Maria Cecília dos Santos Moreira

A intervenção fisioterapêutica no ambulatório de cuidado a pessoa com síndrome de Down no Instituto de Medicina Física e Reabilitação HC FMUSP

Down Syndrome (SD) is the most common chromosomopathy in humans. It is known that, if properly stimulated, these people have the potential for full social inclusion. The objective of this study is to show the work done with this population by the Physiotherapy service provided by the multiprofessional team at the Clinic for the Care of Persons with DS at the Institute of Physical Medicine and Rehabilitation at HC FMUSP. This clinic develops therapeutic activities for persons up to 18 years of age. The work is carried out in models, which are subdivided into: a DS General Stimulation Model which serves patients up to three years of age whose objectives are focused on the acquisition of motor marks, essential for neuropsychomotor development; a DS Child Development Model which helps children from four to eleven years of age that focuses on the development of more advanced motor skills, strength, posture, improvement of mobility, balance, and proprioception to optimize cerebellar activity and the consequent enhancement of static and dynamic balance; a DS Adolescent Model for those aged twelve to eighteen; and a DS Adult Model starting at age nineteen aimed at orthopedic and postural restoration in addition to providing health guidance. Physiotherapeutic monitoring is fundamental within the clinic for the care of a person with DS, for it stimulates the motor development of these children, along with the multiprofessional team and the family, respecting their time and favoring their potentials, in addition to acting to educate the family on health so as to prevent problems and promote the health of the person with DS and their nuclear family.

Lesão medular: reabilitação

Spinal cord injured (SCI) persons open experience chronic pain. Methods of dealing with pain that the SCI client found helpful in the past may not be beneficial afrer the injury. This article describes a study of self-medication for the purpose of pain relief. Over-the-counter, prescription, or illicit drugs or alcohol are among the agents employed in self-medication. The rehabilitation nurse has a role in helping the SCI person to identify appropriate methods of managing chronic pain throughout life.

Comparação da pontuação obtida por videogame com variáveis biomecânicas em pacientes pós-acidente vascular encefálico

Virtual reality (VR) promotes intensive training of a single task, enabling the motor learning, thereby affecting the recovery of postural control (PC) in individuals with stroke. Video game with balance platform are used as a form of intervention and, at the end of the game, a score is provided, but there is no evidence that it can be used as a quantitative parameter of PC. Objective: To determine whether there is a correlation between the score obtained by a video game and stabilometric variables. Methods: Nine individuals with stroke participated in an experimental protocol using the game Penguin Slide as intervention. The score was collected in the first and last sessions. The 2.0 AMTI force platform was used, with an acquisition frequency of 200Hz for evaluating before and after intervention. The volunteers were positioned with open eyes (OE) and closed eyes (CE) in the upright position for 1 minute, with one foot on each platform. Using the Matlab software, the variables of center of pressure (COP) were obtained: total COP area (ACOPt), COP area on the mediolateral (ACOPx) and anteroposterior (ACOPy) axis, average speed of COP (VCOP). The non-parametric paired Wilcoxon test (p < 0.05) was used to compare the initial and final results of Penguin Slide game score and the pre and post intervention data obtained by the force platform in the OE and CE conditions. The analysis were done with the software R. Results: Comparison of initial and final score (p = 0.003). In OE condition, the initial and final comparison: ACOPt (p = 0.91), ACOPx (p = 0.57), ACOPy (p = 0.49), VCOP (p = 0.09). In CE condition, the initial and final comparison: ACOPt (p = 0.73) ACOPx (p = 1.0), ACOPy (p = 0.73) VCOP (p = 0.73). Conclusion: The VR did not provide PC improvement of the patients despite the score of the Penguin Slide game have increased significantly at the end of the protocol. Thus, there was no correlation between the score obtained by video game and the stabilometric variables

Efeitos do treino de marcha com assistência robótica em pacientes pós - acidente vascular encefálico

