Versão Final

ISSN 1413-3555
Tutorial
471
Tutorial for writing systematic reviews for the Brazilian Journal of Physical Therapy (BJPT)
Marisa C. Mancini, Jefferson R. Cardoso, Rosana F. Sampaio, Lucola C. M. Costa,
Cristina M. N. Cabral, Leonardo O. P. Costa
Systematic Review
481
Static body postural misalignment in individuals with temporomandibular disorders:

a systematic review
Thas C. Chaves, Aline M. Turci, Carina F. Pinheiro, Letcia M. Sousa, Dbora B. Grossi
502
Walking training associated with virtual reality-based training increases walking speed of individuals with chronic
stroke: systematic review with meta-analysis
Juliana M. Rodrigues-Baroni, Lucas R. Nascimento, Louise Ada, Luci F. Teixeira-Salmela
Brazilian Journal of Physical Therapy
2014 Nov-Dec; 18(6)
ISSN 1413-3555
Original Articles
513
Relationship between the climbing up and climbing down stairs domain scores on the FES-DMD, the score on the Vignos
Scale, age and timed performance of functional activities in boys with Duchenne muscular dystrophy
Lilian A. Y. Fernandes, Ftima A. Caromano, Silvana M. B. Assis, Michele E. Hukuda, Mariana C. Voos, Eduardo V. Carvalho
521
Muscular performance characterization in athletes: a new perspective on isokinetic variables

Giovanna M. Amaral, Hellen V. R. Marinho, Juliana M. Ocarino, Paula L. P. Silva, Thales R. de Souza, Srgio T. Fonseca
530
Characteristics and associated factors with sports injuries among children and adolescents
Franciele M. Vanderlei, Luiz C. M. Vanderlei, Fabio N. Bastos, Jayme Netto Jnior, Carlos M. Pastre
538
Can the adapted arcometer be used to assess the vertebral column in children?
Juliana A. Sedrez, Cludia T. Candotti, Fernanda S. Medeiros, Mariana T. Marques, Maria I. Z. Rosa, Jefferson F. Loss
544
Breathing exercises: inluence on breathing patterns and thoracoabdominal motion in healthy subjects
Danielle S. R. Vieira, Liliane P. S. Mendes, Nathlia S. Elmiro, Marcelo Velloso, Raquel R. Britto, Vernica F. Parreira
553
Application of positive airway pressure in restoring pulmonary function and thoracic mobility in the postoperative
period of bariatric surgery: a randomized clinical trial
Patrcia Brigatto, Jssica C. Carbinatto, Carolina M. Costa, Maria I. L. Montebelo, Irineu Rasera-Jnior, Eli M. Pazzianotto-Forti
563
Functional priorities reported by parents of children with cerebral palsy: contribution to the pediatric rehabilitation process
Marina B. Brando, Rachel H. S. Oliveira, Marisa C. Mancini
572
Ground reaction forces during level ground walking with body weight unloading
Ana M. F. Barela, Paulo B. de Freitas, Melissa L. Celestino, Marcela R. Camargo, Jos A. Barela
2014 Nov-Dec; 18(6)
Editorial Rules
2014 Nov-Dec; 18(6)
ASSOCIAO BRASILEEIR
IRA DE PESQUISA
E PS-GRADUAO
O EM FISIOTERAPIA
FINANCIAL SUPPORT
EDITORS
Dbora Bevilaqua Grossi Universidade de So Paulo - Ribeiro Preto, SP, Brazil
Srgio Teixeira Fonseca Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
ADMINISTRATIVE EDITOR
Aparecida Maria Catai Universidade Federal de So Carlos - So Carlos, SP, Brazil
INTERNATIONAL EDITOR
David J. Magee University of Alberta - Canada
LIBRARIAN AND GENERAL COORDINATOR
Dormlia Pereira Cazella FAI/ Universidade Federal de So Carlos - So Carlos, SP, Brazil
SPECIALIST EDITORS
Ana Beatriz de Oliveira - Universidade Federal de So Carlos - So Carlos, SP, Brazil
Ana Cludia Mattiello-Sverzut Universidade de So Paulo - Ribeiro Preto, SP, Brazil
Anamaria Siriani de Oliveira Universidade de So Paulo - Ribeiro Preto, SP, Brazil
Anielle Cristhine de Medeiros Takahashi Universidade Federal de So Carlos - So Carlos, SP, Brazil
Audrey Borghi e Silva Universidade Federal de So Carlos - So Carlos, SP, Brazil
Christina Danielli Coelho de Morais Faria - Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
Elaine Caldeira de Oliveira Guirro Universidade de So Paulo - Ribeiro Preto, SP, Brazil
Francisco Albuquerque Sendin - Universidad de Salamanca Spain
Helenice Jane Cote Gil Coury Universidade Federal de So Carlos - So Carlos, SP, Brazil
Hugo Celso Dutra de Souza - Universidade de So Paulo - Ribeiro Preto, SP, Brazil
Isabel Camargo Neves Sacco Universidade de So Paulo - So Paulo, SP, Brazil
Joo Luiz Quagliotti Durigan - Universidade de Braslia Braslia, DF, Brazil
Leani Souza Mximo Pereira Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
Leonardo Oliveira Pena Costa Universidade Cidade de So Paulo - So Paulo, SP, Brazil
Luci Fuscaldi Teixeira-Salmela Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
Marisa Cotta Mancini Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
Nivaldo Antonio Parizotto Universidade Federal de So Carlos - So Carlos, SP, Brazil
Patrcia Driusso Universidade Federal de So Carlos - So Carlos, SP, Brazil
Paula Lanna Pereira da Silva Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
Paula Rezende Camargo Universidade Federal de So Carlos - So Carlos, SP, Brazil
Pedro Dal Lago Universidade Federal de Cincias da Sade de Porto Alegre - Porto Alegre, RS, Brazil
Rosana Ferreira Sampaio Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
Stela Mrcia Mattiello Universidade Federal de So Carlos - So Carlos, SP, Brazil
Tatiana de Oliveira Sato Universidade Federal de So Carlos - So Carlos, SP, Brazil
Thiago Luiz de Russo - Universidade Federal de So Carlos - So Carlos, SP, Brazil
Vernica Franco Parreira Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
BRAZILIAN EDITORIAL BOARD
Ada Clarice Gastaldi - Universidade de So Paulo - Ribeiro Preto, SP
Amlia Pasqual Marques Universidade de So Paulo - So Paulo, SP
Ana Cludia Muniz Renn Universidade Federal de So Paulo - Santos, SP
Andr Luiz Felix Rodacki Universidade Federal do Paran- Curitiba, PR
Anna Raquel Silveira Gomes Universidade Federal do Paran - Matinhos, PR
Armle Dornelas de Andrade Universidade Federal do Pernambuco - Recife, PE
Carlos Marcelo Pastre Universidade Estadual Paulista - Presidente Prudente, SP
Celso Ricardo Fernandes de Carvalho Universidade de So Paulo - So Paulo, SP
Cludia Santos Oliveira Universidade Nove de Julho - So Paulo, SP
Cristiane Shinohara Moriguchi Universidade Federal de So Carlos - So Carlos, SP
Cristina Maria Nunes Cabral Universidade Cidade de So Paulo - So Paulo, SP
Daniela Cristina Carvalho de Abreu Universidade de So Paulo - Ribeiro Preto, SP
Dirceu Costa Universidade Nove de Julho - So Paulo, SP
Ester da Silva Universidade Federal de So Carlos - So Carlos, SP
Fbio de Oliveira Pitta Universidade Estadual de Londrina - Londrina, PR
Fbio Viadanna Serro Universidade Federal de So Carlos - So Carlos, SP
Ftima Valria Rodrigues de Paula Universidade Federal de Minas Gerais - Belo Horizonte, MG
Guilherme Augusto de Freitas Fregonezi Universidade Federal do Rio Grande do Norte - Natal, RN
Jefferson Rosa Cardoso Universidade Estadual de Londrina - Londrina, PR
Joo Carlos Ferrari Corra Universidade Nove de Julho - So Paulo, SP
Jos Angelo Barela Universidade Cruzeiro do Sul - So Paulo, SP
Josimari Melo de Santana Universidade Federal de Sergipe - Aracaj, SE
Juliana de Melo Ocarino Universidade Federal de Minas Gerais - Belo Horizonte, MG
Lucola da Cunha Menezes Costa Universidade Cidade de So Paulo - So Paulo, SP
Luis Vicente Franco de Oliveira Universidade Nove de Julho - So Paulo, SP
Luiz Carlos Marques Vanderlei Universidade Estadual Paulista - Presidente Prudente, SP
Luzia Iara Pfeifer Universidade de So Paulo - Ribeiro Preto, SP
Marco Aurlio Vaz Universidade Federal do Rio Grande do Sul - Porto Alegre, RS
Naomi Kondo Nakagawa Universidade de So Paulo - So Paulo, SP
Nelci Adriana Cicuto Ferreira Rocha Universidade Federal de So Carlos - So Carlos, SP
Paulo de Tarso Camillo de Carvalho Universidade Nove de Julho - So Paulo, SP
Raquel Rodrigues Britto Universidade Federal de Minas Gerais - Belo Horizonte, MG
Renata Noce Kirkwood Universidade Federal de Minas Gerais - Belo Horizonte, MG
Ricardo Oliveira Guerra Universidade Federal do Rio Grande do Norte - Natal, RN
Richard Eloin Liebano Universidade Cidade de So Paulo - So Paulo, SP
Rinaldo Roberto de Jesus Guirro Universidade de So Paulo - Ribeiro Preto, SP
Rosana Mattioli Universidade Federal de So Carlos - So Carlos, SP
Rosimeire Simprini Padula Universidade Cidade de So Paulo - So Paulo, SP
Sara Lcia Silveira de Menezes Centro Universitrio Augusto Motta - Rio de Janeiro, RJ
Simone Dal Corso Universidade Federal do Rio Grande do Sul - Porto Alegre, RS
Stella Maris Michaelsen Universidade do Estado de Santa Catarina - Florianpolis, SC
Tania de Ftima Salvini Universidade Federal de So Carlos - So Carlos, SP
Thas Cristina Chaves Universidade de So Paulo - Ribeiro Preto, SP
INTERNATIONAL EDITORIAL BOARD
Alan M. Jette Boston University School of Public Health - USA
Chukuka S. Enwemeka University of Wisconsin - USA
Edgar Ramos Vieira Florida International University - USA
Gert-Ake Hansson Lund University - SWEDEN
Janet Carr University of Sydney - AUSTRALIA
Kenneth G. Holt Boston University - USA
LaDora V. Thompson University of Minnesota - USA
Liisa Laakso Grifith University - AUSTRALIA
Linda Fetters University of Southern California - USA
Paula M. Ludewig University of Minnesota - USA
Rik Gosselink Katholieke Universiteit Leuven - BELGIUM
Rob Herbert The George Institute for International Health - AUSTRALIA
Sandra Olney Queens University - CANADA
Braz J Phys Ther. 2014 Nov-Dec; 18(6):471-579
The Brazilian Journal of Physical Therapy is published by the Associao Brasileira de Pesquisa e PsGraduao em Fisioterapia ABRAPG-Ft (Brazilian Association for Research and Graduate Studies
in Physical Therapy). Published since 1996, the Brazilian Journal of Physical Therapy adopts a peer
review process. Each article is only published after it is accepted by the reviewers, who are maintained
anonymous during the process.
The editors accept no responsibility for damage to people or property, which may have been caused by
the use of ideas, techniques or procedures described in the material published by this journal.
The submission of articles presupposes that these articles, with the exception of extended summaries,
have not been previously published elsewhere, nor submitted to any other publication.
The abbreviated title of the journal is Braz J. Phys. Ther. and this must be used in references, footnotes
and bibliographic legends.
The Brazilian Journal of Physical Therapy is freely accessible at the homepage on the web:
http://www.scielo.br/rb is.
Mission
To publish original research articles on topics related to the areas of physical therapy and rehabilitation
sciences, including clinical, basic or applied studies on the assessment, prevention, and treatment of
movement disorders.
Indexed in
Cataloguing Card
Brazilian Journal of Physical Therapy / Associao Brasileira de Pesquisa
e Ps-Graduao em Fisioterapia. v. 1, n. 1 (1996). So Carlos: Editora
Cubo, 1996v. 18, n. 6 (Nov/Dec 2014).
Bimonthly
Continued Revista Brasileira de Fisioterapia
ISSN 1413-3555
1. Physical Therapy. 2. Studies. I. Associao Brasileira de Pesquisa e
Ps-Graduao em Fisioterapia.
Librarian: Dormlia Pereira Cazella (CRB 8/4334)
Contact Address

Rod. Washington Lus, Km 235,
Caixa Postal 676, CEP 13565-905
So Carlos, SP - Brasil
+55(16) 3351-8755
contato@rbf-bjpt.org.br
www.rbf-bjpt.org.br
Technical and Administrative Support
Ana Paula de Luca

Leonor A. Saidel Aizza
Raquel Mariane da Silveira
Desktop Publishing and Editorial Consulting
Printed in acid free paper.

No part of this publication can be reproduced or transmitted by any media, be it electronic, mechanical or photocopy,
without the express authorization of the editors.
summary
Tutorial
471
Systematic Review
481

a systematic review
502
Walking training associated with virtual reality-based training increases walking speed of
individuals with chronic stroke: systematic review with meta-analysis
Original Articles
513
Relationship between the climbing up and climbing down stairs domain scores on the FESDMD, the score on the Vignos Scale, age and timed performance of functional activities in
boys with Duchenne muscular dystrophy
Lilian A. Y. Fernandes, Ftima A. Caromano, Silvana M. B. Assis, Michele E. Hukuda,
Mariana C. Voos, Eduardo V. Carvalho
521

530
538
544
Breathing exercises: inluence on breathing patterns and thoracoabdominal motion in

healthy subjects
553
Application of positive airway pressure in restoring pulmonary function and thoracic

mobility in the postoperative period of bariatric surgery: a randomized clinical trial
Patrcia Brigatto, Jssica C. Carbinatto, Carolina M. Costa, Maria I. L. Montebelo,
Irineu Rasera-Jnior, Eli M. Pazzianotto-Forti
563
Functional priorities reported by parents of children with cerebral palsy: contribution to

the pediatric rehabilitation process
572
Editorial Rules
tutorial
Tutorial for writing systematic reviews for the

Brazilian Journal of Physical Therapy (BJPT)
Tutorial para elaborao de revises sistemticas para o
Brazilian Journal of Physical Therapy (BJPT)
Marisa C. Mancini1, Jefferson R. Cardoso2, Rosana F. Sampaio3,
Lucola C. M. Costa4, Cristina M. N. Cabral4, Leonardo O. P. Costa4,5
ABSTRACT | Systematic reviews aim to summarize all evidence using very rigorous methods in order to address a specific
research question with less bias as possible. Systematic reviews are widely used in the field of physical therapy, however
not all reviews have good quality. This tutorial aims to guide authors of the Brazilian Journal of Physical Therapy on
how systematic reviews should be conducted and reported in order to be accepted for publication. It is expected that
this tutorial will help authors of systematic reviews as well as journal editors and reviewers on how to conduct, report,
critically appraise and interpret this type of study design.
Keywords: rehabilitation; physical therapy; literature review; systematic review; meta analysis.
HOW TO CITE THIS ARTICLE
Mancini MC, Cardoso JR, Sampaio RF, Costa LCM, Cabral CMN, Costa LOP. Tutorial for writing systematic reviews for the Brazilian
Journal of Physical Therapy (BJPT). Braz J Phys Ther. 2014 Nov-Dec; 18(6):471-480. http://dx.doi.org/10.1590/bjpt-rbf.2014.0077
RESUMO | Revises sistemticas tm como objetivo sumarizar toda a evidncia disponvel, atravs de mtodos
rigorosos, para responder a uma pergunta de pesquisa especfica com o mnimo de vis possvel. Revises sistemticas
so amplamente utilizadas na fisioterapia, porm nem todas as revises possuem boa qualidade. Esse tutorial tem
como objetivo guiar os autores do Brazilian Journal of Physical Therapy sobre como revises sistemticas deveriam
ser conduzidas e descritas para que sejam aceitas para publicao. Espera-se que esse tutorial ir auxiliar autores de
revises sistemticas, assim como editores e revisores de peridicos em como conduzir, descrever, fazer anlise crtica
e interpretar esse tipo de delineamento de pesquisa.
Palavras-chave: reabilitao; fisioterapia; reviso da literatura; revises sistemticas; metanlise.
Introduo
Uma reviso de literatura pode ser definida
como sntese e anlise da informao com foco nas
contribuies cientficas dos estudos publicados1. Tais
estudos no se restringem simplesmente a citaes
bibliogrficas e servem para estabelecer novas
concluses1. Esse conceito no novo, h snteses
do conhecimento que remontam ao incio do sculo
passado1,2. Na dcada de 60, estudos j integravam
resultados de pesquisas e apontavam novas evidncias
cientficas, principalmente nas cincias sociais,
educao e psicologia. O reconhecimento da
importncia da aplicao da melhor informao
cientfica disponvel no campo da sade trouxe
a necessidade de se ancorar a prtica clnica em
evidncias e, consequentemente, um aumento

gradativo da demanda por esse tipo de informao2.
Evidncia refere-se ao conjunto de
informaes utilizadas para confirmar ou
negar uma teoria ou hiptese cientfica e
produzida por um processo sistemtico de
investigao1.
Apesar da reconhecida caracterstica cumulativa
da cincia, os mtodos estatsticos para sintetizar
evidncias s foram desenvolvidos no sculo
XX. Concomitante a esses avanos, os cientistas
reconheceram que organizar e avaliar a informao
cientfica acumulada ultrapassa a simples escolha
do mtodo. Tem sido destacada, desde ento, a
Programa de Ps-graduao em Cincias da Reabilitao, Departamento de Terapia Ocupacional, Escola de Educao Fsica, Fisioterapia e Terapia
Ocupacional (EEFFTO), Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brasil
2
Laboratrio de Biomecnica e Epidemiologia Clnica, Grupo PAIFIT, Universidade Estadual de Londrina (UEL), Londrina, PR, Brasil
3
Programa de Ps-graduao em Cincias da Reabilitao, Departamento de Fisioterapia, EEFFTO, UFMG, Belo Horizonte, MG, Brasil
4
Programa de Mestrado e Doutorado em Fisioterapia, Universidade Cidade de So Paulo (UNICID), So Paulo, SP, Brasil
5
Musculoskeletal Division, The George Institute for Global Health, Sydney, NSW, Australia
Received: 12/02/2014 Revised: 12/04/2014 Accepted: 12/05/2014
1
http://dx.doi.org/10.1590/bjpt-rbf.2014.0077
471
Mancini MC, Cardoso JR, Sampaio RF, Costa LCM, Cabral CMN, Costa LOP
necessidade de maior rigor metodolgico para garantir

a validade dos estudos de reviso, assim como se exige
para os estudos considerados primrios3.
H consenso de que a sntese do conhecimento
fundamental para o avano da prtica, da pesquisa e
para a implementao de polticas de sade. No entanto,
sintetizar o conhecimento de forma clara e precisa exige
habilidades e competncias especficas do pesquisador.
Investigar e selecionar todos os estudos relevantes,
avaliar a sua qualidade e sintetizar dados so alguns dos
desafios presentes na elaborao desse tipo de estudo4.
Passos comuns aos mtodos de sntese
do conhecimento: a) uma clara definio
do objetivo; b) desenvolvimento de um
protocolo metodolgico; c) estratgias
abrangentes de busca para encontrar todos
os artigos relevantes; d) um mtodo de
avaliao do potencial risco de vis nos
estudos individuais e e) detalhamento
da coleta de dados e dos procedimentos
empregados4.
Uma variedade de termos tem sido usada para
descrever os processos de integrao das evidncias:
pesquisa-sntese, reviso sistemtica, reviso integrativa,
meta-anlise, entre outros1. A crescente popularidade
desse tipo de estudo ilustrada pelo fato de que muitos
profissionais, para manterem-se atualizados, escolhem
a leitura de estudos de reviso da literatura. Entre os
diferentes tipos de estudos que disponibilizam snteses de
evidncias cientficas, as revises sistemticas cumprem
critrios rigorosos de avaliao e produzem concluses
slidas e aplicveis prtica clnica. Alm disso, revises
sistemticas podem apontar importantes lacunas no
conhecimento e servir de argumento para sinalizar a
necessidade de novos estudos.
Diretrizes, reporting guidelines e checklists
visam a normatizar o processo de elaborao de
revises sistemticas, desde a avaliao dos estudos
selecionados at a estrutura final de comunicao
dos resultados5. Cabe ao pesquisador escolher, entre
as regras e normas existentes, aquelas que melhor
se adequam ao tema a ser investigado e ao peridico
selecionado para submisso do seu trabalho.
Exemplos de diretrizes e reporting guidelines
para estudos de reviso sistemtica:
Cochrane Handbook, encontrado em http://
www.cochrane.org/handbook e PRISMA,
www.prisma-statement.org/, entre outros.
Os primeiros ensaios clnicos em Fisioterapia
foram estudos que avaliaram os efeitos da irradiao
ultravioleta em crianas escolares e em crianas com
problemas respiratrios, publicados, respectivamente,
472
por Colebrook6 em 1929 e por Doull et al.7 em 1931.

A primeira reviso sistemtica na rea8 estabeleceu os
efeitos dos tratamentos sobre as leses ligamentares
do tornozelo, tendo sido publicada pelo sueco
Kolind-Sorensen9 em 1975. Desde ento, tem havido
um crescimento exponencial desse tipo de estudo
em Fisioterapia. Torna-se, assim, imprescindvel
que os peridicos cientficos envidem esforos no
sentido de definir regras claras que possam ajudar os
pesquisadores a alcanarem a qualidade exigida para
publicao desse tipo de estudo, disponibilizando
informao cientfica para o avano do conhecimento.
Fazendo eco a esse movimento internacional e
buscando manter uma vigilncia epistemolgica
sobre a pesquisa em Fisioterapia e em outras reas
da sade, o Brazilian Journal of Physical Therapy
(BJPT) preparou o presente tutorial. Ele busca
alinhar qualitativamente os seus estudos de reviso
sistemtica, prezando pelo cuidado com as condies
e limites das tcnicas e conceitos empregados nesse
processo.
O que reviso sistemtica e metaanlise?

Reviso sistemtica, segundo o Handbook da
Colaborao Cochrane10, um estudo secundrio
que tem por objetivo reunir estudos semelhantes,
publicados ou no, avaliando-os criticamente
quanto validade interna e reunindo-os em uma
anlise estatstica, quando possvel. Ainda, a reviso
sistemtica visa a minimizar os vieses usando mtodos
explcitos e pontuais. O mtodo estatstico utilizado
para integrar os resultados dos estudos includos em
revises sistemticas chamado de meta-anlise8.
Muitas vezes, os termos meta-anlise
e reviso sistemtica so usados
equivocadamente ou de forma alternada.
A agregao estatstica dos dados numa
meta-anlise no significa que os estudos
individuais tenham sido criteriosamente
analisados. Dessa forma, as revises
sistemticas podem ser desenvolvidas
com e sem meta-anlise. A distino entre
reviso sistemtica e meta-anlise muito
importante, pois sempre possvel revisar
de forma sistemtica um conjunto de
dados (com critrios para avaliao do
risco de vis dos estudos que compem a
reviso), porm, algumas vezes, pode ser
inapropriado, ou mesmo enganoso, realizar
a agregao estatstica dos resultados de
estudos independentes.
Tutorial reviso sistemtica
De forma geral, a sntese resultante de uma reviso

sistemtica fornece a melhor evidncia sobre o tema
em questo, tais como os efeitos de uma interveno
sobre determinado desfecho, a incidncia de uma
doena ou a acurcia de um teste diagnstico, entre
outros temas.
Em uma reviso sistemtica, necessrio:
estipular uma pergunta clnica; determinar
as fontes e mtodos de seleo dos estudos,
como bases de dados (i.e., bibliogrficas,
referenciais e textuais) e estratgias de
busca empregadas; selecionar estudos
com mtodos semelhantes; realizar
avaliaes de possveis vieses e explicitar
mecanismos de avaliao da validade dos
estudos selecionados; preparar snteses
para apresentaes/disseminaes (tanto
qualitativas descries dos estudos, como
quantitativas meta-anlises , quando
apropriado)10.
As revises sistemticas so consideradas estudos
secundrios porque, em outras palavras, resumem as
informaes de mltiplas publicaes consideradas
primrias, como estudos de tratamento e preveno
(ensaios controlados aleatorizados-ECAs), estudos
de prognstico (coorte), estudos de diagnstico
(acurcia), estudos de etiologia (caso-controle), entre
muitos outros. As revises sistemticas mais comuns
so as de tratamento, que avaliam e/ou comparam a
eficcia ou a efetividade de diferentes abordagens,
sejam exerccios, medicamentos ou cirurgias,
ou outras modalidades teraputicas. A qualidade
desse tipo de reviso deve ser assegurada para que
profissionais, pacientes e agncias reguladoras em
sade possam tomar decises mais assertivas.
Neste tutorial, sero enfatizadas as revises
de tratamento/preveno que utilizam os ECAs.
Esse modelo de estudo leva em considerao que
os participantes foram aleatorizados ou tiveram a
mesma chance de participar em um dos grupos de
tratamento propostos. Um exemplo desse tipo de
reviso foi a avaliao da efetividade de um programa
de exerccios (i.e., principalmente de fortalecimento
e de amplitude de movimento) e outros recursos
(i.e., termoterapia, estimulao eltrica, faixas
compressivas etc.) para pacientes submetidos
meniscectomia parcial artroscpica. A busca dos
estudos publicados foi realizada de 1950 a 2013, e
18 ECAs foram includos na reviso, mas apenas
seis participaram da anlise estatstica, ou seja, da
meta-anlise. Como concluso, os autores indicaram
que a realizao dos procedimentos de fisioterapia

ambulatorial citados acima associados s orientaes
para execuo em domiclio melhorou a funo
do joelho, relatada pelo paciente, e a amplitude de
movimento de flexo e extenso dessa articulao,
quando comparada aos procedimentos de fisioterapia
apenas ambulatorial11.
H estruturas bem estabelecidas para nortear
a comunicao de um ECA (www.consortstatement.org) e de uma reviso sistemtica
(www.prisma-statement.org/ e Handbook da
Colaborao Cochrane10).
Em sntese, toda reviso sistemtica envolve
uma anlise criteriosa da qualidade dos estudos, e
algumas delas empregam meta-anlise. Na anlise
de risco de vis, so observadas a validade interna, a
validade externa e as anlises estatsticas empregadas
em cada um dos estudos selecionados. A metaanlise, por sua vez, um procedimento sistemtico
e rigoroso, passvel de ser reproduzido por outros
pesquisadores e que permite combinar os resultados
dos diferentes estudos. A meta-anlise ajusta ou
pondera os resultados levando em considerao o
tamanho amostral de cada estudo primrio, podendo
ainda ser ajustada para outros fatores, tais como o
risco de vis de cada estudo.
Tipos de reviso sistemtica

importante salientar que diversas perguntas de
pesquisa podem ser sintetizadas em uma reviso
sistemtica. Provavelmente, o tipo mais comum
e popular de reviso sistemtica aquela que tem
como objetivo medir o efeito de alguma interveno
(i.e., reviso sistemtica de ECAs). Porm,
revises sistemticas podem ser extremamente
teis para resumir outras perguntas clnicas, como:
prevalncia12, incidncia13, fatores prognsticos14,
acurcia diagnstica15, custo-efetividade16, fatores
de risco 17, definio de termos de pesquisa 18,
adaptaes transculturais de questionrios 19 ,
propriedades de medida de instrumentos de
mensurao 20 e ainda revises sistemticas de
estudos qualitativos21,22.
Um problema decorrente de todas essas
possibilidades que o autor deve identificar qual
delineamento de estudo deve ser utilizado para cada
tipo de reviso sistemtica. Embora isso parea
bvio, esse tem sido um dos principais problemas
identificados no processo de reviso por pares de
manuscritos de reviso sistemtica submetidos
473
ao BJPT. Nesse caso, o autor deve sempre optar

pelo delineamento ideal para cada tipo de pergunta
cientfica.
Opes mais adequadas de delineamento
seriam ensaios controlados aleatorizados para
revises com o objetivo de medir efeitos de
interveno, estudos de coorte longitudinal
prospectivos para revises prognsticas ou
de fatores de risco ou estudos transversais
para revises de prevalncia.
Em alguns tipos de pergunta, possvel que o
uso de diferentes delineamentos de pesquisa seja
adequado. Um exemplo seria uma reviso sistemtica
de acurcia diagnstica que pode permitir a incluso
de estudos de caso-controle, estudos transversais e at
mesmo ensaios clnicos, em alguns casos. Deve-se
ter em mente que a combinao de delineamentos
distintos muito mais uma exceo do que uma regra.
Itens essenciais de uma reviso

sistemtica
As revises sistemticas vo diferir muito em
relao pergunta de pesquisa, assim como na
elegibilidade dos tipos de estudos. Certas regras so
obrigatrias em algumas revises e irrelevantes em
outras. No entanto, existem itens que so essenciais
e que devem estar presentes em todas as revises,
a saber:
1. Definio clara da pergunta de pesquisa:
uma boa reviso no aquela que responde
a vrias perguntas, mas aquela que responde
a perguntas especficas de forma clara e
com o mnimo de vis possvel. Sendo
assim, a definio da pergunta de pesquisa
essencial. Uma orientao para delimitar
bem uma pergunta para revises sistemticas
de interveno usar a estrutura do
PICO (Patient, Intervention, Comparison
and Outcomes (Pacientes, Interveno,
Comparao e Desfechos). Por exemplo:
as tcnicas de terapia manual associadas
a um programa de exerccios (Interveno)
so melhores que somente exerccios
(Comparao) para a reduo da dor e
incapacidade funcional (Desfechos) em
pacientes adultos com dor lombar crnica
(Pacientes)? A redao de perguntas pode
fazer uso da estrutura PICO de forma flexvel,
por exemplo, deixar o termo de comparao
ser conhecido posteriormente na reviso:
quais so os efeitos da mobilizao articular
474
(Interveno) na melhora da amplitude de

movimento, dor e incapacidade (Desfechos)
em pacientes que receberam imobilizao
no tornozelo (Pacientes)? Nesse caso, os
grupos de comparao seriam qualquer tipo
de grupo controle possvel. Outra forma
de flexibilizar a estrutura PICO quando a
reviso no avalia o efeito de interveno;
nesse caso, o termo I atribudo ao foco
do estudo (vide tipos de reviso sistemtica
acima).
Para a redao de uma pergunta de pesquisa
clara:
a) essencial que o pesquisador defina
claramente a interveno (ou o foco do
estudo), os desfechos e a amostra de
interesse. Esses trs itens so fundamentais
na formulao de uma pergunta clnica.
b) recomendado que o autor, ao formular
sua pergunta de um estudo de interveno,
busque identificar a interveno de
forma especfica (i.e., exerccio resistido,
orientao para cuidadores etc.), ao invs de
denominar a(s) interveno(es) testada(s)
no estudo como sendo a profisso ou rea
(i.e., Fisioterapia, Reabilitao).
c) Outros tipos de reviso sistemtica que
no de estudos de interveno devem seguir
os mesmos princpios de elaborao de uma
pergunta de pesquisa: perguntas claras,
diretas e bem formuladas.
d) Uma pergunta bem formulada tambm
ir guiar vrios aspectos do processo de
elaborao de uma reviso sistemtica,
incluindo as estratgias de busca,
elegibilidade dos estudos, extrao de dados
e concluses da reviso.
2. Definio dos artigos elegveis: uma vez
formulada a pergunta de pesquisa, o autor
deve definir, a priori, os critrios de incluso
e excluso dos artigos que sero considerados
elegveis para a reviso. Essa definio
passa pelo delineamento dos estudos a serem
includos, caractersticas intrnsecas de cada
estudo (i.e., amostra, tipos de tratamento,
durao dos sintomas, equipamentos utilizados,
entre outros), intervalo de tempo da publicao
a ser considerado e idioma da publicao.
Idealmente, artigos no deveriam ser excludos
com base no perodo de publicao, risco de
vis e idioma de publicao.

3. Certificao de que todos os artigos elegveis
foram encontrados8,23: uma das tarefas mais
difceis de uma reviso, pois ela deve sintetizar,
de preferncia, TODA a evidncia disponvel.
Sendo assim, as buscas devem ser realizadas
no maior nmero de bases de dados possvel.
Isso, muitas vezes, representa um problema
para alguns pesquisadores, uma vez que, muitas
dessas bases de dados, no so de acesso livre.
Alguns exemplos so EMBASE, CINAHL,
MEDLINE, PSYCHINFO. importante
salientar que somente 14 revistas de Fisioterapia
esto indexadas no PubMed (que a verso
gratuita do MEDLINE) e, portanto, grande a
probabilidade de se perderem artigos realizando
buscas somente em bases de acesso livre.
O mesmo raciocnio deve ser usado para o
idioma das bases acessadas: muitos autores
buscam em vrias bases nacionais, como
SCIELO e LILACS. Porm, essas bases
indexam somente artigos em portugus e
espanhol, que equivalem a menos de 2% da
literatura cientfica mundial24.
Alm do cuidado com a seleo das bases,
outro item fundamental para que todos os
artigos sejam encontrados formular uma
estratgia de busca eficiente. Estratgia de
busca se faz com os descritores adequados,
que modificam de acordo com cada base
e seus operadores booleanos (AND,
OR e NOT). Uma estratgia eficiente
aquela que captura todos os artigos
potencialmente elegveis (i.e., busca com
alta sensibilidade), mas que tambm elimina
artigos no relevantes (i.e., busca com alta
especificidade).
4. Apresentao clara dos aspectos relacionados
extrao de dados: aps a definio dos artigos
elegveis, fundamental que o autor apresente
claramente os dados que sero extrados de
cada artigo, afinal, esses dados determinaro os
resultados da reviso.
5. Avaliao do risco de vis dos artigos elegveis:
existem vrias escalas que avaliam o risco de
vis de vrios tipos de delineamento de estudos.
Esse vis est relacionado ao erro sistemtico
que pode ocorrer nos ECAs. Exemplos incluem:
seleo (selection), performance (performance),
deteco (detection), atrito (attrition), relato
(reporting), entre outros. fundamental que as
concluses de uma reviso sistemtica sejam

ponderadas de acordo com o risco de vis
apresentado nos artigos.
Entre os instrumentos disponveis para avaliao
do risco de vis de ECAs includos em uma
reviso sistemtica esto a escala de qualidade
PEDro24 e o instrumento de avaliao do risco
de vis da Cochrane25. A escala PEDro avalia a
qualidade metodolgica e a descrio estatstica
dos estudos. composta pelos seguintes itens:
especificao dos critrios de elegibilidade;
distribuio aleatria dos sujeitos por grupos;
alocao secreta; semelhana entre os grupos
com respeito aos indicadores de prognstico
mais importantes; cegamento dos sujeitos,
terapeutas e avaliadores; mensuraes de, pelo
menos, um resultado-chave em mais de 85% dos
sujeitos aleatorizados; tratamento ou condio
de controle recebida conforme alocao ou
anlise de dados por inteno de tratamento;
resultados das comparaes estatsticas
intergrupos descritos para pelo menos um
resultado-chave e apresentao de medidas de
preciso e variabilidade para, pelo menos, um
resultado-chave24. A avaliao do risco de vis
da Cochrane considera a gerao da sequncia
aleatria; ocultao de alocao; cegamento
de participantes, profissionais e avaliadores
de desfecho; desfechos incompletos; relato de
desfecho seletivo; similaridade dos grupos na
linha de base; realizao de cointervenes;
similaridade das intervenes; anlise por
inteno de tratamento; momento de avaliao
dos desfechos e outras fontes de vis25,26.
possvel observar que ambos os instrumentos
so bem similares, com exceo da avaliao
do risco de performance e de deteco, que
realizada pela avaliao do risco de vis da
Cochrane.
6. Sntese dos resultados: h duas formas de
apresentar os resultados de uma reviso
sistemtica: 1) por meio de meta-anlise (esse
tpico ser descrito na prxima seo) ou 2) de
forma descritiva. Esses resultados devem ser
sintetizados levando-se em considerao no
somente o resultado dos estudos, mas tambm o
risco de vis de cada um dos estudos includos
na reviso.
7. Discusso: Espera-se que uma reviso
sistemtica apresente uma discusso que
aborde, pelo menos, os seguintes aspectos27:
475
1) apresentar os principais resultados e

explicar o significado dos mesmos; 2)
comparar os resultados encontrados com
os j existentes na literatura e apresentar
argumentos para semelhanas e diferenas;
3) identificar os pontos fortes e as limitaes
da reviso; 4) apresentar aspectos na
literatura que nunca foram investigados ou
no foram investigados de forma apropriada,
direcionando o rumo/tema de novos estudos
e 5) disponibilizar as implicaes para a
prtica clnica, tanto para pacientes quanto
para profissionais e gestores de sade.
Detalhamento de uma meta-anlise

fundamental salientar que a meta-anlise serve
para se obter o efeito combinado de um tratamento28.
Na realizao de uma meta-anlise, importante
atentar para a homogeneidade dos procedimentos
adotados pelos autores dos ECAs, ou seja, as
caractersticas dos estudos, como: a avaliao do
risco de vis, as caractersticas de implementao
do(s) tratamento(s) que se pretende(m) avaliar, por
exemplo, se a intensidade, frequncia e durao
(i.e., dos exerccios ou outras intervenes) foram
similares, bem como a forma como as variveis ou
desfechos clnicos foram medidos ou classificados.
Se a reviso for realizada de forma adequada, com
uma estratgia de busca coerente com a pergunta
e que gere um conjunto de estudos razoavelmente
completo sobre o tema e sem vis e, considerando
que os estudos primrios sejam vlidos, ento
a meta-anlise tambm ir abordar a pergunta
pretendida. Por outro lado, se a estratgia de busca
for inadequada nos conceitos ou na sua execuo ou
se os estudos apresentarem resultados tendenciosos,
os problemas da reviso no podero ser corrigidos
com a meta-anlise29.
Na leitura de uma meta-anlise, importante
compreender quatro pontos de sua estrutura28,29,
indicados no quadro abaixo.
A apresentao dos resultados de uma
meta-anlise deve permitir ao leitor
compreender29:
1. Qual foi a medida sumria utilizada?
2. O que o forest plot demonstra?
3. O que o efeito agregado (efeito mdio)
informa?
4. vlido combinar os estudos?
476
1. A medida sumria da meta-anlise

Como a meta-anlise faz a sntese estatstica do
efeito de interesse, importante compreender
a natureza dos dados que so combinados, se
categricos ou contnuos. Em acrscimo, o
efeito, em cada estudo, pode ser apresentado de
formas distintas (i.e., por meio das mdias das
diferenas, mdias das diferenas padronizadas,
razo de chance, risco relativo, entre outras
medidas de efeito).
As variveis desfecho de estudos individuais
(primrios) podem ser numricas (i.e.,
amplitude de movimento em graus,
presso inspiratria mxima em mmHg) ou
categricas (i.e., classificao da gravidade
da doena, presena ou ausncia de melhora
da funcionalidade, nmero de pacientes que
obtiveram melhora etc.).
2. O grfico de forest plot10
A representao grfica das medidas dos efeitos
de cada estudo individual, assim como a dos
efeitos combinados, denominada forest plot. O
termo forest foi criado porque o grfico parece
uma floresta de linhas. A linha vertical central
do forest plot indica quando no h diferena(s)
estatisticamente significativa(s) entre os grupos.
Os pontos representam as mdias das diferenas
de cada estudo e as linhas horizontais, os
intervalos de confiana ao redor das mdias
das diferenas. O losango, tambm chamado
de diamante, representa a mdia combinada
de todos os efeitos dos estudos da comparao
analisada pela meta-anlise. A interpretao de
uma figura forest plot simples: se o diamante
ou os intervalos de confiana tocarem a linha
central do grfico, indica que no h diferena
estatisticamente significativa entre os grupos.
Por outro lado, se o diamante no tocar a linha
central, h diferena significativa entre os grupos
analisados. Todo forest plot contm tambm os
valores numricos descritos, o que permite que
os leitores possam interpretar se as diferenas
observadas so clinicamente importantes ou
no. Finalmente, o forest plot pode informar,
a critrio dos autores ou da revista, o peso de
cada estudo individual na formao final do
efeito combinado, assim como apresenta dados
estatsticos sobre a heterogeneidade dos dados.
Abaixo encontram-se trs forest plots
recentemente publicados no BJPT30 (Figura 1).
Esses forest plots fazem parte de uma reviso
sistemtica que comparou os efeitos dos
Figura 1. Grficos Forest Plots publicados em: Miyamoto et al.30, pag. 525. Reproduzidos com permisso.
exerccios de Pilates em pacientes com dor

lombar. Os grficos A e C comparam Pilates
com interveno mnima (i.e., cartilhas
educativas) para os desfechos intensidade
da dor e incapacidade, respectivamente, e o
grfico B compara Pilates com outros tipos
de exerccios. Observa-se que o diamante no
toca a linha central dos grficos A e C, mas
toca a linha central no grfico B. A concluso
dessas meta-anlises que Pilates superior
a interveno mnima, mas no melhor que
outras modalidades de exerccios para pacientes
com dor lombar.
3. O efeito mdio
O efeito mdio (em ingls pooled effect)
representa o efeito combinado de todos os
estudos individuais em cada comparao. Esse
efeito leva em considerao os efeitos de cada
estudo, sendo que a estimativa do intervalo de
confiana ponderada pelo tamanho amostral
de cada um deles.
4. vlido combinar os estudos?

