Rehabilitación neuromotora en unidades de tratamiento del ataque cerebrovascular / Neuromotor rehabilitation in stroke treatment units

RESUMEN: Introducción: El Ataque Cerebro Vascular (ACV) es la segunda causa de muerte a nivel mundial y primera causa de discapacidad en el adulto. Su complejidad requiere de una atención integral a través de un equipo multiprofesional, implementado en las denominadas Unidades de Tratamiento del Ataque Cerebrovascular (UTAC). Considerando su relevancia e impacto en el pronóstico, es fundamental conocer las acciones desarrolladas en el ámbito de la rehabilitación neuromotora en estas unidades, información que actualmente es limitada. Método: Estudio descriptivo de corte transversal, la muestra fue por conveniencia, participaron 5 kinesiólogos de establecimientos públicos de salud. La recolección de información se realizó con una encuesta en línea enfocada a las acciones que se realiza en la UTAC. El análisis de datos se realizó con STATA 15 y ATLAS TI 8.0. Resultados: El inicio y frecuencia de la rehabilitación neuromotora es variable, ocurre entre las 24 y 48 horas posterior al diagnóstico. Diariamente se realizan entre una a tres sesiones por usuario, su duración varía desde 25 a 90 minutos. Las acciones neuromotoras son de carácter integral y multiprofesional, el abordaje incluye el componente neuromotor, respiratorio y estado cognitivo. Las acciones neuromotoras incorporan técnicas de facilitación de la postura más alta lograda por el usuario y estimulación sensorial, entre otras. Conclusiones: La rehabilitación neuromotora en las UTAC de Chile muestra realidades diferentes en cuanto a la identificación, funcionamiento y la intervención neuromotora.

ABSTRACT Background: Stroke is the second leading cause of death in the world and the first cause of disability in adults. Its complexity requires comprehensive care provided by a multiprofessional team, implemented in the so-called Stroke Treatment Units (STUs). In view of their relevance and impact on the prognosis, identifying activities developed in the framework of neuromotor rehabilitation is of fundamental importance, information which, at present, is not readily available. Methods: Cross-sectional descriptive study, convenience sampling with the participation of 5 kinesiologists from public health centers in Chile. Information was collected by means of an online survey focused on the work being carried out in the STUs. Data analysis was performed using STATA 15 and ATLAS TI 8.0 software. Results: Initiation and frequency of neuromotor rehabilitation is variable and occurs between 24 and 48 hours after diagnosis. Between one and three daily sessions per user are performed and their duration varies from 25 to 90 minutes. Neuromotor activities are integral and multiprofessional; the approach includes neuromotor, respiratory and cognitive components. Neuromotor activities incorporate facilitation techniques for the most advanced user posture achieved and sensory stimulation, among others. Conclusions: Neuromotor rehabilitation in Chile´s STUs shows different realities in terms of identification, functioning and neurokinetic intervention.

Follow control of upper limb rehabilitation training based on Kinect and NAO robot / 生物医学工程学杂志

Gesture imitation is a common rehabilitation strategy in limb rehabilitation training. In traditional rehabilitation training, patients need to complete training actions under the guidance of rehabilitation physicians. However, due to the limited resources of the hospital, it cannot meet the training and guidance needs of all patients. In this paper, we proposed a following control method based on Kinect and NAO robot for the gesture imitation task in rehabilitation training. The method realized the joint angles mapping from Kinect coordination to NAO robot coordination through inverse kinematics algorithm. Aiming at the deflection angle estimation problem of the elbow joint, a virtual space plane was constructed and realized the accurate estimation of deflection angle. Finally, a comparative experiment for deflection angle of the elbow joint angle was conducted. The experimental results showed that the root mean square error of the angle estimation value of this method in right elbow transverse deflection and vertical deflection directions was 2.734° and 2.159°, respectively. It demonstrates that the method can follow the human movement in real time and stably using the NAO robot to show the rehabilitation training program for patients.

Effects of whole body vibration combined with extracorporeal shock wave therapy on spasticity and balance gait parameters in hemiplegic patients with stroke / 中南大学学报(医学版)

OBJECTIVES@#Stroke patients may have various sensory-motor disorders, such as spasticity, muscle weakness or sensory damage. Spasticity affects 20% to 40% of stroke patients. Patients with spasticity may have problems such as pain, motor function damage, and the decreased range of motion, which leads to decline of activity and quality of daily life. Extracorporeal shock wave therapy (ESWT) is a technique that can improve post-stroke spasticity. Whole body vibration (WBV), as a passive neuromuscular muscle stimulation technique, can improve the posture control, muscle strength, and muscle work of different people. At present, there are still few studies using WBV combined with ESWT for the treatment of hemiplegic patients with stroke. This study aims to explore the effects of WBV combined with ESWT on spasticity of the affected lower limb and gait function in stroke patients.@*METHODS@#From March 2020 to March 2021, 50 hemiplegic patients with stroke were treated in the Department of Rehabilitation Medicine of the First Hospital of Changsha and they were assigned into a control group and a combined group, 25 cases per group. Both groups carried out conventional treatment, while the control group undertook the ESWT and fake WBV based on conventional treatment, and the combined group undertook ESWT after WBV and conventional treatment. Modified Ashworth Scale (MAS), Lower Extremity portion of the Fugl-Meyer Motor Assessment (FMA-LE), Berg Balance Scale (BBS), and parameters of three-dimensional gait analysis including kinematic parameters (peak value of hip flexion and knee flexion) and spatiotemporal parameters (velocity, cadence and stride length) were assessed before and after 4-week treatment between the 2 groups.@*RESULTS@#After 4 weeks of treatment, MAS scores in 2 groups were lower than before (both P<0.05), and the combined group was lower than the control group (P<0.001); BBS and FMA-LE scores were higher than those before treatment (both P<0.05), and the combined group was higher than the control group (both P<0.001); in the control group, the walking speed, stride frequency, and stride length were higher than those before treatment (all P<0.05), and there was no significant difference between the peak value of flexion hip and peak value of flexion knee (both P<0.05); the peak value of hip flexion, peak value of knee flexion, step speed, step frequency, and stride length in the combined group were higher than those before treatment (all P<0.05), and were higher than those in control group (P<0.05 or P<0.001).@*CONCLUSIONS@#WBV combined with ESWT can improve the spasticity and motor function of the affected lower extremity, balance, and gait in hemiplegic patients with stroke.

