INTRODUÇÃO: A doença renal crônica (DRC) favorece o desenvolvimento de inúmeras complicações entre elas a amiloidose. Nos ombros os depósitos de amilóide desencadeiam reações inflamatórias e dor intensa o que compromete a qualidade de vida dos pacientes acometidos. As propostas terapêuticas para o tratamento dessa complicação são escassas. OBJETIVO: O objetivo do presente estudo foi avaliar o efeito da estimulação elétrica nervosa transcutânea (do inglês, TENS) no tratamento da dor e capacidade funcional do ombro e dos fatores relacionados à qualidade de vida em pacientes com DRC. MÉTODOS: Trinta pacientes foram avaliados 5 vezes num período de 6 semanas. Na 1ª semana, o aparelho foi programado para não transmitir a corrente elétrica (placebo) e nas 5 semanas subseqüentes, utilizamos corrente de baixa frequência (10Hz, 150 µs, 2xdia, 40 minutos). A dor (escala visual analógica), a funcionalidade do ombro (Escore de Constant e Escala da UCLA) e os fatores relacionados à qualidade de vida (SF-36) foram avaliados. RESULTADOS: Nossos resultados mostram que o tratamento com a TENS reduziu significativamente a dor (p<0,05), melhorou a funcionalidade do ombro (tanto pelo Escore de Constant quanto Escala da UCLA; p<0,05) já na primeira semana e estes benefícios permaneceram até o final do tratamento (5 semanas) quando comparado com o período placebo. Os domínios capacidade funcional, dor, vitalidade e aspectos sociais apresentam uma melhora após 5 semanas de tratamento quando comparado com o período placebo (p<0,05). Foi verificado ainda que este efeito foi observado mesmo com a redução da quantidade de medicação analgésica. CONCLUSÃO: Nossos resultados mostram que a TENS de baixa frequência reduz a dor e melhora a funcionalidade do ombro e os fatores relacionados à qualidade de vida de pacientes com DRC. / INTRODUCTION: Chronic kidney disease (CKD) favors the development of numerous complications such as amyloidosis. In the shoulders, amyloid deposits promote inflammatory reactions and severe pain, which compromises the quality of life of patients with this disease. There are few therapeutic options for the treatment of this complication. OBJECTIVE: The objective of the present study was to evaluate the effect of transcutaneous electrical nerve stimulation (TENS) in the treatment of pain and in shoulder functional capacity, as well as factors related to the quality of life in patients with CKD. METHODS: Thirty patients were evaluated 5 times over a period of 6 weeks. At week 1, the equipment was programmed to not transmit the electrical current (placebo) and in the 5 subsequent weeks we used low frequency current (10Hz, 150 µs, twice a day, 40 minutes). Pain (visual analog scale), shoulder functional capacity (Constant score and UCLA Shoulder Rating Scale) and factors related to the quality of life (SF-36) were evaluated. RESULTS: Our results show that the treatment with TENS significantly reduced pain (p<0.05), improved shoulder functional capacity (using both Constant score and UCLA Shoulder Rating Scale; p<0.05) at week 1 and these benefits remained until the end of the treatment (5 weeks) when compared with the placebo period. The domains of functional capacity, pain, vitality and social functioning present improvement after 5 weeks of treatment when compared with the placebo period (p<0.05). It was also found that this effect was observed even after the administration of analgesics was reduced. CONCLUSION: Our results show that low frequency TENS reduces pain and improves shoulder functional capacity and factors related to the quality of life of patients with CKD.

