Influência da crioterapia no tendão quadricipital na força máxima, na sensação de força produzida e na funcionalidade do membro inferior

Enquadramento: A aplicação de crioterapia utiliza-se como coadjuvante na reeducação neuromuscular e tem como objetivo atingir o mais rápido possível a capacidade funcional, devido aos seus efeitos analgésicos e anti- inflamatórios, contudo, o seu efeito negativo ao nível da propriocepção tem vindo a ser questionado. Objetivo: Verificar se a aplicação de crioterapia no tendão quadricipital tem influência na força máxima, na sensação de força produzida e na funcionalidade do membro inferior. Metodologia: Tratou-se de um estudo experimental, do tipo laboratorial e com um desenho cruzado. Quarenta sujeitos foram distribuídos inicialmente e de forma aleatória em um grupo experimental e um grupo controlo, sendo que, após uma semana os elementos que pertenceram ao grupo experimental passaram para grupo controlo e vice-versa. O grupo experimental foi submetido a um programa com gelo dinâmico durante 10 minutos, avaliando-se a força máxima, sensação de força produzida e funcionalidade do membro, enquanto grupo controlo esteve em repouso o mesmo período de tempo. Resultados: Verificaram-se que não houve diferenças estatisticamente significativas relativas a todas variáveis estudadas (p>0,05). Conclusão: O uso da crioterapia na região mio-tendinosa do quadrícipete não provoca défices significativos ao nível das respostas sensório-motoras do joelho, e que à luz destes resultados, esta pode ser utilizada antes da realização de outras técnicas terapêuticas, sem qualquer risco adicional a nível motor.

Anti-vibration gloves and the forearm efforts during tools operations

The objective of this paper is to analyze the forearm muscular contraction levels associated to the use of anti-vibration gloves, by comparing the contraction levels with gloves and without gloves. Two different vibration tools were used in a simulated work environment: (1) A compact Duty Multi-Cutter Bosch and (2) and a Percussion Drill with a drill bit Ø20 mm. Standard operations were performed by each subject in the following materials: (1) Performing cross- sectional cuts in 80x40 mm pine section and (2) performing 20 mm diameter holes in a concrete slab 2 x 2 m, 70 mm thick. The forearm contraction level were measured by surface electromyography in four different muscles: Flexor Digitorum Superficialis (FDS), Flexor Carpi Ulnaris (FCU), Extensor Carpi Radialis Longus (ECRL) e Extensor Carpi Ulnaris (ECU). For the flexor muscles (FDS, FCU), an increase tendency in muscular contraction was observed when the operations are performed without gloves (2-5% MVE increase in the FDS and 3-9% MVE increase in the FCU). For the extensor muscles ECU a decrease tendency in muscular contraction was observed when the operations are performed without gloves (1-10% MVE decrease). Any tendency was found in the ECRL muscle. ECU was the muscle with the highest contraction level for 79% and 71% of the operators, during the operations respectively with the multi-cutter (P50= 27-30%MVE) and with the percussion drill (P50=46-55%MVE). As a final conclusion from this study, anti- vibration gloves may increase the forearm fatigue in the posterior region of the forearm (ECU muscle) during operations with the mentioned tools

Avaliação dos ajustes posturais em indivíduos com instabilidade funcional do tornozelo

