Brazilian Journal of Physical Therapy

Transcrição

1 Brazilian Journal of Physical Therapy Journal affiliated with the Associação Brasileira de Editores Científicos A B E C ISSN Rev Bras Fisioter, São Carlos, v. 14, n. 4, p , jul./ago Revista Brasileira de Fisioterapia

2 ISSN Rev. Bras. Fisioter., São Carlos, v. 14 n. 4 INFORMAÇÕES BÁSICAS A Revista Brasileira de Fisioterapia/ Brazilian Journal of Physical Therapy é o veículo da Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia (ABRAPG-Ft). Publicada a partir de 1996, a Revista adota o processo de revisão por especialistas (peer review), sendo que cada artigo somente é publicado apenas após a aceitação dos revisores, mantidos no anonimato. Os editores não assumem nenhuma responsabilidade por danos a pessoas ou propriedades que possam ser causados por uso das idéias, técnicas ou procedimentos contidos no material publicado nesta revista. A submissão de artigos pressupõe que estes artigos, com exceção dos resumos ampliados, não tenham sido publicados anteriormente, nem submetidos a qualquer outra publicação. O título abreviado da revista é Rev. Bras. Fisioter., forma que deve ser usada em bibliografias, notas de rodapé, referências e legendas bibliográfi cas. Nenhuma parte desta publicação pode ser reproduzida ou transmitida, por qualquer meio, seja eletrônico, mecânico ou fotocópia sem expressa autorização dos editores. MISSÃO: publicar artigos científi cos relativos ao objeto básico de estudo e campo de atuação profi ssional da Fisioterapia, veiculando estudos básicos e aplicados sobre a prevenção e tratamento das disfunções de movimento. BASIC INFORMATION The Revista Brasileira de Fisioterapia/ Brazilian Journal of Physical Therapy is published by the Brazilian Association for Research and Graduate studies in Physical Therapy. Published since 1996, the Brazilian Journal of Physical Therapy adopts a peer review process. Each article is only published after it is accepted by the reviewers, who are maintained anonymous during the process. The editors accept no responsibility for damage to people or property, which may have been caused by the use of ideas, techniques or procedures described in the material published by this journal. The submission of articles presupposes that these articles, with the exception of extended summaries, have not been previously published elsewhere, nor submitted to any other publication. The abbreviated title of the journal is Rev. Bras. Fisioter., and this must be used in references, footnotes and bibliographic legends. No part of this publication can be reproduced or transmitted by any media, be it electronic, mechanical or photocopy, without the express authorization of the editors. MISSION: to publish scientifi c articles related to the areas of study and professional activity in Physical Therapy, specially basic and applied research on the prevention and treatment of movement disorders. Indexada nos seguintes bancos de dados/ Indexed in the following databases: MEDLINE (National Library of Medicine), CINAHL, CSA, EMcare, JCR (Journal Citation Reports), LILACS, LATINDEX, Periódica, SciELO, SciSearch (Science Citation Index Expanded), Scopus and SPORTDiscus Endereço para contato/ Contact adress: Revista Brasileira de Fisioterapia/ Brazilian Journal of Physical Therapy, UFSCar, Rod. Washington Luís, Km 235, Caixa Postal 676, CEP , São Carlos, SP - Brasil Tel/Fax: +55(16) ; contato@rbf-bjpt.org.br Suporte Técnico - Administrativo/ Technical - Administrative Support: Ana Paula de Luca, Daiane Rossi, Leonor A. Saidel Aizza and Lucilda P. Rosales Produção Editorial/ Editorial Production: Zeppelini Editorial, Rua Dr. César, 530, Cj. 1308, Santana, São Paulo, SP Tel/Fax: (11) ; Printed in acid free paper Assinatura: consulte o site/subscription: see web site Revista Brasileira de Fisioterapia (Brazilian Journal of Physical Therapy)/Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. v. 1, n. 1 (1996). São Carlos: v. 14, n. 4 (jul./ago. 2010). Bimestral Sumários em Inglês e Português ISSN Fisioterapia/periódicos I. Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Revisão/Review Librarian: Dormélia Pereira Cazella CRB 8/4334 ii

3 Sumário / Summary ISSN Rev Bras Fisioter, São Carlos, v. 14, n. 4, p , jul./ago Revista Brasileira de Fisioterapia EDITORIAL v Um triênio de conquistas conjuntas no CNPq Three years of accomplishments at CNPq Helenice J. C. G. Coury, Marisa C. Mancini ARTIGOS ORIGINAIS/ORIGINAL ARTICLES 276 The effects of knee extensor eccentric training on functional tests in healthy subjects Os efeitos do treino isocinético excêntrico dos extensores do joelho nos testes funcionais em sujeitos saudáveis Heleodório H. Santos, Mariana A. Ávila, Daniela N. Hanashiro, Paula R. Camargo, Tania F. Salvini 284 Quality of life and discriminating power of two questionnaires in fibromyalgia patients: Fibromyalgia Impact Questionnaire and Medical Outcomes Study 36-Item Short-Form Health Survey A qualidade de vida e o poder de discriminação de dois questionários em pacientes com fi bromialgia: Fibromyalgia Impact Questionnaire e Medical Outcomes Study 36-Item Short-Form Health Survey Ana Assumpção, Tatiana Pagano, Luciana A. Matsutani, Elizabeth A. G. Ferreira, Carlos A. B. Pereira, Amélia P. Marques 290 Ventilação não invasiva no pós-operatório imediato de derivação gastrojejunal com bypass em Y de Roux Noninvasive ventilation in the immediate postoperative of gastrojejunal derivation with Roux-en-Y gastric bypass Kivânia C. Pessoa, Gutemberg F. Araújo, Alcimar N. Pinheiro, Maria R. S. Ramos, Sandra C. Maia 296 Relação entre o ângulo quadriciptal (ÂQ) e a distribuição da pressão plantar em jogadores de futebol Relationship between quadriceps angle (Q) and plantar pressure distribution in football players Rafael G. Braz, Gustavo A. Carvalho 303 Aferição dos equipamentos de laser de baixa intensidade Calibration of low-level laser therapy equipment Thiago Y. Fukuda, Julio F. Jesus, Marcio G. Santos, Claudio Cazarini Junior, Maury M. Tanji, Helio Plapler 309 Avaliação do desempenho motor global e em habilidades motoras axiais e apendiculares de lactentes frequentadores de creche Assessment of global motor performance and gross and fi ne motor skills of infants attending day care centers Carolina T. Souza, Denise C. C. Santos, Rute E. Tolocka, Letícia Baltieri, Nathália C. Gibim, Fernanda A. P. Habechian 316 Determinação da relação potência-duração em exercício com membros superiores Determination of the power-duration relationship in upper-limb exercises Domingos Belasco Junior, Fernando R. Oliveira, José A. N. Serafi ni, Antonio C. Silva 322 Fatores determinantes da capacidade funcional em idosos longevos Determinant factors of functional status among the oldest old Silvana L. Nogueira, Rita C. L. Ribeiro, Lina E. F. P. L. Rosado, Sylvia C. C. Franceschini, Andréia Q. Ribeiro, Eveline T. Pereira 330 Alinhamento de cabeça e ombros em pacientes com hipofunção vestibular unilateral Head and shoulder alignment among patients with unilateral vestibular hypofunction Adamar N. Coelho Júnior, Juliana M. Gazzola, Yeda P. L. Gabilan, Karen R. Mazzetti, Monica R. Perracini, Fernando F. Ganança 337 Ventilatory and muscular assessment in healthy subjects during an activity of daily living with unsupported arm elevation Avaliação ventilatória e muscular de indivíduos saudáveis durante atividade de vida diária com os braços elevados e sem apoio Giselle F. L. Panka, Marina M. Oliveira, Danielle C. França, Verônica F. Parreira, Raquel R. Britto, Marcelo Velloso 344 Effects of treadmill-walking training with additional body load on quality of life in subjects with Parkinson s disease Efeitos do treino da marcha em esteira com aumento da carga corporal sobre a qualidade de vida de sujeitos com doença de Parkinson Nadiesca T. Filippin, Paula H. Lobo da Costa, Rosana Mattioli iii

4 351 Electromyographic activity during active prone hip extension did not discriminate individuals with and without low back pain Atividade eletromiográfi ca durante o movimento de extensão do quadril em prono não discrimina indivíduos com dor lombar Cristiano Q. Guimarães, Ana C. L. Sakamoto, Glória E. C. Laurentino, Luci F. Teixeira-Salmela CARTA AO EDITOR/LETTER TO THE EDITOR 358 O acesso aos Programas de Reabilitação Pulmonar na rede pública de saúde Access to pulmonary rehabilitation programs within the public healthcare service Cristiane Mecca Giacomazzi 359 O acesso aos Programas de Reabilitação Pulmonar na rede pública de saúde (réplica dos autores) Access to pulmonary rehabilitation programs within the public healthcare service (reply by the authors) Vanessa Suziane Probst, Fábio Pitta ÍNDICE/INDEX INSTRUÇÕES GERAIS AOS AUTORES/GENERAL INSTRUCTIONS TO AUTHORS iv

