A estimativa das forças musculares durante o movimento humano tem inúmeras aplicações na área da Biomecânica. Nesse trabalho descrevo a aplicação de métodos de estimativa das forças musculares a dois diferentes problemas. O primeiro consiste em se quantificar as cargas a que os músculos e as articulações do membro inferior de adultos jovens estão sujeitos durante o andar em ambiente aquático e terrestre. Já o segundo consiste na investigação do efeito do aumento da complacência do tendão de Aquiles (TAq; tendão do triceps sural) na dinâmica de produção de força dos músculos gastrocnêmio e sóleo (G e S respectivamente; ambos músculos do triceps sural), visando compreender se o aumento da complacência, observado com o envelhecimento, poderia contribuir para as alterações na biomecânica da marcha de idosos. A hipótese no primeiro estudo era de que as forças desenvolvidas pelos músculos do membro inferior durante o andar em ambiente aquático não seriam menores em relação ao ambiente terrestre. Especificamente, esperávamos observar um aumento nas forças geradas nos flexores e extensores de quadril e joelho. No segundo estudo, nossas hipóteses eram de que o aumento na complacência do TAq faria com que as fibras musculares operassem mais distantes do seu comprimento ótimo, aumentando os níveis de ativação e o consumo metabólico dos músculos G e S. Com o objetivo de verificar as hipóteses levantadas nos dois estudos propostos utilizamos o software OpenSim 3.1 e dados experimentais dos movimentos estudados, para realizar simulações do andar humano e estimar as forças nos músculos do membro inferior durante essa tarefa. Em ambos os estudos os dados experimentais foram adquiridos através de sistemas de análise do movimento humano compostos por câmeras, para filmar os movimentos corporais dos voluntários, e plataformas de força, para medir as forças de reação do solo. Os resultados obtidos no primeiro estudo confirmaram nossas hipóteses, uma vez que indicam que durante determinadas fases do ciclo da marcha as forças geradas pelos músculos flexores e extensores de joelho e quadril, tais como os músculos isquiotibiais e o gluteo máximo, podem exceder as forças geradas em ambiente terrestre. Esses resultados corroboram a idéia de que o andar em ambiente aquático pode ser efetivo no ganho de força muscular. As hipóteses para o segundo estudo também foram confirmadas. Adicionalmente, nossos resultados previram que, para o triceps sural gerar a potência necessária para manter o indivíduo andando com velocidade confortável, os tendões dos músculos G e S devem se movimentar de maneira independente. A diferença no movimento dos feixes do TAq é tanto maior quanto maior a sua complacência. Além disso, verificamos que há um mínimo no consumo metabólico do gastrocnêmio em um nível específico de complacência do TAq, enquanto para o sóleo o consumo aumenta sistematicamente com o aumento da complacência. Esses resultados indicam que um aumento na complacência do TAq pode comprometer o desempenho dos músculos do triceps sural e aumentar o seu consumo energético, contribuindo para as alterações na biomecânica da marcha de idosos. As informações fornecidas nos dois estudos aqui apresentados podem auxiliar profissionais de área da saúde no planejamento de programas de treinamento e reabilitação para adultos e idosos, tanto no ambiente terrestre quanto no ambiente aquático. / Muscle force estimation during human motion has numerous applications in Biomechanics. In this work, we describe the application of methods of muscle force estimation to solve for two different problems. The first problem is to quantify lower limb muscle and joint loads that young adults are subjected to when walking in the aquatic and terrestrial environment. The second problem is to understand the effect of increased Achilles tendon compliance (AT; the triceps surae tendon) in the gastrocnemius and soleus contractile dynamics (G and S respectively; both triceps surae muscles), aiming at understanding if increased AT compliance, that occurs with aging, could play a role in the elderly gait alterations. Our hypothesis for this first study was that the forces developed by the lower limb muscles in water are not always lower than on land. Specifically, we hypothesized that the forces developed by the hip and knee flexors and extensors would be grater in water than on land. For the second study our hypothesis was that the compliant AT would cause the fibers to operate far from its optimal length resulting in higher levels of activation in both G and S, as well as higher specific metabolic consumption. In order to verify our hypotheses for both studies we used the software OpenSim 3.1 together with experimental data of volunteers walking in aquatic and terrestrial environments to simulate human walking and to estimate the forces developed by the lower limb muscles during this task. In both studies, experimental data were acquired through human movement analysis systems composed of cameras, to record the movements of the volunteers\' body, and force plates, to measure ground contact forces. We confirmed our hypotheses to the first study since our results showed that in certain periods of the gait cycle the forces developed in the knee and hip flexors and extensors, such as the hamstrings and the gluteus maximus, inside water exceeded the forces in corresponding periods of land walking. Those results corroborate the idea that walking inside water may be effective in muscle strengthening. We also confirmed our hypotheses to the second study. Additionally, we predicted that to generate the necessary power to walk with comfortable speed the triceps surae G and S tendon must move independently. This differential behavior becomes larger the greater the AT compliance. In addition, we also observed that G metabolic energy consumption was minimized for a specific level of AT compliance while S systematically increased. Those results suggest that increased AT compliance can compromise the triceps surae performance and increase metabolic consumption, contributing to the alterations on the elderly gait biomechanics. The results of our two studies may assist health professionals to better plan training and rehabilitation programs for adults and elderly in both, terrestrial and aquatic environment.

