Hydrotherapy on exercise

Hydrotherapy on exercise capacity, muscle strength and quality of life in patients with heart failure: A meta-analysis

Mansueto Gomes Neto, Cristiano Sena Conceição, Fabio Luciano Arcanjo de Jesus , Vitor Oliveira Carvalho

Heart failure (HF) is clinically characterized by exercise intolerance, poor health related quality of life (HRQOL) and high mortality. Exercise training is a well-established method to improve exercise intolerance and to restore HRQOL in patients with HF. However, the most efficient modality is unknown. In this context, hydrotherapy (i.e. exercise in warm water) has been proposed as an alternative tool in the rehabilitation of patients with HF. There is no meta-analysis of the efficacy of this intervention in HF patients. The aim of this systematic review with meta-analysis was to analyze the published randomized controlled trials (RCTs) that investigated the effects of hydrotherapy on exercise capacity and HRQOL in HF patients. This review was planned and conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched for references on MEDLINE, EMBASE, CINAHL, PEDro, and the Cochrane Library up to May 2014 without language restrictions. This systematic review included all RCTs that studied the effects of hydrotherapy in aerobic capacity, muscle strength and/or HRQOL of the HF patients. Two authors independently evaluated and extracted data from the published reports. Methodological quality was also independently assessed by two researchers. Studies were scored on the PEDro scale a useful tool for assessing the quality of physical therapy trials based on a Delphi list that consisted of 11 items with a score range of 0 to 10.



Pooled-effect estimates were obtained by comparing the least square mean percentage change from baseline to study end for each group. Two comparisons were made: hydrotherapy versus control group (non exercise) and hydrotherapy versus aerobic exercise group. All analyses were conducted using Review Manager Version 5.0 (Cochrane Collaboration). Six papers met the eligibility criteria. Fig. 1 shows the PRISMA flow diagram of studies in this review. The results of the assessment of the PEDro scale are presented individually in Table 1. The final sample size for the selected studies ranged from 14 to 25 and mean age of participants ranged from 51 to 75 years. All studies analyzed in this review included outpatients with documented HF and New York Heart Association (NYHA) classes II–III. Table 2 summarizes the characteristics. Hydrotherapy was considered as aerobic and strength exercises in warm water and the duration of the programs ranged from 3 to 24 weeks. Regarding the time of the session, there was a variation from 30  to 90 minutes. The frequency of sessions was three times per week in three studies and five times per week in others. Four studies assessed peak VO2 as an outcome, two compared hydrotherapy versus no exercise [10,11] and two hydrotherapy versus conventional aerobic exercise in land. The meta-analyses showed a significant improvement in peak VO2 of 2.97 mL·kg−1 ·min−1 (95% CI: 1.99, 3.94, N = 42) for participants in the hydrotherapy group compared with the no exercise group (Fig. 2A). A non significant change in peak VO2 of −0.66 mL·kg−1 ·min−1 (95% CI: −2.05, 0.72, N = 48) was found for participants in the hydrotherapy group compared with conventional aerobic exercises (Fig. 2B). Three studies assessed the 6-minute walk test (6WMT) as an outcome [10,11,14], two compared hydrotherapy versus no exercise and one hydrotherapy versus aerobic exercises in land. Significant improvements were found when comparing hydrotherapy with no exercise controls. The meta-analyses showed (Fig. 3) a significant improvement in 6WMT of 43.8 m (95% CI: 7.36, 80.16, N = 42) for participants in the hydrotherapy group compared with the no exercise group. Three studies assessed muscle strength as an outcome, two compared hydrotherapy versus no exercise and one hydrotherapy versus aerobic exercise in land. Significant improvements were found when comparing hydrotherapy with no exercise controls. The meta-analyses showed (Fig. 4) a significant improvement in muscle strength of 23.7 Nm (95% CI: 4.49, 42.89, N = 42) for participants in the hydrotherapy group compared with the no exercise group. Two studies measured HRQOL. The meta-analyses showed non significant improvement in HRQOL of −4.5 (95% CI: −14.40, 5.49, N = 42) for participants in the hydrotherapy group compared with the no exercise group (Fig. 5). Meta-analysis demonstrated a significant difference in peak VO2, distance in the six-minute walking test, muscle strength and DBP between patients with HF submitted to hydrotherapy and controls. Moreover, hydrotherapy was as efficient as conventional aerobic exercise in land for peak VO2. It is now known that cardiac function actually improves during water immersion due to the increase in early diastolic filling and decrease in heart rate, resulting in improvements in stroke volume and ejection fraction. These data created a positive scenario to discuss hydrotherapy as a potential tool in cardiovascular rehabilitation. This systematic review with meta-analysis is important because it analyzes the hydrotherapy as a potential co-adjutant modality in the rehabilitation of patients with HF. The mean of peak VO2 in the analyzed studies was 17.05 at the beginning and 18.3 mL·kg−1 ·min−1 at the end of the intervention. It has been demonstrated that improvements above 10% after a cardiovascular rehabilitation program represent a good prognosis in patients with HF. It has also been demonstrated that a minimum VO2 peak of 15 mL·kg−1 ·min−1 in women and 18 mL·kg−1 ·min−1 in men aged 55–86 years seems to be necessary for full and independent living. Thus the improvement generated by the hydrotherapy program can contribute to those patients with CHF to have better conditions to carry out their everyday activities.




