (mean = 33.6 weeks; SD = 1.25 weeks)
with mean weight of 1968 grams (SD ± 527 grams); and b) fullterm group composed of 10 infants (seven females and three
males) with a mean gestational age of 39.1 weeks (SD ± 0.73
weeks) and mean weight of 3270 grams (SD ± 574 grams).
Study design
General procedures
This was a longitudinal study on a convenience sample that
was selected from among the infants born at Santa Casa de
Misericórdia de Araraquara (nursery and neonatal intensive
care unit - NICU), between September and December 2007,
who resided in this municipality and fulfilled the inclusion
and exclusion criteria. Because this was a convenience sample,
The present study was approved by the Ethics Committee of
Universidade Federal de São Carlos (UFSCar), São Carlos (SP),
Brazil, approval no. 160/2007. The parents and/or guardians of
the selected infants signed an informed consent form. All infants
were evaluated with the original version of the TIMP14. They were
filmed during this stage using a Sony D8 digital camera.
397
The TIMP is an instrument with recognized predictive
validity15,16 and ecological validity17. It is capable of discriminating
between infants at various degrees of risk for motor deficits18,19
and detecting lower functional motor performance as early as
age three months20. This instrument evaluates infants’ posture
and selective control over movements from 32 weeks gestational age to four months corrected age14. The test consists of
42 items (13 observed and 29 elicited) that evaluate both head
control and spatial orientation in different positions in response
to visual and auditory stimuli. It is constructed as a hierarchy
of difficulty, i.e. starting with simple items and progressing to
items of greater complexity that require greater motor maturity.
The total raw score is obtained by summing the scores from all
items: for the observed items, the score is zero when the item is
not observed during spontaneous movement and one when it
is observed; the elicited items can be scored on a five point scale
(0 – 4) or a seven point scale (0 – 6) according to the performance. After summing the observed and elicited items, the raw
score ranges from 0 to 142 points. To use this test, investigators
were trained by a skilled researcher (study of test manual and
specific training CD-ROM). After that, intraclass correlation
coefficients (ICCs)21 were obtained: intra-observer coefficient
of 0.87 and inter-observer (three investigators) of 0.88.
Test procedure
The infants were evaluated on five occasions, always by the
same investigator for each infant. The first evaluation was made
no later than the fifth postnatal day for the full-term group and
no later than the fifth day corrected age for the preterm group.
At the time of this first contact with the parents, they were interviewed to obtain information on the gestational and perinatal history, socioeconomic level, schooling level, mother’s age,
and family composition (number of children). The birth data
(weight, gestational age, Apgar score, and complications) were
gathered from the hospital medical files (NICU and nursery).
The remaining evaluations took place when the infants
were one, two, three, and four months of age, on the birth
date (± 7 days) and using corrected age for the preterm group.
On these occasions, information was also obtained from the
parents regarding the infant’s routine in relation to the main
caregiver and the daily stimuli (toys) that were presented to the
infant, using a structured questionnaire. The evaluations were
performed at the infants’ homes, thus making it possible to observe them in their natural environment. The evaluations lasted
around 30 minutes, during the interval between feedings. The
infants were undressed, and then the TIMP was applied, starting with the observable items followed by the elicited items.
According to the TIMP manual, during these evaluations,
the infants should be in state 3 (drowsy, with eyes opening
398
and closing), state 4 (awake, with eyes open and minimal body
movements), or state 5 (totally awake, with vigorous body
movements), as defined by Brazelton21. If the infant cried, the
caregiver was allowed to soothe him or her; if the infant did
not calm down, thus making it impossible to conclude the test,
another appointment was set for the next day.
Description of the variables
In the present study, the independent variables were the
infant’s age and birth condition ( full-term or preterm). The
dependent variables were the total TIMP score, motor skill
acquisition and the percentage of motor skill acquisition each
month, and the normative data provided by the TIMP.
Total score
This was the sum of the scores obtained from all of the
items in the TIMP (both observed and elicited).
Motor skill acquisition
“Motor skill acquisition” was defined as the behavioral
changes observed in the infant over the months. These changes
were related to the emergence of new skills and were calculated in terms of acquisition of points within the total TIMP
score compared to the preceding month:
Motor acquisition = [score for month X – score for month (X-1)]
Through this variable, the pattern of motor skill acquisition
was characterized to determine whether or not it was linear
(increase in motor performance occurring in a gradual and
sequential manner).
Monthly percentage motor acquisition
The monthly percentage motor acquisition was obtained
through the following equation:
% acquisition = [score for month X – score for month (X-1)]/ score
for month X * 100
Through this variable, the rate of motor skill acquisition was
characterized to determine whether or not this rate was similar
each month, i.e. whether or not it was constant over time.
Normative data from TIMP
The progression curve of the mean scores in each group
was compared with the progression curve of the normative
TIMP values for the same ages.
The statistical software packages SPSS 13.0, Statistica 7.0,
and GraphPad 3.05 were used to perform the analyses. Firstly,
the economic and sociodemographic characteristics were
compared using the chi-square test (main caregiver, mother’s
schooling level, number of pregnancies, economic class, and
stimulation received) and Student’s t test (mother’s age) to
determine whether the groups were similar regarding these
variables. For the dependent variables, which did not present normal distribution, the following tests were selected: the
Mann-Whitney test for intergroup analysis, comparing the total scores obtained in the full-term and preterm groups each
month, and to find any differences in acquisition between
the two groups at each age in relation to the total score (one
month minus newborn, two months minus one month, three
months minus two months, and four months minus three
months); and the Friedman test to compare the percentage of
monthly acquisition within each group (intragroup analysis).
If significant differences were found, the Dunn post-hoc multiple comparisons test was performed. To compare the mean
monthly scores in each group with the mean monthly score
provided by the TIMP, the Kruskal-Wallis test was performed
in relation to both the gestational age condition ( full-term,
preterm, and TIMP) and the chronological age condition
(0=newborn, 1=one month, 2=two months, 3=three months,
and 4=four months). The Kendall correlation ( for ordinal
variables) was performed to determine whether the groups
correlated with each other. The α value used was p<0.05.
Results
The preterm and full-term infants were initially characterized in relation to economic and sociodemographic conditions
and in relation to the stimulation with toys in each month.
Table 1 shows that, in relation to the economic and sociodemographic characteristics, there were no significant differences
between the groups, which were thus comparable with each
other. With regard to the start of stimulation, it was prevalent
from the first to the third month in the preterm group compared to the full-term group, and it was significant (p<0.35)
only in the first month.
The number of infants evaluated each month was 12 in the
preterm group and 10 in the full-term group. Three evaluations
were excluded due to colic ( full-term group: one newborn
and one at age four months) and due to reactions to routine
vaccinations (preterm group: one at age two months), which
affected the performance of these infants in two subsequent
attempts (on two consecutive days).
Total score
Figure 1 shows that, over the months, there was a progressive increase in motor performance evaluated through the
TIMP in both groups. There was a clear variability in the infants’ total scores at all ages.
Table 1. Characteristics of the infants studied.
VARIABLES
Mother’s age1 mean ± SD
Mother’s schooling level2
Elementary
High school
University level
Number of pregnancies2
Primiparae
Multiparae
Main caregiver2
Mother
Others
Stimulation (toys)2
1M
2M
3M
4M
Social Class (ABEP#)2
B1
B2
C1
C2
31±8
FULLTERM
28±5
3
6
3
2
6
2
0.896
4
8
2
8
0.484
10
2
9
1
0.650
9
9
11
12
2
5
6
9
0.035*
0.285
0.225
0.513
3
6
3
2
5
3
0.175
PRETERM
p value
0.261
# Brazilian Association of Research Companies (ABEP)22 presents the social classes in
decreasing order. B1 and B2 = upper middle class; C1 and C2 = middle class. 1 Two-sample
Student’s t test, 2 chi-square test; * statistically significant.
Motor acquisition and percentage of monthly
motor acquisition
There were no significant differences in the motor acquisition and the percentage of monthly motor acquisition between
the groups as a function of time, but there was a significant
difference in the percentage of monthly motor acquisition in
the preterm group (p=0.016). This difference in percentage
gain in relation to the score for the previous month occurred
between the intervals of newborn-one month (52%) and threefour months (12%).
Normative data of the TIMP scale
The Kendall correlation showed a strong, positive, and significant correlation between the full-term, preterm, and TIMP
groups (correlation coefficient=1). However, the Kruskal-Wallis
test showed no statistically significant differences between
them. Nonetheless, Figure 2 shows that the infants evaluated
had lower scores than predicted by the test in the period between birth and three months and that the preterm group had
a higher mean score than the full-term group in the period
399
between one and four months, thus reaching the mean predicted by the test.
Boxplot - Escore Tim p
140
120
400
Score Timp
In relation to the total TIMP score each month, there were
no significant differences between the preterm and full-term
groups of infants. This may be explained by the variability in
performance observed between the members of each group. In
each group, there were infants with high and low performance,
according to the standards supplied by the test. This can be
understood from the perspective of dynamic systems that
emphasize interactions between intrinsic factors (maturation
of various organic systems), motor activities, and the environmental and sociocultural context23-26. Although the preterm
and full-term infants were healthy in relation to the clinical
characteristics of birth, it is believed that each infant’s environment and the stimulation received were determined by the
intrinsic dynamics of each family. For this reason, the quantity
and quality of stimuli received varied for each infant, generating different extrinsic restrictions within the sphere of the task
and context and culminating in asynchronous development of
the various subsystems. Furthermore, in this respect, Kamm,
Thelen, and Jensen27 and Rocha, Tudella, and Barella28 stated
that, although the subsystems act together for acquisition of
skills and behavior, they present individual stages and rates of
maturation.
One interesting finding was the difference in the percentage of motor acquisition in the preterm group over the course
of time. There was an accelerated and significant increase in
performance in the period between birth and one month of age
compared to the period between three and four months of age.
This behavioral pattern was not observed among the full-term
infants. According to data in the literature, premature infants
need to adapt to the action of gravitational force and to sensory
stimuli (pain, sounds, light, and manipulation) using nervous
and muscle systems that are still immature. However, the exposure of an immature organism to these stimuli will influence
the maturation process. Thus, upon reaching 40 weeks corrected age, the preterm infants presented characteristics that
differed from those of full-term infants, with lower TIMP scores.
It is known that preterm infants’ difficulties in integrating and
modulating the stimuli received by different subsystems (such
as tactile, visual, and vestibular stimuli) affect muscle activation and consequently postural control. This frequently leads
them to present a lower level of behavioral organization than
seen among typical infants of this age29,30.
It is believed that the greater speed of motor acquisition between birth and one month corrected age occurs because this
100
80
60
40
20
0
Newborn
1M
2M
3M
4M
Age (months)
Figure 1. Total TIMP score over the months.
Full-term
Preterm
TIMP
140
120
TIMP Score
Discussion
Full-term
Preterm
* Outliers
100
80
60
40
20
0
Newborn
1M
2M
Age (months)
3M
4M
Figure 2. Comparison between mean monthly total scores of the preterm
and full-term groups and the mean normative values of the TIMP scale.
is the period during which infants achieve their peak capacity
to adapt to the stimuli received through a self-organization
process27, combining motor and perceptual components while
performing each activity to organize and reorganize their responses to stimuli from the environment. Similar results were
obtained by Medoff-Cooper and Ratcliffe30, who observed that
preterm infants presented significant neurobehavioral maturation between the ages of 40 and 44 weeks (postconception).
This suggests that these infants develop strategies to deal with
the organic disadvantages and thus adapt to the environment
through behavioral organization (sucking/swallowing/breathing and alertness) and intense motor maturation. Corroborating these findings, Lopes, Lima, and Tudella10 observed 70
typical full-term infants, with application of the Alberta Infant
Motor Scale (AIMS), and did not find any significant difference
in raw score between zero and one month of age, indicating
that, for full-term infants, this period is not marked by the same
adaptations as observed among preterm infants.
The results obtained demonstrate that the preterm group
had a relatively better performance than the full-term group, as
evidenced by the comparison between the total scores of both
groups with the normative TIMP values. This result differs from
other studies that have stated that preterm infants generally
present a poorer performance compared to full-term infants,
even after correcting the chronological age. These differences
may be due to variation in the eligibility criteria for the infants,
such as gestational age and birth weight31,32, and experimental
design13, along with differences in the period studied (which
ranged from 40 weeks of age to two and a half years of chronological age) and particular cultural characteristics (different
nationalities), thus hindering a direct comparison.
Regarding the intrinsic (organic) restrictions, the gestational
age correction may have been partly responsible for the better
performance of the preterm group. The group studied had a mean
gestational age of 33.6 weeks, which is classified as moderate prematurity33. The infants’ ages were corrected as part of the assessment protocol, in accordance with the TIMP scale. Several studies
have demonstrated that infants born with a moderate degree of
prematurity present a prognosis for motor development that is
close to normal. In a longitudinal study, Persson and Stromberg34
found little difference regarding the mean motor performance
level between groups with different motor impairment risks, particularly between the group of moderately preterm infants and the
control group. Campbell and Hedeker17 compared five groups of
infants with different degrees of motor impairment risk and also
observed that there was no significant difference in performance
on the TIMP scale between full-term infants (low risk) and preterm infants without significant clinical complications (medium
risk). Thus, the better performance among the preterm infants
evaluated may have been due to the age correction, which was
applied to a group of infants who already presented motor skill acquisition similar to typical acquisition given the moderate degree
of prematurity. Further studies are needed to determine the range
of gestational age for which this correction is necessary, the time
until which this correction should be made, and the domains for
which it should be made35.
Another factor that may have influenced the better performance of the preterm infants was the fact that they had been
participating in a periodic follow-up program provided by the
municipal outpatient service, in which the parents and/or caregivers received guidance on positioning and adequate means
of stimulating their infants. The guidance received may have
helped to overcome the patterns of insecurity often observed
among the parents of premature infants, who usually seem apprehensive about manipulating and stimulating their children36.
It is believed that this follow-up may have influenced the extrinsic (environmental) restrictions, thereby providing the infants
with early exploration of different motor patterns, such as ear-
eye-head and hand-eye coordination, reaching and exploring objects, among others. Consequently, this may have favored motor
acquisition at an age close to what the scale suggests.
This idea is reaffirmed through comments made by the
mothers of the preterm infants assessed who had already had
full-term children. They had perceived differences in the way
in which daily care and stimulation were performed in the two
situations and reported that they felt more at ease leaving their
full-term children sleeping and spending a good proportion of
the day in the crib or stroller, which was not the case in relation
to children who were born premature. They also stated that
they felt the need to give more attention and stimulation to the
preterm infants, in order to compensate for the problems that
they presented at birth. In agreement with this idea, Andraca
et al.23 stated that the mother’s responsiveness to the infant’s
demands and her capacity to interact with it had a direct effect
on the motor and cognitive performance that it would attain.
In view of the results obtained, it can be stated that the
initial hypothesis that the pattern of motor skill acquisition of
preterm infants would differ from that of full-term infants was
not confirmed as both groups presented statistically similar
patterns. Regarding the hypothesis that preterm infants would
acquire motor skills at a slower pace than full-term infants, it
was observed that while the full-term infants presented a linear increasing pattern of motor acquisition, the preterm group
presented a higher rate of motor skill acquisition between birth
and one month corrected age, maintained an increasing rate
between the first and third months, and presented a decelerating rate between the third and fourth months. Despite this, the
two groups achieved similar final values, compared with the
TIMP scores. Similar findings were presented by van Haastert
et al.13, who evaluated 800 preterm infants between one and
18 months corrected age and concluded that the characteristic
pattern of motor development of preterm infants would be a
variation of the typical pattern of motor development.
Limitation of the study and future research
It was not possible to evaluate a greater number of infants
to allow the generalization of the conclusions, nor was it possible to make separate evaluations of infants with different
degrees of prematurity. Furthermore, the results suggested
that, for this group, it would not be necessary to correct for the
degree of prematurity when evaluating motor skill acquisition.
However, in order to generalize this observation, studies with
more extensive population-based samples will be necessary.
For future studies, it would be of interest to apply validated
tools to evaluate mother-infant bond and interaction and thus
determine how these factors might affect the speed of motor
and cognitive skill acquisition among preterm infants. It would
401
also be of interest to conduct studies comparing the use of
chronological age and corrected age with the aim of determining which of these would have greater predictive value for motor prognosis among preterm infants.
Conclusions
Knowledge of the rate and pattern of motor skill acquisition among preterm infants can help professionals to ascertain
whether these infants’ development is taking place as expected,
or whether they present motor deficits. Through such knowledge, it will be possible to judge the best moment to start or
indicate an intervention, thus boosting the intrinsic capacities
of these infants. This knowledge may also minimize unnecessary indications for interventions that, in addition to being a
burden on the public healthcare system, generate high levels of
stress for the families involved.
From the results obtained, it is concluded that these healthy,
preterm infants with gestational age above 32 weeks presented
a pattern of motor skill acquisition that was similar to that of
typical infants with regard to the sequence of skills acquired, but
with a particular pace that can be considered a variation within
the spectrum of normality. From a clinical point of view, it is important to note that, for infants with characteristics resembling
those of the infants that comprised this study, it is recommended
that follow-up programs should focus not only on evaluating the
infants but also on instructing their parents and caregivers in the
particular features of these infants’ motor development, thereby
minimizing parents’ fear of manipulating and providing daily
care so that they can correctly stimulate their children. With
this care, it is believed that it will be possible to strengthen the
mother-child bond and promote full development of the intrinsic capacities through favorable extrinsic constraints.
Acknowledgements
The Maria Beatriz Linhares and Vanessa Maziero Barbosa for
their valuable suggestions while this manuscript was being finalized; and the infants and their families who participated in this
study and allowed us to gather knowledge that will help other families in the future. This study received research funding from Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP).
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403
ISSN 1413-3555
©
ORIGINAL ARTICLE
Analysis of partial body weight support during
treadmill and overground walking of children
with cerebral palsy
Análise do uso de suporte parcial de peso corporal em esteira e em piso fixo
durante o andar de crianças com paralisia cerebral
Vânia M. Matsuno1,, Muriel R. Camargo1, Gabriel C. Palma1, Diego Alveno1, Ana Maria F. Barela1,2
Abstract
Objective: To analyze the spatial-temporal characteristics and joint angles during overground walking without body weight support
(BWS) and with 0% and 30% BWS, and during treadmill walking with the same BWS in children with cerebral palsy. Methods: Six children
with hemiplegic and spastic cerebral palsy (7.70 ± 1.04 years old) were videotaped during overground walking at a comfortable speed
with no BWS, with 0% and 30% BWS, and during treadmill walking with 0% and 30% BWS. Reflective markers were placed over main
bony landmarks in both body sides to register the coordinates “x”, “y”, “z”. Results: During overground walking, children walked faster
and presented longer and faster strides, longer duration of single-stance and swing periods, and shorter duration of double-stance
period, than treadmill walking, regardless of BWS use. The hip was the only joint that presented a difference between body sides and
experimental conditions; i.e. range of motion (ROM) was reduced in the plegic side when compared to the nonplegic side, and during
overground walking without BWS when compared to 30% BWS. Conclusion: Children with hemiplegic and spastic cerebral palsy were
able to walk overground and on a treadmill with different percentages of BWS, and their performance was superior during overground
walking, regardless of BWS use.
Key words: joint angles; spatial-temporal parameters; hemiplegia; children.
Resumo
Objetivo: Analisar características espaço-temporais e ângulos articulares de crianças com paralisia cerebral andando sem o uso de
suporte parcial de peso corporal (SPPC) em piso fixo e com 0% e 30% de SPPC em piso fixo e em esteira. Métodos: Seis crianças com
paralisia cerebral hemiplégica espástica (7,70±1,04 anos) foram filmadas andando com velocidade confortável sem o uso de SPPC,
com 0% e 30% de SPPC em piso fixo e com 0% e 30% de SPPC em esteira. Marcadores refletivos foram afixados nos principais pontos
anatômicos dos dois hemicorpos para registro das coordenadas “x”, “y”, “z”. Resultados: As crianças andaram mais rapidamente e
com passadas mais longas e mais rápidas, com duração dos períodos de apoio simples e balanço maiores e apoio duplo menor no
piso fixo do que na esteira, independentemente do uso do SPPC. O quadril foi a única articulação que apresentou diferenças entre os
hemicorpos e entre as condições, sendo que o hemicorpo plégico apresentou menor amplitude de movimento (ADM) que o hemicorpo
não plégico, e a ADM foi maior na condição sem o uso de SPPC do que com 30% de SPPC em piso fixo. Conclusão: Crianças com
paralisia cerebral hemiplégica espástica são capazes de andar em piso fixo e esteira com diferentes porcentagens de SPPC, sendo
que seus desempenhos foram melhores no piso fixo, independentemente do uso de SPPC, do que na esteira.
Palavras-chave: ângulos articulares; parâmetros espaço-temporais; hemiplegia; crianças.
1
Movement Analysis Laboratory, Institute of Physical Activity and Sport Science, Universidade Cruzeiro do Sul, São Paulo (SP), Brasil
2
Post-Graduate Program in Human Movement Sciences, São Paulo (SP), Brasil
Correspondence to: Ana Maria Forti Barela, Instituto de Ciências da Atividade Física e Esporte (ICAFE), Universidade Cruzeiro do Sul, Rua Galvão Bueno, 868 – 13o. Andar, Bloco B,
Liberdade, CEP 01506-000, São Paulo (SP), Brasil, e-mail: [email protected]
404
Body weight support and cerebral palsy
Introduction
Systems involving the use of a suspension vest and partial body weight support (BWS) have been used as a form of
walking training1. In this type of training, subjects practice
treadmill walking while their weight is partially supported by
a suspension vest. The BWS can be used in different ways that
allow various degrees of body motion. The height of the vest
and the subject’s body weight can be adjusted by the calibration of load cells, counterweights, pneumatic lift, springs, etc.
Thus, the system may support a percentage of the subject’s
body weight (partial BWS) or the total body weight, according
to the examiner’s wish.
