Efeitos imediatos da eletroestimulação nervosa transcutânea e crioterapia na espasticidade e na atividade eletromiográfica de sujeitos hemiparéticos

Cerebrovascular accident (CVA) is a term used to characterize an ischemic or hemorrhagic vascular injury, which has got as main clinic manifestations, the motor and reflex function disturbance. In the first stage there is flaccidity and loss of voluntary movements that afterwards is substituted by mass patterns and spasticity. The spasticity brings with itself functional deficits and can generate negative impacts in various motor patterns. The aim of this research was to investigate the hyperreflexia and identify the immediate effects of transcutaneous nervous stimulation (TENS) and cryotherapy in the spasticity and electromyographic activity of hemiparetic subjects. The study is characterized as an almost experimental type, in which were selected, to compose the sample, 16 patients of both sex with CVA sequel. These individuals were evaluated by collecting the amplitude peak to peak and H reflex latency, Motor response (M response) in solear muscle and the electromyography (EMG) of the injured and healthy legs anterior tibial muscles. In the injured limb the evaluations occurred in different days for cryotherapy, TENS and control, in two moments, before and after the interventions. The healthy limb was evaluated one single time to serve as baseline, for comparison with the injured limb. It was used an statistic analysis, the t paired student test to identify the H reflex differences, latency and EMG of the injured and healthy limbs and to compare the results before and after the recourses application. The ANOVA for related samples was used to identify the differences among the recourses used. It was attributed for the statistic tests a significance level of 5%. The amplitude peak to peak of normalized maximum H reflex through the maximum motor response (Hmax/Mmax), showed itself significantly increased in the injured limb (p=0.0245). The H reflex latency was presented reduced in the injured limb (p=0, 0375). The electromyographic activity was showed decreased in the injured limb (p< 0.0001). After the TENS there was a Hmáx/Mmáx ratio decrease (0.60±0.16 versus 0.49.±0.18; P = 0.0006). Nonetheless, Just after the cryotherapy application there was an increase of Hmáx/Mmáx ratio (0.58 ± 0,15 to 0.77 ± 0.13, P=0,0007) and increase of signal latency (30.41 ± 1.87 versus 33.24 ± 2.19; P=0.0001). The electromyographic activity wasn t altered significantly by any resource. It was met statistic significant differences when the Hmáx/Mmáx P<0.0001) ratio and H reflex latency (P<0.0001) were compared between the post TENS, cryotherapy and control. One can conclude that the TENS can be used to spasticity immediate reduction, and that the cryotherapy can increase the hyperreflexia state in spastic patients. Nonetheless, the spasticity decrease or increase didn t provoke lectromyographic activity change in the muscle that is opponent to the spastic one

Influência do biofeedback no treino de marcha de sujeitos hemiparéticos: ensaio clínico randomizado

BACKGROUND: Treadmill training with partial body weight support (BWS) has shown many benefits for patients after a stroke. But their findings are not well known when combined with biofeedback. OBJETIVE: The purpose of this study was to evaluate the immediate effects of biofeedback, visual and auditory, combined with treadmill training with BWS on on walking functions of hemiplegic subjects. METHODS: We conducted a clinical trial, randomized controlled trial with 30 subjects in the chronic stage of stroke, underwent treadmill training with BWS (control), combined with visual biofeedback, given by the monitor of the treadmill through the symbolic appearance of feet as the subject gave the step; or auditory biofeedback, using a metronome with a frequency of 115% of the cadence of the individual. The subjects were evaluated by kinematics, and the data obtained by the Motion Analysis System Qualisys. To assess differences between groups and within each group after training was applied to ANOVA 3 x 2 repeated measures. RESULTS: There were no statistical differences between groups in any variable spatio-temporal and angular motion, but within each group there was an increase in walking speed and stride length after the training. The group of visual biofeedback increased the stance period and reduced the swing period and reason of symmetry, and the group auditory biofeedback reduced the double stance period. The range of motion of the knee and ankle and the plantar flexion increased in the visual biofeedback group. CONCLUSION: There are no differences between the immediate effects of gait training on a treadmill with BWS performed with and without visual or auditory biofeedback. However, the visual biofeedback can promote changes in a larger number of variables spatiotemporal and angular gait

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

Efeitos do treinamento de marcha sobre superfícies inclinadas em indivíduos com hemiparesia crônica: ensaio clínico controlado randomizado

