The application of the technique of Percutaneous Diafibrólise on range of motion associated with thoracic Lumbar flexion and Hip

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RIOS, Eliziane das Chagas dos Santos [1], SANTOS, Débora Regina Almeida dos [2], NASCIMENTO, Andrew Matheus Brito Queiroz [3]

RIOS, Eliziane das Chagas dos Santos; SANTOS, Débora Regina Almeida dos Santos; NASCIMENTO, Andrew Matheus Brito Queiroz. The application of the technique of Percutaneous Diafibrólise on range of motion associated with thoracic Lumbar flexion and Hip. Multidisciplinary Core scientific journal of knowledge. 03 year, Ed. 06, vol. 06, pp. 15-27, June 2018. ISSN:2448-0959

Summary

The present study aimed to analyze the effects of the technique of Percutaneous Diafibrólise on range of motion (ADM) associated with thoracic lumbar flexion and hip, attended by volunteers full in the caretaker in an educational institution (IES) of Porto Velho-RO. A descriptive and explanatory case study about a practical intervention which evaluated 8 women with some degree of restriction of WMD in the age group of 18 to 45 years. As criteria for inclusion, use relatively healthy volunteer, no tissue lesions in areas handled, sedentary, with moderate shortening of muscle and fascia to reach participate voluntarily. Being previously evaluated were subjected to measurements of flexibility through the sit and Reach Test (SRT) with Bank of Wells and 3rd Finger on the floor (T3DC), quantification of discomfort through the Visual analogue scale (EVA) and the Protocol on the implementation of (Percutaneous Diafibrólise-Crochetagem), in addition to evaluation questionnaires. It was obtained as a result of the increase in local blood supply, therapeutic relaxation, decrease pain, reduce muscle tension, increasing flexibility of soft tissue, increased ADM shortly after application with this maintenance, 3 days after, and no discomfort of Crochetagem. We conclude then that the Percutaneous Diafibrólise proved to be effective in treating joint constraints increasing ADM associated thoracic lumbar flexion and hip in women, not causing any discomfort, low cost, easy handling and portability.

Key words: Percutaneous Diafibrólise, Crochetagem, stretching, physical therapy.

1. Introduction

Knowledge has become the watchword in our days and academic research has raised and contributed much to the development and improvement of professionals, with an emphasis on the physical therapist. With that, sometimes surprising and innovative techniques such as Percutaneous Diafibrólise, also popularly known as Crochetagem.

The Crochetagem is a method of treatment of the locomotor system mechanical pain, by the destruction of the adhesions and the corpuscles voiding or inter-aponeuróticos mio-aponeuróticos through hooks placed and mobilized on the skin, Fibrólise if about stretching, rupture of the fibers and Percutaneous is nothing more than a projection of the anatomical structures on the skin.

This technique is relatively new in Brazil, however, was drafted in the late 40 by Swedish physiotherapist Dr. Kurt Ekman, which based on the principles of Deep Transverse Massage (MTP), created by Dr. James Cyriax, and having noted the limitations of palpation, has drawn up an instrument with specific purpose to overcome these impediments (JORDAN, 2004).

The steel used for application is positioned in such a way as to perform a pull on the muscle belly, causing a mechanical stress by applying a load to the tissue, acting on the component muscle visco elastic, thus increasing your flexibility ( LAGÔA; CARDOSO, 2008).

The field of intervention of this technique is broad and operates mainly in the tissues deep aponeuróticos in mio-adhesions, deposits of uric acid and/or calcium (corpuscles), and other soft tissue dysfunctions, such as reduction of muscular flexibility (BARBOSA and JUNIOR, 2012).

Second Kisner and Colby (2009) apud Barbosa and Junior (2012) flexibility is the ability to move one or several joints so smooth and comfortable in a range of motion (ADM) without pains and restrictions. In contrast, the loss of muscular flexibility is revealed by the reduced ability of a muscle to stretch, limiting WMD.

Soft tissue flexibility arises through a harmonic and complex combination of physical, chemical and emotional factors, being necessary for the various activities of daily life and also for the professional activities, in case that is reduced, will involve painful discomfort or not, due to produce muscular chains imbalance, reduced productivity and work efficiency, bad quality of life, stress, irritability and other diseases that impair the health of human beings, leading to an overload of public or private health services, and may even affect the pension system because of departures or retirements for occupational diseases (BARBOSA and JUNIOR, 2012).

Consequently, this survey sought a group of workers where this flexibility is indispensable for the performance of the tasks and that'd probably be compromised due to the sedentary populations observed.

