Brazilian Journal of Physical Therapy

Transcrição

Brazilian Journal of Physical Therapy
ISSN 1413-3555
Rev Bras Fisioter, São Carlos, v. 14, n. 4, p. 276-359, July/Aug. 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. 4
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.
MISSÃO: publicar artigos científicos relativos ao objeto básico de estudo e campo de atuação profissional da Fisioterapia, 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.
MISSION: to publish scientific articles related to the areas of study and professional activity in Physical Therapy, 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 adress: 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, Daiane Rossi, 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. 4 (July/Aug. 2010).
Bimonthly
Abstracts in English and Portuguese
ISSN 1413-3555
1. Physical Therapy/journals I. Brazilian Association for
Research and Graduate Studies in Physical Therapy.
Revisão/Review
Librarian: Dormélia Pereira Cazella
CRB 8/4334
ii
Summary / Sumário
ISSN 1413-3555
EDITORIAL
v
Three years of accomplishments at CNPq
Um triênio de conquistas conjuntas no CNPq
Helenice J. C. G. Coury, Marisa C. Mancini
ORIGINAL ARTICLES/ARTIGOS ORIGINAIS
276
The effects of knee extensor eccentric training on functional tests in healthy subjects
Os efeitos do treino isocinético excêntrico dos extensores do joelho nos testes funcionais em sujeitos saudáveis
Heleodório H. Santos, Mariana A. Ávila, Daniela N. Hanashiro, Paula R. Camargo, Tania F. Salvini
284
Quality of life and discriminating power of two questionnaires in fibromyalgia patients:
Fibromyalgia Impact Questionnaire and Medical Outcomes Study 36-Item Short-Form Health Survey
A qualidade de vida e o poder de discriminação de dois questionários em pacientes com fibromialgia:
Fibromyalgia Impact Questionnaire e Medical Outcomes Study 36-Item Short-Form Health Survey
Ana Assumpção, Tatiana Pagano, Luciana A. Matsutani, Elizabeth A. G. Ferreira, Carlos A. B. Pereira,
Amélia P. Marques
290
Noninvasive ventilation in the immediate postoperative of gastrojejunal derivation with Roux-en-Y gastric bypass
Ventilação não invasiva no pós-operatório imediato de derivação gastrojejunal com bypass em Y de Roux
Kivânia C. Pessoa, Gutemberg F. Araújo, Alcimar N. Pinheiro, Maria R. S. Ramos, Sandra C. Maia
296
Relationship between quadriceps angle (Q) and plantar pressure distribution in football players
Relação entre o ângulo quadriciptal (ÂQ) e a distribuição da pressão plantar em jogadores de futebol
Rafael G. Braz, Gustavo A. Carvalho
303
Calibration of low-level laser therapy equipment
Aferição dos equipamentos de laser de baixa intensidade
Thiago Y. Fukuda, Julio F. Jesus, Marcio G. Santos, Claudio Cazarini Junior, Maury M. Tanji, Helio Plapler
309
Assessment of global motor performance and gross and fine motor skills of infants attending day care centers
Avaliação do desempenho motor global e em habilidades motoras axiais e apendiculares de lactentes
frequentadores de creche
Carolina T. Souza, Denise C. C. Santos, Rute E. Tolocka, Letícia Baltieri, Nathália C. Gibim,
Fernanda A. P. Habechian
316
Determination of the power-duration relationship in upper-limb exercises
Determinação da relação potência-duração em exercício com membros superiores
Domingos Belasco Junior, Fernando R. Oliveira, José A. N. Serafini, Antonio C. Silva
322
Determinant factors of functional status among the oldest old
Fatores determinantes da capacidade funcional em idosos longevos
Silvana L. Nogueira, Rita C. L. Ribeiro, Lina E. F. P. L. Rosado, Sylvia C. C. Franceschini, Andréia Q. Ribeiro,
Eveline T. Pereira
330
Head and shoulder alignment among patients with unilateral vestibular hypofunction
Alinhamento de cabeça e ombros em pacientes com hipofunção vestibular unilateral
Adamar N. Coelho Júnior, Juliana M. Gazzola, Yeda P. L. Gabilan, Karen R. Mazzetti, Monica R. Perracini,
Fernando F. Ganança
337
Ventilatory and muscular assessment in healthy subjects during an activity of daily living with
unsupported arm elevation
Avaliação ventilatória e muscular de indivíduos saudáveis durante atividade de vida diária com os braços
elevados e sem apoio
Giselle F. L. Panka, Marina M. Oliveira, Danielle C. França, Verônica F. Parreira, Raquel R. Britto, Marcelo Velloso
344
Effects of treadmill-walking training with additional body load on quality of life in subjects with
Parkinson’s disease
Efeitos do treino da marcha em esteira com aumento da carga corporal sobre a qualidade de vida de sujeitos
com doença de Parkinson
Nadiesca T. Filippin, Paula H. Lobo da Costa, Rosana Mattioli
iii
351
Electromyographic activity during active prone hip extension did not discriminate individuals with and
without low back pain
Atividade eletromiográfica durante o movimento de extensão do quadril em prono não discrimina indivíduos
com dor lombar
Cristiano Q. Guimarães, Ana C. L. Sakamoto, Glória E. C. Laurentino, Luci F. Teixeira-Salmela
LETTER TO THE EDITOR /CARTA AO EDITOR
358
Access to pulmonary rehabilitation programs within the public healthcare service
O acesso aos Programas de Reabilitação Pulmonar na rede pública de saúde
Cristiane Mecca Giacomazzi
359
Access to pulmonary rehabilitation programs within the public healthcare service (reply by the authors)
O acesso aos Programas de Reabilitação Pulmonar na rede pública de saúde (réplica dos autores)
Vanessa Suziane Probst, Fábio Pitta
INDEX/ÍNDICE
GENERAL INSTRUCTIONS TO AUTHORS/INSTRUÇÕES GERAIS AOS AUTORES
iv
ISSN 1413-3555
EDITORIAL
Rev Bras Fisioter, São Carlos, v. 14, n. 4, p. v-vi, July/Aug. 2010
©
Revista Brasileira de Fisioterapia
Three years of accomplishments at CNPq
Um triênio de conquistas conjuntas no CNPq
I
t was with great satisfaction that we represented the areas of Physical Therapy and Occupational Therapy before
Conselho Nacional de Pesquisa (CNPq) funding agency during the July 2007 - June 2010 triennium. We will now
present a brief report of the activities undertaken and some of the results of our activities. This was the first representation elected by the community of researchers in our area, a fact that made us feel honored and committed to
the task entrusted to us.
During this period, we participated in the grant selection panel of CNPq’s annual notice (Edital Universal)
and supported the organization of scientific events, special grants (national and overseas post-doctoral grants,
short-term overseas doctoral grants, visiting scholar grants), undergraduate research fellowships, technical support grants, and research productivity grants. We also participated in occasional selection panels such as the 2008
Young Researcher Grant and the 2009 New Campus Grant. To justify the need for more funding and grants, we
engaged in discussions on the selection criteria and policies for the area, systematically showing the rapid growth
in our research community through data-supported documentation.
The work was very intensive and often very frustrating, as in the case of the selection panel for the Young
Researcher Grant that attracted many qualified applications in experimental sciences (79 applications of up to R$
500,000) and non-experimental sciences (11 applications of up to R$ 120,000). However, the available funding was
only R$ 413,000 for both categories combined. At other times, the work brought great satisfaction, as in the case of
Notice MCT/CNPq/CT-Saúde N.58/2009 entitled “Aging, Work and Health: promoting quality of life in the Brazilian
population through physical activity, occupational activity, and language”. This was the first notice prepared by
the Multidisciplinary Health Committee for our areas, and it was achieved through our own enterprise in writing
letters and contacting the board of directors and the president of CNPq. Furthermore, we received funding from
government departments that we visited after overcoming several obstacles given that we were unfamiliar with
this type of activity. Nevertheless, we had the generous support of Prof. Marco Antonio Zago, president of CNPq
at the time, and Dr. Isaac Roitman, of the Department of Science and Technology, whom we wish to thank here.
It is also important to remember that we have learned the ropes with these experiences, and this will help future
representatives to seek new funding alternatives for our research.
The existence of selection criteria and a clear résumé scoring system, available on the CNPq website, made our
task easier and more transparent. Every year, we prepared reports of our activities for the selection participants.
Next, we will briefly provide some information on two regular notices that have the Committee in their annual
selection panels and that can help the community to understand the selection process and learn about some of
their results.
v
Rev Bras Fisioter. 2010;14(4):v-vii.
Edital Universal
In this triennium, the Edital Universal, previously issued biannually, became an annual notice, which doubled the chances of
researchers to receive funding. Another characteristic of this notice is that 30% of the available funding is awarded to qualified
applicantions from the country’s North, Northeast and Midwest regions. In 2007, we had 111 total applications distributed into
three tiers (A, B, and C), and there was funding available for 20 projects from 10 different institutions. In 2008, we received 81 applications and awarded CNPq funding to 23 recipients in all three tiers. In 2009, we received 117 applications and awarded funding
to 27 recipients across 13 institutions from eight Brazilian states, providing different groups throughout the country with good
conditions for research development.
The number of funding recipients depends on the funding made available by CNPq for each tier, and it is related to the competitiveness of the applicants of that group. However, it also depends on the overall demand per area, as the amount of funding
for each committee is defined by CNPq according to the amount requested by its researchers in each notice. Therefore, qualified
applications are a consistent way of supporting the area, particularly in the annual notices of Edital Universal and research productivity grants. Regular visits to the CNPq website also keep researchers informed about the large number of funding notices and
opportunities.
The applications that meet the requirements of each notice are selected on the basis of merit, taking into account the quality of
the project and the résumé score for each participant. In the selections conducted during the triennium, there was a progressive increase in the participants’ score. Table 1 shows some numbers relating to the résumé selection of the last Edital Universal (2009).
Table 1. Order of magnitude of the scores for the applications recommended in 2009. Dispersion of the application scores per tier.
Group mean
Standard deviation
Mean résumé score for recommended applications
Tier A
75.0
74.4
108.7
Tier B
66.2
70.7
132.0
Tier C
60
73.8
188.0
Research Productivity Grants
In 2007, when we began our activities at CNPq, the areas of physical therapy and occupation therapy had 28 research productivity (RP) grant holders from nine different institutions. Today, we have 52 grant holders from 16 institutions. This represents an
extraordinary increase of 85.7% in three years. It also represents an increase in diversity as a result of the expansion of our research
in different institutions and regions.
The number of applications for RP grants has been high (in 2007, N=50; in 2008, N=49; and in 2009, N=76). The number of qualified applications has also increased (approximately 50% of these applications were qualified, and some of them, highly qualified),
which is very positive for our area. Our selection criteria are public and available on our section of the CNPq website. These criteria
were approved by the community, which was invited in writing to participate in the process.
The fact that many qualified applications have been submitted must be recognized and celebrated, as it means that the community believes in the selection process for which they have applied. Furthermore, with the increasing number of qualified applications, the community helps its representatives to justify the requests for more funding and grants. These requests were made
systematically and consistently through a number of letters to the president of CNPq, visits to the board of directors and the
president, and through final reports to CNPq for all selection panels. Thus, by submitting a large number of qualified applications,
the researchers actively support the growth of the area.
vi
Therefore, we wish to recognize the response from our community expressed through the submission of many qualified applications, which has contributed to the increase in the visibility of the areas of physical therapy and occupational therapy within
CNPq and to encourage more funding for the development of knowledge in our areas. Please continue to be involved and to submit
your qualified applications!
Finally, we would like to announce that new representatives for the next triennium are being nominated by CNPq. We wish
them a very productive period and enormous success in this activity.
Helenice Jane Cote Gil Coury
Representative of the Areas of Physical Therapy and Occupational Therapy
CNPq Multidisciplinary Health Committee, July 2007- June 2010 Triennium
Marisa Cotta Mancini
Substitute Representative of the Areas of Physical Therapy and Occupational Therapy
CNPq Multidisciplinary Health Committee, July 2007- June 2010 Triennium
vii
ISSN 1413-3555
©
ORIGINAL ARTICLE
The effects of knee extensor eccentric training
on functional tests in healthy subjects
Os efeitos do treino isocinético excêntrico dos extensores do joelho nos testes
funcionais em sujeitos saudáveis
Heleodório H. Santos1, Mariana A. Ávila2, Daniela N. Hanashiro2, Paula R. Camargo2, Tania F. Salvini2
Abstract
Background: It is well known that eccentric training increases muscle strength and promotes greater neural activation, and therefore
has been used in the recovery of knee extensors. The hypothesis of this study was that there would be a strong correlation between
knee extensor torque and functional tests. Objectives: To investigate the relationship between knee extensor peak torque and functional
tests of agility (runs) and propulsion (hop for distance) after short-term isokinetic eccentric training. Methods: Twenty healthy and active
male undergraduate students (age 22.52.1 years; height 1.720.10 m; weight 67.89.5 kg; body mass index: 22.52.0 kg/m2), with no
abnormalities or history of injury of the limbs, performed an isokinetic assessment of the knee extensors and flexors and also functional
tests before and after isokinetic training, which consisted of 3 sets of 10 MVECs at 30o/s, with 3 minutes of rest between sets, twice a
week for 6 weeks. Results: The eccentric training increased the extensor peak torque (16, 27 and 17%; P<0.01) and decreased the
H/Q ratio (10, 20 and 13%; P<0.01) for the isometric and eccentric modes at 30°/s and 120°/s, respectively. It also decreased the time
in two of the five agility tests (carioca and pivot diagonal; P<0.01), and increased the distance in the hop tests, for both dominant and
non-dominant limbs (P<0.01). Conclusions: Although the eccentric training led to an increase in extensor peak torques as well as an
improvement in most of the functional tests, the hypothesis that a strong correlation would be observed between peak torques and
functional tests was not confirmed.
Article registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) under the number 12607000590460.
Keywords: hop tests; agility tests; torque; knee; eccentric training; H/Q ratio.
Resumo
Contextualização: Sabe-se que o treino excêntrico aumenta a força muscular, promovendo uma maior ativação neural e, portanto, tem
sido usado na recuperação do torque extensor. A hipótese deste estudo foi a de que possa existir uma forte correlação entre o torque
extensor do joelho e os testes funcionais. Objetivos: Correlacionar o torque extensor do joelho com os testes funcionais de agilidade
(corridas) e impulsão (saltos em distância) após o treino isocinético excêntrico de curta duração. Métodos: Vinte homens universitários,
ativos e saudáveis (22,52,1 anos; 1,720,10 m; 67,89,5 kg; IMC 22,52,0 kg/m2), sem reportar anormalidades ou história de lesão
no membro inferior, realizaram avaliação isocinética do torque extensor e flexor do joelho e testes funcionais antes e depois do treino
isocinético que consistiu em três séries de 10 CEVM a 30º/s, com 3 minutos de repouso entre as séries, realizado duas vezes por
semana, durante seis semanas. Resultados: O torque extensor aumentou (16, 27 e 17%; P<0,01), a razão I/Q diminuiu (10, 20 e 13%;
p<0,01) para os modos: isométrico e excêntrico a 30°/s e 120°/s, respectivamente; diminuiu o tempo em dois dos cinco testes de
corridas (carioca e pivô diagonal; P<0,01) e aumentou a distância nos testes de saltos tanto para o membro dominante quanto para
o não dominante (P<0,01). Conclusões: Embora o treino excêntrico tenha aumentado o torque dos extensores do joelho, bem como
melhorado a maioria dos testes funcionais, a hipótese de uma forte correlação entre essas variáveis não se confirmou.
Artigo registrado no Australian New Zealand Clinical Trials Registry (ANZCTR) sob o número 12607000590460.
Palavras chave: testes de saltos; testes de agilidade; torque; joelho; treino excêntrico; razão I/Q.
Received: 06/10/2008 – Revised: 22/04/2009 – Accepted: 15/09/2009
1
Physical Therapy Department, Universidade Federal da Paraíba (UFPB), João Pessoa (PB), Brazil
2
Physical Therapy Department, Universidade Federal de São Carlos (UFSCar), São Carlos (SP), Brazil
Correspondence to: Tania de Fátima Salvini, Departamento de Fisioterapia, Universidade Federal de São Carlos, Rodovia Washington Luis, Km 235, CP 676, CEP 13565-905,
São Carlos (SP), Brazil, e-mail: [email protected]
276
Rev Bras Fisioter. 2010;14(4):276-83.
Eccentric training versus functional tests
Introduction
Methods
Due to its anatomic and functional characteristics,
the knee is one of the most overloaded joints in the musculoskeletal system1. Many studies have demonstrated the
effectiveness of resistance training2 in improving physical performance and treating musculoskeletal injuries to
this joint1,3,4. Because eccentric exercise promotes greater
neural activation compared to isometric and concentric
contractions5, it is considered to be a powerful stimulus to
hypertrophy6 and muscle strength7. However, the extent of
these morphofunctional changes depends on the intensity,
frequency and duration of training8,9.
Regular exercise programs with heavy loads have led to
muscle hypertrophy, but the strength gain acquired before
the hypertrophy has been attributed to increased neural
activity10. Widrick et al.11 observed an increase of more
than 60% in the strength of the vastus lateralis muscle after
short-term resistance training, which changed the muscle’s
functional properties. Some studies that evaluated the knee
flexors and extensors recorded higher torque during the
eccentric12,13 and concentric14 contraction, respectively, at
low speeds.
The most common tool to evaluate the effects of resistance
training is isokinetic dynamometry because it allows the control of significant movement variables, such as range of motion, angular velocity, work load, exercise mode (isometric,
concentric or eccentric) and identifies the agonist/antagonist
ratio1,2,4,13,15,16. Additionally, the functional tests of agility (runs)
and hop for distance17-19 provide security and efficiency parameters, being extensively used to assess the athlete’s capacity to
resume training after injury20.
Although these functional tests are considered reliable
(>80%) and sensitive (>82%), their relationship with the
muscle torque of knee extensors and flexors is still controversial in the literature21, given that the methodologies differ in:
concentric2,15,22-24 and/or eccentric mode13,16,25; velocity of movement (30, 60, 70, 90, 120, 150, 180, 240, 270, 300 and 400°/s)13,16,25
and muscle group (extensors25,26 and/or flexors2,13,15,16).
In light of the above considerations, the hypothesis of the
present study was that the strengthening of knee extensors
would lead to an improvement in joint function, which could
be evidenced by the agility and hop for distance tests. Due
to the fact that eccentric movement at low speed generates
higher torque than the other contraction modes12-14, this study
analyzed the short-term effects of isokinetic eccentric training
at low speed (30°/s) on the knee extensors in healthy subjects
with the aim of verifying a possible linear correlation between
knee torque and performance in functional tests.
Subjects
The initial sample consisted of 25 healthy and active male
undergraduate students selected from a school of physical therapy. Five of them were excluded from the study: three due to knee
pain during training and two due to absence. A total of 20 subjects completed the study (age 22.52.1 years; height 1.720.10 m;
weight 67.89.5 kg; body mass index/BMI 22.52.0 kg/m2). After
answering a questionnaire, the subjects were selected according to the following criteria: a) no regular muscle strength
training; b) BMI below 24 kg/m2; and 3) no musculoskeletal
injuries or balance disorders (Lachman test, varus and valgus
tests at 0 and 30º).
The study was conducted in accordance with the Human Research Ethics Committee of Universidade Federal de São Carlos
(UFSCar), São Carlos (SP), Brazil, and all subjects signed an informed
consent form (approval number 144/2004 – CEP/UFSCar).
Torque evaluation
The dominant leg (right=5; left=15) was identified before the
torque evaluation by asking the subject which leg he would use
to kick a ball and by asking the subject to hop over an obstacle.
The tests were conducted on the non-dominant leg because it
is the one used for postural support and propulsion27,28. Initially,
the subjects warmed up on a stationary bicycle (75W) for 5 min
at 20 km/h, followed by a set of three 30-s stretches ( followed
by 30-s intervals) focused on knee flexors, knee extensors and
plantar flexors. Next, the subjects were positioned in an isokinetic dynamometer (Biodex Multi-Joint System 3, Shirley, NY)
with the backrest reclined 5º from vertical and knees flexed at
90º. To avoid compensatory movements, straps were positioned
across the subject’s trunk, pelvis, and thigh. The dynamometer
axis was aligned with the axis of rotation of the knee joint (lateral femoral epicondyle) and the dynamometer lever arm was
attached to the distal leg (5 cm above the medial malleolus) so
as to allow full ankle dorsiflexion29. The familiarization period
consisted of three submaximal eccentric contractions of the
knee extensors, followed by a 3-min rest period. The effect of
gravity on torque was corrected with the knee flexed at 60°,
and the adjustment for correction was calculated by using the
instrument’s software, according to Dvir29.
The knee extensor and flexor torques were evaluated under
isometric and eccentric isokinetic (30º/s and 120º/s) conditions. To measure the maximal isometric torque, the dynamometer lever arm was fixed at 60º for knee extension25 and at 30º
for knee flexion30. The evaluation consisted of one set of three
277
maximal voluntary isometric contractions (MVIC) lasting 5s
each, with 1-min rest intervals31. The mean peak torque (MPT)
of the three contractions was calculated for each subject7,8.
The range of motion (ROM) for the eccentric isokinetic
evaluations was set to 70° (extension from 20° to 90°, and flexion from 90° to 20°). Each test (30º/s and 120º/s) consisted of
one set of five consecutive maximal voluntary eccentric contractions (MVEC) with a 1-min rest period between velocities29.
The MPT obtained for the 5 contractions of knee extensors and
flexors was calculated at the end of each set.
During the evaluations and training, the subjects received
verbal stimulation provided by the same examiner in a standardized manner to encourage maximal contraction. Additionally, the subjects were provided with visual feedback displayed
as a graph on the instrument’s screen22. The conventional hamstring/quadriceps (H/Q) ratio was calculated by dividing the
flexor peak torque by the extensor peak torque and multiplying
this result by 10032 for all contraction modes (isometric and eccentric) and velocities (30o/s and 120o/s).
Isokinetic training
Prior to each training session, the equipment was calibrated
and the subjects underwent the same warm-up and stretch protocols as previously described. Afterwards, they followed an eccentric (bilateral) training protocol focused on the strengthening
of the knee extensors. This consisted of three sets of 10 MVECs23
at 30º/s, with a 3-min rest period between sets9. Studies that examined eccentric contraction in the knee flexors and extensors at
Figure 1. Functional tests: shuttle run (1); pivot diagonal run (2);
figure-eight run (3); lateral run (4); carioca (5); single hop (6); triple
hop (7).
278
low speeds13,16 found higher torque. Training was performed twice
a week for six weeks (12 sessions), alternating dominant and nondominant limbs, with an interval of at least 48h between sessions.
Functional tests
Initially, the subjects performed a brief warm-up that consisted of running around the court at low velocity (trotting) for
5 minutes. Afterwards, they followed the same stretch protocol
as the one used for torque evaluations. Functional tests were
carried out before and after the eccentric isokinetic training of
the knee extensors (pre- and post-training) and consisted of five
agility tests (shuttle run, lateral run, carioca, pivot diagonal run
and figure-eight) at maximal velocity, and two hop for distance
tests (single and triple). One- and two-min rest intervals were allowed between the sets of the agility and hop tests, respectively.
For the shuttle and lateral runs, and carioca, a 6-m distance
was marked with two cones placed one in front of the other.
In the shuttle run (Figure 1.1), the subjects were instructed
to run back and forth. For the pivot diagonal run (zigzag),
two parallel columns were demarcated by two cones on each
side, keeping a 6-m distance between the cones on the same
side and a 5m distance between the cones on opposite sides
placed diagonally (Figure 1.2). The subjects were instructed
to run from one cone to the opposite cone, then turn around
(pivot) to the right or the left, alternately, and run diagonally
toward another cone, thus completing a distance of 15 m33.
For the figure-eight run (Figure 1.3), two parallel columns
were placed 4 m apart. Each column was formed by three
cones positioned 1 m apart. The subjects were instructed to
run around the two columns so as to form a figure eight33,34.
The lateral run (Figure 1.4) was in a straight line, but the subjects had to run sideways from right to left (round trip). In
the carioca (Figure 1.5), the displacement was also performed
sideways from right to left, but the subjects used a cross over
step, alternating one leg in front of the other18,19. In all agility
tests, verbal commands (i.e. “ready, set, go!”) were given to the
subjects with the aim of standardizing the beginning of the
test and the time-keeping process.
For the hop for distance tests (single and triple), the subjects
were instructed to stand on one foot, behind the starting line, find
their balance and then perform the hop when they felt ready. For
the single hop for distance test (Figure 1.6), the distance between
the starting point and the landing point of the tested foot was
measured35-39. For the triple hop for distance test (Figure 1.7), the
same procedure was used to calculate the distance relative to
three consecutive hops18,19,40. For each type of hop, three attempts
were performed, alternating right and left legs.
In both pre- and post-training, all subjects performed the
functional tests (agility and hop for distance) in the same
sequence (runs: shuttle, lateral, carioca, pivot diagonal and
figure-eight; hop for distance test: single and triple). For the
post-training, a 72-h interval was allowed after the last session
of isokinetic training. With the purpose of standardizing the
procedures, all the tests were initiated by the non-dominant
limb. Three attempts were performed for each of the functional
tests of agility and horizontal propulsion, and the means of
the three attempts were calculated for both time and distance
variables.
Data analysis
The Statistical Package for the Social Sciences (SPSS) was
used for the statistical analysis (mean, standard deviation,
paired t-test, Wilcoxon, one-way ANOVA, and ICC). The MPT
and the variance of the conventional H/Q ratio for peak torque
were analyzed for all modes and velocities evaluated in pre- and
post-training. The functional tests were used to investigate the
differences between pre- and post-training means and to investigate a possible relationship with MPT (ICC). With regard
to the correlation tests (ICC), values ranging from 0 to 0.5 were
considered weak, values ranging from 0.51 to 0.75 were considered moderate, and values above 0.75 were considered strong.
A significance level of 5% (P<0.05) was used for all analyses.
Hamstring/Quadriceps Ratio (H/Q)
As shown in Table 3, there was a significant decrease in
the conventional H/Q ratio after training in all modes and
velocities analyzed, but the greatest decrease percentage
(20%) was observed in the eccentric mode at 30°/s, followed
by the eccentric mode at 120°/s (13%), and the isometric
mode (10%).
The one-way ANOVA test showed that the training protocol
used in the study increased the difference in the H/Q ratio between contraction modes. For pre-training, there was a difference
between isometric mode and eccentric mode at 120°/s (P<0.05).
For post-training, there was a difference between isometric mode
and eccentric mode at 30º/s (P<0.05), and a difference between
the velocities of 30º/s and 120º/s in the eccentric mode (P<0.01).
Table 1. Comparisons of the means of peak torque (Nm) before and
after 6 weeks of isokinetic eccentric training of the knee extensors.
Mean of peak torque (Nm)
Torque
t-test
(paired)
Gain
(%)
Pre-training
Post-training
Isometric
217.542.5
259.351.2**
0.0001
16
Eccentric 30º/s
232.255.9
318.855.6**
<0.0001
27
Eccentric 120º/s
215.750.4
259.867.4**
0.0001
17
108.727.1
115.132.2
0.0587
6
Extensors
Flexors
Results
Isometric
Eccentric 30º/s
113.928.4
123.320.8*
0.0159
8
Isokinetic dynamometry
Eccentric 120º/s
108.329.8
111.831.2
0.2380
3
Nm=Newton.meter; * significant difference at P<0.05; ** significant difference at p<0.01.
MPT
For the comparisons of MPT for knee extensors between
pre- and post-training, there was a gain of 16% (P<0.01) for the
isometric mode, 27% (P0.01) for the eccentric mode at 30º/s
and 17% (P<0.01) at 120º/s. Also, the knee flexors had an increase
of 8% (P<0.05) for MPT in the eccentric mode at 30°/s, although
this mode did not compose the training protocol (Table 1).
Time to peak torque (TPT)
Table 2. Time to Peak Torque (ms) between pre- and post-training after
6 weeks of isokinetic eccentric training of knee extensors.
Torque
Time to peak torque (ms)
Pre-training
Post-training
Eccentric 30º/s
2723755
2185219*
Eccentric 120º/s
951368
775236
Eccentric 30º/s
2343541
2259636
Eccentric 120º/s
555113
52875
Extensors
Flexors
In general, the means of the TPT tended to decrease, although it was only statistically significant in the eccentric
mode at 30º/s (P<0.01; Table 2).
* P=0.003 (Wilcoxon).
Table 3. Hamstrings/Quadriceps ratio between pre- and post-training in non-dominant limb.
Contraction Modes
Isometric
Eccentric 30º/s
Eccentric 120º/s
Pre-training
49.88.3
50.47.5
54.810.3
Hamstrings/quadriceps ratios (%)
Post-training
t-test (paired)
45.17.8
0.0057
40.37.0
<0.0001
47.712.3
0.0023
Difference (%)
10
20
13
279
Table 4. Comparison of the means of the functional tests before and after 6 weeks of isokinetic eccentric training of the knee extensors.
Functional Tests
Shuttle run (s)
Lateral run (s)
Carioca (s)
Pivot diagonal run (s)
Figure-eight run (s)
SHDL (m)
SHNDL (m)
THDL (m)
THNDL (m)
Pre-training
13.800.87
14.922.24
19.483.95
34.583.09
16.682.95
1.950.15
1.960.16
5.810.35
5.770.32
Evaluations
Post-training
13.570.88
14.481.47
16.911.97
32.402.54
16.142.59
2.020.13
2.050.12
5.930.36
5.950.35
p value
0.19◊
0.33†
<0.01†
<0.01†
0.15◊
<0.05†
<0.01◊
<0.05†
<0.01†
Results: meanstand deviation; SHDL=single hop dominant limb; SHNDL=single hop non-dominant limb; THDL=triple hop dominant limb; THNDL=triple hop non-dominant limb;
s=second; m=meter; ◊ (Wilcoxon); † (t test).
Functional tests
There were significant differences (P<0.01) for two of the five
agility tests (carioca and pivot diagonal run) when comparing
the means of functional tests in pre- and post-eccentric training
of the knee extensors (Table 4). For the hop for distance tests,
there were significant differences in the single and triple hop for
distance tests for both limbs, however the non-dominant limb
showed greater significance (P<0.01) than the dominant limb.
Correlation: MPT versus functional tests
There were weak correlations (r0.5) between the MPT of
knee extensors and flexors and the functional agility tests for
all modes and velocities, in both pre- and post-training. The
correlations for the hop for distance tests in pre- and posttraining for both test types (single and triple) were generally
weak (r0.5). However, there was a weak and moderate correlation, in pre-training, between the MPT of knee extensors and
the single hop for distance test in the eccentric mode at 30º/s
and 120º/s (r=0.50 and 0.53, respectively). There was also a
moderate correlation between the MPT of knee extensors and
the triple hop for distance test in the eccentric mode at 30º/s
(r=0.56). Moderate and strong correlations were also observed
between the MPT of knee flexors in the eccentric mode at both
velocities and the single hop for distance test (r=0.63 and 0.78,
respectively). In the post-training, the correlation between the
MPT of knee flexors, in the eccentric mode, at 120°/s was also
moderate (r=0.60), although it was shown to be lower than the
correlation seen for the pre-training.
Discussion
The results of the present study showed that peak torque
increased after isokinetic eccentric training in all of the
280
contraction modes and velocities analyzed (isometric, and
eccentric at 30º/s and 120º/s), therefore in agreement with
several authors9,28,41-46. The greatest torque gain was observed
in the eccentric mode at 30°/s, as supported by previous
studies25,26, however a torque increment was also observed in
the isometric mode and eccentric mode at 120°/s, a fact also
evidenced by Blazevich47.
According to several studies, resistance training promotes
changes in the neurological system, leading to force gain43,46,
especially in the first eight weeks, without significant increase
in the cross-sectional area of the muscle28. Using functional
magnetic resonance imaging, Duchateau and Enoka48 showed
an increase in the modulation of the motor cortex area on
muscles of the hand after 3 weeks of training. Although variables such as number, firing rate and synchronization of the
active motor units were not analyzed in the current study, it is
possible to assume that the torque gained in response to the
training protocol (6 weeks) is a result of the changes in muscle
recruitment patterns9,44,45.
The flexor peak torque was also increased in the eccentric
mode at 30°/s, which indicates that this muscle group plays
a role in the eccentric contraction of the extensors. This gain
may be explained by the active (isometric) exercise of the contralateral flexors during the eccentric training of the extensors.
Although the exercise was not monitored by electromyography,
it was possible to visually identify an isometric contraction of
the contralateral flexors during the eccentric training of the
extensors.
The results showed that, although TPT tended to decrease
in all analyzed modes and velocities, the relationship was specific to the mode and velocity of training (eccentric at 30°/s).
This is probably associated with force gain and improved motor unit recruitment, because a low TPT at the beginning of
training was followed by a substantial peak torque gain in the
eccentric mode at 30°/s. In a study on the activation patterns
of knee extensors, McHugh et al.49 verified that a lower TPT
is related to the fact that isokinetic eccentric exercise requires
higher recruitment of type II muscle fibers. Similarly, Miller
et al.50 demonstrated that TPT was significantly lower after
eccentric training when compared to concentric training for
both knee extensors and flexors, indicating improved neuromuscular function.
The conventional H/Q ratio was used because it was not
possible to calculate the functional H/Q ratio due to the lack
of records for concentric peak torques during evaluations. The
conventional H/Q is used as a standard test of knee muscle
balance2,12,13,16,32,50-53. For the comparison of the H/Q ratio between pre- and post-training, the training protocol lead to a
decrease of 20%, 13% and 10% in the eccentric mode at 30º/s,
120º/s and isometric mode, respectively. These decreases in
H/Q ratio were due to the increased extensor peak torque
rather than the decreased flexor peak torque. Although there
was a gain in the knee flexor torque, this gain was lower than
the gain recorded for the knee extensors, therefore leading to
a decrease in the antagonist/agonist ratio. In a review study
on the contribution of the eccentric contraction to injury, prevention, rehabilitation and sports, LaStayo et al.5 reported that
this contraction, when exclusively applied to a single muscle
group, may compromise knee stability due to changes in the
H/Q ratio.
Despite this significant decrease, the lower rate of flexor
torque represented 40% of the extensor torque for all analyzed
contraction modes. However, this percentage is within the
range of variability (40-80%) described in many other studies
on H/Q ratio, depending on the studied population, age and
gender7,52. Therefore, in spite of the fact that the current protocol only elicited the knee extensors and lead to a decrease in
H/Q ratio, the percentage of the ratio seen here (40%) does
not compromise the stability of the knee joint.
It can be observed in the present results that the three
torque variables (MPT, TPT and H/Q ratio) showed more significant differences for the specific training mode and speed of
eccentric training at 30°/s, which characterizes the principle
of training specificity when compared to the other assessed
modes and speeds25,54. Duchateau and Enoka48 corroborate the
results of the current study by demonstrating that the performance in functional tests is improved to a maximum level in
similar tasks and can be affected by contraction mode, load,
velocity and posture. Indeed, the distances in both types of
hop for distance (single and triple) may have increased due to
a greater similarity to the task of the training protocol (high
force, low velocity). In contrast, an improved performance was
only observed in two (carioca and pivot diagonal run) of the
five agility tests. Furthermore, Kraemer et al.9 demonstrated
that strength training alone elicits no significant improvement
in running performance. Also, these same authors verified that
tests conducted at velocities above 180°/s were better indicators of agility, thus being more closely related to knee joint
function.
In light of these considerations, it is possible that the results obtained after training would have been more significant,
especially for the agility tests, if the training protocol had been
conducted at a medium velocity (180º/s) in the concentric
and eccentric modes because positive (shortening) and negative (lengthening) work of the knee muscles was observed in
the completion of all the functional tests used in the present
study. Sheppard and Young20 argue that the ability to perform
an agile movement involves not only physical but also cognitive factors, suggesting that the decreased time in functional
tests (such as the carioca and pivot diagonal run) as well as the
increased distance in the hop for distance tests may be due to
a combination of both factors. However, this hypothesis may
be rejected as the subjects performed the tests only twice (preand post-training), with a 6-week interval between them. Furthermore, in the post-training evaluation, the subjects asked
the examiner to show them how to perform the test as they
could not remember how to do it.
The manual timing used for the agility tests, although recorded by the same examiner, probably influenced the results
because it is an evaluator-dependent measure, therefore not as
reliable as a record obtained by an electronic synchronization
system or photo-cells. Another factor that may also have influenced the results of this study was the total number of tests
(5 runs and 2 hops), because each of the tests was performed
three times consecutively. Unlike the present study, most of the
studies found in the literature34-39,48,55 used only one or two trials, while a few18,19,33 used a maximum of five trials to combine
activities of agility and hop.
There is considerable disagreement in the literature
regarding which muscle group is most involved in the functional movements of the knee. Li et al.56 found correlations
between the knee flexor forces and functional abilities, while
other authors57,58 found this correlation only with the extensors. However, these correlations were classified as weak or
moderate.
The results of the present study are in agreement with the
literature because there were weak correlations between functional tests and torque for both knee extensors and flexors,
however most studies included subjects with deficient or reconstructed ACLs. Other studies included healthy subjects23 or
athletes13,16,24 in their sample, and although they found similar
results to those of the present study (weak and moderate correlation), the discussion is hampered by differences in methodology such as closed kinetic chain23 or open kinetic chain13,16,24,
linear isokinetic test23 or angular isokinetic test13,14,16,24, training protocol (mode of contraction, muscle group, number of
281
repetitions, frequency, duration, time to rest, speed of contraction, etc.) and quantity and type of functional tests used in the
relationship analysis59.
The fact that isokinetic tests are performed in open kinetic
chain and functional tests are performed in closed kinetic
chain may have influenced the relationship analysis, which
suggests that the muscles of the joints proximal and distal to
the knee (hip and ankle) could increase the performance of
functional tests49. The low speed of contraction used in the
training protocol (30°/s) when compared with the velocities of contraction developed in the various functional tests
(60°/s)2,13,15,50,51 and the lack of evaluation in the concentric
mode15,23,24 may also have influenced the results. Another factor in our study that could justify the moderate correlations
between the torque and hop tests would be the similarity between the speed of movement in the training (30°/s) and the
specific hop task. Thus, the weak correlations with the agility
tests (runs) can also be explained by the difference in speed
between the tasks.
Conclusions
Although the training protocol elicited a substantial increase in the extensor peak torque, especially at 30°/s, along
with improved performance in most of the functional tests (carioca and pivot diagonal run, and single and triple hop), the hypothesis that a strong correlation would be observed between
these variables was not confirmed. This suggests that the functional tests and isokinetic tests assess different measures, and
it seems that the combination of measures is important for a
full assessment of functional capacity.
Acknowledgements
To Fundação de Amparo à Pesquisa do Estado de São Paulo
(FAPESP), Conselho Nacional de Desenvolvimento Científico e
Tecnológico (CNPq) and Coordenação de Aperfeiçoamento de
Pessoal de Nível Superior (CAPES) for their financial support.
