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Hartshorne MT, Turner JA, Cameron KL, Padua DA. Strength of the Uninvolved Limb Following Return to Activity After ACL Injury: Implications for Symmetry as a Marker of Sufficient Strength. Int J Sports Phys Ther 2024; 19:657-669. [PMID: 38835985 PMCID: PMC11144673 DOI: 10.26603/001c.117547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/24/2024] [Indexed: 06/06/2024] Open
Abstract
Background Muscular strength deficits are common after ACL injury. While the Limb Symmetry Index (LSI), using the uninvolved limb as a reference, is widely used, negative strength adaptations may affect both limbs post-injury. It is uncertain how the strength of the uninvolved limb in those with an ACL injury compares to uninjured individuals, making it unclear whether it is appropriate as a benchmark for determining sufficient strength. Purpose To compare the strength of key lower extremity muscles of the uninvolved limb in those with history of ACL injury (ACL-I) to the dominant limb in individuals with no history of ACL injury (control). Study Design Cross-sectional study. Methods: A total of 5,727 military cadets were examined, with 82 females and 126 males in the ACL-I group and 2,146 females and 3,373 males in the control group. Maximum isometric strength was assessed for six muscle groups measured with a hand-held dynamometer. Separate two-way ANOVAs with limb and sex were performed for each muscle group. Results Significant main effects for limb were observed with the uninvolved limb in the ACL-I group displaying greater strength compared to the dominant limb in the control group for the quadriceps, hamstrings, and gluteus medius, but effect sizes were small (Cohen's d <0.25). Significant main effects for sex were observed with greater male muscular strength in all six muscle groups with small to large effect sizes (Cohen's d 0.49-1.46). No limb-by-sex interactions were observed. Conclusions There was no evidence of reduced strength in the uninvolved limb in those with a history of ACL injury compared to the dominant limb in those with no prior ACL injury. This finding suggests that, after clearance to return to activities, the uninvolved limb can be used as a standard for comparison of sufficient strength, including when using the LSI. Level of Evidence: Level 3.
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Affiliation(s)
| | - Jeffrey A Turner
- Human Movement Science CurriculumUniversity of North Carolina at Chapel Hill
| | | | - Darin A Padua
- Department of Exercise and Sport ScienceUniversity of North Carolina at Chapel Hill
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Bühl L, Müller S, Nüesch C, Boyer KA, Casto E, Mündermann A, Egloff C. Ambulatory knee biomechanics and muscle activity 2 years after ACL surgery: InternalBrace TM-augmented ACL repair versus ACL reconstruction versus healthy controls. BMC Musculoskelet Disord 2023; 24:785. [PMID: 37794432 PMCID: PMC10548591 DOI: 10.1186/s12891-023-06916-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/24/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Little is known about knee mechanics and muscle control after augmented ACL repair. Our aim was to compare knee biomechanics and leg muscle activity during walking between the legs of patients 2 years after InternalBraceTM-augmented anterior cruciate ligament repair (ACL-IB) and between patients after ACL-IB and ACL reconstruction (ACL-R), and controls. METHODS Twenty-nine ACL-IB, 27 sex- and age-matched ACL-R (hamstring tendon autograft) and 29 matched controls completed an instrumented gait analysis. Knee joint angles, moments, power, and leg muscle activity were compared between the involved and uninvolved leg in ACL-IB (paired t-tests), and between the involved legs in ACL patients and the non-dominant leg in controls (analysis of variance and posthoc Bonferroni tests) using statistical parametric mapping (SPM, P < 0.05). Means and 95% confidence intervals (CI) of differences in discrete parameters (DP; i.e., maximum/minimum) were calculated. RESULTS Significant differences were observed in ACL-IB only in minimum knee flexion angle (DP: 2.4°, CI [-4.4;-0.5]; involved > uninvolved) and maximum knee flexion moment during stance (-0.07Nm/kg, CI [-0.13;-0.00]; involved < uninvolved), and differences between ACL-IB and ACL-R only in maximum knee flexion during swing (DP: 3.6°, CI [0.5;7.0]; ACL-IB > ACL-R). Compared to controls, ACL-IB (SPM: 0-3%GC, P = 0.015; 98-100%, P = 0.016; DP: -6.3 mm, CI [-11.7;-0.8]) and ACL-R (DP: -6.0 mm, CI [-11.4;-0.2]) had