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1.
JAMA ; 322(3): 216-228, 2019 07 16.
Artigo em Inglês | MEDLINE | ID: mdl-31310297

RESUMO

Importance: The effects of intensive care unit (ICU) visiting hours remain uncertain. Objective: To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium. Design, Setting and Participants: Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018. Interventions: Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation. Main Outcomes and Measures: Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory). Results: Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation. Conclusions and Relevance: Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium. Trial Registration: ClinicalTrials.gov Identifier: NCT02932358.


Assuntos
Delírio/prevenção & controle , Família/psicologia , Unidades de Terapia Intensiva/organização & administração , Visitas a Pacientes , Ansiedade , Brasil , Esgotamento Profissional , Cuidados Críticos/psicologia , Estudos Cross-Over , Depressão , Feminino , Educação em Saúde , Hospitalização , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
2.
Crit Care ; 23(1): 213, 2019 06 11.
Artigo em Inglês | MEDLINE | ID: mdl-31186070

RESUMO

BACKGROUND: As more patients are surviving intensive care, mental health concerns in survivors have become a research priority. Among these, post-traumatic stress disorder (PTSD) can have an important impact on the quality of life of critical care survivors. However, data on its burden are conflicting. Therefore, this systematic review and meta-analysis aimed to evaluate the prevalence of PTSD symptoms in adult critical care patients after intensive care unit (ICU) discharge. METHODS: We searched MEDLINE, EMBASE, LILACS, Web of Science, PsycNET, and Scopus databases from inception to September 2018. We included observational studies assessing the prevalence of PTSD symptoms in adult critical care survivors. Two reviewers independently screened studies and extracted data. Studies were meta-analyzed using a random-effects model to estimate PTSD symptom prevalence at different time points, also estimating confidence and prediction intervals. Subgroup and meta-regression analyses were performed to explore heterogeneity. Risk of bias was assessed using the Joanna Briggs Institute tool and the GRADE approach. RESULTS: Of 13,267 studies retrieved, 48 were included in this review. Overall prevalence of PTSD symptoms was 19.83% (95% confidence interval [CI], 16.72-23.13; I2 = 90%, low quality of evidence). Prevalence varied widely across studies, with a wide range of expected prevalence (from 3.70 to 43.73% in 95% of settings). Point prevalence estimates were 15.93% (95% CI, 11.15-21.35; I2 = 90%; 17 studies), 16.80% (95% CI, 13.74-20.09; I2 = 66%; 13 studies), 18.96% (95% CI, 14.28-24.12; I2 = 92%; 13 studies), and 20.21% (95% CI, 13.79-27.44; I2 = 58%; 7 studies) at 3, 6, 12, and > 12 months after discharge, respectively. CONCLUSION: PTSD symptoms may affect 1 in every 5 adult critical care survivors, with a high expected prevalence 12 months after discharge. ICU survivors should be screened for PTSD symptoms and cared for accordingly, given the potential negative impact of PTSD on quality of life. In addition, action should be taken to further explore the causal relationship between ICU stay and PTSD, as well as to propose early measures to prevent PTSD in this population. TRIAL REGISTRATION: PROSPERO, CRD42017075124 , Registered 6 December 2017.

3.
BMJ Open ; 9(6): e028570, 2019 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-31243035

RESUMO

INTRODUCTION: There is an increasing demand for multi-organ donors for organ transplantation programmes. This study protocol describes the Donation Network to Optimise Organ Recovery Study, a planned cluster randomised controlled trial that aims to evaluate the effectiveness of the implementation of an evidence-based, goal-directed checklist for brain-dead potential organ donor management in intensive care units (ICUs) in reducing the loss of potential donors due to cardiac arrest. METHODS AND ANALYSIS: The study will include ICUs of at least 60 Brazilian sites with an average of ≥10 annual notifications of valid potential organ donors. Hospitals will be randomly assigned (with a 1:1 allocation ratio) to the intervention group, which will involve the implementation of an evidence-based, goal-directed checklist for potential organ donor maintenance, or the control group, which will maintain the usual care practices of the ICU. Team members from all participating ICUs will receive training on how to conduct family interviews for organ donation. The primary outcome will be loss of potential donors due to cardiac arrest. Secondary outcomes will include the number of actual organ donors and the number of organs recovered per actual donor. ETHICS AND DISSEMINATION: The institutional review board (IRB) of the coordinating centre and of each participating site individually approved the study. We requested a waiver of informed consent for the IRB of each site. Study results will be disseminated to the general medical community through publications in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER: NCT03179020; Pre-results.