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283
ISSN 1413-3555
©
ORIGINAL ARTICLE
Quality of life and discriminating power of two
questionnaires in fibromyalgia patients: Fibromyalgia
Impact Questionnaire and Medical Outcomes
Study 36-Item Short-Form Health Survey
A qualidade de vida e o poder de discriminação de dois questionários em
pacientes com fibromialgia: Fibromyalgia Impact Questionnaire e Medical
Outcomes Study 36-Item Short-Form Health Survey
Ana Assumpção1, Tatiana Pagano2, Luciana A. Matsutani3, Elizabeth A. G. Ferreira1, Carlos A. B. Pereira4, Amélia P. Marques1
Abstract
Background: Fibromyalgia is a painful syndrome characterized by widespread chronic pain and associated symptoms with a negative
impact on quality of life. Objectives: Considering the subjectivity of quality of life measurements, the aim of this study was to verify the
discriminating power of two quality of life questionnaires in patients with fibromyalgia: the generic Medical Outcomes Study 36-Item ShortForm Health Survey (SF-36) and the specific Fibromyalgia Impact Questionnaire (FIQ). Methods: A cross-sectional study was conducted
on 150 participants divided into Fibromyalgia Group (FG) and Control Group (CG) (n=75 in each group). The participants were evaluated
using the SF-36 and the FIQ. The data were analyzed by the Student t-test (=0.05) and inferential analysis using the Receiver Operating
Characteristics (ROC) Curve - sensitivity, specificity and area under the curve (AUC). The significance level was 0.05. Results: The sample
was similar for age (CG: 47.88.1; FG: 47.07.7 years). A significant difference was observed in quality of life assessment in all aspects of
both questionnaires (p<0.05). Higher sensibility, specificity and AUC were obtained by the FIQ (96%, 96%, 0.985, respectively), followed
by the SF-36 (88%, 89% and 0.948 AUC). Conclusion: The FIQ presented the highest sensibility, specificity and AUC showing the most
discriminating power. However the SF-36 is also a good instrument to assess quality of life in fibromyalgia patients, and we suggest that
both should be used in parallel because they evaluate relevant and complementary aspects of quality of life.
Key words: fibromyalgia; quality of life; questionnaires; disability evaluation; health status indicators.
Resumo
Contextualização: A fibromialgia é uma síndrome dolorosa caracterizada por dor espalhada e crônica e sintomas associados com um
impacto negativo na qualidade de vida. Objetivos: Considerando a subjetividade da mensuração de qualidade de vida, o objetivo
deste estudo foi avaliar o poder de discriminação de dois questionários que avaliam a qualidade de vida de pacientes com fibromialgia:
o genérico Medical Short Form Healthy Survey (SF-36) e o específico Questionário do Impacto da Fibromialgia (QIF). Métodos: Foi
conduzido um estudo transversal com 150 indivíduos, divididos em dois grupos: grupo fibromialgia (FM) e grupo controle (GC) (n=75
em ambos). Os pacientes foram avaliados pelo SF-36 e pelo QIF. Na análise dos dados, utilizou-se o teste “t de Student” com =0,05
e a Curva ROC (Receiver Operating Characteristics Curve). Resultados: As amostras foram estatisticamente semelhantes para a idade
– 47,8 (8,1) no GC e 47,0 (7,7) no FM – e estatisticamente diferentes em todos os aspectos dos dois questionários (SF-36 e QIF). Alta
sensibilidade, especificidade e área abaixo da curva (AUC) foram obtidas com o QIF (96%, 96%, 0,985 respectivamente), seguido
pelo SF-36 (88%, 89% e 0,948 AUC). Conclusão: O QIF mostrou-se mais discriminativo do que o SF-36 para avaliar a qualidade de
vida de fibromiálgicos. No entanto, o SF-36 é também um bom instrumento de avaliação e sugere-se que ambos sejam usados uma
vez que avaliam aspectos relevantes e complementares da qualidade de vida.
Palavras-chave: fibromialgia; qualidade de vida; questionários; avaliação da deficiência; indicadores básicos de saúde.
1
Physical Therapy Department, Speech Therapy and Occupational Therapy, Faculdade de Medicina (FM), Universidade de São Paulo (USP), São Paulo (SP), Brazil
2
Physical Therapist
3
Physical Therapy Department, Fundação Instituto de Educação de Osasco (FIEO), Osasco (SP), Brazil
4
Statistics Department, Instituto de Matemática e Estatística (IME), USP
Correspondence to: Amélia Pasqual Marques, Rua Cipotânea, 51, Cidade Universitária, CEP 05360-000, São Paulo (SP), Brazil, e-mail: [email protected]
284
Discriminating power of quality of life questionnaires
Introduction
Methods
“Health is […] not simply the absence of disease; it is something
positive, a joyful attitude toward life, and a cheerful acceptance of
the responsibilities that life puts upon the individual”1. According
to WHO2, quality of life refers to the perception that people have
about their position in life, within a context of culture and system
of values in which they live and in relation to their aims, expectations and social standards. Considering the chronic diseases, the
role of healthcare in improving quality of life has been increasingly
underlined, particularly as concerns the relief of pain and suffering3. As in other chronic syndromes, improving the quality of life
of patients is the main objective of fibromyalgia management.
Fibromyalgia syndrome has been described as a frequent
rheumatological disorder in the world’s population4-7 and in
the primary healthcare system, representing 7% of all health
complaints and increasing health costs8. According to the criteria of the American College of Rheumatology (ACR), it is a
painful syndrome characterized by widespread and chronic
musculoskeletal pain and by the presence of at least 11 of the
18 tender points. These symptoms are frequently associated
with morning stiffness, sleep disorders, fatigue, chronic headache, anxiety, depression, and irritable bowel syndrome9.
Considering the role of the symptoms, the negative impact
on quality of life is frequently reported10,11. According to White
et al.12, this negative impact on the quality of life of active individuals leads to loss of function, affects work capacity and
consequently lowers family income. Although the functional
disability is not caused by movement restriction, the impact
of the symptoms on all aspects of daily life (e.g. work, family life
and leisure13) aggravates the psychological conditions, causing
depression and anxiety14,15 and increasing the impact on the
patient’s quality of life10,11.
As in other syndromes, accurate quality of life measurements play an important role in the scientific and clinical context because they allow the identification of patients’ needs,
serve as outcome measures in experimental studies and provide
parameters for the cost-benefit and cost-effectiveness analysis
of treatment16-18. In this sense, quality of life assessment has
great relevance, and the use of specific and generic instruments
could improve the diagnosis, treatment efficacy and research
results18,19. While the generic questionnaires are usually more
representative of overall quality of life, the specific instruments
have a higher discriminating power20. Consequently, it is important that quality of life instruments have a reliable discriminating power16,18. The aim of the present study was to verify the
discriminating power of two instruments used to assess quality
of life in patients with fibromyalgia: the generic Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the
specific Fibromyalgia Impact Questionnaire (FIQ).
Type of study
This is a cross-sectional study.
Sample
This study included 150 participants. Seventy-five participants had a diagnosis of fibromyalgia according to the ACR9
criteria and were selected at the rheumatology outpatient
service of Hospital das Clínicas, Faculdade de Medicina da
Universidade de São Paulo (HC-FMUSP), Brazil. For the healthy
control group (CG), another 75 participants without fibromyalgia were selected among workers doing different jobs at Universidade de São Paulo.
The inclusion criteria were age between 35 and 60 years. All
eligible participants were evaluated until the desired sample
was completed and any sample losses were recorded. The participants from the fibromyalgia group (FG) were already under
medical treatment. The study was approved by the Ethics Committee of HC-FMUSP – Comissão para Análise de Projetos de
Pesquisa (Cappesq) – protocol number 210/01. All participants
gave written informed consent.
Instrument and proceedings
All participants from both groups were evaluated at a
single face-to-face interview regarding demographic data
(age, height, weight, gender, educational level, occupational
activity and medical diagnosis). Two physical therapists were
previously trained to read the questions in a standard format
and clarify any questions. Because of the participants’ limited
reading skills, especially in the FG, the researchers decided to
read the questionnaires along with them, avoiding problems in
the comprehension and completion of the questionnaires.
Quality of life was assessed by two questionnaires: the
FIQ16,17 and the SF-3618,19. The FIQ21 was used to assess the FG,
and it was translated to Portuguese and validated for the Brazilian population by Marques et al.22. The FIQ captures information on the following items: physical function, well-being,
missed work, job difficulty, pain, fatigue, morning stiffness,
morning tiredness, anxiety and depression. This questionnaire
has been widely used in research and has shown good sensitivity, validity and reliability. Scores range from 0 to 100, and
higher scores are associated with increased impact. As per
Bennett, the mean value is 50, and severely affected patients
have scores above 7023.
The SF-36 is a generic multidimensional instrument that
assesses eight scales: Physical Functioning, Role-Physical,
285
Ana Assumpção, Tatiana Pagano, Luciana A. Matsutani, Elizabeth A. G. Ferreira, Carlos A. B. Pereira, Amélia P. Marques
Table 1. Socio-demographic data of participants in the control group
and fibromyalgia group.
Demographic data
Age (years)
Weight (Kg)
Height (m)
Body Mass Index (Kg/cm2)
Gender
Female (%)
Male (%)
Educational level
More than 12 years
9 to 11 years
0 to 8 years
Occupation
Housekeeper
Retired
Other
Control group
n=75
Mean (SD)
47.8 (8.1)
64.6 (11.7)
1.6 (0.8)
25.2 (4.5)
Fibromyalgia group
n=75
Mean (SD)
47.0 (7.7)
69.1 (14.5)
1.6 (0.7)
26.8 (4.7)
73 (97%)
2 (3%)
73 (97%)
2 (3%)
57%
26%
17%
17%
37%
46%
31%
0%
69%
37%
14%
49%
Statistical analysis
Table 2. Data from the Fibromyalgia Impact Questionnaire (FIQ) in the
control group and fibromyalgia group.
FIQ variables
Physical function
Well-being
Missed work
Job difficulty
Pain
Fatigue
Morning tiredness
Morning stiffness
Anxiety
Depression
Control group
n=75
Mean (SD)
4.7 (5.0)
6.2 (1.8)
0 (0.0)
0.4 (1.0)
0.8 (1.7)
2.3 (2.8)
1.5 (2.6)
0.7 (1.6)
3.5 (3.1)
1.8 (2.3)
Fibromyalgia group
n=75
Mean (SD)
12.7 (5.9)
1.6 (1.9)
0.2 (1.0)
7.0 (2.5)
7. 6 (2.0)
7.6 (2.3)
7.1 (2.8)
6.6 (2.9)
7.7 (2.5)
6.0 (3.0)
p
<0.001*
<0.001*
<0.001*
0.04*
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
* Significantly different according to the Mann-Whitney Test.
Table 3. Data from the Medical Outcomes Study 36-item Short Form
Health Survey (SF-36) in the control group and fibromyalgia group.
Control group Fibromyalgia group
n=75
n=75
Mean (SD)
Mean (SD)
Physical functioning
86. 3 (15.8)
39.1 (23.2)
Role-physical
89.3 (24.0)
16.05 (30.1)
Bodily pain
79.3 (21.1)
30.1 (16.1)
General health
83.1 (18.3)
49.5 (25.9)
Vitality
70.2 (20.4)
36.3 (27.1)
Social functioning
84.2 (20.8)
46.6 (30.9)
Role-emotional
81.9 (35.1)
38.4 (40.4)
Mental health
77.3 (16.0)
48.75 (24.0)
SF-36 variables
* Significantly different according to the Mann-Whitney Test.
286
Bodily Pain, General Health, Vitality, Social Functioning,
Role-Emotional and Mental Health24. The score for each
scale varies from 0 to 100, and the higher the score the better the quality of life. Two final measures are used: Physical
Health and Mental Health17,25. A score based on the mean
of the eight scales is reported in order to compare it with
other questionnaires15. This partial score is used in the
present study. The SF-36 has been widely used in research
with excellent metric properties (sensitivity, validity and
reliability)17,19, and it has been translated and validated for
the Portuguese language26.
p
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
<0.001*
All variables were tested for normality using ShapiroWilk’s test. Only demographic data (age and BMI) had adherence to normality and were analyzed using a two-tailed
t-test for independent samples. The questionnaire variables
were analyzed with the non-parametric Mann-Whitney test.
The significance level adopted was 0.05. The discriminating
power of the questionnaires was assessed using the Receiver
Operating Characteristics (ROC) curve with its sensitivity,
specificity and area under the curve (AUC). For these analyses, we used the total FIQ score23 and the partial SF-36 score,
as used in a previous study15.
Results
Table 1 shows the patients’ demographic data. The groups
are similar for age, gender and body mass index (BMI). For educational level, the CG had more years of education than the FG,
which may be related to the socioeconomic status of patients
in a public hospital.
The results obtained with the FIQ showed significant differences (p<0.05) between the CG and FG for all variables
(Table 2). Table 3 shows the results obtained with the SF-36.
There were significant differences (p<0.05) between the CG
and FG for all variables.
Discriminating power of the questionnaires
The FIQ was applied to the FG and CG. In the ROC
analysis, the AUC was 0.985 (95% CI: 0.969 - 1.000). The cut-off
score of 36.76 for the FIQ gave a sensitivity of 96% and specificity of 96% (Figure 1).
The SF-36 was applied to both groups. In the ROC analysis, the AUC was 0.948 (95% CI: 0.917 - 0.980). The cut-off score
of 60.06 for the SF-36 gave a sensitivity of 88% and specificity of
89% (Figure 2).
0.8
0.6
Sensitivity
0.4
0.2
0.0
cut off: 36.76
Sensitivity: 0.9600
Specificity: 0.9600
AUC: 0.9856
0.0
0.2
0.4
0.6
0.8
1.0
1-Specificity
Cut-off that minimizes the distance between the curve and upper left corner.
0.6
0.4
0.2
Sensitivity
0.8
1.0
Figure 1. ROC curve for the Fibromyalgia Impact Questionnaire (FIQ).
cut off: -60.06
Sensitivity: 0.8800
Specificity: 0.8933
AUC: 0.9482
0.0
The main objective of the present study was to analyze the
discriminating power of two quality of life questionnaires. The
results showed that the FIQ and the SF-36 are efficient to measure quality of life and to discriminate between participants
with fibromyalgia and healthy participants, with excellent
metric properties. Currently, the improvement in the quality of
life of patients is one of the main objectives of treatments for
several health conditions16. However, it is difficult to measure
quality of life because it is related to a perception of living in
terms of health, socioeconomic, psychological and cultural
aspects1. In this sense, questionnaires are the most important
instruments to indirectly quantify quality of life17,19,23.
Several studies have reported a negative impact of fibromyalgia on quality of life10,11. The combination of physical
and mental symptoms interferes in different aspects of living
such as work, family and leisure13,27,28. As in other syndromes,
questionnaires are the most important form of assessing quality of life in order to compare patients with fibromyalgia and
other chronic diseases18,29 to healthy subjects30 and to quantify
the effectiveness of treatments20,25,31. Therefore, knowledge of
the metric properties of the questionnaires is essential to evaluate their efficacy.
In the present study, both questionnaires showed a significant
difference in quality of life between the FG and the CG (p<0.05)
in all aspects of the FIQ and SF-36. Studies in the literature report
similar results supporting the negative impact of fibromyalgia,
assessed with specific14,15,23 and generic3,10,11 instruments. For the
FIQ, the ROC curve analyses show an AUC of 0.985, a cut-off
score of 36.76, a sensitivity of 96%, and specificity of 96%. These
data demonstrate the excellent metric properties and the high
discriminating power of this questionnaire. The efficacy of the
FIQ has been demonstrated for comparisons with healthy subjects32, with other diseases33, when comparing subjects before
and after a treatment program23,31 and in prospective studies34.
The FIQ is certainly the most widely used quality of life instrument in studies on fibromyalgia, which can be attributed to
the fact that it is a specific questionnaire measuring all aspects
of the syndrome. According to Bennett23, the FIQ has credible
construct validity, reliable test-retest characteristics and good
sensitivity in demonstrating therapeutic change. In the same
study, the author noted that the average score for fibromyalgia
patients is around 50 and that severely affected patients usually score 70 or above. In our study, the cut-off score between
the CG and the FG was 36.76. In addition, the FIQ is short and
easy to apply, thus allowing brief and efficient records.
For the SF-36, the ROC analysis showed an AUC of 0.948,
a sensitivity of 89% and specificity of 89%. The SF-36 is the
most generic instrument used to assess quality of life17,24. For
1.0
Discussion
0.0
0.2
0.4
0.6
0.8
1.0
1-Specificity
Cut-off that minimizes the distance between the curve and upper left corner.
Figure 2. ROC curve for the Medical Outcomes Study 36-item Short-Form
Health Survey (SF-36).
fibromyalgia patients, this instrument have been widely used
for comparisons with other diseases10,11,35, other kinds of pain
and healthy subjects12,13,36. However, its discriminating properties in fibromyalgia were not described in the same way as they
were in psychiatric disorders37,38. Our results have shown that
the SF-36 was an excellent instrument for screening the FG
and CG, with a cut-off score of 60.06.
When compared, both instruments provided objective and
direct measures of quality of life and good discriminating power
287
to distinguish fibromyalgia patients from healthy individuals.
According to Contopoulos-Ioannidis et al.25, the data from quality of life and health surveys should be used more systematically
in randomized trials. In this sense, the qualities of both diseasespecific and generic instruments can be useful25. In fibromyalgia
patients, quality of life instruments can even detect subgroups
of the syndrome39,40. Oswald et al.39 showed that the SF-36 was
able to distinguish a psychological dysfunction subgroup among
fibromyalgia patients and that this subgroup did not differ in
terms of the physical well-being scores. The FIQ cluster analysis
also found two subgroups among fibromyalgia patients. Pain and
stiffness are universal symptoms for these patients but psychological distress was a feature only in some of them40.
In our study, the FIQ was the most sensitive and specific
instrument for assessing quality of life in individuals with fibromyalgia. Similar results have been reported by Garratt et
al.41 and Gliklich and Hilinski42, who compared the SF-36 with
specific instruments and observed a higher efficacy of the
specific questionnaire. However, the authors emphasized the
discriminating power of the SF-36. For chronic pain, Angst et
al.18 suggest that, although specific questionnaires are more
responsive than the SF-36, the generic one is recommended
for comprehension of the biological, psychological and social
effects of pain.
In the present study, the SF-36 had less discriminating power,
however it was efficient in identifying poor quality of life in individuals with fibromyalgia and in screening for fibromyalgia in
control subjects. Considering the WHO definition of quality of life,
social and psychological aspects are important when assessing
quality of life, therefore generic and specific questionnaires provide
complementary evaluations and should be applied in parallel43.
Conclusions
The participants with fibromyalgia presented a poorer quality
of life than the healthy participants, demonstrating that fibromyalgia interferes with quality of life. The FIQ presented the highest
sensitivity, specificity and AUC, with greater discriminating power,
however the SF-36 was also a good instrument for assessing quality of life in the participants with fibromyalgia and for discriminating participants with fibromyalgia from healthy participants.
We suggest that both instruments be used in parallel because the
SF-36 evaluates relevant aspects not evaluated in the FIQ.
Acknowledgements
This study was supported for two years (200-2002) by
Programa Institucional de Bolsas de Iniciação Científica,
Conselho Nacional de Desenvolvimento Científico e Tecnológico (PIBIC/CNPq) - No. 109187/2000-8, and by Fundação de
Amparo à Pesquisa do Estado de São Paulo (FAPESP) - Grant
No. 01/00484-0, Brazil.
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289
ISSN 1413-3555
©
ORIGINAL ARTICLE
Noninvasive ventilation in the immediate
postoperative of gastrojejunal derivation with
Roux-en-Y gastric bypass
Ventilação não invasiva no pós-operatório imediato de derivação gastrojejunal
com bypass em Y de Roux
Kivânia C. Pessoa1, Gutemberg F. Araújo1, Alcimar N. Pinheiro1, Maria R. S. Ramos1, Sandra C. Maia2
Abstract
Background: Morbidly obese patients develop more atelectasis during general anesthesia than non-obese ones, and these atelectasis
persist for 24 hours after the end of the surgical procedure. Objectives: This study evaluated the effect of noninvasive ventilation with two
pressure levels (BiPAP) in the pulmonary function, incidence of immediate postoperative pulmonary complications and the development of
anastomotic dehiscence in morbid obese patients submitted to gastrojejunal derivation in Roux-en-Y (RYGB). Methods: It was an analytical
and clinical study involving patients who were submitted to RYGB, had a body mass index (BMI) of at least 35 kg/cm², and were randomly
chosen to receive BiPAP (experimental group) or standard oxygen therapy (control group), in the first four hours of the post-operation
period. Patients with chronic or acute pulmonary disease were not included, and neither were the ones who needed invasive mechanical
ventilation by the end of the surgery. Vital capacity, maximal inspiratory and expiratory pressure, and arterial blood gases were measured
in the preoperative and in the first postoperative. Chest X-ray was performed in the third postoperative. Results: Eighteen patients were
chosen for the study: ten received BiPAP and eight received standard oxygen therapy. The study group had better partial oxygen pressure
and lower maximal expiratory pressure levels in the postoperative state than the control group. Anastomotic dehiscence was not observed
in any group. There was no significant difference between the control group and the study group relating to the loss of vital capacity,
maximal inspiratory pressure in the postoperative period or the incidence of atelectasis. Conclusion: The BiPAP in the postoperative period
of gastroplasty was useful to improve oxygenation and did not increase the incidence of anastomotic dehiscence.
Article registered in the Australian New Zealand Clinical Trials Registry under the number ACTRN12609000979257.
Key words: morbid obesity; oxygenation; noninvasive ventilation.
Resumo
Contextualização: Pacientes obesos mórbidos desenvolvem mais atelectasias durante a anestesia geral que pacientes não obesos, e elas
persistem 24 horas após o término do procedimento cirúrgico. Objetivos: Este estudo avaliou o efeito da ventilação não invasiva com dois
níveis pressóricos (BiPAP) na função pulmonar, a incidência de complicações pulmonares no pós-operatório imediato e o desenvolvimento
de deiscência de anastomoses em pacientes obesos mórbidos submetidos a derivação gastrojejunal em Y-de-Roux (RYGB). Métodos:
Estudo analítico, ensaio clínico envolvendo pacientes submetidos à RYGB, com índice de massa corpórea (IMC) de pelo menos 35 kg/cm2,
randomizados para receber BiPAP (estudo) ou terapia padrão com oxigênio (controle), nas primeiras quatro horas de pós-operatório. Não foram
incluídos pacientes com doença pulmonar aguda ou crônica ou que necessitaram de ventilação mecânica invasiva ao término da cirurgia.
Capacidade vital, pressão inspiratória e expiratória máxima, gasometria arterial foram mensurados no pré-operatório e no 1º pós-operatório;
radiografia de tórax foi realizada no 3º pós-operatório. Resultados: Dezoito pacientes foram incluídos no estudo, 10 receberam BiPAP e 8 terapia
padrão com oxigênio. O grupo do estudo teve melhor pressão parcial de oxigênio e menor pressão expiratória máxima no pós-operatório que o
controle. Não se observou deiscência de anastomose em nenhum grupo. Não houve diferença significante entre o grupo controle e o do estudo
com relação à perda da capacidade vital, pressão inspiratória máxima no pós-operatório e incidência de atelectasias. Conclusão: O BiPAP no
pós-operatório de gastroplastia foi útil para melhorar a oxigenação, não aumentando a incidência de deiscência de anastomose.
Artigo registrado no Australian New Zealand Clinical Trials Registry sob o número ACTRN12609000979257.
Palavras-chave: obesidade mórbida; oxigenação; ventilação não-invasiva.
1
Universidade Federal do Maranhão (UFMA), São Luis (MA), Brazil
2
Centro Universitário do Maranhão (CEUMA), São Luís, (MA), Brazil
Correspondece to: Kivania Carla Pessoa, Avenida dos Holandeses, 02, Quadra 02, Bairro Calhau, CEP 65071-380, São Luis (MA), Brazil, e-mail: [email protected]
290
Noninvasive ventilation in bariatric surgery
Introduction
Methods
Mortality in bariatric surgery is more common in patients
with respiratory comorbidities. Approximately 50% of the
patients in need of such surgery have associated chronic
respiratory comorbidities, such as Obstructive Sleep Apnea
(OSA), Obesity Hypoventilation Syndrome (OHS) and Chronic
Obstructive Pulmonary Disease (COPD)1. The OSA is a common condition in morbidly obese patients, with prevalence
ranging from 12 to 78%, however most patients are not diagnosed before the surgery2. Consequently, the combination
of preexisting OSA and laparotomy significantly increases
the morbidity and mortality of obese patients by respiratory
complications3.
The acute respiratory insufficiency is a frequent complication after abdominal surgery and is associated with
the increase in morbidity and mortality4. General anesthesia and some types of surgery that affect the abdominal
or thoracic muscles cause a negative effect on pulmonary
mechanics by altering gas exchange and favoring the emergence of pulmonary complications in the immediate postoperative (PO) period5. Pulmonary atelectasis is the main
cause of these negative effects and can occur in 85 to 90% of
healthy adult subjects during the first minutes after the anesthesia. Morbidly obese patients develop more atelectasis
during general anesthesia than non-obese patients, and this
condition persists for 24 hours after the end of the surgical
procedure6.
Oxygen administration and the use of incentive spirometers are efficient in the treatment of the majority of hypoxemia cases. Despite this, respiratory insufficiency might
occur in the PO period of abdominal surgery, and so the performance of tracheal intubation and mechanical ventilation
is necessary in 8 to 10% of the patients7. Noninvasive ventilation (NIV) is considered the therapy of choice for patients
with COPD exacerbation, but has also been used successfully in patients with hypoxemic respiratory insufficiency
of several sources, including PO abdominal surgeries4,8,9. In
the PO period, the use of continuous positive airway pressure (CPAP) improves the gas exchange in obese patients
without compromising the integrity of the upper gastrointestinal anastomosis10.
The NIV uses two levels of pressure (BiPAP) and has
shown itself to be effective in preventing respiratory insufficiency in morbidly obese subjects if performed within 48
hours of extubation11. The effects of BiPAP on pulmonary
function of the patients were assessed, and so was the incidence of pulmonary complications and dehiscence of
gastrojejunal anastomosis in the PO period of gastric derivation in RYGB.
An analytical study was performed, consisting of a
clinical trial with 20 patients at the University Hospital of Presidente Dutra, São Luis (MA), Brazil, from July
2005 to August 2006. A convenience sample was used
and the selected patients were over 18 years old and had
body mass index (BMI) equal or superior to 35 kg/m2.
The participants were submitted to a gastrojejunal derivation
with Roux-en-Y gastric bypass in the Bariatric Surgery Service
of the hospital. Patients with chronic or acute pulmonary disease were not included, and neither were the ones who needed
invasive mechanical ventilation by the end of the surgery. The
patients were randomly divided into two groups by a draw using sealed envelopes. The first group (experimental) received
NIV four hours into the immediate PO period, right after the
extubation, and while they were at the post-anesthetic recovery room. The second group (control) received oxygen support
after the extubation, with a flow of 4 L per minute through
a nasal catheter (type glasses), as described in the hospital
protocol.
The pulmonary function test and the chest X-ray were
performed in the preoperative period during evaluation by a
pulmonologist to determine the surgical risk. According to the
American Thoracic Society guidelines, obstructive pulmonary
disease was defined as a reduction in the ratio between forced
expiratory volume in the first second and forced vital capacity (FEV1/FVC), and restrictive ventilatory defect was defined
as a reduction of the FVC with an increased ratio FEV1/FVC
(>85-90%). The degree of gravity of the respiratory disorders
was based on the predicted FEV1 percentage: low when
FEV1>70%, moderate when 60FEV169, moderately high
when 50FEV159, high when 35FEV149 and very high
when FEV1<35%12.
Associated pulmonary diseases were considered absent
when test results for pulmonary function and chest X-ray were
normal and when there were no respiratory symptoms, such as
cough, mucus production, dyspnea or bronchospasm.
The procedures performed in both groups were: quantification of the risk of pulmonary complications in the PO period by
the Torrington & Henderson scale, and measurement of the vital capacity (VC), maximal inspiratory pressure (MIP), maximal
expiratory pressure (MEP) and arterial blood gas (ABG). These
evaluations were performed preoperatively and during the first
PO period. The preoperative period was considered as the day
before the surgery, and first PO period as the first day after the
surgery. The same examiner performed all the measurements.
As in other studies13-16, the VC was measured by use of an
analogue ventilometer (Ohmeda Respirometer®, model RM
121, Japan). During this procedure, the patients sat down
291
with their feet supported and nostrils occluded by a nose clip.
Three measurements were performed from the total lung capacity (TLC) to the residual volume (RV), with an interval of
one minute between them and adopting the greatest measure
as the result.
The MIP and the MEP were measured by use of a manovacuometer (Suporte®, class B, Brazil) with scale varying from
0 to 159 cmH2O, connected to the patients through a hard
plastic mouthpiece. The MIP was obtained through the RV
value and the MEP through the TLC value, and was measured
at all times with the patients in the sitting position with their
nostrils occluded by a nose clip. A small hole was made in the
mouthpiece to prevent glottal closure during the procedure
and the patients’ cheeks were held by one of their hands. Each
effort was sustained for at least one second. The procedure was
repeated three to five times, with intervals of one minute, until
three values with a difference between them of less than 10%
were obtained. The greatest measure was adopted as the result,
except for the last procedure17. Reference equations for maximal respiratory pressures proposed by Pereira18 were used.
The ABG was collected from the radial artery during the
preoperative and first PO period, using a 1 ml syringe lubricated with sodium heparin and needle size of 4.5 x 13 mm. The
patient was in the supine position, breathing ambient air. The
examination was performed using a blood gas analyzer (ABL
700® Series, Radiometer Medical). The variables assessed were
partial pressure of oxygen in arterial blood (PaO2) and oxyhemoglobin saturation of arterial blood (SaO2)19.
The NIV was performed by a noninvasive ventilator (BiPAP
synchrony ST®, Respironics, Murrysville, USA), which was set in
the spontaneous-timed (S-T) mode. Inspiratory positive airway
pressure (IPAP) and expiratory positive airway pressure (EPAP)
were adjusted to 12 cmH2O20 and 8 cmH2O21, respectively. The
inspiratory time was 0.8 seconds, the breathing frequency was
8 bpm, the rise time was 1 second, the ramp was 0.5 cmH2O
and the oxygen flow rate was 4 L per minute. A nasal mask with
headgear was used as a patient-ventilator interface.
All the participants were submitted to daily respiratory
physical therapy in the preoperative and PO periods under
the guidance of the physical therapist, who had no knowledge
about which patient had used the NIV. In the preoperative period, the subjects were guided in terms of the surgical incision,
importance of coughing, early ambulation and respiratory patterns. Respiratory physical therapy was initiated in the first PO
period and consisted of the performance of respiratory exercises associated to free global active exercises, assisted cough,
incentive spirometry and ambulation.
The surgeon in charge assessed the integrity of the gastrojejunal anastomosis before starting a meal and during the
second PO period. The methylene blue test was used for the
292
procedure, as follows: 5 ml of the solution were diluted into
100 ml of saline solution; the solution was then taken orally
in portions of 20 ml every 20 minutes until the solution was
finished. The result was assessed by the abdominal cavity drain
tube, which was placed next to the gastrojejunal anastomosis22.
The chest X-ray was performed during the third PO period. For
pain control in the PO period, Tramadol 100 mg 12/12h and
Dipirona 2 g 6/6h were provided via intravenous injection.
The study was approved by the Research Ethics Committee of
the University Hospital of Presidente Dutra, Universidade Federal
do Maranhão (UFMA), São Luís (MA), Brazil (Record: 162/05),
under the number 104/06, following the provisions of resolution
196/06. The informed consent was obtained from all participants.
The software used for statistical analyses was Bioestat 3.023.
The quantitative variables were presented in terms of means
and standard deviations, and qualitative variables in terms of
frequencies and percentages. The Shapiro-Wilk test was used
to test the normality of the variables. Differences between the
groups were assessed by the Student’s t-test for independent
samples ((normally distributed variables), or by the MannWhittney test (non-normal variables). The significance level of
5% was adopted.
Results
Twenty patients participated in the study: 18 women (90%)
and 2 men (10%). Two of the selected patients were excluded
from the study: one patient did not accept noninvasive ventilatory support in the immediate PO period, and one patient was
not able to perform the evaluation during the first PO period. Of
the 18 patients included, 10 were randomized to the experimental group (EG) and 8 to the control group (CG). The demographic
variables, vital capacity values, respiratory pressures and arterial
blood gases in the preoperative period were similar between the
groups (Table 1). Two patients in the EG were ex-smokers and
had stopped smoking about 10 years ago. In the CG, there was
one ex-smoker, which had not smoked for a year.
The pulmonary function test demonstrated the following
means and percentages of the predicted values, respectivelly:
FVC 2.980.56 L, 95.0516.01%; FEV1 2.460.51 L, 94.8915.05%;
FEV1/FVC 82.626.48%, 99.267.43%. These data were within
the established limits based on age, gender and height. All the
patients demonstrated normal chest X-rays in the preoperative
period, with low risk of developing pulmonary complications in
the PO period, according to the Torrington & Henderson scale.
Table 2 presents the partial pressure of oxygen, the oxyhemoglobin saturation, and the loss of vital capacity, respiratory
pressures and PaO2 for each group in the first PO period. No
statistically significant difference was detected between the
groups on the losses of VC and MIP (p=0.62 and p=0.53, respectively). The EG showed a greater loss of MEP (p=0.01), whereas
the CG showed lower PaO2 and SaO2 values (p=0.04 and p=0.02,
respectively) (Table 2).
Abdominal distension and/or anastomotic dehiscence
were not observed among the participants of this study. Three
patients in the CG demonstrated radiological alterations in
the chest X-ray performed in the third PO period: two patients
demonstrated right lower lobe atelectasis, and one patient
demonstrated bilateral pneumoperitoneum. One patient in the
EG demonstrated right lower lobe atelectasis. All the patients
remained in the hospital for five days.
Discussion
Obesity might cause damages to pulmonary function
due to its effects on mechanical ventilation, air resistance,
lung volumes and respiratory mucles24. This condition is
considered an independent risk factor for PO pulmonary
complications25. The prophylactic use of the NIV during
the PO period of lung resections and gastroplasty has been
shown to be effective in improving gas exchange and pulmonary function, when compared to treatments using nothing
but oxygen8.
A convenience sample was recruited in the present study,
including all the subjects submitted to the gastrojejunal derivation in RYGB during the period in which the study was performed. The sample size was similar to that of other studies
that also used a convenience sample to evaluate surgical procedures or procedures applied postoperatively in patients with
morbid obesity6,20,26-29.
In this study, the Torrington & Henderson scale was used
to estimate the risks of pulmonary complications in the PO
period. This scale was validated for use in a Brazilian population in 2000, and it was shown to be an appropriate measure to
identify patients with low, medium or high risks of pulmonary
complications, or death by pulmonary cause, during the PO period of elective general surgery31. All the patients demonstrated
low risks of pulmonary complications in the PO period.
Previous studies have shown that the prophylactic use of
BiPAP in the first 12 to 24 hours following a gastric bypass
surgery in morbidly obese patients significantly increases the
pulmonary function, when compared to a control group20,32.
In the present study, BiPAP was applied to patients submitted to gastroplasty four hours into the immediate PO period,
while they were in the post-anesthetic recovery room. The
measurement of the pulmonary function was performed 24
hours later. No statistically significant difference was detected
between the group that received BiPAP and the control group
Table 1. Patient demographic variables, vital capacity, respiratory
pressures and arterial blood gases in the preoperative period.
Variables
NIV (n=10)
Control (n=8)
p value
Age (years)
36.710.7
43.17.5
0.13
Gender (M/F)
2/8
0/8
__
BMI (kg/cm2)
48.58.2
46.35.7
0.50
3.037864
2.576492
0.14
MIP (cmH2O)
-110.521.7
-102.713.7
0.33
MEP (cmH2O)
VC (ml)
102.328.1
92.723.4
0.39
pH
7.410.02
7.420.01
0.44
PCO2 (mmHg)
38.23
38.33
0.94
PaO2 (mmHg)
77.037.32
73.997.66
0.46
HCO3 (mEq/L)
24.11.9
24.81.6
0.38
Data presented as mean and standard deviation. BMI=body mass index; VC=vital
capacity; MIP=maximal inspiratory pressure; MEP=maximal expiratory pressure;
PaCO2=partial pressure of carbon dioxide in arterial blood; PaO2=partial pressure of
oxygen in arterial blood; HCO3=bicarbonate concentration in arterial blood.
Table 2. Partial pressure of oxygen and oxyhemoglobin saturation in
the 1st postoperative, and loss of vital capacity, respiratory pressures
and partial pressure of oxygen in the postoperative period.
Variable
Group NIV
Control Group
p value
PaO2 ( mmHg) 1st PO
71.66.69
64.036.1
0.04
95.51.6
93.41.8
0.02
VC (ml)
32.289.81
30.039.15
0.62
st
SaO2 (%) 1 PO
MEP (cmH2O)
39.3215.24
22.9310.20
0.01
MIP (cmH2O)
32.874.87
31.7810.97
0.53
Loss of PaO2 (%)
6.963.52
13.315.30
0.02
Data presented as mean and standard deviation; PaO2=partial pressure of oxygen in arterial blood; SaO2=oxyhemoglobin saturation in arterial blood; MEP=maximal expiratory
pressure; MIP=maximal inspiratory pressure; VC=vital capacity. P>0.05.
in terms of VC reduction during the first PO period. Joris et
al.32 and Ebeo et al.20 used BiPAP during 12 to 24 hours, in
periods from 3 to 4 hours. They observed an increase in the
FVC and FEV1 from 24 to 30% in the group that used NIV
in comparison to the control group during the measurement
of the pulmonary function in the PO period. The absence of
difference observed in the present study can be justified by
the use of NIV for a smaller amount of time, as the subjects
remained in the post-anesthetic recovery room for about 5
hours, and were then sent to a ward. Joris et al.32 reported a
dose-dependent effect of the IPAP in restrictive lung disease,
as the group that used BiPAP of 8/4 cmH2O did not demonstrate a statistically significant reduction in disease intensity
when compared to the control group. Therefore, this effect
would be considered dependent of dosage and time.
The dysfunction of respiratory muscles after upper abdominal surgery (UAS) is well established, as are the reductions in
293
MIP and MEP values after laparotomy. This is due to several
factors such as irritation and inflammation, or trauma next to
the diaphragm, which lead to local mechanical failure, reflex
inhibition and pain33. Few studies have evaluated the alterations in respiratory pressures of morbidly obese patients during the PO period of UAS. Paisani, Chiavegato and Faresin13
found a 51% reduction in the mean MIP and a 39% reduction in
the mean MEP during the first day of the PO period in patients
submitted to Fobi-Capella gastroplasty surgery. In the present
study, the group that used the NIV (EG) demonstrated a greater
loss of expiratory pressure in the preoperative period than the
group that did not use the NIV (CG). No statistically significant
difference was detected between the groups in terms of the
inspiratory pressure.
When analyzing the effects of NIV on the activity of
inspiratory muscles in obese patients, Pankow et al.34 found
a 46% reduction in diaphragm’s activity with the use of the
BiPAP. The authors concluded that the assisted NIV can cause
partial inactivation of the respiratory muscles in patients
with severe obesity34. Cambonio et al.35 assessed the effects
of CPAP in children with severe acute viral bronchiolitis
by monitoring the pressure x time product of the gastric
pressure (GP) as an indicator of expiratory muscle activity.