Le XIXe siècle est l’âge d’or du thermalisme en France. Tout le monde prend alors les eaux. Les hommes et les femmes de lettres, Chateaubriand, Lamartine, Michelet, Balzac, Hugo, Sand, les frères Goncourt, Mirbeau, Maupassant n’échappent pas au phénomène thermal et fréquentent les villes thermales. Sand en profite pour faire des excursions, Dumas fuit le choléra qui sévit à Paris, Balzac y courtise la marquise de Castries, Zola accompagne sa femme curiste, Mallarmé retrouve sa maîtresse... Mais la plupart des écrivains se rend en cure pour des raisons de santé. Ainsi, Bashkirtseff tente d’enrayer sa phtisie, Daudet, Maupassant et Lorrain y soignent leur syphilis, Chateaubriand ses rhumatismes, Verlaine ses ulcères à la jambe, et Proust pour son asthme. Tous ces écrivains curistes ont témoigné de leur expérience, que ce soit dans leur correspondance ou dans leurs romans, poèmes, récits de voyage. Leurs personnages séjournent également dans ces villes d’eaux : Raphaël de Valentin, héros de La Peau de chagrin, tente de rétablir sa santé à Aix-les-Bains ; Christiane Andermatt assiste à l’exploitation de la source du Mont-Oriol, la cure lui permet surtout de rencontrer son amant et d’avoir un bébé, sans que les eaux aient joué un rôle particulier ; Verdinet, Galinois et autres personnages de la comédie de Labiche, J’ai compromis ma femme, sont à Bagnères-de-Bigorre, et le neurasthénique de Mirbeau à Luchon. Voici une promenade dans le monde des eaux, vu par les écrivains, entre 1800 et 1914. / The nineteenth century is the golden age of hydrotherapy in France. Everybody comes to take the waters. Men and women of letters, Chateaubriand, Lamartine, Michelet, Balzac, Hugo, Sand, the Goncourt brothers, Mirabeau, Maupassant take part in this thermal cure phenomenon and attend water cities. Sand takes the opportunity to make excursions, Dumas runs away from rampant cholera over Paris, Balzac is involved in a courtship with the Marchioness of Castries, Zola accompanies his wife who is a patient, Mallarmé joins his mistress… But most of writers go to thermal cures for health purposes. In this way Bashkirtseff seeks to eradicate tuberculosis, Daudet, Maupassant and Lorrain treat their syphilis, Chateaubriand his rheumatism, Verlaine his leg ulcers, Proust his asthma. All these writers patients shared about their experience, in their correspondence or in their novels, poems, travel stories. Their characters live in these water cities as well ; Christiane Andermatt gets to the springs of Mont Oriol’s exploitation, the cure mostly is the opportunity for her to meet her lover and to have a baby, without waters playing a specific role ; Verdinet, Galinois and other protagonists of Labiche’s comedy, I compromised my wife, are in Bagnères-de-Bigorre, and Mirabeau’s neurasthenic, in Luchon. This is a walk in the world of waters, as seen by writers, between 1800 and 1914.

