Uso de três princípios de intervenção aumenta a efetividade da terapia por contensão induzida: estudo de caso

CIT has three components: repetitive task oriented training, restraining the less impaired extremity and applying a package of adherence enhancing behavioral methods designed to transfer gains made in the clinical setting to the patient´s real world environment. But only two of these components are used with frequency. The aim of the present study was characterizing the intervention protocol through a longitudinal case report of a patient after stroke. The patient was evaluated by Motor Activity Log (MAL) and Wolf Motor Function Test (WMFT) and results suggest that behavioral aspects pertaining to technique have great influence on the success and TCI may have more action in the daily activities of patients with hemiplegia when applied to all three types of intervention that is.Terapia por Contensão Induzida (TCI) é formada por três componentes: treino repetitivo de tarefa orientada, restrição da extremidade do membro superior menos acometido e da aplicação de um conjunto de métodos comportamentais de reforço de adesão para transferir os ganhos obtidos na clinica para o ambiente real do paciente. Porém apenas dois desses princípios são aplicados com freqüência. O objetivo deste estudo foi de caracterizar o protocolo de intervenção através de um relato longitudinal de caso de um paciente com seqüela de hemiparesia crônica após AVE. O paciente foi avaliado pela Motor Activity Log (MAL) e pelo Wolf Motor Function Test (WMFT) e os resultados sugerem que os aspectos comportamentais pertencentes a técnica têm grande influência nos bons resultados e a TCI pode ter maior ação nas atividades de vida diária de pacientes com hemiplegia quando aplicados todos os três tipos de intervenção em que consiste

Grupo de atividades de vida diária: influência do procedimento em pacientes adultos com acidente vascular encefálico isquêmico

Strokes affect people’s daily lives because they create difficulties in many functional aspects of the individual’s daily life. Occupational therapists can intervene with stroke patients by trying to decrease their acquired limitations. Treatment can be done individually or in groups where experiential interchange is possible. This study sought to analyze the progress in the various Daily Life Activities (DLAs) of ischemic stroke patients. Ten patients were included in the study and were evaluated before and after the intervention using two different scales: the HAQ (Health Assessment Questionnaire) and the FAQ (Functional Activities Questionnaire). The Wilcoxon statistic test was used to analyze data with p ≤ 0.05. Analysis of results revealed statistical differences for both scales between the two analyzed moments (HAQ p=0.001 and FAQ p=0.0117). The study showed the effectiveness of the procedure on the progress of the DLAs for a group of subjects suffering from chronic ischemic EVA by measuring the functional gains shown in the HAQ and FAQ, but larger studies are necessary to allow more generalized conclusions.O acidente vascular encefálico (AVE) pode gerar seqüelas motoras acarretando dificuldades em vários aspectos funcionais da vida diária do indivíduo. O terapeuta ocupacional pode intervir com essa população, com o objetivo de diminuir as limitações adquiridas. Uma das modalidades de tratamento é o atendimento em grupo, em função da riqueza das trocas existentes no mesmo. Este estudo visou analisar os resultados do procedimento do grupo de Atividades de Vida Diária (AVDs) composto por pacientes com seqüelas de AVE isquêmico. Foram incluídos 10 sujeitos com seqüelas de AVE isquêmico, que participaram do grupo de AVDs, sendo os mesmos avaliados por meio da HAQ (Health Assessment Questionnaire) e da FAQ (Functional Activities Questionnaire), em dois momentos pré e pós intervenção. Para a análise dos dados foi utilizado o teste Wilcoxon com p ≤ 0,05. Após análise de resultados pré e pós intervenção verificou-se diferença significativa para ambos os instrumentos de avaliação (HAQ p=0.001 e FAQ p=0,0117). O estudo mostrou a eficácia do procedimento - grupo de AVDs, composto por sujeitos com sequelas de AVE isquêmico em fase crônica, através da mensuração dos ganhos funcionais obtidos pela HAQ e FAQ. Estudos com um número maior de pacientes são necessários para uma maior generalização das conclusões

