Realidade virtual como ferramenta de intervenção para os membros superiores na doença de Parkinson: série de casos / Realidad virtual como herramienta de intervención para los miembros superiores en la enfermedad de Parkinson: una serie de casos / Virtual reality as an intervention tool for upper limbs in Parkinson's disease: a case series

RESUMO A doença de Parkinson (DP) é uma desordem neurodegenerativa na qual ocorre a perda dopaminérgica na região dos núcleos da base. Uma das principais queixas associadas à DP são os déficits motores dos membros superiores (MMSS) frequentemente relatados em dificuldades para realizar as atividades de vida diária (AVDs), podendo interferir negativamente na qualidade de vida. Nos últimos anos novas tecnologias surgiram para auxiliar no processo de reabilitação dos MMSS na DP, sendo a realidade virtual uma delas. Portanto, este estudo teve como objetivo verificar os efeitos de uma intervenção nos MMSS com equipamento de realidade virtual semi-imersiva nas AVDs e na qualidade de vida de indivíduos com DP. Foram selecionados seis indivíduos com DP para intervenção, avaliados por meio do miniexame do estado mental, da escala de Hoehn e Yahr, da escala unificada de avaliação para a DP (UPDRS), do questionário sobre a doença de Parkinson (PDQ-39) e do test d'évaluation des membres supérieurs de personnes âgées (Tempa). Seis sujeitos foram submetidos à intervenção com duração de 27 minutos por sessão, duas vezes na semana, por cinco semanas, utilizando o Leap Motion Controller. Obteve-se melhora na força muscular, na resistência muscular, nas AVDs e na qualidade de vida, todos com significância estatística. Dessa forma, verificou-se que o protocolo baseado em realidade virtual aplicada nos MMSS foi eficaz para melhorar as AVDs e a qualidade de vida dos indivíduos com DP deste estudo.

RESUMEN La enfermedad de Parkinson (EP) es un trastorno neurodegenerativo con pérdidas dopaminenérgicas en la región de núcleos basales. Una de las principales quejas asociadas a la EP son los déficits motores de los miembros superiores (MMSS), que muchas veces resultan en dificultades de realizar las actividades de la vida diaria (AVD), lo que impacta negativamente la calidad de vida. En los últimos años surgieron nuevas tecnologías para ayudar en el proceso de rehabilitación de los MMSS en la EP, y una de ellas es la realidad virtual. Por lo tanto, este estudio tuvo como objetivo comprobar los efectos de una intervención en los MMSS utilizando un equipo de realidad virtual semiinmersivo en las AVD y en la calidad de vida de individuos con EP. Se seleccionaron a seis individuos con EP para la intervención, que fueron sometidos a evaluación por el Miniexamen del Estado Mental, la Escala de Hoehn y Yahr, la Escala Unificada de Evaluación de la Enfermedad de Parkinson (UPDRS), el Cuestionario de la Enfermedad de Parkinson (PDQ-39) y el test d'évaluation des membres supérieurs de personnes âgées (Tempa). Seis sujetos se sometieron a una intervención de 27 minutos por sesión, dos veces por semana, durante cinco semanas, utilizando el Leap Motion Controller. Hubo una mejora en la fuerza muscular, en la resistencia muscular, en las AVD y en la calidad de vida, todos con significación estadística. Así se constató que el protocolo basado en realidad virtual aplicado a los MMSS fue eficaz en la mejora de las AVD y en la calidad de vida de los individuos con EP de este estudio.

ABSTRACT Parkinson's disease (PD) is a neurodegenerative disorder in which dopaminergic loss occurs in the basal nuclei region. One major complaint associated with PD is upper extremity motor deficits (UE), frequently reported in difficulties to perform activities of daily living (ADL), which may negatively affect quality of life. In recent years new technologies have emerged to assist the UE rehabilitation process in PD, such as virtual reality. Therefore, this study sought to verify the effects of an intervention in the UE with semi-immersive virtual reality equipment on ADLs and quality of life of individuals with PD. Six individuals with PD were selected for intervention, and evaluated by the Mini Mental State Examination, the Hoehn & Yahr Scale, the Unified Parkinson's Disease Rating Scale (UPDRS), the Parkinson's Disease Questionnaire (PDQ-39) and the test d'évaluation des membres supérieurs de personnes âgées (TEMPA). The interventions lasted 27 minutes per session, twice per week, for 5 weeks, using the Leap Motion Controller. Individuals showed improvement in muscle strength, muscle endurance, ADLs, and quality of life, all statistically significant. In conclusion, the protocol based on virtual reality applied to the upper limbs effectively improved the activities of daily living and quality of life in individuals with PD.