Among the different percentages of BWS that can be used,
the majority of studies evaluating treadmill walking adopted a
30% BWS due to its effectiveness in improving walking performance2-5. In addition to selecting the appropriate percentage of
BWS during training sessions, another aspect to be considered
is the type of walking surface, as it should preferably replicate
situations encountered during daily life activities in order to
facilitate the transfer of skills to that context6,7.
The differences between overground and treadmill
walking without BWS have been investigated in healthy
individuals8-11 and in hemiparetic stroke patients12,13. The
characteristics of locomotion, such as joint angles or spatialtemporal parameters8,14,15, foot contact with the surface11, and
muscle activation13, are influenced by the type of walking
surface. Thus, it may be that walking training on a treadmill
may interfere with the proper transfer of skills to overground
walking7,10,16, which is the walking surface used by individuals
on a daily basis.
Among those individuals with locomotor impairment,
one group that can benefit from walking training with BWS
is children with cerebral palsy, since the development of an
independent and efficient walking is one of the major targets
for this group. Cerebral palsy (CP) describes a group of permanent disorders of the development of movement and posture,
causing activity limitation17. These disorders are attributed
to nonprogressive disturbances that occurred in the developing fetal or infant brain17. To date, there are few studies
using BWS for walking training in children with CP18,19, and
these are mostly case studies20-23. In previous studies, the improvement in walking performance was generally evaluated
by motor tests, such as the Gross Motor Function Measure24,
and their results suggest that BWS can improve walking in
children with CP.
Few studies have investigated the use of BWS during overground walking3,25-27, and none of them had samples consisting
of children. Additionally, little information is available regarding
the impact of surface type (e.g. treadmill or overground) on
walking performance with BWS. Thus, before recommending
walking training with BWS to children with CP, it would be
important to evaluate their walking performance in different
types of surface.
The aim of this study was to analyze the spatial-temporal
characteristics and joint angles during overground walking
without BWS and with 0% and 30% BWS, and during treadmill
walking with the same BWS in children with cerebral palsy.
Methods
Sample
Six children with hemiplegic and spastic CP, aged between 6 and 9 years, participated in this study. To be included
in the study, they had to present spastic hemiplegia without
any cognitive, verbal or visual impairments that could interfere with the performance of tasks, and had to be classified
as level I to III of the Gross Motor Function Classification
System (GMFCS)28. Children who were currently attending
an intervention program offered by the Universidade Federal de São Carlos (UFSCar), São Carlos (SP), Brazil, or who
had previously participated in that program, were contacted through telephone. The characteristics of children are
shown in Table 1.
Table 1. Characterization of children with hemiplegic and spastic cerebral palsy in terms of age, gender, plegic side, weight, height, Gross Motor
Function Classification System (GMFCS), and Ashworth scale30.
Participant
1
2
3
4
5
6
Mean
SD
Age (yrs)
6.3
6.7
7.8
8
8.3
9.1
7.70
1.04
Gender
M
F
M
F
F
M
Plegic side
L
R
R
R
R
L
Weight (kg)
21.7
18.5
21.9
28.1
26.7
46.9
27.30
10.23
Height (cm)
120
112
130
125
131
142
126.67
10.27
GMFCS
I
II
I
II
II
III
Ashworth scale
1
1
1
2
1
2
GMFCS= Gross Motor Function Classification System; M= male; F= female; L= left; R, right; SD= standard deviation.
405
Vânia M. Matsuno,, Muriel R. Camargo, Gabriel C. Palma, Diego Alveno, Ana Maria F. Barela
Procedures
Children accompanied by their parents or guardians attended the Learning, Biomechanics, Assessment and Training
Laboratory (LABAT) of the UFSCar, where the data were
acquired. Initially, the objectives and procedures of the study
were explained, and each parent or guardian signed a consent
form approved by the Ethics Committee of the Cruzeiro do Sul
University, São Paulo, Brazil (No. 100/2007). While the parent
or guardian was requested to complete the Pediatric Evalualion
of Disability Inventory (PEDI)29, which covers issues related to
mobility, self care and social function, study investigators measured children’s weight and height, and a physical therapist
used the Ashworth scale to assess the degree of spasticity30.
Then, reflective markers were placed bilaterally over the fifth
metatarsal, lateral malleolus, lateral femoral condyle, greater
trochanter, and greater tubercle of the humerus for the identification of foot, leg, thigh and trunk segments, respectively,
and to calculate joint angles. Thus, the foot and leg segments
defined the angle of the ankle, the leg and thigh segments defined the angle of the knee, and the thigh and trunk segments
defined the angle of the hip.
Children were videotaped at 60 Hz by four digital cameras (Panasonic, model AG-DVC7P) bilaterally arranged,
while walking in five experimental conditions: (1) overground
walking without BWS; (2) overground walking with 0% BWS;
(3) overground walking with 30% BWS; (4) treadmill walking
with 0% BWS; and (5) treadmill walking with 30% BWS.
For overground walking, children walked at a self-selected
and comfortable speed over a 10-meter course. Before videotaping, the children were given the chance to practice each
experimental condition to familiarize themselves with the procedures. For treadmill walking, the treadmill was positioned at
the center of the 10-meter course and children were requested
to walk at a comfortable speed, while one investigator progressively increased the speed and checked if the child could accomplish the task. After reaching the speed that was adequate
for each child, the practice of the five experimental conditions
commenced. The children wore shoes and did not use any kind
of orthoses during all experimental conditions.
Four repetitions of each experimental condition were
videotaped, and the procedure always started with children
walking overground without BWS (control condition). To reduce the time spent in the laboratory, experimental conditions
involving BWS were first performed overground and then on
the treadmill. The sequence for the percentage of BWS (0% or
30%) was chosen at random by the child. All children were allowed to rest between tasks, when needed.
The BWS system used in this study consists of a vest with
adjustable belts and coated handles in the pelvis and thigh,
406
which is suspended by a steel cable attached to a motor that
slides on a rail of approximately 10 meters fixed to the ceiling.
A load cell, positioned between the vest and the steel cable,
was used to determine the approximate percentage of BWS. To
adjust the percentage of BWS, the motor was used to reduce or
increase the length of the steel cable according to the desired
percentage.
Data treatment
Videotaped data were transferred to a computer through a
capture card (ieee1394). One stride of both the plegic and nonplegic limbs were selected from two trials under each experimental condition using the Ariel Performance Analysis System
Program (APAS). These data were digitized using the same program to obtain the coordinates x, y and z, which corresponded
to the markers placed over children’s anatomical landmarks.
The procedure for processing the real coordinates of the acquired data was the direct linear transformation (DLT). These
coordinates were filtered with a fourth-order Butterworth lowpass filter (10 Hz), and the following variables were calculated
using the Matlab program (MathWorks, Inc.): walking speed;
stride length; speed and cadence; duration of the single-stance,
double-stance and swing periods; range of motion (ROM) of the
hip, knee and ankle joints during the walking cycle. The data
corresponding to the coordinate x of the marker placed over
the greater trochanter (referring to the plane of progression)
were used to calculate mean walking speed, and the markers
placed over the right and left lateral malleolus were used to
calculate stride length. Stride speed was calculated by the ratio
between stride length and duration. ROM was calculated by
the difference between the maximum and minimum angles of
each joint.
To compare the walking performance among the five
experimental conditions in children with hemiplegic and
spastic CP, univariate (ANOVA) and multivariate (MANOVA)
repeated-measures analyses of variance were employed. For
the first ANOVA, the factor was the experimental condition
and the dependent variable was the mean walking speed; for
the second ANOVA, the factors were the experimental condition and body side (plegic or nonplegic), and the dependent
variable was cadence. For all the MANOVAs, the factors were
the experimental condition and body side; the dependent
variables were stride length and speed for the first MANOVA,
duration of single-stance, double-stance and swing periods
for the second MANOVA, and ROM of the hip, knee and ankle
joints for the third MANOVA. When necessary, Tukey’s post
hoc tests were employed. The significance level (α) was set
at 0.05 for all statistical tests, which were performed with the
software Statistical Package for Social Sciences (SPSS version
10.0, SPSS Inc.).
Results
Table 2 shows the values for all variables, except for ROM,
which is shown in Figure 1. The ANOVAs indicated that the
experimental condition was significantly associated with
different walking speeds (F4,20 = 19.33, p<0.001) and cadence
(F4,20 = 29.21, p<0.001). There was no indication of differences
in cadence between body sides (F1,5 = 1.84, p>0.05), and no association between the experimental condition and body side
(F4,20 = 0.48, p>0.05). Post hoc analyses indicated that children
walked faster and with a higher cadence overground without
BWS and with 0% BWS than on the treadmill with 0% or 30%
BWS. When BWS was set at 30%, the children also showed higher cadence walking overground than on the treadmill.
The first MANOVA indicated that the experimental condition was significantly associated with different stride length
and speed (Wilk’s Lambda = 0.15, F8,38 = 7.57, p<0.001). There
was no indication of differences in stride length and speed between body sides (Wilk’s Lambda = 0.37, F2,4 = 3.34, p>0.05), and
no association between the experimental condition and body
side (Wilk’s Lambda = 0.87, F8,38 = 0.33, p>0.05). The univariate
analyses of the experimental condition showed significant
differences in stride length (F4,20 = 21.19, p<0.001) and speed
(F4,20 = 22.99, p<0.001). Post hoc analyses indicated that children
walked with longer and faster strides overground without BWS
and with 0% BWS, than on the treadmill with 0% or 30% BWS.
The second MANOVA indicated that the experimental condition was significantly associated with different durations of stance
and swing periods (Wilk’s Lambda = 0.11, F12,47 = 5.31, p<0.001).
There was no indication of differences between body sides
(Wilk’s Lambda = 0.75, F3,3 = 0,80, p>0.05), and no association between the experimental condition and the body side
(Wilk’s ambda = 0.63, F12,47 = 0.76, p>0.05). The univariate
analyses of the experimental condition showed significant differences in the duration of single-stance (F4,20 = 12.84, p<0.001),
double-stance F4,20 = 25.57, p<0.001) and swing periods
(F4,20 = 9.33, p<0.001). Post hoc analyses indicated that the singlestance period (without BWS and with 0% BWS) was longer when
children walked overground than on the treadmill. The duration
of the double-stance period was shorter when children walked
overground without BWS and with 0% BWS than on the treadmill, and shorter when they walked overground with 30% BWS
than on the treadmill with 0% BWS. The duration of the swing
period was longer during overground walking without BWS and
with 0% BWS than on treadmill walking with 0% BWS.
The third MANOVA indicated that the experimental condition was significantly associated with ROM
(Wilk’s Lambda = 0.15, F12,47 = 4.25, p<0.001). There
was an indication of differences between body sides
(Wilk’s Lambda = 0.05, F3,3 = 18.66, p<0.05), but no association
Table 2. Walking speed, stride length and speed, cadence, and duration of single-stance, double-stance, and swing periods during five experimental
conditions in children with hemiplegic and spastic cerebral palsy (n=6).
Condition
Overground
walking
No BWS
Plegic side
Nonplegic side
0% BWS
Plegic side
Nonplegic side
30% BWS
Plegic side
Nonplegic side
Treadmill walking
0% BWS
Plegic side
Nonplegic side
30% BWS
Plegic side
Nonplegic side
Walking Speed
(m/s)
Stride Length
(m)
1.03±0.28
1.01±0.19
Stride Speed
(m/s)
Cadence
(steps/min)
Single-stance
(%)
Double-stance
(%)
Swing
(%)
1.08±0.29
128±16
38.03±4.86
21.92±6.37
40.06±2.83
1.00±0.20
1.05±0.30
126 ±17
40.83±3.45
21.43±7.23
37.74±4.41
0.87±0.21
0.86±0.16
0.84±0.15
0.90±0.20
0.89±0.18
126±10
127±13
36.66±2.00
39.77±4.57
19.71±4.50
20.44±5.82
43.62±4.99
39.80±6.79
0.67±0.15
0.79±0.15
0.77±0.16
0.72±0.17
0.70±0.17
110±17
110±17
39.03±6.88
39.64±6.51
23,51±5,76
23,07±6,78
37,46±4,61
37,29±4,21
0.41±0.07
0.59±0.09
0.58±0.11
0.40±0.06
0.38±0.07
82±6
79±5
30.61±3.17
29.41±3.42
43.05±8.92
42.58±8.31
26.33±7.92
28.01±7.62
0.41±0.05
0.56±0.13
0.56±0.11
0.37±0.06
0.37±0.05
81±9
80±9
30.28±4.06
29.32±3.43
36.52±6.38
36.66±4.51
33.20±6.63
34.01±4.65
Values are means or percentages and standard deviations. BWS= body weight support.
407
A)
408
Plegic side
Nonplegic side
Hip ROM (º)
70
60
50
40
30
20
10
B)
80
70
Discussion
60
50
40
30
20
10
C)
80
70
Ankle ROM (º)
This study analyzed the spatial-temporal characteristics
and the joint angles of children with CP during overground
and treadmill walking and under different contexts of BWS.
Few studies have investigated the use of BWS during overground walking3,25,27, and their focus was on patients who had
suffered a stroke. The present study was the first to analyze
overground walking performance of children with CP using a
BWS system, and to compare it to walking without BWS and
with treadmill walking with BWS. According to our findings,
the children walked faster and had longer and faster strides
when walking overground than on the treadmill, regardless
of BWS use. In terms of joint angles, the hip was the only
joint showing differences between the body sides and among
the experimental conditions, with the plegic side showing a
more limited ROM than the nonplegic side, and overground
walking without BWS showing a greater ROM than walking
with 30% BWS.
Regarding the type of walking surface, most of the differences found in spatial-temporal variables may have been due
to the characteristics of the treadmill and the speed at which
children walked. For example, the length of the treadmill may
interfere with the length of the stride31. Additionally, due to
the fact that the treadmill is a moving surface, walking on
that surface is more unstable than walking overground, and
this may also decrease the length and speed of the stride32.
Because the mean walking speed interferes with spatial-temporal characteristics of walking33, the stride length and speed
could have been similar between the two types of surfaces if
the treadmill speed had been set closely to the speed at which
children walked overground. However, because children with
CP are not used to walk on the treadmill, this may have prevented them to feel comfortable walking at a faster speed.
80
Knee ROM (º)
was found between the experimental condition and the body
side (Wilk’s Lambda = 0.38, F12,47 = 1.77, p>0.05). The univariate
analyses of the experimental condition showed significant
differences in the ROM of the hip (F4,20 = 5.91, p <0.005), knee
(F4,20 = 3.75, p<0.05), and ankle joints (F4,20 = 3,87, p<0.05). The
univariate analysis of body sides also indicated a significant
difference in the ROM of the hip joint (F1,5 = 32.64, p<0.005); i.e.
the plegic side showed a more limited ROM than the nonplegic side. Post hoc analyses indicated that the ROM of the hip
was greater during overground walking without BWS than
with 30% BWS. There was no indication of such differences in
the ROM of the knee and ankle joints.
60
50
40
30
20
10
No BWS
0% BWS OG
30% BWS OG
0% BWS T
30% BWS T
ROM=range of motion; BWS=body weight support; OG=overground walking;
T=treadmill walking.
Figure 1. Range of motion of the hip (A), knee (B), and ankle (C) joints
during five experimental conditions in children with hemiplegic and
spastic cerebral palsy (n=6).
The differences found in the duration of the stance and
swing periods between overground and treadmill walking
may also be a reflection of a greater degree of instability associated with the latter. It is well established that a longer
single-stance period indicates the ability to sustain the limb34,
and in the same way, a shorter double-stance period indicates
stability to walk. Because the treadmill is a moving surface,
the children needed to spend more time with both feet on
the surface during the walking cycle than when they walked
overground. Consequently, they spent less time with only
one foot on the surface during treadmill walking than during
overground walking. One factor that contributes to improved
stability and balance is the increase in the base of support35.
In the case of this study, the children spent more time with
both feet on the treadmill to ensure greater stability while
walking on that surface.
The use of the treadmill for walking training in children
with CP has advantages and disadvantages. In terms of the advantages, the treadmill can be used in a limited space, it favors
the practice of complete walking cycles with symmetrical and
consistent steps36, the number of walking cycles per training
sessions can be high given that the child cannot stop walking
while the treadmill is in motion, and the speed of locomotion
can be precisely controlled.
In terms of the disadvantages, treadmill walking requires a higher control of propulsion and balance compared to
overground walking37. In terms of propulsion, while walking
overground requires the application of enough force to alternately move the right and left limbs forward, walking on
a treadmill using some type of external support (e.g. BWS,
side bars) generates a force that is not necessarily proportional to the speed38. It is also possible that in this situation
the limbs might be passively moved by the treadmill without
any change in muscular activation13, with the child simply
raising and lowering the limbs while the treadmill belt is
moving. In terms of balance control, because the treadmill
is a moving surface, the walking strategy to keep stability
can be different from that used for overground walking. This
aspect was observed in this study through the variables duration of single-stance and double-stance periods, which
were previously discussed. The disadvantages of using a
treadmill may limit the transfer of skills to overground
walking37, since the strategies required for treadmill walking
are not necessarily the same for overground walking, which
is the type of surface that we normally walk.
In the case of walking training in children with CP, one
should be concerned with the conditions imposed to these
children and should work for enabling a more effective learning
from this form of locomotion. And perhaps most importantly,
one should understand whether the different types of training
facilitate or hinder the transfer of learning to the child’s daily
context. Thus, studies like the present one are important because they compare the walking training in different types of
surfaces to verify the impact of each procedure on the ability of
locomotion, and consequently on the activities of daily living
in children with CP.
Regarding the joint ROM, the absence of differences observed for the knee and ankle joints may be due to the small
sample size and the variability among the children, as reflected by the standard deviation values (Figure 1B and 1C). On
the other hand, there was less variability for the hip ROM,
possibly because it is a more proximal joint than the knee
and ankle joints. The hip ROM showed differences between
the plegic and nonplegic sides, and the differences found between the experimental conditions may be attributed to the
use of the suspension vest, which can restrict the movement
of this joint26,37.
Finally, for most of the parameters examined, no differences
were found between the two selected percentages of BWS for treadmill and overground walking. This result contradicts a previous
study investigating the use of BWS during overground walking in
hemiplegic subjects26. Again, this result can be attributed to the
small sample size and the wide variability among the children.
To our knowledge, there are currently no published studies
to investigate walking parameters under different percentages of BWS in children with CP. For future studies, it is important to include a larger number of children with CP, especially
because there is great variability in the type of brain injury in
these children. This study demonstrated that it is possible to
use BWS systems for walking training overground and on the
treadmill in children with hemiplegic and spastic CP, and that
differences in walking parameters can be observed between
these types of surfaces.
This study has some limitations that need to be acknowledged, such as the nonrandomized sequence of surface types, the
limited time to familiarize with the experimental conditions,
the differences between the speed of treadmill and overground
walking, and the small sample size. In this study, only children
who were able to walk independently were selected to participate, but they showed great variability in task execution in the
different experimental conditions.
Future studies should be performed with larger sample sizes
and with children presenting different types of CP and greater
impairment in locomotion. These studies should also include
other walking parameters in their analyses. Finally, studies that
investigate the effects of walking training in different types of
surfaces must be conducted to clarify whether BWS systems
are effective per se or whether it is the combination of the system and the type of surface that favors walking performance in
children with CP.
Acknowledgments
To Paula Hentschel Lobo da Costa, for providing the LABATE for data acquisition; to Diogo Costa Garção, for helping
with the selection of children; to Catarina de Oliveira Sousa
and André Rocha Viana, for their assistance in data collection;
to the National Council of Scientific and Technological Development (CNPq), process 119254/2009-3 and 121626/2009-1
(scientific grant), and to the legal guardians of children who
participated in the study.
409
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ISSN 1413-3555
ORIGINAL ARTICLE
©
Breathing pattern and thoracoabdominal
motion in healthy individuals: influence of age
and sex
Padrão respiratório e movimento toracoabdominal em indivíduos saudáveis:
influência da idade e do sexo
Verônica F. Parreira1, Carolina J. Bueno2, Danielle C. França3, Danielle S. R. Vieira3, Dirceu R. Pereira2, Raquel R. Britto1
Abstract
Objective: To describe the breathing pattern and thoracoabdominal motion of healthy individuals, taking age and sex into consideration.
Methods: The study included 104 individuals aged 20 to 39, 40 to 59, and 60 to 80 years (41 males and 63 females), with normal
body mass index and spirometric values. Participants were evaluated at rest in the supine position, by means of respiratory inductive
plethysmography. The following variables were measured: tidal volume (Vt), respiratory frequency (f), minute ventilation (VE), inspiratory
duty cycle (Ti/Ttot), mean inspiratory flow (Vt/Ti), rib cage motion (%RC), inspiratory phase relation (PhRIB), expiratory phase relation
(PhREB), and phase angle (PhaseAng). Comparisons between the age groups were performed using one-way ANOVA or KruskalWallis H, while comparisons between the sexes were performed using Student’s t test or the Mann-Whitney U test, depending on the
data distribution; p<0.05 was taken to be significant. Results: Comparison between the sexes showed that, in the age groups 20 to 39
and 60 to 80 years, women presented significantly lower values for Vt, VE, and Ti/Ttot than men, and there was no significant difference
in the age group 40 to 59 years. Comparisons between the age groups showed that participants aged 60 to 80 presented significantly
greater PhRIB and PhaseAng than participants aged 20 to 39 years, without significant differences in the breathing pattern. Conclusion:
The data suggest that breathing pattern is influenced by sex whereas thoracoabdominal motion is influenced by age.
Key words: respiratory physical therapy; assessment; breathing pattern; thoracoabdominal motion; healthy individuals.
Resumo
Objetivo: Descrever o padrão respiratório e o movimento toracoabdominal de indivíduos saudáveis considerando a idade e o sexo.
