Métodos de avaliação do estado nutricional de crianças e adolescentes com Paralisia Cerebral Tetraespástica / Assessment of nutritional status of children and adolescents with spastic quadriplegic cerebral palsy

ABSTRACT BACKGROUND: Due to several factors, such as gastrointestinal's diseases and difficulty in feeding, children with Spastic Quadriplegic Cerebral Palsy tend to present nutritional deficits. OBJECTIVE: To assess the nutritional status of pediatric patients with Spastic Quadriplegic Cerebral Palsy according to reference curves for this population and with the measures of folds and circumferences, obtained by the upper arm circumference and triceps skin fold. METHODS: The data were obtained from: knee-height, estimated height, weight, upper arm circumference, and triceps skin fold. Values of folds and circumferences were compared with Frisancho, and specific curves for these patients were used as reference. The relationship between the values in the growth curve for healthy children, Z-Score, and comparison with the reference curve were verified by Fisher's exact test. We adopted the significance level of 5%. RESULTS: We evaluated 54 patients. The mean age was 10.2 years, and 34 were male, 25 fed by gastrostomy and 29, orally. The frequency of low weight by the reference curve was 22.22%. More than half of the patients presented the parameters indicating lean mass below the 5th percentile. The height of all patients was classified as adequate for the age by the reference curve. CONCLUSION: Low weight was found in 22% of patients, and there is a greater tendency to present reduced muscle mass and increased fat mass, showing the need for evaluation and appropriate interventions for patients with Spastic Quadriplegic Cerebral Palsy.

RESUMO CONTEXTO: Devido a diversos fatores, como doenças do trato gastrointestinal e dificuldade de alimentação, frequentemente crianças com Paralisia Cerebral Tetraespástica apresentam prejuízo no estado nutricional. OBJETIVO: Avaliar o estado nutricional de pacientes pediátricos com Paralisia Cerebral Tetraespástica de acordo com curvas de referência para essa população e comparar com as curvas de referência utilizadas para a população pediátrica em geral. MÉTODOS: Foram obtidos os dados de: altura do joelho, estatura estimada, peso, circunferência braquial e dobra cutânea triciptal. Valores de dobras e circunferências foram comparados com Frisancho e curvas específicas para esses pacientes foram utilizadas como referência. A relação entre os valores plotados na curva de crescimento para crianças saudáveis, Escore-Z e comparação com a curva referencial foram verificados através do teste exato de Fisher. O nível de significância adotado foi de 5%. RESULTADOS: Foram avaliados 54 pacientes. A média de idade foi de 10,2 anos, 34 eram do sexo masculino. Vinte cinco se alimentavam via gastrostomia e 29 via oral. A frequência de baixo peso pela curva referencial foi de 22,22%. Mais da metade dos pacientes apresentaram os parâmetros indicativos de massa magra abaixo do percentil 5. A estatura de todos os pacientes foi classificada como adequada para idade pela curva referencial. CONCLUSÃO: O baixo peso foi encontrado em 22% dos pacientes, e há maior tendência para que esses pacientes apresentem massa muscular reduzida e aumento da massa gorda, mostrando a necessidade de avaliação e intervenções apropriadas para pacientes com Paralisia Cerebral Tetraespástica.

Efectos del entrenamiento muscular inspiratorio/espiratorio sobre función respiratoria de pacientes tetrapléjicos / Effects of inspiratory/expiratory muscular training on respiratory function in quadriplegic patients