Pacientes acometidos por acidente vascular encefalico (AVE) apresentam deficit significativo de marcha em decorrencia da complexidade de suas deficiencias. O treino de marcha com assistencia robotica (TMR), alem de diminuir a carga fisica imposta sobre o terapeuta, garante um ambiente simplificado e seguro para o treino de marcha, no qual padroes simetricos e constantes de movimentos de membros inferiores podem ser desenvolvidos e em maiores velocidades, alem de permitir uma terapia com maior tempo de duracao. Apesar do uso crescente deste equipamento em reabilitacao pouco se sabe sobre os efeitos promovidos na reabilitacao da marcha pos-AVE, assim como os protocolos de intervencao empregados para se alcanca-los. Objetivo: Avaliar as evidencias atuais quanto a eficacia do TMR em individuos pos-AVE, com enfase no desempenho da marcha. Metodo: Para isso, foi realizado um levantamento literario dos estudos publicados nos ultimos 10 anos (2003-2013) com os termos “stroke” and “gait” and “robotics” nas bases de dados PubMed, MedLine e LILACS. Resultados: Foram selecionados 5 estudos que preencheram os criterios de inclusao, entre eles o de utilizar o dispositivo robotico Lokomat (Hocoma, Volketswil) para o treino de marcha em pacientes pos-AVE. A analise dos resultados obtidos em cada estudo considerou os ganhos promovidos nos parâmetros lineares da marcha (velocidade e distância percorrida) pela terapia robotica em comparacao a terapia convencional. Conclusao: Os dados sugerem que o emprego da terapia robotica na reabilitacao da marcha do paciente pos-AVE nao produz ganhos adicionais aos obtidos com a terapia convencional.

Quantificação do equilíbrio pelo videogame: estudo piloto

generation video games (VG) propose various balancing tests to asses stability of the user. However, the parameters used to provide the score of these tests are not reported in the literature, as well as their relation to clinical practice and user functionality. Objective: The objective of this study was to correlate the scores obtained by balancing tests of VG with kinetic variables provided by a force platform in simultaneous measurements. Method: This pilot study included two subjects with stroke and two with traumatic brain injury. Kinetic variables acquired were: area, velocity and root mean square of center of pressure position in the medial-lateral and anterior-posterior directions. Kinetic variables have been processed in Matlab 7.0® and correlated with the score provided by the console (balancing tests: Single-leg test -SL- and Steadiness test - ST -) using the Pearson correlation coefficient with p < 0.05. Results: A moderate correlation was found between the SL score and RMSy (r = 0.5839). When comparing the ST score to the variables: area (r = 0.8164), RMSx (r = -0.6418) and RMSy (r = -0.8094) the correlation was moderate to strong. Conclusion: No correlation was found with none of the tests of the console when compared with the velocity of displacement of the center of pressure measured on the force platform. It is concluded that the score of VG presented significant correlation with kinetic variables, but the method is impractical for being employed in clinical evaluation.Seventh generation video games (VG) propose various balancing tests to asses the stability of the user. However, the parameters used to provide the score of these tests are not reported in the literature, nor is their relationship to clinical practice and user functionality. Objective: The objective of this study was to correlate the scores obtained by the balance platform of the Wii video game with kinetic variables provided by a force platform in simultaneous measurements. Methods: This pilot study included two subjects with stroke and two with traumatic brain injury. The kinetic variables analyzed were: area, movement speed, and root mean square of center of pressure (COP) position in the medial-lateral and anterior-posterior directions, and were processed in Matlab 7.0® and correlated with the score provided by the console (balancing tests: Single-leg test - SL - and Steadiness test - ST -) using the Pearson and Spearman correlation coefficients, both with p < 0.05. Results: A moderate correlation was found between the SL score and RMSy (r = 0.5839). When comparing the ST score to the variables: area (r = 0.8164), RMSx (r = -0.6418) and RMSy (r = -0.8094) the correlation was moderate to strong. Conclusion: No correlation was found between the console tests and the movement speed of the center of pressure measured on the force platform. It is concluded that the score of VG presented significant correlation with the kinetic variables, but the method is not practical for being employed in a clinical evaluation.

Análise do controle postural após a aplicação da eletroestimulação funcional no acidente vascular encefálico

