2. GENEL BĠLGĠLER
2.2. KORONER ARTER VE VENLERĠN ANATOMĠSĠ
2.2.1. Koroner Arter Anatomisi
Esta revisão sistemática tentou garantir grupos de estudo homogéneos por variáveis, estabelecendo critérios de inclusão completos e detalhados. Mesmo depois de uma seleção cuidadosa dos estudos, os seus métodos, análises e resultados foram diversos.
Pelo facto de apenas haver uma revisão sistemática que aborda as alterações biomecânicas durante a gravidez (Mann et al., 2010), e pela mesma não ser específica quanto às alterações biomecânicas que ocorrem na marcha de mulheres grávidas com dor lombo-pélvica, com este trabalho pretendeu-se rever de uma forma sistemática a evidência disponível sobre este assunto. No final do estudo considera-se que o objetivo do mesmo foi alcançado, apesar dos resultados terem sido díspares entre estudos devido à falta de estandardização das variáveis e dos métodos de análise.
Não obstante, pode-se concluir que durante a marcha da mulher grávida, existem alterações das FRA e verifica-se uma redistribuição dessas cargas na área plantar, sendo necessário estabelecer a sua relação com a ocorrência de dor lombo-pélvica. Por outro lado, a disponibilidade de equipamento mais sofisticado de análise do movimento, permitirá, através de estudos laboratoriais prospetivos, verificar as adaptações cinemáticas e cinéticas da marcha na gravidez normal e aquando da ocorrência de dor.
Num terço dos estudos selecionados avaliou-se as mulheres no período pós-parto. Em oito estudos foram comparadas grávidas (ou mulheres no pós-parto) com mulheres não grávidas.
Uma meta-análise permitiria sumariar os resultados dos estudos com diferentes tamanhos e confiabilidades da amostra, providenciando assim uma revisão quantitativa da literatura. Contudo, dada a natureza dos dados e os objetivos do estudo, tornar-se-ia inadequado sumariar os efeitos de forma transversal a todos os subgrupos.
Como sugestão para a prática, seria interessante utilizar-se a pressão plantar na avaliação da marcha como um indicador mais objetivo do efeito da intervenção em Fisioterapia, nos casos de dor lombo-pélvica, (não apenas relacionados com a gravidez).
Esta revisão sistemática revela a escassa pesquisa realizada na área da biomecânica em grávidas/ mulheres no período pós-parto, e sugere direções para futuros estudos, como a
realização de estudos de natureza descritiva e correlacional com o objetivo de caraterizar a marcha de mulheres grávidas/ no pós-parto na presença de DLPRG.
Sugere-se ainda a realização de mais estudos de revisão que pretendam rever de uma forma sistemática a evidência disponível sobre as alterações biomecânicas que ocorrem nas mulheres grávidas e no período pós-parto, com dor a nível do membro inferior: anca, joelho e pé.
Ainda como sugestão de pesquisa, a existência de um baseline que apresente os valores pré-gestacionais representativos dos padrões de marcha normais, embora impraticável será de grande utilidade. Será ainda vantajoso, os estudos recolherem avaliações não apenas no período da gravidez (2.º e 3.º trimestres), mas também ter medidas de resultados no período pós-parto para determinar a existência de alterações residuais da marcha na gravidez.
A estandardização das variáveis biomecânicas da marcha em estudo nas grávidas/ mulheres no período pós-parto é necessária para permitir a comparação de resultados entre estudos. Deverá ser considerada, na medida em que permitirá desenhar estratégias mais adequadas de avaliação objetiva da marcha em Fisioterapia.
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Anexo I - Checklist for measuring study quality
Reporting
1. Is the hypothesis/aim/objective of the study clearly described? Yes= 1 No=0
2. Are the main outcomes to be measured clearly described in the Introduction or Methods section? If the main
outcomes are first mentioned in the Results section, the question should be answered no. Yes= 1 No=0
3. Are the characteristics of the patients included in the study clearly described? In cohort studies and trials, inclusion and/or exclusion criteria should be given. In case-control studies, a case-definition and the source for controls should be given.
Yes= 1 No=0
4. Are the interventions of interest clearly described? Treatments and placebo (where relevant) that are to be
compared should be clearly described. Yes= 1 No=0
5. Are the distributions of principal confounders in each group of subjects to be compared clearly described? A
list of principal confounders is provided Yes= 1 No=0
6. Are the main findings of the study clearly described? Simple outcome data (including denominators and numerators) should be reported for all major findings so that the reader can check the major analyses and conclusions. (This question does not cover statistical tests which are considered below).