The lumbar region has an area of high concentration of fibrous tissue, and when a strain is exerted, this structure comes into State of rigidity. In these tissues there is a plasticity, and this answer according to the given sliding velocity, when fast tissue becomes rigid, but when promotes slow and gradual increase in your length (BARBOSA and JUNIOR, 2012).

Finally, the technique of Percutaneous Diafibrólise WINS space of great importance and prominence, because of your low cost, great benefits and the complex application not of this technique, in addition to being portable and can be taken anywhere without difficulty for transports him, adding a working tool in the arsenal of physiotherapists, aiming to achieve your ultimate goal in the treatment of total recovery ADM of joints, especially thoracic lumbar spine and hip.

2. Materials and methods

The present study was characterized by a descriptive and explanatory case study about an intervention practice (YIN, 2001 apud VENTURA, 2007). Held at the Faculdades Integradas Aparício Carvalho-FIMCA in Porto Velho/RO, the dependency named rehabilitation center, with 8 female volunteers, age 18 to 45 years occupants of the caretaker of the above-mentioned INSTITUTIONS.

As inclusion criteria relatively healthy volunteer women attended, they played warm-ups where function with that perform movements of flexion and extension inappropriately, with no tissue lesions in areas handled, sedentary (If a practitioner of physical activity at most 2 x per week), with moderate muscle fascia later shortening of thoracic lumbar and hip, above 18 years, janitor, and who accepted to participate in the research.

As a criterion of exclusion diagnosis of osteomyoarticular lesions in the lower limbs disorders, dysfunctions in the column or lumbago booked without or with diagnosis, as well as the existence of cutaneous disorders or scars in treated areas and people with  contraindications of Crochetagem, namely, bad skin and/or circulatory condition, lesion/skin irritation, varicose veins and adenomas in the posterior region of thigh and lumbar spine, individuals who made use of anticoagulants, hiper-histam reactions ínicas, as well as inflammation and hyperalgesia in the area of application of the technique, practitioners of regular physical activity, good flexibility and no accepted research including your revaluation participate.

For data collection were used the following instruments: Crochet or hook, which are instruments made of a stainless steel structure with two curves at the ends that have different formats, greater and smaller, to allow the contact with the various structures to be treated, and, in these small spatulas and ends between the hooks a central area for support of the hand and fingers of the therapist.

Instruments used to perform the search were a digital camera, Kodak EasyShare M531 model mark of 14 megapixels, for the record, the Microsoft Office Excel 2010 software for tabulating the results and preparation of tables and charts, plus the t test is designed to assess the degree of significance; Terms of informed consent (TFCC), in addition to evaluation and intervention sheets;  Visual analogue scale (EVA), being a scale that introduces subjective results, valued between 0 to 10.  Was used to quantify the degree of discomfort and/or pain of the individual.

The same was printed in color in the 20×7 cm size in A4 paper; The Bank of Wells and Dillon that was designed and customized by the authors themselves, following previous models, having as main objective to measure the flexibility of the posterior of trunk and CO. sit and Reach test (SRT). Measures 30 cm of height and width, 56 cm long with a standard ruler at the top crossing in 16 cm the surface of footrest; a tape measure 30 cm custom, being affixed to the rear face of the Bank to Wells, where the individual sits in profile in front of tape and performs the test "3 finger to the ground" (T3DC).

The research was approved by the Committee of ethics in research involving humans – CEP FIMCA, paragraph 30447114.0.0000.0012 CAAE, following all ethical-legal precepts established in accordance with resolution No. 466, December 2012 National Council of Sa úde (CNS) which features about the guidelines and regulatory norms for research involving humans.

Were invited to attend the meeting where it was explained on the project as well as the reading of informed consent (TFCC), crowded in the role of collaborating janitor, being 30 subtotal women on that occasion was real marginalised after the explanation and reading the FICS the individual record of assessment, where it was possible to select the volunteers that fit inclusion criteria for further testing and application are submitted method object of this research.

After analysis of the evaluation sheets and left only 8 women, FICS on another date was conducted the intervention with those that fit the criteria. All were subjected to the following tests and procedures:

The first consisting of results in centimeters (cm) third test finger to floor (T3DC), being obtained by measuring using tape measure 30 cm custom affixed to the rear face of the Bank of Wells before, immediately after, and 3 days after the application of Crochetagem technique.

