EFFECTS OF TECAR THERAPY ASSOCIATED WITH MANUAL THERAPY ON GLUTEAL SKIN FLACCIDITY

Background: A new technology called Tecar therapy, widely used in the orthopaedic area, has been studied in aesthetics in order to treat skin flaccidity. The equipment allows the association of radiofrequency with manual therapy. This study These results corroborate with a study carried out by Bohnert et al. (2017) in which the use of the Global Aesthetic Improvement Scale (GAIS) showed analysesreliabilityregarding the use of radiofrequency for skin texture improvement, demonstrating a statistically significant increase in the skin condition enhancementof subjects with initial reports ofirregular skin texture.


Introduction:-
The skin is a complex biological structure, due to its multifactorial nature. Regarding itsmechanical properties, the human skin has a viscoelastic behaviour, that is, it presents elastic and plastic characteristics (Dematini et al., 2015). Changes in the mechanical properties of the skin during adulthood include elasticityloss and increased time for skin to return to its original state after a clamping and, over the years, it entails a significant decrease in skin thickness (Cunha et al., 2016).
Flaccidity is considered an unsightly condition of the skin that results from tissueatrophy, resulting in loose appearance, affecting skin and muscles. From 25 (twenty-five) years of age, anelastic and collagen fibres decrease occurs and the process of their collapse begins (Silva et al., 2014). In addition to chronological aging, several factors contribute to the saggingappearance or worsening of the skin conditions, such as restrictive diets, weight loss, liposuction, and post-pregnancy, favouring skin elasticity losseven in young patients (Cunha et al., 2016).
In the last years, the concern with body aesthetics has gained much importance insociety, as beauty reflects on selfesteem and quality of life. Nowadays, there are several invasive and non-invasive treatments for aesthetic dysfunctions (Araújo et al., 2015). Action in the treatment of flaccidity ranges from prevention and aesthetic care to the use of resources such as electrotherapy, LEDs, laser phototherapy, and radiofrequency, which have been highlightsin the treatment of skin flaccidity (Silva et al., 2014).
Radiofrequency is a type of high-frequency current that generates heat by conversion, penetrating the deeptissue layers and promoting oxygenation, nutrition, and vasodilation. It acts to denature collagen fibres, resulting in their shortening, leading to contraction of redundant connective tissue. When passing through the tissues, the current generates a slight friction or resistance, promoting tissue temperatureincrease (Tagliollato, 2015).
The treatment consists of exposing the tissue to an electromagnetic wave between 30 KHz and 300 MHz, the most commonly used frequency being between 0.5 and 1.5 MHz. Its energy is applied through two electrodes, an active electrode that causes large current density, causing localized thermal effect on tissues, promoting collagen stimulation, fibrous septa retraction, muscle relaxation, and analgesia. The passive electrode consists of a large contact conductive plate that closes the current circuit, causing the energy to return to the patient (Carvalho et al., 2011).
A well-known type of radiofrequency used in Europe is the Tecartherapy, which is already known in the area of orthopaedicrehabilitation, and has a slightly more current use in aesthetics. It is a type of radio frequency with electromagnetic radiation that generates deep high frequency heat between 0.3 and 1.5 MHz, but these values may vary among manufacturers (Meyer, 2018). According to Ribeiro et al. (2018), the Tecar therapy works through two modes of charge transfer: the capacitive and the resistive modes. The capacitive mode is used in tissues with higher electrolyte content, such as skin and muscles, and the resistive mode in more resistant structures such as tendons, bones, and joints.
The Tecartherapy can be an important tool for the treatment of fibrous tissues, scars, cellulite with fibrous adhesions, the lifting effect in various regions of the body such as glutes, abdomen, and other areas of flaccidity. Furthermore, it allows the association with the technique of manual therapies (Meyer, 2018). According to , the connective tissue, when in contact with the manual techniques, suffer stimuli resulting in morphologicaladaptations capable of promoting tissue plasticity.
The use of the Tecartherapy associated with manual therapy in orthopaedic dysfunctions has been well studied. The Tecartherapy in combination with the soft tissue technique has itstherapeutic effect enhanced by blood perfusionimprovement, nutrient supplying, and oxygen delivery to the treated tissue (Ekelem et al., 2019). However, with respect to the use of the Tecartherapy associated with manual therapy in aesthetics is not mentioned in enough studies to prove its efficacy. Therefore, this research aims to analyse the effects of the Tecartherapyin association with a manual therapy to treat gluteal flaccidity.

Patients And Methods:-
The study was characterized as an experimental research that aims to analyse the effects of the Tecar Therapywhen associated with manual therapy on skin flaccidity.

