Characteristics and perceptions of telerehabilitation consultations by neuropediatric physical therapists during the COVID-19 pandemic / Características e percepções das consultas por telerreabilitação pelos fisioterapeutas neuropediátricos durante a pandemia da COVID-19

Abstract Introduction: The COVID-19 pandemic brought a strong discussion about telerehabilitation, especially in countries where its practice was not allowed previous the pandemic. In the neuropediatric rehabilitation field evidence of the effectiveness of this modality of assistance and data about provider and family's perceptions are scarce. Objective: To evaluate the characteristics of telerehabilitation physical therapy consultations for children with neurological diseases during the COVID-19 pandemic and report the perceptions of physical therapists about this modality of assistance. Methods: An online survey was created and administered to Brazilian neuropediatric physical therapists. The survey consisted of demographics data, questions about the characteristics of telerehabilitation consultations, and physical therapists' perception of telerehabilitation assistance. Results: From July to September 2020, 394 physical therapists responded to the questionnaire. The most of them took 21 to 30 minutes per telemonitoring session (26.9%), offered one session per week (61.0%), and used electronic messages as the main method of delivery (39.9%). The main difficulty reported was caregivers' lack of understanding about handling during sessions (41.2%) and problems with internet connection (16.7%). Additionally, most of them reported that it is highly important important to provide healthcare via telerehabilitation to the economically disadvantaged. Conclusion: The findings of this study provide insight into the complex and challenging process of telerehabilitation assistance during the first wave of the COVID-19 pandemic. Despite the reported challenges, telerehabilitation can be an opportunity to better understand children's activities and participation in home context.

Resumo Introdução: A pandemia da COVID-19 trouxe uma forte discussão sobre o uso da telerreabilitação, especialmente em países onde a sua prática ainda não havia sido permitida antes da pandemia. Na área da reabilitação neuropediátrica as evidências sobre a efetividade dessa modalidade de atendimento e informações sobre as percepções dos provedores e família são escassas. Objetivo: Avaliar as características das consultas fisioterapêuticas por telerreabilitação em crianças com condições neurológicas durante a pandemia de COVID-19 e relatar as percepções dos fisioterapeutas sobre essa modalidade de atendimento. Métodos: Um questionário online foi criado e administrado para fisioterapeutas neuropediátricos brasileiros. O questionário consistiu em dados demográficos, questões sobre as características das consultas por telerreabilitação e percepção dos fisioterapeutas sobre a assistência via telerreabilitação. Resultados: Entre julho e setembro de 2020, 394 fisioterapeutas responderam o questionário. A maioria dos fisioterapeutas levaram de 21 a 30 minutos por sessão (26,9%), ofereceram uma sessão por semana (61,0%) e usaram mensagens eletrônicas como principal método de entrega (39,9%). A principal dificuldade reportada foi a falta de entendimento sobre os manuseios durante as sessões (41,2%) e problemas com a internet (16,7%). Além disso, a maioria reportou ser muito importante prover cuidados de saúde por telerreabilitação para a população economicamente menos favorecida. Conclusão: Os dados apresentados fornecem um entendimento do processo complexo e desafiador das consultas por telerreabilitação durante a primeira onda da pandemia da COVID-19. Apesar dos desafios reportados, a telerreabilitação pode ser uma oportunidade para melhor entender as atividades e participação das crianças no contexto do lar.

Strength training during pregnancy influences hippocampal plasticity but not body development in neonatal rats.

OBJECTIVE: To describe the effects of strength exercise practice during pregnancy on the offspring's development parameters: growth and motor performance, hippocampal neuroplasticity, and stress levels. METHODS: Pregnant Wistar rats were divided into two groups: sedentary and exercised rats. Exercised pregnant rats were subjected to a strength training protocol (vertical ladder climbing) throughout the gestational period. Male offspring's body weight, length, and head size were evaluated during the neonatal period (postnatal days [P]2-P21), as well as motor milestones during P0-P8. At P8, a set of male pups were subjected to global hippocampal DNA methylation, hippocampal cell proliferation, and plasma corticosterone concentration. RESULTS: Offspring from trained mothers presented a transient change in body morphometric evaluations, no differences in milestone assessments, enhancement of cell proliferation in the dentate gyrus of the hippocampus, and decreased global hippocampal DNA methylation compared with the offspring from sedentary mothers. Furthermore, strength training during pregnancy did not change the corticosterone concentration of exercised mothers and their offspring. CONCLUSIONS: These data indicate that strength training can protect offspring's development and could impact positively on parameters linked to cognitive function. This study provides a greater understanding of the effects of strength exercise practiced during pregnancy on the offspring's health.

Maternal resistance exercise promotes changes in neuroplastic and epigenetic marks of offspring's hippocampus during adult life.