Introduction: Functional impairment in patients with high spinal cord injuries is associated to ventilatory dysfunction due to paretic respiratory muscles, which causes alterations in the ventilatory and in the cough mechanisms. Respiratory muscle training has been studied as a therapeutic alternative for this group of patients with no conclusive results, whereas a mixed protocol, which stimulates both inspiratory and expiratory muscles, had not been previously investigated. Objective: To evaluate the effects of systematic respiratory muscle training during four months, on pulmonary function, respiratory muscles strength and effort tolerance, cough efficacy and dyspnea perception, in a group of quadriplegic patients with at least one year of evolution post injury. Method: A quasi-experimental design was used. Six adults with cervical spinal cord injuries were enlisted and incorporated in a mixed respiratory muscles training for four months. Pulmonary function, respiratory muscles strength and resistance, cough efficacy and dyspnea perception were assessed pre and post training. Results: The application of the mixed training protocol significantly improved inspiratory muscle strength (p = 0,028),respiratory muscles effort tolerance (p = 0,028) and cough efficacy (p = 0,034).The other measures did not reach statistical significance. Conclusion: Mixed(inspiratory/expiratory) muscular training, shows partially favorable results in the improvement of pulmonary function. Studies using greater numbers of patients are necessary to achieve more categorical results.

Introducción: El compromiso funcional en pacientes con lesiones medulares altas se asocia a disfunción ventilatoria por paresia de musculatura respiratoria y provoca alteraciones ventilatorias y en el mecanismo de la tos. El entrenamiento de la musculatura respiratoria ha sido analizado como alternativa terapéutica para neumo este grupo de pacientes sin resultados concluyentes, mientras que un protocolo mixto, que estimule músculos inspiratorios y espiratorios no ha sido estudiado con anterioridad. Objetivo: Evaluar la respuesta del sistema respiratorio al entrenamiento sistemático de la musculatura respiratoria durante cuatro meses, sobre la función pulmonar, fuerza y tolerancia al esfuerzo de la musculatura respiratoria, eficacia de la tos y percepción de disnea de un grupo de pacientes tetrapléjicos. Materiales y Métodos: Se aplicó un diseño cuasi-experimental. Seis pacientes con lesiones medulares cervicales de al menos un año de evolución fueron reclutados e incluidos en un programa de entrenamiento mixto de la musculatura respiratoria durante 4 meses. Se evaluó la función pulmonar, fuerza y resistencia de la musculatura respiratoria, eficacia de la tos y percepción de disnea antes y después del período de entrenamiento. Resultados: El protocolo de entrenamiento mixto aplicado incrementó significativamente la fuerza muscular inspiratoria (p= 0,028), la tolerancia al esfuerzo de los músculos respiratorios (p = 0,028) y la eficacia de la tos (p = 0,034). El incremento en todas las otras variables medidas no alcanzó significancia estadística. Conclusión: El entrenamiento muscular mixto(inspiratorio/espiratorio) muestra resultados parcialmente favorables en la mejoría de indicadores de función pulmonar. Estudios de mayor número de pacientes son necesarios para acceder a resultados más categóricos.

Naturaleza muerta: transformaciones psíquicas en un caso de tetraplejia / Still life: psychic transformations in a quadriplegia case

En los últimos años se ha observado un considerable aumento en el número de personas que sobreviven a lesiones medulares altas (tetraplejias). Si bien existe un adecuado conocimiento respecto a los cuidados médicos que un individuo con tetraplejia requiere, la comprensión de la experiencia subjetiva de vivir con una lesión medular alta, odel impacto de la inmovilización prolongada en la vida psíquica, es escasa. El siguiente trabajo describe las transformaciones psíquicas en una mujer con lesión cervical C6, durante los doce meses posteriores a su accidente. Se sugiere que la lesión medular alta impacta diversos ámbitos de la experiencia, generando: a) una hiper-activación de los procesos imaginativos por sobre los destinados a la resolución de problemas; b) un desacoplamiento del cuerpo virtual y material; c) cambios en las fronteras somáticas del Self.

