Toxina botulínica para la secreción descontrolada de saliva : presentación de un caso

La neurotoxina botulínica es producida por la bacteria anaerobia Clostridium botulinum (NTBo). Bloquea la transmisión neuromuscular por lo cual es utilizada para el tratamiento de enfermedades con hiperactividad muscular, bloqueando la liberación de acetilcolina y así la transmisión sináptica en la unión neuromuscular, lo que lleva al debilitamiento y atrofia de los músculos. Este mecanismo de acción motivó el uso de la toxina botulínica en las enfermedades con elevado tono muscular, como la distonía y la espasticidad, por lo cual también ha revolucionado la opción de tratamiento de los trastornos autónomos de hipersecreción. La sialorrea es un síntoma común en diversas enfermedades neurológicas. Las inyecciones de toxina botulínica, guiadas por ultrasonidos en las glándulas salivales, produce una disminución de la salivación excesiva en niños con deficiencias neurológicas como parálisis cerebral. La utilización de la toxina botulínica tipo A ha sido sugerida como tratamiento de la sialorrea en pacientes con parálisis cerebral (PC). Esta recomendación ha sido hecha por el efecto anticolinérgico de esta sustancia, principalmente por su capacidad para bloquear la liberación de acetilcolina a nivel de las membranas pre-sinápticas Aunque la respuesta al tratamrento es distinta en cada niño, en general se ha observado que cuanto más a menudo se utiliza la toxlna botulínica y más alta es la dosis utilizada, los resultados son mejores. Los expertos consideran conveniente el procedimiento porque muchos de estos pacientes están utilizando la toxina botulínica para sus problemas musculares y las distrntas condiciones pueden ser tratadas al mismo tiempo Se reporta la descripción de la aplicación de toxina botulínica en una paciente niña que concurre al Instituto de Rehabilitación Infantil TELETON de la ciudad de Valparaíso, Chile, con un trastorno motor severo y con salivación incontrolada persistente que provoca enfermedades respiratorias a repetición

An Adjustable Compliant Joint for Lower-Limb Exoskeletons

The field of exoskeletons and wearable devices for walking assistance and rehabilitation has advanced considerably over the past few years. Currently, commercial devices contain joints with stiff actuators that cannot adapt to unpredictable environments. These actuators consume more energy and may not be appropriate for human-machine interactions. Thus, adjustable compliant actuators are being cautiously incorporated into new exoskeletons and active orthoses. Some simulation-based studies have evaluated the benefits of incorporating compliant joints into such devices. Another reason that compliant actuators are desirable is that spasticity and spasmodic movements are common among patients with motor deficiencies; compliant actuators could efficiently absorb these perturbations and improve joint control. In this paper, we provide an overview of the requirements that must be fulfilled by these actuators while evaluating the behavior of leg joints in the locomotion cycle. A brief review of existing compliant actuators is conducted, and our proposed variable stiffness actuator prototype is presented and evaluated. The actuator prototype is implemented in an exoskeleton knee joint operated by a state machine that exploits the dynamics of the leg, resulting in a reduction in actuation energy demand and better adaptability to disturbances.

Getting muscles moving again after botulinum toxin: novel therapeutic challenges

The use of botulinum neurotoxins for the treatment of muscle hyperactivity and spasticity disorders has been remarkably successful, owing to the abilities of the toxins to elicit prolonged localized paralysis and the rarity of serious adverse effects. However, botulinum toxins are the most deadly protein toxins known, and existing antidotes possess limited effectiveness. Paradoxically, in situ, the intoxicated motoneuron does not die. It reacts by emanating a sprouting network known to implement new functional synapses, leading to resumption of neurotransmission. Recent studies have highlighted ways of accelerating this natural recovery process to overcome paralysis successfully. Developing new therapeutic strategies and treatments for botulism will require more research into the molecular understanding of this 'naturally occurring' recovery process.