The second was the sit and reach Test (SRT), being measured by the measuring tape from the Bank of Wells before, immediately after, and 3 days after the Crochetagem technique. The run mode consists of the individual sits facing the Bank, putting the feet in support with knees extended, raise your arms with parallel or overlapping hands, taking both forward and pushing the marker to the farthest possible . The most widely used classification of the results is up to 11 cm = weak, of 12 to 13 cm = regular, 14 to 18 cm = medium, from 19 to 21 cm = good and 22 cm or more = excellent.

All of the results, both T3DC, as the TSA, recorded by a digital camera. In the T3DC the machine was placed at the time of 5 to 8 cm from the ground and with distance of about 60 to 80 cm between the machine and the measuring tape.  Already the Bank of Wells, the machine was in a top view in relation to the individual, in order to show the value obtained.

The third item to be evaluated were the results of the EVA, applied 5 times in 3 different dates. The first date was applied before and after the active stretching for free, aim to quantify the discomfort during active stretching, application of EVA before the lengthening was to eliminate any bias. Being shown for the individual and the same quantified your discomfort, assigning this a value of 0 to 10. On the second date, EVA was applied before the Crochetagem Protocol in thoracic lumbar column and hamstrings, as well to eliminate any discomfort before, thus eliminating errors, and after the Protocol again was quantified the discomfort of the technique through EVA .

And on the third date, being completed the intervention sheet with EVA padding 3 days after the application of the Protocol and the issue with the following statement: "there is presence of pain, discomfort or hassle previously reported during execution and some activity? ".

The application protocol was divided into 3 regions, the quadratus lumborum, the posterior thigh and paravertebral.  The quadratus lumborum region comprises the following anatomical accidents, posterior superior iliac spine and bilateral last floating rib (12th) bilaterally, forming a rectangle, this region covers the muscles quadratus lumborum and a portion of the Group  the Erector Spina (GEE). The paravertebral region comprises all the thoracic vertebrae (T1-T12) forming a "corridor" of approximately 14 cm wide, having as the vertebral column, including the thoracic portion of the GEE.  The posterior region of thigh hamstring muscle group covers.  In each region were carried out first phase of digital palpation, instrumental and 3 sets of 10 repetitions in the fibrólise, drainage and scraping. The fibrólise had upwards.

3. Results and discussion

The analyses were made using MS Office Excel 2010 software for data tabulation, graphic representations and tables, showing the results obtained in the field and in percentages. The variables were expressed as mean and standard deviation. For comparison between the TSA values (Before, immediately after, and 3 days after), T3DC (Before, immediately after, and 3 days after) and Eve (Before and after the active stretching for free, before and after crochetagem and after 3 days of crochetagem). It was used the T-test for dependent samples. Statistical significance was set at 5%.

Chart 1: the figures before, immediately after, and 3 days after application of measured through Bank of Wells (TSA).
Chart 1: the figures before, immediately after, and 3 days after application of measured through Bank of Wells (TSA).

According to chart 1, 37.5% of participants continued gaining range of motion after 3 days. In 12.5% retained after 3 days what you've won. In 25% gain, having failed to obtain a reduction in relation to the result soon after application. In 12.5% returned to the previous result to the application of the technique.  Already at 12.5 percent had a reduction in value shortly after application, however, kept the gain in relation to the previous result to Crochetagem.

Chart 2: the figures before, immediately after, and 3 days after application of measured by testing 3rd Finger on the ground.  
Chart 2: the figures before, immediately after, and 3 days after application of measured by testing 3rd Finger on the ground.

Second graph 2 for before and after application of 62.5% of the participants achieved lower results, comparing prior to application. However, 37.5% had higher values immediately after application. I have already referred to the results after 3 days 75% of the participants maintained the positive values, and 25% have shown negative values, these retained results similar to those immediately after application. A note to end paragraph 4, which showed favorable outcome in this different measurement of negative found shortly after application by the same participant.

Chart 3: values for the quantification of discomfort and/or pain by Visual analogue scale (EVA).
Chart 3: values for the quantification of discomfort and/or pain by Visual analogue scale (EVA). Chart 3: values for the quantification of discomfort and/or pain by Visual analogue scale (EVA).

Second graph 3, 100% of participants reported some discomfort after Active stretching free showing average of 4.6 points. In 87.5% of the participants reported no pain after application of the crochetagem, only 12.5% reported pain 3 days after application by assigning 2 points in EVA.

Chart 4: values for the comparison between the degree of discomfort of active stretching the application of Crochetagem measured by Visual Analog Scale (EVA).
Chart 4: values for the comparison between the degree of discomfort of active stretching the application of Crochetagem measured by Visual Analog Scale (EVA).