Métodos: Foram estudados 104 indivíduos com idades entre 20-39, 40-59 e 60-80 anos, 41 homens e 63 mulheres, com índice de
massa corporal e valores espirométricos normais. A pletismografia respiratória por indutância foi utilizada para mensurar, durante o
repouso e em decúbito dorsal, as seguintes variáveis: volume corrente (Vc), frequência respiratória (f), ventilação minuto (VE), razão
entre o tempo inspiratório e o tempo total do ciclo respiratório (Ti/Ttot) e fluxo inspiratório médio (Vc/Ti), deslocamento da caixa torácica
(%CT), relação de fase inspiratória (PhRIB), relação de fase expiratória (PhREB) e ângulo de fase (AngFase). As comparações entre
as faixas etárias foram realizadas por meio da ANOVA one-way ou Kruskal-Wallis H, comparações entre os sexos foram realizadas
por meio dos testes t de Student para amostras independentes ou Mann-Withney U, de acordo com a distribuição dos dados,
considerando significativo p<0,05. Resultados: Na comparação entre os sexos, mulheres apresentaram valores significativamente
menores em relação aos homens nas variáveis Vc, VE e Ti/Ttot nas faixas etárias de 20 a 39 e de 60 a 80 anos, sem nenhuma
diferença na faixa etária de 40 a 59 anos. Na comparação entre as faixas etárias, indivíduos com 60 a 80 anos apresentaram PhRIB e
AngFase significativamente maiores em relação aos adultos entre 20 e 39 anos, sem diferenças significativas nas variáveis do padrão
respiratório. Conclusão: Os dados encontrados sugerem influência do sexo sobre o padrão respiratório e da idade sobre o movimento
toracoabdominal.
Palavras-chave: fisioterapia respiratória; avaliação; padrão respiratório; movimento toracoabdominal; indivíduos saudáveis.
1
Physical Terapy Department, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil
2
Physical Therapy course, UFMG
3
Graduate Program in Rehabilitation Sciences, UFMG
Correspondence to: Verônica Franco Parreira, Departamento de Fisioterapia, Escola de Educação Física, Fisioterapia e Terapia Ocupacional, Universidade Federal de Minas Gerais (UFMG),
Av. Presidente Antônio Carlos, 6627, Campus Pampulha, CEP 31.270-901, Belo Horizonte (MG), Brazil, e-mail: [email protected]
411
Verônica F. Parreira, Carolina J. Bueno, Danielle C. França, Danielle S. R. Vieira, Dirceu R. Pereira, Raquel R. Britto
Introduction
The respiratory system consists primarily of the lungs,
whose main function is to ensure gas exchanges with the
environment, and the thoracic wall, which moves as a result
of continual muscle action1. The thoracic wall represents the
thoracoabdominal area composed of the rib cage and the
abdomen, separated by the diaphragm2,3. Thus, normal thoracoabdominal motion consists of expansion and retraction
of these compartments during inspiration and expiration,
respectively4,5. Although the rib cage and abdomen move in
unison, each of the compartments has independence of movement6. When the displacement between the compartments
ceases to be harmonious, the thoracoabdominal motion becomes asynchronous4,5,7. Healthy men and women in different
age groups present symmetry between the movements on the
right and left sides of the chest and abdomen8.
Breathing pattern and thoracoabdominal motion may
be influenced by several factors, such as the individual’s
positioning9,10, age10,11, sex10, respiratory overload12, neuromuscular diseases13, lung diseases associated with increased airway resistance4,14,15, and chronic obstructive pulmonary disease
(COPD)5,16-18. Higher rates of asynchrony may be related to
worse prognosis and significantly greater mortality16.
Among the factors that may influence the respiratory system in healthy individuals, age and sex can be highlighted. In
the elderly, the structural changes to the respiratory system encompass modifications that occur in the lungs, rib cage, respiratory muscles, and respiratory drive. The main change relating
to the rib cage is its reduction in compliance. Among healthy
individuals, these changes are more evident after the age of 80,
although they are present from the age of 50 onwards11. Studies using plethysmography have demonstrated that the mean
values of the components of the breathing pattern of healthy
elderly individuals do not differ significantly from what is
found among non-elderly adults7,10,11. This suggests that, in the
populations studied, the process of aging of the respiratory system did not cause a great impact on the parameters analyzed.
In relation to sex, a study that made comparisons between
men and women showed that there were differences in respiratory times3. The inspiratory time, expiratory time, and total time
of the respiratory cycle were shorter among the women. In addition, the women presented higher respiratory frequency, thus
suggesting that they tended to breathe more rapidly than the
men3. In the analysis of thoracoabdominal motion during quiet
breathing, men and women presented the same response3,10.
Data on breathing pattern and thoracoabdominal asynchrony are important sources of information on respiratory
function10,11,14,19 and represent an important tool in physical therapy evaluations of patients with acute and chronic respiratory
412
dysfunctions. Its importance starts in primary healthcare as
the patient enters the public healthcare system and goes up
to high-complexity environments such as intensive care units.
Data relating to breathing pattern, e.g. tidal volume and respiratory frequency, are useful for follow-ups within different types
of respiratory physical therapy interventions. Examples would
include pulmonary rehabilitation and patient care before
and after chest and abdominal surgery, among other clinical
situations, thus making it possible to observe whether different parameters have evolved favorably or not. One instrument
frequently used in studies evaluating breathing pattern and
thoracoabdominal motion is the inductive plethysmography,
which measures displacement of thoracoabdominal compartments and changes in time and pulmonary volume3,7,10.
To the best of our knowledge, studies on breathing pattern
and thoracoabdominal motion among healthy adults have either
evaluated few individuals3, very different numbers of individuals in
different age groups7, or a limited number of variables10. Given the
importance of evaluating breathing pattern and thoracoabdominal motion for clinical practice, it would be of interest to obtain
data on different variables from a significant number of Brazilian individuals. Within this context, the aim of this study was to
describe the breathing pattern and thoracoabdominal motion of
healthy Brazilian individuals according to sex and age.
Methods
Sample
For this study, 109 participants were recruited. Data were
gathered at the Laboratório de Avaliação e Pesquisa em
Desempenho Cardiorrespiratório. The inclusion criteria were:
age between 20 and 80 years; body mass index (BMI) without
indication of excess weight (18.5 and 29.9 kg/m2)20; non-smoker;
absence of ventilatory disorders of any kind in pulmonary function tests, in accordance with the values predicted by Pereira21;
absence of evident chest or abdominal deformity; absence of
cardiac or neuromuscular diseases; and absence of previous
chest or abdominal surgery. The exclusion criterion was inability to understand and/or undergo any of the procedures.
The study was approved by the Research Ethics Committee of
Universidade Federal de Minas Gerais (UFMG), Belo Horizonte
(MG), Brazil (Approval ETIC 148/07), and all participants
signed an informed consent form.
Procedures and measurement instruments
After the participants had read and signed the consent
form, their weight and height were measured using a calibrated
Breathing pattern and thoracoabdominal motion in healthy individuals
scale (Filizola Ind. Ltda, São Paulo, SP, Brazil) to calculate
the BMI, and the pulmonary function test was performed by
means of a forced maneuver, using spirometry (Vitalograph
2120, Buckingham, England). To evaluate the breathing pattern and thoracoabdominal motion, respiratory inductive plethysmography was used (Respitrace®, Nims, Miami, FL, USA).
This is a noninvasive method that requires little exertion by the
participant; it has been shown to be accurate22-24 and has been
used in previous studies3,5,7,10-12,14-17,25-32. Respiratory inductive
plethysmography measurements are based on changes to the
cross-sectional area detected by two inductance bands. Each
band is composed of two thin, adhered elastic bands around
a plastic-coated transducer wire that is arranged in a sinusoidal pattern. One of the strips was positioned on the axilla and
the other, on the umbilical line. The bands were given a slight
stretch to fit tightly around the participant and minimize signal distortion, but without limiting chest movement or causing
discomfort.
The participant was positioned in supine and asked to
remain comfortably in this position while breathing quietly
without raising the head (0º), speaking, sleeping, or moving
any of the body segments until the data recording had finished. The signal was calibrated during spontaneous breathing, by means of a specific procedure (Qualitative Diagnostic
Calibration) that was first described by Sackner et al.34. This
procedure was carried out in two stages. Firstly, the participant breathed spontaneously to balance the electrical gain
of the signals relating to the rib cage and abdomen. When
correctly amplified and divided, these signals allow relative
calibration, which lasts about five minutes. Next, after using
a syringe of known volume, the participant breathed through
a spirometer (Vitatrace, Pro Médico, Rio de Janeiro, RJ, Brazil)
for 30 to 60 seconds using a nose clip. During this stage, the
electrical signals from the rib cage and abdomen were used to
obtain the tidal volume in ml.
The calibration was performed by means of a software program (RespiPanel, NIMS, Miami, FL, USA). A detailed description of the calibration has been published previously28,35. After
the calibration, the plethysmographic data were recorded for
around 10 minutes by means of specific software (RespiEvents
5.2, NIMS, Miami, FL, USA). To analyze the data, intervals of at
least 30 seconds of stable tracing were selected. In addition, the
sum of these intervals had to reach a minimum of five minutes
of recording.
Variables analyzed
For the breathing pattern, the following volume and time
variables were analyzed11: tidal volume (Vt); respiratory frequency (f); minute ventilation (VE); inspiratory duty cycle
(Ti/Ttot); and mean inspiratory flow (Vt/Ti). In relation to
thoracoabdominal motion, the following were analyzed: rib
cage motion (%RC); phase angle (PhaseAng), which reflected
the delay between rib cage and abdomen excursions4,5,12,14,15,27
,29,30
; inspiratory phase relation (PhRIB) and expiratory phase
relation (PhREB), which reflected the percentage of time during one breath in which the rib cage and abdomen moved in
opposite directions, respectively29,30.
The data were presented as central tendency and dispersion. To analyze the data, the individuals were divided into
three groups according to age: 20 to 39 years, 40 to 59 years,
and 60 to 80 years. For the comparisons between the sexes, the
age groups were divided into women and men.
The normality of the data was checked by means of the
Shapiro-Wilk test. The comparisons between the sexes were
made using Student’s t test for independent samples or the
Mann-Whitney U test, depending on the data distribution. The
comparisons between the age groups were made using oneway ANOVA or Kruskal-Wallis H, according to the data distribution. The significance level was set at p<0.05. The analyses
were performed using the Statistical Package for the Social
Sciences, version 13.0.
Results
Of the 109 participants, five were excluded due to technical
problems during the data collection. Thus, the data relate to 104
participants (48 between 20 and 39 years of age; 18 between 40
and 59, and 38 between 60 and 80 years). In all, 8667 respiratory
cycles were analyzed, with a mean of 84 cycles per participant.
Table 1 describes the anthropometric, demographic, and spirometric characteristics of the sample.
Table 2 presents the values of the breathing pattern and thoracoabdominal motion variables among the men and women
in the three age groups. Comparisons between the sexes were
made in each age group, and these showed that Vt, VE, and
Ti/Ttot were significantly lower among the women in the age
group 20 to 39, but without any significant differences in the
other variables. There were no significant differences in the age
group 40 to 59. Among the women in the elderly group, Vt, VE,
and Vt/Ti were significantly lower, but without significant differences in the other variables.
Table 3 presents comparisons of breathing pattern
and thoracoabdominal motion between the age groups.
No significant differences were observed in any of the
variables relating to the breathing pattern. In relation to
413
thoracoabdominal motion, PhRIB and PhaseAng were significantly greater in individuals over the age of 60 than in
adults between 20 and 39 years.
In addition, comparisons between the age groups were
made for the men and women separately. No significant differences between the age groups were found among the women.
Among the men, there was only a significant difference in the
Table 1. Anthropometric, spirometric, and demographic data of the
sample.
Participants
n=104
Age (years)
Weight (kg)
Height (m)
BMI (kg/m2)
FEV1 (% predicted)
FVC (% predicted)
FEV1/FVC
FEF25-75% (% predicted)
46.24±19.57
67.12±14.45
1.65±0.09
24.66±5.36
96.38±10.45
97.02±10.34
99.67±7.32
90.7±25.96
Data are presented as mean ± standard deviation. BMI: body mass index; FVC: forced vital
capacity; FEV1: forced expiratory volume in the first second; FEV1/FVC: ratio of FEV1 to
FVC; and FEF25-75%: forced expiratory flow at 25 and 75% of FVC.
variable Ti/Ttot. Men aged 20 to 39 presented significantly
lower values than did the men over 60 years.
Discussion
The main result from this study was that there were significant differences in some of the breathing pattern variables between the sexes and in the thoracoabdominal motion variables
between the participants in the three age groups evaluated.
Comparison between the sexes showed that women presented
significantly lower values than men for the variables Vt, VE,
and Ti/Tot in the age group between 20 and 39 years and for
the variables Vt, VE, and Vt/Ti in the elderly group, but without
significant differences in the variables related to thoracoabdominal motion. Comparison between the age groups showed
that the participants over the age of 60 presented significantly
greater PhRIB and PhaseAng, in relation to the participants
aged 20 to 39, but without significant differences in the breathing pattern variables.
To the best of our knowledge, previous studies that evaluated breathing pattern and thoracoabdominal motion variables
Table 2. Respiratory pattern and thoracoabdominal motion data in age and sex subgroups.
Vt (ml)
f (breaths/min)
VE (l/min)
Ti/Ttot
Vt/Ti(ml/s)
%RC
PhRIB (%)
PhREB (%)
PhaseAng (°)
20 to 39 years
Women
Men
325±127
441±114 *
15±2
13±4
4.69±1.34
5.61±1.13 *
0.39±0.03
0.42±0.04 *
199±56
221±46
46±15
39±10
7±3
8±3
15±6
12±6
11±5
10±6
40 to 59 years
Women
Men
309±111
325±115
14±2
16±3
4.43±1.51
4.65±2.08
0.39±0.03
0.41±0.02
193±80
192±90
40±9
32±7
7±3
11±6
13±6
16±6
12±4
17±9
60 to 80 years
Women
Men
283±83
383±124 *
15±2
15±3
4.26±1.29
5.98±1.76 *
0.38±0.04
0.39±0.04
187±49
259±68 *
45±18
37±14
10±4
12±6
16±9
18±8
13±7
17±9
Data are presented as mean ± standard deviation. Vt: tidal volume; f: respiratory frequency; VE: minute ventilation; Ti/Tot: inspiratory duty cycle; Vt/Ti: mean inspiratory flow; %RC: rib
cage motion; PhRIB: inspiratory phase relation; PhREB: expiratory phase relation; PhaseAng: phase angle. * significant difference (p<0.05) for comparisons between women and men in
each age subgroup.
Table 3. Comparison of respiratory pattern and thoracoabdominal motion variables between the three age subgroups.
Vt (ml)
f (breaths/min)
VE (l/min)
Ti/Ttot
Vt/Ti(ml/s)
%RC
PhRIB (%)
PhREB (%)
PhaseAng (°)
20 to 39 years
352±133
15±3
4.9±1.3
0.40±0.04
204±55
44±14
8±3
15±7
11±6
40 to 59 years
302±117
15±3
4.6±1.7
0.40±0.03
193±82
36±11
9±5
15±6
14±7
60 to 80 years
338±118
16±3
5.2±1.8
0.38±0.04
227±70
40±16
11±5*
17±8
15±8*
p
0.323
0.532
0.370
0.079
0.085
0.058
0.002
0.093
0.032
Data are presented as mean ± standard-deviation. Vt: tidal volume; f: respiratory frequency; VE: minute ventilation; Ti/Tot: inspiratory duty cycle; Vt/Ti: mean inspiratory flow; %RC: rib
cage motion; PhRIB: inspiratory phase relation; PhREB: expiratory phase relation; PhaseAng: phase angle. * significant difference (p<0.05) for comparisons between adult (20 to 39 years)
and elderly (60 to 80 years) participants.
414
Breathing pattern and thoracoabdominal motion in healthy individuals
among healthy adults were conducted among populations in
other countries and/or using limited numbers of variables or
individuals3,7,10. The present study adds important information, considering that the values observed among individuals
in different age groups can be used both in the evaluation
process and physical therapy treatment of patients with acute
or chronic respiratory dysfunctions. The participants were recruited as a convenience sample from residents of the city of
Belo Horizonte, Minas Gerais, Brazil, which may be considered
to be a limitation of this study. Nonetheless, the number of participants analyzed is similar to the numbers in other studies related to respiratory function parameters that have put forward
reference values36,37.
Regarding the measurement instrument used, it should
be emphasized that respiratory inductive plethysmography is
an appropriate method for evaluating breathing pattern and
thoracoabdominal motion, as proposed in the present study. It
is also worth noting that there is a new method for obtaining
information that gives greater detail about the operational volumes of the thoracic wall. The main innovation of this method
is that it provides greater accuracy of analysis during exercise,
given that it can produce a three-dimensional analysis that
takes into consideration three compartments of the thoracic
wall (pulmonary rib cage, abdominal rib cage, and abdomen),
thus differing from the respiratory inductive plethysmography
that analyzes two compartments. This point is particularly important in the presence of dynamic hyperinflation38,39. It is unlikely that there was any hyperinflation among the participants
in the present study, given that the evaluation was performed
on healthy individuals at rest.
Regarding comparisons between the sexes, significant differences in the breathing pattern variables were observed.
In relation to the men, the women in the age group 20 to 39
presented significantly lower Vt, VE, and Ti/Ttot. To the best
of our knowledge, only one other study made a comparison of
breathing patterns between men and women, in which individuals aged between 20 and 45 years were evaluated3. Our data
corroborate what was observed previously in relation to Vt,
which was significantly lower among females. This result can
be attributed to the difference in physical constitution between
men and women. However, this difference was insufficient to
significantly influence VE, which did not present any difference
between women and men in these two studies. Regarding the
time components of the breathing pattern, Feltrim3 found a
lower inspiratory time in the female group. This result may help
to explain the significantly lower Ti/Ttot among the women
in the present study. In the elderly group, the significant differences observed in Vt and VE were similar to those observed
among adults aged 20 to 39, and the difference in Vt/Ti seemed
to result from the change in Vt, given that no change in Ti/Ttot
was observed. In relation to participants aged 40 to 59, no significant difference was observed.
In relation to the comparison between the sexes, the only
difference was in the Ti/Ttot among the men over 60 years,
compared with those aged 20 to 39. Despite the difference observed, the values were within the normal range7. Verschakelen
and Demedts10 evaluated the influence of sex on individuals in
this age group, but only in relation to the variables of thoracoabdominal motion.
Comparison of the variables relating to thoracoabdominal
motion between the sexes in the present study did not show
any significant difference between men and women. This result
corroborates the findings in the literature. The influence of sex
on thoracoabdominal motion was previously evaluated in two
studies3,10, none of which found any significant difference in the
percentage displacement of the chest and abdominal compartments between men and women in the supine position at rest.
Thus, it seems to be well established that displacement of the
abdominal compartment is proportionally greater in both men
and women in the supine position.
Regarding thoracoabdominal asynchrony, no significant
differences were found between men and women. To the best
of our knowledge, the influence of sex on thoracoabdominal
asynchrony has not been evaluated in any studies. The values
observed in the present study are close to those described in
the literature for healthy individuals at rest26.
Comparison between the three age groups did not show
any significant differences in the breathing pattern variables.
These results are in agreement with other studies that compared breathing pattern variables between healthy adults and
elderly individuals. No significant differences were observed in
the parameters analyzed at rest in these studies7,11. Recently,
Britto et al.40 evaluated two groups of elderly people, one aged
60 to 69 and one over 69 years, also without significant differences in the respiratory pattern.
In relation to thoracoabdominal motion in the present
study, the elderly participants presented significantly greater
PhRIB and PhaseAng than the participants aged 20 to 39.
The presence of greater thoracoabdominal asynchrony observed among the elderly participants may have been due
to structural modifications to the rib cage, weakness of the
respiratory muscles, and changes to the respiratory drive41,
given that these factors may increase respiratory overload25.
The influence of age on thoracoabdominal asynchrony was
previously evaluated among 18 elderly individuals7. This study
evaluated the ratio of maximum compartmental amplitude
to Vt, which is a parameter measuring thoracoabdominal
asynchrony, and did not observe any significant difference. It
is possible that the limited number of individuals may have
influenced the results.
415
In conclusion, the present study made it possible to describe values for variables relating to breathing pattern and
thoracoabdominal motion in men and women of different age
groups. The data found in this study suggest that the breathing
pattern is influenced by sex whereas the thoracoabdominal
motion is influenced by age.
Acknowledgements
Fundação de Amparo à Pesquisa do Estado de Minas Gerais
(FAPEMIG) and Conselho Nacional de Desenvolvimento
Científico e Tecnológico (CNPq).
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416
ISSN 1413-3555
ORIGINAL ARTICLE
©
Anna L. M. Margre, Maria G. L. Reis, Rosane L. S. Morais
Abstract
Background: Cerebral Palsy (CP) is a group of permanent disorders of the development of movement and posture that cause functional
limitation and are attributed to non-progressive disorders which occur in the fetal or infant brain. In recent years, with the increase
in life expectancy of individuals with CP, several studies have described the impact of musculoskeletal disabilities and functional
limitations over the life cycle. Objective: To characterize adults with CP through sociodemographic information, classifications, general
health, associated conditions, physical complications and locomotion. Methods: Twenty-two adults with CP recruited from local
rehabilitation centers in an inner town of Brazil participated in this study. A questionnaire was used to collect data on sociodemographic
characteristics, comorbities, and physical complications. A brief physical therapy evaluation was carried out, and the Gross Motor
Function Classification System (GMFCS) and the Manual Ability Classification System (MACS) were applied. Data were analyzed
through descriptive statistics. Results: The mean age was 28.7 (SD 10.6) years, 86.4% of participants lived with parents, and 4.5% were
employed. Most of the sample consisted of spastic quadriplegic subjects, corresponding to levels IV and V of the GMFCS and MACS.
Different comorbidities and important physical complications such as scoliosis and muscle contractures were present. More than half of
the participants were unable to walk. Coclusions: Most participants demonstrated important restrictions in social participation and lower
educational level. Adults with CP can be affected by several physical complications and progressive limitations in gait.
Key words: cerebral palsy; aging; sociodemographic data; classification; complications; locomotion.