This study determined the effect of a water-based programme on the motor proficiency of children with Development Coordination Disorder (DCD). The water-based programme promoted an alternative environment for DCD children, involving all dimensions of movement. Thirty-one (31) children from Port Elizabeth participated, with an experimental group (n=15) following the eight-week water-based programme, while a control group (n=16) carried on with daily activities. Motor proficiency was measured during three tests, utilizing the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP). Results indicated positive effects of the intervention on all the variables of the BOTMP (p < 0.05). Confirming this, three variables obtained practical significance with Cohen’s d > 0.8, and one with 0.2 < d < 0.8. At the end of the three-month duration of the study, the experimental group indicated better performances at the end of the study than at the start, thereby confirming the positive and lasting effect of the water-based intervention programme. Therefore, the use of a water-based programme in improving motor proficiency is supported. However, implementation of the programme over a longer period is recommended.

Contextualização. A Fisioterapia carece de programas de intervenção previamente testados para aplicação, em meio aquático, visando indução de relaxamento muscular. Estudos prévios fornecem bases suficientes para a construção de programas. Delineamento e objetivo: Estudo quase experimental visando: 1. Desenvolver e descrever, em manual, um programa de massagem em imersão visando relaxamento denominado Programa de Relaxamento, Massagem e Mobilização em Imersão (RMI); 2. Avaliar pertinência e qualidade técnica da RMI pela submissão a pareceristas; 3. Avaliar a usabilidade e a autoaprendizagem a partir do estudo do manual da RMI; 4. Avaliar o efeito da intervenção fisioterapêutica com RMI em mulheres idosas e saudáveis. Método: 1. Desenvolvimento do Programa de Relaxamento, Massagem e Mobilização em Imersão (RMI), com base em revisão de literatura, reuniões dos pesquisadores e construção do manual. 2. Avalição da técnica por 20 pareceristas por meio de ficha de avaliação. 3. Análise de usabilidade do manual para autoaprendizagem teórico-prática por 10 graduandos em Fisioterapia. A atividade prática foi avaliada, pelo pesquisador e examinador independente, utilizando roteiro de avaliação baseado na descrição do programa. 4. Análise do efeito nos indicadores de relaxamento (frequência cardíaca, pressão arterial, flexibilidade, mobilidade, dor e qualidade de vida) em 12 mulheres idosas e saudáveis, após programa RMI de 10 sessões com duração de uma hora e meia cada. O estudo foi realizado no Laboratório de Fisioterapia e Comportamento do Curso de Fisioterapia da Faculdade de Medicina da Universidade de São Paulo e na piscina de reabilitação da Clínica Integrada Simmm. A análise constou de 1. Organização de respostas dos pareceristas por categoria e análise descritiva por questão; 2. Análise estatística descritiva das notas de desempenho dos estudantes e análise de confiabilidade interexaminadores; 3. Análise descritiva e comparativa dos dados pré e pós-intervenção das variáveis de flexibilidade, mobilidade articular, resposta cardiovascular, escores nos questionários DASH, FAOS e WHOQOL e por categorização das respostas sobre relatos para análise de efeito de programa em mulheres idosas. Resultados: Foi possível desenvolver o programa de intervenção e construir o manual descritivo e ilustrativo de massagem em imersão visando relaxamento, enriquecido com as sugestões dos pareceristas. O manual mostrou-se usável e suficiente para autoaprendizagem teórico-prática. O estudo de casos em série indicou que a prática da RMI melhora a mobilidade articular do ombro (rotação medial e lateral direita e esquerda com p=0,001) e tornozelo (extensão à esquerda p<0,001,extensão à direita p=0,0017 e flexão esquerda p=0,001). Afeta as respostas cardiovasculares indicando relaxamento com p=0,04. Houve melhora na função motora dos membros superiores, avaliada pelo questionário DASH. Na avaliação pelo questionário WHOQOL-bref, encontramos melhora no domínio psicológico, consequente à intervenção. Cada participante do programa de intervenção RMI relatou pelo menos um estado de relaxamento e satisfação. Conclusão: Foi possível desenvolver e descrever um método de massagem em imersão visando relaxamento, utilizável por graduandos em Fisioterapia, a partir de seu manual, e apropriado para induzir adequações nos sistemas musculoesquelético e cardiovascular, como indicadores de resposta fisiológica de relaxamento muscular. Estes dados são compatíveis com os relatos das participantes / Contextualization: Physiotherapy lacks intervention programs previously tested to be used in the aquatic environment aiming muscle relaxation induction. Previous studies provide sufficient basis for build programs. Design