lower (maximum) anterior tibia position around heel strike. ACL-R also had lower maximum knee extension moment (DP: -0.13Nm/kg, CI [-0.23;-0.02]) and internal knee rotation moment (SPM: 34-41%GC, P < 0.001; DP: -0.03Nm/kg, CI [-0.06;-0.00]) during stance, and greater maximum semitendinosus activity before heel strike (DP: 11.2%maximum voluntary contraction, CI [0.1;21.3]) than controls. CONCLUSION Our results suggest comparable ambulatory knee function 2 years after ACL-IB and ACL-R, with ACL-IB showing only small differences between legs. However, the differences between both ACL groups and controls suggest that function in the involved leg is not fully recovered and that ACL tear is not only a mechanical disruption but also affects the sensorimotor integrity, which may not be restored after surgery. The trend toward fewer abnormalities in knee moments and semitendinosus muscle function during walking after ACL-IB warrants further investigation and may underscore the importance of preserving the hamstring muscles as ACL agonists. LEVEL OF EVIDENCE Level III, case-control study. TRIAL REGISTRATION clinicaltrials.gov, NCT04429165 (12/06/2020).
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Affiliation(s)
- Linda Bühl
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland.
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland.
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland.
| | - Sebastian Müller
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland
| | - Corina Nüesch
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland
- Department of Spine Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Katherine A Boyer
- Department of Kinesiology, University of Massachusetts Amherst, Amherst, MA, 01003, USA
- Department of Orthopedics and Physical Rehabilitation, University of Massachusetts Medical School, Worcester, MA, 01655, USA
| | - Erica Casto
- Department of Kinesiology, University of Massachusetts Amherst, Amherst, MA, 01003, USA
| | - Annegret Mündermann
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland
- Department of Spine Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Christian Egloff
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, Basel, 4031, Switzerland
- Department of Biomedical Engineering, University of Basel, Allschwil, 4123, Switzerland
- Department of Clinical Research, University of Basel, Basel, 4031, Switzerland
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Norte GE, Cousins M, Hogarth DA, Knaus KR, Slater LV, Blemker SS, Hart JM. Personalized volumetric assessment of lower body muscles in patients with knee injuries: A descriptive case series. Knee 2022; 39:38-49. [PMID: 36126493 DOI: 10.1016/j.knee.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 08/10/2022] [Accepted: 08/26/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients with knee joint pathology present with variable muscular responses across the muscles of the lower limb and pelvis. Conventional approaches to characterizing muscle function are limited to gross strength assessments that may overlook subtle changes both in the thigh, hip and shank musculature. PURPOSE To describe individualized patterns of lower extremity muscle volumes in patients with knee pathologies. METHODS This was a retrospective case series performed in a University medical center. Nine patients diagnosed with meniscus tear recommended to undergo meniscectomy volunteered. Participants underwent 3.0 Tesla magnetic resonance imaging (MRI) of the lower extremities. Thirty-five MRI-derived muscle volumes were compared between limbs and expressed as percentage asymmetry. For additional context, z-scores were also calculated for mass- and height-normalized muscles and pre-determined muscle groupings relative to a normative database. RESULTS There were no consistent patterns observed when considering between-limb asymmetries among all patients. The ankle musculature (dorsiflexors, plantar flexors, and invertors) was the only muscle group to be consistently smaller than normal for all patients, with the psoas major and flexor hallucis longus being the only individual muscles. The severity or chronicity of injury and presence of surgical intervention did not appear to have a clear effect on muscle volumes. CONCLUSION Patients with a history of meniscal pathology demonstrate inconsistent patterns of lower extremity muscle volumes about the hip, knee, and ankle between limbs and in comparison to uninjured individuals. These data support the need for individualized assessment and intervention in this population.
