Anterior knee pain (AKP) is a common, chronic lower limb musculoskeletal overuse condition that represents substantial morbidity to those affected, and has a significant impact on the health care industry. Health practitioners frequently prescribe foot orthoses in the management of AKP as an alternative or adjunct to multimodal physiotherapy. The primary aim of this thesis was to investigate the clinical efficacy of foot orthoses in AKP, utilising high-quality research methodologies. The two systematic reviews conducted have identified a significant gap in the literature regarding evidence from randomised clinical trials (RCTs) for foot orthoses in AKP and other lower limb overuse conditions. While the best evidence for AKP management was for multimodal physiotherapy, there was insufficient evidence to support or refute the use of foot orthoses in the treatment of lower limb overuse conditions, including AKP. Meta-analysis provided evidence to support the use of foot orthoses in the prevention of the first incidence of lower limb overuse conditions. An interesting finding was evidence from pooled and individual study data of no difference between custom and prefabricated foot orthoses in both treatment and prevention of lower limb overuse conditions, inferring that either type of orthosis may be utilised. Both systematic reviews highlighted substantial methodological flaws of the included studies, and recommended that future studies include larger participant numbers, longer participant follow-up, more consistent use of reliable and valid outcome measures and reporting of outcome data, and utilisation of the CONSORT guidelines in the design and reporting of RCTs. A 12-month prospective RCT investigated the short- and long-term clinical efficacy of prefabricated foot orthoses in the treatment of 179 participants with AKP. Foot orthoses were more effective than flat shoe inserts in the short term, implying that their contoured form has some therapeutic effect. Foot orthoses were not significantly different to multimodal physiotherapy over 12 months, nor was there any benefit in adding foot orthoses to physiotherapy. Considering that all groups experienced clinically meaningful long-term improvements in pain and function, clinicians may prescribe foot orthoses for AKP to hasten recovery. Findings of post-hoc analyses to develop a clinical prediction rule indicate that those of older age and shorter height, who have a lower severity of AKP and a more mobile midfoot, are more than twice as likely to experience a successful outcome with foot orthoses. As a secondary aim, this thesis has provided a more comprehensive profile of AKP as a condition. Baseline data from the RCT participants confirms previous reports of higher rates of AKP in females, and a tendency towards bilaterality and chronicity. This AKP sample did not differ from asymptomatic individuals in terms of body mass index, physical activity level, general and mental health, and foot posture, although they tended to have a more mobile foot under load. These characteristics tend to be homogenous across a number of published RCTs, indicating that the findings of the RCT described above are likely to be generalisable to the broader population with AKP. An additional finding in this group was that those with AKP of long duration, higher pain levels, lower functional levels, and an overall lower score on a specific measure of AKP have a poorer prognosis over 12 months, irrespective of their age, gender or morphometry. These findings suggest that, in order to improve prognosis and the chance of a successful outcome, the primary goals of intervention should be to reduce the severity and duration of AKP, through the use of early intervention with foot orthoses, multimodal physiotherapy, or a combination of the two.

A Síndrome da Dor Anterior no Joelho (SDAJ) caracteriza-se por uma dor difusa retropatelar e peripatelar na articulação do joelho, exacerbada por atividades de sobrecarga sobre a articulação femoropatelar. Muitos estudos têm sido realizados no sentido de compreender os mecanismos causadores da SDAJ e suas consequências. Entre os aspectos pesquisados encontram-se a ativação muscular, relação de ativação e de capacidade de geração de força entre os músculos vasto medial e vasto lateral, a força quadriciptal e dos músculos do quadril, e as alterações mecânicas do membro inferior. Segundo a literatura, um dos principais fatores de risco para o desenvolvimento dessa patologia é a fraqueza dos extensores do joelho. A fraqueza dos extensores do joelho pode estar associada à inibição muscular (IM) que o músculo quadríceps femoral sofre em função dos estímulos dolorosos. Esta alteração na geração de força e na capacidade de ativação muscular parecem alterar a morfologia do quadríceps e influenciar as alterações mecânicas ao nível da articulação femoropatelar. Para o melhor do nosso conhecimento, não foi encontrado na literatura nenhum estudo sistemático que investigasse simultaneamente os diversos aspectos da SDAJ, tentando assim estabelecer uma relação entre os aspectos morfológicos, mecânicos e elétricos dos extensores do joelho com a SDAJ. O presente estudo tem por objetivo comparar as propriedades mecânicas, morfológicas e mioelétricas dos extensores do joelho entre sujeitos acometidos pela SDAJ e um grupo controle saudável (GC). Nossa hipótese era de que os pacientes com SDAJ apresentarão uma redução nas propriedades mecânicas, morfológicas e mioelétricas dos extensores do joelho em decorrência da inibição muscular (IM) crônica produzida pela síndrome. Além disso, o estudo também tem por objetivo avaliar se existe diferença na metodologia de aplicação da técnica de interpolação de abalo para avaliação da IM do quadríceps a partir da comparação do uso de estímulos elétricos supramáximos sobre o nervo femoral (padrão ouro) com a estimulação sobre o ponto motor (nova metodologia) em sujeitos saudáveis e indivíduos com SDAJ. Nossa hipótese era de que a estimulação sobre o ponto motor será menos desconfortável que sobre o nervo