Strokes cause the main neurological impairments in adults around the world. They can result in neuromotor and cognitive deficits. Among the neuromotor deficits there is spasticity; this affects the planning of movements and posture control. The postural control system is essential for functional independence in daily life activities and is, therefore, one of the main goals to achieve in rehabilitation programs. These programs have various therapeutic elements aimed at providing stimulus to the individual, which help them control their movements and stance more efficiently. Among these techniques is neuromuscular electrical stimulation, which contributes to decreasing spasticity and other benefits. When used for functional tasks it is called Functional Electrical Stimulation (FES). Objective: The purpose of this study was to verify the response of the postural control in two individuals with hemiparesis by stroke after the application of the FES over a short period time. Method: The experimental protocol had four phases. A: pre-FES; B: Immediately after the application of FES; C: 45 minutes after the application of FES; D: 90 minutes after application of FES. In each phase, the participants were positioned on a force platform and made three attempts to do the chosen task: touching the fingertip-to-floor test. Results: The software Matlab 7.0 provided the variable center-of-pressure velocities along the mediolateral (Vmx) and anteroposterior (Vmy) axes. In this way it was possible to see that, even when the participants showed a reduction in Vmx and Vmy, it was by less than 1%. Conclusion: This may indicate postural regulatory activity similar to before the application of FES, and even less postural regulatory activity when the centerof-pressure velocities were greater at the start, even 90 minutes after the application of FES.O Acidente Vascular Encefalico (AVE) e o principal acometimento neurologico em adultos no mundo. Pode resultar em deficits neuromotores e cognitivos. Entre os deficits neuromotores observase a espasticidade, esta interfere no planejamento dos movimentos e no controle da postura. O sistema de controle da postura e primordial para a independencia funcional nas atividades de vida diaria e, por isso, e um dos principais objetivos a se atingir em programas de reabilitacao. Nestes, diversas condutas terapeuticas visam dar estimulos ao individuo para que consiga realizar mais eficientemente os movimentos e controlar a postura. E, entre tantas tecnicas, esta a estimulacao eletrica neuromuscular, a qual contribui para diminuicao da espasticidade, alem de outros beneficios. Quando utilizada para tarefas funcionais e entao denominada estimulacao eletrica funcional conhecida como Functional Eletrical Stimulation (FES). Tendo em vista a importância do controle da postura nas atividades de vida diaria e as contribuicoes advindas da FES. Objetivo: O objetivo do presente estudo foi de observar a resposta do controle postural em dois individuos com hemiparesia por AVE apos a aplicacao de FES em um curto periodo de tempo. Metodo: O protocolo experimental contou com quatro fases; A: pre FES; B: Imediatamente apos a aplicacao da FES; C: 45 minutos apos a aplicacao da FES; D: 90 minutos apos aplicacao da FES. Em cada fase o participante posicionava-se sobre uma plataforma de forca e realizava por tres tentativas a tarefa escolhida, o teste do terceiro dedo ao chao. Resultados: O software Matlab 7.0 forneceu a variavel de Velocidade media do Centro de Pressao no sentido medio-lateral (Vmx) e ântero-posterior (Vmy). Dessa forma, foi possivel constatar que mesmo quando os participantes apresentaram uma reducao na Vmx e Vmy estas foram menores que 1%. Conclusao: Isto possivelmente indique atividade regulatoria postural semelhante a etapa pre FES, e, ainda uma menor atividade regulatoria postural, quando a Vmx ou Vmy foram maiores que do inicio, mesmo apos a aplicacao da FES (90 minutos).

Benefícios da marcha com assistência robótica na lesão medular: uma revisão sistemática

Objetivo: Avaliar a qualidade atual de evidencias quanto a eficacia da marcha robotica com suspensao de peso corporal em individuos com lesao medular, com enfase no desempenho da marcha. Metodo: O levantamento bibliografico foi realizado nas bases de dados PubMed, LILACS e EMBASE referentes as publicacoes de ensaios clinicos dos ultimos doze anos (2000-2012), utilizando-se a relacao entre as palavras chave Spinal cord injury AND ( gait OR walking OR deambulation) reahbilitation AND robotic AND ( lokomat OR ReoAmbulator OR Formador Gait). Resultados: Dos oito estudos selecionados, apenas um nao observou melhora no padrao de desempenho da marcha. Dos estudos que encontraram melhora, 6 encontraram melhora estatisticamente significativa e um nao encontraram nenhuma diferenca significativa, apesar de uma tendencia de melhora ter sido observada. As conclusoes destes estudos foram obtidas por meio de ferramentas de avaliacao como o teste de caminhada de 6 minutos e de 10 metros, MIF (medida de independencia funcional, WISCI II (Indice de caminhada de Lesao Medular), entre outros. Alguns estudos apontam uma diminuicao na necessidade de orteses e dispositivos auxiliares nesse grupo. Quanto a qualidade metodologica, seis artigos apresentaram escores inferiores a 3 pontos e apenas um artigo teve a pontuacao maxima de 5 na escala JADAD (baixa qualidade pontuacao inferior a 3) Implicacao/Impacto na reabilitacao. Conclusao: Apesar da pequena quantidade de artigos encontrados, da baixa qualidade metodologica e o fato desta ser uma intervencao nova e de alto custo, os resultados sao significativos quando comparados com a terapia fisica convencional e outras tecnicas bem estabelecidas na fisioterapia.Objective: To evaluate the quality of current evidence regarding effectiveness of body weightsupported, robot-assisted gait in subjects with spinal cord injury, with emphasis on gait performance. Method: A survey was conducted in PubMed, LILACS and EMBASE using the keywords “spinal cord injury” AND (gait OR walking OR deambulation) reahbilitation AND robotic AND (Lokomat OR ReoAmbulator OR Formador Gait). Clinical trials published between 2001-2012 which compared locomotor training with or without other intervention were included. Results: From the 8 selected studies, only one did not findimprovement in gait performance. From the studies which found improvement, 6 found statistically significant improvement and one found no significant difference, although a tendency to improvement was noticed. The findings of these studies were obtained through assessment tools like the six-minute and the ten-meter walk tests, FIM (Functional Independence Measure, WISCI II (Walking Index for Spinal Cord Injury), among others. Some studies pointed to a decrease in the need for orthotics and assistive devices in this group. Regarding methodological quality, 6 articles presented scores lower than 3 points and only one article got the maximum score 5 in JADAD scale (low quality less than 3). Implication/Impact on rehabilitation. Conclusion: In spite of the small quantity of articles found, of the low methodological quality noted and the fact that this is a costly and new modality of intervention, the results are significant when compared to conventional physical therapy and to other well-established techniques in physical therapy.

