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quarta-feira, 21 de novembro de 2012

TRAINING ERRORS AND RUNNING RELATED INJURIES: A SYSTEMATIC REVIEW


Rasmus Oestergaard Nielsen, PT,1,,4 Ida Buist, PhD,2 Henrik Sørensen, PhD,1 Martin Lind, PhD,3 and Sten Rasmussen, MD4

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Abstract

Purpose:

The purpose of this systematic review was to examine the link between training characteristics (volume, duration, frequency, and intensity) and running related injuries.

Methods:

A systematic search was performed in PubMed, Web of Science, Embase, and SportDiscus. Studies were included if they examined novice, recreational, or elite runners between the ages of 18 and 65. Exposure variables were training characteristics defined as volume, distance or mileage, time or duration, frequency, intensity, speed or pace, or similar terms. The outcome of interest was Running Related Injuries (RRI) in general or specific RRI in the lower extremity or lower back. Methodological quality was evaluated using quality assessment tools of 11 to 16 items.

Results:

After examining 4561 titles and abstracts, 63 articles were identified as potentially relevant. Finally, nine retrospective cohort studies, 13 prospective cohort studies, six case-control studies, and three randomized controlled trials were included. The mean quality score was 44.1%. Conflicting results were reported on the relationships between volume, duration, intensity, and frequency and RRI.

Conclusion:

It was not possible to identify which training errors were related to running related injuries. Still, well supported data on which training errors relate to or cause running related injuries is highly important for determining proper prevention strategies. If methodological limitations in measuring training variables can be resolved, more work can be conducted to define training and the interactions between different training variables, create several hypotheses, test the hypotheses in a large scale prospective study, and explore cause and effect relationships in randomized controlled trials.

Level of evidence:

2a
Keywords: Duration, frequency, injuries, intensity, running, training, volume

INTRODUCTION

Weight loss and smoking cessation have been associated with running, and it has been stated that running has positive effects on health and fitness. However, Running Related Injuries (RRI) of the lower extremities are commonly a negative side effect. Depending on injury definition and length of follow up period, the injury incidence among runners varies between 11–85%,– or 2.5 to 38 injuries per 1000 hours of running.,– Several risk factors contributing to injuries have been reported–and general consensus exists with regard to training characteristics and previous running injuries being associated with the development of RRI. Training characteristics are of particular importance, since the training regimen is under the control of the runners (and coaches) and can be modified in contrast to previous injuries which cannot be modified., Furthermore, anecdotal evidence suggests that training errors (i.e. excessive distance, sudden change of training routines, etc.) are the cause of 60–70% of all running injuries.,, In a review of the etiology and prevention of and intervention for overuse injuries in runners, Hreljac concluded that the causes of all overuse running injuries could be classified as training errors, and thus, all overuse running injuries should be preventable. In order to summarize and present the information that examines the evidence about training errors and RRI, a systematic review may be a starting point to identify which training errors have been reported to be associated with injury development. To date, the authors have found no published systematic review that aims to present an overview of the literature, investigating the relation between volume, duration, intensity, and frequency of running, herein defined as training characteristics, and the development of RRI. Therefore, the purpose of this systematic review was to investigate the association between training characteristics and running related injuries.

METHOD

Search strategy and inclusion criteria

The Cochrane database was searched, revealing no systematic reviews about training characteristics and RRI. A search of the Pubmed, Web of Science, Embase, and Sportdiscus databases was conducted October 11th 2011 to identify studies that met the inclusion criteria using the search strategy presented in Appendix 1. The search was limited to studies of humans, published in English, and included only original articles.
Prospective cohort studies, cross-sectional studies, case-control studies, and randomized controlled trials were included in the current systematic review if a relationship between training characteristics and RRI was investigated. Studies with novice, recreational, and elite runners between the ages of 18 to 65 were included. Articles were excluded if participants were sprinters or middle distance runners, or were predominantly exposed to types of sporting activity other than running such as triathlons, and military training programs. Articles on cadavers, computer modeling/simulation studies were excluded.
The exposure variables of interest were training characteristics including volume, distance, mileage, time, duration, frequency, intensity, speed, and pace. Different methods for analyzing or reporting these characteristics were accepted. For instance, volume could be measured as kilometers or miles per day, per week, per month or as the gradual increase in mileage per week over a given period of time. The outcome of interest was RRI in general or specific RRI of the lower extremity or spine. Muscle cramps, corns, blisters, and calluses were not included as RRI.

Data collection and analysis

Each study identified as a result of the electronic search was initially evaluated independently by two authors (RON and IB) by screening the title and abstract. Articles without an abstract were excluded. All articles of interest were retrieved and evaluated for eligibility. Articles were excluded if no information was provided on injuries during follow up, in case of overview articles, or articles about degenerative diseases only.

Methodological quality assessment

The methodological quality of the cross sectional studies, case-control studies, and prospective cohort studies was assessed by means of a methodological quality assessment list developed and used by van der Worp et al, which was based on a list developed by van der Windt et al. The list was adapted slightly to make it specific for training and RRI. The assessment contains items on information and validity and/or precision in five categories: study objective, study population, outcome measurements, assessment of the outcome, and analysis and data presentation. Separate quality assessment lists were constructed for cross-sectional studies, case-control studies, and prospective cohort studies. The items of the quality assessment list are presented in Table 1. Each item was evaluated as either positive (+) or negative (−) by two reviewers independently. In cases where it was unclear whether a study did or did not meet an item, or if no clear information regarding the item was stated, the item was scored as negative (−). Results of the quality assessment made by the two reviewers were compared, and any disagreement concerning an item was resolved in a consensus meeting. The total quality of each study was calculated by counting the number of items being positive (+) from item 3 to 16 divided by the total number of items for the study type (11 for case-control studies, 9 for prospective cohort studies, and 8 for cross sectional studies).
Table 1.
Summary of quality scoring criteria for cross-sectional studies, case control studies, and prospective cohort studies.
The methodological quality of the randomized controlled trials included was rated using the PEDro rating scale which is based on the Delphi list developed by Verhagen and colleagues. The total methodological quality score was found by evaluating the internal validity and statistical reporting using an 11 criteria list. The total quality of each randomized controlled trial was calculated by counting the number of items being positive (+) from item 2 to 11 divided by 10. Previously, the PEDro scale has demonstrated an inter-rater agreement of [k] = 0.73–0.82.

Results

After examining 4561 titles and abstracts, 62 articles were identified as potentially relevant. After reference checking, one additional study was identified. The full texts of all 63 articles were retrieved and were subsequently evaluated by both RON and IB. Review of the complete texts excluded 32 articles. Of the excluded articles, four were overview articles,– four included persons less than 18 years of age,– three included persons with degenerative diseases only,– eight articles did not describe the relationship between training characteristics and RRI,– three had no control group,– two were modeling articles,, seven had a faulty injury definition or none at all,–and one was a design article. Finally, 30 articles were included in the review.

Risk of bias in included studies

The quality of included studies is presented in Table 2. The overall methodological quality of the included prospective studies, case-control studies, and cross sectional studies was 44.1% ranging from 9 to 89%. The most problematic areas were 1) the main purpose of many of the studies was different than the relation between training and RRI, 2) description of the demographic characteristics (gender, age, body mass index) of the participants was lacking, and 3) lack of adjustment for the effect of multiple training variables. The overall quality of the three randomized controlled trials was 43%.
Table 2.
Summary of quality scoring for all included studies. Scores given for the items of the quality assessment list for prospective cohort studies, cross sectional studies, and case-control studies and the PEDro scale for randomized controlled trials.

Description of studies and injury definition

The year of publication for the included studies ranged from 1977 to 2008. The studies represented populations in USA, Canada, New Zealand, The Netherlands, Denmark, Switzerland, Germany, and Sweden. The total sample size of included participants was 24,066, ranging from 28 to 4,335 subjects in each study. Of the 30 included studies, nine were retrospective cohort studies, 12 were prospective cohort studies, six were case-control studies, and three randomized controlled trials. The study characteristics of the selected studies were described to obtain insight into the homogeneity of the study populations (Table 3). The types of participants (novice, recreational, and elite), and the injury definition used varied considerably between the studies. For instance, Lysholm et al used “all injuries that markedly hampered training or competition for at least 1 week were noted” while Valliant used “injury was defined as physiological damage or bodily pain which interfered with one×s ability to run”. The mean age of all participants in the 30 studies varied from 19.5 years to 44 years with an average of 35.4 years. Mean body mass index was 22, ranging from 20.97 to 25.86. Four studies included only males while two included only females. For the remaining studies, an average of 67.6% of the participants included were males. Table 3 presents summary data from each study regarding the type of runner, demographic characteristics, and injury definition as quoted verbatim from the article.
Table 3.
Descriptions of included studies characteristics. Injury definitions are quoted verbatim unless stated otherwise.

Description of training characteristics

In 22 studies, the training characteristics were assessed retrospectively by a questionnaire. The recall period varied from two weeks to 10 years. In eight studies, daily running diaries,,,,– or an internet based log were used. In five studies, training interventions were used.,,,, Odds Ratio (OR), Hazard Ratio (HR), and Relative Risk (RR) were the most common measures of association. The unit of measurement in this review is miles. However, some articles used kilometers. In these cases, kilometers were converted into miles using 0.62137 as conversion factor. Different definitions were used in the reviewed studies for training volume, duration, intensity, and frequency.

Volume

In 28 articles out of 30 articles, the link between training volume and RRI was investigated. The most commonly used approach to define exposure was to measure the average weekly miles,,,,,–,– or kilometers,,, of running over a period of time. In other studies, weekly distance per weekly frequency or total running distance, were used as the measure of exposure.

Duration

In three articles, average hours,, or minutes spent running per week were used as the exposure variable. In another study, the weekly progressive increase in duration during a graded training program was used, while two other studies used minutes per day, as their measure of exposure.

Intensity

In 16 articles, training intensity was described.,,,,,,,,– In a majority of these, average pace of workout was used to express intensity during training, measured as minutes per mile (min/mile) or minutes per kilometer (min/km).,,,–, Other studies used kilometers per hour,, 16 km running time, or percentage of maximal attainable heart rate.

Frequency

The number of weekly training sessions was reported in a variety of ways as number of training sessions, times, frequency,, days,,,,, runs, or workouts per week. Most often the data were analyzed by dividing the weekly amount of days running into different categories. The comparisons vary widely across studies, however. The reference groups were defined as either 1, 1-2, 1-3, 1-4, or 1-5 days per week, and were compared to either one or several exposure groups varying between 3, 4, 5, 6, 7, 4-5, 5-7, 6-7 days per week. In one article, a regression model was used to investigate the risk of RRI as the weekly frequency increased during training prior to a marathon.

