Knee joint dysfunctions that influence gait in cerebrovascular injury

INTRODUCTION: There is still no consensus among different specialists on the subject of kinematic variation during the hemiparetic gait, including the main changes that take place during the gait cycle and whether the gait velocity changes the patterns of joint mobility. One of the most frequently discussed joints is the knee. OBJECTIVES: This study aims to evaluate the variables found in the angular kinematics of knee joint, and to describe the alterations found in the hemiparetic gait resulting from cerebrovascular injury. METHODS: This study included 66 adult patients of both genders with a diagnosis of either right or left hemiparesis resulting from ischemic cerebrovascular injury. All the participants underwent three-dimensional gait evaluation, an the angular kinematics of the joint knee were selected for analysis. RESULTS: The results were distributed into four groups formed based on the median of the gait speed and the side of hemiparesis. CONCLUSIONS: The relevant clinical characteristics included the important mechanisms of loading response in the stance, knee hyperextension in single stance, and reduction of the peak flexion and movement amplitude of the knee in the swing phase. These mechanisms should be taken into account when choosing the best treatment. We believe that the findings presented here may aid in preventing the occurrence of the problems found, and also in identifying the origin of these problems

Knee Joint Dysfunctions That Influence Gait in Cerebrovascular Injury

INTRODUCTION: There is still no consensus among different specialists on the subject of kinematic variation during the hemiparetic gait, including the main changes that take place during the gait cycle and whether the gait velocity changes the patterns of joint mobility. One of the most frequently discussed joints is the knee. OBJECTIVES: This study aims to evaluate the variables found in the angular kinematics of knee joint, and to describe the alterations found in the hemiparetic gait resulting from cerebrovascular injury. METHODS: This study included 66 adult patients of both genders with a diagnosis of either right or left hemiparesis resulting from ischemic cerebrovascular injury. All the participants underwent three-dimensional gait evaluation, an the angular kinematics of the joint knee were selected for analysis. RESULTS: The results were distributed into four groups formed based on the median of the gait speed and the side of hemiparesis. CONCLUSIONS: The relevant clinical characteristics included the important mechanisms of loading response in the stance, knee hyperextension in single stance, and reduction of the peak flexion and movement amplitude of the knee in the swing phase. These mechanisms should be taken into account when choosing the best treatment. We believe that the findings presented here may aid in preventing the occurrence of the problems found, and also in identifying the origin of these problems

Alteração do mecanismo de resposta à carga da articulação do joelho durante a marcha hemiparética oriunda de AVC, analisada por cinemática tridimensional

PURPOSE: The aims of this study were to evaluate the variables found in the alteration of the load-response mechanism on 3-dimensional kinematic analysis of the knee joint during hemiparetic gait following stroke. METHODS: We evaluated 66 adult patients (33 men and 33 women), aged 45.4 ± 8.5 years (mean ± SD), with a diagnosis of ischemic cerebrovascular accident either right or left hemiparesis and brachial prevalence. All the participants underwent 3-dimensional gait evaluation with a Vicon 370, and the values of the angular kinematics of the knee joint were selected for analysis. RESULTS: There were no statistically significant differences (by the Kruskal-Wallis test) between the subjects regarding the following variables: angular knee position at initial contact and time of peak knee flexion in the stance. The clinically relevant characteristics found were: an increase in knee joint flexion during the initial contact and a movement amplitude below that anticipated in this phase of the walking cycle. These should be taken into account when choosing the best treatment, because they are the ones which exhibit the most important alteration in the load-response mechanism in all patients. CONCLUSION: There is still no consensus among the different specialists regarding the variations in kinematics during the hemiparetic gait. One of the most frequently discussed joints is the knee-the way the main changes take place during the gait cycle and whether the gait velocity changes the patterns of joint mobility.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 (

Functional electrical stimulation for shoulder subluxation after chronic stroke: a case report

