Cambios en la marcha asociados con demencia por cuerpos de Lewy: una revisión narrativa de la literatura / Gait changes associated with Lewy body dementia: a narrative review of the literature

RESUMEN INTRODUCCIÓN: La demencia por cuerpos de Lewy (DCL) es una enfermedad neurodegenerativa con alta prevalencia y a menudo subdiagnosticada. En las demencias pueden presentarse alteraciones en la marcha que potencialmente permitan identificar su subtipo y dar una orientación clínica, diagnóstica y terapéutica temprana. Esta revisión narrativa de la literatura busca revisar los cambios de la marcha que se han descrito asociados con DCL. MATERIALES Y MÉTODOS: Se realizó una revisión de la literatura sobre la relación de las alteraciones de la marcha con la DCL. Se seleccionaron los siguientes parámetros de búsqueda mediante el buscador Scopus: ((falls and dementia and gait and (evaluation or analysis))). Los datos se ordenaron según relevancia y se obtuvieron 267 resultados. Igualmente, se hizo una búsqueda en PubMed, para a la que se introdujeron los términos (gait and lewy-body-disease), y no se utilizaron otros filtros; se obtuvieron 139 resultados. Se hizo una selección no sistemática de los artículos para llevar a cabo una revisión narrativa acerca de los cambios en la marcha asociados con DCL. RESULTADOS: Las alteraciones en la marcha pueden tener un valor predictor importante en la DCL. Los pacientes con demencias no debido a EA o causas vasculares muestran un deterioro de la funcionalidad física más rápido comparado con pacientes con EA y sin problemas cognitivos. La priorización incorrecta de las tareas, evidenciada en la EP, también es observable en los pacientes con DCL, y se asocia con el paradigma de doble tarea en el paciente con trastorno neurocognitivo mayor. El congelamiento de la marcha, también conocido como bloqueo de la marcha, se ha asociado con mayor progresión de la alteración cognitiva. Los pacientes con DCL también presentan un mayor compromiso en el tiempo de balanceo y la variabilidad de duración de la zancada, como también peor desempeño en ritmo y variabilidad de la marcha, e inestabilidad de la marcha, con posturas inadecuadas. CONCLUSIONES: Existe una relación entre la DCL y las caídas en el adulto mayor. En este grupo de edad, los cambios en la marcha y en las pruebas de desempeño podrían tener una utilidad clínica como factores asociados a con DCL, así como con las caídas. Al parecer, existe una variación característica entre los parámetros de la marcha y los subtipos de demencias que puede tener un valor como marcador diagnóstico. Se requieren más estudios con respecto a este tema puesto que hay escasa evidencia disponible hasta el momento, lo cual impide definir con mayor precisión las alteraciones más sensibles de cada dominio de la marcha que permitan diferenciar el envejecimiento normal del patológico.

ABSTRACT INTRODUCTION: Lewy body dementia is a highly prevalent neurodegenerative disease and often goes unnoticed due to little knowledge about it. In dementias there may be gait alterations that potentially allow the identification of its subtype and provide early clinical, diagnostic, and therapeutic guidance. This narrative review of the literature aims to review gait changes that have been described as associated with Lewy body dementia. MATERIALS AND METHODS: A literature review was carried out on the relationship of gait disturbances and LBD. The following search parameters were selected using the Scopus search engine: ((falls and dementia and gait and (evaluation or analysis))). The data were ordered according to relevance, obtaining 267 results. Likewise, a search was made in PubMed, using the terms (gait and lewy-body-disease), and no other filters were used, obtaining 139 results. A non-systematic selection of literature was made to carry out a narrative review about the changes in gait associated with LBD. RESULTS: We found that gait disturbances may have an important predictive value in LBD. Patients with dementias not due to AD or vascular causes have a faster deterioration of physical function compared to patients with AD and without cognitive problems. The incorrect prioritization of tasks evidenced in PD is also observable in patients with LBD and is associated with the "dual-task" paradigm in patients with major neurocognitive disorder. Freezing of gait, also known as motor block or "freezing of gait" has been associated with a greater progression of cognitive impairment. Patients with LBD also show greater compromise in swing time, stride duration variability, poorer performance in gait pace and variability, and gait instability with inappropriate postures. CONCLUSIONS: We observe that there is a relationship between LBD and falls in the elderly. Changes in gait and performance tests could have clinical utility as factors associated with LBD as well as falls in the elderly. There appears to be a characteristic variation between gait parameters and dementia subtypes that may have value as a diagnostic marker. More studies are required on this subject since there is little evidence available to date, which makes it impossible to define with greater precision the most sensitive alterations in each domain of gait that make it possible to differentiate normal from pathological aging.