and purpose: quasi-experimental study with four objectives: 1. Develop and describe in descriptive and illustrated manual a Technique of Massage and Mobilization during Immersion for Relaxation (RMI); 2. Evaluate the relevance and technical quality of RMI through submission to referees; 3. Evaluate usability and self learning through the study of the RMI manual; 4. To evaluate the effect of physiotherapy intervention with RMI in healthy older women. Methods: In order to achieve these goals the study was executed in four phases: 1. Development of Technique of Massage and Mobilization during Immersion for Relaxation (RMI), carried out through literature review, meetings of researchers and construction of descriptive and illustrated manual. 2. Evaluation of the manual by 20 referees using a form. 3. Usability and self-learning analysis. Participated 10 Physiotherapy undergraduate. The student applied the RMI in healthy volunteers. The practical activity was assessed by the research and independent examiner using valuation script based on the program description. 4. Analysis on the effect of the RMI in relaxation indicators, applied in 12 healthy elderly women. The intervention consisted of 10 sessions lasting an hour and a half each one, once a week. The study was conducted at Laboratory of Physiotherapy and Behaviour of Physiotherapy Course, Medical School, University of São Paulo and in the SIMMM Integrated Rehabilitation Clinic\'s pool. Statistical analysis was pertinent to each phase of the study: 1. Development of physiotherapy intervention program based on literature and manual writing; 2. Organization of responses from referees by category of answers and statistical descriptive analysis of the degrees from referees; 3. Analysis of the statistical analysis of degrees and inter-rater reliability analysis of the evaluation executed by the examinators; 4. Descriptive and comparative analysis of pre and post-intervention data of flexibility, joint mobility, cardiovascular response, scores in the DASH, FAOS and WOGOOL questionnaires and categorization of answers. Results: The methodology applied allowed the development of the RMI and construction of descriptive manual, enriched with suggestions from referees. The manual proved to be usable and sufficient to convey practical knowledge, no third part intervention, targeting education. The number of case studies showed that the practice of RMI improved shoulder joint mobility (medial and lateral rotation right and left with p=0,001) and ankle joint mobility (extension - left p < 0.001, extension - right p=0,0017 and bending left p=0,001) and affected the cardiovascular response showing relaxation (p=0,04). Each participant in the RMI intervention program reported at least one state of relaxation and satisfaction. Conclusion: It was possible to develop and describe a method of massage and mobilization in immersion to induced relaxation usable by students in Physiotherapy from its manual (with adjustments by referees) appropriate for change musculoskeletal and cardiovascular systems, as response indicators of physiological muscular relaxation. There was improvement in motor function of the upper limbs, assessed by DASH questionnaire. In the evaluation by WHOQOL-bref questionnaire it was found an improvement in the psychological domain, consequent to the intervention. These data are consistent with the reports from the participants

<p>Background: Increased physical activity has a modest effect on the spatial distribution of bone mineral. The risks and benefits of exercise for women with osteoporosis at high risk to fracture are not known. The decompression of aquatic exercise is an option to increase exercise compliance. The dual energy absorptiometry (DXA) vertebral fracture assessment (VFA) images 2D bone geometry however measurement properties have not been established for this outcome.</p> <p>Purpose: To determine relative and absolute intra-rater reliability of DXA-based vertebral height (VH) measures and to assess the feasibility of investigating bone outcomes in women with established osteoporosis before and after a 6 month aquatic exercise program.</p> <p>Methods: DXA VFA scans of 32 women over 60 years old were analyzed on 2 occasions, 4 weeks apart. Relative reliability, intraclass correlation coefficient (95% CI) and absolute reliability, standard error of measurement (95% CI) were estimated for visible anterior, middle and posterior VHs from T4 to L4. Women with osteoporosis at high risk to fracture (clinical practice guidelines used) were recruited from two osteoporosis clinics. Feasibility of recruitment, adherence to the exercise, adherence to the assessment protocols (DXA, pQCT, physical performance measures), safety and retention were assessed.</p> <p>Results: Intra-rater reliability ICC >0.87 (0.74, 0.94) and SEM <1.17 from T10 to L4. Recruitment of 9 women in 10 weeks; average adherence 68%; pQCT data loss 46%; 1 fracture after class; retention 89% at 12 months.</p> <p>Conclusion: Further study of measurement properties of VH and protocols for recruitment, data management and safety are required.</p> / Master of Science Rehabilitation Science (MSc)

