Contribución a un enfoque no convencional de la Función Vascular Periférica : estudio del impacto fisiológico del masaje en la circulación del miembro inferior
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2021
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A massagem é uma técnica manipulativa há muito conhecida, utilizada com múltiplas finalidades associadas principalmente à saúde e ao bem-estar, designadamente na reabilitação e no tratamento e alívio de sintomas associados a múltiplos contextos osteo-mio-articulares e vasculares. Aceite como benéfica em muitas condições de saúde e bem acolhida pelo paciente, recomendada para todos os grupos etários, desde a infância aos indivíduos mais velhos, a demonstração do seu impacto fisiológico e mecanismos envolvidos é ainda muito limitada, porventura até controversa ou inconclusiva. Alguns estudos têm sugerido uma contribuição positiva da massagem na modulação da dor, alívio da fadiga e no controle da ansiedade e do stress, independentemente das patologias de base. Contudo, a utilização de diferentes técnicas e protocolos de massagem, múltiplas e variadas técnicas de registo, e a quase impossibilidade de compararmos resultados, são algumas das dificuldades que justificam estas complexidades. O nosso trabalho teve por objetivo central, estudar o impacto fisiológico da massagem no membro inferior humano e os mecanismos de adaptação envolvidos, em populações saudáveis, previamente selecionadas e caracterizadas. Para registo de eventos da microcirculação e no sentido de garantir o total conforto e segurança dos participantes, recorremos a técnicas óticas não invasivas, amplamente testadas, fiáveis e reconhecidas para este fim, como a fluxometria por laser Doppler (FLD) um dos mais reconhecidos “gold-standards” e a fotopletismografia (FPG), que vem sendo usada como meio complementar de quantificação da microcirculação. Adicionalmente, e com o objetivo de estender a capacidade de análise direta destes sinais biológicos, necessariamente complexos pela sua natureza oscilatória e não-estacionária, recorremos a outras estratégias matemáticas para processamento de sinais. Utilizámos a transformada de Ondeleta (TO), que tem vindo a ser adaptada e utilizada para decomposição destes sinais biológicos com o intuito de melhorar expandir as capacidades de quantificação, passando por contribuir para a normalização de procedimentos, desde logo ao nível da definição do desenho experimental e, mais recentemente a análise de entropia como forma de analisar a complexidade de sinais biológicos. O presente projeto contou com a colaboração de 98 participantes (32.6 ± 15.5 anos) de ambos os sexos (47 homens e 51 mulheres). Nos artigos aqui descritos, utilizamos um total de quatro grupos, sendo o primeiro de massagem com 32 participantes (19.8 ± 1.5 anos), com 16 homens e 16 mulheres, e no segundo grupo, do procedimento de RVA (Reflexo Veno-Arteriolar), foi de 12 participantes (26.0 ± 5.0 anos), com 5 homens e 7 mulheres. Os dois últimos grupos, com indivíduos mais velhos, foram um de massagem (52.6 ± 6.2 anos), com 11 homens e 11 mulheres, e no último grupo, submetido ao procedimento de RVA (50.3 ± 5.6 anos), com 5 homens e 5 mulheres. Todos os participantes selecionados foram confirmados como sendo normotensos e sem sinais de comprometimento vascular, com índice tornozelo-braço (ITB) > 1.0. O projeto foi previamente avaliado pela Comissão de Ética institucional (CE 03/2013.12) e todos os procedimentos observaram os princípios da boa pratica clínica estabelecidos pela Declaração de Helsínquia e subsequentes emendas. O protocolo de massagem foi avaliado em duas das suas variantes em termos de direção da aplicação: proximal ou ascendente e descendente ou distal. Em todos os casos o procedimento foi aplicado num dos membros inferiores (perna e pé) previamente aleatorizado, servindo o outro membro como controlo. O procedimento experimental de massagem, envolveu três fases de registo continuo, em supinação, com a Fase I a corresponder ao registo em repouso (baseline), durante 10 minutos, a Fase II, de provocação com aplicação de massagem da perna e pé durante 5 minutos e a Fase III, de recuperação durante por 10 minutos. A perfusão sanguínea foi avaliada simultaneamente por FPG (PLUX Biosystems, Portugal) e por FLD (PF 5010, Perimed, Suécia), com as sondas aplicadas em ambos os pés, na superfície plantar dos dedos 1 e 2, respetivamente. A pressão arterial, medida no braço foi igualmente registada nas três fases do protocolo. A aplicação das duas variantes do protocolo, cuja ordem de aplicação foi previamente aleatorizada foi intermediada por um período de washout de trinta minutos. Para “refinamento analítico” dos sinais de FLD, foi também analisado um subgrupo de massagem com 29 voluntários (19.9 ± 1.6 anos, 13 homens e 16 mulheres), conforme