femoral e os resultados de IM serão menos variáveis (com uma menor dispersão) em função desse menor desconforto. No Capítulo I, foi realizado um levantamento da literatura sobre as variáveis que foram avaliadas no decorrer do estudo, buscando informar ao leitor o que já foi feito na área, as lacunas e contradições acerca da SDAJ. No Capítulo II, foi realizado um estudo transversal sobre a avaliação da IM do quadríceps femoral, a partir da Técnica de Interpolação de Abalo (ITT), com a aplicação do abalo sobre o nervo femoral (NF) e sobre o ponto motor (PM). Vinte e nove sujeitos do sexo feminino, com idade entre 20 e 40 anos, sintomáticas (SDAJ, n=16) e assintomáticas (GC, n=13) para SDAJ, foram submetidas a avaliação da IM sobre o PM e NF no ângulo de 60° de flexão do joelho (0°=extensão máxima). Os resultados demonstraram que, para o grupo SDAJ, o PM apresenta resultados inferiores de IM comparado ao NF; já para o GC, os resultados foram semelhantes entre os dois pontos de estimulação. No Capítulo III foram realizadas avaliações da capacidade funcional, da IM e das propriedades mecânicas, morfológicas e mioelétricas dos extensores do joelho. Trinta e duas mulheres, com idade entre 20 e 40 anos, sintomáticas (SDAJ, n=16) e assintomáticas (GC, n=16) para SDAJ, foram avaliadas. Os resultados apontam para uma maior IM e reduções na capacidade funcional, no torque isométrico, na espessura da cartilagem femoropatelar e na arquitetura muscular do grupo SDAJ em relação ao GC. A revisão de literatura realizada no Capítulo I demonstrou que a literatura apresenta divergências sobre as alterações neuromecânicas decorrentes da SDAJ em mulheres. Os resultados do Capítulo II indicam que a avaliação da IM por meio da ITT é melhor tolerada por mulheres jovens sintomáticas para SDAJ quando avaliada no NF em comparação ao PM. Já no Capítulo III foram observados maiores valores de IM e reduções na capacidade funcional, torque isométrico, espessura da cartilagem femoropatelar e arquitetura muscular nos sujeitos com SDAJ em comparação ao GC saudável. / The Anterior Knee Pain (AKP) syndrome is characterized by retropatellar and peripatellar diffuse pain in the knee joint, exacerbated by overloading activities on the patellofemoral joint. Many studies have been carried out to understand the causal mechanisms of AKP and its consequences. Among the researched aspects are muscle activation, relationship of activation and capacity of strength generation between the vastus medialis and the vastus lateralis muscles, the strength of quadriceps and hip muscles, and mechanical changes of the lower limb. According to the literature, one of the main risk factors for the development of this pathology is the knee extensors weakness. This knee extensors weakness might be associated with the muscle inhibition (MI) that the femoral quadriceps muscle suffers as a result of painful stimuli. These changes in strength generation and muscle activation capacity appear to change the quadriceps morphology and influence mechanical changes at the patellofemoral joint level. To the best of our knowledge, there is no systematic study in the literature that simultaneously investigated the various aspects of AKP, trying to establish a relationship between the morphological, mechanical and electrical aspects of the knee extensors in subjects with AKP. This study aimed to compare the knee extensors mechanical, morphological and myoelectric properties between subjects affected by AKP and a control group (CG). Our hypothesis was that patients with AKP should present a reduction in the knee extensors mechanical, morphological and myoelectric properties due to chronic muscle inhibition (MI) produced by the syndrome. In addition, the study also aimed to evaluate whether there are differences in methodology for application of the interpolated twitch technique for evaluation of the quadriceps MI by comparing the use of supramaximal electrical stimulation on the femoral nerve (gold standard) with stimulation on the motor point (new methodology) in healthy subjects and subjects affected by AKP. Our hypothesis was that the stimulation on the motor point should be less uncomfortable than on the femoral nerve and MI results should be less variable (with lower dispersion) due to such lower discomfort. In Chapter I, a literature review on the variables that were evaluated throughout the study was carried out, seeking to inform the reader on what has already been done in the area, on gaps and contradictions regarding AKP. Chapter II presents a transversal study on the assessment of the quadriceps MI with the use of the Interpolated Twitch Technique (ITT), with application of twitch on the femoral nerve (FN) and on the motor point (MP). Twenty-nine women, aged between 20 and 40 years, symptomatic (AKP, n=16) and asymptomatic (CG, n=13) for AKP, were subjected to evaluation of MI on the MP and FN at an angle of 60° of knee flexion (0°=fully extended). Results showed that, for the AKP group, MP has inferior results of MI when compared to FN; results are similar between the two stimulation points for the CG. In Chapter III, evaluations of functional capacity, MI and knee extensors mechanical, morphological and myoelectric properties were carried out. Thirty-two women, aged between 20 and 40 years, symptomatic (AKP, n =16) and asymptomatic (CG, n =16) for AKP were evaluated. Results indicated greater MI and reductions in functional capacity, in isometric torque, in patellofemoral cartilage thickness and in muscle architecture in the AKP group compared to CG. Results from literature review conducted in Chapter I showed disagreement about neuromechanics changes resulting from SDAJ in women. Chapter II results indicated that the evaluation of IM through ITT is better tolerated by young women symptomatic for SDAJ when evaluated in the NF compared to the PM. Chapter III showed higher MI values and reductions in functional capacity, isometric torque, patellofemoral cartilage thickness and muscle architecture in subjects with SDAJ compared to a healthy GC.

