ARTICLE IN PRESS
BJHH 2392 1–8
rev bras hematol hemoter. 2 0 1 4;x x x(x x):xxx–xxx
Revista Brasileira de Hematologia e Hemoterapia Brazilian Journal of Hematology and Hemotherapy www.rbhh.org
Original article
1
Pilot randomized controlled trial to evaluate the effect of aquatic and land physical therapy on musculoskeletal dysfunction of sickle cell disease patients
2
3
4
5
7
Camila Tatiana Zanoni, Fábio Galvão, Alberto Cliquet Junior, Sara Teresinha Olalla Saad ∗
8
Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
6
Q1
9
10
a r t i c l e
i n f o
a b s t r a c t
11 12
Article history:
Objective: To compare the effect of aquatic and land-based physiotherapy in reducing mus-
13
Received 11 June 2014
culoskeletal hip and lower back pain and increasing overall physical capabilities of sickle
14
Accepted 25 July 2014
cell disease patients.
15
Available online xxx
Methods: Informed written consent was obtained from all volunteers who were submitted to evaluations using different functional scales: Lequesne’s Algofunctional Questionnaire and
16
Oswestry Disability Index, trunk and hip range of motion, goniometry, trunk and hip muscle
17
Keywords:
18
Anemia, sickle cell
strength assessment using load cell, and surface electromyography of the iliocostalis, long
19
Hydrotherapy
dorsal (longissimus), gluteus maximus, gluteus medius and tensor fasciae latae muscles.
20
Physical therapy modalities
Ten patients were randomized into two groups: aquatic physiotherapy with a mean age of 42 years (range: 25–67) and conventional physiotherapy with a mean age of 49 years (range: 43–59). Both groups were submitted to a twelve-week program of two sessions weekly. Results: After intervention, significant improvements were observed regarding the Lequesne index (p-value = 0.0217), Oswestry Disability Index (p-value = 0.0112), range of motion of trunk extension (p-value = 0.0320), trunk flexion muscle strength (p-value = 0.0459), hip extension and abduction muscle strength (p-value = 0.0062 and p-value = 0.0257, respectively). Range of motion of trunk and hip flexion, extension, adduction and abduction, trunk extensor muscle strength and all surface electromyography variables showed no significant statistical difference. Conclusion: Physical therapy is efficient to treat musculoskeletal dysfunctions in sickle cell disease patients, irrespective of the technique; however, aquatic therapy showed a trend toward improvement in muscle strength. Further studies with a larger patient sample and longer periods of therapy are necessary to confirm these results. © 2014 Associac¸ão Brasileira de Hematologia, Hemoterapia e Terapia Celular. Published by Elsevier Editora Ltda. All rights reserved.
∗ Corresponding author at: Hemocentro Unicamp, Instituto Nacional de Ciência e Tecnologia do Sangue, Rua Carlos Chagas, 480, Cidade Universitária Zeferino Vaz, 13083-878 Campinas, SP, Brazil. E-mail address:
[email protected] (S.T.O. Saad). http://dx.doi.org/10.1016/j.bjhh.2014.11.010 1516-8484/© 2014 Associac¸ão Brasileira de Hematologia, Hemoterapia e Terapia Celular. Published by Elsevier Editora Ltda. All rights reserved.