The authors concluded that the reduction in the GP wave
could be related to alterations in the breathing pattern after
the use of CPAP, such as the increase in expiratory time,
which favors passive expiration with no expiratory muscle
activity. The present study did not assess the respiratory
muscle activity during the use of NIV. However, the greater
loss of MEP in the EG might have been a consequence of the
inactivation of the muscles due to ventilatory assistance.
Considering expiratory muscles, this inactivation persisted
for 24 hours after the NIV.
With respect to oxygenation, patients who used NIV demonstrated greater PaO2 and SaO2 during the PO period than
those who did not use NIV. This indicates better oxygenation
levels with the use of NIV, probably due to an increase in
functional residual capacity (FRC). Several ventilation strategies have been assessed for their effect on improving arterial
oxygenation during the intraoperative period in patients with
morbid obesity21. The use of CPAP restores the FRC to preoperative levels, improving PO oxygenation3.
The ideal levels of IPAP and EPAP for obese patients submitted to abdominal surgery are not yet established. Previous
studies20,32 suggest that an IPAP of 12 cmH2O promotes lung inflation and an EPAP of 4 cmH2O prevents alveolar collapse at the
end of expiration. Erlandsson et al.36 analyzed the optimization
of the positive end-expiratory pressure (PEEP) using electrical
impedance tomography during laparoscopic gastric bypass. The
authors concluded that PEEP levels of around 15 cmH2O were
294
necessary to prevent lung collapse and to improve gas exchange
in morbidly obese patients. Chalhoub et al.21 assessed the effects
of the vital capacity maneuver (VCM) in morbidly obese subjects
submitted to open bariatric surgery and found that PEEP levels
of 8 cmH2O associated to VCM were sufficient to significantly
improve arterial oxygenation and to avoid hemodynamic instability. The levels of IPAP and EPAP used in the present study were
based on these previous findings.
The use of CPAP during the PO period potentially increases
the risk of anastomotic dehiscence as a result of the increase in
air pressurization in the stomach and proximal anastomosis3.
However, anastomotic dehiscence was not observed in any participant of this study, suggesting that the procedure can be safely
applied during the PO period of upper abdominal surgery, given
that the appropriate pressures are used. The recommended lung
inflation pressure is 20 cmH2O or lower10,27,29 , in order to avoid
the opening of the lower esophageal sphincter and consequent
gastric insufflation, regurgitation and bronchoaspiration. Huerta
et al.3 assessed the safety and efficiency of CPAP after gatroplasty
and concluded that it is safe for treating patients with risks of
PO apnea. However, Jensen at al.32 suggested that in patients
with OSA the use of CPAP/BiPAP during the PO period of laparoscopic gastrojejunal derivation in RYGB, and also its previous
use, can be safely suppressed once the patients are monitored
and their pulmonary function is optimized by intensive incentive spirometry and early ambulation.
Two patients (onein the CG and one in the EG) demonstrated segmental atelectasis in the third PO period. The incidence of atelectasis during the early PO period of bariatric
surgery is known to be underestimated when the diagnosis
is performed by chest X-ray1. Chest tomography could not be
used in the present study to diagnose atelectasis in the PO period because the capacity of the service’s tomograph was 150
kg. The NIV has been successfully used to correct atelectasis in
the PO period and thus restore the FRC, prevent the collapse
of upper airways and increase the lung compilance38. On the
other hand, inpatient treatment through breathing exercises
has been shown to improve respiratory muscle strength, oxygenation, cough mechanisms, chest mobility and pulmonary
ventilation. These exercises also appear to decrease the respiratory work and prevent pulmonary complications in the PO
period39. In the present study, there was no difference in the
incidence of atelectasis between the groups. This fact can be
a consequence of the sample size or the period of application
of the NIV.
It is concluded that the use of NIV in the PO period of gastrojejunal derivation with Roux-en-Y gastric bypass is effective
in improving oxygenation, without increasing the incidence of
fistulas or anastomotic dehiscence, once the appropriate levels
of inflation pressure are applied.
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ISSN 1413-3555
©
ORIGINAL ARTICLE
Relationship between quadriceps angle (Q) and
plantar pressure distribution in football players
Relação entre o ângulo quadriciptal (ÂQ) e a distribuição da pressão plantar
em jogadores de futebol
Abstract
Objectives: To determine whether there is an association between the Q-angle (Q) and the distribution of plantar pressure in football
players, and to compare the characteristics of these athletes with non-practitioners of this sport. Methods: 121 male participants were
selected: 50 football practitioners (FP) and 71 non-practitioners (NP). We concurrently evaluated the Q-angle and the plantar pressure
through the software of postural assessment (SPA) and the F-Mat System, respectively. To verify the correlation between the Q-angle
and peak pressure values in four segments of the foot (medial and lateral forefoot, medium-foot and hind-foot), the Pearson coefficient
(r) for parametric analysis was used. The independent t-test was used to compare these variables between the groups. Data normality
was verified by the skewness values, adopting a significance level of 5%. Results: A negative and weak correlation was found (r=-0.32)
between the Q-angle and the plantar pressure in the right medium-foot. The groups differed with regards to the right Q-angle (11.36° in
FP versus 13.80° in NP) and the left Q-angle (11.03° in FP versus 13.96° in NP). Plantar pressure was also different between the groups,
with FP showing higher mean values for the right side and for the left side of the forefoot (0.77 kg/cm2 in FP versus 0.63 kg/cm2 in NP,
and 0.65 kg/cm2 in FP versus 0.54 kg/cm2 in NP, respectively). However, mean peak pressure values for the left medium-foot were higher
among NP (0.37 kg/cm2 in FP versus 0.46 kg/cm2 in NP). Conclusions: There was no evidence of an association between the Q-angle
and the distribution of plantar pressure in FP. The athletes showed reduced Q-angle values and higher mean peak pressure values for
the right and left aspects of the forefoot, suggesting a varus malalignment and a supine distribution of plantar bases.
Key words: football; Q-angle; plantar pressure; baropodometry; photogrammetry.
Resumo
Objetivos: Verificar possível associação entre ângulo quadriciptal (ÂQ) e distribuição de pressão plantar em jogadores de futebol,
comparando-os com indivíduos não praticantes da modalidade. Métodos: Cento e vinte e um participantes do sexo masculino foram
selecionados: 50 jogadores de futebol (JF) e 71 sujeitos para o grupo controle (GC). Avaliaram-se concomitantemente o ÂQ, por meio
do Software para Avaliação Postural (SAPO), e a pressão plantar, pela plataforma F-Scan/F-Mat System. Para verificar correlação
entre o ÂQ e os valores de picos de pressão em quatro segmentos do pé (antepé medial e lateral, médio-pé e retropé), utilizou-se
o Coeficiente de Pearson (r) para análises paramétricas. O teste t independente foi empregado para comparar isoladamente essas
mesmas variáveis entre os grupos. A normalidade dos dados foi verificada pelos valores de skewness, adotando nível de significância
de 5%. Resultados: Encontrou-se correlação negativa e fraca (r=-0,32) somente entre ÂQ e médio-pé direito. Os grupos diferiram
quanto ao ÂQ bilateralmente, sendo que o grupo JF teve média de 11,36º, e GC, de 13,80º à direita e de 11,03º contra 13,96º à
esquerda, respectivamente. Em relação à pressão plantar, o JF teve maior média de força nas faces laterais do antepé direito (0,77
contra 0,63 kg/cm2) e esquerdo (0,65 e 0,54 kg/cm2), enquanto o GC apresentou maior pico de pressão no médio-pé esquerdo
(JF: 0,37 e GC: 0,46 kg/cm2). Conclusões: Não houve relação entre os valores de ÂQ na distribuição da pressão plantar nos jogadores
de futebol. Os atletas apresentaram, porém, ÂQ diminuído e maiores picos de pressão nas faces laterais de ambos os pés, o que
sugere alinhamento em varo dos joelhos e distribuição supinada das bases plantares.
Palavras-chave: futebol; ângulo Q; pressão plantar; baropodometria; fotogrametria.
Laboratory of Biomechanics, Universidade Católica de Brasília (UCB), Brasília (DF), Brazil
Correspondance to: Rafael Gonçalves Braz, QND 07 casa 25, CEP 72120-070, Taguatinga (DF), Brazil, e-mail: [email protected]
296
Relationship between Q-angle and plantar pressure in football players.
Introduction
Football is one of the most popular sports in the world and
it is characterized by short duration and high intensity motor
actions, which are alternated with periods of longer duration
and lower intensity motor actions1. Despite the health benefits associated with football, its regular practice increases the
likelihood of mechanical instabilities due to excessive training
load and competitions, which can result in changes in both
muscular and articular systems2.
The concept of overtraining is applied to high level athletes and reflects an imbalance between stress and recovery,
causing greater vulnerability to physical injuries3. According
to Fuller et al.4, these injuries should be classified according
to their site, laterality, type, mechanism of injury and recurrence. Within this context, a traumatic injury refers to an
identifiable specific event; however, overtraining injuries
caused by repetitive microtraumas are not linked to a single
apparent factor.
Even though sedentarism is a key determinant to changes
in posture, repetition of the sport gesture and the biotype of
the football athlete contribute to the development of sportspecific biomechanical changes5. The knee joint is often
affected, with patellofemoral dysfunction being the most
common problem6. One factor that favors the onset of pain
and/or instability is the patellar malalignment in relation to
the femur. This malalignment is measured by the quadriciptal
angle (Q-angle)7, which is the acute angle formed by imaginary lines drawn from the anterior superior iliac spine to the
center of the patella, and from the tibial tuberosity to the
center of the patella8.
There is no consensus on what an ideal Q-angle value
would be, but it is known that men show smaller Q-angle values than women due to their higher mean height and smaller
pelvic width8-10. According to Hamill and Knutzen10, Q-angles
higher than 15 degrees are considered a genu valgum, whereas
values lower than 10 degrees indicate a genu varum.Schweitzer
and Miqüelluti11 analyzed the postural pattern of young football players and found changes such as flexed knees and genu
varum, which are due to the repetitive use of flexor and abductor muscles during kicking. One study with individuals 12 to 17
years old found that competitive football favors genu varum in
male athletes when compared to non-athletes. It is assumed
that repetitive microtraumas over the intern condyles due to
training favor varism12.
Bipedal postural control relies on sensory and motor information that is controlled by the central nervous system. Corrections in the vertical body axis in the upright posture induce
slight and constant oscillations that have an important role in
distributing plantar pressure13. The position of osseous parts of
the lower limbs is controlled by the tonus of the muscles to
which they are attached. However, joints also move around
their own mechanical axes, causing tonic reactions and modifying pelvic and lower limb alignment. Thus, variations occurring at the feet may influence superior segments when load is
received, and vice versa14.
Structural changes in the knee joint and their influence on
plantar pressure distribution can contribute to an increased
incidence of overtraining injuries. Thus, the identification
of overload areas that are capable to induce microtrauma or
mechanical dysfunctions is relevant for athletes, as it provides
information that is important for the maintenance of their
physical integrity and is also useful for preventive research.
One of the techniques used to assess the pressure exerted at
the foot during standing is baropodometry, which quantifies
the antero-posterior and lateral oscillations while the subject
stands on a force platform14.
The aims of this study were to verify the existence of an association between the Q-angle and the distribution of plantar
pressure in football players, and to compare the characteristics of these athletes with non practitioners of this sport.
The specific aims were to compare Q-angle values between
football practitioners and non practitioners, and to compare
plantar pressure values for different foot segments between
the groups.
Methods
Design
A cross sectional study was undertaken.
Sample
A convenience sample of 121 male subjects 18 to 30 years
old was selected: 50 football practitioners (FP) and 71 non
practitioners (NP), totalizing 242 lower limbs. Subjects were
not considered for inclusion if they presented with any of the
following: subjects who were goal keepers (due to the specific
requirements of this position) or amateur athletes; had suffered a recent traumatic/orthopedic injury to the lower limb
that would make the assessment difficult to perform; had congenital malformation of the lower limbs; had sensory alteration
in the feet; had body mass index (BMI) equal or superior to
31,6 kg/m2 or inferior to 18.8 kg/m2 (these limits were based on
the findings of Pontes, Souza and Lima15).
The FP group was formed by professional players and
university academics from Distrito Federal, Brazil. Professional players were recruited from Brazlândia Esporte Clube
297
and Esporte Clube Dom Pedro II. University academics were
recruited from Universidade Católica de Brasília (UCB), Faculdade Santa Terezinha (FAST) and União Pioneira de Integração Social (UPIS). The NP group was formed by academics
and employees from UCB. Participants in the FP group practiced football-related activities on a regular basis; i.e., they had
a minimum of three years of practice and enjoyed financial
benefits (salary or scholarship) related to sport. Participants
in the NP group were sedentary or practiced another nonprofessional sport modality.
After a brief explanation of the study, all participants signed
an informed consent form, which was written according to the
196/96 resolution of the Conselho Nacional de Saúde, Brazil.
The study was approved by the Research Ethics Committee of
UCB (CEP/UCB nº 177/2007).
A
Environmental assessment
This study was carried out in the Laboratory of Biomechanics of UCB between December 2007 and March 2008. In
order to prepare the environment for photogrammetry, two
plumb lines (parallel to each other and 100 cm apart) were
fixed on the ceiling. Each line was marked with two styrofoam
balls with 4.5 cm diameter and 50 cm apart. Superior marks
were placed 150 cm from the floor (thus, inferior marks were
100 cm away from the floor). A pressure sensing floor mat
(F-Scan/F-Mat System®, model 3100, version 4.21, Tekscan Inc,
South Boston) was positioned between the two plumb lines,
and the system was connected to a computer (Figure 1-A).
The evaluation room was equipped with a table, two computers, a properly calibrated weighing scale (Filizola, max
150 kg), a wall-mounted stadiometer (Seca, precision 0.1
cm) and a digital camera (Sony DSC-W35, 7,2 megapixels)
mounted on a tripod (Manfrotto, model 3047). The tripod
was placed 300 cm away from the plumb lines and the camera
lens was positioned at half of the participant’s height16.
Procedure and data collection
B
Figure 1. Environment for assessment and capture of previous view
image, concomitant with plantar pressure.
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Participants were instructed to wear only shorts to facilitate the placing of anatomical markers for Q-angle measurement and to avoid any interference with the measurement of
total body mass (TBM). First, participants’ TBM and height (H)
were measured. BMI was calculated by the software of postural
assessment (SPA, version 0.68, updated in July 2007) through
the formula BMI (kg/m2) = TBM (kg) / H2 (m). To screen for
any sensory alteration in the feet (one of the exclusion criteria),
sensation was evaluated by an estesiometer (0.2 g SemmesWeinstein monofilament).
Then, for the assessment of Q-angle values, participants
were asked to lay supine with the quadriceps muscle in a
relaxed position and markers were placed on the center of
the anterior aspect of the patella, tibial tuberosity and the
anterior superior iliac spine17. Palpation skills were used for
the correct placement of these markers, which followed the
standards established by France and Nester17, Hoppenfeld18
and Kendall, McCreary and Provance19. Styrofoam balls similar to those previously described were used to identify the
anatomical structures relevant for the measurement of the
right and left Q-angles. The Q-angle value was determined by
digital photogrammetry, with the software validated by Braz,
Goes and Carvalho16.
The participant was then instructed to stand between the
two plumb lines, with both feet positioned on the pressure
sensing floor mat. This positioning allowed simultaneous image
caption of participant’s anterior view and the static plantar
pressure distribution (Figure 1-B). If necessary, the examiner
corrected any rotation of the hip. The second toe, considered
the feet midline and the axis of the tibiotarsal joint20,21, was
positioned in the same direction of the ipsilateral calcaneus
without losing its contact with the platform. The second toe
was also positioned perpendicular to the frontal plane not to
influence Q-angle measurement22. As soon as the plantar pressure assessment began, an anterior view photograph was taken
for the Q-angle analysis by SPA16. After the image caption, the
participant was instructed to remain still on the platform for
10 seconds for the plantar pressure analysis23. The variables
considered in the static pressure analysis were total peak
pressure (kg/cm2), right and left peak pressures (kg/cm2) and
force distribution in medial and lateral areas of the forefoot,
medium-foot and hind-foot in each lower limb. Thus, four areas of interest were selected for the analysis of bilateral plantar
pressure (Figure 2): medial region of the forefoot divided by the
second toe line (D1 and E1); lateral region of the forefoot (D2 e
E2); medium-foot (D3 e E3); calcaneus (D4 e E4).
Statistical and data analysis
Statistical tests were selected as follows: (a) Student-t test
for independent samples was used to compare the groups
with respect to age, BMI, bilateral Q-angle value and bilateral
plantar pressure in the four areas of interest; b) Pearson correlation coefficient was used to assess the correlation between
the Q-angle value and peak pressure values in all areas of interest (this was done independently for each group and for each
lower limb). Exploratory analyses and tests for normality of
data were performed, showing that all variables were normally
distributed with the exception of peak pressure values in the
medial region of the left forefoot among NP. In this case, nonparametric tests were performed. All statistical procedures
were performed using the Statistical Package for Social Science
software for Windows (SPSS, version 10.0). A level of significance of 0.05 was considered for all analyses.
When plantar pressure values were analyzed by foot segment, groups showed statistically significant differences in
two segments (Table 2): FP presented higher peak pressures
in the lateral region of the right (p=0.01) and left forefoot
(p=0.05); NP presented higher peak pressures in the medium-foot area of the left foot (p=0.001). A strong trend was
observed (p=0.06) for greater peak pressures in the medial
region of the right forefoot among NP. No significant differences between the groups were found for plantar pressure
values in the other segments. The Mann-Whitney nonparametric test was performed to compare peak pressure
values in the medial region of the left forefoot and results
showed no significant differences between the groups (z=1.34; p=0.18) (Table 2).
Results of correlation analyses for the FP group showed
a negative and weak correlation between the right Q-angle
value and the peak pressure in the medium-foot area of the
right foot (r=-0.32; p=0.02); i.e., in the right lower limb, a
reduced Q-angle is associated with a higher peak pressure
in the medium-foot area (Table 3). For the remaining foot
areas, no evidence of correlation was found between their
peak pressure and the Q-angle value in this group. However,
a positive and weak trend (r=0.24; p=0.09) was found
between Q-angle and peak pressure values in the left hindfoot. Results of all correlation analyses for the NP group
were non-significant (Table 3).
Results
No significant differences were found between groups with
regards to age (p=0.31) and BMI (p=0.47), indicating some
homogeneity within the sample. The t-test for independent
samples demonstrated that bilateral Q-angle values were
significantly smaller among FP than NP (p=0.001). Groups
showed similar total peak pressures and peak pressures in each
foot (Table 1).
D1=right forefoot, medial; D2=right forefoot, lateral; D3=mid-right foot; D4=right
hind-foot; E1=left forefoot, medial; E2=left forefoot, lateral; E3=mid-left foot; E4=left
hind-foot.
Figure 2. Separation of the feet in four areas in the FSCAN program
version 4.21.
299
Table 1. Characterization of the sample by age, BMI, right and left
Q-angles, right and left peak pressures, and maximum peak pressure.
Variables
Age (years)
BMI (kg/m2)
Right Q-angle (degrees)
Left Q-angle (degrees)
Right Peak (kg/cm2)
Left Peak (kg/cm2)
Maximum peak (kg/cm2)
FP (n=50)
23.73.2
23.82.2
11.41,8º
11.01,6º
1.330.31
1.26 0.37
1.430.34
NP (n=71)
24.32.5
24.23.3
13.81.4º
13.91.3º
1.360.33
1.260.31
1.440.32
t
-1.02
-0.73
-7.98
-10.41
-0.56
-0.07
-0.28
p
0.31
0.47
0.001*
0.001*
0.57
0.94
0.77
*p0.05.
Table 2. Distribution of plantar pressures (kg/cm2) for different foot
segments in study groups.
Areas
D1: Right forefoot, medial
D2: Right forefoot, lateral
D3: Mid-right foot
D4: Right hind-foot
E2: Left forefoot, lateral
E3: Mid-left foot
E4: Left hind-foot
FP (n=50)
0.450.22
0.770.32
0.510.24
1.230.41
0.650.32
0.370.16
1.160.40
NP (n=71)
0.520.16
0.630.22
0.540.18
1.320.39
0.540.26
0.460.13
1.220.35
t
-1.91
2.66
-1.00
-1.25
1.97
-3.39
-0.88
p
0.06
0.01*
0.32
0.21
0.05*
0.001*
0.38
*p0.05. The E1 area, corresponding to the medial region of the left forefoot, was analyzed
separately using the Mann-Whitney test, which showed no difference between the groups
(z=-1.34; p=0.18).
Discussion
This study demonstrated a negative and weak association
between Q-angle values and peak pressures in the medium-foot
area of FP (right lower limb), which reflects a smaller angular
value at the knee for a higher pressure at the osseous region of
anterior tarsus and part of the metatarsus. No correlation was
found between peak pressures in segmental areas of both feet
and Q-angles among NP.
Tillman et al.23 pointed out that an excessively large Q-angle
can increase calcaneal eversion, thus positioning the subtalar
joint in pronation. These changes would partially be responsible for the drop of foot’s longitudinal arches. Tillman et al.23
compared the Q-angle value and the positioning of the subtalar joint between genders and found a significant discrepancy
only with regards to the Q-angle value (13.13.0º in men versus
17.53.8º in women). Olerud and Berg24 assessed changes in
Q–angle values following the positioning of lower limbs and
found that values decreased as the feet moved from pronation
to supination. This may suggest that a more pronated foot posture leads to higher medium-foot pressures, an indication that
is consistent with our results for the FP group, even though the
observed correlation was negative and weak.
When comparing the FP and the NP groups only in relation
to the Q-angle, results of the present study are in agreement
300
with the literature. Hahn and Foldspang25 used goniometry to
evaluate Q-angle values in 339 athletes, of whom 173 were FP
participating in sports activities for a mean of 10 years. They
found mean values of 10.00.5º for the right Q-angle and of
6.00.5º for the left Q-angle, and concluded that this variable
was negatively associated to football. In the present study,
photogrammetry was used to evaluate Q-angle values in 50 FP
with mean sports participation of 12 years. Mean values found
in this study were 11.41.8º for the right Q-angle and 11.01.6º
for the left Q-angle.
As mentioned by Hamill and Knutzen10, structural changes
in the knee (genu valgus or genu varum) have an influence on
Q-angle measurement. The greater the intercondylar distance,
the smaller would be the angle formed by the anterior superior
iliac spine, the center of the patella and the tibial tuberosity.
Yaniv et al.27 assessed the intercondylar distance in tennis
players and FP and observed a higher prevalence of genu varum
among FP (i.e., mean distances were 1.31 cm in tennis players
and 2.99 cm in FP). According to the authors, this finding
would indicate a genetic predisposition with a consequent
natural selection process to the modality.If the Q-angle of these
athletes had been investigated, it would be possible to observe
smaller values among FP, as observed in the present study.
Woodland and Francis28 stated that the Q–angle value can
suffer changes due to muscle imbalance, tibial torsion, femoral
anteversion and a high or low patella. In football, Abreu,
Barbosa and Coelho12 atributted the genu varus malalignment
and the consequent decrease in the Q-angle to microtraumas
over the femoral condyles of the athletes, which can be justified
by constant changes in direction with greater load distributed
over the lateral border of the foot. Chaudhari, Hearn and
Andriacchi29 associated the reduction in genu valgum to the
practice of high-level football. Junge et al.30 verified changes to
the intercondilar space related to age, suggesting that the longterm practice of sports is associated with greater varism.
Hebert et al.31 highlighted the popularity of the baropodometric exam, but warned that the standardization of data
presentation is not yet in use. The authors therefore suggested
that the following is assessed: plantar area; peak pressures (kg/
cm2); identification and quantification of overload areas; sensory perception. Wong et al.32 evaluated peak plantar pressures
in 15 FP while they were performing specific gestures for the
sport. The authors divided the foot into 10 regions, including
the medial and lateral regions of the forefoot, the medium-foot
(medial, central and lateral parts), and the calcaneus (medial
and lateral parts). Cavanagh and Rodgers33 also divided the
foot into segments to measure peak plantar pressures in 107
subjects with a mean age of 30.19.9 years old. Considering
both limbs, mean pressure values were 1.40 kg/cm2 in the calcaneus, 0.48 kg/cm2 in the mid-foot, 0.71 kg/cm2 in the lateral
Table 3. Correlation between the Q-angle and the distribution of plantar pressures for different foot segments in study groups.
Groups
FP Right lower limb
Foot area D1
Foot area D2
Foot area D3
Foot area D4
NP Right lower limb
Foot area D1
Foot area D2
Foot area D3
Foot area D4
Right Q-angle
r
-0.17
0.02
-0.32
0.21
r
0.00
0.09
0.11
-0.06
p
0.22
0.88
0.02*
0.15
p
1.00
0.46
0.37
0.61
Groups
FP Left lower limb
Foot area E1
Foot area E2
Foot area E3
Foot area E4
NP Left lower limb
Foot area E1†
Foot area E2
Foot area E3
Foot area E4
Left Q-angle
r
-0.08
-0.17
-0.14
0.24
r
0.04
-0.08
-0.13
p
0.59
0.23
0.34
0.09
p
0.72
0.50
0.28
*p0.05. †For the distribution of plantar pressure in area E1 of NP (left lower limb), the Spearman correlation test was performed, which showed no association between variables
(r=-0.006; p=0.96).
aspect of the forefoot, and 0.57 kg/cm2 in the medial aspect
of the forefoot. In the current study as well as in previous
studies32,33, the foot was divided into the four areas considered
to be the most relevant for analysis. Results for NP were similar
to those reported by Cavanagh and Rodgers33, except for the
lateral aspect of the forefoot, which presented a mean value of
0.58 kg/cm2. FP presented mean values that were quite inferior
to the mentioned study for the calcaneus (1.19 kg/cm2) and the
medial aspect of the forefoot (0.37 kg/cm2).
When analyzing the plantar pressure variables in isolation,
the FP group presented higher pressures in the lateral aspect of
the right and left forefoot when compared to the NP group. In
the region of the left medium-foot, the mean pressure value was
significantly higher among NP. Gross and Foxworth34 indicated
that a larger Q-angle leads to a greater amount of pronation at
the subtalar joint and consequently to greater levels of pressure
in the medium-foot area. Therefore, smaller Q-angles would
be associated with greater pressures in the lateral aspects of
the foot. In the present study, even though participants in the
FP group presented smaller Q-angle values and a greater area
of contact in the middle-foot (which would suggest a greater
flattening of the medial longitudinal arch), they also presented
higher peak pressure values in the lateral aspect of the forefoot,
confirming the assumptions made by Gross and Foxworth34.
In the present study, there was an attempt to use only valid
measurement instruments for the assessments. The authors
acknowledge that the goniometer is not ideal to assess the
Q-angle since the distance between the points disrupts the positioning of both fixed and mobile arms of the instrument28,35.
Braz, Goes and Carvalho16 validated the SPA for the assessment
of body angles. Luo, Berglund and An36 consider the pressure
sensing floor mat as a reliable method and recommend it for
the measurement of the static distribution of plantar pressure.
One possible limitation of this study was the change in subjects’ position during data collection. However, the investigators sought to minimize this problem.
Biomechanical investigations in FP contribute to the prolongation of their sport career, avoiding its interruption due to
chronic-degenerative causes. Future studies should investigate
biomechanical changes in beginner athletes to allow for early
intervention, and evaluate the best intervention options; i.e.,
orthoses, posture correction or sport gesture appropriateness.
Conclusion
No association was detected between Q-angle values and
the distribution of plantar pressure in NP. A weak and negative correlation was found only between the Q-angle value and
peak pressure in the right medium-foot among FP. However,
the athletes showed reduced Q-angle values and higher pressure peaks in the lateral aspects of both feet, suggesting the
presence of a genu varus malalignment in the knee and a supine distribution of plantar bases.
301
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ISSN 1413-3555
ORIGINAL ARTICLE
©
Calibration of low-level laser therapy
equipment*
Thiago Y. Fukuda1,2, Julio F. Jesus1, Marcio G. Santos1, Claudio Cazarini Junior2, Maury M. Tanji3,4, Helio Plapler2
Abstract
Background: Despite the increase in the use of low-level laser therapy (LLLT), there is still a lack of consensus in the literature regarding
how often the equipment must be calibrated. Objective: To evaluate the real average power of LLLT devices in the Greater São Paulo
area. Methods: For the evaluation, a LaserCheck power meter designed to calibrate continuous equipment was used. The power meter
was programmed with data related to the laser’s wavelength to gauge the real average power being emitted. The LLLT devices were
evaluated in two ways: first with the device cooled down and then with the device warmed up for 10 minutes. For each condition, three
tests were performed. The laser probe was aligned with the power meter, which provided the real average power being emitted by the
LLLT device. All of the data and information related to the laser application were collected with the use of a questionnaire filled in by
the supervising therapists. Results: The 60 devices evaluated showed deficit in real average power in the cooled-down and warmedup condition. The statistical analysis (ANOVA) showed a significant decrease (p<0.05) in the real average power measured in relation
to the manufacturer’s average power. On average, the most common dose in the clinics was 4 J/cm², and the most desired effects
were healing and anti-inflammatory effects. According to the World Association for Laser Therapy (WALT), 1 to 4 J of final energy are
necessary to achieve these effects, however only one device was able to reach the recommended therapeutic window. Conclusion: The
LLLT devices showed a deficit in real average power that emphasized a lack of order in the application of this tool. The present study
also showed the need for periodical calibration of LLLT equipment and a better technical knowledge of the therapists involved.
Key words: low-level laser therapy; gauging; calibration.
Resumo
Contextualização: A laserterapia de baixa intensidade (LBI) vem sendo cada vez mais utilizada, porém ainda não há consenso na literatura
quanto ao tempo em que os equipamentos devem ser submetidos à aferição ou calibragem. Objetivo: Analisar a potência média real
(PmR) dos equipamentos de LBI na região da Grande São Paulo. Métodos: Para análise dos equipamentos, utilizou-se um potenciômetro
(Lasercheck), próprio para aferição de equipamentos contínuos, o qual foi programado com dados referentes ao comprimento de onda do
laser a ser avaliado, obtendo-se assim a PmR emitida. Os equipamentos foram analisados de duas formas: uma, com o LBI desaquecido,
e outra, após 10 minutos de uso (aquecido), sendo que três análises foram feitas para cada condição. A caneta emissora foi acoplada ao
potenciômetro, o qual fornecia a PmR emitida pelo LBI. Todos os dados e informações referentes à aplicação do laser foram coletados por um
questionário respondido pelos responsáveis. Resultados: Os 60 equipamentos avaliados mostraram déficit na PmR com os equipamentos
desaquecidos e aquecidos. A análise estatística (ANOVA) mostrou diminuição significativa (P<0,05) da PmR aferida em relação à potência
média do fabricante (PmF). Em média, a dose mais empregada nas clínicas foi de 4 J/cm², tendo os efeitos de cicatrização e anti-inflamatório
como os mais desejados. Segundo a World Association for Laser Therapy (WALT), para atingir esse efeito, necessita-se de 1 a 4 J de
energia final, sendo que apenas um dos 60 aparelhos conseguiria atingir a janela terapêutica preconizada. Conclusão: Os equipamentos
de LBI apresentam um déficit acentuado na PmR, o que mostra uma desordem na utilização desse recurso. Neste estudo, observou-se a
necessidade de aferição periódica dos aparelhos de LBI bem como melhor conhecimento técnico dos profissionais envolvidos.
Palavras-chave: terapia laser de baixa intensidade; aferição; calibragem.
Received: 16/02/2009 – Revised: 29/06/2009X – Accepted: 21/10/2009
1
Physical Therapy Sector, Irmandade Santa Casa de Misericórdia de São Paulo (ISCMSP), São Paulo (SP), Brazil
2
Experimental Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil
3
Laboratory of Investigation in Dermatology and Immunodeficiency (LIM56), Faculdade de Medicina, Universidade de São Paulo (FMUSP), São Paulo (SP), Brazil
4
Universidade do Grande ABC (UNIABC), Santo André (SP), Brazil
Correspondence to: Thiago Yukio Fukuda, Setor de Fisioterapia, Santa Casa de São Paulo, Rua Dr. Cesário Motta JR., 112, Santa Cecília, CEP 01221-020, São Paulo (SP), Brasil, e-mail:
[email protected]; [email protected]
*Preliminary analysis of this research was presented and awarded as one of the top ten studies at the Poster Session of the 6th Conference of the Brazilian Society for Laser and Photodynamic Therapy in 2008.
303
Introduction
Low-level laser therapy (LLLT) has been investigated
and used clinically for over 30 years, which justifies the increasing interest in the effects of laser and the significant
amount of scientific publications in the literature1-3. Therefore, LLLT equipment users should have knowledge of
physical and biochemical principles to make better use of
its resources. LLLT devices can have pulsed or continuous
emission and the wavelengths most commonly used range
from 630 nm to 1300 nm, thus including visible and invisible
(infrared) light spectra1.
According to in vitro studies, the effects of light activate
mechanisms of cellular metabolic control. Such mechanisms
involve acceleration of the electron transport chain, increase
in the synthesis of adenosine triphosphate (ATP) and decrease in intracellular pH. These reactions form the basis of the
effects of LLLT4-6.
Laboratory studies, conducted mostly in animals, show
strong evidence that LLLT has the ability to modulate inflammatory processes and relieve acute pain conditions triggered
by lesions in soft tissues. This activity may occur through the
decrease in nerve conduction, release of endogenous opioids,
increase in angiogenesis and, consequently, increase in local
microcirculation7,8. It may also have inhibitory effects on the
release of prostaglandins, cytokine levels, and cyclooxygenase
(Cox2), and it may accelerate cell proliferation, collagen synthesis and tissue repair9,10. However, several topics still need to
be clarified and standardized for a safe and effective use. Some
of these topics concern the type of LLLT, wavelength and dose,
which may change the desired effect during the use of this
equipment1.
According to Fukuda and Malfatti11, many therapists and
researchers have based their choice of laser dose on energy
density or fluence (E), but the wide variety of LLLT equipment may lead to differences in therapeutic results because the
parameters vary according to manufacturer. This poses another problem in relation to the clinical reproducibility of the
research, because when the same values are used in different
equipments, there are differences in the total energy emitted
to the tissue.
Other important aspects in the variability of clinical outcomes and in the quality of the proposed treatments are the
electrotechnical failures of LLLT equipment, as well as the
amount of energy being delivered to the tissue. There is still
little concern among therapists and manufacturers about
the frequency with which the equipment needs to be calibrated12-14. Thus the aim of the present study was to analyze the
real average power (RAP) of LLLT devices and therapeutic
304
doses applied during the use of this tool in clinics, physical
therapy practices, universities, outpatient units, and hospitals in the Greater São Paulo area.
Methods
Survey of LLLT equipment
This was a calibration study of LLLT equipment used in
clinics, physical therapy practices, universities, outpatient
units, and hospitals with physical therapy service in the
Greater São Paulo area. Initially, 261 locations were found
through healthcare directories, Internet search engines and
personal knowledge. All locations were contacted by phone
or personal visit. Only 140 had LLLT equipment, and 52 of
them could not be evaluated because the supervising therapist did not allow access or because the equipment was
being repaired.
At the 88 establishments where the tests were performed, there were 127 devices, 60 of which were selected for
evaluation as they were continuous-wave devices. They
were divided into seven brands (six national and one imported) with 11 different models. Thirteen devices had red laser
(eight with 660nm wavelength and five with 670nm) and 47
infrared (ten with 808nm wavelength, 26 with 830nm, and
11 with 850nm; Figure 1).
The study included LLLT devices in perfect condition, with
a minimum of three months of use within the scope of physical
therapy.
Questionnaire
For the data collection, we designed a questionnaire to be
filled in before the evaluation with information about the equipment, such as brand, model, laser color, manufacturer average
power (MAP), and wavelength. We also included questions
about the device’s main operator, such as main desired therapeutic effect, dose used to achieve this effect15, information
about their knowledge of the need of calibration, and whether
the device had undergone maintenance and calibration. Information was collected from the user manuals, and when these
were not available, we contacted the respective companies by
telephone and/or email.
Procedures
Before the data collection, a consent form was given to
the therapists responsible for the equipment to inform them
Low-level laser equipment calibration
of the absence of physical hazards to the equipment, physical
and emotional stress, or expenses to the therapists. The RAP
was gauged with a power meter (Lasercheck, Coherent, USA)
calibrated by the manufacturer prior to the study and with
5% accuracy. The power meter has a full wavelength range between 400 and 1064nm, and it is intended for the evaluation of
continuous emission equipment. This tool has a protective lens
used for equipment with a MAP above 10 mW. Below this level,
the protective lens remained open according to manufacturer
instructions.
As a standard, all devices were evaluated in two ways:
first, immediately after being switched on (cooled-down
condition), then after 10 minutes of use (warmed-up condition). There were three tests with the warmed-up device
and three with the cooled-down device, after which the
mean for each condition was calculated. The lens of the
laser probe was cleaned with disposable gauze and a swab
moistened in hydrated ethyl alcohol, and the evaluation
was performed in a room with the lowest possible lighting
to avoid interference.
To begin the evaluation, the dose was set in two ways as
each device has a different form of emission (energy density
and final energy). It must be noted, however, that this difference did not interfere with data collection because the
evaluated parameter was the device’s RAP compared to the
MAP. Thus, after performing the pilot project, the standard
dose of 4 J or 4 J/cm2 was set depending on each device’s form
of emission.
Next, the power meter was set to the device’s wavelength,
and the laser probe was aligned at a 90° angle. The laser beam
was fired and the power meter was turned on simultaneously,
which provided the RAP emitted by the LLLT device (Figure 2).
These RAP values were also within the standards of the Brazilian National Standards Association (Associação Brasileira de
Normas Técnicas [ABNT]), which allows an output variation of
up to 20%12-14.
Pilot project
A prior study was conducted to standardize the dose
to be gauged on all devices. Different doses of energy were
tested (2, 4 and 6 J) on the same LLLT device with MAP
equal to 100mW and 808nm wavelength. After data analysis, no significant difference was found in the MAP gauged
in the described doses (p=0.2). Therefore, to gauge the RAP,
the standard energy dose was set to 4 J or 4 J/cm2 because
it allows a radiant exposure time compatible with the performance of the entire gauging procedure. With this selected
dose, the analysis would not exceed 15 minutes, thus avoiding
88 establishments
11 models
127devices
13 LLLT red
67 pulsed
60 continuous
47 LLLT infrared
7 brands
1 imported
6 national
Figure 1. Diagram with the model of the study in relation to the survey
of the equipments.
Figure 2. Simulation of the analysis of a LLLT equipment and the
consequent gauging of the real average power by the power meter.
inconvenience to the therapists. To compare both evaluators,
we included statistical analyses performed by means of the
t-test for independent samples (p=0.80) and the intraclass
correlation coefficient (ICC=0.81). According to the results,
both evaluators were considered to be appropriately trained
to perform the measurement.
Data analysis
To better understand and employ the analysis, the devices were divided into four groups according to the time of
use: group 1, 3 months to 2.5 years (n=18); group 2, 2.5 to
5 years (n=12); group 3, 5 to 7.5 years (n=10); and group 4,
7.5 to 10 years (n=20). After data collection, the statistical
software GraphPad InStat was used for processing. First,
the Kolmogorov-Smirnov (K-S) test was performed to verify
305
data normality, with a significance level of 5%. We chose a
non-parametric test for analysis of variance (ANOVA) with
Friedman’s post-test to compare MAP, RAP (warmed-up) and
RAP (cooled-down).