Effects of treadmill training on gait of elders with Parkinson's disease: a literature review / Efeitos do treinamento de marcha em esteira em idosos com doença de Parkinson: uma revisão da literatura

ABSTRACT Parkinson's disease is the second most common neurodegenerative disorder in old age. Aging process for elders with Parkinson's disease can induce gait disturbances with more functional disabilities than for elders without the disease. Treadmill training as a therapy has resulted in notable effects on the gait of patients with Parkinson's disease and may be a resource for geriatric neurological rehabilitation. This review aimed to study the effects on gait after treadmill training in elderly patients with Parkinson's disease. The search was performed in the databases PubMed®, LILACS, PEDro and EMBASE, with the following keywords: "Parkinson's disease", "elderly", "treadmill training" and "gait evaluation". The quality of the studies included was assessed by PEDro Scale. Eleven studies met the inclusion and exclusion criteria. Eight studies were randomized, and only one did a follow-up. One can observe in this review that treadmill training with or without weight support (at least 20 minutes, two to three times a week, with progressive increase of loads, for minimum of 6 weeks) in elderly patients with the Parkinson's disease was effective to improve gait. In addition, both were considered safe (since some studies described the use of belts, even in unsupported training) and can be associated with therapies complementary to gait, such as repetitive transcranial magnetic stimulation, visual cues or anodal transcranial direct current stimulation. Treadmill training in elderly patients with Parkinson's disease is an intervention that improves gait outcomes, but further studies are required for better proofs.

RESUMO A doença de Parkinson é o segundo distúrbio neurodegenerativo mais comum na velhice. O processo de envelhecimento de idosos com doença de Parkinson pode levar a distúrbios de marcha com mais incapacidades funcionais do que para idosos sem a doença. O treinamento em esteira como terapia pode resultar em efeitos notáveis na marcha de pacientes com Parkinson e ser um recurso para a reabilitação neurológica geriátrica. Esta revisão teve como objetivo estudar os efeitos da marcha após o treinamento em esteira na doença de Parkinson em idosos. A pesquisa foi realizada nas bases de dados PubMed®, LILACS, PEDro e EMBASE, com os seguintes descritores: "doença de Parkinson", "idosos", "treinamento em esteira" e "avaliação da marcha". A qualidade dos estudos incluídos foi avaliada pela escala de PEDro. Atenderam aos critérios de inclusão e exclusão 11 estudos. Oito estudos foram randomizados, e apenas um fez follow-up . Foi possível observar que treinamento em esteira com ou sem suporte de peso (por pelo menos 20 minutos, duas a três vezes por semana, com aumento progressivo de cargas, por, no mínimo, 6 semanas) em idosos com doença de Parkinson foi efetivo para melhorar a marcha. Além disso, ambos os treinamentos foram considerados seguros (pois alguns estudos relataram o uso de cintos, mesmo no treinamento sem suporte de peso) e podem ser associados a terapias complementares à marcha, como estimulação magnética transcraniana repetitiva, estímulos visuais ou estimulação transcraniana direta anódica. O treinamento em esteira em pacientes idosos com doença de Parkinson é uma intervenção que melhora os resultados da marcha, mas requer mais estudos para melhor comprovação.

Two Siblings with Adolescent/Adult Onset Niemann-Pick Disease Type C in Korea

Niemann-Pick disease, type C (NP-C), is caused by NPC1 or NPC2 gene mutations. Progressive neurological, psychiatric, and visceral symptoms are characteristic. Here, we present cases of a brother (Case 1) and sister (Case 2) in their mid-20s with gait disturbance and psychosis. For the Case 1, neurological examination revealed dystonia, ataxia, vertical supranuclear-gaze palsy (VSGP), and global cognitive impairment. Case 2 showed milder, but similar symptoms, with cortical atrophy. Abdominal computed tomography showed hepatosplenomegaly in both cases. NPC1 gene sequencing revealed compound heterozygote for exon 9 (c.1552C>T [R518W]) and exon 18 (c.2780C>T [A927V]). Filipin-staining tests were also positive. When a young patient with ataxia or dystonia shows VSGP, NP-C should be considered.

