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Dayican DK, Keser I, Yavuz O, Tosun G, Kurt S, Tosun OC. Can pelvic floor muscle training positions be selected according to the functional status of pelvic floor muscles? Niger J Clin Pract 2023; 26:1309-1318. [PMID: 37794544 DOI: 10.4103/njcp.njcp_53_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Background Pelvic floor muscle (PFM) training varies according to the functional status of PFM. It is used to strengthen underactive PFM and relax overactive PFM. Aim This study aimed to determine the appropriate PFM training positions according to the functional status of the PFM in women with pelvic floor dysfunction. Materials and Methods Seventy-six women diagnosed with pelvic floor dysfunction were included. After the digital palpation, participants were divided into four groups according to the functional status of PFM: normal, overactive, underactive, and nonfunctional. Participants' PFM and abdominal muscle functions were assessed with superficial electromyography in three positions (modified butterfly pose-P1, modified child pose-P2, and modified deep squat with block pose-P3). Friedman's analysis of variance and the Kruskal-Wallis test were used to assess whether the function of the muscles differed according to the functional status of the PFM and training positions. Results Normal PFM maximally contracted and relaxed in P1, whereas nonfunctional PFM was in P3 (P > 0.05). Overactive and underactive PFM was most contracted in P2 (P > 0.05) and relaxed in P1 (P < 0.001). In each functional state of the PFM, all abdominal muscles were most relaxed in P1, while their most contracted positions varied (P < 0.05). Conclusion This study showed that the positions in which the PFM relaxes and contracts the most may vary according to the functional status of the PFM. Therefore, different PFM training positions may be preferred according to the functional status of the PFM in women with pelvic floor dysfunction. However, more study needs to be done in this subject.
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Affiliation(s)
- D K Dayican
- Department of Physiotherapy and Rehabilitation, Biruni University, Faculty of Health Sciences; Department of Physiotherapy and Rehabilitation, Biruni University, Graduate Education Institute, Istanbul, Turkey
| | - I Keser
- Dokuz Eylül University, Faculty of Physical Therapy and Rehabilitation, Izmir, Turkey
| | - O Yavuz
- Department of Obstetrics and Gynecology, Dokuz Eylül University, Izmir, Turkey
| | - G Tosun
- Department of Obstetrics and Gynecology, Tepecik Education and Research Hospital, Izmir, Turkey
| | - S Kurt
- Department of Obstetrics and Gynecology, Dokuz Eylül University, Izmir, Turkey
| | - O C Tosun
- Dokuz Eylül University, Faculty of Physical Therapy and Rehabilitation, Izmir, Turkey
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Wang Y, Liu L, Chen Q, Gao K, Wang H, Xu N, Chen Y, Wong DWC, Lam WK. Modified lumbo-pelvic exercise to alleviate mild stress urinary incontinence in middle-aged females. Sci Rep 2023; 13:7142. [PMID: 37130891 PMCID: PMC10153777 DOI: 10.1038/s41598-023-34417-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 04/29/2023] [Indexed: 05/04/2023] Open
Abstract
Urinary incontinence is one of the common clinical problems of females passing middle age. Traditional pelvic floor muscle training to alleviate urinary incontinence is too dull and unpleasant. Therefore, we were motivated to purpose a modified lumbo-pelvic exercise training incorporating simplified dancing components with pelvic floor muscle training. The objective of this study was to evaluate the 16-week modified lumbo-pelvic exercise program that incorporated dance and abdominal drawing-in maneuvers. Middle-aged females were randomly assigned into the experimental (n = 13) and control (n = 11) groups. Compared to the control group, the exercise group significantly reduced body fat, visceral fat index, waistline, waist-hip ratio, perceived incontinence score, frequency of urine leakage, and pad testing index (p < 0.05). In addition, there were significant improvements in pelvic floor function, vital capacity, and muscle activity of the right rectus abdominis (p < 0.05). This indicated that the modified lumbo-pelvic exercise program can promote benefits of physical training and alleviate urinary incontinence in middle-aged females.