Results
The average MAP was 30.7 mW, the RAP of the cooleddown devices was 18.1 mW, and the RAP of the warmed-up
devices was 18.3 mW. The correlation between RAP and MAP,
including all cooled-down devices, was extremely significant
(p<0.001). The same happened when comparing MAP and
RAP with the warmed-up devices (p<0.001; Figure 3). The
percentage of RAP deficit in relation to MAP with the cooleddown devices was 64.3%, and 63.7% with the warmed-up
devices (Table 1).
The analysis results showed that among the 60 evaluated devices, only eight were within the standards set by
the ABNT12,14, therefore, 52 devices had RAP outside the
standard range. The analyses according to time of use showed the following average deficits: group 1, 34.73%; group
2, 65%; group 3, 68.40%; and group 4, 90.70%. The E most
commonly used by the therapists was 4 J/cm2 per point, and
the most desired therapeutic effects were healing and antiinflammatory effects.
It must be noted that, among the 18 devices in group 1,
only two had undergone maintenance, and six were within
ABNT standards. The questionnaire filled in by the therapists
showed that 16 of them used the dose in E and two used total
energy, but none of the devices reached the desired therapeutic
window. Of the 12 devices in group 2, only six had undergone
maintenance, and only one was within ABNT standards. All
therapists used the dose in E, and none of the devices reached
the therapeutic window.
Among the ten devices in group 3, seven had undergone
maintenance, but none were within ABNT standards. As noted in the previous group, all therapists used the dose in E,
and none of the devices reached the therapeutic window.
For group 4, only ten of the 20 devices had undergone maintenance, and one was within ABNT standards; the dose was
in E, and only one device reached the desired therapeutic
window (Table 2). It is worth noting that the distribution
into four groups was only used to analyze the data from the
questionnaire; it was not maintained, therefore, for gauging
the RAP.
Discussion
The present study aimed to show the actual condition
of LLLT equipment used in clinics and physical therapy
practices in the Greater São Paulo area, finding a lack of
order in the use and maintenance of this therapeutic resource. The evidence shows that the devices are not within
the standards of inspection agencies. The therapists also
lack technical knowledge in choosing the ideal dose, type
of laser and methods to achieve the real desired therapeutic effect.
After prolonged use, LLLT devices are prone to degradation of the laser radiation structure, which decreases the power of radiation emitted by the devices16. Therefore, annual
calibration should be conducted in accordance with the specifications found in the manuals provided by manufacturers
Table 1. Results of the evaluations performed in the three conditions.
Type
MAP a
RAP b
RAP b
Deficit
Deficit
R * I.R. ** (mW) (mW) C+ (mW) W++ C+ (%) W++ (%)
60 13 47 30.7 (4) 18.1 (3.6) 18.3 (3.6) 64.3 (4.6) 63.7 (4.6)
N
* Red; ** infrared; a manufacturer average power; b real average power; + cooled-down;
++ warmed-up.
Table 2. Information of the data contained in the questionnaire,
distributing the equipments in four groups.
* Significant difference in relation to the MAP; ** Manufacturer average power;
*** Real average power with cooled-down equipment; **** Real average power
with warmed-up equipment.
Figure 3. Average power (averageSEM) of devices for the three
evaluated conditions.
306
Groups
Time of Use
n
Group 1
3 mo.-2.5 yrs
18
Group 2
2.5-5 yrs
12
Group 3
5-7.5 yrs
10
Group 4
7.5-10 yrs
20
ABNT
6 within
standards
1 within
standards
0 within
standards
1 within
standards
Therapeutic
Window (WALT)
18 did not reach
12 did not reach
10 did not reach
1 reached /
19 did not reach
Low-level laser equipment calibration
in order to achieve a truly functional application of this therapeutic method. Considering that electrical devices used
by therapists may be mishandled over the years, it is very
difficult to predict when and how the faults will occur, or
even how to prevent them12-14. The analysis conducted in
the present study shows the reality of LLLT equipment and
highlights the fact that the minority of the analyzed devices
had undergone calibration, further compromising the quality and effectiveness of treatment.
ABNT regulations NBR IEC 601-2-22 and IEC 60825-1 and
ABNT Technical Report 60825-8 IEC recommend a variation
no greater than 20% in relation to the output power of the
manufacturer12-14, however the present study found that only
eight of the 60 evaluated LLLT devices were within this standard. The evaluation of the MAP in relation to the RAP found a
difference of 64%, reflecting the lack of order in the use of this
tool. These findings explain why only one device reached the
therapeutic window recommended by the World Association
for Laser Therapy (WALT)15.
Regarding the application method, the vast majority of
therapists used the dose based on E. Of the 60 devices, only
two provided the direct calculation of the final energy as a parameter, but due to their deficit in RAP, they failed to reach the
desired therapeutic window. One device reached the treatment
threshold as it was the only one that applied a high E and the
only one within ABNT standards, leading to the real desired
therapeutic effect.
In a study that conducted comparative simulations between national LLLT devices, the authors concluded that
E does not seem to be the parameter that best describes
the dose to be used, as it can vary from device to device given that its parameters will be different when compared to
other brands and LLLT models11. This fact corroborates the
results of the present analysis. Furthermore, it was observed
that, even in devices with high RAP and within ABNT standards, it would not be possible to reach the recommended
therapeutic window due to the therapist’s lack of knowledge
regarding the desired dose. In the present study, the therapists based their dose on E only, and the main value was
4 J/cm2, aiming to achieve anti-inflammatory and healing
effects. According to the WALT, 1 to 4 J of final energy are
needed to achieve these effects, thus the therapists would
need to use a higher E15.
This can be seen in the evaluation of two randomized
controlled trials. The first trial applied LLLT in patients
with osteoarthritis of the hand, with standard dose in E
equal to 3 J/cm2. The results obtained in the study showed
no significant differences between groups, indicating that
the E may have been too low, not reaching the therapeutic
window15,17. The second trial was conducted in patients with
low back pain, divided into three groups: the first received
LLLT combined with exercises; the second received LLLT
only; and the third performed exercises only. According to
the dose parameters provided in this trial, the parameters
established by the WALT were met as were the therapeutic effects desired by the researchers. Thus, the two groups
that received LLLT showed a significant difference in pain
level when compared to the group that performed exercises
only15,18.
The current lack of standardization in the calibration of
devices used in physical therapy also includes therapeutic
ultrasound (TUS). The results showed an excessively long
period between calibrations, thus interfering in the therapeutic effect of the device. Some studies point to the need for
periodic calibration of TUS devices19,20. This emphasizes the
importance of conducting periodical checks on the devices,
giving the therapist a resource with greater reliability and
reproducibility. It has also been stated that scientific research
should follow the same path, i.e., calibrate equipment prior
to a study19-21.
The analysis of these studies and their results leads us
to believe that, to make better and more efficient use of the
beneficial effects of LLLT, it is extremely important that the
average power of the device be within ABNT standards and
that the physical therapist be able to dose the applied energy
correctly12-15. Therefore, there is a need for annual or even biannual calibration of LLLT devices, investments in quality improvement by manufacturers, and more technical knowledge for
therapists who use these devices.
A limitation of the present study was that only laser devices
with continuous emission were evaluated, as the power meter
used was specific to continuous emission. For future studies,
we propose that the devices be calibrated again to analyze a
possible change in the current scenario and the inclusion of
devices with pulsed emission.
Conclusion
LLLT devices used in clinics, physical therapy practices
and hospitals located in the greater São Paulo area showed a
marked deficit in average power, which shows a lack of order in
the clinical use of this tool. Moreover, many of the devices were
not within ABNT standards, and the applications may not be
reaching the recommended therapeutic window, showing the
need for periodic calibration.
307
References
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Kitchen SS, Partridge CJ. A review of low level laser therapy. Physiotherapy. 1991;77(3):161-8.
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Moshkovska T, Mayberry J. It is time to test low level laser therapy in Great Britain. Postgrad Med
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3.
Gam AN, Thorsen H, Lonnberg F. The effect of low level laser therapy on musculoskeletal pain: a
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Karu TI. Photobiology of low power laser effects. Health Phys. 1989;56(5):691-704.
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Karu TI, Pyatibrat LV, Afanasyeva NI. Cellular effects of low power laser therapy can be mediated
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Karu TI. Molecular mechanism of low-power lasertherapy. Lasers Life Sci. 1998;2:53-74.
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Bjordal JM, Johnson MI, Iversen V, Aimbire F, Lopes-Martins RAB. Photoradiation in acute
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Bjordal JM, Couppé C, Chow RT, Tunér J, Ljunggren EA. A systematic review of low level
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12. Associação Brasileira de Normas e Técnicas. NBR IEC 601-2-22: Equipamento eletromédico:
Prescrições particulares para a segurança de equipamento terapêutico e de diagnóstico a laser.
Rio de Janeiro; 1997 (Pt. 2).
13. IEC. IEC 60825-1: Safety of laser products: Equipment classification, requirements and user’s
guide. 1ª e 2ª ed. Switzerland; 2001 (Pt.1).
14. IEC. IEC TR 60825-8: Safety of laser products: Guidelines for the safe use of medical laser
equipment. Switzerland; 1999 (Pt. 8).
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Disponível em: http://www.walt.nu/dosage-recommendations.html.
16. Bettiati M, Starck C, Pommies M, Broqua N, Gelly G, Avella M, et al. Gradual degradation in
980nm InGaAs/AlGaAs pump lasers. Material Science & Engineering B. 2002;91(92):486-90.
17. Brosseau L, Wells G, Marchand S, Gaboury I, Stokes B, Morin M, et al. Randomized controlled
trial on low level laser therapy (LLLT) in the treatment of osteoarthritis of the hand. Lasers Surg
Med. 2005;36(3):210-9.
18. Gur A, Karakoc M, Cevik R, Nas K, Sarac AJ. Efficacy of low power laser therapy and exercise on
pain and functions in chronic low back pain. Lasers Surg Med. 2003;32(3):233-8.
19. Artho PA, Thyne JG, Warring BP, Willis CD, Brismée JM, Latman NS. A calibration study of
therapeutic ultrasound units. Phys Ther. 2002;82(3):257-63.
10. Amaral AC, Parizotto NA, Salvini TF. Dose-dependency of low-energy HeNe laser effect in
regeneration of skeletal muscle in mice. Lasers Med Sci. 2001;16(1):44-51.
20. Guirro R, Serrão F, Elias D, Bucalon AJ. Calibration of acoustic intensity of therapeutic ultrasound
equipment in use in the city of Piracicaba. Rev Bras Fisioter. 1997;2(1):35-37.
11. Fukuda TY, Malfatti CA. Analysis of low-level laser therapy doses in Brazilian equipment. Rev
Bras Fisioter. 2008;12(1):70-4.
21. Guirro R, Santos SCB. A realidade da potência acústica emitida pelos equipamentos de ultrasom terapêutico: Uma revisão. Rev Fisioter Univ São Paulo. 1997;4(2):76-82.
308
ISSN 1413-3555
ORIGINAL ARTICLE
©
Assessment of global motor performance and
gross and fine motor skills of infants attending
day care centers
Avaliação do desempenho motor global e em habilidades motoras axiais e
apendiculares de lactentes frequentadores de creche
Carolina T. Souza1, Denise C. C. Santos1, Rute E. Tolocka2, Letícia Baltieri3, Nathália C. Gibim3, Fernanda A. P. Habechian3
Abstract
Objective: To analyze the global motor performance and the gross and fine motor skills of infants attending two public child care centers
full-time. Methods: This was a longitudinal study that included 30 infants assessed at 12 and 17 months of age with the Motor Scale of the
Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). This scale allows the analysis of global motor performance, fine
and gross motor performance, and the discrepancy between them. The Wilcoxon test and Spearman’s correlation coefficient were used.
Results: Most of the participants showed global motor performance within the normal range, but below the reference mean at 12 and 17
months, with 30% classified as having “suspected delays” in at least one of the assessments. Gross motor development was poorer than
fine motor development at 12 and at 17 months of age, with great discrepancy between these two subtests in the second assessment. A
clear individual variability was observed in fine motor skills, with weak linear correlation between the first and the second assessment of this
subtest. A lower individual variability was found in the gross motor skills and global motor performance with positive moderate correlation
between assessments. Considering both performance measurements obtained at 12 and 17 months of age, four infants were identified as
having a “possible delay in motor development”. Conclusions: The study showed the need for closer attention to the motor development of
children who attend day care centers during the first 17 months of life, with special attention to gross motor skills (which are considered an
integral part of the child’s overall development) and to children with suspected delays in two consecutive assessments.
Key words: day care centers; infant; child development.
Resumo
Objetivo: Analisar o desempenho motor global em habilidades motoras axiais e apendiculares de lactentes que frequentavam, em tempo
integral, duas Escolas Municipais de Educação Infantil. Métodos: Estudo longitudinal do qual participaram 30 lactentes avaliados aos
12 e 17 meses de vida com a escala motora das Bayley Scales of Infant and Toddler Development-III, que possibilita a análise do
desempenho motor global, apendicular e axial e a discrepância entre eles. Utilizaram-se o teste de Wilcoxon e o Coeficiente de Correlação
de Spearman. Resultados: A maioria dos participantes apresentou desempenho motor global dentro dos limites de normalidade, porém
abaixo da média de referência aos 12 e 17 meses, com 30% classificados como suspeitos de atraso em pelo menos uma das avaliações.
O desempenho motor axial foi inferior ao apendicular aos 12 e aos 17 meses, com grande discrepância entre eles especialmente na
2ª avaliação. Observou-se marcada variabilidade individual nas habilidades motoras apendiculares, com fraca correlação linear no
desempenho entre a 1ª e a 2ª avaliações nesse domínio. Nas habilidades axiais e no desempenho motor global, encontrou-se menor
variabilidade individual, com correlações moderadas e positivas entre a 1ª e a 2ª avaliações. Identificaram-se quatro lactentes com
suspeita de atraso no desenvolvimento motor em ambas as avaliações. Conclusões: O estudo aponta necessidade de maior atenção ao
desenvolvimento motor durante os primeiros 17 meses de crianças que frequentam creches, com especial vigilância à motricidade axial
(considerando que ela é parte integrante do desenvolvimento global da criança) e às crianças com desempenho suspeito de atraso em
duas avaliações consecutivas.
Palavras-chave: creches; lactente; desenvolvimento infantil.
1
Graduate Program in Physical Therapy, Faculdade de Ciências da Saúde (FACIS), Universidade Metodista de Piracicaba (UNIMEP), Piracicaba (SP), Brazil
2
Graduate Program in Physical Education, FACIS, UNIMEP
3
Physical Therapy Course, FACIS, UNIMEP
Correspondence to: Denise Castilho Cabrera Santos, Universidade Metodista de Piracicaba, Rodovia do Açúcar, Km 156 – Taquaral, CEP 13400-911, Piracicaba (SP), Brazil,
e-mail: [email protected]
309
Carolina T. Souza, Denise C. C. Santos, Rute E. Tolocka, Letícia Baltieri, Nathália C. Gibim, Fernanda A. P. Habechian
Introduction
References to child day care centers worldwide are unanimous in stating that these centers were created to provide care
to infants whose mothers began to work outside the home.
This change in the style of rearing and educating children
started during the Industrial Revolution in 18th-century Europe and spread throughout the Western world. Until today,
the women-work-children triad is responsible for a large part
of the demand for placement in day care centers or early childhood education centers1.
In several parts of the world, researchers and governments
have become concerned with non-maternal care and its repercussions for children’s development, combined with the inclusion of infants in collective care institutions or day care centers.
In the United States, this concern increased in the 1980s, when
studies first began to report undesirable results in child behavior and in mother-child relationships related to day care center
attendance2. These findings, combined with the growing reality
of American children attending day care centers, were the driving force behind the largest study conducted up to that point on
the impact that this scenario can have on child development,
the Study of Early Child Care (SECC) by the National Institute
of Child Health and Human Development. From 1991, more
than 1200 infants had longitudinal follow-up from birth until
adolescence. The results of the SECC highlight that exposure to
quality day care is predictive of functional advance in cognitive
and language areas. In contrast, in the first four years of life,
a higher exposure (in hours) to day care environments, even
quality ones, is related to high levels of behavioral problems2.
Similar results were observed in another wide study performed
in England, known as the EPPE Study (Early Effective Provision
of Preschool Education), which followed up 3000 infants3.
The international literature shows significant concern for
the impact of long hours of day care on increasingly younger
children in terms of cognitive, linguistic, social, emotional,
and behavioral development2-4. Nevertheless, foreign studies
in particular do not include motor development as an aspect
to be investigated. In Brazil, however, there has been increasing concern with this model of care and its repercussions for
children’s motor development, possibly due to the number of
studies that point to issues related to the professionals’ qualification, infrastructure, strict routines focused mainly on feeding
and hygiene, and greater exposure to infectious processes5-8.
Santos et al9 pointed out that, in Brazil, several studies have
reported suspected delays in development, including motricity;
however, the results are inconclusive because the prevalence
of delays or suspected delays is very heterogeneous among the
studies, ranging from 10% to 43%10-15. Other prominent aspects
310
in the literature are the common discrepancies or differences in
performance between the gross and fine motor subtests11,13,15,16,
in addition to reports that the learning environment does not always promote infant motor development17,18. The Brazilian studies reviewed in this article pointed to delays or suspected delays
in motor development, however they did not analyze the process
of this development in infants that attend day care centers, and
the majority of studies performed only one developmental assessment (cross-sectional design). It is accepted that only longitudinal studies allow the comprehension of the emergence
pattern of developmental functions19 and the identification of
the inconsistent, non-linear nature of child development20.
In this context, the present study aimed to analyze the
overall motor development and the gross and fine motor skills
of infants enrolled full time in two public child care centers in
the city of Piracicaba, SP, Brazil. The infants were assessed longitudinally at 12 and 17 months of age. The specific objectives
of the study were: (a) to analyze the global motor performance
and compare gross and fine motor skills at 12 and 17 months
of age to identify discrepancies between them; (b) to analyze
the process of overall, gross and fine development from the 12th
to the 17th month of age; (c) to identify infants with suspected
delays in motor development considering the two assessments
of overall motor development.
Methods
This was a descriptive and longitudinal study that assessed
30 infants (50% female) attending two public day care centers
of Piracicaba, SP, Brazil. Their overall motor development and
gross and fine motor skills were assessed at 120.61 months
(1st assessment) and 170.33 months (2nd assessment). The
present study was approved by the Research Ethics Committee of Universidade Metodista de Piracicaba, Piracicaba (SP),
Brazil (protocol no. 61/06).
The participating day care centers were recommended
by the city’s Education Secretary, considering the interest expressed by the local managers and the regional supervisors in
taking part in this project and because they did not have any
physical therapy, physical education or other intervention activities. In order to select the study group, the following inclusion criteria were considered: a) full-time attendance at day
care center; b) chronological age or corrected age for preterm
infants between 11 and 13 months (1st assessment) and 17-18
months (2nd assessment); c) informed consent form signed
by the family. Children with neurological disorders, genetic
syndromes or malformation were excluded. To assess motor
development, we used the Motor Scale of the Bayley Scales of
Assessment of motor performance
Infant and Toddler Development, Third Edition (Bayley-III)21,
which allows the analysis of overall, gross, and fine motor development, in addition to the analysis of possible discrepancies between the last two. The performance in the gross and
fine subtests was expressed through a standard score that
ranges from 1 to 19 points, with a reference mean of 103. The
global motor performance is the result of the gross and fine
performances and is expressed through a standardized score
that ranges from 40 to 160 points, with a reference mean of
10015. Considering the possible variations above or below
the reference mean, the scale recommends that the overall
motor development be classified as high superior (score
equal to or above 130 points), superior (120-129 points), high
average (110-119 points), average (90-109 points), low average
(80-89 points), borderline (70-79 points) and extremely low
(score equal to or below 69). In the present study, the cutoff
score established for the classification of suspected delay in
global motor performance was a score below 90. In other
words, the children considered to have suspected delays were
those with a performance classified as low average, borderline or extremely low.
Each child was assessed by two raters considering the
chronological age or corrected age for preterm infants. One
rater was responsible for the test application, and the other
for recording the results. The raters received Bayley-III training
and took part in a reliability study including 15 infants assessed
independently by each rater. The inter-rater correlation coefficient and the corresponding confidence interval (95%) for
the fine, gross and global motor performances were 0.98 (0.950.99), 0.99 (0.98-0.99), and 0.99 (0.98-0.99), respectively. For the
assessment sessions, we used a mat, a table and chair, and the
original Bayley-III kit. The assessed child had to be alert and
should not be wearing clothing that could restrain movement.
The test was scheduled around the day care center’s feeding,
bathing and nap times.
Data were stored and processed using the Statistical
Package for Social Sciences (version 11.0). For the normality analysis, the Shapiro-Wilk test was used for the gross
(p=0.019), fine (p=0.002) and overall (p=0.792) motor performances. Considering that only the global motor performance
showed a normal distribution, non-parametric data analysis
was used. The group characterization was performed through
descriptive analysis. The continuous variables were expressed
by measures of central tendency and dispersion, and the categorical variables by frequencies. The Wilcoxon test was used
for the analysis of the paired data, Spearman’s rank correlation coefficient (r) was used for the correlation analysis, and
the scatter plot was analyzed. The level of significance set in
the present study was of 5%.
Results
The study included 30 infants, of whom four (13.8%) were
born preterm (less than 37 weeks) and two (7%) were born
with low birth weight (below 2500 grams). With regard to
Apgar scores, the lowest score was eight at the 1st minute of
life. None of the infants showed clinical complications at birth.
Participants attended two public day care centers full time. At
these centers, the child:staff ratio was 7:1 in the studied age
groups, with 14 children per room.
Considering the classification recommended by the scale,
most participants showed global motor performance within
normal range (above 80) but below the reference mean (100) at
12 months (median = 97, minimum = 70, maximum = 121) and
17 months (median = 98, minimum = 79, maximum = 124) with
nine (30%) participants classified as having suspected delays,
according to the cutoff score adopted for the study (low average
performance or borderline) in at least one of the assessments
(Figure 1A). More specifically, four infants were classified as
having suspected delays only in the 1st assessment, four in the
1st and 2nd assessments and only one in the 2nd assessment. In
both assessments, none of the children had an extremely low
performance (score 69).
The comparison of the performances in the gross and
fine motor subtests (Wilcoxon test) showed significant differences, with poorer gross performance both in the 1st assessment at 12 months (p=0.008) and in the 2nd assessment at
17 months (p<0.001) with great discrepancy between them,
especially in the 2nd assessment, in which 63.3% of the infants
showed significant difference between the gross and fine subtests (Figure 1B).
The trajectory of overall, fine and gross motor development between the 1st and 2nd assessments was analyzed
using Spearman’s correlation coefficient and scatter plots
(Figure 2). The first scatter plot (Figure 2A) showed a significant variability in individual performances between the 1st
and 2nd assessments of fine motor skills and a weak correlation in this area (r=0.291, p=0.119). There was less variability
in gross motor skills and in global motor performance, as
indicated by the moderate and positive linear correlations
between 1st and 2nd assessments in the gross motor subtest
(r=0.616, p<0.001) and in overall performance (r=0.543,
p=0.02; Figures 2B and 2C).
In the 1st assessment, 22 infants were classified as having
adequate performance and eight as having suspected delays.
Of the 22 infants with adequate performance in the 1st assessment, only one was classified as having a suspected delay in
the 2nd assessment. In contrast, of the eight infants with suspected delays in the 1st assessment, four had suspected delays
311
A
A
14
2nd assessment - fine motor
Global motor performance
120
110
100
90
80
13
12
11
10
9
8
70
7
1st assessment 2nd assessment
7
B
Fine motor performance
Gross motor performace
18
16
*
54
B
8
9
10
11
12
13
1st assessment - fine motor
14
18
16
2nd assessment - gross motor
14
12
10
8
6
4
14
12
10
8
6
2
4
2nd assessment
A) Global motor performance. B) Fine and gross motor performance. Continuous line
(average reference). Dashed line highlights the cutoff score for the classification of
suspected delay.
Figure 1. Motor performance on 1st and 2nd assessments.
in the 2nd assessment, while the others showed adequate motor performance. Thus, of the 30 infants followed up in the
present study, four (13%) had suspected delays in overall
performance (scores below 90) in both assessments. Of these,
only one was born preterm (32 weeks gestation) and with low
birth weight (1670g). The others were born at term weighing
over 2500 grams.
2
4
6
8
10
12
14
1st assessment - gross motor
C
130
2nd assessment - global motor
1st assessment
120
110
100
90
80
70
70
80
90
100
110
120
1st assessment - global motor
Discussion
In the present study, although most participants presented
global motor performance within normal range, 30% were
312
A) Fine motor performance (r=0.291; p=0.119). B) Gross motor performance
(r=0.616; p<0.001). C) Global motor performance (r=0.543; p=0.02).
Figure 2. Scatter plot.
classified as having suspected delays in global motor performance in at least one of the assessments. The gross motor performance was poorer than the fine motor performance at 12
and 17 months of life, and there was great discrepancy between
them, especially in the 2nd assessment. Corroborating the findings of the present study, the reviewed literature indicates
frequent cases of suspected or actual developmental delays
among children attending day care centers. In general, these
studies indicate the multiplicity of possible factors affecting
motor development, including biological hazards (i.e. low birth
weight, preterm birth), unfavorable socioeconomic conditions,
poor parental education, multiple stress situations, and poor
stimulation, often due to the day care environment10,12,14,22.
Also supporting the findings of the present study, the reviewed literature highlights frequent situations of discrepancy
or difference between gross and fine motor performances, with
better fine motor performance in some instances and better
gross motor performance in others11,13,15,16. In addition to the
disadvantage in gross motor skills compared to fine motor
skills, the present study showed greater individual variability
in the trajectory of fine motor performance compared to the
gross and global motor performances, e.g. the poorest performance (gross) also showed less individual variability between
12 and 17 months of age.
These findings corroborate other studies that show that the
course of development is characterized by intense variability
in which periods of developmental quiescence or stability are
followed by periods of high rates of acquisition, resulting in
variability in intra-individual and inter-individual scores and
between different domains of development. Contemporary
researchers have reinforced the premise that variability, not
linearity, is a characteristic of typical development19,20,23,24.
These assumptions make it more difficult to correctly identify
instances of delay or change in development. Darrah et al.19
examined intra-individual stability in the gross motor performance scores of typical infants during the first 18 months of
life and found that the individual scores varied considerably,
which made it impossible to identify a systematic pattern of
changes among them. This finding corroborates the result of
the present study, especially regarding fine motor skills for
which there was great individual variability.
In 2003, Darrah et al.23 investigated the stability of scores
in the areas of fine and gross motor development and communication in a longitudinal study on infants between 9
and 21 months of age. The authors found a high variability
in intra-individual scores, between individuals and between
the different areas studied. The authors emphasize that the
development process is marked by a typical non-linearity,
rather than at a constant rate, with little correlation between
the gross and fine motor development, suggesting that these
two motor areas are developed independently, contradicting
the assumptions of ipsative or intra-individual stability.
Considering the challenge of the early diagnosis of
abnormalities, Rosenbaum24 suggests that the identification of differences and variations in development should
be interpreted with caution, keeping in mind that normal
variations occur in early childhood and that there is always
the possibility of monitoring the child’s development rather
than basing a decision on a single assessment. The concept
of monitoring development was also emphasized in a study
that followed the trajectory of the gross and fine motor development of a group of children from 9 months until 5 years
of age20. The results of the study from Darrah, Senthilselvan
and Magill-Evans20 support the hypothesis that the trajectory of acquisition of gross and fine motor skills is characterized by intra-individual variability and by fluctuation in
their rate of emergence.
The difference between the motor domains of infants in
the present study can also be justified by the low level of environmental stimulation or lack of opportunities to reach the
developmental potential. The National Curriculum Reference
for Children’s Education17 points to evidence that, in many
institutions, infants spend most of the day in their cribs,
which limits the opportunities to explore the environment
and interact with other children, with possible effects on motor skills.
A study conducted by Barros, Halpern and Menegon25
aimed to verify the operational practices of day care centers
in aspects related to child care (health control, hygiene, and
nutrition), organization (supervisors, training, minimum staff
and child:staff ratio), and infrastructure ( facilities and minimum areas, building standards). The results showed that the
number of children in public day care centers was greater than
the number of children in private ones, and that each employee
is responsible for six children aged zero to two years. In the day
care centers that took part in the present study, the child:staff
ratio was 7:1, with groups of up to 14 children, sometimes
reaching 15. Although in Brazil, the ratio in municipal day care
centers is acceptable26, the National Center for Education in
Maternal and Child Health27, in line with the American Public
Health Association and the American Academy of Pediatrics,
recommends that the child:staff ratio during the first year of
life should be 3:1 with groups of up to six children and that, in
the age group of 13-30 months, this ratio should be 4:1 with
groups of up to eight children.
Other studies11,14,22 have also reported unfavorable conditions for motor development in children attending day care
centers. De Barros et al.11 considered environmental risk factors
313
for motor development in healthy children attending private or
public day care centers. The authors pointed to a) the use of
inappropriate toys for the children’s age, b) the inadequacy of
the places where the children were kept at a premature age,
c) the lack of pedagogic supervision, d) premature extra-familial socialization, and e) low familial socioeconomic status. The
results indicated that the development of biologically healthy
children may be negatively influenced by environmental risk
factors. In the study by Eickmann et al.22, the fall in development
rates (after weekly iron supplementation) in children aged four
to 24 months was attributed to the low level of stimulation received, resulting from poor socioeconomic and environmental
conditions, in addition to long hours in day care with an insufficient number of caregivers. Maciel14 indicates that, in child
care centers, work overload combined with a lack of knowledge
about developmental stimulation techniques can affect the
quality of psychosocial stimulation provided to children and,
consequently, their mental and motor development.
Another result to be discussed in the present study was
the identification of four infants with suspected delays in
motor development when considering both assessments at
12 and 17 months of age. Although this result must be observed with caution due to the fact that there were only two
assessments over the course of the study, it is important to
emphasize that it stemmed from a diagnostic tool designed
for assessing child development. Diagnostic tests are more
expensive and time-consuming, however they are considered
the gold standard for measuring developmental outcomes
and providing objective, valid, and reliable measures of child
development28. Therefore, this result is relevant in terms of
prevention as it identified four (13%) children with suspected delays in two repeated measures, and it showed the
importance of developmental monitoring and follow-up as a
strategy for identifying risk, which has been strongly recommended by the literature20,23,24.
It is worth noting that, for at least one of the four children
with suspected delay in both assessments, the motor performance scores may have been influenced by preterm birth and
low birth weight. Although the influence of neonatal risk factors in motor development is widely recognized, the present
study did not find medical complications, and the preterm infants were evaluated according to their corrected age. There
is evidence that, in the absence of clinical complications and
with age correction for preterm infants, their motor development may be similar to that of full-term children29.
Rosenbaum24 highlights at least two reasons that justify
developmental monitoring. First, most developmental disorders manifest themselves over time, and second, the diagnosis
314
of these disorders is based on the observation of phenomena
or on a judgment of the child’s history and evaluation. Darrah
et al.23 point out that the combined results of repeated assessments may elucidate low scores by determining whether
they represent a true delay or just a period of developmental
quiescence.
Although the results for the motor performance of the
group studied are not alarming, it is noteworthy that the motor domain with the poorest outcome (gross) also showed less
variability from 12 to 17 months of age. For a reliable diagnosis of motor development, the presence of three conditions20
is recommended: a) unfavorable results in the assessment(s);
b) expressions of concern by the family regarding the child’s
development (in this case, concerns on the part of the caregivers should also be considered); c) the rater’s observation
and clinical impression. Of the four children with suspected
delays in both assessments, two of them met these three
conditions, which together contribute to the identification of
changes in development.
Overall, the present study suggests the need for greater
attention to motor development during the first 17 months of
life in infants attending public day care centers full time, with
particular surveillance of gross motor development (considering that this is part of the child’s overall development) and
of children with suspected delays in motor performance in
consecutive assessments. A clinical implication of this suggestion would be surveillance by specialists in early childhood
education institutions, which would allow the analysis of the
trajectory of development during the first months and years
of life, the identification of children at risk of delay, and hence
the establishment of intervention strategies to promote development. This implication is in line with the guidelines for
the establishment of developmental surveillance outlined in
the literature in the areas of pediatrics, physical therapy, and
rehabilitation sciences20,23,24,28. The limitations of the present
study were the short follow-up only until 17 months of age,
the use of only two measures of motor performance, and the
lack of investigation of the quality of care given to the children
at the day care centers and in the household.
Acknowledgements
Fundo de Apoio à Pesquisa da UNIMEP/Protocol 369/05;
Fundo de Apoio à Extensão da UNIMEP/Protocol 21/06; Bolsas de Iniciação Científica PIBIC/CNPq and FAPIC/UNIMEP;
Núcleo de Estudos e Pesquisas em Pedagogia do Movimento
– NUPEM/UNIMEP.
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ISSN 1413-3555
©
ORIGINAL ARTICLE
Determination of the power-duration
relationship in upper-limb exercises
Determinação da relação potência-duração em exercício com membros
superiores
Domingos Belasco Junior1, Fernando R. Oliveira2, José A. N. Serafini3, Antonio C. Silva4
Abstract
Objectives: To determine the power-duration relationship in upper limb exercises and to investigate the relationships between parameters
derived from this function with physiological indicators of aerobic fitness. Methods: Ten healthy men (26.22.3 years, 75.011.8 kg,
178.211.5 cm and 15.05.7% body fat) performed a ramped test on an arm cycle ergometer with increments of 20 W/min. Subsequently,
five tests with constant load were performed until exhaustion, with 70, 80, 90, 95 and 100% difference between VT1 and VO2peak.
The critical power (CP) was obtained by means of linearization of the power-duration function. Results: The power-duration relationship
was described using an adjusted function (r=0.980.02). The VO2 at CP (2.660.62 l/min) was higher than VT1 (1.620.38 l/min) and
VT2 (2.360.59 l/min), but lower than VO2peak (3.060.62 l/min). The CP workload (103.026 W) was significantly different from VT1
(69.521 W) and VO2peak workloads (151.026.3), but was no different of VT2 (103.530.8 W). The association between critical power
and aerobic condition indexes were always significant when expressed as VO2 (0.73 to 0.78, p<0.05) and in W (0.83 to 0.91, p<0.05).
Determination of CP in upper-limb dynamic exercises is simple and inexpensive, and can be used by physical therapists for prescribing
and evaluating upper-limb training programs. Conclusions: The power-duration relationship in upper-limb exercises can be described by
a hyperbolic function and it is associated with physiological indicators of aerobic fitness.
Key words: critical power; upper limbs; metabolic thresholds.
Resumo
Objetivos: Determinar a relação potência-duração em exercícios de membros superiores (MMSS) e verificar a relação dos parâmetros
derivados dessa função com indicadores fisiológicos de aptidão aeróbia. Métodos: Dez homens saudáveis (26,22,3 anos, 75,011,8 kg,
178,211,5 cm e 15,05,7% de gordura) realizaram um teste de rampa em cicloergômetro de braço com incrementos de 20 W/min.
Posteriormente, cinco testes de carga constante até a exaustão a 70, 80, 90, 95 e 100% da diferença entre LV1 e o VO2pico foram
realizados. A potência crítica (PC) foi obtida por meio da linearização da função potência-duração. Resultados: A relação potênciaduração foi descrita pela função ajustada (r=0,980,02). O VO2 na PC (2,660,62 l/min) foi maior do que no LV1 (1,620,38 l/min) e
LV2 (2,360,59 l/min, respectivamente), mas menor do que o VO2pico (3,060,62 l/min). A carga da PC (103,026,0 W) foi diferente
da encontrada em LV1 (69,521 W) e VO2pico (151,026,3 W), mas não da em LV2 (103,530,8 W). A associação entre a PC e esses
indicadores de aptidão aeróbia foram todas significantes quando expressas em VO2 (0,73 a 0,78; p<0,05) e em W (0,83 a 0,91; p<0,05).
A determinação da PC em exercícios dinâmicos de MMSS é simples e de baixo custo, podendo ser utilizada pelo fisioterapeuta na
prescrição e avaliação do treinamento de MMSS. Conclusão: A relação potência-duração em exercícios com os MMSS pode ser descrita
por uma função hiperbólica e está associada a indicadores fisiológicos da aptidão aeróbia.
Palavras-chave: potência crítica; membros superiores; limiares metabólicos.
1
Undergraduate Physical Therapy Course, School of Health, Universidade Metodista de São Paulo, São Paulo (SP), Brazil
2
Department of Physical Education, Universidade Federal de Lavras (UFLA), Lavras (MG), Brazil
3
Department of Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil
4
Department of Physiology, UNIFESP
Correspondence to: Domingos Belasco Junior, Rua Edson Regis, 426, Jd Guarapiranga, CEP 04770-050, São Paulo (SP), Brazil, e-mail: [email protected]
316
Power-duration relationship in upper-limb exercises
Introduction
When assessing and prescribing exercises for prevention
of orthopedic, cardiothoracic or neurological lower-limb (LL)
dysfunctions and functional rehabilitation among such individuals, it is necessary for physical therapists to know about the
physiological basis that characterizes load threshold determinations between upper-limb (UL) work intensity domains. The
most commonly used parameters are the physiological transition threshold (PTT) and the maximum oxygen uptake or peak
(VO2max/peak)1.
Another parameter used is the power that in theory
could be sustained over the long term without fatigue. This
is known as the critical power (CP) or critical velocity (CV).
It is determined by analyzing the rectangular hyperbolic relationship between power developed (W) and time elapsed
until exhaustion (t) for high-intensity and constant load exercises2-4. In other words, it appears that when analyzing the
resulting equation, the endurance (capability to perform an
exercise for a prolonged period of time) relies directly on the
curvature constant and inversely on the power applied above
CP2,3. Within this context, CP is found to be above the ventilatory anaerobic threshold (VT1), in which the load is approximately 60-65% of the difference between VT1 and VO2max,
at least for LL exercises performed by young individuals4-6.
Thus, Whipp and Ozyener7 proposed that VT1 would mark
the transition between moderate and high-intensity exercises, and that the CP would divide intense and very intense
domains close to the respiratory compensation point (VT2)8.
This would extend to the VO2max load.
The W-t relationship has been extensively studied in exercises performed using small or large muscle groups at different
levels of physical activity, in response to several interventions,
even in patients with ventilatory restriction3,9. Moreover, as
seen in relation to PTT, it has been demonstrated that CP is
sensitive to the effects of training. In this respect, there is little
data in the literature regarding whether the response to high
intensity UL exercises would be hyperbolic10-14. In addition,
little is known about the relationship between the parameters
describing the W-t relationship for UL and other aerobic fitness indicators10.
There are significant differences in maximum and submaximal physiological responses to LL exercises, in comparison
with exercises that use a smaller amount of muscle mass
(notably UL exercises), have already been described15-18. Furthermore, LL ergometers are a useful tool for assessing and
training individuals with functional limitation of LL movements, or for lung disease and cardiac patients, thereby assisting in the process of cardiopulmonary rehabilitation19. In this
light, the objectives of the present study were to analyze the
power-duration relationship in constant load exercises performed in UL ergometer and to investigate the relationship
between parameters that derive from this function and from
physiological indicators of aerobic fitness. In addition, this
study investigated whether CP for UL can be used as an assessment tool for the endurance and whether, in this type of
activity, CP is associated with PTT and VO2peak.
