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SÃO PAULO
2013
2
SÃO PAULO
2013
FICHA CATALOGRÁFICA
BC-FCMSCSP/70-13
DEDICATÓRIA
Dedico aos meus pais, pelo incansável apoio e incentivo, que com carinho e amor
iluminaram meu caminho. A minha esposa e sogra que sempre com inspiração e
carinho me apóiam em todos os momentos mais difíceis, a todos que torcem e me
apóiam o tempo todo. Ao meu irmão que ensina a viver através de sonhos.
Agradeço a DEUS a benção e o privilégio de tê-los em minha vida.
"Emprega maior tempo no aperfeiçoamento de ti mesmo, e nenhum tempo em
criticar os outros"
(Carlos Gracie)
AGRADECIMENTOS
1- INTRODUÇÃO................................................................................................. 1
2- OBJETIVOS..................................................................................................... 4
3- MÉTODOS ..................................................................................................... 6
3.1 – Artigo 1 :
Campo eletromagnético pulsado e exercícios em pacientes com síndrome do
impacto do ombro: ensaio clínico controlado.
3.1.1 Texto enviado para publicação para JARCET, versão em
português.................... 7
3.2.2 Texto enviado para publicação para JARCET, versão em inglês.........19
3.2 – Artigo 2 :
Campo eletromagnético pulsado em pacientes com síndrome do impacto do
ombro: em estudo duplo-cego, randomizado controlado.
3.2.1 Texto enviado para publicação para APMR, versão em
português....................32
3.2.2 Texto enviado para publicação para APMR, versão em inglês............ 56
4- CONSIDERAÇÕES FINAIS............................................................................ 76
5- REFERÊNCIAS BIBLIOGRÁFICAS................................................................ 78
6- FONTES CONSULTADAS.............................................................................. 81
7- ANEXOS........................................................................................................ 83
7.1 – Anexo 1: Email de aceite JARCET........................................................ 84
7.2 – Anexo 2: Email de submissão APMR ................................................... 85
7.3 – Anexo 3: Autorização Comitê de Ética.................................................. 86
7.4 – Anexo 4: Carta de solicitação de troca de titulo CEP........................... 87
7.5 – Anexo 5: Normas das Revistas............................................................. 88
7.5.1 - The Journal of Applied Research....................................................... 88
7.5.2 - Archives of Physical Medicine and Rehabilitation............................. 90
1. INTRODUÇÃO
2
1. INTRODUÇÃO
2. OBJETIVOS
5
2. Objetivos
3. MÉTODOS
7
3. Métodos
CONTROLADO.
Diego Galace de Freitas (PT, MSc)1, Renan Monteiro de Lima (PT, candidato
MSc)1, Freddy Beretta Marcondes (PT, candidato MSc)1 , Katrin Fenzl (PT)1,
Karen Vantin (PT) 1, Thiago Yukio Fukuda (PT, PhD) 1, Patrícia Maria de
Moraes Barros Fucs (MD, PhD)2
RESUMO
ESTUDO: Duplo-cego, randomizado controlado.
INTRODUÇÃO: Estudos recentes mostram que um programa do campo de
eletromagnético pulsado (CEMP) é indicado para distúrbios músculo-
esqueléticos. No entanto, existem poucos estudos clínicos para avaliar os
resultados deste tipo de programa para a síndrome do impacto do ombro (SIO).
OBJETIVOS: Avaliar os efeitos do CEMP na redução da dor, melhora da força
muscular e função em pacientes com SIO.
MÉTODOS: Cinquenta e seis pacientes foram recrutados, com idades entre 40
e 59 anos, diagnosticados com SIO. Os participantes foram aleatoriamente
divididos em dois grupos: grupo CEMP (n = 26, média de idade de 50,77 anos)
e o grupo Placebo (n = 30, média de idade de 50,15 anos). As variáveis do
questionário UCLA, escala de constante Murley, Escala Visual Analógica
(EVA), amplitude de movimento de rotação interna, externa e elevação, e força
muscular dos músculos rotadores internos e externos foram mensurados.
RESULTADOS: Ao final do tratamento, ambos os grupos apresentaram
melhora em todas as variáveis, quando comparadas aos valores basais.
Mudanças ao longo do tempo na UCLA, constante-Murley e EVA não foram
diferentes entre o grupo CEMP e placebo.
CONCLUSÃO: O CEMP foi eficaz no alívio da dor e função de pacientes com
SIO. Houve ligeira melhora da dor em ambos os grupos, após a aplicação do
CEMP e Placebo, com diferença estatisticamente significativa entre os grupos,
que sugeriu que houve efeito placebo.