Relationship between training characteristics and RRI

Volume

Hootman et al found an increased risk of injury among males (HR = 1.66 [1.43, 1.94]) and females (HR = 2.08 [1.45, 2.98]) running more than 20 miles per week. Lysholm et al found a significant correlation (r = 0.59) in long-distance/marathon runners between the distance covered in a given month and the number of injury days during the following month. Walter et al found no significant difference in relative risk between the reference group who ran less than 10 miles per week and the groups who ran distances between 10 and 39 miles per week. However, the relative risk of injury was significantly higher among males (2.22 [1.30-3.68]) and females (3.42 [1.42-7.85]) running ≥40 miles per week. This was supported by Macera et al who found a significantly increased odds ratio for sustaining injury among males running ≥40 miles per week over a period of 3 months (2.9 [1.1-7.5]). In the same study, no association was found between weekly mileages and risk of injury among women.Although a majority of studies reported a relationship between weekly mileage and RRI, no significant association between miles per week and likelihood of injury was found in two prospective studies and one retrospective study.,,
In retrospective studies, several authors compared total volume per week between injured and non-injured subjects. Koplan et al investigated the proportion of injuries over a 10 year period in different mileage strata. The proportion of women reporting injury was highest in those who ran 40-49 miles per week. For men, the proportion was highest among those who ran 30-39 miles per week. Those running more or less miles per week had a smaller proportion of injuries. Marti et al found that runners who sustained injuries during the study period ran greater weekly mileage when compared to non-injured runners (26.3 km [3.2-83.8] versus 22.0 km [2.1-78.6], p 0.01). In a one-way analysis, Valliant also indicated that injured runners ran significantly more miles per week than non-injured runners (47.5 ± 20.5 miles versus 29.6 ± 16.7 miles, p < 0.01). This is supported by Jacobs et al and Koplan et al who found mileage run per week to be highly associated with injury.
In two studies, the RRI per 1000 hours of running in groups running different mileages per week were investigated., The number of injuries per 1000 hours of running appeared to decrease with increasing weekly mileage (Figure 1).
Figure 1.
Relationship between miles per week and Running Related Injury (RRI) reported as mean [95% confidence interval] for different comparisons. Results from the articles by Bovens and Jakobsen are calculated based on figures in the articles. RRI = Running ...
Walter et al investigated the relationship between longest run per week and risk of injury. The relative risk of sustaining an injury when the longest run each week is >5 miles, is 2.49 [1.64-3.71] among males and 1.78 [0.99-3.13] among females compared with a reference group having their longest run below 5 miles. Van Middelkoop et al measured weekly distance per weekly frequency. Running an average of 6.8–9.3 miles per training session was not associated with increased or decreased risk of sustaining an injury compared to average runs above or below 6.8–9.3 miles.
Several authors have investigated the relationship between training volume and specific running injuries. Reinking et al investigated subjects sustaining exercise related lower leg pain and found no significant difference in injuries between individuals training more or less than 40 miles per week. Satterthwaite et al found an increased odds ratio for hamstring (1.07 [1.02, 1.13]) and knee (1.13 [1.04, 1.23]) injuries by a weekly increase in mileage of 6 miles. Wen et al found a significant difference in weekly mileage between subjects sustaining hip (18.7 miles per week) or hamstring injuries (22.4 miles per week) compared to controls (13.3 and 13.4 miles per week). Kelsey et al found miles run per week in the past year to be non-predictive of stress fractures. Wen et al found weekly mileage and hours per week protective against overall injuries, knee injuries, and foot injuries. In case-control studies, no difference in weekly mileage was found between controls and persons with plantar fasciitis, shin splints, achilles tendinitis, or anterior knee pain, while patients with patellofemoral pain ran significantly less than healthy controls. For iliotibial band friction syndrome, Messier and colleagues found conflicting results in two different studies. In one study, injured participants ran significantly less than healthy controls, and in the other study no significant difference in weekly mileage between injured and healthy participants was reported.,

Duration

Pollock et al found an increasing injury incidence among novice runners who ran in 15, 30, and 45 minute duration groups of 22%, 24%, and 54%, respectively. Jakobsen et al reported 7.4 and 6.9 RRI per 1000 hours of running among marathon runners who ran 204 [95% CI: 198-210] and 162 [95% CI: 156-168] minutes per week on average over a one year period. Over a time period of 18 months, Bovens et al reported 12.1, 10.0, and 7.0 injuries per 1000 hours of running among marathon runners who ran 162, 192, and 240 minutes per week. Buist et al found an average of 33 [95% CI: 27-40] RRI per 1000 hours of running in two groups of novice runners. One group was instructed to run an average of 52 minutes per week over a 13 week period (30 RRI/1000 hours), while the other group were instructed to run an average of 59 minutes per week over a 8 week period (38 RRI/1000 hours). Figure 2 shows the RRI/1000 hours of running in groups running different minutes per week.
Figure 2.
Relation between minutes per week and number of Running Related Injury (RRI) per 1000 hours of running. Results from the articles by Bovens and Jakobsen are calculated based on figures in the articles. Int = intervention. Con = controls. RRI = Running ...
Buist et al investigated the relationship between weekly progression in running duration and likelihood of injury. There was no significant difference in the incidence of RRI in a group of runners with a 13 week training program with a mean duration increase of 10% per week compared to the incidence of RRI in a group of runners training an 8 week training program with a mean duration increase of 24% per week. However, although not significant, the mean survival time of runners in the 13 week training group was 212 minutes, compared to 167 minutes in runners of the 8 week training group.

Intensity

In fourteen studies, the relationship between training intensity and development of RRI was investigated.,,,,,,– Jacobs et al found a pace above 8 min/mile to increase the risk of injury as compared with a pace below 8 min/mile (p<0 .05=".05" al="al" et="et" hootman="hootman" style="border: 0px; font-size: 0.8461em; font: inherit; line-height: 0; margin: 0px; padding: 0px; position: relative; top: -0.5em; vertical-align: baseline;" sup="sup">
 found a reduced odds ratio (0.51 [0.35, 0.74]) for sustaining an injury among males who ran at above a 15 min/mile pace compared to those who ran at a faster pace (p=0.0004). A similar significant difference was found for female subjects (p≤0.05). However, lack of adjustment for other predictor variables such as weekly mileage weakened this association. This is supported by Marti et al, who found that running speed calculated from 10 mile race time was positively related to injury incidence in univariate analysis, but adjustment for mileage clearly weakened this association. In eight studies, no significant relationship between average training pace and likelihood of injury were found.,,,–, Wen et al,reported that no association was found between running pace and injury. However, it was reported that interval training increased the risk of shin injury (p<0 .05=".05" style="border: 0px; font-size: 0.8461em; font: inherit; line-height: 0; margin: 0px; padding: 0px; position: relative; top: -0.5em; vertical-align: baseline;" sup="sup"> In a case-control study, Messier et alfound runners with iliotibial band friction syndrome to run on average 3 seconds/mile faster than the control group during non-competition training (p=0.05). McCrory et al found training pace to be a significant (p≤0.05) discriminator between persons with achilles tendinitis when they examined pace in minutes per kilometer, where the pace of those injured was 4.64 ± 0.08 as compared to controls which was 4.87 ± 0.07.

Frequency

In eight articles, the relationship between training frequency and development of RRI was investigated.,,,,,,,, Results are presented in Figure 3. In six articles, RRIs in general were investigated;,,,, one investigated front thigh injuries, and one shin splint. In several studies, an increased risk, relative risk, or odds ratio for sustaining an RRI was reported when the weekly running frequency increased.,,,,,, Persons running 6-7 times per week had the highest risk. On the contrary, Taunton et al found an increased risk of injury among females running one time per week. Males also showed a similar trend, although it was not statistically significant (p=0.064). Satterthwaite et al found the odds ratio for sustaining an anterior thigh injury increased by 1.19 [1.05-1.34] per one day increment in running frequency. No significant association was found for hamstring, hip, knee, or calf injuries. Knobloch et al reported an increased risk of shin splints among individuals running more than five days per week.
Figure 3.
Relationship between running frequency (days per week) and Running Related Injury (RRI). OR = odds ratio; RR = relative risk; CI = Confidence Interval.

DISCUSSION

The purpose of this study was to investigate the relationship between training characteristics and running related injuries using a systematic review of the literature. Training characteristics were categorized into four groups: volume, duration, intensity, and frequency. The majority of the included prospective studies had a higher methodological quality when compared with the case-control studies and cross sectional studies.

Volume and duration

Previously, several authors, proposed that a high weekly mileage is associated with an increased risk of sustaining RRI. This is generally supported by the findings from the current systematic review. However, Fields et al questions the reliability of mileage as an injury predictor, since they found injured runners averaging essentially the same mileage as healthy runners. According to Jakobsen et al, it is therefore correct to use the incidence (injury per time) for comparison purposes because the risk of injury must be related to the time spent engaged in running. When injuries are related to exposure time, expressed as 1000 hours of exercise, Bovens et al, found that the number of injuries decreased when weekly mileage during an 18 month period increased from 15 miles per week to 37 miles per week. The assumption that injury incidence is decreased when running greater distances is supported in other studies which investigated injury incidence among runners training different mileages per week. In the study by Bovens et al, the mileage increase was accompanied by maturation as a runner, which possibly can explain the reduced risk of injury as weekly mileage increase; experienced runners may know the injury threshold better than novice runners. If this is the case, maturation as a runner would have to be considered an uncontrolled, confounding factor. The incidence is reported from 2.5 to 7.4 injuries per 1000 hours of exercise among marathon runners,, while injury incidence per 1000 hours of running among novice runners who trained 30 to 90 minutes per week is 33. Based on these findings, a hypothetical example of the number of RRI over a 26 week period can be calculated for novice and marathon runners. If novice runners run for 30 minutes 3 times per week over 26 weeks they will run 39 hours in total. Taking into account the risk of injury of 33 per 1000 hours of running reported by Buist et al the novice runner will sustain 1.29 injuries when running 39 hours. Similarly, marathon runners with the risk of 7.4 RRI per 1000 hours of running reported by Jakobsen et al can expect 1.15 injuries if they run 156 hours (2 hours 3 times per week) over the same period of time. In this hypothetical example, the absolute numbers of injuries would be higher among novice runners. This is consistent with the findings by Walter et al who stated that the risk of injury per mile of training declines with total mileage, so the small absolute increment in risk associated with increasing mileage may be acceptable to many athletes. All in all, these findings suggest that the relative injury threshold becomes higher in runners with higher weekly mileage.
In overview articles, authors, have suggested a maximal increase of weekly volume of no more than 10% per week, the so called “10% rule”, in order to reduce the risk of injury. This suggests that runners who increase the weekly volume by less than 10% have reduced risk of RRI when compared with runners whose weekly increase is above 10%. In a randomized controlled trial by Buist et al, the 10% rule was tested in novice runners. No significant difference in injury rates were found between runners following a graded training program with an increase in weekly duration of 10.5% compared to runners with an increase in weekly duration of 23.7%. However, it must be noted that both groups had a progression rate above 10%. If runners with a progression rate below 10% per week were compared with runners who increase their weekly volume for instance 40–60%, a statistically significant difference in injury rates may be shown. However, it may be unethical to conduct a randomized controlled trail with the intervention group having an increase in weekly mileage above 40%. In the study by Taunton et al,all runners had to participate in one weekly training session. The length of this weekly training session was increased every week. An increased risk of injury was found among females who only participated in one training session compared to runners who ran more training sessions per week. Although not significant, a similar trend was found for males. Taunton et al suggest that it stands to reason that a person who does not build an adequate training base during the other weekly training sessions will be more likely to be injured when they participate in a program that steadily increases in volume. However, information on progression rates were not reported in the study by Taunton et al, and because of this it is not possible to relate the results to the 10% rule.
In conclusion, there is some evidence suggesting weekly mileages to be associated with injury. However, the relative injury threshold becomes greater in runners with higher weekly mileage. Clearly, more studies must be conducted to investigate the link between weekly increase in running volume and development of RRI, taking into account the influence of intensity, duration, and frequency.