Methods
The sample consisted of 10 young male adults (22 to 32
years of age) with no orthopedic restrictions on performing
UL exercises. They were classified as physically active, with
scores ranging from 8 to 12 according to the Baecke, Burema
and Frijters20 physical activity questionnaire. The study was
conducted at the Stress Physiology Study Center (CEFE) after
its approval by the Ethics Committee of the Federal University
of São Paulo (UNIFESP) (040/00). The subjects were included
only after they had signed an informed consent statement.
A single physician performed a clinical examination on all
subjects, composed of full anamnesis and general physical
examination.
Anthropometric data on the subjects were obtained using
calibrated scales (Filizola, Brazil), and the body mass index
was calculated (Table 1). The subjects were then subjected to
an incremental ramped test up to the limit of tolerance. The
incremental ramping rate (20 W/min) was adjusted between
the subjects so that the test duration would be between 4 and
10 minutes.
The metabolic, ventilatory and cardiovascular responses
during the UL cycle ergometer test (MET 300, Cybex, Lumex,
Ronkonkoma, NY, USA) were obtained via an integrated digital system for cardiopulmonary exercise tests (Vista CX,
Vacumed, Hans Rudolph, USA). Metabolic and cardiopulmonary variables were obtained and sampled as arithmetic
averages of values determined every 20 seconds. The gas
analyzers were calibrated before each test by using a precise
mixture of gases (16% O2 and 4% CO2). The flow meter was
also calibrated before each test using a syringe with a preestablished volume of three liters (Wyandotte model 7200,
Hans Rudolph, USA), with different flow settings (slow, moderate and fast). The following variables were determined:
Table 1. Mean and standard deviation (SD) values of age, fitness level
according to the Baecke, Burema and Frijters20 score and body mass
index (BMI).
Mean
SD
Age (years)
26.7
2.8
Baecke score
9.2
1.2
BMI (kg/m2)
22.5
1.4
317
Domingos Belasco Junior, Fernando R. Oliveira, José A. N. Serafini, Antonio C. Silva
O2 uptake (VO2, l/min STPD); carbon dioxide production
(VCO2 l/min STPD); respiratory quotient (R); minute ventilation (VE, l/min BTPS); respiratory equivalent for O2 and
CO2 (VE/VO2 and VE/VCO2); partial pressure of O2 and CO2
(PO2 and PCO2, mmHg) and heart rate (HR, bpm). The VO2
of the final last 20 seconds of the ramp was considered to
be the VO2peak. The VT1 VO2 was estimated by means of
the pulmonary gas exchange method, using readings of the
VCO2 inflection point in relation to VO2 (modified V-slope)21
and using the ventilator method. In this, both VE/VO2 and
PO2 increased, while VE/VCO2 and PCO2 remained stable. To
determine VT1, two regions were excluded from the analysis:
the initial two minutes of the protocol, when slower VCO2
kinetics affect the relationships of pulmonary gas exchange,
and the points beyond the respiratory compensation point
(RCP)22. The readings were performed independently by two
experienced observers who did not know the identity of the
subject under evaluation, or the other results relating to
this subject. Taking into account that, for rapid-increment
protocols, the load corresponding to the VO2 point values is
the one that was developed during the preceding time constant23, the VT1 load was considered to be the one manifested
45 seconds prior to the VO2 that was associated with VT121.
VT2 was identified by determining the point at which a progressive increase in the equivalent VE/VCO2 occurred, with
a drop in PCO2 and/or a second abrupt increase in VE after
VT1, plotted as a function of VCO2.
Subsequently, each subject underwent a set of five
different constant load tests performed up to the limit of
tolerance: each test was taken on a different day in a randomized sequence. The protocol was composed of five rectangular loading functions, with a minimum interval of three
days between loads. The aim was to provide better graphic
distribution and greater validity for the CP and anaerobic
work capacity findings3. Loads were selected based on the
results from the incremental test and they corresponded
to approximately 70, 80, 90, 95 and 100% of the difference
found between the VT1 load and VO2peak (VT1 - MAX).
Workloads that could induce exhaustion before reaching one
minute or after a duration of 20 minutes were deliberately
avoided3. In addition, all the subjects were also tested with
a load equivalent to the intercept of the W-1/t relationship.
In this load, VO2 behavior was measured by determining the
Table 2. Mean (SD) values of VO2 and power (W) at peak effort, CP,
VO2peak, VT1 and VT2.
VO2 (l/min)
Power (W)
Peak effort
CP
VT1
VT2
3.060.62
2.660.62
1.620.38
2.360.59
151.0026.30 103.0026.00 69.5021.00 103.5030.80
318
VO2 CP, through identifying the time at which VO2 stabilized. This was found to be between 5 and 10 minutes for all
subjects.
Finally, all the subjects underwent an additional test at a
load that was 5% greater than the load equivalent to the intercept of the W-1/t relationship. Neither the subjects nor the
investigator were informed of the duration of the test or the
power that they should develop. The subjects received encouragement from the investigator, to ensure that they would perform the test to the best of their abilities.
The tests were performed with the subjects maintaining a
cycling frequency of 80 rpm, in accordance with a preestablished protocol for UL ergometry24,25. All the tests were preceded by three minutes under baseline resting conditions and
two minutes of load-free exercise, during which the ventilatory and metabolic parameters were verified. The time taken
to reach fatigue was determined as the interval between the
imposition of the load and the point at which the subject
could not maintain the required pace of cycling (drop greater
than 10%).
The W-t relationship was linearized by means of a load (in
watts) versus the reciprocal of time (1/t), i.e.:
W=W’/t+PC
Therefore, the curvature constant (W’, in kJ) and its asymptote (PC, in W) were determined from the slope and the intercept, respectively, of the line obtained from the difference
between least squares26.
Statistical analysis
After verifying that the variables presented normal distribution (Kolmogorov-Smirnov test), the means and the standard
deviations were identified. The mean values were compared
using one-way ANOVA for paired samples. The levels of association between CP, VT1, VT2 and VO2peak were determined
using the Pearson correlation test. For all tests, significance
level of 5% (=0.05) was established.
Results
The relationship between the power applied and its respective time duration (W-t) was described by a rectangular
hyperbolic function for all assessed subjects, with the following
values: CP=10326 W; W´=7.082.14 kJ; and r=0.98.02. Table 2
shows the values found for the study variables from the progressive test and in relation to CP.
The value of VO2 at CP (VO2CP) was significantly greater
than the values found for VT1 (P<0.001) and VT2 (p<0.05)
and lower than to VO2peak (p<0.05). No significant difference
in W was found between CP and VT2. There were significant
associations between the VO2 and W values at CP and between the values of these variables at peak effort, VT1 and
VT2 (Table 3).
The volunteers continued to perform the rectangular
loading test corresponding to CP for 42.912.9 minutes. One
subject (10%) could not complete 30 minutes of exercise at CP,
reaching fatigue after 20 minutes of exercise. The other subjects
tolerated at least 30 minutes in the rectangular test. However,
at the load that was 5% greater than CP, the subjects reached
fatigue after 13.71.4 min (range: 11.7 to 16.0 min).
Discussion
There has been a series of discussions regarding the mathematical model that would best represent the relationship
between W and t26, the number of loads that would be ideal for
composing the distribution of points on the W versus t graph3
and the amount of time for which a CP load would be bearable.
The high r values for all subjects demonstrated that by using
the reciprocal of time, the relationship was properly linearized with a hyperbolic function. The findings from the present
study emphasize that, similar to LL exercises, the relationship
between W and t for UL exercises is hyperbolic (with r values
ranging from 0.94 to 1.00; p<0.01). This assertion can be seen
from the high r values that were found through linearization
of the relationship between W and the inverse of time duration
(1/t), in accordance with previous observations made by other
authors in LL-related research2,9.
VO2max is an aerobic index that, when measured during
UL exercises, presents values that are around two thirds of the
values obtained during LL exercises among healthy individuals27. The smaller muscle mass of the UL can cause localized
fatigue and cause exercises to be interrupted before the maximum cardiac output is reached. This is why the parameter is
named VO2peak, regardless of whether a plateau is reached21.
Loads that led to CP were calculated as fractions of the
difference between maximum power and VT1. VO2PC and
VO2peak were associated (r=0.73; p<0.05), with significant
differences between the parameters, of 2.660.617 l/min and
3.060.619 l/min, respectively. VO2CP was also significantly greater and correlated with VO2VT1 (1.6210.378 l/min;
r=0.76) and VO2VT2 (2.360.587 l/min; r=0.78). The same trend
was observed among the loads of these variables, with greater
association values found between them (Table 2). These results suggest that the nature of CP is predominantly aerobic,
Table 3. Level of correlation between VO2 and W corresponding to
peak effort, VT1 and VT2 in upper-limb cycle ergometry.
VO2CP (l/min)
WCP (W)
Peak effort
0.73
0.91
VT1
0.76
0.83
VT2
0.78
0.86
as previously reported28,29. Reinforcing this model, W´ did not
correlate significantly to any of the aerobic parameters used
(r=0.04-0.25). This result suggests that these indexes provide
different metabolic representations.
VT2 was calculated from the behavior of ventilatory variables during the ramp protocol. At submaximal intensities,
this usually reveals VO2 values that are lower than those obtained in rectangular loading functions of longer duration, i.e.
over five minutes, like the VO2CP measurement that was used
in this study. The phenomenon that explains this discrepancy
between protocols is the small component of the VO2 kinetics that occurs above VT1. This makes VO2 dependent not
only on load but also on the duration of the exercise, which
can determine different levels of stress when assessing these
variables8.
The associations found between CP and VT1 and VT2
are in agreement with data for UL found by Moritani et al.30.
Among well-trained young students, Dekerle et al.8 found that
CP was greater than VT1 and similar to VT2, with non-significant associations between CP and VT1 (r=-0.08) and LV2
(r=0.07). In contrast to these results, Dekerle et al.8 demonstrated that the intensity at CP was similar to the VT1 intensity, while Nakamura et al.14 found that CP was significantly
greater than VT1 (r between 0.86 and 0.93) and smaller than
VT2 (r between 0.79 and 0.85). These conflicts relating to the
physiological domain of CP can be extended to comparisons
with the intensity of maximum lactate steady state (MLSS)8.
Although a high level of association was found between these
variables (r=0.95), it has been demonstrated that CP is greater
in intensity or that no significant differences occur between
these variables31. Moreover, it was not possible to find a steady state of blood lactate concentration [la] in rectangular
loadings at CP, despite the similarity with the intensity of
MLSS at VO26,32 and perceived exertion14.
Factors related to costs and the small numbers of laboratories that perform ergospirometry tests using UL ergometers
hinder and sometimes even prevent physical therapists from
prescribing appropriate exercises during cardiopulmonary
rehabilitation programs. Methodologically, CP determination
and its use as an estimate of the MLSS is advantageous for
physical therapists who prescribe UL exercises during cardiopulmonary rehabilitation programs. It is easy and feasible to
apply CP determinations, and to produce valid information
for monitoring aerobic endurance ability and the individual
319
Domingos Belasco Junior, Fernando R. Oliveira, José A. N. Serafini, Antonio C. Silva
response to training, while avoiding, for instance, problems of
estimation based strictly on blood lactate values33. However,
it should be noted that the results from the present study did
not make it possible to establish whether CP corresponds to
a greater metabolic need associated with steady lactate. Even
though it was verified that VO2 stabilized under constant loading at CP, no direct measurements of lactate were made, either at this or at other, lower or higher loads. Nonetheless, the
mean time duration at CP was 42.912.9 min (minimum of 20
min). None of the subjects maintained the load of 5% above
CP for more than 20 minutes (13.71.4 min), which favors the
use of CP as an approximation for the intensity of the MLSS in
UL exercises. Regardless of the way in which CP is expressed,
it appears to belong to a transition zone between intense and
very intense domains.
Regarding the CP load, the value found for the pulmonary exchange rate was 0.980.02, which corresponded to
an intensity predominantly from the use of energy from carbohydrate metabolism34. Over a period of time sustaining
this load, this energy path is progressively depleted, and its
depletion may be the main cause of fatigue. From the time
taken to reach exhaustion and the features of the UL exercises practiced at intensities higher than CP, the main reason
for terminating the exercises was correlated with increases
in metabolic acidosis.
Future investigations with larger samples and involving the
W-t relationship for UL exercises should be performed using
different protocols, cycling paces and interruption criteria.
They should also include the use of analogue scales of perceived effort and located electromyography10,11,24,35, particularly
emphasizing additional studies on the relationship between
the maximum lactate steady accumulation rate and CP.
The power applied and the respective duration of a tolerance relationship for high-intensity dynamic UL exercises
were characterized by a rectangular hyperbolic function. The y
asymptote of this relationship (CP) represented a load similar
to VT2, which was likely to be sustained for a prolonged period
of time and with t similar to the one commonly found in LL. CP
was significantly associated with indicators of aerobic metabolism, such as VO2peak, VT1 and VT2.
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ISSN 1413-3555
©
ORIGINAL ARTICLE
Determinant factors of functional status
among the oldest old
Silvana L. Nogueira1, Rita C. L. Ribeiro1, Lina E. F. P. L. Rosado1, Sylvia C. C. Franceschini1, Andréia Q. Ribeiro1, Eveline T. Pereira2
Abstract
Background: The fastest-growing age group in Brazil and around the world is the oldest-old group (aged 80 and over). Among
these individuals, the prevalence of disability and morbidity is higher than in other groups. Objectives: To investigate the influence of
socioeconomic, demographic, biological, health, nutritional, and social factors, as well as perceived health, on the functional status of
the oldest old. Methods: This was a cross-sectional population-based study in which the data were collected by means of questionnaires
and anthropometric measurements. The functional status was evaluated according to the model developed by Andreotti and Okuma
(1999). Univariate and multivariate analyses were used. Results: The independent factors associated with worse functional status were:
age 85 years and over (OR=2.91), female gender (OR=0.69), continuous use of five or more medications (OR=2.67), no visits to friends
and/or relatives at least once a week (OR=11.91), and worse perceived health relative to peers (OR=4.40). Conclusions: The results
suggest that functional status is associated with a complex web of multidimensional factors. Thus, it is important to develop programs
related to the factors that are susceptible to intervention in order to provide a better quality of life to the oldest old.
Key words: functional status; daily activities; older adult; logistical models; aging; older adult health.
Resumo
Contextualização: A faixa etária que mais cresce no Brasil e no mundo é a de idosos com 80 anos e mais. Entre esses indivíduos,
a prevalência de incapacidades e morbidades é maior que em outros grupos. Objetivos: Investigar a influência de fatores
socioeconômicos, demográficos, biológicos e de saúde, nutricionais, de relações sociais, além da auto-avaliação da saúde sobre a
capacidade funcional de idosos longevos (80 anos e mais). Métodos: Trata-se de um estudo transversal, de base populacional, em
que os dados foram obtidos por meio de questionários e medidas antropométricas. A capacidade funcional foi avaliada utilizando-se
o modelo desenvolvido por Andreotti e Okuma (1999). Foram realizadas análises univariada e multivariada. Resultados: Os fatores
independentes associados à pior capacidade funcional foram: ter 85 anos e mais (OR=2,91), ser do gênero feminino (OR=6,09), fazer
uso contínuo de cinco ou mais medicamentos (OR=2,67), não visitar parentes e/ou amigos pelo menos uma vez por semana (OR=11,91)
e considerar a própria saúde pior que a de seus pares (OR=4,40). Conclusões: Os resultados sugerem que a capacidade funcional está
associada a uma complexa rede de fatores multidimensionais, sendo importante o desenvolvimento de ações relacionadas àqueles
fatores que são passíveis de intervenção, visando propiciar melhores condições de saúde e qualidade de vida a esses indivíduos.
Palavras-chave: capacidade funcional; atividades cotidianas; idoso; modelos logísticos; envelhecimento; saúde do idoso.
1
Department of Nutrition and Health, Universidade Federal de Viçosa (UFV), Viçosa (MG), Brazil
2
Department of Physical Education, UFV
Correspondence to: Silvana Lopes Nogueira, Av. José Maria dos Santos, nº 345, Centro, CEP 36.550-000, Coimbra (MG), Brazil, e-mail: [email protected]
322
Functional status among the oldest old
Introduction
The increase in longevity is a global phenomenon, and the
fastest growing age group in the world is the oldest-old group,
aged 80 and over1. In 1980, this group numbered 591,000 individuals in Brazil, and it is estimated that, by 2050, this number
will reach 13.8 million. This represents an increase of 2,226%,
while the total population will increase 81.6% and the older
adult population 436% in the same period2.
This phenomenon outlines a series of social, cultural and
epidemiological implications due to the greater prevalence of
morbidity and disability in this age group. Nevertheless, there
are few studies on the oldest old to provide knowledge of the
health conditions of this segment of the Brazilian population3,4.
Among the studies on aging, morbidity is one of the main health
indicators analyzed. Few studies have assessed functional status and autonomy, despite the fact that these indicators are often more important than morbidity as they are directly related
to quality of life5.
Functional status refers to the individual’s ability to live
independently and to relate to their environment. Loss of
functional status is associated with increased risk of institutionalization and falls6 and, in some studies on the oldest old,
it was considered an independent risk factor for mortality7,8.
Numerous studies have shown an association between aging
and higher risks of functional dependence9-12, as well as a high
prevalence of functional disability or limited functional ability
in the older adult population13-16. These studies highlight that
the added years of life should be accompanied by quality of
life and should be free from the high cost of dependence. The
decline in functional status may also be associated with a number of multidimensional factors that interact to determine this
status in older adults17-19. Early detection of these factors can
help prevent functional dependence in this group.
The above arguments demonstrate the importance of research on the determinants of functional status in older adults,
considering the possibility of intervention and prevention
measures by healthcare professionals (e.g. physical therapists)
and through public policy planning. Thus, the present study
aimed to determine the factors associated with functional
status in the oldest old, taking into account socioeconomic,
demographic, health, nutritional, and social dimensions.
Methods
This was a cross-sectional population-based study on
the oldest old (80 years and over) carried out in São Geraldo,
MG, Brazil, between February and May 2008. The town of
São Geraldo is among the 20 municipalities of the state of
Minas Gerais with the highest percentage of older adults. It
also has the highest rate of oldest old in its county. The study
was approved by the Human Research Ethics Committee of
Universidade Federal de Viçosa (UFV), Viçosa (MG), Brasil
(protocol no. 058/2007).
The sample included 129 non-institutionalized oldest-old
participants of both genders, which represents 96.3% of the
total population of that age group living in the urban area of
São Geraldo. The participants were contacted based on records kept by the Family Health Program (FHP), and all of them
signed an informed consent form. Screening for dementia was
conducted by searching FHP records and by taking reports
from the caregivers. Although in some cases the questions
were answered by the caregivers, and it is believed that this has
not compromised the validity of the results.
Prior to the data collection, a pilot study was carried out
to train the interviewers and adjust the assessment tools. The
questionnaire with the variables of interest was administered by
the interviewers. The main researcher took the anthropometric
measurements and administered the questionnaires to evaluate
functional status (FS) and social relations. Data collection was
carried out at the participant’s home, and most of the participants answered the questionnaires alone, but in the presence of
a caregiver. In 12.4% of the cases, the answers were supplied by
the caregiver because the participant was unable to do so.
Based on the anthropometric measures of weight and
height, the body mass index (BMI) was calculated using the
formula: weight/height2. For the diagnosis of nutritional
status, the cut-off points proposed by Lipschitz20 were
used. This author classifies BMI values lower than 22 kg/m2
as underweight, values between 22 kg/m2 and 27 kg/m2 as
normal, and values above 27 kg/m2 as overweight. Waist
circumference (WC) was measured during the normal expiratory movement at the midpoint between the last rib and
the iliac crest, with the individual in the standing position.
The cut-off points recommended by the World Health Organization21 were adopted. The WC was not measured in the
participants who were unable to stand, and their height was
estimated by measuring knee height and using the equation
proposed by Nahas22. There was a sample loss of 9.3% for
these measures.
Besides the anthropometric measures described, the questionnaire consisted of the following groups of variables:
• Socioeconomic and demographic characteristics: gender,
age, educational level, marital status, income, history, and
time of residence in rural areas23.
• Biological and health variables: use of health services and
medications, self-rated vision and hearing, occurrence
323
Silvana L. Nogueira, Rita C. L. Ribeiro, Lina E. F. P. L. Rosado, Sylvia C. C. Franceschini, Andréia Q. Ribeiro, Eveline T. Pereira
•
•
of falls in the three months prior to the study, and self-reported morbidities, grouped according to the International
Classification of Diseases (ICD)24. The information on continuous medications was confirmed by checking the labels.
Polypharmacy was defined as the simultaneous use of five
or more medications25.
Social relations: visiting friends and/or relatives at least
once a week, taking part in social programs, being part of a
religious group, and attending social events.
Perceived health: self-rated health and health relative to
peers.
Statistical analyses were performed using Epi Info 6.04 and
STATA 7.0 and consisted of univariate and multivariate data
analysis. FS was considered the dependent variable. To evaluate FS, we used a model developed by Andreotti and Okuma26,
which includes 40 questions (worth 4 points each) on activities
of daily living (ADLs) and instrumental activities of daily living (IADLs). According to the total score, the participants were
classified as having very poor, poor, regular, good or very good
FS. For data analysis, the participants were grouped into two
categories: those with very poor, poor and regular FS (worse
functional status) and those with good and very good FS (better functional status).
For the univariate analysis, the Chi-Square test and Fisher’s
exact test were carried out, and the association measure selected was odds ratio (OR). According to the results of the univariate analysis, the variables associated with the dependent
variable with a p value <0.20 were selected for multivariate
modeling. The multivariate analysis was performed by means
of multiple logistic regressions using a hierarchical selection
model.
The construction of models was based on the theoretical model proposed by Victora et al.27, in which the variables
were grouped into blocks according to the order of influence
on functional status. Thus, the more distal variables served
as adjustment factors for the hierarchically inferior blocks
and were maintained in the other models, even if their statistical significance was not preserved. As demonstrated in
Appendix 1, the socioeconomic and demographic variables
were considered distal determinants; the biological, health
and social variables were considered intermediate determinants; and the self-reported health variables were considered
proximal determinants.
For the interpretation of the regression results, p<0.05 was
considered to indicate statistically significant differences and
independent association between a particular factor and worse
functional status (WFS) after adjustment for possible factors in
the same block and in the higher hierarchical blocks. The Wald
324
test comparing the models of the different blocks was carried
out to test the statistical significance.
Results
One hundred and twenty-nine older adults were evaluated, and almost 53% were female. The age ranged from 80
to 96 years (median=83 years), with approximately 65% under 85. A considerable percentage of the older adults were
widowed (46.5%), most of them earning between one-half
and three times the minimum wage. The mean educational
level was 2.4 years. The vast majority had resided in rural
areas (80%), and more than half lived in the countryside for
more than 26 years. Most of the participants had very good
or good functional status (71.3%), and nearly one-quarter of
them were underweight. Approximately one-third used public health services exclusively, and 41% rated their health as
good or excellent.
Table 1 shows the results of univariate analysis between
the socioeconomic and demographic variables and FS. Female
gender, age group and the absence of a spouse were significantly associated with WFS. As described in Table 2, several
factors related to biological and health aspects have also been
associated with WFS, such as polypharmacy and certain morbidities such as depression, arthropathies, and nervous system diseases. Regarding the social relations aspects (Table 3),
the factor “no visits to friends and/or relatives at least once
a week” showed a positive association with WFS as did the
factor “not taking part in social programs and not attending
social events”. There was also a positive association between
worse perceived health in relation to peers and worse FS.
Table 4 shows the results of the multiple logistic regressions using a hierarchical selection model. Model 1 shows
that the individuals over 85 years of age are three times more
likely to have functional dependence than younger individuals. Additionally, the older women are six times more likely to
have WFS than older men. After adjusting for socioeconomic
and demographic factors (Model 2), we found a positive and
independent association between polypharmacy and WFS.
WFS was also independently associated with the factor “no
visits to friends and/or relatives at least once a week” after
the adjustment for socioeconomic, demographic, biological
and health factors (Model 3). Worse perceived health relative to peers, after adjustment for the variables of the more
distal blocks, was an independent factor associated with
WFS (Model 4). The Wald test showed that the inclusion of
each block of variables contributed significantly to the model
adjustment.
Table 1. Association between socioeconomic/demographic variables and functional status. São Geraldo, MG, Brazil, 2008.
Variables
Gender
Male
Female
Group age
<85 years
85 years
Spouse
Living
Deceased/None
Education level (years)
>2 years
2 years
Worse functional
status %
Better functional
status %
Gross OR
(IC 95%)
4.7
24
42.6
28.7
1.00
7.68 [2.70-22.91]
<0.001
13.2
15.5
53.5
17.8
1.00
3.53 [1.58-7.86]
0.002
6.2
22.5
34.1
37.2
1.00
3.32 [1.28-8.88]
0.006
12.4
16.3
40.3
31
1.00
1.71 [0.74-3.96]
0.172
p
Table 2. Association between biological/health variables and functional status. São Geraldo, MG, Brazil, 2008.
Variables
Number of medications
Up to four
Five or more
Nervous system disease
No
Yes
Circulatory system disease
No
Yes
Arthropathy
No
Yes
Depression
No
Yes
WC
Appropriate
IR or HIR
Falls in the last 3 months
No
Yes
Self-rated vision
Good/excellent
Regular/poor/very poor/blind
Self-rated hearing
Good/excellent
Regular/poor/very poor
Worse functional
status %
Better functional
status %
Gross OR
(IC 95%)
p
10.8
17.8
47.4
24
1.00
3.23 [1.46-7.14]
0.003
16.3
12.4
57.4
13.9
1.00
3.13 [1.26-7.81]
0.005
3.1
25.6
17
54.3
1.00
2.59 [0.76-9.70]
0.071*
8.5
20.1
37.2
34.2
1.00
2.58 [1.07-6.33]
0.021
17.8
10.8
57.4
14
1.00
2.50 [1.00-6.30]
0.03
5.1
20.5
29
45.4
1.00
2.57 [0.88-7.86]
0.057
17.8
10.9
55.8
15.5
1.00
2.19 [0.88-5.44]
0.060
11.6
17.1
41.1
30.2
1.00
1.99 [0.92-4.33]
0.079
14
14.7
45.7
25.6
1.00
1.89 [0.87-4.09]
0.105
* Fisher’s exact test; WC=waist circumference; IR=increased risk; HIR=high increased risk.
Discussion
The relevance of the present study is in the fact that there
are few studies on the living and health conditions of the oldest
old in Brazil. Therefore, it investigated the determinants of FS,
one of the most important health indicators in older adults. It is
also important to conduct studies outside large urban centers
as 71% of Brazilian towns have up to 20,000 residents and account for 18% of the total population28. It is worth noting that,
although the present study was conducted with older residents
in an urban area, it took place in a provincial town with typically rural characteristics, e.g. less motorized transport, more
contact with the rural environment, and country traditions
such as meeting friends in the town square.
325
Table 3. Association between social relations/perceived health and functional status. São Geraldo, MG, Brazil, 2008.
Variables
Visiting friends and/or relatives
Yes
No
Taking part in social programs
Yes
No
Attending social events
Yes
No
Being part of a religious group
Yes
No
Perceived health in relation to peers
Better/same
Worse
Worse functional
status %
Better functional
status %
Gross OR
(IC 95%)
p
2.3
26.4
36.4
34.9
1.00
11.84 [3.16-52.18]
<0.001*
6.2
22.5
31.8
39.5
1.00
2.91 [1.12-7.79]
0.015
1.5
27.2
17
54.3
1.00
5.5 [1.15-35.93]
0.010*
17
11.7
51.9
19.4
1.00
1.83 [0.76-4.39]
0.138
16
8.4
68
7.6
1.00
4.26 [1.55-11.69]
0.003
* Fisher’s exact test.
Table 4. Factors independently associated with worse functional status
among the oldest old. Multiple logistic regressions using a hierarchical
selection model. São Geraldo, MG, Brazil, 2008.
Variables
Adjusted OR [CI 95%]
p
Model 1 – socioeconomic and demographic aspects
Age group
< 85 years
1.00
 85 years
2.91 [1.21-6.99]
0.017
Gender
Male
Female
1.00
6.09 [2.16-17.14]
0.001
Model 2 – Biological and health
aspects *
Number of medications
Up to four
Five or more
1.00
2.67 [1.01-7.04]
0.047
Model 3 – Social activity aspects **
Visits to friends and/or relatives at
least once a week
Yes
1.00
No
11.91 [2.89-49.07]
0.001
Model 4 – Perceived health ***
Perceived health in relation to peers
Better/same
Worse
1.00
4.40 [1.09-17.76]
0.037
*Adjusted by socioeconomic and demographic aspects; ** Adjusted by biological and
health aspects; *** Adjusted by social activity aspects.
It was observed that 71% of the oldest old in this study had
good or very good FS, reflecting a high degree of independence
326
in this population, particularly as concerns individuals with
advanced age. Considering the methodological differences,
this result is similar to that observed in studies conducted in
developed countries such as Portugal and China. In Portugal,
62% of patients aged 75 and over had better FS29. In China, a
longitudinal study on the oldest old identified a prevalence of
ability to perform ADLs of 83% among octogenarians and of
63% among nonagenarians30. We found no national surveys
that evaluated the prevalence of functional disability specifically in the oldest old. Moreover, the protocols used by other
studies were different, besides the cultural issues, which limit
the comparison with the present results.
The higher risk of functional dependence with age demonstrated in the present study confirms the results of other
national and international studies with respect to aging as
an important risk factor for the reduction in FS10,12,17,31,32. The
present study also showed a strong association between female
gender and FS after adjustment for the control variables. This
result is consistent with the findings of other studies on older
adults in general11,19,33,34 and on the oldest old35,36. In contrast,
this result differs from that observed in studies carried out in
Belo Horizonte and São Paulo, although these studies were not
specific to the oldest old14,18.
The greater risk of disability among the female older
adults can be attributed to a longer survival rate and also
to the slight inability shown in adulthood, thus leading to
increased risk of developing some degree of functional disability35. In a cohort of older adults, Murtagh and Hubert37
compared the determinants of functional disability in men
and women and observed a high prevalence of non-fatal
conditions associated with functional disability such as
depression, fractures, and osteoporosis, which contribute
substantially to greater disability among the older women
compared to older men.
The study participants showed, on average, five self-reported
morbidities, with 96% reporting at least one disease. However,
there was no independent association between morbidities
(both grouped and isolated) and FS. Although advanced age is
often accompanied by several morbidities, having a diagnosed
illness does not necessarily imply the same degree of impairment in health levels and in ADL and IADL performance38. Independence is predictive of successful aging in both men and
women39.
With regard to the observed association between polypharmacy and WFS, few studies that observed this issue were identified in the literature, and the present results are consistent
with some of them40-43. Pérès et al.43 observed a positive association between the progression of disability and the number of
medications ( four or more) in a cohort of older adults (65 years
and over). High medication intake may constitute a measure
of the individual’s health status43. Furthermore, it may reflect
aspects other than co-morbidities, such as the severity of the
co-morbidity or the probability of iatrogenesis and/or the use
of inadequate medications44. Hanlon et al.45 found a significant
association between inappropriate use of medications and the
decline in FS in a cohort of community-dwelling older Americans (65 to 105 years).
Certain medications can be associated with a worse functional performance, such as anticholinergic drugs46. Moreover,
polypharmacy and the use of specific medications (such as
benzodiazepines) may be associated with increased risk of
falls in older adults47,48. This fact highlights the important role
of medications in maintaining health and FS in this age group.
Therefore, steps must be taken to promote the appropriate prescription of medicine in health care.
Among the observed results, it is important to point out the
independent association between social relations and FS. Although it is not possible to determine the direction of this association due to the cross-sectional design of the present study, the
results are consistent with the findings of other longitudinal49,50
and cross-sectional14,18,51 studies. Besides improving FS, the social
life of older adults seems to positively affect memory capacity.
Older adults who are more integrated into the community have
slower memory loss than those who have no active social life52.
They are also less likely to have depression53.
In a longitudinal study carried out in Denmark, the diversity of social relations and high social participation were
important factors in maintaining FS among older adults
aged 75 and over. Conversely, the lack of social support was
a risk factor for functional decline among men aged 80 and
over49. Boult et al.54 also identified social support as a protective factor against functional decline, although another
study55 did not find a significant association between social
support and FS.
The association observed between worse perceived
health in relation to peers and WFS was also found in other
studies11,14,17,31. Perceived health is a general subjective measure
that includes cognitive, emotional and physical aspects56
that has emerged as an important health indicator. In some
studies8,57-59, it was considered a strong indicator of mortality
in older adults.
Conclusion
After hierarchical modeling, it was observed that age of 85
years and over, female gender, continuous use of five or more
medications, no visits to relatives and/or friends at least once
a week, and worse perceived health relative to peers are factors independently associated with worse FS in the oldest old,
which shows the existence of a complex web of factors associated with FS in this population. Caution is advised when
extrapolating the results to other groups of oldest old due
to cultural, socioeconomic and lifestyle differences. It is also
important to note that FS was assessed by self-reports as the
advanced age of the participants would hinder a direct evaluation, especially considering ethical issues. Further studies are
needed in this direction.
Considering the significant increase in the number of the
oldest old forecasted in the coming decades in Brazil and
the relevance of this topic, it is important to emphasize the
preventable nature of some of the factors associated with the
FS level in the present study, such as the number of medications and social relations. Actions that promote the rational
use of medications and strategies that enhance the social
inclusion of older adults may help to reduce the prevalence
of functional dependence and improve health and quality of
life in the oldest old.
327
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Appendix 1
Theoretical mark for the investigation of socioeconomic, demographic,
epidemiological and nutritional determinants of functional status in the
oldest old, structured in hierarchical blocks.
Socioeconomic and demographic aspects: age, gender,
educational level, time of residence in rural areas, marital status,
income
Biological and health aspects: use of health services health and
medications, self-rated vision and hearing, occurrence of falls in
the last three months, number of daily meals, waist circumference
and self-reported morbidities.
Social relations: Visiting friends and/or relatives at least once a
week, taking part in social programs, attending social events and
being part of a religious group.
Perceived health: perceived health and perceived health in relation to peers.
FUNCTIONAL DISABILITY
329
ISSN 1413-3555
©
ORIGINAL ARTICLE
Head and shoulder alignment among patients
with unilateral vestibular hypofunction
Alinhamento de cabeça e ombros em pacientes com hipofunção
vestibular unilateral
Adamar N. Coelho Júnior1, Juliana M. Gazzola1, Yeda P. L. Gabilan2, Karen R. Mazzetti2, Monica R. Perracini3, Fernando F. Ganança2
Abstract
Objectives: To investigate head and shoulder alignment among patients with unilateral vestibular hypofunction (UVH), using computerized
biophotogrammetry (CB) and to correlate these measurements with gender, age, duration of clinical evolution, self-perception of intensity
of dizziness and occurrences of falls. Methods: This was a cross-sectional study. Thirty individuals with UVH and 30 with normal vestibular
function and without complaints of dizziness underwent CB in the anterior, right and left and posterior views, in an upright standing
position. Alcimage™ 2.0 was used to evaluate three angles in order to verify the anterior deviation and inclination of the head, and the
alignment of the shoulders. The groups were paired according to age, gender and height. The statistical analysis consisted of the MannWhitney test, Kruskal-Wallis test followed by the Dunn test, and the Spearman Correlation Coefficient. Results: The patients with UVH had
greater forward (55.4416.33) and lateral (2.031.37) head deviation angles than did the normal individuals (34.344.60 and 1.341.05
respectively), with a statistically significant difference (p<0.001). The increment of forward and lateral deviation in the UVH group was
38.05% and 33.78% respectively. Forward head was associated with the duration of clinical symptoms of the vestibular disease (p=0.003),
age (p=0.006), intensity of dizziness (p<0.001) and occurrence of falls (p=0.002). Conclusions: Patients with UVH had greater forward
and lateral head deviations. Forward head deviation increased with age, duration of clinical symptoms and greater self-perception of the
intensity of dizziness. Forward head deviation was also greater among patients who reported having had falls.
Key words: vestibular diseases; dizziness; posture; assessment; photogrammetry.
Resumo
Objetivos: Avaliar o alinhamento de cabeça e ombros de pacientes com hipofunção vestibular unilateral (HVU) por meio da biofotogrametria
computadorizada e associar esses dados com gênero, idade, tempo de evolução clínica, autopercepção da intensidade de tontura e
ocorrência de quedas. Métodos: Trata-se de estudo transversal em que 30 indivíduos com HVU e 30 indivíduos com função vestibular
normal e sem queixa de tontura foram submetidos à biofotogrametria computadorizada. Foram registradas imagens em vistas anterior,
posterior, laterais direita e esquerda em ortostatismo. O programa Alcimage® 2.0 foi usado para avaliar três ângulos que permitem
verificar anteriorização e inclinação da cabeça e alinhamento dos ombros. Os grupos foram pareados por idade, gênero e estatura. Para
a análise estatística, realizaram-se os testes de Mann-Whitney, Kruskal-Wallis, seguidos do teste de Dunn e Coeficiente de Correlação de
Spearman. Resultados: Pacientes com HVU apresentam maiores valores para os ângulos de anteriorização (55,4416,33) e de inclinação
lateral da cabeça (2,031,37) quando comparados aos indivíduos normais (34,344,60 e 1,341,05, respectivamente), com diferença
estatisticamente significante (p<0,001). O aumento da anteriorização e da inclinação lateral da cabeça do grupo de indivíduos com
HVU foi de 38,05% e 33,78% respectivamente. A anteriorização da cabeça foi associada com o tempo de evolução clínica da doença
vestibular (p=0,003) com a idade (p=0,006), com a intensidade da tontura (p<0,001) e com a ocorrência de quedas (p=0,002). Conclusão:
Pacientes com HVU apresentam maior anteriorização e inclinação lateral da cabeça. A anteriorização da cabeça aumenta com a idade,
com o tempo de evolução clínica, maior auto-percepção da intensidade da tontura e nos pacientes que relataram quedas.
Palavras-chave: doenças vestibulares; tontura; postura; avaliação; fotogrametria
1
Vestibular Rehabilitation and Social Inclusion Program, Universidade Bandeirante de São Paulo (UNIBAN), São Paulo (SP), Brazil
2
Department of Otorhinolaryngology and Head and Neck Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil
3
Master’s Program in Physical Therapy, Universidade Cidade de São Paulo (UNICID), São Paulo (SP), Brazil
Correspondence to: Karen Renate Mazzetti, Rua Cantagalo, 980, apto 124, Tatuapé, CEP 03319-000, São Paulo (SP), Brazil, e-mail: [email protected]
330
Head and shoulder alignment in vestibular hypofunction
Introduction
Peripheral vestibular syndromes have relatively high prevalence from the fourth decade of life onwards, and may manifest through vertigo and other kinds of dizziness, nystagmus,
postural instability, gait disturbances, falls and changes in body
alignment1. In the United States, the general population have
an incidence of dizziness of approximately 5.5%, which implies
that more than 15 million people develop this symptom every
year2.
