Trabalho realizado por:

Lygia Cristina de Brito Borges.

Fisioterapeuta graduado curso de Fisioterapia da Universidade Severino Sombra (USS), em associação com o Laboratório de Patologia Experimental e Biomorphology (LBPE / USS); Vassouras, Rio de Janeiro - Brasil.

Contato: lyly_borges@yahoo.com.br

Henrique Baumgarth.

Professor Mestre em Educação; Professor do curso de Fisioterapia da Universidades Severino Sombra (UFS) e presidente da Associação Brasileira de crochetagem. (ABCROCH) Rio de Janeiro, Rio de Janeiro - Brasil.

Contato: bilblaw@gmail.com

Marco Aurélio dos Santos Silva.

Professor Mestre em Biologia Humana e Experimental (UERJ); Professor do curso de Fisioterapia da Universidade Severino Sombra (USS). Laboratório de Patologia Experimental e Biomorphology (LBPE / USS). Vassouras, Rio de Janeiro - Brasil.

Contato: santos-silvabiomec@hotmail.com

Abstract

Intercostal Crochetagem effects in mechanical ventilation in different groups of ages are still little understood. The purpose of this study is to observe the intercostal Crochetagem effects in mechanical ventilation of different group of ages. It was conducted with 12 males (6 children and 6 adults) no smokers and without respiratory diseases. The Crochetagem technic was applied once. Before and after the appliance of the technic the ensuing assessments: current volume and minute volume by Ventilometry; peak flow, maximum inspiratory and expiratory pressures, respectively. Data were expressed as mean ± standard error of mean T test of Student was used considering statistically significant p<0.05. Our results shown that the respiratory rate didn’t improve in both of groups, however was observed a significant improve of current volume in children (p<0.05) and adults (p<0.01) after Intercostal Crochetagem technic. After Intercostal Crochetagem there was significant improve of minute volume and in Children (p<0.05) and adults (p<0.01). Intercostal Crochetagem significantly improved maximum inspiratory pressure (p<0.05) and maximum expiratory pressure (p<0.01) in adults but didn’t found satisfactory result in children. Our results suggest that intercostal Crochetagem influences on mechanic ventilatory in healthy children and adults without to cause ventilatory work observed by the maintenance of the respiratory rate. We believe that changes in maximum inspiratory and expiratory pressures happen according to age, as there’s only improve in adults.

Key words: Children, Adults, Interscostal muscle,Crochetagem.

Introdution

The synchronicity of chest and belly results in mechanical ventilation. The pressure difference between the osteocartilaginous and neuromuscular structures allows the air flows into and out of lungs increasing and decreasing the thoracic volume. Due the lost of lung elasticity and respiratory muscular efficiency, the lung capacity decreases when a person ages. The aging causes a change in the elastic properties of the lung and the chest wall. While the chest wall becomes harder, the pulmonar parenchyma becomes more complacent.

Children acquire more respiratory insufficiency because they have factors that helps its development: The airways of children have a short diameter, it increases the risk of an obstruction. The toracoabdominal incoordination during restness disfavors a good bronchial hygiene; Infections are facilitated by the children being with their immunological system in grown; The lungs with less elastin generate reduced lung compliance. The ribs of children are more horizontals, while the rib of adults are more horizontals.

The respiratory physical therapy works on prevention and treatment of respiratory diseases by therapeutic technics with order to establish the cinesio functional mechanical. Theses technics enable the patient to perform the daily activities without causing negative effects on their body. The physical therapy is made by manual, postural and kinetic technics. They aim to mobilize and reduce secretions, improve the pulmonar ventilation, promote the pulmonar reexpansion, improve the oxygenation and gas exchange, reduce the respiratory work, reduce the oxygen consuption, increase thoracic mobility, increase respiratory muscle strength, improve endurance, reeducate the respiratory muscles, promote functional respiratory independence, prevent complications and speed the patient recovery. The Crochetagem will act in promoting lung re-expansion, causing a realignment of muscle fibers, allowing increased air volume.

The Crochetagem is a manipulation technic, used by physiotherapists and it's indicated when is presented fibrosis or adhesions due to traumas, bad posture and pathologies where there functional limitation. This technic was created by Kurt Ekman, a swedish physiotherapist, in the 70's, in England. Ekman was a collaborator of Dr. James Cyriax, creator of the deep transverse massage technic that has similar effects to those of Crochetagem. When the creation of the technic, was found that it has capacity to promote a mechanical action in skeletal muscle, restoring the short-term functionality of the previously limited movement.