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Affiliation(s)
- Yi Wang
- Department of Physical Education, Renmin University of China, Beijing, China
- Sports and Social Development Research Center, Renmin University of China, Beijing, China
| | - Liangchao Liu
- Physical Education Department, University of International Business and Economics, Beijing, China
| | - Qi Chen
- Physical Education Department, University of International Business and Economics, Beijing, China
| | - Kuiting Gao
- School of Physical Education, Shandong University of Technology, Shandong, China.
| | - Hongchu Wang
- School of Mathematical Sciences, South China Normal University, Guangzhou, China
| | - Naxin Xu
- Sport Science School, Beijing Sport University, Beijing, China
| | - Yinru Chen
- College of Education, Beijing Sport University, Beijing, China
| | - Duo Wai-Chi Wong
- Department of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Hong Kong, China.
- Research Institute for Sports Science and Technology, The Hong Kong Polytechnic University, Hong Kong, China.
| | - Wing-Kai Lam
- Sports Information and External Affairs Centre, Hong Kong Sports Institute, Hong Kong, China.
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Korkmaz Dayican D, Keser I, Celiker Tosun O, Yavuz O, Tosun G, Kurt S, Baser Secer M. Exercise Position to Improve Synergy Between the Diaphragm and Pelvic Floor Muscles in Women With Pelvic Floor Dysfunction: A Cross Sectional Study. J Manipulative Physiol Ther 2023; 46:201-211. [PMID: 38520441 DOI: 10.1016/j.jmpt.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 02/15/2024] [Accepted: 02/26/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVE This study aimed to investigate the synergy between the diaphragm and pelvic floor muscles (PFM) according to different exercise positions in women with pelvic floor dysfunction. Our secondary aim was to determine the short-term effects of single-week pelvic floor muscle training (PFMT) program on diaphragmatic function. METHODS The cross-sectional study included 64 women with pelvic floor dysfunction. The participants' diaphragm and abdominal muscle functions during voluntary PFM contraction and relaxation were assessed by surface electromyography and ultrasonography. The surface electromyography assessments were performed in supine (P1), crawling (P2) and sitting (P3) positions. A single week-PFMT was conducted on women who agreed to determine the short-term responses of the diaphragm function. The muscle functions according to exercise positions were compared with Friedman Analysis of Variance, and the short-term effects of single-week PFMT on diaphragm function was analyzed with Wilcoxon Signed-Ranks Test. RESULTS The diaphragm activity during voluntary PFM contraction was highest in P2 before and after single-week PFMT (P < .001). Positive significant correlations were found between the activities diaphragm and abdominal muscles in different exercise positions (P < .05). After single-week PFMT, diaphragm thickness increased (P = .030) in P1, but diaphragm activity did not change in all 3 exercise positions (P > .05). CONCLUSION The synergy between the diaphragm and PFM was greater in the crawling position in women with pelvic floor dysfunction. The abdominal muscles seemed to contribute to maintaining this synergy. Therefore, PFMT combined with diaphragmatic breathing exercises in the crawling position should be considered. In addition, single-week PFMT may positively affect diaphragm function in the short-term.
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Affiliation(s)
- Damla Korkmaz Dayican
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, İzmir Tınaztepe University, İzmir, Turkey
| | - Irem Keser
- Department of Physiotherapy and Rehabilitation, Faculty of Physiotherapy and Rehabilitation, Dokuz Eylül University, İzmir, Turkey
| | - Ozge Celiker Tosun
- Department of Physiotherapy and Rehabilitation, Faculty of Physiotherapy and Rehabilitation, Dokuz Eylül University, İzmir, Turkey
| | - Onur Yavuz
- Department of Obstetrics and Gynecology, Dokuz Eylül University, İzmir, Turkey
| | - Gokhan Tosun
- Department of Obstetrics and Gynecology, Tepecik Education and Research Hospital, İzmir, Turkey
| | - Sefa Kurt
- Department of Obstetrics and Gynecology, Dokuz Eylül University, İzmir, Turkey
| | - Melda Baser Secer
- Manisa Celal Bayar University, Vocational School of Health Services, Manisa, Turkey.