Research on electroencephalogram power spectral density of stroke patients under transcranial direct current stimulation / 生物医学工程学杂志

Transcranial direct current stimulation (tDCS) has become a new method of post-stroke rehabilitation treatment and is gradually accepted by people. However, the neurophysiological mechanism of tDCS in the treatment of stroke still needs further study. In this study, we recruited 30 stroke patients with damage to the left side of the brain and randomly divided them into a real tDCS group (15 cases) and a sham tDCS group (15 cases). The resting EEG signals of the two groups of subjects before and after stimulation were collected, then the difference of power spectral density was analyzed and compared in the band of delta, theta, alpha and beta, and the delta/alpha power ratio (DAR) was calculated. The results showed that after real tDCS, delta band energy decreased significantly in the left temporal lobes, and the difference was statistically significant ( P < 0.05); alpha band energy enhanced significantly in the occipital lobes, and the difference was statistically significant ( P < 0.05); the difference of theta and beta band energy was not statistically significant in the whole brain region ( P > 0.05). Furthermore, the difference of delta, theta, alpha and beta band energy was not statistically significant after sham tDCS ( P > 0.05). On the other hand, the DAR value of stroke patients decreased significantly after real tDCS, and the difference was statistically significant ( P < 0.05), and there was no significant difference in sham tDCS ( P > 0.05). This study reveals to a certain extent the neurophysiological mechanism of tDCS in the treatment of stroke.

Effectiveness of physical exercise on the recovery of limb function in stroke patients / Eficácia do exercício físico na recuperação da função dos membros em pacientes com avc / Efectividad del ejercicio físico en la recuperación de la función de las extremidades en pacientes con acv

ABSTRACT Introduction Patients with cerebrovascular accident and hemiplegia need to perform physical exercise and aerobic training, but physical dysfunction restricts the performance of these activities. Objective The article aims to develop physical strength sports for stroke patients with hemiplegia to explore the efficacy of sports to regain limb function in these patients. Methods We randomly selected 30 patients with stroke sequelae and divided them into control and exercise groups. While undergoing rehab, the exercise group performed a certain amount of aerobic exercise. During this period, we compared the relevant physiological indicators of the patients, and, at the same time, we used the Fugle-Meyer motor function scoring method to assess limb function. Results The two groups of patients are significantly different regarding the recovery of physical function and the capacity for daily life. Physiological indicators of patients are also different. Conclusion Low-intensity aerobic exercise can help stroke and hemiplegia patients regain their basic ability to live and exercise. Level of evidence II; Therapeutic studies: investigation of treatment results.

RESUMO Introdução É muito importante que pacientes com acidente vascular encefálico e hemiplegia realizem exercícios físicos e treinamento aeróbio, mas a disfunção física restringe a realização dessas atividades. Objetivo o artigo tem como objetivo desenvolver esportes de força física para pacientes com AVC com hemiplegia para explorar a eficácia dos esportes para recuperar a função dos membros nesses pacientes. Métodos Selecionamos aleatoriamente 30 pacientes com sequela de AVC e os dividimos em grupos controle e exercício. Durante a reabilitação, o grupo de exercícios realmente executou uma certa quantidade de exercícios aeróbicos. Durante esse período, comparamos os indicadores fisiológicos relevantes dos pacientes e, ao mesmo tempo, usamos o método de pontuação da função motora de Fugle-Meyer para avaliar a função dos membros. Resultados Os dois grupos de pacientes são significativamente diferentes em termos de recuperação da função física e capacidade para a vida diária. Os indicadores fisiológicos dos pacientes também são diferentes. Conclusão O exercício aeróbico de baixa intensidade pode ajudar os pacientes com derrame e hemiplegia a recuperar sua capacidade básica de viver e se exercitar. Nível de evidência II; Estudos terapêuticos: investigação dos resultados do tratamento.

RESUMEN Introducción Es muy importante para los pacientes con accidente cerebrovascular y hemiplejía realizar ejercicio físico y entrenamiento aeróbico, pero la disfunción física restringe la realización estas actividades.Objeto: El artículo tiene como objetivo desarrollar deportes de fuerza física para pacientes con accidente cerebrovascular con hemiplejía para explorar la eficacia de los deportes para recuperar la función de las extremidades de estos pacientes. Métodos Seleccionamos aleatoriamente a 30 pacientes con secuelas por accidente cerebrovascular y los dividimos en grupos de control y de ejercicio. Mientras se sometía a rehabilitación, el grupo de ejercicio llegó a realizar una cierta cantidad de ejercicio aeróbico. Durante este período, comparamos los indicadores fisiológicos relevantes de los pacientes y, al mismo tiempo, utilizamos el método de puntuación de la función motora de Fugle-Meyer para evaluar la función de las extremidades. Resultados Los dos grupos de pacientes son significativamente diferentes en cuanto a la recuperación de la función física y la capacidad para la vida diaria. Los indicadores fisiológicos de los pacientes también son diferentes. Conclusión El ejercicio aeróbico de baja intensidad puede ayudar a los pacientes con accidente cerebrovascular y hemiplejía a recuperar su capacidad básica de vida y ejercicio. Nivel de evidencia II; Estudios terapéuticos: investigación de los resultados del tratamiento.