Yes= 1 No=0
8. Have all important adverse events that may be a consequence of the intervention been reported? This should be answered yes if the study demonstrates that there was a comprehensive attempt to measure adverse events. (A list of possible adverse events is provided).
Yes= 1 No=0
9. Have the characteristics of patients lost to follow-up been described? This should be answered yes where there were no losses to follow-up or where losses to follow-up were so small that findings would be unaffected by their inclusion. This should be answered no, where a study does not report the number of patients lost to follow-up.
Yes= 1 No=0
10. Have actual probability values been reported (e.g. 0.035 rather than <0.05) for the main outcomes except
where the probability value is less than 0.001? Yes= 1 No=0
External validity
All the following criteria attempt to address the representativeness of the findings of the study and whether they may be generalised to the population from which the study subjects were derived.
11. Were the subjects asked to participate in the study representative of the entire population from which they were recruited? The study must identify the source population for patients and describe how the patients were selected. Patients would be representative if they comprised the entire source population, an unselected sample of consecutive patients, or a random sample. Random sampling is only feasible where a list of all members of the relevant report the proportion of the source population from which the patients are derived, the question should be answered as unable to determine.
Yes= 1 No=0 Unable to
determine=0
12. Were those subjects who were prepared to participate representative of the entire population from which they were recruited? The proportion of those asked who agreed should be stated. Validation that the sample was representative would include demonstrating that the distribution of the main confounding factors was the same in the study sample and the source population.
Yes= 1 No=0 Unable to
determine=0
13. Were the staff, places, and facilities where the patients were treated, representative of the treatment the majority of patients receive? For the question to be answered yes the study should demonstrate that the intervention was representative of that in use in the source population. The question should be answered no if, for example, the intervention was undertaken in a specialist centre unrepresentative of the hospitals most of the source population would attend.
Yes= 1 No=0 determine=0 Unable to
Internal validity – bias
14. Was an attempt made to blind study subjects to the intervention they have received? For studies where the patients would have no way of knowing which intervention they received, this should be answered yes
Yes= 1 No=0 Unable to
determine=0
15. Was an attempt made to blind those measuring the main outcomes of the intervention? Yes= 1 No=0 Unable to determine=0 16. If any of the results of the study were based on “data dredging”, was this made clear?
Any analyses that had not been planned at the outset of the study should be clearly indicated. If no retrospective unplanned subgroup analyses were reported, then answer yes.
Yes= 1 No=0 Unable to
determine=0 17. In trials and cohort studies, do the analyses adjust for different lengths of follow-up of
patients, or in case-control studies, is the time period between the intervention and outcome the same for cases and controls? Where follow-up was the same for all study patients the answer should yes. If different lengths of follow-up were adjusted for by, for example, survival analysis the answer should be yes. Studies where differences in follow-up are ignored should be answered no.
Yes= 1 No=0 Unable to
determine=0
18. Were the statistical tests used to assess the main outcomes appropriate? The statistical techniques used must be appropriate to the data. For example nonparametric methods should be used for small sample sizes. Where little statistical analysis has been undertaken but where there is no evidence of bias, the question should be answered yes. If the
distribution of the data (normal or not) is not described it must be assumed that the estimates used were appropriate and the question should be answered yes.
Yes= 1 No=0 Unable to
19. Was compliance with the intervention/s reliable? Where there was non compliance with the allocated treatment or where there was contamination of one group, the question should be answered no. For studies where the effect of any misclassification was likely to bias any association to the null, the question should be answered yes.
Yes= 1 No=0 Unable to
determine=0
20. Were the main outcome measures used accurate (valid and reliable)? For studies where the outcome measures are clearly described, the question should be answered yes. For studies which refer to other work or that demonstrates the outcome measures are accurate, the question should be answered as yes.
Yes= 1 No=0 Unable to
determine=0
Internal validity - confounding (selection bias)
21. Were the patients in different intervention groups (trials and cohort studies) or were the cases and controls (case-control studies) recruited from the same population? For example, patients for all comparison groups should be selected from the same hospital. The question should be answered unable to determine for cohort and case-control studies where there is no information concerning the source of patients included in the study.