Quadriceps mass and strength are related to maximal exercise capacity in HF. Moreover, changes in muscle performance with exercise training have been demonstrated to be related to changes in physical function and quality of life. In the present systematic review, our meta-analysis demonstrated a significant difference in muscle strength between patients with HF submitted to hydrotherapy and sedentary controls. Despite the fact that hydrotherapy was shown to be efficient in improving peak VO2 and muscle strength, it is not possible to conclude about the benefits of hydrotherapy compared to no exercise in HRQOL. Considering the available data, our meta-analysis showed that hydrotherapy was efficient to improve exercise capacity in patients with HF. Well controlled RCTs are needed to understand the potential bene- fits of hydrotherapy in patients with HF.

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Idosos com osteoartrite de joelho obesos e não obesos

Durante o processo de envelhecimento, ocorrem perdas funcionais que se acentuam devido à falta de atividade do sistema neuromuscular e à redução da força muscular e do condicionamento físico. Além da redução da funcionalidade, o idoso perde de maneira mais acentuada a capacidade de reter água e de produzir proteoglicanos, o que causa alterações degenerativas articulares, como a osteoartrite (OA). Um dos fatores de risco para a OA é a obesidade. Além de ser um fator de risco para a OA, a associação entre OA e obesidade pode aumentar a intensidade da dor e das limitações funcionais, devido a uma maior descarga de peso na articulação acometida, com estreitamento do espaço intra‐articular, que pode aumentar a dor articular, rigidez e atrofia muscular. Numa recente metanálise que avaliou o risco para o inicio da OA, reportam que pessoas obesas têm três vezes mais risco de desenvolver OA em relação a indivíduos sem sobrepeso.

O peso excessivo aumenta tanto a pressão quanto a força sobre a articulação, ativa mecanismos de degradação da cartilagem articular, esclerose do osso subcondral e formação de osteófitos e leva ao agravamento da AO. Esses fatores podem influenciar negativamente na qualidade de vida (QV) de idosos obesos acometidos pela doença. A OA por si só ou em conjunto com a obesidade está associada a um maior risco de morbimortalidade e pode reduzir a QV do idoso. Um atributo essencial na saúde do idoso é a sua capacidade funcional, um componente chave para avaliação global da saúde. Além de ser fator de risco para a AO, a obesidade pode agravar sintomas e aumentar o declínio funcional de idosos com OA. Compreender fatores que interferem na capacidade funcional e QV de idosos com AO pode contribuir na formulação de estratégias de prevenção e tratamento. Diante disso, este estudo teve como objetivo comparar a capacidade funcional e a QV de idosos com OA de joelho, obesos e não obesos.

Leia o artigo completo: http://www.sciencedirect.com/science/article/pii/S0482500415001035


Mansueto Gomes-Neto, Anderson Delano Araujo, Isabel Dayanne Almeida Junqueira, Diego Oliveira, Alécio Brasileiro, Fabio Luciano Arcanjo

Comparative study of functional capacity and quality of life among obese and non-obese elderly people with knee osteoarthritis

Revista Brasileira de Reumatologia (English Edition), Volume 56, Issue 2, March–April 2016, Pages 126-130


Dynamic leg length asymmetry during gait is not a valid method for estimating mild anatomic leg length discrepancy

Gustavo Leporace, Luiz Alberto Batista, Raphael Serra Cruz, Gabriel Zeitoune, Gabriel Armondi Cavalin, Leonardo Metsavaht


