Daniela Virgínia Vaz

Muscle stiffness and strength and their relation to hand function in children with hemiplegic cerebral palsy

This study compared the passive stiffness of wrist flexors and the strength of wrist flexors and extensors in three different wrist positions (30 degrees of flexion, neutral, and 30 degrees of extension) between children with cerebral palsy (CP) and typically developing (TD) comparison children. It also examined associations between these characteristics and manual function in children with CP. Eleven children with spastic hemiplegic CP (six females, five males; mean age 8y 5mo [SD 1y 8mo], range 6-11y) and 11 TD children, matched for age and sex, took part in this study. Passive stiffness of muscles was measured as the torque/angle relation during passive motion. Isometric strength tests were performed and the time needed to complete three tasks based on the Jebsen-Taylor Hand Function Test was recorded. Flexor stiffness was higher in the group with CP. Strength of flexors and extensors in the group with CP was lower with the wrist extended. No difference among test positions was found in the TD group. Moderate correlations were observed between manual function and variables related to strength and stiffness of wrist muscles in the group with CP. Children with CP showed muscle alterations coherent with the use of the wrist in flexion. Intervention on these characteristics could have a positive impact on manual function.

Adapted version of constraint-induced movement therapy promotes functioning in children with cerebral palsy: a randomized controlled trial

Objective: To evaluate the effects of constraint-induced movement therapy on the use of the affected arm and on daily functioning in children with hemiplegic cerebral palsy. Design: A single-blinded randomized clinical trial. Subjects: Sixteen children with cerebral palsy randomized to intervention (n = 8, 4 males, 4 females, mean age 5 years and 6 months) and control groups (n = 8, 4 males, 4 females, mean age 6 years and 7 months). Interventions: Non-affected arm of intervention group was restricted for 10 hours/ day and the affected arm intensively trained for 3 hours/day for two weeks. The intervention protocol included one week of bimanual functional training following constraint therapy. The control group maintained usual rehabilitation throughout the intervention period. Main measures: Pediatric Evaluation of Disability Inventory (self-care domain) and an adapted version of the Jebsen—Taylor test were administered before and after intervention, and at one month follow-up. General linear models tested differences in gain scores and the number needed to treat estimated relative effectiveness of intervention protocol for functional skills and independence in self-care. Results: Results are reported for 15 children who completed assessments and intervention. Higher gains were observed in the intervention group for functional skills and independence post intervention (dfunctional skills = 1.61, P =0.0134; dindependence=1.37; P =0.0001) and follow-up (dfunctional skills = 2.08, P =0.004; dindependence = 0.85; P =0.0016). No group difference in manual dexterity gains was observed. Low indices of number needed to treat (1.75 and 2.33) illustrate clinical relevance of intervention. Conclusions: The protocol associating constraint-induced movement therapy and bimanual functional training was effective in promoting daily living functioning among children with cerebral palsy.

Treadmill training for ataxic patients: a single-subject experimental design

Objective: To investigate changes in gait quality, balance and mobility associated with treadmill training for ataxic individuals. Design: Single-subject ABA design. Baseline phases (A) lasted three weeks and intervention (B) lasted four weeks. Setting: University rehabilitation clinic. Subjects: A woman (25 years) and a man (53 years) with chronic ataxia due to head trauma. Intervention: Three 20-minute treadmill training sessions each week with progression in velocity and step length. Main measures: Rivermead Visual Gait Assessment, Timed Up and Go, time to complete a balance task, walking speed, cadence, and stride length assessments three times a week during the 10 weeks. Data were analysed with the celeration line technique and two standard deviation band. Results: Both individuals demonstrated gains in all parameters over initial baseline and subsequent phases, with performance increases ranging from 26% to 233% when first and last assessments were compared. Significantly superior effects of treadmill training over baseline conditions on cadence were detected (P<0.05). Gains in walking speed were not significantly better during intervention, but intervention withdrawal produced deceleration of performance gains. Gains in Timed Up and Go, step length and balance were not consistent and were possibly caused by a learning effect of the association between repeated testing and treadmill training. Rivermead Visual Gait Assessment gains reached significance only for subject 2 (P<0.05), probably because of increased variability of performance of subject 1. Results suggest that the association between repeated testing and treadmill training might have been responsible for the observed gains in the two ataxic patients.