Consonant chart after stretching 4 100% of participants reported some discomfort and no reported pain free active soon after application of the technique, i.e. There is no discomfort produced by Crochetagem. Second Kiffer (2004) the percutaneous Diafibrólise is a noninvasive technique to treat several dysfunctions osteomyoarticular lesions in tissue underlying the skin.

Under the prism of this research, these dysfunctions are caused mainly by anti-ergonômicas postures adopted by employees in the performance of your labor, generating soft limiting, returning and/or functional.  The Crochetagem acted reorganizing the tissues increasing the extensibility of the same capacity. This was observed by the values obtained by tests of flexibility (TSA and T3DC).

The Crochetagem protocol used in this research out applied with low voltage, relatively long time, average of 20 minutes, and with small temperature increase, because local hyperemia.  Still, in regions (thoracic lumbar fascia and membranous semi) that have been selected for implementation, have high concentration of collagen.  Studies help to understand the importance of these performed by Facio (2007) showed that increased information, such as the muscle is necessary low strength plastic, long time and high temperature, and this also applies in the connective tissue (tendons, l igamentos and other) in which the temperature increases, decreases and rigidity increases extensibility.

One of the results of this research was the increase in ADM, because restoration of flexibility through the hook.  Similar results were found in a study done by Fernandes and Baumgahrt (2009) where applied to Crochetagem in a high performance rowing athlete, noted that because of mechanical action of the hook there was restoration of mobility, capacity contrá tilde and the ADM, with consequent increased muscle flexibility.

Another study, which likewise acted returning mobility and the increase in ADM, was directed by Anniboleti et al. (2006) in which the Crochetagem associated with elongation were applied to Dupuytren's Contracture, the treatment lasted 60 days,  with 40-minute sessions and 2 times a week.  After 45 days the result off full recovery in joint mobility of the left hand and part of the right hand, as well as return to (ADL's) daily life activities.

These studies described the results observed in this survey confirmed, where the participants had recovery of ADM, and played professional activities (AVP's) with more comfort, safety and efficiency, according to reports of the same.

Another result was the reduction of pain, found in the participants, through the hook. Such a result has been found in several studies, as directed by Samir (2004) in the treatment of plantar Fasciitis bilaterally using only the technique of Crochetagem, where there was significant reduction of pain after 10 sessions, and the individual Duo has returned to daily life activities, what before was limited due to the pain.

In another study by Silva, Vieira and Santamaria (2008) assessed the Crochetagem applied in generalized pain in 11 patients. Significant decreases were observed in all patients and in one of those reduced from 8 to 0 point in EVA.

Also in the study by Mello, Baumgarth and Silva (2011) analyzed the effect of Crochetagem on pain and ADM in lateral epicondylitis, and obtained significant decrease of pain (p < 0.01) and increase in ADM (p < 0.01), the authors concluded that  the technique proved to be effective in reducing pain and increasing prices, as well as at the level of functional activity.

Another result of this research was the superficial and profound vasodilation hyperemia, assisting in the removal of metabolites and improving tissue nutrition. Even not realizing any specific test, we can affirm, based on studies and on visual observation.  One of these studies was conducted by birth (2007) assessed the changes in diameter of arterioles in the tendons of rats after the Crochetagem technique, demonstrating that there was a deep vasodilatation, increasing the blood supply, temperature, location tissue nutrition, oxygen supply and also showed that every 20 seconds of rubbing in the fabric are produced approximately of 50-minute deep hyperemia, aiding in the Elimination of the metabolites.

The specific objective of examining the effects soon after application were very satisfactory, showing in either one of the participants achieved 8 cm of increased flexibility with just a Crochetagem session.

These results were corroborated by found in the research of Barbosa and Junior (2012), where they applied a single session of Physiotherapy Crochetagem in thoracic lumbar fascia and hamstrings in Group of 20 healthy young women. The pré-aplicação average was 23.1 cm and immediately after applying 29.4 cm. The authors concluded that the technique was effective in gaining flexibility, where there has been significant increase in ADM immediately after application of the Crochetagem, including statistically significant improvement.

The results of this research were similar to those found in the research described above, in terms of flexibility, where the participants gained at ADM parsed immediately after application of the Crochetagem.  The difference between this research and Barbosa and Junior (2012) was the inclusion of one more test of assessment of flexibility, that is, the T3DC, in addition to the number of the sample and the high significance.

