The changing face of neurological rehabilitation

INTRODUÇÃO: A reabilitação neurológica e a contribuição da fisioterapia mudaram consideravelmente nas últimas décadas, uma vez que o desenvolvimento científico e tecnológico permitiu uma maior compreensão dos mecanismos de reorganização cerebral e dos mecanismos envolvidos no controle e desempenho motores, em suas dificuldades e adaptações. OBJETIVO: Este artigo apresenta uma perspectiva histórica da segunda metade do século passado. DISCUSSÃO: Pesquisas científicas atuais e a subseqüente reavaliação do efeito funcional dos problemas que aparecem pela lesão do neurônio motor superior estão levando à mudança de foco das intervenções clínicas, com ênfase na otimização motora através de exercícios de tarefas orientadas, de ganho de força e de treino de desempenho físico. Achados em modelos animais e humanos sugerem que, para que a reabilitação seja eficiente em otimizar a reorganização neural e a recuperação funcional, uma ênfase maior deve ser colocada em tarefas úteis que sejam desafios interessantes com um treino que promove o aprendizado. As questões da intensidade do treino de tarefas e da extensão do estresse cardiovascular durante a atividade física também são discutidos. Embora exista muito que se aprender em achados de pesquisa clínica, a prática clínica da reabilitação continua ser altamente variada, dependendo largamente do método preferido pelo terapeuta individual, e com predomínio dos métodos terapêuticos desenvolvidos meio século atrás. Fisioterapeutas necessitam assumir a responsabilidade do uso de técnicas baseadas em evidências, ou pelo menos usar métodos de intervenção e medidas objetivas de resultados que sejam cientificamente aceitáveis.

Functional strength training in cerebral palsy: a pilot study of a group circuit training class for children aged 4-8 years.

OBJECTIVE: To determine the effects of intensive task-specific strength training on lower limb strength and functional performance in children with cerebral palsy. DESIGN: A nonrandomized ABA trial. SETTING: Sydney school. SUBJECTS: Eight children with cerebral palsy, aged 4-8 years, seven with diagnosis of spastic diplegia, one of spastic/ataxic quadriplegia. INTERVENTION: Four weeks of after-school exercise class, conducted for one hour twice weekly as group circuit training. Each work station was set up for intensive repetitive practice of an exercise. Children moved between stations, practising functionally based exercises including treadmill walking, step-ups, sit-to-stands and leg presses. MAIN OUTCOME MEASURES: Baseline test obtained two weeks before training, a pre-test immediately before and a post-test following training, with follow-up eight weeks later. Lower limb muscle strength was tested by dynamometry and Lateral Step-up Test; functional performance by Motor Assessment Scale (Sit-to-Stand), minimum chair height test, timed 10-m test, and 2-minute walk test. RESULTS: Isometric strength improved pre- to post-training by a mean of 47% (SD 16) and functional strength, on Lateral Step-up Test, by 150% (SD 15). Children walked faster over 10 m, with longer strides, improvements of 22% and 38% respectively. Sit-to-stand performance had improved, with a reduction of seat height from 27 (SD 15) to 17 (SD 11) cm. Eight weeks following cessation of training all improvements had been maintained. CONCLUSIONS: A short programme of task-specific strengthening exercise and training for children with cerebral palsy, run as a group circuit class, resulted in improved strength and functional performance that was maintained over time.

Exercise and training to optimize functional motor performance in stroke: driving neural reorganization?

Neurorehabilitation is increasingly taking account of scientific findings. Research areas directing stroke rehabilitation are neurophysiology; adaptability to use and activity; biomechanics; skill learning; and exercise science (task, context specificity). Understanding impairments and adaptations enables a reappraisal of interventions-for example, changes in motor control resulting from impairments (decreased descending inputs, reduced motor unit synchronization), secondary soft tissue changes (muscle length and stiffness changes) are adaptations to lesion and disuse. Changes in interventions include increasing emphasis on active exercise and task-specific training, active and passive methods of preserving muscle extensibility. Training has the potential to drive brain reorganization and to optimize functional performance. Research drives the development of training programs, and therapists are relying less on one-to-one, hands-on service delivery, making use of circuit training and group exercise and of technological advances (interactive computerized systems, treadmills) which increase time spent in active practice. Emphasis is on skill training, stressing cognitive engagement and practice, aiming to increase strength, control, skill, endurance, fitness, and social readjustment. Rehabilitation services remain slow to make the changes necessary to upgrade environments, attitudes, and rehabilitation methodologies to those shown to be more scientifically rational and for which there is evidence of effectiveness.

