Effects of a 6-month self-rehabilitation programme in addition to botulinum toxin injections and conventional physiotherapy on limitations of patients with spastic hemiparesis following stroke (ADJU-TOX): protocol study for a randomised controlled, investigator blinded study.

INTRODUCTION: Home-based self-rehabilitation programmes combined with botulinum toxin injections (BTIs) appear to be a relevant approach to increase the recommended intensive rehabilitation of patients with spasticity following a stroke. The literature highlights a lack of evidence of beneficial effects of this adjuvant therapy to reduce limitations of patients with stroke. The aim of this study is to assess the effects of a 6-month self-rehabilitation programme in adjunction to BTI, in comparison with BTI alone, to reduce limitations of patients with spasticity following a stroke. METHODS AND ANALYSIS: 220 chronic patients will participate to this multicentre, prospective, randomised, controlled, assessor blinded study. All patients will benefit from two successive BTI (3 months apart), and patients randomised in the self-rehabilitation group will perform in adjunction 6 months of self-rehabilitation at home. All patients continue their conventional physiotherapy. The main outcome is the primary treatment goal (PTG), which will be determined jointly by the patient and the medical doctor using Goal Attainment Scaling. Impairments and functions, quality of life, mood and fatigue will be assessed. Botulinum toxin will be injected into the relevant muscles according to the PTG. Patients in the self-rehab group will be taught the self-rehabilitation programme involving respectively 10 min of stretching, 10 min of strengthening and 10 min of task-oriented exercises, corresponding to their PTG. Compliance to the self-rehabilitation programme will be monitored. ETHICS AND DISSEMINATION: Patients will sign written informed consent. Ethical approval was obtained from ethics committee. The results will be disseminated in a peer-reviewed journal and presented at international congresses. The results will also be disseminated to patients. TRIAL REGISTRATION NUMBER: NCT02944929.

Personalized upper limb training combined with anodal-tDCS for sensorimotor recovery in spastic hemiparesis: study protocol for a randomized controlled trial.

BACKGROUND: Recovery of voluntary movement is a main rehabilitation goal. Efforts to identify effective upper limb (UL) interventions after stroke have been unsatisfactory. This study includes personalized impairment-based UL reaching training in virtual reality (VR) combined with non-invasive brain stimulation to enhance motor learning. The approach is guided by limiting reaching training to the angular zone in which active control is preserved ("active control zone") after identification of a "spasticity zone". Anodal transcranial direct current stimulation (a-tDCS) is used to facilitate activation of the affected hemisphere and enhance inter-hemispheric balance. The purpose of the study is to investigate the effectiveness of personalized reaching training, with and without a-tDCS, to increase the range of active elbow control and improve UL function. METHODS: This single-blind randomized controlled trial will take place at four academic rehabilitation centers in Canada, India and Israel. The intervention involves 10 days of personalized VR reaching training with both groups receiving the same intensity of treatment. Participants with sub-acute stroke aged 25 to 80 years with elbow spasticity will be randomized to one of three groups: personalized training (reaching within individually determined active control zones) with a-tDCS (group 1) or sham-tDCS (group 2), or non-personalized training (reaching regardless of active control zones) with a-tDCS (group 3). A baseline assessment will be performed at randomization and two follow-up assessments will occur at the end of the intervention and at 1 month post intervention. Main outcomes are elbow-flexor spatial threshold and ratio of spasticity zone to full elbow-extension range. Secondary outcomes include the Modified Ashworth Scale, Fugl-Meyer Assessment, Streamlined Wolf Motor Function Test and UL kinematics during a standardized reach-to-grasp task. DISCUSSION: This study will provide evidence on the effectiveness of personalized treatment on spasticity and UL motor ability and feasibility of using low-cost interventions in low-to-middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02725853 . Initially registered on 12 January 2016.

A comprehensive person-centered approach to adult spastic paresis: a consensus-based framework.