Among the therapeutic approaches that can be used to achieve this goal is the gait training on sloping surfaces, but there are few scientific findings that elucidate the results of this practice. OBJECTIVE: To evaluate the effects of training on sloping surfaces on the gait of subjects with chronic hemiparesis. MATERIALS AND METHODS: A controlled, randomized, blinded clinical trial was conducted. Concluded the study twenty-four subjects with age between 40 and 70 years (54,91±9,3). Their neurological function, functional independence, motor function and balance assessed, besides the gait evaluation through kinemetry. The subjects were allocated into two groups: control group (CG) underwent gait training on treadmill with partial body weight support (PBWS) without inclination; and the experimental group (EG) submitted to gait training on treadmill with PBWS and inclination of 10%. Twelve training sessions were performed. The paired t Student test and Wilcoxon test were used in statistical analysis to compare findings before and after training for each group, and the t student test for independent samples and Mann-Whitney.test were used to compare the to groups. RESULTS: After training within-group changes were observed on balance recovery, motor function and functionality, in both experimental conditions. The EG showed changes after training on speed, stride length, step length of paretic and non-paretic side, paretic single support, double support time and non-paretic swing time. The CG the differences were detected on double support, paretic single support and hip range of movement. The EG showed better results when compared to CG on the variables: speed (p=0,034), non-paretic single support (p=0,02) and paretic swing time (p=0,02). CONCLUSION: gait training on sloping surfaces represents a promising strategy for gait training of subjects with chronic hemiparesis since it is can influence a greater number of gait variables, when compared with gait training on flat surface

Desempenho e efeitos agudos da espirometria de incentivo volume-orientada sobre os volumes pulmonares em pacientes após AVC e sujeitos saudáveis

O Acidente Vascular Cerebral (AVC) é uma síndrome clínica caracterizada por uma perturbação focal da função cerebral. Geralmente ocasiona quadro de disfunção motora acompanhada de prejuízo da função respiratória. Tendo em vista tal quadro e suas possíveis repercussões, a fisioterapia respiratória tem sido amplamente requisitada com o intuito reverter ou minimizar as complicações. Dentre os recursos utilizados para este fim, os espirômetros de incentivo são utilizados com o objetivo de restaurar os volumes pulmonares, modificando o padrão respiratório e de ventilação pulmonar, prevenindo a incidência das complicações pulmonares. O objetivo do presente estudo foi comparar o desempenho na realização da espirometria de incentivo volume-orientada (EI) e seus efeitos agudos sobre os volumes pulmonares em pacientes após AVC e sujeitos saudáveis. Foram selecionados 40 voluntários, de ambos os gêneros, divididos em grupo experimental (GE), composto por 20 pacientes após AVC e grupo controle (GC) composto por 20 sujeitos saudáveis, pareados quanto à idade, gênero e Índice de Massa Corpórea (IMC). A coleta dos dados foi realizada em duas etapas: (1) Avaliação cognitiva e neurofuncional (Mini Exame do Estado Mental, National Institute Stroke Scale, Medida de Independência Funcional, teste de desempenho da aprendizagem) (2) Avaliação Respiratória (espirometria, manovacuometria e cinemática tóraco-abdominal, através da Pletismografia Opto-eletrônica). A análise estatística foi realizada através do software Graphpad Prism 4.0, em que foram utilizados os testes t Student e ANOVA two-way para comparação intergrupos e adotado nível de significância de 5%. Os resultados mostraram que os pacientes apresentam desempenho inferior na aprendizagem da espirometria de incentivo, com uma média de erros maior 2,95 ± 1,39, quando comparados aos sujeitos saudáveis, 1,15 ± 0,98. Em relação à prática observacional utilizada não foi encontrada diferença entre a aprendizagem através do vídeo ou do terapeuta. Em relação aos efeitos agudos da espirometria de incentivo volume-orientada, os pacientes após AVC apresentaram valores de volume corrente 24,7%, 18% e 14,7% inferiores quando comparados aos sujeitos saudáveis nos momentos pré-EI, EI e pós-EI, porém a espirometria de incentivo induziu incrementos de volume similares em ambos os grupos estudados, com 75, 3% para os pacientes e 73,3% para os sujeitos saudáveis. A espirometria de incentivo promove ganhos significativos no volume corrente da parede torácica, tanto em pacientes acometidos por AVC como em sujeitos saudáveis, no entanto o desempenho da aprendizagem é inferior para os pacientes, para ambas as práticas com vídeo ou terapeuta

Avaliação por ressonância magnética funcional e estimulação magnética transcraniana da intervenção única da terapia espelho em pacientes após acidente vascular cerebral isquêmico

