Diss. (sammanfattning) Stockholm : Karolinska institutet, 2010.

Submitted by ANA ELISA ZULIANI STROPPA MARQUES null (anastropa@hotmail.com) on 2016-03-10T12:43:55Z No. of bitstreams: 1 1 versão para autoarquivamento.pdf: 2100357 bytes, checksum: 8397a25247c5aff053a5892d9cc6a1bd (MD5) / Approved for entry into archive by Juliano Benedito Ferreira (julianoferreira@reitoria.unesp.br) on 2016-03-10T20:55:21Z (GMT) No. of bitstreams: 1 marques_aezs_dr_rcla.pdf: 2100357 bytes, checksum: 8397a25247c5aff053a5892d9cc6a1bd (MD5) / Made available in DSpace on 2016-03-10T20:55:21Z (GMT). No. of bitstreams: 1 marques_aezs_dr_rcla.pdf: 2100357 bytes, checksum: 8397a25247c5aff053a5892d9cc6a1bd (MD5) Previous issue date: 2016-02-12 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / A manutenção da postura ortostática revela um comportamento inerente ao ser humano, de oscilação postural. Essa contínua oscilação, fornece input vindo da área plantar, para ativação do sistema nervoso central, que resulta em ajustes na manutenção da postura em equilíbrio. O aumento na ativação muscular é uma importante estratégia para suprir a instabilidade, sendo o músculo trapézio superior (TS) um importante marcador de controle postural. No idoso as estratégias de manutenção da postura ficam comprometidas, o que aumenta o risco de quedas e compromete a mobilidade funcional. Assim, entende-se que a qualidade do apoio plantar pode auxiliar a população idosa na manutenção da postura em equilíbrio e menor necessidade de ativação muscular. O objetivo desse estudo foi verificar o efeito da manobra de mobilização miofascial plantar na área de apoio dos pés, bem como a implicação das variações do suporte plantar em postura ortostática, no tempo de manutenção das posturas, no equilíbrio, na mobilidade funcional, na ativação do músculo trapézio superior de idosas. Foram recrutadas por triagem, 28 idosas saudáveis, com 69,03 ±3,32 anos, e divididas aleatoriamente em dois grupos: Manobra (GM) com 15 idosas e Sham (GS) com 13 idosas . O protocolo de manobra foi aplicado, pelo mesmo avaliador, bilateralmente com 5 repetições, divididos em duas semanas. Para o GM foi realizado deslizamentos plantar com vigorosa pressão das mãos do pesquisador, no intuito de alcançar a musculatura intrínseca do pé. No GS, a manobra foi realizada de forma suave, auxiliado por óleo de massagem, para favorecer o deslizamento na pele. A análise dos dados aconteceu em três momentos diferentes: momento antes da primeira manobra (pré), imediatamente após (pós) e no último dia de coleta (D6). Os resultados foram divididos em dois estudos. O estudo1 analisou dados de avaliação de área e de arco plantar, índice do arco plantar, tempo de manutenção na postura unipodal com olhos abertos (TAUoa) e fechados (TAUof) e o teste de mobilidade funcional – Timed Up and Go (TUG). O estudo 2 analisou dados da avaliação como área plantar, e tempo de manutenção nas posturas mais desafiadoras, ativação eletromiográfica do músculo TS no momento pré intervenção, em variações do apoio plantar e após o protocolo de mobilização. No estudo 1 houve significativo aumento, nas condições após a intervenção, somente para o GM, para a área de contato plantar em ambos os pés (F=7,577, p=0,001), no TUG (F=15,099, p<0,001), no TAUoa (F=14,592, p<0,0001) e TAUof (F=3,398, p=0,048) o que mostra efeito benéfico da técnica de mobilização miofascial plantar para o aumento de área de contato, equilíbrio e mobilidade funcional. No estudo 2 houve aumento da atividade eletromiográfica com a redução da base de apoio para os olhos abertos (F=7,456; p=0,0002) e fechados (F=23,019, p<0,0001). Nas condições olhos abertos e fechados notaram-se valores significativos (p<0,0001) para tandem e unipodal. Houve significativo aumento para o GM, para a área de contato plantar em ambos os pés (F=7,577, p=0,001) e pé direito (F=5,332, p=0,011), o tempo de manutenção das posturas desafiadoras mostrou resultados significativos no momento pós (p<0,05), no GM, para tandem complacente olho fechado e para as duas condições em unipodal; já para o D6 o as posturas em tandem rígida olho fechado e unipodal olho aberto foram significativos. Os dados da atividade mioelétrica normalizados não apresentaram significância estatística. Os resultados deste estudo apresentaram efeitos benéficos da manobra de mobilização miofascial plantar para todas as variáveis estudadas, exceto para a ativação do músculo trapézio superior após a aplicação dos protocolos de mobilização. / Maintaining upright posture reveals an inherent to the human behavior, of postural sway. This continuous oscillation, provides input from the plantar area, for activating the central nervous system, resulting in adjustments to maintain posture in balance. The increase in muscle activation is an important strategy to address instability, and the upper trapezius muscle (UT) an important reference for postural control. In the elderly the position of maintenance strategies are compromised, which increases the risk of falls and compromises functional mobility. Thus, it is