Resumo
Contextualização: Paralisia Cerebral (PC) é um grupo de perturbações permanentes no desenvolvimento de movimentos e posturas
que causam limitação nas atividades funcionais e que são atribuídas a distúrbios não-progressivos que ocorrem no cérebro fetal ou
infantil. Nos últimos anos, com o aumento na expectativa de vida dos indivíduos com PC, vários estudos têm descrito a instalação
de deficiências musculoesqueléticas e limitações funcionais ao longo do ciclo vital. Objetivo: Caracterizar adultos com PC por
meio de informações sociodemográficas, classificações, saúde geral e condições associadas, complicações físicas e locomoção.
Métodos: Participaram deste estudo 22 adultos com PC residentes em uma cidade no interior do Brasil, recrutados nos centros de
reabilitação locais. Aplicou-se um questionário para caracterização sociodemográfica, de comorbidades e complicações físicas.
Além disso, realizou-se breve avaliação fisioterapêutica e aplicaram-se as classificações padronizadas, Sistema de Classificação da
Função Motora Grossa (GMFCS) e Sistema de Classificação das Habilidades Manuais (MACS). Os dados foram analisados de forma
descritiva. Resultados: A média de idade foi de 28,7 anos, 86,4% participantes moravam com os pais, 4,5% possuíam emprego. A maior
parte da amostra era composta por quadriplégicos espásticos, níveis IV e V do GMFCS e do MACS. Houve presença de diferentes
comorbidades e importantes complicações físicas, como escoliose e contraturas musculares. Mais da metade dos participantes não
deambula. Conclusões: A maioria dos participantes demonstrou ter importante restrição na participação social, além de escolaridade
baixa. Adultos com PC estão sujeitos ainda a instalação de várias complicações físicas e limitações progressivas na marcha.
Palavras-chave: paralisia cerebral; envelhecimento; dados sociodemográficos; classificação; complicações; locomoção.
Physical Therapy Department, Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina (MG), Brazil
Correspondence to: Rosane Luzia de Souza Morais, Rua José Amaral, 255/102, Bairro: Ouro Preto, CEP 31320-020, Belo Horizonte (MG), Brasil, e-mail: [email protected]
417
Introduction
Cerebral Palsy (CP) is a “group of permanent disorders of the
development of movement and posture that cause limitations
in functional activities and are attributed to non-progressive
disorders which occur in the fetal or infant brain”1. The natural course of CP has changed a lot over the past 50 years. For
example, studies in several countries have demonstrated that
life expectancy of individuals with CP has increased2-4. According to Donkervoort et al.5, children with CP who have no significant comorbidities and receive adequate medical care may
have survival similar to that of the general population.
CP is a permanent condition, and although the neurological
lesion is static, its associated musculoskeletal sequels may change
throughout life6. In recent years, studies have described a gradual
onset of sequels such as orthopedic deformities6,7, decreased muscle strength and flexibility8,9, joint degeneration10, osteoporosis11,12,
fatigue13,14 and pain14,15. Besides, there are reports of progressive
limitations in functional activities such as gait5,14,16,17.
Research on the health-related characteristics of adults
with CP is important to assist healthcare professionals in providing appropriate care, to evaluate the need of targeted public
health policies, as well as to contribute to the formulation of
adequate preventive strategies for children with CP16,17.
In recent years, there is a growing stream of studies on adults
with CP2,3,13,16,18-22, especially in developed countries2,3,13,16,18-20,22. It
is known that within a biopsychosocial perspective, the physical, social, cultural and political environments can influence
the health of adults with CP23. Therefore, it is important to
know the needs, living conditions, functional limitations and
social restrictions of Brazilian adults with CP.
The aim of this study was to characterize Brazilian adults
with CP through socio-demographic information (age, gender,
education, marital status, economic level, employment, housing status and family formation), CP classification (neuromotor dysfunction, topographic distribution, gross and fine motor
function), general health, associated conditions, physical complications, and mode of locomotion.
Methods
Study design and participants
This was a descriptive study to characterize Brazilian adults with
CP. Twenty-two adults with CP recruited from three rehabilitation
centers in the city of Diamantina participated in this study. Inclusion
criteria were: diagnosis of CP in the medical records; age 18 years or
above; resident of the city of Diamantina. All participants or their
guardians signed an informed consent. The study was approved
418
by the Ethics in Research Committee of the Universidade Federal
dos Vales do Jequitinhonha e Mucuri (UFVJM), Diamantina (MG),
Brazil, protocol 011/09.
Instruments
To verify the participant’s economic level, the Economic
Classification Criterion Brazil (Critério de Classificação Econômica Brasil24) was used. This questionnaire was developed by
the Brazilian Association of Research Companies (ABEP), and
its score is based on the number of material goods an individual possesses, and their educational level. The general economic classification resulting from the questionnaire ranges from
A1 (indicating the highest economic class) to E (indicating the
lowest economic class)24.
To classify the participant’s gross motor function, the Gross
Motor Function Classification System (GMFCS)25 was applied.
The GMFCS is based on voluntary movements, with emphasis
on the sitting position and gait. The distinction among the levels
of motor function, i.e. I to V, is based on functional limitations
and the need for assistive technology25. Although the expanded
GMFCS includes an age band from 12 to 18 years of age26, some
studies have used the GMFCS in adults with CP8,27-29.
To classify the fine motor function, the Manual Ability Classification System (MACS)30 was used. The MACS is a system that
evaluates how children with CP handle objects in daily activities,
and their need for assistance or adjustments30. There are five levels of classification, i.e. I to V, with higher levels corresponding
to increased limitation in handling objects. According to Haak et
al.23 and Donnelly et al.29, although the MACS has been designed
for children, it can also contribute to studies on adults with CP.
A questionnaire addressing several aspects of life in adults
with CP has been developed for use in this study (Appendix 1).
The questionnaire includes questions on sociodemographic
characteristics, classifications, general health, associated conditions, physical complications, and mode of locomotion.
Procedures
First, medical records of each participant were reviewed to
extract information on the type of CP and its topographic distribution. Then, questionnaires and interviews were completed
by the participant. In cases where it was difficult for the participant to express themselves or to understand the questions,
the participant’s caregiver was asked to answer the questions.
If participants reported the presence of associated conditions
or physical complications, they were asked to show the results
of tests or exams that could confirm that diagnosis.
Inspection and evaluation of passive movements were
carried out to verify the presence of deformities, such as
Adults with Cerebral Palsy
scoliosis, pelvic obliquity, contractures, or other abnormalities.
According to Tardieu33, muscle contracture is the loss of muscle extensibility that is observed in the absence of muscle contraction. Because a clinical measure of muscle contracture was
used in this study, instead of a measure of electromyographic
activity, we acknowledge that neural factors also contributed
to an increased resistance to passive movements34.
The participant’s mode of locomotion was assessed in those
who were currently unable to walk by asking if they had been able
to walk at some stage in their life. For those who were currently
able to walk, the type of walking was assessed according to the
“Criteria for Functional or Non-functional Ambulation”35, as
follows: community walking (i.e. able to walk outdoors and in the
community with or without a walking aid); home/ school walking
(i.e. able to walk indoors or inside the classroom with or without a
walking aid, but requiring wheelchair assistance or support from
others for walking outdoors or in the community); non-functional
or non therapeutic walking (i.e. able to take some steps on level
ground with or without a walking aid, but requiring supervision).
Data analysis
Descriptive statistics (means, standard deviations, and
frequencies) were used to describe each variable. All analyses
were performed with the Statistical Package for Social Sciences
(SPSS), version 15.0, SPSS Inc..
Results
Sociodemographic characteristics
The sample was composed of 22 participants. Caregivers of 17 participants (77.3%) were requested to answer the
questionnaires.
Table 1 shows the sociodemographic characteristics of
adults with CP. Participants aged between 18 to 52 years, with
a mean age of 28.7 (SD 10.6) years. The sample had a higher
percentage of male participants (63.6%). Regarding the educational level, seven participants (31.8%) had no schooling, 10
(45.5%) were students or had been educated at special schools,
two (9.1%) had complete or incomplete elementary school level, three (13.6%) had complete or incomplete high school level.
Nineteen participants (86.4%) were living with their parents,
one (4.5%) was living with her sister, one (4.5%) was living with
his wife and biological children, and one (4.5%) was living in a
long-term care institution. Only one participant (4.5%) had a
job. With regard to the economic status, one participant (4.5%)
was classified as level A2, two (9.1%) as level B2, seven (31.8%)
as level C1, eight (36.4%) as level C2, two (9.1%) as level D, and
one (4.5%) as level E. It was not possible to assess the economic status of the participant who resided in a long-term care
institution.
Table 1. Sociodemographic data.
Participant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Interviewee
Own
Caregiver
Caregiver
Caregiver
Caregiver
Caregiver
Own
Caregiver
Caregiver
Caregiver
Caregiver
Own
Own
Caregiver
Caregiver
Caregiver
Caregiver
Caregiver
Caregiver
Caregiver
Caregiver
Own
Age (yrs)
37
52
20
19
39
22
35
21
18
52
23
37
23
24
29
18
24
23
20
30
21
44
Gender
M
F
M
F
M
M
M
M
F
M
M
F
F
F
F
M
F
M
M
M
F
M
Employment
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Schooling
CHS
NS
NS
SS1
SS1
SS1
CHS
IES
SS1
SS1
SS1
SS2
CES
NS
NS
SS1
NS
SS2
NS
NS
SS2
IHS
Marital Status Housing Status
Single
Parents
Single
Institution
Single
Parents
Single
Parents
Single
Parents
Single
Parents
Single
Parents
Single
Parents
Single
Parents
Single
Brother
Single
Parents
Single
Parents
Single
Parents
Single
Parents
Single
Parents
Single
Parents
Single
Parents
Single
Parents
Single
Parents
Single
Parents
Single
Parents
Married
Wife/children
Children
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
EL
C2
*
C1
C1
B2
E
C2
C1
D
C2
C1
B2
C1
C1
C2
C2
C2
C1
C2
D
A2
C2
CP: Cerebral Palsy; M: male; F: female; NS: No Schooling; SS1: Special School (unable to read or write); SS2: Special School (able to read and write); IES: Incomplete Elementary School;
CES: Complete Elementary School; IHS: Incomplete High School; CHS: Complete High School; EL: Economic Level; A2 to E: Economic Classification Criterion Brazil. *Participant lives
in a philanthropic institution of long permanence.
419
Table 2. Classification according to the neuromotor dysfunction, topographic distribution, GMFCS and MACS
Hemiplegia (n)
Spastic
Diplegia (n)
Quadriplegia (n)
Dyskinetic
(n)
Total
(n)
3
1
0
1
0
5
3
1
1
0
0
5
0
0
0
1
8
9
1
0
0
1
1
3
7
2
1
3
9
22
4
0
1
0
0
5
0
2
1
2
0
5
0
0
0
4
5
9
0
1
1
0
1
3
4
3
3
6
6
22
GMFCS
Level I
Level II
Level III
Level IV
Level V
Total
MACS
Level I
Level II
Level III
Level IV
Level V
Total
GMFCS: Gross Motor Function Classification System; MACS: Manual Ability Classification System; (n): number of participants.
Table 3. General health, associated conditions and physical
complications in adults with CP.
General health, associated conditions
and physical complications
Epilepsy
Aphasia/dysarthria
Subnormal vision
Swallowing disorders
Bowel and/or bladder dysfunction
Gastroesophageal reflux
Dental problems
Hip luxation
Pelvic Obliquity
Scoliosis
Fatigue
Osteopenia
Osteoarthritis
Fractures
Contractures
Absent
Present
Joint Contractures
Elbow
Grip
Hip
Knee
Ankle
n
%
12
17
4
9
12
4
11
2
13
20
9
0
1
2
54.5
77.3
18.2
40.9
54.5
18.2
50
9.1
59.1
90.9
40.9
0.0
4.5
9.1
4
18
18.2
81.8
4
7
11
15
18
18.2
31.8
50.0
68.2
81.8
n: number of participants; %: percentage of participants.
CP Classification
The classification of neuromotor dysfunction, topographic
distribution and function through the GMFCS and MACS are
shown in Table 2. Of the 22 participants, 86.4% had spastic CP
and 13.6% had dyskinetic CP. Other types of CP (e.g. ataxic, hypotonic) were not observed. For practical purposes, patients
420
with mixed CP (spastic and dyskinetic) were classified as
dyskinetic CP. Of the participants with spastic CP, 22.7% were
hemiplegic, 22.7% were diplegic, and 40.9% were quadriplegic.
As for the GMFCS, 45.4% of participants were classifi ed as level I or II, and 54.5% as level IV or V, as follows: all participants
with spastic quadriplegia and two of the three participants
with dyskinetic CP were classified as level IV or V; four of
the five hemiplegic participants and four of the five diplegic
participants were classified as level I or II. As for the MACS,
proportions similar to the GMFCS were observed, with 45.4%
of all participants being classified as level I or II, and 54.5% as
level IV or V. All quadriplegic participants were classified as
level IV or V of the MACS, all hemiplegic participants were
classified as level I or II, and three of the five diplegic participants and two of the three dyskinetic participants were
classified as level I or II.
General health, associated conditions and physical
complications
Information about the general health, associated conditions and physical complications are described in Table 3.
Locomotion
Of the 22 participants, 12 (54.5%) did not walk (i.e. 10
never acquired gait and two lost this ability after childhood).
Of the 10 participants (45.5%) who were able to walk, eight
(36.4%) had community walking, one (4.5%) had walking at
home and one (4.5%) had therapeutic walking. Three participants (13.6%) who walked used fixed ankle-foot orthoses.
Of the participants who were unable to walk, nine (40.9%)
were assisted by another person in a manual wheelchair in
Table 4. Mode of Locomotion.
Locomotion
Have walked in the past
Walk
Wheelchair
Crawl
None
Gait Classification
Community
Home
Therapeutic
Ortheses
Hemiplegic
n
Diplegic
n
Quadriplegic
n
Dyskinetic
n
Total
n (%)
0
4
1
0
0
0
6
0
0
0
1
0
6
1
2
1
0
2
0
0
2 (9.0)*
10 (45.5)
9 (40.9)
1 (4.5)
2 (9.1)
4
0
0
1
4
1
1
2
0
0
0
0
0
0
0
0
8 (36.4)
1 (4.5)
1(4.5)
3 (13.6)
n: number of participants, %: percentage of participants. *Two participants who have walked in the past currently use a wheelchair for locomotion.
and out of house, and one (4.5%) crawled on the ground. The
other two participants (9.1%) did not have a wheelchair for
locomotion (Table 4).
Discussion
The present study characterized a sample of 22 adults with
CP living in an inner city of Brazil. Most participants were classified as spastic CP, with a higher proportion of quadriplegics.
Although there is a consensus in the literature that the spastic
type is the most prevalent CP, the topographic distribution
is variable among studies19,36,37. According to Andersson and
Mattsson19, one possible explanation for this fact can be the
difference in definitions among researchers, especially when
it comes to distinguishing severe diplegic and quadriplegic
cases.
In the present study, most hemiplegic and diplegic participants were classified as levels I or II of the GMFCS, and most
quadriplegics and dyskinetic were classified as levels IV or V.
Although our study is a descriptive report and did not include
any inferential analysis, our results appear to be consistent with
those of Shevell et al.38, who verified a relationship between the
GMFCS and the type of CP in 301 children. The authors concluded that there is a correlation between spastic or dyskinetic CP
and higher levels of gross motor disability, and between hemiplegia or diplegia and lower levels of gross motor disability38.
As for the MACS, quadriplegic and hemiplegic participants
showed results similar to those observed for the GMFCS. As for
the diplegic and dyskinetic participants, there was a more similar distribution between the levels of minor and major disabilities. These results are consistent with those of studies that have
verified the association between the GMFCS and the MACS39,40.
The MACS is related with the degree of neuromotor compromise of the upper limbs, which is variable among diplegic
individuals, as well as with the preservation of cognition, which
is very frequent in dyskinetic and diplegic individuals 39,40.
With regard to sociodemographic characteristics, most
participants were male and were classified as belonging to an
intermediate economic class. Considering the participants’ age
group (18-52 years old), it is possible to observe an increased
life expectancy, as observed in other countries. Hemming et al.3
followed a cohort of individuals with CP born between 1940
and 1960 in the UK. The authors verified that of those individuals who were still alive at 20 years of age, 86% survived to
age 50. According to Hutton and Pharoah4, the severity and the
number of comorbidities play an important role in the survival
of individuals with CP. For example, in a study carried out by
those authors, 99% of individuals with mild CP survived to age
30, whereas only 33% of individuals with four serious comorbidities survived to the same age. According to Strauss et al.2,
since the 1980s a greater importance has been given to the proper nutritional status of children and adults with disabilities,
and to the early detection and vigorous treatment of infections,
which has been facilitated by the improved technological support in healthcare services.
In Brazil, life expectancy has increased in the general population, given the improved living conditions and healthcare41.
However, this study showed that the maximum age of participants is still below the expectation of life in Brazil, which is 71.3
years41. This is a reality observed in other studies with individuals with CP2-4,23,42. Although life expectancy of individuals with
CP has increased, it is still below that of the general population,
even in developed countries2-4,23,42.
The participants in this study showed restrictions in social participation, except for one participant, who was able to
obtain employment, form his own family, and be independent
from his parents. Furthermore, participants showed lower
levels of education. This reality is different from that of developed countries; nevertheless, even in developed countries,
421
social participation of adults with CP is still lower than that
observed in the general population19,20. In a study carried out in
Denmark20, from 486 adults with CP who were born between
1965 and 1970, 68% lived independently, 28% formed their own
family, 19% had children, and 45% had a job22. In another study
in Sweden19, from 221 adults with CP, 61% lived independently, 24% worked full-time, 57% completed two or three years
of education after the age of 16 years, and 14% formed their
own family. According to the authors of these studies19,20, the
restrictions in social participation of adults with CP are associated to the severity of their disability, type of neuromotor and
topographical classification, degree of functional dependence,
absence of gait, and to associated conditions such as epilepsy
and cognitive impairment. In the present study, the patient
who showed better social participation had incomplete high
school, was diplegic with a GMFCS level I and MACS level II,
and showed community walking. This participant was capable
of independently answering the questionnaire and reported
not to have epilepsy.
It is possible that the important restrictions in social participation and the lower educational level of the study participants may be related to their associated conditions, since 54%
of them reported epilepsy, and 77.3% reported communication
disorders. Furthermore, 77.3% of participants needed assistance to answer the questionnaire due to cognitive impairment
or communication disorders. However, it is also necessary to
consider the possible influence of environmental factors23,32.
Although Brazil has shown economic and social progresses in
recent years, such as the decrease in poverty and the increase
in the Human Development Index (HDI)41, the reality of the
social, cultural and economic environments as well as the process of social inclusion are still very different from the situation
observed in developed countries.
Participants or caregivers were asked about the existence
of health problems and associated conditions. The main disturbances reported were related to communication, such as aphasia/dysarthria, epilepsy, bowel and/or bladder dysfunction,
swallowing disorders and dental problems. These results are
in conformity with others from previous studies16,23,31,32,36,42, although gastroesophageal reflux, hearing and visual deficits are
also frequently reported in the literature16,23,31,36,42. According to
Turk42, most of the health problems or associated conditions of
adults with CP are the same ones that accompany childhood.
However, adults with CP complain more of dental, urinary and
intestinal problems, pain, and especially of disorders of the
musculoskeletal system36,42.
A large number of participants with scoliosis, pelvic
obliquity and muscle contractures was observed in this
study. Only two participants reported fractures due to falls
during childhood. No participant reported osteoporosis, one
422
reported osteoarthritis, and two reported hip luxation. However, such findings should be interpreted with caution, since
the participants did not have exams to confirm these diagnoses, and also showed little knowledge about the concepts and
the evolution of CP.
In a descriptive study of 72 adults with CP in Italy, Bottos
et al.16 observed scoliosis above 30° in 20.3% of the participants, and hip luxation or subluxation in 28.2% of them. In
a study with 63 adult women with CP, Turk et al.36 observed
hip deformities (pelvic obliquity or hip luxation) in 40% of the
participants, spinal deformities (scoliosis or kyphosis) in 53%,
and muscle contractures in 75% of them. According to the
literature6,7,16,19,43, deformities such as scoliosis, pelvic obliquity
and hip luxation are more common in severely affected adults,
typically those with quadriplegic CP or those unable to walk.
On the other hand, muscle contractures, feet deformity and osteoarthritis are observed in all types of CP. In this study, there
was a large proportion of individuals with contractures (81.8%),
with these being more common in the ankle extensors, followed by the knee, hip, wrist and elbow flexors. Two hemiplegic,
one diplegic and one dyskinetic participant had no contractures, whereas all quadriplegics had two to five muscle groups
affected by contractures. Contractures were observed in all
participants who did not walk and in 60% of those who walked.
These results are similar to those reported by Andersson and
Mattsson19 in a previous study with adults with CP. The authors
identified contractures in 80% of the sample: of the 27 quadriplegic, 25 couldn’t walk and, between then, only one reported
not having contracture; of the 47 hemiplegics who could walk,
31 reported contractures19. Ultrasound studies investigating
muscular changes in individuals with CP8,9 show that tissue
adaptations that occur in this population are similar to those
following immobilization and disuse, or those due to excessive
use or unfavorable biomechanical load. Contractures, muscle
atrophy and changes in muscle architecture are consequences
of these adaptations, reflecting the dynamic nature of the muscular system19, 44.
Fatigue is described as the decreased ability to maintain
muscle strength and to perform tasks; it is the experience of
feeling exhausted, tired, weak or lacking energy13. In this study,
fatigue was reported by nine participants (40.9%), most of
whom were able to walk. According to Jahnsen et al.13, fatigue
requires a certain amount of activity; thus, individuals with
severe motor disabilities may not have sufficient motor skills
to become physically fatigued.
Walking was observed in 10 participants (45.5%), including
four hemiplegic and six diplegic individuals. Most of these individuals had community walking. Twelve quadriplegic participants did not walk. According to literature17,45,46, although the
analysis on the prognosis for ambulation in individuals with
CP is complex and multifactorial, the topographic diagnosis of
CP is an important prognostic factor; that is, hemiplegic, followed by diplegic individuals, generally have a more favorable
prognosis for the development of gait, while the prognosis is
less favorable for quadriplegic individuals17,45,46.