Is the use of computerized electrical stimulation associated with cycloergometrics in individuals with medullary lesion beneficial for the muscular parameters

Este artigo tem como objetivo revisar a literatura sobre o uso do Computerized Functional Electrical Stimulation (CFES) com desfechos musculares para os individuos com lesao medular. Metodo: Foi realizada revisao bibliografica sistematica nas bases eletronicas de dados MEDLINE, PubMed, LILACS e Portal SciELO, sem delimitacao de tempo ou idioma. Utilizou-se da estrategia PICO para pesquisa, as palavras-chave foram selecionadas a partir dos descritores em ciencias de saude e relacionaram-se com lesao medular, estimulacao eletrica e parâmetros musculares. Resultados: Foram encontrados 554 artigos. Desses, 432 foram excluidos pelo titulo, resultando em 122 artigos. Destes, foram excluidas as duplicidades, resultando num total de 73 artigos; 36 foram excluidos pelo resumo e 33 apos a leitura do estudo. Quatro estudos foram selecionados. Dois artigos incluiram homens e mulheres em seus estudos, dois apenas homens. Tres estudos incluiram tetraplegicos e paraplegicos no mesmo estudo, um incluiu apenas tetraplegicos. Um dos estudos utilizou frequencia de treinamento maior, sete vezes por semana, tres fizeram uso de uma frequencia de treinamento de tres vezes por semana. A duracao dos estudos teve grande variacao, de seis semanas ate um ano. As medidas de resultado para a avaliacao de forca e resistencia foram realizadas de diversas maneiras, por medida de area de seccao transversal dos musculos, circunferencia do membro e a biopsia muscular; contudo, todos os estudos apresentavam ao menos uma das medidas fornecidas pelo equipamento, a avaliacao de potencia gerada (power output) ou do trabalho realizado (work output). Em todos os estudos, houve melhora da potencia gerada ou do trabalho realizado. Apesar da heterogeneidade encontrada nestes estudos, os desfechos dos estudos avaliados indicam aumento significativo de potencia gerada e trabalho realizado apos os periodos de treinamentos, com ganhos a partir de seis semanas e treinamentos a partir de tres vezes por semana. Conclusao: Estudos futuros sao necessarios para avaliar as respostas em diferentes grupos de sujeitos, paraplegicos e tetraplegicos, em diferentes frequencias de treinamento e em diferentes periodos de treinamento, proporcionando, assim, a elaboracao de protocolos de treinamento cada vez mais direcionados.

The effect of Functional Electric Stimulation in stroke patients' motor control – a case report

Functional Electric Stimulation (FES) has been studied as a therapeutic resource to reduce spasticity in hemiplegic patients, however there are no studies about the effects of FES in motor control of these patients during functional tasks like balance maintenance. Muscular activation of gastrocnemius medialis and semitendinosus was investigated in both limbs of a hemiparetic patient during self-disturbed quiet stance before and after FES on tibialis anterior, by surface electromyography. The instant of maximum activation peak of GM and ST were calculated immediately after a motor self-disturbance, in order to observe muscular synergy between these two muscles, and possible balance strategies used (ankle or hip strategy). At the preserved limb there occurred distal-proximal synergy (GM followed by ST), expected for small perturbations; however, at spastic limb there was inversion of this synergy (proximal-distal) after FES. It is possible that intervention of electricity had inhibited synergical pathways due to antidromic effect, making it difficult to use ankle strategy in the spastic limb.