Atividade muscular durante a marcha após acidente vascular encefálico

Biomedical Serious Game System for Balance Rehabilitation of Hemiparetic Stroke Patients

Hemiparetic stroke patients can have several muscular and postural disorders which compromise their balance. Serious games (SG) emerged as a new approach to enhance conventional treatment by making it a motivating method to meet individual needs. This paper evaluated the therapeutic effects of a biomedical SG system developed for balance evaluation and training of hemiparetic stroke patients. The system consists of a balance board with inertial sensors and a computer system that runs the game. A novel scoring system for balance evaluation, which extracts metric information regarding patients' performance while gaming, was proposed. A quasi-experimental study was performed with six hemiparetic patients in an exercise program using the SG twice per week for 10 weeks. Twelve healthy subjects were recruited for determining the baseline score for balance by using the proposed system. Significant effect sizes (ES) were observed for dynamic balance (ES = 0.9), functional mobility (ES = 0.4), and center of pressure displacement of the balance board (ES = 1.9).Significant correlations between game scores and clinical scales suggest that the use of the scoring system for balance evaluation is feasible. The results of this paper support the clinical potential of a biomedical SG for balance rehabilitation of hemiparetic stroke patients.

Neurophysiological Assessment of the Electrostimulation Procedures Used in Stroke Patients during Rehabilitation

The aim of this study was to evaluate the effectiveness of the associated electrotherapeutical and kinesiotherapeutical treatment in patients after ischemic stroke (N=24), mainly by means of neurophysiological tests. All patients underwent the same 20 days of neurorehabilitation procedures. Particular attention was paid to three-stage modified electrotherapy procedures such as: oververtebral functional electrical stimulation (FES), transcutaneous electrical nerve stimulation (TENS) and the alternate neuromuscular functional electrical stimulation (NMFES) of antagonistic muscles of the wrist and the ankle (N=16). Electrotherapy was supplemented with kinesiotherapeutic (mainly PNF) procedures acting as an amplifier. Clinical assessment included muscle tension (Ashworth's scale), muscle force (Lovett's scale) and reflex scoring at wrist and ankle. However, the effectiveness of the procedures was measured by the assessment of results in complex and repetitive, bilaterally performed global electromyography (EMG) and electroneurography (ENG; M-wave studies). The statistical analysis obtained from results in clinical and neurophysiological examinations suggested that the dorsiflexion of wrist and ankle was improved in the majority of patients who took part in this study. EMG and ENG examinations showed that 20 days of therapy improved both activity in muscle motor units on the more paralyzed side (mainly within upper extremities) and to a lesser degree in the transmission of efferent impulses within motor fibers of nerves. The results obtained suggest that patients after ischemic strokes never show an isolated unilateral disability in motor functions.

No definite similarities between the results of clinical and neurophysiological studies were found, which may suggest greater accuracy of the neurophysiological evaluation.

A new EMG-based index towards the assessment of elbow spasticity for post-stroke patients

The commonly used method for grading spasticity in clinical applications is Modified Ashworth Scale (MAS). The MAS-based method depends on the subjective evaluations and the experience of physicians, which may lead to imprecise and inconsistent evaluations. In this study, we propose a novel index (A-ApA, which was calculated with the root mean square (RMS) of agonist muscle activity by the mean between the RMS of agonistic and antagonistic muscle activations extracted from surface electromyography (sEMG) signals to quantitatively assess elbow spasticity. 39 post-stroke patients with elbow spasticity caused by hemiplegia participated in the experiments, and their elbow spasticity was assessed with MAS by one experienced physiotherapist. Patients were thereafter divided into four groups according to the MAS scales. The sEMG signals were recorded simultaneously on the patients' biceps and triceps when they extended or bended their elbows passively. The correlations between MAS and RMS of sEMG signals as well as the newly proposed index were calculated. The results demonstrated that the correlation between the MAS and the sEMG-based index in the assessment of elbow spasticity was significant. This suggests that the EMG-based index would be helpful for the assessment of spasticity..

Effects of treadmill training with load addition on non-paretic lower limb on gait parameters after stroke: A randomized controlled clinical trial

The addition of load on the non-paretic lower limb for the purpose of restraining this limb and stimulating the use of the paretic limb has been suggested to improve hemiparetic gait. However, the results are conflicting and only short-term effects have been observed. This study aims to investigate the effects of adding load on non-paretic lower limb during treadmill gait training as a multisession intervention on kinematic gait parameters after stroke. With this aim, 38 subacute stroke patients (mean time since stroke: 4.5 months) were randomly divided into two groups: treadmill training with load (equivalent to 5% of body weight) on the non-paretic ankle (experimental group) and treadmill training without load (control group). Both groups performed treadmill training during 30min per day, for two consecutive weeks (nine sessions). Spatiotemporal and angular gait parameters were assessed by a motion system analysis at baseline, post-training (at the end of 9days of interventions) and follow-up (40days after the end of interventions). Several post-training effects were demonstrated: patients walked faster and with longer paretic and non-paretic steps compared to baseline, and maintained these gains at follow-up. In addition, patients exhibited greater hip and knee joint excursion in both limbs at post-training, while maintaining most of these benefits at follow-up. All these improvements were observed in both groups. Although the proposal gait training program has provided better gait parameters for these subacute stroke patients, our data indicate that load addition used as a restraint may not provide additional benefits to gait training.