Spastic paresis is a common feature of an upper motor neuron impairment caused by stroke, brain injury, multiple sclerosis and other central nervous system (CNS) disorders. Existing national and international guidelines for the treatment of adult spastic paresis tend to focus on the treatment of muscle overactivity rather than the comprehensive approach to care, which may require life-long management. Person-centered care is increasingly adopted by healthcare systems in a shift of focus from "disease-oriented" towards "person-centered" medicine. The challenge is to apply this principle to the complex management of spastic paresis and to include an educative process that engages care providers and patients and encourages them to participate actively in the long-term management of their own disease. To address this issue, a group of 13 international clinicians and researchers used a pragmatic top-down methodology to evaluate the evidence and to formulate and grade the strength of recommendations for applying the principles of person-centered care to the management of spastic paresis. There is a distinct lack of clinical trial evidence regarding the application of person-centered medicine to the rehabilitation setting. However, the current evidence base supports the need to ensure that treatment interventions for spastic paresis should be centered on as far as reasonable on the patient's own priorities for treatment. Goal setting, negotiation and formal recording of agreed SMART goals should be an integral part of all spasticity management programs, and goal attainment scaling should be recorded alongside other standardized measures in the evaluation of outcome. When planning interventions for spastic paresis, the team should consider the patient and their family's capacity for self-rehabilitation, as well as ways to enhance this approach. Finally, the proposed intervention and treatment goals should consider the impact of any neuropsychological, cognitive and behavioral deficits on rehabilitation. These recommendations support a person-centric focus in the management of spastic paresis.

Effects of superficial heating and insulation on walking speed in people with hereditary and spontaneous spastic paraparesis: A randomised crossover study.

OBJECTIVES: Cooling of the lower limb in people with Hereditary and Spontaneous Spastic Paraparesis (pwHSSP) has been shown to affect walking speed and neuromuscular impairments. The investigation of practical strategies, which may help to alleviate these problems is important. The potential of superficial heat to improve walking speed has not been explored in pwHSSP. Primary objective was to explore whether the application of superficial heat (hot packs) to lower limbs in pwHSSP improves walking speed. Secondary objective was to explore whether wearing insulation after heating would prolong any benefits. METHODS: A randomised crossover study design with 21 pwHSSP. On two separate occasions two hot packs and an insulating wrap (Neo-G™) were applied for 30minutes to the lower limbs of pwHSSP. On one occasion the insulating wrap was maintained for a further 30minutes and on the other occasion it was removed. Measures of temperature (skin, room and core), walking speed (10 metre timed walk) and co-ordination (foot tap time) were taken at baseline (T1), after 30 mins (T2) and at one hour (T3). RESULTS: All 21 pwHSSP reported increased lower limb stiffness and decreased walking ability when their legs were cold. After thirty minutes of heating, improvements were seen in walking speed (12.2%, P<0.0001, effect size 0.18) and foot tap time (21.5%, P<0.0001, effect size 0.59). Continuing to wear insulation for a further 30minutes gave no additional benefit; with significant improvements in walking speed maintained at one hour (9.9%, P>0.001) in both conditions. CONCLUSIONS: Application of 30minutes superficial heating moderately improved walking speed in pwHSSP with effects maintained at 1hour. The use of hot packs applied to lower limbs should be the focus of further research for the clinical management of pwHSSP who report increased stiffness of limbs in cold weather and do not have sensory deficits.

Superficial warming and cooling of the leg affects walking speed and neuromuscular impairments in people with spastic paraparesis.