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Tosun ÖÇ, Dayıcan DK, Keser İ, Kurt S, Yıldırım M, Tosun G. Are clinically recommended pelvic floor muscle relaxation positions really efficient for muscle relaxation? Int Urogynecol J 2022; 33:2391-2400. [PMID: 35201370 DOI: 10.1007/s00192-022-05119-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Various positions for pelvic floor muscle (PFM) relaxation are recommended during PFM training in physiotherapy clinics. To our knowledge, there is no study addressing the most effective position for PFM and abdominal muscle relaxation. Therefore, the current study aimed to investigate the effect of different relaxation positions on PFM and abdominal muscle functions in women with urinary incontinence (UI). METHODS Sixty-seven women diagnosed with UI were enrolled in the study. The type, frequency, and amount of UI were assessed with the International Incontinence Questionnaire-Short Form and bladder diary. Superficial electromyography was used to assess PFM and abdominal muscle functions during three relaxation positions: modified butterfly pose (P1), modified child pose (P2), and modified deep squat with block (P3). Friedman variance analyses and Wilcoxon signed rank test with Bonferroni corrections were used to evaluate the difference between positions. RESULTS The most efficient position for PFM relaxation was P1 and followed by P3 and P2, respectively. The order was also the same for abdominal muscles (p < 0.001), P1 > P3 > P2. The rectus abdominis (RA) was the most affected muscle during PFM relaxation. The extent of relaxation of RA muscle increased as the extent of PFM relaxation increased (r = 0.298, p = 0.016). No difference was found between different types of UI during the same position in terms of PFM relaxation extents (p > 0.05). CONCLUSIONS Efficient PFM relaxation is maintained during positions recommended in physiotherapy clinics. The extent of PFM and abdominal muscle relaxation varies according to the positions.
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Affiliation(s)
- Özge Çeliker Tosun
- Faculty of Physical Therapy and Rehabilitation, Dokuz Eylül University, Izmir, Turkey
| | - Damla Korkmaz Dayıcan
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Biruni University, Istanbul, Turkey.
| | - İrem Keser
- Institute of Health Sciences, Dokuz Eylül University, Izmir, Turkey
| | - Sefa Kurt
- Department of Obstetrics and Gynecology, Dokuz Eylül University, Izmir, Turkey
| | - Meriç Yıldırım
- Faculty of Physical Therapy and Rehabilitation, Dokuz Eylül University, Izmir, Turkey
| | - Gökhan Tosun
- Department of Obstetrics and Gynecology, Tepecik Education and Research Hospital, Izmir, Turkey
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Assessment of the Elastographic and Electromyographic of Pelvic Floor Muscles in Postmenopausal Women with Stress Urinary Incontinence Symptoms. Diagnostics (Basel) 2021; 11:diagnostics11112051. [PMID: 34829398 PMCID: PMC8618737 DOI: 10.3390/diagnostics11112051] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/01/2021] [Accepted: 11/04/2021] [Indexed: 12/03/2022] Open
Abstract
Background. Shear wave elastography is an effective method for studying the condition of various musculoskeletal soft tissues. The primary aim of this study was the objective elastographic and electromyographic assessment of the pelvic floor during the rest and contraction of the pelvic floor muscles (PFM) in postmenopausal women. Methods. This was a prospective observational study that was carried out at the University Hospital in Wroclaw, Poland, between January 2017 and December 2019. Patients. The target group of the study included postmenopausal women with stress urinary incontinence. The primary outcomes were the features of the elastographic assessment of the pelvic floor during rest and contraction of the PFM obtained using shear wave elastography. Results. Based on the inclusion and exclusion criteria for the study, 14 patients took part in the measurements. There was a significant difference between the elastographic assessment of the pelvic floor during rest and contraction of the PFM at all locations in front of the urethra. No statistically significant correlation was found between the results of elastography and the bioelectrical activity of PFM. Conclusion. The elasticity of the periurethral structures is higher during active pelvic floor muscle contraction than at rest, it seems that shear wave elastography is an effective test that objectively assesses the strength of PFM contraction.
