Purpose This study performed to investigate the effect of elastic band exercise program on the posture of subjects with rounded shoulder and forward head posture. Subjects and Methods The body length, forward shoulder angle, craniovertebral angle, and cranial rotation angle of participants (n=12) were measured before and after the exercise program. Furthermore, the thicknesses of the pectoralis major, rhomboid major, and upper trapezius were measured using an ultrasonographic imaging device.
German good evening, can u please tell me what kind of battery is the one that uses de cmos of the sonoace 5500, and where is it located, also i want to know if i can loose the software of the ultrasound if i change it, thanks a lot for your atention, please write me if you can to jver28@hotmail.com thanks again ( i speak spanish, im from mexico). Medison SonoAce X8. The least you could ship this for would be to wrap it appropriately and ship it via “air-ride padded van” with a company like Atlas, Bekins, sonoace x8 United. Select your product from the menus sonoace x8 and we’ll show you where your number is. SONY RM VL600 MANUAL PDF; By admin September 30, 2018.
The exercises program was conducted with elastic bands, with 15 repetitions per set and 3 sets in total. Results The length of the pectoralis major, forward shoulder angle, and craniovertebral angle showed significant changes between before and after the exercise program, whereas the changes in the other measurements were not significant. The thickness of the upper trapezius showed a significant increase between before and after the elastic band exercise. Conclusion These findings suggest that the elastic band exercise program used in the study is effective for lengthening the pectoralis major and correcting rounded shoulder and forward head posture. INTRODUCTION Most people employed in economic activities complain neck, shoulders, and lower back disease. In particular, when one uses a computer in an inappropriate posture for a long time, the centerline of the head moves forward and upward, which causes an increase in the weight of the head supported by the neck, ultimately resulting in changes in the head, neck, and areas connecting the shoulders, ). If the head is located anteriorly for long periods, the bending moment of the head increases, and compensatory excessive straightening of the upper neck joints and atlanto-occipital joints is required to fix the gaze to the front.
This can cause shortening of the posterior head and neck muscles, and the upper neck bones can protrude relatively forward when the face is oriented upward, ). Moreover, due to structural characteristics, this can cause rounded shoulder with rounding of the back ). Rounded shoulder is a typical bent posture in which the scapulae are elevated and the acromion is protruded forward in comparison with the center of gravity of the body. The angle between the lower neck bone and upper back bone was increased, and the protraction, upward rotation, and anterior tilt of the scapulae were increased, ). Such changes cause imbalance in the surrounding muscles and eventually cause pain in the head, temporomandibular joints, neck, back, shoulders, and arms, ). Changes in the skeletal alignment can indicate imbalance in stretching and shortening of muscles, imbalance in use of antagonist and agonist muscles, or skeletal defects that promote such muscular changes, and inappropriate postures aggravate pain and damage.
Therefore, various posture correction programs that can correct skeletal alignment, decrease pain, and facilitate recovery of tissue and changes in the body have been suggested ). Although surgeries that can result in fast improvements within a short period are drawing attention, surgery alone cannot be used as the optimal treatment because symptoms can recur even after treatment of malpositioned vertebrae due to imbalance in peripheral soft tissues. An elastic band is a rubber band with elasticity and resistance, and the velocity and intensity of the resistance of an elastic band can be controlled. Elastic bands can be used to apply resistance in a way that is different from that of exercise equipment with weights such as dumbbells. Moreover, they can be used in various ways just as exercise can be performed in all directions. Considering that exercise using elastic bands, which are easy to carry, is economical and safe, elastic bands can be used to improve muscular strength, flexibility, and balance control in the elderly and young, regardless of gender, ).
Exercise using elastic bands can be applied not only to ordinary people but also to patients with diseases. The application of elastic resistance band exercise programs to orthostatic hypotensive elderly was reported to be a safe method of improving strength, functional ability, and physical activity ). The application of elastic band exercise programs in patients with chronic obstructive pulmonary disease was found to increase the patients’ functional capacity and muscular function ). The effects of elastic band exercise programs have been reported to improve physical and postural control. However, programs for people with forward head posture and rounded shoulder are lacking.