Home-based exercises with minimal oversight in Parkinson's Disease motor function: a systematic review and meta-analysis / Exercícios domiciliares com mínima assistência na função motora da Doença de Parkinson: uma revisão sistemática com meta-análise

Aims: this study aimed to present the latest available evidence on the effects of home-based exercises with minimal oversight (HBEMO) on motor function and quality of life of Parkinson's Disease (PD) subjects. Methods: in this systematic review MEDLINE (PubMed), LILACS, PEDro, EMBASE, Cochrane and Google Scholar were searched for randomized clinical trials investigating the effects of HBEMO on PD subjects. Results: four studies were included in the meta-analysis. HBEMO was almost as beneficial as conventional therapies in lowering motor impairment through Unified Parkinson's Disease Rating Scale-III (UPDRS-III) analysis (Mean difference = -1.70 [95%CI = -4.39 to 0.99]; I2 = 88%; p < 0,01) and improving quality of life through The Parkinson's Disease Questionnaire (PDQ-39) (Mean difference = 0.39 [95%CI = -3.41 to 4.19]; I2 = 93%; p < 0,01). Conclusions: minimally assisted home-based exercises are almost as effective as the usual care to improve motor function and quality of life of Parkinson's Disease subjects.

Objetivos: este estudo teve como objetivo apresentar as últimas evidências disponíveis sobre os efeitos de exercícios domiciliares com mínima supervisão na função motora e na qualidade de vida de indivíduos com doença de Parkinson. Métodos: nesta revisão sistemática foram pesquisados ensaios clínicos randomizados investigando os efeitos de exercícios domiciliares em indivíduos com doença de Parkinson nas bases de dados MEDLINE (PubMed), LILACS, PEDro, EMBASE, Cochrane e Google Scholar. Resultados: quatro estudos foram incluídos na meta-análise. O exercício domiciliar com supervisão mínima foi quase tão benéfico quanto as terapias convencionais na redução do comprometimento motor por meio da análise da Unified Parkinson's Disease Rating Scale-III (UPDRS-III) (diferença média = -1.70 [95%IC = -4.39 a 0.99]; I2 = 88%; p < 0,01) e melhoria da qualidade de vida por meio do Parkinson's Disease Questionnaire (PDQ-39) (diferença média = 0.39 [95%IC = -3.41 a 4.19]; I2 = 93%; p < 0,01). Conclusões: a fisioterapia domiciliar com supervisão mínima é quase tão eficaz quanto as terapias convencionais para melhorar a função motora e a qualidade de vida da doença de Parkinson.

Upper limbs cycle ergometer increases muscle strength, trunk control and independence of acute stroke subjects: A randomized clinical trial.

BACKGROUND: Studies demonstrate the benefits of upper limbs cycle ergometer (ULCE) in subacute and chronic stroke subjects, but the literature still needs to explore the acute phase of the disease. OBJECTIVE: Verify the effects of ULCE on muscular strength, trunk control and independence of post-stroke subjects in hospital acute phase. METHODS: In this randomized clinical trial participants were allocated into two groups. The control group (CG) performed two daily sessions of conventional physiotherapy, while the intervention group (IG) had one daily session of conventional physiotherapy and one of ULCE. The interventions were carried out for 20 minutes for five days. Both groups were assessed before and after the treatment for upper limbs strength by manual dynamometer, trunk control by Trunk Impairment Scale and level of independence by the Modified Rankin Scale. RESULTS: Twenty subjects with mean ages of 63.5±4.5 were enrolled. There was a significant intra-group difference of palmar grip, shoulder abductors, elbow flexor and wrist extensor strength, trunk control and functional independence only in IG. Inter-group difference for all variables showed superiority in IG. CONCLUSIONS: ULCE is an effective device for increasing muscle strength, trunk control and consequently improving the independence of post-stroke subjects in the acute hospital phase.

Effects of aerobic cycling training on mobility and functionality of acute stroke subjects: A randomized clinical trial.