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The sample selectionwas made by non-probabilistic convenience and started after the approval of the CAAE (Ethics Committee of the 4.062.746) with protocol number: 29253720.8.0000.5537. The sample consisted of 15 (fifteen) volunteers. To be considered for the study, the volunteers who were all female, aged 21 (twenty-one) to 54 (fiftyfour), needed to present gluteal skin flaccidity condition, as well as comprehension capacity, and preservedlocal sensitivity.
Exclusion criteria applied to all individuals included cutaneous lesions, pregnancy, or noavailability to attend sessions. At the end of the selection, according to the exclusion criteria, the sample ended up with seven (7) volunteers.
The instruments used to collect survey data were a of a mobile phone camera(IPHONE, APPLE INC., USA), a directed radiofrequency device (TR THERAPY ELITE 6000, BTL TM , Bulgaria) registered before ANVISA under number #80991690005, the Global Aesthetic Improvement Scale form (GAIS) by Narinset al. After sample selection, they individuals wereoriented regarding researchobjectives, treatmentbenefits, and the procedures performed in this study. They signed the free and informed consent form (TCLE) and then were submitted to the metric measurement, followed by early photographic recording and Tecartherapy application in association with manual therapy. More photos were taken shortly after the session, then sent for software (AutoCAD)and photogrammetric analysis. The volunteers were evaluated and reassessed during all sessions, and only in the last session the adapted satisfaction questionnaire and the global aesthetic improvement scale form (GAIS) were used.
The photographic record was performed in orthostatism, with posterior/lateral views (right and left) and the volunteer was asked to perform a 90º shoulder flexion for photo taking. The same camera was used for all photos. With the aid of a tripod, the camera was positioned 90 cm of height from the floor, a distance of 50 cm of the volunteers and 80 cm from the walland photos of the left and right gluteus were taken during and after radiofrequencytreatment. The application was performed in the ventral, right, and left lateral decubitus, and the neutral electrode was positioned on the abdominal and hip region, respectively. The conductive cream supplied by the manufacturer, suitable for use with such radiofrequency device, was applied, and with the capacitive applicator between the index and the middle fingers, a sliding movement was performed from the gluteal foldupwards. The sitetemperature was monitored through volunteer reporting and measured with a digital thermometer (BENETECH). The setparameters were the following: capacitive mode, 500 KHz frequency, 100% duty cycle and 80% power. At the desired temperature, the application in the region was maintained for 4 (four) min in an area corresponding 7 cm², resulting 12 quadrants, totalling an average application time of 60 min. The treatment consisted of one session per week, totalling four sessions. At the end of each session, the photos were sent to an examinerwho analysedthe gluteal fold measurements using the AutoCAD software. The analysis was carried outas follows: a ruler was positioned laterally to the hip of the volunteeras reference, then the measuring softwarewas used, measuring the gluteal fold on the right and left sides. The marking performed in the posterior waist region of the volunteerwas also used as parameter.
If the distance from the gluteal fold to the line marked at the volunteer's back (shown in the arrow below) decreases, it implies a reduction in the measure of the gluteal fold, otherwise, an increase in the measure of the gluteal fold is obtained.A transverse line was drawn 5 cm above the umbilical scar and marked with the aid of a FIBER TM tape measure, by wrapping it around the waist of the volunteer and marking a second point. From this second point, a line was drawn for the measuring of the gluteal fold from the left and right side.

Results:-
Initially, the group consisted of 15 (fifteen) female volunteers, with a mean age of 37 (thirty-seven) years. Due to incompatibility of time availability for the sessions as one of the exclusion criteria, the study was completed with 7 (seven) volunteers. The number of volunteers in the study (7), as well as the minimum (22.0), mean (37.0) and maximum (54.0) ages within the group, presenting a standard deviation of ± 14.04.