Respiratory function and functional capacity in chronic stroke patients 1

Abstract Introduction: Cerebrovascular accident (CVA) or stroke results in weakness of the trunk muscles and physical unfitness. Objectives: To evaluate respiratory changes caused by stroke and correlate them with the functional capacity of chronic stroke patients who were treated at the Clinical Center of Physical Therapy of the Pontifical Catholic University of Minas Gerais, Betim. Methods: Fifteen patients were recruited for assessment of respiratory function and functional capacity. We measured maximum inspiratory pressure (MIP), maximal expiratory pressure (MEP), peak expiratory flow (PEF), vital capacity (VC), and functional capacity using the six-minute walk test (6MWT). Test results were compared with reference values using an unpaired Student's t-test or the Mann-Whitney test. Respiratory variables were correlated with the distance walked in the 6MWT using Spearman's correlation test. Results: The sample had a mean age of 58.2 ± 13.4 years, and most patients had a diagnosis of ischemic stroke and left hemiparesis. The following values were obtained: MIP (47.7 ± 22.2 cmH2O); MEP (47.5 ± 20.3 cmH2O); PEF (351.3 ± 90.8 L/min); VC (3.0 ± 0.91 L); and 6MWT (222.4 ± 101.6 m). The MIP, MEP, PEF, and 6MWT values measured in this study were statistically significantly lower (p < 0.001) than the reference values. There was no statistically significant correlation between the distance walked in the 6 MWT and respiratory variables (p > 0.005). Conclusion: Our results suggest that, despite the decrease in respiratory muscle strength, PEF, and VC, these variables did not correlate with the functional capacity of the chronic stroke patients assessed in this study.

Controlled Study of Correlation of Biomechanical Profile of Hemiparetic Patients with Distance Travelled in Six Minutes

The six-minute walking test (6MWT) is used to assess exercise tolerance that is associated with motor function of the lower limbs in hemiparetic patients. It is suggested that, for post-stroke subjects, performance in the 6MWT may be limited by biomechanical and cardiovascular factors. Our aim is to determine the correlation between the six-minute walk distance (6MWD) and the biomechanical profile of hemiparetic patients. During this cross-sectional controlled study, 10 hemiparetic patients with heart failure underwent 6MWT (ATS protocol). Tonus (Ashworth Scale) and goniometry of the lower limbs were measured. The average of 6MWD in two tests was 279±8 m. There was a negative correlation between the degree of spasticity for both the sural triceps (r=-0.57, P<0.05), quadriceps (r=-0.58, P<0.05) and the limitation in ankle dorsiflexion and the 6MWD (r=-0.76, P<0.05). Also, there was correlation between hip extension and ankle dorsiflexion limitations with 6MWD (r=0.66, P<0.05), (r=0.77, P<0.05). The negative correlation between the highest spasticity in paretic limb and the 6MWD and the correlation between the lower movement range of paretic hip and ankle suggest association with these factors and gait velocity in 6MWT. Loss percentage represents the percentage calculation between distance traveled and the distance predicted achieved by patients. In this study, the negative correlation between the percentage of loss of 6MWD and the limitation in the ankle dorsiflexion movement suggests that for a minor motion arch of the ankle, there is a higher percentage of walking distance loss foretold.

Kinematic gait analysis using inertial sensors with subjects after stroke in two different arteries

[Purpose] The aim of the present study was described the kinematic characteristics of gait in stroke patients with two different arteries involved. [Subjects and Methods] Two patients who had suffered a basilar (A) or middle (B) cerebral artery ischemic stroke were compared with a control (C). Seventeen inertial sensors were used with acquisition rate of 120 Hz. The participants walked 3 times on a 10 meter walkway. From the raw data, the three gait cycles from the middle of each trial were chosen and analyzed. [Results] During the stance phase, patients A and B had a lower hip angle at initial contact and maximum flexion angle during load response than the control. Patient A and the control subject had similar knee angle values at initial contact, and patient B presented a flexed position in the initial phase of the gait cycle. The maximum flexion angles during loading response were also higher for patient B. The sagittal plane excursion for the ankle joint was lower for patient B in comparison with the other subjects. [Conclusion] Differences during walking between patients who had stroke in different arteries may be related to an alternative compensatory strategy. Patient A and the control subject had similar gait cycle curves at all joints, while patient B showed a rigid synergic pattern.

