Fatores explicativos dos resultados obtidos na medida de independência funcional aplicada a doentes com lesão neurológica

RESUMO - A medicina baseada na evidência e as iniciativas para melhorar a qualidade dos cuidados de saúde, têm aumentado bem como o reconhecimento da necessidade de medir os resultados funcionais em todos os cuidados de saúde. A reabilitação tem dado grande importância à necessidade de existência de instrumentos clínicos sensíveis aos resultados funcionais e, tem procurado instrumentos que possam ser usados em ambientes clínicos. A doença cérebro-vascular não é uma entidade patológica ou clínica única, podendo apresentar-se segundo quadros clínicos distintos. É uma ameaça à qualidade de vida não só pela sua elevada incidência e mortalidade, mas também pela alta morbilidade. Considerando estas premissas, pretendeu-se estudar a influência das características individuais, demográficas e de prognóstico neurológico dos doentes em reabilitação nas avaliações de funcionalidade. Utilizou-se a base de dados do Centro de Medicina de Reabilitação de Alcoitão, com todos os episódios de internamento de adultos (2647) que ocorreram entre 2006 e 2011, avaliados com a Medida de Independência Funcional (MIF). Este estudo revela que as variáveis com maior impacto na MIF, quer ao nível do score motor quer no score cognitivo são: a idade, o tempo de evolução e o tempo de internamento. A MIF não apresenta grandes variações entre grupos de diagnóstico no score motor mas releva valores estatisticamente significativos, no que diz respeito a esta variável, ao nível do score cognitivo. Os resultados deste estudo suportam ainda a validade da escala de avaliação e sugerem que esta fornece informações fundamentais para um bom programa de reabilitação.

Proprioceptive neuromuscular facilitation in HTLV-I-associated myelopathy/tropical spastic paraparesis

Introduction: Human T cell lymphotropic virus type I-associated myelopathy/tropical spastic paraparesis (HAM/TSP) can impact the independence and motricity of patients. The aims of this study were to estimate the effects of physiotherapy on the functionality of patients with HAM/TSP during the stable phase of the disease using proprioceptive neuromuscular facilitation (PNF) and to compare two methods of treatment delivery. Methods: Fourteen patients with human T cell lymphotropic virus type I (HTLV-I) were randomly allocated into two groups. In group I (seven patients), PNF was applied by the therapist, facilitating the functional activities of rolling, sitting and standing, walking and climbing and descending stairs. In group II (seven patients), PNF was self-administered using an elastic tube, and the same activities were facilitated. Experiments were conducted for 1h twice per week for 12 weeks. Low-back pain, a modified Ashworth scale, the functional independence measure (FIM) and the timed up and go test (TUG) were assessed before and after the interventions. Results: In the within-group evaluation, low-back pain was significantly reduced in both groups, the FIM improved in group II, and the results of the TUG improved in group I. In the inter-group analysis, only the tone was lower in group II than in group I. Conclusions: Both PNF protocols were effective in treating patients with HAM/TSP.

Perceived stress in elderly stroke survivors after hospital discharge to home

AbstractOBJECTIVETo evaluate the relationship between perceived stress and comorbidities, neurological deficit, functional independence and depressive symptoms of stroke survivors after hospital discharge.METHODCross-sectional study with 90 elderly stroke survivors. The National Institutes of Health Stroke Scale instrument, the Functional Independence Measure instrument, the Geriatric Depression Scale and the Perceived Stress Scale were used. Bivariate Pearson correlation, independent t test and multiple regression analysis were used to evaluate the relationship between perceived stress and other variables.RESULTSThe final regression model showed that higher perceived stress was related to less functional independence (p= 0.022) and more depressive symptoms (p <0.001).CONCLUSIONAt hospital discharge, interventions should be planned for the treatment of depressive symptoms and to create adaptation strategies to the reduction of functional independence, in order to reduce the stress of the survivors.

The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial.