Em indivíduos saudáveis o desempenho motor e os parâmetros cinemáticos e espaçotemporais da tarefa de alcance já estão descritos na literatura. Até o momento nenhum estudo investigou a influência da dor crônica no ombro nessas variáveis durante a tarefa de apontamento com o corpo todo em diferentes demandas, e nem estabeleceram como é o comportamento motor. Por este motivo, o objetivo do presente estudo foi caracterizar o comportamento motor de uma tarefa de apontamento em indivíduos com dor no ombro e avaliar parâmetros de padrão de movimento, desempenho motor e equilíbrio. Trata-se de um estudo transversal realizado no Laboratório de Bioengenharia Elétrica da Escola Politécnica da USP. Participaram do estudo 20 sujeitos, sendo 11 no grupo controle (GC) e 9 no grupo com dor (GD). O experimento consistiu em realizar um alcance em três angulações distintas (menor, igual e maior que 90°) em duas velocidades (normal e rápida). Foram coletados dados de cinemática e plataforma de força. As principais medidas foram (1) índice de retidão (IR); (2) tempo de reação e movimento (3) deslocamentos angulares e lineares (4) COP e COM. Os resultados mostraram que o GD apresentou pior IR, maior tempo de reação e de movimento, os deslocamentos lineares e angulares foram mais estereotipados, os deslocamentos do COM e a velocidade de deslocamento do COP foram menores e as estratégias de equilíbrio foram menos utilizadas, gerando manutenção do controle em bloco. Desta forma, conclui-se que o comportamento motor é alterado no GD e as variáveis de padrão de movimento, desempenho motor e de equilíbrio foram piores na comparação com indivíduos saudáveis / In healthy subjects the motor performance and the kinematic parameters and spatiotemporal parameters of the task of reaching have already been described in the literature. Until now no study has investigated the influence of chronic shoulder pain on these variables during whole body pointing in different demands and did not establish how motor behavior works. For this reason, the aim of the present study was to characterize the motor behavior of a pointing task in individuals with shoulder pain and to evaluate patterns of movement pattern, motor performance and balance. This is a cross-sectional study conducted at the Bioengineering Laboratory of the Polytechnic School of USP. Twenty subjects participated in the study, being 11 in the control group (CG) and 9 in the pain group (PG). The experiment consisted in achieving a range in three distinct angles (smaller, equal and greater than 90 °) in two speeds (normal and fast). Kinematics and force platform data were collected. The main measures were (1) straightness index (RI); (2) reaction time and movement (3) angular and linear displacements (4) COP and COM. The results showed that the GD presented worse IR, longer reaction time and movement, linear and angular displacements were more stereotyped, the COM displacements and the COP displacement velocity were smaller and the equilibrium strategies were less used, generating maintenance of block control. However, we conclude that motor behavior is altered in GD and the variables of movement pattern, motor performance and balance were worse in comparison with healthy individuals

<p>Musculoskeltal pain is the most common diagnosis for being on sick leave two months or longer in Sweden. The societal costs have been estimated at almost 30 billion Swedish kronor per year. Research aimed at improving occupational rehabilitation is therefore crucial.</p><p>In Study I a multidisciplinary cognitive-behavioral in-patient program conducted at a rehabilitation clinic was empirically evaluated. A randomized controlled trial with 36 chronic pain patients showed a difference in favor of the treated patients compared to their controls on measures of occupational training and activity level at a 1-month follow-up. A consecutive trial with 85 chronic patients showed a decrease in sick leave, pain intensity, depression, and use of analgesics, and an increase in life control and physical fitness from pre-treatment to a 2-month and a 1-year follow-up. Study II was a randomized controlled evaluation of a return-to-work focused cognitive-behavioral out-patient program with a 6-month follow-up conducted by a psychologist. Effects were compared over 36 pain patients on short-term sick leave (2-6 months) and 36 patients on long-term sick leave (>12 months). The treated patients on short-tem sick leave reduced their sick leave and returned to work more than their controls. They also improved their abilities to control and decrease the pain more. However, the patients on long-term sick leave did not improve on any outcome variables compared to their controls. In Study III a questionnaire aimed at identifying obstacles to return to work was developed and evaluated. The questionnaire was administrated to 154 chronic pain patients and was found to predict sick leave nine months after assessment. Important obstacles were perceived prognosis of a work return, social support at work, physical workload and harmfulness of work, pain intensity, and depression.</p><p>In conclusion, this thesis shows that cognitive-behavioral treatment focused on return to work is effective in helping chronic musculoskeletal pain patients back to work. A questionnaire developed to identify obstacles to return to work was shown to predict sick leave. </p>