The Crochetagem technic uses a hook made of stainless steel which has two non- invasive and non-perforating bends made by Brazilian Association of Crochetagem located in the city of Rio de Janeiro. Each hook has a different bend allowing the contact with multiple anotomical accidents that comes between the skin and the structures to be treated.

Understanding the Crochetagem effects on the intercostal muscles in healthy children and adults may be fundamental to use this technic in pathologies which limit the ventilatiory mechanic in individuals in this age group.

The study has objective to invest the Crochetagem effects in the intercostal muscles in ventilatiory mechanic in differents ages without pulmonary diseases and/or smokers.

Metods

This study was realized at the Laboratory of Biomorphology and Experimental Pathology of Severino Sombra University (USS) in the city of Vassouras, Rio de Janeiro. The study had the participation of 12 males (six child aged 8 to 12 years - Children group; and six adults aged 20 to 25 years - Adult group) without pulmonary diseases, no smokers and to sign the Consent Free and Enlightened Term. This project was submited and accept by ethics committee and research, protocol 0163/2011-02 and participants or their parents receiving a Consent Free and Enlightened Term reserving them the right to choose to accept or not the participation in the study.

Groups and experimental procedures

Child and Adult groups have been subjected to Crochetagem technic, where have been used a hook made of stainless steel which and applied on the skin painless, the technic application is the patient supine, therapist on the opposite the tested. The technic was realized during one day with a single session per day composed of three longitudinal friction in the last three intercostal spaces palpable from anterior to posterior, this procedure was repeated three times in a continuos and without intervals. The experiment duration was 15 minutes, from the session, exam and applying of the procedure in each pacient.

Avaliation of ventilatory parameters

Before and after the session all of the groups were submitted to an avaliation of mechanical ventilation. Ventilatory volumes, current volume (CV) and minute volume (MV) and respiratory rate (RR) were checked by the ventilometry (Wright Mark 8® Analogical ventilometer). The inspiratory (Pimax) and expiratory (Pemax) pressures meansured by manometer (Bourdon® manometer scale ® Maximum +150 cmH2O positive, negative scale up to -150 cmH2O). Peak flow was measured by Peak Flow Meter Hudson ®.

Statistic Analisys

Data were expressed as mean ± standard error of mean. T test of Student was used considering statistically significant p<0.05. GraphPad InStat software was used for statistical analysis of the performance (GraphPad InStat version 3.00 for Windows 95, GraphPad Software Inc.; San Diego, CA, USA).

Results

Observed in this study that Intercostal Crochetagem effect on the respiratory rate didn't change significantly in children and adults, there was an increase trend of respiratory rate of 19% in children and 22% in adults. After intercostal Crochetagem technic, our results shown there was an increase of minute volume in children (144%, p<0.05) in adults (148%; p<0,01) (Picture 1).

Picture 1: Intercostal Crochetagem effects in minute volume. Empty Column - Before; Full Column - After. Data were expressed as mean ± standard error of mean. T test of Student was used considering statistically significant p<0.05. *p<0.05 and **p<0.01.

On investigating the intercostal Crochetagem effect on current volume as shown in the Picture 2, was observed that there was a significative improve of current volume in children (76%; p<0.01) and adults (170%; p<0.001) after intercostal Crochetagem.

Picture 2: Intercostal Crochetagem effects in current volume. Empty Column - Before; Full Column - After. Data were expressed as mean ± standard error of mean. T test of Student was used considering statistically significant p<0.05. **p<0.01 and ***p<0.001.

Similarly to the result observed in current volume, was presented an improve of expiratory peak flow in children (22%; p<0.05) and adults (38%; p<0,01) after Intercostal Crochetagem (Picture 3).

Picture 3: Intercostal Crochetagem effects in Expiratory PeakFlow. Empty Column - Before; Full Column - After. Data were expressed as mean ± standard error of mean. T test of Student was used considering statistically significant p<0.05. *p<0.05; **p<0.01.

There was no considerable change in Pimax and Pemax in children. However we observe there was a significative improve of Pimax in adults (64%; p<0.05) after intercostal Crochetagem (Picture 4).