Studies indicate that gestational exercise practice positively impacts the offspring's cognition. Nevertheless, the influence of maternal resistance exercise, different periods of exercise practice, and the inter- and transgenerational effects involved in these responses are not known. This study sought to report the influence of the maternal practice of resistance exercise on offspring's cognitive function, exploring behavior, and neuroplastic and epigenetic marks in the hippocampus. Female Wistar rats were divided into four groups: sedentary (SS), exercised during pregnancy (SE), exercised before pregnancy (ES), and exercised before and during pregnancy (EE). Exercised rats were submitted to a resistance exercise protocol (vertical ladder climbing). Between postnatal days (P)81 and P85, male offspring were submitted to the Morris water maze test. At P85, the following analyses were performed in offspring's hippocampus: expression of IGF-1 and BrdU+ cells, global DNA methylation, H3/H4 acetylation, and HDAC2 amount. Only the offspring of SE mothers presented subtly better performance on learning and memory tasks, associated with lower HDAC2 amount. Offspring from ES mothers presented an overexpression of hippocampal neuroplastic marks (BrdU+ and IGF-1), as well as a decrease of DNA methylation and an increase in H4 acetylation. Offspring from EE mothers (continuously exercised) did not present modifications in plasticity or epigenetic parameters. This is the first study to observe the influence of maternal resistance exercise on offspring's brains. The findings provide evidence that offspring's hippocampus plasticity is influenced by exercise performed in isolated periods (pre- or gestationally) more than that performed continually.

Effects of Maternal Physical Exercise on Global DNA Methylation and Hippocampal Plasticity of Rat Male Offspring.

Intrauterine exposure to exercise is beneficial to cognition of the offspring. Although it is advisable to start practicing physical exercise during pregnancy, it is probable that practitioners or sedentary women keep their previous habits during gestation. This study was designed to evaluate the effects of maternal aerobic exercise initiated before and maintained during gestation, or performed in these isolated periods, on cognition and plasticity in the hippocampus of offspring. Groups of male pups were categorized by the exposure of their mothers to: treadmill off (sedentary, SS), pregestational exercise (ES), gestational exercise (SE) or combined protocols (EE). Between postnatal day 20 (P20) and P23 the offspring received one daily 5-bromo-2'-deoxiuridine (BrdU) injection and, from P47 to P51, were evaluated by the Morris water maze task. At P53, hippocampal global DNA methylation, survival of progenitor cells (BrdU), Brain-derived Neurotrophic Factor (BDNF) and reelin levels were measured. The offspring from ES, SE and EE mothers demonstrated improved spatial learning compared to SS, but hippocampal DNA methylation was significantly modified only in the offspring from ES mothers. The offspring from ES and SE mothers presented higher number of BrdU+ and reelin+ hippocampal cells than EE and SS. No differences were observed in the BDNF levels among the groups. The maternal pregestational and gestational isolated exercise protocols showed similar effects for offspring plasticity and spatial cognitive ability, while the combined protocol simply improved their spatial learning. Interestingly, only pregestational exercise was able to induce plasticity in the offspring hippocampus associated with modulation of global DNA methylation.

Severe Uncontrolled Maternal Hyperglycemia Induces Microsomia and Neurodevelopment Delay Accompanied by Apoptosis, Cellular Survival, and Neuroinflammatory Deregulation in Rat Offspring Hippocampus.

Maternal diabetes constitutes an unfavorable intrauterine environment for offspring development. Although it is known that diabetes can cause brain alterations and increased risk for neurologic disorders, the relationship between neuroimmune activation, brain changes, and neurodevelopment deficits in the offspring remains unclear. In order to elucidate the short- and long-term biological basis of the developmental outcomes caused by the severe uncontrolled maternal hyperglycemia, we studied apoptosis, neurogenesis, and neuroinflammation pathways in the hippocampus of neonates and young rats born to diabetic dams. Diabetes was induced on gestational day 5 by an injection of streptozotocin. Evaluations of milestones, body growth, and inhibitory avoidance were performed to monitor the offspring development and behavior. Hippocampal modifications were studied through cellular survival by BrdU in the dentate gyrus, expression of apoptosis-regulatory proteins (procaspase 3, caspase 3, and Bcl-2), BDNF, and neuroinflammatory modulation by interleukins, MHC-I, MHC-II, Iba-1, and GFAP proteins. Severe maternal diabetes caused microsomia and neurodevelopmental delay in pups and decrease of Bcl-2, procaspase 3, and caspase 3 in the hippocampus. Moreover, in a later stage of development, it was found an increase of TNF-α and a decrease of procaspase 3, caspase 3, MHC-I, IL-1ß, and BDNF in the hippocampus, as well as impairment in cellular survival in the dentate gyrus. This study showed significant short- and long-term commitments on the development, apoptosis, cell survival, and neuroinflammation in the offspring hippocampus induced by severe uncontrolled maternal hyperglycemia. The data reinforce the need for treatment of maternal hyperglycemic states during pregnancy and breast-feeding.