In the last years there has been a significant increase in the number of people that survive from high-level spinal cord lesions (quadriplegia). Although there is an adequate understanding regarding the medical care these persons need, the comprehension of the subjective experience of living with quadriplegia, or the impact that chronic immobilization has on psychic life, is rare. This article describes psychic transformations in a woman who acquired a C6 spinal cord injury, during the following 12 months after her accident. It is suggested that a spinal cord lesion impacts different aspects of a patient’s experience, generating: a) an hyper-activation of imaginary life in contrast to processes related to real world problem solving; b) a decoupling between the virtual and material body; c) changes in the somatic borders of the Self.

Treinamento de músculos inspiratórios em pacientes com quadriplegia / Inspiratory muscle training in quadriplegic patients

OBJETIVO: Determinar se o treinamento de músculos inspiratórios pode aumentar a força e endurance desses músculos em pacientes com quadriplegia. MÉTODOS: Oito pacientes quadriplégicos (7 homens e 1 mulher) com lesão medular cervical entre C4 e C7 foram submetidos ao treinamento de músculos inspiratórios utilizando-se um resistor de carga linear ajustado em 30 por cento da PImáx. As sessões de treinamento foram realizadas com os pacientes sentados 5 vezes por semana por 8 semanas. Tempo de endurance, PImáx, PEmáx e CVF foram medidos antes do treinamento e nas semanas 4 e 8. RESULTADOS: Em comparação ao valor basal médio, houve um aumento da PImáx, mensurada na posição sentada, nas semanas 4 e 8 (-83,0 ± 18,9 cmH2O vs. -104,0 ± 19,4 e -111,3 ± 22,7 cmH2O). Houve aumento da PEmáx, também na posição sentada, na semana 4 (de 36,8 ± 8,1 a 42,6 ± 8,8 cmH2O). Houve uma melhora na FVC na 4ª semana (de 2,1 ± 0,8 a 2,5 ± 0,6 L, representando um incremento de 24 ± 22 por cento). O tempo de endurance (sentado) não apresentou um aumento significativo entre o momento basal e a semana 8 (29,8 ± 21,0 min vs. 35,9 ± 15,5 min; aumento de 173 ± 233 por cento). CONCLUSÕES: Pacientes com quadriplegia podem se beneficiar com o treinamento com baixas cargas (30 por cento da PImáx), com melhora da força dos músculos inspiratórios, CVF e efetividade dos músculos expiratórios.

OBJECTIVE: To determine whether inspiratory muscle training can increase strength and endurance of these muscles in quadriplegic patients. METHODS: Eight quadriplegic patients (7 males and 1 female) with injury to the lower cervical spine (segments C4-C7) were submitted to inspiratory muscle training with a threshold inspiratory muscle trainer adjusted to 30 percent of MIP. The training sessions were carried out with the patients in a sitting position, 5 days a week for 8 weeks. Endurance time, MIP, MEP and FVC were determined at baseline, week 4 and week 8. RESULTS: In comparison with the mean baseline value, there was an increase in MIP, measured in the sitting position, at weeks 4 and 8 (-83.0 ± 18.9 cmH2O vs. -104.0 ± 19.4 cmH2O and -111.3 ± 22.7 cmH2O). There was an increase in MEP, also in the sitting position, at week 4 (from 36.8 ± 8.1 to 42.6 ± 8.8 cmH2O). There was an improvement in FVC at week 4 (from 2.1 ± 0.8 to 2.5 ± 0.6 L, representing an increase of 24 ± 22 percent). Although there was an increase in endurance (sitting) at week 8, the difference was not significant in comparison with the baseline value (29.8 ± 21.0 vs. 35.9 ± 15.5 min, an increase of 173 ± 233 percent). CONCLUSIONS: Quadriplegic patients can benefit from training at low loads (30 percent of MIP), which can improve inspiratory muscle strength, FVC and expiratory muscle performance.