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Affiliation(s)
- Grant E Norte
- Department of Exercise and Rehabilitation Sciences, University of Toledo, Toledo, OH, United States.
| | | | - Danielle A Hogarth
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, United States
| | - Katherine R Knaus
- Department of Bioengineering, University of California at San Diego, San Diego, CA, United States
| | - Lindsay V Slater
- Department of Physical Therapy, University of Illinois at Chicago, Chicago, IL, United States
| | - Silvia S Blemker
- Springbok Analytics, Charlottesville, VA, United States; Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, United States; Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, United States; Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, VA, United States
| | - Joseph M Hart
- Springbok Analytics, Charlottesville, VA, United States; Department of Orthopaedics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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He X, Qiu J, Cao M, Ho YC, Leong HT, Fu SC, Ong MTY, Fong DTP, Yung PSH. Effects of Deficits in the Neuromuscular and Mechanical Properties of the Quadriceps and Hamstrings on Single-Leg Hop Performance and Dynamic Knee Stability in Patients After Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2022; 10:23259671211063893. [PMID: 35005050 PMCID: PMC8733370 DOI: 10.1177/23259671211063893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/16/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Understanding the role of neuromuscular and mechanical muscle properties in knee functional performance and dynamic knee stability after anterior cruciate ligament reconstruction (ACLR) may help in the development of more focused rehabilitation programs. Purpose: To compare the involved and uninvolved limbs of patients after ACLR in terms of muscle strength, passive muscle stiffness, muscle activation of the quadriceps and hamstrings, hop performance, and dynamic knee stability and to investigate the association of neuromuscular and mechanical muscle properties with hop performance and dynamic knee stability. Study Design: Cross-sectional study; Level of evidence, 3. Method: The authors studied the quadriceps and hamstring muscles in 30 male patients (mean ± SD age, 25.4 ± 4.1 years) who had undergone unilateral ACLR. Muscle strength was measured using isokinetic testing at 60 and 180 deg/s. Passive muscle stiffness was quantified using ultrasound shear wave elastography. Muscle activation was evaluated via electromyographic (EMG) activity. Hop performance was evaluated via a single-leg hop test, and dynamic knee stability was evaluated via 3-dimensional knee movements during the landing phase of the hop test. Results: Compared with the uninvolved limb, the involved limb exhibited decreased peak torque and shear modulus in both the quadriceps and hamstrings as well as delayed activity onset in the quadriceps (P < .05 for all). The involved limb also exhibited a shorter hop distance and decreased peak knee flexion angle during landing (P < .05 for both). Decreased peak quadriceps torque at 180 deg/s, the shear modulus of the semitendinosus, and the reactive EMG activity amplitude of the semimembranosus were all associated with shorter hop distance (R2 = 0.565; P < .001). Decreased quadriceps peak torque at 60 deg/s and shear modulus of the vastus medialis were both associated with smaller peak knee flexion angle (R2 = 0.319; P < .001). Conclusion: In addition to muscle strength deficits, deficits in passive muscle stiffness and muscle activation of the quadriceps and hamstrings were important contributors to poor single-leg hop performance and dynamic knee stability during landing. Further investigations should include a rehabilitation program that normalizes muscle stiffness and activation patterns during landing, thus improving knee functional performance and dynamic knee stability.