Les gonalgies et les aponévrosites plantaires représentent la majorité des motifs de consultations d’un cabinet de podologie. Les patients souffrant de ces pathologies ressentent des douleurs au niveau du genou ou du pied qui peuvent être invalidantes. Bien que le port d’orthèses plantaires représente un traitement conservateur efficace, la prescription de ce traitement repose sur une connaissance empirique des effets de ce dernier. Le but de ce travail était donc d’étudier les effets des semelles orthopédiques à dominante biomécanique (modifiant la posture) ou proprioceptive (stimulant les capteurs de la sole plantaire) sur les modifications de la stratégie neurale chez les patients souffrant de ces pathologies et de déterminer quels pouvaient être les liens avec la diminution de la douleur ressentie. Pour cela, nous avons procédé à une évaluation de la douleur, un examen de la marche, un examen stabilométrique et des enregistrements électrophysiologiques (réflexes mesurés au repos et lors d’une contraction musculaire volontaire). L’évolution de ces différents paramètres a été mesurée après trois, six et neuf semaines de port d'orthèses plantaires. Les résultats obtenus ont été comparés à ceux recueillis chez des patients témoins indemnes de toute pathologie.Même si les résultats obtenus lors de ces études ne sont pas aussi concluants que nous l’aurions souhaité et que de nombreuses questions restent encore en suspend, ce travail a permis toutefois d’ouvrir au domaine de la podologie un champ de recherche jusque-là peu ou pas exploré. / Knee pain and plantar fasciitis represent most of the reasons for consultation of a podiatrist. Patients with these pathologies experience knee or foot pain that can be disabling. Although the use of foot orthoses is an effective conservative treatment, its prescription is based on an empirical knowledge of its effects. The aim of this study was to investigate the effects of foot orthoses based on biomechanical (modifying the posture) or proprioceptive (stimulating sensors of the plantar sole) principles on neural strategy changes in suffering patients and to determine the links with the decrease in perceived pain. For this, we performed a pain assessment, walking and stabilometric examination and electrophysiological recordings (reflexes measured at rest and during voluntary muscle contraction). The evolution of these different parameters was measured after three, six and nine weeks of wearing foot orthoses. The results obtained were compared with those obtained in control patients free from any pathology.Although the results of these studies are not as conclusive as we would have liked and many questions remain unresolved, this work has opened up to the podiatry a field of research until then little or not explored.