Please cite this article in press as: Zanoni CT, et al. Pilot randomized controlled trial to evaluate the effect of aquatic and land physical therapy BJHH 2392 1–8 on musculoskeletal dysfunction of sickle cell disease patients. Rev Bras Hematol Hemoter. 2014. http://dx.doi.org/10.1016/j.bjhh.2014.11.010
BJHH 2392 1–8
ARTICLE IN PRESS
2
rev bras hematol hemoter. 2 0 1 4;x x x(x x):xxx–xxx
Introduction 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77
Sickle cell disease (SCD) is a genetic disorder that results in the sickling of red blood cells, triggering vaso-occlusion episodes which lead to pain and organ damage. This inherited disorder is caused by a point mutation in the beta-globin gene. The mutant form of hemoglobin in SCD (Hb S) is capable of polymerization and complex molecular and structural changes within the red cell. Occurring in homozygotes (Hb SS) and in compound heterozygotes, such as those carrying Hb S and beta-thalassemia (Hb SB+ or Hb SB0 ) and Hb S and hemoglobin C (Hb SC), hemolytic anemia and vaso-occlusion crises are the main complications of SCD. The illness tends to gradually develop toward multisystem organ failure.1 Bone involvement, frequently causing painful vaso-occlusive crises, is the most common clinical manifestation. Furthermore, bone involvement is a source of chronic, progressive disability, with long-term effects upon bone mass density, growth, and bone damage such as avascular necrosis and osteomyelitis. Osteopenia and osteoporosis are often asymptomatic; however, pain, fractures, deformities, and vertebral collapse may occur and require chronic analgesia, mechanical support, and surgical interventions.2,3 Chronic and progressive damage such as, for example, avascular necrosis of the femoral head, the leading cause of hip deformity in these patients, commonly results in gait disturbances, pain, and activity and functional limitations in adult patients. Lower back pain is one of the main complaints among SCD patients and occurs due to the flattening and widening of the vertebral bodies with biconcave depressions of the endplates, probably caused by infarction of the central portion of the vertebral body.4,5 There are few studies in the literature on the role of physiotherapy as a resource to prevent and treat locomotor system disorders in SCD individuals. According to recent studies, the life expectancy of SCD patients’ has improved dramatically over the last century.6 However this longer life span has, as an unfortunate consequence, the development of progressive organ damage which includes osteoarticular lesions.7 Chronic pain is considered a serious public health problem which negatively affects the quality of life of individuals. Therefore, a multi-action therapeutic plan, specifically physiotherapy, could help decrease pain, and improve mobility and the rehabilitation of osteoarticular disorders, positively impacting on the quality of life.8 Despite this fact, there are few studies in the literature on the role of physiotherapy as a resource to prevent and treat locomotor system disorders in SCD patients. One study9 compared the efficacy of physiotherapy alone with physiotherapy associated with surgical femur decompression in SCD patients with osteonecrosis of the femoral head. The results showed no significant difference between the techniques, suggesting that physical therapy alone appeared to be as effective as surgical decompression to improve hip function, thus deferring the need for surgery. Within the existing physiotherapy resources, aquatic physiotherapy used in rehabilitation has demonstrated positive
effects against pain, in regaining physical function and in improving quality of life in adults with musculoskeletal conditions.10 Movements performed in the water are facilitated by the elimination of the effects of gravity, resulting in increased muscle strength (MS) and flexibility. The benefits of water are mainly explained by the physiological effects of immersion and by the hydrodynamic principles of exercise, such as buoyancy, in this environment thereby enabling functional exercises with a reduced gravitational load. Furthermore, the immersion in thermo-neutral water (34 ◦ C) in combination with the effects of hydrostatic pressure reduces the perception of pain. The physical properties and heated water play an important role in improving and maintaining the range of joint motions, reducing muscular tension and promoting relaxation, as well as preparing the muscle for stretching. The buoyancy induces muscle relaxation and the decrease in impact enables increased mobility and flexibility.11,12 This study aimed to evaluate the efficacy of aquatic and land-based physical therapy in decreasing hip and lower back musculoskeletal pain and increasing overall physical wellbeing in SCD patients.
78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99
Methods Adult SCD patients who regularly attended (at least three times a year during the previous three years) the Outpatient Clinic of the Hemocentro of the Universidade Estadual de Campinas (UNICAMP) with chronic hip and lumbar spine pain, and who had not participated in a physical therapy program during the previous 12 months, were invited to participate in this study. Patients with acute episodes, absence of over three physical therapy sessions without justification, or any dermatological issue which would prevent them from entering a therapeutic pool, were excluded from the study. The National Ethics Board approved this study, and all patients provided written informed consent.