Background: In Sweden, as well as in most Western countries, sickness absence is a major public health problem that has increased in recent years. This is a complex phenomenon related not only to ill health factors, but also to other factors on the levels of the individual, the family, the workplace, and the society. Most studies of sickness absence are cross sectional, which makes it difficult to investigate aetiological factors. A longitudinal study design is preferable, because sick-leave spells can have a long duration and are often due to chronic or recurrent disorders. Objectives: The aim of the present research was to conduct a pilot study to gain further information about factors associated with sickness absence and disability pension, perceptions of contacts with rehabilitation professionals, and self-rated health over time among younger persons initially on sick leave with low-back, neck, or shoulder diagnoses. Material and methods: An eleven-year prospective cohort study of all individuals who, in 1985, were aged 25–34 years, lived in the municipality of Linköping, Sweden, and had a sick-leave spell ≥ 28 days with low-back, neck, or shoulder diagnoses (n = 213, 61% women). The following information was obtained from registers: number of sick-leave days and spells in 1982–1984; diagnosis and demographical data in 1985 (age, sex, occupation, citizenship, marital status, and income); data on each sick-leave period (date, full/part time), disability pension (date, diagnoses, temporary/permanent, full/part time); emigration (date), and death (date, cause) from 1985 to 1 September 1996. In 1996, a questionnaire was sent to members of the cohort (response rate 73%). Different measures were used to analyse sickness absence and disability pension over the eleven-year period, possible risk factors for disability pension were tested by Cox regression, and possible factors predicting future low levels of sickness absence were tested by logistic regression. Based on the questionnaire perceptions of encounters with rehabilitation professionals were analysed with factor analyses and linear regression, and the so called health-line (a method to collect data on self-rated health over time) was tested, and the results were compared with data on sickness absence and disability ension. Results: The members of the cohort turned out to be a high-risk group for disability pension. After 11 years, 26% of the women and 14% of the men had been granted such benefits, mainly due to musculoskeletal diagnoses, but also with psychiatric diagnoses for half of the men and 17% of the women. Full-time pension was granted more often to men than to women. The women had higher levels of sickness absence. An extended Cox regression model proved suitable for prediction of disability pension. Taking citizenship and long-term sickness absence into consideration, the women had a 1.9 times higher risk of being granted disability pension than the men. Predictors for future low levels of sickness absence were a history of low sickness absence, having a white-collar job, and being married. These associations were not discerned when a pathogenic approach was used, which implies that factors other than the opposite risk factor for disability pension are associated with future low sickness absence. Three dimensions of the individuals’ contacts with professionals were identified: supportive treatment, distant treatment, and empowering treatment. Women perceived both social insurance officers and health care professionals as more supportive than the men did. Contact with social insurance officers was experienced as more supportive and empowering by persons on disability pension than by those not receiving such benefits. Data collected using the health-line (i.e., self-rated health from 1985 to 1995) was correlated with data on annual mean number of sick-leave days and days on disability pension. No tendency to recall bias was noted. Conclusions: Additional research is needed to elucidate the situation of women on sick leave with low-back, neck, and shoulder diagnoses. Further testing and practical application of statistical and epidemiological models for analysing sickness absence and disability pension data should be carried out to ascertain the validity and usefulness of such models. / On the day of the public defence the status of the article I was: Submitted; article III was: Accepted; article IV was: Submitted and article V was: In press.