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Another method of evaluation used in the study was the metric measurement which, asoccurred with the paired ttest, did not obtain satisfactory statistical results either, presenting a standard deviation>0.05. There, the left and right gluteal fold measurements (34.71 and 35.71 cm) submitted to the intervention protocol did not present statistical differences both immediately after (35.28 and 35.75 cm) and at the end of the 4 sessions (35.42 and 36.0 cm).
Regarding the adapted overall aesthetic improvement scale form, the subjects were asked about their impression regarding the appearance of the treated area, that 57% of the volunteers considered the treated region presentedbetter appearance, 28.6% considered the treatedarea much better, and 14.3% considered the treatedregion far better, so there was no report of no improvement as noticed by the volunteers. On the photogrammetric analysis of the posterior profileimprovement, it was possible to observe that 54.1% of the evaluators noticed improvement of the treated region, and 45% did not report improvements.
As of the right lateral profilephotogrammetric analysis, 66.3% of the evaluators pointed improvement of the treated area, corresponding to the absolute frequency of 65; and 33.7% reported no improvement of the treated region, corresponding to an absolute frequency of 33.
In the left lateral profilephotogrammetric analysis, 55.1% of the evaluators visualized improvement in the region, which corresponds to the absolute frequency of 54; and 44.9% did not observe improvement, which corresponds to the absolute frequency of 44.
The Tecartherapy is a new technology in the aesthetic market, so the volunteers were questioned about the effects and reactions that occurred after the application of this type of radiofrequency. Regarding the presence of localized skin hyperaemia, 42.9% of the sample noticed localized hyperaemia, 28.6% of the sample observed hyperaemia in all sessions, and 28.6% of the sample did not report hyperaemia.
Regarding the hyperaemia observed by the volunteers during the applications of the Tecartherapy radiofrequency, 28.6% (absolute frequency of 2) reported not having observed hyperaemia; while 42.9% (absolute frequency of 3) reported hyperaemia.
Regardingthe duration of hyperaemia in volunteers, 42.9% of the sample said that local hyperaemia disappeared shortly after application, 57.1% said that the localized hyperaemia lingered for about 1 hour.
As for slight shock sensationsduring the applications, 85.7% of the volunteers reported not feeling them, and 14.3% reported feelingslight shocks.
In regard tothe volunteers'perception of the fluid retention decreaseafter radiofrequency application, 71.4% of the sample reported decreased fluid retention and swelling, and 28.6% did not notice improvements in this aspect.
As for the perception of clothes fitting, 85.7% of the sample did not notice looser clothing and 14.3% perceived looser clothing from the second week.
The volunteers were questioned if any difference regarding skin firmness was noticed, 85.7% of the sample (absolute frequency of 6) considered the skin firmer when comparing current skin conditions with conditions perception two months before the application; and 14.3% (absolute frequency of 1) considered the skin much firmer when compared with its firmness two months before the application. When questioned about skinmarks after the applications, and their duration, there was no report by the volunteers.
The data obtained through the adapted satisfaction questionnaire were analysed and it was observed that 100% of the sample were satisfied with the treatment.
As for the evaluation of the volunteers concerning the attribution of an overall perception of treatmentresults, 57.1% stated it was an excellent treatment, 28% said it was a very good treatment, 14.3% found ita good treatment. The alternatives "weak treatment" and "would not indicate this treatmentto anyone", were not indicated.