Intensity

The literature showed conflicting results with regard to training intensity and development of injuries. Thus, the way of assessing and reporting training pace may be the reason for inconsistent results. In all included studies, training intensity was measured subjectively by assessing the self-reported running pace. This may be a major problem, since self-reporting may be affected by recall bias. Furthermore, the participants only reported the average pace. The variation in training pace within and between sessions is therefore not accounted for. Thus, the variation in training intensity is likely unknown and may or may not play a role in the relationship between training intensity and risk of RRI. One possible solution is to measure the training intensity objectively or quasi-objectively in each training session. To date, no studies were found that described a quasi-objective measure such as perceived exertion or other objective measures of training in relationship to injury. Again, more studies have to be conducted to ascertain if there is a relationship between training intensity and development of injury.

Frequency

A “U-shaped” pattern between frequency and development of RRI may exist: Taunton et al found an increased risk of injury among female runners training one time per week. While McKean et al,Jacobs et al, Macera et al, and Walter et al, reported an increased risk among runners training 6-7 times per week compared with those training 2-5 times per week. Based on this, one might conclude that the ideal frequency is 2-5 running sessions per week. However, in the studies by Macera et al and Walter et al no additional risk was found after controlling for running volume. Therefore, Brill and Macera suggested that cumulative distance is a better indicator of injury risk than the lack of rest between runs. Thus, based on all the studies included in this review it must be concluded that it is not possible to determine the specific role of running frequency with regard to injury.

Running experience

The experience of the runners included in the different studies may bias the results, since the included studies include a wide variety of types of runners. Jakobsen et al and Marti et al reported that experience was an important factor for injury risk, because high running experience diminished the risk of injury. In the study by Buist et al novice runners reported the highest number of RRIs per 1000 hours of running. This was supported by Macera et al who reported new runners to be at greater risk for injury than more experienced runners. Perhaps habitual and experienced runners know their own injury threshold better as compared to novice runners and are therefore less likely to sustain RRI. This may seem to lead to the conclusion that novice runners have greater risk of injury. However, novice runners may be more likely to report injuries compared to experienced runners who, in many cases, have sustained several injuries previously and therefore do not consider some conditions or pain severe enough to classify them as injuries.

Definitions of Running Related Injury

In the study by Mechelen et al no attempt was made to compare the injury patterns between studies because of the differences in definitions and research methods, as well as research outcome. A similar problem exists in the current systematic review. In Table 3 the different injury definitions used in the 30 studies included was presented. There is a large variation in injury definition and it must be questioned if the different definitions of RRI in the studies included in this review are comparable. In their review, Ryan et al stated that a standardized definition of running injury would benefit the understanding of injury prevalence, and can ultimately assist in injury prevention. Additionally, Satterthwaite et al and Reinking et al question the validity and reliability of measuring injury by self-reporting, as this method of describing RRI may be affected by subject recall bias.

Measurement of training characteristics

The methods used to collect information on exposure data are very similar. In all studies included in this review, questionnaires, surveys, or self-report diaries were used to collect information on training exposure. In this regard, several authors have concluded that the training exposure may have been estimated or reported incorrectly again due to recall bias., Therefore, the methods used in all studies to measure training exposure by subjective measurements (questionnaires, surveys, diaries) should be taken into careful consideration. Methods that utilize technology such as Global Positioning Systems (GPS) and actual distance recording may provide more valid and reliable information on training volume, frequency, and intensity.

Analysis of training characteristics

Analysis of training characteristics is complex, since one or more training variable may interact with other training variables. In most papers included in the current review, only the crude association between a single training variable and the risk of injury was investigated, without accounting for the confounding or modifying effect of other training variables. Volume and duration are two partially independent variables. Running intensity is dependent on volume and duration, since intensity is volume divided by duration. Since volume, duration, and intensity all affect one another it may be relevant to measure and analyze all three variables. Since it seems likely that the relationship between the exposure variable and RRI may depend on the level of other training variables, future studies should allow for such comparisons. Furthermore, the frequency should be included in the analysis even though it is not directly linked with volume, duration, or intensity. This approach is supported by Buist et al who stated that the increase of running duration, intensity, and frequency should be taken into careful consideration. Hootman et al investigated the relationship between an exposure variable and the risk of RRI while adjusting for other training related variables. However, it was not mentioned which training variables were adjusted for. Walter et al used a better approach by described the training variables which were adjusted for. An increased risk of injury was found among those performing interval training. However, the association was considered unimportant once the result was adjusted for the effect of total training volume. Another example was in the study Marti et al. In this study, running speed was positively related to injury in univariate analysis, but again adjustment for mileage clearly weakened this association. The approaches used by Walter et al and Marti et al are clear examples of authors trying to take into account the interactions between several training variables. It must be emphasized that the analysis of training characteristics should use, to some extent, the same assumption: that training variables are related and affect each other. Based on this, the current approaches used to analyze exposure data in order to investigate the relationship between training characteristics and RRI in a majority of the reviewed articles must be taken into careful consideration when the results are interpreted. In future studies the interaction between running volume, duration, intensity, and frequency must be considered.
Data may also have to be analyzed differently than it has been previously, especially if training variables are measured by GPS or other objective methods. Since data from GPS measurements are extensive they could be analyzed in a variety of ways. For example variability between training sessions or variations within sessions could be analyzed in addition to sudden increases in one or more training variables. Based on their measurements Wen et al stated, that the possibility to examine for sudden increases in training variables was limited. This may be a key point, since it has been suggested that a sudden increase in running duration or intensity can overwhelm the ability for adaptive change, tissue repair, and result in injury. The lack of ability to objectively measure such increases defined as “sudden” may affect the possibility to investigate the relationship between training exposure and RRI, since Jacobs et al reported that one third of those injured described they had changed their training just prior to their injuries. Although it is not possible to examine this statement based on articles included in this review, an interesting focus for future research would be to investigate if the sudden increase in one or more training variables, as suggested by many,,,– is more strongly related to injury than the absolute volume which is currently suggested to be the main contributor to injury.–, It must be emphasized that there is a strong need for future studies regarding RRI with the primary purpose of investigating the link between training characteristics and the development of RRI.

CONCLUSION

Based on the studies reviewed it was not possible to identify which training errors are related to running related injuries. Running experience and injury threshold seem to play a role in the relationship between training characteristics and development of injuries, while volume, duration, intensity, and frequency seem to have a complex interaction with each other which is not accounted for in the majority of the included studies. All training variables should be measured and accounted for when studies on the relationship between training characteristics and injuries are examined in future studies. If methodological limitations can be solved by objectively measuring the training characteristics more studies can be conducted to carefully define training variables and their interactions, and then plan a large scale prospective study or randomized controlled trial to determine whether cause and effect relationships exist.

APPENDIX 1: SEARCH TERMS

(“Running”[Mesh] OR (foot race)) AND (“Exercise”[Mesh] OR exposure OR “Physical Therapy Modalities”[Mesh] OR “Clinical Protocols”[Mesh] OR (regim*) OR program OR programme OR “Healthy People Programs”[Mesh] OR marathon OR marathon OR training OR (training characteristics) OR (running patterns) OR volume OR intensity OR frequency OR speed OR pace OR distance OR mileage) AND (injur* OR syndrome* OR tendin* OR fractur* OR (“pain”[Mesh]) OR fasciitis OR bursitis OR splint* OR tear* OR sprain* OR strain* OR entrapment* OR ostei* OR osteopor* OR osteoa* OR rupture* OR arthros* OR arthri* OR lipoma OR sciatica OR lumbago OR laceration* OR split* OR tenosynovitis OR blister* OR cramp* OR corn OR callus* OR edema* OR sesamoiditis OR ganglion* OR hernia* OR muscle soreness OR delayed onset muscle soreness OR hemorrh* OR ischi* OR neuroma* OR abrasion OR wart* OR mold* OR dislocation* OR damage OR trauma OR displacement OR periostitis) NOT (“addresses”[Publication Type] OR “bibliography”[Publication Type] OR “biography”[Publication Type] OR “case reports”[Publication Type] OR “clinical conference”[Publication Type] OR “comment”[Publication Type] OR “congresses”[Publication Type] OR “dictionary”[Publication Type] OR “directory”[Publication Type] OR “editorial”[Publication Type] OR “festschrift”[Publication Type] OR “government publications”[Publication Type] OR “interview”[Publication Type] OR “lectures”[Publication Type] OR “legal cases”[Publication Type] OR “legislation”[Publication Type] OR “letter”[Publication Type] OR “news”[Publication Type] OR “newspaper article”[Publication Type] OR “retracted publication”[Publication Type] OR “retraction of publication”[Publication Type] OR “review”[Publication Type] OR “scientific integrity review”[Publication Type] OR “technical report”[Publication Type] OR “twin study”[Publication Type] OR “validation studies”[Publication Type] OR pregnancy OR rugby OR soccer OR football OR rheumatoid)

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Relação entre hiperpronação subtalar e as lesões do ligamento cruzado anterior do joelho: revisão de literatura Relationship between subtalar hyperpronation and injuries on the anterior cruciate ligament of the knee: literature review

Autores:

 Rodrigo Scattone da Silva 1
Ana Luisa Granado Ferreira 2
Lívia Maria Veronese 3
Patrícia Driusso 4
Fábio Viadanna Serrão 5
 
Resumo

Introdução: A ruptura do ligamento cruzado anterior (LCA) é uma lesão severa, que resulta em instabilidade funcional e distúrbios articulares degenerativos. Fatores de risco proximais à articulação do joelho têm sido bastante enfatizados na última década, mas pouca atenção tem sido dada para os fatores de risco distais ao joelho. A hiperpronação subtalar (HS) foi sugerida por alguns autores como possível fator de risco às lesões do LCA, mas as evidências da literatura a respeito são escassas e pouco conclusivas. Objetivo: O propósito deste estudo foi realizar uma revisão dos estudos da literatura que avaliaram as alterações de alinhamento da articulação subtalar associadas à lesão do LCA ou associadas a outros fatores de risco Fisioter Mov. 2012 jul/set;25(3):679-88 da Silva RS, Ferreira ALG, Veronese LM, Driusso P, Serrão FV. 680 conhecidos para essa lesão. Materiais e métodos: Foi realizada uma busca em bases eletrônicas (PubMed, MEDLINE, COCHRANE, Web of Science, PEDro, SciELO, LILACS e EMBASE), compreendendo publicações de 1966 até 2011. Resultados e discussão: Foram encontrados nove estudos clínicos considerados pertinentes ao tema. Desses trabalhos, quatro identi􀏐icaram HS em indivíduos com lesão do LCA e um apontou correlação entre HS e outros fatores de risco para lesões do LCA. A não identi􀏐icação de correlação entre essas variáveis nos demais estudos se deve, provavelmente, a diferenças metodológicas nas avaliações. Deve-se ressaltar que a natureza retrospectiva dos estudos encontrados não permite o estabelecimento de causa e consequência nesse contexto. São necessários estudos prospectivos, com mais uniformidade metodológica, para o de􀏐initivo estabelecimento da HS como efetivo fator de risco para as lesões do LCA.