BACKGROUND: People with hereditary and spontaneous spastic paraparesis (HSSP) report that their legs are stiffer and walking is slower when their legs are cold. OBJECTIVES: This study explored the effects of prolonged superficial cooling and warming of the lower leg on walking speed and local measures of neuromuscular impairments. METHODS: This was a randomised pre- and post-intervention study of 22 HSSP participants and 19 matched healthy controls. On 2 separate occasions, one lower leg was cooled or warmed. Measurements included walking speed and measures of lower limb impairment: ankle movement, passive muscle stiffness, spasticity (stretch reflex size), amplitude and rate of force generation in dorsi- and plantarflexors and central and peripheral nerve conduction time/velocity. RESULTS: For both participants and controls, cooling decreased walking speed, especially for HSSP participants. For both groups, cooling decreased the dorsiflexor rate and amplitude of force generation and peripheral nerve conduction velocity and increased spasticity. Warming increased dorsiflexor rate of force generation and nerve conduction velocity and decreased spasticity. CONCLUSIONS: Superficial cooling significantly reduced walking speed for people with HSSP. Temperature changes were associated with changes in neuromuscular impairments for both people with spastic paraparesis and controls. This study does not support the use of localised cooling in rehabilitation for people with spastic paraparesis as reported in other neurological conditions. Rehabilitation interventions that help prevent heat loss (insulation) or improve limb temperature via passive or active means, particularly when the legs and/or environment are cool, may benefit people with spastic paraparesis.

Local muscle injection of botulinum toxin type a synergistically improves the beneficial effects of repetitive transcranial magnetic stimulation and intensive occupational therapy in post-stroke patients with spastic upper limb hemiparesis.

BACKGROUND: The purpose of this study was to determine whether local injection of botulinum toxin type A (BoNT-A) into the spastic muscles has any added benefits to repetitive transcranial magnetic stimulation (RTMS)/occupational therapy (OT) in patients with spastic upper limb hemiparesis. METHODS: The study subjects of 80 post-stroke patients with spastic upper limb hemiparesis (age: 60.2 ± 13.0 years, time after stroke: 55.3 ± 43.0 months), were divided into the BoNT-A plus RTMS/OT group and RTMS/OT group. BoNT-A was injected into the spastic muscles (total dose: 240 units) before RTMS/OT. The latter included 12 sessions of 40 min RTMS over the non-lesional hemisphere and 240-min intensive OT daily over 15 days. Spasticity was evaluated by the modified Ashworth scale (MAS) and the motor function of the affected upper limb was evaluated serially with Fugl-Meyer Assessment and Wolf Motor Function Tests. RESULTS: Both groups showed significant improvements in spasticity and motor function. The addition of BoNT-A resulted in better improvement in FMA score and MAS of finger flexor muscles (p < 0.05). CONCLUSIONS: The triple-element protocol of local injection of BoNT-A into spastic finger muscles, RTMS and intensive OT, is a promising therapeutic program for post-stroke spastic upper limb hemiparesis, although its significance should be confirmed in randomized, placebo-controlled trials.

Effects of repetitive peripheral magnetic stimulation on upper-limb spasticity and impairment in patients with spastic hemiparesis: a randomized, double-blind, sham-controlled study.

OBJECTIVE: To investigate short-term and long-term effects of repetitive peripheral magnetic stimulation (rpMS) on spasticity and motor function. DESIGN: Monocentric, randomized, double-blind, sham-controlled trial. SETTING: Neurologic rehabilitation hospital. PARTICIPANTS: Patients (N=66) with severe hemiparesis and mild to moderate spasticity resulting from a stroke or a traumatic brain injury. The average time ± SD since injury for the intervention groups was 26 ± 71 weeks or 37 ± 82 weeks. INTERVENTIONS: rpMS for 20 minutes or sham stimulation with subsequent occupational therapy for 20 minutes, 2 times a day, over a 2-week period. MAIN OUTCOME MEASURES: Modified Tardieu Scale and Fugl-Meyer Assessment (arm score), assessed before therapy, at the end of the 2-week treatment period, and 2 weeks after study treatment. Additionally, the Tardieu Scale was assessed after the first and before the third therapy session to determine any short-term effects. RESULTS: Spasticity (Tardieu >0) was present in 83% of wrist flexors, 62% of elbow flexors, 44% of elbow extensors, and 10% of wrist extensors. Compared with the sham stimulation group, the rpMS group showed short-term effects on spasticity for wrist flexors (P=.048), and long-term effects for elbow extensors (P<.045). Arm motor function (rpMS group: median 5 [4-27]; sham group: median 4 [4-9]) did not significantly change over the study period in either group, whereas rpMS had a positive effect on sensory function. CONCLUSIONS: Therapy with rpMS increases sensory function in patients with severe limb paresis. The magnetic stimulation, however, has limited effect on spasticity and no effect on motor function.