Introdução: Tem se afirmado que não há a possibilidade de haver melhora da estabilidade dinâmica postural utilizando exercícios na água, isto é, onde a gravidade apresenta-se diminuída. Neste estudo randomizado e controlado avaliamos e comparamos a estabilidade dinâmica postural em indivíduos saudáveis que realizaram exercícios sensório-motor no solo ou na água. Métodos: Através do Biodex Balance System®, foram avaliados os limites de estabilidade postural, antes e após um programa de exercícios, de 60 indivíduos saudáveis do sexo masculino divididos em 3 grupos (solo, piscina e controle). Os indivíduos dos grupos solo e piscina realizaram um treinamento sensório-motor por 2 meses no solo e na água respectivamente; o grupo controle não realizou nenhum tipo de exercício. Resultados: 1) Foram encontradas diferenças significativas na estabilidade dinâmica entre o grupo solo e controle; 2) Foram encontradas diferenças significativas na estabilidade dinâmica entreo grupo piscina e controle; 3) Não foram encontradas diferenças significativas entre o grupo solo e piscina. Conclusões: realizar exercícios sensório-motor melhora a estabilidade postural em indivíduos saudáveis do sexo masculino, sem diferenças significativas entre os ambientes de treino (solo e água) comparados / Introduction: It has been stated that there is no way to improve dynamic postural stability using exercises in water, i.e. where there is reduced gravity. In this controlled, randomized study, we evaluate and compare postural dynamic stability in healthy individuals who performed sensory-motor exercises on the ground or in water. Methods: Through the Biodex Balance System®, the limits of postural stability were evaluated before and after a program of exercises, in 60 healthy males, divided into three groups (ground, swimming pool and control). The individuals in the ground and swimming pool groups carried out sensorial-motor training for two months, on the ground and in the water, respectively; the control group did not perform any kind of exercises. Results: 1) Significant differences were found in dynamic stability between the ground and control groups; 2) Significant differences were found in dynamic stability between the swimming pool and control groups; 3) No significant differences were found between the ground and swimming pool groups. Conclusions: performing sensory-motor exercises improves postural stability in healthy males, without significant differences between the training environments (ground and water) compared in this study

A principal perda no sistema musculoesquéletico com o envelhecimento é a diminuição da flexibilidade e da força muscular, levando ao desequilíbrio e podendo ser a causa de quedas e incapacidades funcionais. Os exercícios físicos podem reverter parcial ou totalmente este quadro. A hidroterapia é um bom meio para realização de fisioterapia preventiva, pois elimina o risco de quedas e sobrecarga nas articulações e estudos deste tipo são raros na literatura. Este estudo avaliou o efeito de um programa de hidroterapia na flexibilidade e força muscular de 16 idosas, com idade entre 65 e 70 anos, saudáveis, sedentárias, moradoras da cidade de São Paulo. Os testes foram realizados antes e após o treinamento e os dados foram analisados por meio de teste paramétrico (T-student). O treinamento constou de 32 sessões, realizadas duas vezes por semana em duplas, com uma hora de duração com controle dos sinais vitais. Encontrou-se melhora na flexibilidade e força muscular nas idosas, mostrando que a população idosa pode se beneficiar com as vantagens da hidroterapia. / The main loss in the muscleskeletical system in consequence of the aging is the decrease of the flexibility and of the muscular force, affecting the balance. It could be the cause of fall and functional inability. The physical exercises can revert partially or totally this effects. The hydrotherapy is a good choice to prevent disabilities because it eliminates the risk of fall and overloaded articulations. Studies focusing this type of treatment are rare. This study evaluated the effect of a hydrotherapy preventive program in the flexibility and muscular force of 16 senior, with age between 65 and 70 years, healthy, sedentary, residents at São Paulo City. The tests were accomplished before and after the training and the data were analyzed through parametric test (T-student paired). The training consisted of 32 sessions, twice a week, with one hour of duration (with control of the vital signs). We found increase in the flexibility and muscular force in the seniors, showing that this population can to obtain benefits with the advantages of the hydrotherapy.