Palavras-chave : Pronação. Articulação talocalcânea. Ligamento cruzado anterior. Articulação do joelho.
 
Abstract

Scattone da Silva[a], Ana Luisa Granado Ferreira[b], Lívia Maria Veronese[c], Patrícia Driusso[d], Fábio Viadanna Serrão[e] [a] Fisioterapeuta, mestre em Fisioterapia pela Universidade Federal de São Carlos (UFSCar), São Carlos, SP - Brasil, e-mail: scattone@fcm.unicamp.br [b] Graduanda em Fisioterapia pela Universidade Federal de São Carlos (UFSCar), São Carlos, SP - Brasil, e-mail: anagranado@live.com [c] Graduanda em Fisioterapia pela Universidade Federal de São Carlos (UFSCar), São Carlos, SP - Brasil, e-mail: livia_veronese@hotmail.com [d] Fisioterapeuta, doutora em Ciências Fisiológicas pela Universidade Federal de São Carlos (UFSCar), professora adjunta do Departamento de Fisioterapia da UFSCar, São Carlos, SP - Brasil, e-mail: pdriusso@ufscar.br [e] Fisioterapeuta, doutor em Fisioterapia pela Universidade Federal de São Carlos (UFSCar), professor adjunto do Departamento de Fisioterapia da UFSCar, São Carlos, SP - Brasil, e-mail: fserrao@ufscar.br [R] Resumo Introdução: A ruptura do ligamento cruzado anterior (LCA) é uma lesão severa, que resulta em instabilidade funcional e distúrbios articulares degenerativos. Fatores de risco proximais à articulação do joelho têm sido bastante enfatizados na última década, mas pouca atenção tem sido dada para os fatores de risco distais ao joelho. A hiperpronação subtalar (HS) foi sugerida por alguns autores como possível fator de risco às lesões do LCA, mas as evidências da literatura a respeito são escassas e pouco conclusivas. Objetivo: O propósito deste estudo foi realizar uma revisão dos estudos da literatura que avaliaram as alterações de alinhamento da articulação subtalar associadas à lesão do LCA ou associadas a outros fatores de risco Fisioter Mov. 2012 jul/set;25(3):679-88 da Silva RS, Ferreira ALG, Veronese LM, Driusso P, Serrão FV. 680 conhecidos para essa lesão. Materiais e métodos: Foi realizada uma busca em bases eletrônicas (PubMed, MEDLINE, COCHRANE, Web of Science, PEDro, SciELO, LILACS e EMBASE), compreendendo publicações de 1966 até 2011. Resultados e discussão: Foram encontrados nove estudos clínicos considerados pertinentes ao tema. Desses trabalhos, quatro identi􀏐icaram HS em indivíduos com lesão do LCA e um apontou correlação entre HS e outros fatores de risco para lesões do LCA. A não identi􀏐icação de correlação entre essas variáveis nos demais estudos se deve, provavelmente, a diferenças metodológicas nas avaliações. Deve-se ressaltar que a natureza retrospectiva dos estudos encontrados não permite o estabelecimento de causa e consequência nesse contexto. São necessários estudos prospectivos, com mais uniformidade metodológica, para o de􀏐initivo estabelecimento da HS como efetivo fator de risco para as lesões do LCA. [P] Palavras-chave: Pronação. Articulação talocalcânea. Ligamento cruzado anterior. Articulação do joelho. [B] Abstract Introduction: Anterior cruciate ligament (ACL) rupture is a severe knee injury, leading to functional instability and degenerative joint disease. Risk factors proximal to the knee joint have been highly emphasized in the last decade, but less attention has been focused on risk factors located distal to the knee. Subtalar hyperpronation (SH) has been suggested by some authors as a possible risk factor for ACL injuries, but the evidences regarding this matter are still scarce and inconclusive. Objective: The purpose of this study was to carry out a review of literature studies that have performed assessments of the subtalar joint alignment associated to ACL injuries or associated to other known risk factors for this injury. Materials and methods: A search in electronic databases (PubMed, MEDLINE, COCHRANE, Web of Science, PEDro, SciELO, LILACS and EMBASE) was performed from 1966 to 2011. Results and discussion: Nine clinical studies were found to be pertinent to this matter. Among these, four studies have identified SH in subjects with ACL injury and one study has found a correlation between SH and other risk factors for ACL injury. The inexistence of correlation between these variables in the other studies is probably due to methodological differences in the assessments. It should be noted that the retrospective nature of the studies found does not allow the establishment of cause and consequence in this context. Prospective studies, with more methodological uniformity, are necessary for the definitive establishment of SH as an effective risk factor for ACL injuries.

Keywords : Pronation. Talocalcaneal joint. Anterior cruciate ligament. Knee joint. risco e dos mecanismos envolvidos na lesão, para que estratégias preventivas e&

1 Fisioterapeuta, mestre em Fisioterapia pela Universidade Federal de São Carlos (UFSCar), São Carlos, SP - Brasil, e-mail: scattone@fcm.unicamp.br
2 Graduanda em Fisioterapia pela Universidade Federal de São Carlos (UFSCar), São Carlos, SP - Brasil, e-mail: anagranado@live.com
3 Graduanda em Fisioterapia pela Universidade Federal de São Carlos (UFSCar), São Carlos, SP - Brasil, e-mail: livia_veronese@hotmail.com
4 Fisioterapeuta, doutora em Ciências Fisiológicas pela Universidade Federal de São Carlos (UFSCar), professora adjunta do Departamento de Fisioterapia da UFSCar, São Carlos, SP - Brasil, e-mail: pdriusso@ufscar.br
5 Fisioterapeuta, doutor em Fisioterapia pela Universidade Federal de São Carlos (UFSCar), professor adjunto do Departamento de Fisioterapia da UFSCar, São Carlos, SP - Brasil, e-mail: fserrao@ufscar.br
Publicada por à(s) Sem comentários:

domingo, 11 de novembro de 2012

Estudo comparativo dos métodos conservador e cirúrgico para tratamento das lesões agudas do tendão do calcâneo




Autores: Marco Túlio CostaI; Jose Soares Hungria NetoII
IMédico Assistente do Grupo de Medicina e Cirurgia do Pé da Santa Casa de Misericórdia de São Paulo
IIConsultor do Grupo de Trauma da Santa Casa de Misericórdia de São Paulo


RESUMO
O tratamento das lesões agudas do tendão do calcâneo ainda permanece controverso. Com o objetivo de estabelecer diretrizes atuais, para o tratamento destas lesões, foi realizada uma revisão da literatura. Nos trabalhos avaliadas foram estudadas 1342 lesões, sendo o tratamento conservador utilizado em 354 lesões e o cirúrgico em 988. A imobilização suropodálica foi a mais utilizada, independentemente do tipo de tratamento. Não houve predomínio de nenhuma técnica cirúrgica, quando utilizado o tratamento cirúrgico. Concluiu-se que: Atualmente, não há, na literatura, um método de tratamento preferencial, conservador ou cirúrgico, que seja consenso entre os autores, o qual possa ser aplicado a todos os pacientes com lesão aguda do tendão do Calcâneo. Atletas de competição devem ser, preferencialmente, tratados com reparação cirúrgica do tendão. O tratamento conservador é o preferencial em pacientes sedentários ou idosos, portadores de doenças que elevem o risco cirúrgico. O tratamento cirúrgico, seguido de movimentação precoce do tornozelo, tem apresentado bons resultados em relação à recuperação funcional do tendão. A imobilização deve ser suropodálica, não sendo necessária a imobilização do joelho tanto no tratamento cirúrgico como no conservador destas lesões. A via de acesso medial é a via preferencial no tratamento cirúrgico, devido à menor probabilidade de lesão do nervo sural.
Descritores: Tendão do calcâneo; Ruptura; Tendões.


INTRODUÇÃO
As lesões do tendão do calcâneo são conhecidas desde o tempo de Hipócrates; estudos sobre elas foram publicados, pela primeira vez por Ambroise Paré, em 1633 apud Cetti et al(1). Entre os tendões, o do calcâneo é, no membro inferior, o que mais freqüentemente se rompe. Maffulli et al.(2) acreditam que a freqüência destas lesões tem aumentado nos dias atuais, devido à busca de um melhor condicionamento físico e ao aumento da prática esportiva por indivíduos de meia idade e idosos.
Embora possam ocorrer em qualquer idade, estas lesões são mais freqüentes entre a terceira e quinta décadas da vida, com predominância evidente no sexo masculino(3,4-6). Parece que a ruptura do tendão do calcâneo ocorre, mais freqüentemente, nos chamados "atletas de final de semana" (5,7).
Existem controvérsias a respeito do tratamento das rupturas agudas do tendão do calcâneo. Há duas tendências quanto ao tratamento: não cirúrgico e cirúrgico (1,5,7-23).
O objetivo do presente estudo é fazer uma análise crítica da literatura, com intuito de reconhecer diretrizes atuais do tratamento das lesões agudas do tendão do calcâneo.

MATERIAIS E MÉTODOS
O material deste trabalho é produto de pesquisa em publicações da literatura científica mundial, publicado entre 1953 e 2000, levantados a partir de pesquisas computadorizadas na Medline, além de pesquisa manual de artigos previamente selecionados, escolhidos por sua relevância científica.
A estratégia de busca, no nosso trabalho, foi executada a partir dos unitermos:
- na língua portuguesa: Aquiles, ruptura (termos existentes na base de dados LILACS);
- na língua inglesa: "Achilles, rupture".
Mediante os resumos obtidos nesta pesquisa, procedemos à leitura dos mesmos e selecionamos os artigos pertinentes. Lidos esses artigos, pesquisamos as referências bibliográficas de cada trabalho cientifico procurando novas referências que fossem importantes e úteis.

RESULTADOS
Encontramos 1378 lesões agudas do tendão do calcâneo, na literatura revisada(1,4,5,7,9-16,19-30). Destas, em 988, o tratamento cirúrgico foi empregado e o tratamento conservador foi o eleito em 390 lesões.
Avaliando com maior detalhe o tratamento conservador, notamos que o gesso mais utilizado foi o suropodálico desde o início do tratamento(1,5,9,10,12,15,30). Alguns autores preferem a imobilização cruropodálica nas primeiras semanas do tratamento(3,11,13). Encontramos, neste universo de 390 lesões tratadas de maneira conservadora, 48 rerrupturas (12,3%) (1,3,9-16,30). O tempo de imobilização variou de cinco a 12 semanas, com predominância de oito semanas de imobilização(9,10,12,13,15,30).
Em relação ao tratamento cirúrgico, não notamos predominância de nenhuma técnica específica de reparação. Quando utilizada imobilização pós-operatória, a imobilização suropodálica a mais comum, com o tempo de imobilização variando entre duas e 10 semanas (1,4,5,9,12,20,24,25,27,29,30). Houve rerruptura em 19 casos, o que corresponde a 1,9% do total de casos tratados com cirurgia, estando, também, incluídos os casos onde foi permitida a mobilidade precoce(26,28). Foram relatados 133 casos (13,5%) que evoluíram com complicações submetidos à cirurgia (rerruptura, distúrbios sensitivos, infecção, aderência) (1,4,5,7,9,14,16,19-24,26-30).