Prospective 12-month study of intrathecal baclofen therapy for poststroke spastic upper and lower extremity motor control and functional improvement.

OBJECTIVES: To assess the effects of intrathecal baclofen (ITB) therapy for the treatment of poststroke spastic hemiparesis on quality of life, functional independence, and upper, lower extremity (UE, LE) motor functions. MATERIALS AND METHODS: Prospective observational study of adult men and women with a minimum 6-month stroke-related spastic hemiparesis graded as ≥2 in UE and LE on Modified Ashworth Scale (MAS). Patients served as their own controls with measures compared pre-implant with 12 months post ITB including: MAS, manual muscle test (MMT), gait distance/velocity, Functional Independence Measures (FIM), stroke-specific quality of life scale (SSQL), and upper extremity manual activity log. RESULTS: After 12-month ITB therapy, 26 patients (poststroke=6.4±9 years) demonstrated 1) reduced MAS/increased MMT for most LE muscle groups (p≤0.0001); 2) reduced MAS/increased MMT most UE muscle groups (p≤0.01); 3) FIM scores improved (p≤0.05) except bed mobility and lower body dressing; 4) gait distance and velocity improved (p≤0.05); 5) SSQL domains of family roles, mobility, personality, self-care, social roles, thinking, UE function, and work/productivity improved (p≤0.05); 6) amount of use and quality of movement of the spastic UE in performing common activities of daily living increased (p<0.0001). CONCLUSIONS: Regardless of duration of spastic hemiparesis, a reduction in tone with ITB therapy facilitates motor strength improvement and is associated with clinically significant improvements in functional independence and quality of life.

Utilização do playground por crianças com paralisia cerebral tipo diparética espástica: preferências e dificuldades relatadas pelas mães / Utilization of playground by children suffering from cerebral palsy, spastic diparetic type: preferences and difficulties reported by mothers

Este estudo teve como objetivo investigar como ocorre a utilização do playground por um grupo de crianças com paralisia cerebral tipo diparética espástica segundo relato verbal de suas mães. Participaram da pesquisa dez mães de crianças entre quatro e oito anos, para as quais foi aplicado um questionário contendo perguntas sobre a utilização desse espaço pela criança. Posteriormente foram selecionadas cinco mães, que preenchiam os critérios estabelecidos para o estudo, que era freqüentar o playground regularmente com seu filho. Foi agendada uma entrevista semi-estruturada, realizada pela pesquisadora e gravada em fita cassete. As mães relataram freqüentar playgrounds de parques públicos com seus filhos, ressaltando que as crianças reagiam bem aos estímulos oferecidos pelos brinquedos, apresentando pouca dificuldade nos relacionamentos sociais. Referiram também ter sido pouco orientadas sobre os benefícios do playground por profissionais que atuam na área do desenvolvimento. O desempenho das crianças mostrou que este ambiente pode ser favorável ao desenvolvimento motor e social, proporcionando os estímulos vestibulares, proprioceptivos e táteis, semelhantes àqueles oferecidos na terapia de integração sensorial. Espera-se apontar uma nova alternativa de estimulação para a criança com paralisia cerebral no ambiente natural do playground, proporcionando melhor desenvolvimento motor, cognitivo e social.

The aim of this study was to investigate how does the use of the playground by a group of children with spastic diparetic cerebral palsy, according to their mothers' verbal report. Ten mothers of children between four and eight years participated of this research and answered a questionnaire with questions about the child performance in the playground space. Subsequently, five mothers were selected to participate in another phase of the study, which consisted in regularly attend the playground with their children. The data was collected in a semi-structured interview, conducted by the researcher and recorded on audiotape. Mothers reported frequenting public parks with playgrounds for their children, stating that the children reacted well to the stimuli offered by the toys, presenting little difficulty in social relationships and refer that they have been little counseling on the benefits of the playground by professionals who working in development. Children's performance showed that this environment may be conducive to the motor and social development, providing the vestibular, proprioceptive and tactile stimulus, like those offered on sensory integration therapy. It is hoped an alternative propose of stimulation for the child with cerebral palsy in the natural environment of the playground, providing a better motor development, cognitive and social development.