understood that the quality of support plant can help the elderly population in the maintaining of posture and less need for muscle activation. The aim of this study was to investigate the effect of maneuver planting myofascial mobilization the feet support area, as well as the involvement of variations of feet support in standing position at the time of maintenance of posture, balance, functional mobility, activation the upper trapezius muscle older. Were recruited for screening, 28 healthy older, with 69.03 ± 3.32 years, and randomly divided into two groups: Maneuver (MG) with 15 elderly and Sham (SG) with 13 elderly. The protocol was applied by the same appraiser, bilaterally, with 5 repetitions, divided into two weeks. For MG was conducted landslides plant with vigorous pressure from the hands of the researcher in order to reach the intrinsic muscles of the foot. In SG, the maneuver was carried out smoothly, aided by massage oil to encourage the slip on the skin. The data analysis took place in three different moments: the moment before the first maneuver (pre), immediately after (post) and on the last day of collection (D6). The results were divided into two studies. The study1 examined area of assessment data and plantar arch, plantar arch index, downtime in single leg stance with eyes open (SLSeo) and closed (SLSec) and functional mobility test - Timed Up and Go (TUG). Study 2 analyzed assessment data as plantar area, and downtime in the most challenging postures, electromyographic activation of the UT muscle in pre intervention time, in support of changes to plant and after mobilization protocol. In Study 1 there were significant increases in the conditions after the intervention only for the MG to contact plantar area of both feet (F = 7.577, p = 0.001) in the TUG (F = 15.099, p <0.001) in SLSeo (F = 14.592, p <0.0001) and SLSec (F = 3.398, p = 0.048) showing the beneficial effect of plant myofascial mobilization technique for increasing the contact area, balance and functional mobility. In study 2 showed an increase in electromyographic activity with reduced support base to open eyes (F = 7.456; p = 0.0002) and closed (F = 23.019, p <0.0001). In the eyes open and closed conditions were notedsignificant values (p <0.0001) for tandem and single leg. There was a significant increase for the MG for the contact area to plant both feet (F = 7.577, p = 0.001) and right foot (F = 5.332, p = 0.011), the maintenance time of challenging postures showed significant results in post time (p <0.05) in MG for accommodating tandem closed eye and the two-leg conditions; already for the D6 postures tandem rigid eye closed and one-leg open eye were significant. The data normalized myoelectric activity were not statistically significant. The results of this study showed beneficial effects of myofascial mobilization maneuver plant for all variables, except for the activation of the upper trapezius muscle after application of mobilization protocols.

Les exercices neurodynamiques sont fréquemment recommandés par les physiothérapeutes pour améliorer la douleur et la fonction chez des individus atteints du syndrome du tunnel carpien (STC). Toutefois, l’efficacité de ces exercices demeure incertaine considérant que leurs mécanismes thérapeutiques reposent largement sur des bases théoriques. En fait, peu d’études ont rapporté quantitativement les effets des exercices neurodynamiques sur l’intégrité biologique et les propriétés biomécaniques du nerf médian au poignet (effets périphériques) et sur la structure et la fonction des aires corticales motrices (effets centraux). Les objectifs principaux de cette thèse étaient 1) d’évaluer les qualités psychométriques des mesures d’excursion longitudinale du nerf médian à l’aide de l’imagerie quantitative par ultrasonographie, 2) de caractériser les adaptations périphériques et centrales potentiellement liées à la performance des exercices neurodynamiques et 3) d’évaluer la faisabilité et l’efficacité d’un programme fondé sur les exercices neurodynamiques offerts à des individus atteints du STC. Pour répondre à ces objectifs, quatre projets distincts ont été menés : Projet no1 : La fidélité test-retest et le changement minimal détectable des mesures d’excursion longitudinale du nerf médian ont été quantifiés chez un groupe de 11 individus asymptomatiques et sept individus atteints du STC. Projet no2: La validité concourante entre les mesures de l'excursion longitudinale d’un modèle artificiel de nerf médian obtenues à l’aide de l’imagerie quantitative par ultrasonographie et d’un système tridimensionnel d'analyse de mouvement a été évaluée. Projet no3 : Une étude clinique exploratoire a été réalisée pour évaluer les effets périphériques et centraux d’un programme d’exercices neurodynamiques auprès d’une cohorte de 14 individus atteints du STC. Projet no4 : Une étude clinique pilote randomisée a été réalisée pour évaluer la faisabilité d’un programme d’exercices neurodynamiques préopératoire exécuté par 15 individus atteints du STC en attente d’une première chirurgie de