Nem sempre possvel combinar os resultados
reportados pelos estudos10,28. importante
que o pesquisador s combine estudos
homogneos do ponto de vista clnico (i.e.,
intervenes similares com doses muito
parecidas), que tenham medido os desfechos
de forma similar, que tenham utilizado grupos
controle semelhantes e cujos dados sejam
matematicamente homogneos. Se qualquer
uma das premissas acima for violada, uma
meta-anlise no deve ser realizada.
H debate sobre a avaliao de
heterogeneidade dos estudos em uma metaanlise. Sugerimos consultar o livro de
Borenstein et al.28 e o prprio Handbook da
Cochrane10. A Cochrane tem um programa
gratuito (http://tech.cochrane.org/revman/
download) que serve para a realizao das
revises sistemticas e das meta-anlises.
477
Avaliao da qualidade de uma

reviso sistemtica da literatura
A avaliao da qualidade de uma reviso sistemtica
inclui diversos parmetros, tais como a qualidade
dos estudos selecionados (i.e., risco de vis) e sua
homogeneidade ou heterogeneidade metodolgica
(i.e., semelhana das caractersticas amostrais,
instrumentao e mensurao dos desfechos, formas
de administrao da interveno, heterogeneidade
estatstica etc.), bem como caractersticas da sua
estrutura (i.e., clareza e pertinncia da pergunta,
adequao da estratgia de busca, clareza e validade
das concluses etc.). Autores interessados em
desenvolver uma reviso sistemtica devem buscar
informaes para que o estudo seja conduzido com
mximo rigor metodolgico, de tal forma que o
produto atenda aos critrios de qualidade.
Nesse sentido, o BJPT tem se empenhado em
manter a qualidade dos estudos de reviso sistemtica
publicados. No perodo entre 2012 e 2014, 77
estudos de reviso sistemtica foram submetidos, dos
quais sete foram publicados, trs encontram-se em
tramitao, 27 foram arquivados por no atenderem
s normas do BJPT, e 40 foram recusados. Isso
significa que 87% dos manuscritos submetidos no
atenderam a critrios de qualidade para publicao
no BJPT, nesse perodo. Segundo anlise realizada,
os principais motivos que pautaram a deciso
editorial de recusa foram: problemas metodolgicos
na conduo e descrio do estudo (incluindo no
ateno estrutura do PRISMA31); o estudo se intitula
reviso sistemtica, mas no atende s caractersticas
da estrutura de uma reviso sistemtica; o estudo
no traz contribuio para a rea e/ou est fora do
escopo do BJPT. Em concordncia, o peridico
Physical Therapy realiza uma avaliao inicial de
todos os artigos de reviso sistemtica submetidos, e
os motivos que mais levam rejeio imediata, sem
envio para revisor ad-hoc, so: 1) no est baseada
numa pergunta de pesquisa clara e objetiva, 2) no
tem grande utilidade clnica ou est fora do escopo
da Fisioterapia, 3) as buscas dos artigos elegveis
no so consideradas abrangentes para convencer
os editores de que todos os artigos potencialmente
elegveis foram, de fato, includos, 4) no foi utilizada
nenhuma medida de risco de vis dos artigos elegveis
ou o risco de vis no foi levado em considerao na
interpretao dos dados, 5) possui srios problemas
metodolgicos, 6) j existe uma reviso similar
publicada recentemente sem uma justificativa
plausvel para uma nova e 6) apresentao de metaanlise na ausncia de uma reviso sistemtica.
478
H algum tempo, as normas do BJPT sugerem que

seus autores sigam as recomendaes PRISMA31,
que contm itens recomendveis para a apresentao
textual de revises sistemticas. Essas recomendaes
descrevem, em detalhes, 27 itens que devem ser
apresentados pelos autores de revises sistemticas,
alm de um checklist para preenchimento e envio,
juntamente com o manuscrito, no ato da submisso.
O PRISMA checklist31 (verso traduzida)32
pode ser acessado em: http://www.
scielo.br/img/revistas/rbfis/2012nahead/
pt_038anx01.jpg
Em um estudo que objetivou analisar a
apresentao textual de revises sistemticas
publicadas na rea de Fisioterapia e em portugus,
Padula et al. 32 observaram que houve pouca
influncia das recomendaes PRISMA em grande
parte dessas revises, mesmo aps a sua publicao
em 2009. Os autores ressaltam que esse dado no
informa sobre a qualidade metodolgica dessas
revises sistemticas, j que as recomendaes
PRISMA contm itens para a apresentao textual
e no para a avaliao da qualidade metodolgica.
O fato de que boa parte das revises sistemticas
publicadas no segue as recomendaes PRISMA
traz um alerta para a comunidade cientfica sobre
a transparncia dos mtodos e resultados dessas
revises e, consequentemente, sobre at que ponto
tais resultados devem influenciar a prtica clnica.
Isso porque, como grande parte das recomendaes
no seguida, h o risco de que as revises
sistemticas estejam sendo publicadas de forma
seletiva, dependente do resultado32.
A avaliao da qualidade de estudos de reviso
sistemtica sobre intervenes pode ser realizada de
acordo com o instrumento AMSTAR (Assessment
of Multiple Systematic Reviews)33,34. Trata-se de
um instrumento vlido35, composto de 11 itens
que avaliam os processos de busca e de seleo de
artigos, as caractersticas e avaliao da qualidade
cientfica dos artigos selecionados, a adequao do(s)
mtodo(s) usado(s) para sintetizar os resultados dos
estudos, avaliao de vis e conflito de interesses.
Um estudo que avaliou a qualidade das revises
sistemticas sobre intervenes em sade oral em
uma revista brasileira observou que a qualidade
metodolgica das revises sistemticas ainda muito
baixa36. Assim, o processo de anlise de revises
sistemticas submetidas para as revistas deveria
incluir a avaliao da qualidade metodolgica pelo
AMSTAR36.
Em sntese, recomendamos aos autores que

utilizem guias como o Cochrane Handbook, a escala
AMSTAR e o PRISMA checklist na elaborao dos
projetos de pesquisa de revises sistemticas, assim
como na conduo e redao dos manuscritos. Tais
cuidados podero contribuir para a qualidade das
revises e, consequentemente, para sua avaliao
no processo de reviso por pares do BJPT. Em
ltima instncia, esses cuidados podero resultar em
concluses mais precisas e equilibradas, auxiliando
na tomada de deciso clnica dos fisioterapeutas e
demais profissionais da sade.
Consideraes inais
O processo de sntese de pesquisa visa a reunir,
examinar e avaliar sistematicamente os resultados
de estudos que convergem para responder a uma
pergunta clnica cuidadosamente elaborada. O
produto final pode resultar em um estudo de reviso
sistemtica da literatura, com ou sem meta-anlise,
cuja qualidade esteja vinculada aos procedimentos
envolvidos em sua elaborao e transparncia
na apresentao textual da informao. Tal como
acontece com outras publicaes, a qualidade
da informao das revises sistemticas varia,
desafiando a capacidade dos leitores para avaliar os
pontos fortes e fracos das concluses produzidas.
No sentido de colaborar com a qualidade das
revises sistemticas do BJPT, o presente tutorial
forneceu uma viso geral desse tipo de produo
e tentou dar destaque ao fato de que os mtodos e
diretrizes esto evoluindo e se tornando cada vez
mais especficos, portanto a sua importncia no pode
ser subestimada. Mtodos rigorosos de sntese do
conhecimento melhoram a qualidade, a abrangncia
e a aplicabilidade dos resultados, contribuindo para
a prestao do cuidado e o desenvolvimento de
diretrizes para a prtica clnica, o avano da pesquisa
e as decises polticas em sade.
A partir dessa publicao, o BJPT passa a
incorporar o PRISMA no processo de submisso de
estudos de reviso sistemtica. Tal mudana expressa
no s um cuidado com a transparncia e consistncia
da informao apresentada nesse tipo de estudo como
tambm refora as constantes iniciativas do BJPT
no sentido de capacitar os seus autores, editores e
revisores. Espera-se que essas ferramentas fortaleam
o processo de reviso por pares,melhorando as
evidncias disponibilizadas pelos estudos publicados
no BJPT.
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Correspondence
Leonardo Oliveira Pena Costa
Universidade Cidade de So Paulo (UNICID)
Programa de Mestrado e Doutorado em Fisioterapia
Rua Cesrio Galeno, 448, Tatuap
CEP 03071-000, So Paulo, SP, Brasil
e-mail: lcos3060@gmail.com
systematic review
Static body postural misalignment in individuals with

temporomandibular disorders: a systematic review
Thas C. Chaves1, Aline M. Turci2, Carina F. Pinheiro2,
Letcia M. Sousa3, Dbora B. Grossi2
ABSTRACT | Background: The association between body postural changes and temporomandibular disorders (TMD)
has been widely discussed in the literature, however, there is little evidence to support this association. Objectives: The
aim of the present study was to conduct a systematic review to assess the evidence concerning the association between
static body postural misalignment and TMD. Method: A search was conducted in the PubMed/Medline, Embase,
Lilacs, Scielo, Cochrane, and Scopus databases including studies published in English between 1950 and March 2012.
Cross-sectional, cohort, case control, and survey studies that assessed body posture in TMD patients were selected.
Two reviewers performed each step independently. A methodological checklist was used to evaluate the quality of the
selected articles. Results: Twenty studies were analyzed for their methodological quality. Only one study was classified
as a moderate quality study and two were classified as strong quality studies. Among all studies considered, only
12 included craniocervical postural assessment, 2 included assessment of craniocervical and shoulder postures,, and
6 included global assessment of body posture. Conclusion: There is strong evidence of craniocervical postural changes
in myogenous TMD, moderate evidence of cervical postural misalignment in arthrogenous TMD, and no evidence of
absence of craniocervical postural misalignment in mixed TMD patients or of global body postural misalignment in
patients with TMD. It is important to note the poor methodological quality of the studies, particularly those regarding
global body postural misalignment in TMD patients.
Keywords: temporomandibular disorders; body posture; craniocervical posture; systematic review.

Chaves TC, Turci AM, Pinheiro CF, Sousa LM, Grossi DB. Static body postural misalignment in individuals with
temporomandibular disorders: a systematic review. Braz J Phys Ther. 2014 Nov-Dec; 18(6):481-501. http://dx.doi.org/10.1590/
bjpt-rbf.2014.0061
Introduction
Temporomandibular Disorder (TMD) is a set
of disorders characterized by signs and symptoms
involving the temporomadibular joints and
mastication muscles, as well as related structures1.
There is evidence that its etiology is multifactorial
and include psychological, biomechanical, and
neurophysiological factors2-4.
The association between body postural changes and
TMD has been widely discussed in the literature5-19.
It is believed that in biomechanical terms, changes in
head posture may be associated with the development
and/or perpetuation of TMD20. Several studies over
the last decades have reported the Forward Head
Position (FHP) in patients with TMD6,12,20,21, however,
these changes have not been verified in many other

studies5,8,11,22.
Craniocervical posture is only one of the body
segments that must be considered for postural
assessment, specifically because adjacent postural
compensations are expected in other segments
considering that muscle chains are interconnected23,24.
Three systematic reviews regarding the theme
were found in the literature20,25,26, however, the
reviews by Olivo et al.20 and Rocha et al.26 only
considered studies related to craniocervical posture
and TMD, and the review by Perinetti and Contardo25
did not include studies on craniocervical posture.
Moreover, this review25 classified, in the same list,
1
Departamento de Neuroscincias e Cincias do Comportamento, Faculdade de Medicina de Ribeiro Preto (FMRP), Universidade de So Paulo (USP),
Ribeiro Preto, SP, Brazil
2
Departamento de Biomecnica, Medicina e Reabilitao do Aparelho Locomotor, FMRP, USP, Ribeiro Preto, SP, Brazil
3
Departamento de Medicina Social, FMRP, USP, Ribeiro Preto, SP, Brazil
481
Chaves TC, Turci AM, Pinheiro CF, Sousa LM, Grossi DB
studies regarding stabilometry (i.e. postural balance

assessment) and static posture. Therefore, there
was no systematic review available in the present
literature involving body postural alterations (either
segmentary or global) in individuals with TMD.
Given the great interest in the theme and the poor
methodological quality of the studies about body
postural misalignment and the postural assessment
methods employed in these studies 20,25, it was
important to carry out a study that analyzed real
evidence of associations between static postural
changes and TMD in order to guide better controlled
studies in the future.
The confirmation of the evidence of the association
between craniocervical or body postural misalignment
and TMD may help to determine the predisposing
and/or perpetuating factors in the development of
TMD and guide new and well designed research to
confirm this association. Moreover, some studies
have demonstrated the relief of TMD symptoms after
treatment involving postural reeducation27,28.
It was expected that the findings of this systematic
review would demonstrate whether the evidence
available was sufficient to indicate an association
between body postural misalignment and TMD and/
or subtypes. Thus, the aim of this study was to review
the literature available on the main databases (i.e.
PubMed/Medline, Embase, Lilacs, Scielo, Cochrane,
and Scopus) about body postural misalignment in
patients with TMD and subtypes.
Method
Data sources
In order to find studies examining the relationship
between static body posture and TMD, bibliographical
surveys were performed in the following databases:
PubMed/Medline, Embase, Lilacs, Scielo, Cochrane,
and Scopus. PRISMA 29 (Preferred Reporting
Items for Systematic reviews and Meta-Analyses)
guidelines were followed.
The search comprised only studies in English
published between 1950 and March 2012. The search
terms were:
1) temporomandibular disorders
2) myofascial pain
3) stomatognathic system
4) craniofacial disorders
AND
1) body posture
482
2) head posture
3) body posture assessment
4) posture
Searches were performed by the same researcher.
The limits of databases were selected when the option
was available. In the Embase and Pubmed databases,
the limits followed were: Published: 1966 to March
2012, quick limits: humans, only in English, article
in press.
Eligibility criteria
Types of Studies. i) cohort/case-control studies;
and ii) cross-sectional and survey studies. Publications
such as case reports, case series, reviews, and opinion
articles were excluded. As the main objective of this
study was to verify the possible association between
TMD and body postural changes, randomized
controlled clinical trials were excluded, since these
studies are used to verify the effectiveness of an
intervention and, therefore, not adequate to verify
relationships between variables.
Participants. Inclusion was restricted to studies
using human participants who (i) were between 7
and 60 years of age; (ii) had been diagnosed with
TMD; (iii) had not previously had TMJ surgery;
(iv) had no history of trauma or fracture in the TMJ
or craniomandibular system; and, (v) had no other
serious comorbid conditions (e.g. cancer, rheumatic
disease, neurological problems).
Types of Outcome Measures. The following
methods of body postural assessment were
considered: body landmarks, visual inspection,
pictures or radiographs.
Data collection
The reviewers analyzed all studies initially
selected by the title or abstract for the inclusion/
exclusion criteria. The published studies had to
provide enough information to meet the inclusion
criteria and not be eliminated by the exclusion
criteria. In order for studies to be evaluated at the next
level (critical appraisal), the study had to meet all of
the inclusion criteria. When the reviewers disagreed
on whether a study met a criterion, rating forms (form
containing the Critical Appraisal completed by each
reviewer Table 1) were compared, and the criterion
was discussed until a consensus was reached.
As recommended by PRISMA29, the studies were
selected by the title, abstract, and full text. Two
independent reviewers screened the abstracts of the
publications found in the databases.
Body posture and TMD: a systematic review
Table 1. Critical appraisal form used to evaluate included studies. Based on the paper by Olivo et al.20.
Criteria for review and methodological quality assessment

1) Type of Study
a) Randomized Clinical Trial and Random / Cohort
b) Pre-experimental / Non-randomized Clinical Study
c) Case Control/ Cross-Sectional
2) Diagnostic Criteria/Patients Assessment

a) RDC/TMD Diagnostic
b) American Academy of Orofacial Pain (AAOP) Criteria/Image
c) Another Tool Questionnaire
d) Complaint or report
e) Description of the groups: Myogenous / Arthrogenous / Mixed
S = 4/M = 3/W < 2

3) Volunteer Agreement
a) >80%
b) 60 to 80%
c) <60%
d) Cannot answer
4) Sample Size Calculation

a) Appropriate / A priori effect size and power
b) Small, justification provided
c) Small and no justification provided
5) Method
a) Visual Inspection live
Prior training of examiners
Intrarater reliability
Interrater reliability
Reproducibility / Error Analysis
Validity / Sensitivity / Specificity
Well described
1
1
1
1
1
1
1
0
0
0
0
0
0
0
NA
NA
NA
NA
NA
NA
NA
b) Qualitative Photographic Analysis

Well described
1
1
1
1
1
1
0
0
0
0
0
0
NA
NA
NA
NA
NA
NA

Well described
1
1
1
1
1
1
0
0
0
0
0
0
NA
NA
NA
NA
NA
NA
d) Radiography/Cephalometry
Well described
1
1
1
1
1
1
1
0
0
0
0
0
0
0
NA
NA
NA
NA
NA
NA
NA
c) Quantitative Photographic Analysis
483
Table 1. Continued...
Criteria for review and methodological quality assessment
For each item:
S= 5 to 7 points/M = 4 to 3/W <2
NOTE: If an item was classified as NA (not applicable), it shoud be classified as follows: 0 to
33% of the items classified as NA = W/34 to 66% = M/ 67 to 100% = S
6) Blinding
Patients
Na
Examiner of the experiment
Na
Examiner the measure
Na
S= 2 or 3/ M = 1/ W = 0
7) External validity
Internal validity
The results have clinical relevance
Patients are representative of the population / where screened / age / comorbidities / severity
Observed aspects were clarified in the conclusion and discussion
a) Appropriate /suitable statistical tests
b) Precision (P value described)
c) Confidence Interval
Good experimental design / selection bias

Good control of confounding factors
Appropriate statistical and sample calculation
Consistency in results (validity / reliability / sensitivity)
(1 point only if the paper achieve all items described)
S= 4 or 3/M = 2/W= 1 or 0
8) Adequate statistical analysis
S :2/M: 1/W: 0
S=Strong; M=Moderate; W=Weak; NA: Not applicable.
Quality evaluation
In order to document the internal and external
validity of the studies, a modified quality evaluation
instrument was applied20,30. This tool considered:
1- study design, 2- control of confounding variables,
3- subjects agreement to participate, 4- sample
size calculation, 5- validity/reliability of outcomes
measurements, 6- blinding, 7- external validity, and
8 - statistical analysis (Table 1). Two independent
reviewers evaluated the studies based on specific
determined criteria. If there was inadequate
information in the published papers to allow
evaluation of the criteria, the authors of the studies
were contacted to clarify study design and specific
characteristics of the study. If the authors did not
reply, the studies were evaluated with the information
available.
484
Each evaluated study item was then given a grade

of strong (S), moderate (M) or weak (W) in each
category. The rating system was based on a similar
procedure20,31. Critical appraisal was completed
independently by the two reviewers, and their
results were compared. Data were extracted from
each article without blinding of the authors. Finally,
every study was graded depending on the following
criteria (Table 1):
STRONG - Strong for items: 2, 4, 5, 6, 7, and
8 or Moderate or Strong for items 1 and 3;
MODERATE - Moderate for the following
items: 2, 4, 5, 6, 7, and 8 and Weak or Moderate
for items 1 and 3;
WEAK - Weak for at least one of the items: 2,
4, 5, 6, 7, and 8.
Statistical analysis
The kappa coefficient test was used to verify
the agreement between both reviewers before the
consensus stage in the analysis of studies. Results
were obtained using the weighted kappa coefficient
and analyzed using SPSS version 17, and the
agreement was classified as follows: K<0.20 (poor),
0.21 to 0.40 (weak), 0.41 to 0.60 (moderate), 0.61 to
0.80 (good), 0.81 to 1.0 (excellent).
Results
The selection included 1067 studies (271 in
Pubmed, 3 in Scielo, 703 in Scopus, 33 in Lilacs,
and 57 in Embase) considering duplicates/triplicates.
After the removal of duplicates among different
databases, 393 studies remained. After comparison
for the existence of duplicates in the same database,
348 studies remained. The studies were screened
again by verifying the title, and only 36 studies were
selected.
Nevertheless, 16 studies were initially excluded

after the abstract analysis based on the following
inclusion and exclusion criteria : i) studies involving
therapeutic intervention28,32-35; ii) sample eligibility
criteria were not met (patients with TMD)35-38;
iii) studies involving static balance assessment
(stabilometry) or not involving static postural
assessment39-41; and iv) non-experimental studies
(i.e. letters to the editor, narrative literature reviews,
pilot studies)42-45.
After analysis of the abstracts, all 20 studies were
read once in full and five studies were excluded
adopting the criteria previously defined. The studies
were excluded because they consisted of: i) nonexperimental studies 46,47; ii) a study involving
therapeutic intervention27; iii) a study involving
static postural assessment48; and 4) a study with
inappropriate sample eligibility criteria49.
At the end of the process, through the selection
by full text, a total of 15 studies were considered5-19.
Later, 5 more studies were included through
manual search21,22,50-52. Therefore, 20 studies in
Figure 1. Flow diagram through the different phases of the systematic review as recommended by the PRISMA statement30.
485
were: 1) absence of description regarding

sample size calculation5-18,49,50 (n=15 studies); 2)
absence of reliability description of measures
or validity of the method employed5,6,12,14,17,18,50
(n=7 studies); 3) absence of blinding of the
examiners 6,7,10-12,14,17,50,53 (n=9 studies); and, 4)
non-compliance with criteria for internal and
external validity 6,7,10,11,13-15,18,52 (n=9 studies).
Moreover, the randomization procedure for
sample selection, which was observed in only
six studies5,13,14,16,22, was still a significant bias
that hindered the quality of the studies found in
the literature20 (Table 2).
total were reviewed in the present study. All stages

of this process are described in Figure 1.
The agreement between both reviewers for the
final classification of the 20 studies obtained Interrater
Kappa of 0.90 (Confidence Interval 95%: 0.73-1),
demonstrating an excellent level of agreement
between them.
Quality criteria score
Considering the criteria for assessment of
methodological quality, only three studies
were classified as moderate 51 or strong 19,21 .
The main methodological problems observed
Table 2. Methodological scoring of the articles included in the review.
Items / Score*
Studies
Rating
Craniocervical posture
Braun6
WEAK
Hackney et al.11
WEAK
WEAK
Lee et al.
50
Evcik and Aksoy
WEAK
Sonnensen et al.10
WEAK
Visscher et al.
WEAK
DAttilio et al.51
MODERATE
Munhoz et al.13
WEAK
Ioi et al.
WEAK
Iunes et al.22
WEAK
Matheus et al.15
WEAK
De Farias Neto et al.18
WEAK
Armijo-Olivo et al.
STRONG
Armijo-Olivo et al.
STRONG
12
52
19
21
Global Body posture

W
Darlow et al.5
WEAK
Zonnernberg et al.
WEAK
Nicolakis et al.9
WEAK
14
Munhoz et al.
WEAK
Munhoz et al.16
WEAK
Saito et al.17
WEAK
W = 20
W= 6
W=6
W = 15
W=9
W=8
W=9
W=0
Total Score
M=0
M=1
M=1
M=2
M=6
M=5
M=7
M=3
S=0
S = 13
S = 13
S=3
S=5
S=7
S=4
S = 17
S=Strong; M=Moderate; W=Weak; *1- Types of studies; 2 Diagnostic criteria; 3 Volunteer agreement; 4 Sample size; 5 Method;
6 Examiner blinding; 7 External validity; 8 Statistical analyses.
486
- Photograph in sitting and standing

posture - quantitative analysis
- Register and analysis performed
by the same examiner
- Report previous examiner training
- blinding of the examiner not
mentioned
- Report consistency between
without use of suitable statistics
N=44, paired
- Case Group: 22
F: 19/M: 3
Mean age 38.6 years
- Control Group: 22
F: 19/M: 3
Mean age 35.4 years
- sample size calculation not mentioned
- randomization to sample selection not
mentioned
- Paients with TMD arthrogenic selected
from a TMD clinic
Hackney et al.11 - 1993

Relationship between forward
head posture and diagnosed
internal derangement of the
temporomandibular joint
Final Rating:
WEAK
Type of study: Case-control
Strengths and weaknesses
Without
differences
between groups
WEAKNESSES:
- sample size is not justified
- examiners blinding not mentioned
- reliability not mentioned
- Established diagnostic criteria not
used
STRENGTHS:
- paired sample
- adequate statistic
- diagnosis confirmed by imaging
Greater angular WEAKNESSES:

shoulder extension - postural assessment training not
in the symptomatic mentioned
group
- blinding of the examiner
Lower angle
- sample size calculation not
of FHP in the
mentioned
symptomatic
- Established criteria to TMD
group
diagnosis not mentioned
STRENGTHS:
- suitable statistics
- procedures well described
Results
F: Female, M: Male; N: Sample Size; SD: Standard deviation; RDC/TMD: Research Diagnostic Criteria for Temporomandibular Disorders; MRI: Magnetic Resonance Image; AAOP: American Academy of Orofacial
Pain; CVT/EVT: Cervical lordosis angle. The downward opening angle between the CVT and EVT line; CVT: A line through the tangent point of the superior, posterior extremity of the odontoid process of the second
cervical vertebra and the most infero-posterior point on the body of the fourth cervical vertebra; EVT: A line through the most infero-posterior point on the body of the fourth cervical vertebra and the most inferoposterior point on the body of the sixth cervical vertebra; TMJ:Temporomandibular joint.
Established
criteria not
used
Clinical
examination
confirmed by
MRI
- Photograph (sitting) + quantitative Established

analysis
criteria not
- Forward Head Position (FHP)
used
- Reliability of measurement not
mentioned
- blinding of the examiner and
previous training not mentioned
Photographic method
N=49, unpaired
Case Group: 9F
Control Group: 40 (20F e 20M)
- Case Group
F: 38.11 (SD=6.95)years
- Control Group:
F: 28.4 (SD=9.29) years
M: 29 (SD=4.39) years
mentioned
- Patients with mixed TMD attended at an
orofacial pain clinic
Braun 1991
Postural differences between
asymptomatic men and women
and craniofacial pain patients
Final Rating:
WEAK
Type of study: Cross-sectional
study
Criteria used
for assessment/
diagnosis TMD
Sample Size
Studies
Method used to assess posture
Table 3. Characteristics of the studies considered regarding temporomandibular disorders (TMD) and craniocervical posture.
487
- Established
criteria not
mentioned
TMD detailed
clinical
examination +
TMJ MRI
Established
criteria not
used
Criteria used
for assessment/
diagnosis TMD
Lower FHP angle WEAKNESSES:

in TMD
- unpaired sample
Greater shoulder - sample size is not justified
protrusion in TMD - examiners blinding not mentioned
- reliability not reported
STRENGTHS:
- confirmation of diagnostic by
imaging
- Forward Head WEAKNESSES:

Position angle - calibration of raters not mentioned
lower in patient - method reliability not mentioned
- examiners blinding not mentioned
group
- Protrusion head - Established diagnostic criteria not
higher in patients used
with TMD
STRENGTHS:
- paired grouvps
- blinding of patient
Results
- Posture photographs and

N: 38, unpaired.
quantitative analysis (lateral
- Case Group: 18
photograph)
F: 15 - 30.4 (7.6) years
- Information about the examiners
M: 3 - 30.4 (8.7) years
(blinding, training or reliability)
Mean age: 28.5 (SD=12.93)
not mentioned
- Control Group: 20
F: 15
M: 5
Mean age: 29.7 (SD=9.76)
mentioned
- Patients with arthrogenous TMD
Sample Size
Evcik and Aksoy12 - 2000

Correlation of TMJ pathologies,
neck pain and postural
differences
Final Rating:
WEAK
- Craniocervical and shoulder

- N: 66, paired (age and gender)
photographs
- Case Group: 33
- reliability of the measure and
F: 30/M: 3
method not mentioned
Mean age: 31.4 (SD=10.1) years
- Control group: 33
mentioned
F: 19
M: 3
Mean age: not reported
mentioned
- Patients with mixed TMD selected from
an orofacial pain center at the Kentucky
University
Studies
488
Lee et al.50 - 1995

The relationship between
forward head posture and
temporomandibular disorders.
Final Rating:
WEAK
- Difference for
the eye-tragushorizontal angle
in myogenous
TMD patients
compared to
controls head
extension
- The effect size
was 0.48 (the
authors consider
a statistical
difference, but
not clinical)
N=154
- Lateral photographs of posture
- RDC/TMD
- Reliability of measurement
- Case Group:
with myogenous TMD - F/M: 56
reported in a previous publication
with mixed TMD F/M: 48
- Armijo-Olivo et al.19 (2011)
- Control Group: F/M: 50
- Report of previous training
examiner
- Sample size calculation
- randomization of the selected sample was - blinding of the examiners
not mentioned
- Patients with myogenous and mixed TMD
selected from an orofacial pain clinic at the
University of Alberta
Results
WEAKNESSES:
- Randomization of the sample
- Validity of the method, but does not
show it
STRENGTHS:
- sample size is justified
- reliability of the measurements
- adequate statistics
WEAKNESSES:
- randomization of the sample not
mentioned
- Validity of the method, not
demonstrated
STRENGTHS:
- reliability of the measurements
Armijo-Olivo et al.19 - 2011

Clinical relevance vs. statistical
significance: Using neck
outcomes in patients with
temporomandibular disorders as
an example
Final Rating:
STRONG
study
Criteria used
for assessment/
diagnosis TMD
- Difference for
the eye-tragushorizontal angle
for myogenous
TMD patients
compared to
controls (i.e.
greater head
extension)

- RDC/TMD
Sample Size
Armijo-Olivo et al.21 - 2011

- Lateral photographs of posture
N: 172
- Reliability of measurement ICC:
Head and cervical posture in
- Myogenous TMD Group:
patients with temporomandibular F/M: 55, mean age: 31.91 (SD=9.15) years 0.99
- Training of examiner
disorders
- Mixed TMD Group:
Final Rating:
F/M: 49, mean age: 30.88 (SD=8.19) years - Blinding of the examiners
STRONG
- Control Group:
Type of study: Cross-sectional F/M: 50, mean age: 28.28 (SD=7.26) years
study
- randomization of the selected sample was
not mentioned
selected from a orofacial pain clinic at the
University of Alberta
Studies
489
Studies
490
Sample Size
Radiographic method
Criteria used
for assessment/
diagnosis TMD
Results
WEAKNESSES:
STRENGTHS:
- TMD assessed by image
- reliability and error analysis
N=100; unpaired (but similar age range) - Cephalometric radiography

- TMD: clinical Lower Cervical
DAttilio et al.51 - 2004
Cervical lordosis angle measured - Case Group:
- SE2 = D2 2n (where, SE is the
assessment +
lordosis angle
on lateral cephalograms; findings F: 50; mean age 28.6 (SD=3.3) years
standard error, D is the difference MRI + X-ray
(CVT/EVT)
in skeletal class II female
- Control Group:
between duplicated measurements, - The same
for TMD
subjects with and without TMD: F:50; mean age 29.3 (SD=3.2) years
and n is the number of
blinded
compared to
a cross sectional study
duplicated measurements)
examiner
control group
Final Rating:
- randomization to sample selection not - Blinding of the examiner
MODERATE
mentioned
- Paients with TMD arthrogenous
(disk displacement with and without pain )
Sonnesen et al.10 - 2001

N: 96 children
- Postural assessment by
- It did not use Low and moderate WEAKNESSES:
radiography
correlation (r: 0.21 - Standardized criteria- not used
Temporomandibular disorders - 51 girls and 45 boys, between 7 and 13
established
years of age
- Cephalometric radiography
to 0.37) between - sample size is not justified
in relation to craniofacial
criteria
- Excellent reliability of
cervical posture and- examiners blinding not mentioned
dimensions, head posture and
- Good and
cephalometric tracings (ICC: 0.97 excellent
craniocervical and STRENGTHS:
bite force in children selected for - randomization to sample selection not
orthodontic treatment.
mentioned
to 1.00)
pain on palpation - reliability and calibration of raters
reliability
Final Rating:
- Patients with mixed TMD - Children
assessment of of the masticatory - procedure well described
admitted for orthodontic treatment in a
mentioned
muscles, neck and
WEAK
TMD
dental service
shoulders
- Head extension
study
in TMD
Sample Size
Results
- Radiographic posture analysis

Muir and Goss58 - Craniocervical
- Examiners were blinded not
arthrogenous
angles greater in
mentioned
TMD
TMD criteria
- Dahlberg error method: lower than (1990) 0.58 mm and 0.61 degrees
Radiography
Dahlberg method error:
SE2= Sd2/2n (where, SE = Stantard
error, d = difference between
repeated measurements and n = the
number of records)
- TMD: interview- There was

+ clinical
not difference
assessment
between groups
AAOP (to select)
+ Helkimo57
- image analysis
not used
Criteria used
for assessment/
diagnosis TMD
WEAKNESSES:
- unpaired sample
- Examiners blinding not mentioned
STRENGTHS:
- Error analysis of measurements
imaging
WEAKNESSES:
- unpaired sample
STRENGTHS:
- blinded examiners
- reliability
- TMD case definition = AAOP
N: 59, unpaired
Ioi et al.52 - 2008
Relationship of TMJ
- Case Group:
osteoarthritis to head posture and F: 34 (patients)
dentofacial morphology
mean age: 24.7 (SD=6.1) years
- Control Group:
Final Rating:
WEAK
F: 25 (university and employees)
mean age: 23.6 (SD=1.3) anos
- Randomization of the selected sample
not mentioned
- Radiographic posture analysis

N: 50
Munhoz et al.13 - 2004
+ quantitative and qualitative
- Case Group: 30
Radiographic evaluation of
analysis
cervical spine of subjects with F: 27
- Agreement between raters temporomandibular joint internal M: 3
Viikari-Juntura56 method
disorder
- Blinding of the examiner
- Control Group: 20
Final Rating:
F:14/M: 6
WEAK
mentioned
- 3 blinded examiners
- Patients with arthrogenous and mixed
TMD
Selected from a TMD clinic at the
University of So Paulo
Studies
491
Studies
492
- Cephalometric analysis of
N: 60
radiographic craniocervical
F: 47/M: 13
posture
Mean age: 34.2 years
- measurement reproducibility
Case Group: 39
Control Group: 21
mentioned
- Patients with arthrogeneous and mixed
TMD
Sample Size
- RDC/TMD
- RDC/TMD
+ MRI
examination
- Experts and
blinded
examiners to
MRI
Criteria used
for assessment/
diagnosis TMD
- Differences
in atlas plane
angle from
the horizontal
and anterior
translation
Greater flexion
of the first
cervical vertebra,
associated
with cervical
hyperlordosis in
TMD
WEAKNESSES:
- reliability measures not mentioned
- small sample size
mentioned
Disk displacement WEAKNESSES:

and neck posture - sample size is not justified
no association - comparisons among small groups
STRENGTHS:
- experts and blinded examiners
- reproducibility of measurement
- RDC/TMD used
imaging
Results
N=56
de Farias Neto et al.18 - 2010
- Lateral radiographs
Radiographic measurement of - Case Group (12):
- reliability of the measures not
mentioned
the cervical spine in patients withM: 5, mean age 24 (SD=3.1) years
temporomandibular disorders
F: 7, mean age 21.4 (SD=4.4) years
Final Rating:
- Control Group (11):
WEAK
M: 4, mean age 19 (SD=0.8) years
Type of study: Cross-sectional F: 7, mean age 20.6 (SD=3) years
study
mentioned
- Patients with mixed TMD
Research subjects in treatment at a clinic of
orofacial pain
Matheus et al.15 - 2009

The relationship between
temporomandibular dysfunction
and head and cervical posture
Final Rating:
WEAK
study
Criteria used
for assessment/
diagnosis TMD
- RDC/TMD
- Examiner
training not
mentioned
- Radiography and photograph

N= 90 women, paired
- Group 1:
to perform posture analysis
F: 30 (myofascial disorders )
- quantitative and qualitative
analysis
- Blinding of the examiners
- Group 2:
F: 30 (mixed TMD)
- Reliability analysis of
radiographic: ICC between 0.76
- Control Group:
and 0.99
F: 30 (asymptomatic)
mentioned
Iunes et al.22 - 2009

Craniocervical postural analysis
in patients with TMD
Final Rating:
WEAK
WEAKNESSES:
- unpaired sample
- standardized criteria to diagnosis
not used
- despite being large, the sample was
subdivided into 4 groups
STRENGTHS:
- experts examiners, calibrated and
blinded reliability reported
- PHOTOGRAPH: WEAKNESSES:
no difference
- sample size is not justified, but
- RADIOGRAPH: suitable
no difference
STRENGTHS:
- VISUAL
- case definition: RDC/TMD
ANALYSIS: no - blinded and trained examiners
difference
No differences
for head posture
measurements
between the
groups
Results
- Established
criteria not
used
Photographic and radiographic method
- Photography in sitting and

N=250
standing + head/cervical X-ray
Case group: 138
- Reliability of photographic
However, only 130 were subjected to
postural analysis (8 patients had lost points method- ICC: 0.96
in radiographic analysis)
- Experts, calibrated and blinded
TMD Group: 16
examiners
Cervical dysfunction Group: 10
Mixed Group: 59
Control Group: 45
3 Cases Groups:
Temporomandibular Disorders (TMD) Group
Cervical Spine Disorders (CSD) Group
TMD and CSD Group (both conditions
together)
mentioned
- Patients with arthrogenous, myogenous
and mixed TMD consecutively selected
from a dental clinic
Sample Size
Visscher et al. - 2002

Is there relationship
between head posture and
craniomandibular pain?
Final Rating:
WEAK
study
Studies
493
494
- visual inspection by Kendall et al.59- Established criteria - Greater number of

N=50, paired (age and gender)
- Case Group: 25
method
postural changes
not used
F: 20, mean age: 28.9 (SD=7.5) years - Always the same trained examiner
for neck and trunk
M: 5 , mean age: 25.8 (SD=2.8) years - Reproducibility and reliability of
in the frontal and
- Control Group: 25
the measures tested in previous
sagittal planes in
F: 20, mean age: 28.8 (SD=5) years
studies
the TMD
M: 5, mean age: 26.4 (SD=1.5) years
- Sample size calculation not
mentioned
- randomization of the selected sample
not mentioned
selected consecutively at the
Department of Dentistry and the
control group from the University
Nicolakis et al.9 - 2000

Relationship between
craniomandibular disorders
and poor posture
Final Rating:
WEAK
F: female; M: male; N: sample size; SD: standard deviation; AAOP: American Academy of Orofacial Pain.
WEAKNESSES:
- Established Diagnostic criteria not
used
STRENGTHS:
- paired sample
- blinded examiner
- reliability and reproducibility of the
measure
- Visual inspection by
- No differences
WEAKNESSES:
- Established
Kendall et al.59 method diagnosis criteria between the groups - sample size is not justified
parameters graded on a scale 0-5
- TMD definition not established
not used
- Previous training of the examiner
criteria
reported
- reliability of the measurement not
- reliability of measurement not
mentioned
mentioned
STRENGTHS:
- paired sample
mentioned
- trained and blinded examiner
Visual Inspection
N=60, paired
Case Group: 30
F: 23, mean age 35.8 years
M: 7, mean age 38 years
Control Group: 30 (23F & 7M)
F: 23, mean age 29.3 years
M: 7, mean age 35.3 years
mentioned
was mentioned
- Patients with myogeneous TMD
assisted in a facial pain program at a
hospital
Results
Darlow et al.5 - 1987

The relationship of posture to
miofascial pain dysfunction
syndrome
Final Rating:
WEAK
Criteria used
for assessment/
diagnosis TMD
Sample Size
Studies
Table 4. Characteristics of the studies considered regarding TMD and global body posture.
Criteria used
for assessment/
diagnosis TMD
Results
- Photograph to assess posture - TMD: interview + - No differences

N=50, unpaired
/ college students
quantitative analysis
clinical assessment between groups
- Case Group: 30
- reliability of measurement and the AAOP + Helkimo57
method
F: 27/M: 3
- Control Group: 20
mentioned
F: 14/M: 6
- Sample size calculation not mentioned
- Patients with arthrogeneous and
mixed TMD
selected from a TMD clinic
WEAKNESSES:
- unpaired sample
- reliability of the method not
mentioned
- training or blinding of examiners not
mentioned
STRENGTHS:
- AAOP criteria for TMD diagnosis
- Established criteria - Greater tilt of the WEAKNESSES:

for diagnosis
lines between the - TMD not assessed in controls
(AAOP)
pupils and pelvis in- sample size is not justified, but
TMD patients
reasonable/moderate
- blinding or training of examinrs not
mentioned
- posture analysis only in frontal plane
STRENGTHS:
- paired sample
- TMD definition by AAOP
- reliability of the measure (previous
publication)
Munhoz et al.14 - 2005

Evaluation of body posture
in individuals with internal
derangement
Final Rating:
WEAK
Photographic Method
- Photographs of body posture

N=80, paired (age and gender)
- Case Group: 40
(quantitative)
F: 33, mean age: 30.4 (SD=7.6) years - Good reliability of measurement
(previous study)
- Control Group: 40
F: 32, mean age: 35.5 (SD=9.8) years
- Sample size calculation not
mentioned
not mentioned
- Interview + clinical Postural changes

WEAKNESSES:
N: 26 woman
- Visual inspection by
assessment +
on the hip, thoracic - sample size is not justified
- Control Group:
Kendall et al.59 method
image (X-ray)
curve flatted and
- posture procedures not well described
F:16, mean age: 24.4 (SD=2.8) years - expert examiner
- Case Group:
- procedures for photographic record
increased lumbar
- reliability of the method not mentioned
poorly described
lordosis in TMD
- blinding of the examiners not mentioned
F:10, mean age: 24.5 (SD=3) years
- sample size calculation not mentioned - blinding of the examiner not
Greater lateral
STRENGTHS:
- randomization of the selected sample mentioned
flexion of the head in- paired sample
patients with TMD - discusses some limitations of the study
not mentioned
- TMD diagnostic by imaging
Sample Size
Zonnenberg et al. - 1996

Body posture photographs
as a diagnostic aid for
musculoskeletal disorders
related to TMD
Final Rating:
WEAK
Saito et al.17 - 2009

Global body posture
evaluation in patients with
disorder.
Final Rating:
WEAK
Studies
495
WEAKNESSES:
- Established diagnosis criteria not
used
- low interrater agreement
STRENGTHS:
- randomization of the sample
- blinded examiners
Of all 20 studies considered, 12 studies were

classified as case-control5,7,9,11-14,16,17,22,50,52 and eight
were classified as cross-sectional6,8,10,15,18,19,21,51. Only
three studies used random sampling in the process of
group selection5,14,16 (Tables 3 and 4).
TMD assessment/Diagnosis criteria
Seven studies used diagnosis criteria that are not
well established in the literature5,6,9,10,12,16,50. Image
analysis were employed in four studies11,17,51,52, the
criterion of the American Academy of Orofacial
Pain (AAOP) in three studies7,13,14, and the Research
Diagnostic Criteria for Temporomandibular
Disorders (RDC/TMD)3,4 in five studies15,18,19,21,22
(Tables 3 and 4).
TMD: questionnaire - TMD patients

+ Helkimo
presented - lifting
shoulders and
on hip posture
deviations
496
Segmental or global body postural

assessment
- Photograph records used to

N=50, paired
perform qualitative posture
- Case Group: 30
analysis
F: 27/M: 3
- blinding of the examiners
- Interrater agreement: low
- Control Group: 20
reliability (below 0.52)
F: 16/M: 6
mentioned
- Patients with arthrogeneous and
mixed TMD
selected from a TMD clinic
Studies
Munhoz and Marques16- 2009

Body posture evaluations
in subjects with internal
derangement
Final Rating:
WEAK
Sample Size
Criteria used
for assessment/
diagnosis TMD
Results
Type of studies
Of all studies included in this review, six used

body postural assessment5,7,9,14,16,17, five assessed only
craniocervical posture and shoulders6,12,19,21,23, and all
others assessed only craniocervical and/or cervical
posture8,10,11,13,15,18,50-52.
Sample size, posture method assessment,
and examiner blinding
Sample size was calculated in only three
studies19,21,49 (Table 2). Of the studies that analyzed
only craniocervical posture, six studies described the
use of assessment by radiographic analyses10,13,15,18,49,51,
six studies used the photographic method6,11,12,19,21,50,
and two described the use of the both radiographic
and photographic methods8,22 (Tables 3 and 4).
Only six studies assessed global body
posture5,7,9,14,16,17. Five used the visual inspection
method5,9,14,16,17, one used the quantified photographic
method7, and one used the photographic method
with qualitative analysis14 (Table 4). Eleven studies
described examiner blinding to assess body or
craniocervical posture5,8,9,13,15,16,18,19,21,22,51 (Tables 3
and 4).
Considering the reliability of the body posture
measures, seven studies did not provide this
information accurately 5,6,11,12,17,18,50, 11 reported
good levels of reliability among the repeated
measures7-10,13,15,19,21,22,51,52, and one study reported
poor reliability16 (Tables 3 and 4).
Only one of the studies included in this review
mentioned the validity of the measures employed
for postural assessment22, however the reference that
certified the method validity was probably incorrect54.