The sense of head position, and consequently the alignment
expressed by body posture is influenced by proprioceptive sensory information from the receptors located in the neck and
by the information provided by the vestibular system. There
is a vast network of anatomical connections between the vestibular system and the proprioceptive information from the
neck. If one piece of information from the vestibular system
regarding the position and alignment of the head is imprecise,
or if there is a fault in integrating this information with the central nervous system, an error in head position may occur, thus
resulting in a distorted sense of the positional reference sense
of the head and neck3. Humans with sudden unilateral loss of
vestibular function have lateral deviation of the head towards
the side of the injury during this acute phase4.
Patients with uncompensated unilateral vestibular hypofunction (UVH) and those who are not going through a vertigo
crisis may adopt a rigid head posture, tilting it and rotating it
towards the injured labyrinth in an attempt to avoid the symptoms of the disease. Moreover, such postural abnormalities
may negatively affect body alignment and the projection of the
center of gravity within the support base, thereby resulting in
complaints relating to balance1,5.
Lateral deviation of the head may occur because of otolith
dysfunction or simply through contraction of the sternocleidomastoid or trapezius muscles. In turn, backward deviation
of the head may cause mechanical compression of the upper
cervical spine, thus bringing about a reduction in mobility of
the soft tissues and joints in this segment, and increasing the
perception of dizziness6.
In general, patients with peripheral vestibular dysfunction
suffer from reduction in flexibility and in the capacity to relax.
One study pointed out that about half of such patients demonstrate reductions in their range of motion in the neck, temporomandibular joints, shoulders and dorsal spine. Between 70 and
94% of such patients have contractions in the upper trapezius
and sternocleidomastoid muscles when they receive muscle
palpation7.
Postural alignment assessments may be carried out in the
conventional manner, as described by Kendall, McCreary and
Provance8, by observing the individual in an upright standing
position in all four views (anterior, posterior, right and left lateral) and by using a plumb line. More recently, methods using
digital equipment to acquire images, such as computerized
biophotogrammetry (CB), have been used to assess body alignment. CB is a noninvasive, low-cost, high-precision method
that also have good reproducibility of the results9-13.
Investigation of possible abnormalities of body alignment
in individuals with uncompensated UVH might imply a need
to adopt specific therapeutic measures with the aims of correcting these abnormalities and probably improving body
balance, as well as preventing and limiting postural abnormalities in occupational situations or among older individuals.
No studies dealing with assessments on head and shoulder
alignment among such patients using CB were found in the
scientific literature.
The objectives of this study were to compare head and
shoulder alignment measurements between patients with UVH
and individuals without dizziness and normal otoneurological
assessments, by means of CB, and to investigate associations
between such measurements and sex, age, duration of clinical
evolution of the vestibular dysfunction, self-perception of the
intensity of dizziness and occurrences of falls during the preceding year.
Methods
This was a cross-sectional study approved by the Ethics
Committees of Universidade Bandeirante de São Paulo (UNIBAN), in accordance with protocol number 30/2004.
The sample was made up of 60 individuals with ages ranging from 40 to 60. Thirty were in the UVH group (UVHG) and
thirty were in the control group (CG), matched according to
sex, age and height. The UVH patients were recruited from the
otoneurology laboratory of a college hospital. They underwent
anamnesis, physical tests, audiometry test, tympanometry,
assessment of the stapes reflex thresholds and vestibular tests
conducted using electronystagmography. The diagnosis of
UVH was made whenever there was a reduction in or absence
of the vestibular response to the caloric test, i.e. the main phase
of electronystagmography. For the diagnosis to be positive, the
maximum speed of the slow phase of the post-caloric nystagmus, during caloric irrigation with water at 30º C or 44º C, needs to be lower than three degrees per second on the affected
side (with hypofunction), and the asymmetry between the responses of the two ears (both sides) must be greater than 25%,
as measured using Jongkees’ formula14,15. The UVHG reported
suffering from chronic dizziness characterized by the presence
of this symptom on at least three days a week over the preceding three months16.
331
Adamar N. Coelho Júnior, Juliana M. Gazzola, Yeda P. L. Gabilan, Karen R. Mazzetti, Monica R. Perracini, Fernando F. Ganança
The CG individuals, who did not have any dizziness or
other vestibular complaints, and had normal results from
the otoneurological assessment, were recruited from the
university community of students, professors and ancillary
employees.
Individuals in either the UVHG or the CG who had orthopedic diseases in the cervical, dorsal and/or lumbar spine that
might cause postural changes, abnormalities in the girdle or
lesions in the brachial plexus were not included. Patients with
central or mixed vestibular diseases, neurological diseases, physical deformities (both congenital and acquired) and obesity
to the extent that it was impossible to locate the anatomical
spots were also excluded from the study. Finally, patients with
abnormalities in the knee axis (varus or valgus) or in the foot
axis (planus or cavus) were also excluded, in order to avoid any
interference in relation to the body alignment. All the patients
signed a free and informed consent statement in order to participate in this study.
The individuals were assessed in relation to sociodemographic information (sex and age), as well as clinical data (time
elapsed since the onset of the symptoms, self-perception of the
intensity of dizziness and occurrences of falls during the preceding year). The time elapsed from the time when the symptoms
were first noticed was classified as follows: 3 to 12 months;
more than 12 months and up to 36 months; and more than 36
months. The self-perception of the intensity of dizziness was
classified according to a visual analogue scale (VAS) that consisted of a line graded from 0 to 10, in which 0 corresponded to
absence of dizziness, and 10 to the maximum degree of dizziness that could be experienced by patients.
For the postural assessment of head and shoulder alignment, the individuals wore swimsuits and were barefoot. If
they did not have short hair, it was tied at the top of the head.
No accessories (earrings, necklaces, headbands, etc) were worn
during the assessment. The requirements followed the criteria
suggested by Kendall, McCreary and Provance8 and Magee17.
Five anatomical spots were located and were marked using
white styrofoam ball markers of 2cm in diameter, attached
with double-sided scotch tape, in order to facilitate viewing:
spots 1 and 2 (on the two temporomandibular joints); spots 3
and 4 (on both acromia); and spot 5 (on the C7 spinous process). In order to locate the anatomical spots, we followed the
principles of palpatory anatomy18. The same appraiser marked
all the individuals.
The support base adopted for all positions was the one recommended by Kendall, McCreary and Provance8. It consisted
of positioning the ankles at about 7.5cm from each other and
the anterior part of each foot turned out by 10º from the midline, thereby forming a 20º angle between the two first toes.
The distance from the camera to the subject was always set
332
at 3m; from the subject to the nearest wall, 30cm; and from
the camera to the floor, 1.20m (measurement made from the
camera lens to the floor). The individuals were instructed to
remain in an upright standing position and to look at a spot
marked on the wall in front of them, at eye level. They were
allowed to wear glasses or lenses, when necessary. Four images
were taken, with the same support base, in the anterior, right
and left lateral and posterior views. Another researcher stood
near to the individuals to hold them in case the subjects felt
unsteady10,13.
The camera used was a 2.0 megapixel digital Kodak Easy
Share camera, model CX 4200, using optimum resolution and
without using the zoom. The tripod used to fix the camera in
position was a FanCier FT–363, which has a level indicator
consisting of a liquid environment surrounded by acrylic, with
an air bubble inside it. The camera lens was placed perpendicularly to the floor of the room, and in a parallel plane to the
subject who was being photographed. All the images were shot
with the camera in horizontal position10,13.
The operational software ALCIMAGE® that was used in this
study transforms image pixels into Cartesian axes, thus making
it possible to calculate a selected angle through marking out
three Cartesian axes, with accuracy to three decimal places10,13.
This software was incorporated into the CB, thereby promoting
greater reliability in assessing body posture.
In order to determine the extent of head protrusion, the C7
angle was formed between a straight line that was drawn to
join the temporomandibular joint and the C7 spinous process
and another vertical, ascending straight line, starting at the C7
spinous process (Figure 1). The bigger this angle was, the more
the head was slanting backwards. Because this angle was measured twice (right and left profiles), the mean between them
was used in interpreting the data10,13.
To determine the head alignment, the temporomandibular interjoint angle (TMIJ) was used. This was obtained as
the intersection of a line defined by the temporomandibular
joints with a reference horizontal line, parallel to the floor,
originating in one of the temporomandibular joints in the anterior view (Figure 1). The bigger this angle was, the bigger the
head deviation was. To determine the shoulder alignment,
the interacromial angle was measured. This was formed by
the intersection of a straight line between the acromia, with
a horizontal straight line as a reference, parallel to the floor,
starting at one of the acromia in the anterior view (Figure 1).
The bigger this angle was, the greater the asymmetry of the
shoulders was19. The pictures were taken always by the same
appraiser, who did not know which group the subjects belonged to. Backward inclination and deviation of the head were
also calculated as percentages, as was shoulder asymmetry in
the UVHG in relation to the CG.
The Mann-Whitney nonparametric test was used for comparative analysis of the ages ( full years) between the UVHG
and CG. The value of each angle in the UVHG and CG was
compared in relation to sex by using the Mann-Whitney test.
The associations between these angles and the groups were
investigated using the Mann-Whitney test. In the inferential
analyses between the angles studied and the clinical and
demographic variables, only the angles showing a significant difference between the UVHG and CG were considered.
Nonparametric tests were used because of the asymmetry
and variability of the scoring of the variables analyzed, and
because of the absence of normal distribution shown by the
Kolmogorov-Smirnov test (n=60).
For the inferential analysis on the UVHG, the value of each
angle assessed was compared between the variables studied
through the Mann-Whitney and Kruskal-Wallis tests, followed
by Dunn’s test. In order to assess the correlations between the
angles obtained in the UVHG and CG and the quantitative
variables, Spearman correlation coefficients () were used.
Nonparametric tests were used because of the asymmetry and
variability of the scoring of the variables analyzed and because
of the absence of normal distribution shown by the ShapiroWilk test (n=30). The significance level used for the statistical
tests was set at 5% (=0.05).
the cases of 15 patients (50.0%); 12 to 36 full months for 13
(43.3%); and more than 36 months for two patients (6.7%).
The etiologies of the vestibular dysfunction were as follows:
23 cases (38.3%) of benign paroxysmal positional vertigo;
22 cases (36.7%) of Ménière’s disease; six cases (10.0%) of
vascular vestibular disease; five cases (8.3%) of migraine or
migraine equivalents; two cases (3.3%) of vestibular neuritis; and one case (1.7%) each of the etiologies of ototoxicity,
metabolic vestibular disease, presbyvertigo / presbyataxia
/ presbytinnitus / presbycusis and vestibular schwannoma.
Twenty-two patients in the UVHG (73.3%) had had falls during the preceding year. Seven patients (23.3%) of the CG
reported suffering falls over this period.
Table 1 displays the mean values, standard deviations
(SD), medians and minimum and maximum values of the
Results
The two groups were made up of 30 individuals each.
Seven of them were male (23.33%) and 23 were female
(76.67%). No significant differences were noticed between
the median ages ( full years) of the UVHG and CG (p=0.864):
55 years for the UVHG and 53 years for the CG. The mean
age and standard deviation of the UVHG and CG were 52.63
and 6.97, and 52.13 and 7.25 years, respectively. Sixty years
of age was the most prevalent age in both groups (26.7% in
each group).
The time elapsed since the onset of the vestibular disease among the UVHG patients was 3 to 12 full months in
C7=seventh cervical vertebra; TMJ=temporomandibular joint; TMIJ=temporomandibular
interjoint.
Figure 1. Profile (lateral view): Representation of the C7 angle formed
by the intersection between a straight line joining the temporomandibular
joint to the C7 spinous process and another ascending straight vertical
line, for assessing the anterior deviation of the head. Anterior view:
Representation of the temporomandibular interjoint angle formed by the
intersection of a line joining the temporomandibular joints and a straight
horizontal line taken as a reference, for assessing the head inclination.
Representation of the interacromial angle, formed by the intersection of
a straight line between the acromia and a straight horizontal line taken
as a reference, for determining the shoulder alignment.
Table 1. Mean values, standard deviations, confidence intervals, medians, minimum and maximum values of the C7 angle, temporomandibular
angle and interacromial interjoint angle, measured using computerized biophotogrammetry among patients with unilateral vestibular hypofunction
(n=30) and among a control group (n=30).
Angles
C7
TMIJ
Interacromial
a
Groups
UVH
Control
UVH
Control
UVH
Control
Mean
55.445
34.345
2.034
1.347
1.986
1.876
Standard deviation
16.339
4.604
1.376
1.055
1.286
1.544
95% CI
49.34-61.54
32.63-36.07
1.52-2.55
0.95-1.74
1.50-2.46
1.30-2.45
Median
64.533
32.985
2.247
1.145
2.388
1.438
Minimum value
28.560
27.711
0.009
<0.001
<0.001
0.125
Maximum value
74.094
45.165
3.980
3.657
4.002
5.892
p-value
<0.001a
0.038a
0.535
Mann-Whitney; C7=seventh cervical vertebra; UVH=unilateral vestibular hypofunction; TMIJ=temporomandibular interjoint; CI=confidence interval.
333
angles assessed in both groups. The C7 angle value was greater in the UVHG than in the CG, with a statistically significant
difference (p<0.001). The TMIJ angle was also greater in the
UVHG than in the CG, with a statistically significant difference (p=0.038). No significant difference in the interacromial
angle was found between the groups. Regarding the side of
the head deviation, 18 patients (60.0%) had an inclination
that was ipsilateral to the vestibular lesion, and 12 patients
(40%), counterlateral.
The backward deviation of the head, head inclination and
shoulder asymmetry in the UVHG were respectively 38.05%,
33.78% and 5.54% greater than in the CG. No statistically significant differences in the median C7 angle (p=0.641) or TMIJ
angle (p=0.677) in the UVHG were found in relation to sex.
Likewise, no statistically significant differences in the median
C7 angle (p=0.148) or TMIJ (p=0.239) in the CG were found in
relation to sex.
Table 2 displays a descriptive and inferential analysis
between the values of the C7 and TMIJ angles and the timespan of clinical evolution of the UVHG patients. There was a
statistically significant difference (p=0.002) between the duration of clinical evolution and the medians of the C7 angle
values. The longer the duration of clinical evolution was, the
greater the abnormality of this angle. The main difference
occurred between the categories “3 to 12 full months” and
“more than 12 months and up to 36 full months”. No statistically significant difference was found between the duration of clinical evolution and the medians of the TMIJ angle
values. In this table, an association between the values of
the C7 and TMIJ angles and occurrences of falls among the
UVHG patients can be seen. There was a statistically significant association between the medians of the C7 angles
and occurrences of falls, and the abnormalities in this angle
were greater among patients who had suffered falls than
among those who had not. No statistically significant difference in the median TMIJ angle values was found in relation
to occurrences of falls.
The assessment of the intensity of dizziness among the
patients in the UVHG showed a moderate positive statistical
correlation with the C7 angle values. The bigger the VAS score
was, the greater the change in this angle as assessed by the CB
was (Table 3). The age of the UVH patients had a weakly positive statistically significant correlation with the C7 angle, but
did not have any correlation with the TMIJ angle. The age of
the individuals in the CG had a moderate positive correlation
that was statistically significant in relation to the C7 and TMIJ
angle values. As the age increased, so did the values of these
angles (Table 3).
Table 2. Mean values, standard deviations and medians of the C7 angle and temporomandibular interjoint angle, measured using computerized
biophotogrammetry, according to the duration of clinical symptoms and number of falls among patients with unilateral vestibular hypofunction (n=30).
Angles
a
Variables
C7
Duration of clinical
symptoms
TMIJ
Duration of clinical
symptoms
C7
Number of falls
TMIJ
Number of falls
Duration of clinical symptoms /
Number of falls
3 to 12 months (1)
More than 12 and up to 36 months (2)
More than 36 months (3)
3 to 12 months (1)
More than 12 and up to 36 months (2)
More than 36 months (3)
None
1 or more falls
None
1 or more falls
Mean (SD)
Median
44.09 (13.84)
66.65 (9.98)
67.71 (3.43)
1.66 (1.46)
2.39 (1.31)
2.48 (0.37)
38.69 (6.87)
61.53 (14.39)
1.56 (1.43)
2.20 (1.34)
38.80
68.09
67.71
1.74
2.88
2.48
35.62
67.72
1.21
2.51
p-value
Differences
between categories
0.003a
1 and 2 /
1 and 3
0.342a
--
0.002b
0.260b
Kruskal-Wallis; b Mann-Whitney; C7 = seventh cervical vertebra; TMIJ = temporomandibular interjoint.
Table 3. Correlation between self-perception of the intensity of dizziness (as verified using a visual analogue scale) and age, in relation to the C7
angle and temporomandibular interjoint angle, measured using computerized biophotogrammetry among the patients with unilateral vestibular
hypofunction (n=30) and the individuals in the control group (n=30).
Intensity of dizziness
Age
Age
Groups
UVH
UVH
UVH
UVH
Control
Control
Angles
C7
TMIJ
C7
TMIJ
C7
TMIJ
p-value
<0.001
0.057
0.006
0.735
<0.001
<0.001
Spearman correlation ()
+0.772
+0.351
+0.492
-0.065
+0.787
+0.760
C7=seventh cervical vertebra; UVH=unilateral vestibular hypofunction; TMIJ=temporomandibular interjoint.
334
Direction and strength of correlation
positive moderate
positive weak
positive weak
absence of correlation
positive moderate
positive moderate
Discussion
Abnormalities in head and shoulder alignment are common in individuals with peripheral vestibular syndrome
(PVS)7,20. Under cervical spine conditions that are of inflammatory, degenerative and/or tensional nature, several structures in this region, such as the proprioceptors, sympathetic
nervous chain and vertebral arteries may have characteristics
related to otoneurological symptoms21. In addition, chronic
alterations in the vestibulospinal reflex or, more specifically, in
the vestibular-colic reflex, and/or adoption of a compensatory
body posture to seek better balance might alter the body alignment of patients with PVS20,22-25. The increased muscle tension
in the cervical region that patients with peripheral vestibular
dysfunctions demonstrate, probably to reduce their head motion in an attempt to avoid the appearance or aggravation of
otoneurological symptoms,26 may also contribute towards the
onset of such abnormalities in body posture.
The head may be kept in an inclined position to try to avoid
stimulation of the proprioceptors of that region, because stimulation of these proprioceptors might cause or aggravate the
feeling of dizziness through increased sensory conflict between
the information riginating from the cervical proprioception and
the damaged vestibular system5. Cesarani and Alpini5 claimed
that the typical postural pattern of patients with UVH consists
of hyperactivity of the posterior cervical muscles and sternocleidomastoid muscle on the side of the auditory labyrinth,
and of the trapezius muscle on the injured side. According to
these authors, the muscles that apparently have the most important nervous connections with the vestibular centers are
the greater posterior rectus, longus capitis, semispinalis capitis
and splenius capitis.
The use of a control group in the present study, made up
of individuals (matched according to sex, age and height) who
were not experiencing dizziness and did not present any abnormalities in the otoneurological assessment, made it possible to investigate whether greater protrusion and inclination
of the head existed among the patients with UVH. One of the
most important tasks within human postural control is body
balance on the small support base that is provided by the
feet20. This position was used by the individuals during the CB
assessment. Maintaining body balance involves central and
peripheral structures that are responsible for motor execution.
The control of such structures depends on integration of the
information originating from the vestibular, visual and somatosensory systems, which is processed in the vestibular nuclei,
under the surveillance of the cerebellum24,25. Vestibular stimulation triggers several reflexes, especially the vestibular-ocular,
vestibular-colic and the vestibulospinal reflexes, which are
responsible for increasing the tonus of the antigravity muscles
of the neck, trunk and limbs25,27. Whenever a situation of sensory conflict occurs, balance strategies are activated in order
to recover stability. The neck may be kept rigid in an attempt to
stabilize the head in a certain position with the aim of avoiding
vertigo20. This may be associated with postural fixations of the
cervical region, thereby leading to muscle tensions, pain, limitations in joint motion and shortened muscles17,28, in a feedback
process between head motion and the vestibular system.
The sense of position of the neck and head, and consequently the alignment of these two structures, seems to suffer greater impact than does the position of the shoulders, as pointed
out in this study, since the increase in anterior inclination of
the head and deviation was about 30%, hereas the increase in
shoulder asymmetry was approximately 5%. With increasing
age in the UVHG and CG, the protrusion and head deviation
also increased, thus showing that age brings about such alterations regardless of the presence or absence of vestibular
dysfunction.
The association between greater protrusion of the head
and longer periods of clinical symptoms of the disease might
be related to longer periods of decompensation of vestibular
function, which in turn may imply greater impairment of the
vestibular-colic25 and vestibulospinal reflexes. Similarly, head
protrusion was associated with greater self-perception of the
intensity of dizziness, probably because the bigger the vestibular decompensation was, the greater the chance of occurrences
of vestibular episodes of greater intensity was. For instance,
there may be complaints relating to dizziness, and also greater
abnormality of the vestibular-colic25 and vestibulospinal reflexes. Conversely, head protrusion might make it more difficult
to compensate for the vestibular function, thus increasing
the duration of the vestibular disease and the self-perception
of the intensity of dizziness. Nevertheless, within the scope of
this study, it was not possible to make such a claim. Moreover,
no studies corroborating such a hypothesis were found in the
scientific literature.
In the present investigation, it was observed that the patients who reported falls had greater head protrusion than did
those who did not report any such events. The abnormalities
in head alignment, probably triggered by dysfunction of the
vestibular-colic25 and vestibulospinal reflexes, might cause
postural instability and a lack of balance during gait1, thereby
contributing towards greater incidence of falls among individuals with uncompensated vestibular disease.
The association of greater head protrusion with longer clinical evolution of the disease, greater self-perception of the intensity of dizziness and greater incidence of falls does not allow us
to establish a cause and effect relationship. However, it allows
us to suggest that these findings might be related to the same
physiopathological condition, represented by uncompensated
335
UVH. Anterior deviation of the head increases the overload on
the zygapophyseal joints, thus causing a tonic discharge that
might be responsible for the augmented and more frequent
complaints relating to dizziness6.
The finding that patients with UVH, complaints about chronic dizziness and ages between 40 and 60 years have greater
head protrusion may serve as a justification for treatment by
means of a more comprehensive rehabilitation of body balance
disturbances. Within this context, we suggest that the physical
therapy treatment should emphasize maneuvers to increase
the vestibulospinal reflex, along with body proprioceptive
stimulation, kinesiological techniques and stretching of the
posterior chain of the neck.
Patients with uncompensated UVH who underwent aquatic physical therapy for vestibular rehabilitation29 and who
were assessed through CB demonstrated changes to their body
alignment after the treatment, such as reduction of the forward
head inclination and head deviation, regardless of sex or age21,
which evinced a relationship between vestibular diseases and
abnormalities in head alignment.
The results obtained in this study call for further investigations in this field in order to broaden the knowledge about
the relationship between vestibular diseases and body posture abnormalities. Such studies could correlate the side of
the postural deviation with the side of the vestibular injury,
In addition, they could investigate individuals with other
vestibular diseases, or investigate postural abnormalities
using other assessment methods, such as electromyography of the muscle investigated in the present study or other
parts of the body.
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ISSN 1413-3555
ORIGINAL ARTICLE
©
Ventilatory and muscular assessment in
healthy subjects during an activity of daily living
with unsupported arm elevation
Avaliação ventilatória e muscular de indivíduos saudáveis durante atividade de
vida diária com os braços elevados e sem apoio
Giselle F. L. Panka1, Marina M. Oliveira2, Danielle C. França1, Verônica F. Parreira3, Raquel R. Britto3, Marcelo Velloso3.
Abstract
Introduction: Patients with chronic obstructive pulmonary disease (COPD) report dyspnea when performing activities of daily living (ADLs)
with elevated upper limbs. To elucidate the determinants of dyspnea, it is important to study the changes in the respiratory pattern of these
patients and the electromyographic activity of their accessory muscles of respiration during ADLs. In the literature, there are no reports of
a normative parameter, therefore it is necessary to study how these variables behave in healthy subjects. Objectives: To verify, in healthy
subjects, the existence of changes in the respiratory pattern and activation of the sternocleidomastoid (SCM) muscle during an ADL with
unsupported arm elevation. Methods: Thirteen male subjects, 60.57 (6.42) years old, with normal spirometry values for age and sex, were
evaluated using surface electromyography (EMG) and respiratory inductive plethysmography (RIP) collected at rest and during the activity
of combing their hair with elevated and unsupported upper limbs. The data distribution was assessed using Shapiro-Wilk’s test. ANOVA
was used to compare the phases, and when the difference was significant (p<0.05), Tukey’s test was applied. Results: The RIP during the
ADL showed a significant increase in tidal volume, minute ventilation, respiratory frequency and mean inspiratory flow. Thoracoabdominal
asynchrony was identified in percentage of asynchrony in inspiration, expiration, and Phase Angle (p<0.05). The EMG showed an increase
in SMC muscle recruitment (p<0.05). Conclusions: Healthy subjects increased their SCM muscle activation and changed their breathing
pattern when performing the ADL with unsupported arm elevation, resulting in thoracoabdominal asynchrony.
Key Words: Physical therapy; upper limbs; activities of daily living.
Resumo
Introdução: Pacientes com doença pulmonar obstrutiva crônica (DPOC) relatam dispneia quando realizam atividades da vida diária
(AVD) com membros superiores (MMSS) elevados. Estudar as alterações do padrão respiratório e a atividade eletromiográfica
dos músculos acessórios da respiração desses pacientes nas AVD pode contribuir para esclarecer os determinantes de dispneia.
Entretanto, não se encontrou, na literatura, um padrão de normalidade, fazendo-se necessário estudar, primeiramente, o comportamento
dessas variáveis em saudáveis. Objetivos: Verificar, em indivíduos saudáveis, a existência de mudanças no padrão respiratório e na
ativação do músculo esternocleidomastoideo (ECM) durante a realização de uma AVD com os MMSS elevados e sem apoio. Métodos:
Treze voluntários masculinos, com média de idade 60,57 (6,42) anos, com valores espirométricos normais para idade e sexo foram
avaliados com eletromiografia (EMG) de superfície e pletismografia respiratória por indutância (PRI), coletadas durante o repouso
e na atividade de pentear cabelos com MMSS elevados sem apoio. A distribuição dos dados foi analisada pelo teste Shapiro-Wilk.
Para a comparação entre as fases avaliadas, utilizou-se ANOVA e, quando a diferença foi considerada significativa (p<0,05), aplicouse o teste de Tuckey. Resultados: A PRI, durante a AVD, mostrou aumentos significativos do volume corrente, do volume minuto, da
frequência respiratória e do fluxo inspiratório médio. Observou-se assincronia toracoabdominal tanto em porcentagem de assincronia
na inspiração e na expiração quanto na análise do Ângulo de Fase (p<0,05). A EMG mostrou aumento no recrutamento do ECM
(p<0,05). Conclusões: Indivíduos saudáveis apresentam maior ativação do músculo ECM e modificam o padrão respiratório durante
AVD com MMSS elevados sem apoio, gerando assincronia toracoabdominal.
Palavras-chaves: Fisioterapia; membro superior; atividades cotidianas.
1
Graduate Program in Rehabilitation Sciences, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil
2
Physical Therapy Course, UFMG
3
Physical Therapy Department, UFMG
Correspondence to: Marcelo Velloso, Departamento de Fisioterapia, UFMG, Avenida Presidente Antônio Carlos, 6627, CEP 31270-901, Belo Horizonte (MG), Brazil, e-mail: [email protected]
337
Introduction
In healthy subjects1 and in patients with chronic obstructive pulmonary disease (COPD), arm elevation results in changes in the pattern of respiratory muscle recruitment and in an
increase in metabolic demand, the latter being more marked in
subjects with airflow obstruction2-9. This could be explained by
an efficiency reduction in the respiratory mechanics, by a dual
activity of shoulder girdle muscles in COPD and by an increase
in dead space2.
Patients with COPD report fatigue and dyspnea when
performing activities of daily living (ADLs) with unsupported
arm elevation9, such as combing their hair4 and brushing their
teeth. In contrast, they find it less difficult to perform more demanding activities involving their legs1,10. It is likely that these
patients’ ability to sustain unsupported arm elevation is not determined by the endurance and strength of the shoulder girdle
muscles alone. A number of studies suggest that this limitation
in respiratory mechanics is influenced by arm positioning, with
changes being observed in the respiratory breathing pattern
and thoracoabdominal asynchrony during unsupported arm
elevation8,10,11.
According to Epstein et al.6, when COPD patients sustain
arm elevation, two factors become determinants of the altered
respiratory pattern: lung hyperinflation and, to a small degree,
diaphragm reserve strength. During inspiration due to dynamic hyperinflation, the respiratory muscles are placed in an
unfavorable position of their length-tension curve, reducing
the strength generation capacity12. Therefore, unsupported
arm elevation may force the shoulder girdle muscles and the
upper torso to participate simultaneously in the ventilatory
and non-ventilatory activities1,4,6. Simultaneous afferent inputs
and outputs of the central nervous system (CNS), responsible
for the respiratory and tonic functions of these muscles, can
result in a significant lack of coordination of respiratory muscle
action and can result in an increase in dyspnea, with thoracoabdominal asynchrony being observed during unsupported arm
exercise6.
Based on the literature on the possible reasons for dyspnea
and changes in the respiratory pattern and respiratory muscle
recruitment in COPD patients during ADL with unsupported
arm elevation, it is necessary to establish parameters for healthy subjects for further comparison studies involving COPD
patients. The findings of these studies will contribute to the development of future interventions and/or improvements in the
existing ones, providing more functional independence and,
consequently, better quality of life for these individuals. Also, the
findings of the present study will be used in another study, currently underway by our group, comparing the results of healthy
subjects with COPD patients using the same protocol during
338
an ADL with unsupported upper limbs. Therefore, the current
data will also be part of a more comprehensive research. The
aim of the present study was to assess, in healthy subjects, the
breathing pattern, thoracoabdominal motion and electromyographic activity of the sternocleidomastoid (SCM) muscle at
rest and during an ADL with unsupported arm elevation.
Methods
The Ethics Research Committee of Universidade Federal de
Minas Gerais, Belo Horizonte (MG), Brazil, approved the protocol
(ETIC 551/06), and all subjects gave their informed consent. The
sample calculation was accomplished after a pilot study with
the first ten subjects, using all respiratory pattern variables,
thoracoabdominal motion and electromyography (EMG) to a
power of 80% and a significance level of 0.05 (non-directional).
The calculation resulted in a value of 13.8 healthy subjects. The
sample consisted of 13 healthy subjects selected from the community. The inclusion criteria were: male subjects, age between
50 and 80 years, absence of bone and joint impairment in the
shoulder girdle and normal lung function tests according to
Brazilian standards of normality13. The exclusion criteria were:
inability to maintain overhead arm elevation for the five minutes of data collection and inability to perform any of the steps
determined in the protocol. A signed informed consent form
was obtained from all subjects.
The subjects underwent a functional analysis of lung volume and capacity. A portable spirometer (Vitalograph 2120®,
Vitalograph, Buckingham, England) was used to ensure normal
lung function according to the recommendations of the Brazilian Society of Pneumology13. The values of the spirometric
variables were compared to predicted values according to
Pereira et al.14. The breathing pattern was accessed by respiratory inductive plethysmography (RIP) based on the principle
first described by Konno and Mead15, and the electromyographic activity of the SCM muscle was accessed by surface EMG.
Respiratory variables were obtained by RIP (Respitrace®,
Nims, Miami, FL, USA). Teflon-coated inductance coils of appropriate size were placed around the rib cage (RC) and abdomen (AB); the upper edge of the RC band was placed at the level
of the axilla and the AB band at the level of the umbilicus. The
signals were calibrated using qualitative diagnostic calibration
(QDC)16 during five minutes of natural breathing; this is a twostep procedure whereby the RC and AB electrical gains of the
RIP amplifiers are correctly partitioned during tidal breathing
and subsequently compared to the output of a spirometer to
attain equivalence. The subject then breathed into a spirometer via a mouthpiece (Vitatrace, Pro Médico, Rio de Janeiro, RJ,
Brazil) with the nose clipped, for 30 to 60 s, and the electrical
Respiratory pattern and ADL with unsupported arm elevation
spirometer output was recorded with a computer and used
to calibrate the RIP sum signal for absolute volume in mL17.
The spirometer was calibrated with a one-liter syringe (Vitalograph, Ennis, Ireland). The entire procedure was performed
using a computer software (RespiPanel 4.0, Nims Miami, FL,
USA)18,19 that allows a tidal volume (V T) variation 5% during
calibration process.
The following variables were measured by a digital acquisition system on a breath-by-breath basis (RespiEvents®, Nims,
Miami, FL, USA): tidal volume (V T), respiratory frequency (f),
minute ventilation (VE), inspiratory time (Ti), inspiratory duty
cycle (Ti/Ttot), mean inspiratory flow (V T/Ti), RC motion
contribution to V T (RC/V T), phase angle (PhAng; 0° for complete RC-AB synchrony and 180° for complete asynchrony)20,
inspiratory RC-AB synchrony (PhRIB), expiratory RC-AB
synchrony (PhREB), inspiratory and expiratory synchrony
(PhRTB), variables that represent the time percentage during
a respiratory cycle in which the RC and AB move in opposite directions. When the RC and AB are moving in perfect
synchrony, the values are equivalent to 0%, and when there
is paradoxical movement, they are equivalent to 100%20. The
contribution of abdominal motion to V T (AB/V T) was calculated as AB/V T = 100 - RC/V T.
The surface EMG device (EMG System do Brasil LTDA, São
Paulo, SP, Brazil) was used to record the electromyographic activity of the SCM muscle. After the skin was cleansed, ECG bipolar surface electrodes (Mini Medi Trace 100, Kendall – LTP/
Tyco, Canada) were placed on the lower third of the left sternal
portion of the SCM muscle belly. The electrodes were positioned 2.5 cm apart over this area21,22. The EMG signals were
recorded using one of the eight channels of the biological signal acquisition system consisting of a signal conditioner with
a gain of 1000, a high-pass filter of 20 Hz, and a low-pass filter
of 500 Hz, a specific software for data acquisition and analysis
(Aqdados, São José dos Campos, SP, Brazil) and a 12-bit analogto-digital converter, with a sample frequency of 2000 Hz for the
channel and an entry band of 5 mV. The mean amplitude of the
signal was estimated by its root mean square (RMS) value. In
the present study, the data were normalized by rest, given that
the objective was to compare the analyzed variables at rest and
at different moments of an ADL with unsupported arm elevation. The subject was his own control group.
There was a simultaneous collection for the surface EMG
and for the RIP data, there were two different collections. In
the first collection, the data were collected with the subject in
a seated position and arms resting along the body during five
minutes. For the statistical analyses, the last regular minute of
the RIP was considered. Next, the second data collection was
conducted with the subject in a seated position and combing
their hair with unsupported arm elevation for five minutes. The
subjects were instructed to perform the combing movement
on the top of the head, alternating both arms with the dominant hand holding the comb while the other followed the movement. The activity had to be constant and uninterrupted for
the entire period and at a minimum of 90° arm elevation. The
last 30 seconds of the 1st, 3rd and 5th minute were considered for
analyses.
Data are reported as mean and standard deviation (SD).
The data distribution for each variable was assessed using
Shapiro-Wilk’s test. The comparisons between the four
analyzed phases (rest, 1st, 3rd and 5th minute of exercise) were
performed with ANOVA for repeated measures. When the
difference was considered significant, Tukey’s test was performed to identify the difference between pairs. The level
of significance () was set at 0.05 for all tests. Data were
analyzed with the Statistical Package for the Social Sciences
software (SPSS 15.0, Chicago, IL, USA).
Results
Demographic data of the 13 subjects are presented in
Table 1. The values for the variables during rest, 1st, 3rd, and
5th minutes of exercise with unsupported arm elevation and
the respective analysis are presented in Table 2.
Breathing pattern
The V T increased significantly from the 3rd minute; its value
was 31% higher than the rest value. At the 5th minute, a slight
increase in V T was observed when compared with the 3rd minute corresponding to a value 33% higher than rest. There was
a statistically significant difference between rest and the 3rd minute (P=0.008), rest and the 5th minute (P=0.033) and between
the 1st and the 3rd minute (P=0.048) of activity (Table 2).
The f increased between rest and the 1st minute of activity,
which was 21% higher than the baseline value, and then remained stable during the course of the exercise. There was a statistically significant difference between rest and the 1st minute
Table 1. Characteristics of the 13 subjects.
Variables
Age (yr)
Weight (Kg)
Height (m)
BMI (Kg/m2)
FVC % pred
FEV1 % pred
FEV1/FVC (%)
Mean
60.6
72.1
1.7
25.6
105.2
101.4
76.7
SD
6.42
11.14
0.06
3.63
20.41
23.45
0.05
Range
51-71
56-90
1.6-1.8
19.2-30.9
86.7-162.7
73.6-118.8
70.0-83.1
SD=standard deviation; Kg=kilogram; m=meters; BMI=body mass index; FVC=forced vital
capacity; VEF1=forced expiratory volume in one second.
339
Table 2. The analyzed variables during rest, 1st, 3rd, and 5th minutes of exercise with unsupported arm elevation. The values of p, f and Power of
ANOVA for repeated measures are also presented.
Variable
VT (mL)
VE (l/min)
f (bpm)
Ti (s)
Ti/Ttot
VT/Ti (mL/s)
% RC/VT
1st
530.21 (205.66)
8.41 (2.66)*
17.17 (4.64)*
1.54 (0.47)
0.40 (0.05)
361.38 (109.76)*
48.54 (14.79)
Rest
461.42 (199.08)
5.82 (1.64)
14.15 (4.46)
1.81 (0.83)
0.37 (0.04)
265.71 (82.62)
52.27 (15.40)
3rd
603.57 (254.88)*†
9.74 (3.05)*†
17.47 (5.06)*
1.53 (0.58)
0.40 (0.04)
419.62 (139.67)*
46.73 (15.23)
5th
612.48 (204.18)*
9.79 (2.75)*†
17.37 (4.74)*
1.56 (0.48)
0.41 (0.04)
419.52 (146.26)*
48.04 (16.36)
p
0.010
0.000
0.001
0.105
0.103
0.001
0.479
f
4.39
18.48
6.91
2.27
2.22
11.19
0.74
Power
0.83
0.99
0.96
0.40
0.51
0.99
0.16
Data expressed as mean (standard deviation). Significant difference was considered when p<0.05; * Statistically different in comparison to rest; † Statistically different in comparison to
the 1st minute.
rest and the 5th minute (p<0.001), and between the 1st and the
3rd minute (p=0.013) and the 1st and the 5th minute of exercise
(p=0.02; Table 2).
The V T/Ti presented a 36% increase in the 1st minute when
compared with rest, a 56% increase in the 3rd minute, stabilizing
in the 5th minute of activity. There was a significant difference
when comparing rest and the 1st minute (p<0.001), rest and
the 3rd minute (p<0.001) and rest and the 5th minute of activity
(p=0.003; Table 2).
A
#
30
25
20
15
10
5
0
D
e
g
r
e
e
*
†
PhAng
B
*
25
#
*
20
%
*
Thoracoabdominal motion
15
10
5
0
PhRIB
PhREB
PhRTB
C
%
R
M
S
*
28
24
20
16
12
8
4
0
Rest
SCM EMG
1st min.