5 EDITORIAL ISSN Rev Bras Fisioter, São Carlos, v. 14, n. 4, p. v-vii, jul./ago Revista Brasileira de Fisioterapia Um triênio de conquistas conjuntas no CNPq Three years of accomplishments at CNPq Foi com grande satisfação que representamos as áreas de Fisioterapia e Terapia Ocupacional junto ao Conselho Nacional de Pesquisa (CNPq) no triênio julho junho Apresentamos aqui um breve relato das atividades desenvolvidas e alguns resultados de nossa atuação. Essa foi a primeira representação eleita pela comunidade de pesquisadores de nossas áreas, fato que nos deixou muito honrados e compromissados com a tarefa que nos cabia realizar. Nesse período, participamos de julgamentos anuais de Editais Universais, demos apoio à realização de eventos científicos, bolsas especiais (pós-doutorado no país, pós-doutorado no exterior, doutorado sanduíche no exterior, pesquisador visitante), bolsas de iniciação científica, bolsas de apoio técnico, bolsas produtividade em pesquisa e também julgamos editais esporádicos, tais como, o Edital Jovem Pesquisador (2008) e Novos Campi (2009). Participamos também da discussão dos critérios de avaliação e políticas para a área, demonstrando sistematicamente o grande crescimento da nossa comunidade de pesquisadores por meio de documentos apoiados em dados. Isso foi feito sobretudo como forma de justificar a necessidade de maior aporte de auxílios e bolsas. O trabalho foi bastante intenso e nos trouxe, algumas vezes, frustração, como no caso do julgamento do Edital Jovem Pesquisador, quando recebemos muitas propostas qualificadas nas faixas A (79 solicitações de até 500 mil reais) e na faixa B (11 solicitações de até 120 mil reais), mas uma verba total de apenas R$ 413 mil para atender as propostas das duas faixas. Em outras ocasiões, esse trabalho nos trouxe grande satisfação, como no caso da obtenção do Edital MCT/CNPq/CT-Saúde N.58/2009, intitulado Envelhecimento, Trabalho e Saúde: promoção da qualidade de vida da população brasileira por meio da atividade física, ocupacional e linguagem. Esse foi o primeiro edital induzido pelo próprio comitê para as nossas áreas, conseguido por iniciativa nossa após muitas cartas e contatos com a diretoria e presidência do CNPq. Ainda obtivemos verba junto a Ministérios que visitamos com dificuldade por ser uma atividade muito diferente daquelas com que estamos familiarizados. No entanto, tivemos um apoio importante do Prof. Marco Antonio Zago, presidente do CNPq na ocasião, e do Dr. Isaac Roitman, do Ministério de Ciência e Tecnologia, a quem agradecemos. Importante lembrar também que aprendemos o caminho das pedras, e isso poderá ajudar os futuros representantes a buscarem novas alternativas de financiamento para nossas pesquisas. A existência de critérios de avaliação e sistema claro de pontuação dos currículos, disponível on line no site do CNPq, tornou nossa tarefa mais transparente e tranquila. Fizemos relatos da nossa atividade para os participantes dos editais de cada ano no triênio. A seguir, passamos a relatar brevemente algumas informações sobre os dois editais regulares que são julgados anualmente pelo comitê, os quais podem ajudar a comunidade a entender o processo de avaliação e conhecer alguns dos seus resultados. Rev Bras Fisioter. 2010;14(4):v-vii. v

6 Edital Universal As chamadas para este edital eram anteriormente bianuais. Passaram a ser anuais neste triênio, o que duplicou as chances de obtenção de apoio para os pesquisadores. Uma outra característica desse edital é que 30% da verba disponibilizada é atribuída a propostas qualificadas dos estados brasileiros das regiões Norte, Nordeste e Centro-Oeste. Em 2007, tivemos 111 solicitações totais distribuídas nas três faixas (A, B e C), e houve disponibilidade orçamentária para atender 20 projetos, que contemplaram 10 instituições diferentes. Já em 2008, recebemos 81 propostas, ocasião em que foram apoiadas 23 solicitações pelo CNPq nas três faixas do edital. Em 2009, recebemos 117 solicitações, e houve disponibilidade para apoiar 27 propostas, distribuídas em 13 diferentes instituições, situadas em 8 diferentes estados brasileiros, assegurando boas condições de fomento às pesquisas de diferentes grupos do país. O número de propostas apoiadas depende do valor disponibilizado pelo CNPq para cada faixa e guarda relação com a competitividade dos participantes daquele grupo. Mas, depende também da demanda geral apresentada pela área, já que a verba disponibilizada pelo CNPq para cada comitê é estabelecida em função do valor demandado pelos seus pesquisadores em cada edital. Portanto, submeter propostas qualificadas é uma forma consistente de apoiar a área, sobretudo nas chamadas anuais regulares do Edital Universal e de bolsas produtividade em pesquisa. Visitar constantemente os sites do CNPq possibilita conhecer um número grande de editais abertos aos quais podemos submeter solicitações. As propostas que estão enquadradas nos requisitos de cada edital são avaliadas por mérito, quando se considera a qualidade dos projetos e a pontuação dos currículos de cada participante. Nas avaliações realizadas no triênio, constatamos um aumento progressivo nas pontuações dos participantes a cada ano. Na Tabela 1, apresentamos alguns números da avaliação dos currículos dos participantes do último Edital Universal (2009). Tabela 1. Ordem de grandeza das pontuações para as propostas recomendadas em Dispersão da pontuação das propostas por faixas. Faixa A Faixa B Faixa C Média do grupo 75,0 66,2 60 Desvio-padrão 74,4 70,7 73,8 Pontuação média CVs das propostas recomendadas 108,7 132,0 188,0 Bolsas Produtividade em Pesquisa Em 2007, quando iniciamos nossa atuação no CNPq, as áreas de Fisioterapia/Terapia Ocupacional contavam com 28 bolsistas de produtividade em pesquisa (PQ) de 9 instituições diferentes; hoje temos 52 bolsistas de 16 instituições distintas. Isto representa um crescimento extraordinário de 85,7% em um triênio! Representa também um crescimento em diversidade, consequente do processo de ampliação de nossa pesquisa em diferentes instituições e regiões. O número de solicitações para os editais PQ tem sido alto (em 2007, N=50; em 2008, N=49 e, em 2009, N=76). A demanda qualificada também tem crescido (aproximadamente 50% dessas solicitações eram qualificadas, e uma parte delas, altamente qualificada!), o que é muito positivo para a nossa área. Os critérios de avaliação por nós utilizados são públicos e estão disponíveis na nossa área no site do CNPq. Tais critérios foram aprovados após consulta à comunidade, quando enviamos carta convidando-a a participar do processo. O fato de muitas propostas qualificadas serem submetidas precisa ser reconhecido e celebrado, pois significa que a comunidade acredita no processo de avaliação a que se submete. Mais importante ainda é que, com a apresentação de uma demanda qualificada crescente, a comunidade ajuda os representantes a justificarem junto ao CNPq a solicitação de mais verbas e bolsas para a área. Isso foi feito, sistemática e consistentemente por meio de muitas cartas à presidência do CNPq, visitas às diretorias vi Rev Bras Fisioter. 2010;14(4):v-vii.

7 e presidência e por meio dos relatórios finais ao CNPq para todos os editais julgados. Portanto, ao submeterem um número grande de propostas qualificadas, os pesquisadores apoiam, de forma concreta, o crescimento da área. Assim sendo, queremos reconhecer a resposta que tivemos de nossa comunidade, expressa pela submissão de muitas propostas qualificadas, o que contribuiu para aumentar a visibilidade das áreas de Fisioterapia e Terapia Ocupacional no CNPq e impulsionar a obtenção de apoio da agência para a produção do conhecimento em nossas áreas. Continuem participando e enviando propostas qualificadas! Finalmente, gostaríamos de comunicar que os novos representantes para o próximo triênio estão sendo indicados pelo CNPq. Desejamos a eles um período bastante produtivo e que sejam coroados de enorme sucesso nesta atividade. Helenice Jane Cote Gil Coury Representante Titular das Áreas de Fisioterapia e Terapia Ocupacional Multidisciplinar de Saúde CNPq Triênio julho junho 2010 Marisa Cotta Mancini Representante Suplente das Áreas de Fisioterapia e Terapia Ocupacional Multidisciplinar de Saúde CNPq Triênio julho junho 2010 Rev Bras Fisioter. 2010;14(4):v-vii. vii