The authors did not answer the e-mail to clarify this
possible error.
Of the six studies using global body posture, the
standardization for posture analysis and analysis
method was appropriately described in three
studies7,14,16. The photogrammetry method was used
by two studies7,14 and a previously described method
combining photographic and visual inspection was
used in one study16 (Table 4).
Postural changes in TMD
Body posture changes in the group of patients with
TMD in relation to a control group was verified in 13
studies6,7,9,10,12,16-19,21,50-52 (Tables 3 and 4). Among the
studies that assessed craniocervical posture (n=20),
10 studies reported misalignment in the TMD gro
up6,7,9,10,12,17,19,21,50,52. Three studies verified alterations
in FHP angle6,12,50 and two studies19,21 used another
angle measurement (eye-tragus-horizontal angle).
In all of the studies, head protrusion or extension
was observed. Considering the five studies that
performed specific measurements of the cervical
spine8,14,18,22,51, changes of this segment were observed
in two studies18,51. Upper cervical spine flexion and
hyperlordosis were reported by De Farias Neto et al.18
and cervical spine straightening by Dttilio et al.51
(Tables 3 and 4).
Of the studies that verified shoulder postural
changes 5-7,9,12,14,16, four studies verified posture
changes in this segment in the TMD group6,9,12,16.
The misalignments were: greater shoulder extension6,
assymetrical shoulders and abducted scapula 9,
shoulder protrusion12, and elevated shoulder16 (Tables
3 and 4).
Among the six studies that assessed pelvic posture,
four studies7,9,16,17 verified pelvic misalignments
in the frontal plane7, iliac crest9, muscle chain16,
and posterior rotation17 (Tables 3 and 4). Spinal
misalignments were identified by two of the five
studies that included this topic in the postural
assessment5,9,14,16,17: greater thoracic kyphosis and
lumbar hyperlordosis9 and kyphosis straightening
and lumbar hyperlordosis17 (Table 4). However, of
the studies that were classified as moderate or strong
quality, Armijo-Olivo et al.19,21 reported greater head
extension and Dttilio et al.51 observed cervical
spine straightening.
Postural changes in TMD subtypes
Of the five studies that included a group of
patients with myogenous TMD5,8,19,21,22, two found
body posture misalignments (head extension) in

the TMD group in relation to the control group or
mixed TMD group19,21. Both studies were classified
as strong according to the adopted quality criteria
applied (Tables 3 and 4).
Concerning arthrogenous TMD, four studies
verified body posture changes in the TMD
group in relation to the control group or another
TMD group 12,17,51,52 , and three did not report
craniocervical postural changes8,11,15. Only the study
by Dttilio et al.51 was classified as moderate quality.
The authors reported cervical spine straightening
(Tables 3 and 4).
Among the studies that included a group of mixed
TMD patients in relation to a control group or another
TMD group6-10,16,18,19,21,22,50, seven reported body
posture alterations6,7,9,10,16,18,50. Only two studies19,21
were classified as strong quality and they did not
report body posture alterations for the mixed TMD
group (Tables 3 and 4), however in both studies this
group had to have a diagnosis of myiogenous TMD
according to the RDC/TMD but not a diagnosis of
arthrogenous TMD according to these criteria, only
signs and symptoms.
Discussion
The purpose of this systematic review was
to identify the level of scientific evidence for
the association between TMD and body and/or
craniocervical posture misalignment. The quality
criteria adopted for review of the studies have been
described in previous studies20 and the agreement
between the reviewers for the methodological
classification of the studies was high (kappa: 0.91),
demonstrating that the review process was considered
reliable.
This systematic review considered global body
posture misalignment. Regarding the three systematic
reviews on the subject, two of them considered
craniocervical posture only20,26 and the other presented
records of static posture that were analyzed together
with records of balance static posturography25.
Moreover, these authors25 disregard studies about
craniocervical posture. Postural assessments aimed
at finding postural deviations are routinely made by
physical therapists to analyze body segments in the
static position and do not include the assessment
of oscillations that must be considered as balance
assessment.
A significant number of the studies found in
the literature and included in this review (n=14)
considered only the assessment of the head
497
segment6,8,10-13,15,18,19,21,22,50-52. This aspect is probably

related to the fact that it is easier to perform the
procedure in the craniocervical segment, since the
individual does not need to be evaluated in bathing
clothes, and moreover because the radiographic
procedure commonly employed in dentistry only
considers the head and cervical spine, and it does
not enable the analysis of global body posture.
On the other hand, this aspect disregards posture
assessment as a whole and it is possible that
head changes are related to distal changes, since
the connection between the muscles through the
muscular chains would facilitate the emergence of
postural compensation in other body segments23.
Main indings and TMD subtypes
This review demonstrated that there is evidence for
craniocervical postural change (i.e. head extension) in
patients with myogenous TMD in relation to controls.
Of the five studies that included a group of patients
with myogenous TMD5,8,19,21,22, two studies were
classified as strong according to the quality criteria
employed and verified only craniocervical posture
changes in TMD in relation to a control group or a
mixed TMD group19,21.
Considering body posture misalignment in
arthrogenous TMD, only the study of DAttilio et al.51
was classified as moderate according to the criterion
quality adopted. Therefore, it was observed that
there was moderate evidence and risk of bias for
the presence of cervical posture misalignment
(i.e.cervical spine straightening) in patients with
arthrogenous TMD, diagnosed by MRI, in relation
to a control group.
Considering studies involving patients with
mixed TMD, only two studies19,21 obtained a strong
classification according to the quality criteria
adopted and they did not report body postural
misalignment for the mixed TMD group. One of
the reasons for the absence of evidence of body
postural misalignment in mixed TMD patients
compared to myogenous and arthrogenous patients
could be related to the sample selection adopted19,21.
The patients should have a diagnosis of myogenous
TMD according to the RDC/TMD associated with
signs and symptoms of arthrogenic TMD. In this
way, all of the patients must have a diagnosis
of myogenous TMD, but not of arthrogenous
TMD. It is possible that the mixed TMD group
could not fill the criteria for an arthrogenous
TMD diagnosis, since signs and symptoms of
arthrogenous complaints have commonly been
498
observed in the population 55. Hence, there is

no evidence that patients with mixed TMD (i.e.
with myogenous TMD diagnosis and signs and
symptoms of arthrogenous TMD) did not have
body or craniocervical misalignment in relation
to individuals without TMD or myogenous TMD.
DAtillio et al.51 demonstrated cervical spine
straightening in arthrogenous TMD patients and
received a moderate evidence level classification.
However, DAtillio et al. 51 used radiographic
analysis to assess cervical spine misalignment
and Armijo-Olivo et al.19,21 verified only head and
cervical/head posture. In this way, it is possible
that in patients with arthrogenous TMD, cervical
spine misalignment could be more common, and
in patients with myogenous TMD disorders, head
posture misalignment could be more common.
It could explain the absence of body posture
misalignment for mixed TMD group described by
Armijo-Olivo et al.19,21.
However, all of these theories are speculative
and the attention should focus on the need for future
studies to include a large sample size, control the
diagnostic criteria for mixed and arthrogenous
groups, and consider not only photographic records
but also radiographic procedures to analyze the
cervical spine more specifically. Two studies
assessed body posture by both photography and
radiography8,22, however the major flaw of these
papers was their limited sample size. ArmijoOlivo et al.19 described a minimum of 50 subjects
(=0.05, =0.20, power=80%, and effect size of 0.5)
to assess posture by photographic records.
Global body postural misalignment in the group of
TMD patients was verified in four studies7,9,16,17. All
studies obtained a weak classification. Aspects such
as absence of blinding of the examiner7,17, failure in
sample eligibility criterion9,16, and poorly described
or undescribed reliability of the method5,16,17 were
some of the characteristics that did not support the
evidence of possible global body postural changes in
arthrogenous, myogenous or mixed TMD groups in
relation to a control group.
As contribution for future publications, the
authors recommend effect size and power analysis,
a more controlled design, appropriate description
of reliability/validity of the measures (specifically
for global body postural assessment), blinding of
the examiners, random sampling, and, eligibility
criteria of patients with control of subtypes of TMD
according to well stablished criteria.
Conclusion
The main contributions of the present review
are the following: there is evidence and low risk
of bias that patients with myogenous TMD have
craniocervical postural misalignment. For the
arthrogenous TMD group, moderate evidence for
cervical spine alterations was observed. Moreover,
there was no evidence in the literature for the
absence of craniocervical posture misalignment in
mixed TMD patients and for global body posture
misalignment in TMD. The poor methodological
quality of the studies considered in this revision,
especifically for body postural misalignment could
be the explanation for the weak evidence observed.
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Correspondence
Thas Cristina Chaves
Universidade de So Paulo
Faculdade de Medicina de Ribeiro Preto
Departamento de Neuroscincias e Cincias do Comportamento
Avenida dos Bandeirantes, 3900
CEP 14049-900, Ribeiro Preto, SP, Brasil
e-mail: chavestc@fmrp.usp.br
501
systematic review
Walking training associated with virtual reality-based

training increases walking speed of individuals with
chronic stroke: systematic review with meta-analysis
Treino direcionado marcha associado ao uso de realidade virtual
aumenta a velocidade de marcha de indivduos com hemiparesia
crnica: reviso sistemtica com metanlise
Juliana M. Rodrigues-Baroni1, Lucas R. Nascimento2,3, Louise Ada2,
Luci F. Teixeira-Salmela3
ABSTRACT | Objective: To systematically review the available evidence on the efficacy of walking training associated
with virtual reality-based training in patients with stroke. The specific questions were: Is walking training associated
with virtual reality-based training effective in increasing walking speed after stroke? Is this type of intervention more
effective in increasing walking speed, than non-virtual reality-based walking interventions? Method: A systematic
review with meta-analysis of randomized clinical trials was conducted. Participants were adults with chronic stroke and
the experimental intervention was walking training associated with virtual reality-based training to increase walking
speed. The outcome data regarding walking speed were extracted from the eligible trials and were combined using a
meta-analysis approach. Results: Seven trials representing eight comparisons were included in this systematic review.
Overall, the virtual reality-based training increased walking speed by 0.17 m/s (IC 95% 0.08 to 0.26), compared with
placebo/nothing or non-walking interventions. In addition, the virtual reality-based training increased walking speed
by 0.15 m/s (IC 95% 0.05 to 0.24), compared with non-virtual reality walking interventions. Conclusions: This review
provided evidence that walking training associated with virtual reality-based training was effective in increasing walking
speed after stroke, and resulted in better results than non-virtual reality interventions.
Keywords: cerebrovascular disease; virtual reality; gait; systematic review, rehabilitation.
Rodrigues-Baroni JM, Nascimento LR, Ada L, Teixeira-Salmela LF. Walking training associated with virtual realitybased training increases walking speed of individuals with chronic stroke: systematic review with meta-analysis.
Braz J Phys Ther. 2014 Nov-Dec; 18(6):502-512. http://dx.doi.org/10.1590/bjpt-rbf.2014.0062
RESUMO | Objetivo: Revisar estudos sobre a eficcia do treino direcionado marcha associado realidade virtual em
pacientes ps-acidente vascular enceflico (AVE). As perguntas clnicas foram: o treino direcionado marcha associado
realidade virtual eficaz para promover aumento em velocidade de marcha de indivduos com hemiparesia? Essa
modalidade de interveno promove maior aumento em velocidade de marcha comparada a outras intervenes sem uso
de realidade virtual? Mtodo: Foi realizada uma reviso sistemtica com metanlise de ensaios clnicos aleatorizados.
Os participantes eram adultos ps-AVE, e a interveno experimental considerada foi o treino direcionado marcha
associado ao uso de realidade virtual com o objetivo de melhorar a velocidade de marcha. Os dados referentes
velocidade de marcha foram extrados para combinao por metanlise. Resultados: Sete estudos representando oito
comparaes foram includos nesta reviso sistemtica. O treino de marcha associado realidade virtual aumentou a
velocidade de marcha dos participantes, em mdia, 0,17 m/s (IC 95% 0,08 a 0,26) comparado interveno placebo, no
interveno ou interveno no especfica para os membros inferiores. Adicionalmente, o treino associado realidade
virtual aumentou a velocidade de marcha dos participantes, em mdia, 0,15 m/s (IC 95% 0,05 a 0,24) comparado a
diferentes intervenes destinadas aos membros inferiores sem uso de realidade virtual associada. Concluses: Esta
reviso sistemtica apresentou evidncia clnica de que a adio da realidade virtual ao treino de marcha demonstrou ser
eficaz para aumentar a velocidade de marcha de indivduos com hemiparesia e apresentou melhores resultados, quando
se compara a outras intervenes sem uso de realidade virtual.
Palavras-chave: acidente vascular enceflico; realidade virtual; marcha; reviso sistemtica; reabilitao.
Rede Sarah de Hospitais de Reabilitao, Belo Horizonte, MG, Brasil

Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney (NSW), Australia
3
Departamento de Fisioterapia, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brasil
1
2
502
Treino com realidade virtual ps-AVE
Introduo
Os indivduos que sobrevivem a um episdio de
acidente vascular enceflico (AVE) frequentemente
apresentam deficincias motoras, que esto
relacionadas a limitaes em atividades e restries
na participao social. Limitaes em marcha so
consideradas uma das principais incapacidades aps
AVE, uma vez que a capacidade de deambular est
diretamente relacionada independncia funcional1,2.
De acordo com Alzahrani et al.3, um desempenho
ruim durante a marcha ps-AVE determina limitaes
nas atividades domiciliares e comunitrias, tornando
os indivduos restritos ao domiclio e isolados da
comunidade.
Usualmente, os valores mdios de velocidade
de marcha em indivduos com hemiparesia variam
entre 0,4 e 0,8 m/s4-6. Indivduos que deambulam
abaixo de 0,4 m/s so considerados deambuladores
restritos ao domiclio; indivduos que deambulam
com velocidades entre 0,4 e 0,8 m/s so considerados
deambuladores comunitrios; e indivduos com
velocidades acima de 0,8 m/s so capazes de
deambular na sociedade sem limitaes substanciais4.
Dessa forma, de grande interesse em estudos clnicos
avaliar a efetividade de abordagens que promovam
incrementos na velocidade de marcha, uma vez que
adequados valores de velocidade de marcha esto
relacionados maior participao social e melhor
qualidade de vida nessa populao 3,4. Embora
revises sistemticas prvias tenham indicado a
eficcia do treino de marcha em solo e em esteira
ergomtrica para melhora da velocidade de marcha5-7,
continuamente novas tcnicas e instrumentos so
adicionados ao usual treino de marcha, visando
a potencializar os efeitos de interveno para
uma limitao considerada de grande impacto na
populao de indivduos com hemiparesia.
Alguns estudos demonstraram que a realidade
virtual pode ser uma ferramenta til para reabilitao
de indivduos com hemiparesia, e seus efeitos
relacionados velocidade de marcha ps-AVE
comearam a ser investigados8-11. Por definio, a
realidade virtual uma simulao de um ambiente
real gerado por um software de computador que
permite ao usurio interagir com elementos dentro
de um cenrio que simula objetos e tarefas do mundo
real5. Existe uma grande variedade de interfaces para
interagir com o ambiente virtual, incluindo desde
dispositivos mais comuns, como mouse e teclado ou
um joystick, at complexos sistemas de captura de
movimentos ou dispositivos que permitem aferncias
sensoriais, fornecendo ao usurio a sensao de
alcanar alvos e desviar de objetos similares aos

obstculos do mundo real11,12.
De acordo com Dobkin13, a adio de elementos
de realidade virtual durante a reabilitao da marcha
vantajosa por oferecer treinamento aos pacientes em
ambiente virtual similar ao contexto real vivenciado
pelos pacientes no dia a dia. Ademais, ambientes
virtuais so descritos por crianas e adultos como
elementos motivadores capazes de encorajar maior
tempo de prtica e maior nmero de repeties,
fatores considerados importantes na reabilitao
de indivduos com alteraes neurolgicas 8,14.
Especificamente em relao reabilitao da
marcha, a utilizao de ambientes virtuais permite
a terapeutas graduar progressivamente o nvel de
dificuldade de modo a desafiar pacientes e fornecer
feedback imediato sobre desempenho na tarefa,
alm de praticar tarefas consideradas inseguras no
treinamento de marcha em ambiente real, tais como
transpor obstculos e atravessar ruas8,13.
Duas revises sistemticas prvias avaliaram o
efeito de treinos de marcha associados ao uso de
realidade virtual para recuperao de marcha de
indivduos ps-AVE. Uma reviso da Cochrane8
reportou um aumento no significativo de 0.07 m/s
(IC 95% -0.09 a 0.23) baseada em trs ensaios clnicos
aleatorizados. Uma segunda reviso9, publicada
recentemente, incluiu quatro ensaios clnicos
aleatorizados e concluiu que a reabilitao associada
realidade virtual apresentou benefcios na marcha
de indivduos com hemiparesia decorrente de AVE.
Entretanto, os autores relataram heterogeneidade
clnica entre os estudos e impossibilidade de
realizao de metanlise. Dessa forma, os resultados
sobre a associao de realidade virtual ao treinamento
motor para melhora de marcha ps-AVE permanecem
inconclusivos. Ademais, no foram encontradas
revises que analisaram separadamente a eficcia
do treino direcionado marcha associado realidade
virtual e a superioridade desse recurso em comparao
a outras intervenes relacionadas marcha.
Portanto, o objetivo desta reviso sistemtica
examinar o efeito da adio de realidade virtual
ao treino direcionado reabilitao da marcha de
indivduos ps-AVE em relao velocidade de
marcha. As perguntas clnicas especficas so:
1. Treino direcionado marcha associado
realidade virtual eficaz para promover aumento
na velocidade de marcha de indivduos com
hemiparesia?
2. Treino direcionado marcha associado
realidade virtual promove maior aumento na
503
Rodrigues-Baroni JM, Nascimento LR, Ada L, Teixeira-Salmela LF
velocidade de marcha comparado a diferentes

intervenes especficas em membros inferiores
sem uso de realidade virtual?
Com o objetivo de propor recomendaes clnicas
baseadas em um alto nvel de evidncia cientfica,
esta reviso planejou incluir apenas ensaios clnicos
aleatorizados ou ensaios clnicos controlados.
Mtodo
Identiicao e seleo dos estudos
Foi realizada busca bibliogrfica nas seguintes
bases de dados: Medline (1946 a julho de 2013),
PEDro (at julho de 2013) e Embase (1980 a julho
de 2013), sem restrio de idioma de publicao. Para
identificao de estudos relevantes, foram realizadas
buscas utilizando palavras-chave relacionadas a
acidente vascular enceflico (stroke), combinadas
s relacionadas realidade virtual (virtual reality,
videogames, flow optic) e marcha (gait) (Anexo 1). A
anlise do ttulo e resumo dos artigos encontrados foi
realizada por um revisor para identificao de estudos
relevantes. As referncias bibliogrficas dos artigos
encontrados foram revisadas para identificao de
outros estudos potenciais. Dois revisores realizaram
a seleo dos estudos a partir de critrios prdeterminados. Uma sntese dos critrios pode ser
encontrada no material suplementar referente a esse
manuscrito (Anexo 1S*).
Avaliao dos estudos
Qualidade: A qualidade metodolgica dos estudos
includos foi avaliada de acordo com a escala
PEDro, descrita na base de dados Physiotherapy
Evidence Database15. A escala, composta por 11
itens, avalia a qualidade metodolgica (validade
interna e informao estatstica) de ensaios clnicos
aleatorizados. Cada item, exceto o primeiro, contribui
com um ponto para o escore final de 10 pontos.
Foi utilizada a pontuao dos estudos descrita no
endereo eletrnico da base de dados. A pontuao
dos estudos no includos na base de dados PEDro
ou no pontuados foi realizada pelos autores deste
estudo.
Participantes: Estudos cujos participantes
eram adultos com hemiparesia decorrente de AVE,
capazes de deambular com ou sem assistncia, foram
includos. Informaes relacionadas ao nmero de
*Veja material suplementar disponvel na verso online no site
http://www.scielo.br/scielo.php?script=sci_issues&pid=14133555&lng=en&nrm=iso
504
participantes, idade, tempo ps-AVE e velocidade

de marcha inicial foram registrados para analisar
similaridade entre os estudos selecionados.
Interveno: A interveno experimental foi treino
direcionado marcha associado ao uso de realidade
virtual, com o objetivo de melhorar a velocidade de
marcha de indivduos com hemiparesia decorrente de
AVE. Foi considerada realidade virtual a simulao
de um ambiente real gerado por um software de
computador, permitindo ao usurio interagir com
elementos dentro de um cenrio simulado por meio
de diversas interfaces: mouse, teclado, joystick, luvas
e/ou sistemas de captura de movimentos11,12. Foram
includos estudos que utilizaram formas de realidade
virtual imersiva e no imersiva, assim como estudos
com uso de consoles de videogame disponveis
comercialmente8.
O grupo controle foi definido e selecionado de
acordo com cada pergunta clnica: (i) para avaliar a
eficcia do treino direcionado marcha associado ao
uso de realidade virtual, o grupo controle poderia ter
interveno placebo, no interveno ou interveno
no especfica aos membros inferiores (marcha);
(ii) para avaliar a superioridade da reabilitao
associada ao uso de realidade virtual, o grupo controle
poderia incluir uma diferente modalidade de treino
direcionado aos membros inferiores, no associada
ao uso de realidade virtual.
Medida de desfecho: O desfecho clnico
considerado foi a velocidade de marcha confortvel,
apresentada neste estudo em metros por segundos
(m/s). O tempo de mensurao e procedimentos de
mensurao da varivel de desfecho foram analisados
para avaliar a similaridade entre os estudos.
Anlise dos dados
Informaes sobre o mtodo dos estudos (desenho,
participantes, interveno e medidas de desfecho) e
resultados (nmero de participantes e mdias (DP) de
variveis relacionadas marcha) foram extradas por
um revisor e checadas por um segundo revisor. Caso
informaes necessrias no estivessem presentes na
verso publicada dos estudos, detalhes adicionais
seriam solicitados ao autor por correspondncia.
Valores de ps-interveno foram utilizados
para estimar o tamanho de efeito agrupado entre os
estudos. O tamanho de efeito foi extrado utilizando
fixed effects model e reportado como diferena
mdia ponderada (MD) com respectivos intervalos
de confiana de 95%. Em caso de heterogeneidade
estatstica significativa entre os estudos (I2>50%),
o tamanho de efeito seria analisado utilizando

random effects model para avaliar a robustez dos
resultados. As anlises foram realizadas utilizando
o programa estatstico The MIX-Meta-Analysis
Made Easy verso 1.716,17, considerando nvel
de significncia de 5% (two-tailed) para avaliao
de significncia em heterogeneidade estatstica.
Caso os dados no estivessem disponveis para
serem includos na metanlise ou no pudessem ser
includos na combinao, a diferena entre os grupos
de comparao seria descrita.
Resultados
Seleo dos estudos para reviso
A pesquisa nas bases de dados identificou 999
artigos relevantes para leitura de ttulos e resumos.
Aps leitura de ttulo e resumos, foram selecionados

15 estudos potencialmente capazes de responder s
perguntas clnicas desta reviso. Aps a anlise dos
estudos de acordo com os critrios de incluso, foram
selecionados oito estudos. Aps a extrao dos dados,
um estudo18 foi excludo por apresentar duplicao
dos resultados da varivel de desfecho com um
segundo estudo19, totalizando sete estudos como
amostra final desta reviso sistemtica (Figura 1).
Caractersticas dos estudos includos
Sete estudos envolvendo um total de
154 participantes investigaram a eficcia do treino
direcionado marcha associado ao uso de realidade
virtual para melhora de velocidade de marcha em
indivduos com AVE e foram includos nesta reviso
Figura 1. Seleo dos estudos para a reviso sistemtica. ECA = ensaio clnico aleatorizado; ECC = ensaio clnico controlado.
505
Tabela 1. Resumo dos estudos includos (n=7).
Participantes
Interveno
Avaliao da
velocidade de
marcha (semana)
Estudo
Desenho
Cho e Lee23
ECA
n=14
Idade (anos): 65 (4)
Tempo de leso (meses): 10 (2)
VM: 0,53 (0,17)
Exp = Treino em esteira ergomtrica

associado realidade virtual
30min x 3/sem x 6sem
Con = Treino em esteira ergomtrica
Ambos = Fisioterapia usual
Fritz et al.21
ECA
n=28
VM: 0,57 (0,30)
Exp = Exerccios com videogames

Con = Nenhuma interveno
0, 5 e 12
Jaffe et al.24
ECA
n=20
VM: 0,55 (0,19)
Exp = Transpor obstculos virtuais em

esteira ergomtrica
Con = Transpor obstculos no cho
0, 2 e 4
Kang et al.20
ECA
n=30
VM: 0,5 (0,16)

Con1 = Treino em esteira ergomtrica
Con2 = Exerccios de flexibilidade
Todos = Fisioterapia convencional
0e4
Kim et al.22
ECA
n=24
VM: 0,46 (0,15)
Exp = Exerccios com videogames

Con = Nenhuma interveno
Ambos = Fisioterapia convencional
0e4
Mirelman et al.19
ECA
n=18
VM: 0,66 (0,27)
Exp = Movimentos de tornozelo

com alvo e feedback fornecidos por
realidade virtual
Con = Movimentos de tornozelo com
alvo e feedback fornecidos sem uso de
realidade virtual
0, 4 e 7
Yang et al.25
ECA
n=20
VM: 0,70 (0,44)

Con = Treino em esteira ergomtrica
0, 3 e 7
0e6
# Grupos e variveis de desfecho listadas correspondem quelas analisadas nesta reviso sistemtica, podendo haver outros grupos e variveis
nos artigos. ECA = ensaio clnico aleatorizado, VM = velocidade de marcha inicial (m/s), Exp = grupo experimental, Con = grupo controle.
sistemtica (Tabela 1). Como o estudo realizado por

Kang et al.20 apresentou dois grupos controle, um total
de oito comparaes foi realizado. Trs estudos20-22
compararam o treino direcionado marcha associado
realidade virtual com interveno placebo, no
interveno ou interveno no especfica aos
membros inferiores (Questo 1). Cinco estudos19,20,23-25
compararam o treino direcionado marcha associado
realidade virtual com uma diferente modalidade
506
de treino direcionado aos membros inferiores, no

associado ao uso de realidade virtual (Questo 2).
Qualidade: A pontuao mdia de acordo com
a escala PEDro foi de 6.1 pontos, variando de 4
a 8 pontos (Tabela 2). Todos os estudos includos
realizaram a alocao aleatria dos participantes
nos grupos, garantiram a similaridade inicial entre
os grupos e analisaram medidas de tendncia central
e variabilidade. A maioria dos estudos includos
Grupos similares
Cegamento de
participantes
Cegamento de
terapeutas
Cegamento de
avaliadores
<15% de perda
amostral
Anlise por inteno

de tratar
Diferena entre grupos
Fritz et al. 21
Jaffe et al. 24
Kang et al.
20
Kim et al. 22
Mirelman et al.
Yang et al. 25
19
Total (0 to 10)
Alocao cega
Cho e Lee23
Study
Medidas de tendncia
central e variabilidade
Alocao aleatria
Tabela 2. Itens da escala PEDro e pontuao dos estudos includos (n=7).
S= sim; N=no.
informou que a distribuio dos participantes foi cega

(57%), apresentou menos de 15% de perda amostral
(57%), reportou as diferenas estatsticas entre os
grupos (86%) e cegamento dos avaliadores (86%).
Entretanto, a maior parte dos estudos no reportou
anlise por inteno de tratar (86%). Apenas um
estudo realizou o cegamento dos participantes22, e
nenhum estudo realizou cegamento dos terapeutas,
aes consideradas difceis de serem realizadas em
intervenes complexas.
Participantes: A mdia de idade dos participantes
includos nos estudos variou entre 52 e 66 anos. Todos
os estudos avaliaram indivduos com tempo de leso
superior a seis meses, caracterizando um quadro de
hemiparesia crnica (variao: dez a 72 meses). O
tamanho da amostra includa nos estudos variou
entre 14 e 30 participantes, alocados em grupos
experimental e controle(s). Todos os participantes
eram capazes de deambular de forma independente
no incio dos estudos, com velocidade mdia inicial
equivalente a 0,57 m/s, variando entre 0,46 e 0,70
m/s na comparao entre estudos.
Interveno: Em todos os estudos, o grupo
experimental recebeu o treino direcionado marcha
associado ao uso da realidade virtual. O uso da
realidade virtual foi conduzido em conjunto com
treino em esteira ergomtrica em quatro estudos20,23-25,
com exerccios com uso de videogames em dois
estudos21,22 e com cinesioterapia em movimentos
especficos do tornozelo em um estudo19. Trs
estudos20,22,23 descreveram adicionalmente o uso
de tratamento fisioteraputico usual em ambos os
grupos, experimental e controle.
A maioria dos estudos utilizou realidade virtual

imersiva durante o tratamento destinado ao grupo
experimental. Esses estudos20,23-25 utilizaram imagens
virtuais acopladas esteira ergomtrica, permitindo
alteraes de velocidade da esteira de acordo com
as imagens virtuais geradas. A realidade virtual
no imersiva foi o recurso usado nos outros trs
estudos19,21,22. Nos estudos de Kim et al.22 e Fritz et al.21,
cmeras de vdeo para capturar imagem corporal e
permitir a interao com objetos na realidade virtual
foram utilizadas. J o estudo de Mirelman et al.19
utilizou feedback visual na tela do computador e
feedback ttil de movimentos realizados. Dentre os
estudos includos, apenas o estudo de Fritz et al.21
utilizou equipamento de realidade virtual disponvel
comercialmente (Nintendo Wii).
Medida de desfecho: A maioria dos estudos
utilizou um teste clnico para avaliao de velocidade
de marcha baseado no teste de caminhada de 10
metros26, com variaes no tamanho do corredor
utilizado: 12 metros25, 10 metros20,22, 7 metros19,
6 metros 24, e 3 metros 21. Apenas um estudo 23
utilizou equipamento especfico (GAITRite) para
avaliao da velocidade de marcha. Todos os dados
so referentes velocidade de marcha confortvel e
foram descritos em metros por segundo (m/s) nesta
reviso sistemtica.
Efeito do treino associado realidade
virtual em velocidade de marcha
O efeito do treino associado ao uso de realidade
virtual em velocidade de marcha imediatamente
aps interveno foi obtido analisando dados
507
provenientes de trs estudos20-22 com mdia de 7

pontos na escala PEDro, representando boa qualidade
metodolgica27. A associao dos elementos de
realidade virtual ao treino de locomoo aumentou
a velocidade de marcha dos participantes, em mdia,
0,17 m/s (IC 95% 0,08 a 0,26; fixed effects model
I2=0%), comparando-se interveno placebo,
no interveno ou interveno no especfica aos
membros inferiores (Figura 2A).
Efeito do treino associado realidade
virtual em velocidade de marcha comparado
ao treino sem uso de realidade virtual
A superioridade do treino associado ao uso
de realidade virtual em velocidade de marcha
imediatamente aps interveno foi obtida analisando
dados provenientes de cinco estudos19,20,23-25 com
mdia de 5,8 pontos na escala PEDro, representando
moderada qualidade metodolgica27. A associao
dos elementos de realidade virtual ao treino
locomotor aumentou a velocidade de marcha dos
participantes, em mdia, 0,15 m/s (IC 95% 0,05 a
0,24; fixed effects model I2=0%), comparando-se a
outra interveno destinada aos membros inferiores

sem uso de realidade virtual associada (Figura 2B).
Discusso
Esta reviso sistemtica apresentou evidncia
clnica de que o treino direcionado marcha
associado ao uso da realidade virtual demonstrou
ser eficaz para aumentar a velocidade de marcha
de indivduos com hemiparesia. Clinicamente, esse
resultado indica que o treino direcionado marcha
associado ao uso de realidade virtual mais benfico
aos pacientes quando comparado ausncia de
interveno ou a intervenes cujo objetivo no esteja
direcionado melhora da marcha. Alm disso, os
resultados demonstraram que o treino direcionado
marcha associado ao uso da realidade virtual resultou
em maiores ganhos na velocidade de marcha quando
comparado a outras intervenes direcionadas aos
membros inferiores sem uso de realidade virtual.
A metanlise indicou que o treino associado
realidade virtual aumentou a velocidade de marcha
em 0,17 m/s. Esta a primeira metanlise que
avaliou a eficcia dessa interveno para melhorar
Figura 2. A. Diferena mdia (IC 95%) do efeito do treino direcionado marcha associado realidade virtual versus interveno placebo,
no interveno ou interveno no direcionada aos membros inferiores em velocidade de marcha imediatamente aps interveno
(n=72). B. Diferena mdia (IC 95%) do efeito do treino direcionado marcha associado realidade virtual versus treino direcionado
aos membros inferiores sem uso de realidade virtual em velocidade de marcha imediatamente aps interveno (n=92).
508
a velocidade de marcha nessa populao. Ademais,

esse achado aparenta ser clinicamente relevante,
uma vez que Tilson et al.28 relataram que aumentos
maiores que 0,16 m/s na velocidade de marcha
representam melhora de nveis de incapacidade e
sugeriram o uso desse valor como alvo teraputico
em intervenes de reabilitao da marcha. A
metanlise da presente reviso sistemtica tambm
indicou que o treino direcionado marcha associado
realidade virtual aumentou a velocidade de marcha
em 0,15 m/s a mais, comparado a outras intervenes
destinadas melhora da marcha sem uso da realidade
virtual. Uma reviso sistemtica prvia8 reportou
diferena no significativa aps adio do uso da
realidade virtual reabilitao motora. O fato de a
presente reviso incluir dois novos ensaios clnicos
metanlise aumentou o poder estatstico e permitiu a
identificao do efeito de interveno no encontrado
na reviso anterior.
A presente reviso avaliou os efeitos da adio
da realidade virtual a diferentes modalidades de
interveno relacionadas reabilitao da marcha em
indivduos ps-AVE. Embora o treino associado tenha
apresentado caractersticas especficas relacionadas
a cada estudo (treino ergomtrico20,23-25, exerccios
com videogames21,22 ou cinesioterapia especfica19),
de modo geral, os estudos includos so similares
em relao ao tempo de treinamento (mdia:
41 min; DP: 18), durao da interveno (4 sem;
DP: 1), caractersticas dos participantes e propsito
da interveno. Ademais, os resultados estatsticos
(I2=0%) indicaram que os estudos so similares em
termos metodolgicos, possibilitando a combinao
dos dados na metanlise em ambas as perguntas
clnicas. Esses dados atestam similaridade entre
os estudos, garantem ausncia de heterogeneidade
clnica e estatstica e, dessa forma, suportam a
evidncia clnica de que a adio da realidade
virtual ao treino direcionado marcha em indivduos
com AVE benfica quando o objetivo melhorar
velocidade de marcha.
Apesar de intervenes com realidade virtual
apresentarem ganhos superiores, outros fatores no
avaliados na presente reviso sistemtica, como
preferncias do cliente, habilidades do terapeuta
e custo de interveno, devem ser considerados
pelos clnicos antes de definir a modalidade de
interveno mais adequada para a reabilitao da
marcha de indivduos com hemiparesia. Como fator
positivo, observa-se que, recentemente, a indstria
do entretenimento tem disponibilizado sistemas de
realidade virtual de menor custo, tais como Nintendo

Wii, Kinect e Playstation, aumentando o acesso
de centros de reabilitao e usurios domsticos a
essa tecnologia29,30. Entretanto, dentre os estudos
includos na presente reviso sistemtica, apenas
o estudo de Fritz et al.21 utilizou equipamento
disponvel comercialmente, e os resultados isolados
no demonstraram diferenas entre grupos para
velocidade de marcha (diferena mdia: 0,04 m/s
(IC 95% -0,22 a 0,30). Uma anlise por subgrupos
guiada por tipo de realidade virtual no foi possvel
em funo de indisponibilidade de estudos. Dessa
forma, novos ensaios clnicos que avaliem a eficcia
do treino associado realidade virtual por meio
de dispositivos comercialmente disponveis so
encorajados.
A presente reviso apresenta pontos positivos e
limitaes. Os principais vieses relacionados aos
estudos foram falta de cegamento dos terapeutas
e dos participantes. No entanto, vale ressaltar
que cegamento dos participantes e terapeutas
considerado difcil ou impraticvel em intervenes
complexas como as relacionadas reabilitao
da marcha. Alm disso, a maior parte dos ensaios
clnicos aleatorizados encontrados no reportou
anlise por inteno de tratar. Por outro lado, apesar
da presena de algumas limitaes metodolgicas, a
mdia na escala PEDro, equivalente a 6,1, representa
boa qualidade metodolgica27 dos ensaios includos
nesta reviso. Outro ponto positivo foi o fato de todos
os estudos inclurem o mesmo desfecho clnico velocidade de marcha - fator no usual em estudos
de reabilitao. Isso permitiu a apresentao do
efeito de interveno em uma medida clnica real.
Ademais, o fato de a reviso incluir apenas estudos
com reabilitao motora associada realidade virtual
direcionada reabilitao da velocidade de marcha
tornou os resultados especficos s perguntas clnicas
propostas.
Concluses
A atual reviso sistemtica forneceu evidncia
clnica da eficcia da adio da realidade virtual
ao treino direcionado marcha para melhora da
velocidade de marcha de indivduos ps-AVE quando
se compara a intervenes placebo ou ausncia de
interveno. Alm disso, a reviso indicou que o
treino direcionado marcha associado realidade
virtual demonstrou ser mais eficaz do que apenas
o treino usual para melhorar velocidade de marcha.
509
Esses resultados esto embasados na metanlise de

sete ensaios clnicos aleatorizados de boa qualidade
metodolgica. Clnicos devem, portanto, sentir-se
confiantes na prescrio de exerccios com uso de
realidade virtual quando o objetivo for o aumento da
velocidade de marcha ps-AVE. Outros fatores, como
preferncias do cliente, habilidades do terapeuta e
custo de interveno, devem ser considerados antes
de definir a modalidade de interveno mais adequada
a cada cliente.
Agradecimentos
s agncias de fomento nacionais: Coordenao
de Aperfeioamento de Pessoal de Nvel
Superior (CAPES), Brasil, Conselho Nacional de
Desenvolvimento Cientfico e Tecnolgico (CNPq),
Brasil e Fundao de Amparo Pesquisa do Estado
de Minas Gerais (FAPEMIG), Brasil.
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STROKEAHA.110.584979. PMid:20508185.
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Correspondence
Lucas Rodrigues Nascimento
Departamento de Fisioterapia
Universidade Federal de Minas Gerais
Avenida Antnio Carlos, 6627, Pampulha
CEP 31270-901, Belo Horizonte, MG, Brasil
e-mail: lrn@ufmg.br / lucas.nascimento@sydney.edu.au
511
Anexo 1. Estratgia de busca.
MEDLINE, EMBASE
1. Cerebrovascular Disorders.mp. or exp Cerebrovascular Disorders/
2. Brain Ischemia.mp. or exp Brain Ischemia/
3. Cerebral Hemorrhage.mp. or exp Cerebral Hemorrhage/
4. Brain Injuries.mp. or exp Brain Injuries/
5. (Intracranial Embolism and Thrombosis).mp.
6. Intracranial Aneurysm.mp. or exp Intracranial Aneurysm/
7. (Eva or cerebrovascular accident).mp.
8. apoplexy.mp. or exp Stroke/
9. (cerebral infarct$ or cerebral ischemis$ or cerebral thrombo$ or cerebral embolis$).mp.
10. (brain infarct$ or brain ischemis$ or brain thrombo$ or brain embolis$).mp.
11. (cerebral hemorrhage or cerebral haemorrhage or cerebral hematoma or cerebral haematoma).mp.
12. (brain hemorrhage or brain haemorrhage or brain hematoma or brain haematoma).mp.
13. Cerebral Infarction.mp. or exp Cerebral Infarction/
14. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13
15. Hemiplegia.mp. or exp Hemiplegia/
16. exp Paresis/ or Paresis.mp.
17. (Hemiplegi$ or Hemipar$).mp.
18. 15 or 16 or 17
19. exp Walking/ or Walking.mp.
20. Gait.mp. or exp Gait/ or exp Gait Disorders, Neurologic/
21. Locomotion.mp. or exp Locomotion/
22. (walk$ or gait$ or ambulat$ or mobil$ or locomot$ or balanc$ or stride).mp.
23. 19 or 20 or 21 or 22
24. User-computer interface/
25. computers/ or exp microcomputers/ or computer systems/ or software/
26. computer simulation/ or computer-assisted instruction/ or therapy, computer-assisted/
27. computer graphics/ or video games/ or *touch/
28. virtual reality.mp.
29. (computer adj3 (simulat$ or graphic$ or game$ or interact$)).tw.
30. video games.mp. or Play and Playthings/ or exp Video Games/ or exp Television/ or exp Electronics/
31. (haptics or haptic device$).tw.
32. optic flow.mp. or exp Optic Flow/
33. 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33
34. 14 or 18
35. 34 and 23 and 33
36. limit 35 to humans
PEDro
Resumo e Ttulo: gait and stroke
Subdisciplina: neurology
512
original article
Relationship between the climbing up and climbing down

stairs domain scores on the FES-DMD, the score on the
Vignos Scale, age and timed performance of functional
activities in boys with Duchenne muscular dystrophy
Relao entre escore FES-DMD-subir e descer escada com escore Escala Vignos, idade
e tempo de realizao das atividades em meninos com Distro ia Muscular de Duchenne
Lilian A. Y. Fernandes1, Ftima A. Caromano1, Silvana M. B. Assis2,
Michele E. Hukuda1, Mariana C. Voos1, Eduardo V. Carvalho1
ABSTRACT | Background: Knowing the potential for and limitations of information generated using different evaluation
instruments favors the development of more accurate functional diagnoses and therapeutic decision-making. Objective: To
investigate the relationship between the number of compensatory movements when climbing up and going down stairs,
age, functional classification and time taken to perform a tested activity (TA) of going up and down stairs in boys with
Duchenne muscular dystrophy (DMD). Method: A bank of movies featuring 30 boys with DMD performing functional
activities was evaluated. Compensatory movements were assessed using the climbing up and going down stairs domain
of the Functional Evaluation Scale for Duchenne Muscular Dystrophy (FES-DMD); age in years; functional classification
using the Vignos Scale (VS), and TA using a timer. Statistical analyses were performed using the Spearman correlation
test. Results: There is a moderate relationship between the climbing up stairs domain of the FES-DMD and age (r=0.53,
p=0.004) and strong relationships with VS (r=0.72, p=0.001) and TA for this task (r=0.83, p<0.001). There were weak
relationships between the going down stairs domain of the FES-DMDgoing down stairs with age (r=0.40, p=0.032),
VS (r=0.65, p=0.002) and TA for this task (r=0.40, p=0.034). Conclusion: These findings indicate that the evaluation
of compensatory movements used when climbing up stairs can provide more relevant information about the evolution
of the disease, although the activity of going down stairs should be investigated, with the aim of enriching guidance
and strengthening accident prevention. Data from the FES-DMD, age, VS and TA can be used in a complementary way
to formulate functional diagnoses. Longitudinal studies and with broader age groups may supplement this information.
Keywords: disability; evaluation; neuromuscular diseases; rehabilitation; child; motor activity.
Fernandes LAY, Caromano FA, Assis SMB, Hukuda ME, Voos MC, Carvalho EV. Relationship between the climbing up
and climbing down stairs domain scores on the FES-DMD, the score on the Vignos Scale, age and timed performance
of functional activities in boys with Duchenne muscular dystrophy. Braz J Phys Ther. 2014 Nov-Dec; 18(6):513-520.
RESUMO | Contextualizao: Conhecer as potencialidades e limitaes das informaes geradas por diferentes
instrumentos de avaliao favorece o desenvolvimento mais preciso do diagnstico funcional e da tomada de deciso
teraputica. Objetivo: Investigar a relao entre o nmero de movimentos compensatrios ao subir e descer escadas,
idade, classificao funcional e tempo de realizao de atividade (TA) em meninos com Distrofia Muscular de Duchenne
(DMD). Mtodo: Foi utilizado banco de filmes de 30 meninos com DMD realizando atividades funcionais. Os movimentos
compensatrios foram avaliados pela Escala de Avaliao Funcional para Distrofia Muscular de Duchenne (FES-DMD),
domnio subir e descer escada; a idade, mensurada em anos; a classificao funcional foi pesquisada pela Escala de
Vignos (EV), e o TA foi cronometrado. Foi utilizado o teste de correlao de Spearman. Resultados: Existe moderada
relao entre a FES-DMD-subir escada e a idade (r=0,53, p=0,004) e forte relao com a EV (r=0,72, p=0,001) e TA
dessa tarefa (r=0,83, p<0,001). Houve fraca relao entre a FES-DMD-descer escada e a idade (r=0,40, p=0,032), EV
(r=0,65, p=0,002) e o TA dessa tarefa (r=0,40, p=0,034). Concluso: Esses achados indicam que a avaliao da tarefa
de subir escada pode trazer informaes mais relevantes sobre a evoluo da doena, embora a atividade de descer
escada deva ser pesquisada visando orientao e preveno de acidentes. A utilizao conjunta de dados provenientes
da FES-DMD, da idade e do TA pode se complementar para formulao do diagnstico funcional. Estudos longitudinais
e com outras faixas etrias mais amplas podem complementar tal informao.
Palavras-chave: incapacidade; avaliao; doenas neuromusculares; reabilitao; crianas; atividade motora.
Curso de Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Laboratrio de Fisioterapia e Comportamento, Programa de Ps-graduao em
Cincias da Reabilitao, Faculdade de Medicina, Universidade de So Paulo (USP), So Paulo, SP, Brasil
2
Programa de Ps-graduao em Distrbios do Movimento, Universidade Presbiteriana Mackenzie, So Paulo, SP, Brasil
1
513
Fernandes LAY, Caromano FA, Assis SMB, Hukuda ME, Voos MC, Carvalho EV
Introduo
A Distrofia Muscular de Duchenne (DMD)
uma doena gentica decorrente de alterao no
gene Xp21, responsvel pela produo da protena
distrofina. Afeta um em cada 3.500 nascidos vivos
do sexo masculino1. O quadro clnico da doena
caracterizado por fraqueza muscular progressiva,
generalizada e irreversvel, que se desenvolve no
sentido proximal para distal, bilateralmente, de
forma simtrica e ascendente. A evoluo inclui
perda de habilidades motoras com predomnio
em membros inferiores, chegando incapacidade
de deambular entre nove e 13 anos de idade. Os
pacientes necessitam de suporte com ventilao
mecnica no invasiva na segunda dcada de vida,
e o bito frequentemente ocorre por complicaes
cardiorrespiratrias2-4.
O declnio das atividades motoras durante o curso
da doena inevitvel, e o uso de escalas de avaliao
funcional se faz necessrio para acompanhamento
clnico, formulao do diagnstico funcional e
tomada de decises teraputicas5-7.
Atualmente, existem escalas funcionais
especficas para avaliao de pessoas com doenas
neuromusculares. A Escala de Vignos (EV)8 permite o
estadiamento da doena e foca atividades funcionais
que envolvem principalmente os membros inferiores,
que so consideradas como marco no processo de
evoluo da doena. Essa escala classifica a funo de
0 a 10 pontos, sendo que, quanto maior a classificao,
pior o desempenho funcional. A partir dessa clssica
escala, foram criadas outras, que objetivaram
detalhar a capacidade funcional de pessoas com
doenas neuromusculares, como a Motor Functional
Measure Scale9 (MFM), que pontua as atividades
funcionais em trs domnios, a saber, posio em
p e transferncias, funo motora axial, proximal
e distal. Essa escala classifica se a pessoa realiza
parcialmente, parcialmente com compensaes ou
no realiza a tarefa. A MFM mostrou responsividade e
associao com perspectiva de evoluo expressa por
pacientes e mdicos, especialmente quando aplicadas
em pessoas com DMD10. A forma breve da escala
(MFM-short form), para utilizao em crianas com
idade entre dois e sete anos, mostrou confiabilidade
intra e interxaminadores11.
A Escala North Star Ambulatory Assessment12
classifica as atividades funcionais pesquisadas de
0 a 3 pontos, ou seja, se realiza ou no determinada
atividade e se realiza de forma adaptada. Foi criada
para meninos com DMD em fase de deambulao e,
514
de acordo com Mazzone et al.13, deve ser utilizada