Contexte et objectif – Les patients âgés gonarthrosiques présentent une dégradation du contrôle postural. Les méthodes non pharmacologiques sont aujourdhui recommandées comme option de première intention dans la gestion de l’arthrose. L’hydrothérapie fait partie des moyens de rééducation à disposition des patients âgés atteints d’arthrose du genou pour ses effets antalgiques et musculaires. Cependant, peu d’études sont actuellement disponibles concernant l’effet de l’hydrothérapie sur le contrôle postural, associée ou non à des programmes de rééducation individuels ciblés. Par ailleurs, le contrôle postural est susceptible de variations diurnes. Cette étude a eu pour objet de décrire le contrôle postural des personnes gonarthrosiques à quatre périodes de la journée, puis de comparer l’amélioration du contrôle postural au cours de deux programmes de rééducation différents recourant à l’hydrothérapie. Matériel et méthodes - Deux-cent-quatre-vingt quatre patients souffrant d’arthrose du genou ont été inclus dans cette étude. Le bilan posturographique a été réalisé une semaine avant la cure thermale en condition simple (yeux ouverts, support stable) et en conditions sensorielles contradictoires (vision faussée ou indisponible, proprioception perturbée). Pour évaluer les variations diurnes de la stabilité posturale, les patients ont été randomisés à quatre périodes d’essai dans la journée définies comme suit : 8h-10h, 10h-12h, 13h-15h, 15h-17h. L’influence du sexe, de l’âge, de la taille, du poids et de l’indice de masse corporelle sur la stabilité posturale a été évaluée. La gonalgie a également été évaluée à quatre périodes d’essai. Par la suite, les patients ont été randomisés en deux groupes de rééducation différents pour recevoir des traitements aquatiques : groupe cure classique (hydrothérapie efficace prouvée, c’est-à-dire groupe témoin) et groupe cure active (hydrothérapie combinant des programmes de réhabilitation individuels ciblés). Les bilans de posturographie statique ont été réalisés respectivement à 21 jours, 42 jours et 90 jours après le début de l’hydrothérapie. Résultats –Les tests posturographiques ont été réalisés chez 241 patients (âge moyen : 64,8 + 8,7 ans ; 82 hommes). Le contrôle de l’équilibre était plus efficace l’après-midi que le matin à la fois dans les conditions simple (p = 0,012) et sensorielle contradictoire (p = 0,047), en particulier en début d’après-midi lorsque la vision et la proprioception étaient disponibles (p = 0,026) ou perturbées (p = 0,019). La gonalgie a été plus prononcée le matin que l’après-midi (p < 0,001). La variation diurne du contrôle postural était plus marquée chez les patients plus âgés, de poids plus élevé, de sexe masculin, dans les conditions d’essais différentes (p < 0,05). Les deux cures d’hydrothérapie ont eu des effets curatifs considérables sur la restauration du contrôle de l’équilibre. Une meilleure précision des oscillations posturales a été constatée dans le groupe cure active par rapport au groupe cure classique, 42 jours après le début de l’hydrothérapie (p = 0,020), en particulier lorsque la proprioception a été perturbée avec (p = 0,028) ou sans (p = 0,025) vision disponible. Dans les deux groupes a été observée une stabilité posturale comparable dans un délai de trois mois. Conclusions - Cette étude a montré une meilleure stabilité posturale chez les patients atteints d’arthrose du genou, en début d’après-midi par rapport à la fin de matinée dans les situations sensorielles simples ou contradictoires. Il a été constaté que ces variations étaient également liées à l’âge, au sexe, au poids et pourraient être expliquées par la douleur articulaire fluctuante dans la journée. Considérée comme un traitement non pharmacologique applicable et recommandé, l’hydrothérapie est bénéfique à l’amélioration de la stabilité posturale chez les patients âgés atteints d’arthrose du genou, en particulier combinant un programme de réhabilitation individuel ciblé. [...] / Background and Objective – Increasing evidence supports balance control impairment in elderly patients with knee osteoarthritis (OA). Current guidelines recommend non-pharmacologic methods as first-line options in the management of OA. Hydrotherapy is a beneficial training medium for rehabilitation in elderly knee OA patients. However, few indications at present are available concerning the effect of hydrotherapy combining with targeted individual rehabilitation programs to improve balance control. Meanwhile, there is limited data on diurnal variation of balance control in these patients. This study aimed to investigate postural stability in elderly patients with symptomatic knee OA during different periods in a daytime before the spa therapy, then to study the results obtained before and after hydrotherapy to compare the improvement of balance control in these patients in two different water-based rehabilitation programs. Materials and Methods – Two-hundred and eighty-four