8 ISSN Rev Bras Fisioter, São Carlos, v. 14, n. 4, p , July/Aug Revista Brasileira de Fisioterapia ORIGINAL ARTICLE The effects of knee extensor eccentric training on functional tests in healthy subjects Os efeitos do treino isocinético excêntrico dos extensores do joelho nos testes funcionais em sujeitos saudáveis Heleodório H. Santos 1, Mariana A. Ávila 2, Daniela N. Hanashiro 2, Paula R. Camargo 2, Tania F. Salvini 2 Abstract Background: It is well known that eccentric training increases muscle strength and promotes greater neural activation, and therefore has been used in the recovery of knee extensors. The hypothesis of this study was that there would be a strong correlation between knee extensor torque and functional tests. Objectives: To investigate the relationship between knee extensor peak torque and functional tests of agility (runs) and propulsion (hop for distance) after short-term isokinetic eccentric training. Methods: Twenty healthy and active male undergraduate students (age years; height m; weight kg; body mass index: kg/m 2 ), with no abnormalities or history of injury of the limbs, performed an isokinetic assessment of the knee extensors and fl exors and also functional tests before and after isokinetic training, which consisted of 3 sets of 10 MVECs at 30 o /s, with 3 minutes of rest between sets, twice a week for 6 weeks. Results: The eccentric training increased the extensor peak torque (16, 27 and 17%; P<0.01) and decreased the H/Q ratio (10, 20 and 13%; P<0.01) for the isometric and eccentric modes at 30 /s and 120 /s, respectively. It also decreased the time in two of the fi ve agility tests (carioca and pivot diagonal; P<0.01), and increased the distance in the hop tests, for both dominant and non-dominant limbs (P<0.01). Conclusions: Although the eccentric training led to an increase in extensor peak torques as well as an improvement in most of the functional tests, the hypothesis that a strong correlation would be observed between peak torques and functional tests was not confi rmed. Article registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) under the number Keywords: hop tests; agility tests; torque; knee; eccentric training; H/Q ratio. Resumo Contextualização: Sabe-se que o treino excêntrico aumenta a força muscular, promovendo uma maior ativação neural e, portanto, tem sido usado na recuperação do torque extensor. A hipótese deste estudo foi a de que possa existir uma forte correlação entre o torque extensor do joelho e os testes funcionais. Objetivos: Correlacionar o torque extensor do joelho com os testes funcionais de agilidade (corridas) e impulsão (saltos em distância) após o treino isocinético excêntrico de curta duração. Métodos: Vinte homens universitários, ativos e saudáveis (22,5 2,1 anos; 1,72 0,10 m; 67,8 9,5 kg; IMC 22,5 2,0 kg/m 2 ), sem reportar anormalidades ou história de lesão no membro inferior, realizaram avaliação isocinética do torque extensor e fl exor do joelho e testes funcionais antes e depois do treino isocinético que consistiu em três séries de 10 CEVM a 30º/s, com 3 minutos de repouso entre as séries, realizado duas vezes por semana, durante seis semanas. Resultados: O torque extensor aumentou (16, 27 e 17%; P<0,01), a razão I/Q diminuiu (10, 20 e 13%; p<0,01) para os modos: isométrico e excêntrico a 30 /s e 120 /s, respectivamente; diminuiu o tempo em dois dos cinco testes de corridas (carioca e pivô diagonal; P<0,01) e aumentou a distância nos testes de saltos tanto para o membro dominante quanto para o não dominante (P<0,01). Conclusões: Embora o treino excêntrico tenha aumentado o torque dos extensores do joelho, bem como melhorado a maioria dos testes funcionais, a hipótese de uma forte correlação entre essas variáveis não se confi rmou. Artigo registrado no Australian New Zealand Clinical Trials Registry (ANZCTR) sob o número Palavras chave: testes de saltos; testes de agilidade; torque; joelho; treino excêntrico; razão I/Q. Received: 06/10/2008 Revised: 22/04/2009 Accepted: 15/09/ Physical Therapy Department, Universidade Federal da Paraíba (UFPB), João Pessoa (PB), Brazil 2 Physical Therapy Department, Universidade Federal de São Carlos (UFSCar), São Carlos (SP), Brazil Correspondence to: Tania de Fátima Salvini, Departamento de Fisioterapia, Universidade Federal de São Carlos, Rodovia Washington Luis, Km 235, CP 676, CEP , São Carlos (SP), Brazil, tania@ufscar.br 276 Rev Bras Fisioter. 2010;14(4):

9 Eccentric training versus functional tests Introduction Due to its anatomic and functional characteristics, the knee is one of the most overloaded joints in the musculoskeletal system 1. Many studies have demonstrated the effectiveness of resistance training 2 in improving physical performance and treating musculoskeletal injuries to this joint 1,3,4. Because eccentric exercise promotes greater neural activation compared to isometric and concentric contractions 5, it is considered to be a powerful stimulus to hypertrophy 6 and muscle strength 7. However, the extent of these morphofunctional changes depends on the intensity, frequency and duration of training 8,9. Regular exercise programs with heavy loads have led to muscle hypertrophy, but the strength gain acquired before the hypertrophy has been attributed to increased neural activity 10. Widrick et al. 11 observed an increase of more than 60% in the strength of the vastus lateralis muscle after short-term resistance training, which changed the muscle s functional properties. Some studies that evaluated the knee flexors and extensors recorded higher torque during the eccentric 12,13 and concentric 14 contraction, respectively, at low speeds. The most common tool to evaluate the effects of resistance training is isokinetic dynamometry because it allows the control of significant movement variables, such as range of motion, angular velocity, work load, exercise mode (isometric, concentric or eccentric) and identifies the agonist/antagonist ratio 1,2,4,13,15,16. Additionally, the functional tests of agility (runs) and hop for distance provide security and efficiency parameters, being extensively used to assess the athlete s capacity to resume training after injury 20. Although these functional tests are considered reliable (>80%) and sensitive (>82%), their relationship with the muscle torque of knee extensors and flexors is still controversial in the literature 21, given that the methodologies differ in: concentric 2,15,22-24 and/or eccentric mode 13,16,25 ; velocity of movement (30, 60, 70, 90, 120, 150, 180, 240, 270, 300 and 400 /s) 13,16,25 and muscle group (extensors 25,26 and/or flexors 2,13,15,16 ). In light of the above considerations, the hypothesis of the present study was that the strengthening of knee extensors would lead to an improvement in joint function, which could be evidenced by the agility and hop for distance tests. Due to the fact that eccentric movement at low speed generates higher torque than the other contraction modes 12-14, this study analyzed the short-term effects of isokinetic eccentric training at low speed (30 /s) on the knee extensors in healthy subjects with the aim of verifying a possible linear correlation between knee torque and performance in functional tests. Methods Subjects The initial sample consisted of 25 healthy and active male undergraduate students selected from a school of physical therapy. Five of them were excluded from the study: three due to knee pain during training and two due to absence. A total of 20 subjects completed the study (age years; height m; weight kg; body mass index/bmi kg/m 2 ). After answering a questionnaire, the subjects were selected according to the following criteria: a) no regular muscle strength training; b) BMI below 24 kg/m 2 ; and 3) no musculoskeletal injuries or balance disorders (Lachman test, varus and valgus tests at 0 and 30º). The study was conducted in accordance with the Human Research Ethics Committee of Universidade Federal de São Carlos (UFSCar), São Carlos (SP), Brazil, and all subjects signed an informed consent form (approval number 144/2004 CEP/UFSCar). Torque evaluation The dominant leg (right=5; left=15) was identified before the torque evaluation by asking the subject which leg he would use to kick a ball and by asking the subject to hop over an obstacle. The tests were conducted on the non-dominant leg because it is the one used for postural support and propulsion 27,28. Initially, the subjects warmed up on a stationary bicycle (75W) for 5 min at 20 km/h, followed by a set of three 30-s stretches ( followed by 30-s intervals) focused on knee flexors, knee extensors and plantar flexors. Next, the subjects were positioned in an isokinetic dynamometer (Biodex Multi-Joint System 3, Shirley, NY) with the backrest reclined 5º from vertical and knees flexed at 90º. To avoid compensatory movements, straps were positioned across the subject s trunk, pelvis, and thigh. The dynamometer axis was aligned with the axis of rotation of the knee joint (lateral femoral epicondyle) and the dynamometer lever arm was attached to the distal leg (5 cm above the medial malleolus) so as to allow full ankle dorsiflexion 29. The familiarization period consisted of three submaximal eccentric contractions of the knee extensors, followed by a 3-min rest period. The effect of gravity on torque was corrected with the knee flexed at 60, and the adjustment for correction was calculated by using the instrument s software, according to Dvir 29. The knee extensor and flexor torques were evaluated under isometric and eccentric isokinetic (30º/s and 120º/s) conditions. To measure the maximal isometric torque, the dynamometer lever arm was fixed at 60º for knee extension 25 and at 30º for knee flexion 30. The evaluation consisted of one set of three Rev Bras Fisioter. 2010;14(4):

10 Heleodório H. Santos, Mariana A. Ávila, Daniela N. Hanashiro, Paula R. Camargo, Tania F. Salvini 278 maximal voluntary isometric contractions (MVIC) lasting 5s each, with 1-min rest intervals 31. The mean peak torque (MPT) of the three contractions was calculated for each subject 7,8. The range of motion (ROM) for the eccentric isokinetic evaluations was set to 70 (extension from 20 to 90, and flexion from 90 to 20 ). Each test (30º/s and 120º/s) consisted of one set of five consecutive maximal voluntary eccentric contractions (MVEC) with a 1-min rest period between velocities 29. The MPT obtained for the 5 contractions of knee extensors and flexors was calculated at the end of each set. During the evaluations and training, the subjects received verbal stimulation provided by the same examiner in a standardized manner to encourage maximal contraction. Additionally, the subjects were provided with visual feedback displayed as a graph on the instrument s screen 22. The conventional hamstring/quadriceps (H/Q) ratio was calculated by dividing the flexor peak torque by the extensor peak torque and multiplying this result by for all contraction modes (isometric and eccentric) and velocities (30 o /s and 120 o /s). Isokinetic training Prior to each training session, the equipment was calibrated and the subjects underwent the same warm-up and stretch protocols as previously described. Afterwards, they followed an eccentric (bilateral) training protocol focused on the strengthening of the knee extensors. This consisted of three sets of 10 MVECs 23 at 30º/s, with a 3-min rest period between sets 9. Studies that examined eccentric contraction in the knee flexors and extensors at Figure 1. Functional tests: shuttle run (1); pivot diagonal run (2); fi gure-eight run (3); lateral run (4); carioca (5); single hop (6); triple hop (7). Rev Bras Fisioter. 2010;14(4): low speeds 13,16 found higher torque. Training was performed twice a week for six weeks (12 sessions), alternating dominant and nondominant limbs, with an interval of at least 48h between sessions. Functional tests Initially, the subjects performed a brief warm-up that consisted of running around the court at low velocity (trotting) for 5 minutes. Afterwards, they followed the same stretch protocol as the one used for torque evaluations. Functional tests were carried out before and after the eccentric isokinetic training of the knee extensors (pre- and post-training) and consisted of five agility tests (shuttle run, lateral run, carioca, pivot diagonal run and figure-eight) at maximal velocity, and two hop for distance tests (single and triple). One- and two-min rest intervals were allowed between the sets of the agility and hop tests, respectively. For the shuttle and lateral runs, and carioca, a 6-m distance was marked with two cones placed one in front of the other. In the shuttle run (Figure 1.1), the subjects were instructed to run back and forth. For the pivot diagonal run (zigzag), two parallel columns were demarcated by two cones on each side, keeping a 6-m distance between the cones on the same side and a 5m distance between the cones on opposite sides placed diagonally (Figure 1.2). The subjects were instructed to run from one cone to the opposite cone, then turn around (pivot) to the right or the left, alternately, and run diagonally toward another cone, thus completing a distance of 15 m 33. For the figure-eight run (Figure 1.3), two parallel columns were placed 4 m apart. Each column was formed by three cones positioned 1 m apart. The subjects were instructed to run around the two columns so as to form a figure eight 33,34. The lateral run (Figure 1.4) was in a straight line, but the subjects had to run sideways from right to left (round trip). In the carioca (Figure 1.5), the displacement was also performed sideways from right to left, but the subjects used a cross over step, alternating one leg in front of the other 18,19. In all agility tests, verbal commands (i.e. ready, set, go! ) were given to the subjects with the aim of standardizing the beginning of the test and the time-keeping process. For the hop for distance tests (single and triple), the subjects were instructed to stand on one foot, behind the starting line, find their balance and then perform the hop when they felt ready. For the single hop for distance test (Figure 1.6), the distance between the starting point and the landing point of the tested foot was measured For the triple hop for distance test (Figure 1.7), the same procedure was used to calculate the distance relative to three consecutive hops 18,19,40. For each type of hop, three attempts were performed, alternating right and left legs. In both pre- and post-training, all subjects performed the functional tests (agility and hop for distance) in the same