In the present study, we investigated the effect of an elastic band exercise programs on physical alignment and changes in related muscles in subjects with rounded shoulder and forward head posture. SUBJECTS AND METHODS Subjects (n=12; the distance between on the table and the acromion2.5 cm) with rounded shoulder and forward head posture were included in the study ).
Subjects who had scapula damage, had previously received surgery on the neck bone or upper limbs, or had other diseases were excluded. The study subjects performed 3 sets of the exercise program with 15 repetitions per set. Measurements were made before and after the exercise. Before the program, the purpose of the study was explained to the subjects, and only the subjects who agreed to participate in the study were included. Kyungnam University approved this study, which complies with the ethical standards of the Declaration of Helsinki. Presents the general characteristics of the subjects.
General characteristics of the participants The exercise program included the following exercises: 1) a lat pull down, 2) a shoulder external rotation exercise, 3) shoulder horizontal abduction exercise, 4) a seated bend row, 5) a shoulder abduction exercise, 6) a shoulder flexion exercise, and 7) a shoulder extension exercise. For the lat pull down, the subjects held both ends of the elastic band while lifting the arms to shoulder width. They stretched the band slowly in both directions and pulled it down to their chest.
The abdomen remained contracted while performing the exercise. 2) For the shoulder external rotation exercise, the subjects bent their arms to 90°and oriented their palms toward the ceiling, while their elbows at the height of the flank. They held the elastic band and slowly stretched it while rotating their shoulders externally.
They were instructed to not move the elbows forward. 3) For the shoulder horizontal abduction exercise, the subjects extended their arms in front of their body at 90°and placed them shoulder-width apart. Their palms were oriented to face the ground, and they held the elastic band. They then stretched the elastic band horizontally while paying attention to keep their elbows straight. 4) For the seated bend row, the subjects placed the elastic band such that their feet were located at the middle of the band. They then sat on a chair and held the ends of the elastic band.
The subjects stretched the elastic band as if their elbows were being put together and drew their shoulders together. 5) For the shoulder abduction exercise, the subjects stepped on the elastic band with the foot on the side being exercised, held the elastic band with on hand, and kept the hand low in its neutral position. They then opened the shoulders with the elbows slightly bent. 6) For the shoulder flexion exercise, the subjects stepped on the elastic band with the foot on the side being exercised, held the elastic band with one hand, and kept the hand low in its neutral position. They then bent the arm forward with the elbow straightened. 7) For the shoulder extension exercise, the examiner held one end of the elastic band, and the subject held the other. The subject started by holding the elastic band low in its neutral position, and then they extended the arm backward with the elbow straightened as much as possible.
The following body measurements were ascertained: 1) height of the acromion, 2) distance between the third vertebra and the acromion, 3) distance between the third thoracic vertebra and the inferior angle of scapula, 4) distance between the inner surface of the scapula and the vertebrae, and 5) length of the pectoralis major. For the height of the acromion, the examiner measured the distance between the table and the acromion ) while the subject was in the supine position.
For the distance between the third vertebra and the acromion, the distance between the acromion and the middle of the spinous process of the third thoracic vertebra was measured, ). For the distance between the third thoracic vertebrae and the inferior angle of the scapula, the inferior angle of the scapula and the spinous process of the third thoracic vertebra were marked, and then the distance between the two points was measured with a tape ruler. For the distance between the inner surface of the scapula and the vertebrae, the horizontal distance from the scapula to the vertebrae was measured with a tape ruler. For the length of the pectoralis major, the subject sat in a comfortable sitting position in a chair, and the examiner marked the middle of the sternal notch and the inner side of the coracoid process by using a marking tape and measured the distance between the two points with a tape ruler, ).
All measurements were performed on the dominant side. In order to measure the thicknesses of the pectoralis major, rhomboid major muscle, and upper trapezius muscle, a diagnostic ultrasonographic imaging device (SonoAce X8, Samsung, Medison, Republic of Korea) was used in the B-mode setting. The thickness of the pectoralis major was measured by first drawing a line between the halfway point of the sternum and the lateral lip edge of the bicipital groove. A 7.5-MHz linear probe was used as the axis to measure the thickness at the halfway point of the line. The thickness of the rhomboid major muscle was measured by first drawing a line between the inner surface of the scapula and the midpoint between the spinous processes of the third (T3) and fourth (T4) thoracic vertebrae, and a 7.5-MHz linear probe was used as the axis to measure the thickness at the halfway point of the line. The thickness of the upper trapezius muscle was measured by first drawing a line between the acromion process and the spinous process of the second thoracic vertebra (T2). A 7.5-MHz linear probe was used as the axis to measure the thickness at the halfway point of the line.