Study design Initially, the volunteers were evaluated according to functional scales, including the Lequesne’s Algofunctional Questionnaire and Oswestry Disability Index (ODI), range of motion (RoM) measurements of trunk flexion and extension, hip adduction and abduction, assessment of MS of the trunk flexors and extensors, and the flexors, extensors, adductors and abductors of the hip through load cell and surface electromyography (SEMG) of the iliocostalis, long dorsal (longissimus), gluteus maximus, gluteus medius and tensor fasciae latae muscles. Volunteers were then randomized by an investigator not involved in data collection, using the blind allocation method of sequentially numbered, opaque sealed envelopes,13,14 into two different program groups: aquatic physiotherapy (AP) and conventional or land physiotherapy (CP). A total of 24 sessions over a twelve-week period (two sessions per week) were administered. Patients were assessed after the intervention comparing the results before and after the sessions according to data obtained for the dominant side of each patient.15,16
Please cite this article in press as: Zanoni CT, et al. Pilot randomized controlled trial to evaluate the effect of aquatic and land physical therapy BJHH 2392 1–8 on musculoskeletal dysfunction of sickle cell disease patients. Rev Bras Hematol Hemoter. 2014. http://dx.doi.org/10.1016/j.bjhh.2014.11.010
100 101 102 103 104 105 106 107 108 109 110 111
112
113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131
ARTICLE IN PRESS
BJHH 2392 1–8
3
rev bras hematol hemoter. 2 0 1 4;x x x(x x):xxx–xxx
149
The RoM was evaluated by a single examiner using a conventional 360◦ free shaft goniometer. The following movements were assessed: trunk flexion and extension and flexion, extension, adduction and abduction of the hip joint, according to the standardization of the goniometry manual of Marques.18
from each muscle through a four channel electromyography system (MIOTEC® , Porto Alegre, Brazil) using disposable Ag/AgCI circular bipolar electrodes (3M® ). The 10 mm diameter electrodes with adhesive conducting gel were positioned on the skin overlying the muscles with an inter-electrode distance of 20 mm. Abrasion of the skin was performed at the fixation sites with gauze soaked in alcohol to reduce impedance and the electrodes were then fixed at the muscular belly, distant from the motor point, and fixed with transparent tape and elastic band wrapping to avoid movement artifacts. The data acquisition Miograph USB® software system with windowing 32 (RMS – Root Mean Square) and gain of 2000 for each channel was used to capture the electrical potentials of the muscles evaluated in microvolts (V). Butterworth filters were used: order 4 and band pass 20–500 Hz. The four channels were connected to active SDS500® sensors by clamps. Signal analysis was performed using Miograph USB® system software. The sensors were calibrated before data collection. The electrical potentials of the muscles were collected in accordance to international standardization of SENIAM.19
150
Muscle strength
Aquatic physiotherapy The 9 m2 pool in a 16 m2 room was warmed to 34 ◦ C; the patients changed their clothes in this temperaturecontrolled room. Each session consisted of lower limb muscle stretching, jogging in the pool (forward, backward and sideways), suspended bicycle exercises in the vertical position, stair climbing exercises, active exercises in the supine position using floats, and finally relaxation exercises.
160
MS was analyzed by maximal voluntary isometric contraction (MVIC) using a load cell (MIOTEC® , Porto Alegre, Brazil). The load cell was connected to a Miotool 400® apparatus (MIOTEC® ) using a SDS1000® sensor connected via a USB cable to a notebook. During movements, the force generated by traction on the load cell was transmitted to the Miograph® software which produces a plot of MS in kilograms-force (kgf). Volunteers were submitted to isometric MS tests of the trunk flexors and extensors and hip flexors, extensors, adductors and abductors.
161
Surface electromyography
Each session consisted of lower limb stretches, hip exercises to strengthen hip adductors and abductors, supine bridge, exercises using ankle-weights to strengthen the quadriceps and when necessary, transcutaneous electrical nerve stimulation was used for pain relief.
132
Questionnaires
142
The Lequesne’s Algofunctional Questionnaire was developed for patients with osteoarthritis and evaluates symptoms and functional capacity of the hip and knee. This index is composed of 11 questions that evaluate pain, discomfort and function. The ODI is a self-administered questionnaire used to measure the degree of lumbar spine disability, and contains topics concerning intensity of pain and physical activity.17 ODI has been used in scientific research to evaluate patients with nonspecific or specific low-back pain after surgical procedures, medication and rehabilitation.