em combinao de medidas de resultados, a exemplo
do teste de caminhada de 6 minutos, para fornecer
informaes sobre os diferentes aspectos da funo
motora, as quais no podem ser captadas com uma
nica medida.
Essas escalas fornecem descritores de estratgias
compensatrias no desempenho das tarefas, porm
no fornecem detalhes cinesiolgicos quanto s
compensaes observadas no tronco, plvis, joelhos,
tornozelos e ps. No fornecem detalhes sobre os
movimentos de subir e descer escadas que, segundo
Vignos, uma das atividades da rotina diria que
devem ser exploradas8. Outra avaliao comumente
utilizada em pacientes com DMD a mensurao
do tempo cronometrado de atividades funcionais,
tais como o subir escadas, o levantar da cadeira
e a marcha. Normalmente, considera-se que o
acrscimo de movimentos compensatrios durante
essas atividades tendem a aumentar o tempo de sua
execuo, indicando piora no quadro funcional5-12.
Na prtica clnica, a observao de atividades
funcionais um exame simples e acessvel que
pode, inclusive, ser filmado e fornecer um registro
permanente. A anlise observacional sistematizada
foco de interesse dos autores deste estudo, que
desenvolveram uma escala especfica para esse
fim, a Escala de Avaliao Funcional para DMD
(FES-DMD), com o objetivo de esclarecer as
potencialidades e limitaes das informaes
geradas pela observao sistematizada de atividades
funcionais e, assim, contribuir para o desenvolvimento
mais preciso de diagnsticos funcionais e tomadas de
deciso teraputica14.
O domnio subir e descer escada da FES-DMD
foi elaborado com o objetivo de permitir a avaliao
especfica dessas atividades a partir da observao
sistematizada por meio de filmagem, permitindo
anlise descritiva dos movimentos, inclusive os
compensatrios, gerando escore numrico e tempo
de realizao da atividade (TA). Sua confiabilidade
intra e interexaminadores foi demonstrada em estudo
prvio14.
O TA e o escore na EV so duas variveis tambm
comumente utilizadas para classificar o estado
funcional. A idade tambm fornece uma referncia
aproximada sobre o estado de evoluo clnica15.
Entretanto, so poucos os estudos que relacionam
essas variveis com a presena de movimentos
compensatrios em atividades funcionais14,18, e faz-se
necessrio compreender a contribuio de cada uma
delas.
Relao da FES-DM com a idade, funo e tempo
Jung et al.18 estudaram a correlao entre ferramentas

de avaliao existentes com informaes clnicas
sobre Distrofia Muscular de Duchenne, a exemplo
da escala Brooke, EV, fora dos msculos abdutor
do ombro bilateral e extensores do joelho, amplitude
de movimento passivo (PROM) de dorsiflexo do
tornozelo, ngulo de escoliose, pico de fluxo da tosse,
idade, frao de encurtamento (FS), anormalidades
genticas e uso de esteroide com a funo clnica.
Encontraram que os escores das escalas Brooke
e Vignos aumentaram linearmente com a idade,
enquanto a ADM passiva dorsiflexo de tornozelo
diminuiu linearmente. A fora muscular, o ngulo de
Cobb, o pico de fluxo de tosse e a FS apresentaram
diversidade em seus graus, independentemente da
idade. Estatisticamente, as anormalidades genticas
e o uso de esteroides no foram definitivamente
associados com os escores encontrados pela escala.
Tais achados funcionais mostraram claramente que a
idade no deve ser utilizada de forma isolada.
nossa opinio que as escalas existentes se somam
no fornecimento de parmetros de avaliao, embora
esteja claro que existe a necessidade de estabelecer
rotinas de avaliao de forma a acompanhar o
desenvolvimento individual de cada criana,
adolescente e adulto comprometido pela DMD e, em
cada fase da evoluo, associar exames e testes que
esclaream sobre intercorrncias clnicas e funcionais
especficas.
O objetivo do presente estudo foi investigar
possveis relaes entre o nmero de movimentos
compensatrios ao subir e descer escada, a
classificao funcional, a idade e o tempo de
realizao dessas duas atividades em crianas com
DMD.
Mtodo
Sujeitos
Foi utilizado banco de filmes de 30 crianas com
diagnstico de DMD, com mdia de idade de 7,1
anos (DP=2,2), peso mdio de 40,8 Kg (DP=10,4)
e altura mdia de 1,39 m (DP=0,17), cedido pelo
Laboratrio de Miopatias do Instituto de Biocincias
da Universidade de So Paulo (USP), So Paulo, SP,
Brasil. Os filmes mostravam os meninos realizando
diferentes atividades funcionais, a partir de roteiro e
padronizao pr-estabelecidos. Esses filmes foram
realizados aps anuncia esclarecida e voluntria da
criana e assinatura do termo de consentimento livre
e esclarecido pelo responsvel legal.
Foram includos, neste estudo, os filmes de

crianas com diagnstico confirmado de DMD por
meio de exame de DNA e capazes de realizar a
atividade funcional de subir e descer escadas sem
auxilio de terceiros. Tambm foi critrio de incluso
estar em tratamento fisioteraputico pelo menos
uma vez por semana e ser medicado com corticoides
h pelo menos um ano. Foram excludos os filmes
de crianas que necessitavam do uso de rteses de
membros inferiores para realizar a tarefa.
O presente estudo foi realizado no Laboratrio
de Fisioterapia e Comportamento do Curso de
Fisioterapia da Faculdade de Medicina (FM) da USP,
aps a aprovao pelo Comit de tica e Pesquisa da
FM/USP, So Paulo, SP, Brasil (837/05).
Equipamentos
Para a realizao das filmagens, foi utilizado
uma cmera filmadora digital (Filmadora Digital
Full HD Sony HDR-CX220 8.9MP 32x Zoom
ptico) posicionada a 3 metros, perpendicular
escada, em um trip de 1 metro, registrando a
criana no plano sagital durante a realizao das
atividades, conforme preconizado pela FES. A
escada utilizada era composta por seis degraus
para a subida (10 x 27 cm), quatro degraus para a
descida (17 x 25 cm) e corrimo bilateral padro. As
filmagens foram iniciadas com o comando verbal do
pesquisador, que solicitou criana que o fizesse o
mais rpido que conseguisse.
Procedimento
Instrumentos, medidas e coletas dos dados
Para a avaliao da atividade funcional de subir e
descer escada, foi utilizada a FES-DMD, que uma
escala funcional especifica para avaliao funcional
de pessoas com DMD e pesquisa as atividades de
levantar e sentar da cadeira e do cho, subir e descer
escada e marcha. Essa escala registra e descreve os
movimentos realizados, focando as compensaes.
A FES-DMD-subir escada dividida em cinco
fases, a saber, fase de preparo/bipedestao, fase de
propulso, fase de balano, fase membro inferior/
balano e fase de apoio. A avaliao da atividade
de descer, segundo recomendao da FES-DMD,
dividida em quatro fases, fase de preparo/
bipedestao, fase de propulso, fase de balano e
fase de apoio. No domnio subir e descer escada da
FES-DMD, quanto menor o escore final, menor o
nmero de movimentos compensatrios e melhor o
desempenho na atividade14,16,18. A atividade consistiu
515
em subir seis degraus e descer quatro e atingir o

cho. A preparao das crianas para filmagem
incluiu permanecer em sedestao por 5 minutos
antes da realizao de atividades funcionais para no
terem prejuzo no desempenho devido fadiga. Na
sequncia, foram solicitadas as primeiras atividades
da FES-DMD. Foi permitido o uso de apoios.
Os filmes foram analisados por um fisioterapeuta
com experincia clnica de, no mnimo, cinco anos
em neuropediatria e treinamento prvio com a FESDMD, o qual era cego em relao aos objetivos do
estudo.
Para a coleta do TA, foi solicitado que a criana
subisse e descesse a escada o mais rpido possvel.
Foi cronometrado a partir do comando verbal do
pesquisador para iniciar a tarefa e interrompido
quando a criana tocasse os dois ps no ltimo
degrau. O escore de classificao segundo a EV
e a idade foi coletado dos pronturios. A EV
consiste em 10 quesitos funcionais, com dificuldade
decrescente, sendo que, quanto maior o escore, pior
o desempenho motor8.
Anlise dos dados
Para a anlise estatstica dos dados, foi utilizado
o programa Statistica 11.0. Testes de correlao de
Spearman foram utilizados para investigar possveis
relaes entre FES-DMD-subir e descer escada,
EV, TA e idade. A idade foi coletada em meses e
posteriormente transformada em anos por meio de
regra de trs. Foram considerados significativos
valores de p<0,05.
Resultados
A mdia dos escores da FES-DMD-subir escada
foi de 16,7 pontos (DP=8,4) e a da FES-DMDdescer escada, 16,9 pontos (DP=8,6). A mdia das
classificaes na EV foi de 3,1 (DP=1,1). O TA do
subir escada foi de 11,3 segundos (DP=10,7) e o do
descer escada foi de 11,1 segundos (DP=13,5).
O teste de correlao de Spearman mostrou
correlao moderada entre os escores da FES-DMDsubir escada e a idade (r=0,53; p=0,004). Houve
correlao fraca entre os escores da FES-DMD descer
escada e a idade. (Figura 1) Tanto para subir quanto
para descer escadas, quanto maior a idade, maior foi
o escore na FES-DMD (r=0,40; p=0,032).
A classificao na EV tambm apresentou
correlao com a FES-DMD-subir e descer escada
(r=0,72; p<0,001 e r=0,56; p=0,002, respectivamente)
(Figura 2). Quanto pior a classificao funcional pela
EV, maior o nmero de compensaes detectadas
pela FES-DMD em ambas as atividades estudadas.
A FES-DMD-subir escada apresentou correlao
forte com o TA (r=0,83; p<0,001) (Figura 3),
enquanto a FES-DMD-descer escada apresentou
correlao fraca (r=0,40; p=0,034) (Figura 3). Para
ambas as atividades, quanto maior o TA, maior o
escore na FES-DMD, indicando maior nmero de
compensaes.
Discusso
O presente estudo investigou possveis relaes
entre os escores da FES-DMD-subir e descer escada
com a idade e a classificao pela EV. Alm disso,
Figura 1. Correlao entre a pontuao na FES-DMD-subir escadas (A) e na FES-DMD-descer escadas (B) com a idade (anos).
516
Figura 2. Correlao entre a pontuao da FES-DMD-subir escadas (A) e a FES-DMD-descer escadas (B) com a EV.
Figura 3. Correlao entre a FES-DMD-subir escadas (A) e a FES-DMD-descer escadas (B) com o tempo de realizao da atividade
(segundos).
investigou a relao com o tempo de movimento

nessas atividades.
Observou-se de moderada a fraca correlao entre
os escores da FES-DMD-subir e descer escada com a
idade da populao estudada. Como esperado, quanto
maior a idade, pior foi o desempenho. Jung et al.18
relataram correlao entre escores gerados pelas
escalas de Brooke e de Vignos com a idade em um
estudo com 121 garotos com DMD (mdia de idade=
9,9 anos; DP=3,4). No presente estudo, as atividades
pesquisadas so bem especficas, ao contrrio da
aplicao completa de uma escala, que normalmente
inclui a pesquisa de vrias atividades. Portanto, nosso
estudo complementa os achados desses autores.
Pessoas com DMD apresentam perdas funcionais

ao longo dos anos, porm a grande variabilidade
de evoluo clnica nessa doena pode dificultar
predies de prognstico, especialmente quando
se utiliza, como base, somente a idade. No entanto,
essa informao essencial para compreenso
da evoluo da doena no tempo, principalmente
considerando que ela pode variar muito entre as
pessoas acometidas.
As intervenes teraputicas, no momento, tm
como principal objetivo retardar as complicaes
impostas pela doena, modificando seu curso natural
e prolongando a expectativa de vida. Parreira et al.19
investigaram a relao entre a idade e a capacidade
funcional em 90 crianas com DMD, com idades
517
de cinco a 12 anos e tratamento com corticoide

por aproximadamente sete anos. A relao entre a
idade e o desempenho funcional no alcanou nvel
significativo. Os autores sugeriram que essa ausncia
de correlao se deve terapia com esteroides, que
retarda a progresso da DMD. Henricson et al.20, em
estudo de cooperao internacional, com 240 pessoas
com DMD, com idades de dois a 28 anos, mostraram
que o tratamento com glucocorticoides preserva
marcos funcionais clinicamente significativos e reduz
a taxa de progresso da doena, medida pelo teste
muscular manual e outras medidas de resultados de
ensaios clnicos comumente usados, como a prova
de funo pulmonar.
Assim como Parreira et al.19, acreditamos que,
no presente estudo, as relaes entre a idade e a
atividade funcional subir e descer escadas tenham se
apresentado de forma moderada a fraca em funo de
as crianas estarem em tratamento medicamentoso
e fisioteraputico, o que pode ter influenciado e
minimizado a relao entre a idade e a progresso
da doena na amostra. Tambm relevante o fato de
termos estudado crianas somente at oito anos, pois
possvel que um nmero maior de compensaes
ocorram na fase mais tardia da doena.
Ficou evidenciada a relao entre FES-DMD-subir
e descer escada com a EV. Acreditamos que o grande
envolvimento de membros inferiores nas atividades
avaliadas na FES-DMD e na EV tenha favorecido
esse achado8,19-21. Sugerimos estudos posteriores que
busquem sua relao com outras escalas.
A FES-DMD-subir escada apresentou forte
correlao com a EV, enquanto a FES-DMD-descer
escada apresentou correlao moderada. Isso pode
se justificar porque a EV valoriza a atividade
subir escada, considerada um marco na evoluo
degenerativa progressiva da capacidade funcional
de pacientes com DMD8.
Os tempos de subida e de descida de escadas
foram analisados e sugeridos em estudos prvios
como parmetros de avaliao por Vignos et al.8
e Brooke et al.15. Encontramos que os escores na
FES-DMD-subir e descer escada apresentaram
correlao com os TAs. O tempo de subida da escada
teve correlao maior com a FES-DMD que o tempo
de descida (r=0,83 versus r=0,40). Isso pode ser
explicado pela maior dificuldade motora exigida
durante a subida. Na descida da escada, embora seja
exigido grande controle de contrao excntrica
e coordenao, os movimentos compensatrios
ocorreram em menor nmero. Na descida, os
518
pacientes, de modo geral, tenderam a acelerar o

deslocamento do centro de massa para frente. Logo,
no diferiram muito no tempo de movimento nessa
tarefa. Essa estratgia compensatria compatvel
com a encontrada na literatura22. Outro fator que
explica tal diferena a exigncia maior de fora
muscular na subida da escada, necessria para o
suporte do peso corporal contra a ao da gravidade.
Ao descer escadas, os meninos se apoiam no
corrimo, portanto no apresentam medo de quedas,
acelerando, assim, o tempo de descida.
Na avaliao clnica de pacientes com DMD,
interessante utilizar os TAs subir e descer escada
associados FES-DMD, pois, embora tenham
componentes em comum, j que, quanto mais
movimentos compensatrios, maior o tempo de
movimento, em alguns casos, o tempo pode se
manter como consequncia do aumento do nmero
de movimentos compensatrios. Esse achado s
ser possvel com o uso das duas ferramentas de
avaliao. Nesses casos, a FES-DMD permite
acesso caracterizao descritiva dos movimentos
compensatrios.
Em estudo similar, Escorcio et al.16 desenvolveram
e demonstraram confiabilidade da FES-DMDsentar e levantar do cho. Os autores encontraram
correlao entre os escores da FES-DMD-sentar
e levantar do cho com a idade, a EV e os TAs.
Quando investigadas as relaes entre os escores da
FES-DMD e a idade, encontraram baixa correlao
entre a FES-DMD-sentar no solo e a idade e nenhuma
relao na FES-DMD- levantar do solo. A FESDMD-sentar no cho apresentou fraca correlao
com a EV (r=0,21). Porm, a FES-DMD-levantar
do cho apresentou correlao moderada com a EV
(r=0,56). A FES-DMD-sentar no cho no apresentou
correlao com o TA, e houve forte relao somente
entre a FES-DMD-levantar do solo e o TA (r=0,79).
Esses achados so semelhantes aos encontrados
no presente estudo. As relaes ficaram mais
evidenciadas em fases das atividades que exigem
maior fora e controle neuromuscular (subir escadas
e levantar do cho).
Hukuda et al.17 desenvolveram e demonstraram
confiabilidade nas atividades sentar e levantar da
cadeira. Observaram correlao moderada somente
da FES-DMD-sentar na cadeira com a idade (r=0,44).
Relataram correlao moderada da FES-DMD-sentar
e levantar da cadeira com o tempo (r=0,69 e r=0,66,
respectivamente) e com a EV. Nesse caso, h poucos
elementos em comum entre a EV e as atividades
sentar e levantar da cadeira, ao contrrio da atividade

estudada no presente estudo, tambm na escala
classificatria de Vignos.
Nossos achados chamam a ateno para dois fatos
distintos. A idade utilizada de forma isolada no
uma varivel adequada para descrio da evoluo
funcional desses pacientes, pois, minimamente,
no reflete as alteraes funcionais observveis na
atividade de subir e descer escada, o que foi visto
pela baixa relao idade x escore FES-DMD.
Por outro lado, a EV, que a precursora de
escalas funcionais na DMD, mostrou ter forte
relao com a FES-DMD-subir escada e moderada
com o FES-DMD-descer escada. Ambas podem
ser utilizadas de forma complementar, no s
classificando, mas permitindo a compreenso
dos mecanismos de movimentos compensatrios,
utilizados principalmente durante a descida da
escada.
Acreditamos que o tempo de execuo da tarefa
tambm uma varivel a ser considerada, e j
incorporada FES-DMD, pois, durante a subida
da escada, o aumento no nmero de movimentos
compensatrios implica maior tempo na execuo,
enquanto, na descida, o tempo pode diminuir em
funo dos deslocamentos bruscos auxiliados pela
fora da gravidade. Como espervamos, a FESDMD-subir escadas apresentou uma forte correlao
com o tempo de execuo.
Nossa amostra de participantes esclarece as
relaes entre as variveis estudadas para crianas
de at aproximadamente oito anos. Acreditamos
que estudos posteriores podem esclarecer mais
detalhadamente essa relao em grupos com
diferentes faixas etrias.
durante o raciocnio sobre o diagnstico funcional.

Estudos longitudinais e com outras faixas etrias
mais amplas podem complementar essa informao.
Agradecimentos
A Mayana Zatz e Mariz Vainzof pelo acesso ao
banco de dados de imagens (filmes) do Laboratrio de
Miopatias do Instituto de Biocincias da Universidade
de So Paulo.
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Conclumos que existe moderada relao entre a
FES-DMD-subir escada e a idade, e forte relao com
a EV e o TA, especificamente dessa tarefa. Houve
fraca relao entre a FES-DMD-descer escada e a
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de subir escada pode trazer informaes mais precisas
sobre a evoluo da doena, embora a atividade
de descer escada deva ser pesquisada visando
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Correspondence
Ftima Aparecida Caromano
Universidade de So Paulo
Faculdade de Medicina
Programa de Ps-graduao em Cincias da Reabilitao
Laboratrio de Fisioterapia e Comportamento
Curso de Fisioterapia, Fonoaudiologia e Terapia Ocupacional
Rua Cipotnea, 51, Cidade Universitria
CEP 05360-000, So Paulo, SP, Brasil
e-mail: caromano@usp.br
original article
Muscular performance characterization in athletes: a

new perspective on isokinetic variables
Giovanna M. Amaral1, Hellen V. R. Marinho1,2, Juliana M. Ocarino1,
Paula L. P. Silva1, Thales R. de Souza1, Srgio T. Fonseca1
ABSTRACT | Background: Isokinetic dynamometry allows the measurement of several variables related to muscular
performance, many of which are seldom used, while others are redundantly applied to the characterization of muscle
function. Objectives: The present study aimed to establish the particular features of muscle function that are captured by
the variables currently included in isokinetic assessment and to determine which variables best represent these features
in order to achieve a more objective interpretation of muscular performance. Method: This study included 235 male
athletes. They performed isokinetic tests of concentric knee flexion and extension of the dominant leg at a velocity of
60/s. An exploratory factor analysis was performed. Results: The findings demonstrated that isokinetic variables can
characterize more than muscle torque production and pointed to the presence of 5 factors that enabled the characterization
of muscular performance according to 5 different domains or constructs. Conclusions: The constructs can be described
by torque generation capacity; variation of the torque generation capacity along repetitions; movement deceleration
capacity; mechanical/physiological factors of torque generation; and acceleration capacity (torque development). Fewer
than eight out of sixteen variables are enough to characterize these five constructs. Our results suggest that these variables
and these 5 domains may lead to a more systematic and optimized interpretation of isokinetic assessments.
Keywords: physical therapy; muscle strength dynamometer; knee joint; isokinetics; factor analysis.
Amaral GM, Marinho HVR, Ocarino JM, Silva PLP, Souza TR, Fonseca ST. Muscular performance characterization
in athletes: a new perspective on isokinetic variables. Braz J Phys Ther. 2014 Nov-Dec; 18(6):521-529. http://dx.doi.org/10.1590/
bjpt-rbf.2014.0047
Introduction
Over the last decades, the technology of isokinetic
devices has improved1,2. In order to achieve a more
thorough description of muscular performance,
new variables began to be calculated and included
in the assessment reports generated by these
devices1. However, only a few of these variables
have been explored from scientific and clinical
perspectives. For example, peak torque has been
the most widely reported and discussed approach
to the characterization of muscular performance for
several years1,3,4.
Isokinetic assessments of muscle function are
widely used to identify specifi c defi cits, or to
assess the results of interventions. Some authors
have discussed the relevance and meaning of each
variable included in isokinetic assessments1,4-6.
Some publications reported on variables such as
Total Work, Fatigue Index and Power, in addition
to Peak Torque6,7. However, little is known about

the associations among such variables, as well
as the individual contribution of each variable to
the characterization of muscular performance. A
better understanding of these aspects might help to
establish which variables measure similar features
of muscle function and which variables best
represent particular features of performance. Such
understanding would allow the report of variables
in a uniform and rational manner. Therefore,
the aims of the present study were to identify
the specific features of muscle function that are
represented by the variables currently available
in isokinetic assessments and to determine which
variables best represent these features in order to
develop a more objective assessment of muscular
performance.
Programa de Ps-graduao em Cincias da Reabilitao, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
Universidade Estadual de Montes Claros (UNIMONTES), Montes Claros, MG, Brazil
1
2
521
Amaral GM, Marinho HVR, Ocarino JM, Silva PLP, Souza TR, Fonseca ST
Method
Variables selection
Subjects
Sixteen variables available in the Comprehensive

Evaluation Reports generated by Biodex Software
were selected to be included in this study: Peak
Torque, Time to Peak Torque, Angle of Peak
Torque, Torque at 30, Torque at 0.18 s, Coefficient
of Variation, Maximum Work, Maximum Work
Repetition Number, Total Work, Work Last Third,
Work First Third, Work Fatigue Percentage, Average
Power, Acceleration Time, Deceleration Time, and
Average Peak Torque. The windowing option was
turned on to guarantee that only the isokinetic portion
(above 70% of the preset speed) of the test was used.
Peak Torque and Maximum Work normalized by
bodyweight were not included in the analysis, since
normalization would make the results dependent on
the individuals mass. Another variable not used in
the present study was the Agonist:antagonist ratio,
as it does not pertain to the assessment of a specific
muscle group.
Preseason isokinetic assessment reports of knee

joint flexion-extension concentric motions at 60/s
were selected from the laboratorys database. The
reports showing a documented history of lower
limb injury or symptoms were excluded and only
data from the dominant limb were included. The
sample included 235 male elite athletes (soccer and
volleyball players) with mean age 23.074.84 years,
mean height 1.838.09 meters and mean body weight
78.189.33 Kg. All athletes were, at the time of the
evaluation, active in their professional team. The
present study was approved by the Ethics Committee
of Universidade Federal de Minas Gerais (UFMG),
Belo Horizonte, MG, Brazil (approval number
01748412.0.0000.5149), and all athletes signed an
informed consent form.
Procedures
The procedure was explained and the lower
limb dominance was determined by asking the
athlete which leg he uses to kick a ball. The athletes
performed a warm-up consisting of exercises on an
ergometric bicycle for 5 minutes. Next, the athletes
were placed on the isokinetic dynamometer (Biodex
Multi-joint System 3, Biodex Medical Systems
Inc, Shirley, NY, USA) in a sitting position with
hip flexion of 85 and the equipment axis aligned
with the lateral condyle of the femur. The arms
were placed along the sides of the body, the trunk
was stabilized against the backrest using the chair
belts, the thigh of the tested limb was fixed against
the seat by means of a belt, and the contralateral
limb was allowed to hang free. The tested leg was
weighted to correct for the effects of gravity on the
torque measured, according to the specifications of
the Biodex Manual. To assess muscular performance,
the participants were asked to perform alternating
concentric contractions of the knee flexors and
extensors within a range of motion of 85 (90 to
5 of flexion). During the test, the participants were
instructed to keep the maximum force throughout
the entire range of motion. In addition, they were
encouraged to go faster and never stop until the end
of the assessment. The participants were allowed to
familiarize themselves with the procedures before
actual testing by performing 3 repetitions of the tested
motion. Then they performed a set of 5 repetitions at
60/s. When the Coefficient of Variation (CV) of the
Peak Torque was higher than 10%8, the athlete was
allowed to rest and the set was repeated.
522
The present study used an exploratory factor
analysis to identify the factors that could accurately
characterize muscular performance. This approach
assumes the presence of associations and redundancy
among the variables included in the isokinetic report.
Factor analysis is a set of statistical techniques used
to explain the relationship between original observed
variables and non-observed variables (factors).
Therefore, the number of factors identified is lower
than the number of original variables analyzed. Each
factor characterizes one theoretical aspect (construct)
of muscular performance.
Initial exploratory factor analysis with varimax
rotation was performed with the SPSS 15.0 statistical
software (SPSS Inc., Chicago, IL, USA). The factors
that exhibited an eigenvalue >1 were maintained. The
Kaiser-Meyer-Olkin (KMO) measure of sampling
adequacy and Bartletts test of sphericity were run to
confirm the adequacy of factor analysis. The variables
with communality values (proportion of common
variance) lower than 0.6, as well as those with cross
loadings over 0.4, were excluded from the analysis.
These variables were excluded successively, and a
new factor analysis was performed following the
removal of each variable until the goodness-of-fit of
the reduced model was attained.
In order to identify outliers for each factor of the
reduced model, regression scores were computed
for each individual. Following the removal of the
outliers in these scores, the final exploratory factor
Muscular performance: isokinetic variables
analysis was performed. To validate the model

relative to the knee extension torque curve data, the
sample was randomly divided into 2 subsamples
(split-sample method), and factor analysis was
performed in each subsample to assess whether
the initial factor structure was maintained. Finally,
to investigate the capacity of generalization of the
final factor structure, a second exploratory factor
analysis, which included all the variables used in the
first analysis, was performed using the knee flexion
torque curve data. The similarity between the factor
structures generated based on the knee extension
and flexion data was assessed by means of Tuckers
congruence coefficient.
Results
Upon initial exploratory analysis (n=235), Bartletts
test of sphericity was significant (p<0.0001), and the
KMO measure of sampling adequacy was 0.700,
which indicated that factor analysis was appropriate
for the data in the present study. These results pointed
to the presence of 5 factors that clearly represented
different features of muscular performance, and we
chose to maintain this initial (5-factor) structure in

the subsequent analyses (Table 1).
Application of the procedures to reduce the number
of variables in the model resulted in the exclusion of
5 variables. The Coefficient of Variation was the
first variable to be excluded (communality = 0.522).
Next, the variables Torque at 30, Time to Peak
Torque, Average Power, and Peak Torque at 0.18 s
were successively excluded (cross loading >0.4).
Following the identification and removal of outliers
of the resultant scores (n=219), the reduced model
of exploratory factor analysis of the knee extension
data explained 90.746% of the total variability of
the data. The KMO value was 0.723, and Bartletts
test of sphericity was significant (p<0.0001),
indicating that factor analysis was appropriate for the
investigated dataset. The variables exhibited adequate
communality values (Table 2).
Factor analysis of the 2 randomized subsamples
(n1=110, n2=109) exhibited KMO values of 0.698
and 0.683, respectively. Bartletts test of sphericity
was significant (p<0.0001) in both samples.
The total explained variance of the data in these
subsamples was 91.288% and 90.537%, respectively
(Table 3). These 2 analyses converged towards the
Table 1. Factor structure of knee extensor isokinetic assessment data disclosed by the initial exploratory factor analysis.
Factors
Variables
Maximum Work
Communality
0.976
0.042
0.110
0.071
0.073
0.977
Total Work
0.961
0.042
0.036
0.005
0.123
0.943
Work Last Third
0.944
0.062
0.163
0.137
0.106
0.952
Work First Third
0.929
0.037
0.260
0.025
0.155
0.957
Peak Torque
0.883
0.156
0.023
0.081
0.354
0.937
Average Peak Torque
0.865
0.190
0.138
0.072
0.337
0.922
Average Power
0.787
0.216
0.150
0.156
0.421**
0.890
Acceleration Time
0.082
0.865
0.020
0.098
0.277
0.841
Torque at 0.18 s
0.400**
0.824
0.049
0.030
0.290
0.927
Time to Peak Torque
0.113
0.669
0.143
0.389
0.476**
0.859
Work Fatigue Percentage
0.101
0.052
0.795
0.312
0.089
0.750
Maximum Work
Repetition Number
0.035
0.019
0.749
0.167
0.230
0.643
Coefficient of variation
0.045
0.087
0.696
0.071
0.149
0.522*
Angle of Peak Torque
0.004
0.107
0.140
0.940
0.027
0.916
0.210
0.035
0.680
0.098
0.878
0.692
Torque at 30
Deceleration Time
Percentage of Explained
Variance (%)
0.601**
0.033
39.6%
0.001
12.9%
0.045
0.018
0.830
11.7%
10.6%
10.3%
*Communality <0.6; **Cross loading 0.4.
523
Table 2. Factor structure of knee extensor isokinetic assessment data disclosed by the final exploratory factor analysis.
Factors
Torque
Generation
Capacity
Variation
in Torque
Generation
Capacity
Movement
Deceleration
Capacity
Mechanical/
Physiological
Factors
of Torque
Generation
Acceleration
Capacity
Communality
Maximum Work
0.977
0.077
0.060
0.043
0.017
0.966
Total Work
0.958
0.011
0.093
0.018
0.005
0.927
Work Last Third
0.935
0.186
0.078
0.155
0.022
0.940
Work First Third
0.935
0.258
0.095
0.042
0.016
0.952
Peak Torque
0.883
0.095
0.308
0.064
0.044
0.889
Average Peak
Torque
0.859
0.172
0.314
0.072
0.023
0.871
Work Fatigue
Percentage
0.096
0.812
0.031
0.365
0.069
0.808
Maximum
Work Repetition
Number
0.047
0.854
0.074
0.190
0.108
0.784
Deceleration
Time
0.027
0.073
0.960
0.023
0.031
0.929
Angle of Peak
Torque
0.073
0.041
0.020
0.956
0.024
0.923
Acceleration
Time
0.024
0.045
0.028
0.028
0.995
0.993
Percentage
of Explained
Variance (%)
46.9%
14.0%
10.5%
10.2%
9.2%
Variables
same structure in the final model, which therefore

supported its validation.
In the exploratory factor analysis of the knee
flexion data, Bartletts test of sphericity was also
significant (p<0.0001), the KMO value was 0.718,
and the explanatory percentage was 91.322%
(Table 4). Tuckers congruence coefficient between
the flexion model and the final extension model
was 0.95, thus indicating high similarity between
models. These results demonstrate the capacity of
generalization of the final model obtained from the
knee extensor isokinetic assessment data to the knee
flexor isokinetic assessment data at 60/s.
Discussion
The results indicated that the set of variables
included in knee isokinetic assessment reports
could be represented by 5 factors, which together
explained more than 90% of the variance in data. On
the one hand, the results indicate much redundancy
in the information provided by the variables
524
currently included in isokinetic assessments; on

the other, they indicate that 5 different domains of
muscular performance are represented by this set
of variables. These domains were defined as torque
generation capacity, variation in torque generation
capacity along repetitions, movement deceleration
capacity, mechanical/physiological factors of
torque generation, and acceleration capacity (torque
development). The identification of these domains
should enable a more systematic and optimized
interpretation of the data in isokinetic assessments.
Five variables were not included in the final
model. The CV had a low communality with the
other variables, which is due to the fact that this
variable was controlled in our study. The remaining
variables (Time to Peak Torque, Torque at 30, Torque
at 0.18 s, and Average Power) had cross loading >0.4
for more than one factor (i.e. they bring ambiguous
information to test interpretation). For example,
Time to Peak Torque and Torque at 30 depend on
multiple attributes, such as the individuals capacity
to produce torque and to accelerate the limb, as well
48.7%
Percentage
of Explained
Variance
(%)
Maximum
Work
Repetition
Number
0.017
0.012
Work Fatigue
Percentage
Acceleration
Time
0.064
Average
Peak Torque
0.064
0.885
Peak Torque
Angle of
Peak Torque
0.905
Work First
Third
0.050
0.956
Work Last
Third
Deceleration
Time
0.988
0.942
Total Work
0.983
Maximum
Work
Variables
Factors in random sample 2
13.0%
0.065
0.031
0.025
0.816
0.811
0.115
0.041
0.199
0.203
0.008
0.041
10.5%
0.052
0.009
0.963
0.127
0.104
0.287
0.293
0.062
0.108
0.056
0.293
10.0%
0.022
0.950
0.020
0.218
0.353
0.057
0.052
0.049
0.129
0.004
0.052
9.2%
0.989
0.027
0.051
0.137
0.065
0.006
0.030
0.002
0.021
0.006
0.030
0.987
0.908
0.934
0.747
0.801
0.883
0.911
0.960
0.957
0.979
0.974
44.8%
0.031
0.085
0.008
0.101
0.141
0.838
0.866
0.899
0.926
0.917
0.965
15.6%
0.027
0.056
0.115
0.886
0.812
0.243
0.167
0.349
0.154
0.045
0.139
10.6%
0.095
0.014
0.949
0.056
0.126
0.32
0.303
0.124
0.049
0.138
0.047
10.3%
0.068
0.967
0.013
0.150
0.349
0.066
0.059
0.017
0.188
0.03
0.055
9.3%
0.988
0.063
0.100
0.110
0.102
0.046
0.051
0.036
0.04
0.004
0.022
0.991
0.949
0.925
0.833
0.828
0.870
0.875
0.947
0.920
0.863
0.957
Mechanical/
Mechanical/
Variation
Variation
Movement Physiological
Torque
Torque
Movement Physiological
Acceleration
Acceleration
in Torque
in Torque
Factors
Communality Generation
Deceleration
Factors
Communality
Deceleration
Generation
Capacity
Generation
Capacity
Generation
Capacity
Capacity
of Torque
Capacity
of Torque
Capacity
Capacity
Capacity
Generation
Generation
Factors in random sample 1
Table 3. Factor structure of knee extensor isokinetic assessment data disclosed by exploratory factor analysis of the 2 subsamples obtained by means of the split-sample method.
525
Table 4. Factor structure of knee flexor isokinetic assessment data disclosed by the exploratory factor analysis.
Factors
Acceleration
Capacity
Mechanical/
Physiological
Factors
of Torque
Generation
0.091
0.007
0.021
0.962
0.065
0.023
0.045
0.963
0.027
0.036
0.01
0.959
Torque
Generation
Capacity
Variation
in Torque
Generation
Capacity
Movement
Deceleration
Capacity
Maximum Work
0.968
0.128
Total Work
0.977
0.048
Work First Third
0.938
0.276
Variables
Communality
Work Last Third
0.918
0.224
0.183
0.101
0.111
0.948
Peak Torque
0.912
0.007
0.126
0.132
0.115
0.879
Average Peak
Torque
0.912
0.068
0.128
0.16
0.114
0.891
0.845
0.248
0.157
0.2
0.841
0.305
0.098
0.056
0.759
0.938
0.126
0.036
0.899
Work Fatigue
Percentage
0.04
Maximum Work
Repetition Number
0.113
Deceleration Time
0.018
0.032
Angle of Peak Torque
0.019
0.195
0.046
0.969
0.981
Acceleration Time
0.130
0.036
0.122
0.964
0.044
0.964
Percentage of
Explained Variance
(%)
48.3%
14.0%
10.3%
9.4%
9.3%
0.8
as on muscle length. Thus, the non-inclusion of these

variables eliminated redundant information from the
test results, as specific aspects of muscle performance
were better captured by other variables available in
the isokinetic report.
The first factor included the variables that were
related to the construct of Torque Generation
Capacity. Higher values for these variables were
associated with greater torque generation capacity in
athletes. This factor captured the largest percentage
of the data variability (46.9% of the total variance).
The 4 variables that exhibited the greatest factor
loading were Maximum Work (0.977), Total Work
(0.958), Work First Third (0.935), and Work Last
Third (0.935), and these variables also exhibited
strong mutual correlation (>0.90). Work, calculated
as the area under the force vs. displacement curve,
represents the energy spent by muscle exertion
during motion (product of torque times angular
displacement)4,9,10. Maximum Work represents the
capacity to generate muscle torque throughout the
full range of the movement repetition that exhibits
the greatest muscle work production4,9. Total Work
represents the sum of the work calculated for each
repetition9, and Work First Third and Work Last
Third represent the amount of work performed in
526
0.04
those stages of movement in all the test repetitions

taken together11. This factor was also represented by
the variables Peak Torque and Average Peak Torque,
with factor loading values of 0.883 and 0.859,
respectively. Peak Torque represents the maximum
torque generated at a single point of the entire
range of motion among all test repetitions9, whereas
Average Peak Torque represents the mean value of the
maximum torque generated in all 5 repetitions11. The
high association between Peak Torque and Average
Peak Torque was expected, since only tests with small
Coefficient of Variation (<10%) were allowed in this
study. When this criterion is not observed and large
variation occurs, lower association between these
variables can be expected.
The variable Maximum Work best represented
torque generation capacity because it exhibited the
greatest factor loading for the first factor, in addition
to strong correlation with the variables Total Work,
Work First Third, and Work Last Third. Although
Peak Torque (factor loading of 0.883) has been the
variable most widely used in the interpretation of
isokinetic assessments, the results of the present
study reinforce the need to measure Maximum
Work to achieve an accurate characterization of the
torque generation capacity. Therefore, the variable
Peak Torque should not be used alone to represent

that construct, as it could lead to errors in the
interpretation of the results. The limited ability of
Peak Torque to characterize the torque generation
capacity of an individual may be related to the fact
that it corresponds to the torque generated at a single
point of the entire range of motion. Conversely, the
variable Maximum Work provides information on the
ability of the muscle to generate torque throughout
the entire range of motion4. Within that context,
individuals able to generate high peak torque do
not systematically exhibit the greatest values for
Maximum Work4. Moreover, high Peak Torque values
not associated with Maximum Work values may
indicate a condition in which the assessed individual
is able to generate high torque at a given point but
cannot maintain that level of performance throughout
the entire range of motion of the knee joint. The
results of the present study therefore suggest that
both variables (i.e. Maximum Work and Peak Torque)
should be included in reports to achieve a thorough
characterization of torque generation capacity related
to muscular performance12.
The second factor identified was represented by
the variables Maximum Work Repetition Number
(0.854) and Work Fatigue Percentage (0.812),
which were associated with the Variation in Torque
Generation Capacity. This factor contributed 14% of
the total explained variance and provided information
on the consistency of muscular performance, i.e. the
maintenance of torque generation capacity during
repetitions. The discrete variable Maximum Work
Repetition Number represents the number of the
repetition (i.e. 1, 2, 3, 4 or 5) in which the curve
exhibited its greatest magnitude11. The variable Work
Fatigue Percentage represents the percent reduction
in the work generated between the first and last
thirds of the series of repetitions13,14. For lower scores
corresponding to this variable, there is generally
greater consistency in muscular performance13,14.
However, this analysis must be performed with
caution because this variable was calculated based
on only 5 repetitions at a velocity of 60/s, and
it merely represents the effect of the variation of
performance between the beginning and the end of
the test. Therefore, in the present study, Work Fatigue
Percentage seems to have provided information
concerning performance variability. Furthermore,
the variable Maximum Work Repetition Number
exhibited an inverse correlation with this factor. In
other words, the later the Maximum Work repetition
occurs, the lower the variability in the response is.
Due to the weak correlation between these variables
(0.416), combined use of both may provide

information on the ability to maintain the generated
torque during repetitions, which is considered to be
indicative of muscle endurance or the neuromuscular
ability to keep torque generation constant13,14.
The third factor captured the movement
deceleration capacity, represented by the variable
Deceleration Time, and contributed to 10.5% of
the total variance. Deceleration Time represents
the total time to reduce isokinetic velocity to 0/s at
the end of the motion. During an isokinetic testing,
the equipment imposes increasing resistance to any
torque that attempts to produce movement speeds
greater than that selected for the test. Considering
that a proper isokinetic assessment requires that the
individual produce maximum torque at any point
during the test (resulting in an adequate test speed),
the Deceleration Time may characterize the capacity
of the individual to maintain maximum torque, at the
required speed, close to the end of the tested range
of motion (in a position in which the muscle is close
to active insufficiency). Thus, greater Deceleration
Time values may be associated with lower capacity
to maintain torque at the extremes of the range
of motion. As this variable represents a different
condition in comparison to the other variables,
it may add relevant information concerning the
isokinetic test15. Although it is seldom reported in
studies, this variable represents a domain of muscular
performance that should not be neglected.
The fourth factor was represented by the Angle
of Peak Torque, which corresponded to 10.2% of the
total explained variance. This factor was associated
with the muscle function domain that we defined
as Mechanical/Physiological Factors of Torque
Generation. The Angle of Peak Torque corresponds
to the position of the joint at the moment when Peak
Torque is generated7,16-18. Therefore, this variable
represents the optimal point of the torque vs. angular
displacement curve for torque development and
is related to the interaction between physiological
factors such as optimal muscle length (length-tension
relationship) and mechanical factors (changes in
the angle of insertion/lever arm during rotatory
motion) during performance assessment16,18. The
interpretation of this variable must take into account
not only the absolute values of angulation but also
the representation of such angulation relative to the
activity of interest. For instance, the Angle of Peak
Torque values for the knee flexors and extensors
of soccer players were shown to be significantly
decreased and increased, respectively, in comparison
to cyclists18. Furthermore, Angle of Peak Torque
527
that does not meet the specific demands of various

sports may be associated with a higher incidence of
injuries17,19.
The fifth factor was associated with the muscular
performance domain that we termed acceleration
capacity. Acceleration time was the only variable
that contributed to this factor, and this variable
corresponds to the time needed for the limb to reach
the velocity pre-established for the isokinetic test
when starting from the rest position. Furthermore,
this variable may be considered an indicator of an
individuals neuromuscular capacity to develop
torque quickly1,20-22. Reduced Acceleration Time
values may denote superior muscle fiber recruitment
capacity of tested muscles and may be associated
with shorter latency for torque generation in such
muscles20-22. However, the ability to generate high
torque values may not suffice to ensure adequate
performance, as the speed with which torque is
developed must also be taken into account for the
characterization of muscular performance. Thus, for
a complete assessment, Acceleration Time should be
included to address neuromuscular factors related to
muscular performance21,22. However, it is important
to notice that this variable can be more relevant in
test conditions involving higher velocities. In these
situations, the acceleration demand is more evident
and the acceleration capability is crucial for overall
performance in the test.
The aforementioned results were reproduced in the
analysis of the 2 randomized subsamples generated
from the initial sample, the factor structure found in
the analysis of knee extensor isokinetic assessment
data was therefore fully validated. In addition, this
model was also stable during the analysis of the
data resulting from isokinetic assessment of another
variety of movement (knee flexion). Although there
was an inversion in the distribution for the variables
Angle of Peak Torque and Acceleration Time in
factors 4 and 5 in the analysis of knee flexor isokinetic
assessment data (Table 4), the structure of each factor
was maintained (i.e. the way in which these variables
were distributed among the different factors remained
the same), which may be related to the very similar
percentages of variance explained by those factors
(i.e. 9.4% and 9.3%, relative to the flexor data).
This inversion in the distribution of the variables
does not invalidate the structure of the reduced
model because the same 5 constructs were still
represented. Therefore, muscular performance could
be characterized by means of 5 distinct domains.
Factor analysis enabled the identification of
5 different domains that together provided information
528
concerning muscular performance in knee flexionextension isokinetic assessment at a velocity of 60/s

in young athletes. Caution is recommended when
generalizing the results for different velocities or
populations. The results of the present study point
to the relevance of the analysis and the inclusion of
variables that represent distinct constructs but are
often neglected in the interpretation of isokinetic
assessments.
Conclusions
The present study identified five factors that
were accurately represented by only a few variables
included in isokinetic reports. Each factor represents
a different dimension of muscular performance.
Our results suggest that Maximum Work should
be systematically reported to characterize torque
generation capacity. The constructs movement
acceleration and deceleration capacity must be more
thoroughly explored in future studies, as they provide
different information to that supplied by variables
describing torque generation capacity. Finally,
variability in torque generation capacity and the
contribution of mechanical and physiological factors
to torque generation may be accurately represented
by variables of Maximum Work Repetition Number,
Work Fatigue Percentage, and Angle of Peak Torque.
Therefore, the use of just a few variables may suffice
to capture the full scope of information provided by
isokinetic assessments.
Acknowledgements
To the Pro-Deans Office for Research of
Universidade Federal de Minas Gerais (UFMG),
Coordenao de Aperfeioamento de Pessoal de
Nvel Superior (CAPES), Fundao de Amparo
Pesquisa do Estado de Minas Gerais (FAPEMIG),
and Conselho Nacional de Desenvolvimento
Cientfico e Tecnolgico (CNPq), Brazil.
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21. Chen WL, Su FC, Chou YL. Significance of acceleration
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jospt.1994.19.6.324. PMid:8025571
22. van Cingel RE, Kleinrensink G, Uitterlinden EJ, Rooijens
PPGM, Mulder PGH, Aufdemkampe G, et al. Repeated
ankle sprains and delayed neuromuscular response:

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Ther . 2006 ; 36 ( 2 ): 72 - 9 . http://dx.doi.org/10.2519/
jospt.2006.36.2.72. PMid:16494074
13. De Ste Croix MBA, Deighan MA, Ratel S, Armstrong N.
Age- and sex-associated differences in isokinetic knee

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org/10.1139/H09-064. PMid:19767809
14. Silva JP, Pereira DS, Coelho FM, Lustosa LP, Dias JM,
Pereira LS. Clinical, functional and inflammatory factors
associated with muscle fatigue and self-perceived
Correspondence
Giovanna Mendes Amaral
Rua Oscar Trompowisky, 1275/202, Graja
e-mail: giovannamamaral@gmail.com
529
original article
Characteristics and associated factors with sports

injuries among children and adolescents
Franciele M. Vanderlei1, Luiz C. M. Vanderlei1,2, Fabio N. Bastos3, Jayme
Netto Jnior1,2, Carlos M. Pastre1,2
ABSTRACT | Background: The participation of children and adolescents in sports is becoming increasingly common,
and this increased involvement raises concerns about the occurrence of sports injuries. Objectives: To characterize
the sports injuries and verify the associated factors with injuries in children and adolescents. Method: Retrospective,
epidemiological study. One thousand three hundred and eleven children and adolescents up to 18 years of age enrolled
in a sports initiation school in the city of Presidente Prudente, State of So Paulo, Brazil. A reported condition inquiry
in interview form was used to obtain personal data and information on training and sports injuries in the last 12 months.
Injury was considered any physical complaint resulting from training and/or competition that limited the participation
of the individual for at least one day, regardless of the need for medical care. Results: The injury rate per 1000 hours
of exposure was 1.20 among the children and 1.30 among the adolescents. Age, anthropometric data, and training
characteristics only differed with regard to the presence or absence of injuries among the adolescents. The most commonly
reported characteristics involving injuries in both the children and adolescents were the lower limbs, training, noncontact mechanism, mild injury, asymptomatic return to activities, and absence of recurrence. Conclusions: The injury
rate per 1000 hours of exposure was similar among children and adolescents. Nevertheless, some peculiarities among
adolescents were observed with greater values for weight, height, duration of training, and weekly hours of practice.
Keywords: child; adolescent; traumatism in athletes; risk factors; rehabilitation.