Paternal physical exercise modulates global DNA methylation status in the hippocampus of male rat offspring.

It is widely known that maternal physical exercise is able to induce beneficial improvements in offspring cognition; however, the effects of paternal exercise have not been explored in detail. The present study was designed to evaluate the impact of paternal physical exercise on memory and learning, neuroplasticity and DNA methylation levels in the hippocampus of male offspring. Adult male Wistar rats were divided into two groups: sedentary or exercised fathers. The paternal preconception exercise protocol consisted of treadmill running, 20 minutes daily, 5 consecutive days per week for 22 days, while the mothers were not trained. After mating, paternal sperm was collected for global DNA methylation analysis. At postnatal day 53, the offspring were euthanized, and the hippocampus was dissected to measure cell survival by 5-bromo-2'-deoxiuridine and to determine the expression of synaptophysin, reelin, brain-derived neurotrophic factor and global DNA methylation levels. To measure spatial memory and learning changes in offspring, the Morris water maze paradigm was used. There was an improvement in spatial learning, as well as a significant decrease in hippocampal global DNA methylation levels in the offspring from exercised fathers compared with those from sedentary ones; however, no changes were observed in neuroplasticity biomarkers brain-derived neurotrophic factor, reelin and 5-bromo-2'-deoxiuridine. Finally, the global DNA methylation of paternal sperm was not significantly changed by physical exercise. These results suggest a link between paternal preconception physical activity and cognitive benefit, which may be associated with hippocampal epigenetic programming in male offspring. However, the biological mechanisms of this modulation remain unclear.

Paternal physical exercise demethylates the hippocampal DNA of male pups without modifying the cognitive and physical development.

Maternal exercise is known to have beneficial effects in progeny development, but the influence of paternal exercise on the offspring still unclear. Since spermatogenesis is a continuous process, the father's life experiences can reprogram epigenetic content of the sperm and somehow interfere on offspring phenotype. This study was designed to evaluate the effects of paternal physical exercise on cognitive and physical development and on hippocampal DNA methylation levels of the offspring. Adult male Wistar rats were divided into two groups: sedentary and exercised. The exercise protocol occurred before mating and consisted of treadmill running, 5 consecutive days/week for 8 weeks (20 min/day). The mothers were not trained. The following developmental parameters were examined in male offspring: body growth, physical and cognitive performance, weights of adrenal glands, gonadal fat and hindlimb muscles, BDNF expression and global DNA methylation at the hippocampus. The progeny of trained and sedentary fathers did not differ in relation to physical parameters and performance, spatial memory and BDNF expression. However, paternal exercise promoted a decrease in offspring´s relative gonadal fat weight and a lower percentage of global hippocampal DNA methylation compared to offspring of sedentary fathers. These results pointed to interference of male physical activity at the time of conception on adiposity and hippocampal epigenetic reprogramming of male offspring. The data reinforces that exercise does not harm the descendant's development and emphasize the benefits to include the practice of physical exercise in a healthier lifestyle of the parents. Nevertheless, future studies are necessary and should investigate further the long-effects of epigenetic mechanisms in order to elucidate the father's contribution in fetal programming.

Mirror therapy for upper limb rehabilitation in chronic patients after stroke / Terapia do espelho no membro superior de pacientes após acidente vascular cerebral

Abstract Introduction: Individuals with stroke sequelae present changes in the postural alignment and muscle strength associated with hemiplegia or hemiparesis. Mirror therapy is a technique that aims to improve the motor function of the paretic limb. Objective: The aim of this study was to evaluate the effect of mirror therapy, associated with conventional physiotherapy, for range of motion (ROM), degree of spasticity of the affected upper limb, and the level of independence in the activities of daily living (ADL) of chronic patients after stroke. Methods: This was a quasi-experimental (before and after) study. The study included ten stroke survivors undertaking physiotherapy and presenting with upper limb paresis. The following gauges were used for the present study: goniometry, the Modified Ashworth Scale, Fugl-Meyer and Barthel Index. Fifteen sessions were performed, each lasting 30 minutes, consisting of stretching of the flexor and extensor muscles of the wrist and elbow, pronators and supinators, followed by mirror therapy with gradual functional exercises. Results: Improvement was observed in all aspects studied, however with significant differences for ROM wrist extension (p = 0.04) and forearm supination (p = 0.03) Conclusion: It can be concluded that mirror therapy contributed to the participants' good performance in the aspects studied, mainly in relation to ROM of the affected upper limb.