Forward shoulder angle was measured by attaching markers to the tragus, seventh cervical vertebra (C7), and acromion of the subjects and based on sagittal images. ImageJ (version 1.48) was used to measure the angle. For the craniovertebral angle (CVA), the angle between the vertical line and the line connecting C7 and the tragus was measured. For the cranial rotation angle (CRA), the angle between the line connecting C7 and the tragus and the line connecting the external canthal angles of the eyes was measured.
SPSS version 14.0 for Windows was used for the statistical analyses. In order to verify the effects observed in the subjects before and after the exercise program, paired t-tests were conducted. The level of significance was set at p. RESULTS When the distance from the bed and the acromion of the subjects was measured in the supine position, the mean pre- and post-exercise distances were 6.1 ± 2.6 cm and 6.2 ± 1.6 cm, respectively. The mean pre- and post-exercise distances between T3 and the acromion were 21.5 ± 2.1 cm and 21.9 ± 1.2 cm, respectively. The mean distances between T7 and the inferior angle of the scapula were 16.5 ± 1.8 cm and 16.4 ± 1.5 cm before and after the exercise, respectively. The distance from the thoracic vertebrae to the inner surface of the scapula was 8.7 ± 1.3 cm before the exercise program and 8.6 ± 1.2 cm after the program.
The lengths of the pectoralis major before and after the exercise program were 12.9 ± 1.9 cm and 17.6 ± 1.4 cm, respectively. The pre- and post-exercise measurements indicate that the length of the pectoralis major showed a statistically significant change (p0.05; ). The body lengths before and after elastic band exercise (unit: cm) The pre- and post-exercise forward shoulder angles were 32.2 ± 6.2° and 29.5 ± 5.7°, respectively. CVA was 46.5 ± 3.7° before the exercise program and 50.0 ± 4.9° after the exercise program. The pre- and post-exercise CRAs were 164.0 ± 7.0° and 162.1 ± 6.8°, respectively.
Although statistically significant differences were observed in the pre- and post-exercise measurements of forward shoulder angle and CVA (p0.05; ). Forward Shoulder Angle, CVA, and CRA before and after elastic band exercise (unit: °) The thickness of the pectoralis major before and after exercise was 1.2 ± 0.5 cm and 1.2 ± 0.4 cm, respectively. The thickness of rhomboid major before and after exercise was 1.1 ± 0.3 cm and 1.1 ± 0.3 cm, respectively.
Thickness of upper trapezius before and after exercise was 0.8 ± 0.2 cm and 1.0 ± 0.2 cm, respectively. Although statically significant differences were observed in thickness of the upper trapezius (p0.05; ).
DISCUSSION Ideal posture refers to a state in which body parts receive the minimum amount of stress against gravity and the position of the body is appropriately aligned in space. Inappropriate posture can cause inappropriate movements of the joints by affecting the level of tension and contraction of muscles, which can cause pain. Therefore, good posture is a measure of health ).
Typical postural changes were caused by inappropriate posture include forward head posture and rounded shoulder. In forward head posture, the pectoralis major and pectoralis minor contract, and the rhomboid muscles weaken ). If subscapular muscles cannot create an appropriate muscular counterbalance, the head of the humerus can glide anteriorly, the shoulder girdle can descend, or lifting of the scapula can become difficult, leading to functional problems in the pectoralis major ).
In comparison between the pre- and post-elastic band exercise measurements of the subjects with rounded shoulder, we found that the length of the pectoralis major increased by 5 cm. This means that the distance between the sternum and the lateral lip of the bicipital groove increased, and consequently, the pectoralis major, which was shortened previously, was thought to be stretched. Moreover, shortening of the pectoralis major, which contributes to rounded shoulder, seems to be relieved. However, no statistically significant difference was observed in the distance between the bed and the acromion, the distance between the acromion and the third vertebra, the distance between the third vertebra and the inferior angle of scapula, and the distance between the vertebrae and the inner surface of the scapula. This is believed to be due to the exercise program being applied only for 40 minutes per session and being unable to produce greater effects.