4.
J Crit Care ; 52: 115-125, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31035186

RESUMO

PURPOSE: The present systematic review and meta-analysis aimed to synthesize data on subject outcomes associated with post-ICU follow-up. MATERIALS AND METHODS: MEDLINE, PsycINFO, CINAHL, Cochrane CENTRAL, and EMBASE databases were searched according to pre-specified criteria (PROSPERO- CRD42017074734). Non-randomized and randomized studies assessing patient and family outcomes associated with post-ICU follow-up were included. RESULTS: Twenty-six studies were included. Sixteen (61%) were randomized trials; of these, 15 were meta-analyzed. Non-randomized studies reported benefits in survival, functional status, anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms, and satisfaction. In randomized trials, post-ICU follow-up models focusing on physical therapy were associated with fewer depression symptoms (mean difference [MD], -1.21 (see Fig. 2); 95% confidence interval [CI], -2.31 to -0.11; I2 = 0%) and better mental health-related quality of life scores (standardized MD [SMD], 0.26; 95%CI, 0.02 to 0.51; I2 = 6%) in the short term. Post-ICU follow-up models focusing on psychological or medical management interventions were associated with fewer PTSD symptoms (SMD, -0.21; 95%CI, -0.37 to -0.05; I2 = 0%) in the medium term. CONCLUSIONS: Post-ICU follow-up may improve depression symptoms and mental health-related quality of life in the short term for models focusing on physical therapy and PTSD symptoms in the medium term for models focusing on psychological or medical management interventions.

5.
Rev. bras. ter. intensiva ; 30(4): 405-413, out.-dez. 2018. tab, graf
Artigo em Português | LILACS-Express | ID: biblio-977985

RESUMO

RESUMO Objetivo: Avaliar a prevalência de incapacidades físicas, cognitivas e psiquiátricas, fatores associados e sua relação com qualidade de vida em pacientes sobreviventes de internação em unidades de terapia intensiva brasileiras. Métodos: Um estudo de coorte prospectivo multicêntrico está sendo conduzido em dez unidades de terapia intensiva adulto clínico-cirúrgicas representativas das cinco regiões geopolíticas do Brasil. Pacientes com idade ≥ 18 anos que receberam alta das unidades de terapia intensiva participantes e permaneceram internados na unidade de terapia intensiva por 72 horas ou mais, nos casos de internação clínica ou cirúrgica de urgência, e por 120 horas ou mais, nos casos de internação cirúrgica eletiva, serão incluídos de forma consecutiva. Estes pacientes serão seguidos por 1 ano, por meio de entrevistas telefônicas estruturadas 3, 6 e 12 meses pós-alta da unidade de terapia intensiva. Dependência funcional, disfunção cognitiva, sintomas de ansiedade e depressão, sintomas de estresse pós-traumático, qualidade de vida relacionada à saúde, re-hospitalizações e mortalidade em longo prazo serão avaliados como desfechos. Discussão: O presente estudo tem o potencial de contribuir para o conhecimento a respeito da prevalência e dos fatores associados à síndrome pós-cuidados intensivos na população de pacientes adultos sobreviventes de internação em unidades de terapia intensiva brasileiras. Ademais, a associação entre síndrome pós-cuidados intensivos e qualidade de vida relacionada à saúde poderá ser estabelecida.


ABSTRACT Objective: To establish the prevalence of physical, cognitive and psychiatric disabilities, associated factors and their relationship with the qualities of life of intensive care survivors in Brazil. Methods: A prospective multicenter cohort study is currently being conducted at 10 adult medical-surgical intensive care units representative of the 5 Brazilian geopolitical regions. Patients aged ≥ 18 years who are discharged from the participating intensive care units and stay 72 hours or more in the intensive care unit for medical or emergency surgery admissions or 120 hours or more for elective surgery admissions are consecutively included. Patients are followed up for a period of one year by means of structured telephone interviews conducted at 3, 6 and 12 months after discharge from the intensive care unit. The outcomes are functional dependence, cognitive dysfunction, anxiety and depression symptoms, posttraumatic stress symptoms, health-related quality of life, rehospitalization and long-term mortality. Discussion: The present study has the potential to contribute to current knowledge of the prevalence and factors associated with postintensive care syndrome among adult intensive care survivors in Brazil. In addition, an association might be established between postintensive care syndrome and health-related quality of life.