Effect of Rhythmic Auditory Stimulation on Hemiplegic Gait Patterns

PURPOSE: The purpose of our study was to investigate the effect of gait training with rhythmic auditory stimulation (RAS) on both kinematic and temporospatial gait patterns in patients with hemiplegia. MATERIALS AND METHODS: Eighteen hemiplegic patients diagnosed with either cerebral palsy or stroke participated in this study. All participants underwent the 4-week gait training with RAS. The treatment was performed for 30 minutes per each session, three sessions per week. RAS was provided with rhythmic beats using a chord progression on a keyboard. Kinematic and temporospatial data were collected and analyzed using a three-dimensional motion analysis system. RESULTS: Gait training with RAS significantly improved both proximal and distal joint kinematic patterns in hip adduction, knee flexion, and ankle plantar flexion, enhancing the gait deviation index (GDI) as well as ameliorating temporal asymmetry of the stance and swing phases in patients with hemiplegia. Stroke patients with previous walking experience demonstrated significant kinematic improvement in knee flexion in mid-swing and ankle dorsiflexion in terminal stance. Among stroke patients, subacute patients showed a significantly increased GDI score compared with chronic patients. In addition, household ambulators showed a significant effect on reducing anterior tilt of the pelvis with an enhanced GDI score, while community ambulators significantly increased knee flexion in mid-swing phase and ankle dorsiflexion in terminal stance phase. CONCLUSION: Gait training with RAS has beneficial effects on both kinematic and temporospatial patterns in patients with hemiplegia, providing not only clinical implications of locomotor rehabilitation with goal-oriented external feedback using RAS but also differential effects according to ambulatory function.

Validation of the Brazilian version of the Clinical Gait and Balance Scale and comparison with the Berg Balance Scale / Validacao da versao brasileira da escala de marcha e equilibrio e comparacao com a escala de equilibrio de Berg

Objective To validate the Clinical Gait and Balance Scale (GABS) for a Brazilian population of patients with Parkinson's disease (PD) and to compare it to the Berg Balance Scale (BBS). Methods One hundred and seven PD patients were evaluated by shortened UPDRS motor scale (sUPDRSm), Hoehn and Yahr (HY), Schwab and England scale (SE), Falls Efficacy Scale International (FES-I), Freezing of Gait Questionnaire (FOG-Q), BBS and GABS. Results The internal consistency of the GABS was 0.94, the intra-rater and inter-rater reliability were 0.94 and 0.98 respectively. The area under the receiver operating characteristic (ROC) curve was 0.72, with a sensitivity of 0.75 and specificity of 0.6, to discriminate patients with a history of falls in the last twelve months, for a cut-off score of 13 points. Conclusions Our study shows that the Brazilian version of the GABS is a reliable and valid instrument to assess gait and balance in PD. .

Objetivo Validar a Escala Clínica de Marcha e Equilíbrio (GABS) para a população brasileira com doença de Parkinson (DP) e compará-la com a Escala de Equilíbrio de Berg (BBS). Métodos 107 pacientes com diagnóstico de DP foram avaliados através das escalas versão reduzida da UPDRS motora, Hoehn e Yahr, Schwab e England, Escala de Medo de Quedas Internacional, Escala de Congelamento da Marcha, GABS e BBS. Resultados A consistência interna da escala foi 0,94, a confiabilidade inter-examinador 0,98 e intra-examinador 0,94. Curva ROC (receiver operating characteristic curve) de 0,72, com sensibilidade de 0,75 e especificidade de 0,60 para discriminar pacientes com história de queda nos últimos 12 meses, para uma nota de corte de 13 pontos. Conclusão Nosso estudo demonstra que a versão brasileira da GABS é válida para avaliar a marcha e o equilíbrio em pacientes com DP. .

Trastorno de la marcha en la enfermedad de Parkinson: freezing y perspectivas actuales / Freezing and gait disorders in Parkinson's disease

More than one third of patients with Parkinson disease experience freezing. It is characterized by the feeling that one's feet are "glued to the floor", and it is more common in the later stages of the disease. The causes of this gait disorder are not yet fully established, but it may lead patients to suffer falls and lose their independence. As a consequence, the development of therapeutic measures which can overcome freezing is of fundamental important for the autonomy of such individuals. There is no consensus in the literature on the most recommended therapeutic measures for the prevention or attenuation of freezing in gait. What seems to be defined are the phenomenological aspects of the disorder and good therapy, represented by the association between drug therapy and sensorial stimuli or motor coordination training geared towards the specificities to avoid motor difficulties of freezing, when triggering factors are present.