DISCUSSÃO
O tratamento das lesões agudas do tendão do calcâneo tem sido motivo de controvérsia, na literatura, há algum tempo.
Kurtz(8) escreve que Hipócrates associava a lesão deste tendão com febre e morte. No início do século XX, estas lesões eram tratadas com imobilizações gessadas. No entanto, com a melhora de técnicas cirúrgicas e anestésicas, o tratamento cirúrgico ganhou popularidade, sendo o tratamento de escolha nas décadas de 50 e 60(1). Apenas no início dos anos 70, com os trabalhos de Gillies e Chalmers(9) e Lea e Smith(10) , a atenção científica foi voltada, novamente, para o tratamento conservador. Desde então, várias pesquisas foram realizadas, ora demonstrando melhores resultados com o tratamento cirúrgico ora demonstrando melhores resultados com o tratamento conservador.

TRATAMENTO CONSERVADOR
O tratamento conservador é baseado no uso de imobilização gessada até que ocorra a cicatrização do tendão lesado.
Vários autores preferem o tratamento conservador, para as lesões agudas do tendão do calcâneo. Gillies e Chalmers(9), Lea e Smith(10), Keller e Rasmussen(11) escrevem que o tratamento conservador oferece bons resultados. Nistor(5) conclui que tanto o tratamento conservador quanto o cirúrgico podem levar a bons resultados; no entanto o tratamento conservador tem menor morbidade, menor número de queixas no pós-operatório e não necessita de internação. Portanto, deve ser o tratamento de escolha. Garden et al.(12)recomendam o tratamento conservador, para as lesões com diagnóstico nas primeiras 48 horas. Nas lesões com mais de uma semana, o tratamento cirúrgico dá melhores resultados, segundo os autores. Ferrer et al.(13)concluem que, em pacientes acima de 30 anos de idade, com diástase de até 5mm dos cotos com o tornozelo em 20  de flexão plantar, o tratamento conservador apresenta bons resultados. Em todos os casos, o critério para a instituição do tratamento conservador é a mensuração da distância entre os cotos do tendão, através de um exame ultra-sonográfico, com o tornozelo em 20º de flexão plantar. Uma distância menor que 5mm entre os cotos do tendão autoriza o tratamento conservador.
Autores, como Jacobs et al.(14) e Edna(15), após utilizarem o tratamento conservador, não observam bons resultados, principalmente quanto ao índice de re-ruputura, e não consideram o tratamento conservador como o de escolha.

TIPO DE IMOBILIZAÇÃO
Devido à musculatura que compõe o tendão do calcâneo agir não somente sobre articulações do tornozelo e subtalar, mas também na articulação do joelho, alguns autores preferem o gesso cruropodálico, para a imobilização completa destas lesões, no início do tratamento. Keller e Rasmussen(11) e Ferrer et al.(13), utilizam o aparelho gessado cruropodálico, com 45 de flexão do joelho e o tornozelo em posição eqüina, nas primeiras semanas.
A maioria dos autores que utiliza o tratamento conservador, como Cetti et al.(1), Nistor(5) e Lea e Smith(10)recomendam o uso do aparelho gessado suropodálico com o tornozelo mantido na posição eqüina somente nas primeiras semanas de imobilização. Garden et al.(12) comentam que, apesar do uso do gesso cruropodálico ser teoricamente desejável, por neutralizar ação do gastrocnêmio e facilitar a aposição das bordas do tendão lesado, porém, sua análise não revela qualquer relação entre o uso do gesso cruropodálico e melhores resultados. Davis Junior et al.(31) verificam em cadáveres, que uma flexão plantar do tornozelo de 15º a 25º praticamente anula as forças do músculo gastrocnêmio no tendão do calcâneo, independentemente da movimentação do joelho.
Apesar da vantagem teórica da imobilização do joelho, com aparelho gessado cruropodálico, citada por alguns autores, acreditamos que já está claramente definido, tanto por observações em pacientes, como escreve Garden et al.(12) como por experimentos em cadáveres, como os realizados por Davis Junior et al.(31) que a imobilização suropodálica, com o tornozelo mantido nas primeiras semanas, na posição de flexão plantar, em torno de 20º, é suficiente para o tratamento conservador das lesões agudas do tendão do calcâneo.

TEMPO DE IMOBILIZAÇÃO
O tempo de imobilização gessada variou de cinco a 12 semanas nos trabalhos revisados.
A maioria dos autores manteve seus pacientes imobilizados entre seis e oito semanas. Lea e Smith(10) acreditam que são necessárias oito semanas de imobilização e que uma maior incidência de rerruptura está relacionada a um menor período de imobilização que o proposto.
Também, observamos o uso de uma elevação do retropé (salto) de 2,5 cm em média, por mais quatro semanas após a retirada da imobilização gessada, independentemente do uso de gesso cruro ou suropodálico, por grande parte dos autores, para proteção do tendão cicatrizado.

MARCHA COM CARGA
A permissão para carga no membro lesado variou amplamente nos trabalhos pesquisados. Não há um padrão para que seja liberada a carga no membro lesado. Alguns autores permitem carga de imediato e outros preferem manter a membro em repouso por algum tempo. Nistor(5) e Edna(15) permitem carga imediata no membro lesado,. Gillies e Chalmers(9) e Cetti et al.(1) permitem carga total após quatro semanas de tratamento, quando diminuem a posição de flexão plantar inicial do tornozelo,. Ferrer et al.(13) permitem carga somente após seis semanas de tratamento.
A imobilização inicial, em eqüino, parece ser um empecilho para liberação da marcha precoce. A utilização de armações metálicas, utilizadas como saltos, incorporados no gesso pode ser uma alternativa para resolução deste problema.
Apesar disto, parece-nos sensata, a liberação da marcha com carga no membro lesado quando o tornozelo não está mais na posição eqüina, o que facilita a marcha e mantém o membro lesado inicialmente elevado, diminuindo edema local.

RERRUPTURA
A complicação mais comum, no tratamento conservador das lesões do tendão do calcâneo, é a rerruptura. Muitos autores, como Edna(15), após observar 30% de rerruptura nos seus casos, concluem que o tratamento conservador não deve ser o tratamento de escolha para as lesões agudas do tendão do calcâneo. Inglis et al.(16)indicam o tratamento cirúrgico para as rupturas agudas do tendão do calcâneo, após observarem 29% de rerrupturas depois do tratamento conservador. Por outro lado, Garden et al.(12), que não observaram nenhum caso de rerruptura nos 37 pacientes que trataram conservadoramente, tendo iniciado o tratamento nas primeiras 48 horas após a lesão. Keller e Rasmussen(11) observam 5,4% de rerrupturas.
Lea e Smith(10) associam maior incidência de rerruptura com menor tempo de imobilização. Para eles são necessárias oito semanas de imobilização gessada, para diminuir o risco de rerruptura. Mesmo assim, observaram sete (12,7%) casos de rerruptura em 55 casos tratados conservadoramente.
Wills et al.(17) observam 17,7% de rerruptura em revisão de literatura.(40 casos em 226 pacientes tratados). Encontramos 48 casos relatados de rerruptura, após o tratamento conservador, de 390 lesões agudas do tendão do calcâneo (12,3%).
A maioria dos casos de rerruptura parece ocorrer no período logo após a retirada do gesso, quando se permite ao paciente algum tipo de atividade física, porém ainda é necessário observar alguns cuidados. Para Nistor(5) esta "falta de cuidado", após o tratamento conservador, é um fator importante na determinação de incidência de rerruptura, nos casos tratados conservadoramente.
A visibilização da distância entre os cotos do tendão roto, por algum exame de imagem, antes de instituir o tratamento conservador, não foi fato relevante na literatura. Ferrer et al.(13) e Cetti(18) utilizam o exame de ultra-som com este propósito,. Ferrer et al.(13) instituíram o tratamento conservador, quando esta distância foi menor que 5mm no ultra-som, com o tornozelo mantido em 20º de eqüino durante o exame. No entanto, os autores não citam exclusão de nenhum paciente do protocolo de tratamento, por não preencher este pré-requisito para o tratamento conservador. Não encontramos trabalhos que comparem a distância inicial dos cotos do tendão com a incidência de rerruptura na literatura.

TRATAMENTO CIRÚRGICO
O tratamento cirúrgico é realizado apondo-se as bordas do tendão lesado por meio de sutura. Tem sido defendido por muitos autores, como Christensen(3), Mandelbaum et al.(4), Lennox et al.(19) e Cetti e Christensen(20) que acreditam em um melhor resultado funcional após a cirurgia. No entanto, o tratamento cirúrgico também tem suas complicações.
Krueger-Franke et al.(21) comentam que apesar dos bons resultados conseguidos com o tratamento cirúrgico, o alto índice de complicações (15,1%) mostra que novos protocolos de tratamento devem ser pesquisados, assim como o tratamento conservador, a fim de estabelecer o melhor tratamento para estas lesões.
Troop et al.(24) concluíram que a mobilidade precoce apos o tratamento cirúrgico, nos casos de ruptura aguda do tendão do calcâneo, não aumenta o risco de rerruptura em pacientes que colaboram com o tratamento. Eles concluíram, também, que um programa de reabilitação acelerado consegue bons resultados quanto à flexão plantar, à resistência e à força do tendão do calcâneo. A grande questão da mobilidade precoce, nas lesões do tendão do calcâneo, refere-se à rerruptura. Segundo os autores, este risco deve ser avaliado em relação aos benefícios da mobilidade precoce, nestas lesões.

VIA DE ACESSO
Nistor(5) tratou 44 pacientes, com lesão aguda do tendão do calcâneo, com cirurgia, usando ora a via de acesso lateral e ora a via de acesso medial, ambas retilíneas. Observou distúrbios de sensibilidade no nervo sural, em nove pacientes, sendo que, em sete deles a via de acesso utilizada foi a lateral.
Troop et al.(24) e Speck e Klaue(25), também utilizam via de acesso medial, devido à possibilidade de lesão do nervo sural.
Não há dúvidas, na literatura, quanto a via de acesso preferencial no tratamento cirúrgico das lesões do tendão do calcâneo. Devido à possibilidade de lesão do nervo sural com a via lateral, a via de acesso medial é a preferida.

TIPO DE IMOBILIZAÇÃO
Autores como Inglis e Sculco(7), Lennox et al.(19)e Hooker (22) utilizam imobilização inicial cruropodálica no pós-operatório. Hooker(22) utiliza, em alguns casos, gesso suropodálico e não encontra diferenças entre os dois tipos de imobilização no resultado final
A maioria dos trabalhos como Nistor(5), Cetti et al.(1) e Kellam et al.(23) utilizam gesso suropodálico pós-operatório, com o tornozelo sendo imobilizado inicialmente com alguma flexão plantar.
Davis Junior et al.(31) demonstram que é desnecessária a imobilização do joelho. Acreditamos que os resultados deles são válidos, tanto para o tratamento conservador quanto para o tratamento cirúrgico.
Após a retirada da imobilização gessada, a grande maioria dos autores recomenda elevação do retropé (salto) de 2,5 cm, em média, por mais quatro semanas, independentemente se foi usado gesso cruro ou suropodálico.