Correlação entre um questionário de desempenho funcional e capacidade física em pacientes com lombalgia

CONTEXTUALIZACAO: A lombalgia e um conjunto de manifestacoes dolorosas que pode acarretar limitacoes em varios aspectos da vida de um individuo. O modelo de Classificacao Internacional de Funcionalidade, Incapacidade e Saude (CIF) proposto pela Organizacao Mundial da Saude (OMS) fornece uma estrutura para o entendimento da funcionalidade e da incapacidade associadas aos estados de saude, possibilitando uma descricao significativa da saude de um individuo. A CIF utiliza os termos capacidade e desempenho para se referir a aspectos distintos da funcao e para diferenciar o estado funcional dos pacientes. Na pratica clinica, e necessario saber se existe uma associacao entre esses distintos aspectos. OBJETIVOS: Analisar a correlacao entre o questionario de desempenho funcional de Roland Morris e os testes de capacidade fisica (sentado para de pe e a caminhada de 15,24 metros) em pacientes com lombalgia. METODOS: Trinta pacientes com diagnostico de lombalgia, media de idade de 43,16 anos, foram avaliados com o Roland Morris e os testes de capacidade. RESULTADOS: A analise de correlacao de Pearson demonstrou correlacao significativa, porem fraca entre o escore do Roland Morris e o Teste Sentado para de Pe (r=0,38; p=0,0388). Nao foi observada uma correlacao significativa entre o escore do questionario e o teste de caminhada de 15,24 m (r=0,24; p=0,1862). CONCLUSAO: Esses resultados indicam a necessidade de se utilizarem instrumentos que avaliem ambos os aspectos (capacidade e desempenho) em pacientes com lombalgia, para que se possa definir um perfil funcional mais completo desses individuos.

Effects of Strength Training Aided by Electrical Stimulation on Wrist Muscle Characteristics and Hand Function of Children with Hemiplegic Cerebral Palsy

Nine children with spastic hemiplegic cerebral palsy underwent 24 sessions of wrist muscles strengthening in the extended wrist range aided by electrostimulation. Isometric strength of flexors and extensors was registered in three wrist positions (30° of flexion, neutral, and 30° of extension) to infer on angle–torque curves. Passive stiffness of wrist flexors and wrist flexion angle during manual tasks and hand function were also documented. Significant strength gains were observed at 30° of wrist extension for flexors (p = 0.029) and extensors (p = 0.024). No gains were observed at 30° of flexion. The difference in extensor strength between the three test positions changed after intervention (p < 0.034), suggesting a shift in the angle–torque curve. No changes were observed in passive stiffness (p = 0.506), wrist angle (p < 0.586), or hand function (p = 0.525). Strength training in specific joint ranges may alter angle–torque relationships. For functional gains to be observed, however, a more aggressive intervention and contextualized task training would probably be needed.

Efeitos da estimulação elétrica funcional nos músculos do punho e dedos em indivíduos hemiparéticos: uma revisão sistemática da literatura

Effects of functional electrical stimulation applied to the wrist and finger muscles of hemiparetic subjects: a systematic review of the literature Background: a systematization of the available evidence regarding the effects of electrical stimulation for hemiplegic patients following stroke is needed. Objective: to conduct a systematic review of the literature related to the effects of functional electrical stimulation for the wrist and finger muscles of adult hemiplegic patients. Method: a search for studies documenting the effects of electrical stimulation on neuromuscular, musculoskeletal and functional characteristics was carried out in Medline, Lilacs and PEDro databases between February and March 2006. Data were extracted in a standardized manner from each study, and methodological quality was assessed using the PEDro scale. Results: Eight randomized studies were reviewed. The scores on the methodological quality of revised studies were between 3/10 and 7/10 in the PEDro scale. Although the diversity of protocols, participants’ characteristics and instrumentation prevented pooling of results, a synthesis in levels of evidence demonstrated strong evidence for positive effects of electrical stimulation on muscle strength, tonus, motor function and use of the upper limb in daily life. Moderate evidence was found for effects on dexterity and limited evidence for effects on motor coordination and independence in self-care activities. There was no evidence for gains in range of active wrist extension. Conclusion: Despite methodological limitations, randomized studies reported positive effects of electrical stimulation on wrist and fingers, suggesting that this therapy might be effective for promoting function of the affected upper limb of hemiplegic individuals.