Shoulder subluxation is a common complication among stroke survivors; it may cause pain, brachial plexus injuries, adhesive capsulitis and rotator cuff muscle injuries, leading to rehabilitation delay and interference in patients' quality of life. The purpose of this study was to assess the effects of functional electrical stimulation (FES) in post-stroke hemiplegia shoulder subluxation. Three patients with over one year of stroke onset and shoulder subluxation confirmed by X ray were assessed prior to, and after FES treatment, as to: degree of shoulder subluxation and range of motion (ROM); sensory-motor function by the Fugl-Meyer scale; and pain at rest and at passive movement by means of a visual analog scale. All patients were treated with conventional physical therapy and FES in the hemiplegic member for ten sessions. Results showed improvement in final measures of ROM and sensory-motor assessments, pain relief and shoulder subluxation reduction after treatment. FES associated to conventional physical therapy has thus proved effective in decreasing subluxation, increasing upper limb function and in relieving pain in post-stroke shoulder subluxation patients.A subluxação do ombro é comum em indivíduos que sofreram acidente vascular encefálico (AVE), podendo gerar dor, lesões do plexo braquial, capsulite adesiva e lesões nos músculos da bainha rotatória, implicando atraso da reabilitação e interferência na qualidade de vida. O objetivo deste estudo foi verificar os efeitos da estimulação elétrica funcional (EEF) na subluxação crônica do ombro em pacientes hemiplégicos que sofreram AVE. Foram avaliados três pacientes tendo tido AVE há mais de um ano com subluxação do ombro confirmada por exame de raios X. Foram analisados, antes e após o tratamento, o grau de subluxação e amplitude de movimento (ADM) do ombro, função sensório-motora pela escala de Fugl-Meyer e dor em repouso e à movimentação passiva por meio de escala visual analógica. Todos os pacientes foram submetidos a tratamento com fisioterapia convencional e EEF no membro hemiplégico por dez sessões. A análise dos resultados mostrou melhora em relação às medidas iniciais da ADM, da avaliação sensório-motora, dor e subluxação do ombro após o uso da EEF. Concluiu-se que a EEF, asociada à fisioterapia convencional, mostrou-se eficaz em produzir diminuição da subluxação, aumento da função do membro superior e agir no alívio da dor em pacientes com subluxação do ombro pós-AVE.UNIFESP-EPMCentro Universitário São CamiloUniversidade Cidade de São PauloUNIFESP, EPMSciEL

Correlação entre os parâmetros espaçotemporais e a habilidade manual de adultos com paralisia cerebral do tipo discinético