One dyskinetic participant had lost gait at the age of 32
years due to spondylolisthesis followed by myelopathy. According to Murphy43, it is possible that spondylolisthesis occur in
adults with dyskinetic CP due to contort dystonic postures of
the head and neck. Another spastic quadriplegic participant
had lost gait at the age of 12 years due to deterioration of functional capacity. Results of previous studies have shown that a
progressive functional impairment can occur early in individuals with CP, with some of them losing their walking ability
between 25 and 35 years of age14,17,19,23,42. According to Bott and
Gericke17, among the several factors related to the loss of gait
in adults with CP, the principal one would be the degenerative
processes and joint pain resulting from the use of unfavorable
biomechanics, imbalance between the demand for walking in
a dynamic environmental context, and from the onset of fatigue and orthopedic surgeries that do not take into account the
functional and compensatory responses of the individual.
Recently, a longitudinal study14 showed that in 146 adults
with CP, 52% reported functional limitation in walking. This
limitation was mainly associated with bilateral CP type (quadriplegic and diplegic) and GMFCS level III, and it was correlated with pain complaints, fatigue and loss of body balance.
The authors concluded that individuals with bilateral CP and
GMFCS level III overload their musculoskeletal systems in order to meet their functional and social goals. Moreover, other
environmental factors, such as the provision of rehabilitation,
physical training for adults with CP and environmental adaptations are crucial for walking ability.
Several studies16,17,19,23,42 cautioned that, in general, there is
a discontinuity in the rehabilitation of individuals with CP in
adulthood. When offered, these therapies are directed to the
needs of children. Thorpe47 points out that there are only a few
studies on rehabilitation or physical activity in adults with CP,
and given the increase in their life expectancy, it is imperative
that the scientific community promotes grounding for appropriate therapeutics to their needs.
Study limitations
It is important to note that this study relied on a convenience sample, thus there are limitations in generalizing the
results. However, the present findings are important for stimulating discussion about life expectancy, disability, limitations
and needs for assistance for Brazilian adults with CP. Future
studies should include information not collected in this study,
such as cognitive assessment, history of surgeries and neurolysis, and more information about language disorders.
Conclusions
In accordance to previous studies, the present study indicated that adults with CP have specific characteristics and needs.
Participants in the study showed important social restrictions,
and had major musculoskeletal deficiencies and progressive
limitations in gait. Besides, the participants and caregivers demonstrated little knowledge on CP and its evolution.
Considering the increasing life expectancy of these individuals, public policies aiming at better and greater access to
information, medical services, education, work opportunities,
and adaptations to physical environments that provide greater
accessibility to public spaces are needed. It is important to
emphasize the need for the development of specific physical
training programs targeting the deficiency and limitations observed in individuals with CP in the adulthood.
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424
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Child Neurol. 2009;51 Suppl 4:S52-8.
Appendix 1. Characterization of Adults with Cerebral Palsy Residents of Diamantina- MG, Brazil.
I. Sociodemographic and economic data
I.1 Date of birth ________________
I.2 Gender
( ) Male
Age : _________
( ) Female
I.3 Ecomonic Class (ABEP – 2005)
( ) A1 ( ) A2 ( ) B1 ( ) B2
I.4 Schooling and Literacy
( ) No Schooling
( ) Incomplete Elementary School
( ) Complete Elementary School
( ) Incomplete High School
( ) Complete High School
( ) Incomplete Higher Education
( ) Complete Higher Education
IV. Physical Complications
( ) Scoliosis
( ) Hip luxation
( ) Pelvic obliquity ( ) Osteoporosis
( ) Fatigue (“Do you feel tired?”, “Do you have lack of energy?”, “Do you
feel weak?”)
( ) Fractures, which/context__________________________________
( ) Osteoarthritis, joints ____________________________________
( ) Contractures, muscle groups ______________________________
( ) Others _____________________________________________
( ) Stable union
V. Locomotion
Walking
( ) No ( ) Yes
( )C
( )D
(
)E
I.5 Family Characteristcs:
I.5.1 Marital Status
( ) Single
( ) Married
( ) Others _______
III. General Health and Associated Conditions (self-report)
( ) Epilepsy/convulsions
( ) Aphasia or dysarthria
( ) Subnormal vision
( ) Dental problems
( ) Bowel and bladder dysfunction
( ) Gastroesophageal reflux
( ) Oral motricity (swallowing/drooling difficulties)
( ) Others______________________
I.5.2 Housing Status
( ) Independent
( ) Institution
( ) With parents
( ) Others ____________________
I.5.3 Biological Children
( ) No
( ) Yes
I.6 Employment
( ) No
( ) Yes
Type
( ) Community
( ) Home
( ) Therapeutic
Support device
( ) No ( ) Yes, which__________
Ortheses
( ) No ( ) Yes, which__________
II. Diagnostic data
II.1 Neuromotor Dysfunction
( ) Spastic
( ) Dyskinetic
II.2 Topographic Distribution
( ) Hemiplegia
( ) Diplegia
( ) Other ___________
( ) Other________
Weelchair
( ) No
( ) Yes:
( ) Principal
( ) Quadriplegia
Type
( ) Manual
( ) Motorized
Conductor
( ) Participant
( ) Other
II.3 GMFCS
( ) Level I
( ) Level IV
( ) Level II
( ) Level V
( ) Level III
II.4 MACS
( ) Level I
( ) Level IV
( ) Level II
( ) Level V
( ) Level III
( ) Secundary
Who answered:
( ) Participant
( ) Caregiver, parentage ____________________
425
ISSN 1413-3555
©
ORIGINAL ARTICLE
Comparison between a national and a
foreign manovacuometer for nasal inspiratory
pressure measurement
Comparação entre o manovacuômetro nacional e o importado para medida da
pressão inspiratória nasal
Fernanda G. Severino1, Vanessa R. Resqueti2, Selma S. Bruno2, Ingrid G. Azevedo3, Rudolfo H. G. Vieira3, Guilherme A. F. Fregonezi2
Abstract
Background: The measurement of nasal inspiratory pressure, known as the sniff test, was developed as a new test of inspiratory muscle strength,
mainly used in neuromuscular conditions. The test is easy to be performed and noninvasive. Despite the clinical importance of assessment of
nasal inspiratory pressure a national equipment is not available to assess it. Objectives: To compare a national with a foreign manovacuometer
in assessing the nasal inspiratory pressure (sniff test) in healthy subjects. Methods: 18 subjects were evaluated (age 21.44±2.8 years, BMI
23.4±2.5 kg/m2, FVC 102.1±10.3% pred, FEV1 98.4±1% pred). We performed two measures of nasal inspiratory pressure using two different
manovacuometer: a national and a foreign. All subjects performed the tests at the same time of day, in different days being the order of the
testes established randomly. It was used the paired t test, Pearson correlation and the Bland-Altman plots for statistical analysis considering
a 5% significance level. Results: The averages observed for the two measures of nasal pressures were 125±42.4 cmH2O for the foreign
equipment, and 131.7±28.7 cmH2O for the national equipment. The Pearson correlation showed significant correlation between the means
with a coefficient of r=0.63. The t test showed no significant differences between both measurements (p>0,05). The BIAS±SD found in BlandAltman plot analysis was 7 cmH2O with limits of agreement between -57.5 cmH2O and 71.5 cmH2O. Conclusion: The results suggest that the
national electronic device is feasible and safe to the sniff test measurement in healthy subjects.
Key words: respiratory muscle strength; respiratory muscle training; respiratory pressure; nasal inspiratory pressure.
Resumo
Contextualização: A medida da pressão inspiratória nasal, conhecida como sniff teste, desenvolvida como um novo teste de força
muscular inspiratória, utilizada principalmente em doenças neuromusculares, é de fácil realização e não invasiva. Apesar da importância
clínica da avaliação da pressão inspiratória nasal, não existe um instrumento nacional disponível para realizá-la. Objetivos: Comparar os
manovacuômetros eletrônicos nacional e importado para a avaliação da pressão inspiratória nasal em pessoas saudáveis. Métodos: Foram
avaliados 18 voluntários saudáveis (idade 21,4±2,8 anos, IMC 23,4±2,5 Kg/m2, CVF 102,1±10,3%pred, VEF1 98,4±1%pred) por meio de
duas medidas de pressão inspiratória nasal em dois equipamentos diferentes: um nacional e outro importado. Todos os sujeitos realizaram
a manobra no mesmo horário do dia, em dias ocasionais, sendo a ordem determinada aleatoriamente. Para análise estatística, foi utilizado o
teste t pareado, a correlação de Pearson e o Bland-Altman com nível de significância de 5%. Resultados: As médias encontradas durante as
duas medidas das pressões nasais foram de 125±42,4 cmH2O para o aparelho importado e de 131,7±28,7 cmH2O para o nacional. A análise
de Pearson demonstrou uma correlação significativa entre as médias, com um coeficiente r=0,63. Os valores médios não apresentaram
diferenças significativas pelo teste t pareado (p>0,05). Na análise de Bland-Altman, encontrou-se um BIAS igual a 7 cmH2O, desvio-padrão
de 32,9 cmH2O para o DP e um intervalo de confiança de -57,5 cmH2O até 71,5 cmH2O. Conclusão: Os resultados encontrados sugerem
que o manovacuômetro eletrônico nacional é viável e seguro para realização do sniff teste em sujeitos saudáveis.
Palavras-chave: força do músculo respiratório; treinamento dos músculos respiratórios; pressão respiratória; pressão inspiratória nasal.
Received: 29/06/2009– Revised: 02/11/2009 – Accepted: 26/01/2010
1
Physical Therapy Department, Faculdades Nordeste (FANOR), Fortaleza (CE), Brazil
2
Department of Physical Therapy, Physical Therapy Department, Universidade Federal do Rio Grande do Norte (UFRN), Natal (RN), Brazil
3
Physical Therapist
Correspondence to: Guilherme A. F. Fregonezi, Departamento de Fisioterapia, Laboratório de Fisioterapia Pneumocardiovascular, Universidade Federal do Rio Grande do Norte (UFRN),
Caixa Postal 1524, Campus Universitário Lagoa Nova, CEP 59072-970, Natal (RN), Brasil, e-mail: [email protected]
426
Assessment of nasal inspiratory pressure
Introduction
Methods
The respiratory muscle weakness is an important clinical problem, can be acute or chronic and it is a potentially
treatable condition1. Clinically, respiratory muscle weakness
is related to hypercapnia, respiratory infections and ineffective cough, which predispose the development of atelectasis
and respiratory failure1-4. In neuromuscular diseases, disorders of respiratory muscles are associated with the onset of
respiratory failure1-4.
The clinical importance of respiratory muscles assessment with a variety of tests was proposed in previous
studies5,6. Strength of these muscles can be assessed by
means of static or dynamic measures. The more traditional
static measures for respiratory muscle strength assessment are the maximal respiratory pressures (MIP, maximal inspiratory pressure and MEP, maximal expiratory
pressure)7,8. Although the MIP measurement is simple, it
depends on collaboration and coordination of the patient,
which can lead to inaccurate assessments and, hence, an
incorrect diagnosis 9. Some authors suggest that the use of a
single test may not be sufficient to identify the inspiratory
muscle dysfunction. Therefore, the combination of several
tests would improve accuracy of inspiratory muscle weakness diagnosis 5.
A recently developed alternative is the nasal inspiratory
pressure assessment or sniff test10. The test represents the
MIP achieved through an inspiration from functional residual capacity (FRC) transmitted by a connection through
the nasal cavity 11. In this test, the type of activation of
respiratory muscles, the patient/equipment interface,
learning and performance are simpler than the MIP 12,13.
Clinically, the sniff test was considered by some authors
a complementary assessment method for the diagnosis
of inspiratory muscle weakness when associated with the
MEP measure5,9.
Commercially, there is only one equipment of electronic manovacuometry for sniff test assessment. Since
it is a foreign equipment, the costs are high, and the use
of this measure that have a great clinical importance in
the Cardiopulmonary Physical Therapy area becomes,
often, unfeasible. In the national market, the electronic
manovacuometer equipment, similar to the foreign, was
developed for respiratory muscle strength assessment and
it is available commercially. However, the feasibility of
this equipment for the evaluation of sniff test has not yet
been performed. The aim of this study was to compare the
measure of nasal inspiratory pressure in healthy subjects
between two electronic manovacuometers: a national and
a foreign.
This study was conducted in accordance with the resolution 196/96 of the National Health Council. All procedures
in which the subjects were tested were approved by the
Ethics Committee of the University Hospital Onofre Lopes,
Universidade Federal do Rio Grande do Norte (UFRN), Natal
(RN), Brazil, according to the protocol 238/08, and subjects
signed the consent form to participate in the study.
Subjects
A sample of physical therapy students was recruited
from the UFRN where the study was conducted. All the
subjects participated voluntarily. Students without prior
knowledge of the used technique, nonsmokers, students
without cardiopulmonary diseases, asthmatics without
exacerbation of symptoms, subjects without nasal septal
deviation and/or chronic rhinitis diagnosed by specialists,
students without previous history of surgery in the nasal
cavity and without forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and FEV 1/FVC ratio
below the normal limits (<80% of predicted values) were
included. Those students who had nasal congestion during the study period and who were using medications that
could influence the assessments results were excluded.
Procedures
Prior to the beginning of sniff test assessments, all subjects were assessed by otorhinolaryngologist to exclude from
the sample those with nasal septal deviation or rhinitis. This
measure was adopted to ensure that the results of the sniff
test were reliable, although it is not necessary in daily clinical
practice. Assessments conducted by otorhinolaryngologist
consisted of anamnesis and anterior rhinoscopy with nasal
speculum, following a protocol published previously14.
At the beginning of the physical therapy assessment
procedures, subjects were asked about the habits of life
(general health, physical exercise practice and use of medication) and vital signs were measured (blood pressure, body
temperature, heart rate, respiratory rate). Anthropometric
and spirometric measurements were performed by two assessors previously trained for such procedures.
The subjects underwent sniff test assessments using two
different equipments: the national MVD300® (Globalmed,
Brazil) and the foreign MicroRPM® (Micromedical, UK). All
measurements were performed at the same time of day, on
different days, being the order of use of equipments determined randomly by individual sortition.
427
Fernanda G. Severino, Vanessa R. Resqueti, Selma S. Bruno, Ingrid G. Azevedo, Rudolfo H. G. Vieira, Guilherme A. F. Fregonezi
Variables analyzed
Anthropometric characteristics: anthropometric assessment was performed to characterize the sample by
measuring the body weight and the height of the subject
in a WELMY® - model R-110 scale (WELMY, Santa Barbara
d’Oeste, Brazil).
Spirometry: spirometry was used to characterize the
sample in a healthy spirometry point of view, following the
technical procedures and criteria for acceptability of the
Brazilian Society of Pneumology and Tisiology15. Subjects
were instructed in detail about the procedures to be performed during spirometry assessment. Tests were implemented with subjects sitting in a comfortable chair and
a nose clip was used. Subjects were instructed to breathe
through a disposable cardboard mouthpiece placed between the teeth, carefully observed by the assessor to avoid
air leaks during spirometric maneuvers. Subjects were asked
to achieve maximal inspiration, near total lung capacity
(TLC), followed by a maximal expiration, close to residual
volume (RV). A maximum of eight tests in each subject
were performed and the best three were considered, being
the variability between them less than 5% or 200 milliliters.
FEV1, FVC and FEV1/FVC ratio in their absolute and relative values were analyzed. FEV1/FVC ratio was obtained by
comparison with normal curve for all spirometric variables
and with reference values16. The equipment used was the
DATOSPIR 120 (SibelMed Barcelona, Spain) spirometer
conected to a computer and it was calibrated daily.
Nasal Inspiratory Pressure: two sniff test measures were
performed in two electronic manovacuometer equipments:
a measure in the foreign equipment MicroRPM® (SNIP1) and
a measure in the national equipment MVD300® (SNIP2). Although equipments have the same electronic mechanism,
MicroRPM® equipment has a selection switch for option
MIP/MEP and another selection option for SNIP. The foreign equipment has four nasal plugs of polyethylene in a
cylindrical shape with a convex external edge to connect to
the nasal orifice. For each subject, the nasal plug that best
suited the size of the nasal orifice was chosen. In relation to
its size, the bases vary from 1.1 to 1.9 cm in height, thickness
ranges from 3.1 to 4.5 cm and there is an internal orifice of 0.5
cm. The extension is made of silicone and measures 68 cm.
The equipment MVD300® has two connection options, one
for MIP assessment and other for MEP assessment. The maneuver to obtain the SNIP was held at the connection option of MIP assessment, option able to capture the negative
pressure generated by the test. The equipment has a silicone
extension of 60 cm and was used for sniff assessment with a
silicone nasal plug similar to the foreign plug, with conical
428
shape, with base and height of 2.2 cm and an orifice of
0.5 mm of internal diameter for pressure transmission.
Sniff test assessments were performed following the
standard methodological description9-11,17 and reference
values previously reported for the English population9 were
used, since there are no values described and standardized
for the Brazilian population. The test was performed by
placing a nasal plug in one of the nostrils, no preference for
right or left, keeping the contralateral nostril without occlusion. Then the subjects were asked to maintain a normal
breathing and at the end of relaxed expiration, identified
as FRC, the mouth should be closed and then a maximum
inspiratory effort was performed. At this time the pressure
generated was transmitted from the nostril connected to
the nasal plug to the manovacuometer by the silicone extension. During the maneuver, the subjects were verbally
encouraged. The maneuver was performed ten times, the
interval between them was 60 seconds and at the end of
ten maneuvers, the highest value was used, considering it
as the subject’s nasal inspiratory pressure10,11,17. To perform
the sniff test with the equipment MVD300®, the nasal plug
was connected on one end of the extension (place where
the mouthpiece would be connected), while the other end
was connected to the manovacuometer in the connection
of MIP assessment.
To calculate the sample size, 95% reliability power and
standard deviation, previously published by Uldry and Fitting9,
of 29.5 cmH2O were used, considering a maximum difference
between 14-18 cmH2O due to lack of previous results on minimum or maximum established differences. This calculation
indicated a sample of 10 to 17 subjects.
The normality of variables was tested by KolmogorovSmirnov test. The paired t test was conducted to assess
the differences between SNIP1 SNIP2 measures, which are
the values obtained in the national and foreign equipment,
respectively. To assess the correlation between means
performed on both equipments, SNIP1 SNIP2, simple correlation analysis was used by using the Pearson correlation
coefficient (r)18. The Bland-Altman plots analysis, the mean
of differences (BIAS) was assessed, which establishes how
close clinically important discrepancies between the two
used equipments were and which limits of agreement determines the differences between the two equipments located
in the 95% confidence interval19,20. For statistical analysis,
SPSS 15.0 (SPSS, Chicago, IL, USA) and GraphPad Prism® 4
(GraphPad Software Inc.) softwares were used. The level of
significance was set at p<0.05 with a two-tailed approach.
Results
A total of 26 subjects accepted the invitation to participate in this study, but only 18 healthy subjects, aged between 18 and 35 years, of both gender, were included. Eight
subjects were excluded, two due to nasal septal deviation,
one was in a period of asthma attack, four were athletes
and one because he already have knowledge of assessment
techniques used in the study. The sample consisted of nine
male subjects and nine female subjects. The distribution of
variables was considered normal. The sample consisted of
young subjects, with spirometric values close to those considered healthy, FEV1/FVC% ≥ 90%, FVC ≥ 80% predicted, as
shown in Table 1.
Table 2 shows the mean reference value of the sniff
test of the sample, mean±standard deviation of the values
found in each manovacuometer when performing nasal
inspiratory pressure and the percentage of means in relation to reference values for the healthy population. In the
same table, values of paired t test (p>0.05, 95% CI= -23.4
to 9.4) are described, in which no significant differences
were found between the values obtained from different
equipments.
Table 1. Anthropometric and spirometric characteristics of the sample.
Male
09
20.9±1.4
24.8±1.9
93.9±8.5
91.9±10.0
86.1±1.2
Subjects
Age (years)
BMI (Kg/m2)
FVC (% pred.)
FEV1 (% pred.)
FEV1/ FVC (% pred.)
Female
09
22.0±3.8
22.0±2.3
93.5±11.7
98.1±13.6
90.4±0.7
Total
18
21.4±2.8
23.4±2.5
93.8±9.9
95±12
88.3±2.4
BMI=Body Mass Index; FVC= Forced Vital Capacity; FEV1=Forced Expiratory Volume in
the first second; FEV1/ FVC = FEV1/ FVC ratio.
The results of the Pearson correlation analysis (r)
showed a significant correlation between measures with an
r=0.63 (p=0.0049, 95% CI=0.23 to 0.85 and R2=0.39), as shown
in Figure 1. Statistical graphical analysis performed by the
Bland-Altman plots between SNIP1 and SNIP2 measures,
represented in Figure 2, shows a BIAS = 7 cmH2O, a standard
deviation of 32.9 cmH2O for SD and a confidence interval
from -57.5 cmH2O to 71.5 cmH2O were found.
Discussion
This study was conducted to assess the feasibility of sniff
test assessment using a national electronic manovacuometer. No significant differences were found between the mean
results of sniff test in both equipments, weak limits of agreement between measurements were found, while the differences mean found was lower than the measure coefficient
of variation. The sniff test assessment performed with the
national manovacuometer proved to be feasible and safe.
Through analysis of the results, some implications can
be suggested. First, the possibility of easy access to the nasal
inspiratory pressure assessment with a low cost equipment
Table 2. Comparison between the foreign and national manovacuometer.
Mean
Mean SNIP2
Mean SNIP1
RV Sniff
(cmH2O) (cmH2O) (%) (cm H2O) (%)
Male
118±0.6 146.3±46.4 124 141.5±29.2 120
Female 90±0.8 103.1±25.0 114 121.9±26.0 135
All
104±20.3 124.7±42.4 119 131.7±28.7 126
Paired t
test*
p value
0.70
0.58
0.38
RV= reference values; SNIP1= sniff test developed on the foreign manovacuometer;
SNIP2= sniff test developed on the national manovacuometer; * Paired t test between
absolute values of SNIP1 and SNIP2.