In forward head posture and forward shoulder angle, the head is located anteriorly from the centerline and seems rotated. This is because the upper cervical vertebra is straightened as the chin is held upward for correction of gaze. Moreover, this causes structural stress around the neck, which in turn causes shortening or excessive tension of the surrounding muscles ).
Forward head posture can be evaluated by measuring the CVA and CRA. Forward head posture is diagnosed when the CVA is less than 50° and the CRA is greater than 145° ). When comparing the forward shoulder angles measured before and after the elastic band exercise program, we found that the forward shoulder angle decreased by 8.41% and that the CVA increased by 7.48%, showing a significant difference.
However, no significant difference was observed in CRA. Decreased forward shoulder angle and increased CVA mean that the head has moved closer to the gravity line connecting the auricle and the acromion process. In other words, rounded shoulder and forward head posture are changing into good posture. Although the elastic band exercise program was conducted only once in the study, we could confirm changes in the length of the pectoralis major and observe movement of the head and neck bone alignment to close to the gravity line. Exercise programs with elastic bands, which are easily accessible, can be used effectively in the correction of posture, without temporal and spatial limitations.
The limitations of this study include the following: As the number of subjects in this study is small, generalization of the results is difficult. Moreover, the exercise program was conducted only once, and the same type of elastic band with the same strength was used for all the subjects, without consideration of their muscle strength. In future studies, exercise programs need to be applied for longer periods.
In particular, studies on exercise programs that use elastic bands with strengths appropriate for individual subjects are deemed necessary.
Abstract Objectives To compare the ophthalmic artery Doppler indices observed in women with singleton pregnancies complicated by hypertension and to correlate the indices observed in hypertensive pregnant women with those observed in healthy pregnant women. Methods Ophthalmic artery Doppler indices were compared between 30 women with mild preeclampsia, 30 women with severe preeclampsia, and 30 women with chronic hypertension at 20 to 40 weeks' gestation. The control group consisted of 289 normotensive pregnant women. The resistive index, pulsatility index, and peak ratio were measured in the right eye.
The mean and standard deviation were calculated for each group. Analysis of variance and the Tukey method were used to compare the means of the Doppler indices between groups. Receiver operating characteristic curves were used to determine the predictive power of the Doppler indices for identification of women with severe preeclampsia.
Abbreviations BP blood pressure NPV negative predictive value PPV positive predictive value ROC receiver operating characteristic The identification of high-risk pregnancies allows for the adoption of preventive strategies to reduce morbidity and mortality for both pregnant women and their fetuses. Preeclampsia is one of the leading causes of maternal death world-wide. – The incidence of preeclampsia ranges from 5% to 10%. Despite advances in perinatal care, the frequency of preeclampsia has not changed. In addition, there is no single predictor of preeclampsia among women at either low or increased risk of preeclampsia, and there is some controversy regarding whether the prevention of preeclampsia itself, rather than the prevention of the complications of preeclampsia, is a worthy goal. The early identification of women at risk of adverse outcomes must be the target in the management of preeclampsia.
The most severe complication of preeclampsia is eclampsia., The acute cerebral complications in preeclampsia, such as eclampsia, intracranial hemorrhage, and cerebral edema, account for at least 75% of maternal deaths. The role of hemodynamic modifications of the central nervous system in preeclampsia is a controversial issue. Neurologic involvement in preeclampsia-eclampsia syndrome fulfils the criteria of posterior reversible encephalopathy syndrome.