Intervención integral en el ictus / Comprehensive intervention in stroke

Introducción: se mantiene el debate sobre qué tipos de intervenciones para la recuperación del ictus ofrecen mejores resultados para el paciente. Objetivo: evaluar el efecto de una intervención integral durante seis meses sobre la recuperación funcional en pacientes con ictus. Métodos: la muestra estuvo compuesta por 42 participantes con ictus: un grupo experimental (N = 22) con una media de edad de 52,68 años (DE = 14,39) que recibió una intervención integral, intensiva y multidisciplinar, y un grupo control (N = 20) con una media de edad de 56,20 años (DE = 14,82) que no recibió este tipo de intervención. Se valoraron los siguiente índices de severidad del ictus: Escala de Coma de Glasgow, Escala Canadiense, estancia en Unidad de Cuidados Intensivos, signos de enclavamiento uncal, signos de hipertensión endocraneal, volumen del hematoma/área isquémica, desplazamiento de línea media, necesidad de cirugía y tiempo total de hospitalización. Ambos grupos eran equivalentes en estos índices de gravedad. El grado de funcionalidad fue medido con la aplicación de la escala Functional Independence Measure and Functional Assessment Measure. Esta prueba se aplicó al inicio de la intervención y 6 meses después. Resultados: se observó una evolución positiva en ambos grupos en todas las áreas de la escala. La intervención integral y un menor tiempo total de hospitalización se relacionaron con una mejor recuperación funcional en el ictus. Conclusiones: se sugiere la necesidad de realizar estrategias de rehabilitación integral en los pacientes con ictus(AU)

Introduction: debate is currently underway about what types of stroke recovery interventions are more beneficial for patients. Objective: evaluate the effect of a six-month comprehensive intervention on the functional recovery of stroke patients. Methods: the study sample was 42 stroke patients: an experimental group (N = 22), mean age 52.68 years (SD = 14.39), who received a comprehensive intensive multidisciplinary intervention, and a control group (N = 20), mean age 56.20 years (SD = 14.82), who did not receive this type of intervention. The following stroke severity indices were applied: Glasgow Coma Scale, Canadian Scale, intensive care unit stay, uncal latching signs, endocranial hypertension signs, hematoma volume / ischemic area, midline displacement, need for surgery and total hospital stay time. These severity indices were similar in the two groups. Degree of functionality was gauged with the scales Functional Independence Measure and Functional Assessment Measure. This test was applied at the start of the intervention and 6 months later. Results: both groups had a positive evolution in all the areas of the scale. The comprehensive intervention and a shorter total hospital stay were associated to better functional recovery from stroke. Conclusions: the need is suggested to implement comprehensive rehabilitation strategies in stroke patients(AU)

Rehabilitación multidisciplinaria para pacientes adultos con accidente cerebrovascular / Multidisciplinary rehabilitation for adult patients with stroke

Se estima que dos tercios de las personas que han sufrido un accidente cerebrovascular (ACV) tienen secuelas que condicionan su calidad de vida. La rehabilitación del ACV es un proceso complejo, que requiere de un equipo multidisciplinario de profesionales especializados (médicos, kinesiólogos, enfermeros, terapistas ocupacionales, fonoaudiólogos, neuropsicólogos y nutricionistas). Actualmente, las prácticas realizadas en rehabilitación son consecuencia de la combinación de evidencia y consenso, siendo la mayoría aportadas a través de guías internacionales de rehabilitación en ACV. El objetivo de esta revisión es ajustar las recomendaciones internacionales sobre rehabilitación a lo aplicado a la práctica diaria, a fin de unificar criterios en las recomendaciones y reducir la variabilidad de las prácticas empleadas. En este trabajo, se realizó una revisión de la literatura sobre las guías de rehabilitación en ACV realizadas en los últimos 10 años y cada apartado fue supervisado por distintos profesionales especializados en dichas áreas. Se analizaron los tiempos y organización necesaria para desarrollarla, las recomendaciones para la rehabilitación motora, cognitiva y visual, el tratamiento de la disfagia y nutrición, de las comorbilidades (trombosis venosa, úlceras cutáneas, dolor, trastornos psiquiátricos, osteoporosis) y las tareas necesarias para favorecer el retorno a las actividades de la vida diaria.

It is estimated that two thirds of people who have suffered a stroke have sequels that condition their quality of life. The rehabilitation of the stroke is a complex process, which requires the multidisciplinary approach of specialized professionals (doctors, kinesiologists, nurses, occupational therapists, phonoaudiologists, neuropsychologists and nutritionists). Currently, the practices carried out are a consequence of the combination of evidence and consensus, most of them through international stroke rehabilitation guides. The objective of this review is to adjust the international recommendations on stroke rehabilitation to what is applied to daily practice, in order to unify the criteria of the recommendations and to reduce the variability of the practices carried out. This work is a review of the literature on stroke rehabilitation guides developed in the last 10 years. Each section was supervised by different professionals specialized in these areas. We analyze the time and organization necessary to develop rehabilitation, recommendations for motor, cognitive and visual rehabilitation, the management of dysphagia and nutrition, the approach of comorbidities (venous thrombosis, skin ulcers, pain, psychiatric disorders and osteoporosis) and the necessary tasks to favor the return to the activities of daily life.