Mirror therapy (MT) is being used as a rehabilitation tool in various diseases, including stroke. Although some studies have shown its effectiveness, little is known about neural mechanisms that underlie the rehabilitation process. Therefore, this study aimed at assessing cortical neuromodulation after a single MT intervention in ischemic stroke survivors, by means of by functional Magnetic Resonance Imaging (fMRI) and Transcranial Magnetic Stimulation (TMS). Fifteen patients participated in a single thirty minutes MT session. fMRI data was analyzed bilaterally in the following Regions of Interest (ROI): Supplementary Motor Area (SMA), Premotor cortex (PMC), Primary Motor cortex (M1), Primary Sensory cortex (S1) and Cerebellum. In each ROI, changes in the percentage of occupation and beta values were computed. Group fMRI data showed a significant decreased in the percentage of occupation in PMC and cerebellum, contralateral to the affected hand (p <0.05). Significant increase in beta values was observed in the following contralateral motor areas: SMA, Cerebellum, PMC and M1 (p<0,005). Moreover, a significant decrease was observed in the following ipsilateral motor areas: PMC and M1 (p <0,001). In S1 a bilateral significant decrease (p<0.0005) was observed.TMS consisted of the analysis of Motor Evoked Potential (MEP) of M1 hotspot. A significant increase in the amplitude of the MEP was observed after therapy in the group (p<0,0001) and individually in 4 patients (p <0.05). Altogether, our results imply that single MT intervention is already capable of promoting changes in neurobiological markers toward patterns observed in healthy subjects. Furthermore, the contralateral hemisphere motor areas changes are opposite to the ones in the ipsilateral side, suggesting an increase system homeostasis.

Características sociodemográficas, hábitos de sono, estado cognitivo e funcional após acidente vascular cerebral

ABSTRACT Introduction: The cerebrovascular accident (CVA) is an important cause of neurological impairment. Few data about the factors associated with morbidity of cerebrovascular accident are found in Brazil. Objectives: Evaluate sociodemographic characteristics, sleep habits, cognitive and functional status of patients with cerebrovascular accident. Methods: The patients evaluated through questionnaire Step 1 to survey the sociodemographic characteristics and Modified Rankin Scale for functional assessment. The neurological degree was evaluated by the National Institutes of Health Stroke Scale (NIHSS), the sleep Habits questionnaire for sleep and cognitive status by the Mini-Examination of the Mental State (MEMS). The data were analyzed using the chi-square test to determine differences in proportions of variables and linear regression analysis. Results: 305 patients were evaluated and the larger number of subjects was between 50 and 69 years (40%), most patients had no formal education (40.3%) and had ischemic type of cerebrovascular accident (72.5%). In the analysis of the functionality it was found that most patients had moderate impairment (55.1%). The results of the sleep habits showed that 63,6% of patients had one more person in the bedroom,12,3% complained about too much noise in the 11 room and 35% of too much light. From these patients 5,8% were smokers, 7,8% and 70,1% drank coffee drinkers, 28,6% had difficulty in initiate to sleep and woke up 37,6% in the middle of the night. Were showed complaints about nightmares (11%), feeling of suffocation (37,7%) and 35% felt very sleepy during the day. In addition, 95% were unemployed, 80,5% did not perform physical activities and 95,4% did not perform mental activities. The cognitive screening conducted a determined association of cognitive status with age and education level and neurological status. Conclusion: The study showed a high frequency of cases of cerebrovascular accident with functional dependence in a moderate degree, identified that many patients do not follow hygienic measures of sleep and found that the assessment of cognitive deficits must take into consideration the age, educational level and degree of neurological patients. We suggest the need for programs of assistance to victims of cerebrovascular accident patients, with a multidimensional approach including the rehabilitation team, the role of sleep medicine and Neuropsychology, so that patients have access to a more appropriate functional rehabilitation, develop a lifestyle that ensures a good sleep quality and are evaluated and rehabilitated with regard to cognitive impairment

Qualidade subjetiva do sono e queixa de insônia em pacientes com Acidente Vascular Cerebral