– The pathophysiologic mechanism of posterior reversible encephalopathy syndrome remains under investigation. The current and more popular theory suggests that severe hypertension exceeds the limits of cerebral autoregulation and leads to vasodilatation with breakthrough brain edema., Assessment of the cerebral circulation is challenging. Noninvasive techniques, especially transcranial Doppler sonography, are becoming more widely used. Doppler sonography of the ophthalmic artery is a noninvasive method used to study central territory vascular flow during pregnancy., Hata et al were the first to use ophthalmic artery Doppler sonography in the assessment of pregnant women. Since then, several authors have evaluated this method during pregnancy, especially in women with hypertension., – The patterns of normality have been described for the orbital vessels., However, a consensus regarding the reference values for the flow parameters of ocular Doppler sonography in pregnancy complicated by hypertension has not yet been established. This study aimed to compare the ophthalmic Doppler sonographic indices observed in woman with singleton pregnancies complicated by hypertension (mild preeclampsia, severe preeclampsia, or chronic hypertension) and to correlate the indices observed in hypertensive pregnant women with those observed in normotensive pregnant women (control group). Materials and Methods Ophthalmic artery Doppler indices of 30 mild and 30 severe preeclamptic women and 30 pregnant women with chronic hypertension at 20 to 40 weeks' gestation were compared to those of 289 healthy pregnant women in a cross-sectional study.
The control group consisted of normotensive pregnant women at 20 to 40 weeks' gestation who were evaluated by the authors in a previous study with the same methods. The inclusion criteria included having a singleton pregnancy with a gestational age of later than 20 weeks (established by sonography before 15 weeks) and absence of labor.
The exclusion criteria consisted of smoking, the presence of any other maternal disease as detected by prenatal screening, multiple pregnancy, and a serum creatinine level of greater than 1 mg/dL. Written informed consent was obtained from all participants who agreed to participate in the study, which was authorized by the Research Ethics Committee of the Universidade Federal do Rio de Janeiro. The definition of preeclampsia, as established in 2000 by the National High Blood Pressure Education Program criteria, includes increased blood pressure (BP) accompanied by proteinuria (≥0.3 g of protein in a 24-hour specimen or ≥1+ reading on a dipstick in a random urine sample with no evidence of urinary tract infection) after 20 weeks of pregnancy. Gestational BP elevation is defined as a systolic BP of 140 mm Hg or higher or a diastolic BP of 90 mm Hg or higher in a woman who was normotensive before 20 weeks' gestation. Doppler velocimetry of the ophthalmic artery in a pregnant woman with severe preeclampsia. The right eye was evaluated.
The resistive index, pulsatility index, and peak ratio were measured. The peak ratio was defined as the ratio of the flow velocity of the second peak (after the notch) to that of the initial peak (peak systolic velocity) (peak ratio = peak 2/peak 1; )., The gestational age was calculated using the date of last menses, and it was confirmed with an ultrasound scan before 15 weeks' gestation. The criterion of complete weeks, as established by the World Health Organization, was used. The mean time required for ophthalmic Doppler analysis was approximately 5 minutes.
All data underwent statistical analysis (S-PLUS version 8.0; TIBCO Software, Inc, Palo Alto, CA). The mean and standard deviation were calculated for each index assessed (resistive index, pulsatility index, and peak ratio) among the hypertensive group and the normal group (normotensive pregnant women). The Kolmogorov-Smirnov test was used to evaluate whether data obtained from the hypertensive pregnant women had a normal distribution. Analysis of variance was used to compare the means of the Doppler indices between groups. As significant differences were determined by analysis of variance, each group was compared by the Tukey method to determine which means were different. Receiver operating characteristic (ROC) curves were used to determine the predictive power of the ophthalmic artery Doppler indices for identification of severe preeclampsia by comparing patients with severe preeclampsia to other pregnant women with hypertension (mild preeclampsia and chronic hypertension).
The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the cutoff points for the pulsatility index, resistive index, and peak ratio obtained by ROC curves were calculated. Table 1. Characteristics of the Study Participants Group Maternal Age, y Gestational Age, wk Systolic B P, mm Hg Diastolic B P, mm Hg No. Of Pregnancies No.
Medison Sonoace X8 Manual Muscles
Of Previous Births. Values are mean ± SD. P.05 indicates no significant differences. CH indicates chronic hypertension; n, number of pregnant women; and PE, preeclampsia. Mild PE (n = 30) 26.3 ± 5.3 35.2 ± 3.3 139.9 ± 11.4 91.2 ± 11.0 1.8 ± 1.1 0.5 ± 0.7 Severe PE (n = 30) 28.9 ± 4.8 32.5 ± 3.9 157.8 ± 18.2 102.3 ± 14.7 2.1 ± 1.5 0.7 ± 0.9 CH (n = 30) 30.6 ± 6.9 33.4 ± 4.4 142.1 ± 18.5 90.1 ± 12.3 2.1 ± 1.8 0.7 ± 1.1 Normal (n = 289) 28.2 ± 4.7 29.7 ± 6.2 100.1 ± 10.8 60.8 ± 11.0 2.0 ± 1.5 0.6 ± 1.0 P.0083. Table 2. Ophthalmic Artery Doppler Indices of the Study Participants Group Resistive Index Pulsatility Index Peak Ratio.