TEMPO DE IMOBILIZAÇÃO
O tempo de imobilização gessada após o tratamento cirúrgico, foi de no máximo dez semanas, utilizado por Christensen(3). Na maioria dos trabalhos, a imobilização gessada foi mantida de seis a oito semanas(1,5,7,9,12,14,19-25,27,29,30). Quando a imobilização faz-se necessária, preferimos manter o paciente durante oito semanas imobilizado com gesso suropodálico, para diminuir a chance de rerruptura, nas primeiras quatro semanas com o tornozelo em 20  de eqüino e nas outras quatro semanas com o tornozelo na posição neutra. Como demonstrado por Davis Junior et al.(31) é desnecessária a imobilização do joelho, desde que o tornozelo seja imobilizado em 20º de eqüino Após o período de imobilização gessada, consideramos prudente, como vários outros autores, a elevação do retropé por mais quatro semanas. Temos permitido carga no membro inferior lesado, quando trocamos o gesso e o tornozelo é mantido na posição neutra. Apesar de alguns autores permitem carga imediata, a deambulação precoce com o gesso é dificultada pela posição em eqüino do tornozelo. Além disso a elevação do membro inferior lesado nos primeiros dias após a lesão auxilia no tratamento do edema no local da ruptura.

MOBILIDADE PRECOCE
Na busca de melhores resultados funcionais após o tratamento da ruptura do tendão do calcâneo, vários autores iniciaram protocolos com mobilização precoce do tornozelo no pós-operatório. Os efeitos deletérios da imobilização foram descritos por Booth(32): perda de força e redução do volume dos músculos esqueléticos, além de um aumento da fadigabilidade durante o trabalho. A retirada da imobilização, permitindo a mobilidade e a utilização do músculo esquelético seria a maneira de evitar estes danos aos músculos. O uso de imobilizações, que permitam movimentação articular restrita, pode ajudar a diminuir a atrofia muscular.
Mandelbaum et al.(5), Speck e Klaue(25), Carter et al.(26), Cetti et al.(27) e Solveborn e Moberg(28), utilizam um protocolo de mobilidade precoce no pós-operatório e não observam nenhum caso de rerruptura.
Troop et al.(24) observam bons resultados, em todos os pacientes tratados com mobilidade precoce no pós-operatório. A grande questão da mobilidade precoce, nas lesões do tendão do calcâneo, refere-se a rerruptura. Segundo autores, o confronto risco versus benefício deve ser avaliado em relação à mobilidade precoce ao longo do tratamento destas lesões. Afirmam que a mobilidade precoce, nos casos de ruptura aguda do tendão do calcâneo não aumenta o risco de rerruptura, em pacientes que colaboram com o tratamento. Concluem também que, um programa de reabilitação acelerado consegue bons resultados quanto à flexão plantar, à resistência e à força do tendão do calcâneo.
Atualmente, a possibilidade de mobilização precoce do tornozelo e do pé parece ser a principal vantagem do tratamento cirúrgico sobre o tratamento conservador. No entanto, são necessárias a conscientização e a colaboração total do paciente, pois, apesar de alguns protocolos de tratamento permitirem a carga total precoce, nenhum permite dorsiflexão máxima e irrestrita do tornozelo; isto poderia aumentar a incidência de rerruptura do tendão suturado. Os resultados, quanto à mobilidade do tornozelo e à força muscular, após estes protocolos de tratamento, são dados como excelentes por todos os autores.

RERRUPTURA
Embora não tenha sido usado um protocolo de tratamento cirúrgico semelhante nos diversos trabalhos, observamos uma incidência geral de 1,9% de rerrupturas, nos casos de lesão aguda do tendão do calcâneo tratados com cirurgia (19 casos em 988 tendões submetidos a tratamento cirúrgico).
Krueger-Franke et al.(21) observam 2,5% de rerrupturas, em 122 tendões tratados com cirurgia. Comentam que, em rupturas muito próximas da inserção do tendão no calcâneo (a menos de dois centímetros), observam 6,1% de rerrupturas. Discutem que esta incidência alta de rerrupturas, neste tipo de lesão, pode estar associada a uma maior dificuldade na técnica de reparação cirúrgica, já que o coto distal do tendão é muito pequeno. Recomendam o uso, nestes casos, de alguma técnica de reforço da sutura, como o uso do tendão do plantar delgado como reforço, ou de uma refixação transóssea do tendão.

OUTRAS COMPLICAÇÕES
Nistor(5) observa em 44 pacientes com lesão aguda do tendão do calcâneo, tratados por cirurgia, dois casos de infecção profunda, resolvidos com tratamento clínico. Observa também, outras 29 complicações, chamadas pelo autor de complicações secundárias. Foram 20 casos de aderências entre tendão e pele e nove casos de distúrbios sensitivos do nervo sural. Associa os distúrbios sensitivos do nervo sural ao uso da via de acesso lateral. Cita também como complicação, casos de necrose de pele e do tendão, não observados por ele. Wills et al.(17) descrevem incidência geral de 20% de complicações com o tratamento cirúrgico. No entanto, relatam que o índice de complicações tem diminuído nos trabalhos mais recentes. Krueger-Franke et al.(21) encontram 15,1% de complicações com o tratamento cirúrgico, sendo 3,6% casos de infecção na ferida operatória. Leppilahti et al.(29) relatam 26,7% de complicações com o tratamento cirúrgico em 101 tendões submetidos a tratamento cirúrgico, incluindo seromas, eczemas, hipertrofia da cicatriz, desicência de sutura, além de rerruptura, infecção, distúrbios sensitivos e aderências na cicatriz.
Avaliando o número de rerrupturas, distúrbios sensitivos, aderências na cicatriz cirúrgica e infecção, encontramos 133 relatos em 988 tendões (13,5%) submetidos ao tratamento cirúrgico.
É interessante notar que a incidência destas complicações no tratamento cirúrgico (13,5%) é semelhante a incidência de rerruptura no tratamento conservador (12,3%).
Parece-nos que, ainda não há um tratamento universalmente aceito, como a melhor opção para as lesões do tendão do calcâneo. Tanto o tratamento cirúrgico quanto o tratamento conservador têm seus defensores, assim como seus críticos.
Não levando em conta a possibilidade de mobilidade precoce, após a reparação cirúrgica, o tempo e o tipo de imobilização são praticamente os mesmos nos dois tipos de tratamento, o que deixa dúvidas quando se discute com o paciente com lesão do tendão do calcâneo, sobre as possíveis formas de tratamento. Se a imobilização e o período de tempo necessário para a utilização da mesma são iguais nos dois tratamentos, que vantagens tão superiores tem o tratamento cirúrgico, considerando-se que a possibilidade de complicações é praticamente a mesma? Será que somente a vantagem teórica, segundo alguns autores, de maior retorno da força de flexão plantar, da potência e da resistência justificam os riscos de uma cirurgia? Qual é a força de flexão plantar necessária para uma marcha clinicamente normal?
Quando utilizado o tratamento conservador, Ferrer et al.(13) e Cetti(18) indicam o uso de algum método não invasivo (o ultra-som foi utilizado pelos dois) de identificação das bordas rotas do tendão, as mesmas encontram-se em contato após a flexão plantar do tornozelo que será mantida na imobilização inicial A não adoção de tal conduta, causa a impressão que, ou a distância das bordas do tendão lesado não influenciam o tratamento conservador ou estas bordas nunca estão separadas por uma distância maior, do que aquela mínima necessária para a instituição do tratamento conservador, segundo Ferrer et al.(13), 5mm.
Após o excelente trabalho de Davis Junior et al.(31), na nossa opinião, não há mais dúvidas, quanto à imobilização a ser utilizada nestas lesões, já que, a imobilização do tornozelo em 20º de eqüino, praticamente anula o efeito dos gêmeos no tendão quando se mobiliza o joelho.
Uma grande esperança, para os que defendem o tratamento cirúrgico, é a possibilidade de movimentação precoce, logo após a cirurgia(26,28). O resultado deste protocolo de tratamento parece-nos promissor; no entanto, são necessários colaboração e entendimento totais do paciente com relação ao tratamento. Não podemos, portanto, aplicá-lo indiscriminadamente, em todos os pacientes.
Esta revisão da literatura, mostrou que, não há como padronizar um método de tratamento, para todos os pacientes com lesão aguda do tendão do calcâneo. O tratamento preferencial para atletas de competição é o cirúrgico, pois, teoricamente, segundo Inglis et al.(16), ele leva a uma melhor recuperação do tendão em relação ao torque, à resistência e à potência musculares(17). Para sedentários, idosos, com lesão aguda do tendão do calcâneo, e os portadores de doenças que tornem o risco cirúrgico alto, o método conservador é o preferencial.
A dúvida quanto a qual método de tratamento devemos utilizar, está naqueles pacientes que não se encaixam em nenhum destes dois grupos. Eles constituem, exatamente, a maioria dos indivíduos, que sofrem ruptura espontânea deste tendão. Com base em revisão da literatura e com base nos pacientes tratados pelo autor, utilizando os dois métodos, acreditamos que, atualmente, a melhor abordagem seja explicar ao doente o prognóstico, as possíveis complicações, os riscos e os benefícios das duas possibilidades de tratamento, deixando que o próprio paciente escolha o método de tratamento que melhor lhe convenha, que melhor adapte-se à sua vida diária e às suas expectativas. Tornamos, assim, o paciente um aliado no tratamento (seja este cirúrgico ou conservador), disposto a colaborar, a ajudar durante todo o processo, evitando possíveis complicações e facilitando uma melhor recuperação funcional do membro lesado.

CONCLUSÕES
1. Atualmente, não há, na literatura, um método de tratamento preferencial, conservador ou cirúrgico, que seja consenso entre os autores, para que possa ser aplicado a todos os pacientes com lesão aguda do tendão do calcâneo.
2. Atletas de competição devem ser, preferencialmente, tratados com reparação cirúrgica do tendão e mobilização precoce do tornzelo.
3. O tratamento conservador é o preferencial em pacientes sedentários ou idosos, portadores de doenças que elevam o risco cirúrgico.
4. O tratamento cirúrgico, seguido de movimentação precoce do tornozelo tem apresentado bons resultados em relação à recuperação funcional do tendão.
5. A imobilização deve ser suropodálica, não sendo necessária a imobilização do joelho, tanto no tratamento cirúrgico como no conservador destas lesões.
6. A via de acesso medial é a via preferencial no tratamento cirúrgico, devido à menor probabilidade de lesão do nervo sural.

