Evaluación funcional de los músculos del suelo pélvico por la electromiografía: ¿la normalización existe en el análisis de datos? Una revisión sistemática

Ribeiro, Aline Moreira; Mateus-Vasconcelos, Elaine Cristine Lemes; Silva, Thaís Daniel da; Brito, Luiz Gustavo de Oliveira; Oliveira, Harley Francisco de

doi:10.1590/1809-2950/16559525012018

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SYSTEMATIC REVIEW • Fisioter. Pesqui. 25 (1) • Jan-Mar 2018 • https://doi.org/10.1590/1809-2950/16559525012018 linkcopiar

Evaluación funcional de los músculos del suelo pélvico por la electromiografía: ¿la normalización existe en el análisis de datos? Una revisión sistemática

Autoría SCIMAGO INSTITUTIONS RANKINGS

RESUMEN

Se evaluó, en este estudio, el método de análisis de los datos electromiográficos en la evaluación funcional de los músculos del suelo pélvico. Las bases de datos consultadas fueron: Medline, PubMed, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PEDro y IBECS. La investigación fue refinada considerándose artículos publicados en los últimos diez años (2004 a 2014). Se evaluaron de forma independiente los artículos identificados por dos evaluadores, según los siguientes criterios de inclusión: (1) población: mujeres adultas; (2) evaluación de los músculos del suelo pélvico utilizándose la electromiografía (EMG) con sonda vaginal o anal; (3) descripción de cómo es el análisis de los datos electromiográficos. Se utilizó el instrumento Newcastle-Ottawa Scale (NOS) para evaluar la calidad metodológica de los estudios. Se identificaron 508 artículos y 23 de estos fueron incluidos en la revisión. Los datos mostraron diferencias entre los protocolos de recolección y un número significativo de estudios no utilizaron la normalización en el análisis de los datos electromiográficos. Los fisioterapeutas están entre los profesionales que más utilizan la EMG para evaluar la función y disfunción del sistema neuromuscular. Aunque algunos estudios anteriores proporcionen una visión general para orientar el evaluador en el uso de este instrumento, pocos estudios posteriores han seguido sus recomendaciones.

Palabras clave | Diafragma de la Pelvis; Electromiografía; Revisión

References	Selection	Comparability	Outcome
Auchincloss and McLean¹¹⁾	***	-	*
Botelho et al. ³⁾	***	-	*
Chen et al. ¹²⁾	***	-	*
Devreese et al. ¹³⁾	***	*	*
Frederice, Amaral and Ferreira¹⁴⁾	***	-	*
Grape, Dedering and Jonasson¹⁵⁾	***	-	*
Halski et al. ¹⁶⁾	***	-	*
Halski, Ptaszkowski, Słupska and Dymarek¹⁷⁾	***	-	*
Junginger, Baessler, Sapsford and Hodges¹⁸⁾	***	-	*
Lauper, Kuhn, Gerber, Luginbühl and Radlinger¹⁹⁾	***	*	*
Luginbuehl et al. ²⁰⁾	***	*	*
Pereira et al. ²¹⁾	***	*	*
Petricelli et al. ²²⁾	***	-	*
Resende et al. ²³⁾	***	*	*
Resende et al. ⁽²⁴⁾	***	-	*
Sapsford, Richardson, Maher and Hodges²⁵⁾	***	*	*
Smith, Coppieters and Hodges²⁶⁾	***	*	*
Smith, Coppieters and Hodges²⁷⁾	***	*	*
Soljanik et al. ²⁸⁾	***	-	*
Stüpp et al. ²⁹⁾	***	-	*
Thompson, O’Sullivan, Briffa and Neumann³⁰⁾	***	-	*
Thompson. O’Sullivan, Briffa and Neumann³¹⁾	***	-	*
Zhang, Wang and Zheng³²⁾	***	*	*