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Suits WH. Clinical Measures of Pelvic Tilt in Physical Therapy. Int J Sports Phys Ther 2021; 16:1366-1375. [PMID: 34631258 PMCID: PMC8486407 DOI: 10.26603/001c.27978] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 08/19/2021] [Indexed: 01/18/2023] Open
Abstract
Pelvic tilt refers to the spatial position or motion of the pelvis about a frontal horizontal axis on the rest of the body in the sagittal plane. It is relevant for several musculoskeletal conditions commonly seen in physical therapist practice, particularly conditions affecting the hip and groin. Despite the relevance of pelvic tilt identified in biomechanical studies, and the historical precedence for assessing pelvic tilt, there is a lack of clarity regarding the utility of clinical measures that are practical in a rehabilitation setting. There are several options available to assess pelvic tilt which are discussed in detail in this commentary. All of these options come with potential benefits and considerable limitations. The purpose of this commentary is to provide an overview of the relevance of understanding pelvic tilt in the pathology and rehabilitation of conditions affecting the hip joint, with a focus applying evidence towards identifying clinical measures that may be useful in the rehabilitation setting and considerations that are needed with these measures. LEVEL OF EVIDENCE 5.
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Sorrigueta-Hernández A, Padilla-Fernandez BY, Marquez-Sanchez MT, Flores-Fraile MC, Flores-Fraile J, Moreno-Pascual C, Lorenzo-Gomez A, Garcia-Cenador MB, Lorenzo-Gomez MF. Benefits of Physiotherapy on Urinary Incontinence in High-Performance Female Athletes. Meta-Analysis. J Clin Med 2020; 9:jcm9103240. [PMID: 33050442 PMCID: PMC7601720 DOI: 10.3390/jcm9103240] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction: High performance female athletes may be a risk group for the development of urinary incontinence due to the imbalance of forces between the abdomen and the pelvis. Pelvic floor physiotherapy may be a useful treatment in these patients. Objectives: (1) To identify the scientific evidence for pelvic floor (PF) dysfunctions that are associated with urinary incontinence (UI) in high-performance sportswomen. (2) To determine whether pelvic floor physiotherapy (PT) corrects UI in elite female athletes. Materials and methods: Meta-analysis of published scientific evidence. The articles analyzed were found through the following search terms: (A) pelvic floor dysfunction elite female athletes; (B) urinary incontinence elite female athletes; (C) pelvic floor dysfunction elite female athletes physiotherapy; (D) urinary incontinence elite female athletes physiotherapy. Variables studied: type of study, number of individuals, age, prevalence of urinary incontinence described in the athletes, type of sport, type of UI, aspect investigated in the articles (prevalence, response to treatment, etiopathogenesis, response to PT treatment, concomitant health conditions or diseases. Study groups according to the impact of each sport on the PF: G1: low-impact (noncompetitive sports, golf, swimming, running athletics, throwing athletics); G2: moderate impact (cross-country skiing, field hockey, tennis, badminton, baseball) and G3: high impact (gymnastics, artistic gymnastics, rhythmic gymnastics, ballet, aerobics, jump sports (high, long, triple and pole jump)), judo, soccer, basketball, handball, volleyball). Descriptive analysis, ANOVA and meta-analysis. Results: Mean age 22.69 years (SD 2.70, 18.00–29.49), with no difference between athletes and controls. Average number of athletes for each study was 284.38 (SD 373,867, 1–1263). The most frequent type of study was case-control (39.60%), followed by cross-sectional (30.20%). The type of UI was most often unspecified by the study (47.20%), was stress UI (SUI, 24.50%), or was referred to as general UI (18.90%). Studies on prevalence were more frequent (54.70%), followed by etiopathogenesis (28.30%) and, lastly, on treatment (17.00%). In most cases sportswomen did not have any disease or concomitant pathological condition (77.40%). More general UI was found in G1 (36.40%), SUI in G2 (50%) and unspecified UI in G3 (63.64%). In the meta-analysis, elite athletes were found to suffer more UI than the control women. In elite female