Tatiana de Paula Oliveira

Effect of Nintendo Wii™-based motor and cognitive training on activities of daily living in patients with Parkinson's disease: a randomised clinical trial.

OBJECTIVES To investigate the effect of Nintendo Wii™-based motor cognitive training versus balance exercise therapy on activities of daily living in patients with Parkinsons disease. DESIGN Parallel, prospective, single-blind, randomised clinical trial. SETTING Brazilian Parkinson Association. PARTICIPANTS Thirty-two patients with Parkinsons disease (Hoehn and Yahr stages 1 and 2). INTERVENTIONS Fourteen training sessions consisting of 30 minutes of stretching, strengthening and axial mobility exercises, plus 30 minutes of balance training. The control group performed balance exercises without feedback or cognitive stimulation, and the experimental group performed 10 Wii Fit™ games. MAIN OUTCOME MEASURE Section II of the Unified Parkinsons Disease Rating Scale (UPDRS-II). RANDOMISATION Participants were randomised into a control group (n=16) and an experimental group (n=16) through blinded drawing of names. STATISTICAL ANALYSIS Repeated-measures analysis of variance (RM-ANOVA). RESULTS Both groups showed improvement in the UPDRS-II with assessment effect (RM-ANOVA P<0.001, observed power=0.999). There was no difference between the control group and the experimental group before training {8.9 [standard deviation (SD) 2.9] vs 10.1 (SD 3.8)}, after training [7.6 (SD 2.9) vs 8.1 (SD 3.5)] or 60 days after training [8.1 (SD 3.2) vs 8.3 (SD 3.6)]. The mean difference of the whole group between before training and after training was -0.9 (SD 2.3, 95% confidence interval -1.7 to -0.6). CONCLUSION Patients with Parkinsons disease showed improved performance in activities of daily living after 14 sessions of balance training, with no additional advantages associated with the Wii-based motor and cognitive training. Registered on http://www.clinicaltrials.gov (identifier: NCT01580787).

Motor learning, retention and transfer after virtual-reality-based training in Parkinson's disease - effect of motor and cognitive demands of games: a longitudinal, controlled clinical study

OBJECTIVES To evaluate the learning, retention and transfer of performance improvements after Nintendo Wii Fit™ training in patients with Parkinsons disease and healthy elderly people. DESIGN Longitudinal, controlled clinical study. PARTICIPANTS Sixteen patients with early-stage Parkinsons disease and 11 healthy elderly people. INTERVENTIONS Warm-up exercises and Wii Fit training that involved training motor (shifts centre of gravity and step alternation) and cognitive skills. A follow-up evaluative Wii Fit session was held 60 days after the end of training. Participants performed a functional reach test before and after training as a measure of learning transfer. MAIN OUTCOME MEASURES Learning and retention were determined based on the scores of 10 Wii Fit games over eight sessions. Transfer of learning was assessed after training using the functional reach test. RESULTS Patients with Parkinsons disease showed no deficit in learning or retention on seven of the 10 games, despite showing poorer performance on five games compared with the healthy elderly group. Patients with Parkinsons disease showed marked learning deficits on three other games, independent of poorer initial performance. This deficit appears to be associated with cognitive demands of the games which require decision-making, response inhibition, divided attention and working memory. Finally, patients with Parkinsons disease were able to transfer motor ability trained on the games to a similar untrained task. CONCLUSIONS The ability of patients with Parkinsons disease to learn, retain and transfer performance improvements after training on the Nintendo Wii Fit depends largely on the demands, particularly cognitive demands, of the games involved, reiterating the importance of game selection for rehabilitation purposes.

Case Report: Physical therapy management of axial dystonia

Abstract Few studies have described physical therapy approaches to provide functional independence and reduce pain in individuals with dystonia. This report describes the physical therapy treatment of a 46-year-old woman diagnosed with idiopathic segmental axial dystonia. For two years, the patient was treated with kinesiotherapy (active and resisted movements and stretching of neck and trunk muscles), abdominal taping (kinesiotaping techniques), functional training, and sensory tricks. She was assessed with parts I, II and III of Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS-I, TWSTRS-II and TWSTRS-III), Berg Balance Scale (BBS), Six-Minute Walk Test (6-MWT), and the motor domain of Functional Independence Measure (FIM-motor) before and after the two-year treatment and after the one year follow-up. Postural control and symmetry improved (TWSTRS-I: from 30 to 18), functional independence increased (TWSTRS-II: from 27 to 15; BBS: from 36 to 46; 6-MWT: from 0 to 480 meters (m); FIM-motor: from 59 to 81), and the pain diminished (TWSTRS-III: from 12 to 5). The functional improvement was retained after one year (TWSTRS-I: 14/35; TWRTRS-II: 12/30; TWRTRS-III: 5/20; BBS: 48/56; 6-MWT: 450 m; FIM-motor: 81/91). This program showed efficacy on providing a better control of the dystonic muscles and thus the doses of botulinum toxin needed to treat them could be reduced. Outcomes support the therapeutic strategies used to deal with this type of dystonia.