Development and evaluation of a head-controlled human-computer interface with mouse-like functions for physically disabled users

OBJECTIVES: The objectives of this study were to develop a pointing device controlled by head movement that had the same functions as a conventional mouse and to evaluate the performance of the proposed device when operated by quadriplegic users. METHODS: Ten individuals with cervical spinal cord injury participated in functional evaluations of the developed pointing device. The device consisted of a video camera, computer software, and a target attached to the front part of a cap, which was placed on the user's head. The software captured images of the target coming from the video camera and processed them with the aim of determining the displacement from the center of the target and correlating this with the movement of the computer cursor. Evaluation of the interaction between each user and the proposed device was carried out using 24 multidirectional tests with two degrees of difficulty. RESULTS: According to the parameters of mean throughput and movement time, no statistically significant differences were observed between the repetitions of the tests for either of the studied levels of difficulty. CONCLUSIONS: The developed pointing device adequately emulates the movement functions of the computer cursor. It is easy to use and can be learned quickly when operated by quadriplegic individuals.

Effects of sensory stimuli on postural control: a tetraplegic case report

During sessions of physical therapy, a tetraplegic patient with incomplete spinal cord section at C5 level was found to have changes in the posture post intervention. The therapy consisted of tactile stimulation in specific points of his body to generate reflex patterns of muscle activation (Vojta therapy principies). To quantify these postural changes in the subject, the center of pressure displacement in sitting posture was measured. An analysis of the changes observed in postural control through fourteen months of follow-up is presented and discussed in the report bellow.

Durante las sesiones de terapia física, en un paciente tetrapléjico con sección incompleta de la médula espinal a nivel C5, se encontró que hubo cambios en la postura, posterior a la intervención. La terapia consistió en estimulación táctil en puntos específicos del cuerpo para generar patrones reflejos de activación muscular (principios de la terapia Vojta). Para cuantificar estos cambios de postura en el sujeto, se midió el desplazamiento del centro de gravedad en la posición sentada. Un análisis de las variaciones observadas en el control postural, a través de catorce meses de seguimiento, se presentan y discuten en el siguiente informe.

Response of the arterial blood pressure of quadriplegic patients to treadmill gait training

Blood pressure pattern was analyzed in 12 complete quadriplegics with chronic lesions after three months of treadmill gait training. Before training, blood pressure values were obtained at rest, during treadmill walking and during the recovery phase. Gait training was performed for 20 min twice a week for three months. Treadmill gait was achieved using neuromuscular electrical stimulation, assisted by partial body weight relief (30-50 percent). After training, blood pressure was evaluated at rest, during gait and during recovery phase. Before and after training, mean systolic blood pressures and heart rates increased significantly during gait compared to rest (94.16 ± 5.15 to 105 ± 5.22 mmHg and 74.27 ± 10.09 to 106.23 ± 17.31 bpm, respectively), and blood pressure decreased significantly in the recovery phase (86.66 ± 9.84 and 57.5 ± 8.66 mmHg, respectively). After three months of training, systolic blood pressure became higher at rest (94.16 ± 5.15 mmHg before training and 100 ± 8.52 mmHg after training; P < 0.05) and during gait exercise (105 ± 5.22 mmHg before and 110 ± 7.38 mmHg after training; P < 0.05) when compared to the initial values, with no changes in heart rate. No changes occurred in blood pressure during the recovery phase, with the lower values being maintained. A drop in systolic pressure from 105 ± 5.22 to 86.66 ± 9.84 mmHg before training and from 110 ± 7.38 to 90 ± 7.38 mmHg after training was noticed immediately after exercise, thus resulting in hypotensive symptoms when chronic quadriplegics reach the sitting position from the upright position.