6.
Trials ; 19(1): 636, 2018 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-30454019

RESUMO

BACKGROUND: Most adult intensive care units (ICUs) worldwide adopt restrictive family visitation models (RFVMs). However, evidence, mostly from non-randomized studies, suggests that flexible adult ICU visiting hours are safe policies that can result in benefits such as prevention of delirium and increase in satisfaction with care. Accordingly, the ICU Visits Study was designed to compare the effectiveness and safety of a flexible family visitation model (FFVM) vs. an RFVM on delirium prevention among ICU patients, and also to analyze its potential effects on family members and ICU professionals. METHODS/DESIGN: The ICU Visits Study is a cluster-randomized crossover trial which compares an FFVM (12 consecutive ICU visiting hours per day) with an RFVM (< 4.5 ICU visiting hours per day) in 40 Brazilian adult ICUs. Participant ICUs are randomly assigned to either an FFVM or RFVM in a 1:1 ratio. After enrollment and follow-up of 25 patients, each ICU is crossed over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome is the cumulative incidence of delirium measured by the Confusion Assessment Method for the ICU. Secondary and tertiary outcomes include relevant measures of effectiveness and safety of ICU visiting policies among patients, family members, and ICU professionals. Herein, we describe all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of this study. This pre-specified statistical analysis plan was written and submitted without knowledge of the study data. DISCUSSION: This a priori statistical analysis plan aims to enhance the transparency of our study, facilitating unbiased analyses of ICU visit study data, and provide guidance for statistical analysis for groups conducting studies in the same field. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02932358 . Registered on 11 October 2016.

7.
J Musculoskelet Neuronal Interact ; 18(3): 382-388, 2018 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-30179216

RESUMO

BACKGROUND: Whole-body vibration (WBV) is an alternative intervention for patients with diabetic peripheral neuropathy (DPN) but its clinical efficacy is unclear. OBJECTIVE: To summarize the effects of WBV on important outcomes for patients with DPN. DATA SOURCES: Medline, PEDro, Cochrane CENTRAL and Google Scholar were searched up to July 2017. Search terms included diabetic neuropathies and WBV. STUDY SELECTION: Interventional studies that utilized WBV for treating DPN outcomes with at least one-week follow-up were included. DATA EXTRACTION: Data were independently extracted by two reviewers using a standardized checklist. DATA SYNTHESIS: Twenty-two registers were identified. Three studies (83 patients) satisfied the selection criteria. Studies assessed the effect of WBV on the glycemic profile, neuropathic pain, and balance. WBV presented positive effects on these outcomes, but a high risk of bias was identified in most studies. No study assessed plantar tactile sensitivity. LIMITATIONS: Most studies have a high level of bias. No pooling data was possible due to few studies included. CONCLUSIONS: Very low-quality evidence suggests that WBV has a slight positive effect on glycemic control in patients with DPN, improving neuropathic pain and balance. Future studies may change the WBV estimated effect on DPN outcomes.