Authors, year	Publication	Country	Study design	Subjects (age in years)	Objectives
Auchincloss and McLean, 2009¹¹⁾	Journal of Neuroscience Methods	Canada	Cross-sectional	10 women (30.0±3.9)	To determine whether PFM activation amplitude changes when different vaginal probes are inserted into the vagina.
Botelho et al., 2013³⁾	Neurourology and Urodynamics	Brazil	Cross-sectional	307 women (23.93±5.78)	To investigate if digital palpation of PFMs is correlated with its electromyographic activity.
Chen et al., 2009¹²	The Journal of Urology	Taiwan	Cross-sectional	31 women (46.48±7.24)	To examine the effects of passive and active ankle flexion on PFM activity during exercises.
Devreese et al., 2007¹³⁾	The Journal of Urology	Belgium	Cross-sectional	82 women (32 continent, 52.38±9.68; 50 incontinent, 52.78±7.99)	To contribute to the understanding of the mechanisms we investigated, the contraction sequence of superficial versus deep PFM in six positions of continent and incontinent women.
Frederice et al., 2013¹⁴⁾	Journal of Obstetrics and Gynaecology Research	Brazil	Cross-sectional	91 women (24.3±4.9)	To evaluate PFM function and its association with urinary symptoms in the third trimester of pregnancy.
Grape et al., 2009¹⁵⁾	Neurourology and Urodynamics	Sweden	Cross-sectional	17 women (26, range 22-34)	To evaluate the retest reliability of repeated intravaginal EMG of the PFM in healthy women, who were able to correctly perform PFM contractions.
Halski et al., 2013¹⁶⁾	BioMed Research International	Poland	Cross-sectional	20 women (22.3±1.28)	To determine how the depth of probe placement affects functional and resting bioelectrical activity of the PFM and whether the recorded signal might be dependent on the direction in which the probe is rotated.
Halski et al., 2014¹⁷⁾	BioMed Research International	Poland	Cross-sectional	16 women (63.1±4,1, range 55-70)	To evaluate resting and functional bioelectrical activity of the PFM and synergistic muscles, depending on the orientation of the pelvis, in anterior (P1) and posterior (P2) pelvic tilt.
Junginger et al., 2010¹⁸⁾	International Urogynecology Journal	Australia	Cross-sectional	9 women (42, range 32-59)	To investigate the relationship between bladder neck displacement, EMG activity of the PFM and abdominal muscles and intra-abdominal pressure during different pelvic floor and abdominal contractions.
Lauper et al. 2009¹⁹⁾	Neurourology and Urodynamics	Switzerland	Cross-sectional	38 women (21 control, 30.0±4.7; 17 post-partum, 31.7±3.4)	To determine if two different whole-body vibrations, sinusoidal vibration and SR-WBV, lead to a reactive activation of PFM when using various intensities.
Luginbuehl et al., 2012²⁰⁾	Neurourology and Urodynamics	Switzerland	Cross-sectional	50 women (28 np/pp group, 47.0±9.6; 22 pp group 33.1±4.8)	To determine the SR-WBV load modality regarding PFM activity to complete the SR-WBV training methodology for future PFM training with SR-WBV.
Pereira et al., 2013²¹⁾	Neurourology and Urodynamics	Brazil	Cross-sectional	81 women (20 nulliparous, 24.4±3.6; 25 pregnant, 24.6±5.6; 19 vaginal delivery, 21.8±3.1; 17 cesarean section, 23.1±5.9)	To simultaneously evaluate both transversus abdominis/internal oblique muscles and PFM during isometric exercises in nulliparous, pregnant, and postpartum women.