Values are mean ± SD. Multiple comparison (Tukey method) of the means and 95% confidence intervals of the resistive index in the following study groups: mild preeclampsia, severe preeclampsia and chronic hypertension (n = 30 in each group), and normotensive pregnant women (n = 289). CH indicates chronic hypertension; and PE, preeclampsia. When the means of the pulsatility index were analyzed by the Tukey method, statistically significant differences were observed when patients with severe preeclampsia were compared to the control group, the group with chronic hypertension, and the group with mild preeclampsia. The same results were observed when the means of the pulsatility index were compared between those with mild preeclampsia and the control group and between those with chronic hypertension and the control group. No significant differences were found between the means of the pulsatility index when pregnant women with chronic hypertension were compared to those with mild preeclampsia.
The graph of multiple comparisons (Tukey method) showed statistically significant differences between the means of the peak ratio when all of the groups were compared, except for the comparison between those with chronic hypertension and those with mild preeclampsia. Multiple comparison (Tukey method) of the means and 95% confidence intervals of the peak ratio in the following study groups: mild preeclampsia, severe preeclampsia and chronic hypertension (n = 30 in each group) and normotensive pregnant women (n = 289). CH indicates chronic hypertension; and PE, preeclampsia. Receiver operating characteristic curves used to determine the cutoff point of the ophthalmic artery Doppler indices for identification of women with severe preeclampsia are shown in –. The values used as the cutoff points of the pulsatility index, resistive index and peak ratio for identifying severe preeclampsia are shown in. The sensitivity, specificity, PPV, and NPV of the cutoff points of the pulsatility index, resistive index, and peak ratio are shown in. The box plots for each index are shown in –.
Medison Sonoace Pico
Table 4. Sensitivity, Specificity, PPV, and NPV of the Doppler Index Cutoff Points for Identifying Severe Preeclampsia by Analyzing the ROC Curve Index Sensitivity Specificity PPV NPV Pulsatility index 0.633 0.919 0.404 0.967 Resistive index 0.733 0.888 0.361 0.975 Peak ratio 0.833 0.974 0.758 0.984 Discussion Hypertension is the most common disorder that complicates pregnancy worldwide. – Among the hypertensive disorders that affect pregnancy, preeclampsia is the primary cause of perinatal and maternal morbidity, and the acute cerebral complications associated with preeclampsia are the primary causes of maternal death.
– The identification of women who are at risk of cerebral complications that are associated with adverse pregnancy outcomes must be the goal of preeclampsia management. Persistent interest has been observed in the evaluation of the intracranial circulation in preeclamptic patients. Embryologic, anatomic, and functional similarities between the orbital and intracranial vasculature have enabled investigators to obtain information on the intracranial circulation by examining the orbital vessels with color Doppler imaging., In this study, pregnant women with chronic hypertension and preeclampsia were compared. This study was observational, and the analyses were not adjusted by possible confounders such as the use of antihypertensive medications or BP, which may limit the results. Patients with mild preeclampsia and those with severe preeclampsia were evaluated as separate groups. Approximately three-fifths of the patients in the severe preeclampsia and chronic hypertension groups were using antihypertensive medication for BP control. No patients in the mild preeclampsia group used antihypertensive medication.
The possible influence of the use of antihypertensive drugs on the orbital flow was a limitation of this study, and further studies are necessary to evaluate the influence of their use on cerebral blood flow in pregnant women with hypertension. Although the mean gestational age in the group of normotensive pregnant women was statistically earlier than that observed in the hypertensive pregnant patients, no significant differences were observed in the values of the ophthalmic Doppler indices in 289 normotensive pregnant women evaluated in a previous study. Because the Doppler indices evaluated did not change significantly with advancing gestational age, the differences between the means of these indices are not relevant. Neurologic involvement in preeclampsia-eclampsia syndrome fulfils the criteria of posterior reversible encephalopathy syndrome.