8.
Crit Care Med ; 46(7): 1175-1180, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29642108

RESUMO

OBJECTIVES: To synthesize data on outcomes related to patients, family members, and ICU professionals by comparing flexible versus restrictive visiting policies in ICUs. DATA SOURCES: Medline, Scopus, and Web of Science. STUDY SELECTION: Observational and randomized studies comparing flexible versus restrictive visiting policies in the ICU and evaluating at least one patient-, family member-, or ICU staff-related outcome. DATA EXTRACTION: Duplicate independent review and data abstraction. DATA SYNTHESIS: Of 16 studies identified for inclusion, seven were meta-analyzed. Most studies were rated as having a moderate risk of bias. Among patients, flexible visiting policies were associated with reduced frequency of delirium (odds ratio, 0.39; 95% CI, 0.22-0.69; I = 0%) and lower severity of anxiety symptoms (mean difference, -2.20; 95% CI, -3.80 to -0.61; I = 71%). Flexible visiting policies were not associated with increased risk of ICU mortality (odds ratio, 0.71; 95% CI, 0.38-1.36; I = 86%), ICU-acquired infections (odds ratio, 0.98; 95% CI, 0.68-1.42; I = 11%), or longer ICU stay (mean difference, -0.26 d; 95% CI, -0.57 to 0.05; I = 54%). Among family members, flexible visiting policies were associated with greater satisfaction. Among ICU professionals, flexible visiting policies were associated with higher burnout levels. CONCLUSIONS: Flexible ICU visiting hours have the potential to reduce delirium and anxiety symptoms among patients and to improve family members' satisfaction. However, they may be associated with an increased risk of burnout among ICU professionals. These conclusions are based on few studies, with small samples and moderate risk of bias.

9.
BMJ Open ; 8(4): e021193, 2018 04 13.
Artigo em Inglês | MEDLINE | ID: mdl-29654049

RESUMO

INTRODUCTION: Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals. METHODS AND ANALYSIS: A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5 hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals. ETHICS AND DISSEMINATION: The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through conferences and peer-reviewed journals. TRIAL REGISTRATION: NCT02932358.

11.
Rev Bras Ter Intensiva ; 30(4): 405-413, 2018 Oct-Dec.
Artigo em Português, Inglês | MEDLINE | ID: mdl-30652780

RESUMO

OBJECTIVE: To establish the prevalence of physical, cognitive and psychiatric disabilities, associated factors and their relationship with the qualities of life of intensive care survivors in Brazil. METHODS: A prospective multicenter cohort study is currently being conducted at 10 adult medical-surgical intensive care units representative of the 5 Brazilian geopolitical regions. Patients aged ≥ 18 years who are discharged from the participating intensive care units and stay 72 hours or more in the intensive care unit for medical or emergency surgery admissions or 120 hours or more for elective surgery admissions are consecutively included. Patients are followed up for a period of one year by means of structured telephone interviews conducted at 3, 6 and 12 months after discharge from the intensive care unit. The outcomes are functional dependence, cognitive dysfunction, anxiety and depression symptoms, posttraumatic stress symptoms, health-related quality of life, rehospitalization and long-term mortality. DISCUSSION: The present study has the potential to contribute to current knowledge of the prevalence and factors associated with postintensive care syndrome among adult intensive care survivors in Brazil. In addition, an association might be established between postintensive care syndrome and health-related quality of life.


Assuntos
Unidades de Terapia Intensiva , Qualidade de Vida , Sobreviventes/psicologia , Ansiedade/epidemiologia , Brasil , Disfunção Cognitiva/epidemiologia , Estudos de Coortes , Cuidados Críticos , Depressão/epidemiologia , Seguimentos , Humanos , Alta do Paciente , Prevalência , Estudos Prospectivos , Fatores de Tempo
12.
Crit Care Med ; 45(10): 1660-1667, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28671901

RESUMO

OBJECTIVES: To evaluate the effect of an extended visitation model compared with a restricted visitation model on the occurrence of delirium among ICU patients. DESIGN: Prospective single-center before and after study. SETTING: Thirty-one-bed medical-surgical ICU. PATIENTS: All patients greater than or equal to 18 years old with expected length of stay greater than or equal to 24 hours consecutively admitted to the ICU from May 2015 to November 2015. INTERVENTIONS: Change of visitation policy from a restricted visitation model (4.5 hr/d) to an extended visitation model (12 hr/d). MEASUREMENTS AND MAIN RESULTS: Two hundred eighty-six patients were enrolled (141 restricted visitation model, 145 extended visitation model). The primary outcome was the cumulative incidence of delirium, assessed bid using the confusion assessment method for the ICU. Predefined secondary outcomes included duration of delirium/coma; any ICU-acquired infection; ICU-acquired bloodstream infection, pneumonia, and urinary tract infection; all-cause ICU mortality; and length of ICU stay. The median duration of visits increased from 133 minutes (interquartile range, 97.7-162.0) in restricted visitation model to 245 minutes (interquartile range, 175.0-272.0) in extended visitation model (p < 0.001). Fourteen patients (9.6%) developed delirium in extended visitation model compared with 29 (20.5%) in restricted visitation model (adjusted relative risk, 0.50; 95% CI, 0.26-0.95). In comparison with restricted visitation model patients, extended visitation model patients had shorter length of delirium/coma (1.5 d [interquartile range, 1.0-3.0] vs 3.0 d [interquartile range, 2.5-5.0]; p = 0.03) and ICU stay (3.0 d [interquartile range, 2.0-4.0] vs 4.0 d [interquartile range, 2.0-6.0]; p = 0.04). The rate of ICU-acquired infections and all-cause ICU mortality did not differ significantly between the two study groups. CONCLUSIONS: In this medical-surgical ICU, an extended visitation model was associated with reduced occurrence of delirium and shorter length of delirium/coma and ICU stay.