Effective re-education of "two joints muscle synergism" to promote gait variables in spastic cerebral palsy: an empirical study

To identify and compare the [two joint muscles] mechanics of spastic cerebral palsies and to manipulate the [two joint muscles] mechanics to improve gait quality in spastic CPs. Nine Spastic CPs, [two males and seven females, of mean age 4.9 years], were studied, following the categorical selection criteria. The therapeutic regimen was reinforced by, [specific muscle reeducation techniques] focusing to inhibit the abnormal synergism. The spastics had higher stiffness due to the primary impairments [muscle tone/ movement patterns, distribution, balance etc.], differences in the landing angles of feet due to secondary impairments [ROM, joint alignment, force production, etc.] and higher energy requirements. Interventions to enhance outcomes were positively correlated. The potential determinants of motor change in two joint muscles could assist in the functional performance with regard to gait and posture. Biochemical studies on energy requirements in CPs are recommended

Effects of the addition of functional electrical stimulation to ground level gait training with body weight support after chronic stroke / Efeitos da adição da estimulação elétrica funcional ao treino de marcha em piso fixo com suporte parcial de peso após acidente vascular encefálico crônico

BACKGROUND: The addition of functional electrical stimulation (FES) to treadmill gait training with partial body weight support (BWS) has been proposed as a strategy to facilitate gait training in people with hemiparesis. However, there is a lack of studies that evaluate the effectiveness of FES addition on ground level gait training with BWS, which is the most common locomotion surface. OBJECTIVE: To investigate the additional effects of commum peroneal nerve FES combined with gait training and BWS on ground level, on spatial-temporal gait parameters, segmental angles, and motor function. METHODS: Twelve people with chronic hemiparesis participated in the study. An A1-B-A2 design was applied. A1 and A2 corresponded to ground level gait training using BWS, and B corresponded to the same training with the addition of FES. The assessments were performed using the Modified Ashworth Scale (MAS), Functional Ambulation Category (FAC), Rivermead Motor Assessment (RMA), and filming. The kinematics analyzed variables were mean walking speed of locomotion; step length; stride length, speed and duration; initial and final double support duration; single-limb support duration; swing period; range of motion (ROM), maximum and minimum angles of foot, leg, thigh, and trunk segments. RESULTS: There were not changes between phases for the functional assessment of RMA, for the spatial-temporal gait variables and segmental angles, no changes were observed after the addition of FES. CONCLUSION: The use of FES on ground level gait training with BWS did not provide additional benefits for all assessed parameters.

CONTEXTUALIZAÇÃO: A adição da estimulação elétrica funcional (EEF) ao treino de marcha em esteira, com sistema de suporte parcial de peso corporal (SPPC), tem sido proposta como estratégia para melhorar a marcha em hemiparéticos. Entretanto, nenhum estudo verificou a eficácia da adição da EEF ao treino de marcha com SPPC em piso fixo, a superfície mais habitual de locomoção. OBJETIVO: Investigar os efeitos da adição da EEF do nervo fibular comum, ao treino de marcha com SSPC, em piso fixo, sobre os parâmetros espaço-temporais da marcha, ângulos segmentares e função motora. MÉTODOS: Participaram do estudo 12 hemiparéticos crônicos. O sistema adotado foi o A1-B-A2. A1 e A2 corresponderam ao treino em piso fixo com SPPC, e B, ao mesmo treino, associado à EEF. As avaliações foram realizadas por meio da Escala de Ashworth Modificada (EAM), da Categoria de Deambulação Funcional (CDF), da Avaliação Motora de Rivermead (AMR) e de filmagens. As variáveis cinemáticas analisadas foram: velocidade média de locomoção; comprimento do passo; comprimento, velocidade e duração da passada; duração dos períodos de apoio duplo inicial e final, apoio simples e balanço; ângulos máximos e mínimos e amplitude de movimento (ADM) dos segmentos pé, perna, coxa e tronco. RESULTADOS: Na AMR, não houve alterações entre as fases. Para as variáveis espaço-temporais e ângulos segmentares, não houve nenhuma alteração após a adição da EEF. CONCLUSÃO: A adição da EEF ao treino de marcha em piso fixo com SPPC não promoveu melhora adicional nos parâmetros mensurados.