Petricelli et al., 2014²²⁾	BioMed Research International	Brazil	Cross-sectional	60 women (26.06±5.58)	To compare the role of the PFM between nulliparous and multiparous women in the third trimester of pregnancy, analyzing the relationship between EMG, vaginal palpation (modified Oxford Grading Scale), and perineal distensibility (EPI-NO).
Resende et al., 2012²³⁾	International Urogynecology Journal	Brazil	Cross-sectional	30 women (Group 1, 28.2±6.5; Group 2, 26.4±3.2)	To compare the MVC and strength of PFM of pregnant and non-pregnant women using sEMG.
Resende et al., 2011²⁴⁾	International Urogynecology Journal	Brazil	Cross-sectional	34 women (28±5.9)	To determine whether Paula method of circular muscles contraction (those surrounding the eyes, mouth and fingers) can increase PFM activity.
Sapsford et al., 2008²⁵⁾	Archives of Physical Medicine and Rehabilitation	Australia	Cross-sectional	17 women (9 asymptomatic, 45, range 32-66; 8 symptomatic, 41.8, range 33-55)	To determine whether resting activity of the PFM and abdominal muscles varied in different sitting postures in parous women with and without SUI.
Smith et al., 2007²⁶⁾	Neurourology and Urodynamics	Australia	Cross-sectional	30 women (14 continent, 52.5±12.5; 16 incontinent, 49.8±12.0; 7 mild-incontinence, 48.1±12.2; 9 more severe incontinence, 51.0±12.4)	To determine whether activity of the PFM and abdominal muscles differs between continent and incontinent women in response to a postural perturbation with a moderately full or empty bladder.
Smith et al., 2008²⁷⁾	Neurourology and Urodynamics	Australia	Cross-sectional	29 women (16 with SUI, 49.8± 12.0; 13 controls, 53.1±12.7)	To investigate whether there are differences in center of pressure displacement, trunk motion, and trunk muscle activity in women with and without SUI during static balance tasks when the bladder is empty and moderately full.
Soljanik et al., 2012²⁸⁾	Archives of Gynecology and Obstetrics	Germany	Cross-sectional	23 women (22±3.7)	To evaluate the role of the ischioanal fossa in functional relations between the levator ani and gluteus maximus muscles in healthy female volunteers.
Stüpp et al., 2011²⁹⁾	International Urogynecology Journal	Brazil	Cross-sectional	34 women (28.1±6.0)	To investigate PFM and transversus abdominis activation during the abdominal hypopressive technique through sEMG.
Thompson et al., 2006³⁰⁾	Neurourology and Urodynamics	Australia	Cross-sectional	13 women (38±7)	To investigate the muscle activation patterns of the abdominopelvic region used by incontinent women during a PFM contraction and a Valsalva maneuver compared to healthy and asymptomatic subjects.
Thompson et al., 2006b³¹⁾	Neurourology and Urodynamics	Australia	Cross-sectional	13 women (37±9)	To investigate the different muscle activation patterns around the abdominopelvic cavity in continent women and their effect on pressure generation during a correct PFM contraction and a Valsalva maneuver.
Zhang et al., 2006³²⁾	International Journal of Gynecology and Obstetrics	China	Cross-sectional	114 women (57 with SUI, 41.3±10.2; 57 controls, 38.8±11)	To obtain perineal electrophysiological data and assess the clinical usefulness of measuring the sEMG activity of the PFM in predicting and diagnosing SUI.