NÍVEL DE EVIDÊNCIA: terapia, nível 1ª.
PALAVRAS-CHAVE: CEMP, diatermia, magnetoterapia, manguito rotador
9
INTRODUÇÃO
MATERIAIS E MÉTODOS
AVALIAÇÃO
Dor e função
Força muscular
RESULTADOS
DISCUSSÃO
CONCLUSÃO
REFERÊNCIAS
3- Neer cs. acromioplasty for the chronic Anterior impingement syndrome in the
shoulder: a preliminary report. J Bone Joint Surg am. 1972; 54: 41-50.
15
4- Van der Windt DA, Koes BW, Bouter LM, de Jong. Shoulder disorders in
general practice: incidence, patient characteristics, and management. Ann
Rheum Dis 1995; 54: 959-64
5- Luime JJ, Koes BW, Hendriksen IJ, Burdorf, Verhagen AP, Miedema HS, et
al. Prevalence and incidence of shoulder pain in the general population: a
systematic review. Scand J Clauw DJ, 2004; 33: 73-81
7- Ostor AJ, Richards CA, Prevost AT, AC, Speed Hazlemen BL. Diagnosis and
relation to general health of shoulder disorders presenting to primary care.
Rheumatology. 2005; 44: 800-5.
9- Haahr JP, Ostergaard, Dalsgaard J., Norup K, Frost P, Lausen S, Holm And
Andersen. Exercises arthroscopic decompression versus in patients with
subacromial impingement: a randomised, controlled study in 90 cases with a
one year follow up. Ann Rheum Dis 2005; 64: 760-764.
11- Tashjian R.Z.; Deloach J.; Porucznik , C. A,; Powell, A.M.; Minimal clinically
important differences (MCID) and patient acceptable symptomatic state (PASS)
for visual analog scales (VAS) measuring pain in patients treated for rotator cuff
disease; Journal of Shoulder and Elbow Surgery, 18, (6); 927-32; 2009
16
13- Markov Ms. Pulsed electromagnetic field therapy history, state of the art and
future. Environmentalist 2007; 27: 465-75.
17- Neer CS 2nd. Impingement lesions. Clin Orthop Res. 1983 Report: 70-7.
18- Constant CR, Murley MB. The clinical method of functional assessment of
the shoulder. Clin Orthop. 1987; 214: 160-4.
19- Ellman H, Hanker G, Bayer m. Repair of the rotator cuff. J Bone Joint Surg
am. 1986; 68: 1136-44.
21- Kuhlman JR, Iannotti JP, Kelly MJ, et al. measurement of isometric and
Isokinetic strength of external rotation and abduction of the shoulder. J Bone
Joint Surg Am. 1992; 74: 1320-33.
17
22- Sutbeyaz ST, Sezer N, Koseoglu BF. The effect of pulsed electromagnetic
fields in the treatment of cervical osteoarthritis: a randomized, double-blind,
sham-controlled Trial. Clauw DJ int. 2006; 26: 320-324.
Figura 1:
Tabela 1:
18
Tabela 2:
19
Diego Galace de Freitas (PT, MSc)1, Renan Lima Monteiro (PT, MSc
candidate)1, Freddy Beretta Marcondes (PT, MSc candidate)1 , Katrin Fenzl
(PT)1, Karen Vantin(PT) 1, Thiago Yukio Fukuda (PT, PhD) 1, Patrícia Maria de
Moraes Barros Fucs (MD, PhD)2
1.Physical Therapy Sector, Irmandade da Santa Casa de Misericordia
(ISCMSP), São Paulo, Brazil
2.Orthopaedic and Traumatology Department, Irmandade da Santa Casa de
Misericordia (ISCMSP), São Paulo, Brazil
20
SUMMARY
INTRODUCTION
pain in adults (Imhoff et al., 2004; Jerosch et al.; 2002; Neer.; 1972). It is
It´s prevalence in patients under 70 years is about 7 to 27%, and above this age
it varies between 13.2 to 26% and is the third most pain cause in
musculoskeletal disorders being only behind the spine and knee pain (Van der
anterolateral region of the shoulder and the lateral aspect of the arm (Fodor et
al.; 2009). Most patients complain of night pain and difficulty to lie down on the
Several interventions have been used on the treatment of the SIS, which
include the use of medications, surgery and physiotherapy (Rabini et al.; 2012;
therapeutic applications on shoulder pain (Akta et al.; 2007), among them, the
regeneration, muscular, tendinous and mostly bone and nerve tissues. However
treatment of shoulder pain (Leclaire et al.;1991) (Markov et al.; 2007) and little
22
evidence for its positive effects (Quittan et al., 2000; Green et al.; 1998; Aktas et
al.; 2009).