Assuntos
Delírio/prevenção & controle , Unidades de Terapia Intensiva , Visitas a Pacientes , Idoso , Brasil/epidemiologia , Coma/epidemiologia , Estudos Controlados Antes e Depois , Infecção Hospitalar/epidemiologia , Delírio/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Tempo
13.
Braz J Phys Ther ; 21(4): 233-243, 2017 Jul - Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28571697

RESUMO

BACKGROUND: Monochromatic infrared energy (MIRE) or phototherapy has been used to improve plantar sensitivity and pain in lower limbs of patients with diabetic sensorimotor peripheral neuropathy (DSPN), but the available primary results are inconsistent. OBJECTIVE: To review systematically the effects of MIRE on plantar sensitivity and neuropathic pain in patients with DSPN. METHODS: Medline, EMBASE, Cochrane CENTRAL, and Google Scholar were searched up to September 2016. Randomized controlled trials addressing the effects of MIRE on plantar sensitivity and neuropathic pain in patients with DSPN were selected. Study inclusion, risk of bias and quality assessment, and data extraction were completed by two independent reviewers. RESULTS: Of 2549 records identified, six studies met the selection criteria, with 304 patients (594 feet) randomized. MIRE was not associated with improvement in plantar tactile sensitivity (SMD=0.22, 95%CI -0.07 to 0.51, low quality of evidence). Subgroups of studies with short-term (up to 2 weeks) follow-up showed significant improvement in plantar sensitivity (SMD=0.41, 95% CI 0.18-0.64). Neuropathic pain increased significantly in patients who received MIRE (MD=0.49, 95% CI 0.30-0.68, low quality of evidence). CONCLUSIONS: There was limited evidence that MIRE results in short-term improvement of tactile sensitivity probably not sustained over time. Limited evidence also suggested that MIRE does not provide relief for neuropathic pain. As quality of evidence is low, further studies are likely to change the estimated effect.


Assuntos
Neuropatias Diabéticas/terapia , Fototerapia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
14.
Clin Biomech (Bristol, Avon) ; 30(6): 521-7, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25896448

RESUMO

BACKGROUND: Exercise therapy is an evidence-based intervention for the conservative management of knee osteoarthritis. It is hypothesized that exercise therapy could reduce the knee adduction moment. A systematic review was performed in order to verify the effects of exercise therapy on the knee adduction moment in individuals with knee osteoarthritis in studies that also assessed pain and physical function. METHODS: A comprehensive electronic search was performed on MEDLINE, Cochrane CENTRAL, EMBASE, Google scholar and OpenGrey. Inclusion criteria were randomized controlled trials with control or sham groups as comparator assessing pain, physical function, muscle strength and knee adduction moment during walking at self-selected speed in individuals with knee osteoarthritis that underwent a structured exercise therapy rehabilitation program. Two independent reviewers extracted the data and assessed risk of bias. For each study, knee adduction moment, pain and physical function outcomes were extracted. For each outcome, mean differences and 95% confidence intervals were calculated. Due to clinical heterogeneity among exercise therapy protocols, a descriptive analysis was chosen. FINDINGS: Three studies, comprising 233 participants, were included. None of the studies showed significant differences between strengthening and control/sham groups in knee adduction moment. In regards to pain and physical function, the three studies demonstrated significant improvement in pain and two of them showed increased physical function following exercise therapy compared to controls. Muscle strength and torque significantly improved in all the three trials favoring the intervention group. INTERPRETATION: Clinical benefits from exercise therapy were not associated with changes in the knee adduction moment. The lack of knee adduction moment reduction indicates that exercise therapy may not be protective in knee osteoarthritis from a joint loading point of view. Alterations in neuromuscular control, not captured by the knee adduction moment measurement, may contribute to alter dynamic joint loading following exercise therapy. To conclude, mechanisms other than the reduction in knee adduction moment might explain the clinical benefits of exercise therapy on knee osteoarthritis.


