Proprioceptive neuromuscular facilitation induces muscle irradiation to the lower limbs - A cross-sectional study with healthy individuals.

INTRODUCTION: This study aimed to evaluate the effectiveness of proprioceptive neuromuscular facilitation (PNF) in promoting muscle irradiation to the lower limbs and to relate these findings with muscle activation during the sit-to-stand task. METHODS: Twenty-four healthy women were recruited via convenience sampling and submitted to four PNF patterns: upper limb pattern with flexion-abduction-external rotation (UL), lower limb pattern with flexion-adduction-external rotation with knee flexion (lower limb pattern 1 [LL1]), lower limb pattern with flexion-abduction-internal rotation with knee flexion (lower limb pattern 2 [LL2]), and lifting to the right. Electromyography was recorded from the gluteus maximus, gluteus medius, vastus medialis, vastus lateralis, and soleus during the PNF patterns and during the sit-to-stand task. RESULTS: The most recruited muscles during the sit-to-stand task were the vastus lateralis, vastus medialis, and soleus (p < 0.05). Lifting to the right induced the greatest activation of the gluteus maximus (p < 0.001). Lifting to the right and LL2 were better than UL at recruiting the gluteus medius (p < 0.05). Lifting to the right and LL1 were better than UL at recruiting the vastus medialis and lateralis (p < 0.05; p < 0.05). and Lower limb pattern 1 and 2 were better than UL at recruiting the soleus muscle (p < 0.05). CONCLUSION: PNF can be used to induce muscle irradiation to maintain or improve muscle activity to the muscles recruited during the sit-to-stand task. The best PNF pattern for inducing muscle irradiation to muscles recruited during the sit-to-stand task are lifting to the right, LL2, and LL1.

Bi-cephalic transcranial direct current stimulation combined with functional electrical stimulation for upper-limb stroke rehabilitation: A double-blind randomized controlled trial.

BACKGROUND: Stroke survivors often present poor upper-limb (UL) motor performance and reduced movement quality during reaching tasks. Transcranial direct current stimulation (tDCS) and functional electrical stimulation (FES) are widely used strategies for stroke rehabilitation. However, the effects of combining these two therapies to rehabilitate individuals with moderate and severe impairment after stroke are still unknown. OBJECTIVE: Our primary aim was to evaluate the effects of concurrent bi-cephalic tDCS and FES on UL kinematic motor performance and movement quality of chronic post-stroke subjects with moderate and severe compromise. Our secondary aim was to verify the effects of combining these therapies on handgrip force and UL motor impairment. METHODS: We randomized 30 individuals with moderate and severe chronic hemiparesis after stroke into tDCS plus FES (n=15) and sham tDCS plus FES (n=15) groups. Participants were treated 5 times a week for 2 weeks. Kinematic motor performance (movement cycle time, velocity profile) and movement quality (smoothness, trunk contribution, joint angles) were assessed during an UL reach-to-target task.Handgrip force and motor impairment were also recorded before and after the intervention. RESULTS: Participants allocated to the tDCS plus FES group improved movement cycle time (P=0.039), mean reaching velocity (P=0.022) and handgrip force (P=0.034). Both groups improved the mean returning phase velocity (P=0.018), trunk contribution (P=0.022), movement smoothness (P=0.001) and UL motor impairment (P=0.002). CONCLUSIONS: Concurrent bi-cephalic tDCS and FES slightly improved reaching motor performance and handgrip force of chronic post-stroke individuals with moderate and severe UL impairment. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02818608).

Fugl-Meyer Assessment Scores Are Related With Kinematic Measures in People with Chronic Hemiparesis after Stroke.

BACKGROUND: Stroke often results in motor impairment and limited functional capacity. This study aimed to verify the relationship between widely used clinical scales and instrumented measurements to evaluate poststroke individuals with mild, moderate, and severe motor impairment. METHODS: This cross-sectional study included 34 participants with chronic hemiparesis after stroke. Fugl-Meyer Assessment and Modified Ashworth Scale were used to quantify upper and lower limb motor impairment and the resistance to passive movement (i.e., spasticity), respectively. Upper limb Motor performance (movement time and velocities) and movement quality (range of motion, smoothness and trunk displacement) were analyzed during a reaching forward task using an optoelectronic system (instrumented measurement). Lower limb motor performance (gait and functional mobility parameters) was assessed by using an inertial measurement unit system. FINDINGS: Fugl-Meyer Assessment correlated with motor performance (upper and lower limbs) and with movement quality (upper limb). Modified Ashworth scale correlated with movement quality (upper limb). Cutoff values of 9.0 cm in trunk anterior displacement and .57 m/s in gait velocity were estimated to differentiate participants with mild/moderate and severe compromise according to the Fugl-Meyer Assessment. CONCLUSIONS: These results suggest that the Fugl-Meyer Assessment can be used to infer about motor performance and movement quality in chronic poststroke individuals with different levels of impairment.