Introdução:O Controlo Postural é um processo neural complexo envolvido na organização da estabilidade e orientação da posição do corpo no espaço. A Instabilidade Funcional (IF) do tornozelo é descrita como uma perceção subjetiva de instabilidade articular, que afeta o controlo postural. Apesar de vários estudos terem investigado os fatores inerentes à IF ainda existe inconsistência nos resultados da literatura sobre os mecanismos envolvidos nesta. Objetivo (s):avaliar os ajustes posturais envolvidos na resposta a uma perturbação externa realizada de forma previsível e imprevisível em indivíduos com IF. Métodos:Estudo observacional analítico transversal, teve uma amostra de 20 indivíduos, que foram divididos em grupo com IF e grupo de controlo. Foi recolhida atividade eletromiográfica bilateral dos músculos longo e curto peroneal (PL e PC), tibial anterior (TA) e solear (SOL) associado a uma perturbação externa aplicada de forma previsível e imprevisível. Os ajustes posturais foram avaliados através da análise do início da atividade muscular, da magnitude global dos ajustes posturais compensatórios e antecipatórios e magnitude das respostas de curta e média latência Resultados: Na perturbação imprevisível não se verificaram diferenças significativas no início da atividade muscular (p>0,05). Enquanto na magnitude das respostas de curta e média latência verificou-se diferenças nos músculos TA (Ia,p=0,000; II, p=0,011), CP (Ia,p=0,029; II, p=0,001) e LP (Ia, p=0,030) entre o membro com IF e o controlo e no LP (II, p=0,011) entre o membro sem IF do grupo com IF e o controlo. Na perturbação previsível observaram-se diferenças nos ajustes posturais antecipatórios (APA) dos músculos TA (p=0,006) e LP (p=0,020) entre o membro sem IF do grupo com IF e o controlo. Conclusão: Os indivíduos com IF apresentam défices na magnitude das respostas de média e curta latência numa perturbação imprevisível e nos APA na perturbação previsível.

Força Muscular Isocinética após Reconstrução do Ligamento Cruzado Anterior – Influência do Tipo de Enxerto (Osso-Tendão-Osso/Isquio-Tibiais)

Introdução: É reconhecida a importância do ligamento cruzado anterior (LCA) no funcionamento normal do joelho. Em caso de rotura ligamentar, nomeadamente em desportos com marcada solicitação dos movimentos de rotação do joelho, é justificada a necessidade de reconstrução do LCA na maioria dos casos. Objetivo (s): Avaliar a influência do tipo de enxerto na reconstrução do ligamento cruzado anterior na força muscular isocinética, assim como na funcionalidade e sintomas após 6 meses. Métodos: Estudo transversal analítico, constituído por 20 indivíduos voluntários do sexo masculino, que haviam sido submetidos a uma ligamentoplastia do cruzado anterior, pelo mesmo cirurgião, seguido de uma intervenção individualizada por um fisioterapeuta. Em 10 indivíduos, o procedimento cirúrgico foi realizado com enxerto do tendão rotuliano (grupo OTO), e nos restantes 10 com enxerto do semitendinoso e gracilis (grupo STG). Como forma de avaliar a Força Muscular Isocinética (Peak Torque, Trabalho Total Muscular, ratio Isquiotibiais/Quadricipite), foi utilizado o Dinamómetro Isocinético Biodex. A avaliação foi efectuada apenas aos 6 meses após o procedimento cirúrgico. Para observação da funcionalidade, amplitude de movimento e sintomas, utilizou-se o questionário International Knee Documentation Committee (IKDC). Resultados: Foi possível observar que entre os grupos apenas se observaram diferenças significativas no peak torque de extensão a 180º no membro não lesado (p=0,019). Contudo, foi observada uma tendência para o grupo OTO apresentar um maior défice no peak torque e trabalho total muscular em extensão. Comparativamente ao membro contra-lateral, o membro lesado apresentou valores significativamente inferiores na maioria das variáveis ( p < 0,05). Conclusão: Após 6 meses de pós-cirúrgico com reabilitação de fisioterapia, não foi possível apontar qual o enxerto que garante uma melhor recuperação da força muscular. Aos 6 meses, ambos os grupos ainda apresentaram limitações musculares, quando comparados com o lado contra-lateral. Relativamente ao rácio isquiotibiais/quadricípite, assim como no IKDC, não se observaram diferenças entre os dois tipos de enxertos.

Acute flare induced by the calcific tendonitis of the rotator cuff: inhibition of IL-1 a potential therapeutic target?