Anatomic limb length discrepancy (ALLD) has been related to different orthopedic conditions, such as posterior tibial tendon dysfunction and hip osteoarthritis, due to an inadequate distribution of mechanical loads, as well as gait kinematics asymmetries resulted from ALLD have been related to plantar fasciitis, low back pain, and anterior knee pain. On the other hand, some studies have shown that limb length discrepancy (LLD) lower than 35 mm would not have a hazardous outcome in both function and etiology of orthopedic conditions. Khamis and Carmeli suggested that the controversy regarding the role of LLD on orthopedic conditions is related to the poor validity of measurement methods and the several abnormal biomechanical alterations that could be caused by LLD. Although there is no established gold standard method for assessing ALLD, the most accurate and reliable tools used to assess this condition currently involve radiation emission. Also, these methods are subject to minor errors, such as magnification or rotation and may require compliance of the patient to stand still for a long time. Therefore, a radiation-free tool to provide information about the patients’ LLD effects becomes very attractive. Recently, Khamis and Carmeli published a case report on a new promising concept for measuring LLD using a 3D motion analysis. The authors utilized a gait analysis biomechanical model to access dynamic leg length discrepancy (DLLD) and compared the results to ALLD, measured by standing x-ray, with concordant findings. Although 3D motion analysis (3DMA) is a recognized tool to analyze the consequences of LLD on gait parameters so far it has not been validated to determine ALLD. The purpose of this study was to test the validity of dynamic leg length discrepancy (DLLD) during gait as a radiation-free diagnostic screening method for measuring anatomic leg length discrepancy (ALLD). To achieve that purpose, we calculated the correlation and difference between DLLS, acquired by a 3D motion analysis system during gait, and ALLD values, acquired by x-ray scanogram. It was expected that DLLD between hip joint center (HJC) and heel marker (HEE) and HJC and ankle joint center (AJC) in the loading response and single support phase would be a valid strategy, i.e. have high correlation and no significant difference, to measure ALLD. Following the same philosophy, DLLD between HJC and toe marker (TOE) was expected to be a valid strategy to measure ALLD during pre-swing phase, as proposed by Khamis and Carmeli. These hypotheses relied on the presumption of the inverted pendulum model during support phase of gait and the movement of the distal markers in relation to the ground during each gait phase.


2.1. Participants

Thirty-three subjects (17 females) with average age, mass and height of 43.0 ± 22.1 years, 71.2 ± 18.3 kg, 169.2 ± 11.8 cm, respectively, participated in the study. All subjects presented rearfoot strike during gait. The inclusion criteria were all subsequent subjects seen by the same Orthopedic Surgeon (L.M.), with lower-limb and/or lower back complaints that on clinical examination the LLD ranged from 0 to 2 cm. This range was chosen because the prevalence of LLD of 2 cm or less has been reported to be higher than 99% on the general population. ALLD was assessed by measuring the length of the femur and tibia by the scanogram method as described in Sabharwal and Kumar. All participants did the digital radiographic exam (Model DR-F, GE Hualum Medical Systems) in the same radiology laboratory and measurements performed by the same Radiologist. The exclusion criteria were history of lower limb fractures, realignment or joint reconstruction surgery, radiologic scoliosis 10° or higher according to Cobb angles, pregnancy, discomfort or inability to perform the exams accordingly. The study was approved by the local institutional Ethical Committee for Human Experiments. All participants were informed about the purpose of the study and risks and consented before participation.

2.2. Procedures

Initially, a standing trial in a static position was collected for each subject to individualize marker position, calculate joint centers and segment positions during walking. Then, participants performed a barefoot walk along an eight meters long walkway. Subjects were instructed to walk at their self-selected speed performing six trials along the walkway, and the last three gait cycles for each lower limb captured by the motion analysis system were used for analysis.

2.3. Data reduction

Kinematic data were collected using an 8 high-speed cameras motion analysis system (Vicon, Oxford, UK) with a sample rate of 100 Hz. Markers, segments and joint centers were set according to Plug-In Gait recommendations. Data were filtered by a fourth order zero-lag low pass Butterworth filter, with a cut-off frequency of 6 Hz, and Euler angles of lower limbs were calculated using Nexus software (Vicon, Oxford, UK). To determine stance and swing phases of each cycle, the Foot Velocity Algorithm was used. Dynamic leg length (DLL) was defined as the effective length of the lower limb, measured by three variables, according to Khamis and Carmeli: (i) the distance from the HJC to the HEE (HJC-HEE); (ii) the distance from the HJC to the AJC (HJC-AJC); (iii) the distance from the HJC to the TOE (HJC-TOE). Dynamic leg length discrepancy (DLLD) was measured by the difference between functional leg lengths of both sides. Predictor variables were the peak and average DLLD (HJC-HEE; HJC-AJC; HJC-TOE) during loading response, single limb support, and pre-swing phases of gait. Interest variable was ALLD.

2.4. Data analysis

Pearson correlation coefficients were calculated to determine the associations between predictors (peak and average DLLD, in cm, in the three gait phases described above) and interest (ALLD) variables. Predictor variables that presented significant correlations with coefficient higher than 0.4 were included in a multiple linear regression with ALLD as output. Stepwise approach was used to find the best model among all predictor variables possibilities, using the Akaike information criterion (AIC) to include variables into the models. To assess the fitting of the model, a leave-one-out cross-validation procedure was used. All coefficients of the models were calculated using data from 38 subjects, and data from the subject left out of the analysis were used to simulate ALLD. Paired Student t-tests were applied to compare the differences between each predictor variable and ALLD. To estimate the magnitude of the difference between groups, Cohen’s d effect size was calculated. Cohen classified effect sizes as small (d < 0.2), medium (0.2 < d < 0.5), and large (d > 0.8). Significance level was set at 5%. Statistical significance was set at α = 0.05. All statistical analyses were performed using MATLAB (version 8.6.0, The Mathworks, USA).