Barriers for inclusion of patients with stroke in a proof-of-principle study of rehabilitation and repetitive trancranial magnetic stimulation

INTRODUÇÃO: A recuperação motora é o principal foco dos estudos sobre reabilitação de indivíduos com acidente vascular cerebral (AVC), já que a hemiparesia ocorre em 75% dos casos. No intuito de diminuir o impacto da paresia do membro superior na funcionalidade, diversas modalidades de tratamento têm sido estudadas. O interesse pelo uso de técnicas de neuroestimulação não invasivas, como a estimulação magnética transcraniana repetitiva (EMTr), cresceu de forma acelerada nas últimas décadas. Apesar de cerca de dois terços dos AVCs ocorrerem em países de baixa ou média renda e em desenvolvimento, a maior parte dos estudos sobre o emprego da EMTr na reabilitação após AVC tem sido realizada em países desenvolvidos. Dificuldades de recrutamento são comuns em ensaios clínicos ou estudos de comprovação de conceitos ligados a reabilitação em geral, ou ao uso da EMTr em pacientes com AVC em particular, mesmo em países desenvolvidos. Este trabalho teve como objetivo descrever as barreiras para a inclusão de participantes em um protocolo de reabilitação do membro superior utilizando EMTr em pacientes com AVC, realizado em nosso meio. CASUÍSTICA E MÉTODO: Este estudo foi realizado como parte de um ensaio clínico aleatorizado, controlado e duplo-cego conduzido no Hospital das Clínicas da Universidade de São Paulo. Foi realizada uma avaliação prospectiva da frequência dos motivos de não inclusão de pacientes para um protocolo de tratamento com EMTr de baixa frequência do hemisfério não afetado, em pacientes com paresia da mão após AVC. RESULTADOS: A mediana da idade dos indivíduos triados foi de 63 anos (intervalo, 14-102 anos). Houve leve predomínio do sexo masculino (57%), e 78% dos indivíduos foram considerados brancos. Dos 673 indivíduos triados, foram coletadas informações completas de 571 pacientes. Destes, apenas 32 (5,6%) foram incluídos. O critério de não inclusão mais frequente foi lesão afetando mais que 50% do território da artéria carótida interna (53,4%). As principais razões para exclusão foram AVC recorrente (45,4%), condições clínicas não controladas (17,2%) e presença de contraindicações para a EMT (11,7%). CONCLUSÕES: Considerando que 85% dos AVCs ocorrem nos países em desenvolvimento ou subdesenvolvidos onde a taxa de recorrência é alta, protocolos de reabilitação com critérios de exclusão menos restritivos são necessários para torná-los mais adequados para a população estudadaINTRODUCTION: Considering that hemiparesis occurs in 75% of patients with stroke, motor recovery is the main goal of rehabilitation research protocols. Different modalities of treatment have been developed to minimize the burden of upper limb paresis. The number of studies concerning the use of transcranial magnetic stimulation (TMS) as a potential tool for stroke rehabilitation has grown in the last decades. In spite of the fact that two-thirds of the strokes worldwide occur in low- or middle-income countries, most of TMS stroke rehabilitation studies have been performed in high-income countries. Recruitment barriers are a common issue in clinical trials or proof-of-principle studies related to rehabilitation in patients with stroke, even in developed countries. The main goal of this study was to describe the barriers to participant inclusion in an upper limb rehabilitation protocol with TMS in patients with stroke in Brazil. METHODS: This study was developed as part of a randomized clinical trial conducted at Hospital das Clínicas of the University of São Paulo, Brazil. We analyzed the frequency of reasons for participant non-inclusion in a proof-of-principle rehabilitation trial that applied low-frequency TMS to the non-affected hemisphere of patients that presented hand paresis after stroke. RESULTS: The median age of patients screened for the protocol was 63 years (interval, 14-102 years). Seventy-eight percent of them were White and 57% were male. From the 673 screened patients, complete data were collected from 571 participants but only 32 (5.6%) of them were included. The inclusion criterion that was fulfilled less frequently was a lesion affecting more than 50% of the internal carotid artery territory (53.4%). The three most frequent exclusion criteria were multiple strokes (45.4%), uncontrolled clinical conditions (17.2%) and contraindications to TMS (11.7%). CONCLUSION: Considering that 85% of strokes occur in low- and middle-income countries, where the incidence of recurrent stroke is high, rehabilitation protocols with less stringent exclusion criteria are suggested, in order to make them applicable to more patient