Thus, the objective of this study was to evaluate the effects of PEMF in
shoulder. We hypothesized that the group that receives the PEMF would
Misericórdia de São Paulo (ISCMSP) from April 2009 to August 2011 in patients
with SIS. The study was approved in advance by the Ethics Committee of the
The study sample was selected from a list of patients of the rehabilitation
individuals. The sample size was calculated assuming an 80% power to detect
level of 5% across the study by Bang (Bang et al., 2000) and resulted in a
imaging. The study subjects were of both genders, aged between 35 and 67
or II, according to criteria of Neer (Neer; 1983) with symptoms over 3 months.
pain syndrome. During the screening, all individuals who made use of the
medications cited previously interrupted the use seven days prior to starting
treatment.
envelope containing the name of the two groups: PEMF - treatment with PEMF
All subjects underwent nine sessions, three times a week with a 48-hour
interval. The time of each application was 30 minutes, and the electrodes were
EVALUATION
about pain, function and muscle strength. This same procedure was performed
regarding the allocation of individuals. The research subjects were unaware that
The Visual analogue scale of pain (EVA) was used to evaluate the pain,
California at Los Angeles Shoulder Rating Scale - UCLA (Ellman et al.; 1986)
Muscular strength
The measurement of the strength of the rotator cuff (internal and external
rotation) and elevation of the shoulder was performed with a brand manual
To measure the internal and external rotators strength, the subject was
positioned in supine, with the shoulder abducted to 45° and with 30° of
horizontal adduction (scapular plane), the elbow flexed at 90° and neutral
rotation (MacDermid et al.; 2004, Kuhlman et al.; 1992) , with the dynamometer
For the evaluation of strength during the elevation of the shoulder, the
subject was kept in a sitting position, with a 45° shoulder abduction, 30°
was positioned on the dorsal surface of the wrist. It was required for the patients
were performed three times using the average of the three measurements.
25
medial rotators (ICC = 0.50), excellent for evaluation of lateral rotators (ICC =
Data were analyzed with the SPSS program, version 13.0 (SPSS Inc,
age, body mass, height, weight, pain scales, scales to determine muscle
were performed by the independent t test. The results for the pain scales (EVA),
functional scales (UCLA and Constant), and muscle strength were analyzed
using paired t-test. The statistical significance was considered when (p < 0.05).
RESULTS
height and body weight (p <. 05). There was also no statistical difference (p <.
05) between the groups for the studied variables at baseline (before
intervention).
26
Fifty-six patients started treatment, however 4 patients did not reach final
The comparison between the groups did not show statistically significant
differences (p <. 05) for pain, muscle strength and functionality in all scales.
showed improvement in pain and function after the application of PEMF (< p
0.05). However, the placebo group showed only improvements in the levels of
Intention-to-treat analysis
Sample loss of 4 participants during the study (Post-PEMF) did not affect
the potential validity of the study because this dropout did not exceed 10% of
DISCUSSION
showed that the use of PEMF is effective for pain relief and function
improvement.
27
decrease in the levels of pain to 1.4 centimeters (Tashjian et al., 2009). It was
observed that both groups improved in pain levels, with a significant clinical
improvement of 1.7 for the PEMF group and 2.0 cm for the placebo PEMF
group. For the functional assessment using Constant and UCLA, the PEMF
Meanwhile, Aktas (Aktas et al., 2007), conducted a study that used the
PEMF as auxiliary conduct in the treatment of SIS. The results showed that the
combined use of PEMF and exercise for SIS compared to the placebo group did
not differ for the pain and function. Our results corroborate previous studies
generally found in the literature. Sutbeyaz et al. (2006), observed that the PEMF
suggested that further studies with different frequency and intensity modulations
with SIS.
CONCLUSION
28
individuals with SIS. However the PEMF did not obtain significant differences
REFERENCES
3- Neer cs. acromioplasty for the chronic Anterior impingement syndrome in the
shoulder: a preliminary report. J Bone Joint Surg am. 1972; 54: 41-50.
4- Van der Windt DA, Koes BW, Bouter LM, de Jong. Shoulder disorders in
general practice: incidence, patient characteristics, and management. Ann
Rheum Dis 1995; 54: 959-64
5- Luime JJ, Koes BW, Hendriksen IJ, Burdorf, Verhagen AP, Miedema HS, et
al. Prevalence and incidence of shoulder pain in the general population: a
systematic review. Scand J Clauw DJ, 2004; 33: 73-81
7- Ostor AJ, Richards CA, Prevost AT, AC, Speed Hazlemen BL. Diagnosis and
relation to general health of shoulder disorders presenting to primary care.