descrito acima e com recurso à TO, foram decompostos os sinais de FLD nas suas componentes oscilatórias, para avaliar os potenciais mecanismos envolvidos. Foram considerados os seguintes intervalos de frequência de 0.05 a 2Hz: cardíaca de 0.6 Hz a 2 Hz; respiratória de 0.145 Hz a 0.6 Hz; miogénica de 0.052 Hz a 0.145 Hz; simpática de 0.021 Hz a 0.052 Hz; endotelial dependente de Óxido Nítrico (endoDON) de 0.0095 Hz a 0.021 Hz; e endotelial independente de Óxido Nítrico (endoION) de 0.005 a 0.0095 Hz. Para validação da TO nos sinais de FPG, usamos outra ferramenta de refinamento analítico, a análise de textura (AT) e dados de um grupo com 12 voluntários (26.0 ± 5.0 anos, 5 homens e 7 mulheres), submetidos a dois protocolos, um de massagem conforme descrito acima e também a um protocolo de RVA, em que os participantes realizaram um procedimento de 10 minutos em supina com as pernas estendidas, Fase I (baseline); 10 minutos com um membro pendente a 50 cm em relação ao nível do coração, Fase II (teste); e 10 minutos após retorno à posição inicial, Fase III (recuperação). O membro de teste foi aleatorizado e o contralateral permaneceu imóvel e serviu como controlo. Nesta validação da complexidade do sinal de FPG, analisamos ainda a textura dos escalogramas da TO, usando como comparação a entropia multiescala (EME), procedimento padrão, tendo sido confirmada a utilidade da AT na análise da complexidade em sinais de FPG, pese embora ter sido verificada uma menor sensibilidade desta técnica nas zonas espectrais de menores frequências em relação à entropia multiescala. Foram usados ainda neste estudo, dois grupos de indivíduos saudáveis, mas mais velhos, sujeitos à aplicação de mesmos protocolos, de massagem e de RVA, para avaliação e comparação das respostas identificadas com os grupos de jovens. O nosso projeto foi estruturado em quatro marcos, sendo o primeiro a definição do procedimento experimental, o qual permitiu observar de imediato que o impacto da massagem na perfusão se observava em ambos os membros, apesar de aplicada em apenas uma dos membros. O segundo marco, em que pretendemos aprofundar a análise da perfusão, verificamos também que a análise de correlação dos sinais brutos de LDF e FPG confirmou existirem correlações significativas, em especial nas fases I e III, existindo ainda correlações fracas a moderadas na análise de correlação dos componentes de ambos os sinais obtidos com a TO, sendo a direção da resposta dos sinais e das suas componentes em geral coincidentes, embora com distintas intensidades de registo. Com este marco, ainda confirmamos a utilidade da análise de textura na análise da complexidade em sinais de FPG, embora exista uma menor sensibilidade desta técnica nas zonas espectrais de menores frequências em relação à entropia multiescala. No terceiro marco confirmamos a adequação das tecnologias de medição não invasivas escolhidas e verificamos que o espectro médio dos perfis dos sinais de FLD e de FPG possuem diferentes amplitudes, independentemente dos estímulos que os fazem variar, tendo observado que o FLD parece ser mais sensível para os componentes de baixa frequência, enquanto o FPG parece possuir maior capacidade de discriminação. Este estudo confirmou a vantagem da utilização simultânea das duas tecnologias para avaliar, complementarmente, eventos que envolvam a alteração da perfusão microcirculatória de forma mais abrangente, já que as tecnologias óticas utilizadas interagem de modo diferente com os tecidos. No último marco, confirmámos que, nas presentes condições experimentais, a massagem envolve mais do que uma alteração da microcirculação local que designamos por Resposta Imediata de Adaptação Hemodinâmica (ou PAHR Prompt Adaptive Hemodynamic Response) que impacta toda a hemodinâmica cardiocirculatória sistémica. Esta resposta foi abordada complementarmente em indivíduos igualmente saudáveis, mas mais velhos, constituindo o último manuscrito desta coleção, recentemente submetido para publicação. Aqui demonstramos que, embora os tipos de respostas obtidas sejam semelhantes às obtidas nos participantes jovens, esta PAHR é dependente da idade e por isso menos evidente embora presente, reforçando o interesse da utilização deste potencial indicador em meio clínico. Com base nos resultados obtidos nestas publicações, pudemos então fundamentar as seguintes principais conclusões: - que o procedimento experimental que desenhamos, demonstrou ser rigoroso, facilmente reprodutível e totalmente adequado aos propósitos do estudo, assegurando ainda o total conforto, e bem-estar dos participantes. - que as tecnologias escolhidas para avaliar a microcirculação, nomeadamente a FLD e a FPG, demonstraram ser adequadas ao estudo, pois os resultados permitiram descrever quantitativamente com rigor, a microcirculação periférica in vivo, em condições dinâmicas como as envolvidas na massagem, tendo sido verificado que a utilização de ambas as tecnologias, fornece uma análise mais sustentada sobre os fenómenos em causa. - que a manobra de massagem quando aplicada no membro inferior de indivíduos jovens e saudáveis, permite aumentar o fluxo microcirculatório no membro inferior massajado, mas igualmente no membro contralateral, sendo este efeito, independente do sentido em que é aplicada a massagem, influenciando a hemodinâmica em geral, afetando a frequência cardíaca e a pressão arterial. - que esta resposta hemodinâmica à massagem que identificamos neste estudo (PAHR), embora seja semelhante, é claramente dependente da idade.