Authors, year	Probe used	Data collection protocol	Frequencies and approaches to filter the signal	Normalization?
Auchincloss and McLean, 2009¹¹⁾	Vaginal: Periform and FemiScan	One MVC and maximal effort cough.	The signals were preamplified using a Delsys™ DE-2.1 Sensor for active electrode amplifiers (200×) before final amplification using Delsys™ AMT-8 amplifiers [common mode rejection ratio (CMRR)=90 dB at 60 Hz, bandwidth of 20-450 Hz, input impedance>10¹⁵ Ω] to produce an overall gain of 1000.	No
Botelho et al., 2013³⁾	Vaginal: PhysioMed Services	Three 5-s MVCs with 10-s rest.	Band-pass filter with cutoff frequencies at 20-500 Hz, an amplifier gain of 1,000 times and a CMRR>120 dB. A 12-bit A/D signal converter plate was used, to convert analog signals into digital ones with a 2.0 kHz anti-aliasing filter sampling frequency, with an input range of 5 mN.	No
Chen et al., 2009¹²⁾	Vaginal: FemiScan	One contraction standing and one contraction in eight different positions of the ankle joint.	No description.	No
Devreese et al., 2007¹³⁾	Vaginal: No description	Supine + knees flexed, supine + knees straight, sit leaning forward, sit upright, stand leaning forward and stand upright: 2-min rest preceded by a MVC for 6 s. The onset of increased activity was defined as any muscle activity with a minimum amplitude of a sliding window of 25 ms exceeding resting EMG by 2 SD.	Band-pass filter of 10 to 500 Hz. Data were sampled by a 12- bit analog-to-digital converter at a rate of 1,000 samples per second, stored on a computer, full-wave rectified and low-pass filtered at 50 Hz to smooth the data.	No
Frederice et al., 2013¹⁴⁾	Vaginal: Miotec	Basal tone at rest, one contraction with 1-min rest, MVC (highest of 3 contractions), and one 10-s contraction.	No description.	No
Grape et al., 2009¹⁵⁾	Vaginal: FemiScan	Three series of contractions with 10-s sustenance and 10-s rest.	A band-pass filter of 8 to 500 Hz (3 dB points) and a low-pass filter of 500 Hz was used. The signal was sampled at 10 Hz after full-wave rectification.	No
Halski et al., 2013¹⁶⁾	Vaginal: Periprobe Optima 3	Standing position: five contractions with 5-s rest between each contraction (resting activity).	This device is characterized by a continuous amplitude of 0.2-2000 µVRMS in the frequency band of 2-100 Hz and pulse-width modulation from 50-450 µS for signals recorded generated by muscles. Device sensitivity is established at a level of 0.1 µV (4% accuracy; readings ±0.3 mV at 200 Hz), with selectable band-pass filter (3 dB bandwidth) and 50 Hz notch filter (33 dB; 0.1% accuracy).	No
Halski et al., 2014¹⁷⁾	Vaginal: Lifecare PR-02 Vaginal Probe	EMG activity was recorded with the pelvis rotated forward (P1) and backward (P2) around the transverse axis. In P1 and P2, the participants made five 5-s MVCs (functional sEMG activity) with a 5-s rest (resting sEMG activity). They took 60 s of rest between trials.	Analog output gain: x1000 standard (5000 selected units); minimum CMRR: 100 dB at 50-60 Hz; input impedance>100 MΩ on sEMG channels (isolated to>3000 V; sEMG amplifier performance: 1 µV sensitivity and <1 µVRMS baseline noise; data acquisition: 8 channels of 12-bit resolution, and USB update to PC every millisecond; cutoff of high-pass filter: 10 Hz first-order filter on sEMG channels; selectable low-pass cutoff of 500 or 1000 Hz on sEMG channels.	No
Junginger et al., 2010¹⁸⁾	Vaginal: Periform	One 5-s MVC with 30- to 120-s rest.	EMG data were amplified 2,000 times, bandpass-filtered between 10 Hz to 1 kHz and sampled at 2 kHz.	Yes
Lauper et al., 2009¹⁹⁾	Vaginal: Periform	PFM activity at rest and in 5-s MVC.	The EMG was sampled at a rate of 1 kHz, the cutoff frequency of the low-pass filter (Butterworth, 24dB/Oct.) was set at 500 Hz. Expecting vibration artifacts in the EMG, no high-pass filter was applied to detect the fundamental frequency of vibration as well as the harmonic content in the EMG signal.	Yes
Luginbuehl et al., 2012²⁰⁾	Vaginal: Periform	Orthostatism: PFM activity at rest and two 5-s MVCs with 60-s rest.	The EMG signal was transmitted to a measurement amplifier (UMVE, uk-labs). The cutoff frequency of the low-pass filter was set at 500 Hz to avoid aliasing in accordance with the Nyquist-Shannon sampling theorem.	Yes
Pereira et al., 2013²¹⁾	Vaginal: PHYSIOMED Services	Three 5-s MVCs with 10-s rest	Band-pass filter with cutoff frequencies at 20-500 Hz, an amplifier gain of 1,000 and a CMRR>120 dB. A 12-bit A/D signal converting plate was used to convert analog signals to digital ones with a 2.0 kHz anti-aliasing filter sampling frequency, with an input range of 5 mn.	No