Medison Sonoace R7
– The pathophysiologic mechanism of posterior reversible encephalopathy syndrome remains under investigation. The current and most popular theory suggests that severe hypertension exceeds the limits of cerebral autoregulation and leads to vasodilatation with breakthrough brain edema., Endothelial damage is recognized as a major feature in the pathophysiologic mechanism of preeclampsia-eclampsia and as a relevant risk factor for posterior reversible encephalopathy syndrome. – Studies suggest that posterior reversible encephalopathy syndrome associated with substantial endothelial damage may develop without a relevant increase in BP.
–, Thus, the identification of cerebral overflow in patients with preeclampsia may be a marker of risk of cerebral hemorrhage and may be able to identify the severity in patients with preeclampsia. The differences observed in the ophthalmic Doppler indices of pregnant women with severe preeclampsia (lower resistive and pulsatility indices and a higher peak ratio) compared to those observed in pregnant women with mild preeclampsia and chronic hypertension show a lower impedance to ocular blood flow (central overperfusion) in the group with severe preeclampsia. The same results (orbital hyperperfusion) in patients with preeclampsia were also described by Ohno et al, Ayaz et al, and Diniz et al. In the only study with a comparative assessment of the peak ratio in women with mild and severe preeclampsia and normotensive pregnant women, Diniz et al observed that the resistive index, pulsatility index, and peak ratio in 20 pregnant women with severe preeclampsia were 0.64 ± 0.13, 1.00 ± 0.29, and 0.84 ± 0.08, respectively. We also observed a statistically significant difference between the pulsatility index and the peak ratio of normotensive pregnant women and those observed in women with mild preeclampsia and chronic hypertension (a lower peak ratio and a higher pulsatility index in normotensive pregnant women, showing high impedance to orbital flow in this group). In 2006, Diniz et al reported lower impedance to flow in the ophthalmic artery in women with preeclampsia (not classified) compared to women with chronic hypertension (resistive index, 0.63 ± 0.17 and 0.74 ± 0.06, respectively; pulsatility index, 1.12 ± 0.28 and 1.68 ± 0.41; and peak ratio, 0.82 ± 0.09 and 0.64 ± 0.13, respectively; P =.0001 for all indices).
In 1995, Hata et al compared normotensive pregnant women and patients with mild preeclampsia and observed the same results (pulsatility index, 2.75 ± 0.66 and 1.58 ± 0.47, respectively; P.05). The peak ratio, which is a ratio of the values for the peak diastolic velocity (after the protodiastolic notch) and the initial peak (peak systolic velocity), was first described in 2002 in studies by Nakatsuka et al. The increased values of this index in patients with severe preeclampsia suggest that there is a reduction in the impedance to flow in the ophthalmic artery. Although the mechanism of elevation of this index remains unclear, the peak ratio has been proposed to be the most sensitive indicator of vascular changes associated with the orbital overperfusion., The ROC curves showed a higher probability of severe preeclampsia for peak ratio values of greater than 0.784. The results of the ROC analysis suggest that the peak ratio is the best index for the identification of severe preeclampsia (major: area under the ROC curve, sensitivity, specificity, PPV, and NPV).
The high NPV observed for the peak ratio highlights the use of ophthalmic artery Doppler sonography as an important method in clinical practice. The prevalence of preeclampsia in the population is approximately 5% to 10%, and approximately 25% of these patients have severe preeclampsia. Because preeclampsia is a disease of low prevalence, peak ratio values of less than 0.78 suggest a low risk of cerebral overflow and, therefore, a low risk of severe complications due to preeclampsia.
The discrimination of women with a lower risk of cerebral complications may allow conservative management of preeclampsia (ie, medical treatment of preeclampsia with maintenance of pregnancy), so that very premature fetuses may have a greater chance of survival or survival without severe morbidity. In 2010, Barbosa et al evaluated the resistive index of the ophthalmic artery in 112 pregnant women with severe preeclampsia. Values of less than 0.56 were identified by the ROC analysis as being associated with clinical evidence of posterior reversible encephalopathy syndrome (odds ratio, 12.67; 95% confidence interval, 4.08–39.39; P.