Vanderlei FM, Vanderlei LCM, Bastos FN, Netto Jnior J, Pastre CM. Characteristics and associated factors with sports injuries
among children and adolescents. Braz J Phys Ther. 2014 Nov-Dec; 18(6):530-537. http://dx.doi.org/10.1590/bjpt-rbf.2014.0059
Introduction
The participation of children and adolescents
in the practice of physical activities and sports has
increased in recent decades1. It is estimated that 30
to 45 million individuals between six and 18 years
of age participate in sports2.
The practice of sports provides benefits to the
cardiopulmonary, musculoskeletal, and endocrine
systems. Sports lead to improvements in motor skills
and daily habits as well as the acquisition of dexterity,
exerting an influence on the social and psychological
aspects of practitioners1-4.
However, constant exposure to repetitive motor
actions and excessive load poses the risk of injury5,6.
Indeed, Adirim and Barouh7 reported that when
children practice a sport, they are exposed to injury
and, in this context, several risk factors can be
considered, such as musculoskeletal immaturity,
obesity, and characteristics of training. Thus, it is

important to identify the factors associated with injury
to establish preventive strategies.
The first step to knowledge regarding such
occurrences is to carry out investigations of an
epidemiological nature. Thus, the aim of the present
study was to characterize the sports injuries and
verify the associated factors with injuries in children
and adolescents.
Method
Subjects
A total of 1311 student athletes (939 males and
372 females) enrolled with the City of Presidente
Prudente Municipal Sports Department (State of So
Laboratrio de Fisioterapia Desportiva, Departamento de Fisioterapia, Faculdade de Cincias e Tecnologia, Universidade Estadual Paulista, UNESP,
Presidente Prudente, SP, Brazil
2
Laboratrio de Fisioterapia Desportiva, Programa de Ps-Graduao em Fisioterapia, Faculdade de Cincias e Tecnologia, UNESP, Presidente
Prudente, SP, Brazil
3
Programa de Ps-Graduao em Patologia Experimental, Universidade Estadual de Londrina, UEL, Londrina, PR, Brazil
1
530
Sports injuries in children and adolescents
Paulo, Brazil) in the sports modalities of athletics,

basketball, football, soccer, gymnastics, karate,
kung fu, swimming, table tennis, and volleyball
were randomly selected for participation in the
present study. The volunteers were divided into two
groups: children (n=509) aged up to 12 years of
age and adolescents (n=802) aged 12 to 18 years,
based on the classification set by Brazils Child and
Adolescent Statute enacted in 19908. All volunteers
were amateurs and beginners in the practice of sports.
This study received approval from the Human
Research Ethics Committee of Universidade
Estadual Paulista (UNESP), Presidente Prudente,
SP, Brazil, under process number 08/2010 and all
volunteers signed an informed consent form.
Study design and ield procedures
The data were collected through individual
interviews addressing the occurrence of injuries and
respective characteristics in the previous 12 months
of training and/or competition. To avoid interfering
in the normal dynamics and routine of the sport,
the volunteers were approached either prior to or
following training sessions.
A reported condition inquiry was used, which
has been used for the acquisition of information
on general health status in specific populations due
mainly to its applicability and objectivity9-12. A pilot
study was first conducted with 200 individuals to
test the applicability of this instrument, the results of
which demonstrated adequate comprehension of the
questions on the part of the respondents.
Data were collected individually in interview
form by a single examiner familiarized with the
instrument. Pastre et al.9 suggests this procedure due
to the different degrees of understanding regarding
the annotation of answers on the part of interviewees.
Information was provided by the volunteers as well as
their coaches and/or parents/guardians, as suggested
by Pereira13 for the acquisition of data related to
health conditions.
Injury reporting
Sports injury in the present study was defined as
any physical complaint resulting from training and/
or competition that limited the participation of the
individual for at least one day, regardless of the need
for medical care. This definition has been employed
in previous studies14,15.
The inquiry addressed personal data, such as
gender, age, weight, height, and duration of training
in years, which were considered the independent
variables. Body mass was determined using a Filizola

scale with a precision of 0.1 Kg and height was
determined using a Sanny portable stadiometer with
millimeter measurements. For these measurements,
the volunteers were barefoot and wore light clothing.
The inquiry addressed sports injuries, such as
the anatomic site affected, injury mechanism, when
the injury occurred, severity of the injury, return to
normal activities, and recurrences. To facilitate the
identification of the anatomic site of the injury, an
illustration of the human body was shown, on which
the subject marked the region of the body referring to
the sensation of pain or musculoskeletal discomfort.
The determination of the injury mechanism consisted
of the volunteers perception regarding the contact or
exact action performed when signs and symptoms of
an acute episode emerged and/or the type of activity
in which such manifestations were accentuated.
This variable was divided into direct contact and
non-contact16-18. The moment of occurrence of the
injury was analyzed based on the specific phase of
training or competition. The severity of the injury
was classified based on the National Athletic Injury
Reporting System, which classifies sports injuries
based on the time the athlete spends away from
the sport for recovery19,20. The determination of the
return to normal activities addressed whether or
not this event occurred and whether the return to
the sport without any alterations in normal training
occurred with or without signs and/or symptoms. The
recurrence of injury was investigated to determine
whether injury had occurred on other occasions and
in the same anatomic site on other occasions19.
Organization and description of categories
of variables
To facilitate the analysis and presentation of the
results, the variables were subdivided into categories
based on the most expressive clusters of results
without affecting the essence of their origin or the
conclusions of the study. Regarding anatomic site of
pain or discomfort, the questionnaire listed 20 bodily
regions, which were grouped into the following
segments: upper limbs, lower limbs, and trunk.
The following two injury mechanisms were
considered: i) injury due to direct contact caused
by a single traumatic incident, such as a fall or
collision with an opponent16-18; ii) non-contact injuries
stemming from aspects inherent to the sport itself,
such as short and long-distance runs, rapid changes
in movement, jumps, and landing16-18.
531
Vanderlei FM, Vanderlei LCM, Bastos FN, Netto Jnior J, Pastre CM
Severity was categorized as mild injury (1 to

7 days away from sport), moderate injury (8 to
21 days away from sport) or severe injury (more than
21 days away from sport or permanent injury)19,21.
Descriptive statistics were used for the analysis
of the profile of the population and description
of the variables. The results were expressed as
mean and standard deviation values, percentages,
and absolute numbers. The odds ratio (OR) test
with a 95% confidence interval (CI) was used to
determine whether the presence/absence of injury
was associated with age group and gender. The
Kolmogorov-Smirnov was used to test the normality
of the data. Students t-test for non-paired data was
used in cases of normal distribution (height in the
group of children) and the Mann-Whitney test was
used for cases in which normal distribution was not
found (all other independent variables). Goodmans
test for contrasts between and within multinomial
populations was used to test associations between the
characteristic of the group of variables to be analyzed
and anatomic site, injury mechanism, when the injury
occurred, severity, return to normal activities, and
recurrence. The frequency of injury was calculated
by the number of athletes interviewed who reported
injury in the period x 100.000/total number of athletes
interviewed. The risk of injuries for injured athlete
was calculated by the number of athletes interviewed
who reported injury in the period/number of injuries.
The injury rate per 1000 hours of exposure was
calculated by numbers of injuries divided by the
number of exposure hours multiplied by 1000. The
statistical analyses were conducted using the Minitab
program, version 13.3, with the significance level set
at 5% (p<0.05).
Results
Among the group of children, the mean age was
10.461.61 years, weight was 41.2811.34 kg, height
was 1.460.10 m, duration of training was 1.601.04
years, and weekly hours of practice were 2.902.04.
Among the group of adolescents, mean age was
14.551.36 years, weight was 58.9512.15 kg, height
was 1.460.10 m, duration of training was 2.682.10
years, and weekly hours of practice were 5.203.72.
Among the 1311 interviewees, 234 athletes
reported a total of 261 injuries, corresponding to
more than one injury per injured athlete. Statistically
significant differences were found in the frequency
distribution of injuries between the two age groups,
with the adolescents demonstrating a greater risk
of injury than the children (OR: 1.97; 95% CI:
1.442.70). As no significant gender differences were
found among either the children (OR: 0.82; 95% CI:
0.451.50) or the adolescents (OR: 0.98; 95% CI:
0.681.41), the analyses were performed without
gender distinctions. The frequency of injury was 12%
among the children and 21% among the adolescents.
The frequency per injured athlete was 14% among the
children and 25% among the adolescents. The injury
rate per 1000 hours of exposure was 1.20 among the
children and 1.30 among the adolescents (Table 1).
Among the adolescents, weight, height, duration of
training, and weekly hours of practice were associated
with injuries, with higher median values for these
variables among individuals affected by injuries than
non-affected individuals (Table 2).
Table 3 shows that the lower limbs had a
significantly greater number of injuries in both groups
in comparison to the upper limbs and trunk. A greater
number of injuries occurred during training in both
groups. Among the adolescents, the non-contact
Table 1. Mean values, followed by the standard deviation, and confidence interval of injury rate per 1000 hours of exposure and absolute
(n) and relative (%) frequency of injured athletes, injuries reported and frequency of injury.
Variables
Injury rate per 1000 hours of exposure
Groups
Children (n=509)
Adolescents (n=802)
1.203.6 [0.891.52]
1.303.05 [1.091.51]
Injured athletes
62 (12.18)
172 (21.44)
Injuries reported
64 (12.57)
197 (24.56)
0.12
0.24
Injury risk
Injury risk per injured athlete
1.03
1.14
Frequency
12%
21%
Injury risk per athlete = total number of injuries divided by total number of athletes interviewed; injury risk per injured athlete = total number
of injuries divided by total number of injured athletes; Injury rate per 1000 hours of exposure = numbers of injuries divided by the number of
exposure multiplied by 1000.
532
Table 2. Mean, standard deviation, median, and confidence interval values for anthropometric measures and training variables according
to age group and occurrence of injury.
Variables
Weight (kg)
Groups
Injured
Non-injured
p-value
Children
43.311.03 (42.80)
[40.5946.10]
40.9911.37 (39.20)
[39.9342.04]
0.09
Adolescents
Height (m)
Duration of training (years)
Weekly hours of practice
62.4013.08 (60.30)* 57.8711.64 (56.40)

[60.5764.23]
[56.9658.78]
0.0001
Children
1.480.10 (1.48)
[1.461.51]
1.460.10 (1.46)
[1.451.47]
0.10
Adolescents
1.690.09 (1.70)*
[1.681.71]
1.650.08 (1.66)
[1.641.66]
0.0001
Children
1.821.18 (1.00)
[1.522.11]
1.571.02 (1.00)
[1.471.66]
0.06
Adolescents
3.442.52 (3.00)*
[3.093.80]
2.441.90 (2.00)
[2.302.59]
0.0001
Children
3.462.98 (2.00)
[2.724.21]
2.821.86 (2.00)
[2.653.00]
0.44
Adolescents
6.634.36 (6.00)*
[6.027.24]
4.753.38 (4.00)
[4.495.01]
0.0001
Kolmogorov-Smirnov normality test; *Statistically significant difference in relation to non-injured athletes; The Mann-Whitney test was used to
compare medians between injured and non-injured athletes for height, weight, duration of training, and weekly hours of practice in adolescents.
Table 3. Absolute (n) and relative (%) frequency of anatomic site,

when injury occurred, and injury mechanisms.
Variables
Groups
Children (n=509) Adolescents (n=802)
Anatomic Site
Upper limbs
12 (18.75)
42 (21.32)
Lower limbs
48 (75.00)*
131 (66.50)*
Trunk
4 (6.25)
24 (12.18)
Total
64 (100)
197 (100)
59 (92.18)
160 (81.22)
Competition
5 (7.82)
37 (18.78)
Total
64 (100)
197 (100)
Direct contact
27 (42.19)
48 (24.36)
Non-contact
37 (57.81)
149 (75.64)
64 (100)
197 (100)
When injury occurred

Training
Mechanism
Total
Goodmans test for contrasts between and within multinomial

populations; *Difference in relation to upper limbs and trunk;
Difference in relation to competition; Difference in relation to
direct contact.
mechanism (72.59%) differed significantly from the

direct contact mechanism (24.36%).
Table 4 shows that, in both groups, a greater
frequency of mild injury was found in comparison
to moderate and severe injury. The majority of
the children returned to their normal activities
asymptomatic, whereas similar proportions of

adolescents returned to their normal activities with
and without the presence of signs and/or symptoms. A
statistically significant difference was found between
the absence and presence of recurring injury among
the adolescents.
Discussion
The investigation into injuries associated with the
different sports practiced in Brazil among individuals
under 18 years of age demonstrates that the injury
rate per 1000 hours exposure does not appear to
show significant differences between children and
adolescents, which does not allow for a comparison
of characteristics of injuries between the groups.
Despite the correction in relation the exposure of each
athlete, each group studied seems to have particular
characteristics regarding the occurrence of injuries.
In the group of adolescents the occurrence of injuries
was associated with age, anthropometric data and
training variables, and among the children was found
random distribution for these variables.
The frequency of injury was 12% among the
participants aged six to 11 years and 21% among those
aged 12 to 18 years. Conn et al.22 estimate that 22% of
injuries among individuals aged five to 24 years are
sports-related. A study carried out in Norway reports
this figure to be around 17%23. However, when the
correction for exposure of the athlete is applied, mean
values of the injury rate per 1000 hours exposure are
533
Table 4. Absolute (n) and relative (%) frequency of injuries

according to severity, return to activities, and recurrence.
Variables
Groups
Children (n=509) Adolescents (n=802)
Severity
Mild
Moderate
56 (87.50)*
159 (80.71)*
4 (6.25)
20 (10.15)
Severe
4 (6.25)
18 (9.14)
Total
64 (100)
197 (100)
Return to normal activities

Asymptomatic
50 (78.12)
111 (56.35)
Symptomatic
14 (21.88)
86 (43.65)
64 (100)
197 (100)
No
37 (57.82)
133 (67.51)
Yes
27 (42.18)
64 (32.49)
Total
64 (100)
197 (100)
Total
Recurrence
Goodmans test for contrasts between and within multinomial

populations; *Difference in relation to moderate and severe injury;
Difference in relation to symptomatic return; Difference in
relation to recurrence.
confirmed to be similar for both groups, in contrast

with the findings of Knowles et al.5, who reported a
rate of 1.41 for children under 14 years and 2.52 for
individuals 18 years of age.
Each group studied seems to have particular
characteristics regarding the occurrence of injury.
The results of the present study demonstrate that
the frequency of injury increased in the adolescents,
which is in agreement with findings described in
previous studies24,25. The reasons for this are related to
the greater involvement in sports with the advance in
age, in addition to the characteristics of training such
as high intensities of physical stimuli and inadequate
recovery time26.
Regarding anthropometric and training
characteristics, injuries were significantly associated
with intrinsic and extrinsic risk factors only in the
group of adolescents. The median values for weight,
height, duration of training, and weekly hours of
practice were higher among the athletes with a recent
history of injury. Studies report a greater frequency of
injury among heavier and taller adolescents due to the
generation of a greater magnitude of forces absorbed
by soft tissues and joints; the greater dynamism and
collision force also contribute toward the occurrence
of injury in this specific population27-29. In the present
study, adolescents with a greater duration of training
and greater number of weekly hours of practice
534
reported more injuries. The increase in exposure

may be related to an increased risk of injury due
to repetitive and cumulative trauma, as reported by
Turbeville et al.30.
Among the children, no specific profiles were
observed for the variables studied with regard to the
presence or absence of injury, which does not allow
the establishment of associations with the occurrence
of injury in this age group. Among the adolescents,
however, there was a tendency toward an increase
in confidence interval values among the injured
individuals in comparison with the non-injured
individuals. Thus, the results of the present study
indicate the need for specific care when exceeding
three years of practice within a given sport and six
hours of practice per week.
Regarding the anatomic site, there was a
predominance of injuries in the lower limbs,
especially the knees and ankles. Sharma et al.31
found that the frequency of sports injuries among
children up to 12 years of age was 43.8% in the upper
limbs, 34.5% in the lower limbs, and 16% in the
head, which differs from the findings of the present
study. However, in a study involving adolescents
up to 16 years of age practicing 15 different sports,
Hootman et al.17 found that the lower limbs were the
most affected during both training and competitions,
which is in agreement with the results of the present
study. This finding may be explained by the fact that
sports generally involve common activities, such as
running, jumping, and rapid changes in direction,
which directly affect the lower limbs and increase
the risk of injury in this anatomic site32.
Most of the injuries occurred during the training
period. This finding may be related to the greater
exposure of the present sample during training
sessions, as participation in competitions is far more
limited. However, there is no consensus on this
issue. A number of authors report that injuries are
more common during competitions17,30. Moreover,
Rechel et al.32 report similar proportions of injuries
occurring during competition (51.5%) and training
(48.5%).
Non-contact injuries were more commonly
reported by adolescents than children. Thus, the
biomechanical aspects of the specific actions and/
or metabolic expenditures involved in the sport
seem to become more pronounced with age17. This
underscores the importance of addressing issues
linked to the biomechanics and physiology of effort
as causal agents of injury17.
However, descriptively, both children and
adolescents showed the non-contact mechanism as
being the most frequent. Ribeiro and Costa26 describe

that high incidence rates of non-contact injuries
can indicate that athletes had insufficient time of
preparation for the demands of training and/or there
was not sufficient time for the recovery of the stimuli
during training. Thus, special attention should be
given to the type of training and the biomechanical
and physiological characteristics trained to prevent
this type of injury.
Regarding severity, there was a predominance of
mild injuries. Rechel et al.32 found that the majority
of injuries resulted in at least one week away from
normal activities, whereas 30.3% of injuries led to
one to three weeks away, 6.8% resulted in more than
three weeks away from activities, without ending the
athletes career and 10.4% of injured athletes did not
return to either the season or their career. The fact that
the majority of injuries in the present study were mild
may be explained by the characteristics of the sample,
which was mostly made up of individuals in the
sports initiation phase, who experience lesser training
intensity and physical contact in comparison to the
training category, as suggested by Rechel et al.32.
There was a greater frequency of asymptomatic
return to normal activities, which is of fundamental
importance to children and adolescents as they are
in a period of growth and development. Therefore,
along with adequate musculoskeletal rehabilitation,
instructions regarding the prevention of further injury
should be emphasized33.
Descriptively, the percentage of recurrence in
children was 42% and in adolescents was 32%,
being considered high for several types of injury.
Powell and Barber-Foss34, who reported a recurrence
risk of only 10% (range: 8.4% to 13.9%) among the
different sports analyzed, posed the hypothesis that
this may be an indicator of the positive influence
of the participation of injured players in prevention
programs aimed at minimizing the likelihood of
further injury. However, it should be pointed out that
the sample in the present study was not submitted
to any type of specific preventive work, which may
explain the high percentage found in this population.
Thus, the importance of preventive programs on the
recurrence of injury is evident.
The data collection instrument has been used for
the acquisition of information on high-performance
athletes9 and there are no records of its use on
children and adolescents in Brazil. However, the
analysis tool and approach involved the utmost
care, as described in the Methods section, to ensure
maximum reliability. Thus, the reported condition
inquiry appears to be an excellent way to record

epidemiological data with ease and coherence.
Nevertheless, the retrospective design constituted
a limitation of the present study, as data may have
been lost in the time interval analyzed and the
actual magnitude of the injuries may have been
underestimated by recall bias. Another limitation
found was the lack of registration of exposure in
hours separated by different periods, training and
competition, precluding further analysis about the
time the injury occurred.
Joint actions uniting health and sports sciences,
specially physical therapy35,36, should be encouraged
for the establishment of strategies aimed at offering
greater safety to beginners in the practice of any
sports modality. Actions of this nature may have a
positive impact on health, especially among children
and adolescents, as well as consequences in the social
realm.
Conclusion
The injury rate per 1000 hours of exposure was
similar among children and adolescents, whereas
the frequency of injury without exposure correction
overestimated the occurrence of injury in adolescents.
Nevertheless, some peculiarities among adolescents
were observed with greater values for weight, height,
duration of training, and weekly hours of practice.
The following characteristics of injury predominated
in both groups: lower limbs, training period, the noncontact mechanism, mild injuries, and asymptomatic
return to normal activities. Furthermore, the presence
of recurrence was considered high for both groups.
Acknowledgments
The Brazilian fostering agency Coordenao
de Aperfeioamento de Pessoal de Nvel Superior
(CAPES) and the Secretaria Municipal de Esportes
de Presidente Prudente (SEMEPP), Brazil for funding
the present study.
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Correspondence
Franciele Marques Vanderlei
Universidade Estadual Paulista
Faculdade de Cincias e Tecnologia
Laboratrio de Fisioterapia Desportiva
Rua Roberto Simonsen, 305
CEP 19060-900, Presidente Prudente, SP Brazil
e-mail: franmvanderlei@gmail.com
537
original article
Can the adapted arcometer be used to assess the

vertebral column in children?
Juliana A. Sedrez, Cludia T. Candotti, Fernanda S. Medeiros, Mariana
T. Marques, Maria I. Z. Rosa, Jefferson F. Loss
ABSTRACT | Background: The adapted arcometer has been validated for use in adults. However, its suitability for use
in children can be questioned given the structural differences present in these populations. Objective: To verify the
concurrent validity, repeatability, and intra- and inter-reproducibility of the adapted arcometer for the measurement of the
angles of thoracic kyphosis and lumbar lordosis in children. Method: Forty children were evaluated using both sagittal
radiography of the spine and the adapted arcometer. The evaluations using the arcometer were carried out by two trained
evaluators on two different days. In the statistical treatment, the intraclass correlation coefficient (ICC), Pearsons product
moment correlation, Spearmans rho, the paired t test, and Wilcoxons test were used (=.05). Results: A moderate
and significant correlation was found between the x-ray and the adapted arcometer regarding thoracic kyphosis, but
no correlation was found regarding lumbar lordosis. Repeatability and intra-evaluator reproducibility of the thoracic
kyphosis and lumbar lordosis were confirmed, which was not the case of inter-evaluator reproducibility. Conclusion: The
adapted arcometer can be used to accompany postural alterations in children made by the same evaluator, while its use
for diagnostic purposes and continued evaluation by different evaluators cannot be recommended. Further studies with
the aim of adapting this instrument for use in children are recommended.
Keywords: physical therapy; evaluation; spine; children; validity of tests.
Sedrez JA, Candotti CT, Medeiros FS, Marques MT, Rosa MIZ, Loss JF. Can the adapted arcometer be used to assess the
vertebral column in children? Braz J Phys Ther. 2014 Nov-Dec; 18(6):538-543. http://dx.doi.org/10.1590/bjpt-rbf.2014.0060
Introduction
The early identification of spinal alterations is
fundamental, particularly in childhood, because
during this phase such alterations are unconsolidated
and may therefore be delayed or even reverted1.
To classify postural alterations and follow up any
treatment, an accurate assessment of the spinal
curvature is essential, given that treatments are
generally based on the degree of curvature and its
progression2.
Generally, physiotherapeutic postural evaluation
employs methods based on observation that do not
permit objective quantification of the degree of
alteration, which constitutes a limitation in clinical
practice. The need for early quantitative identification
of postural alterations, without overexposing the
patient to radiation, has encouraged the development
of non-invasive instruments designed to objectively
measure the curvature of the spine and postural
alterations3-5.
The choice of assessment instrument should be
based on scientific parameters, such as precision,
accuracy, concurrent validity, repeatability,

reproducibility, and the diagnostic capacity of the
measurements provided. In addition, the choice
should also consider practical parameters, such as
ease of transport and ease of use of the instrument,
in order to ensure that the patient can be assessed
quickly and comfortably6. The arcometer proposed
by DOsualdo et al.7 in 1997 for the assessment of
the thoracic spine incorporates most of these features.
Recently, Chaise et al.5 proposed modifications to
the structure of the original instrument and to the
method used to calculate the spinal curvature and
were, thus, also able to validate its use in the lumbar
spine5. Although the original instrument was assessed
in a younger sample7, the concurrent validity and
intra- and inter-evaluator reproducibility of the
adapted arcometer have only been confirmed in an
adult population5.
However, given the structural differences between
adults and children, such as the size of the trunk and
the magnitude of the spinal curvature, the applicability
Escola de Educao Fsica, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
538
Adapted Arcometer in spine assessment in children
of this instrument in this specific population may be

questioned. Hence, the objective of this study was to
verify the concurrent validity, repeatability, and interand intra-evaluator reproducibility of the adapted
arcometer when assessing the angles of sagittal
curvature in the spines of children.
Method
The sample consisted of 40 individuals, 15
female and 25 male, average age 10.72.7 years,
average body mass 38.713.1 kg, and average height
1.390.17 m. The sample size was calculated using
GPower Software with effect size of 0.5, a probability
error of 5%, and power test of 95%, resulting in a
recommendation of 34 individuals. Six children were
added to ensure sufficient sample size during the data
collection period. With the childs agreement, the
parents signed an informed consent form authorizing
participation in the study, which was approved by the
Ethics Committee of Universidade Federal do Rio
Grande do Sul (UFRGS), Porto Alegre, RS, Brazil,
under the number 19685.
The assessment consisted of two procedures: a
panoramic X-ray examination of the vertebral column
and an evaluation using the adapted arcometer5. The
X-ray was carried out in the sagittal plane, while
the child stood still with the shoulders and elbows
flexed at 90 degrees. Based on the X-ray, the angles
of the thoracic and lumbar curvatures were calculated
using the two-line Cobb method8,9. To obtain the
Cobb angle (CA) of the thoracic curvature, the
upper vertebral plateau of T1 and the lower vertebral
plateau of T12 were marked, and for the CA of the
lumbar curvature, the upper vertebral plateau of L1
and the lower vertebral plateau of L5 were marked.
Two independent evaluators carried out all of the
procedures to obtain the CA for each participant on
two different occasions. Based on the assumption
in the literature that five degrees is considered the
mean error when measuring the CA10, in those cases
in which the measurements obtained for a particular
participant varied by more than five degrees, either
between the evaluators or between the measurements
obtained by the same evaluator, a new evaluation was
performed. The mean values of the angles obtained
were used in the statistical analyses.
To evaluate the thoracic kyphosis and lumbar
lordosis with the adapted arcometer, as with the
X-ray examination, the child stood still with the
shoulders and elbows flexed at 90 degrees. The spinal
process of T1 and T12, and L1 and L5 respectively,
were identified by means of palpation. The upper
rod (FA) and the lower rod (FB) of the adapted

arcometer were positioned on the palpated spinal
process and the central rod (f) was positioned on
the apex of the curvature. Figure 1 illustrates the
position of the adapted arcometer when evaluating
thoracic kyphosis. Based on the measurements
obtained with the adapted arcometer, the angles of the
sagittal curvature of the spine were calculated using
trigonometry, according to the method described by
Chaise et al.5.
Two trained evaluators (evaluator A and evaluator
B) performed the evaluations with the adapted
arcometer on two different days, with a minimum
interval of one day and maximum interval of ten
days. Evaluator A assessed the children twice on the
same day (to verify the repeatability) while evaluator
B assessed the children twice on two different days
(to verify intra-evaluator reproducibility). For the
concurrent validity, the Cobb angle results of the
thoracic and lumbar spine were used together with the
results obtained by evaluator A in the first evaluation,
and to verify the inter-evaluator reproducibility, the
results from the second evaluation of evaluator A were
compared with those obtained by evaluator B in the
first evaluation (Figure 2). The statistical treatment
was conducted using SPSS version 17 software.
The normality of the data was assessed using the
Shapiro-Wilk test. The paired t-test or Wilcoxon
test was used to verify the differences between
measurements. Intraclass Correlation Coefficient
(ICC), Pearsons product-moment correlation or
Spearmans rho was used to calculate the correlation
between measurements. The correlation rates were
classified as trivial (.00 to .10), small (.10 to .30),
moderate (.30 to .50), large (.50 to .70), very large
Figure 1. The adapted arcometer being used to measure thoracic

kyphosis. H1: distance between T1 spinal process and the apex
of the curvature. H2: distance between the apex of the curvature
and T12 spinal process. FA, f and FB: upper rod, central rod and
lower rod, respectively.
539
Sedrez JA, Candotti CT, Medeiros FS, Marques MT, Rosa MIZ, Loss JF
(.70 to .90), and practically perfect (.90 to 1.00)11. The

level of significance adopted in all the tests was .05.
Results
The results of the evaluations for thoracic kyphosis
and lumbar lordosis carried out using the adapted
arcometer showed no significant difference when
compared with the evaluations based on X-rays
(Table 1). Regarding the tests of repeatability and
intra- and inter-evaluator reproducibility, there were
no significant differences in terms of either thoracic
kyphosis or lumbar lordosis (Table 1).
When the correlation between the measurements
obtained with the adapted arcometer and those
obtained with X-rays were evaluated, there was
only a moderate correlation for thoracic kyphosis,

while for lumbar lordosis the correlation was not
statistically significant. Similarly, the inter-evaluator
reproducibility was not statistically significant for
either thoracic kyphosis or lumbar lordosis. The
correlations between the remaining evaluations can
be classified as moderate (Table 2).
Discussion
The aim of the present study was to verify the
validity, repeatability, and intra- and inter-evaluator
reproducibility of the adapted arcometer when used to
measure the angles of sagittal curvature in the spine
of children. To achieve this, the study conducted by
Chaise et al.5 with adults was used as reference. In that
Figure 2. Schematic diagram showing the evaluations conducted using the adapted arcometer and X-rays.
Table 1. Average values and standard deviations (SD) of the different evaluations made with X-ray and adapted arcometer.
Evaluated aspect
Concurrent validity
Repeatability
Inter-evaluator
reproducibility
Intra-evaluator
reproducibility
Evaluation
Thoracic kyphosis
AverageSD ()
X-ray
Cobb angle
49.411.2
Evaluator A
1st evaluation
53.611.5
Evaluator A
1st evaluation
53.611.5
Evaluation A
2nd evaluation
51.812.1
Evaluation A
2nd evaluation
51.812.1
Evaluator B
1st evaluation
53.28.8
Evaluator B
1st evaluation
53.28.8
Evaluator B
2nd evaluation
53.210.1
Paired t test; bWilcoxon test.
540
Lumbar lordosis
AverageSD ()
42.18.7
0.070b
0.131a
39.722.2
39.722.2
0.349a
0.791b
39.119.8
39.119.8
0.640a
0.361b
36.319.0
36.319.0
0.643a
0.762b
30.518.2
Table 2. Statistical results referring to the correlations between the different evaluations.
Region
Thoracic
kyphosis
Lumbar
lordosis
Evaluated aspect
Variable
Correlation test
Concurrent validity
X-ray vs. Eva A (1st)
0.407a
0.009*
Repeatability
Eva A (1st) vs. Eva A (2nd)
0.439b
0.002*
Inter-evaluator reproducibility
Eva A (2nd) vs. Eva B (1st)
0.257b
0.052
Intra-evaluator reproducibility
Eva B (1 ) vs. Eva B (2 )
0.504
0.001*
Concurrent validity
X-ray vs. Eva A (1 )
0.037
Repeatability
Eva A (1st) vs. Eva A (2nd)
0.445b
Inter-evaluator reproducibility
Eva A (2nd) vs. Eva B (1st)
0.258b
0.052
Intra-evaluator reproducibility
Eva B (1st) vs. Eva B (2nd)
0.433b
0.003*
st
nd
st
b
c
0.983
0.002*
Eva A evaluator A; Eva B evaluator B; 1st first evaluation; 2nd second evaluation; aPearsons r; bICC; cSpearmans rho; *significant
correlation (p<0.05).
study, the adapted arcometer was found to provide

valid and reproducible results in both the intra- and
inter-evaluations5. By contrast, in the present study,
when used to evaluate children, the adapted arcometer
did not present good levels of concurrent validity or
inter-evaluator reproducibility, which indicates it
is inappropriate for use in the diagnosis of postural
alterations in the spine of children and for clinical
follow-up when performed by different evaluators.
Despite this, the instrument presented adequate
repeatability and intra-evaluator reproducibility,
which indicates that it is appropriate for use in the
clinical follow-up conducted by the same evaluator.
Despite the existence of non-invasive methods,
when attempting to determine the position of the spine,
the X-ray will probably remain the most accurate
method and, therefore, the gold standard diagnosis
and treatment follow-up method12. However, the
X-ray depends on advanced technological resources
and is often inappropriate for routine use, as the
individual is exposed to physical risk13. Consequently,
a variety of methods has been used to evaluate spinal
curvature. This evaluation is equally important
for diagnostic purposes, to accompany postural
alterations to the spine, and assess the efficacy of
treatments. Among the non-invasive instruments and
methods used are DIPA (Digital Image-based Postural
Assessment), which is a postural evaluation software
based on photogrammetry14, kypholordometry15,16,
Moirs topography17, the flexible ruler6,18,19, the
plumbline distance20,21, the Inclimed21, and the
arcometer7.
Two studies in the literature consider the validation
aspects of the arcometer. DOsualdo et al.7, the
first to describe the method in their evaluation of
children with different degrees of kyphosis, obtained
excellent correlations for validity (r=.98), intraevaluator reproducibility (r=.99), and inter-evaluator
reproducibility (r=.99) and consequently suggest that

the arcometer can be used to accompany postural
alterations to the thoracic spine. The second study,
by Chaise et al.5, proposed structural modifications to
the original instrument that provided a greater degree
of freedom in upper and lower rods, thus allowing
them to present different lengths. The alteration to
the length of the rods led to the modification of the
method of calculating the angle of the curvature,
which could then be carried out considering two
distinct arcs. With these modifications, Chaise et al.5
improved the original proposal and thus also managed
to validate the instrument for use in measuring lumbar
curvature. However, the very strong and significant
correlation found for the validity of thoracic curvature
(r=.94, p<0.01) and the strong and significant
correlation found for the validity of lumbar curvature
(r=.71, p<0.01) were only verified in an adult sample.
Given that in the present study there is a
considerable difference in the age, body mass,
and height of the sample in relation to that of
Chaise et al.5, these characteristics may explain the
divergent results obtained between the studies, since
the evaluators were previously duly trained in both
the palpation technique and the collection protocol
with the adapted arcometer. Moreover, the greater
variability in terms of body posture and the greater
flexibility of the spine in the young, could also
partially explain the contrasting results in this and the
cited papers with older subjects, since the position
used in both exams was the same.
Furthermore, if the estimated error, due to
variation in the execution of the protocol (palpation,
positioning the rods, etc), is considered the same in
adults and children, the repercussion of the error in
the calculated angle will be proportionally much
greater in children. For example, when measuring
an adult, a 1 cm error represents less than 10% of the
541
Sedrez JA, Candotti CT, Medeiros FS, Marques MT, Rosa MIZ, Loss JF
distance between the rods, while in children the same

error could represent more than 40%, due to the size
of the trunk. Moreover, when using the arc tangent
to calculate angles, the smaller the value using this
trigonometric function the greater the impact any
error will have on the estimated angle. In adults, the
numbers used as input in the arc tangent function
will be approximately 1 unit, while in children it will
be approximately 0.5. If we have 0.1 of variance in
1 unit (from 1.0 to 1.1), the angle calculated using
the arc tangent will change from 45.0 to 47.7. By
contrast, the same variation of 0.1 in 0.5 (from 0.5 to
0.6), the angle calculated using the arc tangent will
change from 26.5 to 30.9. These differences arise
from variations in the positions of the rods when
placed on the spine. Therefore, due to the variations
that occur over short lengths of the trunk, there is a
clear need to find a more appropriate procedure that
can be used in children. For example, when using
the adapted arcometer in clinical practice, the risk
of error could be reduced by registering the length
of the rods and maintaining the same length during a
second evaluation. This issue is particularly important
when one considers the intrinsic postural variability
of children and adolescents. It should be noted that
the results assessed herein refer to a specific range of
thoracic and lumbar curvatures. Thus, the fact that this
study did not evaluate straighter or more accentuated
curvatures may be considered a limitation.
2.
Vrtovec T, Pernus F, Likar B. A review of methods for