Introduction: Calcific tendonitis of rotator cuff is observed on plainradiographs in 10% of adults, but remains asymptomatic in half thesecases. Sometimes, these calcifications induce acute flares withmassive inflammation similar to gout or CPPD crisis. Analgesics/anti-inflammatory medications are usually not sufficient to controlssymptoms in these situations. Local steroid infiltration with or withoutremoval of the calcific deposition with a needle aspiration may beuseful. A new approach could be IL-1 inhibitors. Indeed, basic calciumphosphate crystals are capable of stimulating the release of activeIL-1β in vitro. These crystals trigger IL-1β release, in an analogousmanner to MSU crystals in acute gout, suggesting that IL-1β blockademay be clinically useful.Case presentation: This report describes a 70-year old woman withacute rest pain of the right shoulder since 48 hours. On examination,we found massive limitations of active and passive movements. Thepatient evaluated, on the visual scale, her symptoms at 10/10 the nightand 5/10 the day. The radiography and showed a rounded, 8 mmcalcification in the subscapularis tendon. The ultrasound aspectrevealed a heterogeneous calcification partially non solid, surroundedby massive inflammation on Doppler. C-reactive protein anderythrocyte sedimentation rate were high (74 mg/ml, 54 mm/hour).The patient received subcutaneous injections of anakinra: 100 mgdaily for 3 days (D1-D3). We evaluated the patient in our consult at dayD1, D2, D3, D7, D16 and by phone at D70.This treatment rapidly relieved the inflammatory symptoms (within afew hours with no relapse). The mobility of the shoulder, the biologicsparameters improved and the size of the calcification as well thedegree of inflammation regressed on ultrasound after 3 days.Conclusion: This is the first report of a woman with an acute flareinduced by calcific tendonitis who received anakinra. IL-1 inhibitionmay be a therapeutic target in calcific tendonitis. To analyse thisresponse more precisely and elaborate definitive conclusions, aprospective pilot study is on-going in our ambulatory institute.

Extensor carpi ulnaris (ECU) subsheath: Normal MRI appearance and findings in athletic injuries : 40

Purpose: First, to report ECU subsheath's normal MRI appearance and the findings in athletic injuries. Second, to determine the best MRI sequence for diagnosis. Methods and materials: Sixteen patients (13 males, 3 females, mean age 30.3 years) with ECU subsheath's athletic injuries sustained between January 2003 and June 2009 were retrospectively reviewed. Wrist MRI studies were performed on 1.5-T units and consisted of at least transverse T1 and STIR sequences in pronation, and FS Gd T1 in pronation and supination. Two radiologists assessed the following items, in consensus: injury type (A to C according to Inoue), ECU tendon stability, and associated lesions (ulnar head oedema, extensor retinaculum injury, ECU tendinosis and tenosynovitis). Then, each reader independently rated the sequences' diagnostic value: 0 = questionable, 1 = suggestive, 2 = certain. Follow-up studies were present in 8 patients. ECU subsheath's normal visibility (medial, central and lateral parts) was retrospectively evaluated in 30 consecutive control MRI studies. Results: FS Gd T1 sequences in supination (1.63) and pronation (1.59) were the most valuable for diagnosis, compared to STIR (1.22) and T1 (1). The study group included 9 type A, 1 type B and 6 type C injuries. There were trends towards diminution in pouches' size, signal intensity and enhancement in follow-up studies, along with tendon stabilization within the ulnar groove. In control studies, ECU subsheath's visibility in medial, central and lateral parts were noted in 66.7-80%, 63.3-80% and 30-50% respectively. Conclusion: ECU subsheath's athletic injuries are visible on 1.5-T MRI studies. FS Gd T1 sequences in supination and pronation are the most valuable.

Cell therapies for tendons: old cell choice for modern innovation.