Massage is a long-known technique, applied with your hands for multiple purposes associated to health and well-being, namely for rehabilitation and symptoms relief in osteo-myo-articular and vascular contexts. Recognized as beneficial in many health conditions and well accepted by all age patients, from infants to the elderly, the demonstration of its physiological impact and mechanisms is still limited, and sometimes controversial or inconclusive. Some studies suggested a positive contribution of massage in pain modulation fatigue anxiety relief and stress control regardless of other underlying pathologies. The use of different massage protocols, varied assessment technologies, and the absence of results comparison are some of the difficulties that justify these complexities. Our main objective was to study the physiological impact of massage in the human lower limb and the involved adaptive mechanisms in previously selected and characterized healthy groups. We used well known reliable non-invasive optical techniques to register microcirculation events with total comfort and safety of participants. Laser Doppler flowmetry (LDF), one of the most recognized gold standards and photoplethysmography (PPG) were our chosen technologies to quantify microcirculation in vivo. In addition, we also used other mathematical strategies for signal processing such as the Wavelet transform (WT), applied to the decomposition of these signals and texture analysis. The present project involved 98 participants (32.6 ± 15.5 years) of both sexes (47 male and 51 female). In the papers here described, we used four groups of participants. The first one for massage with 32 participants (19.8 ± 1.5 years), with 16 male and 16 female, the second group, for the VAR (Veno-Arteriolar Reflex) procedure, with 12 participants (26.0 ± 5.0 years), 5 male and 7 female; . The last two groups, with older individuals, were one for massage (52.6 ± 6.2 years), with 11 male and 11 female, and a subset of this group submitted to VAR procedure (50.3 ± 5.6 years), involving 5 male and 5 female. All selected participants were confirmed to be normotensive and without signs of vascular impairment, with an ankle brachial index (ABI) > 1.0. The project was previously approved by the institutional Ethics Committee (CE 03/2013.12) and all procedures followed the principles of good clinical practice established by the Declaration of Helsinki and subsequent amendments. The massage protocol was evaluated in two of its variants in terms of the direction of application: proximal or ascending and distal or descending. In all cases the procedure was applied to one of the lower limbs (leg and foot) previously randomized, with the other limb serving as control. The experimental massage procedure involved three phases of continuous recording with participants lying down in supination - Phase I corresponding to the resting record (baseline) for 10 minutes, Phase II, provocation with the application of the procedure for 5 minutes and Phase III, recovery for 10 minutes. Blood perfusion was evaluated simultaneously by PPG (PLUX Biosystems, Portugal) and by LDF (PF 5010, Perimed, Sweden), with the probes applied to both feet, on the plantar surface of toes 1 and 2, respectively. Blood pressure, measured in the arm, was also recorded in all phases of the protocol. The application of the two protocol variants, whose application order was previously randomized, was intermediated by a washout period of thirty minutes. For “analytical refinement” of the LDF signals, an massage subgroup was also analyzed, with 29 volunteers (19.9 ± 1.6 years, 13 male and 16 female), as described above and using the WT, the LDF signals were decomposed into their oscillatory components, to assess the potential mechanisms involved. The following frequency ranges between 0.05 and 2Hz were considered: heart rate from 0.6 Hz to 2 Hz; respiratory from 0.145 Hz to 0.6 Hz; myogenic from 0.052 Hz to 0.145 Hz; sympathetic from 0.021 Hz to 0.052 Hz; endothelial dependent of Nitric Oxide (endoNOD) from 0.0095 Hz to 0.021 Hz; and endothelial independent of Nitric Oxide (endoNOI) from 