Assuntos
Terapia por Exercício , Articulação do Joelho/fisiopatologia , Osteoartrite do Joelho/fisiopatologia , Osteoartrite do Joelho/terapia , Humanos , Força Muscular/fisiologia , Dor/fisiopatologia , Dor/prevenção & controle , Medição da Dor
16.
Man Ther ; 18(6): 628-31, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24188382

RESUMO

Manual therapy is an important tool for the treatment of musculoskeletal disorders of mechanical origin. Since the hip is an important structure for weight bearing as well as static and dynamic balance, it is suggested that hip impairments may affect weight distribution. Both static and dynamic balance are dependent on adequate joint mobility which in the presence of any kind of alteration can lead to modifications of plantar pressure distribution patterns which, in turn, can be detected by computerized baropodometry. The aim of this study was to verify clinical and baropodometric immediate effects of a single session of hip mobilization in a patient with chronic anterior hip pain. A physically active 21-year old patient underwent a pre-intervention assessment which included pain rating, active and passive range of movement, passive accessory movement as well as static and dynamic barodometry. The intervention consisted of an anteroposterior grade III + mobilization of the right hip, which was conducted with patient in left side-lying with the right hip flexed at approximately 45°. After the intervention, the patient's pain was reduced and there was an improvement in the active movement related to the pain generation. Baropodometric assessment showed plantar peak pressures shift on both feet, from forefoot to rear foot, and there was also reduction in anteroposterior center of pressure displacement on static recording.


Assuntos
Traumatismos em Atletas/fisiopatologia , Traumatismos em Atletas/reabilitação , Dança/lesões , Articulação do Quadril/fisiopatologia , Manipulações Musculoesqueléticas/métodos , Fenômenos Biomecânicos , Diagnóstico Diferencial , Feminino , Pé/fisiologia , Humanos , Medição da Dor , Exame Físico , Amplitude de Movimento Articular/fisiologia , Caminhada/fisiologia , Adulto Jovem
17.
J Diabetes Sci Technol ; 7(5): 1113-21, 2013 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-24124936

RESUMO

BACKGROUND: Since elevated mechanical stress along with loss of plantar protective sensation are considered relevant factors in skin breakdown resulting in diabetic foot ulcerations, the assessment of plantar pressure is important for the prevention of diabetic foot complications. Prediabetes subjects are at risk of chronic hyperglycemia complications, among them neuropathy, but information about plantar loading in this population is not available. We aimed to compare baropodometric parameters of individuals with prediabetes versus healthy persons and persons with diabetes mellitus (DM). METHODS: Baropodometric data from 73 subjects (15 with prediabetes (pre-DM), 28 with type 2 DM, 30 healthy) aged between 29 and 69 years of both genders were registered through a pressure platform with self-selected gait speed and first-step protocol. Peak plantar pressure, stance time, percentage of contact time, percentage of contact area and pressure-time integral were assessed in five plantar foot regions: heel, midfoot, metatarsals, hallux, and toes 2 to 5. Groups were compared by one-way analysis of variance with Scheffé post hoc (α = 0.05). RESULTS: Age, body mass index, gender, and arch height index did not differ between groups. Pre-DM and DM subjects presented increased peak pressure and pressure-time integral in metatarsals (p = .010; p > .001), as well as increased percentage of contact time in midfoot (p = .006) and metatarsals (p = .004) regions when compared with healthy subjects. Stance time was significantly higher (p = .017) in DM subjects. CONCLUSIONS: Pre-DM subjects seem to exhibit an altered plantar pressure distribution pattern similar to that often found in DM subjects.