BACKGROUND: Studies demonstrate the benefits of aerobic cycling training in subacute and chronic stroke subjects, but there is a lack in the literature about its effects on the acute phase. OBJECTIVE: Verify the effects of aerobic cycling training on lower limbs muscle strength, gait speed, balance, mobility and functionality of acute stroke subjects. METHODS: Control group (CG) performed conventional physiotherapy twice a day and the intervention group (IG) performed a conventional physiotherapy and a cycle ergometer session, for five consecutive days. Subjects were assessed for muscle strength by a digital dynamometer, gait speed by the 10-meter-walk-test, balance by the Berg Balance Scale, mobility by the ICU-Mobility-Scale and functionality by the Perme Score. RESULTS: Twenty subjects were enrolled in the study, 10 in the CG and 10 in the IG. Lower limbs muscle strength, the main endpoint, was better in the IG compared to the CG. The same was found in the secondary endpoints. The intragroup analysis was also positive for the CG in the mobility and functionality. CONCLUSIONS: Conventional physiotherapy combined with cycling exercise showed better results in the improvement of muscle strength of lower limbs, mobility and functionality of subjects who suffered from acute stroke.

Is the dopaminergic loss associated with gait and postural impairments in subjects with Parkinson's disease at different motor stages?

Gait and postural control deficiencies in Parkinson's disease (PD) involve several specific motor aspects. The aim of this study was to identify and compare the main changes in gait kinematics and postural control with dopaminergic loss in the striatum region. This is a cross-sectional study that included 42 individuals with PD at different motor stages, according to the Hoehn & Yahr scale (H&Y). Motor subsection of the Movement Disorder Society-Unified Parkinson Disease Rating Scale-part III (MDS-UPDRS III) was used to evaluate general motor aspects. Gait kinematics was assessed using a three-dimensional motion capture system. Postural control was assessed by stabilometry using force platforms. Dopamine depletion was verified through 99mTc-TRODAT-1 (SPECT-CT) examination. We included 12, 15 and 15 individuals classified as H&Y I, II and III, respectively. We identified worse values of dopamine transporter uptake, MDS-UPDRS III, gait parameters (velocity, step length and stride length) and center of pressure displacement as the disease progressed. Our results indicate that higher dopaminergic loss and gait and postural control deficits occur between the H&Y levels II and III.

Cicloergômetro na melhora da função motora grossa de crianças com paralisia cerebral: uma revisão sistemática com meta-anális / Cicloergómetro en la mejora de la función motora gruesa de niños con parálisis cerebral: una revisión sistemática con metaanálisis / Cycle ergometer in the improvement of gross motor function of children with cerebral palsy: a systematic review with meta-analysis

RESUMO A paralisia cerebral é um grupo de desordens neurológicas causadora de inúmeros déficits, principalmente relacionados à função motora, comprometendo os movimentos e o seu controle seletivo. Dentre as diversas terapias disponíveis para tentar amenizar esse processo, o cicloergômetro aparece como um aparato estacionário que tem por finalidade facilitar a movimentação dos membros inferiores. Portanto, o objetivo deste estudo foi analisar os efeitos do cicloergômetro na função motora grossa de crianças com paralisia cerebral através da escala Gross Motor Function Measure (GMFM-66). Trata-se de uma revisão sistemática, com inclusão de ensaios clínicos randomizados publicados até julho de 2017. A busca foi realizada nas bases de dados: MEDLINE (PubMed), Physiotherapy Evidence Database (PEDro), SciELO e Embase. Para a avaliação da qualidade metodológica das investigações foi utilizada a escala da Cochrane Handbook. Foram selecionados artigos que aplicaram o cicloergômetro em crianças com paralisia cerebral, comparadas a crianças com paralisia cerebral no grupo-controle ou em outra intervenção, e que avaliaram a função motora grossa com a GMFM. A revisão incluiu três artigos e um total de 127 pacientes. Os resultados mostraram um aumento nos valores da GMFM-66, porém não significativo estatisticamente nem relevantes para uma melhora clínica. Por meio desta revisão sistemática, verificou-se uma grande heterogeneidade nos estudos que abordam esta área e que, apesar do incremento de valores no grupo que realizou o cicloergômetro, não houve diferença estatística quando comparado ao grupo-controle, demonstrando não beneficiar a função motora grossa dessa população quando avaliada pela GMFM66.