Although tissue engineering and cell therapies are becoming realistic approaches for medical therapeutics, it is likely that musculoskeletal applications will be among the first to benefit on a large scale. Cell sources for tissue engineering and cell therapies for tendon pathologies are reviewed with an emphasis on small defect tendon injuries as seen in the hand which could adapt well to injectable cell administration. Specifically, cell sources including tenocytes, tendon sheath fibroblasts, bone marrow or adipose-derived stem cells, amniotic cells, placenta cells and platelet-derivatives have been proposed to enhance tendon regeneration. The associated advantages and disadvantages for these different strategies will be discussed and evolving regulatory requirements for cellular therapies will also be addressed. Human progenitor tenocytes, along with their clinical cell banking potential, will be presented as an alternative cell source solution. Similar cell banking techniques have already been described with other progenitor cell types in the 1950's for vaccine production, and these "old" cell types incite potentially interesting therapeutic options that could be improved with modern innovation for tendon regeneration and repair.

The influence of skeletal muscle cell volume on the regulation of carbohydrate uptake and muscle metabolism

This study investigated the regulation of carbohydrate metabolism and glucose uptake through changes in skeletal muscle cell volume. Using an established invitro isolated whole muscle model, soleus (SOL) and extensor digitorum longus (EDL) muscles were dissected from male rats and incubated in an organ bath containing Sigma medium-199 with 8 mM D-glucose altered to target osmolality (hypo-osmotic: HYPO, iso-osmotic: ISO, hyper-osmotic: HYPER; 190, 290, 400 mmol/kg). Muscles were divided into two groups; metabolite (MM) and uptake (MU). MM (N=48) were incubated for 60 minutes and were then immediately flash frozen. MU (N=24) were incubated for 30 minutes and then the extracellular fluid was exchanged for media containing ^H-glucose and ^'*C-mannitol and incubated for another 30 minutes. After the incubation, the muscles were freeze clamped. Results demonstrated a relative water decrease and increase in HYPER and HYPO, respectively. EDL and SOL glucose uptakes were found to be significantly greater in HYPER conditions. The HYPER condition resulted in significant alterations in muscle metabolite concentrations (lower glycogen, elevated lactate, and G-6-P) suggesting a catabolic cell state, and an increase in glycogen synthase transformation when compared to the HYPO group. In conclusion, skeletal muscle cell volume alters rates of glucose uptake with further alterations in muscle metabolites and glycogen synthase transformation.

The influence of skeletal muscle cell volume on carbohydrate metabolism in contracting skeletal muscle

This study investigated the regulation of carbohydrate metabolism through changes in skeletal muscle cell volume immediately post contraction and during recovery. Using an established in vitro isolated muscle strip model, soleus (SOL) and extensor digitorum longus (EDL) were dissected from male rats and incubated in an organ bath (perfused with 95% O2; 5% CO2, pH 7.4, temperature 25°C) containing medium- 199 altered to a target osmotic condition (iso-, hypo- or hyper-osmotic; 290, 1 80, 400 mmol/kg). Muscles were stimulated for 10 minutes (40 Hz SOL; 30 Hz EDL) and then either immediately flash frozen or allowed to recover for 20 minutes before subsequent metabolite and enzyme analysis. Results demonstrated a relative water decrease in HYPER vs. HYPOosmotic condition (n=8/group; p<0.05) regardless of muscle type. Specifically, the SOL HYPER condition had elevated metabolite concentrations after 10 minutes of stimulation in comparison to both HYPO and ISO (p<0.05), while EDL muscle did not show any significant difTerences between the HYPER or HYPO conditions. After 20 minutes of recovery, metabolic changes occurred in both SOL and EDL with the SOL HYPER condition showing greater relative changes in metabolite concentrations versus HYPO. The results of the current study have demonstrated that osmotic imbalance induces metabolic change within the skeletal muscle cell and muscle type may influence the mechanisms utilized for cell volume regulation.