Use of hippotherapy in gait training for hemiparetic post-stroke / Utilização da hipoterapia no treino de marcha em indivíduos hemiparéticos pós-acidente vascular cerebral

OBJECTIVE: To evaluate the hippotherapy influence on gait training in post-stroke hemiparetic individuals. METHOD: The study was constituted of 20 individuals divided into two groups. Group A performed the conventional treatment while group B the conventional treatment along with hippotherapy during 16 weeks. The patients were evaluated by using the Functional Ambulation Category Scale, Fugl-Meyer Scale, only the lower limbs and balance sub items, Berg Balance Scale, and functional assessment of gait (cadence) in the beginning and end of the treatment. RESULTS: Significant improvements were observed in the experimental group including motor impairment in lower limbs (p=0.004), balance, over time (p=0.007) but a significant trend between groups (p=0.056). The gait independence, cadence and speed were not significantly in both groups (p=0.93, 0.69 and 0.44). CONCLUSION: Hippotherapy associated with conventional physical therapy demonstrates a positive influence in gait training, besides bringing the patients' gait standard closer to normality than the control group.

OBJETIVO: Avaliar a influência da hipoterapia no treino de marcha em indivíduos hemiparético pós-AVC. MÉTODO: O estudo constou de 20 indivíduos divididos em dois grupos (A e B); o grupo A realizou tratamento convencional e o grupo B, tratamento convencional e hipoterapia, durante 16 semanas. Os pacientes foram avaliados pela Escala de Fugl-Meyer, Escala de Equilíbrio de Berg, Escala de Deambulação Funcional e a Cadência, no início e no final do tratamento. RESULTADOS: Melhoras significativas foram observadas no grupo experimental incluindo comprometimento motor em membros inferiores (p-valor=0,004), o equilíbrio, em relação ao tempo (p-valor=0,007) porém uma tendência significância entre os grupos (p=0,056). A independência na marcha, cadência e a velocidade não apresentaram relevância estatística em ambos os grupos (p-valor=0,93, 0,69 e 0,44). CONCLUSÃO: A Hipoterapia associada ao tratamento convencional mostra ter influência no treino de marcha, além de tornar o padrão de marcha dos pacientes mais próximo da normalidade em relação ao grupo controle.

A simple method to assess freezing of gait in Parkinson's disease patients

Freezing of gait (FOG) can be assessed by clinical and instrumental methods. Clinical examination has the advantage of being available to most clinicians; however, it requires experience and may not reveal FOG even for cases confirmed by the medical history. Instrumental methods have an advantage in that they may be used for ambulatory monitoring. The aim of the present study was to describe and evaluate a new instrumental method based on a force sensitive resistor and Pearson's correlation coefficient (Pcc) for the assessment of FOG. Nine patients with Parkinson's disease in the "on" state walked through a corridor, passed through a doorway and made a U-turn. We analyzed 24 FOG episodes by computing the Pcc between one "regular/normal" step and the rest of the steps. The Pcc reached ±1 for "normal" locomotion, while correlation diminished due to the lack of periodicity during FOG episodes. Gait was assessed in parallel with video. FOG episodes determined from the video were all detected with the proposed method. The computed duration of the FOG episodes was compared with those estimated from the video. The method was sensitive to various types of freezing; although no differences due to different types of freezing were detected. The study showed that Pcc analysis permitted the computerized detection of FOG in a simple manner analogous to human visual judgment, and its automation may be useful in clinical practice to provide a record of the history of FOG.

Escalas de controle de tronco como prognóstico funcional em pacientes após acidente vascular encefálico / Trunk Control Scales as functional predictors for stroke patients