Use of three principles of intervention increases the effectiveness of constraint induced therapy: case report

Terapia por Contensão Induzida (TCI) é formada por três componentes: treino repetitivo de tarefa orientada, restrição da extremidade do membro superior menos acometido e da aplicação de um conjunto de métodos comportamentais de reforço de adesão para transferir os ganhos obtidos na clinica para o ambiente real do paciente. Porém apenas dois desses princípios são aplicados com freqüência. O objetivo deste estudo foi de caracterizar o protocolo de intervenção através de um relato longitudinal de caso de um paciente com seqüela de hemiparesia crônica após AVE. O paciente foi avaliado pela Motor Activity Log (MAL) e pelo Wolf Motor Function Test (WMFT) e os resultados sugerem que os aspectos comportamentais pertencentes a técnica têm grande influência nos bons resultados e a TCI pode ter maior ação nas atividades de vida diária de pacientes com hemiplegia quando aplicados todos os três tipos de intervenção em que consiste.CIT has three components: repetitive task oriented training, restraining the less impaired extremity and applying a package of adherence enhancing behavioral methods designed to transfer gains made in the clinical setting to the patient´s real world environment. But only two of these components are used with frequency. The aim of the present study was characterizing the intervention protocol through a longitudinal case report of a patient after stroke. The patient was evaluated by Motor Activity Log (MAL) and Wolf Motor Function Test (WMFT) and results suggest that behavioral aspects pertaining to technique have great influence on the success and TCI may have more action in the daily activities of patients with hemiplegia when applied to all three types of intervention that is

A Brazilian-Portuguese version of the Kinesthetic and Visual Motor Imagery Questionnaire

ABSTRACT Motor imagery has emerged as a potential rehabilitation tool in stroke. The goals of this study were: 1) to develop a translated and culturally-adapted Brazilian-Portugese version of the Kinesthetic and Visual Motor Imagery Questionnaire (KVIQ20-P); 2) to evaluate the psychometric characteristics of the scale in a group of patients with stroke and in an age-matched control group; 3) to compare the KVIQ20 performance between the two groups. Methods Test-retest, inter-rater reliabilities, and internal consistencies were evaluated in 40 patients with stroke and 31 healthy participants. Results In the stroke group, ICC confidence intervals showed excellent test-retest and inter-rater reliabilities. Cronbach’s alpha also indicated excellent internal consistency. Results for controls were comparable to those obtained in persons with stroke. Conclusions The excellent psychometric properties of the KVIQ20-P should be considered during the design of studies of motor imagery interventions for stroke rehabilitation

Translation, cultural adaptation and reliability of the brazilian version of the Graded Wolf Motor Function Test in adults with severe hemiparesis