A Síndrome da Dor Anterior no Joelho (SDAJ) caracteriza-se por uma dor difusa retropatelar e peripatelar na articulação do joelho, exacerbada por atividades de sobrecarga sobre a articulação femoropatelar. Muitos estudos têm sido realizados no sentido de compreender os mecanismos causadores da SDAJ e suas consequências. Entre os aspectos pesquisados encontram-se a ativação muscular, relação de ativação e de capacidade de geração de força entre os músculos vasto medial e vasto lateral, a força quadriciptal e dos músculos do quadril, e as alterações mecânicas do membro inferior. Segundo a literatura, um dos principais fatores de risco para o desenvolvimento dessa patologia é a fraqueza dos extensores do joelho. A fraqueza dos extensores do joelho pode estar associada à inibição muscular (IM) que o músculo quadríceps femoral sofre em função dos estímulos dolorosos. Esta alteração na geração de força e na capacidade de ativação muscular parecem alterar a morfologia do quadríceps e influenciar as alterações mecânicas ao nível da articulação femoropatelar. Para o melhor do nosso conhecimento, não foi encontrado na literatura nenhum estudo sistemático que investigasse simultaneamente os diversos aspectos da SDAJ, tentando assim estabelecer uma relação entre os aspectos morfológicos, mecânicos e elétricos dos extensores do joelho com a SDAJ. O presente estudo tem por objetivo comparar as propriedades mecânicas, morfológicas e mioelétricas dos extensores do joelho entre sujeitos acometidos pela SDAJ e um grupo controle saudável (GC). Nossa hipótese era de que os pacientes com SDAJ apresentarão uma redução nas propriedades mecânicas, morfológicas e mioelétricas dos extensores do joelho em decorrência da inibição muscular (IM) crônica produzida pela síndrome. Além disso, o estudo também tem por objetivo avaliar se existe diferença na metodologia de aplicação da técnica de interpolação de abalo para avaliação da IM do quadríceps a partir da comparação do uso de estímulos elétricos supramáximos sobre o nervo femoral (padrão ouro) com a estimulação sobre o ponto motor (nova metodologia) em sujeitos saudáveis e indivíduos com SDAJ. Nossa hipótese era de que a estimulação sobre o ponto motor será menos desconfortável que sobre o nervo femoral e os resultados de IM serão menos variáveis (com uma menor dispersão) em função desse menor desconforto. No Capítulo I, foi realizado um levantamento da literatura sobre as variáveis que foram avaliadas no decorrer do estudo, buscando informar ao leitor o que já foi feito na área, as lacunas e contradições acerca da SDAJ. No Capítulo II, foi realizado um estudo transversal sobre a avaliação da IM do quadríceps femoral, a partir da Técnica de Interpolação de Abalo (ITT), com a aplicação do abalo sobre o nervo femoral (NF) e sobre o ponto motor (PM). Vinte e nove sujeitos do sexo feminino, com idade entre 20 e 40 anos, sintomáticas (SDAJ, n=16) e assintomáticas (GC, n=13) para SDAJ, foram submetidas a avaliação da IM sobre o PM e NF no ângulo de 60° de flexão do joelho (0°=extensão máxima). Os resultados demonstraram que, para o grupo SDAJ, o PM apresenta resultados inferiores de IM comparado ao NF; já para o GC, os resultados foram semelhantes entre os dois pontos de estimulação. No Capítulo III foram realizadas avaliações da capacidade funcional, da IM e das propriedades mecânicas, morfológicas e mioelétricas dos extensores do joelho. Trinta e duas mulheres, com idade entre 20 e 40 anos, sintomáticas (SDAJ, n=16) e assintomáticas (GC, n=16) para SDAJ, foram avaliadas. Os resultados apontam para uma maior IM e reduções na capacidade funcional, no torque isométrico, na espessura da cartilagem femoropatelar e na arquitetura muscular do grupo SDAJ em relação ao GC. A revisão de literatura realizada no Capítulo I demonstrou que a literatura apresenta divergências sobre as alterações neuromecânicas decorrentes da SDAJ em mulheres. Os resultados do Capítulo II indicam que a avaliação da IM por meio da ITT é melhor tolerada por mulheres jovens sintomáticas para SDAJ quando avaliada no NF em comparação ao PM. Já no Capítulo III foram observados maiores valores de IM e reduções na capacidade funcional, torque isométrico, espessura da cartilagem femoropatelar e arquitetura muscular nos sujeitos com SDAJ em comparação ao GC saudável. / The Anterior Knee Pain (AKP) syndrome is characterized by retropatellar and peripatellar diffuse pain in the knee joint, exacerbated by overloading activities on the patellofemoral joint. Many studies have been carried out to understand the causal mechanisms of AKP and its consequences. Among the researched aspects are muscle activation, relationship of activation and capacity of strength generation between the vastus medialis and the vastus lateralis muscles, the strength of quadriceps and hip muscles, and mechanical changes of the lower limb. According to the literature, one of the main risk factors for the development of this pathology is the knee extensors weakness. This knee extensors weakness might be associated with the muscle inhibition (MI) that the femoral quadriceps muscle suffers as a result of painful stimuli. These changes in strength generation and muscle activation capacity appear to change the quadriceps morphology and influence mechanical changes at the patellofemoral joint level. To the best of our knowledge, there is no systematic study in the literature that simultaneously investigated the various aspects of AKP, trying to establish a relationship between the morphological, mechanical and electrical aspects of the knee extensors in subjects with AKP. This study aimed to compare the knee extensors mechanical, morphological and myoelectric properties between subjects affected by AKP and a control group (CG). Our hypothesis was that patients with AKP should present a reduction in the knee extensors mechanical, morphological and myoelectric properties due to chronic muscle inhibition (MI) produced by the syndrome. In addition, the study also aimed to evaluate whether there are differences in methodology for application of the interpolated twitch technique for evaluation of the quadriceps MI by comparing the use of supramaximal electrical stimulation on the femoral nerve (gold standard) with stimulation on the motor point (new methodology) in healthy subjects and subjects affected by AKP. Our hypothesis was that the stimulation on the motor point should be less uncomfortable