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Affiliation(s)
- Xin He
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Jihong Qiu
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Mingde Cao
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Yui Chung Ho
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Hio Teng Leong
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Sai-Chuen Fu
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Michael Tim-Yun Ong
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Daniel T P Fong
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Patrick Shu-Hang Yung
- Department of Orthopaedics & Traumatology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Limb Differences in Hamstring Muscle Function and Morphology After Anterior Cruciate Ligament Reconstruction: Letter to the editor. Phys Ther Sport 2021; 49:139-140. [PMID: 33684843 DOI: 10.1016/j.ptsp.2021.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 02/26/2021] [Indexed: 11/21/2022]
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Hamstrings Muscle Morphology After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis. Sports Med 2021; 51:1733-1750. [PMID: 33638795 DOI: 10.1007/s40279-021-01431-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Hamstrings muscle morphology is determinant of muscle function (i.e. strength). Among individuals with ACL reconstruction (ACLR), less cross-sectional area (CSA) and volume in the ACLR-limb are associated with muscle weakness, and may contribute to lower rates of return to preinjury activity level and an increased risk for long-term sequelae. OBJECTIVES To effectively treat muscular impairments, an accurate understanding of differences in hamstrings morphology following ACLR is needed. A systematic review and meta-analysis were undertaken to describe the morphology of the hamstring muscle complex after ACLR. METHODS We searched five databases for studies evaluating the difference between hamstrings size and architecture in individuals with ACLR. Two independent reviewers assessed each paper for inclusion and quality. Means and standard deviations were extracted from each included study to allow fixed-effect size meta-analysis calculations for comparison of results. RESULTS Twenty-four studies were included for final review. Eight categories of morphological outcomes were identified, and studies were grouped accordingly: (1) volume, (2) cross-sectional area (CSA), (3) muscle length, (4) muscle thickness, (5) fascicle length, (6) pennation angle, (7) fiber area, and (8) fiber type. Meta-analysis demonstrated lower hamstrings volume in the ACLR-limb in both contralateral and control group comparisons, and lower CSA, length, and thickness in the ACLR-limb in contralateral comparisons. The semitendinosus and gracilis were most profoundly impacted. Limited moderate evidence demonstrated greater biceps femoris pennation angle in the ACLR-limb. CONCLUSIONS Individuals with ACLR demonstrated large deficits in semitendinosus and gracilis muscle CSA and volume in the ACLR-limb compared contralaterally, with no differences observed in the biceps femoris or semimembranosus. Clinical implications regarding assessment and treatment of individuals with ACLR are discussed.
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Sherman DA, Glaviano NR, Norte GE. Hamstrings Neuromuscular Function After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis. Sports Med 2021; 51:1751-1769. [PMID: 33609272 DOI: 10.1007/s40279-021-01433-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Hamstrings neuromuscular function is a crucial component of functional movement, and changes after anterior cruciate ligament (ACL) injury contribute to risk factors for secondary injury and long-term sequelae. To effectively treat muscular impairments, an accurate understanding of hamstrings neuromuscular function in patients with ACL reconstruction (ACLR) is needed. OBJECTIVE A systematic review and meta-analysis were undertaken to describe and quantify hamstrings neuromuscular function in individuals with ACLR compared to controls. METHODS We searched PubMed, Web of Science, SPORTDiscus, CINAHL, and EBSCOhost databases in October of 2020 for studies evaluating the difference between hamstrings electromyography (EMG) between individuals with ACLR and controls. Two independent reviewers assessed each paper for inclusion and quality. Means and standard deviations were extracted from each included study to allow random-effect size (ES) meta-analysis calculations for comparison of results. RESULTS Thirty-four studies were included for final review. From these, 5 categories of neuromuscular outcomes were identified, and studies were grouped accordingly: (1) muscle activation levels (EMG amplitude), (2) co-activation, (3) onset timing, (4) electromechanical delay, and (5) time-to-peak activity. Moderate to strong evidence indicates that individuals with ACLR demonstrate higher hamstrings EMG amplitude (normalized to % maximum voluntary isometric contraction) and hamstrings-to-quadriceps co-activation during gait and stair ambulation compared to controls. In addition, there was moderate evidence of longer electromechanical delay during knee flexion and greater hamstrings-to-quadriceps co-activation during knee extension compared to controls. CONCLUSIONS Greater hamstrings EMG amplitude and co-activation during gait and ambulation tasks and longer electromechanical delay of the hamstrings in individuals with ACLR align with clinical impairments following ACLR and have implications for re-injury risk and long-term joint health, thus warranting attention in rehabilitation.