knee OA patients were enrolled in this study. Static posturography using a vertical force platform was performed one week before spa therapy in simple (eyes open, firm support) and conflicting sensory (vision altered or unavailable, proprioception altered) conditions. To assess diurnal postural variations, patients were randomized to four testing sessions in a daytime defined as follows: 8-10am, 10-12am, 1pm-3pm, 3pm-5pm. Influence of sex, age, height, weight, and body mass index on postural stability was evaluated. Knee pain was also assessed in four testing sessions. Patients were then randomized to two different rehabilitated groups to receive spa therapies. Classic treatment group as a control received the efficacy proven spa water therapy, and active treatment group received spa water therapy combining with targeted individual rehabilitation programs. Static posturographies were carried out respectively in 21 days, 42 days and 90 days after the beginning of hydrotherapy. Results – Posturographic tests were completed for 241 patients (mean age: 64.8 + 8.7 years; 82 males). Balance control was more efficient in the afternoon than in the morning both in simple (p = 0.012) and conflicting sensory conditions (p = 0.047), especially in early afternoon when vision and proprioception were available (p = 0.026) or disturbed (p = 0.019). Patients’ knee pain was more pronounced in the morning than in the afternoon (p < 0.001). Diurnal variation of balance control was more noticeable in older, heavier, and male patients under different testing conditions (p < 0.05). Both the water-based therapies had considerable curative effect on balance control restoration. Better postural sway precision were found in active group than classic group 42 days after the beginning of hydrotherapy (p = .020), especially when proprioception was interfered with (p = .028) or without (p = .025) an available vision. Both of the groups have been observed a comparable postural stability in a three-month term. Conclusions – This study showed that better postural stability was observed in patients with knee OA in early afternoon than in late morning in simple and conflicting sensory situations. These variations appeared also to be related to age, sex, and weight and could be explained by fluctuant joint pain in a daytime. As feasible and recommended non-pharmacologic treatment, hydrotherapy is beneficial to the improvement of postural stability in elderly patients with knee OA, especially combining with targeted individual rehabilitation programs. These findings are important for future studies aiming at enhancing postural stability in knee OA patients and should be taken into account in the management of knee OA to generate applicative approaches to prevent the occurrence of adverse events in patient’s daily life.

A principal perda no sistema musculoesquéletico com o envelhecimento é a diminuição da flexibilidade e da força muscular, levando ao desequilíbrio e podendo ser a causa de quedas e incapacidades funcionais. Os exercícios físicos podem reverter parcial ou totalmente este quadro. A hidroterapia é um bom meio para realização de fisioterapia preventiva, pois elimina o risco de quedas e sobrecarga nas articulações e estudos deste tipo são raros na literatura. Este estudo avaliou o efeito de um programa de hidroterapia na flexibilidade e força muscular de 16 idosas, com idade entre 65 e 70 anos, saudáveis, sedentárias, moradoras da cidade de São Paulo. Os testes foram realizados antes e após o treinamento e os dados foram analisados por meio de teste paramétrico (T-student). O treinamento constou de 32 sessões, realizadas duas vezes por semana em duplas, com uma hora de duração com controle dos sinais vitais. Encontrou-se melhora na flexibilidade e força muscular nas idosas, mostrando que a população idosa pode se beneficiar com as vantagens da hidroterapia. / The main loss in the muscleskeletical system in consequence of the aging is the decrease of the flexibility and of the muscular force, affecting the balance. It could be the cause of fall and functional inability. The physical exercises can revert partially or totally this effects. The hydrotherapy is a good choice to prevent disabilities because it eliminates the risk of fall and overloaded articulations. Studies focusing this type of treatment are rare. This study evaluated the effect of a hydrotherapy preventive program in the flexibility and muscular force of 16 senior, with age between 65 and 70 years, healthy, sedentary, residents at São Paulo City. The tests were accomplished before and after the training and the data were analyzed through parametric test (T-student paired). The training consisted of 32 sessions, twice a week, with one hour of duration (with control of the vital signs). We found increase in the flexibility and muscular force in the seniors, showing that this population can to obtain benefits with the advantages of the hydrotherapy.