Effect of Leap Motion-based 3D Immersive Virtual Reality Usage on Upper Extremity Function in Ischemic Stroke Patients / Efeito do uso imersivo da realidade virtual 3D baseada em movimento de salto na função de extremidade superior em pacientes com AVC isquêmico

ABSTRACT Immersive virtual reality (VR) is a technology that provides a more realistic environmental design and object tracking than ordinary VR. The aim of this study was to investigate the effectiveness of immersive VR on upper extremity function in patients with ischemic stroke. Sixty-five patients with ischemic stroke were included in this randomized, controlled, double-blind study. Patients were randomly divided into VR (n = 33) and control (n = 32) groups. The VR group received 60 minutes of the upper extremity immersive VR rehabilitation program and the control group received 45 minutes of conventional therapy and 15 minutes of a sham VR program. Rehabilitation consisted of 18 sessions of therapy, three days per week, for six weeks. The outcome measures were the Action Research Arm Test (ARAT), Functional Independence Measure (FIM), Fugl-Meyer Upper Extremity Scale (FMUE) and Performance Assessment of Self-Care Skills (PASS). In both the VR and control groups all parameters except the PASS improved over time. However independent t-test results showed that all of the FMUE, ARAT, FIM and PASS scores were significantly higher in the VR group compared with the control (p < 0.05). The minimal clinically important difference (MCID) scores of the FMUE and ARAT were higher than the cut-off MCID scores described in the literature in the VR group, whereas the FIM scores were below the cut-off MCID scores. All scores in the control group were below the cut-off scores. Immersive VR rehabilitation appeared to be effective in improving upper extremity function and self-care skills, but it did not improve functional independence.

RESUMO A VR imersiva é uma tecnologia que fornece design ambiental e rastreamento de objetos mais realistas do que a VR comum. O objetivo deste estudo foi investigar a eficácia da VR imersiva na função da extremidade superior em pacientes com AVC isquêmico. Sessenta e cinco pacientes com AVC isquêmico foram incluídos neste estudo randomizado, controlado e duplo-cego (clinictrials.gov. ID: NCT03135418). Os pacientes foram divididos aleatoriamente em VR (n = 33) e controle (n = 32). O grupo VR recebeu 60 minutos do programa de reabilitação imersiva da extremidade superior e o grupo controle recebeu 45 minutos de terapia convencional e 15 minutos de um programa falso de VR. A reabilitação consistiu em 18 sessões de terapia, 3 dias por semana, durante 6 semanas. As medidas de resultado foram Teste de braço de pesquisa-ação (ARAT), Medida de independência funcional (FIM), Escala de extremidades superiores de Fugl-Meyer (FMUE) e Avaliação de desempenho de habilidades de autocuidado (PASS). Nos grupos VR e controle, todos os parâmetros, exceto o PASS, melhoraram com o tempo. No entanto, os resultados dos testes t independentes mostraram que todos os escores FMUE, ARAT, FIM e PASS foram significativamente maiores no grupo VR em comparação ao controle (p <0,05). Os escores de FMUE e ARAT de diferença minimamente clinicamente importante (MCID) foram maiores que os pontos de corte de MCID descritos na literatura no grupo VR, enquanto os escores de FIM estiveram abaixo dos pontos de corte de MCID. Todas as pontuações no grupo controle estiveram abaixo das pontuações de corte. A reabilitação imersiva da VR parece ser eficaz para melhorar a função da extremidade superior e as habilidades de autocuidado, mas não melhora a independência funcional.

Use of client-centered virtual reality in rehabilitation after stroke: a feasibility study / Uso da realidade virtual centrada no cliente na reabilitação após acidente vascular encefálico: um estudo de viabilidade

ABSTRACT Patient-centered virtual reality (VR) programs could assist in the functional recovery of people after a stroke. Objectives: To analyze the feasibility of a rehabilitation protocol using client-centered VR and to evaluate changes in occupational performance and social participation. Methods: This was a mixed methods study. Ten subacute and chronic stroke patients participated in the rehabilitation program using games in non-immersive VR for 40 minutes/day, three days/week, for 12 weeks. Sociodemographic information was collected and the outcome variables included were the Canadian Occupational Performance Measure (COPM) and the Participation Scale. A field diary was used to record the frequency of attendance and adherence of participants and an interview was conducted at the end of program. Results: There were significant and clinically-relevant statistical improvements in the COPM performance score (p < 0.001; CI = 1.29 − 4.858) and in the COPM satisfaction score (p < 0.001; CI = 1.37 − 5.124), with a difference greater than 4.28 points for performance and 4.58 points for satisfaction. The change in the scores for participation was statistically significant (p = 0.046), but there was no clinical improvement (dcohen = −0.596, CI = −1.862 − 0.671). The majority of participants reported more than 75% consecutive attendance of sessions and there was 100% adherence to the program. In the interviews, the participants described their post-stroke difficulties; how the video game motivated their engagement in rehabilitation; and the improvement of occupational performance and social participation after participating in the program. Conclusions: VR is a viable tool for the rehabilitation of stroke patients with functional gains, mainly regarding occupational performance and performance satisfaction.