Técnicas fisioterapêuticas utilizadas para tratar a espasticidade em indivíduos paraplégicos com lesão medular: uma revisão de literatura

Mestrado em Fisioterapia

Task-oriented training and lower limb strengthening to improve balance and function after stroke: a pilot study

This study investigated the effects of task-oriented training and strengthening of the affected lower limb on balance and function in people who have suffered a stroke. Sixteen male adults, with a mean age of 58 (SD 6.3) years, undergoing outpatient physiotherapy less than 1 month after a single stroke in the territory of the middle cerebral artery were recruited. Participants were allocated to one of two groups: the strengthening group (SG) or control group (CG). The main measures used were the Berg Balance Scale (BBS), Barthel Index (BI) and Modified Ashworth Scale (MAS). After 12 weeks of intervention, both groups showed improvements in outcome measures. For BBS, there was a significant difference between groups, with an increase of 26 points in the SG and 11 points in the CG. For BI, the SG improved by 39 points and the CG improved by 22 points. After intervention, the difference between groups was not significant. For MAS, differences were not significant, showing that for both groups intervention programmes did not increase spasticity. In conclusion, physiotherapy intervention for postural control dysfunctions after stroke seems to benefit from strength training of the affected lower limb and the practising functional tasks. A large randomized controlled trial is recommended to further investigate the effects of this intervention.

Correlação entre o sinal mecanomiográfico e a escala modificada de Ashworth durante avaliação clínica da espasticidade

Spasticity is a common disorder in people who have upper motor neuron injury. The involvement may occur at different levels. The Modified Ashworth Scale (MAS) is the most used method to measure involvement levels. But it corresponds to a subjective evaluation. Mechanomyography (MMG) is an objective technique that quantifies the muscle vibration during the contraction and stretching events. So, it may assess the level of spasticity accurately. This study aimed to investigate the correlation between spasticity levels determined by MAS with MMG signal in spastic and not spastic muscles. In the experimental protocol, we evaluated 34 members of 22 volunteers, of both genders, with a mean age of 39.91 ± 13.77 years. We evaluated the levels of spasticity by MAS in flexor and extensor muscle groups of the knee and/or elbow, where one muscle group was the agonist and one antagonist. Simultaneously the assessment by the MAS, caught up the MMG signals. We used a custom MMG equipment to register and record the signals, configured in LabView platform. Using the MatLab computer program, it was processed the MMG signals in the time domain (median energy) and spectral domain (median frequency) for the three motion axes: X (transversal), Y (longitudinal) and Z (perpendicular). For bandwidth delimitation, we used a 3rd order Butterworth filter, acting in the range of 5-50 Hz. Statistical tests as Spearman's correlation coefficient, Kruskal-Wallis test and linear correlation test were applied. As results in the time domain, the Kruskal-Wallis test showed differences in median energy (MMGME) between MAS groups. The linear correlation test showed high linear correlation between MAS and MMGME for the agonist muscle as well as for the antagonist group. The largest linear correlation occurred between the MAS and MMG ME for the Z axis of the agonist muscle group (R2 = 0.9557) and the lowest correlation occurred in the X axis, for the antagonist muscle group (R2 = 0.8862). The Spearman correlation test also confirmed high correlation for all axes in the time domain analysis. In the spectral domain, the analysis showed an increase in the median frequency (MMGMF) in MAS’ greater levels. The highest correlation coefficient between MAS and MMGMF signal occurred in the Z axis for the agonist muscle group (R2 = 0.4883), and the lowest value occurred on the Y axis for the antagonist group (R2 = 0.1657). By means of the Spearman correlation test, the highest correlation occurred between the Y axis of the agonist group (0.6951; p <0.001) and the lowest value on the X axis of the antagonist group (0.3592; p <0.001). We conclude that there was a significantly high correlation between the MMGME and MAS in both muscle groups. Also between MMG and MAS occurred a significant correlation, however moderate for the agonist group, and low for the antagonist group. So, the MMGME proved to be more an appropriate descriptor to correlate with the degree of spasticity defined by the MAS.