Introduction: Musculoskeletal disorders constitute the greatest cause of sickness absence from work. Despite research and efforts at rehabilitation, sickness absence due to these disorders has not decreased, but has instead increased, particularly in women. Clients’ perceptions of care and rehabilitation, i.e. knowledge generated from a lay perspective, is a neglected area of research. This thesis deals with lay experiences of rehabilitation following sickness absence due to back, neck or shoulder problems, termed musculoskeletal disorders (MSD). Aim: The overall aim was to examine hindering and promoting processes in rehabilitation after sickness absence due to MSD from a lay perspective. Specific aims were to study how lay persons experience rehabilitation agents and rehabilitation activities (paper I), how they describe themselves and their experience in relation to work (paper II), the significance of the private arena regarding return to work (paper III), and how clients who have experienced sickness absence due to MSD perceive contact with rehabilitation agents (paper IV). Method: The study population in the four papers is part of a cohort of persons living in the same municipality and who in 1985 were aged 25-34 years and were sick-listed due to back, neck or shoulder diagnoses for 28 days or  more, n=213. During 1995, 148 persons in the cohort responded to a questionnaire, and in 1997-1998, 20 of these persons were interviewed concerning their experiences with rehabilitation. In papers I, II and III the qualitative method of Grounded Theory was used with a focus on creating an empirically-based theory concerning the area under study. Data collection was strategic and analysis of the tape-recorded interviews was done on a continual basis. How previously sick-listed persons experienced contact with professional rehabilitation agents in t he health care sector and social insurance office was investigated in paper IV. Factor analysis and multiple regression analysis were used to analyse the data in this study. Results: The interview study shed light on lay persons’ experiences with medical, social and work-related measures in rehabilitation, their perceptions of rehabilitation actors and family members in relation to rehabilitation, and their self-presentations. The descriptions of lay persons concerned three arenas, the health care arena, the occupational arena, and the private arena. Dilemmas and difficulties in these arenas were described, such as handling the duty to work, experiencing domestic strain, and the experience of lacking socioemotional support from significant persons during the rehabilitation process. In paper I some ideal types of rehabilitation agents emerged from the interviewees’ descriptions concerning the health care arena, and we called these the routine bureaucrat, the empathic administrator, the distant technician, and the professional mentor. The latter agent was requested and was described as a person who could provide socioemotional support, who had professional competence, and who could function as a unifying link during the rehabilitation process. The results from paper II showed that in their self-presentations, the interviewees expressed having a duty to work and that there were differences in how they handled this sense of duty. The selfpresentations contained descriptions of work as a part of personal identity and could be summarised in the following ideal types: the work manic, the workhorse, the workaholic and the relaxed worker. The latter used a strategy that can be considered to promote rehabilitation in that the individual himself/herself had control over his/her work and worked in accordance with his/her own needs rather than those of others. Paper III focused on the private arena. Different patterns were found in the experiences of men and women. Women related that their responsibility for the home and domestic work seldom left any time for themselves, including any time for rehabilitation. Men more often reported having time for themselves that could be used for leisure activities and rehabilitation. Some of the women said that they lacked socioemotional support from their partner and that they had a great deal of responsibility for housework, which seemed to be a hindrance in returning to work after sickness absence. Furthermore, these women, like most of the men, had little education, which could make finding other work alternatives more difficult. Based on the interviews, a hypothesis was developed regarding domestic strain that is related to the distribution of domestic work, the distribution of responsibility for the home, and the quality of the marital relationship. Paper IV dealt with clients’ perceptions of contact with rehabilitation agents in health care and the social insurance office. Three latent dimensions were found in the respondents’ ratings of these contacts: supportive treatment, distant treatment, and empowering treatment. Sex, disability pension status, mental health and diagnostic group were significantly related to how these dimensionswere rated. Women perceived the treatment from both types of rehabilitation agents as more supportive than men. Contact with the social insurance offices were rated higher by persons with disability pensions than by those who had returned to work. Men rated their contact with rehabilitation agents at social insurance offices high on the dimension of distant treatment. Respondents with mental health problems rated the contact as distant for both types of rehabilitation agents, but contact with health care was also scored low on the supportive dimension. Finally, respondents with neck/shoulder diagnoses rated contact with rehabilitation agents in health care as more empowering than was done by persons with back diagnoses. Conclusions: From a lay perspective rehabilitation following sickness absence due to MSD occured in three arenas, the health care arena, the occupational arena and the private arena, where the quality of relationships both with rehabilitation agents, persons at work and in one’s private life was described as important regarding the rehabilitation process. This thesis also showed that both sex and health were important factors regarding how lay persons’ perceived contacts with rehabilitation agents during the rehabilitation process following sickness absence due to MSD.