11 Eccentric training versus functional tests sequence (runs: shuttle, lateral, carioca, pivot diagonal and figure-eight; hop for distance test: single and triple). For the post-training, a 72-h interval was allowed after the last session of isokinetic training. With the purpose of standardizing the procedures, all the tests were initiated by the non-dominant limb. Three attempts were performed for each of the functional tests of agility and horizontal propulsion, and the means of the three attempts were calculated for both time and distance variables. Data analysis The Statistical Package for the Social Sciences (SPSS) was used for the statistical analysis (mean, standard deviation, paired t-test, Wilcoxon, one-way ANOVA, and ICC). The MPT and the variance of the conventional H/Q ratio for peak torque were analyzed for all modes and velocities evaluated in pre- and post-training. The functional tests were used to investigate the differences between pre- and post-training means and to investigate a possible relationship with MPT (ICC). With regard to the correlation tests (ICC), values ranging from 0 to 0.5 were considered weak, values ranging from 0.51 to 0.75 were considered moderate, and values above 0.75 were considered strong. A significance level of 5% (P<0.05) was used for all analyses. Results Isokinetic dynamometry MPT For the comparisons of MPT for knee extensors between pre- and post-training, there was a gain of 16% (P<0.01) for the isometric mode, 27% (P 0.01) for the eccentric mode at 30º/s and 17% (P<0.01) at 120º/s. Also, the knee flexors had an increase of 8% (P<0.05) for MPT in the eccentric mode at 30 /s, although this mode did not compose the training protocol (Table 1). Time to peak torque (TPT) In general, the means of the TPT tended to decrease, although it was only statistically significant in the eccentric mode at 30º/s (P<0.01; Table 2). Hamstring/Quadriceps Ratio (H/Q) As shown in Table 3, there was a significant decrease in the conventional H/Q ratio after training in all modes and velocities analyzed, but the greatest decrease percentage (20%) was observed in the eccentric mode at 30 /s, followed by the eccentric mode at 120 /s (13%), and the isometric mode (10%). The one-way ANOVA test showed that the training protocol used in the study increased the difference in the H/Q ratio between contraction modes. For pre-training, there was a difference between isometric mode and eccentric mode at 120 /s (P<0.05). For post-training, there was a difference between isometric mode and eccentric mode at 30º/s (P<0.05), and a difference between the velocities of 30º/s and 120º/s in the eccentric mode (P<0.01). Table 1. Comparisons of the means of peak torque (Nm) before and after 6 weeks of isokinetic eccentric training of the knee extensors. Torque Pre-training Mean of peak torque (Nm) Post-training t-test (paired) Gain (%) Extensors Isometric ** Eccentric 30º/s ** < Eccentric 120º/s ** Flexors Isometric Eccentric 30º/s * Eccentric 120º/s Nm=Newton.meter; * significant difference at P<0.05; ** significant difference at p<0.01. Table 2. Time to Peak Torque (ms) between pre- and post-training after 6 weeks of isokinetic eccentric training of knee extensors. Torque Time to peak torque (ms) Pre-training Post-training Extensors Eccentric 30º/s * Eccentric 120º/s Flexors Eccentric 30º/s Eccentric 120º/s * P=0.003 (Wilcoxon). Table 3. Hamstrings/Quadriceps ratio between pre- and post-training in non-dominant limb. Contraction Modes Hamstrings/quadriceps ratios (%) Pre-training Post-training t-test (paired) Difference (%) Isometric Eccentric 30º/s < Eccentric 120º/s Rev Bras Fisioter. 2010;14(4):

12 Heleodório H. Santos, Mariana A. Ávila, Daniela N. Hanashiro, Paula R. Camargo, Tania F. Salvini Table 4. Comparison of the means of the functional tests before and after 6 weeks of isokinetic eccentric training of the knee extensors. Functional Tests Evaluations Pre-training Post-training p value Shuttle run (s) Lateral run (s) Carioca (s) <0.01 Pivot diagonal run (s) <0.01 Figure-eight run (s) SHDL (m) <0.05 SHNDL (m) <0.01 THDL (m) <0.05 THNDL (m) <0.01 Results: mean stand deviation; SHDL=single hop dominant limb; SHNDL=single hop non-dominant limb; THDL=triple hop dominant limb; THNDL=triple hop non-dominant limb; s=second; m=meter; (Wilcoxon); (t test). Functional tests There were significant differences (P<0.01) for two of the five agility tests (carioca and pivot diagonal run) when comparing the means of functional tests in pre- and post-eccentric training of the knee extensors (Table 4). For the hop for distance tests, there were significant differences in the single and triple hop for distance tests for both limbs, however the non-dominant limb showed greater significance (P<0.01) than the dominant limb. Correlation: MPT versus functional tests There were weak correlations (r 0.5) between the MPT of knee extensors and flexors and the functional agility tests for all modes and velocities, in both pre- and post-training. The correlations for the hop for distance tests in pre- and posttraining for both test types (single and triple) were generally weak (r 0.5). However, there was a weak and moderate correlation, in pre-training, between the MPT of knee extensors and the single hop for distance test in the eccentric mode at 30º/s and 120º/s (r=0.50 and 0.53, respectively). There was also a moderate correlation between the MPT of knee extensors and the triple hop for distance test in the eccentric mode at 30º/s (r=0.56). Moderate and strong correlations were also observed between the MPT of knee flexors in the eccentric mode at both velocities and the single hop for distance test (r=0.63 and 0.78, respectively). In the post-training, the correlation between the MPT of knee flexors, in the eccentric mode, at 120 /s was also moderate (r=0.60), although it was shown to be lower than the correlation seen for the pre-training. Discussion The results of the present study showed that peak torque increased after isokinetic eccentric training in all of the contraction modes and velocities analyzed (isometric, and eccentric at 30º/s and 120º/s), therefore in agreement with several authors 9,28, The greatest torque gain was observed in the eccentric mode at 30 /s, as supported by previous studies 25,26, however a torque increment was also observed in the isometric mode and eccentric mode at 120 /s, a fact also evidenced by Blazevich 47. According to several studies, resistance training promotes changes in the neurological system, leading to force gain 43,46, especially in the first eight weeks, without significant increase in the cross-sectional area of the muscle 28. Using functional magnetic resonance imaging, Duchateau and Enoka 48 showed an increase in the modulation of the motor cortex area on muscles of the hand after 3 weeks of training. Although variables such as number, firing rate and synchronization of the active motor units were not analyzed in the current study, it is possible to assume that the torque gained in response to the training protocol (6 weeks) is a result of the changes in muscle recruitment patterns 9,44,45. The flexor peak torque was also increased in the eccentric mode at 30 /s, which indicates that this muscle group plays a role in the eccentric contraction of the extensors. This gain may be explained by the active (isometric) exercise of the contralateral flexors during the eccentric training of the extensors. Although the exercise was not monitored by electromyography, it was possible to visually identify an isometric contraction of the contralateral flexors during the eccentric training of the extensors. The results showed that, although TPT tended to decrease in all analyzed modes and velocities, the relationship was specific to the mode and velocity of training (eccentric at 30 /s). This is probably associated with force gain and improved motor unit recruitment, because a low TPT at the beginning of training was followed by a substantial peak torque gain in the eccentric mode at 30 /s. In a study on the activation patterns of knee extensors, McHugh et al. 49 verified that a lower TPT 280 Rev Bras Fisioter. 2010;14(4):