Rheumatology. 2005; 44: 800-5.
9- Haahr JP, Ostergaard, Dalsgaard J., Norup K, Frost P, Lausen S, Holm And
Andersen. Exercises arthroscopic decompression versus in patients with
29
11- Tashjian R.Z.; Deloach J.; Porucznik , C. A,; Powell, A.M.; Minimal clinically
important differences (MCID) and patient acceptable symptomatic state (PASS)
for visual analog scales (VAS) measuring pain in patients treated for rotator cuff
disease; Journal of Shoulder and Elbow Surgery, 18, (6); 927-32; 2009
13- Markov Ms. Pulsed electromagnetic field therapy history, state of the art and
future. Environmentalist 2007; 27: 465-75.
16- Bang MD, GD Deyle. Comparison of supervised exercise with and without
manual physical therapy for patients with shoulder impingement syndrome. J
Orthop Sports Phys Ther. 2000 Mar; 30 (3): 126-37.
17- Neer CS 2nd. Impingement lesions. Clin Orthop Res. 1983 Report: 70-7.
18- Constant CR, Murley MB. The clinical method of functional assessment of
the shoulder. Clin Orthop. 1987; 214: 160-4.
19- Ellman H, Hanker G, Bayer m. Repair of the rotator cuff. J Bone Joint Surg
am. 1986; 68: 1136-44.
21- Kuhlman JR, Iannotti JP, Kelly MJ, et al. measurement of isometric and
Isokinetic strength of external rotation and abduction of the shoulder. J Bone
Joint Surg Am. 1992; 74: 1320-33.
30
22- Sutbeyaz ST, Sezer N, Koseoglu BF. The effect of pulsed electromagnetic
fields in the treatment of cervical osteoarthritis: a randomized, double-blind,
sham-controlled Trial. Clauw DJ int. 2006; 26: 320-324.
Figure 1:
Table 1:
31
Table 2:
32
Diego Galace de Freitas (PT, MSc)1, Renan Monteiro de Lima (PT, candidato
MSc)1, Freddy Beretta Marcondes (PT, candidato MSc)1 , Thiago Yukio
Fukuda (PT, PhD) 1, Patrícia Maria de Moraes Barros Fucs (MD, PhD)2
RESUMO
Objetivo: Avaliar os efeitos de campo eletromagnético pulsado (CEMP) e
exercícios na redução da dor, melhora da força muscular e função em
pacientes com síndrome de impacto do ombro (SIO).
Design: Ensaio clínico randomizado, duplo-cego, com acompanhamento de 3
meses pós-tratamento.
Configuração: Reabilitação ambulatorial de um hospital público.
Participantes: Cinquenta e seis pacientes entre 40 e 60 anos de idade, com
diagnóstico de SIO, foram aleatoriamente alocados no grupo CEMP ativo (n =
26; média de idade= 50,1 anos) ou CEMP placebo (n = 30; média de idade=
50,8 anos de idade).
Intervenções: Após 3 semanas de ativo ou placebo CEMP, ambos os grupos
realizaram o mesmo programa de exercícios que incidiu sobre o ombro reforço.
Principais desfechos: A escala visual analógica (VAS), escala de avaliação
funcional da Universidade da Califórnia/Los Angeles (UCLA), Constante-
Murley, e a Dinamometria manual para força muscular ombro foram usadas
como medidas de resultado na linha de base (pré-tratamento), em 3 semanas
(pós-CEMP ativo ou placebo), em 9 semanas (pós-exercícios) e na avaliação
pós-tratamento de 3 meses.
Resultados: Os pacientes no grupo CEMP ativo apresentaram maior nível de
função e menos dor em todos os seguimentos em relação à linha de base (P <
05). No entanto, o grupo de CEMP placebo tinha maior função e menor dor
somente no seguimento 9 semanas e 3 meses (P < 05), ou seja, melhora
apenas após associar os exercícios. Para a dinamometria de ombro, o grupo
CEMP ativo aumentou a força de rotação lateral em 9 semanas (P < 05) e
rotação medial em 9 semanas e 3 meses (ambos, P < 05), quando comparado
à linha de base. Não houve diferença para a força do ombro no grupo CEMP
placebo (P > 05), e análise intergrupos (P > 05) para todas as medidas de
resultado.
Conclusão: A combinação de exercícios de ombro ao CEMP é eficaz na
melhora da força muscular, função e para diminuir dor em pacientes com SIO.
No entanto, esses resultados devem ser interpretados com cuidado em
consequência da falta de diferenças entre grupos.
Palavras-chave: Terapia com campo magnético, diatermia, manguito rotador.
