Nos últimos anos, o treinamento aeróbio vem sendo empregado como forma de recuperação da marcha em pessoas pós-acidente vascular cerebral. O objetivo desta Tese foi avaliar os efeitos do treinamento aeróbio em piscina e em esteira rolante na marcha de indivíduos hemiparéticos crônicos. Participaram 12 pessoas, randomizadas por sorteio para Grupo Piscina e Grupo Esteira. Para as avaliações funcionais, os testes e escalas foram divididos de acordo com a Classificação Internacional de Funcionalidade, Incapacidade e Saúde: Avaliação Fugl-Meyer; a Escala de equilíbrio de Berg, Escala de avaliação do controle postural para pacientes pós-acidente vascular cerebral, Timed Up and Go Test e o Questionário de qualidade de vida SF-36. Na avaliação biomecânica foram avaliados os parâmetros cinemáticos de amplitude de movimento, ângulo mínimo e máximo da articulação do joelho e tornozelo e parâmetros eletromiográficos (EMG) dos músculos tibial anterior, gastrocnêmio lateral, reto da coxa, vasto lateral, bíceps da coxa, semitendíneo. Foi realizada análise de variância para inferir o efeito do treinamento aeróbio em ambos os grupos. Para estudar o comportamento das variáveis eletromiográficas em função das avaliações funcionais foi realizada a análise de regressão linear múltipla. O treinamento aeróbio melhorou o comprometimento sensório-motor, equilíbrio, agilidade e qualidade de vida relacionada à saúde dos participantes de ambos os grupos, como alterações nos padrões eletromiográficos dos músculos na locomoção dos participantes de ambos os grupos. Não houve efeito do treinamento aeróbio para os parâmetros cinemáticos das articulações analisadas. Houve a fraca relação entre os parâmetros EMG e as variáveis funcionais. Os participantes foram beneficiados pela prática do treinamento aeróbio que propiciou a melhora da funcionalidade dos participantes, independente do meio o qual foi realizado / Stroke is the leading cause of adult disability in the world. Clearly, walking retraining is a major goal in a rehabilitation program for person with stroke. Our study was designed to evaluate the effect of a training program involving both treadmill and aquatic walking to reduce the disability due to poor walking performance in chronic stroke persons. Twelve participants were randomly assigned to treadmill group and aquatic group for the 9 week program (3 days/week) progressive graded, high-intensity aerobic treadmill exercise or aquatic exercise. Data from functional assessments were selected according to levels of the International Classification of Functioning, Disability and Health: Fulg-Meyer scale to body function, Brazilian Berg balance scale, Timed and up & go test and The Postural Assessment Scale for Stroke Patients to activity and Medical Outcomes Study short-form 36-item questionnaire (SF-36) to participation. Biomechanical data were the lower limb kinematic variables (peak and minimal angle and maximal range) and surface electromyogram signals was recorded from tibialis anterior, lateral gastrocnemius, rectus femoris, vastus lateralis, biceps femoris and semitendinosus bilaterally during gait. A five-way analysis of variance was performed to test for differences among groups, phases, muscles, sides and gait phases. Multiple linear regression models were ran to examine the relationships between functional assessment and the electromyography variables. The aerobic training improved the functional variables in both groups. The electromyography variables showed influence of the training program in both groups. Weak relationship exists between functional assessment and the electromyography variables. The aerobic training programs in chronic hemiparetic stroke were beneficial and improving functional status in stroke person for both groups

Understanding the underlying coordination mechanisms that lead to a patient’s poor walking performance is critical in developing effective rehabilitation interventions. However, most common measures of rehabilitation effectiveness do not provide information regarding underlying coordination mechanisms. The overall goal of this research was to analyze the relationship between two potential measures of walking performance (step length asymmetry and module composition) and underlying walking mechanics. Experimental analyses were used to analyze the walking mechanics of hemiparetic subjects grouped by step length asymmetry. All groups had impaired plantarflexor function and the direction of asymmetry provided information regarding the compensatory mechanism used to overcome this plantarflexor impairment. Those subjects who walked with longer paretic than nonparetic steps compensated using increased output from the nonparetic leg, while those with symmetric steps compensated using a bilateral hip strategy. These results suggest that step length asymmetry may provide information regarding underlying coordination mechanisms that can be used to guide rehabilitation efforts. Another way to assess walking performance is to directly analyze deficits in muscle coordination. Recent studies have suggested that complex muscle activity during walking may be generated using a reduced neural control strategy organized around the co-excitation of multiple muscles, or modules, which may provide a useful framework for characterizing coordination deficits. Simulation analyses using modular control were performed to understand how modules contribute to important biomechanical functions of non-impaired walking and how the generation of these functions is altered in groups of post-stroke hemiparetic subjects who commonly merged different sets of non-impaired modules. The non-impaired simulation found that six modules are needed to generate the three-dimensional tasks of walking (support, forward propulsion, mediolateral balance control and leg swing control). When the plantarflexor module was merged with the module controlling the knee extensors and hip abductors, forward propulsion and ipsilateral leg swing were impaired. When the module controlling the hamstrings was merged with the module controlling the knee extensors and hip abductors, forward propulsion, body support and mediolateral balance control were impaired. These results suggest that module analysis may provide useful information regarding the source of walking deficits and can be used to guide rehabilitation efforts. / text