13 Eccentric training versus functional tests is related to the fact that isokinetic eccentric exercise requires higher recruitment of type II muscle fibers. Similarly, Miller et al. 50 demonstrated that TPT was significantly lower after eccentric training when compared to concentric training for both knee extensors and flexors, indicating improved neuromuscular function. The conventional H/Q ratio was used because it was not possible to calculate the functional H/Q ratio due to the lack of records for concentric peak torques during evaluations. The conventional H/Q is used as a standard test of knee muscle balance 2,12,13,16,32, For the comparison of the H/Q ratio between pre- and post-training, the training protocol lead to a decrease of 20%, 13% and 10% in the eccentric mode at 30º/s, 120º/s and isometric mode, respectively. These decreases in H/Q ratio were due to the increased extensor peak torque rather than the decreased flexor peak torque. Although there was a gain in the knee flexor torque, this gain was lower than the gain recorded for the knee extensors, therefore leading to a decrease in the antagonist/agonist ratio. In a review study on the contribution of the eccentric contraction to injury, prevention, rehabilitation and sports, LaStayo et al. 5 reported that this contraction, when exclusively applied to a single muscle group, may compromise knee stability due to changes in the H/Q ratio. Despite this significant decrease, the lower rate of flexor torque represented 40% of the extensor torque for all analyzed contraction modes. However, this percentage is within the range of variability (40-80%) described in many other studies on H/Q ratio, depending on the studied population, age and gender 7,52. Therefore, in spite of the fact that the current protocol only elicited the knee extensors and lead to a decrease in H/Q ratio, the percentage of the ratio seen here ( 40%) does not compromise the stability of the knee joint. It can be observed in the present results that the three torque variables (MPT, TPT and H/Q ratio) showed more significant differences for the specific training mode and speed of eccentric training at 30 /s, which characterizes the principle of training specificity when compared to the other assessed modes and speeds 25,54. Duchateau and Enoka 48 corroborate the results of the current study by demonstrating that the performance in functional tests is improved to a maximum level in similar tasks and can be affected by contraction mode, load, velocity and posture. Indeed, the distances in both types of hop for distance (single and triple) may have increased due to a greater similarity to the task of the training protocol (high force, low velocity). In contrast, an improved performance was only observed in two (carioca and pivot diagonal run) of the five agility tests. Furthermore, Kraemer et al. 9 demonstrated that strength training alone elicits no significant improvement in running performance. Also, these same authors verified that tests conducted at velocities above 180 /s were better indicators of agility, thus being more closely related to knee joint function. In light of these considerations, it is possible that the results obtained after training would have been more significant, especially for the agility tests, if the training protocol had been conducted at a medium velocity ( 180º/s) in the concentric and eccentric modes because positive (shortening) and negative (lengthening) work of the knee muscles was observed in the completion of all the functional tests used in the present study. Sheppard and Young 20 argue that the ability to perform an agile movement involves not only physical but also cognitive factors, suggesting that the decreased time in functional tests (such as the carioca and pivot diagonal run) as well as the increased distance in the hop for distance tests may be due to a combination of both factors. However, this hypothesis may be rejected as the subjects performed the tests only twice (preand post-training), with a 6-week interval between them. Furthermore, in the post-training evaluation, the subjects asked the examiner to show them how to perform the test as they could not remember how to do it. The manual timing used for the agility tests, although recorded by the same examiner, probably influenced the results because it is an evaluator-dependent measure, therefore not as reliable as a record obtained by an electronic synchronization system or photo-cells. Another factor that may also have influenced the results of this study was the total number of tests (5 runs and 2 hops), because each of the tests was performed three times consecutively. Unlike the present study, most of the studies found in the literature 34-39,48,55 used only one or two trials, while a few 18,19,33 used a maximum of five trials to combine activities of agility and hop. There is considerable disagreement in the literature regarding which muscle group is most involved in the functional movements of the knee. Li et al. 56 found correlations between the knee flexor forces and functional abilities, while other authors 57,58 found this correlation only with the extensors. However, these correlations were classified as weak or moderate. The results of the present study are in agreement with the literature because there were weak correlations between functional tests and torque for both knee extensors and flexors, however most studies included subjects with deficient or reconstructed ACLs. Other studies included healthy subjects 23 or athletes 13,16,24 in their sample, and although they found similar results to those of the present study (weak and moderate correlation), the discussion is hampered by differences in methodology such as closed kinetic chain 23 or open kinetic chain 13,16,24, linear isokinetic test 23 or angular isokinetic test 13,14,16,24, training protocol (mode of contraction, muscle group, number of Rev Bras Fisioter. 2010;14(4):

14 Heleodório H. Santos, Mariana A. Ávila, Daniela N. Hanashiro, Paula R. Camargo, Tania F. Salvini repetitions, frequency, duration, time to rest, speed of contraction, etc.) and quantity and type of functional tests used in the relationship analysis 59. The fact that isokinetic tests are performed in open kinetic chain and functional tests are performed in closed kinetic chain may have influenced the relationship analysis, which suggests that the muscles of the joints proximal and distal to the knee (hip and ankle) could increase the performance of functional tests 49. The low speed of contraction used in the training protocol (30 /s) when compared with the velocities of contraction developed in the various functional tests ( 60 /s) 2,13,15,50,51 and the lack of evaluation in the concentric mode 15,23,24 may also have influenced the results. Another factor in our study that could justify the moderate correlations between the torque and hop tests would be the similarity between the speed of movement in the training (30 /s) and the specific hop task. Thus, the weak correlations with the agility tests (runs) can also be explained by the difference in speed between the tasks. Conclusions Although the training protocol elicited a substantial increase in the extensor peak torque, especially at 30 /s, along with improved performance in most of the functional tests (carioca and pivot diagonal run, and single and triple hop), the hypothesis that a strong correlation would be observed between these variables was not confirmed. This suggests that the functional tests and isokinetic tests assess different measures, and it seems that the combination of measures is important for a full assessment of functional capacity. Acknowledgements To Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for their financial support. 282 References 1. Aquino MA, Leme LE, Amatuzzi MM, Greve JM, Terreri ASAP, Andrusaitis FR, et al. Isokinetic assessment of knee flexor/extensor muscular strength in elderly women. Rev Hosp Clin Fac Med Univ São Paulo. 2002;57(4): Rosene JM, Forgarty TD, Mahaffey BL. Isokinetic hamstrings: quadriceps ratios in intercollegiate athletes. J Athl Train. 2001;36(4): Kannus P. Isokinetic evaluation of muscular performance: implications for muscle testing and rehabilitation. Int J Sports Med. 1994;15 Suppl 1:S Siqueira CM, Pelegrini FR, Fontana MF, Greve JM. Isokinetic dynamometry of knee fl exors and extensors: comparative study among non-athletes, jumper athletes and runner athletes. Rev Hosp Clin Fac Med Univ São Paulo. 2002;57(1): LaStayo PC, Woolf JM, Lewek MD, Snyder-Mackler L, Reich T, Lindstedt SL. Eccentric muscle contractions: their contribution to injury, prevention, rehabilitation and sport. J Orthop Sports Phys Ther. 2003;33(10): Goldspink G. Molecular mechanisms involved in the determination of muscle fiber mass and phenotype. Adv Exerc Sports Physiol. 1999;5(2): Seger JY, Thorstensson A. Effects of eccentric versus concentric training on thigh muscle strength and EMG. Int J Sports Med. 2005;26(1): Clebis NK, Natali MRM. Lesões musculares provocadas por exercícios excêntricos. Rev Bras Ciênc Mov. 2001;9(4): Kraemer WJ, Adams K, Cafarelli E, Dudley GA, Dooly C, Feigenbaum MS, et al. Progression models in resistance training for healthy adults. Med Sci Sports Exerc. 2002;34: Fitts RH. Effects of regular exercise training on skeletal muscle contractile function. Am J Phys Med Rehabil. 2003;82(4): Widrick JJ, Stelzer JE, Shoepe TC, Garner DP. Functional properties of human muscle fi bers after short-term resistance exercise training. Am J Physiol Regul Integr Comp Physiol. 2002;283(2):R Kellis E, Baltzopoulos V. Muscle activation differences between eccentric and concentric isokinetic exercise. Med Sci Sports Exerc. 1998;30(11): Dauty M, Potiron-Josse M. Correlations and differences of performance between soccer players, professionals, young players and amateurs, from the 10-meter sprint test and knee isokinetic assessment. Sci Sports. 2004;19(2):75-9. Rev Bras Fisioter. 2010;14(4): Newton RU, Gerber A, Nimphius S, Shim JK, Doan BK, Robertson M, et al. Determination of functional strength imbalance of the lower extremities. J Strength Cond Res. 2006;20(4): Croce RV, Pitetti KH, Horvat M, Miller J. Peak torque, average power, and Hamstrings/Quadriceps ratios in nondisabled adults and adults with mental retardation. Arch Phys Med Rehabil. 1996;77(4): Jidovtseff B, Croisier JL, Mordant B, Crielaard JM. Isokinetic profi le of knee fl exors and extensors in a jumpers population. Sci Sports. 2005;20(5-6): Keskula DR, Duncan JB, Davis VL, Finley PW. Functional outcome measures for knee dysfunction assessment. J Athl Train. 1996;31(2): Keays SL, Bullock-Saxton JE, Keays AC, Newcombe P. Muscle strength and function before and after anterior cruciate ligament reconstruction using semitendonosus and gracilis. Knee. 2001;8(3): Keays SL, Bullock-Saxton JE, Newcombe P, Keays AC. The relationship between knee strength and functional stability before and after anterior cruciate ligament reconstruction. J Orthop Res. 2003;21(2): Sheppard JM, Young WB. Agility literature review: classifi cations, training and testing. J Sports Sci. 2006;24(9): Phillips N, Benjamin M, Everett T, Van Deursen RWM. Outcome and progression measures in rehabilitation following anterior cruciate ligament injury. Phys Ther Sport. 2000;1(1): Campenella B, Mattacola CG, Kimura IF. Effect of visual feedback and verbal encouragement on concentric quadriceps and hamstrings peak torque of males and females. Isokinet Exerc Sci. 2000;8: Manske RC, Smith BS, Rogers ME, Wyatt FB. Closed kinetic chain (linear) isokinetic testing: relationships to functional testing. Isokinet Exerc Sci. 2003;11: D Alessandro RL, Silveira EAP, Anjos MTS, Silva AA, Fonseca ST. Análise da associação entre dinamometria isocinética da articulação do joelho e o salto horizontal unipodal, hop test, em atletas de voleibol. Rev Bras Med Esporte. 2005;11(5): Seger JY, Arvidsson B, Thorstensson A. Specifi c effects of eccentric and concentric training on muscle strength and morphology in humans. Eur J Appl Physiol. 1998;79(1):49-57.