Discussion:-
A major advantage of Tecartherapyradiofrequencyis the possibility of its association with a manual therapy. The ability to change the fascia structure through manual therapy may be responsible for its traction and lifting effect, since it promotesthe biological effect of increasing collagen distensibilitywhen associated with radiofrequency (Meyer, 2018;. Manual therapy has the basic principles of muscle relaxation, nutrition, and tissueoxygenation, as well as circulationimprovement and lymph nodes'drainage flow. According to the pressure and speed applied with the technique, it is possible to promote capillarydilation by increasing the region'sblood flow, tissuetraction in the chosen direction and the re-education of this position through proprioceptive stimuli. All these effects added to the radiofrequencyeffects are important when the objective is to decreasegluteal regionsagging (Gondimand Almeida, 2018).
In the study conducted bySilva et al.,(2013), with a sample of 40 (forty) volunteers, whose objective was to analyse the effects of manual therapy on facial skin flaccidity, it was concluded that manual therapy presented some satisfactory results, also being used as a dermatofunctional physiotherapy resource.
In the results found in this study that sought to demonstrate the association of radiofrequency in the form of Tecartherapy with manual therapy, it was noticed that the majority of the quantitative results were not as positive as the qualitative results regarding the description of the volunteers'results and their satisfaction, which may have been due to a large influence of the small number of the sample and also the methodological limitation of the study, which did not present a control group nor compared the use of Tecartherapy with and without associated manual therapy.
One of the tools used in this study was the AutoCAD software. According to Amorim (2005), the AutoCAD program has been widely used for research in physiotherapy, as it makes it possible to quantify ADM digital photography, providingvisual feedback to the patient. Wong et al. (2012) reported that the reliability of the results may have been enhanced by the fact that the digital photographs analysis was performedwith AutoCAD. However, in this study, the results of the gluteal fold analysis with AutoCAD did not obtain a significant statistical analysisresponse, probably due to the subjectivity of the analysis and low sample number (n = 7), thus interfering with the statistical results. However, in the results obtained through volunteersresponse concerning the global aesthetic improvementscale, it was observed that after radiofrequencyapplication, the volunteers noticed improvement in the texture of the treated region and there were no negative perception reports. These results corroborate with a study carried out by Bohnert et al. (2017) in which the use of the Global Aesthetic Improvement Scale (GAIS) showed analysesreliabilityregarding the use of radiofrequency for skin texture improvement, demonstrating a statistically significant increase in the skin condition enhancementof subjects with initial reports ofirregular skin texture.
Regarding photogrammetry, a tool which has been previously used in radiofrequency studies concerningtissue sagging analysis, it is assumed that the changes caused by radiofrequency have not been completely observed, sincephotographic analysis alone hinders the assessmentaccuracy and interpretation (Silva et al., 2017). In this study, the photogrammetric results of the photos seen in the right lateral profile angle were more satisfactory (66.3%), probably becausethe from a lateral perspective, flaccidity of the gluteal region maybe better visualized, thus justifying the best results described by the evaluators, which is in line with the findings by Bravo et al. (2013), which showed improvement in gluteal region flaccidity, demonstrated through photographic records of lateral profile before and after 30 days of radiofrequencytreatment.
Regarding the sensations reported by the volunteers, hyperaemia was present in the answers described in the questionnaires, but these are part of the routine of any application of radiofrequency applied to skin sagging treatments. The increase in temperature in the Tecartherapytreatment is caused by the movement of electrolytes along the tissue, which propagates to skinsurface. This thermogenesis causes a biostimulating action and produces a vasodilation with increased blood and lymphatic circulationthrough the stimulation of nerve endings and chemical mediators. The cellular oxygenation is linked to vasodilatation and consequent increase in blood flow, thus increasing the supply of oxygen through the bloodstream. Therefore, vasodilation and hyperaemiaarise as a consequence of the thermal effect, in which vasodilation promotes an increase in local peripheral circulation, generating hyperaemiaofthe skin. The hyperaemia only occurs with long and high intensity applications (Fonseca et al., 2018) Regarding the duration of hyperaemia, Bravo et al. (2013) reported that the only side effect found in volunteers in treatment with gynoid lipodystrophy using radiofrequency was a moderate to severe erythema, with a maximum duration of one to two hours. On the other hand, Bohnert et al. (2017) stated that during treatment, several volunteers presented mild erythema after application, which ceased within a few hours. Silva (2017), in his study on the efficacy of the radiofrequency associated with vitamin C in facial rejuvenation, observed that all participants presented controlled hyperaemia during radiofrequencyapplication; however, the face rednessdisappeared hours after treatment. In this study, most volunteers reported that hyperaemia disappeared an hour after application According to Bravo et al. (2013), RF works through two actionmechanisms: producing dermal heating and vasodilation. This thermal injury activates an inflammatory cascade and stimulates the fibroblasts' collagensynthesis through neocolagenesis, promoting dermisthickening. The vasodilation leads to hyperaemia and lymphatic drainage of fatty tissue and the association of these mechanisms in the dermis and in the subcutaneous tissue favours the skinappearanceimprovement.
Carvalho et al. (2011) report that temperature,when increasedabove the physiological level, facilitates vasodilation with capillary opening, favouring tissue trophism, and reabsorption of excessive intracellular fluids, increasing circulation and promoting nutritional gain of oxygen, nutrients and trace elements to the tissue, which facilitates the drainage of toxins and free radicals. This explains the decreasein fluid retention and swelling, as 74.1% of the volunteers observed improvement in this aspect, as well as improved skin texture, in which 85.7% noticed firmer skin, and 14.3% found skin stronger.
This study of the radiofrequency combined with manual therapy in gluteal cutaneous flaccidity promotedsatisfaction to all the volunteers, which coincides with the prospective study carried outby Bohnert et al. (2017), which analysed the effects of radiofrequency on facial skin texture. In their study, satisfaction questionnaires were applied one month after the application, and results demonstrated that 82% of the volunteers were satisfied with the treatment.
According to Fonseca (2018), the results in his study showed unanimity when two (2) physicians, three (3) physiotherapists, and three (3) beauticians were interviewed, highlightingthe application of radiofrequency as an effective treatment for tissue flaccidity, corroborating with the findings of this research, despite its limitations regarding sample sizeand possiblydue to the subjective analysis of the resources used as the evaluation methods.

Conclusion:-
Thus, it is understood that Tecartherapy is a radiofrequency modality that improves appearance of cutaneous aspects, minimizing the effects of tissue flaccidity.

Declaration of Conflicting Interests:
The Author(s) declare(s) that there is no conflict of interest.