Yes= 1 No=0 Unable to
determine=0
22. Were study subjects in different intervention groups (trials and cohort studies) or were the cases and controls (case-control studies) recruited over the same period of time? For a study which does not specify the time period over which patients were recruited, the question should be answered as unable to determine.
Yes= 1 No=0 Unable to
determine=0
23. Were study subjects randomised to intervention groups? Studies which state that subjects were randomized should be answered yes except where method of randomisation would not ensure random allocation. For example alternate allocation would score no because it is predictable.
Yes= 1 No=0 Unable to
determine=0
24. Was the randomised intervention assignment concealed from both patients and health care staff until recruitment was complete and irrevocable? All non-randomised studies should be answered no. If assignment was concealed from patients but not from staff, it should be answered no.
Yes= 1 No=0 Unable to
determine=0
25. Was there adequate adjustment for confounding in the analyses from which the main findings were drawn? This question should be answered no for trials if: the main conclusions of the study were based on analyses of treatment rather than intention to treat; the
distribution of known confounders in the different treatment groups was not described; or the distribution of known confounders differed between the treatment groups but was not taken into account in the analyses. In nonrandomized studies if the effect of the main confounders was not investigated or confounding was demonstrated but no adjustment was made in the final analyses the question should be answered as no.
Yes= 1 No=0 Unable to
determine=0
26. Were losses of patients to follow-up taken into account? If the numbers of patients lost to follow-up are not reported, the question should be answered as unable to determine. If the proportion lost to follow-up was too small to affect the main findings, the question should be answered yes.
Yes= 1 No=0 Unable to
determine=0
Power
27. Did the study have sufficient power to detect a clinically important effect where the probability value for a difference being due to chance is less than 5%? Sample sizes have been calculated to detect a difference of x% and y%.
Size of smallest intervention group A <n1 0 B n1–n2 1 C n3–n4 2 D n5–n6 3 E n7–n8 4 F n8+ 5
INGLÊS
PREGNANCY AND LUMBAR PAIN PREGNANT AND LUMBAR PAIN GESTATION AND LUMBAR PAIN
PREGNANCY AND LOW BACK PAIN PREGNANT AND LOW BACK PAIN GESTATION AND LOW BACK PAIN
PREGNANCY AND LUMBOPELVIC PAIN PREGNANT AND LUMBOPELVIC PAIN GESTATION AND LUMBOPELVIC PAIN
PREGNANCY AND LUMBOCIATALGY PREGNANT AND LUMBOCIATALGY GESTATION AND LUMBOCIATALGY
PREGNANCY AND LUMBOPELVICOCIATALGY PREGNANT AND
LUMBOPELVICOCIATALGY GESTATION AND LUMBOPELVICOCIATALGY
PREGNANCY AND PELVIC PAIN PREGNANT AND PELVIC PAIN GESTATION AND PELVIC PAIN
PREGNANCY AND PELVIC GIRDLE PAIN PREGNANT AND PELVIC GIRDLE PAIN GESTATION AND PELVIC GIRDLE PAIN