RESUMO Programas de realidade virtual (RV) centrados no paciente poderiam auxiliar na recuperação funcional de pessoas após acidente vascular cerebral (AVC). Objetivos: Analisar a viabilidade de um protocolo de reabilitação usando RV centrada no cliente e avaliar mudanças no desempenho ocupacional e na participação social. Métodos: Dez pacientes com AVC participaram do programa de reabilitação utilizando RV por 40 min/dia, 3 dias/semana, durante 12 semanas. Foram coletadas informações sociodemográficas e as medidas de desfecho incluíram a Medida Canadense de Desempenho Ocupacional (COPM) e a Escala de Participação. Empregou-se um diário para registro da frequência e adesão de cada participante e uma entrevista foi usada para analisar a percepção dos participantes sobre o programa. Resultados: Houve melhora estatisticamente significativa e clinicamente relevante no escore de desempenho da COPM (p < 0,001; IC = 1,219 − 4,858) e no escore de satisfação com o desempenho da COPM (p < 0,001; IC = 1,37 − 5,154); com diferença maior que 4,28 pontos para o desempenho; e 4,58 pontos para a satisfação. A mudança no escore de participação foi estatisticamente significativa (p = 0,046), mas não houve melhora clínica (dcohen = −0,596, IC = −1,862 − 0,671). A maioria dos participantes apresentou mais de 75% de frequência consecutiva e houve 100% de adesão ao programa. Nas entrevistas os participantes relataram as dificuldades pós-AVC; como o video game motivou seu engajamento na reabilitação; e a melhora do desempenho ocupacional e da participação social após participar do programa. Conclusões: Os resultados indicam a viabilidade da RV para reabilitação de pacientes com AVC, com ganhos funcionais, principalmente no desempenho ocupacional e satisfação com o desempenho.

Can the positions of the spastic upper limb in stroke survivors help muscle choice for botulinum toxin injections? / A posição do membro superior de indivíduos com doença cerebrovascular pode auxiliar na escolha de músculos para a injeção de toxina botulínica?

ABSTRACT Motor impairments in stroke survivors are prevalent and contribute to dependence in daily activities, pain and overall disability, which can further upper-limb disability. Treatment with botulinum toxin A (BoNT-A) is indicated for focal spasticity and requires knowledge of biomechanics and anatomy to best select muscles to be injected in the limb. Objective: We aimed to describe the frequency of posture patterns in a Brazilian sample of stroke survivors and correlate them with recommendations of muscle selection for treatment with BoNT-A. Methods: Fifty stroke patients with spastic upper limbs scheduled for neuromuscular block were photographed and physically examined, to be classified by three independent evaluators according to Hefter's classification. Muscles that were injected with BoNT-A by their routine doctors were retrieved from medical charts. Results: Pattern III and IV were the most common (64.7%, 21.6%). We further subclassified pattern III according to the rotation of the shoulder, which effectively interfered in muscle choice. The muscles most frequently treated were shoulder adductors and internal rotators, elbow flexors and extensors, in forearm, the pronator teres and finger and wrist flexors, and, in the hand the adductor pollicis. Conclusion: Frequencies of upper-limb postures differed from previous reports. Other clinical features, besides spasticity, interfered with muscle choice for BoNT-A injection, which only partially followed the recommendations in the literature.

RESUMO As deficiências motoras que ocorrem nos indivíduos com doença cerebrovascular (DCV) são prevalentes e contribuem para dependência, dor e incapacidade, o que pode atrasar a reabilitação do membro superior e sua funcionalidade. O tratamento com toxina botulínica do tipo A (BoNT-A) é indicado para a espasticidade focal e requer conhecimento da biomecánica e anatomia para melhor selecionar os músculos a serem injetados. Objetivo: Descrever a frequência de padrões posturais numa amostra de brasileiros com sequelas de DCV e correlacioná-los com as recomendações de seleção de músculos. Métodos: Cinquenta pacientes com comprometimento do membro superior devido a DCV do ambulatório de bloqueios neuromusculares foram fotografados e examinados para categorização de acordo com a Classificação de Hefter. Os músculos tratados pelos seus médicos de rotina foram obtidos a partir dos prontuários. Resultados: Os padrões III e IV de Hefter foram mais comuns (64,7%; 21,6%). Nós propusemos a subclassificação do padrão III de acordo com a rotação do ombro, pois isso interferiu na escolha dos músculos tratados. Os músculos tratados com maior frequência foram os adutores e rotadores internos do ombro; flexores e extensores do cotovelo; no antebraço, o pronador redondo, flexores dos dedos e do carpo e na mão, o adutor do polegar. Conclusão: As frequências das posições do membro superior diferiram de relatos prévios. Além da espasticidade, outros fatores interferiram na escolha dos músculos tratados, que seguiram parcialmente as recomendações da literatura.

Virtual reality in the rehabilitation of patients with stroke: an integrative review / Realidade virtual na reabilitação de pacientes após acidente vascular cerebral: uma revisão integrativa

ABSTRACT Objective: To describe the intervention protocols to using commercial video games as virtual reality (VR) in rehabilitation of patients with stroke. Methods: Integrative review using the descriptors "rehabilitation", "virtual reality exposure therapy" and "videogames" in the LILACS and PUBMED databases. Articles published from 2011 to 2018 were selected. Results: We found 1,396 articles, 1,383 were excluded and 13 were selected. Most of the articles were randomized clinical trials published in 2014 or later. The sample size varied from 5-47 adults, or adults and elders, with chronic stroke. The Nintendo Wii® was the most used video game system. The intervention happened two or three times a week, each session lasting from 30 to 60 minutes, over 2-12 weeks. Balance, upper limb motor functions, quality of life and daily living activities were the most common evaluated outcomes. The Fugl-Meyer Assessment, Berg Balance Scale, Timed Up and Go test, Barthel Scale and SF-36 were the most common outcome measurement tools. Conclusions: The studies indicated improvement in dynamic balance, upper limb motor function and quality of life after rehabilitation using VR. The VR was more effective than conventional treatments for the outcome of dynamic balance. Two studies did not find any changes in static balance and daily living activities. Physical aspects and quality of life were the outcomes most evaluated by the researchers; as were the population with chronic strokes and protocols of long duration and low intensity. Few studies targeted immediate VR effects, performance in daily living activities and social participation.