Introduction: The Graded Wolf Motor Function Test (GWMFT) was developed as a modification of the Wolf Motor Function Test (WMFT), designed to address moderate-to-severe upper-extremity motor impairment, consequent to a stroke or brain injury, by combining time and quality of movement measures in both isolated movements and functional tasks. Objectives: To translate and adapt the GWMFT form and instructions manual to Brazilian Portuguese and evaluate the inter-rater reliability. Materials and methods: Tem individuals, mean age 53.2 ± 11.39 (range: 28-72) years and a mean time since stroke onset of 82.5 ± 85.83(16-288) months participated in the study. After translation and cultural adaptation, two independent evaluators, based on the instructions manual information, administered GWMFT. Video observations were used to rate the time and the compensatory movements in the Functional Ability Scale (FAS). Intra-class Correlation Coefficients (ICCs) and Bland-Altman plots were calculated to examine the inter-rater reliability for performance time and FAS. Results: The translated and adapted version obtained a total ICC inter-rater time 0.99 (0.95-1.00), showing less reliability in the task of lifting a pen, with ICC = 0.71 ( 0.15-0.93). The ICC of the total FAS was 0.98 (0.92-0.99) and the task of elbow extension has shown the lowest ICC rate = 0.83 (0.31-0.96). Conclusion: The GWMFT scale reliability proved to be appropriate to evaluate the paretic upper limb in individuals with chronic hemiparesis post severe stroke

Translation, cultural adaptation and reliability of the brazilian version of the Graded Wolf Motor Function Test in adults with severe hemiparesis

Abstract Introduction : The Graded Wolf Motor Function Test (GWMFT) was developed as a modification of the Wolf Motor Function Test (WMFT), designed to address moderate-to-severe upper-extremity motor impairment, consequent to a stroke or brain injury, by combining time and quality of movement measures in both isolated movements and functional tasks. Objectives : To translate and adapt the GWMFT form and instructions manual to Brazilian Portuguese and evaluate the inter-rater reliability. Materials and methods : Ten individuals, mean age 53.2 ± 11.39 (range: 28-72) years and a mean time since stroke onset of 82.5 ± 85.83 (16-288) months participated in the study. After translation and cultural adaptation, two independent evaluators, based on the instructions manual information, administered GWMFT. Video observations were used to rate the time and the compensatory movements in the Functional Ability Scale (FAS). Intra-class Correlation Coefficients (ICCs) and Bland-Altman plots were calculated to examine the inter-rater reliability for performance time and FAS. Results : The translated and adapted version obtained a total ICC inter-rater time 0.99 (0.95-1.00), showing less reliability in the task of lifting a pen, with ICC = 0.71 (- 0.15-0.93). The ICC of the total FAS was 0.98 (0.92-0.99) and the task of elbow extension has shown the lowest ICC rate = 0.83 (0.31-0.96). Conclusion : The GWMFT scale reliability proved to be appropriate to evaluate the paretic upper limb in individuals with chronic hemiparesis post severe stroke

Increase in Short-Interval Intracortical Facilitation of the Motor Cortex after Low-Frequency Repetitive Magnetic Stimulation of the Unaffected Hemisphere in the Subacute Phase after Stroke

Low-frequency repetitive transcranial magnetic stimulation of the unaffected hemisphere (UH-LF-rTMS) in patients with stroke can decrease interhemispheric inhibition from the unaffected to the affected hemisphere and improve hand dexterity and strength of the paretic hand. The objective of this proof-of-principle study was to explore, for the first time, effects of UH-LF-rTMS as add-on therapy to motor rehabilitation on short-term intracortical inhibition (SICI) and intracortical facilitation (ICF) of the motor cortex of the unaffected hemisphere (M1UH) in patients with ischemic stroke. Eighteen patients were randomized to receive, immediately before rehabilitation treatment, either active or sham UH-LF-rTMS, during two weeks. Resting motor threshold (rMT), SICI, and ICF were measured in M1UH before the first session and after the last session of treatment. There was a significant increase in ICF in the active group compared to the sham group after treatment, and there was no significant differences in changes in rMT or SICI. ICF is a measure of intracortical synaptic excitability, with a relative contribution of spinal mechanisms. ICF is typically upregulated by glutamatergic agonists and downregulated by gabaergic antagonists. The observed increase in ICF in the active group, in this hypothesis-generating study, may be related to M1UH reorganization induced by UH-LF-rTMS