BACKGROUND: Upper limb paresis remains a relevant challenge in stroke rehabilitation. AIM: To evaluate if adding mirror therapy (MT) to conventional therapy (CT) can improve motor recovery of the upper limb in subacute stroke patients. DESIGN: Prospective, single-center, single-blind, randomised, controlled trial. SETTING: Subacute stroke patients referred to a Physical and Rehabilitation Medicine Unit between October 2009 and August 2011. POPULATION: Twenty-six subacute stroke patients (time from stroke <4 weeks) with upper limb paresis (Motricity Index â0/00¤ 77). METHODS: Patients were randomly allocated to the MT (N.=13) or to the CT group (N.=13). Both followed a comprehensive rehabilitative treatment. In addition, MT Group had 30 minutes of MT while the CT group had 30 minutes of sham therapy. Action Research Arm Test (ARAT) was the primary outcome measures. Motricity Index (MI) and the Functional Independence Measure (FIM) were the secondary outcome measures. RESULTS: After one month of treatment patients of both groups showed statistically significant improvements in all the variables measured (P<0.05). Moreover patients of the MT group had greater improvements in the ARAT, MI and FIM values compared to CT group (P<0.01, Glass's Î" Effect Size: 1.18). No relevant adverse event was recorded during the study. CONCLUSION: MT is a promising and easy method to improve motor recovery of the upper limb in subacute stroke patients. CLINICAL REHABILITATION IMPACT: While MT use has been advocated for acute patients with no or negligible motor function, it can be usefully extended to patients who show partial motor recovery. The easiness of implementation, the low cost and the acceptability makes this therapy an useful tool in stroke rehabilitation.

Ideal timing to transfer from an acute care hospital to an interdisciplinary inpatient rehabilitation program following a stroke: an exploratory study

Affiliation: Dany Gagnon & Sylvie Nadeau: École de réadaptation, Faculté de médecine, Université de Montréal & Centre de recherche interdisciplinaire en réadaptation, Institut de réadaptation de Montréal

Evuloção cognitiva e funcional de pacientes pós-acidente vascular cerebral - AVC

PURPOSE: Stroke is a high-incidence cerebrovascular disease with elevated morbidity that results in impairments such as functional disabilities. This study aimed to investigate the functional evolution of individuals in the first six months post-stroke. METHOD: Longitudinal study with 42 stroke patients. The functional independence measure (FIM) and The National Institutes of Health Stroke Scale (NIHSS) were used by multidisciplinary staff 3 times in each participant; the first application was at admission to rehabilitation and the others three and six months later. RESULTS: Sample predominantly female (57%), married (52%), mean age 65.26 ±10.72 years, elementary schooling level (43%), ischemic stroke (91%), and right cerebral hemisphere (74%). Motor FIM scores and NIHSS scale showed improvement in the 3 evaluations, with significant p-value (<0.001). There was a strong relation between motor FIM evolution and NIHSS evolution (r = - 0.69 p-value< 0.001). CONCLUSIONS: It was observed that functional evolution at 6 months post-stroke was significant and the smaller the evolution of clinical impairment in these patients, the larger the evolution of their functional independence. The study is important because it allows a more appropriate therapeutic planning according with functional evolution in stroke rehabilitation