athletes, in general, physiotherapy contributed to gain in urinary continence more than in control women (risk ratio 0.81, confidence interval 0.78–0.84)). In elite female athletes, former elite female athletes and in pregnant women who regularly engage in aerobic activity, physiotherapy was successful in delivering superior urinary continence compared to the control group. The risk of UI was the same in athletes and in the control group in volleyball female athletes, elite female athletes, cross-country skiers and runners. Treatment with PT was more effective in control women than in gymnastics, basketball, tennis, field hockey, track, swimming, volleyball, softball, golf, soccer and elite female athletes. Conclusions: There is pelvic floor dysfunction in high-performance athletes associated with athletic activity and urinary incontinence. Eating disorders, constipation, family history of urinary incontinence, history of urinary tract infections and decreased flexibility of the plantar arch are associated with an increased risk of UI in elite female athletes. Pelvic floor physiotherapy as a treatment for urinary incontinence in elite female athletes, former elite female athletes and pregnant athletes who engage in regular aerobic activity leads to a higher continence gain than that obtained by nonathlete women.
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Affiliation(s)
- Alba Sorrigueta-Hernández
- Section of Urology, Department of Surgery, University of Salamanca, 37007 Salamanca, Spain; (A.S.-H.); (M.-C.F.-F.); (M.-B.G.-C.); (M.-F.L.-G.)
- Department of Physiotherapy, University of Salamanca, 37007 Salamanca, Spain;
| | | | - Magaly-Teresa Marquez-Sanchez
- Multidisciplinary Renal Research Group of the Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain;
| | - Maria-Carmen Flores-Fraile
- Section of Urology, Department of Surgery, University of Salamanca, 37007 Salamanca, Spain; (A.S.-H.); (M.-C.F.-F.); (M.-B.G.-C.); (M.-F.L.-G.)
| | - Javier Flores-Fraile
- Section of Urology, Department of Surgery, University of Salamanca, 37007 Salamanca, Spain; (A.S.-H.); (M.-C.F.-F.); (M.-B.G.-C.); (M.-F.L.-G.)
- Correspondence:
| | | | | | - Maria-Begoña Garcia-Cenador
- Section of Urology, Department of Surgery, University of Salamanca, 37007 Salamanca, Spain; (A.S.-H.); (M.-C.F.-F.); (M.-B.G.-C.); (M.-F.L.-G.)
| | - Maria-Fernanda Lorenzo-Gomez
- Section of Urology, Department of Surgery, University of Salamanca, 37007 Salamanca, Spain; (A.S.-H.); (M.-C.F.-F.); (M.-B.G.-C.); (M.-F.L.-G.)
- Multidisciplinary Renal Research Group of the Institute for Biomedical Research of Salamanca (IBSAL), 37007 Salamanca, Spain;
- Urology Service of the University Hospital of Salamanca, 37007 Salamanca, Spain
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Lee K. Investigation of Electromyographic Activity of Pelvic Floor Muscles in Different Body Positions to Prevent Urinary Incontinence. Med Sci Monit 2019; 25:9357-9363. [PMID: 31813929 PMCID: PMC6918805 DOI: 10.12659/msm.920819] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background This study aimed to determine whether trunk stability muscles co-contract with body position as a factor of pelvic floor muscle (PFM) activity. Material/Methods Sixty-one healthy adults without pelvic floor dysfunction were examined for pelvic floor and trunk stability muscle activity in 4 body positions (ankle dorsiflexion and plantar flexion in standing position, and ankle dorsiflexion and plantar flexion in long sitting position). The activities of the PFMs via anal/vaginal probes, internal oblique (IO), multifidus (MF), tibialis anterior, and gastrocnemius muscles were measured by surface electromyography. Three-dimensional motion analysis measured the movement of the pelvis in real time according to the change in body position. Results There was a significant increase in PFM activity from the ankle neutral position while standing for both ankle dorsiflexion and plantar flexion in standing position (p<0.05). In maximal contraction of PFM in the standing position, IO and MF were found to co-activate (p<0.05). Conclusions In standing position, the ankle dorsiflexion and plantar flexion positions activated PFMs, which was found to co-activate with trunk stability muscles. Pelvic floor training programs based on the results of this study may be helpful in patients with incontinence.