Force potentiation in the MDX mouse

Large forces are the primary mechanism of injury in muscular dystrophy, and muscular dystrophy is especially damaging to type IIB muscle fibers. It was hypothesized that post-tetanic potentiation (PTP) would be down-regulated to prevent damage in Xlinked muscular dystrophy (mdx) mice since PTP increases force and PTP effects are greatest in IIB fibers. PTP experiments were performed on the extensor digitorum longus (EDL) of 50 day old mdx (YM) and C57BL/10 (YC) mice and 10 month old mdx (OM) and C57B1710 (OC) mice. Twitch and tetanic forces were lower in mdx than controls and lower in younger than older mice. Contrary to the hypothesis, PTP was higher in both mdx groups compared to controls. OM potentiated more than any other condition (OM: 29.8%, OC: 23.2%, YM: 21.9%, YC: 17.2%). In accordance with literature PTP increased in the older groups. To explain PTP changes, fiber typing and Western blots for myosin light chain kinase (MLCK) were performed. YM and YC had similar fiber type profiles (2% I, 58% IIX/D and 40% IIB). In accordance with literature but contrary to expected conditions for elevated PTP, OM had a slower fiber type profile (1.7% I, 69% IIX/D and 29% IIB) than OC (0.4% I, 61% IIX/D and 38% IIB). No differences were found in MLCK expression. It seems that PTP is up-regulated to maintain muscle function rather than being down-regulated to prevent muscle damage. Ca""^ transient and myosin phosphorylation measurements would be beneficial in explaining increased PTP seen in this study.

Reliability of a new measure of motoneuron excitability

Objectlve:--This study examined the intraclass reliability· of different measures of the excitability of the Hoffmann reflex, derived from stimulus-response curves. The slope of the regression line of the H-reflex stimulus-response curve advocated by Funase et al. (1994) was also compared to the peak of the first derivative of the H-reflex stimulus-response curve (dHIdVmax), a new measure introduced in this investigation. A secondary purpose was to explore the possibility of mood as a covariate when measuring excitability of the H-reflex arc. Methods: The H-reflex amplitude at a stimulus intensity corresponding to 5% of the maximum M-wave (Mmax) is an established measure that was used as an additional basis of comparison. The H-reflex was elicited in the soleus for 24 subjects (12 males and 12 females) on five separate days. Vibration was applied to the Achilles tendon prior to stimulation to test the sensitivity of the measures on test day four. The means of five evoked potentials at each gradually increasing intensity, from below H-reflex threshold to above Mmax, were used to create both the H-reflex and M-wave stimulus response curves for each subject across test days. The mood of the subjects was assessed using the Subjective Exercise Experience Scale (SEES) prior to the stimulation protocol each day. Results: There was a modest decrease in all H-reflex measures from the first to third test day, but it was non-significant (P's>0.05). All measures of the H-reflex exhibited a profound reduction following vibration on test day four, and then returned to baseline levels on test day five (P's<0.05). The intraclass correlation coefficient (ICC) for H-reflex amplitude at 5% of Mmax was 0.85. The ICC for the slope of the regression line was 0.79 while it was 0.89 for dH/dVmax. Maximum M-wave amplitude had an ICC of 0.96 attesting to careful methodological controls. The SEES subscales of fatigue and psychological well-being remained unchanged IV across the five days. The psychological distress subscale (PO.05). Conclusions: The peak of the first derivative of the H-reflex stimulus-response curve (dH/dVmax) was shown to have comparable reliability and sensitivity to other more established measures of excitability. Psychological distress and the amplitude of the H-reflex at 5% Mmax follow similar trends across days, however there was no significant correlation between the two measures. Significance: The proposed method appears to be a more robust measure ofH-reflex excitability than the other methods tested. As such it would be an advantageous method to apply in clinical and investigative settings. Additionally, the results suggest that the relationship between psychological distress and H-reflex amplitude should be investigated further.

TIME COURSE OF SIGNALING PROCESSES INVOLVED WITH EXTRACELLULAR OSMOTIC - INDUCED GLUCOSE UPTAKE IN MAMMALIAN SKELETAL MUSCLE

Extracellular hyper-osmotic (HYPER) stress increases glucose uptake to defend cell volume, when compared to iso-osmotic (ISO) conditions in skeletal muscle. The purpose of this study was to determine a time course for changes in common signaling proteins involved in glucose uptake during acute hyper-osmotic stress in isolated mammalian skeletal muscle. Rat extensor digitorum longus (EDL) muscles were excised and incubated in a media formulated to mimic ISO (290 ± 10 mmol/kg) or HYPER (400 ± 10 mmol/kg) extracellular condition (Sigma Media-199). Signaling mechanisms were investigated by determining the phosphorylation states of Akt, AMPK, AS160, cPKC and ERK after 30, 45 and 60 minutes of incubation. AS160 was found to be significantly more phosphorylated in HYPER conditions compared to ISO after 30 minutes (p<0.01). It is speculated that AS160 phosphorylation increases glucose transporter 4 (GLUT4) content at the cell surface thereby facilitating an increase in glucose uptake under hyper-osmotic stress.