Brain injury can be associated with changes in the sleep-wake cycle. However, studies about sleep disturbances and their relationship with quality of sleep are scarce. Besides, it remains to be known how stroke affects the mechanisms of sleep. The aim of this study was to investigate quality of sleep, complaints of sleep disturbances and associated factors in stroke patients from the Physical Therapy services in Natal -RN. This was a cross-sectional descriptive study involving 70 individuals (aged 45-65 years), 40 patients (57 ± 7 years), 11 ± 9 months after injury, and 30 healthy individua ls (52 ± 6 years), evaluated with the Pittsburgh Sleep Quality Index (PSQI) and Sleep Habits Questionnaire. The data were analyzed by Chi-square test, t Student test and logistic regression. Poor quality sleep was found in 57,5% of the patients (6,3 ± 3,5) and was significantly higher than in the control population (3,9 ± 2,2) (t Student test, p=0,002). The patients showed significantly higher value of PSQI than controls: sleep latency (p=0,019), length of sleep (p=0,039) and dysfunction during the day (p=0,001). Regarding complaints of sleep disturbances (dyssomnias and parasomnias) analyzed by Chi-square test, the complaint of insomnia was the most prevalent (patients: 37,5%; healthy subjects: 6,7%; p=0,007). Regression analysis showed that sl eep latency (p=0,036) and complaint of insomnia (p=0,036) were associated with quality sleep. In addition, female gender (p=0,036) and complaint of broken sleep (p=0,003) were considered risk factors for the presence of insomnia. Our results show that stroke affects the homeostatic process of sleep. Shorter sleep latency and the absence of insomnia are considered protective factors for good sleep quality and this should be taken into consideration in the diagnostic and therapeutic strategies

Proposta de Intervenção para Auxiliar a Reabilitação Motora e Cognitiva de Pacientes com Acidente Vascular Cerebral

Stroke is the leading cause of combined motor and cognitive disability worldwide. The rehabilitation of stroke patients is mostly directed towards motor recovery through the training of the affected member under supervision of a Physical Therapist. In the present study we introduce a new approach for both cognitive and motor therapy, which relies on motor imagery of the upper limbs and working memory training. This therapy should be utilized as an adjuvant to physical therapy. Ten individuals (5 men and 5 women) were selected for the pilot study, all of them in the acute phase of the first ischemic stroke episode. The control group had 5 individuals who were submitted to physical therapy only, whilst the other 5 patients in the experimental group also performed the cognitive and motor training with a video game specially built for this study. Two patients left the experimental group before the end. Total training lasted for 9 weeks, 2 times a week, for half an hour. Patients reported they enjoyed playing the game, even though it required a lot of mental effort, according to them. Plus, they considered it had a beneficial influence in their activities of daily living. No side effects were reported. Preliminary results suggest there is a difference between groups in cognitive and upper limb motor evaluation following the intervention. It is important to notice that our conclusions are limited due the small sample number. Overall, this work is supported by other studies in literature focused in rehabilitation with motor imagery and working memory and indicate a continuity of the research, increasing total training hours

Reconhecimento de seqüências de atividades funcionais em pacientes com acidente cascular encefálico

During the motor rehabilitation of patients with neurological pathologies, there are many factors that have an influence on the therapeutical process. It is possible that the demonstration using videotapes or photographs of movements that will be learned can assist the codification, classification and reorganization of the elements of the task in familiar diagrams and thus facilitate the process of motor rehabilitation. The aim of this study was to analyze the performance in the test of recognition of sequences of functional activities such as water drinking and hair combing presented partially (by photos) and completely (by video) to the patients with encephalic vascular accident . The sample was generated from 12 patients (62 ± 8 years) and 10 healthy subjects (53 ± 5 years), of both sex, divided in two groups for which 5 functional activities were presented partially and completely, in 4 sequences that varied between reached and not reached objectives and correct and incorrect movements, during 24 trials. The test t'Student was applied to verify differences in the recognition time between the groups, and to compare the performance between the tests carried through at 9:00 am and retests at 9:00 am and 4:00 pm. To compare the frequency between the types of reply, the test Qui-square was used. It was verified that the patients presented a greater recognition time and a lower number of correct answers than the healthy subjects, and had better performances in the recognition of the complete sequence than the partial one. Bigger frequency was observed in the reply that the objective and the movement were being presented correctly, however the healthy subjects had soon indicated the correct reply in the first trials. An improvement tendency was observed in the performance, when the stages of tests and retests had been carried through in the same schedule. According to the results, it is suggested that the patients with stroke can better recognize the correct movements of a functional activity when it is presented completely in video form, what can influence the choice of the therapeutical strategy during the process of motor rehabilitation

Reconhecimento de seqüências de atividades funcionais em pacientes com acidente cascular encefálico