Elaboração de um manual ilustrado de exercícios domiciliares para pacientes com hemiparesia secundária ao acidente vascular encefálico (AVE)

The practice of exercises for patients with motor sequels post-stroke is essential for the functional recovery. Educational programs can facilitate the repetition of the exercises at home and contribute to the treatment. The objective of this study was to elaborate a home exercise manual for stroke patients. The study consisted of two stages: in the first one, a home exercise manual was made (pilot) with pictures and simple text to facilitate understanding. We made functional assessment of each patient and select the most appropriate exercises that everyone should do at home. This manual has been applied to 17 patients, 70% chronic and acute 30%. After 15 days the patient returned and was asked to reproduce the exercises and report the level of understanding of pictures and text of the manual and if felt pain in perform them. Photos and exercises reported such as difficult were reviewed and created a test version that was applied in another 23 patients resulting in the final version of the manual. The evaluation of the manual pilot was unsatisfactory, with only 56% reported approval of photos and 87% approval of text. After reformulation, the comprehension of the photos and text reached values above 98%. It was possible to obtain an illustrated manual of home exercises, easy understanding and application specific and personal for stroke patients and adaptable for different motor conditions.

Improvement in Gait Performance after Training Based on DeclarativeMemory Cues in Patients with Parkinsons Disease: A Randomized ClinicalTrial

Background: Deficits in automatic motor control, a typical feature of Parkinson’s disease (PD), contribute to progressive impairment in gait performance. The use of declarative memory cues in order to promote the engagement of attention and activation of the next movement in gait may minimize the consequences of lack of automatic control. Objectives: To verify the long-term efficiency of a new strategy based on declarative memory cues to improve the gait performance and independence in activities of daily living (ADL) in patients with PD. Design: Parallel prospective, single blind, randomized clinical trial. Setting: Brazil Parkinson Association. Participants: Forty-four patients with PD in stages 2-3 of disease evolution according to Hoehn and Yahr Classification. Interventions: The experimental training (ET) consisted of eight gait training sessions, twice a week, using the declarative memory cue strategy (DMCS). The control training (CT) consisted of a similar gait training without DMCS. Primary outcome measure: Gait performance in terms of speed and stride length. Secondary outcome measure: Independence in ADL according to Section II of the Unified Parkinson’s Disease Rating Scale. Randomization: Participants were randomized into a control group (CG), which performed the CT, and an experimental group (EG), which performed the ET, through blinded drawing of names. Statistical analysis: Gait performance and independence in ADL before, 2 and 60 days after the end of training were compared for CG and EG using RM-ANOVA. Results: RM-ANOVA revealed a significant improvement of the gait performance in terms of speed and stride length and independence in ADL, remained until 2 months after the end of training, exclusively for the EG after ET. Conclusion: Gait training associated to declarative memory cues promotes significant long-term improvements in gait performance and can be considered a new useful strategy to compensate the deficiency in automatic motor control of gait in PD patients.

Diretrizes para avaliação e tratamento fisioterapêutico da Síndrome de Pusher: estudo de caso

A Sindrome de Pusher (SP) e uma alteracao perceptual presente em 10% dos casos de hemiparesia causada por Acidente Vascular Encefalico (AVE). Caracteriza-se por queda para o lado paretico, comportamento de empurrar-se para o lado acometido com o hemicorpo nao paretico e resistencia a correcao externa. Este estudo visou descrever a avaliacao, o tratamento e a evolucao de uma paciente com hemiparesia a esquerda e SP, devido a um AVE no hemisferio cerebral direito. Seis meses apos a lesao, a paciente realizou testes perceptuais (do desenho da figura humana, comportamental de inatencao, escala de avaliacao do sintoma de empurrar, miniexame do estado mental) e de desempenho funcional (escala de avaliacao postural para pacientes com AVE, teste de funcao manual de Jebsen-Taylor, medida de independencia funcional e indice de Barthel) e iniciou fisioterapia duas vezes por semana. Cada sessao teve 3 partes de 20 minutos: estimulacao sensorial, treino motor e integracao sensorio-motora. Apos o tratamento a paciente foi reavaliada e apresentou melhora em todas as escalas. A de avaliacao do sintoma de empurrar e o teste de funcao manual de Jebsen-Taylor foram os que registraram maiores percentuais de melhora, 79% e 46%, respectivamente. O protocolo utilizado, mesmo tendo sido iniciado seis meses apos a lesao, proporcionou melhora perceptual e funcional, o que sugere a importância da fisioterapia na recuperacao da SP.