The subjects showed a mean ALLD of 1.0 ± 0.7 cm. There were no significant correlations between predictors and interest variables (Table 1, Table 2). As no predictor variable showed significant results, no multiple linear regression models were possible to be developed.

table 1 table2

Peak DLLD values presented significant difference from ALLD in loading response (Peak HJC-TOE), single leg support (Peak HJC-AJC and Peak HJC-TOE) and Pre-Swing (Peak HCJ-HEE), although all effect sizes had medium values (Table 3). There were no significant differences between average DLLD and ALLD in any phase of gait. All effect sizes values were lower than 0.8 (Table 3).

table 3


The aim of this study was to test the validation of a radiation-free method to predict anatomic leg length discrepancy (ALLD). The results of our study did not support our initial hypothesis. There were no significant correlations between DLLD measures with ALLD during the different support phases of gait. As the coefficients of correlation were not significant, no regression equation was developed to predict ALLD from dynamic leg length asymmetries. This result suggests DLLS during gait is not a valid metric to predict ALLD. On the other hand, most of paired t-tests did not reveal differences between all DLLD measures and ALLD, what may explain the similar value found by Khamis and Carmeli in their case report. Although gait analysis is a valid and reliable tool to calculate joint angles and moments, such alterations may occur to compensate ALLD, in order to minimize the deleterious effect of LLD and decrease displacement of center of mass due to the limb discrepancy. Pelvic elevation of the longer leg in single limb support phase of gait is a kinematic variable that has been found in patients with different ALLD magnitudes. Alterations in sagittal plane as hip, knee and ankle flexion were found in some studies. Despite the lack of validity of DLLD to predict ALLD, there are evidences of association between the magnitudes of limb discrepancy and compensatory strategies during gait. This could explain the negative correlation coefficients between predictor and interest variables found in the present study. Therefore it is recommended further research to determine if joint angles in the sagittal and frontal planes could provide a more accurate prediction of ALLD. Our study included only subjects with mild discrepancy so, it is acceptable that our negative results may be related to the lack of significant biomechanical alterations associated to leg length asymmetry and it is not possible to predict accurately ALLD without image exams. The purpose of this study was to test the validation of DLLD during gait to predict ALLD with a radiation free strategy, so we decided to include all subjects with ALLD lower than 2 cm to be more realistic with clinical practice. A possible strategy to deal with that is developing non-linear models, as neural networks to predict ALLD to take into consideration these subjects without clinically significant asymmetries. Further studies should include subjects with higher asymmetry to develop a more general model to screen subjects with significant ALLD.


The data analysis revealed no correlation between anatomic leg length discrepancy and dynamic leg length discrepancy, measured by a 3d motion analysis. Although the dynamic leg length discrepancy during gait analysis is an interesting tool to depict movement asymmetries, it was not proved to be a valid method to predict ALLD in subjects with mild limb discrepancy. So, DLLD during gait should not be used as a screening tool to predict ALLD in orthopedic injured patients.

Link do artigo: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5895928/


Condromalácia patelar

Condromalácia patelar é o amolecimento e degeneração da cartilagem da patela, decorrente do uso excessivo, trauma direto ou indireto decorrente de alteração biomecânica da articulação patelo femoral, representando uma causa comum de dor anterior no joelho.

O tratamento visa o fortalecimento do músculo que está em desequilíbrio, a fim de melhorar a disfunção e o reequilíbrio muscular. Assim, o paciente passa por tratamentos e medidas que fortaleçam a musculatura do joelho e quadril. O trabalho da AF Fisioterapia é realizar junto com o paciente exercícios para a região, com o objetivo de melhorar a função e encorajar o paciente ao retorno da prática esportiva.


Fisioterapia especializada

A Clínica AF Fisioterapia foi idealizada com o intuito de proporcionar um tratamento personalizado, respeitando a individualidade de cada paciente. Está sentindo dor no quadril ou joelho? Procure nossos especialistas qualificados e conheça o nosso protocolo de atendimento baseado em evidências:

1. Avaliação Clínica Detalhada: o corpo clínico formado por fisioterapeutas avaliam de forma global e funcional cada, colhendo todos os dados importantes para início do tratamento:

2. Avaliação Cinemática: caso seja necessário, o paciente pode ser encaminhado para avaliação com sistema 2D que permite analisar quaisquer alterações na força ou funcionalidade pode ser utilizado;

3. Protocolo Exclusivo de Atendimento: foco no alinhamento biomecânico possibilitando maior qualidade de vida.



Síndrome femoropatelar, via Instituto Trata

O que é?