0.005 to 0.0095 Hz. To validate WT in PPG signals, another analytical refinement tool was used, texture analysis (TA), with data from a group of 12 volunteers (26.0 ± 5.0 years, 5 male and 7 female), submitted to two protocols, one of massage as described above and also to a VAR protocol, where the participants performed a 10-minute supine procedure with the legs extended, Phase I (baseline); 10 minutes with a pending limb 50 cm in relation to the heart level, Phase II (test); and 10 minutes after returning to the initial position, Phase III (recovery). The test limb was randomized while the contralateral remained immobile serving as control. In this validation of the complexity of the PPG signal, we also analyzed the texture of the WT scalograms, using multiscale entropy (MSE), a standard procedure, as a comparison, and the usefulness of TA in the analysis of the complexity of PPG signals was confirmed, although a lower sensitivity of this technique was found in the spectral zones of lower frequencies in relation to multiscale entropy. In this study, two groups of healthy, but older individuals were also used, subjected to the application of the same protocols, massage and VAR, to evaluate and compare the responses identified with the groups of young individuals. Our project was structured in four milestones, the first being the definition of the experimental procedure, which allowed us to immediately observe that the perfusion impact of massage was observed in both limbs, despite being applied to only one of the limbs. The second milestone, in which we intended to deepen the data analysis we confirmed by correlation analysis of raw LDF and PPG signals the existence of significant proximity of these signals in phases I and III. Weak to moderate correlations still existing in the correlation analysis of the components of both signals obtained with WT, with the direction of the response of the signals and their components in general coincidental, although with different recording intensities. We also confirm the usefulness of texture analysis in the analysis of PPG signals complexity, although there is less sensitivity of this technique in the lower frequency spectral zones in relation to multiscale entropy. In the third milestone, we confirm the adequacy of the chosen non-invasive measurement technologies and we verify that the average spectrum of the LDF and PPG signal profiles have different amplitudes, regardless of the stimuli that make them vary, having observed that the LDF seems to be more sensitive to the low frequency components, while the PPG seems to have a greater capacity for discrimination. This study confirmed the advantage of the simultaneous use of the two technologies to complementarily assess events that involve altering the microcirculatory perfusion in a more comprehensive way, since the used optical technologies interact differently with the tissues. In the last milestone, we confirmed that in the present experimental conditions, massage involves more than a change in the local microcirculation that we named as the Prompt Adaptive Hemodynamic Response (PAHR) impacting the entire systemic cardiocirculatory hemodynamics. This answer was addressed in a complementary way in equally healthy individuals, but older, constituting the last manuscript of this collection, recently submitted for publication. Here we demonstrate that, although responses here obtained are similar to those obtained in young participants, this PAHR is age dependent and therefore less obvious, suggesting its potential interest to be used as a clinical indicator. Based on the results obtained in these four milestones, we were able to substantiate the following main conclusions: - that the experimental procedure we designed, proved to be rigorous, easily reproductible and totally adequate to the purposes of the study, while also ensuring the total comfort and well-being of the participants. - that the technologies chosen to evaluate microcirculation, namely LDF and PPG, proved to be suitable for the study, as the results allowed to quantitatively and accurately describe the peripheral microcirculation in vivo, under dynamic conditions such as those involved in massage, having been verified that the use of both technologies provides a more sustained analysis of the phenomena in question. - that the massage maneuver when applied to the lower limb of young and healthy individuals, allows to increase the microcirculatory flow in the massaged lower limb, but also in the contralateral limb, being this effect, regardless of the direction in which the massage is applied, influencing the hemodynamics in general, affecting heart rate and blood pressure. - that this hemodynamic response to massage that we identified in this study (PAHR), although similar, is clearly dependent on age.