15 Eccentric training versus functional tests 26. Kellis E, Baltzopoulus V. The effects of the antagonist muscle force on intersegmental loading during isokinetic efforts of the knee extensors. J Biomech. 1999;32(1): Gobbi LTB, Secco CR, Marins FHP. Preferência pedal: comportamento locomotor em terreno regular. In: Teixeira LA. Avanços em comportamento motor. São Paulo: Movimento; p Knight CA, Kamen G. Adaptations in muscular activation of the knee extensor muscles with strength training in young and older adults. J Electromyogr Kinesiol. 2001;11(6): Dvir Z. Isokinetics: muscle testing, interpretation and clinical applications. Edinburgh: Churchill Livingstone; Davies GJ, Ellenbecker TS. Aplicação da isocinética nos testes e na reabilitação. In: Andrews JR, Harrelson GL, Wilk KE. Reabilitação física das lesões desportivas. 2ª ed. Rio de Janeiro: Guanabara Koogan; p Wilk KE, Arrigo CA, Andrews JR. Standardized isokinetic testing protocol for the throwing shoulder: the throwers series. Isokinet Exerc Sci. 1991;1: Aagaard P, Simonsen EB, Magnusson SP, Larsson B, Dyhre-Poulsen P. A new concept for isokinetic hamstring: quadriceps muscle strength ratio. Am J Sports Med. 1998;26(2): Ortiz A, Olson SL, Roddey TS, Morales J. Reliability of selected physical performance tests in young adult women. J Strength Cond Res. 2005;19(1): Hasebe Y, Tanabe Y, Yasuda K. Anterior-Cruciate-Ligament reconstruction using doubled hamstring-tendon autograft. J Sport Rehabil 2005;14(4): Augustsson J, Thomeé R, Karlsson J. Ability of a new hop test to determine functional deficits after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2004;12(5): McDevitt ER, Taylor DC, Miller MD, Gerber JP, Ziemke G, Hinkin D, et al. Functional bracing after anterior cruciate ligament reconstruction a prospective, randomized and multicenter study. Am J Sports Med. 2004;32(8): Swanik CB, Lephart SM, Swanik KA, Stone DA, Fu FH. Neuromuscular dynamic restraint in women with anterior cruciate ligament injuries. Clin Orthop Relat Res. 2004;425: Pollet V, Barrat D, Meirhaeghe E, Vaes P, Handelberg F. The role of the Rolimeter in quantifying knee instability compared to the functional outcome of ACL-reconstructed versus conservativelytreated knees. Knee Surg Sports Traumatol Arthrosc. 2005;13(1): O Donnell S, Thomas SG, Marks P. Improving the sensitivity of the hop index in patients with an ACL deficient knee by transforming the hop distance scores. BMC Musculoskelet Disord. 2006;7(9): Holm I, Fosdahl MA, Friis A, Risberg MA, Myklebust G, Steen H. Effect of neuromuscular training on proprioception, balance, muscle strength, and lower limb function in female team handball players. Clin J Sport Med. 2004;14(2): Hickson RC, Hikada K, Foster C. Skeletal muscle fiber type, resistance training, and strengthrelated performance. Med Sci Sports Exerc. 1994;26(5): Ploutz LL, Tesch PA, Biro RL, Dudley GA. Effect of resistance training on muscle use during exercise. J Appl Physiol. 1994;76(4): Staron RS, Karapondo DL, Kraemer WJ, Fry AC, Gordon SE, Farkel JE, et al. Skeletal muscle adaptations during early phase of heavy-resistance training in men and women. J Appl Physiol. 1994;76(3): Carroll TJ, Stephan R, Carson RG. Neural adaptations to resistance training: implication for movement control. Sports Med. 2001;31(12): Lieber RL. Skeletal muscle: structure, function and plasticity the physiological basis of rehabilitation. 2ª ed. Baltimore: Willians & Willians; Tomiya A, Aizawa T, Nagatomi R, Sensui H, Kokubun S. Myofi bers Express IL-6 after eccentric exercise. Am J Sports Med. 2004;32(2): Blazevich AJ. Effect of movement pattern and velocity of strength training exercise on training adaptations during concurrent resistance and sprint/jump training [thesis]. Lismore (NSW): School of Exercise Science and Sport Management Southern Cross University; Duchateau J, Enoka RM. Neural adaptation with chronic activity patterns in able-bodied humans. Am J Phys Med Rehabil. 2002;81(11 Suppl):S McHugh MP, Tyler TF, Greenberg SC, Gleim GW. Differences in activation patterns between eccentric and concentric quadriceps contractions. J Sports Sci. 2002;20(2): Miller LE, Pierson LM, Nickols-Richardson SM, Wootten DF, Selmon SE, Ramp WK, et al. Knee extensor and fl exor torque development with concentric and eccentric isokinetic training. Res Q Exerc Sport. 2006;77(1): Calmels PM, Nellen M, van der Borner I, Jourdin P, Minaire P. Concentric and eccentric isokinetic assessment of fl exor-extensor torque ratios at the hip, knee, and ankle in a sample population of healthy subjects. Arch Phys Med Rehabil. 1997;78(11): Hiemstra LA, Webber S, MacDonald PB, Kriellaars DJ. Hamstring and quadriceps strength balance in normal and hamstring anterior cruciate ligament-reconstructed subjects. Clin J Sport Med. 2004;14(5): Tourny-Chollet C, Leroy D. Conventional vs. dynamic hamstrings-quadriceps strength ratios: a comparison between players and sedentary subjects. Isokinet Exerc Sci. 2002;10: Folland JP, Williams AG. The adaptations to strength training: morphological and neurological contributions to increased strength. Sports Med. 2007;37(2): Aune AK, Holm I, Risberg MA, Jensen HK, Steen H. Four-strand hamstring tendon autograft compared with patellar tendon-bone autograft for Anterior Cruciate Ligament reconstruction: a randomized study with two-year follow-up. Am J Sports Med. 2001;29(6): Li RC, Maffulli N, Hsu YC, Chan KM. Isokinetic strength of the quadriceps and hamstrings and functional ability of anterior cruciate ligament defi cient knees in recreational athletes. Br J Sports Med. 1996;30: Wilk KE, Romaniello WT, Soscia SM, Arrigo CA, Andrews JR. The relationship between subjective knee scores, isokinetic testing and functional testing in the ACL- reconstructed knee. J Orthop Sports Phys Ther. 1994;20(2): Itoh H, Kurosaka M, Yoshiya S, Ichihashi N, Mizuno K. Evaluation of functional defi cits determined by four different hop tests in patients with anterior cruciate ligament defi ciency. Knee Surg Sports Traumatol Arthrosc. 1998;6(4): Özçakar L, Kunduracyoolu B, Cetin A, Ülkar B, Guner R, Hascelik Z. Comprehensive isokinetic knee measurements and quadriceps tendon evaluations in footballers for assessing functional performance. Br J sports Med. 2003;37(6): Rev Bras Fisioter. 2010;14(4):

16 ISSN Rev Bras Fisioter, São Carlos, v. 14, n. 4, p , July/Aug Revista Brasileira de Fisioterapia ORIGINAL ARTICLE Quality of life and discriminating power of two questionnaires in fi bromyalgia patients: Fibromyalgia Impact Questionnaire and Medical Outcomes Study 36-Item Short-Form Health Survey A qualidade de vida e o poder de discriminação de dois questionários em pacientes com fi bromialgia: Fibromyalgia Impact Questionnaire e Medical Outcomes Study 36-Item Short-Form Health Survey Ana Assumpção 1, Tatiana Pagano 2, Luciana A. Matsutani 3, Elizabeth A. G. Ferreira 1, Carlos A. B. Pereira 4, Amélia P. Marques 1 Abstract Background: Fibromyalgia is a painful syndrome characterized by widespread chronic pain and associated symptoms with a negative impact on quality of life. Objectives: Considering the subjectivity of quality of life measurements, the aim of this study was to verify the discriminating power of two quality of life questionnaires in patients with fibromyalgia: the generic Medical Outcomes Study 36-Item Short- Form Health Survey (SF-36) and the specific Fibromyalgia Impact Questionnaire (FIQ). Methods: A cross-sectional study was conducted on 150 participants divided into Fibromyalgia Group (FG) and Control Group (CG) (n=75 in each group). The participants were evaluated using the SF-36 and the FIQ. The data were analyzed by the Student t-test ( =0.05) and inferential analysis using the Receiver Operating Characteristics (ROC) Curve - sensitivity, specificity and area under the curve (AUC). The significance level was Results: The sample was similar for age (CG: ; FG: years). A significant difference was observed in quality of life assessment in all aspects of both questionnaires (p<0.05). Higher sensibility, specificity and AUC were obtained by the FIQ (96%, 96%, 0.985, respectively), followed by the SF-36 (88%, 89% and AUC). Conclusion: The FIQ presented the highest sensibility, specificity and AUC showing the most discriminating power. However the SF-36 is also a good instrument to assess quality of life in fibromyalgia patients, and we suggest that both should be used in parallel because they evaluate relevant and complementary aspects of quality of life. Key words: fi bromyalgia; quality of life; questionnaires; disability evaluation; health status indicators. Resumo Contextualização: A fi bromialgia é uma síndrome dolorosa caracterizada por dor espalhada e crônica e sintomas associados com um impacto negativo na qualidade de vida. Objetivos: Considerando a subjetividade da mensuração de qualidade de vida, o objetivo deste estudo foi avaliar o poder de discriminação de dois questionários que avaliam a qualidade de vida de pacientes com fi bromialgia: o genérico Medical Short Form Healthy Survey (SF-36) e o específi co Questionário do Impacto da Fibromialgia (QIF). Métodos: Foi conduzido um estudo transversal com 150 indivíduos, divididos em dois grupos: grupo fi bromialgia (FM) e grupo controle (GC) (n=75 em ambos). Os pacientes foram avaliados pelo SF-36 e pelo QIF. Na análise dos dados, utilizou-se o teste t de Student com =0,05 e a Curva ROC (Receiver Operating Characteristics Curve). Resultados: As amostras foram estatisticamente semelhantes para a idade 47,8 (8,1) no GC e 47,0 (7,7) no FM e estatisticamente diferentes em todos os aspectos dos dois questionários (SF-36 e QIF). Alta sensibilidade, especifi cidade e área abaixo da curva (AUC) foram obtidas com o QIF (96%, 96%, 0,985 respectivamente), seguido pelo SF-36 (88%, 89% e 0,948 AUC). Conclusão: O QIF mostrou-se mais discriminativo do que o SF-36 para avaliar a qualidade de vida de fi bromiálgicos. No entanto, o SF-36 é também um bom instrumento de avaliação e sugere-se que ambos sejam usados uma vez que avaliam aspectos relevantes e complementares da qualidade de vida. Palavras-chave: fi bromialgia; qualidade de vida; questionários; avaliação da defi ciência; indicadores básicos de saúde. Received: 17/12/2008 Revised: 19/08/2009 Accepted: 21/10/ Physical Therapy Department, Speech Therapy and Occupational Therapy, Faculdade de Medicina (FM), Universidade de São Paulo (USP), São Paulo (SP), Brazil 2 Physical Therapist 3 Physical Therapy Department, Fundação Instituto de Educação de Osasco (FIEO), Osasco (SP), Brazil 4 Statistics Department, Instituto de Matemática e Estatística (IME), USP Correspondence to: Amélia Pasqual Marques, Rua Cipotânea, 51, Cidade Universitária, CEP , São Paulo (SP), Brazil, pasqual@usp.br 284 Rev Bras Fisioter. 2010;14(4):284-9.