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Affiliation(s)
- Kyeongjin Lee
- Department of Physical Therapy, Kyungdong University, Wonju, Gangwon, South Korea
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García-Vidal JA, López-Nicolás M, Sánchez-Sobrado AC, Escolar-Reina MP, Medina-Mirapeix F, Bernabeu-Mora R. The Combination of Different Ergonomic Supports during Dental Procedures Reduces the Muscle Activity of the Neck and Shoulder. J Clin Med 2019; 8:jcm8081230. [PMID: 31443308 PMCID: PMC6723175 DOI: 10.3390/jcm8081230] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 11/23/2022] Open
Abstract
Ergonomic supports have become popular for the prevention of musculoskeletal disorders. This study sought to evaluate the efficacy of different ergonomic supports and their combination to reduce muscle activity of the neck and shoulder muscles. A one-way repeated measures design was used to evaluate 36 practicing dentists while they performed three posterior composite restoration procedures on a phantom head. Portable surface electromyography (sEMG) recordings were used to measure the muscle activity of three muscles (Upper Trapezius, Lateral Deltoid and Anterior Deltoid) in the dominant upper extremity, with and without the use of different ergonomic supports (ergonomic stool, magnification lenses and both) during the performance of these tasks. A repeated measures analysis of variance was used. The muscle activity of all muscles differed significantly across the four ergonomic conditions during the three tasks. The use of ergonomic supports such as magnification lenses, the ergonomic stool, or the combination of both, is effective for decreasing the muscle activity of the three muscles during the three tasks, when compared to standard practice. In addition, the decrease of muscle activity was higher using magnification lenses when compared to the ergonomic stool. Furthermore, the greatest decrease was found with the combination of both supports.
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Affiliation(s)
- José A García-Vidal
- Departament of Physiotherapy, University of Murcia, Campus de Espinardo, 30100 Murcia, Spain.
- Research group Fisioterapia y Discapacidad, Institute of Biomedical Research (IMIB)-Virgen de la Arrixaca University Clinical Hospital, El Palmar, 30120 Murcia, Spain.
| | - Manuel López-Nicolás
- Department of Dermatology, Stomatology, Radiology and Physical Medicine, University of Murcia, 30008 Murcia, Spain
| | - Ana C Sánchez-Sobrado
- Department of Dermatology, Stomatology, Radiology and Physical Medicine, University of Murcia, 30008 Murcia, Spain
| | - María P Escolar-Reina
- Departament of Physiotherapy, University of Murcia, Campus de Espinardo, 30100 Murcia, Spain
- Research group Fisioterapia y Discapacidad, Institute of Biomedical Research (IMIB)-Virgen de la Arrixaca University Clinical Hospital, El Palmar, 30120 Murcia, Spain
| | - Francesc Medina-Mirapeix
- Departament of Physiotherapy, University of Murcia, Campus de Espinardo, 30100 Murcia, Spain
- Research group Fisioterapia y Discapacidad, Institute of Biomedical Research (IMIB)-Virgen de la Arrixaca University Clinical Hospital, El Palmar, 30120 Murcia, Spain
| | - Roberto Bernabeu-Mora
- Division of Pneumology, Morales Meseguer University Clinical Hospital, 30007 Murcia, Spain
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