PREGNANCY AND GAIT PREGNANT AND GAIT GESTATION AND GAIT
PREGNANCY AND GRF PREGNANT AND GRF GESTATION AND GRF
PREGNANCY AND PLANTAR PRESSURE PREGNANT AND PLANTAR PRESSURE GESTATION AND PLANTAR PRESSURE
GAIT AND LUMBAR PAIN GRF AND LUMBAR PAIN PLANTAR PRESSURE AND LUMBAR PAIN
GAIT AND LOW BACK PAIN GRF AND LOW BACK PAIN PLANTAR PRESSURE AND LOW BACK PAIN
GAIT AND LUMBOPELVIC PAIN GRF AND LUMBOPELVIC PAIN PLANTAR PRESSURE AND LUMBOPELVIC PAIN
GAIT AND LUMBOCIATALGY GRF AND LUMBOCIATALGY PLANTAR PRESSURE AND LUMBOCIATALGY
GAIT AND LUMBOPELVICOCIATALGY GRF AND
LUMBOPELVICOCIATALGY
PLANTAR PRESSURE AND LUMBOPELVICOCIATALGY
GAIT AND PELVIC GIRDLE PAIN GRF GAIT AND PELVIC GIRDLE PAIN
PLANTAR PRESSURE GAIT AND PELVIC GIRDLE PAIN
PORTUGUÊS
GRAVIDEZ AND DOR LOMBAR GRÁVIDA AND DOR LOMBAR GESTAÇÃO AND DOR LOMBAR GESTANTE AND DOR LOMBAR
GRAVIDEZ AND DOR LOMBO-PÉLVICA GRÁVIDA AND DOR LOMBO-
PÉLVICA
GESTAÇÃO AND DOR LOMBO- PÉLVICA
GESTANTE AND DOR LOMBO- PÉLVICA
GRAVIDEZ AND DOR PÉLVICO-
LOMBAR
GRÁVIDA AND DOR PÉLVICO- LOMBAR
GESTAÇÃO AND DOR PÉLVICO- LOMBAR
GESTANTE AND DOR PÉLVICO- LOMBAR
GRAVIDEZ AND LOMBO -CIATALGIA GRÁVIDA AND LOMBO-
CIATALGIA
GESTAÇÃO AND LOMBO-
CIATALGIA
GESTANTE AND LOMBO-
CIATALGIA
GRAVIDEZ AND LOMBALGIA GRÁVIDA AND LOMBALGIA GESTAÇÃO AND LOMBALGIA GESTANTE AND LOMBALGIA
GRAVIDEZ AND LOMBO-PÉLVICO-
CIATALGIA
GRÁVIDA AND LOMBO-
PÉLVICO-CIATALGIA
GESTAÇÃO AND LOMBO-PÉLVICO- CIATALGIA
GESTANTE AND LOMBO-
PÉLVICO-CIATALGIA
GRAVIDEZ AND DOR PÉLVICA GRÁVIDA AND DOR PÉLVICA GESTAÇÃO AND DOR PÉLVICA GESTANTE AND DOR PÉLVICA
GRAVIDEZ AND MARCHA GRÁVIDA AND MARCHA GESTAÇÃO AND MARCHA GESTANTE AND MARCHA
GRAVIDEZ AND FRA GRÁVIDA AND FRA GESTAÇÃO AND FRA GESTANTE AND FRA
GRAVIDEZ AND PRESSÃO PLANTAR GRÁVIDA AND PRESSÃO
PLANTAR
GESTAÇÃO AND PRESSÃO
PLANTAR
GESTANTE AND PRESSÃO
PLANTAR
MARCHA AND DOR LOMBAR FRA AND DOR LOMBAR PRESSÃO PLANTAR AND DOR LOMBAR
MARCHA AND DOR PÉLVICO-LOMBAR FRA AND DOR PÉLVICO-LOMBAR PRESSÃO PLANTAR AND DOR PÉLVICO-LOMBAR
MARCHA AND LOMBO –CIATALGIA FRA AND LOMBO -CIATALGIA PRESSÃO PLANTAR AND LOMBO -CIATALGIA
MARCHA AND LOMBALGIA FRA AND LOMBALGIA PRESSÃO PLANTAR AND LOMBALGIA
MARCHA AND LOMBO-PÉLVICO-CIATALGIA FRA AND LOMBO-PÉLVICO-
CIATALGIA
PRESSÃO PLANTAR AND LOMBO-PÉLVICO-CIATALGIA
MARCHA AND DOR PÉLVICA FRA AND DOR PÉLVICA PRESSÃO PLANTAR AND DOR PÉLVICA
FRANCÊS
GROSSESSE AND LOMBALGIE ENCEINTE AND LOMBALGIE
GROSSESSE AND LOMBALGIES ENCEINTE AND LOMBALGIES
GROSSESSE AND DOULEUR PELVIENNE ENCEINTE AND DOULEUR PELVIENNE
GROSSESSE AND DOULEUR PELVIENNE LOMBAIRE ENCEINTE AND DOULEUR PELVIENNE LOMBAIRE
GROSSESSE AND LONGE LA DOULEUR PELVIENNE ENCEINTE AND LONGE LA DOULEUR PELVIENNE
GROSSESSE AND PELVIENNE SCIATIQUE ENCEINTE AND PELVIENNE SCIATIQUE
GROSSESSE AND MARS ENCEINTE AND MARS
GROSSESSE AND FRS ENCEINTE AND FRS
GROSSESSE AND PRESSION PLANTAIRE ENCEINTE AND PRESSION PLANTAIRE
MARS AND LOMBALGIE FRS AND LOMBALGIE PRESSION PLANTAIRE AND LOMBALGIE