RESUMO Objetivo: Descrever os protocolos de intervenção utilizando sistemas de vídeo game comerciais como realidade virtual (RV) na reabilitação de pacientes após AVE. Método: Revisão integrativa usando os descritores "reabilitação", "terapia de exposição a realidade virtual" e "videogames", nas bases de dados LILACS e PUBMED, e artigos publicados entre 2011 e 2018. Resultados: Foram encontrados 1.396, excluídos 1.383 e selecionados 13 artigos. A maioria era ensaio clínico aleatorizado publicados a partir de 2014. O tamanho da amostra variou de 5 a 47 participantes adultos ou adultos e idosos com AVE crônico. O Nintendo Wii® foi o videogame mais empregado. A intervenção constava de duas ou três sessões semanais, com duração de 30 ou 60 minutos por um período de duas a 12 semanas. Equilíbrio, função motora de membro superior, qualidade de vida e atividade de vida diária foram os principais desfechos. Empregou-se principalmente Escala Fugl-Meyer, Escala de Equilíbrio de Berg, teste Timed Up and Go, Índice de Barthel e SF-36 como medidas de desfecho. Conclusões: Os estudos indicaram melhora do equilíbrio dinâmico, função motora de membro superior e qualidade de vida após reabilitação usando RV. A RV se mostrou mais eficaz que tratamentos convencionais para o desfecho equilíbrio dinâmico. Dois estudos não encontraram mudanças no equilíbrio estático e atividade de vida diária. Observou-se maior foco em desfechos relacionados a aspectos físicos e qualidade de vida, em população com AVE crônico e protocolo com maior duração e menor intensidade. Poucos estudos voltados para efeitos imediatos da RV, desempenho em atividades de vida diária e participação social.

Effects of virtual reality therapy on upper limb function after stroke and the role of neuroimaging as a predictor of a better response / Efeitos da terapia de realidade virtual na função do membro superior após AVC e o papel da neuroimagem como preditor de melhor resposta

ABSTRACT Background: Virtual reality therapy (VRT) is an interactive intervention that induces neuroplasticity. The aim was to evaluate the effects of VRT associated with conventional rehabilitation for an upper limb after stroke, and the neuroimaging predictors of a better response to VRT. Methods: Patients with stroke were selected, and clinical neurological, upper limb function, and quality of life were evaluated. Statistical analysis was performed using a linear model comparing pre- and post-VRT. Lesions were segmented in the post-stroke computed tomography. A voxel-based lesion-symptom mapping approach was used to investigate the relationship between the lesion and upper limb function. Results: Eighteen patients were studied (55.5 ± 13.9 years of age). Quality of life, functional independence, and dexterity of the upper limb showed improvement after VRT (p < 0.001). Neuroimaging analysis showed negative correlations between the internal capsule lesion and functional recovery. Conclusion: VRT showed benefits for patients with stroke, but when there was an internal capsule lesion, a worse response was observed.

RESUMO Introdução: A realidade virtual (RV) é uma intervenção interativa que induz a neuroplasticidade. O objetivo deste estudo foi avaliar os efeitos da RV associado à reabilitação convencional na função do membro superior após o AVC e as características preditores de neuroimagem de melhor resposta a esta terapia. Métodos: os pacientes com AVC foram selecionados, e as características neurológicas, a função do membro superior e a qualidade de vida foram avaliadas. A análise estatística foi realizada por meio de modelo linear geral comparando resultados pré e pós-intervenção. As lesões foram segmentadas na tomografia computadorizada após o AVC. A abordagem de mapeamento da lesão-sintoma baseada em voxel foi utilizada para avaliar a relação entre a lesão e a função do membro superior. Resultados: Foram estudados 18 pacientes (8 mulheres, 55,5 ± 13,9 anos). A qualidade de vida, independência funcional, características funcionais e destreza do membro superior apresentaram melhora após RV (p < 0,001). A análise de imagem mostrou correlações negativas principalmente entre a cápsula interna e a recuperação funcional do membro superior. Conclusão: A RV mostrou benefícios para pacientes com AVC, mas quando houve lesão da cápsula interna apresentaram pior resposta à terapia.

Efeitos do fenômeno da irradiação do método de facilitação neuromuscular proprioceptiva no acidente vascular encefálico sobre o membro inferior: estudo preliminar / Effects of the irradiation phenomena of the Proprioceptive Neuromuscular Facilitation method on the cerebrovascular accident on the lower limb: preliminary study

Introdução: A irradiação pelo método de Facilitação Neuromuscular Proprioceptiva (FNP) não se restringe somente a ativação da musculatura agonista, mas aos músculos homólogos e contralaterais. Objetivo: avaliar o efeito da irradiação sobre a ativação muscular do membro inferior parético, equilíbrio e marcha de indivíduos na fase subaguda pós-AVE. Métodos: cinco indivíduos, avaliados antes e após a intervenção de 12 sessões, incluindo o padrão extensor da diagonal primitiva (D2) de membro superior bilateralmente, em várias posições, por meio da eletromiografia, da escala Fulg-Meyer (FM) e Índice do Andar Dinâmico (IAM). Resultados: As avaliações da FM e do IAM não apresentaram diferenças significativas. A anova fatorial revelou que as variáveis independentes tarefa (p=,00000), músculo (p=,0016) e avaliação (p=,01882) mostraram diferença significativa entre as avaliações. Conclusão: A irradiação do método FNP não promoveu mudanças significativas no equilíbrio e na marcha, mas mostrou ser eficaz na ativação dos músculos do membro inferior nestes pacientes hemiparéticos em recuperação.