De acordo com a Organização Mundial de Saúde (OMS), o acidente vascular encefálico (AVE) é considerado uma síndrome com desenvolvimentorápido de sinais clínicos de perturbação focal ou global da função cerebral, com possível origem vascular e com mais de 24horas de duração. Além de o AVE causar déficits no movimento dos membros, marcha e linguagem, o déficit de controle da mobilidadedo tronco é também um problema muito importante. O Objetivo deste estudo foi identificar a relação entre a alteração no controle detronco, através de escalas, e incapacidade funcional de pacientes hemiparéticos após AVE. Foi realizado um estudo de revisão de literaturaatravés do acesso aos indexadores de produção científica, sendo selecionados oito artigos clínicos, longitudinais e descritivos.Todos os autores observaram relação prognóstica entre o controle de tronco e habilidades funcionais. As escalas utilizadas foram a Trunk Control Test (TCT), Postural Assessment Scale for Stroke Patients (PASS-TC) e Trunk Impairment Scale (TIS) (Fujiwara e Verheyden).Concluiu-se que a avaliação clínica do controle de tronco, através das escalas, constitui uma ferramenta importante para o prognósticodas habilidades funcionais de pacientes hemiparéticos após AVE, e para o planejamento de um tratamento específico e diferenciado paraesses pacientes. Entretanto, há poucos estudos comprovando esta relação, sendo que estes utilizaram diferentes escalas, não havendoum consenso entre os autores. Além das escalas, não há concordância nos dados para a avaliação do balance e marcha.

triad of idiopathic normal-pressure hydrocephalus a clinical practice case report

An 89-year-old white male presented with memory impairment, slowness in responsiveness, and frequent falls over a two-year duration. Six months earlier, the patient was believed to have had a [dementia with parkinsonian features,] but showed no response to incrementing doses of both donepezil and carbidopa-levodopa. Urinary urgency was believed to have been due to prostate hypertrophy. A head CT with contrast revealed moderate ventriculomegaly in the setting of mild diffuse cortical atrophy. A diagnosis of idiopathic normal-pressure hydrocephalus [INPH] was made

Changes in cortical relative power in patients submitted to a tendon transfer: a pre and post surgery study

The aim of this study is analyze possible modifications in the cerebral cortex, through quantitative electroencephalography (qEEG) in patients submitted to a tendon transfer procedure (posterior tibialis) by the Srinivasan's technique. Four subjects (2 men and 2 women), 49.25 age average (SD±21.4) were studied. All subjects have been through surgical procedure due to leprosy and had, at least, two years of drop foot condition. The qEEG measured the electrocortical activity (relative power) between 8 and 25 Hz frequencies pre and post surgery. A paired t test analyzed all data (p<0,05). The results show significant alterations in the alpha relative power, electrodes F7 (p=0.01) and F8 (p=0.021). Altogether, based on findings of the current literature, we can conclude that the tendon transfer procedure suggests electrocortical alterations sensitive to specific qEEG bands.

O objetivo deste estudo é analisar possíveis modificações no córtex cerebral, através da electrencefalografia quantitativa (EEGq), em pacientes submetidos a um procedimento de transferência de tendão (tibial posterior) pela técnica de Srinivasan. Quatro sujeitos (2 homens e 2 mulheres), com média de idade de 49,25 anos (±21,4 DP) foram estudados. Todos os sujeitos realizaram o procedimento cirúrgico devido a hanseníase e tinham, pelo menos, dois anos de pé caído. O EEGq mediu a atividade electrocortical (potencia relativa) entre freqüências de 8 e 25 Hz, no pré e pós-operatório. Um teste t pareado analisou todos os dados (p<0,05). Os resultados mostram alterações significativas na potência relativa em alfa, nos elétrodos F7 (p=0,01) e F8 (p=0,021). Baseados em recentes achados na literatura, podemos concluir que o procedimento de transferência de tendão sugere alterações eletrocorticais sensíveis às freqüên-cias específicas do EEGq.

Alteration of the load-response mechanism of the knee joint during hemiparetic gait following stroke analyzed by 3-dimensional kinematic