than on the femoral nerve and MI results should be less variable (with lower dispersion) due to such lower discomfort. In Chapter I, a literature review on the variables that were evaluated throughout the study was carried out, seeking to inform the reader on what has already been done in the area, on gaps and contradictions regarding AKP. Chapter II presents a transversal study on the assessment of the quadriceps MI with the use of the Interpolated Twitch Technique (ITT), with application of twitch on the femoral nerve (FN) and on the motor point (MP). Twenty-nine women, aged between 20 and 40 years, symptomatic (AKP, n=16) and asymptomatic (CG, n=13) for AKP, were subjected to evaluation of MI on the MP and FN at an angle of 60° of knee flexion (0°=fully extended). Results showed that, for the AKP group, MP has inferior results of MI when compared to FN; results are similar between the two stimulation points for the CG. In Chapter III, evaluations of functional capacity, MI and knee extensors mechanical, morphological and myoelectric properties were carried out. Thirty-two women, aged between 20 and 40 years, symptomatic (AKP, n =16) and asymptomatic (CG, n =16) for AKP were evaluated. Results indicated greater MI and reductions in functional capacity, in isometric torque, in patellofemoral cartilage thickness and in muscle architecture in the AKP group compared to CG. Results from literature review conducted in Chapter I showed disagreement about neuromechanics changes resulting from SDAJ in women. Chapter II results indicated that the evaluation of IM through ITT is better tolerated by young women symptomatic for SDAJ when evaluated in the NF compared to the PM. Chapter III showed higher MI values and reductions in functional capacity, isometric torque, patellofemoral cartilage thickness and muscle architecture in subjects with SDAJ compared to a healthy GC.

Submitted by Nadir Basilio (nadirsb@uninove.br) on 2016-05-25T15:44:32Z No. of bitstreams: 1 Nayra Deise dos Anjos Rabelo.pdf: 1274728 bytes, checksum: 2fb87109dfbed0d375542469df6e6186 (MD5) / Made available in DSpace on 2016-05-25T15:44:32Z (GMT). No. of bitstreams: 1 Nayra Deise dos Anjos Rabelo.pdf: 1274728 bytes, checksum: 2fb87109dfbed0d375542469df6e6186 (MD5) Previous issue date: 2014-12-04 / Patellofemoral pain syndrome (PFPS) is a common complaint, especially in women. The hip muscles strengthening is an effective technique for the treatment of this disorder. In addition, the neuromuscular training has received attention as a therapeutic tool, but results in individuals with PFPS are still very evident and inconclusive. Therefore, the aim of this study was to compare the effects of a neuromuscular training program of the trunk and lower limbs associated with the hip and knee muscles strengthening in women with PFPS with a program that involves the isolated strengthening of those muscles. Thirty-four women aged 18 to 35 years with a clinical diagnosis of PFPS were randomized into two groups: Strengthening Group (SG) and Neuromuscular Group (NMG). Patients underwent 12 sessions of the strengthening (Knee extensors, hip abductor and hip external rotator) and the NMG, associated with this, received the balance, coordination and control of the lower limb training. Because of the nature of the study, we chose to report now, only the results of force and kinematics, since the clinical analysis is still in progress. Thus, the effects of treatment on muscle strength and kinematics were calculated using paired t test for parametric measures and the Friedman test with post hoc, for nonparametric measures. At the end of 4 weeks of treatment, significantly increased the strength of the hip abductor muscles (percentage of improvement from 20.7% to 19% for SG and NMG), hip external rotators (percentage of improvement of 18.2% was observed for SG and 17% for NMG) and knee extensors (percentage of improvement from 19.7% to 16.2% for SG and NMG) in both groups, and effectively reduce the range of motion of hip adduction in the voluntary NMG. We conclude that both programs proposed treatment promoted increased strength of the muscles evaluated, but only the associated neuromuscular training to strength training was able to effectively create change in kinematics, real improvement in hip adduction. / A síndrome da dor femoropatelar (SDFP) é uma queixa comum, sobretudo em mulheres. O fortalecimento dos músculos do quadril é uma técnica eficaz para o tratamento dessa disfunção. Além disso, o treino neuromuscular vem recebendo destaque como ferramenta terapeutica, porém seus resultados em indivíduos com SDFP ainda são pouco evidentes e inconclusivos. Sendo assim, o objetivo desse estudo foi comparar os efeitos de um programa de treinamento neuromuscular do tronco e membros inferiores associado ao fortalecimento dos músculos do quadril e joelho de mulheres com SDFP com um programa que envolve o fortalecimento isolado desses mesmos músculos. Trinta e quarto mulheres, entre 18 e 35 anos, com diagnóstico clínico de SDFP, foram aleatorizadas em dois grupos: Grupo Fortalecimento (GF) e Grupo Neuromuscular (GNM). As pacientes foram submetidas a 12 sessões de fortalecimento da musculatura extensora do joelho e abdutora e rotadora lateral do quadril e o GNM, associado a isso, recebeu treinamento de equilíbrio, coordenação e controle do membro inferior. Por conta da natureza do estudo, optamos por reportar, nesse momento, apenas os resultados de força e cinemática, uma vez que a análise clínica ainda está em andamento. Sendo assim, os efeitos dos tratamentos foram calculados através de test t pareado para medidas paramétricas e teste de Friedman com post hoc, para medidas não paramétricas. Ao final das 4 semanas de tratamento foi observado aumento significante de força dos músculos abdutores (porcentagem de melhora de 20,7% para GF e 19% para GNM) e rotadores laterais (porcentagem de melhora de 18,2% para GF e 17% para GNM) do quadril e extensores do joelho (porcentagem de melhora de 19,7% para GF e 16,2% para GNM), em ambos os grupos, além de redução efetiva da amplitude de movimento da adução do quadril nas voluntárias do GNM. Concluímos que ambos os programas de tratamento propostos promoveram ganho de força da musculatura avaliada, mas apenas o treinamento neuromuscular associado ao treino de força foi capaz de, efetivamente, gerar mudança na cinemática, com melhora real da adução do quadril.