Abreviaturas: CEMP, campo eletromagnético pulsado; SIO, síndrome do
impacto do ombro; EVA, escala visual analógica; UCLA, Universidade da
Califórnia/Los Angeles.
34
INTRODUÇÃO
as principais queixas dos pacientes com SIO são dor nas articulações, rigidez e
local.10,13,16,17
MÉTODOS
Participantes
alocados para o grupo CEMP ativo (n = 26; média de idade, 50.1 ± 8,2 anos)
ou CEMP placebo (n = 30; média 9,6 anos de idade, 50,8 ±). Após 3 semanas
Saúde 196/96. O estudo foi aprovado pelo Comitê de Ética da Pesquisa, com
36
de registro: NCT01452204).
detectar melhora de 30% nos níveis de dor (escala visual analógica), e que se
estudo.
anos de idade, com diagnóstico médico de SIO de grau I ou II, com base em
história de dor no ombro pelo menos havia 3 meses. Além disso, esses
da cabeça. Essa elevação ativa do braço foi uma preocupação pelo fato de que
inicial, mas antes da primeira sessão de tratamento. Um único terapeuta (A) foi
placebo. Finalmente, o examinador (D) era cego para a alocação do grupo dos
Intervenções
20 miliTesla (mT) ou 200 Gauss (G). Como a dosimetria ideal para terapia com
Avaliação
e 10 à pior dor imaginável, foi usada. A EVA mostrou ser confiável e válida
de 1,4 pontos.23
máxima de 30, com escores mais altos indicando melhor função. 26 O MCID da
13%.27
EUA) foi usado para medir a força dos músculos do manguito rotador (rotação
medial e lateral) e elevação do braço. Para medir a força dos rotadores mediais
submáximos para familiarizar os sujeitos com cada posição de teste. Isso foi
muscular. Para análise dos dados, foram utilizados os valores médios das 3
elevação de ombro, com ICC de 0,88; e satisfatória para a rotação medial, com
(Figura 2).
Análise de dados
definida como p < 05. Após a análise de dados por protocolo, ocorreu a análise
41
RESULTADOS
dados por protocolo foram realizadas com 22 indivíduos no grupo CEMP ativo
entre os participantes nos grupos ativo e placebo CEMP (tabela 2). Não houve
com a linha de base (constante-Murley, intervalo, P < P.05 - <. 001; UCLA,
intervalo, P < P 01 - <. 001; e VAS, intervalo P < P 01 - < 001. A mesma análise
42
força muscular (todas, P > 05) (tabela 3). Os resultados da análise de intenção
tratamento.
Análise MCID
com a linha de base, foi de 61% no grupo ativo e 43% no grupo placebo.
de melhora foi 65% no grupo ativo e 24% no grupo placebo para a constante-
Murley, e 91% no grupo ativo e 54% no grupo placebo para a escala UCLA.
DISCUSSÃO
contraste com o grupo que realizou CEMP placebo e exercícios, que não
pode ser ferramenta útil quando usada para facilitar a cicatrização de úlceras
base na análise dos efeitos isolados dos CEMP e quando combinado com
autores aplicaram o CEMP durante 25 minutos por sessão, 5 dias por semana,
sessão, três dias por semana, para um total de 9 sessões. No entanto, foram
CEMP de baixa frequência pode melhorar função, dor, fadiga e estado global
muscular.
sintomas e força muscular dos pacientes. Por outro lado, podem ser limitações
46
acreditamos que esse viés foi minimizado porque selecionamos pacientes que
aplicação isolada do CEMP parece não ser tão significativo como a associação
Estudos futuros devem incluir seguimento mais longo e grupo que recebe o
após os exercícios.
47
CONCLUSÃO
REFERÊNCIAS
1- Cools AM, Cambier D, Witvrouw EE. Screening the athlete’s shoulder for
impingement symptoms: a clinical reasoning algorithm for early detection of
shoulder pathology. Br J Sports Med. 2008;42:628-35.
5- Roy JS, Moffet H, McFadyen BJ. Upper limb motor strategies in persons with
and without shoulder impingement syndrome across different speeds of
movement. Clin Biomech (Bristol, Avon) 2008;23:1227-36.
11- Guerkov HH, Lohmann CH, Liu Y, Dean DD, Simon BJ, Heckman JD,
Schwartz Z, Boyan BD. Pulsed electromagnetic fields increase growth factor
release by nonunion cells. Clin Orthop Relat Res 2001;384:265-79.
13- Prato FS, Thomas AW, Cook CM. Extremely low frequency magnetic fields
(ELFMF) and pain therapy. In: Advances in Electromagnetic Fields in Living
Systems 2005;4:155-87.