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PMid:22522063
15. Barana MA, Canto RST, Sanchez HM, Bustamante JCF,
Ventura-Silva RA, Malus S. Validade e confiabilidade
intra-indivduo do cifolordmetro na avaliao da

convexidade torcica. Rev Bras Fisioter. 2005;9(3):318-25.
16. Souza FR, Ferreira F, Narciso FV, Makhoul CMB, Canto
RST, Barauna MA. Evaluation of lumbar concavity using
a radiographic method and kypholordometry. Rev Bras
Fisioter. 2009;13(2):103-9. http://dx.doi.org/10.1590/
S1413-35552009005000016
17. Takasaki H. Moir topography. Appl Opt. 1970;9(6):146772. http://dx.doi.org/10.1364/AO.9.001467. PMid:20076401
18. Hart DL, Rose SJ. Reliability of a noninvasive method
for measuring the lumbar curve. J Orthop Sports
jospt.1986.8.4.180. PMid:18802227
19. Teixeira FA, Carvalho GA. Reliability and validity of
thoracic kyphosis measurements using the flexicurve

method. Rev Bras Fisioter. 2007;11(3):173-7. http://dx.doi.
org/10.1590/S1413-35552007000300005
20. Zaina F , Atanasio S , Ferraro C , Fusco C , Negrini
A , Romano M , et al . Review of rehabilitation and
orthopedic conservative approach to sagittal plane diseases

during growth: hyperkyphosis, junctional kyphosis,
and Scheuermann disease. Eur J Phys Rehabil Med.
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Correspondence
Jefferson Fagundes Loss
Universidade Federal do Rio Grande do Sul
Escola de Educao Fsica
Rua Felizardo, 750,
CEP 90690-200, Porto Alegre, RS, Brazil
e-mail: jefferson.loss@ufrgs.br
543
original article
Breathing exercises: inluence on breathing pattern and

thoracoabdominal motion in healthy subjects
Exerccios respiratrios: in luncia sobre o padro respiratrio e o
movimento toracoabdominal em indivduos saudveis
Danielle S. R. Vieira1, Liliane P. S. Mendes2, Nathlia S. Elmiro3,
Marcelo Velloso4, Raquel R. Britto4, Vernica F. Parreira4
ABSTRACT | Background: The mechanisms underlying breathing exercises have not been fully elucidated. Objectives:
To evaluate the impact of four on breathing exercises (diaphragmatic breathing, inspiratory sighs, sustained maximal
inspiration and intercostal exercise) the breathing pattern and thoracoabdominal motion in healthy subjects.
Method: Fifteen subjects of both sexes, aged 231.5 years old and with normal pulmonary function tests, participated in
the study. The subjects were evaluated using the optoelectronic plethysmography system in a supine position with a trunk
inclination of 45 during quiet breathing and the breathing exercises. The order of the breathing exercises was randomized.
Statistical analysis was performed by the Friedman test and an ANOVA for repeated measures with one factor (breathing
exercises), followed by preplanned contrasts and Bonferroni correction. A p<0.005 value was considered significant.
Results: All breathing exercises significantly increased the tidal volume of the chest wall (Vcw) and reduced the respiratory
rate (RR) in comparison to quiet breathing. The diaphragmatic breathing exercise was responsible for the lowest Vcw,
the lowest contribution of the rib cage, and the highest contribution of the abdomen. The sustained maximal inspiration
exercise promoted greater reduction in RR compared to the diaphragmatic and intercostal exercises. Inspiratory sighs
and intercostal exercises were responsible for the highest values of minute ventilation. Thoracoabdominal asynchrony
variables increased significantly during diaphragmatic breathing. Conclusions: The results showed that the breathing
exercises investigated in this study produced modifications in the breathing pattern (e.g., increase in tidal volume and
decrease in RR) as well as in thoracoabdominal motion (e.g., increase in abdominal contribution during diaphragmatic
breathing), among others.
Keywords: breathing exercises; rehabilitation; optoelectronic plethysmography; breathing pattern; thoracoabdominal
motion; physical therapy.
Vieira DSR, Mendes LPS, Elmiro NS, Velloso M, Britto RR, Parreira VF. Breathing exercises: influence on
breathing pattern and thoracoabdominal motion in healthy subjects. Braz J Phys Ther. 2014 Nov-Dec; 18(6):544-552.
RESUMO | Contextualizao: Os mecanismos envolvidos na execuo dos exerccios respiratrios no foram
completamente elucidados. Objetivos: Avaliar o impacto de quatro exerccios respiratrios(diafragmtico, suspiros
inspiratrios, inspirao mxima sustentada e intercostal) sobre o padro respiratrio e o movimento toracoabdominal
em indivduos saudveis. Mtodo: Participaram do estudo15 indivduos de ambos os sexos (231,5 anos com prova de
funo pulmonar normal). Os indivduos foram avaliados por meio da pletismografia optoeletrnica na posio supina
com inclinao de tronco de 45 durante a respirao tranquila e durante a realizao dos exerccios respiratrios. A ordem
dos exerccios foi randomizada. Os dados foram analisados pelo teste de Friedman e ANOVA para medidas repetidas
com um fator (exerccios respiratrios) seguidos de contrastes pr-planejados e correo de Bonferroni, sendo p<0,005
considerado significativo. Resultados: Todos os exerccios respiratrios promoveram aumento significativo do volume
corrente da parede torcica (VCpt) e reduo da frequncia respiratria (f) quando comparados respirao tranquila. O
exerccio diafragmtico foi responsvel pelo menor VCpt, menor contribuio da caixa torcica e maior contribuio do
abdmen. A inspirao mxima sustentada promoveu reduo significativamente maior da f comparada aos exerccios
diafragmtico e intercostal. Os exerccios suspiros inspiratrios e intercostal foram responsveis pelos maiores valores
de ventilao minuto. Os ndices de assincronia toracoabdominal aumentaram significativamente durante o exerccio
Curso de Fisioterapia, Universidade Federal de Santa Catarina (UFSC), Ararangu, SC, Brasil
Programa de Ps-graduao em Cincias da Reabilitao, Departamento de Fisioterapia, Universidade Federal de Minas Gerais (UFMG), Belo
Horizonte, MG, Brasil
3
Programa de Residncia Multiprofissional, Hospital das Clnicas, UFMG, Belo Horizonte, MG, Brasil
4
Departamento de Fisioterapia, UFMG, Belo Horizonte, MG, Brasil
Received: 01/14/2014 Revised: 05/19/2014 Accepted:05/26/2014
1
544
Exerccios respiratrios em indivduos saudveis
respiratrio diafragmtico. Concluses: Nossos resultados demonstraram que os exerccios estudados promoveram
alteraes do padro respiratrio (por exemplo, aumento do volume corrente e diminuio da f), assim como do movimento
toracoabdominal (por exemplo, maior deslocamento abdominal com o exerccio diafragmtico); dentre outras.
Palavras-chave: exerccios respiratrios; reabilitao; pletismografia optoeletrnica; padro respiratrio; movimento
toracoabdominal; fisioterapia.
Introduo
Os exerccios respiratrios so tcnicas manuais
frequentemente utilizadas na prtica clnica.
Eles podem influenciar o padro respiratrio e o
movimento toracoabdominal, sendo capazes de
priorizar um compartimento da parede torcica em
relao ao outro e de modificar o grau de participao
dos msculos respiratrios1.
Um dos exerccios respiratrios mais
frequentemente estudado e utilizado na prtica
clnica o exerccio respiratrio diafragmtico2-5.
Ele objetiva melhorar a ventilao pulmonar,
sobretudo nas zonas dependentes dos pulmes, por
promover maior deslocamento do compartimento
abdominal2-4,6. Outros exerccios tambm fazem parte
das intervenes utilizadas no cotidiano da fisioterapia
respiratria. O exerccio suspiros inspiratrios e
o exerccio inspirao mxima sustentada tm o
objetivo de aumentar o volume pulmonar e melhorar
a hematose7,8, porm utilizando diferentes estratgias:
inspiraes sucessivas (suspiros inspiratrios) ou um
esforo inspiratrio mximo (inspirao mxima
sustentada). Alm desses, o exerccio respiratrio
intercostal enfatiza a atividade dos msculos da caixa
torcica (CT), promovendo maior deslocamento
desse compartimento8,9. Os exerccios respiratrios
suspiros inspiratrios e intercostal foram propostos
por Cuello et al.8.
Os mecanismos envolvidos na execuo desses
exerccios respiratrios no foram completamente
elucidados, principalmente em relao aos suspiros
inspiratrios, inspirao mxima sustentada e
intercostal. Visto que a literatura escassa, os
profissionais baseiam-se principalmente nos
benefcios observados em sua aplicao ou nos
mecanismos propostos pelos seus idealizadores. O
entendimento de quais compartimentos da parede
torcica so prioritariamente movimentados durante
esses exerccios poder contribuir para embasar a
aplicao de um determinado exerccio em condies
que acometem diferentes regies pulmonares.
Atualmente, o padro respiratrio e o
movimento toracoabdominal podem ser avaliados
pela pletismografia optoeletrnica (POE). Com
esse instrumento, possvel analisar de forma
tricompartimental as variaes de volume, sem a
necessidade de pr-estabelecer graus de liberdade

para a parede torcica, possibilitando, assim, um
estudo mais minucioso da influncia desses exerccios
sobre a ventilao dos diferentes compartimentos da
parede torcica10,11.
Os exerccios respiratrios avaliados neste estudo
foram selecionados por se proporem a priorizar
diferentes zonas pulmonares1. Como o freno-labial12,13
frequentemente utilizado em associao aos
exerccios respiratrios na prtica clnica, optou-se
por incorpor-lo aos exerccios em que a expirao
pode ser feita de forma oral.
Nesse contexto, o objetivo deste estudo foi
avaliar o impacto dos exerccios respiratrios
(diafragmtico, suspiros inspiratrios, inspirao
mxima sustentada e intercostal) sobre o padro
respiratrio e o movimento toracoabdominal em
indivduos saudveis.
Mtodo
Amostra
Trata-se de um estudo observacional transversal.
Os critrios de incluso foram idade entre 20 e
30 anos; ndice de massa corporal (IMC) entre 18,5
e 29,99 Kg/m2; ausncia de distrbios ventilatrios
de qualquer ordem na prova de funo pulmonar14;
no relatar a presena de doenas neuromusculares e
no ter conhecimento prvio do modo de realizao
dos exerccios respiratrios. Foi considerado como
critrio de excluso a incapacidade de compreender
e/ou realizar algum dos procedimentos da coleta de
dados. O estudo foi aprovado pelo Comit de tica
em Pesquisa da Universidade Federal de Minas
Gerais (UFMG), Belo Horizonte, MG, Brasil (ETIC
0194.0.203.000-11), e todos os indivduos assinaram
o termo de consentimento livre e esclarecido (TCLE).
Instrumentos de medida
A POE (BTS Bioengineering, Milo, Itlia)
foi utilizada para avaliar o padro respiratrio e o
movimento toracoabdominal. um instrumento no
invasivo15,16 que fornece, com acurcia e preciso,
uma medida indireta dos volumes absolutos da parede
torcica e de seus trs compartimentos (CT pulmonar,
CT abdominal e abdmen - AB) durante a respirao
545
Vieira DSR, Mendes LPS, Elmiro NS, Velloso M, Britto RR, Parreira VF
tranquila e durante o exerccio17,18 e em diferentes

posies 15,16,19. Para isso, so adotados limites
anatmicos entre os diferentes compartimentos. O
limite entre a CT pulmonar e a CT abdominal est
localizado no nvel do processo xifoide, enquanto o
limite entre a CT abdominal e o AB localiza-se ao
longo da margem costal anteriormente e no nvel
do ponto mais baixo da margem costal inferior
posteriormente20. Esse instrumento mede as posies
tridimensionais e deslocamentos de cada ponto da
parede torcica, que so analisados por meio de
seis cmeras sincronizadas que captam a luz de
marcadores passivos (esferas plsticas cobertas por
papel reflexivo). Quando na posio ortosttica ou
sentada, os marcadores so distribudos em 89 pontos
e, na posio supina, em 52 pontos, referentes s
estruturas anatmicas da CT e do AB10,11,20.
Procedimentos
A coleta de dados foi realizada em dois dias com
um intervalo mximo de uma semana. No primeiro
dia, os participantes receberam informaes a respeito
da pesquisa e, aps assinatura do TCLE, responderam
a um questionrio para coleta de dados clnicos e
demogrficos. Posteriormente, a massa corporal e a
altura foram aferidas por meio de balana calibrada.
Aps mensurao dos dados iniciais (presso
arterial-PA, frequncia respiratria-f, frequncia
cardaca-FC e saturao perifrica da hemoglobina
em oxignio-SpO2), os participantes receberam
orientaes sobre como realizar a prova de funo
pulmonar (Vitalograph 2120 Buckinghan, Inglaterra).
Aps a espirometria, os participantes responderam
ao Perfil de Atividade Humana (PAH)21. Tanto a
espirometria como o PAH foram administrados por
um mesmo avaliador.
Em seguida, ensinou-se aos participantes como
realizar os exerccios respiratrios. O exerccio
respiratrio diafragmtico foi realizado solicitandose inspirao nasal de forma suave e profunda,
priorizando o deslocamento anterior da regio
abdominal, evitando o deslocamento da CT4,22.
Para o exerccio suspiros inspiratrios, solicitou-se
inspiraes nasais breves, sucessivas e lentas at
atingir a capacidade inspiratria7. O exerccio de
inspirao mxima sustentada foi realizado com
um esforo inspiratrio mximo, de forma lenta,
pela via nasal, at atingir a capacidade inspiratria
mxima, seguido de uma pausa ps-inspiratria de
3 segundos23. Por fim, o exerccio intercostal foi
realizado por meio de inspirao nasal, enfatizando
o deslocamento da regio superior do trax9. Nos
trs primeiros exerccios (diafragmtico, suspiros
inspiratrios e inspirao mxima), a expirao foi
546
realizada usando o freno-labial de maneira suave e

controlada, sendo que, no exerccio intercostal, a fase
expiratria foi nasal, conforme preconizado7.
No segundo dia, os 52 marcadores foram
posicionados por um mesmo avaliador na parede
toracoabdominal anterior em pontos anatmicos
pr-estabelecidos. Na sequncia, foram realizadas
as calibraes esttica e dinmica da POE, conforme
protocolo estabelecido20.
Em todas as situaes, os indivduos foram
avaliados em decbito dorsal, com inclinao de
45, postura em que frequentemente os exerccios
respiratrios so realizados no ambiente hospitalar.
Foram registrados inicialmente 5 minutos de
respirao tranquila, definida pelo padro respiratrio
naturalmente adotado pelo indivduo, seguidos de
5 minutos de um determinado exerccio respiratrio.
Foram realizadas duas sries de 2 minutos para cada
exerccio, com um intervalo de 1 minuto entre as
sries. A segunda srie foi utilizada para anlise dos
dados.
A ordem dos exerccios foi aleatorizada, e os
sujeitos receberam a instruo padronizada para cada
exerccio respiratrio, no incio e aos 60 segundos
de cada srie. Todos os exerccios foram instrudos
e monitorados por um nico avaliador. Um intervalo
de pelo menos 10 minutos de repouso foi observado
entre cada exerccio, objetivando o retorno dos
valores de FC, f, SpO2 e escala de Borg modificada
aos valores iniciais.
Variveis analisadas
As seguintes variveis foram consideradas:
volume corrente
da parede torcica-VCpt; f; ventilao
minuto-V E; porcentagem de contribuio da CT

pulmonar-V ctp%; porcentagem de contribuio
da CT abdominal-V cta %; porcentagem de
contribuio do AB-Vab% e variveis relativas ao
assincronismo: ngulo de fase-PhAng e relao de
fase inspiratria-PhRIB entre a CT e o AB e entre a
CT pulmonar e a CT abdominal.
Anlise estatstica
Devido ausncia, na literatura, de dados
necessrios para o clculo amostral, ele foi realizado
aps avaliao de dez indivduos para as seguintes
variveis: VCpt, f, , Vctp%, Vcta%, Vab%. O tamanho
de efeito foi estimado por meio da raiz quadrada da
soma dos quadrados do fator dividido pela soma
dos quadrados do erro. Esses dados foram obtidos a
partir da tabela ANOVA gerada por meio do software
SPSS (verso 13.0, Chicago, IL, USA). A amostra foi
ento estimada considerando-se o tamanho de efeito
encontrado para cada varivel bem como um nvel de

significncia de 5% e um power de 80%24. A amostra
foi estimada em, no mximo, dez indivduos para as
variveis consideradas para o clculo amostral.
Os dados foram apresentados como medidas
de tendncia central e disperso, e a normalidade
da distribuio foi verificada por meio do teste de
Shapiro-Wilk.
Para os dados com distribuio normal, foi
utilizada ANOVA para medidas repetidas com um
fator (exerccios respiratrios), seguida de contrastes
pr-planejados e correo de Bonferroni para
ajuste do valor de p de acordo com o nmero de
comparaes (n=10). Para os dados com distribuio
diferente de normal, teste no paramtrico anlogo
(teste de Friedman) foi utilizado. Aps ajuste, foi
considerado significativo p<0,005.
Resultados
Dos 20 indivduos recrutados, cinco foram
excludos (trs apresentaram distrbios ventilatrios
na prova de funo pulmonar, um apresentou IMC
acima de 29,99 Kg/m2, e um no compareceu no
segundo dia de coleta do protocolo). Dessa forma,
15 indivduos concluram o estudo. Assim, a amostra
avaliada proporcionou um conforto amostral de 50%
em relao ao nmero ideal calculado.
A Tabela 1 descreve os dados demogrficos,
antropomtricos, espiromtricos e nvel de atividade
fsica dos participantes. Todos apresentaram prova de
funo pulmonar normal e foram classificados como
ativos pelo PAH.
A Figura 1 apresenta os resultados relativos
s variveis do padro respiratrio (VCpt, f, e VE)

no repouso e durante a realizao dos exerccios
respiratrios associados ao freno-labial, exceto
no intercostal, em que a fase expiratria foi nasal.
O VCpt apresentou aumento significativo durante
todos os exerccios em relao ao repouso. O
VC pt foi significativamente maior durante os
exerccios suspiros inspiratrios, inspirao mxima
sustentada e intercostal quando comparado ao do
exerccio diafragmtico. Alm disso, o VCpt foi
significativamente menor durante o intercostal,
quando comparado ao dos suspiros inspiratrios.
Durante a realizao de todos os exerccios, os
indivduos apresentaram reduo significativa da
f em relao ao repouso. O exerccio inspirao
mxima sustentada promoveu reduo significativa
da f tambm em relao aos exerccios diafragmtico
e intercostal.
Houve aumento significativo da V E durante

os exerccios suspiros inspiratrios e intercostal
Tabela 1. Dados demogrficos, antropomtricos e espiromtricos

dos 15 indivduos avaliados.
VARIVEIS
X(DP)
Sexo
8H/7M
Idade (anos)
23,13 (1,46)
IMC (Kg/m2)
23,22 (2,76)
VEF1 (L)
3,76 (0,56)
VEF1 (% previsto)
94,65 (8,02)
CVF (% previsto)
92,81 (6,81)
VEF1/CVF
0,87 (0,05)
PAH
86,67 (5,22)
Dados apresentados como mdia (X) e desvio padro (DP), entre

parnteses. H: homens; M: mulheres; IMC: ndice da massa
corporal; VEF1: volume expiratrio forado no primeiro segundo;
CVF: capacidade vital forada; VEF1/CVF: razo entre volume
expiratrio forado no primeiro segundo e capacidade vital forada
ou ndice de Tiffeneau; PAH: perfil de atividade humana.
em relao ao repouso.
Na comparao entre os
exerccios, a V E foi significativamente maior

durante os suspiros, inspirao mxima sustentada e
intercostal
em relao ao diafragmtico. Alm disso,
a VE foi significativamente maior durante os suspiros

inspiratrios e o intercostal quando comparados
inspirao mxima sustentada.
A Figura 2 apresenta os resultados relativos ao
percentual de contribuio de cada compartimento
da parede torcica no repouso e durante a realizao
dos exerccios respiratrios associados ao freno-labial
durante a expirao, exceto no exerccio intercostal.
A Vctp% foi significativamente menor durante o
exerccio diafragmtico e significativamente maior
durante os demais exerccios em relao ao repouso.
Na comparao entre os exerccios, observou-se
Vctp% significativamente maior durante os suspiros
inspiratrios, inspirao mxima sustentada e
intercostal quando comparados ao diafragmtico.
Em relao contribuio da CT abdominal,
apenas o exerccio diafragmtico apresentou Vcta%
significativamente menor em relao ao repouso.
A Vab% foi significativamente maior durante o
exerccio diafragmtico e menor durante os demais
exerccios em relao ao repouso. Na comparao
entre os exerccios, a Vab% foi significativamente
menor durante os exerccios suspiros inspiratrios,
inspirao mxima sustentada e intercostal em
relao ao diafragmtico.
As Figuras 3 e 4 apresentam as variveis relativas
ao assincronismo toracoabdominal no repouso e
durante a realizao dos exerccios respiratrios
associados ao freno-labial durante a expirao,
exceto no exerccio intercostal. Os resultados
relativos ao PhAng so apresentados na Figura 3.
547
Figura 1. Dados relativos s variveis do padro respiratrio no repouso e durante os quatro exerccios respiratrios. Dados apresentados
como mdia (X) e desvio padro. VCpt: volume corrente da parede torcica; f: frequncia respiratria e VE : ventilao minuto. * p<0,005
para repouso exerccios respiratrios; p<0,005 para exerccio diafragmtico suspiros inspiratrios, inspirao mxima sustentada
e intercostal; p<0,005 para exerccio suspiros inspiratrios inspirao mxima sustentada e intercostal; p<0,005 para exerccio
inspirao mxima sustentada intercostal.
Figura 2. Dados relativos ao percentual de contribuio de cada compartimento da parede torcica. Dados apresentados como mdia
(X) e desvio padro. Vctp%: porcentagem de contribuio da caixa torcica pulmonar para o volume corrente; Vcta%: porcentagem de
contribuio da caixa torcica abdominal para o volume corrente e Vab%: porcentagem de contribuio do abdmen para o volume
corrente. * p<0,005 para repouso exerccios respiratrios; p<0,005 para exerccio diafragmtico suspiros inspiratrios, inspirao
mxima sustentada e intercostal.
548
Houve aumento significativo do PhAng entre a CT

e o AB apenas durante a realizao dos exerccios
diafragmtico e intercostal quando comparados ao
repouso, e nenhuma diferena estatstica quando
comparados os exerccios entre si. Houve aumento
significativo do PhAng entre a CT pulmonar e a CT
abdominal apenas durante o diafragmtico quando
comparado ao repouso. Na comparao entre os
exerccios, o PhAng entre a CT pulmonar e a CT
abdominal foi significativamente menor durante os
suspiros, inspirao mxima sustentada e intercostal
em relao ao diafragmtico.
A Figura 4 apresenta os resultados relativos
varivel PhRIB. Houve aumento significativo da
PhRIB entre a CT e o AB durante os exerccios
diafragmtico e suspiros inspiratrios em relao ao
repouso. No houve diferena significativa quando
os exerccios foram comparados entre si. Houve
aumento significativo da PhRiB entre a CT abdominal
e a CT pulmonar apenas durante o exerccio
diafragmtico em relao ao repouso. Na comparao
entre os exerccios, a PhRIB foi significativamente
menor durante a realizao da inspirao mxima
sustentada em relao aos exerccios diafragmtico

e suspiros inspiratrios.
Discusso
Os principais resultados deste estudo foram:
1) os quatro exerccios respiratrios associados
ao freno-labial, exceto o exerccio intercostal, em
que a fase expiratria foi nasal, foram capazes
de aumentar o VCpt e reduzir a f em relao ao
repouso; 2) o exerccio respiratrio diafragmtico
produziu aumento significativo da contribuio do
AB quando comparado ao repouso e aos demais
exerccios; 3) os exerccios suspiros inspiratrios e
intercostal produziram aumento significativo da VE

quando comparados aos demais exerccios e 4) os
ndices de assincronia toracoabdominal aumentaram
significativamente durante o exerccio respiratrio
diafragmtico.
Levando-se em considerao a fisiologia da
inspirao lenta e profunda associada ao freno-labial,
provvel que um aumento no VCpt associado
reduo da f observada durante a realizao dos
Figura 3. ngulo de fase (PhAng) entre os compartimentos da caixa torcica e abdmen (A) e entre a caixa torcica pulmonar e a caixa
torcica abdominal (B). Dados apresentados como mdia (X) e desvio padro. CT: caixa torcica; AB: abdmen; CTP: caixa torcica
pulmonar; CTA: caixa torcica abdominal. *: p<0,005 para repouso exerccios respiratrios; : p<0,005 para exerccio diafragmtico
suspiros inspiratrios, inspirao mxima sustentada e intercostal.
Figura 4. Relao de fase inspiratria (PhRIB) entre os compartimentos da caixa torcica e abdmen (A) e entre a caixa torcica
pulmonar e a caixa torcica abdominal (B). Dados apresentados como mdia (X) e desvio padro. CT: caixa torcica; AB: abdmen; CTP:
caixa torcica pulmonar; CTA: caixa torcica abdominal. *: p<0,005 para repouso exerccios respiratrios; : p<0,005 para exerccio
diafragmtico suspiros inspiratrios, inspirao mxima sustentada e intercostal; : p<0,005 para exerccio suspiros inspiratrios x
inspirao mxima sustentada e intercostal.
549
exerccios respiratrios tenha contribudo para uma

melhor relao ventilao/ perfuso1,3,13.
O exerccio respiratrio associado ao freno-labial
favorece uma reduo da f, uma vez que prolonga
o tempo expiratrio. A associao da expirao
lenta e prolongada com a resistncia para a sada
do ar contribui para a manuteno da presso
intrabrnquica, que pode contribuir para melhora da
oxigenao7,12,13.
O exerccio diafragmtico objetiva melhorar
a ventilao pulmonar, sobretudo em regies
basais2-4. Observou-se que, durante a realizao
desse exerccio, houve aumento significativo
do deslocamento do compartimento abdominal
em relao ao repouso (com cerca de 60% de
contribuio para o VCpt). Dessa forma, foi possvel,
com esse exerccio, aumentar a contribuio do
AB para o VCpt, contribuindo possivelmente para a
distribuio de ar para as bases pulmonares3.
Alguns autores estudaram o padro respiratrio
durante o exerccio diafragmtico em indivduos
saudveis2,3,22, no entanto, em nenhum desses estudos,
foi realizada uma anlise tricompartimental da parede
torcica, possibilidade que s a POE oferece.
Os resultados do presente estudo foram
semelhantes queles encontrados por Brach et al.3,
que avaliaram a distribuio da ventilao durante
a execuo desse exerccio e concluram que ele foi
capaz de direcionar a ventilao das zonas superiores
para as inferiores em indivduos saudveis sem
que
alteraes significativas ocorressem na V E. No

entanto, no estudo de Tomich et al.22, os autores
encontraram aumento significativo da V E durante
esse exerccio. Essa diferena provavelmente
relacionada a um volume corrente maior associado a
uma menor reduo da f observado por esses autores.
A presena de VCpt significativamente maiores
durante os exerccios suspiros inspiratrios, inspirao
mxima sustentada e intercostal em comparao ao
diafragmtico deve estar relacionada realizao da
inspirao at a capacidade pulmonar total, conforme
proposta dos exerccios. A maior reduo da f durante
a realizao da inspirao mxima sustentada em
relao aos exerccios diafragmtico e intercostal
pode ser explicada pela pausa ps-inspiratria de
3 segundos utilizada durante a sua execuo. A
ausncia de diferena significativa em relao ao
exerccio suspiros inspiratrios est provavelmente
ligada ao fato de esse exerccio ser realizado com
inspiraes fracionadas. Apesar de o VCpt aumentar
significativamente durante
a realizao da inspirao
mxima sustentada, a VE permaneceu sem diferena

significativa em relao ao repouso. Por outro lado,
o aumento do VCpt durante os exerccios suspiros
inspiratrios e intercostal foi capaz de compensar a
550
reduo da f e, com isso, promover aumento da VE.

A realizao da inspirao em um nico esforo
ou utilizando inspiraes sucessivas recrutou VCpt
semelhantes e reduziu igualmente a f, porm a
realizao de inspiraes sucessivas promoveu maior
aumento da VE. Assim, na presena de diminuio
generalizada da ventilao pulmonar, pode ser mais
interessante utiliz-los em detrimento do exerccio
diafragmtico.
Para a realizao dos exerccios inspirao mxima
sustentada e suspiros inspiratrios, no h instruo
de direcionamento do ar para um dos compartimentos
da parede torcica. Adicionalmente, durante esses
exerccios, os indivduos so solicitados a realizar
uma inspirao at a capacidade pulmonar total.
Esses aspectos podem explicar a menor contribuio
do compartimento abdominal observada durante a
execuo dos mesmos.
Segundo Fixley et al.9, o exerccio intercostal
favorece a ventilao nas regies pulmonares no
dependentes. Isso pode ser explicado pelo gradiente
de presso transpulmonar regional gerado pela
contrao dos msculos da CT, uma vez que esse
exerccio enfatiza a atividade desses msculos.
Em nosso estudo, os indivduos foram orientados a
realizar o exerccio direcionando o ar para a regio
superior da CT, o que favoreceu o aumento da Vctp%
e a reduo da Vab% em relao ao repouso. Esse
resultado no confirma o fato de que a expirao nasal
realizada durante o exerccio intercostal seja um fator
diferencial para uma maior contribuio da CT para
o VCpt, como preconizado por Cuello et al.8, uma vez
que os exerccios suspiros inspiratrios e inspirao
mxima sustentada apresentaram contribuies
semelhantes s do exerccio intercostal.
O PhAng um ndice frequentemente utilizado
para avaliar o assincronismo toracoabdominal22,25-27.
Esse ndice tem a vantagem de incorporar dados
de todo o ciclo respiratrio, porm assume,
para o seu clculo, que as curvas formadas pelo
movimento de ambos os compartimentos tm formato
aproximadamente senoidais. Dessa forma, curvas no
senoidais podem comprometer a sua quantificao.
Dentro do nosso conhecimento, em apenas um
estudo22, foi avaliado o PhAng entre a CT e o AB
em indivduos saudveis, no entanto os indivduos
estavam na posio supina, com inclinao de tronco
de 30. Adicionalmente, os instrumentos de avaliao
utilizados foram diferentes, POE no presente estudo
e pletismografia respiratria por indutncia no estudo
de Tomich et al.22, dificultando uma comparao mais
aprofundada dos achados. Em relao ao PhAng
entre a CT pulmonar e a CT abdominal, os valores
observados no presente estudo foram semelhantes
aos encontrados no estudo de Aliverti et al.27, que
avaliaram sujeitos saudveis na posio sentada

utilizando a POE.
No presente estudo, observou-se aumento
do PhAng entre a CT e o AB para os exerccios
diafragmtico e intercostal quando comparados ao
repouso. Em relao ao PhAng entre a CT pulmonar
e a CT abdominal, observou-se aumento apenas
para o diafragmtico, tanto comparado ao repouso
quanto comparado aos demais exerccios. Utilizando
a pletismografia respiratria por indutncia,
Tomich et al.22 observaram aumento significativo
do PhAng entre a CT e o AB em relao ao repouso
durante a realizao desse exerccio. interessante
observar que o assincronismo toracoabdominal
ocorreu principalmente durante os exerccios que
envolvem o uso voluntrio de grupos musculares
especficos, como ocorre nos exerccios respiratrios
diafragmtico e intercostal, o que pode comprometer
o sincronismo entre os compartimentos.
Para quantificao do movimento assincrnico,
sem a necessidade de assumir que as curvas
so senoidais, a varivel PhRIB utilizada 28.
Os valores encontrados para a PhRIB foram
semelhantes ao descrito na literatura para indivduos
saudveis no repouso27. A PhRIB entre a CT e o
AB apresentou aumento significativo durante a
realizao dos exerccios diafragmtico e suspiros
inspiratrios em relao ao repouso. Para a PhRIB
entre a CT pulmonar e a CT abdominal, tambm foi
observado aumento significativo durante o exerccio
diafragmtico. No foram encontrados na literatura
estudos que avaliassem a PhRIB durante a realizao
dos exerccios respiratrios.
No que diz respeito aos resultados relacionados
aos ndices de assincronia, observou-se o
aumento consistente desses ndices entre todos
os compartimentos avaliados apenas durante o
diagramtico, tanto para PhRIB quanto para o PhAng.
importante considerar esse aumento em indivduos
saudveis, uma vez que, em indivduos com doenas
pulmonares crnicas que cursam com alteraes da
biomecnica da CT, esse aumento poderia ser ainda
maior. Gosselink et al.6, em pacientes com DPOC,
observaram alteraes significativas da relao da
excurso do AB e da CT para o exerccio realizado
com ou sem a carga linear.
Os resultados apresentados contribuem para
fundamentar a utilizao mais direcionada dos
exerccios respiratrios estudados. Apesar de os
resultados terem sido observados em sujeitos
saudveis, o comportamento das variveis estudadas
pode ser semelhante naqueles pacientes em
ps-operatrio, j que, apesar das alteraes prprias
desse perodo, muitos pacientes apresentavam funo
pulmonar normal previamente. Dessa forma, os
efeitos dos exerccios observados, principalmente em

relao ao aumento do volume corrente e reduo da
f, podem beneficiar pacientes que apresentam reduo
do volume corrente por diferentes causas, como dor,
colapso de parnquima pulmonar ou qualquer outra
restrio. Por fim, o direcionamento da ventilao
para determinados compartimentos pode ser benfico
para pacientes com reduo da ventilao em regies
pulmonares especficas, como nas atelectasias.
Uma limitao do presente estudo consiste no fato
de que os valores relativos aos volumes foram obtidos
de forma indireta, sem associao com uma medida
direta por meio de um pneumotacgrafo. Portanto,
esses valores no podem ser utilizados como valores
absolutos.
Concluso
Nossos resultados sugerem que os quatro
exerccios respiratrios estudados promovem
aumento do volume corrente e reduo da f.
Somente com o exerccio diafragmtico, a ventilao
foi direcionada, prioritariamente, para a regio
abdominal. Com os exerccios suspiros inspiratrios
e intercostal, houve aumento significativo da V E

em relao aos demais exerccios. No se observou
assincronia durante a realizao da inspirao
mxima sustentada. Os resultados apresentados neste
estudo podem contribuir para elucidar os efeitos
desses quatro exerccios respiratrios sobre o padro
respiratrio e o assincronismo toracoabdominal de
indivduos saudveis e, assim, permitir a utilizao
mais criteriosa na prtica clnica.
Agradecimentos
Coordenao de Aperfeioamento de Pessoal de
Nvel Superior (CAPES PROCAD NF 779/2010),
ao Conselho Nacional de Desenvolvimento Cientfico
e Tecnolgico (CNPq - Processo 309494/2013-3) e
Fundao de Amparo Pesquisa do Estado de Minas
Gerais (FAPEMIG - PPM-00374-12), Brasil, pelo
apoio financeiro.
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Correspondence
Vernica Franco Parreira
Universidade Federal de Minas Gerais
Avenida Antnio Carlos, 6627, Pampulha
e-mail: veronicaparreira@yahoo.com.br; veronica.parreira@
pq.cnpq.br
original article
Application of positive airway pressure in restoring

pulmonary function and thoracic mobility in the
postoperative period of bariatric surgery:
a randomized clinical trial
Aplicao de presso positiva nas vias areas na restaurao da
funo pulmonar e da mobilidade torcica no ps-operatrio de
cirurgia baritrica: um ensaio clnico randomizado
Patrcia Brigatto1, Jssica C. Carbinatto1, Carolina M. Costa1,
Maria I. L. Montebelo2, Irineu Rasera-Jnior3, Eli M. Pazzianotto-Forti1
ABSTRACT | Objective: To evaluate whether the application of bilevel positive airway pressure in the postoperative period
of bariatric surgery might be more effective in restoring lung volume and capacity and thoracic mobility than the separate
application of expiratory and inspiratory positive pressure. Method: Sixty morbidly obese adult subjects who were hospitalized
for bariatric surgery and met the predefined inclusion criteria were evaluated. The pulmonary function and thoracic mobility
were preoperatively assessed by spirometry and cirtometry and reevaluated on the 1st postoperative day. After preoperative
evaluation, the subjects were randomized and allocated into groups: EPAP Group (n=20), IPPB Group (n=20) and BIPAP
Group (n=20), then received the corresponding intervention: positive expiratory pressure (EPAP), inspiratory positive pressure
breathing (IPPB) or bilevel inspiratory positive airway pressure (BIPAP), in 6 sets of 15 breaths or 30 minutes twice a day in the
immediate postoperative period and on the 1st postoperative day, in addition to conventional physical therapy. Results: There
was a significant postoperative reduction in spirometric variables (p<0.05), regardless of the technique used, with no significant
difference among the techniques (p>0.05). Thoracic mobility was preserved only in group BIPAP (p>0.05), but no significant
difference was found in the comparison among groups (p>0.05). Conclusion: The application of positive pressure does not
seem to be effective in restoring lung function after bariatric surgery, but the use of bilevel positive pressure can preserve
thoracic mobility, although this technique was not superior to the other techniques.
Keywords: bariatric surgery; physical therapy specialty; spirometry.

Registered on Clinicaltrials.gov under identi ier NCT01872663.
Brigatto P, Carbinatto JC, Costa CM, Montebelo MIL, Rasera-Jnior I, Pazzianotto-Forti EM. Application of positive airway
pressure in restoring pulmonary function and thoracic mobility in the postoperative period of bariatric surgery: a randomized
clinical trial. Braz J Phys Ther. 2014 Nov-Dec; 18(6):553-562. http://dx.doi.org/10.1590/bjpt-rbf.2014.0054.
RESUMO | Objetivo: Avaliar se a aplicao de dois nveis de presso positiva nas vias areas no ps-operatrio de cirurgia
baritrica pode ser mais efetiva do que quando aplicadas presses positivas expiratria e inspiratria separadamente na
restaurao dos volumes e capacidades pulmonares e na mobilidade torcica. Mtodo: Foram avaliadas 60 voluntrias
adultas, obesas mrbidas, internadas para realizao da cirurgia baritrica. A funo pulmonar e a mobilidade torcica foram
avaliadas por meio da espirometria e da cirtometria no pr-operatrio e reavaliadas no primeiro ps-operatrio. Aps a
avaliao pr-operatria, as voluntrias foram randomizadas e alocadas nos grupos G EPAP (n=20), G RPPI (n=20) e G
BIPAP (n=20) e ento receberam a interveno proposta, presso positiva expiratria nas vias areas (EPAP), respirao
por presso positiva inspiratria (RPPI) ou presso positiva binvel nas vias areas (BIPAP), em sesses de seis sries de 15
respiraes ou de 30 minutos, duas vezes ao dia no ps-operatrio imediato e no primeiro ps-operatrio, alm do tratamento
fisioteraputico convencional. Resultados: Houve reduo significativa das variveis espiromtricas no ps-operatrio
(p<0,05), independente do recurso utilizado, no havendo diferena significativa entre as tcnicas (p>0,05), e preservao
da mobilidade torcica somente nas voluntrias do grupo BIPAP (p>0,05), porm sem diferena nas comparaes entre os
grupos (p>0,05). Concluso: A aplicao de presso positiva parece no ser efetiva na restaurao da funo pulmonar
no ps-operatrio de cirurgia baritrica, porm a aplicao de dois nveis de presso positiva pode preservar a mobilidade
torcica, embora no tenha demonstrado superioridade em relao s outras tcnicas.
Palavras-chave: cirurgia baritrica; fisioterapia; espirometria.

Registrado no Clinicaltrials.gov sob o identi icador NCT01872663.
Faculdade de Cincias da Sade, Universidade Metodista de Piracicaba (UNIMEP), Piracicaba, SP, Brasil
Faculdade de Cincias Exatas e da Natureza, UNIMEP, Piracicaba, SP, Brasil
3
Clnica Baritrica de Piracicaba, Piracicaba, SP, Brasil
1
2
553
Brigatto P, Carbinatto JC, Costa CM, Montebelo MIL, Rasera-Jnior I, Pazzianotto-Forti EM
Introduo
Em indivduos obesos, a combinao de fatores,
como menor complacncia dos pulmes e da parede
torcica, maior resistncia elstica pulmonar e
distenso exagerada do diafragma, pode influenciar
o sistema respiratrio, resultando em diminuio de
volumes e capacidades pulmonares. Essa condio
especialmente importante se considerarmos que
as alteraes respiratrias causadas pela cirurgia
abdominal podem ser mais acentuadas em pacientes
obesos1,2.
A cirurgia baritrica pode causar comprometimento
da funo pulmonar no ps-operatrio, expresso pela
reduo dos volumes pulmonares e da mobilidade
diafragmtica e toracoabdominal3. A alterao da
mecnica pulmonar gera um padro restritivo com
reduo da capacidade vital (CV) e da capacidade
residual funcional (CRF). A CV e a capacidade vital
forada (CVF) esto geralmente reduzidas no psoperatrio aproximadamente de 40 a 50% dos valores
pr-operatrios, e isso persiste por, no mnimo, dez
a 14 dias4. A utilizao de anestsicos, bloqueadores
musculares e analgsicos5-7, o trauma cirrgico,
a perda da integridade muscular abdominal8, a
manipulao das vsceras, a consequente inibio
reflexa do nervo frnico e a dor ps-operatria9,
geram disfuno diafragmtica5,7, que tem seu pico
entre duas e oito horas aps a cirurgia10, e desencadeia
reduo dos volumes e capacidades pulmonares,
alterao da relao ventilao/perfuso, diminuio
da expansibilidade toracoabdominal2, ineficincia
nos mecanismos de defesa das vias areas, como a
tosse, e depresso do sistema imunolgico, fatores
que aumentam o risco de desenvolvimento de
complicaes respiratrias, como atelectasias11,12,
hipoxemia grave, embolia pulmonar, pneumonia por
aspirao e insuficincia respiratria aguda2,7,11,12,.
Pelos motivos citados, algumas evidncias
sugerem que o acompanhamento fisioteraputico
pr e ps-operatrio de pacientes submetidos a essa
modalidade cirrgica de fundamental importncia
na preveno das complicaes inerentes ao processo
cirrgico e na recuperao da funo pulmonar13,
enquanto outras sugerem que a utilizao da
fisioterapia respiratria na rotina ps-operatria no
se justifica, uma vez que poucos ensaios clnicos
mostram sua eficcia em carter profiltico14. Em
2012, Hanekom et al.15 concluram que, devido m
qualidade das pesquisas elaboradas, a incerteza sobre
o valor da fisioterapia realizada rotineiramente na
preveno de complicaes pulmonares aps cirurgia
abdominal ainda permanece. Assim, so necessrios
554
estudos bem elaborados sobre o assunto que possam

contribuir para se estabelecerem procedimentos
fisioteraputicos de maior eficcia a serem realizados
no ps-operatrio de cirurgia abdominal16,17.
Dentre os recursos da fisioterapia respiratria
com o objetivo de preservar ou melhorar a funo
pulmonar, promovendo incremento ou manuteno
dos volumes e capacidades pulmonares, esto os
equipamentos com presso positiva nas vias areas,
que podem ser utilizados em ps-operatrios
toracoabdominais como mtodo de preveno ou
tratamento da insuficincia respiratria hipoxmica,
na melhora da oxigenao arterial, na reduo de
atelectasias e no decrscimo do trabalho ventilatrio,
sem gerar aumento na incidncia de fstulas ou
deiscncia da anastomose cirrgica18-21.
A utilizao de presso positiva nas vias areas
tem se mostrado efetiva na restaurao da CRF,
alm de promover a modificao de outros volumes
e capacidades pulmonares, como volume de reserva
inspiratrio (VRI), volume de reserva expiratrio
(VRE) e CVF, entretanto ainda h controvrsias em
relao manuteno produzida pela presso positiva
nas vias areas4. A EPAP (Expiratory Positive Airway
Pressure), a BIPAP (Bilevel Positive Airway Pressure)
e a respirao com presso positiva intermitente
(RPPI) so recursos com presso positiva nas vias
areas que visam reexpanso pulmonar, evitando
o colapso precoce das vias areas e prevenindo
assim as atelectasias pulmonares, podendo contribuir
para a reduo das complicaes ps-operatrias
da sndrome pulmonar restritiva associada
obesidade22-24. A tcnica de EPAP utiliza somente
a presso positiva expiratria (PEEP - positive
end-expiratory pressure), gerando reduo do fluxo
expiratrio22, j a BIPAP combina a PEEP com os
benefcios da presso de suporte, sendo possvel
ajust-las para manter o pulmo expandido durante
todo o ciclo respiratrio, promovendo insuflao
pulmonar23,24, e a tcnica de RPPI possibilita, alm
do recrutamento alveolar, a sincronizao do tempo
inspiratrio, buscando reduzir o esforo respiratrio
e retomar a funo pulmonar normal10.
Considerando que a populao obesa pode
apresentar caractersticas pulmonares restritivas, que
podem ser ainda mais acentuadas em ps-operatrio
abdominal, e que os recursos de presso positiva
nas vias areas podem ser capazes de restaurar a
funo pulmonar e a mobilidade torcica de forma
diferenciada, a hiptese deste estudo que a tcnica
de RPPI busca favorecer a capacidade inspiratria
(CI) por promover presso positiva nas vias
areas somente na fase de inspirao. J a presso
Presso positiva na gastroplastia
positiva expiratria gerada pela EPAP favorece

principalmente a CRF na tentativa de promover a
manuteno ou recuperao do VRE. A BIPAP, por
sua vez, por ofertar presso positiva nas duas fases
do ciclo respiratrio, tende a favorecer a capacidade
vital (CV), englobando os benefcios das outras duas
tcnicas. Assim, o objetivo deste estudo foi avaliar se
a aplicao de dois nveis de presso positiva nas vias
areas no ps-operatrio de cirurgia baritrica pode
ser mais efetiva do que quando aplicadas presses
positivas expiratria e inspiratria separadamente na
restaurao dos volumes e capacidades pulmonares
e na mobilidade torcica.
Mtodo
Desenho experimental
Este ensaio clnico foi desenvolvido respeitando as
normas de condutas em pesquisa experimental com
seres humanos aps ter sido aprovado pelo Comit
de tica em Pesquisa da Universidade Metodista de
Piracicaba (UNIMEP), Piracicaba, SP, Brasil, sob o
parecer n 89/12, e registrado no Clinicaltrials.gov,
sob o identificador NCT01872663.
O clculo do tamanho da amostra foi realizado
com base em estudo piloto, sendo considerada a
mdia (0,13) e o desvio padro (0,17) das diferenas
dos valores do VRE obtidos entre o pr e o psoperatrio a partir do teste ANOVA, no aplicativo
BioEstat 5.3, adotando-se um poder estatstico de
90% e um alfa de 0,05. Dessa forma, foi determinado
o nmero de 17 voluntrios por grupo.
Participantes
Foram avaliadas 68 mulheres adultas, obesas
mrbidas, internadas em um hospital da cidade de
Piracicaba, SP, Brasil para realizao da cirurgia
baritrica eletiva, com prescrio de fisioterapia
respiratria pelo mdico responsvel, as quais
preencheram os critrios de incluso: ndice de massa
corprea (IMC) entre 40 e 55 kg/m2, idade entre 25
e 55 anos, candidatas cirurgia baritrica do tipo
derivao gstrica em Y de Roux por laparotomia,
no tabagistas, com exame radiolgico de trax e
prova de funo pulmonar pr-operatrios dentro
dos parmetros de normalidade e que assinaram o
termo de consentimento livre e esclarecido. Foram
excludas as voluntrias com presena de asma,
doena pulmonar obstrutiva crnica (DPOC) e
sndrome da apneia obstrutiva do sono (AOS), as
que apresentaram instabilidade hemodinmica,
permanncia hospitalar maior que trs dias, presena
de complicaes ps-operatrias e incapacidade

de compreenso ou recusa para a realizao das
avaliaes ou do tratamento proposto.
Procedimentos
A funo pulmonar e a mobilidade torcica das
voluntrias foram avaliadas no pr-operatrio, logo
aps a admisso hospitalar, e reavaliadas no primeiro
ps-operatrio, aps a finalizao das sesses de
fisioterapia. O pesquisador que realizou as avaliaes
foi cego em relao ao tratamento das voluntrias,
e o pesquisador que realizou os tratamentos, cego
em relao s avaliaes. Durante a avaliao properatria, foi registrada a presena de comorbidades,
como hipertenso arterial sistmica (HAS), diabetes
mellitus e dislipidemias.
Aps a avaliao pr-operatria, as 68 voluntrias
foram alocadas em trs grupos a partir de um processo
de randomizao em bloco no programa Microsoft
Excel 2007, realizado por um pesquisador cego
em relao aos dados clnicos e avaliao das
voluntrias. Foram os grupos: G EPAP (Expiratory
Positive Airway Pressure), G RPPI (Respirao com
Presso Positiva Intermitente) e G BIPAP (Bilevel
Positive Airway Pressure). Durante a aplicao
das intervenes, oito voluntrias foram excludas,
totalizando, ao final, 60 voluntrias, compondo trs
grupos com 20 cada (Figura 1).
Todas as voluntrias receberam a interveno
proposta duas vezes ao dia no ps-operatrio
imediato e no primeiro ps-operatrio (1 PO) e,
associada terapia com presso positiva nas vias
areas, todas as voluntrias receberam o tratamento
fisioteraputico convencional, tambm realizado
duas vezes ao dia no ps-operatrio, e composto por
exerccios de inspiraes diafragmticas, inspiraes
profundas, inspiraes fracionadas, exerccios
respiratrios associados movimentao de membros
superiores 25 e incentivador respiratrio, sendo
realizada uma srie de 15 repeties para cada um
deles, com durao mdia de 20 a 30 minutos, alm
de exerccios para preveno de trombose venosa
profunda e deambulao.
A funo pulmonar foi avaliada pela espirometria
das voluntrias, realizada utilizando-se um
espirmetro ultrassnico computadorizado da
marca MicroQuark, modelo USB (Cosmed, Roma,
Itlia). Foi realizada a manobra de capacidade vital
lenta (CVL) de acordo com as normas da American
Thoracic Society (ATS) e European Respiratory
Sociaty (ERS)26, sendo repetida at se obterem
trs curvas aceitveis e duas reprodutveis, no
555
excedendo mais do que oito tentativas. Para calcular