REFERÊNCIAS BIBLIOGRÁFICAS
1. Cetti R, Christensen S, Ejsted R, Sen NM, Jorgensen U. Operative versus nonoperative treatment of achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. 1993; 21:791-9.        [ Links ]
2. Maffulli N, Barrass V, Ewen SW. Ligth microscopic histology of achilles tendon ruptures. a comparision with unruptured tendons. Am J Sports Med. 2000; 28:857-63.        [ Links ]
3. Christensen IB. Rupture of the achilles tendon: analysis of 57 cases. Acta Chir Scand. 1953; 106: 50-60.        [ Links ]
4. Mandelbaum BR, Myerson MS, Forster R. Achilles tendon ruptures: a new method of repair, early of motion, and functional rehabilitation. Am J Sports Med. 1995; 23:392-5.        [ Links ]
5. Nistor L. Surgical and non-surgical treatment of achilles tendon rupture: A prospective randomized study. J Bone Joint Surg Am. 1981; 63:394-9.        [ Links ]
6. Lieberman JR, Lozman J, Czajka J, Dougherty J. Repair of achilles tendon ruptures with dacron vascular graft. Clin Orthop Relat Res. 1988; 234:204-8.        [ Links ]
7. Inglis AE, Sculco TP. Surgical repair of ruptures of tendon achillis. Clin Orthop Relat Res. 1981; 156:160-9.        [ Links ]
8. Kurtz RC, Almeida AL, Apfel MR, Elias N, Mesquita KC. Cicatrização nas lesões agudas do tendão calcâneano. Estudo experimental comparativo entre tratamento conservador e cirúrgico. Rev Bras Ortop. 1996; 31:857-61.        [ Links ]
9. Gillies H, Chalmers J. The management of fresh ruptures of the tendon achillis. J Bone Joint Surg Am. 1970; 52:337-43.        [ Links ]
10. Lea RB, Smith L. Non-surgical treatment of tendon achilles rupture. J Bone Joint Surg Am. 1972; 54:1398-407.        [ Links ]
11. Keller J, Rasmussen TB. Closed treatment of achilles tendon rupture. Acta Orthop Scand. 1984; 55:548-50.        [ Links ]
12. Garden DG, Noble J, Chalmers J, Lunn P, Ellis J. Rupture of the calcaneal tendon: Early and late management. J Bone Joint Surg Br. 1987; 69:416-20.        [ Links ]
13. Ferrer MA, Ferrer LA, Filgueira EG, Delazzari RF, Alencar EA Jr, Martins FA. Lesão do tendão do calcâneo: tratamento conservador. Rev Bras Ortop. 2000; 35:290-4.         [ Links ]
14. Jacobs D, Martens M, Audekercke RV, Mulier JC, Mulier FR. Comparision of conservative and operative treatment of achilles tendon rupture. Am J Sports Med. 1978; 6:107-12.        [ Links ]
15. Edna T. Non-operative treatment of achilles tendon ruptures. Acta Orthop Scand. 1980; 51:991-3.        [ Links ]
16. Inglis AE, Scott N, Sculco TP, Patterson AH. Ruptures of the tendon achillis. An objeticve assessment of surgical and non-surgical treatment. J Bone Joint Surg Am. 1976; 58:990-3.        [ Links ]
17. Wills CA, Washburn S, Caiozzo V, Prietto CA. Achilles tendon rupture: a review of the literature comparing surgical versus nonsurgical treatment. Clin Orthop Relat Res. 1986; 207: 156-63.        [ Links ]
18. Cetti R. Rupture of the achilles tendon. Operative vs. nonoperative options. Foot Ankle Clin. 1997; 2:501-19.        [ Links ]
19. Lennox DW, Wang GJ, McCue FC, Stamp GW. The operative treatment of achilles tendon injuries. Clin Orthop Relat Res. 1980; 148:152-5.        [ Links ]
20. Cetti RE, Christensen S. Surgical treatment under local anesthesia of achilles tendon rupture. Clin Orthop Relat Res. 1983; 173:204-8.        [ Links ]
21. Krueger-Franke M, Siebert CH, Scherzer S. Surgical treatment of ruptures of the achilles tendon: a review of long-term results. Br J Sports Med. 1995; 29:121-5.        [ Links ]
22. Hooker CH. Rupture of the tendon calcaneus. J Bone Joint Surg Br 1963; 45:360-4.         [ Links ]
23. Kellam JF, Hunter GA, McElwain MB. Review of the operative treatment of achilles tendon rupture. Clin Orthop Relat Res. 1985; 201:80-3.        [ Links ]
24. Troop RL, Losse GM, Lane JG. Robertson DB, Hastings PS, Howard ME. Early motion after repair of achilles tendon ruptures. Foot Ankle Int. 1995;16:705-9.        [ Links ]
25. Speck ME, Klaue K. Early full weight bearing and functional treatment after surgical repair of acute achilles tendon rupture. Am J Sports Med. 1998; 26:789-93.        [ Links ]
26. Carter TR, Fowler PJ, Blokker C. Functional postoperative treatment of achilles tendon repair. Am J Sports Med. 1992; 20:459-62.        [ Links ]
27. Cetti R, Henriksen LO, Jacobsen KS. A new treatment of ruptured achilles tendons. a prospective randomized study. Clin Orthop Relat Res. 1994; 308:155-65.        [ Links ]
28. Solveborn SA, Moberg A. Immediate free ankle motion after surgical repair of acute achilles tendon ruptures. Am J Sports Med. 1994; 22:607-10.        [ Links ]
29. Leppilahti J, Forsman K, Puranen J, Orava S. Outcome and prognostic factors os achilles rupture repair using a new scoring method. Clin Orthop Relat Res. 1998; 346:152-61.        [ Links ]
30. Nestorson J, Movin T, Möller M, Karlsson J. Function after achilles tendon rupture in the elderly. 25 patients older than 65 years followed for 3 years. Acta Orthop Scand. 2000; 71:64-8.        [ Links ]
31. Davis WL Jr, Singerman R, Labropoulos PA, Victoroff B. Effect of ankle and knee position on tension in the achilles tendon. Foot Ankle Int. 1999; 20:126-31.        [ Links ]
32. Booth FW. Physiologic and biochemical effects of immobilization on muscle. Clin Orthop Relat Res. 1987; 219:15-20.        [ Links ]


 Endereço para correspondência:
Rua Cesário Mota Jr. n. 112 - Vila Buarque
São Paulo – SP - CEP: 01224-000
Email: tuliom@uol.com.br

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quarta-feira, 7 de novembro de 2012

3D Spine simulator

http://base.chiromatrix.com/3d_spine/nerve_chart/index.htm
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sexta-feira, 2 de novembro de 2012

Guidelines for the Physiotherapy management of older people at risk of falling


©AGILE: Chartered Physiotherapists working with Older People
Produced by the AGILE Falls guidelines working group:
Victoria Goodwin & Louise Briggs
August 2012


Since the publication of the ‘Guidelines for the rehabilitative management of elderly people who have fallen’1  there has been a wealth of new research evidence,  national and  international guidelines relating to the prevention of falls in older people. 
This update to the guidelines is intended to provide a physiotherapy focussed summary of  the current evidence and to supplement Chartered Society of Physiotherapy and AGILE  Standards of Practice.  
Evidence supports the provision of physiotherapy interventions, such as exercise, as part of  a uni-professional service, or, as part of a multi-disciplinary team, undertaking multifactorial assessments and tailored interventions.  


Practice points to consider:

• Establish the extent to which older people and their carers are able to participate in  a falls prevention programme. 

• Establish baselines of appropriate outcome measures as part of a pre-intervention  assessment, against which ongoing or post-interventions outcome scores can be  compared. This will enable an evaluation of the impact of any interventions, taking  into account other plausible explanations for observed changes over time. 
  
• Patient goal setting (as opposed to therapy goals)  should form part of any rehabilitation programme. Short and longer term SMART goals should be identified  (Specific, Measurable, Achievable, Realistic, Timed). 

• Physiotherapists should employ strategies for  o motivating older people to actively participate in rehabilitation programmes, and  o promoting adherence, whilst taking into consideration patient beliefs, 
attitudes and preferences 2
. 
• When planning falls prevention programmes, supplementary interventions for bone  health should also be considered for those older people at risk of fragility fracture, such as bone loading exercises, nutrition and medication. This may involve other members of the multi-disciplinary team or fracture liaison service.  

• The provision of mobility aids should not be undertaken in isolation and should always form part of a broader rehabilitation programme including strength and balance training.  

• Where current evidence for the effectiveness of interventions is inconclusive or absent, physiotherapists should make clinical decisions relating to the care of an individual patient based upon the best available evidence, in conjunction with contextual factors and information obtained during  subjective and objective assessment of the individual.

Aim 1: To prevent falls


Assessment including outcome measurement 
Older people should be routinely asked whether they have fallen in the past year and asked 
about the frequency, context and characteristics of any falls 2.
  
Management 

In a Cochrane systematic review, multi-component exercise programmes (home and group delivered) and Tai Chi have been found to reduce falls among community-dwelling older people 3.
 Exercise programmes may be delivered as a single  intervention or as part of a multi-factorial intervention. Programmes should be  delivered by qualified health  professionals or exercise professionals, tailored to the individual, and, should include  regular review, progression and adjustment of the exercise prescription as appropriate 4.  
Systematic reviews by Sherrington and colleagues regarding exercise interventions to  reduce falls reported the most effective programmes included a high balance challenge,  used a higher dose of exercise (50 hours- roughly twice a week for six months) and did not  include a walking programme 5;6. 
The effectiveness of exercise interventions for preventing falls among people with stroke 7 and Parkinson’s disease 8 is inconclusive. Neither exercise nor multi-factorial interventions appear to be effective at reducing falls among people with cognitive impairment 4.
In nursing care facilities, the effectiveness of exercise interventions is uncertain although supervised  exercise programmes are effective in sub-acute hospital settings 9. 
Multi-factorial interventions (which may include exercise) appear to be effective at reducing hospital falls and may be effective with people in nursing homes 9


Key messages

• Assess falls history over the past year 
• Exercise interventions can be delivered as a single intervention or as part of a multifactorial intervention 
• Exercise programmes to reduce falls should be high dose (> 50 hours over 6  months) 
• Exercise programmes to reduce falls should have a high balance challenge  component 

.  

Aim 2: To improve the older person’s ability to withstand threats to  their balance

Balance impairment is a major risk factor for falls among older people and those with long 
term conditions, such as stroke or Parkinson’s disease 10;11. 

Assessment including outcome measurement 

Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance 4.
 Assessment should identify risk factors relating  to balance and mobility limitations, such as muscle strength and gait, and establish which factors are  modifiable with exercise or rehabilitation interventions.
There are a wide range of outcome measures for assessing balance. When selecting an  outcome measure, consideration should be taken in relation to the properties of the measure (reliability, validity, sensitivity to change).  
Measures you may consider include: 

• Berg Balance Scale 
• Timed Up and Go Test 
• Performance-Orientated Mobility Assessment  
• 180 degree turn 
• Four-square step test  

Management  

A recent Cochrane systematic review 12 examining exercise interventions to improve balance among older people reported exercise interventions  that included: (a) gait, balance, coordination and function training; (b) strength training; (c) three dimensional training e.g. 
dance, tai chi; and (d) mixed training were beneficial in relation to balance outcomes. The 
most effective programmes involved dynamic exercise programmes that ran three times 
weekly training for three months.  

Key messages

• Use appropriate reliable and valid outcome measures
• Include exercise components for gait, balance, coordination and function 
• Include strength training and three dimensional activities 
• Ensure balance training is sufficiently dynamic 


Aim 3: To prevent the consequences of a long lie 

Up to half of non-injured fallers are unable to get up again 13;14. The inability to get up from  the floor independently following a fall is associated with subsequent serious fall-related injury 15;16 and increased mortality 14. The consequences of a long lie on the floor (> 1 hour)  include pressure sores, hypothermia and dehydration and increased risk of admission to  hospital with a subsequent fall, or moving into long term care 17. In a national UK audit only  4% of fallers were taught how to get up again 18
. 
Assessment including outcome measurement 

Older people and their carers should be asked: 
• If they are able to get up from the floor following a fall; 
• How they move around on the floor, and keep warm; 
• How they are able to get help. 
Those that report they are able to get up should be observed doing so. 