Assuntos
Diabetes Mellitus/fisiopatologia , Pé Diabético/fisiopatologia , Neuropatias Diabéticas/fisiopatologia , Adulto , Idoso , Feminino , Pé/inervação , Humanos , Masculino , Pessoa de Meia-Idade , Estado Pré-Diabético , Pressão
18.
J Diabetes Sci Technol ; 7(5): 1130-7, 2013 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-24124938

RESUMO

OBJECTIVE: Infrared (IR) thermography has been used as a complementary diagnostic method in several pathologies, including distal diabetic neuropathy, by tests that induce thermoregulatory responses, but nothing is known about the repeatability of these tests. This study aimed to assess the repeatability of the rewarming index in subjects with type 2 diabetes mellitus (T2DM) and nondiabetic control subjects. METHODS: Using an IR camera, plantar IR images were collected at baseline (pre-) and 10 min after (post-) cold stress testing on two different days with 7 days interval. Plantar absolute average temperatures pre- and post-cold stress testing, the difference between them (ΔT), and the rewarming index were obtained and compared between days. Repeatability of the rewarming index after the cold stress test was assessed by Bland-Altman plot limits of agreement. RESULTS: Ten T2DM subjects and ten nondiabetic subjects had both feet analyzed. Mean age did not differ between groups (p = .080). Absolute average temperatures of plantar region pre- (p = .033) and post-cold stress test (p = .019) differed between days in nondiabetic subjects, whereas they did not differ in T2DM subjects (pretest, p = .329; post-test, p = .540). ΔT and rewarming index did not differ between days for both groups, and the rewarming index presented a 100% agreement of day-to-day measurements from T2DM subjects and 95% with nondiabetic subjects. CONCLUSIONS: The rewarming index after cold stress testing presented good repeatability between two days a week in both groups. Despite T2DM subjects presenting no differences on absolute temperature values between days, ΔT or rewarming index after cold stress testing remain recommended beside absolute temperature values for clinical use.


Assuntos
Diabetes Mellitus Tipo 2/diagnóstico , Pé Diabético/diagnóstico , Termografia/métodos , Adulto , Idoso , Feminino , Pé/irrigação sanguínea , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Reprodutibilidade dos Testes
19.
Clinics ; 67(12): 1419-1425, Dec. 2012. ilus, tab
Artigo em Inglês | LILACS | ID: lil-660470

RESUMO

OBJECTIVES: This study evaluated plantar thermography sensitivity and specificity in diagnosing diabetic polyneuropathy using cardiac tests (heart rate variability) as a reference standard because autonomic small fibers are affected first by this disease. METHODS: Seventy-nine individuals between the ages of 19 and 79 years old (28 males) were evaluated and divided into three groups: control (n = 37), pre-diabetics (n = 13) and type 2 diabetics (n = 29). The plantar images were recorded at baseline and then minutes after a provocative maneuver (Cold Stress Test) using an infrared camera that is appropriate for clinical use. Two thermographic variables were studied: the thermal recovery index and the interdigital anisothermal technique. Heart rate variability was measured in a seven-test battery that included three spectral indexes (in the frequency domain) and four Ewing tests (the Valsalva maneuver, the orthostatic test, a deep breathing test, and the orthostatic hypotension test). Other classically recommended tests were applied, including electromyography (EMG), Michigan inventory, and a clinical interview that included a neurological physical examination. RESULTS: Among the diabetic patients, the interdigital anisothermal technique alone performed better than the thermal recovery index alone, with a better sensitivity (81.3%) and specificity (46.2%). For the pre-diabetic patients, the three tests performed equally well. None of the control subjects displayed abnormal interdigital anisothermal readouts or thermal recovery indices, which precluded the sensitivity estimation in this sample of subjects. However, the specificity (70.6%) was higher in this group. CONCLUSION: In this study, plantar thermography, which predominately considers the small and autonomic fibers that are commonly associated with a sub-clinical condition, proved useful in diagnosing diabetic neuropathy early. The interdigital anisothermal test, when used alone, performed best.


Assuntos
Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Doenças do Sistema Nervoso Autônomo/diagnóstico , /diagnóstico , Pé Diabético/diagnóstico , Neuropatias Diabéticas/diagnóstico , Termografia/métodos , Diagnóstico Precoce , Eletromiografia , Métodos Epidemiológicos , Frequência Cardíaca/fisiologia
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