143
Range of motion
133 134 135 136 137 138 139 140 141
144 145 146 147 148
151 152 153 154 155 156 157 158 159
162 163 164
Myoelectric signals of the gluteus maximus, gluteus medius, tensor fascia lata, long dorsal (longissimus) and iliocostalis muscles were sampled at 2000 Hz in single differential mode
Group Age (years) Gender Type of disease Transfusions ␣-Thalassemia Leukocytes (×109 /L) Hemoglobin (g/dL) MCV (fL) Reticulocytes (%) Platelet count (×109 /L) Fetal hemoglobin (%) LDH (U/L) HU dose (mg/kg)
166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185
186
Conventional physiotherapy
187 188 189 190 191 192 193 194
195
Table 1 – Clinical and laboratory data of sickle cell disease patients submitted to two physiotherapy programs. Patient
165
1
2
3
4
5
6
7
8
9
10
Aquatic 42 Female Hb SS No Neg 6.13 7.4 113.7 12.68 331 7.3 1680 10
Aquatic 25 Female Hb SS Yes Neg 8.41 7.1 101.0 3.51 335 4.0 944 11
Aquatic 67 Male Hb SC No Neg 6.80 10.4 67.0 3.59 508 0.2 405 0
Aquatic 28 Male Hb SS No Neg 6.04 10.1 104.7 11.81 304 23.7 1000 26
Aquatic 53 Female Hb SC Yes Neg 7.49 9.6 91.9 7.48 392 2.8 535 0
Land 59 Female Hb SC No Neg 10.88 10.2 82.4 7.56 163 1.4 445 0
Land 49 Female Hb SS No Neg 13.61 10.6 85.4 2.70 175 28.1 862 21
Land 45 Male Hb SC No Neg 4.44 11.7 76.9 4.83 94 0.5 403 0
Land 58 Male Hb SC No Neg 5.97 12.7 77.2 5.55 275 1.0 529 0
Land 43 Female Hb SC No H 6.34 10.0 69.3 4.90 114 1.2 431 0
MCV: mean corpuscular volume; LDH: lactate dehydrogenase; HU: hydroxyurea; Neg: negative.
Please cite this article in press as: Zanoni CT, et al. Pilot randomized controlled trial to evaluate the effect of aquatic and land physical therapy BJHH 2392 1–8 on musculoskeletal dysfunction of sickle cell disease patients. Rev Bras Hematol Hemoter. 2014. http://dx.doi.org/10.1016/j.bjhh.2014.11.010
196 197 198 199 200
BJHH 2392 1–8
ARTICLE IN PRESS
4
rev bras hematol hemoter. 2 0 1 4;x x x(x x):xxx–xxx
Questionnaires 20
80
AP CP
60
Oswestry
Lequesne
15
10 P=.3125
40 P=.1250 P=.0625
20
P=.1250
5
AP CP
0 Pre
Post
Pre
Post
Figure 1 – Median, minimum and maximum values of the Lequesne index (Lequesne’s Algofunctional Questionnaire) and Oswestry Disability Index evaluated before and after interventions for the aquatic physiotherapy (AP) and conventional physiotherapy (CP) groups. The p-value refers to the comparison between time points for each group (Wilcoxon test).
207 208 209 210
The final sample comprised ten volunteers randomized into two groups: AP and CP. Median age was 42 years old (range: 25–67) for the AP group and 49 years old (range: 43–59) for the CP group. The clinical and laboratory data of the participants are shown in Table 1.
Range of Motion 120 P=1,0000 P=,2500
100
AP CP
80 60
Pre
40
P=,6250 P=,1250
20
10 Pre
AP CP
140
AP CP
30
Post
160
120 P=,6250 P=,1250
100
RoM Trunk Extension
206
80
Post
30
AP CP
25 20
P=1,0000 P=,6250
15 10
Pre
Post
40
Pre
AP CP
35 30
P=1,0000 P=,5000
25 20 Pre
Post
211 212
Results
RoM Hip Extension
205
Post
80
RoM Hip Abduction
204
RoM Trunk Flexion
203
The statistical analysis system (SAS) computer program for Windows (version 9.2) and GraphPad Prism (version 5.00 – Trial) were used for statistical analysis. A p-value of 0.05 or less was considered statistically significant. The following tests were then performed. Fisher’s exact test to compare proportions, the Mann–Whitney test to compare numerical measurements between the two groups, ANOVA to compare numerical values over time with repeated measurements with transformation
RoM Hip Flexion
202
stations and the Wilcoxon test for paired samples before and after the intervention.