Sitting balance II: reach direction and thigh support affect the contribution of the lower limbs when reaching beyond arm's length in sitting.

The effects of reach direction and extent of thigh support on the contribution of the lower limbs during seated reaching were examined. Twelve healthy subjects aged 59-79 years performed self-paced reaching forwards and diagonally to both sides and under three thigh support conditions. Vertical ground reaction forces (GRF) and leg muscle activity were monitored bilaterally. Reach direction affected both the magnitude of peak vertical GRF and the relative distribution of vertical GRF through the feet, demonstrating that the lower limbs work cooperatively to control the motion of the body mass. Extent of thigh support also affected the magnitude of peak vertical GRF through the feet. In addition, the EMG data confirmed the active contribution of the lower limbs when reaching beyond arm's length, with muscles in both lower limbs activated in all trials.

Muscle length effect on the pendulum test.

OBJECTIVE: An investigation of the effect of the length of knee extensor muscles on the pendulum test. DESIGN: Descriptive. Statistical analysis utilized analysis of variance with planned comparisons. SETTING: Community clubs and a stroke rehabilitation unit. PARTICIPANTS: Twenty subjects aged 54 to 83 yrs, more than 6 weeks after stroke, and 31 healthy subjects aged 60 to 79 yrs. OUTCOME MEASURES: Two tests: pendulum test and knee extensor muscle length test. RESULTS: For both affected and intact legs, stroke subjects had significantly smaller angle of reversal (p < .001), peak angular velocity (p < .001), and maximum passive knee flexion (p < .001) than healthy subjects. When angle of reversal was normalized for passive knee flexion, there were no significant differences between healthy and stroke subjects. There were no significant differences in any variable between the intact and affected legs of the stroke subjects. CONCLUSION: Soft tissue changes, rather than hyperreflexia, may explain the decreased angle of reversal and peak angular velocity in the stroke subjects studied.

Frequency-volume chart data from incontinent children.

OBJECTIVE: To establish the mean and standard deviation about the mean for voiding variables of incontinent children aged 6-11 years as measured on a frequency-volume chart (FVC), and to determine the effect of type of incontinence, gender and age on these values. PATIENTS AND METHODS: All children attending two continence clinics over a 3-year period completed a FVC as a routine part of their assessment. Voided volume and voiding interval data were collected from these charts. The mean maximum, mean minimum and overall mean voided volume and voiding interval were established for the whole group and then for each age, gender and type of incontinence. RESULTS: The voiding patterns of incontinent children were very variable and thus the standard deviation for each voiding parameter was large. Multivariate analysis showed that the only variable that affected any of these apparent storage parameters was the child's age; gender and type of incontinence did not influence bladder storage patterns. Children with day-time incontinence did not have smaller voided volumes than those with nocturnal enuresis. CONCLUSION: Both the mean and the standard deviation about the mean of all voided volumes varied widely amongst incontinent children. Only age appeared to influence trends in voided volumes. Any clinical investigation using the FVC in children should consider the high standard deviation when calculating sample size.

Task-related training improves performance of seated reaching tasks after stroke. A randomized controlled trial.

BACKGROUND AND PURPOSE: After stroke, the ability to balance in sitting is critical to independence. Although impairments in sitting balance are common, little is known about the effectiveness of rehabilitation strategies designed to improve it. The purpose of this randomized placebo-controlled study was to evaluate the effect of a 2-week task-related training program aimed at increasing distance reached and the contribution of the affected lower leg to support and balance. METHODS: Twenty subjects at least 1 year after stroke were randomized into an experimental or control group. The experimental group participated in a standardized training program involving practice of reaching beyond arm's length. The control group received sham training involving completion of cognitive-manipulative tasks within arm's length. Performance of reaching in sitting was measured before and after training using electromyography, videotaping, and two force plates. Variables tested were movement time, distance reached, vertical ground reaction forces through the feet, and muscle activity. Subjects were also tested on sit-to-stand, walking, and cognitive tasks. Nineteen subjects completed the study. RESULTS: After training, experimental subjects were able to reach faster and further, increase load through the affected foot, and increase activation of affected leg muscles compared with the control group (P < .01). The experimental group also improved in sit-to-stand. The control group did not improve in reaching or sit-to-stand. Neither group improved in walking. CONCLUSIONS: This study provides strong evidence of the efficacy of task-related motor training in improving the ability to balance during seated reaching activities after stroke.

The epidemiology of childhood enuresis in Australia.