Large national series of patients with Xq28 duplication involving MECP2: Delineation of brain MRI abnormalities in 30 affected patients.

Xq28 duplications encompassing MECP2 have been described in male patients with a severe neurodevelopmental disorder associated with hypotonia and spasticity, severe learning disability, stereotyped movements, and recurrent pulmonary infections. We report on standardized brain magnetic resonance imaging (MRI) data of 30 affected patients carrying an Xq28 duplication involving MECP2 of various sizes (228 kb to 11.7 Mb). The aim of this study was to seek recurrent malformations and attempt to determine whether variations in imaging features could be explained by differences in the size of the duplications. We showed that 93% of patients had brain MRI abnormalities such as corpus callosum abnormalities (n = 20), reduced volume of the white matter (WM) (n = 12), ventricular dilatation (n = 9), abnormal increased hyperintensities on T2-weighted images involving posterior periventricular WM (n = 6), and vermis hypoplasia (n = 5). The occipitofrontal circumference varied considerably between >+2SD in five patients and <-2SD in four patients. Among the nine patients with dilatation of the lateral ventricles, six had a duplication involving L1CAM. The only patient harboring bilateral posterior subependymal nodular heterotopia also carried an FLNA gene duplication. We could not demonstrate a correlation between periventricular WM hyperintensities/delayed myelination and duplication of the IKBKG gene. We thus conclude that patients with an Xq28 duplication involving MECP2 share some similar but non-specific brain abnormalities. These imaging features, therefore, could not constitute a diagnostic clue. The genotype-phenotype correlation failed to demonstrate a relationship between the presence of nodular heterotopia, ventricular dilatation, WM abnormalities, and the presence of FLNA, L1CAM, or IKBKG, respectively, in the duplicated segment.

Efetividade de técnicas de fisioterapia no equilíbrio em pacientes com Acidente Vascular Cerebral

Projeto de Graduação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Licenciada em Fisioterapia

Gli interventi riabilitativi nei pazienti affetti da sclerosi multipla con spasticita (scoping review)

Background :La sclerosi multipla è una malattia neurodegenerativa che colpisce il sistema nervoso centrale. La presa in carico di questi pazienti necessita di un approccio globale. Uno dei sintomi più diffusi in queste persone è la spasticità la cui valutazione e gestione necessità di un approccio multidisciplinare. L’elevato grado di immobilità derivante dalla spasticità interferisce in modo considerevole con l’autonomia quotidiana del paziente e porta ad una significativa riduzione della qualità della vita . Obiettivo: L’obiettivo di questa Scoping review è quello di identificare e mappare la letteratura corrente nell’ambito riabilitativo nella gestione della spasticità nei pazienti affetti da sclerosi multipla ,secondo la checklist della PRISMA Extension per le Scoping Review per identificare concetti chiave , implicazioni per la pratica clinica e individuare spunti per nuove ricerche . Disegno dello Studio: Scoping Review costruita seguendo le indicazioni del PRISMA Extension for Scoping Reviews Fonti di ricerca: La tipologia di questo lavoro di tesi è una revisione sulle evidenze nella letteratura. Per la ricerca del materiale si sono utilizzate riviste specialistiche e banche dati quali: Pubmed, The Cochrane Library, PeDro, e il motore di ricerca Google Schoolar. Risultati: Sono stati inclusi 5 articoli nello studio ( 2 revisioni sistematiche , 3 studi controllati randomizzati ) . Essendo una scoping review non è stata applicata nessuna scala per valutare la qualità degli articoli selezionanti per questa revisione . Conclusioni: la letteratura disponibile fornisce evidenze sugli approcci in merito al trattamento della spasticità nei pazienti affetti da sclerosi multipla però sono necessari altri studi per verificare l’efficacia dei trattamenti riabilitativi disponibili