Resumo Introdução: Indivíduos com sequelas de acidente vascular encefálico (AVE) apresentam alterações no alinhamento postural e força muscular associada a uma hemiplegia ou hemiparesia. A terapia de espelho é uma técnica que visa melhorar a função motora do membro parético. Objetivo: O objetivo deste estudo foi avaliar o efeito da terapia do espelho, associada à fisioterapia convencional, na amplitude de movimento (ADM), grau de espasticidade do membro superior acometido e no nível de independência das Atividades de Vida Diária (AVD) de paciente pós Acidente Vascular Cerebral (AVC). Métodos: Trata-se de um estudo quase experimental do tipo antes e depois. Participaram do estudo 10 pacientes pós AVC, os quais se encontrassem em atendimento fisioterapêutico e apresentassem paresia em membro superior. Para a avaliação utilizou-se goniometria, escala de Ashworth modificada, Fugl-Meyer e Índice de Barthel. Foram realizadas 15 sessões com duração de 30 minutos, compostas de alongamento dos músculos flexores e extensores de punho e cotovelo, pronadores e supinadores, seguidos da terapia do espelho com exercícios funcionais gradativos. Resultados: Observou-se melhora em todos os aspectos estudados, porém com diferenças estatisticamente significantes para ADM de extensão de punho (p = 0,04) e supinação de antebraço (p = 0,03). Conclusão: Pode-se concluir que a terapia do espelho contribuiu para que os participantes desta pesquisa obtivessem boa evolução nos aspectos estudados, principalmente em relação à ADM do membro superior acometido.

Eficácia da eletroestimulação muscular expiratória na tosse de pacientes após acidente vascular encefálico / Effectiveness of electrical stimulation in expiratory muscle on cough of patients after stroke

Indivíduos com sequelas de acidente vascular encefálico (AVE) apresentam como complicação comum a hipotonia de tronco com consequente fraqueza da sua musculatura, em especial, o reto abdominal que é o principal músculo acionado para a tosse. As correntes elétricas têm sido amplamente utilizadas para recrutamento de fibras musculares nas mais diversas patologias. O presente estudo teve como objetivo avaliar a eficácia da eletroestimulação transcutânea de média frequência (ETMF) na força muscular expiratória e tosse de pacientes com sequela de AVE. Trata-se de um estudo quase-experimental (antes e depois) onde foram selecionados 11 indivíduos pós-AVE entre 40 a 65 anos, ambos os sexos e estáveis hemodinamicamente. Os pacientes foram avaliados quanto a parâmetros clínicos e pneumofuncionais (ventilometria, pico de fluxo expiratório (PFE) e manovacuometria) e submetidos ao protocolo, que constava de ETMF no músculo reto abdominal com o aparelho de corrente Russa, frequência portadora de 2.500 Hz modulada a 40 Hz, durante 15 minutos, por 15 sessões. Na avaliação inicial observou-se diminuição da força muscular inspiratória e expiratória (Pimáx; Pemáx) e do PFE quando comparados aos valores de normalidade preditos na literatura. Após a ETMF houve incremento da Pimáx e Pemáx sem significância estatística (p=0,18 e p=0,29) já o PFE teve um acréscimo de 283,73 L/minuto para 347,27 L/minuto (p=0,03). Pode-se observar que a ETMF foi eficaz no incremento dos parâmetros avaliados, com o PFE sendo o de maior impacto e significância estatística, no entanto, mais estudos com populações maiores se fazem necessários para análise dessa nova abordagem terapêutica.

Individuals with sequelae of stroke present as a common complication hypotonia and weakness of trunk muscles, in special the rectus abdominal muscle which is the main muscle activated for cough. The electrical stimulation (ES) is being widely used to fiber recruitment in many muscle groups and pathologies. The present study aimed to evaluate the efficiency of electrical stimulation with median frequencies (ETMF) in expiratory muscles strength and cough in patients with sequels of stroke. It is a quasi-experimental study (before and after) where 11 individuals were selected after stroke between 40 and 65 years, both sexes and hemodynamically stable. Patients were evaluated about clinic and respiratory scores (ventilometer, peak of expiratory flow (PEF) and manometer (MIP and MEP) and submitted to the protocol, which consisted of ETMF in expiratory muscle (abdominals rectus) with the unit of Russian current with 2,500 Hz carrier frequency modulated at 40 Hz for 15 minutes by 15 sessions. In the initial assessment evidenced decreasing in inspiratory and expiratory muscular strength (MIP, MEP) and PEF when compared to predicted values in literature. In the end of ETMF it happened an increase in MIP, MEP without statistical significance (p=0.18 and p=0.29) but the PEF has had an increase of 283.73 L/minute to 347.27 L/minute (p=0.03). It can be seen that the ETMF was effective in the improvement of the parameters evaluated, with PEF being the greatest impact and statistical significance, however further studies with larger populations are necessary to analyze this new therapeutic approach.