14- Lee EW, Maffulli N, Li CK, Chan KM. Pulsed magnetic and electromagnetic
fields in experimental achilles tendonitis in the rat: a prospective randomized
study. Arch Phys Med Rehabil 1997;78:399-404.
15- Strauch B, Patel MK, Rosen DJ, Mahadevia S, Brindzei N, Pilla AA. Pulsed
magnetic field therapy increases tensile strength in a rat achilles’ tendon repair
model. J Hand Surg 2006; 31(7):1131-5.
17- Shupak NM, McKay JC, Nielson WR, Rollman GB, Prato FS, Thomas AW.
Exposure to a specific pulsed low-frequency magnetic field: A double-blind
placebo-controlled study of effects on pain ratings in rheumatoid arthritis and
fibromyalgia patients. Pain Res Manag 2006;11(2):85-90.
20- Bang MD, Deyle GD. Comparison of supervised exercise with and without
manual physical therapy for patients with shoulder impingement Syndrome. J
Orthop Sports Phys Ther 2000;30:126-37
49
21- Neer CS. Impingement lesions. Clin Orthop Relat Res. 1983;173:70-7.
23- Tashjian RZ, Deloach J, Porucznik CA, Powell AP. Minimal clinically
important differences (MCID) and patient acceptable symptomatic state (PASS)
for visual analog scales (VAS) measuring pain in patients treated for rotator cuff
disease. J Shoulder Elbow Surg, 2009;18:927-32.
24- Constant CR, Murley AH. A clinical method of functional assessment of the
shoulder. Clin Orthop Relat Res. 1987;214:160-4.
25- Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of
factors influencing reconstruction. J Bone Joint Surg Am 1986;68(8):1136-44.
26- Oku EC, Andrade AP, Stadiniky SP, Carrera EF, Tellini GG. Tradução e
adaptação cultural do Modified-University of California at Los Angeles shoulder
rating scale para a lingual portuguesa. Rev Bras Reumatol 2006;46(4):246-52.
27- Schmitt JS, Fabio RPD. Reliable change and minimum important difference
(MID) proportions facilitated group responsiveness comparisons using individual
threshold criteria. J Clin Epidemiol. 2004; 57(10):1008-18
28- Kuhlman JR, Iannotti JP, Kelly MJ, et al. Isokinetic and isometric
measurement of strength of external rotation and abduction of the shoulder. J
Bone Joint Surg Am 1992;74:1320-33.
30- Marcondes FB, Rosa SG, Vasconcelos RA, Basta A, Freitas DG, Fukuda
TY. Força do manguito rotador em indivíduos com síndrome do impacto
comparado ao lado assintomático. Acta Ortop Bras 2011;19(6):333-7.
33- Fukuda TY, Ovanessian V, Cunha RA, Jacob Filho Z, Cazarini Jr C, Rienzo
FA, Centini AA. Pulsed short wave effect in pain and function in patients with
knee osteoarthritis. J Appl Res 2008;8(3):189-98.
50
34- Fukuda TY, Cunha RA, Fukuda VO, Rienzo FA, Cazarini C, Carvalho NAA,
Centini AA. Pulsed shortwave treatment in women with knee osteoarthritis: a
multicenter, randomized, placebo-controlled clinical trial. Phys Ther
2011;91(7):1009-17.
35- Weintraub MI, Hermann DN, Smith AG, Backonja MM, Cole SP. Pulsed
electromagnetic fields to reduce diabetic neuropathic pain and stimulate
neuronal repair: a randomized controlled trial. Arch Phys Med Rehabil.
2009;90(7):1102-9.
Figura 1:
Figura 2:
Tabela 1:
53
Tabela 2:
Tabela 2 - Exercícios Fundamentais de Ombro
Exercício Pendular:
Alongamento de Peitoral:
Alongamento de Tríceps:
Traga o braço sobre seu corpo e use a outra mão para aplicar
pressão suportável, puxando o cotovelo.
Protração Escapular:
Tabela 3:
56
ABSTRACT
Objective: To evaluate the effects of pulsed electromagnetic field (PEMF) and
exercises in reducing pain and improving function and muscle strength in
patients with shoulder impingement syndrome (SIS).
Design: Double-blind randomized clinical trial, with a 3 month post-treatment
follow-up.
Setting: Outpatient Rehabilitation of a public hospital
Participants: Fifty-six patients between 40 and 60 years of age, with a
diagnosis of SIS, were randomly assigned active PEMF (n = 26; mean age,
50.1 years) or placebo PEMF (n = 30; mean age, 50.8 years old).
Interventions: After 3 weeks of active or placebo PEMF, both groups
performed the same program of exercises that focused on shoulder
strengthening.