Massage is a long-known technique, applied with your hands for multiple purposes associated to health and well-being, namely for rehabilitation and symptoms relief in osteo-myo-articular and vascular contexts. Recognized as beneficial in many health conditions and well accepted by all age patients, from infants to the elderly, the demonstration of its physiological impact and mechanisms is still limited, and sometimes controversial or inconclusive. Some studies suggested a positive contribution of massage in pain modulation fatigue anxiety relief and stress control regardless of other underlying pathologies. The use of different massage protocols, varied assessment technologies, and the absence of results comparison are some of the difficulties that justify these complexities. Our main objective was to study the physiological impact of massage in the human lower limb and the involved adaptive mechanisms in previously selected and characterized healthy groups. We used well known reliable non-invasive optical techniques to register microcirculation events with total comfort and safety of participants. Laser Doppler flowmetry (LDF), one of the most recognized gold standards and photoplethysmography (PPG) were our chosen technologies to quantify microcirculation in vivo. In addition, we also used other mathematical strategies for signal processing such as the Wavelet transform (WT), applied to the decomposition of these signals and texture analysis. The present project involved 98 participants (32.6 ± 15.5 years) of both sexes (47 male and 51 female). In the papers here described, we used four groups of participants. The first one for massage with 32 participants (19.8 ± 1.5 years), with 16 male and 16 female, the second group, for the VAR (Veno-Arteriolar Reflex) procedure, with 12 participants (26.0 ± 5.0 years), 5 male and 7 female; . The last two groups, with older individuals, were one for massage (52.6 ± 6.2 years), with 11 male and 11 female, and a subset of this group submitted to VAR procedure (50.3 ± 5.6 years), involving 5 male and 5 female. All selected participants were confirmed to be normotensive and without signs of vascular impairment, with an ankle brachial index (ABI) > 1.0. The project was previously approved by the institutional Ethics Committee (CE 03/2013.12) and all procedures followed the principles of good clinical practice established by the Declaration of Helsinki and subsequent amendments. The massage protocol was evaluated in two of its variants in terms of the direction of application: proximal or ascending and distal or descending. In all cases the procedure was applied to one of the lower limbs (leg and foot) previously randomized, with the other limb serving as control. The experimental massage procedure involved three phases of continuous recording with participants lying down in supination - Phase I corresponding to the resting record (baseline) for 10 minutes, Phase II, provocation with the application of the procedure for 5 minutes and Phase III, recovery for 10 minutes. Blood perfusion was evaluated simultaneously by PPG (PLUX Biosystems, Portugal) and by LDF (PF 5010, Perimed, Sweden), with the probes applied to both feet, on the plantar surface of toes 1 and 2, respectively. Blood pressure, measured in the arm, was also recorded in all phases of the protocol. The application of the two protocol variants, whose application order was previously randomized, was intermediated by a washout period of thirty minutes. For “analytical refinement” of the LDF signals, an massage subgroup was also analyzed, with 29 volunteers (19.9 ± 1.6 years, 13 male and 16 female), as described above and using the WT, the LDF signals were decomposed into their oscillatory components, to assess the potential mechanisms involved. The following frequency ranges between 0.05 and 2Hz were considered: heart rate from 0.6 Hz to 2 Hz; respiratory from 0.145 Hz to 0.6 Hz; myogenic from 0.052 Hz to 0.145 Hz; sympathetic from 0.021 Hz to 0.052 Hz; endothelial dependent of Nitric Oxide (endoNOD) from 0.0095 Hz to 0.021 Hz; and endothelial independent of Nitric Oxide (endoNOI) from 0.005 to 0.0095 Hz. To validate WT in PPG signals, another analytical refinement tool was used, texture analysis (TA), with data from a group of 12 volunteers (26.0 ± 5.0 years, 5 male and 7 female), submitted to two protocols, one of massage as described above and also to a VAR protocol, where the participants performed a 10-minute supine procedure with the legs extended, Phase I (baseline); 10 minutes with a pending limb 50 cm in relation to the heart level, Phase II (test); and 10 minutes after returning to the