Balance Training In Virtual Reality In Patients With Chronic Sequels Of Stroke: Effects On ICF Domains, Preliminary Data

Objectives: To compare the effect of balance training performed in Virtual Reality environment (VR) with conventional balance training on Body Functions, Activity Level and Participation level according to the International Classification of Functioning, Disability and Health (ICF) model in patients with chronic sequels of stroke. Study Design: A prospective, single-blind, parallel-group randomized clinical trial. Participants: Twenty-three patients with chronic sequels of stroke. Interventions: Fourteen sessions of balance training performed in VR by using Nintendo Wii Fit™ games (NWF), for Experimental Group (EG), or conventional balance training for Control Group (CG). Main outcome measures: The Lower limb subscale of the Fulg-Meyer Assessment (FMA-LE) as a measure of Body Function domain; the Balance Evaluation Systems Test (BESTest), as a measure of Activity domain; and the Stroke-Specific Quality of Life Scale (SS--QOL), as a measures of Participation domain according to ICF. All outcome measures were administered at baseline, 1-week and at a 2-month follow-up. Results: The ANOVA for repeated measure showed that there were statistical significant improvements in FMA-LE and BESTest scores after training, which were kept at 2-month follow-up, for EG only. There was not statistically significant improvement in Participation level for both groups. Conclusions: Balance training performed in VR by using NWF was more efficient than conventional balance training to improve the Body Function and Activity level in patients with chronic sequels of stroke.

Lack To Transfer The Performance's Improvements Obtained In Virtual Reality Environment To Balance Control In Patients With Chronic Sequels Of Stroke

Objectives: Despite the recent enlargement in the usage of Virtual Reality environments for rehabilitation in Stroke, the potential for transference/generalization of gains to similar task performed in real environments remains uncertain. Thus, the purpose of this study was to verify the transference/generalization of gains obtained by training in Virtual Reality environments (VR) to similar balance tasks in real environment in patients with chronic sequels of Stroke. Participants: Twenty-nine chronic stroke patients. Interventions: Three sessions of balance training in VR using five games from Nintendo Wii Fit™ for experimental group (EG). Verbal orientation about falls preventions for control group (CG). Main outcome measures: The transference/generalization of gains obtained in VR training was assessed through performance in four balance tests with similar demand than games using a force plate in two assessment time points: at baseline (BA) and at end of study (EA). Results: The ANOVA for repeated measure showed that there were statistically significant improvements for all trained games after the training. However, there were no statistical significant differences in the balance tests performance between BA and EA, for both groups. Conclusions: Patients with chronic sequels with stroke were unable to transfer/generalize the gains obtained in VR to similar balance tasks performed in real environment.

Upper Limb Training Using Virtual Reality in Patients with Chronic Sequels of Stroke

Objectives: A large number of studies have showed a positive effect of training associated to virtual reality (VR) to improve the function of paretic upper limb (PUL) in patients with Stroke. However, there is a lack in the evidences about the transfers potential of the gains obtained in the VR to real environment. Thus, the purpose of this study was to investigate the transfer of gains obtained through training in VR to motor function of the PUL tested in real environment (RE) in individuals with chronic sequels of stroke (CSS). Participants: Twenty-two patients with chronic sequels of stroke with a mean age of 66.4 ±7.14 years, 15 men and 7 women, mean time post stroke, 4.1± 5.14 years; 13 with left hemiparesis. Interventions: Three sessions of training in VR using four games of the Nintendo Wii (NW) that elicited large and fast upper limb movements. Main outcome measures: Goniometric measures were used as the main outcome to evaluate the transfer of gain to range of motion. As well as a computerizing test was used to evaluate the transfer of gains to movement velocity. Additionally, the scores obtained from the patients in the four games were also used as measure of learning. All measures were evaluated in two assessment time points: baseline (BA) and at end of study (EA). Results: The ANOVA for repeated measure showed that there were statistically significant improvements for all trained games and transfer tests (range of motion and movement velocity). Conclusions: Patients with CSS were able to transfer the gains obtained in the VR to motor function, specifically in range of motion and movement velocity in the PUL.