Abordagem baseada nas alterações do movimento escapular e investigação do medo relacionado à dor em indivíduos com dor no ombro
Kamonseki, Danilo Harudy
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Introduction: Shoulder pain is a common complaint with multifactorial characteristics that include biomechanical and psychosocial factors. Some interventions for shoulder pain are based on biomechanical changes commonly observed in those patients, such as changes in scapulothoracic muscles activation and scapular kinematics. However, there is no consensus on the efficacy of the biomechanics-based approach on scapular kinematics, scapulothoracic muscles activity, and clinical outcomes. The pain-related fear seems to play an important role in shoulder pain, but more information is needed to verify if it is a common condition for individuals with shoulder pain or if there are subgroups of individuals with distinct characteristics. Furthermore, the measurement properties of the Brazilian versions of two instruments that measure pain-related fear were not established in individuals with shoulder pain. This thesis is composed of four studies: Study 1: Objective: Systematically review the literature about the efficacy of electromyographic biofeedback for improving pain and function of individuals with shoulder pain. Methods: The databases Medline, EMBASE, CINAHL, PEDro, CENTRAL, Web of Science, and SCOPUS were searched in December 2020. Randomized controlled trials that investigated the effects of biofeedback electromyographic in individuals with shoulder pain and assessed pain and function were included. The level of evidence was assessed according to GRADE. Results and conclusion: Five studies were included with a pooled sample of 272 individuals. The biofeedback electromyographic was not superior to the other treatments for improving pain and function. However, the limited number of studies and very low quality of evidence do not support a definitive recommendation on the efficacy of biofeedback electromyographic for treating individuals with shoulder pain. Study 2: Objective: To compare the effects of scapular movement training to standardized exercises in individuals with shoulder pain. Methods: This is a single-blinded randomized controlled trial. Sixty-four individuals with chronic shoulder pain were randomly allocated to scapular movement training or standardized exercises for 8 weeks (2x/week). The primary outcome measure was the three-dimensional scapular kinematics. The secondary outcome measures were muscle activity of upper, middle, and lower trapezius, and serratus anterior, pain intensity, disability, fear-avoidance beliefs, kinesiophobia, and self-perceived health status. The scapular kinematics and muscle activity were assessed at baseline and 8th week, and the self-reported outcomes were collected at baseline, 4th, 8th, and 12th weeks. Results and conclusion: The scapular movement training showed significantly decreased scapular internal rotation in all angles of arm elevation and lowering at sagittal and scapular planes (mean difference [MD]: 2,8 - 4,1°), and at 30o of arm elevation and lowering at frontal plane (MD: 3,4 e 2,4 °, respectively), increased upper trapezius activity during arm lowering at scapular plane (MD: 10,3%), decreased middle trapezius (MD: 60.44%) and serratus anterior (MD: 9.9%) activity during arm lowering at frontal plane and arm elevation at the scapular plane, respectively, compared to standardized exercises. Both groups significantly improved pain, disability, fear-avoidance, kinesiophobia, and self-perceived changes over 4 weeks, which was sustained the remaining assessments. The observed between-group differences in scapular kinematics and muscle activity may not be clinically important. Both groups presented similar improvement over time on pain, disability, fear-avoidance beliefs, kinesiophobia, and self-perceived change in health condition. Study 3: Objective: To identify and describe phenotypes related to kinesiophobia, fear-avoidance, and pain catastrophizing, and determine clinical and demographic characteristics related to each phenotype as a function of self-reported function of the upper limbs in individuals with shoulder pain. Methods: One hundred and seventy-seven individuals with shoulder pain participated in this study. Tampa Scale of Kinesiophobia, Fear-Avoidance Beliefs Questionnaire, Pain Catastrophizing Scale, Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), Numerical Pain of Rating Scale, and the angular onset of pain during the elevation of the arm were measured in all participants. A cluster analysis was performed considering kinesiophobia, fear-avoidance, and pain catastrophizing, then clinical and demographic characteristics of clusters were used to model individual’s chance to belong to one of the clusters as a function of DASH. Results and conclusion: Two clusters were identified based on kinesiophobia, fear-avoidance, and pain catastrophizing. The cluster with worse pain-related fear profile presented (p < 0.05) higher age, worse function and higher pain intensity. This same cluster was also associated with involvement of the dominant side and worse function. Study 4: Objective: To verify the measurement properties of Brazilian versions of Fear-avoidance Beliefs Questionnaire (FABQ) and Tampa Scale of Kinesiophobia-11 (TSK) in individuals with shoulder pain. Methods: Individuals with shoulder pain and older than 18 years were included in this study. Structural validity was verified by exploratory and confirmatory factor analysis, which were used to identify dimensionality and to compare different structures of the FABQ and TSK. Test-retest reliability was assessed with intraclass correlation coefficient (3,1) and internal consistency with Cronbach’s alpha. Floor or ceiling effects were also investigated. Responsiveness was verified by effect sizes and area under ROC curve (AUC). Results and conclusion: Exploratory factor analysis identified three and two factors in the FABQ and TSK-11, respectively. All structures tested in this study did not fulfilled the criteria for adequate model fitting. FABQ and TSK-11 presented moderate to substantial reliability. One factor from FABQ and another from TSK-11 did not present adequate internal consistency. The floor effect was present in two factors from FABQ. The FABQ and TSK-11 showed small to large effect sizes and did not show adequate AUC. Therefore, FABQ and TSK-11 are multidimensional instruments, the internal structure was not clear and well-defined. The structural validity, reliability and responsiveness were found to be suboptimal in individuals with shoulder pain.
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