A Síndrome da Dor Femoropatelar (SDFP) é ocasionada por um desequilíbrio biomecânico, que atinge a articulação do joelho, mais especificamente a articulação entre o fêmur e a patela. Acomete até 25% da população, sendo mais comum em mulheres sedentárias e indivíduos com grau de treinamento elevado.

Diversas causas podem estar relacionadas com a SDFP como: largura excessiva da pelve, joelho valgo, fraqueza muscular dos músculos do quadril e da coxa, patela alta, insuficiência ligamentar, dentre outros.


Dor na região anterior do joelho, ao subir e descer escadas, ao agachar e saltar, após longo período sentado (sinal do cinema), estalos ao andar e correr, sensação de areia dentro da articulação.

Diagnóstico e exames

Um exame físico deve ser realizado pelo fisioterapeuta especializado ou médico a fim de avaliar prováveis insuficiências de partes moles, acometimento de estruturas articulares, além de fatores que afetem as força e o alinhamento articular.

O tratamento depende da causa da dor no joelho, sendo geralmente conservador, baseado em técnicas de Fisioterapia. A fisioterapia específica visa melhorar o deslizamento da patela sobre o sulco troclear no fêmur, utilizando exercícios de fortalecimento muscular e correção biomecânica. Os resultados das sessões de fisioterapia vão depender das características individuais de cada paciente.

Postagem original: http://ojoelho.com.br/sindrome-da-dor-femoropatelar/


A trajetória de Bino Lopes

Por: Fabrício Fernandes

Comecei a ficar de olho nesse garoto e a primeira vez que vi sua performance ao vivo foi em uma etapa do Nordestino em Stella Maris, Salvador, em um mar mexido e pequeno. Bernardo Lopes era seu nome, ou simplesmente Bino, e ele ganhou essa etapa com um nível bem superior a todos! Logo me veio aquela opinião de colunista crítico na cabeça: “Quero ver em ondas de verdade!”.

E a resposta de Bino veio em um dos maiores mares da Cacimba do Padre, Fernando de Noronha, de todos os tempos. Ondas massivas de mais de 12 pés, rodando pesado no beachbreak, fazendo muito garotão devolver o dinheiro da competição, ou se esconder na praia, como me contou um amigo juiz. Na grande quarta-feira, como ficou chamada, a etapa chegou a ser adiada pelo tamanho das ondas. O que Bino fez? Não só dropou as maiores como faturou a etapa, que contou com nomes como ninguém menos que Bruno “Mr.Tube” Santos!

Em mares de responsa, também com 12 pés plus, nos QS primes de Sunset e Haleiwa, teve performances espetaculares em algumas baterias, sendo destaque nas mídias havaianas. Depois disso, o garoto local de Villas do Atlântico continuou sua saga mundo afora, chegando ao seu auge no ano de 2015 com a vitória no QS de Anglet, na França, e uma etapa do SuperSurf na Joaquina (SC), se tornando campeão brasileiro e terminando o QS em 38º do mundo!

Bino, depois de ter chegado tão perto da sonhada vaga do CT, veio ainda mais renovado. Fazendo um trabalho forte com o preparador físico Ricardo Lobão, o fisioterapeuta Fabio Arcanjo e o treinador Adson Maurício, ele tem se dedicado com total afinco aos treinos.

Resultados expressivos vem aparecendo ao longo dos anos e da carreira do atleta!



Lower limb muscle strength in patients with low back pain: a systematic review and meta-analysis

Camila Santana de Sousa, Fabio Luciano Arcanjo de Jesus, Mariana Barcelos Machado, Grimaldo Ferreira, Isabela Guimarães Tinoco Ayres, Letícia Moraes de Aquino, Thiago Yukio Fukuda, Mansueto Gomes-Neto