During the motor rehabilitation of patients with neurological pathologies, there are many factors that have an influence on the therapeutical process. It is possible that the demonstration using videotapes or photographs of movements that will be learned can assist the codification, classification and reorganization of the elements of the task in familiar diagrams and thus facilitate the process of motor rehabilitation. The aim of this study was to analyze the performance in the test of recognition of sequences of functional activities such as water drinking and hair combing presented partially (by photos) and completely (by video) to the patients with encephalic vascular accident . The sample was generated from 12 patients (62 ± 8 years) and 10 healthy subjects (53 ± 5 years), of both sex, divided in two groups for which 5 functional activities were presented partially and completely, in 4 sequences that varied between reached and not reached objectives and correct and incorrect movements, during 24 trials. The test t'Student was applied to verify differences in the recognition time between the groups, and to compare the performance between the tests carried through at 9:00 am and retests at 9:00 am and 4:00 pm. To compare the frequency between the types of reply, the test Qui-square was used. It was verified that the patients presented a greater recognition time and a lower number of correct answers than the healthy subjects, and had better performances in the recognition of the complete sequence than the partial one. Bigger frequency was observed in the reply that the objective and the movement were being presented correctly, however the healthy subjects had soon indicated the correct reply in the first trials. An improvement tendency was observed in the performance, when the stages of tests and retests had been carried through in the same schedule. According to the results, it is suggested that the patients with stroke can better recognize the correct movements of a functional activity when it is presented completely in video form, what can influence the choice of the therapeutical strategy during the process of motor rehabilitation

Avaliação do risco ocupacional de trabalhadores expostos a agrotóxicos no município de Touros/Rio grande do Norte

The use of pesticides is being used intensively with severe consequences for exposed farmers. This study aimed to describe the socioeconomic and health profiles of 60 farmers in the city of Touros / RN through the questionnaire recommended by: (International Commission for Protection against Environmental Mutagens and Carcinogens (ICPEMC). The analysis of these data allowed to prove the importance of knowledge about the socioeconomic and health profile of rural farmers as a way to understand the reality of this population, that is vulnerable to exposure due to the lack of knowledge and conditions. Aiming to analyze the frequency of micronucleus (MN) and other nuclear abnormalities in oral mucosa cells of 54 farmers that work in the city of Touros / RN it was applied the micronucleus test (MN) in oral mucosa. Our results showed an increased frequency of MN and other nuclear abnormalities related to the exposure and effects of pesticides on health. Based on the results, it is clear that farmers are using pesticide in the wrong way and compromising their health. A Cordel has been developed as a method to taking the results to the people affected by the pesticides. Therefore this study alerts to the need for profound changes in the social, cultural and health context to reduce health risks for both people and for the environment

Vivenciando a sobrecarga ao vir-a-ser um cuidador familiar de pessoa com acidente vascular cerebral (AVC): análise do conhecimento

Trata-se de trabalho do tipo bibliográfico com a finalidade de fazer uma análise temática da produção do conhecimento em periódicos, acerca da sobrecarga em cuidadores familiares de pessoas com Acidente Vascular Cerebral (AVC). O corpus de análise reuniu artigos localizados nas décadas de 80 e 90, a partir das bases de dados Medline, Lilacs e Cinahl. A análise de conteúdo foi o referencial metodológico que permitiu organizar todo o conhecimento, em um corpo de categorias e subcategorias, denominadas: Categoria 1 - As seqüelas do AVC gerando sobrecarga; Categoria 2 - Aspectos gerando sobrecarga, congregando as subcategorias: o isolamento social, as mudanças e as insatisfações conjugais, as dificuldades financeiras e os déficits na saúde física e no autocuidado do cuidador; Categoria 3 - Outras análises relacionadas à sobrecarga em cuidadores familiares.

Revascularização clínica e intervencionista no acidente vascular cerebral isquêmico agudo: opinião nacional

The Brazilian Stroke Society constituted a committee composed by specialists from different areas of Brazil that emitted a viewpoint called National Opinion, considering the interventional procedures and thrombolysis in the treatment of the acute ischemic stroke. This study presents the conclusions of this committee.

Incidência de disfagia orofaríngea após acidente vascular encefálico em hospital público de referência

A doença vascular encefálica (AVE) é a principal causa de morte no Brasil. As seqüelas em indivíduos pós-acidente vascular encefálico incluem distúrbios motores, distúrbios de fala ou de linguagem e distúrbios de deglutição. A disfagia orofaríngea ocorre em cerca de 50% dos pacientes com AVE. Este estudo teve por objetivo determinar a incidência da disfagia após AVE. Foram avaliados todos os pacientes que deram entrada em hospital universitário de referência no período de um ano, tão logo apresentassem condições para avaliação clínica, fonoaudiológica e neurológica (102 pacientes), com análise objetiva da deglutição (61 pacientes). Foi observada incidência de disfagia em 76,5% dos pacientes avaliados clinicamente, este percentual elevando-se a 91% com avaliação videofluoroscópica. A alta incidência de disfagia observada neste estudo que avaliou pacientes com amplo espectro de gravidade, em diferentes fases de recuperação, ressalta a importância de equipe multidisciplinar, incluindo fonoaudiólogos capacitados, para avaliar os distúrbios da deglutição nos diversos momentos de recuperação dos AVEs.