Statistical analyses
RoM Hip Abduction
201
AP CP
60
P=,8750 P=,5000
40
Pre
Post
Figure 2 – Median, minimum and maximum values of Range of Motion (RoM) of truck flexion and extension and hip flexion, extension, adduction and abduction measured by goniometry. Variables evaluated before and after interventions for the aquatic physiotherapy (AP) and conventional physiotherapy (CP) groups. The p-value refers to the comparison between time points for each group (Wilcoxon test). Please cite this article in press as: Zanoni CT, et al. Pilot randomized controlled trial to evaluate the effect of aquatic and land physical therapy BJHH 2392 1–8 on musculoskeletal dysfunction of sickle cell disease patients. Rev Bras Hematol Hemoter. 2014. http://dx.doi.org/10.1016/j.bjhh.2014.11.010
213 214 215 216 217
ARTICLE IN PRESS
BJHH 2392 1–8
5
rev bras hematol hemoter. 2 0 1 4;x x x(x x):xxx–xxx
Muscle Stren 25
AP CP
15
10 P=,3125 P=,1250
5
MS Trunk Extension
MS Trunk Flexion
20
Pre
P=,4375 P=,1875 10
Post
Pre
Post
30
AP CP
20
20
P=,7500 P=,5000
10
MS Hip Extension
25
MS Hip Flexion
20
5
0
5
AP CP
25 20
P=,3125 P=,0625
15 10 5
Pre
Post
Pre
Post
25
AP CP
20
20 P=,1250 P=,6250
10
5
MS Hip Abduction
25
MS Hip Adduction
AP CP
20
AP CP
20
P=,0625
20
P=,1875 10
5 Pre
Post
Pre
Post
Figure 3 – Median, minimum and maximum values of muscle strength (MS) of the trunk flexors and extensors, and hip flexors, extensors, adductors and abductors by load cell. Variables evaluated before and after the interventions for the aquatic physiotherapy (AP) and conventional physiotherapy (CP) groups. The p-value refers to the comparison between time points for each group (Wilcoxon test).
218 219 220 221 222 223 224 225 226 227 228
Comparison of numerical values over time between the two groups showed a statistically significant difference after the intervention in respect to the Lequesne index (p-value = 0.0217), ODI (p-value = 0.0112), RoM of trunk extension (p-value = 0.0320), trunk flexion MS (p-value = 0.0459), and hip extension and abduction MS (p-value = 0.0062 and p-value = 0.0257, respectively). There were no significant statistical differences in the RoM of trunk and hip flexion, extension, adduction and abduction, trunk extensor MS and hip flexion and adduction MS and all SEMG variables (Figures 1–4).
Discussion 229 230 231 232 233 234
The present study aimed to evaluate two types of physiotherapy intervention for hip and lumbar spine functionality of adult SCD patients. The dominant side of each patient was considered in the results.15,16 The major limitation of this study was the recruitment of volunteers, as most of the patients live far from the center
and find it very difficult to attend the clinic twice every week. Therefore, only ten patients, six compound heterozygous for Hb S and Hb C and four Hb S homozygotes, completed the physiotherapeutic program. In view of the high frequency of avascular necrosis of the femoral head in SCD patients, the intervention was focused on the hip joint. The Lequesne questionnaire was used to evaluate the functionality of this joint. This scale assesses pain and hip function for daily activities. The results of the Lequesne Algofunctional questionnaire showed a statistically significant improvement after the intervention for both the groups. The AP group had very severe impairment (13.5 points) in the first assessment and moderate impairment (5.5 points) in the second. The CP group also had very severe impairment (11.5 points) in the first assessment and severe impairment (8 points) in the second. These results suggest that aquatic physiotherapy may lead to a greater improvement in hip functionality and are in agreement with Wang et al.20 and Hinman et al.21 who observed improvement in physical function after a program of aquatic physical therapy for patients with hip and knee osteoarthritis. Other studies carried out in individuals
Please cite this article in press as: Zanoni CT, et al. Pilot randomized controlled trial to evaluate the effect of aquatic and land physical therapy BJHH 2392 1–8 on musculoskeletal dysfunction of sickle cell disease patients. Rev Bras Hematol Hemoter. 2014. http://dx.doi.org/10.1016/j.bjhh.2014.11.010
235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255
BJHH 2392 1–8
ARTICLE IN PRESS
6
rev bras hematol hemoter. 2 0 1 4;x x x(x x):xxx–xxx
AP CP 400 P=,3125 200 P=,8125 0
SEMG Gluteus Maximus
Pro
600
AP CP 400 P=,3125 P=,6250 200
0
Post
Pro
800
Post
800
AP CP
600
P=,3125
400
200
P=,6250
0
SEMG Gluteus Medius
SEMG IIiocostalis
600
SEMG Dorsal Longissmus
Surface Electromyography
AP CP
600
400
P=,3125 P=1,0000
200
0 Post
SEMG Tensor Fascia Lata
Pro
Pro
800
Post
AP CP
600
P=,3125 P=,8125
400
200 0 Pro
Post
Figure 4 – Median, minimum and maximum values of surface electromyography (SEMG) of iliocostalis, long dorsal (longissimus), gluteus maximus, gluteus medius and tensor fasciae latae muscles. Variables evaluated before and after interventions for the aquatic physiotherapy (AP) and conventional physiotherapy (CP) groups. The p-value refers to the comparison between time points for each group (Wilcoxon test).