Stability is a key component of any mechanical system. Lumbar and pelvic instability may be associated with dysfunctions in the lumbar spine, hip, and knee regions. Weakness, shortening, and/or muscle stiffness of muscles of the lumbar and pelvic regions can contribute to dysfunction manifested as low back pain (LBP). Lumbar instability and inefficient lumbopelvic motor control appear to be related to the amount of pain and disability present in nonspecific LBP. Since the proposed stability model of Panjabi, the muscles of the lumbar region have been the subject of studies in patients with chronic LBP. Hodges and Richardson evaluated patients with and without LBP and showed that patients with pain demonstrate delayed activation of the transverse muscle of the abdomen. However, other biomechanical factors such as the pelvic tilt during functional activities, altered motor control of the lumbopelvic region, and the lack of coordination between the mobility of the pelvis and trunk may also be associated with the presence of LBP. Lumbopelvic imbalance due to inefficiency of muscles of the hip has been explained as a factor associated with the presence of LBP. Lower limb muscles, especially the hip muscles, have an important role in lumbar spine stability. Strength and proper activation of the lower limb muscles can contribute to the coordination between the hip and trunk, aiding in the transfer of forces between the lower limbs and the lumbopelvic region. Although studies establish the relationship of the coordination of forces generated between the hip and lumbar spine during functional activities, there are controversies in the literature about the role of lower limb muscles in lumbar stability and the inefficiency of these muscles in people with chronic LBP. In addition, a complete understanding of motor impairments associated with LBP would optimize exercise interventions for patients with LBP. Moreover, as far as we know, there is no meta-analysis of lower limb muscle strength in patients with low back pain. Thus, the aims of this study were to systematically review the published studies that compare lower limb muscle strength in patients with LBP to that of matched healthy controls.


This meta-analysis was completed in accordance with Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) guidelines.

Eligibility criteria

This systematic review included articles that evaluated lower limb muscle strength in patients with LBP. Studies were eligible for this systematic review if they met the following criteria: 1) included patients with chronic, nonspecific LBP were included in this systematic review. For this study, chronic, nonspecific LBP was defined as LBP of longer than 3 months’ duration without leg pain; 2) only studies comparing lower limb muscle strength in patients with LBP to that of a healthy control group. No restriction was made in terms of number of participants, gender, publication status or language. Studies that enrolled Studies that enrolled patients with acute LBP or LBP in association with neurologic diseases were excluded from this systematic review.

Search methods for identification of studies

We searched for references using Medline, SciELO, Cumulative Index to Nursing and Allied Health (CINAHL), and Scopus up until December 2017, without language restrictions. A standard protocol for this search was developed and controlled vocabulary Medical Subject Headings [MeSH] terms for Medline) was used. Key words and their synonyms were used to sensitize the search (“pain”; “low back pain “; “leg”; “lower limb”; “strength”; “torque”; “force’’). For the preparation of the search strategy, two groups of keywords were used: participants and outcomes. We checked the references used in the articles included in this systematic review to identify other potentially eligible studies. For ongoing studies, authors were contacted by e-mail to obtain confirmation of any data or additional information.

Data collection and analysis

The aforementioned search strategy was used to obtain titles and abstracts relevant to this review. Each identified abstract was independently evaluated by two reviewers. If at least one of the researchers considered a reference eligible, the full text was obtained for complete assessment. Two reviewers independently assessed the full text of selected articles to verify their conformity to the eligibility criteria. Two reviewers independently extracted data from the published studies using standard data extraction forms adapted from Higgins and Green. Aspects of the study population, devices and instruments used to assess muscle strength outcomes, muscle strength data, and results were reviewed. Any further information required from the original author was requested by e-mail. A flow diagram of the study selection process based on PRISMA recommendations is seen in Figure 1.

Data extraction

Two authors, independently blinded, extracted descriptive and outcome data from the included studies using a standardized form developed by the authors and adapted from the Cochrane Collaboration’s model for data extraction. We considered the following data: 1) aspects of the study population, such as the diagnosis, disease duration, average age, and sex; 2) aspects of the measures performed (sample size, instruments, muscles, joints, movements, positions, strength, dynamometer device, total time); and 3) study results.

Assessment of risk of bias

The methodological quality was assessed across four domains (sample, study design, analysis of outcomes, and presentation of information), culminating in a total of 14 items. This tool was based on the list of items developed by Lankhorst et al.16, which used the Cochrane criteria, the Newcastle-Ottawa Scale, and studies conducted by van Rijn et al.17 and Tulder et al.18.

Statistical assessment

Means and standard deviations of lower limb muscle strength were extracted for the purpose of calculating differences between groups. In studies reporting absolute values of muscle strength (Newtons [N] or Newton-meters [Nm]) and/or explosive muscle strength (N/s or Nm/s), these values were subsequently normalized to the body mass reported by the respective studies. If body mass was not reported, the corresponding author of the study was contacted to obtain the data. When necessary, standard deviation was extracted or calculated using available data (e.g., confidence intervals [CIs]) or information presented in graphical format.

Data analysis

Standardized mean differences (SMDs) were calculated from means and standard deviations of muscle strength data. The SMDs of 0.2, 0.5, and 0.8 were considered small, moderate, and large, respectively.19 The percentage difference in muscle strength was also calculated to provide a further indication of the relative difference in strength between patients with LBP and control participants [(LBP strength – control strength)/control strength × 100]. Results were grouped according to the type of strength measurement (e.g., isometric or isokinetic) or joint action performed. Data were pooled for multiple studies in a meta-analysis within each group using a random-effects model. An α value <0.05 was considered statistically significant. Statistical heterogeneity of the treatment effect among studies was assessed using Cochran’s Q test and the I2 inconsistency test, for which values between 25% and 50% were considered indicative of moderate heterogeneity, and values greater than 50% were considered indicative of high heterogeneity18. All analyses were conducted using Review Manager Version 5.3 (Cochrane Collaboration).