250
200
SNIP2 (cmH2O)
150
150
Upper limits of agreement
71.57 cmH2O
100
r=0.63
p=0.0049
100
50
BIAS 7 cmH2O
0
-50
50
Lower limits of agreement 57.2 cmH2O
-100
0
0
50
100
150
200
250
-150
0
50
100
150
200
250
SNIP1 (cmH2O)
SNIP1= value of sniff test on foreing manovacuometer; SNIP2= value of sniff test on
national manovacuometer.
Figure 1. Pearson’s Correlation between the sniff values in both equipment.
Figure 2. Bland-Altman plot among the sniff test in both equipments.
429
Fernanda G. Severino, Vanessa R. Resqueti, Selma S. Bruno, Ingrid G. Azevedo, Rudolfo H. G. Vieira, Guilherme A. F. Fregonezi
compared to the foreign one. Secondly, the origin of the
equipment is national and it is standardized by the National Institute of Metrology, Standardization and Industrial
Quality, and its marketing, acquisition and maintenance
are carried out more easily in Brazil. Currently, the foreign
equipment used for sniff test assessment is the only worldwide commercially available for this type of assessment, fact
that hampers it access due to the costs of the equipment,
importation and maintenance.
The nasal inspiratory pressure measured by the sniff test
stared to be used in the 90’s9, when the reference values for
the British population were established. But only in the last
decade, the parameters and clinical information about the
importance of the test in the follow-up and in the assessment of inspiratory muscle strength17,21-23 were demonstrated
in some publications, especially in patients with restrictive
diseases of the chest cavity of musculoskeletal origin and
with neuromuscular diseases.
In a recent study, Maillard et al. 22 demonstrated that
the sniff test shows a similar reproducibility to the values
reported for MIP in healthy subjects with a coefficient of
variation of 6%. Thus, the study by Luo et al. 23, also with
healthy subjects, showed that the sniff test demonstrates
similar levels of reproducibility to the values reported
for the transdiaphragmatic pressure with a coefficient of
variation of 11%. Both results reinforced the hypothesis
that the sniff test is considered a reliable test that largely
reflects the strength of the diaphragm muscle. Physiologically, during its performance, there is a strong neuromuscular activation of diaphragm and scalene muscles 12,13. This
contraction, due to the characteristics of the test, occurs
rapidly and it is considered a ballistic muscle contraction,
rather than sustained isometric contraction of the inspiratory muscles, as occurs in the MIP maneuver assessment.
The maneuver performance is simpler than MIP, since there
is less need for coordination between the end of expiration
and fitting with the mouthpiece9. Despite some similarities between maneuvers to obtain MIP and the sniff test,
the limits of agreement between them are large, indicating
that these measures are not interchangeable and therefore
are considered complementary for inspiratory muscle
strength assessment 24,25.
Findings in this study showed no significant difference
between the means assessed by both equipments. The results of the correlation between means in both equipments
should be interpreted with caution because, in the BlandAltman plots analysis, the range found within the limits of
agreement was extensive, although the BIAS, or mean of differences between the assessed measures, showed to be close
to zero, below the values of variability found in other studies
(6-11%)21-23 and below the coefficient of reproducibility of
23-32 cmH2O, observed by Maillard et al.22.
The study has some potential limitations such as the
absence of a retest for the sniff test measures, which can
be minimized by the number of maneuvers performed, ten
trials, in each assessment to obtain the measure. Another
potential limitation is the wide range of limits of agreement
found in the Bland-Altman plots analysis. Due to the characteristics of the sniff test, which is dependent on effort,
possibly the low performance of four subjects may have
contributed to raising the standard deviation of differences,
as well as the limits of agreement.
Conclusion
The sniff test assessment conducted by the national
electronic manovacuometer was found to be a feasible and
safe measurement. These results can help to spread the
technique of nasal inspiratory pressure assessment.
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11. Uldry C, Janssens JP, de Muralt B, Fitting JW. Sniff nasal inspiratory pressure in patients with
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during three maximal inspiratory maneuvers. Thorax. 1993;48(7):702-7.
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activity during a sniff. Respir Med. 2003;97(9):1027-35.
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em Curitiba, Brasil. Arq Int Otorrinolaringol. 2005;9(4):288-94.
15. Sociedade Brasileira de Pneumologia e Tisiologia. Diretrizes para testes de função pulmonar. J
Bras Pneumol .2002;28 Suppl 3:S1-221.
16. Pereira CAC, Sato T, Rodrigues SC. Novos valores de referência para espirometria forçada em
adultos de raça branca. J Bras Pneumol. 2007;33(4):397-406.
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what is the optimal number of sniffs? Eur Respir J. 2006;27(5):980-2.
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ISSN 1413-3555
ORIGINAL ARTICLE
©
Inter and intra-rater reliability of the
scoliometer
Guilherme H. Bonagamba1, Daniel M. Coelho2, Anamaria S. de Oliveira3
Abstract
Background: The scoliometer was developed to analyze the axial rotation of the trunk in patients with idiopathic scoliosis. However, there is
controversy regarding the reliability of the measures obtained with this device. Objective: To test the intra-rater and inter-rater reliability of the
scoliometer in patients with scoliosis. Methods: 24 volunteers of both sex with idiopathic scoliosis diagnostic (18±4 years-old) and curvatures
with mean and standard deviation of 24.8±12.7° Cobb. The measurement procedure was accomplished in one day by two trained examiners.
The palpation and determination of each spinal level was accomplished by just one examiner. Each examiner obtained one measure with the
device for each vertebra from the thoracic and lumbar levels in each evaluation. For statistical analysis the measurements were divided by
spinal levels into upper thorax, medium thorax, lower thorax and lumbar segments. The Intraclass Correlation Coefficient type 1,1 (ICC1,1) was
used to determine the intra-rater reliability while the ICC3,1 was used to determine the inter-rater reliability. Results: The observed intra-rater
reliability values for the medium and lower thorax and lumbar segments of the subjects ranged from very good to excellent. The inter-rater
reliability of the measures of axial trunk rotations was considered good to the upper thorax and excellent for the medium and lower thorax and
lumbar spine. Conclusion: The scoliometer is a device that has intra-rater reliability estimates ranging from very good to excellent. The interrater reliability for the upper and low thorax and for the lumbar spine is relatively lower than the intra-rater values for the same spinal segments,
even when the errors from palpation and positioning of the instrument were eliminated.
Key-words: scoliosis; reproducibility of tests; evaluation studies; reliability.
Resumo
Contextualização: O escoliômetro foi desenvolvido para medir a rotação axial do tronco de portadores de escoliose idiopática. No entanto,
a confiabilidade das medidas obtidas por esse dispositivo é controversa. Objetivo: Testar a confiabilidade interavaliadores e intra-avaliador
do escoliômetro em pacientes com escoliose. Métodos: Foram avaliados 24 voluntários de ambos os sexos com escoliose idiopática (18±4
anos), com curvaturas médias de 24,8±12,7° Cobb. As medidas foram realizadas em um só dia e por dois examinadores treinados, com
os níveis vertebrais demarcados por um só examinador. Os avaliadores registraram uma medida para cada vértebra dos níveis torácico
e lombar em cada avaliação. Na análise dos dados, as medidas foram separadas em níveis vertebrais: torácico alto, torácico médio,
torácico baixo e lombar. O ICC (1,1) foi o teste estatístico utilizado para determinar a confiabilidade intra-avaliador e o ICC (3,1), para a
confiabilidade interavaliador. Resultados: A confiabilidade intraexaminador das medidas dos segmentos torácicos médio e baixo e lombar foi
considerada de muito boa a excelente. A confiabilidade interexaminadores das medidas de rotação axial do tronco foi considerada boa para
o segmento torácico alto e excelente para os segmentos torácicos médio e baixo e lombar. Conclusões: O escoliômetro é um instrumento
que possui valores de confiabilidade de muito bons a excelentes para as medidas repetidas de um mesmo examinador. A confiabilidade
interavaliadores nos segmentos torácicos médio e baixo e lombar em indivíduos com escoliose idiopática é relativamente menor que a
medida intra-examinador, mesmo que sejam eliminados os erros de palpação e marcação do local de posicionamento do instrumento.
Palavras-chave: escoliose; reprodutibilidade dos testes; estudo de avaliação; confiabilidade.
1
Course of Physical Therapy, Faculdade de Medicina de Ribeirão Preto (FMRP), Universidade de São Paulo (USP), Ribeirão Preto (SP), Brazil
2
Program of Post Graduation in Orthopedics, Traumatology and Rehabilitation
3
Department of Biomechanics, Medicine and Rehabilitation of the Locomotor System
Correspondence to: Anamaria Siriani de Oliveira, Av. Bandeirantes, 3900, Vila Monte Alegre, CEP 14049-900, Ribeirão Preto (SP), Brasil, e-mail: [email protected]
432
Reliability of the scoliometer
Introduction
Scoliosis is a spinal deformity of a curvature of, at least, 5º.
The prevalence of scoliosis ranges from 0.5% to 3.0% in the general population affecting mainly young adults and women1,2.
The diagnosis and clinical follow-up of idiopathic scoliosis
are performed by anteroposterior radiography of the spine, in
which the Cobb angle is measured, which is considered the
gold standard measure for the diagnosis of scoliosis3.
Several attempts were made in order to validate some methods of scoliotic curvature identification by non-radiological
analysis. These methods emerged as an alternative to the radiographic evaluation method as it reduces exposure of patients
who have scoliosis to excessive radiation, it is easier to evaluate
in the clinic and it has a reduced cost, when compared to radiographic examination. Examples of these non-radiographic
methods are the Moiré photograph4-6, the Quantec System7, the
electric goniometer8 and the scoliometer2,3,9-14.
The scoliometer is a device similar to the inclinometer,
in which there is a metal sphere inside a water recipient that
indicates the angle of axial trunk rotation. The sphere can be
dislocate on a range of 0-30° for both sides on an increasing
unit scale, as shown in Figure 1. The scoliometer is positioned
by the examiner, perpendicularly to the axial axis of the spine
on the spinous processes of vertebrae in the same level of the
marks regarding the center of the scoliometer9,12.
In the literature, there is no established correlation between values of axial trunk rotation observed by the evaluation
with the scoliometer and their corresponding values for Cobb
angles. The reference value obtained with the scoliometer, as
suggested by its creator, for characterization of scoliotic curvature of at least 10° Cobb is, at least, 5° to either sides12. Amendt
et al.2 suggest that values of axial trunk rotation of 7° to 10°
correspond to scoliosis of, at least, 20° Cobb.
Some studies were conducted on subjects with scoliosis,
predominantly female, aged between 15 and 37 years, in order
to determine the reliability of the scoliometer2,3,9,10,13. In two studies, the scoliometer showed excellent inter-rater and intra-rater reliability estimates and, therefore, was recommended as a
reliable, practical and cheap device to use in clinical practice2,12.
However, in one of these studies2, statistical analysis was performed with the Pearson’s “r” correlation coefficient, which is
not the best statistical test used to analyze reliability, because it
tends to overestimate association between the measures3.
Côté et al.3 and Murrell et al.9 found excellent values of intrarater reliability, but low estimates of inter-rater reliability for
the scoliometer due to low accuracy of the measure inherent to
the measurement, which would limit the use of this instrument
in clinical practice. In these studies, other procedures beyond
the evaluation with the scoliometer were performed, such as
the test of Adam and palpation and determination of the apical
vertebra of the curvature of patients.
Since there is no description about the resting time between
evaluations and the duration of all measurements performed,
the patient could present discomfort due to the maintenance
of posture adopted for the test and could present postural
changes that could generate errors during the measurement
procedure. Moreover, in all cited studies, the entire method
of measurement with the scoliometer was tested, since each
examiner performed the entire procedure, from positioning
the patient to the documentation of the value of axial trunk rotation, and not only the analysis of reliability of the instrument
alone2,3,9,10,13.
The palpation of the spinous processes of the spine is
an essential technique in the evaluation with the scoliometer. Some studies in the literature showed good inter-rater
repeatability15,16 and excellent intra-rater repeatability of the
technique15-17, both in thorax and in lumbar segments. They
also state that if the palpation was carried out by a manual
therapy specialist, repeatability is even better.
Given the above, the quantification of intra and inter-rater
reliability of measures with a scoliometer is still described controversially in the literature and the aim of the present study
was to test the inter-rater and intra-rater reliability of axial
trunk rotation measures obtained with the scoliometer in patients diagnosed with idiopathic scoliosis.
Methods
Participants
Figure 1. Scoliometer.
Twenty-four volunteers of both sexes (2 men and 22 women) with a diagnosis of idiopathic scoliosis agreed to participate in this study and were evaluated. From the sample, four
subjects had only simple scoliotic curvature at the thoracic
level (16.7%); three, in the lumbar spine (12.5%) and five in the
thoracolumbar transition (20.8%). Twelve volunteers had thoracolumbar double curve (50%). The mean age of the sample
was 18 (± 4) years and the mean height was 1.60 (± 0.89) m; the
433
mean weight was 54.4 (± 9.4) kg; the mean BMI was 21.1 (± 3.0),
and the mean Cobb angle was 24.8±12.7°.
An orthopedic physician specialist in spinal conditions
performed the diagnosis of the deformity during the consultations. The diagnosis was confirmed from the patient’s clinical
history, physical examination and special tests and inspection
of radiographs of the spine in anteroposterior view to obtain
the values of the Cobb angle.
The participants of this study were recruited by convenience
from the consultation list of the Clinic of Orthopedics and Spine
of the Clinics Hospital of the Medicine School of Ribeirão Preto,
Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto (SP),
Brazil, during the period from October 2006 to July 2007.
Subjects who previously underwent surgical treatment of
spine or lower limb, who had length discrepancy of the lower
limbs larger than 2.5 cm, which showed no idiopathic scoliosis
or who presented antalgic scoliotic postures were excluded.
The procedures performed in the study were explained and
the consent form was provided for the subject or guardian, if
the subject was younger than 18 years old. All subjects signed
the consent form. The approval of the research protocol was
granted by the Committee of Ethics in Human Research of the
HCFMRP-USP, number 2439/2006, on August 28, 2006.
trunk, with trunk anteriorly flexed and almost parallel to
the ground, with relaxed arms, hanging perpendicular to
the trunk and hands folded, as shown in Figure 2. The value
indicated by the metal sphere after placing the scoliometer
over the spinous process is used to indicate the value of axial
trunk rotation. Each examiner performed his measurement,
which lasted approximately three minutes, without breaks.
Examiners positioned the center of the device on the mark
regarding the spinous process of each vertebra with the
scoliometer perpendicular to the axial axis of the spine and
measured the axial trunk rotation. Examiners had no access
to the results of the other measures to avoid recall of the
previous values.
Between each evaluation, the subject was instructed to leave
the evaluation position to rest. Evaluation of rater 2 was made
soon after the rest period, which had variable duration, according to the report of the patient. Between the first and second
evaluation of rater 1, there were 15-20 minutes of interval, time
when the evaluation of rater 2 was performed. Thus, two of the
three evaluations, the first and last, were performed by rater 1
and one evaluation, the second, was performed by rater 2.
In each evaluation, the examiners evaluated once the 17 spinous processes from T1 to L5 from each of 24 subjects, totaling
408 measurements obtained at the end of each evaluation.
Procedures
Data analysis and statistics
The measurement procedure was performed by two examiners previously trained by an average of 10 hours with the
scoliometer. Although there is no recommendation in the literature regarding the training time necessary for correct use
of the instrument, 10 hours of training was considered sufficient by the examiners of this study for learning the evaluation
method. The same scoliometer, developed by Ortophaedics
Systems Incorporation®, was used by the examiners for the
evaluation of all subjects in order to reduce the error associated with the measurement.
During the measurement, all subjects were barefoot. Female
participants had their hair tied and were using a standard shirt
that allowed the viewing of the entire back. Male subjects were
evaluated shirtless. In order of not including the variability of
identification by palpation of the spine levels as a variable in the
study, the spinous process of each thoracic and lumbar vertebra
of the spine, from T1 to L5, was indentified by palpation with the
subject in the standing position. The spinous processes were marked with dermographic pen by examiner 2, who had four years
of experience working with manual therapy techniques.
The scoliometer is able to analyze, in degrees, the asymmetry and axial trunk rotation in the frontal plane, with the
patient positioned with the trunk in anterior flexion12. The
patient should be placed in standing position, with bare
434
Measures of axial rotation performed on the 17 spinous
processes (T1 to L5) were analyzed in categories according to
four vertebral levels: upper thorax (T1 to T4), medium thorax
(T5 to T8), lower thorax (T9 to T12) and lumbar (L1 to L5).
Figure 2. Evaluation performed with the scoliometer with the participant
standing in trunk flexion.
The rotations to the left of the 0° mark of the scoliometer
were recorded as negative, and the rotations located on the
right of the center mark, as positive, in order to identify the
side of the concavity of the curvature. However, values were
considered in module or absolute values for reliability testing.
To determine inter-rater reliability, the measurements of
each vertebral level obtained in the first evaluation of rater 1
and in the evaluation of rater 2, in the same segment, were subjected to statistical analysis using Intraclass Correlation Coefficient type 3,1 (ICC3,1)18. To determine intra-rater reliability,
the measurements of each vertebral level obtained in the first
evaluation of rater 1 and in the second evaluation of the same
rater, in the same segment were subjected to statistical analysis
using (ICC1,1)18. Measures of axial trunk rotation were also used
to calculate the standard error and confidence interval.
For values ranging from 1.0 to 0.81, the reliability was considered excellent; from 0.80 to 0.61, very good; from 0.60 to 0.41, good;
from 0.40 to 0.21, reasonable and, finally, from 0.20 to 0.00, poor18.
Results
The mean, standard error and confidence interval (CI=95%;
p<0.0001) of axial rotation values of the sample (n=24), by spine
levels, are shown in Table 1.
Inter-rater and intra-rater reliability estimates for all segments of the spine to all subjects in the sample (n=24) are
shown in Table 2.
The intra-rater reliability of axial trunk rotation measures
measured by the scoliometer was considered excellent for the
medium and lower thorax and lumbar segments (ICC1,1=0.87
to 0.92) and very good for the upper thorax (ICC1,1=0.74). The
highest intra-rater reliability coefficients were obtained in measures of axial trunk rotation in the medium (T5-T8) and lower
thorax segments (T9-T12).
The inter-rater reliability of axial trunk rotation measures
was considered good (ICC3,1 0.57) for upper thorax segment
and excellent for the medium and lower thorax and lumbar
segments (ICC3,1 0.84 to 0.95).
Discussion
In the present study, the scoliometer showed to be a reliable device to evaluate the axial trunk rotation in vertebrae of
patients with idiopathic scoliosis. However, the device proved
to be more reliable if used by the same examiner in patients
with idiopathic scoliosis in particular to evaluate curvatures in
medium and lower thorax segments of the spine.
The intra-rater reliability was very good in the upper
thorax segment, excellent in the medium and lower thorax
and lumbar segments of the spine, and higher values were
found for the medium and lower thorax segments of subjects,
similar to results found by other authors2,3,9,12,14. These results
indicate that the scoliometer is a reliable device to measure
axial trunk rotations of patients with idiopathic scoliosis in
all segments of the spine, especially if the evaluation is performed by the same examiner and in the medium and lower
thorax segments.
Regarding inter-rater reliability, excellent reliability values
were observed for the medium and lower thorax and lumbar
segments, while the upper thorax segment showed good reliability, since the error of determination of the vertebral level was
not included as a variable.
The relatively lower values found for the inter-rater reliability in upper thorax segment may be due to the fact that, in the
evaluated region, any accessory movement of cervical rotation
of small-amplitude may generate postural compensation in the
thoracic region. Thus, as the scoliometer is a device in which
the value obtained depends on the oscillation of a metal sphere
in the transverse plane, any placement of the upper thoracic
vertebrae in rotation can generate a corresponding oscillation
in the metallic sphere introducing bias in the measure obtained in the evaluation.
The palpation and the demarcation of vertebrae with dermographic pen was performed only by rater 2, since it was
not aimed at the reliability analysis of the complete method
of measurement with the scoliometer, but the reliability of
the device. This may have contributed to better estimates of
inter-rater reliability for the medium and lower thorax segments, when compared to those previously reported in the
literature.
In the study by Côté et al.3 the authors obtained estimates of inter-rater reliability of 0.91 for the thoracic level and
0.74 for the lumbar level, and the examiners reproduced
the entire evaluation, from the patient positioning, determination of vertebrae and record of the measure with the
scoliometer. In the study by Amendt et al.2, the authors reported that the scoliometer was a highly reliable device in
both inter and intra-rater analysis (r= 0.86 to 0.97). However,
the authors did not stratify the results by levels of the spine.
Furthermore, in a previous study2, the statistical test used
to analyze the reliability of the scoliometer was the Pearson
Correlation Coefficient, which tends to overestimate the
association of data and increase the reliability values. The
most appropriate statistical test for the reliability analysis is
the ICC, because it presents an analysis of data association
in a given interval3.
435
Table 1. Measures of axial trunk rotation determined with the scoliometer by two different examiners in 24 participants with idiopathic scoliosis.
Vertebrae Segment
Upper Thorax
(T1-T4)
Medium Thorax
(T5-T8)
Lower Thorax
(T9-T12)
Lumbar
(L1-L5)
Rater 1/
First assessment
mean (standard error)
(95% CI)
3.5 (±0.2)
(2.9 to 4.0)
4.2 (±0.3)
(3.4 to 4.9)
5.3 (±0.4)
(4.4 to 6.2)
2.9 (±0.2)
(2.7 to 3.7)
Rater 2/
Single assessment
(95% CI)
4.2 (±0.3)
(3.5 to 4.9)
4.8 (±0.4)
(3.9 to 5.7)
5.9 (±0.4)
(4.9 to 6.8)
2.5 (±0.2)
(2.3 to 3.2)
Rater 1/
Second assessment
(95% CI)
3.6 (±0.3)
(3.0 to 4.3)
4.3 (±0.3)
(3.7 to 5.0)
5.3 (±0.4)
(4.5 to 6.2)
2.8 (±0.2)
(2.6 to 3.5)
Data corresponding to mean (standard error) and 95% CI. Both assessments of rater 1 occurred between 15 and 20 minutes.