The aim of this study was to verify relation between kinematic variables of temporal-spatial parameters and manual ability and between own temporal-spatial variables during the movement of bring a mug to the mouth in adults with dyskinetic cerebral palsy (DCP). Sixteen adults with DCP were evaluated by MACS (Manual Ability Classification System), and by temporal-spatial variables of tridimensional kinematics of the movement to bring a bug to the mouth by means of 9 cameras infra-red Vicon(r) MX 40 (Oxford Metrics Group, Oxford, UK). The Spearman correlation coefficient (ρ) was used to correlate variables. As a result, we found weak correlation between the classification of manual ability and the adjusting phase (ρ=0.219), the velocity variables - average velocity (ρ=-0.313), peak velocity (ρ=-0.282) and time to peak velocity (ρ=-0.250). No correlation was found between the variables going and returning phase and MACS. Moderate correlation was found between going and returning phase (ρ=0.559), between the going phase and time to peak velocity (ρ=0.518) and between the adjusting phase and peak velocity (ρ=-0.562). A strong correlation was found between the mean velocity and peak velocity (ρ=0.947) and between the adjusting phase and average velocity (ρ=-0.635). In conclusion, functional impairment may be related to longer adjusting phase and decrease of movement speed in subjects with PCD. Kinematic variables were related to each other in moderate and strong way and indicated that the phases runtime influences the movement speed.El objetivo de este estudio fue verificar si hay una relación entre las variables cinemáticas espacio-temporales y la habilidad manual y entre las propias variables espacio-temporales estudiadas durante el movimiento de traer una taza a la boca en adultos con parálisis cerebral tipo discinética (PCD). Dieciséis adultos con PCD fueron sometidos a una evaluación de habilidad manual por medio de la escala MACS (Manual Ability Classification System) y análisis de las variables espacio-temporales de la cinemática tridimensional del movimiento para llevar una taza a la boca por medio de 9 cámaras infrarrojas Vicon(r) MX 40 (Oxford Metrics Group, Oxford, UK). El coeficiente de correlación de Spearman (r) fue aplicado para verificar la relación entre las variables estudiadas. Como resultado, fue encontrada una débil correlación entre la clasificación de la habilidad manual y la fase de ajuste del movimiento (r=0,219), las variables de velocidad - velocidad media (r=-0,313), velocidad máxima (r=-0,282) y tiempo para alcanzar la velocidad máxima (r=-0,250). No se encontró correlación entre la variable tiempo de ida y la variable de regreso del movimiento y la MACS. Correlación moderada se encontró entre la fase de ida y la fase de regreso del movimiento (r=0,559), entre la fase de ida y el tiempo para alcanzar la velocidad máxima (r=0,518) y entre la fase de ajuste y la velocidad máxima (r=-0,562). Fuerte correlación se encontró entre la velocidad media y la velocidad máxima (r=0,947) y entre la fase de ajuste y la velocidad media (r=-0,635). A modo de conclusión, el perjuicio funcional puede ser relacionado con más tiempo de ejecución de la fase de ajuste y con la reducción de la velocidad del movimiento en sujetos con PCD. Las variables cinemáticas se relacionaban de manera moderada y fuerte eO objetivo deste estudo foi verificar se existe relação entre as variáveis cinemáticas espaçotemporais e a habilidade manual e entre as próprias variáveis espaçotemporais estudadas durante o movimento de levar uma caneca à boca em indivíduos adultos com paralisia cerebral do tipo discinético (PCD). Dezesseis adultos com PCD foram submetidos à avaliação da habilidade manual por meio da escala MACS (Manual Ability Classification System) e análise das variáveis espaçotemporais da cinemática tridimensional do movimento de levar uma caneca à boca por meio de 9 câmeras de infravermelho Vicon(r) MX 40 (Oxford Metrics Group, Oxford, UK). O coeficiente de correlação de Spearman (ρ) foi aplicado para verificar relação entre as variáveis estudadas. Como resultado, foi encontrada fraca correlação entre a classificação da habilidade manual e a fase de ajuste do movimento (ρ=0,219), as variáveis de velocidade - velocidade média (ρ=-0,313), velocidade máxima (ρ=-0,282) e tempo para atingir o pico de velocidade (ρ=-0,250). Não foi encontrada correlação entre a variável tempo de ida e a variável tempo de retorno do movimento e a MACS. Correlação moderada foi encontrada entre a fase de ida e a fase de retorno do movimento (ρ=0,559), entre a fase de ida e o tempo para atingir o pico de velocidade (ρ=0,518) e entre a fase de ajuste e a velocidade máxima (ρ=-0,562). Forte correlação foi encontrada entre a velocidade média e o pico de velocidade (ρ=0,947) e entre a fase de ajuste e a velocidade média (ρ=-0,635). Como conclusão, o prejuízo funcional pode ser relacionado ao maior tempo de execução da fase de ajuste e com a redução da velocidade do movimento em indivíduos com PCD. As variáveis cinemáticas se relacionaram de maneira moderada e forte e indicaram que o tempo de execução das fases influencia a velocidade do movimento

Mudanças na cinemática articular em crianças com paralisia cerebral durante o andar com e sem órteses de reação ao solo