No description available.

The ability to kneel is an important function of the knee joint, as it is required for many daily activities, including religious practices, professional occupations and recreational pursuits. The inability to kneel following total knee arthroplasty (TKA) is frequently a source of disappointment. This work investigates patients' understanding of the term 'kneeling' and what proportion of patients can kneel before and after TKA, as well as identifying the factors that can affect the ability to kneel following TKA. The underlying hypothesis tested was: 'There are no differences between kneeling ability before and after TKA'. Kneeling ability after TKA may be affected by many factors, including patient-specific factors, the extent of wear on RPC (Retro patellar Cartilage), postoperative AKP (Anterior Knee Pain) and post-operative ROM (Range of Motion). Thus a consecutive series of TKA patients were assessed to test the afore-mentioned hypothesis. In particular, the thesis has examined: • Interpretation of kneeling and perceptions of kneeling ability after TKA. • The extent of wear on Retro Patellar Cartilage (RPC) and its correlation to kneeling ability. • Sensory changes in the knee after TKA. • Preoperative and Postoperative Anterior Knee Pain (AKP) assessment. • The reality of kneeling ability before and after TKA. • Postoperative ROM of the knee and its correlation to kneeling function. The advice offered by healthcare professionals may contribute to a low postoperative rate of kneeling. The patellofemoral joint plays an essential role in knee function and a person's kneeling ability, may be greatly affected by the performance of this joint. Firstly, this study analysed the responses of two samples of participants drawn from diverse cultural backgrounds (Christian and Muslim), it examined their primary interpretation of what kneeling constitutes, along with a subjective assessment of the importance of kneeling in their everyday lives. Secondly, it explored patients' perceptions of their kneeling ability after TKA, with a comparative analysis of their responses to the kneeling questionnaire specifically constructed by the author and also the question in relation to kneeling in the Oxford Knee Score (OKS). The third component investigated retro-patellar cartilage (RPC) morphology using intraoperative examination and standardised photography. Fourthly, a cohort of patients listed for TKAs was followed prospectively, in order to assess their kneeling ability prior to and following treatment, along with identifying the factors that could affect this function, i.e. knee pain, range of motion, sensory changes and sensitivity to pain on the anterior aspect of the knee as assessed with dolorimetry. Differences were detected in the subjective interpretation of the kneeling function, as well as its importance, for the two diverse cultures involved in this study. Pain, as opposed to poor range of movement, was identified as the main reason which led to kneeling difficulties. The majority of respondents reported that it was either extremely difficult or impossible to kneel on the operated knee. The high flexed position (required for prayer in certain cultures) was the most difficult position to achieve for most of the patients. Prior to surgery, 30 patients were seen during this period, 15 (50%) out of 30 consecutive patients were unable to kneel in any position whatsoever. Of those who could kneel to some degree, the most common posture that they could achieve was the upright kneeling position. Considerable variations were found to occur in patients' understanding of the term 'kneeling'. Consequently, this has significant implications for the design and interpretation of questions in relation to kneeling for diverse cultures, which are characterised by distinct lifestyles. The current patient-based selfV administered questionnaires, such as the OKS, although useful as a simple measure of overall knee function, were found to have limitations as an effective assessment tool in the measurement of kneeling function either before or after TKA and indicate that there is a need for a culturally appropriate questionnaire to assess kneeling function. Retro-patellar cartilage lesions were very prevalent in patients undergoing TKA. However, no significant correlation existed between the total amount of retro-patellar cartilage wear and the ability to kneel. Patients were more likely to be able to kneel if the cartilage of the superior facets of the patella were disease free (P=0.02). At the six months post-surgery stage, of the 14 consecutive patients, who could kneel pre-operatively 6 were able to kneel post-operatively. Of the 13 consecutive patients who were unable to kneel pre-operatively, all were unable to kneel post-operatively. Knee pain was the main reason attributed to this difficulty. However, no link was found to occur between sensory changes and kneeling function in the patients who participated in the study, after TKA performed via an anterior midline incision.