A technology-based stimulation program to reduce hand mouthing by an adolescent with multiple disabilities.

This study assessed the possibility of reducing hand mouthing, i.e., bringing fingers into or over the mouth, by an adolescent with multiple disabilities through a technology-based stimulation strategy. The strategy ensured that (a) the participant received 10 sec. of preferred stimulation contingent on the response of bringing both hands into a box with objects, and (b) the stimulation would be interrupted prematurely if the participant removed one or both hands from the box for 2 sec. The study involved an ABAB sequence (in which A represented baseline and B intervention phases) and a 3-mo. postintervention check. Data showed that the response of bringing both hands into the box increased from a mean frequency of about four per 10-min. session during baseline to a mean frequency of over 30 per session during the second intervention phase and the postintervention check. During these periods, the participant's mean hand-mouthing time per session was below 1.5 min. (compared to above 7 min. during baseline) and the mean stimulation time per session was about 4 min. Practical implications of the findings are discussed.

Adult case of acrodysostosis with severe neurologic involvement.

OBJECTIVE: Acrodysostosis is a rare syndrome characterized by peripheral dysostosis, nasal hypoplasia and frequently mental retardation. Only one adult case of acrodysostosis has been reported to have neurologic symptoms. We report one further adult case of acrodysostosis with severe neurologic findings including myelopathy and spastic paraparesis due to diffuse spinal stenosis and recurrent deep vein thrombosis possibly caused by neurologic deficits. RESULTS: We report a 43-year-old woman who had back and neck pain with weakness in the extremities of several years. 1~year before admission to our hospital, she had been treated with a missed diagnosis of sero (-) spondyloarthropathy but had not benefited. She became unable to walk, thereafter she underwent decompression surgery with a diagnosis of degenerative spinal stenosis. She presented at our outpatient department complaining of lowback pain and difficulty walking. She had marked facial and peripheral appearance of acrodysostosis. Spinal MRI revealed extensive spinal stenosis. A diagnosis was made through the genetic investigation, clinical and radiological findings. Spastic paraparesis were detected. There was widespread neuropathic pain. 15 days after admission, she developed swelling and redness of the left lower extremity and the venous doppler ultrasonography showed left acute and right past DVT. We treated DVT with anticoagulant therapy. Gabapentin and Baclofen were initiated for neuropathic pain and spasticity. A conventional rehabilitation program was performed. She left walking with a walker without pain and spasticity. CONCLUSIONS: We would like to remind physicians to be aware of peripheral malformations as signs of skeletal dysplasias and to consider acrodysostosis in the differential diagnosis. Although it is a rare condition, if diagnosed early, possible complications can be treated and outcomes may be improved.

The effect of hippotherapy on spasticity and on mental well-being of persons with spinal cord injury.

OBJECTIVES: To determine the effect of hippotherapy on spasticity and on mental well-being of persons with spinal cord injury (SCI), and to compare it with the effects of other interventions. DESIGN: Crossover trial with 4 conditions. SETTING: Swiss paraplegic center. PARTICIPANTS: A volunteer sample of 12 people with spastic SCI (American Spinal Injury Association grade A or B). INTERVENTIONS: Hippotherapy, sitting astride a Bobath roll, and sitting on a stool with rocking seat. Each session lasted 25 minutes and was conducted twice weekly for 4 weeks; the control condition was spasticity measurement without intervention. MAIN OUTCOME MEASURES: Clinical rating by a blinded examiner of movement-provoked muscle resistance, using the Ashworth Scale; self-rating of spasticity by subjects on a visual analog scale (VAS); and mental well-being evaluated with the self-rated well-being scale Befindlichkeits-Skala of von Zerssen. Assessments were performed immediately after intervention sessions (short-term effect); data from the assessments were analyzed 3 to 4 days after the sessions to calculate the long-term effect. RESULTS: By analyzing the clinically rated spasticity, only the effect of hippotherapy reached significance compared with the control condition (without intervention); median differences in the Ashworth scores' sum before and after hippotherapy sessions ranged between -8.0 and +0.5. There was a significant difference between the spasticity-reducing effect of hippotherapy and the other 2 interventions in self-rated spasticity by VAS; median differences of the VAS before and after hippotherapy sessions ranged between -4.6 and +0.05cm. There were no long-term effects on spasticity. Immediate improvements in the subjects' mental well-being were detected only after hippotherapy (P=.048). CONCLUSIONS: Hippotherapy is more efficient than sitting astride a Bobath roll or on a rocking seat in reducing spasticity temporarily. Hippotherapy had a positive short-term effect on subjects' mental well-being.