As presented in the PRISMA flowchart (Figure 1), after screening 37 full texts for eligibility, a total of 14 published studies21-34 were included in the systematic review. A supplementary table with results of the assessment of the methodological quality can be found in Electronic Supplementary File 1.

Study characteristics

The number of participants included in this systematic review ranged from 951 healthy controls to 919 patients with LBP. The mean age of participants ranged from 20.0 to 47.9 years old for healthy controls and 19.3 to 48.6 years old for patients with LBP. 10 studies included patients of both genders, 2 studies included only male patients, 1 study included only female patients, and 1 study did not specify gender. Isokinetic strength testing was used to quantify lower limb muscle strength in 7 studies, and isometric dynamometry was used in 3 studies. Isokinetic strength was expressed as peak torque (Nm) in 2 studies, and as body weight-normalized peak torque (Newton-meters per kilogram [Nm/kg]) in 5 studies. Isometric muscle strength was measured as body weight-normalized peak torque. Two studies measured the muscle strength by manual pressure meter. Sample size, strength measure, joints, and movements of included studies are summarized in Table 1. The muscle strength data of studies included in the systematic review are provided in Table 2. Eight studies contained sufficient information to be pooled in a meta-analysis to compare lower limb muscle strength in patients with LBP to that of healthy control groups. Four studies were able to be pooled to compare isokinetic strength. All studies reported muscle strength data as mean and SD. Thus, there was no need to transform data. Five studies assessed hip abductor muscle strength. A total of 1,003 participants (551 patients with LBP and 452 healthy controls) were included in these 5 studies. Due to the difference between the instruments used in the assessment of hip abductor muscle strength, we performed a meta-analysis using SMD. A significant difference in isokinetic muscle strength of the hip abductors of 0.7 (95% CI: 0.49 to 0.9) was found between participants in the healthy control group and the LBP group. (Figure 2A) Two studies assessed hip extensor muscle strength. A total of 636 participants (318 patients with LBP and 318 healthy controls) were included in these 2 studies. Due to the difference between the instruments used in the assessment of hip extensor muscle strength, we performed a metaanalysis using SMD. A significant difference in isokinetic muscle strength of the hip extensor of 0.93 (95% CI: 0.62 to 1.23) was found between participants in the healthy control group and the LBP group. (Figure 2B) Three studies assessed isokinetic muscle strength of the knee extensors. A total of 194 participants (109 patients with LBP and 85 healthy controls) were included in these 3 studies. A significant difference in isokinetic muscle strength of the knee extensors of 0.31 Nm/kg (95% CI: 0.1 to 0.5) was found between participants in the healthy control group and the LBP group. (Figure 3A) Three studies assessed isokinetic muscle strength of the knee flexors. A total of 194 participants (112 patients with LBP and 82 healthy controls) were included in these 3 studies. A no significant difference in isokinetic muscle strength of the knee flexors of 0.1 Nm/kg (95% CI: -0.07 to 0.4) was found between participants in the healthy control group and the LBP group (Figure 3B).