256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278
with hip and/or knee disorders however, showed no significant differences between the two rehabilitation strategies, suggesting that both techniques are equally effective.22–24 Lower back pain is one of the main complaints of SCD patients. The ODI was herein used to assess lower back pain and function during daily activities. This index also showed statistically significant improvements in both study groups after the intervention. The CP group improved from moderate disability (26.5%) to minimal disability (18%); the AP group, however, despite some significant improvement in the scores of the second assessment (from 35% to 22%) showed no change in the severity of the disability caused by back pain. Longer or more frequent sessions may render better results, as has been described by others.24,25 These studies showed that patients who performed AP two or more times weekly had greater improvement in physical assessment scores than those who exercised only once a week.24,25 Nevertheless, Ariyoshi et al.25 extended the program for six months and concluded that water therapy exercises were useful for patients with back pain as they provide pain relief. In this study, a significant improvement in range of motion of the trunk extension and a trend toward an improvement in trunk flexion goniometry were observed in both groups,
especially in the AP group. However, no significant change was detected in either group regarding motion amplitude, probably due to the inflammatory phenomena and bone infarctions which may have caused permanent limitations. Furthermore, late interventions may not be sufficient to improve joint RoM in this age group in which chronic degenerative hip injuries may have reached a level of severity that precludes greater joint flexibility. Moreover, the fact that there was no significant improvement in goniometry may be a consequence of the techniques used in both groups which may favor strength gain. Thus, perhaps the program should increase the time devoted to stretching certain target muscles during therapy, thereby promoting improved muscle flexibility. Regarding trunk MS, a significant improvement in flexion was observed in both groups after the interventions. Despite the trend toward improvement in trunk extensor MS in the AP group, there were no significant differences between the two groups. These results are in agreement with other studies that showed improved MS after specific trunk land-based and water-based exercises.24,26,27 There was a statistically significant increase in hip extension and abduction MS in both groups after the interventions.
Please cite this article in press as: Zanoni CT, et al. Pilot randomized controlled trial to evaluate the effect of aquatic and land physical therapy BJHH 2392 1–8 on musculoskeletal dysfunction of sickle cell disease patients. Rev Bras Hematol Hemoter. 2014. http://dx.doi.org/10.1016/j.bjhh.2014.11.010
279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301
BJHH 2392 1–8
ARTICLE IN PRESS rev bras hematol hemoter. 2 0 1 4;x x x(x x):xxx–xxx
302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336
Although, hip flexion MS was unchanged in the CP group, there was a trend toward improvement in the AP group, and hip adduction MS showed a slight trend toward improvement in both groups. Thus, albeit slight, the results of this study showed improvement of all MS variables in the AP group, in accordance with Wang et al.20 who also observed improved flexibility and lower limb strength after 12 weeks of aquatic therapy, and Cochrane et al.28 who observed significant improvement in pain and physical function after aquatic exercises in adults with hip and knee osteoarthritis. In another study, Rahmann29 demonstrated a positive effect of a specific program of aquatic physical therapy on early recovery of strength after hip and knee surgeries. Furthermore, Hinman et al.21 observed a slight improvement in pain, physical function, quality of life and MS after aquatic therapy for patients with hip and knee osteoarthritis in a protocol of two sessions per week for six weeks. However, Jigami23 concluded that both programs, land-based and water-based, even when the exercises were performed only once a week, improved overall physical activity and MS in the lower limbs of osteoarthritis patients. Surface electromyography did not show any significant difference after the interventions of both groups. However, there seemed to be an improvement in the electromyography signal of all muscles evaluated in the AP group. The better result obtained in this group may be related to the greater amount of muscle fibers recruited in aquatic therapy added to the physical properties of water such as buoyancy and multidirectional strength. These findings are in agreement with the results reported by Kaneda et al.30 who observed greater electromyography activity of all muscle movements performed in the water with floating devices. The results of this study should be analyzed with caution as the sample size may have been a limiting factor and therefore, further studies are needed to confirm these results.