INTRODUCTION: The floor reaction ankle-foot orthosis is commonly prescribed in the attempt to decrease knee flexion during the stance phase in the cerebral palsy (CP) gait. Reported information about this type of orthosis is insufficient. PURPOSE: The purpose of this study was to determine the effect of clinically prescribed floor reaction ankle-foot orthosis on kinematic parameters of the hip, knee and ankle in the stance phase of the gait cycle, compared to barefoot walking on children with cerebral palsy. METHODS: A retrospective chart review of 2200 patients revealed that 71 patients (142 limbs) had a diagnosis of diplegia, with no contractures in hip, knee or ankle flexion. Their average age was 12.2 ± 3.9. All of them were wearing clinically prescribed hinged floor reaction ankle-foot orthosis undergoing a three dimensional gait analysis. We divided the patients in three groups: Group I, with limited extension (maximum knee extension less than 15º); Group II, with moderate limited extension (maximum knee extension between 15º and 30º) and Group III Crouch (maximum knee extension in stance more than 30º). RESULTS: Results indicate the parameters maximum knee extension and ankle dorsiflexion were significant in Group II e III; no change was observed in Group I. The maximum hip extension was not significant in all three groups. Conclusion: when indicated to improve the extension of the knees and ankle in the stance of the CP patients floor reaction ankle-foot orthosis was effective.INTRODUÇÃO: A órtese de reação ao solo é freqüentemente prescrita com o objetivo de reduzir a flexão do joelho durante a fase de apoio na marcha de pacientes com paralisia cerebral. Não há informações suficientes relatadas na literature sobre este tipo de órteses. OBJETIVOS: O objetivo deste estudo foi determinar o efeito que a órtese de reação ao solo tem na cinamática angular das articulações do quadril, joelho e tornozelo durante a fase de apoio da marcha de crianças com paralisia cerebral, comparando a marcha descalça e com o uso das órteses MÉTODOS: Após um estudo retrospectivo de 2200 pacientes avaliados no laboratório de marcha, 71 pacientes com diagnóstico de paralisia cerebral do tipo diparesia espástica e idade média de 12.2 ± 3.9 foram selecionados (142 membros). Nenhum deles apresentou contratura em flexão dos quadris, joelhos e tornozelos. Todos usavam órteses do tipo reação ao solo articulada durante a avaliação da marcha. Os pacientes foram divididos em três grupos: Grupo I Extensão Limitada (pico de extensão do joelho menor que 15º); Grupo II Extenão Moderadamente Limitada (pico de extensão do joelho entre 15º e 30º) e Grupo III Agachamento (pico de extensão do joelho no apoio maior que 30º). RESULTADOS: Os resultados demostraram que o pico de extensão do joelho e o pico de dorsiflexão tiveram alterações significantes nos grupos II e III enquanto que o grupo I não apresentou alteração. O pico de extensão do quadril não mostrou alteração nos três grupos CONCLUSÃO: A órtese de reação ao solo é eficaz quando indicada para aumentar a extensão do joelho e tornozelo durante a fase de apoio da marcha de crianças com paralisia cerebra

Estimulação elétrica funcional na subluxação crônica do ombro após acidente vascular encefálico: relato de casos

Shoulder subluxation is a common complication among stroke survivors; it may cause pain, brachial plexus injuries, adhesive capsulitis and rotator cuff muscle injuries, leading to rehabilitation delay and interference in patients' quality of life. The purpose of this study was to assess the effects of functional electrical stimulation (FES) in post-stroke hemiplegia shoulder subluxation. Three patients with over one year of stroke onset and shoulder subluxation confirmed by X ray were assessed prior to, and after FES treatment, as to: degree of shoulder subluxation and range of motion (ROM); sensory-motor function by the Fugl-Meyer scale; and pain at rest and at passive movement by means of a visual analog scale. All patients were treated with conventional physical therapy and FES in the hemiplegic member for ten sessions. Results showed improvement in final measures of ROM and sensory-motor assessments, pain relief and shoulder subluxation reduction after treatment. FES associated to conventional physical therapy has thus proved effective in decreasing subluxation, increasing upper limb function and in relieving pain in post-stroke shoulder subluxation patients.A subluxação do ombro é comum em indivíduos que sofreram acidente vascular encefálico (AVE), podendo gerar dor, lesões do plexo braquial, capsulite adesiva e lesões nos músculos da bainha rotatória, implicando atraso da reabilitação e interferência na qualidade de vida. O objetivo deste estudo foi verificar os efeitos da estimulação elétrica funcional (EEF) na subluxação crônica do ombro em pacientes hemiplégicos que sofreram AVE. Foram avaliados três pacientes tendo tido AVE há mais de um ano com subluxação do ombro confirmada por exame de raios X. Foram analisados, antes e após o tratamento, o grau de subluxação e amplitude de movimento (ADM) do ombro, função sensório-motora pela escala de Fugl-Meyer e dor em repouso e à movimentação passiva por meio de escala visual analógica. Todos os pacientes foram submetidos a tratamento com fisioterapia convencional e EEF no membro hemiplégico por dez sessões. A análise dos resultados mostrou melhora em relação às medidas iniciais da ADM, da avaliação sensório-motora, dor e subluxação do ombro após o uso da EEF. Concluiu-se que a EEF, asociada à fisioterapia convencional, mostrou-se eficaz em produzir diminuição da subluxação, aumento da função do membro superior e agir no alívio da dor em pacientes com subluxação do ombro pós-AVE