Musculoskeltal pain is the most common diagnosis for being on sick leave two months or longer in Sweden. The societal costs have been estimated at almost 30 billion Swedish kronor per year. Research aimed at improving occupational rehabilitation is therefore crucial. In Study I a multidisciplinary cognitive-behavioral in-patient program conducted at a rehabilitation clinic was empirically evaluated. A randomized controlled trial with 36 chronic pain patients showed a difference in favor of the treated patients compared to their controls on measures of occupational training and activity level at a 1-month follow-up. A consecutive trial with 85 chronic patients showed a decrease in sick leave, pain intensity, depression, and use of analgesics, and an increase in life control and physical fitness from pre-treatment to a 2-month and a 1-year follow-up. Study II was a randomized controlled evaluation of a return-to-work focused cognitive-behavioral out-patient program with a 6-month follow-up conducted by a psychologist. Effects were compared over 36 pain patients on short-term sick leave (2-6 months) and 36 patients on long-term sick leave (&gt;12 months). The treated patients on short-tem sick leave reduced their sick leave and returned to work more than their controls. They also improved their abilities to control and decrease the pain more. However, the patients on long-term sick leave did not improve on any outcome variables compared to their controls. In Study III a questionnaire aimed at identifying obstacles to return to work was developed and evaluated. The questionnaire was administrated to 154 chronic pain patients and was found to predict sick leave nine months after assessment. Important obstacles were perceived prognosis of a work return, social support at work, physical workload and harmfulness of work, pain intensity, and depression. In conclusion, this thesis shows that cognitive-behavioral treatment focused on return to work is effective in helping chronic musculoskeletal pain patients back to work. A questionnaire developed to identify obstacles to return to work was shown to predict sick leave.

Repetitive and monotonous work is frequently associated with neck and shoulder pain and negative psychosocial factors inducing stress reactions. The present thesis concerns the relations between psychophysiological and subjective stress reactions, muscle activity measured by surface electromyography (SEMG) in the trapezius muscle, and neck and shoulder pain in women performing repetitive and monotonous work. In Study I cardiovascular and subjective stress reactions were investigated during computer work in a laboratory setting. The findings indicated that heart rate variability is a more sensitive and selective measure of mental stress compared with blood pressure recordings. Study II explored the relations between stress reactions and muscle activity during supermarket work. The results showed that perceived negative stress reactions may have a specific influence on muscle activity in the neck and shoulder region, which can be of importance for work-related musculoskeletal disorders in repetitive and monotonous work. In Study III the association between SEMG activity patterns and neck and shoulder pain was investigated during cash register work. It was found that pain-afflicted women had a different muscle activation pattern (more static, more co-contraction, less muscle rest) compared with pain-free women. Study IV was a follow-up study evaluating the introduction of job rotation among female cashiers. The results indicated positive effects on diastolic blood pressure, muscle activity, and partly on neck and shoulder pain, although perceived stress was unchanged. It was concluded that job rotation seems to have a limited effect on chronic neck and shoulder pain, but may be an effective preventive measure. The empirical findings are particularly relevant for women who, compared with men, more often perform repetitive and monotonous work and are also more often affected by neck and shoulder pain.

No description available.

No description available.

Correct muscular activation of the body segments during an overhand throw is achieved when movement originates in the larger and more proximal legs and trunk and moves sequentially to the smaller, distal segments of the shoulder and arm. This sequence permits angular velocity to transfer progressively through the throw as part of an open kinetic chain. The athlete can summate angular velocity and segmental forces only if he is able to create a separation between the body segments during the movement pattern, and this separation is thus essential to effective segmental sequencing for activation of the trunk muscles to occur separately from distal segment motion. Limited mobility of the shoulder and scapula during the kinematic sequence will limit the ability of that segment to receive and contribute to the angular velocity of its proximal neighbors and to apply its own muscle torque to the throwing implement. This may result in compensatory motion of the proximal muscle groups to meet the demands placed on the body. To establish a link between compensatory activation of the trunk muscles and mobility in the rotator cuff and to apply this relationship to the pattern of the overhand throw, activity in the latissimus dorsi and external oblique/quadratus lumborum muscles was measured using surface electromyography in 40 college-age participants during arm flexion and lateral shoulder rotation. Muscle activation was recorded both before and after mobilization of relevant throwing muscles through targeted functional exercise. Results showed no significant change but suggested a general decrease in the level of peak muscle activation after participants engaged shoulder exercises. This is indicative of a downward trend in compensatory trunk activation during the initiation of shoulder motion. An increase in overall trunk muscle activity was also observed after exercise, which may imply a simultaneous engagement of the proximal throwing muscles in response to shoulder motion.