Picture 4: Intercostal Crochetagem effects in PiMax. Empty Column - Before; Full Column - After. Data were expressed as mean ± standard error of mean. T test of Student was used considering statistically significant p<0.05. *p<0.05.

In investigating the intercostal Crochetagem effect on Pemax of adults (Picture 5) we observed a significative improve value after the technic (65%; p<0.01).

Picture 5: Intercostal Crochetagem effects in Pemax. Empty Column - Before; Full Column - After. Data were expressed as mean ± standard error of mean. T test of Student was used considering statistically significant p<0.05. **p<0.01.

Discussion

Evidences suggest that occur an increase number of sarcomeres by stretching of muscular fibers. The best interaction between actin and myosin causes an increase of muscular force because of stretching due of increase of muscle functional extention. Studies indicate that the sarcomere length is set by the length of the muscle tension is subject. The stretching allows the muscle recoverment of their necessary extention to maintain a correct postural alignment, maintain joint stability, mainly ensuring integrity of the function and improves of muscular contraction. Other studies shown that the friction obtained of Crochetagem on muscles improves physiological characteristics of muscular contraction.

Oral Breather Syndrome (OBS) is replacement of nasal respiratory standard by oral that affects children from 2 to 8 years. As the child breathes by mouth, the air comes weaker in the lungs leading to difficulty in the thoracic expansibility. Chronic bronchitis is characterized by mucus accumulation in the bronchial tree and this difficult the thoracic mobility.

The respiratory minute volume is the total amount of new air that comes in the airways every minute and it is equal of the product of current volume multiplied by respiratory rate. So, the minute volume may be raised by increase of respiratory rate or current volume, according with needs of each individual. The more stretched the muscle is in its contractile capacity, the greater its ability to generate tension. Thus, arrives a larger volume of air. Our results shown that the intercostal Crochetagem was able to elevate the minute volume and this effect was caused by the increase of current volume without change the respiratory rate independently of age.

According to Azevedo (2000), the mean values normal of Pimax in healthy young adults is between -90 to -120cmH2O and Pemax between +100 to +150 cmH2O. The maximum pressures generated by a muscle reflect its force (18). This study had the participation of voluntaries that presented normal values of Pimax and Pemax. The Crochetagem was able to improve Pimax and Pemax. These results are associated to increase of minute volume and to best ventilator comfort measured by respiratory rate.

The Crochetagem in external intercostal muscles was used in a study in patients with Parkinson's disease (PD). These patients have a thoracic expansibility decrease due the rigidity of trunk muscles, loss of flexibility musculoskeletal and kyphotic posture. It was observed by study that technic of Crochetagem is able to produce the increase of blood supply to treated region. However, by the values obtained in spirometry in this study, was found that with utilization of technic there is a satisfactory immediate gain of thoracic expansibility, but the same wasn't sustained during treatment.

Until the moment there were not sufficient studies to demonstrate the performance improvement of ventilator function in individuals submitted to Crochetagem, however, it's known that the hook has systemic effects in terms the muscle length, reflecting in power of muscle contraction capacity. The cells react increasing their rigidity in direct proportion with the tension applied on them (21). This tension explains how the cell mechanic behavior emerges of physical interaction between different systems of molecular filaments that form the cytoskeleton. The reality is that the tension transmission by molecular connections within of cytoskeleton forms a network that influences the whole cell may be the tension effect, acquired by the Crochetagem technic, although not directly assessed in our study. Through these studies, we observed that intercostal Crochetagem significantly improve the mechanical ventilation without causing damage the same. Furthermore, we can see that Pimax and Pemax are influenced according the age, as showed better results in adults.

Conclusion

There was a significant improve in minute volume, current volume, peak flow and a not so significant in PiMax and Pemax. The Crochetagem effects in mechanical ventilation have been acquired and appears to be accompanied by a possible comfort, once RR did not improve. We believe that regardless of age the intercostal Crochetagem can change the volumetric characteristics and to influence directly in aspiratory and expiratory forces of adults. It is necessary now studies that may explain these effects in patients with restrictive thoracic disorders.

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Obs:

- Todo crédito e responsabilidade do conteúdo são de sua autora.

- Publicado em 11/09/2012.