In relation to another specific objective to analyze the late effects after implementation, the results were satisfactory and surprising, given that the average TSA suffered minimal attenuation of 0.2 cm, while the T3DC had an increase of 0.2 cm. For comparison, a study by Barbosa and Junior (2012) who applied a single session of Crochetagem in thoracic lumbar fascia and hamstrings in Group of 20 healthy young women, where showed that after 7 days loss of flexibility muscles in comparison to the results obtained after the application of the technique, returning to the same values found before. The factors that may have assisted in the maintenance of the results were the revaluation of 3 days after, not 7 days, and industrial activities performed by the participants of this survey.

With that said, a factor to be considered is labour activities carried out by the participants. One of the criteria for inclusion in this

research were precisely the functions of this labor, i.e. janitor, where the muscles (hamstrings and paravertebral, mostly) are in constant activation, acting through concentric isotonic contractions (extension of the trunk), eccentric (f lexão of trunk), and sometimes in stretching, for example, when a contributor of this function is cleaning the floor of a particular room, need to do several times in a trunk flexion associated with hip flexion, maybe a lev and knee flexion to reduce tension in the hamstrings, i.e. to "loosen", due to the pain that comes on the back of the thigh, and these generally are shortened. Once released the structures through the hook, bring relief from discomfort, increased ADM, improving blood supply and functional efficiency with efficiency.

This does not exclude that the treatment with the technique must maintain regularity, according to Magnusson et al. (2008) apud Barbosa and Junior (2012) observed that the visco elastic properties return the basal condition within about 1 hour after application of a technique of stretching, however, the results of this research have shown dissent, as discussed in the previous paragraphs.

The specific objective concerning the comparison between the Crochetagem and the active stretching free in relation to the perceived discomfort showed satisfactory results, and have not been reported pain after application of the technique. However such results were expected, as were not found in the literature, specific studies assessing the degree of pain after use of Percutaneous Diafibrólise. Nevertheless, Borges (2010) stated that the steps of digital palpation and instrumental are painless, that if the therapist observe the application methodology. However, depending on the State of the fibrous tissue slightly painful sensation can be felt during the steps of fibrólise or scraping.

An observation is that 3 days after application a participant reported pain in the lumbar region by assigning value to 2 on EVA, but we cannot say immediately that has been caused by the technique, because the participant may have injured his lower back in dec Hey 3 days ', we cannot exclude the possibility of applying excessive tension of the hook, and the application was executed by the same researcher in all participants.

Already the active stretching free presented by all participants discomforts. In a literature review of Halbertsma and Goeken (1994) apud Almeida et al. (2009), where he observed that the stretching in hamstrings shortened, made

for four weeks, twice a day, 10 minutes at a time, showed no difference in the length of the muscle fibers and an increase in an individual's tolerance to stretching.  Therefore, did not alter the plasticity of muscle fibers, and Yes, raised the threshold of pain through stretching.

Two important observations must be made about the stretching, the first is that one of the participants showed no increase in pain before and after Active stretching free, keeping the 8 value in EVA. The second is that in another end there was reduction in pain after stretching, demonstrating one of its effects, that for Gandhi, lamb and Coimbra (2011), are reducing the stress and tension, muscle relaxation, increased blood flow, decrease of pain and muscular irritability.

Anyway, because of the small sample size and lacking literary base, further studies should be carried out, mainly for a better clarification on the late effects, that will occur, and not only in patients with constraints of ADM, but in other pathologies, genders and ages.

Conclusion

The technique of Percutaneous Diafibrólise showed great efficacy, according to the objectives proposed by this study, the treatment to increase flexion associate ADM thoracic lumbar and hip, both with immediate effect, as with late effects. In addition, also succeeded in reducing pain affecting the musculoskeletal system, increased blood supply, reduction of edema, among others. Another factor that contributes to the technique is absence of discomfort during and after application.

The Crochetagem requires no complex knowledge and or high financial investment, because this, and within reach of their results, as an essential tool in physiotherapeutic practice, assisting this professional to achieve their goals in treatment.

Finally, more studies should be done to strengthen the literature, but mainly for a better clarification on its effects and benefits, with emphasis on the later, that will happen. Also should be studied not only in patients with constraints of ADM, but in other pathologies, genres and different ages of this study in question.

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[1] Physical therapist Physiotherapy and Orthopedic Trauma specialist-UNIRON (RO), teaching in higher education-Metropolitan (RO), physical therapy Neurofuncional-INSPIRE (PR),

[2] Bachelors in physiotherapy from Faculdades Integradas Aparício Ch-FIMCA;

[3] Bachelors in physiotherapy from Faculdades Integradas Aparício Ch-FIMCA;

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