17 Discriminating power of quality of life questionnaires Introduction Health is [ ] not simply the absence of disease; it is something positive, a joyful attitude toward life, and a cheerful acceptance of the responsibilities that life puts upon the individual 1. According to WHO 2, quality of life refers to the perception that people have about their position in life, within a context of culture and system of values in which they live and in relation to their aims, expectations and social standards. Considering the chronic diseases, the role of healthcare in improving quality of life has been increasingly underlined, particularly as concerns the relief of pain and suffering 3. As in other chronic syndromes, improving the quality of life of patients is the main objective of fibromyalgia management. Fibromyalgia syndrome has been described as a frequent rheumatological disorder in the world s population 4-7 and in the primary healthcare system, representing 7% of all health complaints and increasing health costs 8. According to the criteria of the American College of Rheumatology (ACR), it is a painful syndrome characterized by widespread and chronic musculoskeletal pain and by the presence of at least 11 of the 18 tender points. These symptoms are frequently associated with morning stiffness, sleep disorders, fatigue, chronic headache, anxiety, depression, and irritable bowel syndrome 9. Considering the role of the symptoms, the negative impact on quality of life is frequently reported 10,11. According to White et al. 12, this negative impact on the quality of life of active individuals leads to loss of function, affects work capacity and consequently lowers family income. Although the functional disability is not caused by movement restriction, the impact of the symptoms on all aspects of daily life (e.g. work, family life and leisure 13 ) aggravates the psychological conditions, causing depression and anxiety 14,15 and increasing the impact on the patient s quality of life 10,11. As in other syndromes, accurate quality of life measurements play an important role in the scientific and clinical context because they allow the identification of patients needs, serve as outcome measures in experimental studies and provide parameters for the cost-benefit and cost-effectiveness analysis of treatment In this sense, quality of life assessment has great relevance, and the use of specific and generic instruments could improve the diagnosis, treatment efficacy and research results 18,19. While the generic questionnaires are usually more representative of overall quality of life, the specific instruments have a higher discriminating power 20. Consequently, it is important that quality of life instruments have a reliable discriminating power 16,18. The aim of the present study was to verify the discriminating power of two instruments used to assess quality of life in patients with fibromyalgia: the generic Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the specific Fibromyalgia Impact Questionnaire (FIQ). Methods Type of study This is a cross-sectional study. Sample This study included 150 participants. Seventy-five participants had a diagnosis of fibromyalgia according to the ACR 9 criteria and were selected at the rheumatology outpatient service of Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), Brazil. For the healthy control group (CG), another 75 participants without fibromyalgia were selected among workers doing different jobs at Universidade de São Paulo. The inclusion criteria were age between 35 and 60 years. All eligible participants were evaluated until the desired sample was completed and any sample losses were recorded. The participants from the fibromyalgia group (FG) were already under medical treatment. The study was approved by the Ethics Committee of HC-FMUSP Comissão para Análise de Projetos de Pesquisa (Cappesq) protocol number 210/01. All participants gave written informed consent. Instrument and proceedings All participants from both groups were evaluated at a single face-to-face interview regarding demographic data (age, height, weight, gender, educational level, occupational activity and medical diagnosis). Two physical therapists were previously trained to read the questions in a standard format and clarify any questions. Because of the participants limited reading skills, especially in the FG, the researchers decided to read the questionnaires along with them, avoiding problems in the comprehension and completion of the questionnaires. Quality of life was assessed by two questionnaires: the FIQ 16,17 and the SF-36 18,19. The FIQ 21 was used to assess the FG, and it was translated to Portuguese and validated for the Brazilian population by Marques et al. 22. The FIQ captures information on the following items: physical function, well-being, missed work, job difficulty, pain, fatigue, morning stiffness, morning tiredness, anxiety and depression. This questionnaire has been widely used in research and has shown good sensitivity, validity and reliability. Scores range from 0 to 100, and higher scores are associated with increased impact. As per Bennett, the mean value is 50, and severely affected patients have scores above The SF-36 is a generic multidimensional instrument that assesses eight scales: Physical Functioning, Role-Physical, Rev Bras Fisioter. 2010;14(4):

18 Ana Assumpção, Tatiana Pagano, Luciana A. Matsutani, Elizabeth A. G. Ferreira, Carlos A. B. Pereira, Amélia P. Marques Table 1. Socio-demographic data of participants in the control group and fi bromyalgia group. Demographic data Control group n=75 Mean (SD) Fibromyalgia group n=75 Mean (SD) Age (years) 47.8 (8.1) 47.0 (7.7) Weight (Kg) 64.6 (11.7) 69.1 (14.5) Height (m) 1.6 (0.8) 1.6 (0.7) Body Mass Index (Kg/cm2) 25.2 (4.5) 26.8 (4.7) Gender Female (%) 73 (97%) 73 (97%) Male (%) 2 (3%) 2 (3%) Educational level More than 12 years 57% 17% 9 to 11 years 26% 37% 0 to 8 years 17% 46% Occupation Housekeeper 31% 37% Retired 0% 14% Other 69% 49% Table 2. Data from the Fibromyalgia Impact Questionnaire (FIQ) in the control group and fi bromyalgia group. FIQ variables Control group n=75 Mean (SD) Fibromyalgia group n=75 Mean (SD) Physical function 4.7 (5.0) 12.7 (5.9) <0.001* Well-being 6.2 (1.8) 1.6 (1.9) <0.001* Missed work 0 (0.0) 0.2 (1.0) <0.001* Job difficulty 0.4 (1.0) 7.0 (2.5) 0.04* Pain 0.8 (1.7) 7. 6 (2.0) <0.001* Fatigue 2.3 (2.8) 7.6 (2.3) <0.001* Morning tiredness 1.5 (2.6) 7.1 (2.8) <0.001* Morning stiffness 0.7 (1.6) 6.6 (2.9) <0.001* Anxiety 3.5 (3.1) 7.7 (2.5) <0.001* Depression 1.8 (2.3) 6.0 (3.0) <0.001* * Significantly different according to the Mann-Whitney Test. Table 3. Data from the Medical Outcomes Study 36-item Short Form Health Survey (SF-36) in the control group and fi bromyalgia group. SF-36 variables Control group n=75 Mean (SD) Fibromyalgia group n=75 Mean (SD) Physical functioning (15.8) 39.1 (23.2) <0.001* Role-physical 89.3 (24.0) (30.1) <0.001* Bodily pain 79.3 (21.1) 30.1 (16.1) <0.001* General health 83.1 (18.3) 49.5 (25.9) <0.001* Vitality 70.2 (20.4) 36.3 (27.1) <0.001* Social functioning 84.2 (20.8) 46.6 (30.9) <0.001* Role-emotional 81.9 (35.1) 38.4 (40.4) <0.001* Mental health 77.3 (16.0) (24.0) <0.001* * Significantly different according to the Mann-Whitney Test. p p Bodily Pain, General Health, Vitality, Social Functioning, Role-Emotional and Mental Health 24. The score for each scale varies from 0 to 100, and the higher the score the better the quality of life. Two final measures are used: Physical Health and Mental Health 17,25. A score based on the mean of the eight scales is reported in order to compare it with other questionnaires 15. This partial score is used in the present study. The SF-36 has been widely used in research with excellent metric properties (sensitivity, validity and reliability) 17,19, and it has been translated and validated for the Portuguese language 26. Statistical analysis All variables were tested for normality using Shapiro- Wilk s test. Only demographic data (age and BMI) had adherence to normality and were analyzed using a two-tailed t-test for independent samples. The questionnaire variables were analyzed with the non-parametric Mann-Whitney test. The significance level adopted was The discriminating power of the questionnaires was assessed using the Receiver Operating Characteristics (ROC) curve with its sensitivity, specificity and area under the curve (AUC). For these analyses, we used the total FIQ score 23 and the partial SF-36 score, as used in a previous study 15. Results Table 1 shows the patients demographic data. The groups are similar for age, gender and body mass index (BMI). For educational level, the CG had more years of education than the FG, which may be related to the socioeconomic status of patients in a public hospital. The results obtained with the FIQ showed significant differences (p<0.05) between the CG and FG for all variables (Table 2). Table 3 shows the results obtained with the SF-36. There were significant differences (p<0.05) between the CG and FG for all variables. Discriminating power of the questionnaires The FIQ was applied to the FG and CG. In the ROC analysis, the AUC was (95% CI: ). The cut-off score of for the FIQ gave a sensitivity of 96% and specificity of 96% (Figure 1). The SF-36 was applied to both groups. In the ROC analysis, the AUC was (95% CI: ). The cut-off score of for the SF-36 gave a sensitivity of 88% and specificity of 89% (Figure 2). 286 Rev Bras Fisioter. 2010;14(4):284-9.