Effects of neuromuscular electrical stimulation treatment of cerebral palsy on potential impairment mechanisms: a pilot study.

PURPOSE: This pilot study examined the effects of neuromuscular electrical stimulation (NMES) therapy on upper limb impairment in children with cerebral palsy, specifically addressing spasticity, heightened passive resistance to wrist rotation, coactivation, and weakness. METHODS: Eight subjects, aged five to 15 years, with spastic hemiparesis subsequent to brain injury, participated in three months of NMES therapy, targeting the wrist flexor and extensor muscles. Maximum voluntary wrist extension range of motion against gravity, spasticity, passive torque, maximum voluntary isometric torque, and coactivation were recorded prior to, during, and at the conclusion of the therapy. RESULTS: Seven of the eight subjects demonstrated a significant (>15 degrees) improvement in wrist extension range of motion against gravity following the NMES treatment, with an average gain of 38 degrees. Differences in spasticity (0.01 +/- 0.14 N-m, p = 0.80) and passive torque (0.03 +/- 0.11 N-m, p = 0.52) were not significant for these subjects. Isometric wrist extension torque, however, did increase significantly (p < 0.01), accompanied by a reduction in flexor coactivation (p < 0.01). CONCLUSIONS: Evidence suggests that the NMES treatment protocol affected wrist extension by improving the strength of the wrist extensor muscles, possibly through decreased flexor coactivation. Further studies are required, however, to determine whether electrical stimulation itself or other facets of the therapy paradigm played the key role in improvement.

Electrophysiological and clinical assessment of a simple wrist-hand splint for patients with chronic spastic hemiparesis secondary to stroke.

PURPOSE: The aim of this study is to assess the effect of a simple wrist-hand splint, made of mesh materials, on the spastic paretic hand. METHODS: The participants were 15 patients with hemiparetic stroke. Time from stroke onset was over 120 days. We assessed integrated EMG of flexor digitorum sublimus (FDS), extensor indicis proprius (EIP), flexor carpi radialis (FCR), extensor carpi radialis (ECR), brachioradialis (BR) and triceps brachii (Tri) during active finger extension and shoulder flexion, without and with the wrist-hand splint. H reflexes and M waves were obtained on FCR by stimulating the median nerve, and H/M ratio was calculated. In another 5 patients who used the splint for 8 weeks, its long-term effects were assessed with clinical measures (active range of motion and muscle tone). RESULTS: With the splint, muscle activities of FCR and BR were reduced during shoulder flexion, and those of FDS, FCR and BR decreased during finger Attaching the splint also reduced the H/M ratio of FCR. In five patients who had worn the wrist-hand splint during daytime for 8 weeks, significant increase in the active range of shoulder flexion and finger extension and decrease in muscle tone were demonstrated. The splint reduced co-activation of antagonists not only in wrist but also in finger and elbow muscles. CONCLUSION: It is suggested that the wrist-hand splint is beneficial to improve upper limb motor function in patients with spastic hemiparesis.

Characteristics of velocity-controlled knee movement in patients with cervical compression myelopathy: what is the optimal rehabilitation exercise for spastic gait?