Use of functional bandages in patients with stroke

Introduction Functional bandages have been used in physiotherapeutic practice with the purpose of minimizing disabilities and favoring functional improvement. However, there is still a shortage of research regarding the use of these devices in patients with neurological sequelae, especially those resulting from stroke. Objective To report the motor evolution of patients living with sequelae of stroke, who have been submitted to the use of functional bandages associated with conventional physical therapy. Materials and methods We assessed the active range of motion, strength and degree of spasticity in the flexor and extensor muscles of the wrist and elbow joints, and functionality of the upper limb during the performance of daily activities at the first and the twentieth session of conventional physical therapy associated with the use of functional bandages. Results There was an increase in range of motion and muscle strength of patients, and reduction in spasticity of the wrist and elbow flexor muscles. Conversely, the functionality scores remained similar before and after treatment. Conclusion The subjects of this study showed a good evolution in the aspects studied. Thus, the use of functional bandages associated with conventional physical therapy seems to contribute to the rehabilitation of patients with stroke sequelae. Further research needs to be conducted in order to increase the scientific evidence regarding the effectiveness of functional bandages in the treatment of patients with stroke sequelae.

A new approach to assess the spasticity in hamstrings muscles using mechanomyography antagonist muscular group

Several pathologies can cause muscle spasticity. Modified Ashworth scale (MAS) can rank spasticity, however its results depend on the physician subjective evaluation. This study aims to show a new approach to spasticity assessment by means of MMG analysis of hamstrings antagonist muscle group (quadriceps muscle). Four subjects participated in the study, divided into two groups regarding MAS (MAS0 and MAS1). MMG sensors were positioned over the muscle belly of rectus femoris (RF), vastus lateralis (VL) and vastus medialis (VM) muscles. The range of movement was acquired with an electrogoniometer placed laterally to the knee. The system was based on a LabVIEW acquisition program and the MMG sensors were built with triaxial accelerometers. The subjects were submitted to stretching reflexes and the integral of the MMG (MMG(INT)) signal was calculated to analysis. The results showed that the MMG(INT) was greater to MAS1 than to MAS0 [muscle RF (p = 0.004), VL (p = 0.001) and VM (p = 0.007)]. The results showed that MMG was viable to detect a muscular tonus increase in antagonist muscular group (quadriceps femoris) of spinal cord injured volunteers.

Analysis of electromyographic activity in spastic biceps brachii muscle following neural mobilization

INTRODUCTION

Hypertonia is prevalent in anti-gravity muscles, such as the biceps brachii. Neural mobilization is one of the techniques currently used to reduce spasticity.

OBJECTIVE

The aim of the present study was to assess electromyographic (EMG) activity in spastic biceps brachii muscles before and after neural mobilization of the upper limb contralateral to the hemiplegia.

MATERIALS AND METHODS

Repeated pre-test and post-test EMG measurements were performed on six stroke victims with grade 1 or 2 spasticity (Modified Ashworth Scale). The Upper Limb Neurodynamic Test (ULNT1) was the mobilization technique employed.

RESULTS

After neural mobilization contralateral to the lesion, electromyographic activity in the biceps brachii decreased by 17% and 11% for 90° flexion and complete extension of the elbow, respectively. However, the results were not statistically significant (p gt; 0.05).

CONCLUSIONS

When performed using contralateral techniques, neural mobilization alters the electrical signal of spastic muscles.

Efeito da espasticidade sobre os padrões lineares de marcha em hemiparéticos

INTRODUÇÃO: A hemiparesia após o acidente vascular encefálico (AVE) é a sequela mais frequente, prejudicando a velocidade de execução dos movimentos automáticos, diminuindo a autonomia do indivíduo e gerando incapacidade. OBJETIVOS: Analisar o efeito da espasticidade nos padrões lineares de marcha (PLM) em indivíduos hemiparéticos. MÉTODOS: Foram estudados dois grupos: 20 indivíduos com AVE (G1) e 20 indivíduos sadios, destros, sem sequela neurológica (G2), com média de idade de 54,2 e 52,6 anos respectivamente. Foram avaliados os PLM pelo protocolo de Nagazaki, o tônus muscular pela escala de Ashworth modificada e o arco de movimento por goniometria. Foi feita comparação dos parâmetros nos dois grupos pelo teste t de Student e correlação de Spearman com nível de significância de 5%. RESULTADOS: A média da distância foi de 14,52 m e 32,16 m, e o tempo foi de 23,75 s e 19,02 s no G1 e G2 respectivamente (p < 0,0001). Na comparação entre os grupos, a amplitude média de passo e a velocidade média foram estatisticamente significantes (p < 0,05) e a cadência não mostrou significância (p = 0,1936). Quando os PLM foram comparados com o grau de espasticidade dos músculos gastrocnêmio e sóleo, mostraram associação negativa com distância, amplitude de passo e velocidade e associação positiva com o tempo (p < 0,05). CONCLUSÃO: Quanto maior o grau de espasticidade dos músculos gastrocnêmio e sóleo, menores serão os parâmetros lineares de marcha do indivíduo com sequela de hemiparesia pós-AVE.