Les troubles musculo-squelettiques (TMS) sont la principale cause d’absentéisme au travail. Ils représentent un coût économique important, mais ils ont aussi de graves conséquences au niveau individuel – douleurs persistantes, limitations fonctionnelles ou perte d’emploi. De nombreuses expositions professionnelles ont déjà été mises en évidence pour expliquer la présence de ces symptômes, mais certaines relations restent encore à confirmer.L’objectif de ce travail de thèse était d’étudier l’association entre les facteurs professionnels, en particulier les facteurs physiques, et les TMS au niveau des coudes et des genoux. Les TMS au niveau des coudes ont été étudiés à travers la prévalence des symptômes aux coudes et des épicondylites, et l’incidence des épicondylites. Les douleurs aux genoux ont été étudiées à travers l’incidence des douleurs de courte ou de longue durée. Ce travail a nécessité l’utilisation de méthodologies spécifiques, en particulier les diagrammes causaux et les méthodes de gestion des données manquantes qui seront explicitées dans une partie théorique. La population dans ce travail de thèse était une cohorte de 3 710 sujets représentatifs des actifs des Pays de la Loire. Ils ont été recrutés entre 2002 et 2005 et ont été suivis entre 2007 et 2010. A chaque phase, un questionnaire sur les conditions de travail a été rempli par les participants et un examen clinique qui évaluait la présence de troubles musculo-squelettiques a été réalisé par des médecins du travail volontaires. En conclusion, les facteurs professionnels mis en évidence étaient globalement des facteurs de mouvements répétitifs impliquant les articulations étudiées (torsion des poignets et flexion/extension des coudes ou le fait de s’agenouiller). Le travail en force (manipulation de charges, efforts physiques importants) et les tâches répétitives ont également été mis en évidence comme prédicteurs de TMS ultérieurs / Musculoskeletal disorders (MSDs) are a leading cause of absenteeism from work. In addition to their major economic impact, musculoskeletal disorders have important consequences on individuals with the persistence of pain, disability and potential job loss. Many occupational exposures were highlighted to explain these symptoms, but certain relationships between occupational exposures and MSDs should be examined further.The aim of this thesis is to investigate the association between occupational exposures, especially biomechanical exposures, and elbow or knee MSDs. The elbow MSDs are studied with the prevalence of symptoms and lateral epicondylitis, and the incidence of lateral epicondylitis. The incidence of knee pain is examined according to its duration.The methodologies and theories appropriate to this type of work is briefly presented - a section focuses on the causal diagrams and methods of handling missing data.The population used is a cohort of 3710 subjects representative of the French workforce. Subjects were selected from workers undergoing a mandatory annual health examination between 2002 and 2005 and were followed between 2007 and 2010. For each phase of the study, a self-administered questionnaire on working conditions was completed and a clinical examination was performed in order to evaluate the presence of musculoskeletal disorders. In conclusion, repetitive movements involving the joints studied such as wrist-twisting, flexion/extension of the elbows or kneeling are associated with MSDs. The notion of force, such as load handling and physical exertion, and the notion of repetitive tasks are also identified as predictors of subsequent MSDs

Submitted by Aelson Maciera (aelsoncm@terra.com.br) on 2017-05-23T18:50:24Z No. of bitstreams: 1 TeseAFS.pdf: 13567836 bytes, checksum: c5a315d5c2ca036adaf60af9cd1f3b41 (MD5) / Approved for entry into archive by Ronildo Prado (ronisp@ufscar.br) on 2017-05-31T18:21:04Z (GMT) No. of bitstreams: 1 TeseAFS.pdf: 13567836 bytes, checksum: c5a315d5c2ca036adaf60af9cd1f3b41 (MD5) / Approved for entry into archive by Ronildo Prado (ronisp@ufscar.br) on 2017-05-31T18:21:12Z (GMT) No. of bitstreams: 1 TeseAFS.pdf: 13567836 bytes, checksum: c5a315d5c2ca036adaf60af9cd1f3b41 (MD5) / Made available in DSpace on 2017-05-31T18:27:08Z (GMT). No. of bitstreams: 1 TeseAFS.pdf: 13567836 bytes, checksum: c5a315d5c2ca036adaf60af9cd1f3b41 (MD5) Previous issue date: 2017-05-05 / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / Every year, up to 70% of recreational runners reported some musculoskeletal injury. Patellofemoral pain (PFP) is one of the most common injuries in these athletes. It has been reported that gait retraining may have a beneficial effect on the lower limb biomechanics and consequently may reduce the patellofemoral joint overload. However, the