décompression et évaluer l’efficacité de ce programme chez ces mêmes individus pour améliorer l’intégrité biologique, les propriétés biomécaniques du nerf médian; réduire la douleur, les déficiences sensorimotrices et optimiser la capacité fonctionnelle du membre supérieur en comparaison à un groupe contrôle de 15 individus atteints du STC ne complétant aucun programme d’exercice avant et après la chirurgie (approche actuelle). En résumé, les résultats des projets no1 et 2 soutiennent que i l’imagerie quantitative par ultrasonographie est un outil fidèle et valide pour mesurer l’intégrité biologique et l’excursion longitudinale du nerf médian. Les résultats du projet no3 suggèrent que les changements cliniques observés suite aux exercices neurodynamiques potentialisent les adaptations centrales alors qu’ils n’ont aucun ou peu d’effets sur les adaptations périphériques, notamment l’excursion du nerf médian. Les résultats du projet no4 démontrent que, bien que le programme d’exercices neurodynamiques proposé soit faisable et relativement sécuritaire lorsqu’offert à des individus en attente d’une chirurgie de décompression, ils ne démontrent pas la supériorité du programme proposé sur l'amélioration des déficiences sensorimotrices, de la douleur et des capacités fonctionnelles des membres supérieurs chez les patients atteints de STC immédiatement avant ou un mois après une opération de décompression du canal carpien par rapport à l’approche actuelle. Certains résultats, démontrant des tailles d’effet modérées à importantes ou qui tendaient vers le seuil statistiquement significatif, appuient toutefois la pertinence de poursuivre les efforts de recherche. / Neuromobilizations exercises are frequently advocated by physiotherapists to improve pain and function in individuals with Carpal Tunnel Syndrome (CTS). However, the effectiveness of these exercises remains uncertain since they remain in most part based on theoretical and empirical foundations. In fact, few studies have reported the effects of neurodynamic exercises on the biological integrity and biomechanical properties of the median nerve at the wrist (peripheral adaptations) and on the structure and function of cortical motor areas (central adaptations). The main objectives of this thesis were 1) to evaluate the psychometric properties of median nerve longitudinal excursion measurements using quantitative ultrasound imaging, 2) to characterize the peripheral and central adaptations potentially linked to the performance of neuromobilization exercises and 3) to evaluate the feasibility and effectiveness of a neuromobilization exercise program completed by individuals with CTS. To meet these objectives, four separate projects were conducted. Project # 1: Test- retest reliability and minimal detectable change in median longitudinal nerve excursion measurements were evaluated in a group of 11 asymptomatic individuals and seven individuals with CTS. Project # 2: The concurrent validity between longitudinal excursion measurements of an artificial median nerve model obtained with quantitative ultrasound imaging and a three- dimensional motion analysis system was evaluated. Project # 3: An exploratory clinical study was conducted to evaluate the potential peripheral and central adaptations following completion of a neuromobilization exercise program in a cohort of 14 individuals with CTS. Project # 4: A pilot randomized clinical trial was conducted to evaluate the feasibility of a preoperative neuromobilization exercise program performed by 15 individuals with CTS awaiting decompression surgery and to evaluate the efficacy of this program for these same individuals to improve the biological integrity, biomechanical properties of the median nerve; reduce pain, sensorimotor deficiencies and optimize upper limb functional capacity compared to a control group of 15 individuals with CTS that does not perform any exercise program before and after carpal surgery (standard care). In summary, the results of projects # 1 and 2 demonstrate that ultrasound imaging is a reliable and valid tool for measuring the biological integrity and longitudinal excursion of the iii median nerve. The results of project # 3 suggest that the clinical changes observed following neuromobilization exercises potentiate central adaptations while they have no or little effect on peripheral adaptations, including nerve excursion. The results of project # 4 demonstrate that, although the proposed neuromobilization exercise program is feasible and relatively safe when completed by individuals awaiting decompression surgery, they do not demonstrate the superiority of the proposed program in improving sensorimotor impairments, pain and upper extremity functional abilities in individuals with CTS immediately before or one month after carpal tunnel decompression surgery compared with standard care. However, pain subscales and biological integrity outcomes demonstrated moderate to large effect sizes or trends towards the statistically significance, thus supporting the need for further research.