RESUMEN La parálisis cerebral es un grupo de desórdenes neurológicos causantes de innumerables déficits, principalmente relacionados con la función motora, y que compromete los movimientos y su control selectivo. Entre las diversas terapias disponibles para intentar amenizar ese proceso, el cicloergómetro aparece como un aparato estacionario que tiene por finalidad facilitar el movimiento de los miembros inferiores. Por lo tanto, este estudio buscó analizar los efectos del cicloergómetro en la función motora gruesa de niños con parálisis cerebral por medio de la escala Gross Motor Function Measure (GMFM-66). Se trata de una revisión sistemática, con la inclusión de ensayos clínicos aleatorizados publicados hasta julio de 2017. La búsqueda se realizó en las bases de datos: MEDLINE (PubMed), Physiotherapy Evidence Database (PEDro), SciELO y Embase. En la evaluación de la calidad metodológica de las investigaciones se utilizó la escala de Cochrane Handbook. Se seleccionaron los artículos que aplicaron el cicloergómetro en niños con parálisis cerebral, comparados a niños con parálisis cerebral en el grupo control o el grupo intervención, y que evaluaron la función motora gruesa con la GMFM. La revisión incluyó tres artículos y un total de 127 pacientes. Los resultados mostraron un aumento en los valores de la GMFM-66, pero no fueron significativos estadísticamente ni relevantes para una mejora clínica. Por medio de esta revisión sistemática, se verificó una gran heterogeneidad en los estudios sobre esta área y que, a pesar del incremento de valores en el grupo que realizó el cicloergómetro, no hubo diferencia estadística cuando comparado al grupo control, demostrando que no benefició la función motora gruesa de esa población cuando evaluada por la GMFM-66.

ABSTRACT Cerebral palsy is a group of neurological disorders that causes innumerable deficits, mainly related to motor function, compromising movements and their selective control. Among the various therapies available to try to soften this process, the cycle ergometer appears as a stationary apparatus that aims to facilitate the movement of the lower limbs. Therefore, this study aimed to analyze the effects of the cycle ergometer on the gross motor function of children with cerebral palsy by the Gross Motor Function Measure (GMFM-66) scale. This was a systematic review, with inclusion of randomized clinical trials published until July 2017. The search was performed in MEDLINE (PubMed), Physiotherapy Evidence Database (PEDro), SciELO, and Embase. The Cochrane Handbook Scale was used to evaluate the methodological quality of the investigations. We selected articles that applied the cycle ergometer in children with cerebral palsy, compared to children with cerebral palsy in the control group or other intervention, and that assessed gross motor function with GMFM. The review included three articles and a total of 127 patients. The results have shown a not statistically significant increase in GMFM-66 values, not relevant for clinical improvement. This systematic review has found great heterogeneity in the studies addressing this area and, despite the increase in values in the group that used the cycle ergometer, there was no statistical difference compared to the control group, showing that it does not benefit the gross motor function of this population, when evaluated by GMFM-66.

Impairments in gait kinematics and postural control may not correlate with dopamine transporter depletion in individuals with mild to moderate Parkinson's disease.

Parkinson's disease (PD) is a progressive neurodegenerative disorder caused by the loss of dopamine, an important neurotransmitter involved in regulating movement. Nuclear medicine imaging methods such as single-photon emission computed tomography (SPECT) combined with radiotracers can obtain the density of this neurotransmitter. This reduced density leads to classic PD symptoms, such as bradykinesia, tremor and stiffness, consequently affecting walking and postural control. The aim of this study was to verify the correlation between disorders of gait kinematics and postural instability with dopamine depletion in individuals with mild to moderate PD. This is a descriptive, observational cross-sectional study. Subjects were assessed for spatiotemporal gait parameters by a three-dimensional motion capture system, for postural control by stabilometry on a force plate. Dopamine depletion was verified through 99mTc-TRODAT-1 (SPECT-CT) examination. The subjects were in the off-stage of levodopa in all analysis. We evaluated 71 individuals, 32 with mild to moderate PD (HY 2 and 2.5) and 39 healthy individuals matched for gender, age, and height. There was a significant difference between the groups regarding the spatiotemporal variables of gait, as well as in the stabilometric variables. However, there was no correlation between these disturbances and the uptake values of 99mTc-TRODAT-1. The results indicate that there is no correlation between gait impairments and postural instability of individuals with mild to moderate PD and the dopaminergic depletion measured through the 99mTc-TRODAT-1 (SPECT-CT).