STUDY DESIGN: The isokinetic strength of knee extensors and flexors was measured at various controlled velocities in patients with spastic paraparesis caused by cervical compression myelopathy. OBJECTIVE: To evaluate leg function objectively in patients with myelopathy. SUMMARY OF BACKGROUND DATA: Cervical compression myelopathy causes varying degrees of spastic paresis in the legs and affects the activities of patients. However, the leg function characteristics of the patients have not been fully elucidated. METHODS: Velocity-controlled voluntary knee movements were studied in 39 patients (25 men and 14 women) with compression myelopathy. Their mean age was 60.2 years (range, 44-77 years). The patients were divided into Group A (ambulation without aid, n = 22) and Group AA (ambulation with aid, n = 17). Isometric peak torque values were measured in knee flexor and extensor muscles at 60 degrees of knee flexion, and isokinetic peak torque values were determined in maximal voluntary concentric movements of these muscles at constant angle velocities of 40 degrees, 80 degrees, 120 degrees, 160 degrees, and 180 degrees per second. The relative strength (percentage of isometric peak torque value) of the isokinetic motion was calculated at each velocity. RESULTS: In both groups, the relative strength decreased as the velocity increased, and the degree of reduced strength in the flexors at the high velocities of 160 degrees and 180 degrees per second was significantly greater in Group AA than in Group A (P < 0.05), whereas no significant difference was found in the extensors between the groups. CONCLUSIONS: The results indicate that isokinetic strength at a high velocity may reflect the severity of spastic paresis in the legs resulting from compression myelopathy.

Negligencia unilateral: implicacoes no processo de reabilitacao / Unilateral neglect: implications in rehabilitation process

A negligencia unilateral e frequentemente observada em lesoes do hemisferio cerebral nao dominante, e a lesao afeta a area espacial e de esquema corporal, causando prejuizos na percepcao...

[The optimization of an early rehabilitation program for cerebral stroke patients: the use of different methods of magneto- and laser therapy]. / Optimizatsiia programmy rannei reabilitatsii bol'nykh tserebral'nym insul'tom: primenenie razlichnykh metodik magnito- i lazerterapii.

Magnetotherapy and laser therapy were used in complex and complex-combined regimens in 75 patients after cerebral ischemic or hemorrhagic stroke starting on the poststroke week 4-5. Clinico-neurologic, neurophysiological and cerebrohemodynamic findings evidence for the highest effectiveness of neurorehabilitation including complex magneto-laser therapy in hemispheric ischemic and hemorrhagic stroke of subcortical location in the absence of marked clinico-tomographic signs of dyscirculatory encephalopathy. Complex-combined magneto-laser therapy is more effective for correction of spastic dystonia. Mutual potentiation of magnetotherapy and laser therapy results in maximal development of collateral circulation and cerebral hemodynamic reserve (84% of the patients). Complex effects manifest in arteriodilating and venotonic effects. Complex magneto-laser therapy is accompanied by reduction of hyperthrombocythemia and hyperfibrinogenemia.

Electrically induced recovery of gait components for older patients with chronic stroke.

OBJECTIVE: To compare the gains for chronic stroke patients in volitional gait pattern attained from treatment with functional neuromuscular stimulation (FNS) and intramuscular electrodes (IM) with gains attained using conventional therapy, including treatment with FNS using surface electrodes (surface-stim). DESIGN: This single-subject research design consisted of a series of two subjects. Three months of conventional therapy and surface-stim were followed by treatment using the FNS-IM system. Two stroke patients had cerebrovascular accident 1 or 4 yr before the study and ambulated with a cane. Interventions consisted of 3 months of conventional exercise and gait training including surface-stim, followed by 7-14 months of treatment with the FNS-IM system. Treatments occurred up to 3 times/wk for 1-hr sessions and a home program. Outcome measures consisted of six kinematic gait components, as measured by a six-camera video-based data-acquisition system. Coordination of isolated joint movement was measured according to the Fugl-Meyer scale. RESULTS: Both subjects improved during conventional therapy to some degree. During FNS-IM treatment, gains were made beyond those attained during conventional therapy. Statistically significant differences were found between conventional and FNS-IM therapy. CONCLUSIONS: For these two subjects, gains in volitional control of gait were made during conventional treatment (including surface-stim); for these two subjects during FNS-IM treatment, additional gains were made in volitional gait pattern, beyond those attained during conventional therapy.