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Affiliation(s)
- David A Sherman
- School of Exercise and Rehabilitation Sciences, College of Health and Human Services, The University of Toledo, 2801 W. Bancroft St., HH 2505E, Mail Stop 119, Toledo, OH, 43606, USA.
| | - Neal R Glaviano
- Department of Kinesiology, College of Agriculture, Health and Natural Resources, University of Connecticut, Storrs, CT, USA
| | - Grant E Norte
- School of Exercise and Rehabilitation Sciences, College of Health and Human Services, The University of Toledo, 2801 W. Bancroft St., HH 2505E, Mail Stop 119, Toledo, OH, 43606, USA
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Pompeo KD, da Rocha ES, Melo MA, de Oliveira NT, Oliveira DF, Sonda FC, dos Santos PF, Rodrigues R, Vaz MA. Proximal, Local, and Distal Muscle Morphology in Women With Patellofemoral Pain. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2021. [DOI: 10.1177/8756479320972097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: The objective of this study was to compare proximal, local, and distal muscle morphology in women with and without patellofemoral pain (PFP). Materials and Methods: Proximal, local, and distal muscle thicknesses (MTs) were obtained with B-mode sonography in healthy (control group [CG], n = 20) and PFP (PFP group, n = 20) women. In addition, muscle mass was measured by the sum of the synergistic MTs. Data were analyzed by independent t-test, Mann-Whitney U test, and effect size. Results: PFP women had smaller gluteus medius ( P = .02, d = 0.7), vastus medialis ( P < .01, d = 1.0), and flexor digitorum brevis ( P < .01, d = 1.0) MT and greater gastrocnemius medialis ( P = .04, d = 0.6) MT than CG. Quadriceps muscle mass ( P = .01, d = 0.8) and foot muscle mass ( P = .008, d = 0.9) were smaller, while plantar flexor muscle mass was greater in the PFP group than in CG ( P = .01, d = 0.8). Conclusion: PFP women have proximal, local, and distal MT alterations in comparison with CG, which may explain possible changes in muscle strength and functionality.
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Affiliation(s)
- Klauber Dalcero Pompeo
- Grupo de Pesquisa em Biomecânica e Cinesiologia, Laboratório de Pesquisa do Exercício, Escola de Educação Física, Fisioterapia e Dança, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil
| | - Emmanuel Souza da Rocha
- Grupo de Pesquisa em Biomecânica e Cinesiologia, Laboratório de Pesquisa do Exercício, Escola de Educação Física, Fisioterapia e Dança, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil
| | - Mirella Ayres Melo
- Grupo de Pesquisa em Biomecânica e Cinesiologia, Laboratório de Pesquisa do Exercício, Escola de Educação Física, Fisioterapia e Dança, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil
| | | | | | - Francesca Chaida Sonda
- Grupo de Pesquisa em Biomecânica e Cinesiologia, Laboratório de Pesquisa do Exercício, Escola de Educação Física, Fisioterapia e Dança, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil
| | - Patrícia Freitas dos Santos
- Grupo de Pesquisa em Biomecânica e Cinesiologia, Laboratório de Pesquisa do Exercício, Escola de Educação Física, Fisioterapia e Dança, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil
- Physique Centro de Fisioterapia, Porto Alegre, Brasil
| | | | - Marco Aurélio Vaz
- Grupo de Pesquisa em Biomecânica e Cinesiologia, Laboratório de Pesquisa do Exercício, Escola de Educação Física, Fisioterapia e Dança, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil
- Physique Centro de Fisioterapia, Porto Alegre, Brasil
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