Phosphorylation of Skeletal Muscle Pyruvate Dehydrogenase Phosphatase in Response to Insulin Stimulation

Pyruvate dehydrogenase phosphatase (PDP) regulates carbohydrate oxidation through the pyruvate dehydrogenase (PDH) complex. PDP activates PDH, enabling increased carbohydrate flux towards oxidative energy production. In culture myoblasts, both PDP1 and PDP2 undergo covalent activation in response to insulin–stimulation by protein kinase C delta (PKCδ). Our objective was to examine the effect of insulin on PDP phosphorylation and PDH activation in skeletal muscle. Intact rat extensor digitorum longus muscles were incubated (oxygenated at 25°C, 1g of tension) for 30min in basal or insulin–stimulated (10 mU/mL) media. PDH activity increased 58% following stimulation, (p=0.057, n=11). Serine phosphorylation of PDP1 (p=0.047) and PDP2 (p=0.006) increased by 29% and 48%, respectively (n=8), and mitochondrial PKCδ protein content was enriched by 45% in response to stimulation (p=0.0009, n=8). These data suggest that the insulin–stimulated increase in PDH activity in whole tissue is mediated through mitochondrial migration of PKCδ and subsequent PDP phosphorylation.

Myosin Regulatory Light Chain Phosphorylation and Its Effect on the Contractile Economy of Mouse Fast Muscle

Activated by elevations in myoplasmic calcium concentration, myosin light chain kinase (skMLCK) phosphorylates the regulatory light chains (RLCs) of fast muscle myosin. This covalent modification potentiates force production, but requires an investment of ATP. Our objective was to investigate the effect of RLC phosphorylation on the contractile economy (mechanical output:metabolic input) of fast twitch skeletal muscle. Extensor digitorum longus muscles isolated from Wildtype and skMLCK-/- mice mounted in vitro (25°C) were subjected to repetitive low-frequency stimulation (10Hz,15s) known to cause activation of skMLCK, and staircase potentiation of force. With a 3-fold increase in RLC phosphate content, Wildtype generated 44% more force than skMLCK-/- muscles over the stimulation period (P = .002), without an accompanied increase in energy cost (P = .449). Overall, the contractile economy of Wildtype muscles, with an intact RLC phosphorylation mechanism, was 73% greater than skMLCK /- muscles (P = .043), demonstrating an important physiological function of skMLCK during repetitive contractile activity.

The Role of Membrane Lipid Composition on Skeletal Muscle Damage in the Rodent Model of Duchenne Muscular Dystrophy

Duchenne muscular dystrophy is a X-linked muscle disease, which leads to alterations in membrane phospholipid fatty acid (FA) composition and skeletal muscle damage. Increased membrane saturated FA in muscular dystrophy may suggest its association with increased susceptibility (as being the cause or consequence) to muscle damage. It was hypothesised that increased saturation is positively correlated to increased muscle damage. Correlations were hypothesized to be greater in extensor digitorum longus (EDL) at 20 weeks compared to soleus (SOL) at 10 weeks in dystrophin deficient (mdx) mice. Increased saturation was correlated to damage in EDL at both 10 and 20 weeks, with stronger correlations at 10 weeks. The results suggest that membrane PL FA composition may be associated with damage through two possible means. Increased saturation may be a cause or consequence of membrane damage. Association of membrane composition with eccentric induced damage has underscored the importance of saturated PL FA compositions in damage to dystrophic myofibres.