The impact of tibial torsion measurements on gait analysis kinematics

Objective:To measure and compare tibial torsion values as assessed by goniometry and three-dimensional kinematics. In addition, the impact of each one of these measurements on kinematic and kinetic results for normal gait was determined.Methods:Twenty-three healthy and fully ambulatory patients were assessed, 11 women and 12 men, from 20 to 40 years old. Data were collected at a laboratory for the three-dimensional analysis of movement with 10 cameras and two force plates. Tibial torsion measurements were obtained using goniometry and three-dimensional kinematics based on the Plug-in Gait model. Afterwards, both procedures were compared, and the impact of each result was assessed on the kinematic and kinetic modeling of the knee and ankle.Results:Pearson's linear correlation coefficient (r=0,504) showed a moderate correlation between the three-dimensional kinematics and goniometry, and between the changes in the measurements. Regarding the processed kinematic and kinetic results for every torsion position, no significant differences were noticed among any of the studied variables (p>0.05).Conclusion:Although statistical correlation among tibial torsion angles by goniometry and three-dimensional kinematic were moderate, kinematic and kinetic analysis of the joints did not reveal any significant changes. Level of Evidence I, Diagnostic Studies - Investigating a Diagnostic Test.Universidade Nove de JulhoUniversidade de São PauloHospital Israelita Albert EinsteinUniversidade Federal de São Paulo (UNIFESP)UNIFESPSciEL

Neuromuscular training and muscle strengthening in patients with patellofemoral pain syndrome: a protocol of randomized controlled trial

Background: Patellofemoral pain syndrome (PFPS) is a common musculoskeletal condition, particularly among women. Patients with PFPS usually experience weakness in the gluteal muscles, as well as pain and impaired motor control during activities of daily living. Strengthening the hip muscles is an effective way of treating this disorder. Neuromuscular training has also been identified as a therapeutic tool, although the benefits of this intervention in patients with PFPS patients remain inconclusive.Design: This is a protocol of randomized controlled trial with a blind assessor. Thirty-four women with a clinical diagnosis of PFPS participated. These participants were allocated into two groups (experimental and control). the experimental group performed twelve sessions to strengthen the knee extensors, hip abductor and lateral rotator muscles in association with neuromuscular training of the trunk and lower extremities. the control group performed the same number of sessions to strengthen the muscles of the hip and knee. the primary outcome was functional capacity (Anterior Knee Pain Scale - AKPS) at 4 weeks. Pain intensity, muscle strength and kinematic changes were also measured during the step down test after four weeks of intervention. Follow up assessments were conducted after three and six months to assess functional capacity and pain. the effects of the treatment (i.e. between-group differences) were calculated using mixed linear models.Discussion: the present study was initiated on the 1st of April 2013 and is currently in progress. the results of this study may introduce another effective technique of conservative treatment and could guide physical therapists in the clinical decision-making process for women with PFPS.Univ Nove Julho, Dept Rehabil Sci, Human Mot Anal Lab, São Paulo, BrazilUniversidade Federal de São Paulo, BR-11060000 São Paulo, BrazilIrmandade Santa Casa Misericordia, São Paulo, BrazilUniv Cidade São Paulo, Masters & Doctoral Programs Phys Therapy, São Paulo, BrazilGeorge Inst Global Hlth, Musculoskeletal Div, Sydney, NSW, AustraliaUniversidade Federal de São Paulo, BR-11060000 São Paulo, BrazilWeb of Scienc