OBJECTIVE: To establish the prevalence of enuresis in 5-12-year-old Australian children, to evaluate the impact of enuresis on the children and their families and to identify common methods of managing enuresis. SUBJECTS AND METHODS: A self-administered questionnaire was completed voluntarily by the parents of 2292 5-12-year-old children during attendance at electoral polling booths in Sydney, Australia. The questionnaire inquired specifically after the child's age, gender and frequency of wetting. RESULTS: From a response rate of 74%, the overall prevalence of any reported nocturnal enuresis was 18.9% and any day wetting 5.5%. The prevalence of marked nocturnal enuresis (at least weekly) and marked day wetting was 5.1% and 1.4%, respectively. Using a 10-point visual analogue scale to measure parental concern about their child's enuresis, the mean concern score was 3.1. There was a moderate but significant relationship between the frequency of enuretic episodes and the parental concern score. Of the enuretic children, 34% had consulted with a health worker. These children were 1.4 years older and wet more frequently than those enuretic children who had not sought help. The management of enuresis involved a mean of 3.9 strategies, primarily behavioural techniques administered by the family. The lowest cure rate was seen in the children who wet more frequently. Significantly more of the dry children woke spontaneously at night to void compared with the enuretic children. There was a trend towards greater spontaneous arousal in the children who wet less frequently. CONCLUSION: These results suggest that prevalence rates for day and night wetting in Australia are similar to those in previous studies reported from the northern hemisphere. Australian families did not report a high level of concern about enuresis, even in the older child. The problem was managed primarily within the family.

Some biomechanical consequences of varying foot placement in sit-to-stand in young women.

The position in which the feet are placed prior to the start of sit-to-stand affects the distance to be moved by the body mass forward over the feet. The purpose of this study was to examine the effect of three foot placements, back, preferred and forward, on biomechanical features of the action. Six subjects were videotaped standing up from a seat with feet on a forceplate. XY coordinates and forceplate data were synchronised and kinematic and kinetic variables analysed. A forward foot placement significantly affected both the pre-extension and extension phases of the action. Under this condition, it was evident that body mass was moved the greater distance horizontally: i) by increasing the speed and amplitude of trunk flexion; and ii) by increasing the time over which the shank rotated forward at the ankle. Vertical movement of body mass was achieved largely by a 50% increase in peak moment of force at the hip. It is concluded that a forward foot placement would adversely affect the ease of standing up for individuals with leg muscle weakness and poor motor control. Since the altered biomechanical characteristics may place additional strain on the hip, patients should be cautioned to avoid standing up with feet forward after hip replacement surgery.

Investigation of a new motor assessment scale for stroke patients.

The purpose of this paper is to present and describe a motor assessment scale (MAS) for stroke patients and to report on the investigation of two aspects of its reliability. The MAS is a brief and easily administered assessment of eight areas of motor function and one item related to muscle tone. Each item is scored on a scale from 0 to 6. To check interrater reliability, we videotaped five stroke patients while they were being assessed with the MAS. These scores were used as the criterion ratings. Twenty raters then assessed these patients, and their results were correlated with the criterion ratings. We determined test-retest reliability by assessing on two occasions, separated by a four-week interval, 14 stroke patients whose recovery was considered to be stable and by correlating these scores. The MAS was found to be highly reliable with an average interrater correlation of .95 and an average test-retest correlation of .98.

Some factors influencing the outcome of stroke rehabilitation.

The eventual outcome of a stroke patient's rehabilitation may depend as much upon his experiences following the stroke as upon the actual brain damage. Positive factorsinfluencing rehabilitation include the early stimulation of the body orienting mechanism in upright positions; the prevention of the development of spasticity; the therapist's understanding of the factors involved in learning a motor skill; the ability to analyse an everyday activity and find its missing or abnormal components an understanding of the current hypotheses about the effect of stimution upon the recovering brain. Negative factorsinclude a tendency to be obsessed with techniques of treatment rather than with a detailed analysis of the patient's problems; the perpetuation of certain 'myths' such as proximal to distal recovery of function, and practising movement in a neuro-developmental sequence despite the maturity of the adult patient's brain; a failure to understand the different physiological and behavioural mechanisms underlying apparently similar problems which leads to lack of cortical drive being confused with muscle weakness; the expectations of the therapist who expects a stroke patient will become spastic, will not recover functional use of his upper limb, and will need a quadripod stick in order not to fall over.

An infant enrichment programme.

I will describe briefly a programme which I have devised for the developmental enrichment of infants up to 12 months old. This programme is intended for those infants whose generalized developmental delay is associated with mental retardation. It is not designed for infants with brain damage, who require more specialized care for the complicated movement disorders associated with hypertonus or athetosis. This is a parent-orientated programme carried out by parents under the guidance of a physiotherapist.