os valores preditos, foi utilizada a equao proposta
por Pereira et al.27 para a populao brasileira, e os
valores de CVL, VRE, VRI e volume corrente (VC)
foram selecionados de acordo com as recomendaes
de Pereira28, os valores de CI foram calculados a partir
da soma do VRI e do VC.
A avaliao da mobilidade torcica foi realizada
por meio da cirtometria nos nveis axilar e xifoideano
sempre pelo mesmo avaliador, com a utilizao
de uma fita mtrica escalonada em centmetros,
medindo-se as circunferncias aps uma inspirao
mxima e aps uma expirao mxima, estando as
voluntrias em posio ortosttica. Foram repetidas
trs medidas para cada nvel e computado o maior
valor obtido na inspirao e o menor na expirao. A
diferena absoluta entre esses valores foi considerada

a mobilidade torcica para cada nvel25,29.
De forma a minimizar a interferncia da dor nas
avaliaes ps-operatrias, antes de inici-las, as
voluntrias classificaram o nvel da dor por meio
de uma Escala Visual Analgica (EVA)30,31. Quando
a dor foi classificada acima de 4, foi solicitada
equipe de enfermagem a administrao de analgesia
com dipirona, conforme prescrio mdica, e ento
classificada novamente aps 30 minutos, antes do
incio da reavaliao.
A aplicao da EPAP foi realizada com a utilizao
de uma mscara facial siliconizada com vlvula
unidirecional (Respironics, Seal Flex Multi-Strap,
Irlanda, EUA) e vlvula de PEEP do tipo springloaded (Vital Signs Inc, Totoma/NJ, EUA) ajustada
em 10 cmH2O3, que foi posicionada e fixada pelas
Figura 1. Fluxograma da casustica do estudo. EPAP: Expiratory Positive Airway Pressure; RPPI: Respirao com Presso Positiva
Intermitente; BIPAP: Bilevel Positive Airway Pressure.
556
mos do terapeuta na face da voluntria a fim de evitar

fuga area. As voluntrias foram orientadas a realizar
seis sries de 15 respiraes, com inspirao nasal
de mdia amplitude e expirao contra a resistncia
imposta pela vlvula de PEEP32, priorizando a
respirao diafragmtica, sendo realizado um
descanso de 1 a 2 minutos entre cada srie, com
durao da sesso de aproximadamente 20 minutos.
A aplicao da RPPI foi realizada por meio do
equipamento Reanimador de Mller (Engesp,
Curitiba, Paran, Brasil), utilizando uma presso
endotraqueal de 20 a 30 cmH2O, referente a 2 a
3 kgf/cm na vlvula reguladora de presso de oxignio
e, no micronebulizador, foi utilizado soro fisiolgico
como diluente21,33. As voluntrias foram orientadas
a realizar a inspirao no bocal do equipamento ao
comando do terapeuta, simultaneamente ao disparo
do equipamento, e a sustentar a inspirao por
1 a 2 segundos, e ento expirar livremente. Foram
realizadas seis sries de 15 ciclos respiratrios em
cada sesso, com descanso de 1 a 2 minutos entre
cada srie, totalizando aproximadamente 30 minutos
de durao para cada sesso.
A aplicao de BIPAP de forma no invasiva foi
realizada com a utilizao do equipamento VPAPTM
III ST-A (Resmed, San Diego/CA, EUA) conectado
a uma mscara facial simples, com borda inflvel
por uma traqueia corrugada e acoplada face do
paciente por fixador de borracha. A EPAP foi fixada
em 8 cmH2O, e a presso positiva inspiratria (IPAP)
foi ajustada inicialmente em 12 cmH2O34 e reajustada
a fim de se manter uma frequncia respiratria entre
12 e 20 respiraes por minuto e um VC em torno
de 8 a 10ml/kg de peso ideal, calculado pela frmula
45,5 + 0,91 (estatura 152,4)35. Durante o perodo
de aplicao de 30 minutos, as voluntrias foram
orientadas a realizar a inspirao nasal e a expirao
oral.
Durante todo o tempo de aplicao dos recursos,
as voluntrias permaneceram na posio Fowler
45, e o pesquisador permaneceu ao lado delas,
acompanhando-as e monitorizando os sinais vitais e
o conforto respiratrio.
Anlise estatstica
A anlise estatstica dos dados foi realizada
com a utilizao do software R, verso 3.0.1, e a
normalidade de distribuio dos dados foi verificada
pelo teste de Shapiro-Wilk.
Para as anlises intragrupos das variveis
espiromtricas e de mobilidade torcica no pr e
ps-operatrio, foi realizado o teste t de Student
para amostras pareadas ou teste de Wilcoxon.
Para a comparao intergrupos, foram utilizados

os valores das diferenas entre o pr e o psoperatrio e analisados pelos testes de ANOVA ou
Kruskall-Wallis.
Um nvel de significncia de 5% foi adotado para
todas as anlises.
Resultados
Na Tabela 1 esto apresentados os resultados da
idade, caractersticas antropomtricas e comorbidades
das voluntrias do estudo alocadas nos grupos de
acordo com o tratamento proposto.
Pode-se constatar que no houve diferena entre
os grupos para as variveis idade, massa corporal,
estatura, IMC, presena de HAS e presena de
diabetes mellitus.
Na Tabela 2, esto apresentadas as variveis
espiromtricas da manobra de CVL de cada grupo
nas avaliaes antes e aps a cirurgia, em valores
absolutos e em porcentagens do previsto para a CVL e
o VRE. Pode-se notar que houve reduo significativa
de todas as variveis no ps-operatrio em relao
ao pr. Esto apresentadas tambm as redues entre
os valores pr e ps-operatrios em porcentagem
e, quando comparadas entre si, no apresentaram
diferenas significativas.
A Tabela 3 apresenta os valores das medidas de
mobilidade torcica nos nveis axilar e xifoideano
dos grupos nos momentos pr e ps-cirrgicos. Na
anlise intragrupos, foi possvel observar que houve
uma reduo significativa das mobilidades axilar
e xifoideana para os grupos EPAP e RPPI no psoperatrio; j, para o G BIPAP, no foram encontradas
diferenas significativas. Quando comparadas as
diferenas dos valores pr e ps-operatrios de
mobilidade torcica, no houve diferena para os
dois nveis avaliados, independente do tratamento
recebido.
Discusso
Os principais resultados deste estudo revelaram
reduo significativa das variveis espiromtricas no
ps-operatrio, independente do recurso utilizado,
e preservao da mobilidade torcica somente nas
voluntrias do grupo BIPAP.
O declnio da funo pulmonar aps procedimentos
cirrgicos justificado por fatores inerentes ao prprio
procedimento, como a utilizao de anestsicos e
analgsicos, a perda da integridade da musculatura
abdominal e a consequente diminuio da fora de
contrao muscular e disfuno diafragmtica e
557
Tabela 1. Idade, caractersticas antropomtricas (valores em mdia e desvio padro) e presena de comorbidades das voluntrias alocadas
nos grupos.
Grupo EPAP (n=20)
Grupo RPPI (n=20)
Grupo BIPAP (n=20)
38,858,42
38,708,59
40,608,78
Idade (anos)
Massa corporal (kg)
114,9917,96
110,1314,82
113,6916,08
Estatura (m)
1,590,06
1,610,06
1,610,09
IMC (kg/m )
45,396,82
42,395,36
44,348,14
HAS (n)
12
10
13
Diabetes Mellitus (n)
IMC: ndice de massa corprea; HAS: hipertenso arterial sistmica.
Tabela 2. Valores absolutos e em porcentagens do previsto das variveis espiromtricas na manobra de CVL para cada grupo no pr e
ps-operatrio, expressos em mdia e desvio padro.
Grupo EPAP
(n=20)
Grupo RPPI
(n=20)
Grupo BIPAP
(n=20)
PR
PS
DIF (%)
PR
PS
DIF (%)
PR
PS
DIF (%)
2,920,62
1,860,46*
36,30
3,240,51
2,310,33*
28,70
3,110,68
2,110,59*
32,15
CVL
88,2913,15 56,7414,33
(% prev)
35,74
96,3714,43 68,5810,12
28,83
93,1913,49 63,9017,08
31,43
VRE
(L)
0,270,14*
47,06
VRE
45,5615,44 24,4211,76
(% prev)
46,39
VRI
(L)
1,530,56
0,970,43*
36,60
2,010,60
1,360,29*
32,34
1,730,71
1,200,43*
30,64
VC
(L)
0,910,39
0,620,21*
31,87
0,760,26
0,630,18*
17,11
0,880,27
0,600,26*
31,82
CI
(L)
2,440,61
1,590,47*
34,84
2,770,45
1,980,31*
28,52
2,610,50
1,80 0,43*
31,03
CVL
(L)
0,510,21
0,480,31
0,320,18*
33,33
42,1027,11 28,6114,52
32,04
0,510,34
0,320,27*
37,25
45,1726,63 27,6521,81
38,79
CVL: capacidade vital lenta; VRE: volume de reserva expiratrio; % prev: porcentagem do previsto; VRI: volume de reserva inspiratrio; VC:
volume corrente; CI: capacidade inspiratria; DIF: diferena entre o pr e o ps; *diferena significativa entre o pr e ps-operatrio (p<0,05).
Tabela 3. Valores de mobilidade torcica nos nveis axilar e xifoideano para cada grupo no pr e ps-operatrio, expressos em mdia
e desvio padro.
AXILAR (cm)
XIFOIDEANA (cm)
PR
PS
DIF (%)
PR
PS
DIF (%)
Grupo EPAP (n=20)
3,701,20
2,501,05*
32,43
2,551,11
1,350,84*
47,06
Grupo RPPI (n=20)
3,931,31
2,880,79*
26,72
2,781,25
1,530,82*
44,96
Grupo BIPAP (n=20)
3,751,73
2,781,08
25,87
2,401,73
1,600,79
33,33
DIF: diferena entre o pr e o ps; *diferena significativa entre o pr e ps-operatrio (p<0,05).
tambm por aspectos que interferem na realizao

das manobras espiromtricas, como a dor e o receio
da inspirao profunda6,36. Neste estudo, houve
a preocupao em avaliar a dor e solicitar a
administrao de analgesia conforme prescrio
mdica, quando necessria, antes das avaliaes
ps-operatrias, a fim de evitar que os resultados
pudessem ser influenciados por esse fator. Porm,
558
pode-se sugerir que os efeitos do procedimento

cirrgico, associados obesidade, contriburam de
forma importante para a reduo significativa dos
valores da espirometria e da mobilidade torcica
nos trs grupos.
O excesso de gordura armazenada na cavidade
abdominal exerce efeito mecnico direto sobre a
caixa torcica e o msculo diafragma, restringindo
a expansibilidade torcica, com consequente reduo

dos volumes pulmonares37-39. Essa restrio da parede
torcica maior quando o obeso permanece na posio
supina, como durante o procedimento cirrgico,
ou durante o perodo de internao hospitalar,
acarretando sobrecarga muscular importante para a
ventilao e resultando em disfuno da musculatura
respiratria40,41.
A reduo da complacncia da parede torcica,
devido ao aumento da presso abdominal,
administrao de anestsicos e dor ps-operatria,
pode causar uma reduo prolongada dos volumes
e capacidades pulmonares. Acredita-se que a terapia
com BIPAP possa reverter esses fenmenos por meio
dos efeitos positivos combinados de PEEP e presso
de suporte inspiratria, permitindo o recrutamento de
zonas de colapso alveolar, aumentando a ventilao
pulmonar e melhorando a troca gasosa, alm de
gerar um aumento na expansibilidade torcica9,23,42,43.
Porm, neste estudo, a BIPAP no foi capaz de
restaurar a funo pulmonar no ps-operatrio, e sua
efetividade teve destaque somente na restaurao da
mobilidade torcica em relao s outras tcnicas de
presso positiva utilizadas.
Pessoa et al.18 utilizaram a tcnica de BIPAP
no ps-operatrio imediato de cirurgia baritrica,
ainda em recuperao ps-anestsica, e puderam
observar que a terapia possui um efeito dose e tempo
dependente, demonstrando melhores resultados
quando utilizados nveis pressricos mais altos
por tempos mais prolongados. Considerando essa
afirmao, podemos sugerir que resultados mais
expressivos no foram encontrados neste estudo, pois
a tcnica foi aplicada por curtos perodos, sesses de
30 minutos.
A ausncia de efeitos positivos significativos na
utilizao das tcnicas de presso positiva deste
estudo tambm pode ser justificada pelo momento de
realizao das tcnicas, visto que s foram iniciadas
aproximadamente quatro horas depois do trmino da
cirurgia. Forgiarini Junior et al.43 demonstraram que
a interveno fisioteraputica, quando iniciada na
sala de recuperao ps-anestsica, pode ser benfica
para os pacientes submetidos a cirurgias abdominais,
pois os valores da funo pulmonar nos pacientes
que receberam o atendimento fisioteraputico mais
precocemente apresentaram menor variao dos
valores de espirometria ps-operatrios em relao
aos do pr do que o grupo que iniciou a fisioterapia
na enfermaria.
Segundo a literatura, a anestesia geral pode agravar
a hipoventilao nas primeiras horas de recuperao
ps-cirrgica devido maior instabilidade alveolar
nesse perodo, e a aplicao precoce da presso

positiva pode ser capaz de melhorar a ventilao
alveolar em reas possivelmente colapsadas durante
o procedimento cirrgico44-47. Na sala de recuperao
ps-anestsica, considera-se que a tolerncia do
paciente facilitada pelo efeito sedativo residual dos
agentes anestsicos e de opioides administrados para
analgesia23, permitindo a aplicao dos recursos por
tempo mais prolongado, o que no foi realizado neste
estudo, uma vez que as voluntrias j se encontravam
no quarto.
Outro importante fator a ser considerado no atual
estudo como provvel influncia nos resultados,
principalmente em relao funo pulmonar,
refere-se ao momento da realizao da reavaliao
ps-operatria. As voluntrias foram reavaliadas
aproximadamente 36 horas aps a cirurgia, talvez esse
tempo no tenha sido suficiente para a restaurao dos
volumes e capacidades pulmonares independente
do recurso aplicado, visto que, at esse momento,
a funo diafragmtica no est completamente
retomada. No estudo de Paisani et al.47, que buscou
avaliar o comportamento dos volumes e capacidades
pulmonares de pacientes no ps-operatrio de
gastroplastia, foram verificadas redues das
variveis no primeiro ps-operatrio de 30 a 50%
em relao aos seus valores pr-operatrios e, no
quinto dia de ps-operatrio, a CV ainda no havia
retornado a seus valores iniciais. No presente estudo,
os volumes e capacidades pulmonares, reavaliados
tambm no primeiro ps-operatrio, apresentaram
redues que variaram de 17 a 46%, no sendo
possvel verificar a recuperao das variveis antes
da alta hospitalar.
No estudo de Barbalho-Moulim et al.3, a EPAP
no foi capaz de prevenir a reduo da mobilidade
torcica nos nveis axilar e xifoideano e das medidas
de VC e VRI, como tambm ocorreu neste estudo,
talvez por ser um recurso que no estimula a
realizao de suspiros inspiratrios e por estar
associado a baixos volumes pulmonares e reduo
do fluxo expiratrio.
Segundo Mller et al.33, a tcnica de RPPI permite
um manejo sincrnico entre o operador e o paciente,
respeitando o ciclo respiratrio, promovendo melhor
adaptao ao equipamento e evitando desconforto
respiratrio, sendo, por isso, considerada um recurso
efetivo no ganho de VC e, consequentemente, de
reexpanso pulmonar. Entretanto, esses resultados
benficos no foram observados neste estudo.
Sugere-se que recursos com presso positiva
possuem efeitos semelhantes em relao restaurao
de volumes e capacidades pulmonares e mobilidade
559
torcica no ps-operatrio de cirurgia baritrica,

independente de serem aplicados durante a inspirao,
a expirao ou em ambas, no sendo efetivos quando
aplicados conforme o protocolo estabelecido para
este estudo, demonstrando que, nos primeiros dias de
ps-operatrio, a funo pulmonar ainda se encontra
prejudicada pelos efeitos da obesidade associados ao
procedimento cirrgico abdominal.
Todas as voluntrias foram submetidas mesma
tcnica cirrgica, pela mesma equipe cirrgica,
com tempo de procedimento e tempo anestsico
semelhantes e, durante a anestesia, permaneceram em
ventilao mecnica, com parmetros ventilatrios
padronizados pela equipe mdica responsvel,
portanto no sendo considerados fatores de influncia
nas avaliaes deste estudo.
Apesar da pequena influncia da presso positiva
na funo pulmonar e na mobilidade torcica das
voluntrias estudadas, importante destacar que as
tcnicas aplicadas no proporcionaram nenhum efeito
adverso ou geraram complicaes ps-operatrias,
como fstulas, distenso abdominal ou deiscncia
da anastomose cirrgica. Dessa forma, pode-se
considerar que a aplicao da presso positiva
se mostrou segura no ps-operatrio de cirurgia
baritrica.
Considerou-se como limitao deste estudo o curto
perodo de internao das voluntrias submetidas
cirurgia baritrica eletiva, as quais recebiam
alta no incio do segundo dia ps-operatrio,
impossibilitando uma reavaliao mais tardia.
Concluso
A aplicao de dois nveis de presso positiva nas
vias areas, dentro do protocolo estabelecido neste
estudo, parece no ser efetiva na restaurao dos
volumes e capacidades pulmonares no ps-operatrio
de cirurgia baritrica.
Em relao mobilidade torcica, a aplicao
de dois nveis de presso positiva obteve melhores
resultados do que quando aplicada presso positiva
inspiratria ou expiratria separadamente, sem,
entretanto, demonstrar superioridade em relao s
outras tcnicas.
Agradecimentos
Fundao de Amparo Pesquisa do Estado de
So Paulo (FAPESP), So Paulo, Brasil, processo n.
2013/06334-8 e Coordenao de Aperfeioamento
de Pessoal de Nvel Superior (CAPES/PROSUP),
Braslia, Brasil.
560
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Correspondence
Eli Maria Pazzianotto Forti
Universidade Metodista de Piracicaba
Rodovia do Acar, Km 156
CEP 13400-911, Piracicaba, SP, Brasil
e-mail: empforti@unimep.br
original article
Functional priorities reported by parents of children

with cerebral palsy: contribution to the pediatric
rehabilitation process
Prioridades funcionais identi icadas por pais de crianas com paralisia cerebral:
contribuies para o processo de reabilitao infantil
Marina B. Brando1, Rachel H. S. Oliveira2, Marisa C. Mancini3
ABSTRACT | Background: Collaborative actions between family and therapist are essential to the rehabilitation process,
and they can be a catalyst mechanism to the positive outcomes in children with cerebral palsy (CP). Objectives: To
describe functional priorities established by caregivers of CP children by level of severity and age, and to assess changes
on performance and satisfaction on functional priorities reported by caregivers, in 6-month interval. Method: 75 CP
children, weekly assisted at Associao Mineira de Reabilitao, on physical and occupational therapy services. The
following information was collected: gross motor function (Gross Motor Function Classification System-GMFCS) and
functional priorities established by caregivers (Canadian Occupational Performance Measure-COPM). Data were collected
in two moments, with a 6-month interval. Results: The main functional demands presented by caregivers were related
to self-care activities (48.2%). Parents of children with severe motor impairment (GMFCS V) pointed higher number of
demands related to play (p=0.0036), compared to the other severity levels. Parents of younger children reported higher
number of demands in mobility (p=0.025) and play (p=0.007), compared to other age groups. After 6 months, there
were significant increase on COPM performance (p=0.0001) and satisfaction scores (p=0.0001). Conclusions: Parents
of CP children identified functional priorities in similar performance domains, by level of severity and age. Orienting
the pediatric rehabilitation process to promote changes in functional priorities indentified by caregivers can contribute
to the reinforcement of the parent-therapist collaboration.
Keywords: functional priorities; cerebral palsy; rehabilitation; children.
Brando MB, Oliveira RHS, Mancini MC. Functional priorities reported by parents of children with cerebral palsy: contribution
to the pediatric rehabilitation process. Braz J Phys Ther. 2014 Nov-Dec; 18(6):563-571. http://dx.doi.org/10.1590/bjpt-rbf.2014.0064
RESUMO | Contextualizao: Aes colaborativas entre famlia e terapeuta so essenciais para o processo de reabilitao,
podendo constituir mecanismo catalisador de desfechos funcionais positivos para crianas com paralisia cerebral (PC).
Objetivos: Descrever prioridades funcionais identificadas por cuidadores de crianas com PC por nvel de gravidade
e idade e avaliar mudanas no desempenho e satisfao reportadas pelos cuidadores nas prioridades identificadas no
intervalo de seis meses. Mtodo: De 75 crianas com PC, atendidas semanalmente na Associao Mineira de Reabilitao,
nos servios de fisioterapia e de terapia ocupacional, foram coletadas informaes referentes funo motora grossa
(Sistema de Classificao da Funo Motora Grossa-GMFCS) e s prioridades funcionais estabelecidas pelos cuidadores
(Medida Canadense de Desempenho Ocupacional-COPM). Os dados foram coletados em dois perodos, com intervalo
de seis meses. Resultados: As principais demandas apontadas pelos cuidadores referiram-se s atividades de cuidados
pessoais (48,2%). Pais de crianas com comprometimento motor grave (GMFCS V) apresentaram maior nmero de
demandas relacionadas ao brincar (p=0,036), comparadas com outros nveis de comprometimento. Pais de crianas
mais jovens reportaram maior nmero de demandas em mobilidade (p=0,025) e brincar (p=0,007) em relao aos
outros grupos etrios. Aps seis meses, observou-se aumento significativo dos escores de desempenho (p=0,0001) e de
satisfao (p=0,0001) da COPM. Concluses: Pais de crianas com PC identificaram prioridades funcionais em reas
de desempenho semelhantes por nvel de gravidade da funo motora grossa e por grupo etrio. Direcionar o processo
de reabilitao infantil, visando a promover mudanas nas prioridades funcionais definidas como relevantes pelos pais,
pode contribuir para o fortalecimento da colaborao famlia-terapeuta.
Palavras-chaves: prioridades funcionais; paralisia cerebral; reabilitao; crianas.
Ncleo de Ensino e Pesquisa, Associao Mineira de Reabilitao (AMR), Faculdade de Cincias Mdicas de Minas Gerais, Belo Horizonte, MG,
Brasil
2
Curso de Terapia Ocupacional, Ncleo de Ensino e Pesquisa, AMR, Faculdade de Cincias Mdicas de Minas Gerais, Belo Horizonte, MG, Brasil
3
Programa de Ps-graduao em Cincias da Reabilitao, Departamento de Terapia Ocupacional, Universidade Federal de Minas Gerais (UFMG),
Belo Horizonte, MG, Brasil
1
563
Brando MB, Oliveira RHS, Mancini MC
Introduo
A paralisia cerebral (PC) uma condio de
sade que acomete prioritariamente funes e
estruturas musculoesquelticas, resultante de danos
ao crebro nos perodos pr-natal, perinatal ou no
incio da infncia1. Essas alteraes podem repercutir
de formas distintas na realizao de atividades
da rotina diria, variando da necessidade de total
assistncia do cuidador ao desempenho de atividades
funcionais com independncia, mesmo que de formas
alternativas e/ou com uso de tecnologias assistivas1,2.
Nesse contexto, o conhecimento das manifestaes
neuromusculoesquelticas e da sintomatologia
dessa condio de sade no suficiente para
predizer a funcionalidade da criana em atividades
de autocuidado, mobilidade funcional, brincar e
escola3,4.
A literatura tem demonstrado que o desempenho
funcional da criana com PC no consequncia
direta das caractersticas da condio de sade.
Mancini et al.3 analisaram o impacto da gravidade
motora no desempenho funcional de crianas com
PC. Na comparao entre crianas com gravidades
motoras distintas, aquelas com comprometimento
motor moderado (nvel III do Sistema de Classificao
da Funo Motora Grossa-GMFCS) demonstraram
repertrio funcional de habilidades semelhante s
de gravidade motora leve (nveis I e II do GMFCS),
enquanto, em independncia, a semelhana do grupo
moderado (nvel III do GMFCS) ocorreu com o grupo
de crianas graves (nveis IV e V do GMFCS)3. Esses
resultados so corroborados por Chagas et al.4, que
analisaram o perfil funcional de crianas com PC de
acordo com sistemas de classificao da gravidade
motora grossa (GMFCS)5,6 e da funo manual
(Sistema de Classificao das Habilidades ManuaisMACS)7. Eles observaram que crianas classificadas
como moderadas na funo motora grossa (nvel
III do GMFCS) apresentaram perfil funcional
semelhante ao de crianas leves (nveis I e II do
GMFCS)4. Entretanto, no que se refere gravidade
da funo manual, crianas com comprometimento
moderado (nvel III do MACS) apresentaram maior
similaridade funcional com as crianas graves (nveis
IV e V do MACS)4.
Alm da variabilidade de perfil funcional da criana
com PC nos diferentes nveis de gravidade motora,
observa-se, tambm, no linearidade das limitaes
para a realizao de atividades em diferentes domnios
funcionais, como em autocuidado, mobilidade e
funo social. Mancini et al.3 constataram que crianas
564
com gravidade moderada (nvel III do GMFCS)

apresentaram perfil de habilidades funcionais
similar ao de crianas com comprometimento
leve (nveis I e II do GMFCS) em atividades de
autocuidado e de funo social, enquanto, na rea de
mobilidade, essas mesmas crianas assemelharamse s crianas de grave comprometimento motor
(nveis IV e V do GMFCS). Tais resultados ilustram
a heterogeneidade das manifestaes funcionais da
criana com PC, reforando que uma combinao
de fatores, incluindo as caractersticas do contexto
fsico, atitudinal, social, bem como tecnologias,
podem influenciar o perfil funcional da criana em
sua rotina diria8, restringindo o poder preditivo
exclusivo das alteraes neuromusculoesquelticas.
Assim, considerando a variabilidade das limitaes
funcionais que podem decorrer da condio de PC,
aes de reabilitao com medidas de desfechos
individualizadas podem promover a participao das
crianas em seus diferentes contextos de vida.
Aes colaborativas entre famlia e terapeuta so
essenciais para o desenvolvimento de estratgias
de reabilitao individualizadas que efetivamente
promovam a funcionalidade da criana1,9-13. Egilson10
analisaram as perspectivas dos pais quanto s aes
de reabilitao dirigidas s crianas com deficincia
fsica. Os autores ressaltaram o desejo relatado
pelos pais de serem informados e de participarem
do processo de tomada de deciso teraputica10.
Nesse sentido, os pais buscam indicaes teis para
melhorar o desempenho funcional da criana nas
atividades da rotina diria e esto preocupados com
a transferncia de aprendizado adquirido no ambiente
teraputico para os contextos domstico e escolar10.
Hurlburt et al.11, investigando as caractersticas de
um servio de reabilitao infantil, apontaram que a
incongruncia entre as percepes dos terapeutas e
as dos familiares acerca do processo de reabilitao
pode dificultar o entendimento das famlias sobre
a interveno, potencialmente minimizando os
resultados teraputicos no desempenho funcional
da criana. ien et al.13 exploraram as percepes
dos pais e de profissionais sobre estabelecimento de
objetivos significativos para a famlia de crianas
com PC. Os autores apontaram que o envolvimento
dos pais no estabelecimento de objetivos teraputicos
pode aumentar o sentimento de competncia e de
participao, contribuindo para a relao de parceria
entre pais e profissionais13.
Um dos objetivos centrais da reabilitao est
relacionado promoo da participao da criana
Prioridades funcionais de pais de crianas com PC
em seus contextos significativos de vida. Como

consequncia, importante que os terapeutas
conheam as prioridades e necessidades da criana
sob a perspectiva do cuidador, j que, a partir da
convivncia diria, os pais so grandes conhecedores
das habilidades e necessidades da criana1,9,14. Assim,
o conhecimento dessas prioridades, com uso de
instrumentao que capture as demandas funcionais,
pode auxiliar o terapeuta a desenvolver estratgias
de reabilitao individualizadas, significativas e
adequadas s prioridades da famlia. O objetivo
principal deste estudo compreendeu identificar os
objetivos funcionais estabelecidos por cuidadores
de crianas com PC atendidas em um centro de
reabilitao em relao gravidade e idade das
crianas. Alm disso, o estudo tambm objetivou
avaliar mudanas no desempenho e na satisfao
reportadas pelos cuidadores nas prioridades
identificadas no intervalo de seis meses.
Mtodo
Trata-se de um estudo observacional longitudinal
retrospectivo, no qual foram revisados 75 pronturios
de crianas com PC que estavam em atendimento
semanal na Associao Mineira de Reabilitao
(AMR), Belo Horizonte, MG, Brasil, no perodo de
julho a dezembro de 2011. Este estudo, juntamente
com o termo de consentimento livre e esclarecido,
foi aprovado pelo Ncleo de Ensino e Pesquisa da
AMR e Comit de tica em Pesquisa da Universidade
Federal de Minas Gerais (UFMG), Belo Horizonte,
MG, Brasil (ETIC-02740203000-10).
Participantes
Os participantes foram crianas com PC entre
3 e 16 anos de idade, com o diagnstico clnico
estabelecido a partir do exame neurolgico, as quais
frequentavam atendimentos semanais de fisioterapia
e de terapia ocupacional. Foram excludas crianas
que estavam de licena mdica durante o perodo
de coleta ou que estavam em outra modalidade de
atendimento, como servios de acompanhamento
quinzenal ou mensal. Crianas que faltaram a trs
ou mais atendimentos durante o perodo analisado
tambm foram excludas do estudo.
Instrumentao
Inicialmente, foram coletadas informaes nos
pronturios referentes ao nvel de gravidade da
funo motora grossa das crianas pelo GMFCS4,5.
O GMFCS classifica a funo motora grossa em

cinco nveis, com base nas habilidades de sentar,
manter-se de p e marcha da criana com PC, bem
como no uso de dispositivos de suporte e recursos
adaptativos4,5. No nvel I, a criana capaz de andar
sem dificuldades em diferentes ambientes e apresenta
habilidades como correr e pular. No nvel II, a criana
consegue andar em superfcies estveis, mas pode
apresentar dificuldades e necessitar de apoio ou
equipamentos para longas distncias. As crianas
do nvel III fazem uso de utenslios de suporte em
ambientes internos e cadeira de rodas para ambientes
externos. Crianas do nvel IV apresentam limitaes
de mobilidade, podendo impulsionar a cadeira de
rodas. Por fim, crianas do nvel V apresentam graves
limitaes motoras, sendo necessrio o uso de cadeira
de rodas e auxlio constante4,5.
Informaes acerca das demandas funcionais
estabelecidas pela famlia foram obtidas com a
Medida Canadense de Desempenho Funcional
(COPM)15. Para o presente estudo, foram coletados
dados das crianas em dois momentos, com intervalo
de seis meses, sendo a entrevista com o cuidador
da criana realizada pelos mesmos examinadores,
terapeutas ocupacionais, previamente capacitados
para aplicao do instrumento.
A COPM um instrumento padronizado que
auxilia terapeutas a intervirem com base nas
prioridades estabelecidas pelo cliente15. Na rotina
de avaliao da AMR, a COPM administrada
por entrevista com os cuidadores das crianas.
Nessa avaliao, h a pontuao da importncia das
atividades em uma escala de 10 pontos (1=pouco
importante; 10=muito importante) nas diferentes
reas de ocupao (autocuidado, produtividade,
lazer)15. Os cuidadores foram solicitados a listar as
cinco atividades que julgavam ser as mais importantes
e pontuar o desempenho da criana e o seu nvel de
satisfao com relao maneira que ela realizava
cada uma dessas atividades, em uma escala de 1-1015.
Estudos informam que a COPM apresenta boa
validade e confiabilidade15,16. A reavaliao foi feita
com o cuidador que respondeu primeira entrevista.
Procedimentos de interveno
Os atendimentos de reabilitao foram realizados
na AMR e compreenderam intervenes semanais de
fisioterapia e de terapia ocupacional. A frequncia de
atendimento e os objetivos de tratamento da criana
em cada especialidade so decididos semestralmente
em uma discusso entre os profissionais que atendem
565
a criana. O planejamento de interveno baseado

nos dados obtidos com a aplicao da COPM. No
momento da discusso, os profissionais, conhecendo
as demandas prioritrias dos pais, informadas pela
COPM, estabelecem os objetivos de interveno
para os prximos seis meses de reabilitao. Os
atendimentos realizados foram individuais, com
durao de 45 minutos cada. A Tabela 1 apresenta a
frequncia de atendimentos das crianas nos servios
de fisioterapia e de terapia ocupacional.
Anlise dos dados
Frequncia, porcentagem e mdia descreveram as
caractersticas das crianas com PC, incluindo idade,
sexo, diagnstico e nveis do GMFCS4,5. As cinco
principais atividades funcionais apontadas pelos pais
na aplicao da COPM foram categorizadas em grupos
de atividades: cuidados pessoais, mobilidade, brincar,
escola, socializao/comunicao, participao em
tarefas domsticas, independncia fora de casa. Alm
disso, testes qui-quadrado testaram associao entre
os objetivos funcionais estabelecidos pelo cuidador
na COPM e a gravidade do comprometimento motor,
bem como entre os objetivos funcionais e a faixa
etria. Para averiguar a associao entre frequncia
de atendimentos semanais e mudanas clinicamente
significativas, que no teste COPM correspondem a
2 pontos ou mais entre as medidas longitudinais15,
foram utilizados testes qui-quadrado.
A anlise das mudanas nos escores da COPM
durante o intervalo de seis meses foi precedida
de testes de normalidade. Como os dados no
apresentaram distribuio gaussiana, foi utilizado
o teste no paramtrico de Wilcoxon. Em todas
as anlises, foi considerado nvel de significncia
=0,05.
Resultados
A Tabela 2 apresenta as principais caractersticas
descritivas sobre sexo, idade, diagnstico clnico e
nvel de comprometimento motor grosso das crianas
do estudo.
Prioridades funcionais e gravidade da
funo motora grossa
Das 278 demandas reportadas, 134 (48,2%)
referiram-se s atividades de cuidados pessoais,
seguidas de atividades escolares (19,78%), brincar
(14,39%) e mobilidade (12,95%). As outras demandas
566
incluram atividades de socializao, tarefas

domsticas e independncia fora de casa (4,68%).
A Tabela 3 apresenta as prioridades funcionais
apontadas pelos cuidadores das crianas com PC
durante a aplicao da COPM nos diferentes nveis
de comprometimento motor grosso por reas de
ocupao. Observou-se que as demandas relacionadas
aos cuidados pessoais foram as de maior frequncia
em todos os nveis de comprometimento motor,
Tabela 1. Frequncia (%) de crianas atendidas semanalmente nos
servios de fisioterapia e de terapia ocupacional da Associao
Mineira de Reabilitao no perodo de julho a dezembro de 2011.
Nmero de
atendimentos
semanais*
Fisioterapia
Terapia
Ocupacional
37 (49,3%)
15 (20%)
38 (50,7%)
60 (80%)
*Durao de cada atendimento: 45 minutos.
Tabela 2. Descrio de crianas com paralisia cerebral com relao

ao sexo, idade, diagnstico e nveis de funo motora grossa,
segundo a Classificao da Funo Motora Grossa (GMFCS).
Categorias descritivas
Frequncia (%)
Sexo
Masculino
45 (60%)
Feminino
30 (40%)
Diagnstico Mdico
PC Quadriparesia espstica
36 (48%)
PC Diparesia espstica
14 (18,7%)
PC Discintico
11 (14,7%)
PC Hemiparesia espstica
8 (10,7%)
PC Mista
4 (5,35%)
PC Atxico
2 (2,6%)
Funo motora grossa (GMFCS)

I
6 (8%)
II
15 (20%)
III
6 (8%)
IV
39 (52%)
9 (12%)
Idade (anos)
Idade mdia (desvio padro)
Valores
7,35 (3,28)
Idade mxima
16
Idade mnima
Faixas etrias
3-6 anos
31 (41,33%)
7-10 anos
29 (38,67%)
11-16 anos
15 (20%)
exceo de crianas de GMFCS nvel V. Na anlise

da associao entre as prioridades identificadas por
nveis de comprometimento motor das crianas e as
reas ocupacionais, os pais de crianas classificadas
como GMFCS V relataram demandas relacionadas
ao brincar como de maior importncia (2=10,30;
p=0,036). No foram observadas associaes
significativas entre a gravidade da funo motora
grossa e as outras reas de ocupao.
anlise da associao entre as prioridades identificadas

por faixas etrias e as reas ocupacionais, crianas
de faixa etria mais jovem (3-6 anos) tiveram mais
frequentemente demandas relacionadas mobilidade
(2=7,35; p=0,025) e ao brincar (2=9,99; p=0,007)
em relao s outras faixas etrias. No foram
observadas associaes significativas entre as faixas
etrias e as outras reas de ocupao.
Prioridades funcionais e faixas etrias
Evoluo funcional das crianas ao longo de

seis meses
A Tabela 4 apresenta as prioridades funcionais

apontadas pelos cuidadores das crianas com PC
nas diferentes faixas etrias. As atividades de maior
frequncia de demanda dos pais em todas as faixas
etrias compreenderam as de cuidados pessoais. Na
No intervalo de seis meses entre os dois momentos

de coleta de dados, observou-se aumento significativo
nos escores da COPM, tanto no desempenho (p=0,0001)
quanto na satisfao (p=0,0001) (Figura 1). No se
observou associao entre frequncia de atendimentos
Tabela 3. Frequncia (%) de atividades (n=278) agrupadas em reas de ocupao, listadas como prioridade pelos cuidadores de crianas
com paralisia cerebral de diferentes nveis de funo motora grossa, segundo a Classificao da Funo Motora Grossa (GMFCS).
reas de ocupao
Cuidados
Pessoais
GMFCS I
GMFCS II
Alimentao
4 (18,18%)
5 (8,19%)
2 (9,52%)
19 (12,94%)
3 (11,11%)
Vestir
4 (18,18%)
17 (27,87%)
3 (14,29%)
26 (17,69%)
2 (9,09%)
4 (6,56%)
2 (9,52%)
13 (8,85%)
3 (13,63%)
3 (4,92%)
1 (4,76%)
9 (6,12%)
3 (11,11%)
2 (3,28%)
1 (3,70%)
72 (49%)
7 (25,92%)
2 (3,28%)
7 (4,76%)
7 (25,93%)
3 (13,63%)
3 (4,92%)
2 (9,52%)
11 (7,48%)
1 (3,70%)
Total de demandas
3 (13,63%)
5 (8,2%)
2 (9,52%)
18 (12,24%)
8 (29,63%)
3 (4,92%)
1 (4,76%)
5 (3,40%)
Uso do lpis
Conceitos pedaggicos
2 (9,09%)
7 (11,47%)
4 (19,06%)
18 (12,24%)
1 (3,70%)
Uso de outro material escolar
1 (4,55%)
5 (8,19%)
1 (4,76%)
3 (2,04%)
1 (1,64%)
3 (2,04%)
3 (13,64%)
16 (26,22%)
6 (28,58%)
29 (19,72%)
1 (3,70%)
Estruturao do brincar
6 (4,08%)
2 (7,41%)
Interao no brincar
3 (2,04%)
1 (3,70%)
Uso das mos no brincar
3 (4,92%)
7 (4,76%)
5 (18,53%)
Ateno no brincar
Brincadeiras especficas
Posicionamento no brincar
1 (0,68%)
1 (3,70%)
1 (4,55%)
2 (3,28%)
2 (9,52%)
4 (2,72%)
1 (1,64%)
1 (0,68%)
Total de demandas
1 (4,55%)
6 (9,84%)
2 (9,52%)
22 (14,96%)
9 (33,34%)
Socializao/ comunicao
1 (4,55%)
5 (3,40%)
2 (7,41%)
Tarefas domsticas Tarefas domsticas