information regarding biomechanical and clinical effects after a training protocol in PFP runners and, the comparison between different techniques in a same cohort in order to identify the most effective are sparse. Therefore, the objectives of this thesis were: to evaluate the immediate and long-term effects of gait retraining of kinematic, electromyography, pain and function in PFP runners and; to verify the effectiveness of three running techniques on the patelofemoral joint stress in healthy runners. The three running techniques were: forefoot landing, step rate increase by 10% and forward trunk lean. Kinematic, kinetic and electromyography analysis were done. To assess pain and function, the visual analog scale and two self-reported questionnaires were used. The results showed that the three running techniques reduce pain intensity and improve function in PFP runners after 2 weeks of a supervised gait retraining and, these improvements are maintained 6 months after the intervention. The gait retraining increased the muscle pre-activation before the initial contact. Forefoot landing technique was the most effective condition for reducing patellofemoral joint loading. / Cerca de 70% dos corredores recreacionais apresentam alguma lesão musculoesquelética a cada ano, sendo a dor patelofemoral (DPF) uma das lesões mais comuns nesses atletas. Tem sido relatado que modificações na técnica de corrida promovem efeitos benéficos na biomecânica do membro inferior e, consequentemente, reduzem a sobrecarga sobre a articulação patelofemoral. Porém, há escassez de informação a respeito dos efeitos biomecânicos e clínicos após um protocolo de treinamento aplicado em corredores com DPF, além da ausência de estudos que tenham comparado diferentes técnicas de corrida aplicadas em uma mesma amostra, a fim de identificar a mais eficaz. Dessa forma, os objetivos da tese foram: avaliar os efeitos imediatos e a longo prazo do treinamento das técnicas de corrida sobre variáveis cinemáticas, eletromiográficas, dor e função em corredores com DPF; e verificar a eficácia das técnicas na redução do estresse patelofemoral em corredores sadios. As técnicas de corrida investigadas neste estudo foram: corrida com aterrissagem com o antepé, corrida com aumento de 10% da frequência da passada e corrida com aumento da flexão do tronco. Foram feitas análises cinemáticas, cinéticas e eltromiográficas da corrida. Para avaliação da dor e função, foram utilizadas a escala visual analógica e questionários traduzidos e validados para a língua portuguesa. Os resultados indicaram que as três técnicas de corrida reduzem a intensidade da dor e melhoram a função em corredores com DPF após 2 semanas de treinamento supervisionado e os ganhos clínicos são mantidos após 6 meses de intervenção. E a corrida com aterrissagem com antepé foi a técnica mais eficaz na redução do estresse patelofemoral em corredores sadios. / FAPESP: 2013/26318-7 / FAPESP: 2015/20306-2

Made available in DSpace on 2014-08-20T13:58:01Z (GMT). No. of bitstreams: 1 MARCELO_COZZENSA_DA_SILVA_Tese.pdf: 3903973 bytes, checksum: 26d1830113da932096679982271bb286 (MD5) Previous issue date: 2006-12-08 / Aiming to collect information on knee pain and associated occupational factors among workers, a systematic review was conducted using Medline, Lilacs, Scielo, Free Medical Journals databases, from 1990 to 2006. Keywords were: knee, knee pain, knee joint, knee dislocation, knee injuries, work, workplace, workload, employment, occupations, industry, occupational, workers, arthrosis and osteoarthritis. Equivalent terms in Portuguese and Spanish were also used. From the initial 2263 studies gathered, only 26 met the inclusion criteria of the review. Knee pain prevalence in the last 12 months ranged from 11.2% to 60.9%. Main associated factors were: female, older ages, high body mass index, kneeling working position and lifting at work. / Com o objetivo de reunir informações sobre dor nos joelhos entre trabalhadores e fatores ocupacionais associados, foi realizada uma revisão sistemática nas bases de dados Medline, Lilacs, Scielo, Free Medical Journals, entre outros, referentes ao período 1990-2006, usando os descritores knee, knee pain, knee joint, knee dislocation, knee injuries, work, workplace, workload, employment, occupations, industry, occupational, workers, arthrosis, osteoarthritis e seus equivalentes em português e espanhol. Dos 2263 estudos inicialmente encontrados, somente 26 cumpriram os critérios necessários para permanecer na revisão. As prevalências de dor nos joelhos nos últimos 12 meses variaram entre 11,2% e 60,9% e os principais fatores associados foram: sexo feminino, idade avançada, IMC elevado, trabalhar ajoelhado e carregar peso no trabalho.