Efeitos da inclinação da esteira na marcha de indivíduos hemiparéticos crônicos

Objective: To examine the effects of treadmill inclinations on the walking of hemiparetic chronic subjects. Design: Observational descriptive study. Location: Laboratory of human movement analysis. Participants: Eighteen subjects, 10 men and 8 women were evaluated, with a mean age of 55.3 ± 9.3 years and the time since the injury of about 36 ± 22.8 months. Intervention: Not applicable. Main Outcome Measures: All subjects were evaluated for functional independence (Functional Independence Measure - FIM) and balance (Berg Balance Scale). Angular variations of the hips, knees and ankles in the sagittal plane were observed, as well as the speed of the movement (m/s), cadence (steps/min), stride length (m), cycle time (s), step time on the paretic leg and on the non-paretic leg (s), support phase time and balance phase time on the paretic leg (s) and the ratio of symmetry inter-limb as subjects walked on a treadmill at three conditions of inclination (0%, 5% and 10% ). Results: There were angular increases in the initial contact of the hip, knee and ankle, amplitude increase in the hip between 0% and 10% (37.83 ± 5.23 versus 41.12 ± 5.63, p < 0,001) and 5% and 10% (38.80 ± 5.96 versus 41.12 ± 5.63, p = 0,002), amplitude increases in the knee between 0% and 10% (47.51 ± 15.07 versus 50, 30 ± 12.82, p = 0,040), extension decreases in the hip, dorsiflexion increases in the balance phase and in the time of support phase from 0% to 5% (0.83 ± 0.21 versus 0.87 ± 0, 20, p = 0,011) and 0% and 10% (0.83 ± 0.21 versus 0.88 ± 0.23, p = 0,021). Conclusion: The treadmill inclination promoted angle changes as such as the increase of the angle of the hip, knee and ankle during the initial contact and the balance phase and the increase of the range of motion of the hip and knee; furthermore, it also promoted the increase of the support time of the paretic lower limb

Avaliação eletromiográfica de músculos inspiratórios em hemiparéticos / Eliete Moreira Colaço

The objective was measured by surface electromyography (EMGs), the activity of inspiratory muscles during incremental test in subjects with hemiparesis and show its correlation with the Functional Independence Measure (FIM). Were included in the study 32 individuals hemiparetics and 14 healthy as control group. We performed an evaluation of lung function and anthropometric data. The EMGs were performed during the incremental test with Threshold ® (15, 30, 45 and 60% of MIP) and during maximal inspiratory pressure (MIP). The electromyographic findings were calculated by the signal amplitude (RMS). All data were initially analyzed by Kolmogorov-Smirnov, the anthropometric characteristics of both groups were tested with the Levene and then intra-subject analysis (hemiparetic hemithorax and healthy hemithorax) and inter-group analysis (experimental group and control group) by paired and non-paired Student t tests and Pearson correlation. In intra-subject comparison was observed less activation (p <0.01) of the sternocleidomastoid muscle, scalene and diaphragm paretic side in both sexes - for the Threshold ® incremental test (15, 30, 45 and 60% of the MIP) and during maximal inspiratory pressure (MIP). In inter-group comparison, there was reduced activity in the diaphragm and the scalene, in hemiparetics males and females, respectivelly, during the same test. Our results demonstrate the existence of reduced electromyographic activity of inspiratory muscles in hemiparetics, including changes between different genders and suggests the need of further studies to assess the effects of specific training of inspiratory muscles.

Funcionalidade em pacientes após acidente vascular encefálico: relação com o sono e ritmo de atividade-repouso

It is known that sleep plays an important role in the process of motor learning. Recent studies have shown that the presence of sleep between training a motor task and retention test promotes a learning task so than the presence of only awake between training and testing. These findings also have been reported in stroke patients, however, there are few studies that investigate the results of this relationship on the functionality itself in this population. The objective of this study was to evaluate the relationship between functionality and sleep in patients in the chronic stage of stroke. A cross-sectional observational study was conducted. The sample was composed of 30 stroke individuals in chronic phase, between 6 and 60 months after injury and aged between 55 and 75 years. The volunteers were initially evaluated for clinical data of disease and personal history, severity of stroke, through the National Institute of Health Stroke Scale, and mental status, the Mini-Mental State Examination. Sleep assessment tools were Pittsburgh Sleep Quality Index, the Questionnaire of Horne and Ostberg, Epworth Sleepiness Scale, the Berlin questionnaire and actigraphy, which measures were: real time of sleep, waking after sleep onset, percentage of waking after sleep onset, sleep efficiency, sleep latency, sleep fragmentation index, mean activity score. Other actigraphy measures were intraday variability, stability interdiária, a 5-hour period with minimum level of activity (L5) and 10-hour period with maximum activity (M10), obtained to evaluate the activity-rest rhythm. The Functional Independence Measure (FIM) and the Berg Balance Scale (BBS) were the instruments used to evaluate the functional status of participants. The Spearman correlation coefficient and comparison tests (Student's t and Mann-Whitney) were used to analyze the relationship of sleep assessment tools and rest-activity rhythm to measures of functional assessment. The SPSS 16.0 was used for analysis, adopting a significance level of 5%. The main results observed were a negative correlation between sleepiness and balance and a negative correlation between the level of activity (M10) and sleep fragmentation. No measurement of sleep or rhythm was associated with functional independence measure. These findings suggest that there may be an association between sleepiness and xii balance in patients in the chronic stage of stroke, and that obtaining a higher level of activity may be associated with a better sleep pattern and rhythm more stable and less fragmented. Future studies should evaluate the cause-effect relationship between these parameters