OBJETIVO: O objetivo deste estudo foi avaliar as variáveis resultantes da alteração do mecanismo de resposta à carga por análise tridimensional da cinemática angular da articulação do joelho durante a marcha hemiparética oriunda de acidente vascular cerebral. MÉTODO: Estudo retrospectivo com 66 pacientes adultos de ambos os sexos (33 masculino e 33 feminino), com idade 45,4 ± 8,5 anos, com diagnóstico de acidente vascular cerebral isquêmico com hemiparesia em lado direito ou esquerdo. Todos os pacientes foram submetidos ao protocolo de realização do exame tridimensional computadorizado de marcha por meio de VICON/PEAK® 370. Os valores da cinemática angular do joelho foram selecionados para análise. RESULTADOS: Não foram encontradas diferenças estatisticamente significantes (teste de Kruskal Wallis) entre os sujeitos para as variáveis: posição angular e pico de flexão do joelho (p<0,05). As caracterísitcas clínicas relevantes encontradas foram: aumento da flexão do joelho no contato inicial e amplitude de movimento abaixo do esperado nesta fase do ciclo de marcha, estas são as que devem ser levadas em conta na seleção do melhor tratamento, pois são as que apresentam alterações importantes no mecanismo de resposta à carga na totalidade dos pacientes. DISCUSSÃO: O mecanismo de resposta à carga é fundamental para o andar porque tem como objetivo reduzir o impacto no membro inferior e suavizar o deslocamento do centro de massa no espaço reduzindo assim o consumo energético. Esta capacidade necessita ser compreendida para ser então melhor tratada e reabilitada. A dificuldade é que ainda não há consenso entre os diversos estudiosos do tema sobre as variáveis cinemáticas das articulações durante a marcha hemiparética.

Coerência espectral do eletrencefalograma em pacientes submetidos a transposição tendinosa: estudo pré e pós-operatório / EEG spectral coherence at patients submitted to tendon transfer surgery: study pre and post surgery

A transferência tendinosa do músculo tibial posterior é intervenção cirúrgica bastante utilizada na ortopedia para correção do pé caído por seqüela de hanseníase. Poucos modelos propuseram investigações mais significativas sobre os fenômenos plásticos cerebrais nas transferências tendinosas. O presente estudo teve como objetivo analisar a coerência espectral (CE) na Eletroencefalografia (EEG) em pacientes submetidos a transferência do tendão do tibial posterior pela técnica de Srinivasan através da EEG quantitativa (EEGq). A amostra foi composta de quatro sujeitos com pé caído devido a seqüela de hanseníase. Os parâmetros de CE do EEG foram quantificados no momento pré e pós-operatório. Os resultados mostraram que houve efeito principal para o fator momento, significativo, no par de eletrodos C3-CZ, com aumento da coerência. Entretanto, os achados da ANOVA não revelaram interação significativa entre bandas versus momento. A recuperação funcional promovida por tal cirurgia parece gerar alterações corticais.

Histological characteristics of arterialized medullary vein in spinal dural arteriovenous fistulas related with clinical findings: report of five cases.

The histological features of arterialized medullary vein (MV) in spinal dural arteriovenous fistulas (SDAVF) were studied in five consecutive patients who presented with progressive congestive myelopathy. Retrograde venous filling on preoperative angiography was recognized as being severe in 3 cases and moderate in 2 cases. Direct intradural interruption of the arterialized MV was performed in all patients. The arterialized MV was sampled and examined histologically to determine the percentage of the hyperplasia of venous wall (hypertrophic ratio). Histological examination of arterialized MV showed that hypertrophic alteration of venous wall structure was due to hyperplasia of elastic fibers, ranging from 41 to 82%. Patients with angiographically severe venous hypertension tended to have a higher hypertrophic ratio than patients with moderate venous hypertension. Our observations support the clinical concept that long-standing arterial stress in the spinal venous circulation causes histological alterations of spinal vascular structure associated with the progression of venous hypertension. We suggested that possibly the histological parameter can be used for predicting neurological recovery after occlusion of the fistulas.

Ganglion cyst of the proximal tibiofibular joint causing foot drop-diagnostic problem of differentiating from neuritic leprosy.

A six-year old boy presented with pain around the knee joint and abnormal gait of one month duration. There was no history of hypopigmented anaesthetic patches, neuritis or family history of leprosy. Clinical examination revealed a localized cystic swelling of 1 x 1 cm in size in the region of left common peroneal nerve, with sensory loss on the lateral aspect of the left leg which was mistaken for a nerve abscess.

Spinal cord compression: Need for high index of suspicion

Spinal cord compression in its different forms may be an elusive diagnosis and can result in permanent paraplegia. We present a case of spinal cord compression in a 40 year old female with back pain and progressive gait abnormalities. Patients may present to primary care physicians, who need to maintain a high index of suspicion for spinal cord compression in appropriate settings. History and physical examination can lead to diagnosis and management thus preventing major morbidity. The list of differentials is long and varied, but a judicious history and detailed examination can narrow it down to a few, enabling, appropriate and cost effective investigations and urgent referral to the correct speciality