3rd min.
5rd min.
Significant difference was considered when p<0.05;
* Statistically significant for rest; †Statistically significant for the 1st minute; #Statistically
significant for the 3rd minute; PhAng=Phase Angle; PhRIB=inspiratory RC-AB synchrony;
PhREB=expiratory RC- AB synchrony; PhRTB=inspiratory and expiratory synchrony;
SCM=sternocleidomastoid muscle; EMG=electromyography.
Figure 1. A) Comparison between PhAng during rest and during the
analyzed moments of the hair-combing activity. B) Comparison between
PhRIB, PhREB and PhRTB during rest and during the analyzed moments
of the hair-combing activity. C) Comparison between SCM EMG during
rest and during the analyzed moments of the hair-combing activity.
(P=0.013), rest and the 3rd minute (P=0.003) and between rest
and the 5th minute (P=0.01) of activity (Table 2). Consequently,
the changes in f in the 1st minute, in addition to the changes in
V T, led to a progressive increase in VE until the 3rd minute, with
a 67% higher value than rest that remained unchanged through
the 5th minute. There was a significant difference between rest
and the 1st minute (p=0.001), rest and the 3rd minute (p<0.001),
340
No statistically significant difference was found for
%RC/V T and for %AB/V T during the activity period, however
it was observed that at rest %RC/V T was 4.54% higher than
%AB/V T, and that during the exercise there was a shift to AB
in which the %AB/VC increased its participation by 6.54%
compared with %RC/V T (Table 2). Considering the PhAng,
we observed that the subjects presented a PhAng of 23.82o at
the end of the activity, which corresponds to a 129% increase
from rest. There was a significant difference when considering rest and the 1st minute (p=0.038), rest and the 5th minute
(p=0.003), the 1st and the 5th minute (p=0.045) and the 3rd and
the 5th minute of exercise (p=0.026; Figure 1 - A).
A progressive increase in PhRIB was observed during the
activity, corresponding to 6.36% at rest, 14.77% in the 1st minute,
14.59% in the 3rd minute and 17.73% in the 5th minute, which
represents a 79% increase between rest and the end of the exercise. There was a significant difference when considering rest
and the 1st minute (p<0.001), rest and the 3rd minute (p<0.001),
rest and the 5th minute (p<0.001) and the 3rd and the 5th minute
of exercise (p=0.034; Figure 1 - B). Similarly, a progressive increase in PhREB was observed during the activity, corresponding
to 11.63% at rest, 17.18% in the 1st minute, 18.07% in the 3rd
minute and 19.05% in the 5th minute, which represents a 64%
increase between rest and the end of the exercise. There was a
significant difference when considering rest and the 1st minute
(p=0.042), rest and the 3rd minute (0.021), and rest and the 5th
minute of exercise (p=0.001; Figure 1- B). When we consider
the PhRTB, a progressive increase in synchrony between the
two compartments was also observed during the activity, corresponding to 9.93% at rest, 16.61% in the 1st minute, 17.09% in
the 3rd minute and 19.12% in the 5th minute, which represents
a 92% increase between rest and the end of the exercise. There
was a statistically significant difference when considering rest
and the 1st minute (p=0.005), rest and the 3rd minute (p=0.002)
and rest and the 5th minute of exercise (p<0.001; Figure 1 - B).
Electromyography activity
The subjects’ SCM muscle activity between rest and the activity of combing hair with unsupported arm elevation ranged
in the following magnitude compared with rest: 168% RMS in
the 1st minute, 196% RMS in the 3rd minute and 224% RMS in
the 5th minute. There was a statistically significant difference
when comparing rest with the 1st (p=0.005), the 3rd (p=0.001)
and the 5th minute of exercise (p=0.001; Figure 1 - C). No correlations were found between the respiratory pattern variables,
thoracoabdominal motion and electromyographic activity of
the SCM muscle.
Discussion
The main results of this study were: increased f and V T, followed by increased VE, increased V T/Ti and thoracoabdominal
asynchrony demonstrated by PhAng, PhRIB, PhREB, PhRTB,
and increase in SCM muscle activity during the unsupported
arm elevation. In addition, a change was observed, though not
statistically significant, in the predominance of the contribution of the RC and AB to V T. There was a significant increase in
V T, followed by a slightly increased f, resulting in a significant
increase in VE during the activity time with unsupported arm
elevation. The V T and VE absolute values during rest were comparable with those reported by Tobin et al.23 using RIP in healthy subjects in the supine position. However, when comparing
breathing patterns from different studies, body posture must
also be taken into account23,24.
In the sitting position, Couser, Martinez and Celli3 and
Baarends et al.2 measured VE and V T using other methods, and
the results were markedly higher than those recorded for healthy
subjects during rest in the present study. This difference probably
relates to direct measuring techniques which employ breathing
through a mouthpiece with the nose clipped23. As a consequence
of the small variation in f (21%) and especially in V T in the 3rd
minute (31%), there was a progressive increase in VE until the
3rd minute, achieving 67% of the rest value, remaining stable
until the 5th minute. These results are partially comparable with
those reported by Couser, Martinez and Celli3 and by Baarends
et al.2, who analyzed healthy subjects with static elevated arms
for 2 minutes and observed a VE increase due to an increase in
V T while the f remained unchanged. The difference in f variation
may be due to the type of exercise performed by our subjects,
i.e. combing hair with alternating unsupported arm elevation,
which is more difficult than static arm elevation. Younes and
Kivinen25 also reported that, at low levels of exercise, ventilation
increases primarily due to increases in V T and, at higher levels of
exercise, the changes occur through changes in f. Tobin et al.23
reported that mean inspiratory flow reflects respiratory center
drive input, which explains the increase in the V T/Ti ratio during
unsupported arm elevation and its stabilization by the 3rd minute with 58% of rest value.
When we analyzed the PhAng, we observed that the subject presented a value of 23.82° at the end of the activity that
corresponds to a 129% increase when compared with rest. This
demonstrates an increase in RC-AB asynchrony. To our knowledge, there are no reports in the literature of PhAng values for
healthy adults during unsupported arm elevation. With regard
to rest values, our results were comparable with those found
by Tobin et al.26 and Bloch et al.27 with healthy subjects during
quiet breathing.
The variables PhRIB, PhREB and PhRTB represent the time
percentage during a respiratory cycle in which the RC and the
AB move in opposite directions. If both compartments move in
the same direction along a respiratory phase (inspiratory, expiratory or both), a 0% value is computed. If the compartments
move in opposite directions, a 100% value is computed20. In
the present study, there was a progressive increase in PhRIB,
PhREB and PhRTB, representing an increase of approximately
18% when comparing rest and the last minute of activity.
In healthy subjects, arm elevation leads to increased ventilatory and metabolic demands similar to mild exercise. At
rest, the diaphragm is the dominant active inspiratory muscle,
displacing the abdomen. During exercise, the inspiratory accessories are progressively recruited to assist the diaphragm
and elevate the RC. During arm elevation, some of the upper
torso muscles become involved in arm positioning, their participation in ventilation is decreased, and there is a shift of
ventilatory work to the diaphragm. This disproportionate increase in diaphragmatic work contributes to the generation of
ventilatory pressures3. These changes in RC and/or AB mechanics may be the cause of the increase in asynchrony in COPD
patients and, to a small degree, in healthy subjects. However,
COPD patients have insufficient diaphragmatic function, leading to considerable thoracoabdominal asynchrony.
In a study that assessed healthy subjects, Tobin et al.26
concluded that thoracoabdominal asynchrony and paradox in
compartmental contribution to V T are predominantly due to
341
increases in respiratory load rather than muscle fatigue. In the
present study, the RC and AB movements at rest were similar
to those reported by Tobin et al.23. It appears that the slight
increase in the AB contribution in activity in exchange for RC
contribution at rest is related to the arm elevation and to a greater participation of the diaphragm in ventilation. According
to Goldman et al.28, abdominal wall displacement is intimately
related to diaphragm displacement, however the same cannot
be said for RC displacement.
The changes in the respiratory pattern mentioned above
seem to be related to the hypothesis raised by many authors1,3,4,6
when referring to an increase in diaphragm activity in tasks involving unsupported arms, which may suggest an increase in
diaphragmatic work to generate a V T due to a decrease in participation of the accessory muscles needed to stabilize the shoulder girdle during unsupported arm movements. Tobin et al.23
reported that, although there was a slight predominance of AB
contribution to V T compared to RC contribution in healthy
subjects in the supine position, there was a large individual
variation in the respiratory pattern at rest. Sharp et al.29, in
their study on the sitting position at rest, reported that the RC
was responsible for about 70% of V T whereas, in the supine
position, its contribution was only about 25%. Grimby, Bunn
and Mead30 also reported a 25% contribution of AB to V T in
individuals sitting on a cycle ergometer without exercising.
These findings were attributed to the position of the legs with
a tonic contraction of the muscles in the torso and abdominal
wall that could effectively reduce abdominal compliance.
Grimby, Bunn and Mead30 noted the variability of V T during exercise and the need for caution when analyzing the estimated changes to RC and AB contribution to V T. However, they
reported that, although there is a large individual variation,
there appears to be a consistent pattern of changes in relative
RC and AB movements with an increase in V T between rest and
moderate exercise with a tendency toward a greater AB contribution to V T. In contrast, when exercise intensity increases,
there is an increase in RC contribution.
In the present study, for the calibration of RIP, the QDC was
used during natural breathing, a procedure first described by
Sackner et al.16 in 1989. This method computes the calibration
factor (K) by considering breaths of constant V T31. In 2001, De
Groote, Paiva and Verbandt31 criticized the QDC calibration
method for the possibility of error when there is a variation in
V T during the procedure. It should be noted that, in the present study, there was variation in V T, but this occurred mainly
during the exercise. During the calibration performed at rest,
there was a slight variation in V T in 13 evaluated subjects, with
maximum standard deviation of 12.2 mL (1.98% V T variation).
342
Furthermore, this is the current method employed by various
studies that used RIP to assess the respiratory pattern18,19,32-35.
Regarding surface EMG, we observed a steady increase in
the amplitude of SCM muscle recruitment between rest and
activity. These changes suggest an increase in SCM muscle
participation in upper limb support during activities with
unsupported arm elevation, reducing its respiratory function.
This would lead to an increase in AB contribution to V T during
exercise.
Our findings are comparable with those reported by
Martinez, Couser and Celli8, who observed changes in respiratory muscle recruitment pattern indicating a more effective
contraction of the diaphragm and an increase in SCM muscle
amplitude of activation in EMG during activities with unsupported arm elevation. This suggests that some RC muscles are
recruited during arm elevation. The present study also shows
that there was an increase in V T and f with a subsequent increase
in VE during the activity with unsupported arm elevation, and
there was an increase in V T/Ti as the activity progressed, which
shows a greater neural activation during exercise. We also observed an increase in thoracoabdominal asynchrony during unsupported arm elevation as well as an abrupt increase in SCM
muscle amplitude of activation in the beginning of the exercise,
showing a steady increase until the 5th minute of activity.
The changes detected in the respiratory pattern and the
EMG activity of the respiratory accessory muscle of the healthy
subjects during the studied ADL can contribute to elucidate
the determinants of dyspnea in patients with COPD. However,
no reports of a normative parameter were found in the literature. Therefore, it was necessary to study how these variables
behave in healthy subjects. Considering the findings of the
present study, it is possible to use this data as normality parameters for clinical application to assess upper limb ADLs in
patients with COPD.
Study limitations
Although the sample number was calculated in the pilot
study to find significant differences between the moments
(rest and activity), the number of subjects was insufficient for
the correlations between respiratory pattern variables, thoracoabdominal motion and SCM muscle EMG. For the variables
RC/V T and AB/V T, although the sample calculated to a power
of 80% was small (eight), after the statistical analysis, the power
found by ANOVA was low.
Partially funded by Conselho Nacional de Desenvolvimento
Científico e Tecnológico (CNPq) and Fundação de Amparo à
Pesquisa do Estado de Minas Gerais (FAPEMIG), Brazil.
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343
ISSN 1413-3555
©
ORIGINAL ARTICLE
Effects of treadmill-walking training with
additional body load on quality of life in
subjects with Parkinson’s disease
Efeitos do treino da marcha em esteira com aumento da carga corporal sobre a
qualidade de vida de sujeitos com doença de Parkinson
Nadiesca T. Filippin1, Paula H. Lobo da Costa2, Rosana Mattioli1
Abstract
Background: Parkinson’s disease (PD) causes motor and non-motor impairments that affect the subject’s quality of life. Objective: To
assess the effects of treadmill-walking training with additional body load on the quality of life and motor function of subjects with PD.
Methods: Nine subjects with PD, Hoehn and Yahr stages 2-3, not demented and with capability to ambulate independently took part
in this study. The training program was divided into three phases (A1-B-A2): treadmill training with additional body load (A1), control
condition (conventional physical therapy group; B) and a second period of treadmill training with load (A2). Each phase lasted six
weeks. Quality of life and motor function were assessed by the PDQ-39 and the motor score of the Unified Parkinson’s Disease Rating
Scale (UPDRS), respectively. The evaluations and the training were performed during the on-phase of the medication cycle. Results:
There was improvement in the total PDQ-39 score across the training period. The subscores mobility, activities of daily living and
cognition subscores significantly improved after the training period. The improvement in the total score was associated with motor and
non-motor factors in all of the training phases. The UPDRS motor score also improved, however it did not present any association with
the improvement in quality of life. Conclusions: The results showed that the treadmill-walking training with additional body load allowed
an improvement in motor and non-motor aspects related to quality of life and motor function in subjects with PD.
Article registered in the Clinical Trials.gov under the number NCT 00890669.
Key words: treadmill training; body load; quality of life; Parkinson’s disease.
Resumo
Contextualização: A doença de Parkinson (DP) causa prejuízos motores e não-motores que afetam a qualidade de vida dos sujeitos.
Objetivo: Avaliar os efeitos de um treino de marcha em esteira, com aumento da carga corporal, sobre a qualidade de vida e a função
motora de sujeitos com DP. Métodos: Nove sujeitos com DP idiopática, estágio 2 a 3 da escala de Hoehn & Yahr, sem demência e com
capacidade de andar independentemente participaram do estudo. O programa de treino foi dividido em três fases (A1-B-A2) de seis
semanas cada: treino da marcha em esteira com aumento da carga corporal (A1), condição controle (fisioterapia convencional) (B) e
treino da marcha em esteira novamente (A2). A qualidade de vida e a função motora foram avaliadas, respectivamente, pela PDQ-39
e escore motor da UPDRS (Escala Unificada de Avaliação da Doença de Parkinson). As avaliações e os treinos foram realizados na
fase on do ciclo da medicação. Resultados: Houve melhora no escore total da PDQ-39 ao longo do período de treino. Os subitens
mobilidade, atividades da vida diária e cognição da PDQ-39 melhoraram significativamente após o treino. A melhora no escore
total mostrou correlação com fatores motores e não-motores. O escore motor da UPDRS também melhorou, no entanto, não houve
correlação com a melhora na qualidade de vida. Conclusão: Os resultados mostraram que o treino em esteira com aumento de carga
corporal permitiu uma melhora de aspectos motores e não-motores relacionados à qualidade de vida e à função motora de sujeitos
com DP.
Artigo registrado no Clinical Trials.gov sob o número NCT 00890669.
Palavras-chave: treino em esteira; carga corporal; qualidade de vida; doença de Parkinson.
1
Physical Therapy Department, Laboratory of Neuroscience, Universidade Federal de São Carlos (UFSCar), São Carlos (SP), Brazil
2
Department of Physical Education, Movement Analysis Laboratory, UFSCar
Correspondence to: Nadiesca Taisa Filippin, Laboratório de Neurociências, Departamento de Fisioterapia, Universidade Federal de São Carlos, Rodovia Washington Luis, km 235, CP 676,
CEP 13565-905, São Carlos (SP), Brazil, e-mail: nadifi[email protected]
344
Treadmill training and quality of life in Parkinson’s disease
Introduction
Parkinson’s disease (PD) is a chronic degenerative disorder
that has an adverse impact on patients’ lives1. Symptoms such
as hypokinesia, rigidity, tremor, postural abnormalities, gait
disorders, sleep and communication disorders, pain, difficulty
with manual abilities, and depression lead to falls, social embarrassment, isolation, loss of hobbies and leisure activities, and increased dependence1-3. Treatments for PD aim to improve motor
function3,4, however non-motor symptoms should be considered
because they also affect the quality of life of subjects with PD.
Quality of life refers to the patient’s perception and selfevaluation regarding the physical, psychosocial and emotional
effects of the illness on her or his life. Therefore, the assessment of quality of life is subjective and multidimensional2,
and it varies according to the progression of the disease5. The
assessment of the impact of the illness on quality of life is an
important measure of treatment efficacy6 because the most
common clinical scales do not appropriately assess the nonmotor symptoms related to the disease. One of these scales is
the Parkinson’s Disease Questionnaire (PDQ-39) is a specific
instrument for PD, and has been shown to be viable, valid, consistent, reliable, responsive and reproducible7-9 in the assessment of the functional, emotional and psychosocial aspects of
the patient’s quality of life.
Physical activity promotes improvement in motor aspects
such as strength, gait and, balance of subjects with PD10. The
quality of life of these subjects also improves with exercise10,11.
Different studies involving dancing12, high-intensity eccentric resistance training13, aerobic conditioning and muscular
strengthening14, and Nordic walking15 observed improvement
in the quality of life and motor function of subjects with PD.
The treadmill has been used as an external cue to walking
training of subjects with PD. Studies using the treadmill and
body weight support16 or the treadmill alone17,18 observed improvements in gait and motor performance in these subjects,
as well as improvement in quality of life18. However, subjects
with PD show impairment in the load receptors that affect
proprioceptive function and cause a decrease in leg extensor
muscle activity19. This impairment reduces propulsion, stride
length and gait speed20,21.
There is evidence that the increase in body load during
treadmill walking in healthy subjects improves reflex activity
and leg extensor muscle activity22,23. Thus, training with additional body load would benefit subjects with PD. However,
studies on the effects of treadmill training with additional body
load in PD are lacking. Only one study21 has assessed the effects
of this training on the gait, balance, fall risk, and daily function
of subjects with PD. Therefore, the purpose of the present study
was to assess the effects of treadmill-walking training with
additional body load on the different aspects of the quality of
life and motor function of subjects with moderate PD.
Methods
Subjects
Nine subjects (7 male, 2 female) with idiopathic PD, previously diagnosed by a specialist physician, took part in this
study. Inclusion criteria were: Hoehn and Yahr (H-Y) stages
2-3, absence of dementia (Mini Mental Status Examination –
MMSE, defined according to educational level)24, and capacity
to ambulate independently. Exclusion criteria were: change of
medication (dopaminergics) during the study period; use of
treadmill for at least six months prior to the study; other neurologic problems; musculoskeletal, cardiovascular or respiratory
disease; uncorrected visual deficit that could pose a risk and
interfere in the accomplishment of the training. All subjects
were in a stable drug program and had been adapted to their
current medications for at least two weeks. The mean age was
65.88 (8.13) years, and the mean body mass was 71.51 (17.27)
kg at the beginning of the study. The mean illness duration was
5.44 (4.06) years, the classification mean in the H-Y scale was
2.8 (0.45), and the MMSE score was 27.11 (2.57). The subjects were recruited from the city’s health service. This study
was approved by the Human Research Ethics Committee of
Universidade Federal de São Carlos (UFSCar), São Carlos (SP),
Brazil (Approval report number 234/07), and all subjects gave
their written informed consent according to the declaration of
Helsinki, prior to entering the study.
Experimental setup
The training program was divided into three phases
(A1-B-A2): treadmill training with additional body load (A1),
control condition (conventional physical therapy group; B)
and a second period of treadmill training with additional body
load (A2). Each phase lasted six weeks, totaling 18 weeks. Both
evaluations and training were performed during the on-phase
of the medication cycle. The choice of the A-B-A design was
based on previous clinical studies25-28. This design has been
used for small sample and large intra- and inter-subjects variability. In this methodology, it is recommended that the intervention be tested in duplicate.
Instruments and procedures
All subjects were submitted to a clinical evaluation that
consisted of personal data collection, anamnesis (past and
345
current history, previous treatment, pharmacological treatment and life habits), physical examination and body mass
measurement. The subjects’ quality of life and disability were
assessed in the pretraining condition and after each phase of
the training program ( four evaluations). The quality of life was
measured through the PDQ-39, which comprises 39 questions,
each of them with five different answer options (never, occasionally, sometimes, often or always). Eight subscores (mobility,
activities of daily living - ADLs, emotional wellbeing, stigma,
social support, cognition, communication, and bodily discomfort) and a total score can be calculated. Higher scores indicate
a greater problem, according to the subject’s perception. To
identify the disability, the Unified Parkinson’s Disease Rating
Scale (UPDRS) was used. It is composed of 42 items divided
into four main sections. In this study, only the motor score
(part III) was assessed. This section contains 14 questions with
scores from 0 (normal) to 4 (unable to perform the task). Higher
scores indicate greater impairment.
Training protocol
The training consisted in walking on a treadmill wearing
a weighted scuba-diving belt (Seasub), which increased the
normal body mass by 10% approximately. The treadmill (Athletic Speedy 3) allows tuning of the speed with increments of
0.1 km/h (minimum speed 0.1 km/h) and it has frontal and
adapted lateral bars for hand support. In addition, the subjects
walked with a safety harness to prevent falls. The load was positioned around the waist, close to the center of mass, to avoid
problems with postural adjustment.
The training was performed 50 minutes per day, three
days per week for six weeks in each one of the A phases. Each
PDQ-39
70
**
60
*
*
Total score
50
40
session consisted of a five-minute warm-up in an unloaded
cycle ergometer, 40 minutes of treadmill training with additional body load, followed by five minutes of recovery, with
decreased speed. During training, the treadmill speed was
gradually increased and the subjects were instructed to walk
until the maximum comfortable speed was reached. The speed
was recorded in each session. The heart rate was monitored
during the entire training session through a frequency meter
(Polar A3). If the submaximal value calculated for each subject
was exceeded, the training session was interrupted. The blood
pressure was measured at the beginning and at the end of each
session, and when necessary, during the session, in case the
subject felt any sign of indisposition. The treadmill remained
horizontal throughout the training period. Before the beginning of the training, the subjects were given time to become
familiar with the treadmill, and they were instructed in the
sequence of activities to be performed.
In the control condition (phase B), conventional physical
therapy sessions were performed one hour per day two days
per week. The subjects were treated as a group. This period
included stretch exercises of the main muscle groups, strength,
coordination, mobility and balance exercises, ADL training,
and gait training in different conditions. The subjects were instructed and encouraged to perform the exercises at home.
Data analysis
The total score as well as the subscores of the PDQ-39 were
calculated according to Peto, Jenkinson and Fitzpatrick29. The
UPDRS motor score was calculated as the sum of scores in each
question. Before statistical analysis, data normality and variance were tested using the Kolmogorov-Smirnov and Levene
tests, respectively. The Friedman test was used to compare the
results of the four evaluations. This analysis was followed by
a post-hoc Dunn test. Spearman’s correlation coefficient was
used to investigate the relationship between the total PDQ-39
score, the PDQ-39 subscores and the UPDRS motor score in
each evaluation. A p-value 0.05 was considered statistically
significant.
30
20
Results
10
0
0
1
2
Evaluantions
3
4
* indicates significant differences between pretraining evaluation and evaluations after
phase A1 and B (p0.05); ** indicates significant differences between pretraining evaluation and evaluation after phase A2 (p0.01).
Figure 1. Mean total PDQ-39 score in each evaluation (n=9).
346
The subjects presented a significant decrease in the total
PDQ-39 score (p=0.002) across the evaluations compared to the
pretraining evaluation (p<0.05 for the evaluation after phase
A1 and after phase B, and p<0.01 for the evaluation after phase
A2). Although the score continued to decrease after phase A1,
no significant differences were observed between the second
evaluation and the following evaluations (Figure 1).
and communication (p=0.01). The total PDQ-39 score was not
significantly correlated (p>0.05) with the UPDRS motor score
in any of the evaluations (Table 2).
Discussion
The present study assessed the effects of treadmill-walking
training with additional body load on the quality of life and
UPDRS
22
*
21
*
Motor score
Regarding the PDQ-39 subscores (Table 1), significant differences were observed in mobility (p=0.035), ADL (p=0.006),
and cognition (p=0.001) subscores. For the mobility and ADLs
subscores, the differences were observed between the pretraining evaluation and the final evaluation (p<0.05 and p<0.01,
respectively). For the cognition subscore, differences were observed between pretraining and all other evaluations (p<0.05
for the evaluation after phase A1 and after phase B, and p<0.01
for the evaluation after phase A2; Table 1). The UPDRS motor
score also decreased across the evaluations (p=0.001) and
significant differences were observed between the pretraining
evaluation and the evaluation after phase A1 (p<0.05) and after
phase A2 (p<0.01; Figure 2).
The correlations between the total PDQ-39 score and the
subscores are shown in Table 2. In the pretraining evaluations, the total score showed a significant correlation with
the subscores emotional wellbeing and social support (p=0.02
and p=0.00, respectively). In the evaluation after phase A1,
the subscores mobility, ADLs, emotional wellbeing and communication were significantly correlated with the total score
(p=0.02, p=0.00, p=0.01 and p=0.02, respectively). In the evaluation after phase B, the correlations were observed between
the total score and the subscores mobility (p=0.00), ADLs
(p=0.00), stigma (p=0.03) and communication (p=0.00). Finally,
the evaluation after phase A2 showed significant correlation
between the total score and mobility (p=0.00), ADLs (p=0.00)
20
19
18
17
16
15
0
1
2
3
4
Evaluantions
* indicates significant differences between pretraining evaluation and evaluations after
phase A1 and A2 (p0.05).
Figure 2. Mean UPDRS motor score in each evaluation (n=9).
Table 1. PDQ-39 subscores in each phase.
Measures
Mobility
ADLs
Emotional wellbeing
Stigma
Social support
Cognition
Communication
Bodily discomfort
Pretraining score
Score after A1
Score after B
Score after A2
58.9 (21.9)
73.1 (13.9)
42.6 (27.1)
26.4 (25.5)
14.8 (18.0)
47.9 (18.7)
42.6 (17.9)
41.7 (25.0)
33.9 (16.4)
48.6 (22.5)
25.0 (20.4)
23.6 (17.3)
5.6 (9.3)
22.9 (13.3)a
26.9 (19.9)
32.4 (21.4)
31.7 (19.9)
51.4 (26.1)
26.8 (15.9)
9.7 (13.7)
7.4 (14.7)
20.1 (10.7)b
25.9 (21.0)
28.7 (20.0)
25.6 (16.1)d
43.9 (27.6)c
18.5 (18.3)
9.0 (12.5)
6.5 (10.8)
18.7 (10.4)c
25.0 (23.9)
29.6 (18.2)
Values are means (SD). ADLs (activities of daily living); a Differences between the pretraining and phase A1 measures were significant at p0.05; b Differences between the pretraining
and phase B measures were significant at p0.05; c Differences between the pretraining and phase A2 measures were significant at p0.01; d Differences between the pretraining and
phase A2 measures were significant at p0.05.
Table 2. Correlations between total PDQ-39 score, PDQ-39 subscores and UPDRS motor score.
Correlations
Mobility x total
ADLs x total
Emotional wellbeing x total
Stigma x total
Social support x total
Cognition x total
Communication x total
Bodily discomfort x total
UPDRS x total
Pretraining score
Score after A1
0.6
0.7
0.7*
0.3
0.8**
-0.5
0.4
0.4
-0.1
0.7*
0.9**
0.8*
0.2
0.3
-0.1
0.7*
0.4
0.5
Score after B
0.9**
0.9**
0.6
0.7*
0.6
0.5
0.9**
0.4
0.4
Score after A2
0.9**
0.9**
0.4
0.0
0.1
0.3
0.8**
0.0
0.6
Values are correlation coefficients. ADLs=activities of daily living; * Significant at p0.05; ** Significant at p0.01.
347
motor function of subjects with PD. The key findings were improved quality of life and decreased motor disability related to
the disease after the treadmill training.
The total PDQ-39 score showed a decrease across the
training period, meaning that there was a perceived improvement in quality of life after treadmill training. This
improvement was maintained after the control condition
and after the second phase of the treadmill training with additional body load. The PDQ-39 subscores showed significant
improvement in mobility, ADLs and cognition, i.e. the motor
training had positive effects on motor and non-motor aspects
of quality of life in the subjects with PD. Cognition was the
item most sensitive to changes related to training because it
showed improvement after all phases of the program. Gait
disturbances and difficulty accomplishing self-care activities
often lead to functional dependence and marked impairments in quality of life4,18,30. Carod-Artal et al.31 observed that,
in Brazilian patients, the decrease in quality of life was related
to mobility and ADL. Physical activity promotes functional
motor gains, musculoskeletal conditioning, aerobic fitness
and may prevent or delay secondary complications15,32-34,
therefore exercise may improve the quality of life of subjects
with PD.
Schrag, Jahanshahi and Quinn4 highlight the importance of
cognitive aspects to determine the quality of life of subjects with
PD. Physical activity not only improves the motor aspects but
is also associated with improvement in cognition. One of the
potential mechanisms that could explain this is the increase in
hippocampal neurogenesis that results from moderate aerobic
activity35. The literature also describes that moderate exercise
leads to an increase in the level of dopamine that would be beneficial to subjects with PD36. Furthermore, the improvement in
quality of life after a physical activity can be also attributed to
social interaction and motivation12. In our study, motivation
and enthusiasm were greater in phase A1 compared to phase
A2, possibly due to the long duration of the training program.
A significant difference was found in three subscores, however all of the other subscores (emotional wellbeing, stigma,
social support, communication and bodily discomfort) showed
a decrease at the end of the training period, indicating attenuated symptoms in all of the items included in the questionnaire.
Thus, the treadmill training with additional body load played a
major role in improving the quality of life of the subjects with
PD. Herman et al.18 also identified positive effects of treadmillwalking training, without loading or unloading, on the quality
of life and general wellbeing of subjects with PD, however the
authors highlight its effects on gait.
The use of loading in treadmill walking to train subjects
with PD is promising. The treadmill acts as an external cue,
imposes a rhythm and is a task-specific repetitive training
348
that promotes improvement in locomotor behavior37. Additionally, the increase in body load may improve proprioceptive function, which is essential for the maintenance of body
equilibrium during stance and gait but is impaired in subjects
with PD38. Therefore, this training promotes motor gains that
lead to improved gait and quality of life in these subjects.
The emotional factor may not have improved as much as the
cognitive factor due to the involvement of the amygdala and
basal ganglia in emotional and mood modulation39. Therefore,
the treadmill training may have promoted a qualitative improvement in the emotional aspect. A hypothesis would be
that emotional alterations are an intrinsic symptom of PD.
Regarding the correlations between the total PDQ-39 score
and the subscores, it was observed that, at the beginning of
the study, the quality of life of the subjects with PD was more
related to social and emotional aspects. PD affects the patient’s
life not only with the typical motor symptoms but also in a
multi-dimensional way, including aspects related to mood, cognition, social function, psychological status, communication,
occupation and sleep disorders40-42. The improvement in quality of life observed after the intervention in the present study
was mainly related to motor aspects and communication. The
communication capability may have improved due to the interaction with the therapist and other people at the therapeutic
environment and, therefore, influenced the total PDQ-39 score.
However, this subscore did not present significant differences
across the training period. The sum of the subscores may have
influenced the total score, however a cause-effect relationship
could not be established.
The treadmill training with additional body load was also
able to improve the UPDRS motor score. Studies on the effects of treadmill-walking training on PD16,18 also observed an
improvement in the UPDRS score. The UPDRS shows changes
after specific interventions and is becoming the gold standard
reference scale in PD43. However, in the present study, the improvement in the motor score was not associated with the improvement in quality of life in any of the evaluations. This result
corroborates previous studies1,4,7,44, in which the authors affirm
that the PDQ-39 and the clinical scales are designed to assess
different aspects of PD. The clinical scales used to assess the
physical impairment and the results of treatment do not assess
the psychosocial factors that are important components of
wellbeing and perhaps the most important outcome in treatments43. The UPDRS and the H-Y scales may not be sensitive
measures to evaluate the impact of disease severity on daily
life1. In contrast, other studies9,45,46 found an association between UPDRS scores and quality of life measures. According to
Havlikova et al.9, disease severity evaluated through the UPDRS
was a significant predictor of all subscores, except for social
support and cognition.
In conclusion, therapy for chronic degenerative diseases
such as PD should aim to improve the physical conditions
of the subjects and treat a number of other factors related
to quality of life. Health care professionals should not only
focus on caring of disease or increasing survival but also
enhancing the patients’ quality of life2. The treadmill training with additional body load applied in the present study
allowed the improvement of motor function and quality
of life in subjects with PD. However, a limiting factor was
the small number of subjects evaluated. Despite the large
number of individuals with PD, most of them did not fulfill
the established inclusion criteria. Another limitation was
the possibility of a carryover effect from one phase to the
next. However, the A1-B-A2 design allowed the evaluation
of the same subject in different phases of the training, i.e.
the subjects acted as their own controls. Other factors that
may have interfered in the results were the heterogeneity
of PD and the natural progression of the disease. Based on
the results, we suggest combining the treadmill training and
additional body load with conventional physical therapy to
maximize results. We also suggest that other studies investigating the effects of intervention in PD include the assessment of quality of life. Furthermore, it would be interesting
to evaluate how depression and disease duration/progression are related to quality of life and how these factors can
interfere in a successful intervention.
Acknowledgements
We would like to thank the subjects and their families for
their participation. This work was funded by a Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil
grant to R. Mattioli (300312-2007-5). N.T. Filippin is thankful to
Coordenação de Aperfeiçoamento de Pessoal de Nível Superior
(CAPES) for her scholarship.
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350
ISSN 1413-3555
ORIGINAL ARTICLE
©
Electromyographic activity during active prone
hip extension did not discriminate individuals
with and without low back pain
Atividade eletromiográfica durante o movimento de extensão do quadril em
prono não discrimina indivíduos com dor lombar
Abstract
Background: Changes in activation of the trunk and hip extensor muscles can result in excessive stress on the lumbar spinal structures,
predisposing them to lesions and pain. Objectives: To compare electromyographic activity of the gluteus maximus, semitendinosus and
the erector spinae muscles between asymptomatic and individuals with low back pain during active prone hip extension exercises.
Methods: Fifty individuals were recruited and divided into two groups: 30 asymptomatic (24.53.47 years) and 20 with mechanical low
back pain (28.755.52 years). They performed active prone hip extension exercises, while the activation parameters (latency, duration
and quantity of activation) of the investigated muscles were recorded by electromyography. The beginnings of the movements were
detected by a motion capture system. Differences between the groups were investigated employing Student t-tests or Mann-Whitney-U
tests, according to the data distribution. Results: No significant differences were found between the groups for any of the investigated
muscles. Muscular activation patterns were similar for both groups, starting with the semitendinosus, followed by the erector spinae, and
then, by the gluteus maximus. For both groups, significant delays in the onset of the gluteus maximus were observed. Conclusions: The
assessment of the electromyographic activity was not capable of discriminating individuals with and without low back pain, suggesting
an overlap in the studied populations.
Key Words: gluteus maximus; low back pain; activation patterns; electromyography, prone hip extension.
Resumo
Contextualização: Alterações no padrão de recrutamento dos extensores de tronco e quadril podem resultar em estresse excessivo
sobre estruturas da coluna lombar, predispondo-a à lesão e dor. Objetivos: Comparar a atividade eletromiográfica dos músculos glúteo
máximo, semitendíneo e eretores espinhais entre indivíduos assintomáticos e com dor lombar durante o exercício de extensão de
quadril em prono. Métodos: Cinquenta indivíduos foram recrutados e divididos em dois grupos: 30 assintomáticos (24,53,47 anos)
e 20 com dor lombar (28,755,52 anos). Os parâmetros de ativação (latência, duração e quantidade de ativação) dos músculos
investigados durante os exercícios de extensão de quadril foram registrados por meio da eletromiografia. O início e o término do
movimento foram detectados por um sistema de análise de movimento. Diferenças entre os grupos foram investigadas utilizando-se
teste t de Student ou Mann-Whitney-U, dependendo da distribuição. Resultados: Não foram observadas diferenças significativas entre
os grupos para nenhum dos músculos investigados. O padrão de recrutamento foi similar para os dois grupos, iniciando-se pelo
semitendíneo, seguido pelos paravertebrais e finalizado pelo glúteo máximo. Nos dois grupos, observou-se um aumento significativo
na latência do glúteo máximo comparado aos demais músculos. Conclusões: A avaliação do padrão de recrutamento não foi capaz
de separar indivíduos com e sem dor lombar, sugerindo ocorrer uma sobreposição entre as populações estudadas.
Palavras-chave: glúteo máximo; dor lombar; padrão de ativação; eletromiografia; extensão do quadril.
Physical Therapy Department, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil
Correspondence to: Luci Fuscaldi Teixeira-Salmela, Departamento de Fisioterapia, Universidade Federal de Minas Gerais, Avenida Antônio Carlos, 6627, Campus Pampulha,
CEP 31270-901, Belo Horizonte (MG), Brazil, e-mail: [email protected]
351
Introduction
Relationships between movement patterns and dysfunctions have been studied1,2 and movement is considered to be
a system, which depends on the appropriate functional and
interactions between several elements: basic systems (muscular and skeletal), modulator system (nervous), and the
biomechanical and support systems2. Each element plays an
important role in movement production and can be, in turn,
be modified due to the adaptative physiological responses of
the tissues3.
Sustained postures or incorrect movement habits may
modify the demands made of the involved muscles, leading to
changes in strength, flexibility, stiffness or activation patterns4,5.
As a consequence, changes in movement patterns may emerge,
thus spreading the physical stresses across various structures,
which results in impairments of the muscular and skeletal
systems1,2.
Adequate muscular activation patterns, when the synergic muscles are activated in an appropriate temporal order,
are recognized to be important for the effective functioning
of the lumbar spine5. Even if these muscles have adequate
strength and, if the nervous system does not activate them
at the right moment and with an adequate intensity, movement impairments can still result4, and contribute to low
back pain (LBP).
Active prone hip extension exercises have been used to
evaluate the activation patterns of the lumbar pelvic region.
These movements involve the contraction of the gluteus maximus, hamstring, and erector spinae muscles. In asymptomatic
individuals, it has been discussed whether there are characteristic activation patterns and, if so, what would they be. There is
no consistency concerning ideal activation levels, which makes
the identification of altered patterns difficult in the evaluation
process6-9.
Studies which evaluated the activation patterns during the
active prone hip extension exercises in individuals with LBP
were not found. It is possible that these individuals show lower
variability, as suggested by Nygren Pierce and Lee7, a delayed
activation of the gluteus maximus, compromizing the lumbar
pelvic stabilization; or changes in other muscular parameters.
The identification of differences between LBP and asymptomatic individuals may help in the understanding of the link between altered muscular activation and pain, besides enhancing
the comprehension of the important outcome measures which
should be assessed.
Therefore, the aims of this study were to compare the activation patterns between asymptomatic and LBP individuals
and to investigate changes in the electromyographic activation parameters (latency, duration and amount of muscular
352
activation) of the trunk and hip extensor muscles in individuals with LBP, during active prone hip extension exercises.