Petricelli et al., 2014²²⁾	Vaginal: Cone-shaped intravaginal sensor (Chattanooga Group)	Three MVCs followed by relaxation (10 s). The best of the three contractions was selected for the study.	This is a signal processer with band-pass filters, cutoff frequencies of 20-500 Hz, instrumentation preamplifier (20-fold gain), differential amplifier with bipolar input, and CMRR>100 dB.	No
Resende et al., 2012²³⁾	Vaginal: Chattanooga Group	Two contractions sustained for 5 s with 30-s rest. The best of the contractions was considered as the MVC.	Band-pass filter with cutoff frequencies at 20-500 Hz, an amplifier gain of 1,000, and a CMRR>120 dB and a 12-bit analog-to-digital signal converting plate with a 2.0 kHz anti-aliasing filter sampling frequency for each channel was used.	No
Resende et al., 2011²⁴⁾	Vaginal: Chattanooga Group	Three 30-s MVCs. The best of the 3 contractions was used for the analysis.	Band-pass filter with cutoff frequencies at 20-500 Hz, an amplifier gain of 1,000 and a CMRR>120 dB and an A/D 12-bit analog-to-digital signal converting plate with a 2.0 kHz anti-aliasing filter for each channel and an input range of 5 mV was used.	No
Sapsford et al., 2008²⁵⁾	Vaginal: Periform	PFM activity was conducted for 10 s in 3 different sitting postures: slump supported, upright unsupported, and very tall unsupported.	EMG data were bandpass-filtered between 20 and 1000 Hz and sampled at 2 kHz using an AMLAB-based data acquisition system.	No
Smith et al., 2007²⁶⁾	Vaginal: Periform	EMG activity was recorded prior and subsequent to a postural perturbation in which a 1-kg weight was dropped 30 cm into a bucket held. Subjects were instructed to remain relaxed before loading and to catch the load when it contacted the bucket. In the first ten repetitions the subject held the switch and controlled the timing of the drop of the weight (expected condition). In the subsequent ten trials, subjects wore a blindfold and earplugs and the weight release was controlled by the researcher (unexpected condition).	EMG data were amplified 2,000 times, band-pass filtered between 30 and 1,000 Hz, and sampled at 2,000 Hz.	Yes
Smith et al., 2008²⁷⁾	Vaginal: Periform	Subjects stood on a force plate during six static balance conditions: eyes open, eyes closed, standing on foam with eyes open, standing on foam with eyes closed, tandem stance, and standing on a short base.	EMG data were amplified 2,000 times, band-pass filtered between 30 and 1,000 Hz and sampled at 2,000 Hz.	Yes
Soljanik et al., 2012²⁸⁾	Vaginal: VS0 2000, Haynl-Elektronik Corp.	Six body positions: MVC sustained for 5 s and rest for 10 s, with 10-min rest between positions.	The sEMG signal-processing unit consists of one portable analog-to-digital channel of an EMG unit operating at voltage between 0 and 100 V, band-pass filtered at 50 Hz.	No
Stüpp et al., 2011²⁹⁾	Vaginal: Chattanooga Group	Three 30-s MVCs. The best of the three contractions was used for the analysis.	Band-pass filter with cutoff frequencies at 20-500 Hz, an amplifier gain of 1,000 and a CMRR>120 dB. An A/D 12-bit analog-to-digital signal converting plate with a 2.0 kHz anti-aliasing filter sampling frequency for each channel was used. The plate had an input range of 5 mV.	No
Thompson et al., 2006³⁰	Vaginal: Periform	One contraction for 3 s and a maximal straining Valsalva maneuver. The EMG activity was recorded for 3 s and repeated three times with 1-min rest.	The gain setting was 2,000, and the signal was sampled at 1,000 Hz. The EMG raw data was reduced, rectified, band-pass filtered at 4-400 Hz using a fourth-order zero-lag Butterworth filter (National Instruments).	Yes
Thompson et al., 2006³¹⁾	Vaginal: Periform	One contraction for 3 s and a maximal straining Valsalva maneuver. The EMG activity was recorded for 3 s and repeated three times with 1-min rest.	The amplifier gain was 2,000, and the signal was sampled at 1,000 Hz. The EMG raw data was reduced, rectified, band-pass filtered at 4-400 Hz using a fourth-order zero-lag Butterworth filter (National Instruments).	Yes
Zhang, 2006³²⁾	Vaginal: FemiScan	Four 5-s contractions preceded by 10-s relaxation.	No description.	No

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[TFN1] EMG: electromyography; MVC: maximal voluntary contraction; PFM: pelvic floor muscles; SR-WBV: stochastic resonance whole-body vibration; SUI: stress urinary incontinence; np: nulliparous; pp: primiparous