Upper-limb movement smoothness after stroke and its relationship with measures of body function/structure and activity - A cross-sectional study.

INTRODUCTION: After a stroke, upper limb (UL) motor impairments interfere with functional activities and quality of life. Even though a range of assessment tools has been developed to assess UL, few studies explore the interfaces between different levels of functioning after stroke. OBJECTIVES: (a) verify the correlation between movement smoothness and other measures of body function/structure [UL - Fugl-Meyer Assessment (FMA), and handgrip strength]; (b) verify which body function/structure [UL-FMA and/or handgrip strength] could predict UL movement smoothness; and (c) verify if movement smoothness could predict levels of activity, as assessed by the Box and Block Test (BBT). MATERIALS AND METHODS: Cross-sectional study. Thirty-four individuals with chronic hemiparesis after stroke were enrolled. Measurements of body function/structure included FMA, handgrip strength and kinematic measure of movement smoothness. Levels of activity were measured using the Box and Block Test (BBT). RESULTS: Movement smoothness showed strong correlation with FMA (r = 0.70, p < .001) and moderate correlation with handgrip strength (r = 0.63, p < .001). FMA explained 46.4% of the variation in movement smoothness. Movement smoothness was moderately correlated with BBT (r = -0.560, p < .005) and predicted 31% of the variation in BBT. CONCLUSION: We recommend the use of UL-FMA to predict movement smoothness in chronic post-stroke subjects. This study also showed that movement smoothness influences the level of activity. Then, movement smoothness may be emphasized during stroke rehabilitation to enhance the UL level of activity in chronic post-stroke subjects.

Noninvasive brain stimulation combined with other therapies improves gait speed after stroke: a systematic review and meta-analysis.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are noninvasive brain stimulation (NIBS) techniques able to modulate cortical excitability. OBJECTIVE: To determine the effects of NIBS combined with other therapies on gait speed after stroke. METHODS: Electronic databases searched were PUBMED, EMBASE, COCHRANE, SCOPUS, SCIELO and PEDro. Eligibility criteria were randomized controlled trials that reported the effects of tDCS and rTMS combined with other therapies for improving gait speed, walking cadence, functional ambulation category (FAC) and motricity index (MI-LE) after stroke. Risk of bias was assessed by Cochrane risk of bias assessment tool. Mean differences (MD) and 95% confidence intervals were calculated. Quality of evidence was assessed by Grades of Researches, Assessment, Development and Evaluation approach. RESULTS: Ten studies (226 subjects) were included in the meta-analysis. NIBS combined with other therapies was effective for improving gait speed (MD 0.09 m/s [95% CI, 0.05 to 0.13; I2 0%, p < 0.0001]). Gait speed improved in both acute/subacute (MD 0.08 m/s [95% CI, 0.02 to 0.14]) and chronic phases (MD 0.08 m/s [95% CI, 0.03 to 0.13]). Furthermore, inhibitory (MD 0.09 m/s [95% CI, 0.04 to 0.14]) and excitatory (MD 0.07 m/s [95% CI, 0.02 to 0.12]) protocols were effective to improve gait speed. NIBS was also effective to improve walking cadence but was unable to modify other outcomes (FAC and MI-LE). CONCLUSIONS: This systematic review with meta-analysis synthesizes moderate-quality evidence that NIBS combined with other therapies are effective to improve gait speed after stroke. Systematic Review registration number: PROSPERO registration number CDR42015024237.

Automated Mechanical Peripheral Stimulation Improves Gait Parameters in Subjects With Parkinson Disease and Freezing of Gait: A Randomized Clinical Trial.