19 Discriminating power of quality of life questionnaires Discussion The main objective of the present study was to analyze the discriminating power of two quality of life questionnaires. The results showed that the FIQ and the SF-36 are efficient to measure quality of life and to discriminate between participants with fibromyalgia and healthy participants, with excellent metric properties. Currently, the improvement in the quality of life of patients is one of the main objectives of treatments for several health conditions 16. However, it is difficult to measure quality of life because it is related to a perception of living in terms of health, socioeconomic, psychological and cultural aspects 1. In this sense, questionnaires are the most important instruments to indirectly quantify quality of life 17,19,23. Several studies have reported a negative impact of fibromyalgia on quality of life 10,11. The combination of physical and mental symptoms interferes in different aspects of living such as work, family and leisure 13,27,28. As in other syndromes, questionnaires are the most important form of assessing quality of life in order to compare patients with fibromyalgia and other chronic diseases 18,29 to healthy subjects 30 and to quantify the effectiveness of treatments 20,25,31. Therefore, knowledge of the metric properties of the questionnaires is essential to evaluate their efficacy. In the present study, both questionnaires showed a significant difference in quality of life between the FG and the CG (p<0.05) in all aspects of the FIQ and SF-36. Studies in the literature report similar results supporting the negative impact of fibromyalgia, assessed with specific 14,15,23 and generic 3,10,11 instruments. For the FIQ, the ROC curve analyses show an AUC of 0.985, a cut-off score of 36.76, a sensitivity of 96%, and specificity of 96%. These data demonstrate the excellent metric properties and the high discriminating power of this questionnaire. The efficacy of the FIQ has been demonstrated for comparisons with healthy subjects 32, with other diseases 33, when comparing subjects before and after a treatment program 23,31 and in prospective studies 34. The FIQ is certainly the most widely used quality of life instrument in studies on fibromyalgia, which can be attributed to the fact that it is a specific questionnaire measuring all aspects of the syndrome. According to Bennett 23, the FIQ has credible construct validity, reliable test-retest characteristics and good sensitivity in demonstrating therapeutic change. In the same study, the author noted that the average score for fibromyalgia patients is around 50 and that severely affected patients usually score 70 or above. In our study, the cut-off score between the CG and the FG was In addition, the FIQ is short and easy to apply, thus allowing brief and efficient records. For the SF-36, the ROC analysis showed an AUC of 0.948, a sensitivity of 89% and specificity of 89%. The SF-36 is the most generic instrument used to assess quality of life 17,24. For Sensitivity Sensitivity Specificity Figure 1. ROC curve for the Fibromyalgia Impact Questionnaire (FIQ) Specificity cut off: Sensitivity: Specificity: AUC: Cut-off that minimizes the distance between the curve and upper left corner. cut off: Sensitivity: Specificity: AUC: Cut-off that minimizes the distance between the curve and upper left corner. Figure 2. ROC curve for the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). fibromyalgia patients, this instrument have been widely used for comparisons with other diseases 10,11,35, other kinds of pain and healthy subjects 12,13,36. However, its discriminating properties in fibromyalgia were not described in the same way as they were in psychiatric disorders 37,38. Our results have shown that the SF-36 was an excellent instrument for screening the FG and CG, with a cut-off score of When compared, both instruments provided objective and direct measures of quality of life and good discriminating power Rev Bras Fisioter. 2010;14(4):

20 Ana Assumpção, Tatiana Pagano, Luciana A. Matsutani, Elizabeth A. G. Ferreira, Carlos A. B. Pereira, Amélia P. Marques to distinguish fibromyalgia patients from healthy individuals. According to Contopoulos-Ioannidis et al. 25, the data from quality of life and health surveys should be used more systematically in randomized trials. In this sense, the qualities of both diseasespecific and generic instruments can be useful 25. In fibromyalgia patients, quality of life instruments can even detect subgroups of the syndrome 39,40. Oswald et al. 39 showed that the SF-36 was able to distinguish a psychological dysfunction subgroup among fibromyalgia patients and that this subgroup did not differ in terms of the physical well-being scores. The FIQ cluster analysis also found two subgroups among fibromyalgia patients. Pain and stiffness are universal symptoms for these patients but psychological distress was a feature only in some of them 40. In our study, the FIQ was the most sensitive and specific instrument for assessing quality of life in individuals with fibromyalgia. Similar results have been reported by Garratt et al. 41 and Gliklich and Hilinski 42, who compared the SF-36 with specific instruments and observed a higher efficacy of the specific questionnaire. However, the authors emphasized the discriminating power of the SF-36. For chronic pain, Angst et al. 18 suggest that, although specific questionnaires are more responsive than the SF-36, the generic one is recommended for comprehension of the biological, psychological and social effects of pain. In the present study, the SF-36 had less discriminating power, however it was efficient in identifying poor quality of life in individuals with fibromyalgia and in screening for fibromyalgia in control subjects. Considering the WHO definition of quality of life, social and psychological aspects are important when assessing quality of life, therefore generic and specific questionnaires provide complementary evaluations and should be applied in parallel 43. Conclusions The participants with fibromyalgia presented a poorer quality of life than the healthy participants, demonstrating that fibromyalgia interferes with quality of life. The FIQ presented the highest sensitivity, specificity and AUC, with greater discriminating power, however the SF-36 was also a good instrument for assessing quality of life in the participants with fibromyalgia and for discriminating participants with fibromyalgia from healthy participants. We suggest that both instruments be used in parallel because the SF-36 evaluates relevant aspects not evaluated in the FIQ. Acknowledgements This study was supported for two years ( ) by Programa Institucional de Bolsas de Iniciação Científica, Conselho Nacional de Desenvolvimento Científico e Tecnológico (PIBIC/CNPq) - No /2000-8, and by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) - Grant No. 01/ , Brazil. References Sigerist HE. Medicine and human welfare. New Haven: Yale University Press; The World Health Organization. Quality of life assessment: position paper from the World Health Organization. Soc Sci Med. 1995;41(10): Ferraz MB. Sobrevida e qualidade de vida. Rev Bras Reumatol. 1999;39(9): Carmona L, Ballina J, Gabriel R, Laffon A; EPISER study Group. The burden of musculoskeletal diseases in the general population of Spain: results from a national survey. Ann Rheum Dis. 2001;60(11): Wolfe F, Cathey MA. Prevalence of primary and secondary fibrositis. J Rheumatol. 1983;10(6): Senna ER, De Barros AL, Silva EO, Costa IF, Pereira LV, Ciconelli RM, et al. Prevalence of rheumatic diseases in Brazil: a study using the COPCORD approach. J Rheumatol. 2004;31(3): Assumpção A, Cavalcante AB, Capela CE, Sauer JF, Chalot SD, Pereira CA, et al. Prevalence of fibromyalgia in a low socioeconomic status population. BMC Musculoskelet Disord. 2009;10: Goldenberg DL, Simms RW, Geiger A, Komaroff AL. High frequency of fibromyalgia in patients with chronic fatigue seen in a primary care practice. Arthritis Rheum. 1990;33(3): Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33(2): Hoffman DL, Dukes EM. The health status burden of people with fibromyalgia: a review of studies that assessed health status with the SF-36 or the SF-12. Int J Clin Pract. 2008;62(1): Rev Bras Fisioter. 2010;14(4): Tander B, Cengiz K, Alayli G, Ilhanli I, Canbaz S, Canturk F. A comparative evaluation of health related quality of life and depression in patients with fi bromyalgia syndrome and rheumatoid arthritis. Rheumatol Int. 2008;28(9): White KP, Speechley M, Harth M, Ostbye T. Comparing self-reported function and work disability in 100 community cases of fi bromyalgia syndrome versus controls in London, Ontario: the London Fibromyalgia Epidemiology Study. Arthritis Rheum. 1999;42(1): Henriksson CM. Longterm effects of fi bromyalgia on everyday life. A study of 56 patients. Scand J Rheumatol. 1994;23(1): Santos AMB, Assumpção A, Matsutani LA, Pereira CAB, Lage LV, Marques AP. Depressão e qualidade de vida em pacientes com fibromialgia. Rev Bras Fisioter. 2006;10(3): Pagano T, Matsutani LA, Ferreira EA, Marques AP, Pereira CA. Assessment of anxiety and quality of life in fi bromyalgic patients. São Paulo Med J. 2004;122(6): Carville SF, Choy EH. Systematic review of discriminating power of outcome measures used in clinical trials of fi bromyalgia. J Rheumatol. 2008;35(11): Ware JE Jr. SF-36 health survey update. Spine (Phila Pa 1976). 2000;25(24): Angst F, Verra ML, Lehmann S, Aeschlimann A. Responsiveness of fi ve condition-specifi c and generic outcome assessment instruments for chronic pain. BMC Med Res Methodol. 2008;8: Campolina AG, Ciconelli RM. SF-36 e o desenvolvimento de novas ferramentas de avaliação de qualidade de vida. [SF-36 and the development of new assessment tools for quality of life]. Acta Reumatol Port. 2008;33(2):