Understanding gait control in post-stroke: implications for management

The role of the brain in post-stroke gait is not understood properly, although the ability to walk becomes impaired in more than 80% of post-stroke patients. Most, however, regain some ability to walk with either limited mobility or inefficient, asymmetrical or unsafe gait. Conventional intervention focuses on support of weak muscles or body part by use of foot orthosis and walking aids. This review provides an overview of available evidence of neuro-kinesiology & neurophysiology of normal and post-stroke gait. The role of the spinal cord has been explored, more in animals than humans. Mammalian locomotion is based on a rhythmic, "pacemaker" activity of the spinal stepping generators. Bipedal human locomotion is different from quadripedal animal locomotion. However, knowledge derived from the spinal cord investigation of animals, is being applied for management of human gait dysfunction. The potential role of the brain is now recognized in the independent activation of muscles during walking. The brain modifies the gait pattern during the complex demands of daily activities. Though the exact role of the motor cortex in control of gait is unclear, available evidence may be applied to gait rehabilitation of post-stroke patients.

Crioterapia e cinesioterapia no membro superior espástico no acidente vascular cerebral

INTRODUÇÃO: A espasticidade no paciente com sequela de Acidente Vascular Cerebral (AVC) acarreta limitações nas atividades de vida diária e torna-se um importante fator de risco para o desenvolvimento de deformidades estáticas quando não tratada. OBJETIVO: Avaliar o efeito da crioterapia associada à cinesioterapia no padrão postural flexor e no grau de espasticidade do membro superior de pacientes com AVC. METODOLOGIA: Participaram desta pesquisa sete voluntários que apresentavam espasticidade em membro superior. A rotina de atendimentos incluiu a aplicação de gelo na musculatura extensora do punho e dedos (crioestimulação) durante 1 minuto e 40 segundos e cinesioterapia no membro superior espástico, totalizando 10 minutos de intervenção, duas vezes por semana, durante dez sessões. O padrão postural flexor adotado pelo membro superior espástico foi avaliado a partir da goniometria das articulações do punho, metacarpofalangeas e interfalangeas proximais. A primeira medida goniométrica (MG1) era obtida logo após a chegada do paciente ao serviço. A segunda medida (MG2) ocorreu após a aplicação da crioterapia e a terceira (MG3) após 10 minutos de intervenção (crioterapia e cinesioterapia). A avaliação do grau de espasticidade ocorreu por meio da Escala Modificada de Ashworth aplicada antes e ao fim da intervenção. RESULTADOS: A terapia por meio da crioestimulação e da cinesioterapia foi eficiente na redução do padrão postural flexor do membro superior e do grau de espasticidade nas três articulações, sendo esse efeito observado a cada sessão e ao fim das dez sessões. CONCLUSÃO: São necessários novos estudos utilizando amostra maior para melhor esclarecimento desses achados.

Influência da simetria e transferência de peso nos aspectos motores após Acidente Vascular Cerebral

Introdução. A assimetria e a dificuldade em transferir o peso para o lado afetado interferem na capacidade de manter o controle postural em indivíduos pós-AVC. Objetivo. Averiguar a simetria e transferência de peso e sua correlação com o equilíbrio, marcha e função. Método. foram avaliados 30 pacientes com AVC, com média de idade de 58,91(±9,51) anos. Foram aplicadas as escalas Equilíbrio de Berg (EEB), Índice de Barthel (IB), Avaliação da Simetria e Transferência de Peso (ASTP) e Análise da Marcha Anormal Modificada e Adaptada (EAMA-M-A). Esses dados foram codificados e comparados entre si permitindo verificar o índice de correlação de Pearson. Resultados. Pode-se verificar uma diminuição de todas as habilidades avaliadas (equilíbrio, atividades funcionais e postura e transferência de peso). Ao correlacionar esses dados, houve uma correlação positiva (r:0,76, p:0,04) entre a ASTP e IB, uma correlação positiva (r:0,71, p:0,043) entre ASTP e EEB e uma correlação negativa (r:-0,68, p:0,04) entre ASTP e EAMA-MA. Conclusão. Os indivíduos hemiparéticos após AVC apresentaram menor simetria e dificuldade nas transferências de peso na postura em pé, menor desempenho no equilíbrio, marcha e função motora e esses resultados podem estar correlacionados, uma vez que os dados se mostraram pareados.