Introduction: The method by irradiation of Proprioceptive Neuromuscular Facilitation (PNF) is not only restricted to agonist activation of muscles, but the counterparts and contralateral muscles. Objective: To evaluate the effect of irradiation in the activation of paretic muscles of lower limb, on balance and gait of individuals in post-stroke subacute phase. Methods: five subjects, evaluated before and after 12 sessions of intervention based on extensor pattern of the bilateral upper limb in various positions, through electromyography, Fulg-Meyer (FM) and Dynamic Gait Index (DGI). Results: The evaluations of FM and DGI did not present significant differences. The anova factorial revealed that the independent variables task (p =, 00000), muscle (p =, 0016) and evaluation (p =, 01882) showed significant difference. Conclusion: Irradiation of the FNP method did not promote significant changes in balance and gait, but was shown to be effective in the activation of the lower limb muscles in these hemiparetic patients in recovery.

Motor learning in post stroke subjects: the effects of practice conditions on the temporal synchronization

Abstract AIMS The aim of this study was to investigate the effects of practice schedule on the motor learning of a synchronization timing task in post-stroke subjects. Subjects and METHODS Seventeen post-stroke individuals were assigned to the experimental group and for the control group were selected seventeen healthy individuals. At the acquisition phase, all participants performed 30 trials of a coincident timing task. Nine individuals from each group practiced constantly and eight from each group practiced randomly, with speed changes in the task. Subsequent phases included: 1) immediate transfer test and 2) long term transfer test after 3 days. Data were analyzed in relation to absolute, variable, and constant errors to assess the performance concerning accuracy, consistence, and direction of responses, respectively. RESULTS All groups increased their accuracy through the practice and were able to adapt it in different speeds. The stroke subjects were more variable in their motor responses. There was no effect of the practice schedule on motor learning, regardless the presence or absence of the neurologic damage. CONCLUSION Post stroke individuals were able to learn a synchronizing task and the capacity of adapt their performance after speed perturbation was preserved. There was no effect of the practice schedule on motor learning.

Estimulação transcraniana por corrente contínua: estudo sobre respostas em tarefas de nomeação em afásicos / Transcranial direct current stimulation: a study on naming performance in aphasic individuals

RESUMO Objetivo Comparar os resultados nas tarefas de nomeação de pacientes afásicos após AVC dos grupos ativo e controle. Método Estudo duplo-cego, randomizado controlado com 14 pacientes. Os indivíduos foram submetidos a cinco sessões de 20 minutos de 2 mA em dias consecutivos. O catodo foi posicionado na área homóloga à Broca e o anodo sobre a região supraorbital do hemisfério esquerdo. Os testes de Boston e Snodgrass foram aplicados e os resultados comparados entre os grupos. Resultados Não houve resultados significativos para as sequências 1 e 2 no teste do Snodgrass. No teste de Boston, os dados indicaram uma diferença significativa para o tempo médio de acertos com estratégia. Conclusão Os resultados sugerem que a ETCC simultânea (anódica e catódica) é um método que pode auxiliar a reabilitação de pacientes com afasia do tipo anômica e de Broca, após AVC, e que as estratégias linguísticas deveriam ser consideradas nas análises das respostas dos testes de nomeação.

ABSTRACT Purpose Compare the results in naming tasks of after-stroke aphasic individuals divided into active and placebo groups pre- and post-transcranial direct current stimulation. Methods A double-blind, randomized, controlled study conducted with 14 individuals. Patients underwent five 20-min sessions with stimulation of 2mA's on consecutive days. The cathode was placed over the Broca's homologous area and the anode was placed over the supraorbital region of the left hemisphere. Boston and Snodgrass naming tasks were assessed before and after the stimulation sessions and the results were compared between the groups. Results No significant results were observed for sequences 1 and 2 in the Snodgrass test. The Boston test results indicated significant difference related to mean time for correct responses with strategy. Conclusion The results suggest that simultaneous transcranial direct current stimulation (anodic and cathodic) is a method that can improve the rehabilitation of patients with anomic and Broca's aphasia after stroke, and that language strategies should be considered in the analysis of naming task responses.

Study on the Correlation between Barium Radiography and Pulmonary Infection rate in the Evaluation of Swallowing Function

OBJECTIVES: To compare the results respectively obtained from the utilization of 60% barium sulfate suspension and Iohexol as contrast agents for videofluoroscopic swallowing studies and the relationship between the clinical application of the two kinds of contrast agents and the incidence of pneumonia. METHODS: Sixty cases of stroke patients with dysphagia were selected in rehabilitation department of our hospital, and the gender, age, position of the disease, and stroke nature between groups had no significant difference. Among which, 30 patients who were administered 350 mgI/ml Iohexol, and the other 30 patients with 60% barium sulfate suspension as contrast agent. We performed videofluoroscopic swallowing studies with barium 60% versus Iohexol within 1 week after admission and 2 weeks after admission. RESULTS: After 2 weeks in hospital, the aspiration pneumonia incidence of two groups was statistically significant (p<0.05), the pneumonia incidence of Iohexol group was lower than barium sulfate group which might have a impossble relevance with barium aspiration. CONCLUSIONS: During the videofluoroscopic swallowing study of dysphagia after stroke, barium sulfate can enhance the pneumonia incidence, and Iohexol can be widely applied in videofluoroscopic swallowing study.