Independncia
fora de casa
5 (3,40%)
Locomoo
Total de demandas
Socializao
3 (14,29%)
13 (59,08%) 31 (50,82%) 11 (52,38%)
Transferncia
Ateno/concentrao
Brincar
GMFCS V
Banho
Total de demandas
Escola
GMFCS III GMFCS IV
Higiene
Controle de esfncter
Mobilidade
Nvel GMFCS
Independncia fora de casa
1 (4,55%)
1 (1,64%)
1 (0,68%)
2 (3,28%)
% foram calculadas considerando o total de demandas funcionais por nvel de funo motora grossa (GMFCS).
567
Tabela 4. Frequncia das demandas (n=278) nas reas de ocupao de acordo com faixas etrias de crianas com paralisia cerebral.
reas de Ocupao
Faixas etrias
3-6 anos
7-10 anos
11-16 anos
Cuidados pessoais
46 (42,99%)
55 (50,92%)
33 (52,38%)
Mobilidade/transferncia*
21 (19,63%)
6 (5,56%)
9 (14,27%)
Brincar**
22 (20,56%)
15 (13,89%)
3 (4,77%)
Escola
16 (14,95%)
25 (23,16%)
14 (22,22%)
2 (1,87%)
5 (4,63%)
1 (1,59%)
Tarefas domsticas
1 (0,92%)
2 (3,18%)
Independncia fora de casa
1 (0,92%)
1 (1,59%)
108
63
Socializao/comunicao
Total de demandas
107
*Associao significativa entre faixa etria e mobilidade/transferncia ( =7,35; p=0,025); **Associao significativa entre faixa etria e
brincar (2=9,99; p=0,007).
2
Figura 1. Mudanas nos escores de desempenho (p=0,001) e

de satisfao (p=0,0001) dos pais com relao s prioridades
funcionais (teste COPM) no intervalo de seis meses (momento
2- momento 1).
(duas ou uma vez por semana) e magnitude de

ganho clinicamente significativo nas escalas de
desempenho (pFisioterapia=0,197;pTerapia Ocupacional=0,149)
ou de satisfao da COPM (pFisioterapia=0,514; pTerapia
=0,221).
Ocupacional
Discusso
O presente estudo apresenta as principais demandas
funcionais apontadas por cuidadores de crianas com
PC nas diferentes reas de ocupao e as mudanas
funcionais no intervalo de seis meses. As atividades
de cuidados pessoais foram as mais relevantes para
os pais e cuidadores, seguidas de atividades escolares
e do brincar. Demandas relacionadas ao brincar
ocorreram principalmente em crianas com maior
comprometimento motor (GMFCS nvel V) e de faixa
568
etria mais jovem (3-6 anos). Verificou-se tambm

aumento de escores de desempenho e de satisfao
em atividades funcionais consideradas relevantes
pelos cuidadores no intervalo de seis meses.
No que diz respeito s demandas funcionais
da COPM, as prioridades apontadas pelos pais
das crianas compreenderam, principalmente,
atividades de cuidados pessoais, como vestir,
alimentao, banho, higiene e controle esfincteriano.
Tais resultados so corroborados pelos dados do
estudo realizado por Chiarello et al.2, que tambm
apontaram as atividades de cuidados pessoais como
relevantes por todos os pais das crianas do estudo2.
O foco nas atividades de cuidados pessoais reflete
uma expectativa dos pais de almejarem maior
independncia, autonomia e eficincia na realizao
dessas atividades2. Segundo Barrett e Kielhofner17,
a realizao de atividades de cuidados pessoais
assegura a satisfao de necessidades bsicas e a
independncia no ambiente domiciliar17. Alm disso,
o desempenho da criana nessas atividades permite
a vivncia de experincias de independncia e
desdobramento de competncias para a participao
em outras reas de desempenho, como educao,
lazer e trabalho2.
As atividades de mobilidade funcional no
constituram a demanda principal dos pais de
crianas do presente estudo. Embora a mobilidade
esteja relacionada s alteraes de funes e
estruturas neuromusculoesquelticas acometidas em
crianas com PC, esse no foi o desfecho apontado
pelos cuidadores como prioritrio. Tais resultados
so contrrios aos apresentados por Knox18, que
realizou um estudo retrospectivo por meio da
reviso de pronturios de 121 crianas com PC para
determinar os interesses de desempenho funcional

dos pais, os quais foram relatados aos profissionais.
Nesse estudo, as demandas principais identificadas
por pais de crianas com PC de nvel GMFCS
I focaram-se em ficar de p, andar e na funo
manual, enquanto, nos nveis II a IV, as demandas
principais estavam relacionadas s atividades como
ficar de p e andar18. Pais de crianas classificadas
no GMFCS nvel V apontaram como prioritrias as
habilidades de mobilidade (sentar, mobilidade no
cho) e de comunicao18. As diferenas entre os
resultados do presente estudo e do estudo de Knox18
podem ser atribudas s diferentes caractersticas
da instrumentao utilizada e da idade associada
gravidade da funo motora dos participantes. O
presente estudo utilizou a COPM para discutir as
demandas funcionais da rotina diria da criana
consideradas relevantes pelos pais, enquanto,
no estudo de Knox18, a autora utilizou dados do
pronturio mdico para identificar as prioridades
dos pais. Alm disso, a maioria dos participantes
do estudo de Knox18 compreendeu crianas nos
nveis de gravidade motora GMFCS IV e V (57%),
com idades inferiores a 6 anos (68%), enquanto, no
presente estudo, a maioria das crianas apresentou
nvel de gravidade GMFCS IV e idade superior a 7
anos (58,67%). No presente estudo, as demandas de
mobilidade na faixa etria entre 3 e 6 anos de idade
foram mais frequentes do que nas faixas etrias mais
velhas. De acordo com Rosenbaum et al.19, crianas
com maior gravidade motora tendem a estabilizar
suas aquisies em funes motoras grossas at os
5 anos de idade. Sendo assim, possvel que os pais
das crianas do presente estudo, principalmente as
de idade superior a 7 anos, observando a estabilidade
da funo motora grossa dessas crianas, tenham
valorizado a conquista de demandas de cuidados
pessoais, brincar e escola, privilegiando a maior
participao dessas crianas nesses domnios
funcionais.
Demandas relacionadas ao brincar foram
identificadas como mais relevantes pelos cuidadores
de crianas mais jovens e com comprometimento
motor grave. Considerando a importncia do
brincar como atividade primria da infncia20, tal
desfecho ilustra importante objetivo funcional
para interveno teraputica21. Durante o brincar, a
criana tem oportunidade de descobrir relaes entre
objetos, pessoas e aes, de explorar o ambiente
e de desenvolver papis sociais e ocupacionais20.
Pfeifer et al.22, ao avaliar as habilidades do brincar
espontneo de crianas com PC entre 3 e 6 anos

de idade, descreveram caractersticas do brincar
espontneo, como iniciar uma brincadeira por conta
prpria, explorar um brinquedo, elaborar e sequenciar
uma brincadeira, brincar de faz de conta. Nesse
estudo, crianas com maior comprometimento motor
apresentaram dificuldades importantes para elaborar
aes ldicas mais sofisticadas, apresentando
repertrio limitado de brincar simblico22. Assim,
as restries em mobilidade podem dificultar a
participao em algumas atividades do brincar, por
exemplo, nas que requerem habilidades motoras ou
funes cognitivas mais complexas sem, entretanto,
restringir completamente o envolvimento ldico
dessas crianas. Torna-se importante identificar
formas alternativas e adaptaes que possam
promover o engajamento de crianas com PC de
diversos nveis de gravidade da funo motora em
experincias e interaes ldicas com pais e outras
crianas23.
No presente estudo, houve melhora no desempenho
da criana e na satisfao dos pais em relao aos
objetivos funcionais no intervalo de seis meses.
Tal resultado ilustra a importncia de se utilizar
instrumentao padronizada que documente os
ganhos funcionais definidos como prioritrios para
as famlias de crianas com PC e que possa tambm
servir de facilitador na relao de colaborao
famlia-terapeuta. A participao dos pais no
processo de tomada de deciso acerca dos objetivos
teraputicos a serem alcanados considerada um
elemento importante no processo de reabilitao1,9-13.
ien et al.13 estudaram as percepes dos pais e
dos profissionais sobre a definio de objetivos em
reabilitao de crianas com PC e ressaltaram que o
estabelecimento de prioridades pela famlia contribui
para a competncia dos pais em se posicionarem e
comunicarem as necessidades e preferncias dos
filhos e da famlia. Essa ao de cooperao com os
pais no desenvolvimento de estratgias teraputicas
potencializa a prtica desses objetivos no contexto
familiar13. Anderson e Hinojosa24 afirmam que a
interveno com a criana pode ser otimizada por
meio do desenvolvimento de uma relao positiva
entre terapeutas e familiares. Nessa relao de
parceria, os profissionais devem reconhecer o papel
dos pais no processo teraputico, compreender as
caractersticas da relao pais-filho e ampliar suas
aes, pautando as teraputicas numa colaborao
efetiva com os pais para o benefcio do processo
de reabilitao da criana24. Ao entrevistarem os
569
cuidadores para identificao de objetivos funcionais

relevantes para a famlia, os profissionais podem
tornar a terapia mais eficaz e mais significativa para
a criana e para a famlia25.
Limitaes do estudo
O presente estudo evidenciou melhoria na
percepo dos pais de crianas com PC frente aos
objetivos funcionais considerados prioritrios no
intervalo de seis meses. Entretanto, por se tratar de
um estudo retrospectivo, no foi possvel controlar a
intensidade de trabalho de cada demanda funcional
apontada como relevante pelos pais. Sendo assim,
no possvel afirmar que as mudanas apresentadas
decorreram exclusivamente de aes da reabilitao.
Futuros estudos prospectivos e controlados podero
elucidar sobre os efeitos de intervenes focadas em
demandas especficas apontadas por cuidadores de
crianas com PC.

ptj.20090388. PMid:20576716
3.
Mancini MC, Alves ACM, Schaper C, Figueredo EM,

Sampaio RF, Coelho ZA, et al. Gravidade da paralisia
cerebral e desempenho funcional. Rev Bras Fisioter.
2004;8(3):253-60.
4.
Chagas PSC , Defilipo EC , Lemos RA , Mancini MC ,

Frnio JS, Carvalho RM. Classificao da funo motora
e do desempenho funcional de crianas com paralisia

cerebral. Rev Bras Fisioter. 2008;12(5):409-16. http://dx.doi.
org/10.1590/S1413-35552008000500011.
5.
classify gross motor function in children with cerebral

palsy. Dev Med Child Neurol . 1997 ; 39 ( 4 ): 214 - 23 .
http://dx.doi.org/10.1111/j.1469-8749.1997.tb07414.x .
PMid:9183258
6.
Implicaes clnicas
Agradecimentos
Agradecemos a contribuio das crianas e
participantes do estudo, bem como dos terapeutas
da Associao Mineira de Reabilitao (AMR), Belo
Horizonte, MG, Brasil.
Referncias
1.
Law M, Darrah J, Pollock N, Rosenbaum P, Russell D, Walter

SD, et al. Focus on Function - a randomized controlled
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children with cerebral palsy. BMC Pediatr. 2007;7(1):31.
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Correspondence
Marina Brito Brando
Rua Professor Otvio Coelho de Magalhes, 111, Mangabeiras
e-mail: marinabrandao@amr.org.br
571
original article
Ground reaction forces during level ground walking

with body weight unloading
Ana M. F. Barela1,2, Paulo B. de Freitas1,2,
Melissa L. Celestino1, Marcela R. Camargo1, Jos A. Barela1,2,3
ABSTRACT | Background: Partial body weight support (BWS) systems have been broadly used with treadmills as a
strategy for gait training of individuals with gait impairments. Considering that we usually walk on level ground and
that BWS is achieved by altering the load on the plantar surface of the foot, it would be important to investigate some
ground reaction force (GRF) parameters in healthy individuals walking on level ground with BWS to better implement
rehabilitation protocols for individuals with gait impairments. Objective: To describe the effects of body weight
unloading on GRF parameters as healthy young adults walked with BWS on level ground. Method: Eighteen healthy
young adults (274 years old) walked on a walkway, with two force plates embedded in the middle of it, wearing a
harness connected to a BWS system, with 0%, 15%, and 30% BWS. Vertical and horizontal peaks and vertical valley of
GRF, weight acceptance and push-off rates, and impulse were calculated and compared across the three experimental
conditions. Results: Overall, participants walked more slowly with the BWS system on level ground compared to their
normal walking speed. As body weight unloading increased, the magnitude of the GRF forces decreased. Conversely,
weight acceptance rate was similar among conditions. Conclusions: Different amounts of body weight unloading promote
different outputs of GRF parameters, even with the same mean walk speed. The only parameter that was similar among
the three experimental conditions was the weight acceptance rate.
Keywords: gait; rehabilitation; partial body weight support; kinetics.
Barela AMF, de Freitas PB, Celestino ML, Camargo MR, Barela JA. Ground reaction forces during level ground walking with
body weight unloading. Braz J Phys Ther. 2014 Nov-Dec; 18(6):572-579. http://dx.doi.org/10.1590/bjpt-rbf.2014.0058
Introduction
Walking is the main way human beings transport
their bodies from place to place and it provides
functional autonomy. Therefore, acquiring or
reestablishing a gait pattern is the main goal for
individuals with gait impairments. Among different
strategies for walking acquisition or reestablishment,
partial body weight support (BWS) systems have
been broadly used as a strategy for therapeutic gait
training1-6. Most BWS systems consist of a mounting
frame and a harness to support a percentage of the
individuals weight as they walk on a motorized
treadmill. Only a few studies have investigated the
use of this system on level ground walking5,7-13.
The rationale for using the BWS is that alleviation
of body weight might facilitate the walking
requirements for individuals with gait impairment
and, consequently, promotes a gait pattern close to
normal14. The treadmill is commonly used because
it stimulates rhythmic and repetitive steps15 and
promotes inter-limb symmetry, both contributing to

the improvement of walking temporal characteristics16
and diminishing the need for propulsive force
generation at the end of stance period17. However,
it has been speculated that the conditions for gait
intervention should be as close as possible to daily
life activities in order to promote and maximize skills
transfer18,19. In this way, one could suggest that the
use of the BWS system on ground surface during
gait intervention would be more appropriate because
it is the condition people encounter on a daily basis.
Usually, the percentage of BWS on the treadmill
ranges from 10% to 70% BWS 1,4,14. However,
Threlkeld et al.20 observed that, in hip, knee, and
ankle joint angles, temporospatial gait characteristics
of young healthy adults had minimum variation with
10% and 30% BWS and significantly changed with
50% and 70% BWS on a treadmill. Among all these
different percentage levels, alleviation of 30% BWS
Laboratrio de Anlise do Movimento, Instituto de Cincias da Atividade Fsica e Esporte, Universidade Cruzeiro do Sul, So Paulo, SP, Brazil
Programa de Ps-graduao em Cincias do Movimento Humano, Instituto de Cincias da Atividade Fsica e Esporte, Universidade Cruzeiro do Sul,
So Paulo, SP, Brazil
3
Departamento de Educao Fsica, Universidade Estadual Paulista, Rio Claro, SP, Brazil
1
2
572
Body weight support and ground reaction force
is the most used for individuals with hemiparesis as it

yields better results8,15. Although, 30% BWS during
level ground walking may hinder the production of
force to move the body forward7, to our knowledge,
no one has systematically investigated the results of
ground reaction force (GRF) parameters during level
ground walking with different percentages of body
weight unloading.
Patio et al.11 investigated gait characteristics
of healthy young adults walking with and without
a harness with 0%, 10%, 20%, and 30% BWS on
level ground, including the description of the first
peak (i.e. weight acceptance), second peak (i.e.
push-off), and valley of vertical GRF and the anteriorposterior deceleration and acceleration peaks from
one leg. Overall, they found that vertical GRF curves
were preserved only when the participants walked
without a harness or with harness with 0% BWS,
contrary to anterior-posterior GRF curves, which
were preserved throughout different experimental
conditions. When the participants walked with BWS,
they diminished the contact and propulsive forces11.
Since Patio et al.11 did not control walking velocity
throughout the different experimental conditions, it is
not possible to conclude how much body unloading
could influence these differences, since walking
velocity affects GRF components21,22.
The use of force plates could provide important
information concerning accurate and sensitive
performance variables that could reveal the effects of
walking with BWS on level ground, mainly because
BWS is achieved by altering the load on the plantar
surface of the foot23, and different measurements
can be calculated from the GRF components, which
reflect differences in kinematic measurements24.
Consequently, it would be appropriate to describe the
effects of body weight unloading during level ground
walking in terms of GRF parameters on healthy
adults to better implement rehabilitation protocols for
individuals with gait impairment with BWS systems.
Based on that, in addition to the first and second peaks
and valley of vertical GRF and anterior-posterior
deceleration and acceleration peaks described
previously11, it is important to describe additional
GRF measurements, such as weight acceptance and
push-off rates, impulse, in different conditions and/
or populations21,25-28, keeping walking speed constant.
The purpose of this study was to describe the
effects of body weight unloading on vertical and
anterior-posterior GRF parameters in healthy young
adults during level ground walking with BWS in
order to provide reference values for comparison

when planning gait rehabilitation protocols using
BWS. It is important to note that the knowledge of
the effects of body weight unloading on some kinetic
variables would be valuable for those who employ
BWS systems as a strategy for gait intervention.
Method
Sample
Eighteen healthy young adults (9 males and
9 females) with no apparent gait impairment
participated in this study. Their mean ( standard
deviation, SD) age, height, and mass were 274
years old, 1.660.1 m, and 6614 kg, respectively.
This study was conducted in accordance with the
Declaration of Helsinki, and it was approved by the
Universidade Cruzeiro do Sul Ethics Committee,
So Paulo, SP (protocol: CE/UCS-128/2012). All
procedures were performed with the adequate
understanding and written consent of all participants.
None of the participants had previous experience with
the BWS apparatus used in the study and all of them
wore their own flat shoes during their participation
in the study.
Instrumentations, task and procedures
The customized BWS system (Finix Tecnologia)
used in the present study is shown in Figure 1. It
consists of a suspended rail 7 meters long installed
3 meters from the floor and sustained by steel beams,
a moving cart, and two electrical servo motors.
The moving cart is attached on the bottom of the
rail and is moved backward and forward by a belt
system linked to a servo motor located at one of
the extremities of the suspended rail and controlled
by a customized computational routine written in
LabView 2011 (National Instruments Inc.), which
controls the displacement, velocity, and acceleration
of the moving cart. This moving cart has a second
servo motor within it, which has a belt and a harness at
its other end. Individuals are mechanically supported
by the harness, which is pulled up by a belt from
the second servo motor. A load cell, positioned
between the top of the harness and bottom of the belt,
connected to a digital display, provides information
about the amount of body weight unloaded. In order
to unload the desired amount of body weight, each
individual stayed still as one of the experimenters
activated the motor to decrease or increase the belts
length.
573
Barela AMF, de Freitas PB, Celestino ML, Camargo MR, Barela JA
for 15 m approximately as one of the experimenters

recorded the time they took to walk the central 10 m,
which was used to obtain the mean walking speed.
Next, each participant wore the harness and had
enough time to become familiar with the task, which
consisted of walking with 0%, 15%, and 30% BWS
at the speed he/she considered most comfortable.
The most comfortable speed was recorded by one of
the experimenters and it was controlled by the servo
motor during the experimental session.
Prior to the walking performance with the BWS
system, each participant stood still on each force plate
and their body weight was recorded for calibration
purposes. The order of the BWS unloading was
randomized, and data from at least three trials for each
condition were acquired for further analysis. Trials
were considered valid if only one foot had made full
contact on each force plate during each step. A digital
video camera was used to register which foot landed
on each force plate.
Data analyses
Figure 1. Partial view of the body weight support system employed

in the present study and the walkway with built-in force plates.
Note: during the experimental session, a thin rubber carpet covered
the entire walkway.
Two force plates (Kistler) were embedded into and

at the middle of a 7 m long walkway and used for
acquisition of ground reaction forces of the left and
right lower extremities during the stance periods of
a walking cycle. The force plates were connected via
charge amplifiers to a laptop and data were acquired
via Bioware software (Kistler) at a sampling rate of
240 Hz.
Before the experimental session, participants
were asked to walk freely at a comfortable speed
574
Data analyses from both force plates were

performed using specific routines written in Matlab
(MathWorks, Inc.). These data were digitally filtered
using a 4th order, zero-lag Butterworth low-pass filter
at 20 Hz and were normalized by the participants
body weight and in time from 0% to 100% of the
stance duration. From the vertical GRF component
the following variables were calculated: magnitudes
of first peak (weight acceptance), second peak (pushoff), and valley (mid-stance); weight acceptance
rate (calculated as the magnitude of the first peak
divided by the time between initial contact and first
peak force); and push-off rate (calculated as the
magnitude of the second peak divided by the time
elapsed between second peak force and toe-off)29. As
the peaks are considered the maximum value of the
curve before and after the valley, when the vertical
component tended to be flat, a visual inspection
was made to confirm a correct selection, i.e. the
maximum peak during weight acceptance and pushoff periods. From the anterior-posterior component,
the following variables were calculated: magnitudes
of first (deceleration) and second (acceleration) peaks
and negative (braking) and positive (propulsive)
impulses, calculated as the area under the negative
and positive anterior-posterior force component,
respectively. Also the mean walking speed that
participants walked without the BWS system was
compared to the mean walking speed they selected
to walk with the BWS system.
Statistical analyses
Data of three repetitions under each experimental
condition were averaged for each participant.
Statistical analyses involved repeated measures
univariate analyses of variance (ANOVA) and
multivariate analyses of variance (MANOVA).
Except for the first ANOVA that compared the mean
walking speed of participants with and without the
BWS system, the remaining analyses had as factors
leg (right and left) and BWS conditions (0%, 15%, and
30% of BWS). The dependent variables were: weight
acceptance, push-off force, and mid-stance vertical
GRF valley for the first MANOVA; weight acceptance
and push-off rates for the second MANOVA; anteriorposterior deceleration and acceleration peaks for
the third MANOVA; and negative and positive
impulses for the fourth MANOVA. Post-hoc tests
with Bonferroni adjustments were employed to the
pairwise comparisons when necessary. An alpha level
of 0.05 was used for all statistical tests, which were
performed using the Statistical Package for the Social

Science software.
Results
All participants walked more slower with the BWS
system (1.160.12 m/s) compared to their regular
walking speed (1.440.17 m/s). Figure 2 depicts
time series profiles of vertical and anterior-posterior
GRF curves during stance period averaged across
participants, walking at the three percentages of
BWS, and for the right and left leg. A typical vertical
GRF pattern of well-defined peaks and valley can be
observed when participants walked with 0% BWS.
As the percentage of BWS increased, flatter curves
emerged, with almost no distinction between the two
peaks and valley when they walked with 30% BWS.
The typical anterior-posterior GRF pattern, consisting
of negative phase followed by positive phase, was
observed under the three experimental conditions.
Figure 2. Mean (SD) time series of vertical and anterior-posterior ground reaction forces (GRF) during stance period for both legs
with 0%, 15%, and 30% of body weight support.
575
Table 1 contains the mean (SD) values of the

investigated variables. Peaks and valley from vertical
component and deceleration and acceleration peaks
from anterior-posterior component decreased as the
percentage of BWS increased (P<0.001). The only
variable that revealed difference between right and
left legs was the deceleration peak, in which the left
leg presented a higher magnitude than the right leg
(P<0.005). While no difference was found for weight
acceptance rate among the different percentages of
BWS (P>0.5), the push-off rate decreased as the
percentage of BWS increased (P<0.001).
Figure 3 presents negative and positive impulses for
all participants walking under the three percentages of
BWS and for the right and left leg. Negative impulse
decreased as the percentage of BWS increased
(P<0.001). Participants generated higher positive
impulse when they walked with 0% BWS compared
to both 15% (P<0.001) and 30% BWS (P<0.001)
and did not present differences between 15% and
30% BWS (P>0.05).
unloading, although the patterns of vertical and

anterior-posterior GRF components were mostly
preserved, except for the vertical curve of GRF in
the 30% BWS condition that emerged as the flattest
curve compared to the 0% and 15% BWS conditions.
The vertical and the anterior-posterior curves
in this study are in accordance with a previous
investigation, although Patio et al.11 found a flatter
curve of the vertical GRF compared to the present
study, which might be attributed to a different BWS
system and possibly walking speed. In contrast,
Discussion
The purpose of this study was to describe the
effects of body weight unloading on vertical and
anterior-posterior GRF parameters in healthy young
adults during level ground walking with BWS.
Overall, the results showed that healthy young
adults presented gait alterations due to body weight
Figure 3. Mean values (SD) of negative and positive impulses

from both legs of all participants walking with 0%, 15%, and 30%
of body weight support. * indicates p<0.001.
Table 1. Mean values (SD) of first and second peaks and valley of vertical GRF, weight acceptance and push-off rates, and deceleration
and acceleration peaks during the stance period of walking with 0%, 15%, and 30% of body weight support (BWS) for right and left legs.
Variables
Leg
0% BWS
15% BWS
30% BWS
1st peak (% BW)
Right
Left
104 (4.65)a,b
104 (5.98)
86 (6.77)a,c
87 (8.06)
73 (7.01)b,c
75 (7.71)
2nd peak (% BW)
Right
Left
93 (4.33)a,b
95 (5.08)
76 (4.69)a,c
76 (5.61)
66 (4.88)b,c
67 (5.67)
Valley (% BW)
Right
Left
76 (5.87)a,b
75 (6.31)
67 (3.78)a,c
67 (5.57)
60 (4.82)b,c
60 (5.13)
Weight acceptance rate (BW/s)
Right
Left
5.78 (1.27)
6.07 (1.57)
5.72 (1.90)
6.05 (1.99)
5.82 (2.05)
5.81 (1.91)
Push-off rate (BW/s)
Right
Left
4.66 (0.70)a,b
4.86 (0.87)
3.20 (0.89)a,c
2.89 (0.78)
2.33 (0.52)b,c
2.31 (0.53)
Deceleration peak (% BW)*
Right
Left
12.3 (3.33)a,b
12.9 (3.01)
8.2 (3.08)a,c
9.1 (3.91)
5.5 (2.14)b,c
6.8 (2.59)
Acceleration peak (% BW)
Right
Left
12.7 (1.43)a,b
13.2 (2.07)
8.9 (1.56)a,c
9.3 (1.72)
7.3 (1.44)b,c
7.1 (1.09)
Vertical component
Anterior-posterior component
Same letter indicates difference between conditions; *indicates difference between legs.
576
the mean walking speed remained constant in all

experimental conditions for each participant in
this study. The increase in body weight unloading
explains the flatter shape of the vertical GRF in the
15% and 30% BWS compared to 0% BWS. On the
other hand, the shape of the anterior-posterior GRF
was maintained among conditions. These results are
attributed to the situation to which the participants
were exposed, i.e. mechanically supported in the
vertical direction, which reduces the gravitational
forces acting on both legs and consequently reducing
the load that has to be overcome by the performer. In
shallow water, for example, walking at a comfortable
and self-selected speed, the reduction in speed
and apparent body weight influences the shape of
both vertical and anterior-posterior GRF curves30.
However, as one walks in shallow water, he/she
should deal with the buoyant force that decreases
the apparent body weight, and the drag force that
increases the resistance to move30, differently from
the condition with BWS.
It is known that walking velocity affects the
magnitude of GRF peaks21,22. In this way, the gradual
reduction in the magnitude of the first and second
peaks and the valley as the body weight unloading
increased may be attributed specifically to body
weight unloading, since the walking velocity was kept
constant by the use of the automated BWS system
for the three experimental conditions.
As expected, the magnitude of weight acceptance
as well as push-off peaks decreased at approximately
the same rate as body unloading (0%, 15%, 30%
BWS). In terms of gait rehabilitation, the reduction
in weight acceptance may be beneficial because it
diminishes the need for generating muscle force that
acts on shock absorption and controls limb velocity
and body loading at the beginning of the stance period
and stabilizes body forward progression. Therefore,
individuals who present impaired muscular function
due to any neurological or orthopedic disorder could
benefit from using this type of system, although this
possibility needs further investigation.
Conversely, the reduction in push-off peak seems
to be a drawback of the system given that there is
lower muscle force demand for pushing the body
upward and forward because the BWS system does
it by itself. However, it is important to consider
that the propulsive force to move the limb forward
during the swing phase must be compensated by
the hip muscles31. If push-off is usually limited in
individuals with gait impairment, the reduction in
push-off peak due to BWS may contribute, in the

long term, to increased range of motion of hip joints
after a period of gait intervention. This aspect was
observed previously in individuals with stroke who
trained with BWS on level ground5.
Even though the magnitude of weight acceptance
and push-off forces decreased as the percentage of
body unloading increased, the weight acceptance
rate was similar for the three percentages of body
unloading and the push-off rate decreased. We could
expect that as weight acceptance decreased, weight
acceptance rate would decrease as well. However,
the magnitude of first peak and the time to reach it
decreased as the body unloading increased (Figure 2)
due to the action of the BWS system, which was
kept at a constant mean velocity. If one takes into
account that weight acceptance rate depends on
both magnitude of the first peak of the GRF vertical
component and time to reach this peak, the weight
acceptance rate was similar throughout the three
experimental conditions because the rate of first
peak magnitude and time to reach this peak was
maintained. Similarly, the second peak and the time
to reach it decreased as the body weight unloading
increased (Figure 2), however, since the rate of the
second peak is calculated by dividing the magnitude
of second peak by the time elapsed between second
peak force and toe-off29, the push-off rate decreased
as the body unloading increased. Weight acceptance
and push-off rates are time dependent28, and even
though body weight unloading influences the peaks
of weight acceptance and push-off from vertical GRF
component, only the time of occurrence of the pushoff peak was influenced by the manipulation of body
weight unloading.
Regarding the anterior-posterior GRF component,
the results revealed that the deceleration and
acceleration peaks and the braking and propulsive
impulses reduced as the BWS increased. Both the
deceleration peak and the braking impulse reduced
proportionally more than the body unloading. In the
15% BWS condition, deceleration peak and braking
impulse were 69% and 59% (data from right and
left leg pulled), respectively, in relation to the 0%
BWS condition. In the 30% BWS condition, the
deceleration peak and braking impulse were 50%
and 36%, respectively, in relation to the 0% BWS
condition. The reduction in the deceleration peak
and braking impulse could be partially explained
by a reduction in both weight acceptance and mean
vertical force at the first half of the stance period (data
577
not shown), as the anterior-posterior GRF component

(i.e. tangential to the interaction of foot and force
plate surface) is directly influenced by the vertical
GRF component (i.e. normal to the interaction of foot
and force plate surface). There was also a reduction
in acceleration peak and propulsive impulse as BWS
increased: in the 15% BWs condition, the acceleration
peak and propulsive impulse were 69% and 74%,
respectively, in relation to the 0% BWS condition;
and in the 30% BWS condition, the acceleration
peak and propulsive impulse were 58% and 61%,
respectively, in relation to the 0% BWS condition.
These results could also be partly explained by the
reduction in the magnitude of the vertical GRF
component. Despite reducing the acceleration peak
and propulsive impulse more than the percentage of
body unloading, this reduction was lower than the
reduction in the braking impulse.
This study was focused only on GRF data and
certainly a more detailed description of level ground
walking with BWS including additional analyses
(e.g. kinematic and electromyography) should be
done. For example, the reduction in the magnitude
of the GRF parameters could also be due to different
movement strategies (e.g. higher hip flexion) adopted
during walking with a BWS system. Unfortunately,
our data do not allow us to confirm that. Therefore,
in order to understand the effect of body unloading
on movement generation, both kinematic and kinetic
analyses should be performed simultaneously, and
these analyses should be employed in individuals
with gait impairment.
Few studies have assessed individuals with gait
impairment as they walked with BWS7,8,13, and to
our knowledge, none of them investigated GRF
parameters. We did not aim in this study to identify
the best conditions for the gait training of individuals
with gait impairment. In fact, we aimed to assess the
consequences of manipulating body unloading in
healthy young adults to provide a normal reference
for comparison when preparing gait rehabilitation
protocols using BWS. One of the next steps for
our group is to investigate vertical GRF parameters
during treadmill walking with BWS.
in terms of GRF parameters, even though the walking

speed was maintained among different conditions.
The only GRF parameter that was similar among the
0%, 15%, and 30% BWS conditions was the weight
acceptance rate. Although it has been established that
the BWS system on level ground provides a safe and
effective strategy for intervention of patients with
stroke5, no one to date has investigated the effects of
BWS during gait intervention on the GRF parameters
of individuals with gait impairment.
Acknowledgements
The Fundao de Amparo Pesquisa do Estado de
So Paulo (FAPESP) for the research funding (grants
#2010/15218-3; 2009/15003-0) and fellowship (grant
#2012/14634-9) and CAPES for the scholarship. We
are also grateful to the participants for the time and
effort spent in our laboratory during data acquisition.
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Correspondence
Ana Maria Forti Barela
Rua Galvo Bueno, 868, 13o andar, Bloco B
CEP 01506-000, So Paulo, SP, Brazil
e-mail: ana.barela@cruzeirodosul.edu.br
579
editorial
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Braz J Phys Ther. 2014 Nov-Dec; 18(6)
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THE REVIEW PROCESS

The submissions that meet the standards established and
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Therefore, the manuscript may be rejected based solely
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on the recommendation of the area editor without the

need for further review, in which case, the decision is not
subject to appeal. The manuscripts selected for pre-analysis
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the reviewers. The editors will coordinate the exchange
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the recommendations of the reviewers and area editors.
If accepted for publication, the articles may be subject to
minor changes that will not affect the authors style. If an
article is rejected, the authors will receive a justification
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review process, all documentation regarding the review
process will be destroyed.
AREAS OF EXPERTISE
1. Physiology, Kinesiology, and Biomechanics;
2. Kinesiotherapy/therapeutic resources; 3. Motor
development, acquisition, control, and behavior; 4.
Education, Ethics, Deontology, and Physical Therapy
History; 5. Assessment, prevention, and treatment of
cardiovascular and respiratory disorders; 6. Assessment,
prevention, and treatment of aging disorders; 7. Assessment,
prevention, and treatment of musculoskeletal disorders; 8.
Assessment, prevention, and treatment of neurological
disorders; 9. Assessment, prevention, and treatment of
gynecological disorders; 10. Ergonomics/Occupational
Health.
PROGRAMA DE PS-GRADUAO EM CINCIAS

DA REABILITAO MESTRADO E DOUTORADO
Recomendado pela CAPES Conceito 5
O Programa de Ps-graduao em Cincias da Reabilitao tem como base a perspectiva
apresentada no modelo proposto pela Organizao Mundial de Sade e prope que as
dissertaes e trabalhos cientficos desenvolvidos estejam relacionados com o desempenho
funcional humano. Com a utilizao de um modelo internacional, espera-se estimular o
desenvolvimento de pesquisas que possam contribuir para uma melhor compreenso do
processo de funo e disfuno humana, contribuir para a organizao da informao e estimular
a produo cientfica numa estrutura conceitual mundialmente reconhecida. O Programa de
Ps-graduao em Cincias da Reabilitao tem como objetivo tanto formar como aprofundar o
conhecimento profissional e acadmico, possibilitando aoaluno desenvolver habilidades para
a conduo de pesquisas na rea de desempenhofuncional humano.
O programa conta com parcerias nacionais e internacionais sedimentadas, e os seus laboratrios
de pesquisa contam com equipamentos de ponta para o desenvolvimento de estudos na rea
de Cincias da Reabilitao.
Mais informaes
Fone/Fax: (31) 3409-4781
www.eef.ufmg.br/mreab
Universidade Federal de So Carlos

Programa de Ps-Graduao em Fisioterapia
O Programa de Ps-Graduao em Fisioterapia tem como rea de
concentrao: "Processos
de
Avaliao
Interveno
em
Fisioterapia". Nosso objetivo oferecer condies acadmicas

necessrias para que o aluno adquira um repertrio terico e
metodolgico, tornando-se apto a exercer as atividades de docente
de nvel universitrio e inici-lo na carreira de pesquisador.
Os cursos de mestrado e doutorado (stricto sensu) foram os
primeiros criados na rea de fisioterapia do pas.
Linhas de pesquisa do programa so:
x
Instrumentao e Anlise Cinesiolgica e Biomecnica do

Movimento
Processos de Avaliao e Interveno em Fisioterapia do

Sistema Msculo-Esqueltico
Processos
Bsicos,
Desenvolvimento
Recuperao
Funcional do Sistema Nervoso Central

x
Processos
de
Avaliao
Interveno
Cardiovascular e Respiratria
Recomendado pela CAPES Conceito 6
Mais informaes
Fone: (16) 3351-8448
www.ppgft.ufscar.br
e-mail ppg-cr@ufscar.br
em
Fisioterapia
PHYSIOTHERAPY EVIDENCE DATABASE
FINANCIAL SUPPORT
EDITORS
Dbora Bevilaqua Grossi Universidade de So Paulo - Ribeiro Preto, SP, Brazil
Srgio Teixeira Fonseca Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
ADMINISTRATIVE EDITOR
Aparecida Maria Catai Universidade Federal de So Carlos - So Carlos, SP, Brazil
INTERNATIONAL EDITOR
David J. Magee University of Alberta - Canada
LIBRARIAN AND GENERAL COORDINATOR
Dormlia Pereira Cazella FAI/ Universidade Federal de So Carlos - So Carlos, SP, Brazil
SPECIALIST EDITORS
Ana Beatriz de Oliveira - Universidade Federal de So Carlos - So Carlos, SP, Brazil
Ana Cludia Mattiello-Sverzut Universidade de So Paulo - Ribeiro Preto, SP, Brazil
Anamaria Siriani de Oliveira Universidade de So Paulo - Ribeiro Preto, SP, Brazil
Anielle Cristhine de Medeiros Takahashi Universidade Federal de So Carlos - So Carlos, SP, Brazil
Audrey Borghi e Silva Universidade Federal de So Carlos - So Carlos, SP, Brazil
Christina Danielli Coelho de Morais Faria - Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
Elaine Caldeira de Oliveira Guirro Universidade de So Paulo - Ribeiro Preto, SP, Brazil
Francisco Albuquerque Sendin - Universidad de Salamanca Spain
Helenice Jane Cote Gil Coury Universidade Federal de So Carlos - So Carlos, SP, Brazil
Hugo Celso Dutra de Souza - Universidade de So Paulo - Ribeiro Preto, SP, Brazil
Isabel Camargo Neves Sacco Universidade de So Paulo - So Paulo, SP, Brazil
Joo Luiz Quagliotti Durigan - Universidade de Braslia Braslia, DF, Brazil
Leani Souza Mximo Pereira Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
Leonardo Oliveira Pena Costa Universidade Cidade de So Paulo - So Paulo, SP, Brazil
Luci Fuscaldi Teixeira-Salmela Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
Marisa Cotta Mancini Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
Nivaldo Antonio Parizotto Universidade Federal de So Carlos - So Carlos, SP, Brazil
Patrcia Driusso Universidade Federal de So Carlos - So Carlos, SP, Brazil
Paula Lanna Pereira da Silva Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
Paula Rezende Camargo Universidade Federal de So Carlos - So Carlos, SP, Brazil
Pedro Dal Lago Universidade Federal de Cincias da Sade de Porto Alegre - Porto Alegre, RS, Brazil
Rosana Ferreira Sampaio Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
Stela Mrcia Mattiello Universidade Federal de So Carlos - So Carlos, SP, Brazil
Tatiana de Oliveira Sato Universidade Federal de So Carlos - So Carlos, SP, Brazil
Thiago Luiz de Russo - Universidade Federal de So Carlos - So Carlos, SP, Brazil
Vernica Franco Parreira Universidade Federal de Minas Gerais - Belo Horizonte, MG, Brazil
BRAZILIAN EDITORIAL BOARD
Ada Clarice Gastaldi - Universidade de So Paulo - Ribeiro Preto, SP
Amlia Pasqual Marques Universidade de So Paulo - So Paulo, SP
Ana Cludia Muniz Renn Universidade Federal de So Paulo - Santos, SP
Andr Luiz Felix Rodacki Universidade Federal do Paran- Curitiba, PR
Anna Raquel Silveira Gomes Universidade Federal do Paran - Matinhos, PR
Armle Dornelas de Andrade Universidade Federal do Pernambuco - Recife, PE
Carlos Marcelo Pastre Universidade Estadual Paulista - Presidente Prudente, SP
Celso Ricardo Fernandes de Carvalho Universidade de So Paulo - So Paulo, SP
Cludia Santos Oliveira Universidade Nove de Julho - So Paulo, SP
Cristiane Shinohara Moriguchi Universidade Federal de So Carlos - So Carlos, SP
Cristina Maria Nunes Cabral Universidade Cidade de So Paulo - So Paulo, SP
Daniela Cristina Carvalho de Abreu Universidade de So Paulo - Ribeiro Preto, SP
Dirceu Costa Universidade Nove de Julho - So Paulo, SP
Ester da Silva Universidade Federal de So Carlos - So Carlos, SP
Fbio de Oliveira Pitta Universidade Estadual de Londrina - Londrina, PR
Fbio Viadanna Serro Universidade Federal de So Carlos - So Carlos, SP
Ftima Valria Rodrigues de Paula Universidade Federal de Minas Gerais - Belo Horizonte, MG
Guilherme Augusto de Freitas Fregonezi Universidade Federal do Rio Grande do Norte - Natal, RN
Jefferson Rosa Cardoso Universidade Estadual de Londrina - Londrina, PR
Joo Carlos Ferrari Corra Universidade Nove de Julho - So Paulo, SP
Jos Angelo Barela Universidade Cruzeiro do Sul - So Paulo, SP
Josimari Melo de Santana Universidade Federal de Sergipe - Aracaj, SE
Juliana de Melo Ocarino Universidade Federal de Minas Gerais - Belo Horizonte, MG
Lucola da Cunha Menezes Costa Universidade Cidade de So Paulo - So Paulo, SP
Luis Vicente Franco de Oliveira Universidade Nove de Julho - So Paulo, SP
Luiz Carlos Marques Vanderlei Universidade Estadual Paulista - Presidente Prudente, SP
Luzia Iara Pfeifer Universidade de So Paulo - Ribeiro Preto, SP
Marco Aurlio Vaz Universidade Federal do Rio Grande do Sul - Porto Alegre, RS
Naomi Kondo Nakagawa Universidade de So Paulo - So Paulo, SP
Nelci Adriana Cicuto Ferreira Rocha Universidade Federal de So Carlos - So Carlos, SP
Paulo de Tarso Camillo de Carvalho Universidade Nove de Julho - So Paulo, SP
Raquel Rodrigues Britto Universidade Federal de Minas Gerais - Belo Horizonte, MG
Renata Noce Kirkwood Universidade Federal de Minas Gerais - Belo Horizonte, MG
Ricardo Oliveira Guerra Universidade Federal do Rio Grande do Norte - Natal, RN
Richard Eloin Liebano Universidade Cidade de So Paulo - So Paulo, SP
Rinaldo Roberto de Jesus Guirro Universidade de So Paulo - Ribeiro Preto, SP
Rosana Mattioli Universidade Federal de So Carlos - So Carlos, SP
Rosimeire Simprini Padula Universidade Cidade de So Paulo - So Paulo, SP
Sara Lcia Silveira de Menezes Centro Universitrio Augusto Motta - Rio de Janeiro, RJ
Simone Dal Corso Universidade Federal do Rio Grande do Sul - Porto Alegre, RS
Stella Maris Michaelsen Universidade do Estado de Santa Catarina - Florianpolis, SC
Tania de Ftima Salvini Universidade Federal de So Carlos - So Carlos, SP
Thas Cristina Chaves Universidade de So Paulo - Ribeiro Preto, SP
INTERNATIONAL EDITORIAL BOARD
Alan M. Jette Boston University School of Public Health - USA
Chukuka S. Enwemeka University of Wisconsin - USA
Edgar Ramos Vieira Florida International University - USA
Gert-Ake Hansson Lund University - SWEDEN
Janet Carr University of Sydney - AUSTRALIA
Kenneth G. Holt Boston University - USA
LaDora V. Thompson University of Minnesota - USA
Liisa Laakso Grifith University - AUSTRALIA
Linda Fetters University of Southern California - USA
Paula M. Ludewig University of Minnesota - USA
Rik Gosselink Katholieke Universiteit Leuven - BELGIUM
Rob Herbert The George Institute for International Health - AUSTRALIA
Sandra Olney Queens University - CANADA
ISSN 1413-3555
Tutorial
471
Systematic Review
481

a systematic review
502
Walking training associated with virtual reality-based training increases walking speed of individuals with chronic
stroke: systematic review with meta-analysis
2014 Nov-Dec; 18(6)
ISSN 1413-3555
Original Articles
513
Relationship between the climbing up and climbing down stairs domain scores on the FES-DMD, the score on the Vignos
Scale, age and timed performance of functional activities in boys with Duchenne muscular dystrophy
Lilian A. Y. Fernandes, Ftima A. Caromano, Silvana M. B. Assis, Michele E. Hukuda, Mariana C. Voos, Eduardo V. Carvalho
521

530
538
544
Breathing exercises: inluence on breathing patterns and thoracoabdominal motion in healthy subjects
553
Application of positive airway pressure in restoring pulmonary function and thoracic mobility in the postoperative
period of bariatric surgery: a randomized clinical trial
Patrcia Brigatto, Jssica C. Carbinatto, Carolina M. Costa, Maria I. L. Montebelo, Irineu Rasera-Jnior, Eli M. Pazzianotto-Forti
563
Functional priorities reported by parents of children with cerebral palsy: contribution to the pediatric rehabilitation process
572
2014 Nov-Dec; 18(6)
Editorial Rules
2014 Nov-Dec; 18(6)
ASSOCIAO BRASILEEIR
IRA DE PESQUISA
E PS-GRADUAO
O EM FISIOTERAPIA

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Static body postural misalignment in individuals with temporomandibular disorders:

Brazilian Journal of Physical Therapy

2014 Nov-Dec; 18(6)

Muscular performance characterization in athletes: a new perspective on isokinetic variables

2014 Nov-Dec; 18(6)

2014 Nov-Dec; 18(6)

Braz J Phys Ther. 2014 Nov-Dec; 18(6):471-579

Brazilian Journal of Physical Therapy

Ana Paula de Luca

Printed in acid free paper.

Static body postural misalignment in individuals with temporomandibular disorders:

Muscular performance characterization in athletes: a new perspective on isokinetic variables

Breathing exercises: inluence on breathing patterns and thoracoabdominal motion in

Application of positive airway pressure in restoring pulmonary function and thoracic

Functional priorities reported by parents of children with cerebral palsy: contribution to

Tutorial for writing systematic reviews for the

Palavras-chave: reabilitao; fisioterapia; reviso da literatura; revises sistemticas; metanlise.

evidncias e, consequentemente, um aumento

Braz J Phys Ther. 2014 Nov-Dec; 18(6):471-480

necessidade de maior rigor metodolgico para garantir

Braz J Phys Ther. 2014 Nov-Dec; 18(6):471-480

por Colebrook6 em 1929 e por Doull et al.7 em 1931.

O que reviso sistemtica e metaanlise?

Tutorial reviso sistemtica

De forma geral, a sntese resultante de uma reviso

que a realizao dos procedimentos de fisioterapia

Tipos de reviso sistemtica

ao BJPT. Nesse caso, o autor deve sempre optar

Itens essenciais de uma reviso

Braz J Phys Ther. 2014 Nov-Dec; 18(6):471-480

(Interveno) na melhora da amplitude de

Tutorial reviso sistemtica

vis e idioma de publicao.

concluses de uma reviso sistemtica sejam

1) apresentar os principais resultados e

Detalhamento de uma meta-anlise

Braz J Phys Ther. 2014 Nov-Dec; 18(6):471-480

1. A medida sumria da meta-anlise

Tutorial reviso sistemtica

exerccios de Pilates em pacientes com dor

4. vlido combinar os estudos?

Braz J Phys Ther. 2014 Nov-Dec; 18(6):471-480

Avaliao da qualidade de uma

Braz J Phys Ther. 2014 Nov-Dec; 18(6):471-480

H algum tempo, as normas do BJPT sugerem que

Tutorial reviso sistemtica

Em sntese, recomendamos aos autores que

Cooper H, Hedges LV. The handbook of research synthesis.

Tricco AC, Tetzlaff J, Moher D. The art and science of

Swartz MK. A look back at research synthesis. J Pediatr

Whittemore R, Chao A, Jang M, Minges KE, Park C.

Roundtree AK, Kallen MA, Lopez-Olivo MA, Kimmel B,

and conflict of interest in over 250 narrative and systematic

Colebrook D. Irradiation and health. London: HMSO; 1929.

Doull JA, Hardy M, Clark JH, Herman NB. The effect

Maher CG, Moseley AM, Sherrington C, Elkins MR, Herbert

Kolind-Sorensen V. [Lesions of the lateral ligament of

10. Higgins JPT, Green S, editors. Cochrane Handbook for

physical therapy treatment in patients who have undergone

are the main running-related musculoskeletal injuries? A

Braz J Phys Ther. 2014 Nov-Dec; 18(6):471-480

and fracture in patients with low back pain: systematic