Management with supporting evidence (including quality of evidence) 

There is some evidence that teaching and practicing how to get up from the floor is  acceptable to older people and can be successful 19;20.

Key messages

• Ask all older people if they are able to get up from the floor following a fall 
• Check that older people have a strategy to get help if they fall and are unable to rise 
• Teach and practice how to get up from the floor, when possible   


Aim 4: To optimise confidence and reduce fear of falling

Fear of falling affects many older people, including those that have not experienced a fall.  This can lead to activity avoidance, loss of independence and reduced quality of life, and is  associated with an increased risk of falling. These psychological factors can be more disabling and have a greater impact on function than the fall itself and should therefore be an important consideration in rehabilitation programmes.   

Assessment including outcome measurement 

Assessment should identify fall-related psychological factors that impact on confidence, activity restriction and participation. An appropriate outcome measure should be used such as the Falls Efficacy Scale (FES), FES - International (FES-I) or the Short FES-I. Each of these has been found to be a valid and reliable measure with cognitively intact older people and those with mild to moderate cognitive impairment. These measures are also responsive to change following interventions.  
Considerations when selecting a measure should include: 

• How the measure will be administered (self-completed or by interview) as this will  impact upon response rates.   

• Also, both the FES and the Short FES-I have been reported to have ceiling effects with more active older people. 

Management with supporting evidence (including quality of evidence) 

There is high quality evidence from two systematic  reviews supporting the benefits of 
interventions to improve confidence and reduce fear of falling
21;22. Effective interventions are: exercise (including Tai Chi), hip protectors and multi-factorial falls prevention programmes.  

Key messages

• Assess for fall-related psychological factors 
• Use an appropriate outcome measures such as the FES-I 
• Consider interventions such as exercise and Tai Chi  




Reference List 

 (1)  Simpson JM, Harrington R, Marsh N. Managing falls among elderly people. Physiotherapy 1998; 84:173-177. 

 (2)  National Institute for Health and Clinical Excellence. Falls: The assessment and  prevention of falls in older people. CG21. 2004. London, Royal College of Nursing.  

 (3)  Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG et al. 
Interventions for preventing falls in older people living in the community (Review).  Cochrane Database of Systematic Reviews 2009;(2). 

 (4)  American Geriatrics Society and the British Geriatrics Society. Clinical practice  guideline: Prevention of falls in older persons. American Geriatrics Society [ 2010  [cited 2010 Apr. 8]; Available from: 
URL:www.americangeriatrics.org/education/prevention_of_falls.shtml

 (5)  Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JCT. Effective  exercise for the prevention of falls: a systematic review and meta-analysis. Journal of  the American Geriatrics Society 2008; 56:2234-2243.

 (6)  Sherrington C, Tiedemann A, Fairhall N, Close JCT, Lord SR. Exercise to prevent falls in  older adults: an updated meta-analysis and best practice recommendations. N S W Public Health Bull 2011; 22(4):78-83. 

 (7)  Batchelor F, Hill K, Mackintosh S, Said C. What works in falls prevention after stroke? 
Stroke 2010; 41(8):1715-1722. 

 (8)  Goodwin VA, Richards SH, Taylor RS, Taylor AH, Campbell JL. The effectiveness of  exercise interventions for people with Parkinson's disease: a systematic review and meta-analysis. Movement Disorders 2008; 23:631-640.

 (9)  Cameron ID, Murray GR, Gillespie LD, Robertson MC, Hill KD, Cumming RG et al.  Interventions for preventing falls in older people in nursing care facilities and hospitals. Cochrane Database of Systematic Reviews 2010;(1). 

 (10)  Ashburn A, Stack E, Ballinger C, Fazakarley L, Fitton C. The circumstances of falls among people with Parkinson's disease and the use of falls diaries to facilitate reporting. Disability and Rehabilitation 2008; 30:1205-1212. 

 (11)  Lamb SE, Ferrucci L, Volapto S, Fried LP, Guralnik JM. Risk factors for falling in homedwelling older women with stroke. Stroke 2003; 34:494-501. 

 (12)  Howe TE, Rochester L, Neil F, Skelton DA, Ballinger C. Exercise for improving balance  in older people. The Cochrane Database of Systematic Reviews 2011;(11). 


(13)  Skelton D, Dinan SM, Campbell M, Rutherford OM. Tailored group exercise (Falls Management Exercise - FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age Ageing 2005; 34(6):636-639. 

 (14)  Tinetti ME, Liu WL, Claus EB. Predictors and prognosis of inability to get up after falls  among elderly persons. Journal of the American Medical Association 1993; 269:65-70. 

 (15)  Bergland A, Wyller FB. Risk factors for serious fall-related injury in elderly women living at home. Injury Prevention 2004; 10:308-313.

 (16)  Bergland A, Laake K. Concurrent and predictive validity of "getting up from lying on the floor". Aging Clinical and Experimental Research 2005; 17:181-185. 

 (17)  Fleming J, Brayne C. Inability to get up after falling, subsequent time on floor, and summoning help: prospective cohort study in people over 90. BMJ 2008; 337. 

 (18)  Goodwin V, Martin FC, Husk J, Lowe D, Grant R, Potter J. The national clinical audit of falls and bone health - secondary prevention of falls and fractures: a physiotherapy perspective. Physiotherapy 2010; 96(1):38-43. 

 (19)  Hofmeyer MR, Alexander NB, Nyquist LV, Medell JL, Koreishi A. Floor-Rise Strategy Training in Older Adults. Journal of the American Geriatrics Society 2002; 50(10):1702-1706. 

 (20)  Reece AC, Simpson JM. Preparing older people to cope after a fall. Physiotherapy 1996; 82:227-235. 

 (21)  Rand D, Miller WC, Yiu J, Eng JJ. Interventions for addressing low balance confidence in older adults: a systematic review and meta-analysis. Age Ageing 2011; 40(3):297-306. 

 (22)  Zijlstra GAR, van Haastregt JCM, van Rossum E, van Eijk JTM, Yardley L, Kempen GIJM. Interventions to reduce fear of falling in community-living older people: a systematic review. Journal of the American Geriatrics Society 2007; 55:603-615. 







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quarta-feira, 31 de outubro de 2012

O futuro da Fisioterapia

  1. Sistemas de marcha "sustentada"
São variados, e têm como finalidade permitir um retorno mais rápido e seguro à marcha/corrida por parte dos pacientes. O último funciona com um sistema pneumático que diminui a densidade do ar, "diminuindo" assim o peso do corpo do paciente.





Utilização de imagem de ultra-som em tempo real
A ecografia é uma excelente ferramenta de diagnóstico dos tecidos moles (músculos, tendões, ligamentos). Apesar do seu potencial, ainda é pouco utilizada na prática clínica de fisioterapia. No entanto, a sua utilização permitiria a visualização em tempo real do estado das estruturas afectadas e o impacto que o tratamento seleccionado provocou nessas mesmas estruturas.




Plataformas de força
A reabilitação do equilíbrio e o treino proprioceptivo assumem uma preponderância inegável na abordagem terapêutica de um fisioterapeuta. As plataformas de forças são um óptimo aliado quando toca a envolver o paciente na sua própria reabilitação, sendo que hoje em dia existem soluções simples e funcionais, como o caso da consola Wii.



Sistemas de marcha assistida
Este é o tipo de inovação que provavelmente terá de esperar alguns anos até ver numa clínica perto de si, no entanto a verdade é que poderá assumir um papel preponderante, sobretudo em lesões do sistema nervoso.

Autor : http://fisioterapiajoaomaia.blogspot.pt



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terça-feira, 30 de outubro de 2012

Jornada ERP Lean da Embraer

Autor: Alexandre Baulé 
Publicado: 27/09/2012
A Embraer é a terceira maior produtora de jatos comerciais no mundo. A perturbação econômica desde 2008 apresentou desafios difíceis para a indústria de aeronaves, e a Embraer respondeu com um agressivo programa de excelência empresarial. Baseado nas práticas lean, o programa conquistou fortes melhorias em todas as funções do negócio.
A organização de TI da Embraer participou do esforço, já que quase todos os eventos de kaizen, particularmente os relacionados às atividades administrativas (por exemplo, engenharia, cadeia de suprimentos, apoio ao cliente), tinham o envolvimento significativo da TI. A fim de apoiar a transformação lean na empresa toda, a TI teve que se reinventar também. Além de auxiliar outras unidades de negócio, a TI aplicou os princípios lean a seu próprio desenvolvimento e operações, estabelecendo uma organização celular orientada pelo fluxo de valor. O maior desafio para a TI da Embraer foi mudar sua estrutura de custos, que era de aproximadamente 70% para manutenção e apenas 30% para crescimento e inovação. Essa lacuna (gap) precisava mudar para apoiar metas de crescimento estratégico, mas aumentar o orçamento gera da TI não era uma opção.
Já que aproximadamente 50% dos gastos com manutenção recorrente estavam relacionadas ao ERP, essa foi a primeira meta de melhoria na qual nos focamos. A Embraer tinha investido em um ERP de arquitetura centrada, confiando em um único fornecedor de ERP tier-one. Mas para uma empresa em nicho no mercado aeronáutico de alta tecnologia e indústria de defesa, a inovação da TI, agilidade e flexibilidade são alicerces que não podem ser deixadas a um terceiro. Para responder às necessidades específicas da indústria, um grande nível de customização era necessário, tornando o ambiente ERP caro, lento e inflexível para responder às mudanças e, até certo ponto, menos confiável.
Para melhorar essa situação, uma estratégia de três níveis foi desenvolvida. Primeiro, mudamos para uma arquitetura Java Enterprise Edition-layered, usando a modelagem de processo de negócio baseado no Enterprise Service Bus software por SOA – interface/interoperabilidade (baixo acoplamento). A forte arquitetura aberta e projetada de soluções centradas no processo capacitou o uso de software de código aberto, o que nos ajudou a alterar a estrutura monolítica do ERP, inovando e usando o melhor software dos sistemas de manufatura, gestão do ciclo de vida do produto, gestão do relacionamento com os clientes e a gestão da cadeia de suprimentos, entre outros. Esse investimento aumentou a funcionalidade ao mesmo tempo em que reduziu o custo total de propriedade.
Segundo, entramos em negociação com nosso fornecedor de ERP, esperando revisar nosso contrato para melhor alinhar com nossas novas necessidades de negócio. Apesar de algumas melhorias nesta área terem sido alcançadas, elas ainda estão muito abaixo das metas que estávamos esperando.
Terceiro, diversificamos nossas parcerias de ecossistema do ERP. Aqui, atingimos sucesso tremendo, já que foi possível reduzir drasticamente os custos de manutenção enquanto melhoramos os níveis de serviço. O maior acordo de manutenção e apoio com o fornecedor ERP foi encerrado e um novo contrato com um terceiro foi estabelecido com termos e condições muito melhores. Como resultado desses esforços, nos últimos três anos, nossos custos de manutenção da TI foram reduzidos em aproximadamente 20% enquanto nossos níveis de serviço melhorariam mais de 10% no tempo médio para prover soluções de TI, e a disponibilidade dos sistemas melhoraram mais de 3%.
Alexandre Baulé
Vice-presidente de Sistemas de Informação da Embraer
Fonte: BELL, Steven. Run Grow Transform. Boca Raton: CRC Press, 2012.
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