Efeitos do treino em esteira com suporte parcial de peso e do método de facilitação neuromuscular proprioceptiva na marcha hemiparética: estudo comparativo

Objective: To compare the effects of the treadmill training with partial body-weight support (TPBWS) and Proprioceptive Neuromuscular Facilitation (PNF) method on gait of subjects with chronic stroke. Design: Quasi-experimental study. Setting: Laboratorial research. Participants: Twenty-three subjects (13 men and 10 women), with a mean age of 56,7 ± 8,0 years and a mean time since the onset of the stroke of 27,7 ± 20,3 months, and able to walk with personal assistance or assistive devices. Interventions: Two experimental groups underwent gait training based on PNF method (PNF group, n=11) or using the TPBWS - Gait Trainer System 2, Biodex, USA (TPBWS group, n=12), for three weekly sessions, during four weeks. Measures: Evaluation of motor function - using the Stroke Rehabilitation Assessment of Movement (STREAM) and the motor subscale of the Functional Independence Measure (motor FIM) -, and kinematic gait analyze with the Qualisys System (Qualisys Medical AB, Gothenburg, Sweden) were carried out before and after the interventions. Results: Increases in the STREAM scores (F=49.189, P<0.001) and in motor FIM scores (F=7.093, P=0.016), as well as improvement in symmetry ratio (F=7.729, P=0.012) were observed for both groups. Speed, stride length and double-support time showed no change after training. Differences between groups were observed only for the maximum ankle dorsiflexion over the swing phase (F=6.046, P=0.024), which showed an increase for the PNF group. Other angular parameters remain unchanged. Conclusion: Improvement in motor function and in gait symmetry was observed for both groups, suggesting similarity of interventions. The cost-effectiveness of each treatment should be considered for your choice

Avaliação da intensidade de dor e da funcionalidade no pós-operatório recente de cirurgia cardíaca

OBJETIVO: Avaliar a intensidade de dor e o nível de funcionalidade em pacientes submetidos à cirurgia cardíaca nos períodos pré-operatório, 7º pós-operatório e alta hospitalar, relacionando-os entre si. Relacionar funcionalidade com: sexo, faixa etária, primeira cirurgia cardíaca ou reoperação, uso de circulação extracorpórea (CEC), tipo de cirurgia e acompanhamento fisioterapêutico. MÉTODO: Foram estudados 41 pacientes que realizaram cirurgia cardíaca eletiva por toracotomia médio-esternal (TME) no HC da Faculdade de Medicina de Botucatu/UNESP. A intensidade de dor foi avaliada pela escala de VAS e a funcionalidade, pela escala MIF (medida de independência funcional) no domínio físico. RESULTADOS: A intensidade de dor mais elevada foi no 7º pós-operatório comparado com os momentos pré-operatório e alta. No pré-operatório, não houve índice de dor; na alta, a intensidade mediana foi 3 (dor moderada). Os níveis mais elevados de perda funcional ocorreram no 7º pós-operatório, quando comparados com os escores totais do pré-operatório e da alta. Verificou-se correlação significativa entre dor e funcionalidade, demonstrando que o decréscimo do nível de dor entre o 7º pós-operatório e a alta contribuiu para a elevação dos níveis funcionais. CONCLUSÃO: As avaliações realizadas no pré-operatório proporcionaram resultados preditivos a serem alcançados. As avaliações realizadas no 7º pós-operatório e na alta possibilitaram a classificação dos pacientes de acordo com perdas e ganhos, indicando aqueles que necessitavam de maior cuidado e treinamento em suas capacidades.