initial position, Phase III (recovery). The test limb was randomized while the contralateral remained immobile serving as control. In this validation of the complexity of the PPG signal, we also analyzed the texture of the WT scalograms, using multiscale entropy (MSE), a standard procedure, as a comparison, and the usefulness of TA in the analysis of the complexity of PPG signals was confirmed, although a lower sensitivity of this technique was found in the spectral zones of lower frequencies in relation to multiscale entropy. In this study, two groups of healthy, but older individuals were also used, subjected to the application of the same protocols, massage and VAR, to evaluate and compare the responses identified with the groups of young individuals. Our project was structured in four milestones, the first being the definition of the experimental procedure, which allowed us to immediately observe that the perfusion impact of massage was observed in both limbs, despite being applied to only one of the limbs. The second milestone, in which we intended to deepen the data analysis we confirmed by correlation analysis of raw LDF and PPG signals the existence of significant proximity of these signals in phases I and III. Weak to moderate correlations still existing in the correlation analysis of the components of both signals obtained with WT, with the direction of the response of the signals and their components in general coincidental, although with different recording intensities. We also confirm the usefulness of texture analysis in the analysis of PPG signals complexity, although there is less sensitivity of this technique in the lower frequency spectral zones in relation to multiscale entropy. In the third milestone, we confirm the adequacy of the chosen non-invasive measurement technologies and we verify that the average spectrum of the LDF and PPG signal profiles have different amplitudes, regardless of the stimuli that make them vary, having observed that the LDF seems to be more sensitive to the low frequency components, while the PPG seems to have a greater capacity for discrimination. This study confirmed the advantage of the simultaneous use of the two technologies to complementarily assess events that involve altering the microcirculatory perfusion in a more comprehensive way, since the used optical technologies interact differently with the tissues. In the last milestone, we confirmed that in the present experimental conditions, massage involves more than a change in the local microcirculation that we named as the Prompt Adaptive Hemodynamic Response (PAHR) impacting the entire systemic cardiocirculatory hemodynamics. This answer was addressed in a complementary way in equally healthy individuals, but older, constituting the last manuscript of this collection, recently submitted for publication. Here we demonstrate that, although responses here obtained are similar to those obtained in young participants, this PAHR is age dependent and therefore less obvious, suggesting its potential interest to be used as a clinical indicator. Based on the results obtained in these four milestones, we were able to substantiate the following main conclusions: - that the experimental procedure we designed, proved to be rigorous, easily reproductible and totally adequate to the purposes of the study, while also ensuring the total comfort and well-being of the participants. - that the technologies chosen to evaluate microcirculation, namely LDF and PPG, proved to be suitable for the study, as the results allowed to quantitatively and accurately describe the peripheral microcirculation in vivo, under dynamic conditions such as those involved in massage, having been verified that the use of both technologies provides a more sustained analysis of the phenomena in question. - that the massage maneuver when applied to the lower limb of young and healthy individuals, allows to increase the microcirculatory flow in the massaged lower limb, but also in the contralateral limb, being this effect, regardless of the direction in which the massage is applied, influencing the hemodynamics in general, affecting heart rate and blood pressure. - that this hemodynamic response to massage that we identified in this study (PAHR), although similar, is clearly dependent on age.
Descrição
Diretores de Tese: Luís Monteiro Rodrigues, Júlia Buján Varela
Palavras-chave
DOUTORAMENTO EM CIÊNCIAS DA SAÚDE, CIÊNCIAS DA SAÚDE, MASSAGENS, HEMODINÂMICA, SISTEMA CARDIOVASCULAR, FLUXOMETRIA POR LASER-DOPPLER, FOTOPLETISMOGRAFIA, HEALTH SCIENCES, CARDIOVASCULAR SYSTEM, MASSAGE, HEMODYNAMICS, LASER-DOPPLER FLOWMETRY, PHOTOPLETHYSMOGRAPHY