OBJECTIVE: This study aimed to assess spatiotemporal gait parameters and range of motion of lower limbs in subjects with Parkinson disease (PD) and freezing of gait, treated with automated mechanical peripheral stimulation (AMPS) or AMPS SHAM (placebo). DESIGN: This randomized clinical trial included 30 subjects allocated into two groups: AMPS (15 subjects with PD) and AMPS SHAM (15 subjects with PD). Fourteen age-matched healthy subjects were also included as a reference group. Both PD groups received the treatment twice a week during 4 weeks. Automated mechanical peripheral stimulation was applied using a commercial medical device (Gondola) and consisted of mechanical pressure in four areas of feet. For AMPS SHAM group, a subliminal stimulus was delivered. Gait analysis were measured before, after the first, after the fourth, and after the eighth sessions. RESULTS: We did not find significant differences between AMPS and AMPS SHAM groups either for spatiotemporal gait parameters or for range of motion of lower limbs. However, within-group analysis showed that AMPS group significantly improved spatiotemporal gait parameters and hip rotation range of motion throughout the treatment period. The AMPS SHAM group did not show any improvement. CONCLUSIONS: Automated mechanical peripheral stimulation therapy induces improvements in spatiotemporal parameters and hip rotation range of motion of subjects with PD and freezing of gait. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Understand the impact of reduced plantar sensitivity on gait in individuals with Parkinson disease; (2) Identify the improvements on spatiotemporal gait parameters in subjects with Parkinson disease and freezing of gait after automated mechanical peripheral stimulation therapy; and (3) Recommend the use of new strategies of plantar stimulus for gait disorders of subjects with Parkinson disease. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Electric Stimulation for Pain Relief in Patients with Fibromyalgia: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Fibromyalgia (FM) is a syndrome whose primary symptoms include chronic widespread muscle pain and fatigue. The treatment of patients with FM aims to provide symptomatic relief and improvement in physical capacities to perform daily tasks and quality of life. Invasive or non-invasive electric stimulation (ES) is used for pain relief in patients with FM. OBJECTIVE: This systematic review aimed to assess the effects of treatment with ES, combined or not combined with other types of therapy, for pain relief in patients with FM. STUDY DESIGN: Systematic review and meta-analysis. SETTING: Electronic search was conducted on databases (from the inception to April 2016): MEDLINE (accessed by PubMed), EMBASE, Cochrane Central Register of Controlled Trials (Cochrane CENTRAL), and Physiotherapy Evidence Database (PEDro). METHODS: Two independent reviewers assessed the eligibility of studies based on the inclusion criteria: randomized controlled trials (RCTs) examining the effects of ES combined or not with other types of treatment for pain relief in patients with FM (according to the American College of Rheumatology), regardless of the ES dosages. The primary outcome was pain, assessed by the visual analogue scale (VAS). The secondary outcomes extracted were quality of life, assessed by short form-36 health survey (SF- 36), and fatigue, assessed by VAS. RESULTS: Nine studies were included, with 301 patients. The meta-analysis for pain showed positive effect of ES treatment versus control [-1.24 (95% CI: -2.39 to -0.08; I²: 87%, P = 0.04) n = 8 RCTs]. The sensitivity analysis for pain showed significant results for invasive ES, combined or not with other types of therapy [-0.94 (95% CI, -1.50 to -0.38; I² 0%, P = 0.001) n = 3 RCTs]. No significant improvement was found regarding quality of life [-3.48 (95% CI: -12.58 to 5.62; I²: 0%, P = 0.45), n = 2 RCTs] or fatigue [-0.57 (95% CI, -1.25 to 0.11; I² 34%, P = 0.100; n = 4 RCTs]. LIMITATIONS: This systematic review included a small number of studies and reduced number of participants in each study. Furthermore, most of the studies showed some biases and lack of methodological quality. CONCLUSIONS: This meta-analysis indicates that there is low-quality evidence for the effectiveness of ES for pain relief in patients with FM. However, moderate-quality evidence for the effectiveness of electroacupuncture (EA), combined or not combined with other types of treatment, was found for pain relief. CLINICAL TRIAL REGISTRATION INFORMATION: PROSPERO under the identification CRD42015025323Key words: Electric stimulation, electroacupuncture, transcutaneous electric nerve stimulation, pain, fibromyalgia, review, physical therapy, rehabilitation.