Conclusion 337 338 339 340 341 342 343
The results obtained here suggest that physical therapy is a resource capable of treating musculoskeletal dysfunction in SCD patients regardless of the technique used. However, exercises designed to stretch tone and strengthen the core and limb muscles carried out in the water require greater stabilization of the muscles and may justify the trend toward the better results obtained.
Funding 344 Q2 345 346 347 348 349
This work was supported by the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), and Fundac¸ão de Coordenac¸ão de Aperfeic¸oamento de Pessoal de Nível Superior (CAPES). The Hemocentro, UNICAMP, is a part of Instituto Nacional de Ciência e Tecnologia do Sangue, Brazil (INCT do Sangue – CNPq/MCT/FAPESP).
Conflicts of interest 350
The authors declare no conflicts of interest.
7
Acknowledgments The authors thank Prof. Margareth Castro Ozelo for kindly making the facilities at the Hemophilia Unit available; Dr. Marina Pereira Colella for helping recruit the patients, Márcia Matta, Janaína Bosso Ricciardi and Glenda Feldberg Andrade Pinto for their technical assistance; and Raquel Foglio for the editing and English revision.
351 352 353 354 355 356
357
references 358
1. Baldanzi G, Traina F, Marques Neto JF, Santos AO, Ramos CD, Olalla Saad ST. Low bone mass density is associated with hemolysis in Brazilian patients with sickle cell disease. Clinics. 2011;66(5):801–5. 2. Almeida A, Roberts I. Bone involvement in sickle cell disease. Br J Haematol. 2005;129(4):482–90. 3. Serarslan Y, Kalaci A, Ozkan C, Dogramaci Y, Cokluk C, Yanat AN. Morphometry of the thoracolumbar vertebrae in sickle cell disease. Clin Neurosci. 2010;17(2):182–6. 4. Akinyoola AL, Adediran IA, Asaleye CM, Bolarinwa AR. Risk factors for osteonecrosis of the femoral head in patients with sickle cell disease. Int Orthop. 2009;33(4):923–6. 5. Huo MH, Friedlaender GE, Marsh JS. Orthopaedic manifestations of sickle-cell disease. Yale J Biol Med. 1990;63(3):195–207. 6. Sheth S, Licursi M, Bhatia M. Sickle cell disease: time for a closer look at treatment options? Br J Haematol. 2013;162(4):455–64. 7. Osunkwo I. An update on the recent literature on sickle cell bone disease. Curr Opin Endocrinol Diabetes Obes. 2013;20(6):539–46. 8. Ohara DG, Ruas G, Castro SS, Martins PRJ, Walsh IA. Dor osteomuscular, perfil e qualidade de vida de indivíduos com doenc¸a falciforme. Rev Bras Fisioter. 2012;16(5):431–8. 9. Neumayr LD, Aguilar C, Earles AN, Jergesen HE, Haberkern CM, Kammen BF, et al. Physical therapy alone compared with core decompression and physical therapy for femoral head osteonecrosis in sickle cell disease. Results of a multicenter study at a mean of three years after treatment. J Bone Joint Surg Am. 2006;88(12):2573–82. 10. Barker AL, Talevski J, Morello RT, Brand CA, Rahmann AE, Urquhart DM. Effectiveness of aquatic exercise for musculoskeletal conditions: a meta-analysis. Arch Phys Med Q3 Rehabil. 2014. 11. Becker BE. Aquatic therapy: scientific foundations and clinical rehabilitation applications. PM R. 2009;1(9):859–72. 12. Poyhonen T, Sipila S, Keskinen KL, Hautala A, Savolainen J, Malkia E. Effects of aquatic resistance training on neuromuscular performance in healthy women. Med Sci Sports Exerc. 2002;34(12):2103–9. 13. Doig GS, Simpson F. Randomization and allocation concealment: a practical guide for researchers. J Crit Care. 2005;20(2):187–91. 14. Scales DC, Adhikari NK. Maintaining allocation concealment: following your SNOSE. J Crit Care. 2005;20:191–3. 15. Sadeghi H, Allard P, Prince F, Labelle H. Symmetric and limb in able-bodied gait: a review. Gait Posture. 2000;12:34–45. 16. Martin WL, Porac C. Patterns of handedness and footedness in switched and nonswitched Brazilian left-handers: cultural effects on the development of lateral preferences. Dev Neurophysiol. 2007;31(2):159–79. 17. Coelho RA, Siqueira FB, Ferreira PH, Ferreira ML. Responsiveness of the Brazilian–Portuguese version of the
Please cite this article in press as: Zanoni CT, et al. Pilot randomized controlled trial to evaluate the effect of aquatic and land physical therapy BJHH 2392 1–8 on musculoskeletal dysfunction of sickle cell disease patients. Rev Bras Hematol Hemoter. 2014. http://dx.doi.org/10.1016/j.bjhh.2014.11.010
359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411
BJHH 2392 1–8
ARTICLE IN PRESS
8
rev bras hematol hemoter. 2 0 1 4;x x x(x x):xxx–xxx
412 413 414
18.