Work-related hand injuries: Case analyses in a Brazilian rehabilitation service

Purpose. Professionals who work with rehabilitation of the hand usually assess performance components as their main outcome measures. Intervention is aimed at normalization of deficits of these components, with the expectation that the integrity of the structures and functions of the body will revert to improvements in the clients functional performance. The objectives of this study were to describe changes in patients who received rehabilitation in a Brazilian public hospital after having suffered hand injuries due to workplace accidents, and to examine the relations between performance components and levels of functioning. Methods. Observational cross-sectional study was used. A convenience sample was selected, including 42 patients assessed at service admission and at discharge. Assessed characteristics included grip strength, wrist and finger range of movement (ROM), sensitivity, and self-perceptions of functional performance (COPM). Statistical procedures included correlations between performance components and COPM scores and differences on selected variables at admission and discharge. Results. Significant improvements in all assessed functional components. COPM values increased more than 100% after intervention (effect size d = 1.996 for performance and d = 1.553 for satisfaction) demonstrating improvements in both domains. Low correlations between grip strength and COPM scores were found only at admission (r = 0.314; p = 0.045). When the relationship between gains in strength and COPM scores at discharge were examined, significant correlations were found with the performance (r = 0.324; p = 0.039) and satisfaction (r = 0.0326; p = 0.038) subscales. Conclusions. Results of this study provide evidence for functional gains in clients treated in a rehabilitation service and supply information about the relation between specific components and functional performance.

Clinical changes during an intervention based on constraint‐induced movement therapy principles on use of the affected arm of a child with obstetric brachial plexus injury: a case report

The objective of this study was to test the feasibility of a treatment programme based on the elements of constraint-induced movement therapy (CIMT) to encourage use of the affected arm of a child with obstetric brachial plexus injury (OBP), as well as to document clinical changes observed with this intervention. A 2-year-old female child with Erbs palsy had 14 weeks of daily home-based treatment with 30-minute sessions planned according to the principles of CIMT. The child was assessed every 2 weeks with the Toddler Arm Use Test. Test scores throughout the intervention period demonstrated improvements in quality of movement, amount of use and willingness to use the affected extremity. The childs mother reported improved ability to perform bimanual activities at home. The results suggest that treatment based on CIMT principles has potential to promote functional gains for children with OBP. Experimental studies should test the effects of this kind of intervention for children with OBP.

Effects of constraint-induced movement therapy in children with hemiplegia: a single case experimental study

Objective: To investigate the profile of changes in the use of the upper extremity in three children with hemiplegia submitted to an adapted protocol of constraint-induced movement therapy (CIMT). Methods: A single-subject design (ABA) was replicated in three children aged 8 to 11 years old. Baseline phases (A1) and (A2) and the intervention phase (B) lasted 2 weeks each. During the intervention period, children wore a splint on the non-affected extremity for 10 hours a day and were submitted to 3 hours of therapy a day during 10 days. Training consisted of activities with the affected upper extremity, with gradually increasing complexity and verbal feedback. Hand function was classified according to the Manual Ability Classification System (MACS). Children were assessed four times every week with the Toddler Arm Use Test (TAUT) and three adapted tasks from the Jebsen-Taylor Hand Function test (JTHF), and once a week with the Pediatric Motor Activity Log (PMAL) and self-care scales of the Pediatric Evaluation of Disability Inventory (PEDI). Celeration Line, Two-Standard Deviation Band and visual analysis methods were used for data analyses. Results: Significant improvements in the amount and quality of upper extremity use (PMAL), TAUT quality of use for children 2 and 3, and participation for child 1, as well as decreased time to complete JTHF tasks for children 2 and 3 were observed. No changes were observed in the PEDI self-care scales. Conclusion: CIMT effects were associated with improvements in manual dexterity, amount and quality of use of the affected upper extremity in children with hemiplegia.

Therapeutic effects of electrical stimulation on manual function of children with cerebral palsy: evaluation of two cases.

Purpose. To investigate changes in hand function associated with electrical stimulation for children with hemiplegic cerebral palsy. Method. An ABCA single-subject design, replicated in two children, was used in this study. Each baseline (phase A) lasted 4 weeks. Intervention consisted of electrical stimulation of wrist extensors (phase B) and of wrist extensors and flexors (phase C) for 15 minutes three times a week. Intervention phases also lasted 4 weeks. Active wrist extension range of movement and three timed manual tasks were tested two times a week every week. Data analysis included the Celeration Line and Two Standard Deviation Band methods in addition to visual analysis. Results. Significant performance gains were observed for both children, especially in phase C, when both extensors and flexors were stimulated. After intervention withdrawal, significant performance decreases were observed on most analysed variables. Conclusions. The observed performance changes seem to be associated with the presence of intervention and suggest that electrical stimulation can be a useful adjunct to improve hand function of children with cerebral palsy.