Motor branch block of the rectus femoris: its effectiveness in stiff-legged gait in spastic paresis.

OBJECTIVE: To verify the efficacy of motor branch block of the rectus femoris for stiff-legged gait in spastic patients. DESIGN: Before-after treatment trial. SETTING: University hospital physical medicine and rehabilitation department outpatient clinic. PATIENTS: Thirty-one adult spastic patients with stiff-legged gait. INTERVENTION: Motor branch block of the rectus femoris with 2% lidocaine and 5% phenol. OUTCOME MEASURES: Subjective assessment of gait performance by patients themselves and objective assessment of gait speed and sagittal knee kinematics. RESULTS: Seventy-four percent (23/31) of patients felt an improvement (improved knee bending, disappeared toe dragging) after nerve block with lidocaine. Sixteen of 17 patients with an abnormal swing phase activity of the rectus femoris without that of the vastus medialis or lateralis and 20 of 23 patients with a sufficient hip flexor strength expressed an improvement subjectively. Gait analysis showed increased maximal knee flexion at swing phase and increased slope of knee flexion curve at toe off (p < .05). Phenol block was performed in 19 of 23 patients who had had a subjective improvement in their gait performance after nerve block with lidocaine. Gait speed, maximal knee flexion angle at swing phase, and slope of knee flexion curve at toe off increased significantly after phenol block (p < .05). CONCLUSION: Motor branch block of the rectus femoris can be an effective treatment in stiff-legged gait. Its effect is varied with hip flexor strength and dynamic electromyographic findings of quadriceps.

Spasticity in spinal cord injury: self- and clinically rated intrinsic fluctuations and intervention-induced changes.

OBJECTIVES: (1) To determine patterns of intrinsic fluctuations in spasticity, using repeated self-ratings, in subjects with spinal cord injury (SCI); and (2) To determine the relation between self-ratings of spasticity using a visual analogue scale (VAS) and clinical ratings of spasticity using the Modified Ashworth Scale (MAS) before and after spasticity-reducing treatment. DESIGN: Part I: observational, prospective cross-sectional study; part II: experimental, prospective longitudinal study. SETTING: Outpatient clinic of the Karolinska Hospital, Stockholm, Sweden. PATIENTS: Forty-five persons with SCI (39 men, 6 women); mean age at injury, 26 yrs; mean time since injury, 11 yrs. INTERVENTION: Repetitive passive movements of standardized range of motion in three different body positions, performed by two motorized tables. MAIN OUTCOME MEASURES: VAS ratings of spasticity, every other hour when awake, and of movement-provoked spasticity, rated before and after each treatment session, and MAS ratings of movement-provoked spasticity, before and after each treatment session. RESULTS: The spasticity of cervical SCI subjects fluctuated significantly (p < .05) during the day, unlike the spasticity of thoracic SCI subjects. Immediately after intervention with passive movements, spasticity ratings in thoracic motor complete SCI patients decreased by 11 to 14 mm (90%, p < .001) as self-rated on VAS and by 1 to 2 grades (50%, p < .001) as measured with MAS. A 30% (p < .018) decrease in VAS values of intrinsic pattern of spasticity was maintained over time when treatment was given regularly and was maintained for at least 1 week after discontinuation of treatment. VAS ratings correlated significantly with MAS ratings (r = .44 to .62, p < .001). CONCLUSION: Repetitive passive movement intervention decreased spasticity when performed regularly, as assessed by VAS and MAS ratings. VAS and MAS ratings were significantly correlated. It is recommended that SCI patients repeatedly rate their spasticity to establish a baseline before and to track changes after interventions aimed at reducing spasticity. The time of day when spasticity is measured seems more important in cervically injured individuals, because of their more pronounced intrinsic fluctuations.