Este trabalho discorre sobre como o município de Águas de São Pedro, situado no centro do Estado de São Paulo, constituído na década de 1930 como um espaço voltado à atividade turística, destaca-se pelo potencial termal. Até hoje a estância hidromineral tem no turismo a principal atividade econômica; entretanto, nossa pesquisa busca compreender se o atrativo primordial do Município está atrelado às águas medicinais, ou se outras características singulares da pequena cidade, como tranquilidade, beleza paisagística e segurança, o tornam um lugar propício ao passeio. Buscamos entender por que, dentre tantas opções de cidades interioranas disponíveis em São Paulo, Águas de São Pedro é escolhida como local de residência fixa, lugar de estabelecimento de casas de veraneio, sendo palco de um grande crescimento imobiliário; assim, desvendamos quais fatores da estância são responsáveis por atrair os turistas e veranistas/turistas de segunda residência. Os dados da pesquisa foram obtidos por meio de pesquisa bibliográfica, observação direta, conversas informais, aplicação de questionários e entrevistas com vários atores socioeconômicos, tais como moradores, turistas, veranistas, rede hoteleira, comércios, imobiliárias e gestores municipais. Os resultados apontam que o município já passou por vários ciclos turísticos e, apesar de a estância hidromineral de Águas de São Pedro ser uma referência regional e até nacional de águas termais, e do poder público estar investindo para apresentar à sociedade um lugar cheio de qualidade de vida, símbolo de bem-estar, grande parcela dos turistas procura a cidade pelo passeio, gastronomia e compras, caracterizando um turismo excursionista, sem pernoite. Este é o motivo pelo qual a cidade vem passando por grande reestruturação paisagística, orquestrada pelo poder público e porque recebe incrementos do poder privado no que se refere à variedade de produtos e serviços ofertados. Percebemos que a maior parcela de moradores e turistas não têm o hábito de utilizar as águas medicinais, mesmo sabendo que a água sulfurosa, também chamada de \"Fonte da Juventude\", utilizada para ingestão e banhos terapêuticos, é a segunda melhor do mundo, superada apenas pela fonte de Pergoli, em Tabiano, na Itália (CAMARGO, 1990), porém o reconhecimento da Cidade como cidade das águas, cidade termal, cidade saúde, é resiliente. / This paper discusses how the waters of São Pedro, located in the center of São Paulo, formed in the 1930s as a space oriented to tourism, the thermal potential. To date the health resort has in the main tourism economic activity, however our research seeks to understand the primary attraction of the city is related to medicinal waters, or other unique characteristics of small town like tranquility, natural beauty and safety, make it a place conducive to walking. We try to understand why among so many choices of inner cities available in Sao Paulo Aguas de Sao Pedro is chosen as a fixed place of residence, place of establishment of second homes, the scene of a major real estate growth, thus unveil which resort factors are responsible to attract tourists and vacationers/second residence tourists. The survey data were obtained by means of literature, direct observation, informal conversations, questionnaires, and interviews with various socio-economic actors, such as residents, tourists, vacationers, hotel chain, trade, real estate and municipal managers. The results show that the city has had several tour cycles and that despite the health resort of Aguas de Sao Pedro is a regional and even national reference thermal waters, and the government is investing to present to society a place full of quality life, health symbol, a large proportion of tourists looking for the city by walking, dining and shopping, featuring a hiker tourism without overnight. Why the city has been undergoing major restructuring landscape orchestrated by the government, and receiving increments of private power as regards the variety of products and services offered. We realize that the largest share of locals and tourists do not have the habit of using medicinal waters, even though the source of sulphurous water, also called the \"Fountain of Youth\", used for intake and therapeutic baths, it is the second best in the world, surpassed only by the source of Pergoli in Tabiano, Italy (CAMARGO, 1990), but the recognition of the city as a city of water, spa town, city health, is resilient.