Main Outcome Measures: A visual analogue scale (VAS), the University of
California/Los Angeles (UCLA) shoulder rating scale, the Constant-Murley
shoulder score, and the hand-held dynamometry for muscle strength were used
as outcome measures at baseline (pretreatment), at 3 weeks (post active or
placebo PEMF), at 9 weeks (post-exercises), and at 3 months post-treatment.
Results: The patients in the active PEMF group had a higher level of function
and less pain at all follow-up timeframes compared to baseline (P<.05).
However, the placebo PEMF group had increased function and reduced pain
only at 9 weeks and 3 months follow-ups (P<.05), i.e., after performing the
associated to exercises. For the shoulder dynamometry, the active PEMF group
had increased strength for lateral rotation at 9 weeks (P<.05) and medial
rotation at 9 weeks and 3 months (both, P<.05) when compared to baseline.
There was no difference for shoulder strength in the placebo PEMF group
(P>.05), as well as the analysis between-groups (P>.05) for all outcome
measures.
Conclusion: The combination of PEMF and shoulder exercises is effective in
improving function and muscle strength and decreasing pain in patients with
SIS. However, these results should be carefully interpreted due to the lack of
differences between groups.
Keywords: Magnetic field therapy, diathermy, shoulder impingement
syndrome, and rotator cuff.
Abbreviations: PEMF, Pulsed electromagnetic field; SIS, Shoulder
impingement syndrome; VAS, Visual analogue scale; UCLA, University of
California/Los Angeles
58
INTRODUCTION
METHODS
Participants
Fifty-six patients aged 40 and 60 years (n = 56; mean age, 50.5 ± 8.9
years), with a diagnosis of SIS, were randomly assigned to active PEMF (n =
26; mean age, 50.1 ± 8.2 years) or placebo PEMF (n = 30; mean age, 50.8 ±
9.6 years). After 3 weeks of active or placebo PEMF, both groups performed the
same program of exercises focusing on shoulder strengthening. Four patients
that were in the active PEMF and 6 patients that were in the placebo PEMF
group did not complete the study. All study procedures were explained to the
volunteers, and they signed informed consent forms in accordance with the
National Health Council Resolution No. 196/96. The study was approved by the
Research Ethics Committee of XXXXXXXXXXXXXXX, YYYY, and registered at
clinicaltrials.gov (registration number: NCT01452204).
The study sample included patients of both genders, with a SIS medical
diagnosis of grade I or II based on a history of shoulder pain for at least 3
months. Furthermore, these patients had previously received a clinical
examination and ultrasonographic (USG) or magnetic resonance image (MRI),
according to Neer´s criteria.21 The patients should present an active shoulder
elevation in overhead activities. This active overhead elevation of the arm was a
concern due to the fact that older patients with SIS were being evaluated with
possible moderate rotator cuff degeneration; we attempted to assure that these
patients still had adequate function of this musculature. The participants were
60
The active PEMF and placebo PEMF groups completed 9 sessions that
were provided 3 times per week for 3 weeks. The duration of each application
was 30 minutes and the electrodes were positioned on the anterior and
61
posterior part of the shoulder joint with the subject positioned in lateral
decubitus (FIGURE 1).
Evaluation
Data analysis
Data were analyzed using SPSS, version 13.0 (SPSS Inc, Chicago, IL.
USA). The Kolgomorov-Smirnov test (with Lilliefors correction factor) was used
to test the normality of the data. Descriptive statistics for demographic data and
all outcome measures were expressed as averages and standard deviations
(SD) with a normal curve. The homogeneity within-group for gender at baseline
was confirmed by the chi-square test. Comparison between the groups was
performed using independent t tests for age, body mass, height, pain score, and
functional scales to determine homogeneity of the groups at baseline
(pretreatment). The data for the 2 functional scales (Constant-Murley and
63
UCLA), muscle strength, and the VAS were analyzed using separate 2-by-4
(group-by-time) mixed model analysis of variance. The factor of group had 2
levels (active PEMF and placebo PEMF) and the repeated factor of time had 4
levels (pretreatment, 3 and 9 weeks of treatment, and 3 months post-treatment).
If significant main effects or interactions were detected, then a simple main
effects analysis continued using Bonferroni adjustments. Statistical significance
was defined as p<.05. After the per-protocol data analysis, an intention-to-treat
analysis (ITT) was performed using the mean value obtained from the
remaining subjects of each group.