Functional dependence and caregiver burden in Alzheimer's disease: a controlled trial on the benefits of motor intervention

Background: Cognitive decline has a negative impact on functional activities in Alzheimer's disease. Investigating the effects of motor intervention with the intent to reduce the decline in functionality is an expected target for patients and caregivers. The aim of this study was to verify if a 6-month motor intervention programme promoted functionality in Alzheimer's patients and attenuated caregivers' burden. Methods: The sample comprised 32 community patients with Alzheimer's disease and their 32 respective caregivers. Patients were divided into two groups: 16 participated in the motor intervention programme and 16 controls. Subjects performed 60 minutes of exercises, three times per week during the 6-month period, to improve flexibility, strength, agility and balance. Caregivers followed the procedures with their patients during this period. Functionality was evaluated by the Berg Functional Balance Scale and the Functional Independence Measure. Caregivers completed the Neuropsychiatric Inventory Caregiver Distress Scale and the Zarit Carer Burden Scale. Two-way ANOVA was used to verify the interaction between time (pre- and post-intervention) and the motor intervention program. Results: While patients in the motor programme preserved their functionality, as assessed by the Functional Independence Measure, the controls suffered a relative decline (motor intervention group: from 109.6 to 108.4 vs controls: from 99.5 to 71.6; P= 0.01). Patients from motor intervention also had better scores than the controls on functional balance assessed by Berg scale (F: 22.2; P= 0.001). As assessed by the Neuropsychiatric Inventory and Zarit scale, burden was reduced among caregivers whose patients participated in the motor intervention programme compared with caregivers whose patients did not participate in this programme (Neuropsychiatric Inventory, caregiver's part: F: 9.37; P= 0.01; Zarit: F: 11.28; P= 0.01). Conclusion: Patients from the motor intervention group showed reduced functional decline compared to the controls, and there was an associated decrease in caregivers' burden.

Efeitos de um programa de intervenção motora nos distúrbios neuropsiquiátricos e nas atividades funcionais de pacientes com demência de Alzheimer e em seus cuidadores

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Avaliação da qualidade de vida e funcionalidade em pacientes com doença arterial coronariana submetidos à revascularização cirúrgica ou angioplastia

Pós-graduação em Bases Gerais da Cirurgia - FMB

Quedas em idosos e sua relação com a capacidade funcional

OBJETIVO: determinar a prevalência de quedas em idosos e sua relação com a capacidade funcional. MÉTODO: trata-se de estudo epidemiológico transversal de base populacional, com uma amostra por conglomerado de duplo estágio de 240 sujeitos, com idade acima de 60 anos, de ambos os sexos, residentes em Ribeirão Preto, SP. Os dados foram coletados entre novembro de 2010 e fevereiro de 2011 e utilizaram-se os questionários: perfil social, avaliação de quedas, Medida de Independência Funcional e Escala de Lawton e Brody. Foi adotado o nível de significância de 0,05. Para a identificação da ocorrência das quedas e sua relação com a capacidade funcional, foram utilizadas razão de prevalência e de chances de prevalência e regressão logística múltipla. RESULTADOS: a média de idade foi de 73,5 anos (±8,4), 25% com 80 anos ou mais, predomínio do sexo feminino; 48,8% estudaram de 1 a 4 anos. Média de 1,33 quedas (±0,472); com maior prevalência em mulheres e idosos mais jovens; o local mais frequente foi o quintal e o banheiro. Houve forte correlação entre o nível de independência funcional e as atividades instrumentais com a idade, e não houve relação entre os idosos que sofreram queda e as variáveis sexo e idade. CONCLUSÃO: houve predomínio de mulheres que sofreram quedas relacionadas à independência funcional, podendo-se prevenir com estratégias de promoção à saúde ao idoso, política essa para oferecer condição de vida à pessoa no processo de envelhecer.