Non-invasive brain stimulation and computational models in post-stroke aphasic patients: single session of transcranial magnetic stimulation and transcranial direct current stimulation. A randomized clinical trial

ABSTRACT CONTEXT AND OBJECTIVE: Patients undergoing the same neuromodulation protocol may present different responses. Computational models may help in understanding such differences. The aims of this study were, firstly, to compare the performance of aphasic patients in naming tasks before and after one session of transcranial direct current stimulation (tDCS), transcranial magnetic stimulation (TMS) and sham, and analyze the results between these neuromodulation techniques; and secondly, through computational model on the cortex and surrounding tissues, to assess current flow distribution and responses among patients who received tDCS and presented different levels of results from naming tasks. DESIGN AND SETTING: Prospective, descriptive, qualitative and quantitative, double blind, randomized and placebo-controlled study conducted at Faculdade de Ciências Médicas da Santa Casa de São Paulo. METHODS: Patients with aphasia received one session of tDCS, TMS or sham stimulation. The time taken to name pictures and the response time were evaluated before and after neuromodulation. Selected patients from the first intervention underwent a computational model stimulation procedure that simulated tDCS. RESULTS: The results did not indicate any statistically significant differences from before to after the stimulation.The computational models showed different current flow distributions. CONCLUSIONS: The present study did not show any statistically significant difference between tDCS, TMS and sham stimulation regarding naming tasks. The patients'responses to the computational model showed different patterns of current distribution.

Factores determinantes de la calidad de vida en pacientes sobrevivientes a un ictus / Decisive factors for the quality of life of patients who survived an ictus

Introducción: Las enfermedades cerebrovasculares (ECV) son causa de afectación de la calidad de vida (CV) y de discapacidad; los factores asociados a una afectación de la CV varían entre un estudio y otro, teniendo en cuenta el uso de instrumentos de medición de la calidad de vida (escalas) adaptadas a determinadas áreas geográficas. Objetivo: Determinar aquellos factores más influentes en la afectación de la calidad de vida en pacientes que han sufrido un ictus, a través de los resultados expuestos en la literatura. Material y Métodos: Se consultaron un total de 53 fuentes de información, entre ellas 47 artículos de revistas científicas, 2 tesis doctorales, así como informes estadísticos y se tuvo acceso a los principales gestores de la red informática. Desarrollo:Se consideraron conceptos sobre la calidad de vida relacionada con la salud en pacientes sobrevivientes a un ictus, los factores asociados a su afectación, la valoración de las escalas de calidad de vida para el ictus y la importancia de realizar estudios con un enfoque más integral. Conclusiones: Independientemente de la existencia de un grupo de variables comunes, imprescindibles en todo estudio relacionado con la calidad de vida en pacientes sobrevivientes a un ictus, cada grupo investigador debe tener en cuenta aquellos elementos que más se ajusten según sus objetivos para iniciar el proceso de investigación(AU)

Introduction: Cerebrovascular diseases (CVD) are a cause of affectedness related to quality of life (QL), and disability; the factors related to an affectedness of the quality of life vary from one study to another, considering the use of tools to measure the quality of life (scales) adapted to particular geographic areas. Objective:To determine those factors that influence the most in the affectedness related to the quality of life of patients who have suffered an ictus, through the results presented in the literature on this topic. Material and methods:A total of 53 sources of information were consulted, among them 47 articles from scientific journals, 2 PhD thesis, and statistical reports. Also, it was possible to have access to the main managers of computing networks. Development:Concepts of the health-related quality of life of those patients who survived an ictus were considered, as well as the factors associated with their affectedness, the scales for quality of life assessment of patients with ictus, and the importance to conduct studies with a more integral approach. Conclusions:Independently of the existence of a group of common variables, which are essential in any study related to the quality of life of patients who survive an ictus, each research group has to keep in mind those elements that adapt most to the objectives in order to begin a research process(AU)

Irradiação como princípio da FNP em pacientes hemiparéticos pós AVE, análise funcional e eletromiográfica: estudo piloto / Overflow as principle of PNF in post stroke hemiparetic pacients, functional and EMG analysis: pilot study

Introdução: A irradiação pelo método de Facilitação Neuromuscular Proprioceptiva (FNP) ativa grupos musculares fracos estimulando grupos que estão preservados. Objetivo: Avaliar o efeito da irradiação do método FNP sobre a ativação muscular no membro superior parético, quadro clinico e funcionalidade de indivíduos pós-AVE. Metodologia: Estudo piloto, com 6 voluntários, média de 53,33(±19,22) anos, submetidos ao procedimento de irradiação do método FNP no membro superior parético em 3 tarefas distintas. A intervenção durou 8 sessões, 2 vezes semanais e avaliação foi realizada pela escala de Fugl- Meyer, CIF (Classificação Internacional de Funcionalidade) e eletromiografia. Resultados: A CIF e a Fugl- Meyer apresentaram melhora em alguns dados (p<0,05). A análise eletromiográfica não apresentou alterações significativas (p>0,05). Conclusão: A intervenção com uso de irradiação pelo método FNP propiciou ganhos em força e tônus muscular, controle de punho e funções vestibulares e cognitivas, melhorando o convívio com a comunidade e facilitando suas atividades. A eletromiografia não evidenciou mudanças pós intervenção.

Backgrounds: The overflow by the Neuromuscular Proprioceptive Facilitation (PNF) method activates weak muscle groups by stimulating preserved muscle groups. Objective: To evaluate the effect of overflow by the PNF method on muscle activation in paretic upper limb, in the clinical features and also in the functionality in post-stroke individuals. Methods: A pilot study, with 6 volunteers, mean of 53.33 (± 19.22) years old, submitted to the procedure of overflow by the PNF method in the paretic upper limb in 3 distinct tasks. The intervention lasted 8 sessions, 2 times weekly and the evaluation were based on Fugl-Meyer scale assessment, CIF (International Classification of Functionality) and electromyography. Results: The CIF and Fugl-Meyer presented improvement in some data (p <0.05). An electromyographic analysis showed no significant improvement (p> 0.05). Conclusion: The intervention using overflow by the PNF method provided gains in strength and muscle tone, wrist control, and vestibular and cognitive functions, improving community living and facilitating its activities. The electromyography did not show post-intervention changes.