Avaliação de fatores que influenciam a função respiratória em pacientes portadores de lesão medular completa em níveis cervicais inferiores / Evaluation of factors that influence respiratory function in patients with complete spinal cord lesion at lower cervical levels

Foram prospectivamente estudados 42 pacientes de ambos os sexos, com idade variando de 18 a 45 anos, apresentando lesão medular completa em região cervical inferior. Avaliaram-se as medidas antropométricas, a independência funcional por meio do Teste MIF (Medidas de Independência Funcional), a Capacidade Vital Forçada (CVF) e Ventilação Voluntária Máxima (VVM), aliadas à interferência de algumas variáveis, tendo-se concluído que: o nível de lesão medular, na região estudada, não apresentou interferência significativa, na restrição rspiratória assim como o maior uso cotidiano da musculatura respiratória. Por outro lado, pacientes do sexo feminino apresentaram piores desempenhos nos testes nas variáveis capacidade vital forçada e ventilação voluntária máxima assim como apresentaram maior grau de dependência funcional. Os pacientes que apresentaram maior massa corpórea tiveram melhor desempenho nos testes de avaliação funcional.

Reeducaçäo intestinal no lesado medular com lesäo no neurônio motor superior (tetraplegia) / Intestinal re-education in the spinal cord injury with lesion in the superior motor neuron (tetraplegy)

As dificuldades na eliminaçäo do conteúdo intestinal, após uma lesäo da medula espinhal, säo muito significativas. Por tal motivo, se faz necessária a utilizaçäo de técnicas e métodos para a reeducaçäo da funçäo intestinal, dentre os quais podemos citar a massagem evacuativa e a questäo nutricional. O programa utilizado demonstra resultados muito siginificativos, porém ainda existe a grande necessidade de contínuos estudos

Motor hemiplegia and the cerebral organization of movement in man: I. The pyramidal concept: a restatement

Com base em vinte casos pessoais de sintomas motores puros decorrentes de lesöes encefálicas circunscritas, a literatura pertinente é sumariamente revista e a supermacia estrutural e funcional dos feixes piramidais (corticoespinhais) e corticonucleares no ser humano é enfatizada

Motor hemiplegia and the cerebral organization of movement in man: II. The myth of the human extrapyramidal system

Após revisäo sumária do conceito de sistema extrapiramidal, säo apresentadas evidências clínicas e anatômicas contra sua importância relativa no homem. Propöe-se que as estruturas tradicionalmente agrupadas sob o rótulo extrapiramidal efetuem a maior parte de suas atividades funcionais, respectivamente, por intermédio dos próprios feixes piramidais. Tais estruturas - centradas no núcleos da base dos hemisférios cerebrais, no cerebelo e, possivelmente, também, na áreas límbicas do prosencéfalo -, de acordo com nossa proposiçäo säo, na verdade pre-piramidais. Esse modelo se baseia na análise clínica de pacientes, está de acordo com mais de um século de verificaçöes anatômicas em cérebros humanos e depöe a favor da noçäo de singularidade do cérebro humano

Circadian desynchronization in pulse rate, systolic and diastolic blood pressure, rectal temperature and urine output in traumatic tetraplegics.

An investigation was undertaken to study the circadian rhythmicity in pulse rate, systolic and diastolic blood pressure, rectal temperature and urine output in eight traumatic tetraplegics in view of the fact that diurnal rhythmicity in prolactin response to thyrotropin-releasing hormone was absent in such patients. The data, analysed by single cosinor procedure, showed absence of rhythmicity in all five parameters. Analysis of variance also showed no significant difference in these parameters at various time points. Knowledge of the alterations in circadian biology subsequent to cervical spinal cord trauma would provide useful guidelines towards chronotherapy and vocational rehabilitation of tetraplegics besides possible restoration of euchronism by pharmacological means.

Síndrome de encarceramento: análise fisiopatológica de dois casos / The locked-in syndrome: a physiopathological analysis of 2 cases

Säo descritos dois casos de síndrome de encarceramento com quadro clínico sugestivo de lesäo de origem vascular de situaçäo ventral a nível pontomosencefálico e pontino superior. Esses quadros diferem da forma clássica da síndrome, caracterizada por quadriparesia, mutismo e conservaçäo das miradas verticais. É discutida a extensäo conceitual dessa síndrome, com revisäo da literatura