Table 2. Intra and inter-rater values of reliability found for the thorax
and lumbar spine after evaluation of the scoliometer of 24 subjects with
idiopathic scoliosis.
Vertebrae Segment
Upper Thorax
(T1-T4)
Medium Thorax
(T5-T8)
Lower Thorax
(T9-T12)
Lumbar
(L1-L5)
Inter-Rater
Reliability
Intra-Rater
Reliability
0.57
0.74
0.89
0.92
0.95
0.92
0.84
0.87
When comparing the results obtained in this study with
those of others in which the palpation and determination of
the spinous processes were included as variables2,3, one can
observe that the results found in the present study were similar or even better than those found in the literature when
analyzing the inter-rater reliability for medium and lower thorax and lumbar levels. From this perspective, it can be inferred that the major sources of variability of the measurement
performed with the scoliometer comes from the process of
positioning, palpation and determination of the spinous process and not just the record of the measures of axial rotation
with the device.
The variability of the measurements with the scoliometer
observed between measurements of two examiners justifies
the differences between the values of inter-rater and intra-rater
reliability. This greater variability of inter-rater than intra-rater
was also demonstrated in the study by Murrell et al.9.
The inter-rater error is a measure associated with the
precision of the device or examiner’s error. The variability of
measurements can be related to differences between the readings of examiners at the time of their respective evaluations,
because, as the scoliometer presents inside a metallic sphere
whose size is almost equal to the space between the marks of
436
angular units, and vertebral rotation is recorded at each level
with an entire number, if the ball is positioned between two
marks of the units, an examiner could evaluate the position of
the sphere as an angle above, while the other examiner could
adopt the position of the sphere differently and classify the
axial rotation of the same vertebral one level below, thus generating variability.
One can see that although most evaluated regions showed
excellent reliability measures, and the effect of palpation and
determination of the place of measurement regarding the
vertebral level was excluded from this study, the inter-rater
measures of upper, medium and lower thorax segments should
be interpreted with caution if the value of 5º of the scoliometer is chosen as indicative of a Cobb angle of 10°, which is the
cut-off angle for diagnosing scoliosis12. This is because, in this
sample, the absolute error in these measures may be sufficient
to change the value obtained by the scoliometer to reach out to
the value of 5º and erroneously diagnose a subject, altering the
sensitivity-specificity of this test.
The training time with the scoliometer performed by the
examiners, of approximately 10 hours, was effective for learning
the registration method of the device and may have contributed to the acquisition of good values of reliability. Based on the
findings of our study, we suggest that this same time should be
applied in studies of similar methodology.
Studies aimed to establish better values of the scoliometer,
as an indicative of scoliosis diagnosis will be useful to define
whether the scoliometer measurement error is critical or not
to support its clinical applicability.
Study limitations
One factor that may have contributed to the excellent
results of intra-rater and inter-rater reliability found was the
performance of evaluations of both examiners in a single day
and in periods of 20 minutes of intervals between the first and
last evaluation performed, because, since all the procedure was
performed on the same day, variables such as pain, muscle discomfort, fatigue and emotional stress that can provide changes
of postural alignment19,20, were minimized.
Data from the present study evaluated the inter-rater repeatability of measures without considering the error that palpation
performed by different examiners could add to errors obtained
in the study. In addition, the scoliometer is a device that has the
maximum amplitude of record of 0-30°, and as yet there is not a
certain correspondence in the literature between the value found
by the evaluation with the scoliometer and the corresponding
value in Cobb degrees, there is no way to determine if the measurement error is critical to invalidate its diagnostic applicability.
Conclusion
The scoliometer is a device that has reliability values ranging from very good to excellent for repeated measurements of
a single examiner. The inter-rater reliability of the measures of
axial trunk rotation was considered good to the upper thorax
segment and excellent to the medium and lower thorax and
lumbar segments.
Further studies are needed in the literature to determine
the reliability of the evaluation method of the scoliometer from
palpation to the record of values of axial trunk rotation and if
the measurement error becomes critical its clinical application
for diagnosis.
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Goldberg CJ, Kaliszer M, Moore DP, Fogarty EE, Dowling FE. Surface topography, cobb angles,
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adolescent idiopathic scoliosis measurements. Spine (Phila Pa 1976). 2005;30(4):444-54.
15. Downey BJ, Taylor NF, Niere KR. Manipulative physiotherapists can reliably palpate nominated
lumbar spinal levels. Man Ther. 1999;4(3):151-6.
16. Christensen HW, Vach W, Vach K, Manniche C, Haghfelt T, Hartvigsen L, et al. Palpation of the upper
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ISSN 1413-3555
METHODOLOGICAL ARTICLE
©
Pain Locus of control scale: adaptation and
reliability for elderly
Louise G. Araújo1, Débora M. F. Lima2, Rosana F. Sampaio3, Leani S. M. Pereira3
Abstract
Background: Pain is considered a multidimensional experience and is very common in the elderly. The pain locus of control has become
essential to understand how the perceptions, expectations and beliefs are related to individual behavior, attitudes, coping and adherence of
the elderly with regards to the health conditions and with the proposed treatment. Studies focused on adaptation and reliability of instruments
are necessary for health professionals. Objectives: The present study performed the cross-cultural adaptation of the Pain Locus of Control
Scale (C form of Multidimensional Health Locus of Control) for Brazil and assessed its intra and inter-examiner reliability among a sample of
68 elderly individuals with non-oncological pain living in the community. Methods: The cross-cultural adaptation of the scale was performed
using the methodology standardized by Beaton et al. (2000)*. Pearson’s correlation coefficient (PCC) and the intraclass correlation coefficient
(ICC) were used for the statistical analysis (p≤0.05). Results: Average age of the subjects was 69.6 ± 5.5 years; most were women, with low
levels of income and education. The average pain duration was 10.2 years and the main clinical diagnosis was osteoarthritis. The reliability of
the scale was adequate, with a regular to very strong correlations (PCC = 0.60 to 0.93) and a moderate to nearly perfect ICC (0.60 to 0.93), in
mainly the chance locus of control and medical and healthcare professionals locus of control subscales. Conclusion: An adequate reliability
and applicability was observed in our sample after adjustments and adaptations of the scale for use in elderly
Key words: pain control; reliability; cross-cultural adaptation; elderly.
* Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976).
2000;25(24):3186-91.
Resumo
Contextualização: A dor é considerada uma experiência multidimensional e muito prevalente em idosos. O locus de controle da dor
tem se tornado fundamental para entender como percepções, expectativas e crenças individuais se relacionam a comportamentos,
atitudes, enfrentamento e aderência dos idosos frente às condições de saúde e propostas de tratamento. Estudos focados na adaptação
e confiabilidade de instrumentos são necessários para os profissionais de saúde. Objetivos: Realizar a adaptação transcultural, para o
Brasil, do instrumento Pain Locus of Control Scale (forma C da Multidimensional Health Locus of Control ) e avaliar sua confiabilidade intra
e interexaminadores em uma amostra de 68 idosos comunitários, com dor crônica não oncológica. Métodos: A adaptação transcultural
da escala foi feita conforme metodologia padronizada por Beaton et al. (2000)*. Para análise estatística, foram usados os coeficientes de
correlação de Pearson (CCP) e de correlação intraclasse (CCI) (p≤0.05). Resultados: A média de idade dos idosos foi de 69,6±5,5 anos,
predominando mulheres, de baixa renda e escolaridade. O tempo médio de evolução da dor foi de 10,2 anos, e o principal diagnóstico
clínico foi a osteoartrite. A confiabilidade da escala mostrou-se adequada com correlação de regular a muito forte (CCP=0,60 a 0,93)
e de moderada a quase perfeita (CCI =0,60 a 0,93), principalmente nas subescalas de controle ao acaso e de profissionais médicos
e de saúde. Conclusão: Após as adaptações e as adequações da escala para aplicação em idosos, verificou-se sua aplicabilidade e
confiabilidade adequadas na amostra estudada.
Palavras-chave: controle da dor; confiabilidade; adaptação transcultural; idosos.
* Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976).
2000;25(24):3186-91.
1
Department of Physical Therapy, Centro Universitário de Belo Horizonte (UniBH), Belo Horizonte (MG), Brazil
2
Physical Therapist
3
Department of Physical Therapy, School of Physical Education, Physical Therapy and Occupational Therapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil
Correspondence to: Louise Guimarães de Araújo, Rua Perdigão, 67, Apto 404, Fernão Dias, CEP 31910-190, Belo Horizonte (MG), Brasil, email: [email protected]
438
Pain locus of control scale for elderly
Introduction
Estimates indicate that 80% of elderly have health problems that predispose them to the development of chronic pain.
Brazilian population data showed that over 60% of elderly reported chronic diseases which cause pain1. In American physical therapy clinics, 50% of patients were elderly who reported
pain as the main complaint2.
Impacts of chronic pain on quality of life of the elderly are
associated with depression, disability and mortality3. The high
prevalence of chronic pain requires the use of greater financial
and health resources, which reflects negatively on health systems, on the individual and on the society4.
The most used approach for the treatment of chronic pain
is medication. In the elderly, some limitations of this therapy
deserve consideration: the high cost, the frequent side effects
and lower efficiency in improving symptoms. These limitations
stimulate the search for other approaches, such as physical
therapy, psychotherapy and behavioral therapy5,6.
Pain is considered as a multidimensional experiencel4.
Studies related to the experience of persistent pain point to the
need of considering a biopsychosocial perspective for evaluation and treatment. In this model, the psychosocial factors
interact with the biological ones5,7.
Among the most widely used instruments to assess pain,
there are the Visual Analogue Scale (VAS) and McGill Pain
Questionnaire. The VAS is a unidimensional measure of pain
intensity8. The McGill Pain Questionnaire, although multidimensional (assessing properties, quality, spatial distribution
and pain intensity), does not address the individual’s expectations and beliefs regarding pain. Instruments focused on these
factors are necessary when considering their interference on
individual’s attitudes toward the proposed treatment9.
Evidence show that psychological factors seem to interfere more strongly than social, demographic and physical
factors on the painful experiences and they show to be important mediators in the treatment of chronic pain. Previous
studies, with multivariate statistical analysis in adults and elderly with chronic pain, concluded that psychological factors
(perception of pain control, feeling of incapacity in dealing
with pain and passive coping strategies) are associated with
depression, poorer quality of life, with functional disability
and pain intensity10-12.
According to the factors related to pain, stands the perception of pain control, the locus of control (LC), based on social
learning theory13. The theory argues that, based on personal
previous experiences, people acquire a perception of pain
control that can be influenced by new experiences14. The pain
LC has become critical to understand how the perceptions, expectations and beliefs relate to individual behavior, attitudes,
coping and adherence of older people facing their health conditions and proposed treatment14.
There are two forms which the individuals may experience predominantly who or what has control of the events of
their life: internally (the individuals realize that life events are
controlled by themselves) or externally15. External factors are
divided into chance control (the individual realizes that life
events are controlled by factors such as chance, luck or fate) or
powerful people (the individual realizes that whoever controls
the events are health professionals, family and others)14,15.
Based in this theory, Wallston, Wallston and De Vellis15 formulated the Multidimensional Heath Locus of Control (MHCL)
scale (A and B forms), developed to evaluate LC of general
states of health. These forms have been translated and adapted
for Brazil and its psychometric properties have already been
tested in the Brazilian population16,17. The A and B forms are
more appropriate to observe the perception of LC of general
states of health, limiting their observation to specific health
conditions, such as cancer and pain18-20.
Due to the need for adaptation of the A and B forms to assess
pain, the author of the original scale proposed the development
of a C form20. This scale aims to classify the location in which
individuals realize predominantly who or what stops the control
of their pain. Factor analysis of the main components of this new
scale revealed four dimensions: internal LC, chance LC, other
people LC ( friends and family), doctor and health professional
LC20. There were no other published studies that have crossculturally adapted and evaluated the psychometric properties of
this new specific scale for pain and/or elderly in Brazil. Studies
indicate that individuals who perceive pain control externally
have greater functional disability, exhibit more psychological
changes, use more health services and more often use coping
strategies, such as catastrophic thoughts, prayers, and reduced
activities17,21. In contrast, individuals who have a sense of internal
LC describe pain with less frequency and intensity, have higher
pain threshold, better functionality and use coping strategies focused on the problem. They also show less psychological alterations, greater social integration, more adherence to orientation
treatments and better health conditions22,23.
Although the LC is identified as relevant and widely
studied19,21 in Brazil, in the literature review carried out for the
present study, few studies that use the construct of health and
pain LC16,17 were found. No published study, methodologically
standardized, of translation and cross-cultural adaptation and
about the reliability analysis about the C form scale for the assessment of pain LC in the Brazilian elderly was found.
Behavioral therapy is based on teaching individuals cognitive and behavioral strategies to control pain; inform about the
effect of specific strategies (thoughts, beliefs and attitudes),
emotions ( fear of pain) and behaviors (avoiding activities due
439
to fear of pain) and emphasize the primary role that they have
to control pain and their adaptation against pain2.
Behavior therapy may be comparable with physical therapy
performance because both promote adoption of strategies of
self-management for the treatment of pain24. Knowing the pain
LC of patients allow the physical therapist and other health
professionals to motivate the modification of inadequate behaviors and the use of specific coping skills, which influences
in the improvement of adherence to exercises and of the functional capacity9.
The aim of this study was to perform the translation and
cross-cultural adaptation of the Pain Locus of Control Scale (C
form) for Brazilian elderly with chronic pain, living in the community, and to assess its intra and inter-examiner reliability.
items), doctors and health professionals LC: (3 items) and others LC (3 items)20. Considering the low education level of the
Brazilian elderly, after authorization by the author of the original scale, it was applied as an interview, and were used only four
options of answers: “strongly disagree” (1 point), “slightly disagree“ (2 points), “slightly agree” (3 points) and “strongly agree”
(4 points), unlike the original scale which includes six options.
Each subscale receives an independent score, ranging from 6 to
24 (internal and chance LC subscales) and from 3 to 12 (health
professionals and others LC subscales). Each subscale can be
applied separately and the higher its score, the higher is the LC
dimension. The predominant perceptions of pain control were
analyzed considering the subscales with higher scores.
Procedures
Methods
This study was approved by the Ethics in Research Committee of The Universidade Federal de Minas Gerais (UFMG), Belo
Horizonte (MG), Brazil (ETIC 110/06). Sixty eight community
Brazilian seniors with chronic nonmalignant pain, persistent
for more than three months and aged over 60 years participated: 30 seniors in the pilot phase to observe the applicability
of the scale and 38 during the reliability analysis. Participants
were recruited from outpatient services Clinics School of Belo
Horizonte (MG), Brazil.
Individuals with acute pain, with visual and/or hearing
deficits and those with cognitive impairment assessed by Minimental State Examination (Brazilian version)25 were excluded.
Instruments
For sample characterization, a structured questionnaire
developed by the authors, containing sociodemographic and
clinical data was applied.
The scale translated and adapted for the Brazilian elderly
population used in this study was the C form of the Multidimensional Heath Locus of Control (MHCL) scale, which showed
acceptable psychometric properties in the original study in a
American sample (n=588) composed by adults: internal consistence with Cronbach’s alpha greater than 0.7 in all subscales.
The test-retest reliability, with an interval of six weeks, through
the Pearson’s Correlation Coefficient (PCC), showed correlations from regular (r=0.40) to strong (r=0.80)20.
Following the recommendation of the author the application of the scale was performed by replacing the word health
with the word pain. The scale has 18 items divided into four
subscales, which correspond to the factors measured by the
instrument: internal LC perception (6 items), chance LC (6
440
After the author’s authorization for the cross-cultural adaptation of the scale and the informed consent form was signed
by the participants, the study was divided into two phases.
The first phase took place the process of translation and crosscultural adaptation of the scale, following the methodology
proposed by Beaton et al.26, which comprises the following
steps: translation, synthesis of translations, back translation,
discussion with a committee of specialists and application of
the pre-final version of the scale (pilot phase). In the pilot phase,
the pre-final version was applied to 30 seniors. On that opportunity, some expressions were found difficult to understand by
the participants. They were again submitted for analysis of the
expert committee.
The interdisciplinary discussion with the participants of the
committee, two doctors (anesthesiologists and geriatricians), a
psychologist, a physiotherapist, a methodologist of the scientific research, a translator and back translator, helped in solving
the semantic, idiomatic, cultural and conceptual discrepancies
between the original and adapted version of the scale. After
this second discussion, the final version was established to collect data for reliability analysis (Appendix 1). Discussion with
the expert committee culminated in suggestions to facilitate
understanding of the scale by the elderly: initial explanation
on how to complete the scale, permission for the spontaneous
speech of the elderly after reading each item and use of a visual
scale with the four options of answers.
The explanation on how to complete the scale was performed as following: prior to the application, it was explained to
the participants that there was no right or wrong answers and
that, agreeing or not, would depend on their individual experiences related to pain. The permission of the seniors’ spontaneous speech, after reading each item by the examiner, facilitated
the understanding. At that moment, the elderly, through previously experienced situations and repeating phrases with other
words, they understood better the item and chose answers
more safely. For example, during the completion of item 6: “I
am directly responsible for my pain getting better or worse”, after reading the sentence, the examiner asked the participants:
“Do you think that you can improve or worsen your pain? Give
me an example.
When using the visual scale with the response options for
the score of each item, after reading the sentence, the participants were asked whether they agreed or not with the item.
From that first answer, the visual scale with four options (written in letter size 18 and different colors) were read and shown
to the participant to select the final answer.
The evaluations were performed at office with only the
presence of the examiner and the participant. Two examiners,
previously trained, were responsible for data collection.
In the second phase of the study concerning the analysis
of intra and inter-reliability, the scale was applied independently and blinded to the previous result. For the analysis of
inter-examiner reliability, the participant attended on the first
day of evaluation, and the two examiners applied the scale at
different moments.
For the analysis of intra examiner reliability, the participant
returned in a second day of evaluation, in a maximum interval
of five days and answered the scale to the same examiner. No
additional treatment could be initiated during the period between the two evaluations. The maximum interval of five days
was adopted based on the availability of the participant and in
order to avoid changes on the perception of the pain LC.
Data on the sample characteristics were analyzed using
measures of central tendency and dispersion and frequency
distribution based on the distribution of each variable.
Pearson’s correlation coefficient (PCC) and the intraclass
correlation coefficient (ICC) were used for the reliability analysis. For the PCC analysis, the sample size calculation indicated
the need for 22 seniors and for the ICC analysis, the need of 28
seniors. The calculations considered correlation (PCC) and reliability (ICC) coefficients equal or higher than 0.5, using two repeated measures, a power of 80% and a significance level of 5%.
The interpretation of the results obtained for the ICC
was based on the cutoffs suggested by Landis and Koch27:
below 0 = poor; 0 to 0.20 = weak; 0.21 to 0.40 = regular; 0.41
to 0.60 = moderate; 0.61 to 0.80 good and 0.81 to 1 = nearly
perfect27. For the interpretation of the PCC results, the criteria
adopted was the one suggested by Tiboni28: r=0.0 (no correlation); 0.1 to 0.3 (weak); 0.31 to 0.6 (regular); 0.61 to 0.9 (strong),
0.91 to 0.99 (very strong) and 1.0 (perfect)28.
Results
The mean age was 69.6±5.5 (range from 60 to 81) years.
The clinical and social-demographic data can be observed in
the Table 1.
The results show higher levels of reliability on the subscales of
chance LC and doctors and health professionals LC. The subscale
that showed lower reliability was others LC as family and friends.
The mean values for each subscale in both evaluations to
demonstrate the intra and inter reliability with the PCC and
the ICC can be observed in Tables 2 and 3.
In implementing the first version of the scale, 53.4% reported reasonable difficulty and 20%, a lot of difficulty in
Table 1. Clinical and social-demographic characteristics of the studied
sample (n=68).
Variables
n
Gender
Female
58
Male
10
Age (years)
Mean ± SD (range)
69.6±5.5 (60-81)
Marital status
Married
32
Single
3
Widow
27
Divorced
6
Educational level (years)
0
12
1 to 7
51
8 or more
5
Financial income
No income
6
Up to 2 minimum wages
54
2 to 5 minimum wages
6
5 to 10 minimum wages
2
Major pain location
Cervical spine / head and face
5
Upper limb and shoulder
13
Thoracic spine
3
Lumbar spine
16
Pelvis and hip
5
Lower limb
27
Foot
4
Pain duration (years)
Mean ± SD (range)
10.22±10.43 (0.5-51)
Major clinical diagnosis
Osteoarthritis
50
Osteoporosis and osteoporotic fracture
10
Inflammatory musculoskeletal changes
12
Fibromyalgia
8
Other rheumatological disease
5
%
85.3
14.7
47
4.4
39.7
8.9
17.6
75
7.4
8.8
79.4
8.8
3
7.3
19.1
4.4
23.5
7.3
39.7
5.9
73.5
14.7
17.6
11.8
7.35
SD = Standard Deviation.
441
Table 2. Results from the intra rater reliability analysis through the Pearson’s Correlation Coefficients (PCC) and Intraclass Correlation Coefficients
(ICC).
Locus of control subscale
Internal
Chance
Doctors
Other people
Rater in first time
Mean (SD)
19.6±3,7
14±5.12
10.5±2.13
7.9±3
Rater in second time
Mean (SD)
20±3.25
12.9±5
10.6±2,11
7.35±3.15
ICC
(p value)
0.72*
0.90*
0.93*
0.60*
PCC
(p value)
0.72*
0.90*
0.93*
0.60*
* p<0.0001. SD = Standard Deviation.
Table 3. Results from the inter-rater reliability analysis through the Pearson’s Correlation Coefficients (PCC) and Intraclass Correlation Coefficients
(ICC).