RESULTS
MCID Analysis
Based on the MCID for the VAS (1.4 points), the proportion of patients
who met or exceeded the MCID in the 3-week evaluation (i.e. post active or
placebo PEMF) compared with baseline was 61% in the active group and 43%
in the placebo group. Unfortunately, we did not find an MCID standard value for
the Constant-Murley and UCLA questionnaires, but there is speculation that
improvement can be significant in general shoulder scales when the proportion
of patients who meet or exceed the MCID is above 13%. 27 Thus, when we
examined the 3-week evaluation, the proportion of patients who met or
exceeded 13% of improvement was 65% in the active group and 24% in the
placebo group for the Constant-Murley, and 91% in the active group and 54% in
the placebo group for the UCLA scale.
who surpassed the MCID for Constant-Murley in the placebo group was 67%
and 58%, respectively. Finally, the proportion of patients for the UCLA in the
active group was 82% and 86%, respectively, and the proportion of patients for
the UCLA in the placebo group was 63% for both evaluations.
DISCUSSION
this bias was minimized because we selected patients who had an active
overhead elevation of the arm. This tendon degeneration may have been the
reason for the lack of improvement in arm elevation in both groups. It is
important to highlight that this population is the most frequent age group found
in our shoulder policlinics hospital. We did not control whether the patients
performed their rehabilitation exercises during the 3-month follow-up. However,
immediately after treatment, all patients were instructed to maintain their normal
activities in the same manner that they were performed during treatment.
Another limitation of the study was the absence of a group performing PEMF
and exercises at the same time. However, we intended to observe the isolated
effect of PEMF for pain and function, and subsequently the effect of such an
association.
CONCLUSION
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30- Marcondes FB, Rosa SG, Vasconcelos RA, Basta A, Freitas DG,
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4. CONSIDERAÇÕES FINAIS
77
4. Considerações Finais
5. REFERÊNCIAS BIBLIOGRÁFICAS
79
5. Referências Bibliográficas
7. Tepper OM, Callaghan MJ, Chang EI, Galiano RD, Bhatt KA,
Baharestani S, et al. Electromagnetic fields increase in vitro and in vivo
angiogenesis through endothelial release of FGF-2. The FASEB Journal 2004;
18: 1-16.
8. Cools AM, Cambier D, Witvrouw EE. Screening the athlete’s shoulder for
impingement symptoms: a clinical reasoning algorithm for early detection of
shoulder pathology. Br J Sports Med. 2008;42:628-35.
11. Neer CS. Anterior acromioplasty for the chronic impingement syndrome
in the shoulder: a preliminary report. J Bone Joint Surg Am 1972;54:41-50
12. McCarthy CJ, Callaghan MJ, Oldham JA. Pulsed electromagnetic energy
treatment offers no clinical benefit in reducing the pain of knee osteoarthritis: a
systematic review. BMC 2006;7:51
16. Oku EC, Andrade AP, Stadiniky SP, Carrera EF, Tellini GG. Tradução e
adaptação cultural do Modified-University of California at Los Angeles shoulder
rating scale para a lingual portuguesa. Rev Bras Reumatol 2006;46(4):246-52.
17. Shupak NM, McKay JC, Nielson WR, et al. Exposure to a specific pulsed
low– frequency magnetic field: a double-blind placebo-controlled study of
effects on pain ratings in rheumatoid arthritis and fibromyalgia patients. Pain
Res Manag 2006;11:85-90.
18. Sutbeyaz ST, Sezer N, Koseoglu F, Kibar S. Low-frequency pulsed
electromagnetic field therapy in fibromyalgia: A randomized, double-blind,
sham-controlled clinical study. Clin J Pain 2009; 25:772-8.
19. Schmitt JS, Fabio RPD. Reliable change and minimum important
difference (MID) proportions facilitated group responsiveness comparisons
using individual threshold criteria. J Clin Epidemiol. 2004; 57(10):1008-18
20. Marcondes FB, Rosa SG, Vasconcelos RA, Basta A, Freitas DG, Fukuda
TY. Força do manguito rotador em indivíduos com síndrome do impacto
comparado ao lado assintomático. Acta Ortop Bras 2011;19(6):333-7.
23. Lombardi Jr I, Magri AG, Fleury AM, Da Silva AC, Natour J. Progressive
resistance training in patients with shoulder impingement syndrome: A
randomized controlled trial. Arthritis Rheum 2008;59(5):615-22.
25. Guerkov HH, Lohmann CH, Liu Y, Dean DD, Simon BJ, Heckman JD,
Schwartz Z, Boyan BD. Pulsed electromagnetic fields increase growth factor
release by nonunion cells. Clin Orthop Relat Res 2001;384:265-79.
81
6. FONTES CONSULTADAS
82
6. Fontes consultadas
7. ANEXOS
84
7. Anexos
7.1 Anexo 1
7.2 Anexo 2
7.3 Anexo 3
Comite de Ética
87
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