415 416
19.
417 418 419 420
20.
421 422 423 424
21.
425 426 427
22.
428 429 430 431 432 433 434 435
23.
Oswestry Disability Index in subjects with low back pain. Eur Spine J. 2008;17(8):1101–6. Marques AP. Manual de Goniometria: Segunda edic¸ão revisada e ampliada. Barueri: Manole; 2003. Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development of recommendations for SEMG sensors and sensor placement procedures. J Electromyogr Kinesiol. 2000;10(5):361–74. Wang TJ, Belza B, Thompson F, Whitney JD, Bennett K. Effects of aquatic exercise on flexibility, strength and aerobic fitness in adults with osteoarthritis of hip or knee. J Adv Nurs. 2007;57(2):141–52. Hinman RS, Heywood SE, Day A. Aquatic physical therapy for hip and knee osteoarthritis: results of a single-blind randomized controlled trial. Phys Ther. 2007;87(1):32–43. Batterham SI, Heywood S, Keating JL. Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes. BMC Musculoskelet Disord. 2011;12:123. Jigami H, Sato D, Tsubaki A, Tokunaga Y, Ishikawa T, Dohmae Y, et al. Effects of weekly and fortnightly therapeutic exercise on physical function and health-related quality of life in individuals with hip osteoarthritis. J Orthop Sci. 2012;17(6):737–44.
24. Baena-Beato PA, Arroyo-Morales M, Delgado-Fernández M, Gatto-Cardia MC, Artero EG. Effects of different frequencies (2–3 days/week) of aquatic therapy program in adults with chronic low back pain. A non-randomized comparison trial. Pain Med. 2013;14(1):145–58. 25. Ariyoshi M, Sonoda K, Nagata K, Mashima T, Zenmyo M, Paku C, et al. Efficacy of aquatic exercises for patients with low-back pain. Kurume Med J. 1999;46(2):91–6. 26. Freitas CD, Greve JM. Estudo comparativo entre exercícios com dinamômetro isocinético e bola terapêutica na lombalgia crônica de origem mecânica. Fisioter Pesqui. 2008;15(4):380–6. 27. Carpenter DM, Nelson BW. Low back strengthening for the prevention and treatment of low back pain. Med Sci Sports Exerc. 1999;31(1):18–24. 28. Cochrane T, Davey RC, Matthes Edwards SM. Randomized controlled trial of the cost effectiveness of water-based therapy for lower limb osteoarthritis. Health Technol Assess. 2005;9(31), iii–iv, ix–xi, 1–114. 29. Rahmann AE, Brauer SG, Nitz JC. A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial. Arch Phys Med Rehabil. 2009;90(5):745–55. 30. Kaneda K, Sato D, Wakabayashi H, Nomura T. EMG activity of hip and trunk muscles during deep-water running. J Electromyogr Kinesiol. 2009;19(6):1064–70.
Please cite this article in press as: Zanoni CT, et al. Pilot randomized controlled trial to evaluate the effect of aquatic and land physical therapy BJHH 2392 1–8 on musculoskeletal dysfunction of sickle cell disease patients. Rev Bras Hematol Hemoter. 2014. http://dx.doi.org/10.1016/j.bjhh.2014.11.010
436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 456 457 458 459 460