The main finding of the current systematic review was that lower limb muscle strength was significantly lower in patients with LBP compared with that of healthy controls. In terms of hip strength, there was moderate-quality evidence that patients with LBP have weaker hip abduction/ extension strength when compared with that of healthy controls. When considering isokinetic knee strength, there was moderate-quality evidence that patients with LBP have weaker knee extension when compared with that of healthy controls. The results of this systematic review have significant clinical implications. Muscle strength is a strong predictor of health. In a recent study, Li et al.35 concluded that low muscle strength is independently associated with elevated risk of allcause mortality. In another recent study, Roshanravan et al.36 reported that low isometric muscle strength was associated with persistent severe lower extremity limitation.  range of lower-limb chronic diseases. In addition, muscle strength is a critical aspect of human movement that can influence tissue stress. The hip muscles are tightly coupled with lumbar paraspinal muscles via the thoracolumbar fascia, which allows the load transfer from the lumbar spine to the lower extremities. In addition, the hip muscles help to control rotational alignment of the lower limbs and maintain pelvic stability during single-leg stance. Thus, hip muscle weakness may also contribute to LBP due to abnormal segmental movement of the lumbar spine if the pelvis is not stable during gait or standing. However, the contribution of hip weakness to LBP development is unknown. Moreover, although our findings indicate that hip muscle strength was significantly lower in the LBP group (vs. the healthy control group), other studies have found no relationship between hip strength and development of back pain. In a recent systematic review, Steinberg et al.43 assessed whether hip muscle performance was associated with leg, ankle, and foot injuries. They concluded that there is limited evidence that hip muscle performance variables are related to leg, ankle, and foot injuries, and that emerging evidence indicates that poor hip muscle performance might be a result of the injury rather than a contributor to the injury. Knee strength deficits in patients with LBP are less conclusive. There is very moderate evidence that knee extensor strength was significantly lower in patients with LBP compared with that of healthy controls; however, patients with LBP have isokinetic muscle strength of knee flexors comparable to that of healthy controls. Because LBP is one of the leading causes of pain and disability in adults, it is important to find pragmatic treatments that not only treat the pain, but also decrease disability. Moreover, it is well understood that movement is altered in the presence of pain. Our findings are important for the physiotherapist responsible for reviewing exercise protocols for patients with LBP. The results may provide evidence for innovative interventions that target lower limb muscle strength and motor control in patients with LBP. In addition, while this review identified patients with LBP who also had lower limb weakness, it is not possible to present a single muscle strength value that identifies those in the clinic who are weak versus those who are not. Exercise is effective in reducing the severity of chronic pain, as well as providing more general benefits associated with improved overall physical and mental health. The medical literature suggests that the exercise programs prescribed for patients with LBP have been primarily focused on activation of the deep trunk muscles. However, patients with LBP also require targeted training in muscle endurance and strength; this provides a theoretical basis for prevention of disability and rehabilitation of these patients. The results of this study should be interpreted with caution because muscle strength differences observed between groups were small. Limitations in the present study need attention. Results were limited by heterogeneity between studies, insufficient standardization, and absence of control for confounders in individual studies. This heterogeneity may be associated with the different methods and protocols used to measure muscle strength in the studies and the small number of studies included in the meta-analysis. Furthermore, the small number of studies included in the meta-analysis reduces the I2’s power to adequately detect heterogeneity between studies. In terms of measuring maximal strength, the isokinetic dynamometer muscle strength test is considered the gold standard test; however, studies included in the review assessed muscle strength using other instruments. In addition, the inclusion of studies with both medicated and non-medicated patients could pose significant challenges, with emerging lines of evidence indicating that nonsteroidal anti-inflammatory drugs could improve muscle strength in patients with chronic LBP49,50. The current systematic review highlights the importance of conducting future studies with larger samples to determine the magnitude of the relationship between lower limb muscle strength and the development of LBP.


When compared to that of healthy controls, lower limb muscle strength may be lower in patients with LBP. Clinical trials are required to analyze the inclusion of lower limb muscle strengthening in the rehabilitation protocols used to manage the treatment of patients with LBP.

Confira o artigo original: Lower limb muscle strength in patients with low back pain


Contrologia no Pilates

Quem conhece um pouco sobre a história do Pilates sabe que o nome dado ao método por Joseph Pilates era “contrologia”. Isso porque o mais importante para ele era o controle total do corpo e da mente, por meio dos exercícios e dos princípios, traçados abaixo:

A respiração é um dos princípios mais importantes do método Pilates, e por este motivo está presente em todos os exercícios. Devemos usar um padrão respiratório eupneico (não aumentar nem diminuir a frequência respiratória), utilizando a parte inferior do tronco.
A concentração está diretamente relacionada com a atenção. Para realizar um exercício com concentração, precisamos estar atentos a todos os estímulos que recebemos. Devemos nos concentrar em cada parte do corpo, na sua disposição e se o alinhamento está correto.

Alinhamento Postural:
Melhorar a postura é um dos motivos que levam milhares de pessoas a procurar o método Pilates. Todas as estruturas do corpo devem estar alinhadas durante a prática do Pilates.

Ter controle é realizar os movimentos com consciência, evitando compensações musculares e posições indesejadas. É realizar o exercício de forma exata, tendo plena noção de que ele está saindo da forma planejada, sem que as outras regiões do corpo sejam afetadas pelo movimento.

A fluidez é o princípio que garante que todos os movimentos sejam leves e harmoniosos, sempre seguindo o ritmo da respiração.

A precisão, assim como a concentração, também ajuda a unir corpo e mente. Ela também está muito ligada ao controle, pois juntos eles garantem movimentos precisos e controlados, sendo a chave para exercícios com o máximo de eficiência e o mínimo de lesão.

Centralização da força:
A centralização da força é um dos focos mais importantes da técnica do Pilates. Durante todos os exercícios é necessário estar com o centro do corpo ativado e estável, por meio da contração dos músculos do tronco.

[Informações via Revista Pilates, publicação no dia 29.04.2015: http://revistapilates.com.br/2015/04/29/principios-da-contrologia/]