Locus of control subscale
Internal
Chance
Doctors
Other people
Rater 1
Mean (SD)
20±3.8
13.5±5.4
10.9±2.8
7.9±3.15
Rater 2
Mean (SD)
19.7±4,5
14.1±5.26
11±1.88
6.9±3.11
ICC
(p value)
0.77*
0.90*
0.80*
0.72*
PCC
(p value)
0.79*
0.90*
0.81*
0.72*
* p<0.0001. SD = Standard Deviation.
completing the scale. After the adjustments suggested by the
expert committee, the results indicated that 42% reported no
difficulty; 31.6%, reasonable, 26.4%, little difficulty and no elderly reported lot of difficulty.
Discussion
During the translation and back translation process, a difficulty observed, already reported in the literature, was the choice
of synonyms for terms that were adjectives or described feelings,
as the terms: a big role and plays a big part29. Considering that
some terms have no equivalents in Portuguese, it was necessary
a translation based on the context. Faced with the difficulty of
literal translation, the subjectivity of the construct assessed by
the scale and characteristics of the sample, Brazilian elderly, in
which emotional and cognitive peculiarities rules are inherent to
the aging process, it became indispensable an adaptation in the
application of the scale. This allowed spontaneous speech and
examples by the elderly for the choice of answers. This form of
application facilitated the understanding of items for this specific population.
The accomplishment of a pilot phase (application of the
scale in 30 seniors), before establishing the final version, has
strengthened the importance of this stage as well as the discussion with the expert committee in the translation process
and adaptation of instruments. It is recommended that the
application of the scale in the elderly do the following steps:
explanation about on how to complete the scale, permission of
spontaneous speech and use of a visual scale by the elderly for
the choice of answers. In this sense, Scherest, Fay and Zaidi30
442
point that, often, it is more important to explain the meaning
of an expression than to try pair synonymous words30.
The reliability of the subscales measured by the instrument
shown to be adequate with intra and inter reliability in at least
moderate for ICC and regular to very strong for the PCC. The
comparison of the observed results with the one of other studies was limited due to the different forms of reliability analysis
suggested by the literature. Most of them evaluated the reliability of the scale using only an internal consistency of the A or B
forms of the MHLC scale16, 21. Wallston, Stein and Smith20 used
the C form of the scale, as in this study for analysis of test-retest
reliability in a population of young well-educated, with various
types of chronic nonmalignant pain. These authors observed
a PCC ranging from regular to strong in the subscales in an
interval of six weeks: r=0.80 in internal LC subscale, r=0.72 in
chance LC, r=0.58 in doctors and health professionals LC and
r=0.40 in others LC20.
In the present study, there were observed higher correlations in the PCC when compared to the study of Wallston,
Stein and Smith20. These differences may be related to the
interval between the administrations of the scale that, in the
present study, was a maximum of five days and, in the earlier
study, six weeks. Wallston, Stein and Smith20 justify that the
interval of six weeks among the applications might have influenced the perceptions of control sources by the participants,
interfering in the reliability20. These findings strengthen the
evidence, already reported by other authors, that the pain LC
is a subjective construct that can therefore be influenced by
new experiences21, 22.
In this study, there was a greater reliability of answers in
subscales chance and doctors and health professionals LC and
a lower reliability on the subscales of internal and others LC.
Although no studies that discuss these differences was found,
these findings may be related to events, lived daily experiences
and experiences reported by the elderly that seem to influence
the perceptions of pain control.
During the second administration of the scale for the intra examiner reliability analysis, which allowed an interval of
until five days among the applications, objective situations
were consciously reported: three elderly noticed the difference
in choice of answers provided to the examiner and justified
with happened events. One of them reported to carry excessive weight and have done a lot of cleaning at home, another
reported to have a pleasurable social contact with a neighbor,
and the other reported to have an argument with family members. These facts even trivial may have influenced the choice of
answers and reflected in a lower reliability of the subscales that
assess the pain perception of internal and other LC.
The number of items contained in the others LC subscale
(three items) may have influenced the lower reliability in the
answers, as has already been pointed in another study20. However, this justification must be interpreted cautiously because
lower reliability was not observed in the subscale doctors and
health professionals, which also has three items.
With regards to the factors that seem to influence the belief
of chance and doctors and health professionals LC, it was not
allowed to start new treatments or medical consultations in
the interval between applications. No participant reported different facts from those of the first assessment that might have
influenced their beliefs.
Although the literature indicates that the intra examiner
reliability is, in most studies, better than the inter examiner reliability, in the present study, this result was different. This result
may have been influenced by the interval between applications
to reliability analysis: applications were on the same day for
analysis of inter examiners, with an interval of approximately
60 minutes and it was allowed a maximum of five days between
applications for analyzing the intra examiner. The interval of
five days may have provided the occurrence of events in the
participants’ lives that influenced the reliability estimates of
the subscales. It is emphasized that this is a multidimensional
scale in which daily situations that reflect on the emotional
response possibly impact on the elderly answers. In this study,
even with different scores on the subscales between the two
evaluations, the elderly continued to be classified with the
same preferential belief with regards to pain control.
In this study, it was observed that the form of application of
the scale, allowing the elderly report and using the visual scale
for the choice of answers, contributed to the observed consistency and the reliability indexes.
Some limitations of this study deserve consideration. The
sample was recruited by convenience and there was clinical heterogeneity of the elderly, which may have affected the results.
Conclusions
The study showed the applicability of the pain LC scale in a
community sample of elderly with chronic pain. The use of this
scale will increase the knowledge of pain LC of elderly allowing thus a more appropriate approach to chronic pain among
this population. This study should be viewed as an initial mark
towards the development the version of the instrument Pain
Locus of Control (PLOC-C) to Brazilian Portuguese, since larger
sample and with different characteristics should be evaluated,
besides the accomplishment of studies that investigate other
psychometric properties.
References
1.
Dellarozza MSG, Pimenta CAM, Matsuo T. Prevalência e caracterização da dor crônica em idosos
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8.
Santos CC, Pereira LSM, Resende MA, Magno F, Aguiar V. Aplicação da versão brasileira do
questionário de dor Mcgill em idosos com dor crônica. Acta Fisiatrica. 2006;13(2):75-82.
2.
Beissner K, Henderson CR Jr, Papaleontioul M, Olkhovskaya Y, Wigglesworth J, Reid MC.
Physical Therapists use of cognitive-behavioral therapy for older adults with chronic pain: a
nationwide survey. Phys Ther. 2009;89(5):456-69.
9.
Salvetti MG, Pimenta CAM. Validação da chronic pain self-efficacy scale para a língua
portuguesa. Rev Psiquiatr Clín. 2005;32(4):202-10.
3.
Harris T, Cook DG, Victor C, DeWilde S, Beighton C. Onset and persistence of depression
in older people-results from a 2-year community follow-up study. Age Ageing.
2006;35(1):25-32.
4.
Geertzen JH, Van Wilgen CP, Schrier E, Dijkstrap PU. Chronic pain in rehabilitation medicine.
Disabil Rehabil. 2006;28(6):363-7.
5.
Barry LC, Gill TM, Kerns RD, Reid MC. Identification of pain-reduction strategies used by
community-dwelling older persons. J Gerontol A Biol Sci Med Sci. 2005;60(12):1569-75.
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Blumstein H, Gorevic PD. Rheumatologic illnesses: treatment strategies for older adults.
Geriatrics. 2005;60(6):28-35.
7.
Perez RS. Defining pain. Disabil Rehabil. 2006;28(6):339-41.
10. Tsai YF. Gender differences in pain and depressive tendency among Chinese elders with knee
osteoarthritis. Pain. 2007;130(1-2):188-94.
11. Monsivais D, McNeill J. Multicultural influences on pain medication attitudes and beliefs in
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12. Samwel HJA, Evers AW, Crul BJ, Kraaimaat FW. The role of helplessness, fear of pain, and
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14. Dela Coleta MF. Locus de controle da saúde. In: Dela Coleta MF (editor). Modelos para pesquisa
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control (MHCL) scales. Health Education & Behavior. 1978;6(1):160-70.
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2005;10(4):623-31.
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locus of control. J Pers Assess. 1994;63(3):534-53.
23. Cross MJ, March LM, Lapsey HM, Byrne E, Brooks PM. Patients self-efficacy and health locus
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persons. Pain. 2000;85(3):375-83.
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444
Appendix 1. - Pain locus of control scale- C Form / Pain Locus of Control Scale – C Form (PLOC-C).
Instructions for completing the scale (to be read to the patient, if applied as
an interview): each item below is a belief statement about your pain that you
may agree or disagree. Beside each statement is a scale that ranges from
strongly disagree (1) to strongly agree (4). For each item we would like you
to circle the number that represents the extent to which you agree or disagree
with that statement. The more you agree with a statement, the higher will be
the number you circle. The more you disagree with a statement, the lower
will be the number you circle. Please make sure that you answer EVERY
ITEM and that you circle ONLY ONE number per item. There are no right or
wrong answers.
Scoring instructions for the scale (used by the examiner): The score on
each subscale is the sum of the values circled for each item on the subscale
(where 1 = strongly disagree and 4 = strongly agree). All of the subscales
are independent of one another. There is no such thing as a “total” score.
The score is observed in each subscale so that the subscale with the highest
score reflects the prevailing belief of the individual in the control of pain.
Subscale
Possible range
Items
Internal locus of control
6-24
1,6,8,12,13,17
Chance locus of control
6-24
2,4,9,11,15,16
Doctors and health care professionals locus of control
3-12
3,5,14
Other people locus of control
3-12
7,10,18
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
If my pain worsens, it is my own behavior which determines
how soon I will feel better again.
As to my pain, what will be will be.
If I see my doctor regularly, I am less likely to have problems
with my pain.
Most things that affect my pain happen to me by chance.
Whenever my pain worsens, I should consult a medically trained
professional.
I am directly responsible for my pain getting better or worse.
Other people play a big role in whether my pain improves, stays
the same, or gets worse.
Whatever goes wrong with my pain is my own fault.
Luck plays a big part in determining how my pain improves.
In order for my pain to improve, it is up to other people to see
that the right things happen.
Whatever improvement occurs with my pain is largely a matter
of good fortune.
The main thing which affects my pain is what I myself do.
I deserve the credit when my pain improves and the blame when
it gets worse.
Following doctor’s orders to the letter is the best way to keep my
pain from getting any worse.
If my pain worsens, it’s a matter of fate.
If I am lucky, my pain will get better.
If my pain takes a turn for the worse, it is because I have not
been taking proper care of myself.
The type of help I receive from other people determines how
soon my pain improves.
Strongly disagree Slightly disagree
1
2
Slightly agree
3
Strongly agree
4
1
1
2
2
3
3
4
4
1
1
2
2
3
3
4
4
1
1
2
2
3
3
4
4
1
1
1
2
2
2
3
3
3
4
4
4
1
2
3
4
1
1
2
2
3
3
4
4
1
2
3
4
1
1
1
2
2
2
3
3
3
4
4
4
1
2
3
4
445
Index/Índice
ISSN 1413-3555
MOTOR CONTROL, MOTOR BEHAVIOR AND MOTOR FUNCTION/CONTROLE MOTOR, COMPORTAMENTO E MOTRICIDADE
372
Limitations of the Neurological Evolutional Exam (ENE) as a motor assessment for first graders
Limitações do Exame Neurológico Evolutivo (ENE) como um instrumento de avaliação motora para crianças da primeira série
Priscila M. Caçola, Tatiana G. Bobbio, Amabile V. Arias, Vanda G. Gonçalves, Carl Gabbard
396
Pattern and rate of motor skill acquisition among preterm infants during the first four months corrected age
Padrão e ritmo de aquisição das habilidades motoras de lactentes pré-termo nos quatro primeiros meses de idade corrigida
PHYSICAL THERAPY FOR CARDIOVASCULAR AND RESPIRATORY CONDITIONS/FISIOTERAPIA NAS CONDIÇÕES CARDIOVASCULARES E RESPIRATÓRIAS
426
Comparison between a national and a foreign manovacuometer for nasal inspiratory pressure measurement
Comparação entre o manovacuômetro nacional e o importado para medida da pressão inspiratória nasal
Fernanda G. Severino, Vanessa R. Resqueti, Selma S. Bruno, Ingrid G. Azevedo, Rudolfo H. G. Vieira,
Guilherme A. F. Fregonezi
390
Effects of physical exercise in the perception of life satisfaction and immunological function in HIV-infected patients:
Non-randomized clinical trial
Efeito do exercício físico na percepção de satisfação de vida e função imunológica em pacientes infectados pelo HIV: Ensaio
clínico não randomizado
411
Breathing pattern and thoracoabdominal motion in healthy individuals: influence of age and sex
Padrão respiratório e movimento toracoabdominal em indivíduos saudáveis: influência da idade e do sexo
Verônica F. Parreira, Carolina J. Bueno,Danielle C. França, Danielle S. R. Vieira, Dirceu R. Pereira, Raquel R. Britto
383
Heart rate responses during isometric exercises in patients undergoing a phase III cardiac rehabilitation program
Resposta da frequência cardíaca durante o exercício isométrico de pacientes submetidos à reabilitação cardíaca fase III
PHYSICAL THERAPY IN GERONTOLOGY/FISIOTERAPIA EM GERONTOLOGIA
438
Pain Locus of control scale: adaptation and reliability for elderly
361
A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults
Revisão sistemática sobre os efeitos da reabilitação vestibular em adultos de meia-idade e idosos
Natalia A. Ricci, Mayra C. Aratani, Flávia Doná, Camila Macedo, Heloísa H. Caovilla, Fernando F. Ganança
PHYSICAL THERAPY FOR NEUROLOGICAL CONDITIONS/FISIOTERAPIA NAS CONDIÇÕES NEUROLÓGICAS
404
Analysis of partial body weight support during treadmill and overground walking of children with cerebral palsy
Análise do uso de suporte parcial de peso corporal em esteira e em piso fixo durante o andar de crianças com paralisia cerebral
Vânia M. Matsuno, Muriel R. Camargo, Gabriel C. Palma, Diego Alveno, Ana Maria F. Barela
417
Anna L. M.Margre, Maria G. L. Reis, Rosane L. S. Morais
ASSESSMENT AND MEASUREMENT IN PHYSICAL THERAPY/AVALIAÇÃO E MENSURAÇÃO EM FISIOTERAPIA
432
Inter and intra-rater reliability of the scoliometer
377
Psychometric properties of the Portuguese version of the Jebsen-Taylor test for adults with mild hemiparesis
Avaliação das propriedades pscicométricas da versão em português do teste de Jebsen Taylor para adultos com hemiparesia leve
Karina N. Ferreiro, Renata L. Santos, Adriana B. Conforto
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Uma exposição concisa, que não exceda 250 palavras em um
único parágrafo, em português (Resumo) e em Inglês (Abstract) deve
ser escrita e colocada logo após a página de título. Notas de rodapé e
abreviações não definidas não devem ser usadas. Se for preciso citar
uma referência, a citação completa deve ser feita dentro do resumo.
O Resumo e o Abstract devem ser apresentados em formato estruturado, incluindo os seguintes itens separadamente: Contextualização
(Background), Objetivos (Objectives), Métodos (Methods), Resultados
(Results) e Conclusões (Conclusions).
Corpo do texto: Introdução, Materiais e Métodos, Resultados e Discussão
Incluir, em itens destacados:
Introdução: deve informar sobre o objeto investigado e conter
os objetivos da investigação, suas relações com outros trabalhos
da área e os motivos que levaram o(s) autor(es) a empreender a
pesquisa.
Materiais e Métodos: descrever de modo a permitir que o trabalho possa ser inteiramente repetido por outros pesquisadores.
Incluir todas as informações necessárias – ou fazer referências a
artigos publicados em outras revistas científicas – para permitir
a replicabilidade dos dados coletados. Recomenda-se fortemente
que estudos de intervenção apresentem grupo controle e, quando
possível, aleatorização da amostra.
Resultados: devem ser apresentados de forma breve e concisa.
Tabelas, Figuras e Anexos podem ser incluídos quando necessários para garantir melhor e mais efetiva compreensão dos dados.
Discussão: o objetivo da discussão é interpretar os resultados e
relacioná-los aos conhecimentos já existentes e disponíveis, principalmente àqueles que foram indicados na Introdução do trabalho. As informações dadas anteriormente no texto podem ser
citadas, mas não devem ser repetidas em detalhes na discussão.
Estudos de Revisão Sistemática com Metanálise. Devem incluir:
a) uma seção que descreva os métodos empregados para localizar,
selecionar, obter, classificar e sintetizar as informações, b) número
suficiente de artigos, com qualidade metodológica alta (segundo
mecanismos próprios de avaliação) de tal forma que seja possível
uma análise apropriada sobre o tema de investigação, e c) técnica de
metanálise, que integre os resultados dos estudos selecionados, sobre a questão de pesquisa. Manuscritos de revisão sistemática com
metanálise que apresentem uma quantidade insuficiente de artigos
selecionados e/ou artigos de baixa qualidade, que não utilizem técnica estatística para síntese ponderada dos efeitos dos estudos (metanálise) e que não apresentem uma conclusão assertiva e válida sobre o
tema, não serão considerados para análise de revisão por pares.
Agradecimentos
Quando apropriados, os agradecimentos poderão ser incluídos,
de forma concisa, no final do texto, antes das Referências Bibliográficas, especificando: assistências técnicas, subvenções para a pesquisa
e bolsa de estudo e colaboração de pessoas que merecem reconhecimento (aconselhamento e assistência). Os autores são responsáveis
pela obtenção da permissão documentada das pessoas cujos nomes
constam dos Agradecimentos.
Referências Bibliográficas
O número recomendado é de, no mínimo, 50 (cinquenta) referências bibliográficas para Artigo de Revisão; 30 (trinta) referências
bibliográficas para Artigo Original, Metanálise, Revisão Sistemática e
Metodológico. Para Estudos de Caso recomenda-se, no máximo, 10
(dez) referências bibliográficas.
As referências bibliográficas devem ser organizadas em sequência
numérica, de acordo com a ordem em que forem mencionadas pela
primeira vez no texto, seguindo os Requisitos Uniformizados para
Manuscritos Submetidos a Jornais Biomédicos, elaborados pelo Comitê Internacional de Editores de Revistas Médicas – ICMJE <http://
www.icmje.org/index.html>.
Os títulos de periódicos devem ser referidos de forma abreviada,
de acordo com a List of Journals do Index Medicus <http://www.
index-medicus.com>. As revistas não indexadas não deverão ter seus
nomes abreviados.
As citações das referências bibliográficas devem ser mencionadas
no texto em números sobrescritos (expoente), sem datas. A exatidão
das referências bibliográficas constantes no manuscrito e a correta citação no texto são de responsabilidade do(s) autor(es) do manuscrito.
(Ver exemplos no site: <http://www.nlm.nih.gov/bsd/uniform_requirements.html>).
Tabelas, Figuras e Anexos: as Tabelas, Figuras e Anexos são limitados a
5(cinco) no total.
Tabelas: devem incluir apenas os dados imprescindíveis, evitando-se tabelas muito longas (tamanho máximo permitido: uma
página em espaço duplo), e devem ser numeradas, consecutivamente, com algarismos arábicos e inseridas no final do texto.
Título descritivo e legendas devem torná-las compreensíveis,
sem necessidade de consulta ao texto do artigo. Não devem ser
formatadas com marcadores horizontais nem verticais, apenas
necessitam de linhas horizontais para a separação de suas seções
principais. Devem ser usados parágrafos ou recuos e espaços verticais e horizontais para agrupar os dados.
Figuras: as Figuras não devem repetir os dados já descritos nas
Tabelas. Todas devem ser citadas e devem ser numeradas, consecutivamente, em arábico, na ordem em que aparecem no texto. Não é
recomendado o uso de cores. As legendas devem torná-las compreensíveis, sem necessidade de consulta ao texto. Digitar todas as legendas em espaço duplo e explicar todos os símbolos e abreviações.
Usar letras em caixa-alta (A, B, C, etc.) para identificar as partes individuais de figuras múltiplas. Se possível, todos os símbolos devem
aparecer nas legendas; entretanto, símbolos para identificação de
curvas em um gráfico podem ser incluídos no corpo de uma figura,
desde que isso não dificulte a análise dos dados.
Em relação à arte final, todas as Figuras devem estar no formato
.tiff. Figuras de baixa qualidade podem resultar em atrasos na aceitação e publicação do artigo.
As Tabelas, Figuras e Anexos publicados em outras revistas ou
livros devem conter as respectivas referências e o consentimento, por
escrito, do autor ou editores.
Para artigos submetidos em língua portuguesa, um conjunto
adicional em inglês das Tabelas, Figuras, Anexos e suas respectivas
legendas deve ser anexado como documento suplementar.
Notas de Rodapé
As notas de rodapé do texto, se imprescindíveis, devem ser numeradas consecutivamente em sobrescrito no manuscrito e escritas em
folha separada, colocada no final do texto.
PROGRAMA DE PÓS-GRADUAÇÃO EM CIÊNCIAS
DA REABILITAÇÃO MESTRADO E DOUTORADO
Recomendado pela CAPES – Conceito 5
O Programa de Pós-graduação em Ciências da Reabilitação tem como base a perspectiva
apresentada no modelo proposto pela Organização Mundial de Saúde e propõe que as
dissertações e trabalhos científicos desenvolvidos estejam relacionados com o desempenho
funcional humano. Com a utilização de um modelo internacional, espera-se estimular o
desenvolvimento de pesquisas que possam contribuir para uma melhor compreensão do
processo de função e disfunção humana, contribuir para a organização da informação e estimular
a produção científica numa estrutura conceitual mundialmente reconhecida. O Programa de
Pós-graduação em Ciências da Reabilitação tem como objetivo tanto formar como aprofundar o
conhecimento profissional e acadêmico, possibilitando ao aluno desenvolver habilidades para
a condução de pesquisas na área de desempenho funcional humano.
O programa conta com parcerias nacionais e internacionais sedimentadas, e os seus laboratórios
de pesquisa contam com equipamentos de ponta para o desenvolvimento de estudos na área
de Ciências da Reabilitação.
Maiores informações
Fone/Fax: (31) 3409-4781
www.eef.ufmg.br/mreab

Brazilian Journal of Physical Therapy

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