Methods
Subjects
Fifty individuals of both genders were recruited from the
community and divided into two groups. Thirty asymptomatic
subjects, without complaints of pain, histories of trauma nor
surgery in the lumbar spine or lower limb joints were selected.
Twenty individuals with mechanical LBP, who had pain with
a duration over at least six months, a history of at least one
episode of LBP which had limited their functional activities in
work or sports over the past 18 months, and had experienced
episodes of LBP over the past six months were also selected.
Exclusion criteria included the presence of pain during the
tests, shortening of the hip flexors, as determined by a positive
Thomas test9, neurological disorders, pain in the thoracic spine
and/or in the lower limbs, a history of fractures or surgery in
the lumbar spine or hip joints, pregnancy in the two previous
years, and the presence of tumors or infections. Those who
were submitted to a physical therapy program, which involved
strengthening of the extensors of the trunk or hip, and those
taking analgesics were also excluded.
The groups were matched by age, gender, and physical activity levels. All participants signed a consent form to participate
in the study, which was approved by the ethical review board of
the Universidade Federal de Minas Gerais, Brazil (Parecer ETIC
422/06).
Instrumentation
The activation parameters (latency, duration and amount of
activation) of the gluteus maximus, semitendinosus, and erector spinae muscles were assessed by electromyography (MP150WSW, Biopac Systems Inc.©, Santa Barbara, CA). This device
had two amplifiers connected to a microcomputer, which had
an input impedance of 2 M and a CMRR of 1,000 M and allowed data acquisition at frequencies from 10 to 1,000 Hz. Data
were collected at a frequency of 1,000 Hz. Active, bipolar surface
electrodes (TSD 150), with diameters of 13.5 mm and an impedance of 100 M were used for data collection.
The beginning of the movement was detected by a motion
capture system ProReflex MCU Qualisys (QUALISYS MEDICAL AB, Gothenburg, SW), with an acquisition rate of 120 Hz
and MCU 120 digital cameras equipped with a set of infra-red
light emitters which were reflected by spherical passive markers of 12 mm in diameter and adhered to specific anatomic
Electromyographic activity during hip extension
bony marks. Procedures of linearization and calibration were
performed according to the instructions in the manufacturer’s
manual. Three cameras were employed to capture the images
and were positioned in such a way that all markers were captured during the performance of the active prone hip extension.
Procedures
Demographic and anthropometric data were collected on
all subjects, as well as other clinically relevant information.
Thus, the subjects in both groups were asked to answer the
short version of the International Physical Activity Questionnaire (IPAQ), to evaluate their physical activity levels10. The
individuals with LBP were submitted to a physical examination
to verify the inclusion criteria and characterize the direction
of the spinal movement which triggered their pain ( flexion
and/or extension). They also replied to three questionnaires for
characterization purposes: The Tampa Scale for KinesiophobiaBrazil, to assess their fear of movement/reinjury11; the Roland
Morris-Brazil, to evaluate their functional limitation and disability levels12; and the Qualitative Pain Scale, which evaluated
their pain on a six-point scale12.
To obtain the EMG data, surface electrodes (Ag/AgCl) were
placed in pairs parallel to the muscular fibers8,13. For the gluteus
maximus, the electrodes were placed at the midpoint of the
line running from the last sacral vertebrae to the greater trochanter; for the semitendinosus, medially on the mid-distance
point between the gluteal fold and the knee joint; and for the
erector spinae muscles, at the L3 level, bilaterally two cm lateral from the spinal processes and parallel to the lumbar spine.
The inter-electrode spacing was two cm from center to center.
The reference electrode was placed over the lateral malleolus,
and skin preparation included shaving, rubbing and cleansing
with alcohol.
Passive markers were then placed over the iliac crest and
the greater trochanter ( forming one rigid segment) and the
mid-point of the thigh and the lateral epicondyle of the femur
( forming another segment) of the dominant lower limb. The
subjects were instructed to perform active prone hip extension
at their natural speed (Figure 1). Three trials were obtained
during a two-minute rest period between each trial and the
mean values of the three trials were used for analysis. The
peak EMG values obtained during the movement were used
as reference points for data normalization. The beginnings of
the movements were determined by the changes in the angular
displacements of the rigid segments, obtained from the motion
capture system. A trigger mechanism was used to synchronize
the EMG and the motion capture system data, after assuring
EMG silence. The collected data were stored and exported to
Matlab for processing and analysis.
Figure 1. Participant performing the active prone hip extension
movements.
Data reduction
EMG data processing was performed using the Acknowledge software. The EMG signals were full-wave rectified and
low-pass and high-pass filtered with cut-off frequencies of 500
and 10 Hz, respectively. The quantification of the EMG signals
was based upon peak root mean square (RMS) values from the
dynamic contractions during the active prone hip extension.
Muscular activation patterns were described after determining the EMG onset for each muscle. The onset and the end of
the muscular activity were considered to occur when the values
respectively exceeded and dropped below two standard deviations from the mean values observed at baseline for a 50 ms period14. The onset of the movements was calculated by a specific
routine developed at MATLAB® and was recorded when the
angular velocity was positive and the displacement exceeded
one degree and remained constant8, whereas its termination
was considered when the displacement returned to the mean
values after the movements were terminated. The duration of
both the muscular activity and the movement were calculated,
and a ratio between them, or their duration ratios, were determined to allow for comparisons between groups and individuals performing the movements with different durations.
Data analysis
Descriptive statistics and tests for normality were calculated
for all outcome variables, using the software SPSS 13.0 for Windows (SPSS Inc.©, Chicago, IL). According to the data distribution, Student t-tests or Mann-Whitney-U tests were employed to
investigate differences between the groups regarding their latencies, the duration ratio, and the amount of activation (% of peak
353
EMG values) of the extensors of the trunk and hip joints. Repeated
measure ANOVAs were used to compare the latencies of each
muscle within the groups with a significance level of <0.05.
A
Semitendinosus
Gluteus maximus
**
*
CES
IES
-0.80
-0.60
-0.40
-0.20
0.00
0.20
Latency (s)
B
Semitendinosus
Gluteus maximus
**
*
CES
IES
-0.80
-0.60
-0.40
-0.20
0.00
0.20
Latency (s)
*p<0.05; **p<0.01; IES=Ipsilateral erector spinae; CES=Contralateral erector spinae.
Figure 2. Muscular latencies of all investigated muscles for the
asymptomatic (A) and LBP (B) individuals.
Figure 3. A typical activation pattern of an individual with LBP, determined
by the onset of EMG activity. The dotted lines represent the beginning of the
movement and the straight lines the beginning of the muscular activity.
354
Results
Subject characteristics
For the matching of the groups by their physical activity levels, three individuals of the asymptomatic group were
excluded. Moreover, one individual from the LBP group complained of pain during the assessment, and was also excluded.
Therefore, only 46 subjects participated in the study, with 27 asymptomatics and 19 with LBP (55.6% women and 44.4% men).
The asymptomatic group had a mean age of 24.853.60 years,
a body mass of 67.3612.55 kg, a height of 1.700.09 m, and a
body mass index (BMI) of 23.133.09 kg/m2.
The LBP group had a mean age of 28.795.67 years, body
mass of 66.9216.76 kg, height of 1.680.09 m and BMI of
23.483.84 kg/m2. These individuals had complaints of pain
for periods ranging from one to 10 years (3.52.38 years). Seven
complained of pain in the direction of extension, three in the
direction of flexion, seven in both directions, and two did not
show any specific patterns. Clinically, these individuals had a
score of 28.58 [19-38] on the Tampa Scale for Kinesiophobia;
4.74 [0-11] on the Rolland Morris questionnaire and 1.63 [0-3]
on the qualitative pain scale, indicating that the individuals had
low levels of kinesiophobia, functional limitations and pain.
Outcome measures
Figure 2 shows the muscular latencies of all investigated
muscles for the asymptomatic (2a) and LBP (2b) individuals.
For the asymptomatic group, the muscular activation patterns
were initiated by the semitendinosus, followed by the ipsilateral
erector spinae, contralateral erector spinae and finished by the
gluteus maximus. The ANOVAs demonstrated significant differences in the latencies for the semitendinosus in relation to
the contralateral erector spinae (F=13.91; p=0.001) and gluteus
maximus (F=56.34; p<0.001), indicating that the semitendinosus
was the first muscle to be activated. Significant differences were
also observed for the gluteus maximus latencies in relation to the
other muscles (F>41.78; p<0.001), demonstrating that the gluteus
maximus was the last muscle to be activated (Figure 2A).
For the LBP group, the activation sequences were also initiated with the semitendinosus, followed by the contralateral
erector spinae, ipsilateral erector spinae and gluteus maximus
(Figure 3). As shown in Figure 2B, similar to the asymptomatic
group, significant delays were also observed for the onset times
of the gluteus maximus in comparison to the other muscles
(F>23.64; p<0.001). The ANOVAs also revealed significant differences in latencies for the semitendinosus in relation to the
ipsilateral erector spinae (F=7.49; p=0.014) and gluteus maximus muscles (F=36.70; p<0.001).
As is shown in Table 1, no significant differences were
found between the groups regarding the variables related to
the latencies (0.28<z/t<1.37; 0.18<p<0.78), amount of activation (0.14<z/t<1.14; 0.26<p<0.89), and duration of activation
(0.02<z/t<1.63; 0.10<p<0.98) for all investigated muscles. In
addition, no interaction effects were found between genders
nor physical activity levels for any investigated variables for
both groups (0.03<F<1.14; 0.28<p<0.87).
Discussion
Evaluations of the active prone hip extension have been
extensively carried out, based upon the existence of consistent
activation patterns of the trunk and hip extensor muscles. The
ideal pattern was believed to be characterized by the initial
activation of the gluteus maximus, followed by the hamstring
and erector spinae muscles1,2. In the present study, however,
this pattern was not observed in either of the evaluated groups.
Actually, the most consistent findings were the delayed activation of the gluteus maximus in relation to the other muscles.
Furthermore, comparisons between the asymptomatic and
LBP individuals did not reveal significant differences for any of
the investigated EMG parameters.
For both groups, an activation sequence was observed,
which was initiated by the semitendinosus, followed by the
erector spinae muscles (ipsilateral and then contralateral for
the asymptomatic; contralateral and then ipsilateral for the
LBP) and finally by the gluteus maximus. Previous studies
which evaluated asymptomatic individuals also reported initial activation of the hamstrings7,8, although only Sakamoto et
al.8 found significant differences in the latency of these muscles
in relation to the other hip and trunk extensor muscles. On the
other hand, Vogt and Banzer9 observed different activation
sequences, initiated by the ipsilateral erector spinae, followed
by the contralateral erector spinae, hamstrings and gluteus
maximus muscles.
Although previous studies showed some differences regarding the order of activation of the hamstrings and the
erector spinae muscles, there was a consensus that the
gluteus maximus was the last muscle to be activated6-9,
suggesting that this delay appears to be a normal finding.
One theoretical hypothesis, based upon anatomical and
biomechanical knowledge, is that these delays could lead to
movement impairments, favoring the occurrence of pelvic
anteversion and excessive lumbar extension, generating
excessive stresses in the spine1,2,4. Furthermore, decreases
in the gluteus maximus activation could compromize the
Table 1. Descriptive statistics, critical value, and p values of the investigated EMG parameters for the asymptomatic (A) and LBP groups.
Variable
Latency (s)
Muscle
IES
CES
Gluteus
Semit
Amount of activation (%)
IES
CES
Duration of activation
(ratio: duration of activation/
movement duration)
Gluteus
Semit
IES
CES
Gluteus
Semit
Group
A
LBP
A
LBP
A
LBP
A
LBP
A
LBP
A
LBP
A
LBP
A
LBP
A
LBP
A
LBP
A
LBP
A
LBP
Median
-0.26
-0.22
-0.27
-0.23
0.11
-0.004
-0.34
-0.30
11.48
11.99
11.36
12.39
8.02
9.35
10.58
11.99
1.37
1.28
1.42
1.41
1.04
1.26
1.44
1.46
Confidence Interval
[-0.45; -0.21]
[-0.32; -0.15]
[-0.41; -0.21]
[-0.48; -0.16]
[0.02; 0.25]
[-0.06; 0.10]
[-0.50; -0.26]
[-0.49; -0.22]
[10.49; 12.65]
[10.47; 13.75]
[10.30; 12.53]
[10.63; 13.14]
[7.22; 8.77]
[7.92; 10.43]
[9.88; 12.15]
[11.03; 14.31]
[1.34; 1.57]
[1.17; 1.33]
[1.36; 1.55]
[1.25; 1.46]
[0.99; 1.16]
[1.14; 1.33]
[1.39; 1.59]
[1.37; 1.56]
Critical Value
z=-0.42
p
0.68
z=-0.28
0.78
t=1.37
0.18
z=-0.29
0.77
t=-0.14
0.89
t=-0.28
0.78
t=-0.72
0.48
t=-1.14
0.26
z=-1.63
0.10
z=-0.57
0.57
t=-1.68
0.10
z=-0.02
0.98
IES=Ipsilateral Erector Spinae; CES=Contralateral Erector Spinae; Semit=Semitendinous.
355
stability of the sacroiliac joint during functional activities
and predispose it to pain15,16.
Considering this hypothesis, it could be expected that individuals with mechanical LBP would show increased delays and
decreased durations and amounts of activation of the gluteus
maximus, compared to the asymptomatic individuals, who
were not observed in the present study. These findings, however, deserve some considerations.
Health conditions such as LBP are considered multifactorial, which means that several factors may exist, which are both
mechanical and non-mechanical associated with the onset,
recurrence, or exacerbation of pain17. The mechanical factors
may include muscular weaknesses and shortening, changes in
movement and activation patterns, incorrect postural habits,
repetitive movements employed in work or sport activities,
ergonomic and environmental factors. All of these represent
intrinsic and extrinsic risk factors which may help the understanding of the causes of specific dysfunctions17,18. Changes in
activation patterns represent only one of several risk factors
for lumbar spine dysfunctions. Thus, it is possible that changes
in the activation patterns could be observed in individuals
without pain, making it difficult to find differences between
groups.
Another consideration refers to the characteristics of the
LBP participants: They had low levels of kinesiofobia and pain
and did not have disabilities. It is possible that individuals with
greater functional limitations would show changes in muscular activation parameters which would agree with the reports
of previous studies19-22. However, the selection of participants
with these characteristics was a deliberate decision, since the
aim of the present study was to understand the relationships
between changes in the activation patterns and mechanical
LBP, and not the effects of high levels of pain and disabilities of
muscular activity.
In any case, the fact that significant differences were not
found, suggests that the evaluation of electromyographic activity during active prone hip extension was not capable of
discriminating between individuals with and without LBP, as
suggested by Lehman23. This ability would be even more difficult in clinical environments, where the evaluation is performed in a subjective way through muscular palpation.
Some methodological considerations need to be discussed.
In the present study, the onset of electromyographic activity
was considered to occur when the values exceeded two standard deviations from the mean values observed at baseline for
a 50 ms period8. This method has been demonstrated to be
reliable, when compared to others, and helps the avoidance of
356
type I (when using one standard deviation) and type II (using
three standard deviations) methodological errors, as reported
by Hodges and Bui14.
The EMG data obtained during the performance of prone
hip extension was normalized by the peak values obtained
during the complete movement. These procedures allowed
comparisons between different individuals and studies and
reduced the inter-subject coefficients of variation24. Normalization by the maximum voluntary contractions was not chosen, as previously employed25, because this procedure could
not have been trustworthy for individuals with LBP, as they
would not be able to perform maximum contractions due to
the pain26-29.
Clinical considerations
Considering the high variability observed in the electromyographic activation parameters during prone hip extension,
two factors should be discussed. The first one refers to the
difficulty in defining an ideal activation pattern, which could
be used as a reference point for comparisons. This pattern is
probably different for each individual, according to their own
characteristics.
The second factor is that, in the evaluation of active prone
hip extension, the movement patterns rather than the activation parameters, should be evaluated to identify changes such
as pelvic anteversion or rotation which could generate excessive stress and pain in the spine30.
Conclusions
Comparisons between asymptomatic and LBP individuals
did not reveal significant differences, regarding the latencies,
durations and amount of EMG activation of the trunk and hip
extensor muscles during active prone hip extension movements. Therefore, the evaluation of the electromyographic
activity was not capable of discriminating between the individuals with and without LBP, suggesting interactions between
the studied populations.
Acknowledgments
Brazilian Government Funding Agencies (Conselho Nacional de
Desenvolvimento Científico e Tecnológico/Fundação de Amparo à
Pesquisa do Estado de Minas Gerais - CNPq/ FAPEMIG).
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Sahrmann SA. Diagnosis and treatment of movement impairment syndromes. 1ª ed. St
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Mueller MJ, Maluf KS. Tissue adaptation to physical stress: A proposed “physical
stress theory” to guide physical therapist practice, education, and research. Phys Ther.
2002;82(4):383-403.
Bullock-Saxton J, Murphy D, Norris C, Richardson C, Tunnell P. The muscle designation
debate: The experts respond. J Bodywork Mov Ther. 2000;4:225-41.
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McGill SM, Grenier S, Kavcic N, Cholewicki J. Coordination of muscle activity to assure
stability of the lumbar spine. J Electromyogr Kinesiol. 2003;13(4):353-9.
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Lehman GJ, Lennon D, Tresidder B, Rayfield B, Poschar M. Muscle recruitment patterns
during the prone leg extension. BMC Musculoskelet Disord. 2004;5:3.
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Nygren Pierce M, Lee WA. Muscle firing order during active prone hip extension. J Orthop
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Sakamoto AC, Teixeira-Salmela LF, de Paula-Goulart FR, de Morais Faria CD, Guimarães CQ.
Muscular activation patterns during active prone hip extension exercises. J Electromyogr
Kinesiol. 2009;19(1):105-12.
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Vogt L, Banzer W. Dynamic testing of the motor stereotype in prone hip extension from
neutral position. Clin Biomech. 1997;12(2):122-7.
10. Matsudo S, Araújo T, Marsudo V, Andrade D, Andrade E, Oliveira LC, et al. Questionário
internacional de atividade física (IPAQ): Estudo de validade e reprodutibilidade no Brasil.
Rev Bras Ativ Fís Saúde. 2001;6(2):5-18.
11. Siqueira FB, Teixeira-Salmela LF, Magalhães LC. Análise das propriedades psicométricas
da versão brasileira da Escala Tampa de cinesiofobia. Acta Ortop Bras. 2007;15(1):19-24.
12. Nusbaum L, Natour J, Ferraz MB, Goldenberg J. Translation, adaptation and validation of the
Roland-Morris questionnaire – Brazil Roland-Morris. Braz J Med Biol Res. 2001;34(2):203-10.
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O’Sullivan P. Diagnosis and classification of chronic low back pain disorders: maladaptive
movement and motor control impairments as underlying mechanism. Man Ther.
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18. Bahr R, Krosshaug T. Understanding injury mechanisms: A key component of preventing
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19. Kankaanpaa M, Taimela S, Laaksonen D, Hanninen O, Airaksinen O. Back and hip extensor
fatigability in chronic low back pain patients and controls. Arch Phys Med Rehabil.
1998;79(4):412-7.
20. Leinonen V, Kankaanpaa M, Airaksinen O, Hanninen O. Back and hip extensor activities
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21. Radebold A, Cholewicki J, Panjabi MM, Patel TC. Muscle response pattern to sudden trunk
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22. Dankaerts W, O’Sullivan P, Burnett A, Straker L. Altered patterns of superficial trunk muscle
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23. Lehman GJ. Trunk and hip muscle recruitment patterns during the prone leg extension
following a lateral ankle sprain: A prospective case study pre and post injury. Chiropractic
Osteopathy. 2006;14(4):1-4.
24. Soderberg GL, Knutson LM. A guide for use and interpretation of kinesiologic
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25. Sakamoto ACL, Teixeira-Salmela LF, Rodrigues de Paula F, Guimarães CQ, Faria CDCM.
Gluteus maximus and semitendinosus activation during active prone hip extension
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357
ISSN 1413-3555
©
LETTER TO THE EDITOR
Access to pulmonary rehabilitation programs
within the public healthcare service
Dear Editor,
I congratulate the authors for providing the “Clinical Practice Guidelines: physical therapy practice among
patients with chronic obstructive pulmonary disease (COPD)”1. These guidelines, together with other national and
international studies, have successfully shown, with strong evidence, the role of physical therapists in this growing
public health problem. However, routine access to such programs has not yet been achieved.
In order to benefit from the results of pulmonary rehabilitation programs (PRPs), patients have to go to a
rehabilitation center. This means personal and even family scheduling and weekly or monthly expenses relating to
transportation, especially if the program is provided in another city. The difficulties can be worsened if the subject
is dependent on oxygen, given that the cylinders are heavy and do not last long.
The Brazilian Constitution3 proposes universal and equal access to health actions and services, including rehabilitation, which should be comprehensive, universal and equitable. These principles are a challenge for care practice. The history of the process of healthcare organization demonstrates the difficulties found in PRP functioning,
through the verticalization that divides and complicates the solutions for problems, and through flaws in work
organization within healthcare services, including physical therapy, starting from epidemiology4.
The study by Griffiths et al.5 shows that PRPs have a good cost-effectiveness relationship, which can result in
financial benefits for the public healthcare system, such as reductions in the numbers of hospitalization days, visits
to emergency units, and need for medication. In this manner, PRPs for users of the public healthcare system can be
justified as a measure that may result, in the long run, in decreased expenditure on COPD patients.
The process of developing a PRP within the public health system is still a challenge for physical therapists and
for the system itself. It is essential to draw up strategies to increase patients’ access to these programs, in order to
consolidate the proposal. In conclusion, studies on the incorporation of PRPs within the public healthcare system
need to be conducted, and physical therapists should have the responsibilities of broadening their fields of work,
raising managers’ awareness and demonstrating the need to apply other practices in the public system to better
suit users6.
Sincerely,
Cristiane Mecca Giacomazzi
Physical Therapist
358
References
1.
Langer D, Probst VS, Pitta F, Burtin C, Hendriks E, Schans CPVD, et al . Guia para prática clínica: fisioterapia em pacientes com Doença Pulmonar Obstrutiva Crônica (DPOC). Rev Bras Fisioter. 2009;13(3):183-204.
2.
Roceto LS, Takara LS, Machado L, Zambon L, Saad IAB. Eficácia da reabilitação pulmonar uma vez na semana em portadores de doença pulmonar obstrutiva. Rev Bras Fisioter. 2007;11(6):475-80.
3.
BRASIL. Constituição da República Federativa do Brasil. 1988. Disponível em: http://www.planalto.gov.br/ccivil_03/Constituicao/Constituiçao.htm
4.
Pinheiro R, Mattos RA. Os sentidos da integralidade na atenção e no cuidado à saúde 6ª ed. Rio de Janeiro: IMS/UERJ - CEPESC – ABRASCO; 2006.
5.
Griffiths TL, Phillips CJ, Davies S, Burr ML, Campbell IA. Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax. 2001;56(10):779-84.
6.
Santos FAS, Gouveia GC, Martelli PJL, Vasconcelos EMR. Acupuntura no Sistema Único de Saúde e a inserção de profissionais não-médicos. Rev Bras Fisioter. 2009;13(4):330-4.
Access to pulmonary rehabilitation programs
within the public healthcare service
(reply by the authors)
(réplica dos autores)
In the letter to the editor “Access to pulmonary rehabilitation programs within the public healthcare service” (referring to the
article “Clinical Practice Guideline: physical therapy practice among patients with COPD”, Brazilian Journal of Physical Therapy v. 13, n. 3,
p. 183-204, May/June 2009), the points raised by the authors are relevant to the subject and deserve special attention in Brazil. Indeed,
there are difficulties relating to patients’ access to such programs, as pointed out by the authors of the letter (problems regarding
transportation and oxygen therapy availability, for instance). There are several other difficulties, and they are all part of the daily
routine of patients who require pulmonary rehabilitation. They need to be given due consideration and overcome, in order to ensure
access to this beneficial rehabilitation. This is the reality of the situation in Brazil, and we need to improve it in the most conscientious
manner possible. This means seeking the best available evidence regarding the benefits of such rehabilitation. Even if it seems difficult
to apply this evidence at this moment, we need to seek to disseminate the evidence, so that it is protected and implemented.
As mentioned by the authors, we agree that despite solid evidence that PRPs have good cost-effectiveness relationship, the
organizational characteristics of Brazilian public and private healthcare services hamper the ideal implementation of this type
of program. In other words, it is clear that the struggle to provide the best rehabilitation program possible is not only a scientific
battle, but also a political battle, in terms of raising awareness and convincement.
The implementation of quality PRPs is undoubtedly a challenge, as pointed out by the authors of the letter. It is up to us, physical therapists, who would be responsible for what is considered to be the main part of the program (physical training), to accept
this challenge. By working responsibly, in a well-grounded and thorough manner, not only can we make managers more aware,
but also we can engage other healthcare professionals within the process of the rehabilitation program. This way, we can achieve
implementation of such programs in this country and offer a quality service to patients with chronic lung diseases, who should
always be the main beneficiaries of PRPs.
Vanessa Suziane Probst
Physical Therapy Department, Universidade Norte do Paraná (UNOPAR), Londrina (PR), Brazil
Fábio Pitta
Physical Therapy Department, Universidade Estadual de Londrina (UEL), Londrina (PR), Brazil
359
Index/Índice
ISSN 1413-3555
ANATOMY, PHYSIOLOGY, KINESIOLOGY AND BIOMECHANICS/ ANATOMIA, FISIOLOGIA, CINESIOLOGIA E BIOMECÂNICA
316
Determination of the power-duration relationship in upper-limb exercises
Determinação da relação potência-duração em exercício com membros superiores
Domingos Belasco Junior, Fernando R. Oliveira, José A. N. Serafini, Antonio C. Silva
351
Electromyographic activity during active prone hip extension did not discriminate individuals with and without low back pain
Atividade eletromiográfica durante o movimento de extensão do quadril em prono não discrimina indivíduos com dor lombar
296
Relationship between quadriceps angle (Q) and plantar pressure distribution in football players
Relação entre o ângulo quadriciptal (ÂQ) e a distribuição da pressão plantar em jogadores de futebol
276
The effects of knee extensor eccentric training on functional tests in healthy subjects
Os efeitos do treino isocinético excêntrico dos extensores do joelho nos testes funcionais em sujeitos saudáveis
MOTOR CONTROL, BEHAVIOR AND MOTOR FUNCTION/ CONTROLE MOTOR, COMPORTAMENTO E MOTRICIDADE
309
Assessment of global motor performance and gross and fine motor skills of infants attending day care centers
Avaliação do desempenho motor global e em habilidades motoras axiais e apendiculares de lactentes frequentadores de creche
PHYSICAL THERAPY FOR CARDIOVASCULAR AND RESPIRATORY CONDITIONS/ FISIOTERAPIA NAS CONDIÇÕES CARDIOVASCULARES E RESPIRATÓRIAS
290
Noninvasive ventilation in the immediate postoperative of gastrojejunal derivation with Roux-en-Y gastric bypass
Ventilação não invasiva no pós-operatório imediato de derivação gastrojejunal com bypass em Y de Roux
337
Ventilatory and muscular assessment in healthy subjects during an activity of daily living with unsupported arm
elevation
Avaliação ventilatória e muscular de indivíduos saudáveis durante atividade de vida diária com os braços elevados e sem apoio
PHYSICAL THERAPY FOR GERIATRIC CONDITIONS/ FISIOTERAPIA NAS CONDIÇÕES GERIÁTRICAS
322
Determinant factors of functional status among the oldest old
PHYSICAL THERAPY FOR MUSCULOSKELETAL CONDITIONS/ FISIOTERAPIA NAS CONDIÇÕES MUSCULOESQUELÉTICAS
330
Head and shoulder alignment among patients with unilateral vestibular hypofunction
Alinhamento de cabeça e ombros em pacientes com hipofunção vestibular unilateral
284
Quality of life and discriminating power of two questionnaires in fibromyalgia patients: Fibromyalgia Impact
Questionnaire and Medical Outcomes Study 36-Item Short-Form Health Survey
A qualidade de vida e o poder de discriminação de dois questionários em pacientes com fibromialgia: Fibromyalgia Impact
Questionnaire e Medical Outcomes Study 36-Item Short-Form Health Survey
PHYSICAL THERAPY FOR NEUROLOGICAL CONDITIONS/ FISIOTERAPIA NAS CONDIÇÕES NEUROLÓGICAS
344
Effects of treadmill-walking training with additional body load on quality of life in subjects with Parkinson’s disease
Efeitos do treino da marcha em esteira com aumento da carga corporal sobre a qualidade de vida de sujeitos com doença de
Parkinson
MEASUREMENTS IN PHYSICAL THERAPY/ MEDIDAS EM FISIOTERAPIA
303
Calibration of low-level laser therapy equipment
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Introduction – This should give information on the subject of
investigation and contain the objectives of the investigation, how
it relates to other studies in the same field and the reasons that led
the author(s) to follow this line of research;
Methods – These should be described in detail so that other researchers can repeat the entire study. All the necessary information should
be included (or reference should be made to articles already published
in other scientific journals) to allow the replication of the collected
data. It is strongly recommended that intervention studies present
control groups and, when possible, randomization of the sample.
Results – These should be presented briefly and concisely. Tables,
Figures and Appendices can be included when necessary to ensure better and more effective comprehension of the data.
Discussion – The purpose of the discussion is to interpret the
results and relate them to existing and available knowledge, especially the knowledge already indicated in the Introduction of
the study. Information given earlier in the text may be cited, but
should not be repeated in detail in the Discussion.
Systematic Review and Meta-analysis articles must include a section that describes the methods employed for locating, selecting,
obtaining, classifying and synthesizing information.
Acknowledgements
When appropriate, brief acknowledgements can be included at the
end of the text and before the References, specifying technical assistance, financial support for the research, study grants, and collaboration
from individuals who deserve recognition (counseling and assistance).
The authors are responsible for obtaining permission in writing from
the individuals whose names appear in the Acknowledgements;
References
The recommended number of references is at least 50 references
for review articles; 30 references for original articles, meta-analyses,
systematic reviews and methodological articles. For case studies, no
more than 10 references are recommended.
References should be organized in numerical order of first
appearance in the text, following the Uniform Requirements for
Manuscripts Submitted to Biomedical Journals, drawn up by the
International Committee of Medical Journal Editors (ICMJE http://www.icmje.org/index.html).
Journal titles should be referred to in abbreviated form, in accordance
with the List of Journals of Index Medicus (http://www.index-medicus.com).
Non-indexed journals should not have their names abbreviated.
Citations should be mentioned in the text as superscript numbers, without dates. The accuracy of the references appearing in the
manuscript and their correct citation in the text are the responsibility of the authors of the manuscript. (See examples in the website:
http://www.nlm.nih.gov/bsd/uniform_requirements.html).
Tables, Figures and Appendices
The tables, figures and appendices are limited to a total of five.
Tables – must include only indispensable data and must not be
excessively long. The tables should be numbered consecutively
using Arabic numerals and should be inserted at the end of the
text. Descriptive titles and legends must make the tables intelligible without the need to refer to the text of the article. The tables
should not be formatted with horizontal or vertical markers; only
horizontal lines are needed to separate their main sections. Paragraphs or indentations and vertical and horizontal spaces should
be used to group the data.
Figures – must not repeat the data described in the Tables. All
figures must be cited and numbered consecutively using Arabic
numerals in the order in which they appear in the text. The use of
color is not recommended. The legends should make the figures
intelligible, with no need to refer to the text. They must be double
spaced and explain all symbols and abbreviations. Use uppercase
letters (A, B, C, etc.) to identify the individual parts of multiple
figures. When possible, all the symbols should appear in the
legends. However, symbols identifying curves in a graph can be
included in the body of the figure, provided this does not hinder
the analysis of the data.
With regard to final artwork, all figures must be in high resolution. Poor-quality figures may result in delays in the acceptance and
publication of the article.
Tables, figures and appendices published in other journals or
books must include the respective references and written consent
from the authors or editors.
For articles submitted in Portuguese, an additional set of tables,
figures and appendices with English legends must be included as a
supplementary document.
Footnotes
If absolutely necessary, footnotes should be consecutively numbered as superscripts in the manuscript and placed on a separate page
after the references.
INSTRUÇÕES AOS AUTORES
JULHO 2010
Para submissão de manuscrito (preferencialmente em inglês)
consulte NORMAS EDITORIAIS no website: <http://www.scielo.br/
revistas/rbfis/pinstruc.htm>.
Informações gerais
A submissão dos manuscritos deverá ser efetuada por via eletrônica, no site <http://www.scielo.br/rbfis> e implica que o trabalho não
tenha sido publicado e não esteja sob consideração para publicação em
outro periódico. Quando parte do material já tiver sido apresentada em
uma comunicação preliminar, em Simpósio, Congresso, etc., deve ser
citada como nota de rodapé na página de título, e uma cópia do texto da
apresentação deve acompanhar a submissão do manuscrito.
Os artigos submetidos e aceitos em português serão traduzidos
para o inglês por tradutores da RBF/BJPT. Os artigos submetidos e
aceitos em inglês também serão encaminhados aos revisores de inglês da RBF/BJPT para revisão final.
Para os artigos submetidos a partir de 1 de julho de 2010, a RBF/
BJPT cobrará na submissão do artigo uma taxa de processamento
(para todos os artigos que forem analisados) e taxa de tradução/publicação (para todos os artigos aceitos para publicação), do autor de
correspondência ou pessoa por ele indicado, conforme valores definidos em reunião do seu Conselho Editorial.
Procedimentos para pagamentos:
a) No Brasil os pagamentos serão feitos por meio da quitação de
boleto bancário disponível no site http://www.rbf-bjpt.org.br;
b) Outros paises: solicite informações sobre como efetuar os pagamentos para: [email protected];
c) Não haverá cobrança de taxas dos artigos submetidos por autores
convidados formalmente pelos Editores da RBF;
d) A taxa de processamento não será reembolsada no caso do artigo
não ser publicado.
Forma e preparação dos manuscritos
A RBF/BJPT aceita, no máximo, 6 (seis) autores em um manuscrito.
O manuscrito deve ser escrito preferencialmente em inglês e pode conter
até 3.500 palavras (excluindo Resumo/Abstract, Referências, Figuras, Tabelas e Anexos). Estudos de Caso não devem ultrapassar 1.600 palavras,
excluindo Resumo/Abstract, Referências, Figuras, Tabelas e Anexos.
Ao submeter um manuscrito para publicação, os autores devem
enviar, por via eletrônica, como documento(s) suplementar(es):
1) Carta de encaminhamento do material, contendo as seguintes
informações:
a) Nomes completos dos autores;
b) Tipo e área principal do artigo (ver OBJETIVOS, ESCOPO E
POLÍTICA);
c) Número e nome da Instituição que emitiu o parecer do Comitê
de Ética para pesquisas em seres humanos e para os experimentos em animais. Para as pesquisas em seres humanos,
incluir também uma declaração de que foi obtido o Termo de
Consentimento dos participantes do estudo;
d) Conforme descritos em OBJETIVOS, ESCOPO E POLÍTICA,
os manuscritos com resultados relativos aos ensaios clínicos
deverão apresentar número de identificação, que deverá ser registrado no final do Resumo/Abstract. (Sugestão de site para registro: <http://www.anzctr.org.au/Survey/UserQuestion.aspx>);
2) Declaração de responsabilidade de conflitos de interesse. Os autores devem declarar a existência ou não de eventuais conflitos de
interesse (profissionais, financeiros e benefícios diretos e indiretos) que possam influenciar os resultados da pesquisa;
3) Declaração assinada por todos os autores, com o número de CPF,
indicando a responsabilidade pelo conteúdo do manuscrito e
transferência de direitos autorais (copyright) para a RBF/BJPT,
caso o artigo venha a ser aceito pelos Editores.
Os modelos da carta de encaminhamento e das declarações encontram-se disponíveis no site da RBF/BJPT: http://www.rbf-bjpt.org.br.
É de responsabilidade dos autores a eliminação de todas as informações (exceto na página do título e identificação) que possam
identificar a origem ou autoria do artigo.
Formato do manuscrito
O manuscrito deve ser elaborado com todas as páginas numeradas consecutivamente na margem superior direita, com início na página de título. Os Artigos Originais devem ser estruturados conforme
sequência abaixo:
Página de título e identificação (1ª. página)
A página de identificação deve conter os seguintes dados:
a) Título do manuscrito em letras maiúsculas;
b) Autor: nome e sobrenome de cada autor em letras maiúsculas,
sem titulação, seguidos por número sobrescrito (expoente), identificando a afiliação institucional/vínculo (Unidade/ Instituição/
Cidade/ Estado/ País); para mais de um autor, separar por vírgula;
c) Nome e endereço completo. (É de responsabilidade do autor correspondente manter atualizado o endereço e e-mail para contatos);
d) Título para as páginas do artigo: indicar um título curto, em Português e em Inglês, para ser usado no cabeçalho das páginas do
artigo, não excedendo 60 caracteres;
e) Palavras-chave: termos de indexação ou palavras-chave (máximo
seis), em Português e em Inglês. A RBF/BJPT recomenda o uso do
DeCS – Descritores em Ciências da Saúde para consulta aos termos de indexação (palavras-chave) a serem utilizados no artigo
<http://decs.bvs.br/>.
Resumo/Abstract
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.
Os artigos de Revisão Sistemática e Metanálises devem incluir uma
seção que descreva os métodos empregados para localizar, selecionar,
obter, classificar e sintetizar as informações.
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, 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 em alta
resolução. 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
Universidade Federal de São Carlos
Programa de Pós Graduação em Fisioterapia - PPGFt
Coordenador: Prof. Dr. Maurício Jamami
Vice-Coordenadora: Prof.ª Dr.ª Stela M. Mattiello G. Rosa Apresentação do Programa
O Programa de Pós-Graduação em Fisioterapia (PPGFt) - Nível Mestrado e
Doutorado Stricto Sensu tem como área de concentração
"Processos de Avaliação e Intervenção em Fisioterapia".
O Mestrado foi criado em 18/10/1996 pela Universidade Federal de São Carlos
(São Carlos-SP) e recomendado pela CAPES em 19/12/1996. O Doutorado foi
recomendado em 14/12/2001. Ambos os cursos foram os primeiros criados na
área de Fisioterapia no país.
Este programa tem como objetivo oferecer condições acadêmicas necessárias
para que o aluno adquira um repertório teórico e metodológico, tornando-se
apto a exercer as atividades de docente de nível universitário e iniciá-lo na
carreira de pesquisador.
Linhas de Pesquisas:
Instrumentação e Análise Cinesiológica e Biomecânica do Movimento
Processos Básicos, Desenvolvimento e Recuperação Funcional do
Sistema Nervoso Central
Processos de Avaliação e Intervenção em Fisioterapia Cardiovascular e
Respiratória
Processos de Avaliação e Intervenção em Fisioterapia do Sistema
Músculo-Esquelético
Recomendado pela CAPES – conceito 5
Informações
Rod. Washington Luiz, Km 235. São Carlos - SP. CEP 13.565-905 - Cx Postal 676.
Fone: (16) 3351-8448
Email: [email protected]
Secretaria da Pós-Graduação: localiza-se na rua das Suindaras no prédio do CCBS,
2º andar, Área Norte.
Site: WWW.ufscar.br/~ppgft

Brazilian Journal of Physical Therapy

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