Orientador: Ricardo Machado Leite de Barros / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Educação Física / Made available in DSpace on 2018-08-26T22:39:02Z (GMT). No. of bitstreams: 1 Carmo_AlineAraujodo_D.pdf: 2114205 bytes, checksum: fb76dc00dfca8a6ccd17b301e7e6402f (MD5) Previous issue date: 2015 / Resumo: O objetivo geral deste estudo foi analisar a evolução espontânea dos parâmetros biomecânicos da marcha de sujeitos hemiparéticos acometidos por acidente vascular cerebral-AVC por um período de seis meses, visando responder às seguintes questões norteadoras: 1- Houve evolução dos parâmetros biomecânicos ao longo dos seis meses de avaliação? 2- Os sujeitos acometidos por AVC diferem dos controles na avaliação inicial? 3- Após 6 meses houve evolução espontânea suficiente para reduzir as diferenças entre controles e os sujeitos pós-AVC? Para isso, os parâmetros biomecânicos da marcha selecionados para monitoramento foram os parâmetros espaço-temporais, os ângulos articulares de membros superiores e inferiores e, a trajetória tridimensional do centro de massa do corpo. O grupo hemiparético (HG) foi composto por 10 indivíduos acometidos por AVC e o grupo controle (CG) foi composto por 10 indivíduos sem alterações de marcha. Os sujeitos do HG foram observados por um período de seis meses, e para isso, a avaliação foi composta por três exames de análise da marcha com intervalos de três meses entre eles. Os exames foram divididos em: Exame inicial - E1, Exame intermediário- E2 (três meses após o inicial), e Exame final - E3 (seis meses após a inicial e três meses após o E2). O sistema para análise cinemática tridimensional utilizado foi o sistema DVideo. Foi utilizado um protocolo de marcadores de corpo inteiro compatível com modelo antropométrico para obtenção dos parâmetros inerciais e cálculo do centro de massa. Para obtenção dos ângulos articulares foi utilizado o Visual 3D e, para isso, foi criado um modelo que considera as articulações dos membros superiores e inferiores. Foram utilizados testes estatísticos não paramétricos para a comparação das três avaliações dos hemiparéticos (teste de Friedman de medidas repetidas) e, para a comparação entre os grupos controle e hemiparético (teste U de Mann-Whitney P?0.05). Os resultados apontaram melhora significativa nas variáveis espaço-temporais, nos ângulos articulares e, na trajetória do centro de massa do corpo ao longo de seis meses de observação. Os achados do presente estudo evidenciam que o tempo exerce papel importante na recuperação espontânea do padrão de marcha, foram observadas melhoras importantes para a independência funcional dos indivíduos com hemiparesia / Abstract: The aim of this work was to analyze the spontaneous evolution of the biomechanical gait parameters of post-stroke patients for a period of six months of observation, in order to answer two main questions: 1- There was some evolution of biomechanical parameters of stroke patients over time? 2- Stroke patients are different from healthy subjects in the baseline? 3- After 6 months there was spontaneous evolution enough to reduce the differences between controls and stroke subjects? To do that the following biomechanical gait parameters were selected to analyze: spatiotemporal gait parameter, kinematical joint angles of the upper and lower limbs and three dimensional center of mass trajectories. The hemiparetic group (HG) was composed by 10 post-stroke patients and the control group (CG) was composed by 10 healthy subjects. The HG subjects were evaluated for a period of six months by three gait analysis examinations (E1, E2 and E3) with three-month intervals between each one. The DVideo kinematic analysis system was used. The CoM trajectory was obtained using a gold standard method, the 3D kinematics associate to anthropometry. The Visual 3D software was used to obtain the joint angles of the upper and lower limbs. A full-body model was created in order to calculate the angles of the upper and lower limbs. Nonparametric tests were applied to comparisons of the three examinations of the hemiparetic group (Friedman test for repeated measurements) and, for the comparisons between groups HG and CG (Mann-Whitney test P?0.05). The results revealed significant differences in the spatiotemporal gait parameters, joint angles and center of mass trajectory over the six months of observation. The findings of the present study can evidence that time plays an important role on the spontaneous recovery of the gait pattern after stroke. Significant improvements were found in the gait pattern over the six months of observation, these improvements are important to provide functional independence of the post-stroke patients / Doutorado / Biodinamica do Movimento e Esporte / Doutora em Educação Física

Nos últimos anos, o treinamento aeróbio vem sendo empregado como forma de recuperação da marcha em pessoas pós-acidente vascular cerebral. O objetivo desta Tese foi avaliar os efeitos do treinamento aeróbio em piscina e em esteira rolante na marcha de indivíduos hemiparéticos crônicos. Participaram 12 pessoas, randomizadas por sorteio para Grupo Piscina e Grupo Esteira. Para as avaliações funcionais, os testes e escalas foram divididos de acordo com a Classificação Internacional de Funcionalidade, Incapacidade e Saúde: Avaliação Fugl-Meyer; a Escala de equilíbrio de Berg, Escala de avaliação do controle postural para pacientes pós-acidente vascular cerebral, Timed Up and Go Test e o Questionário de qualidade de vida SF-36. Na avaliação biomecânica foram avaliados os parâmetros cinemáticos de amplitude de movimento, ângulo mínimo e máximo da articulação do joelho e tornozelo e parâmetros eletromiográficos (EMG) dos músculos tibial anterior, gastrocnêmio lateral, reto da coxa, vasto lateral, bíceps da coxa, semitendíneo. Foi realizada análise de variância para inferir o efeito do treinamento aeróbio em ambos os grupos. Para estudar o comportamento das variáveis eletromiográficas em função das avaliações funcionais foi realizada a análise de regressão linear múltipla. O treinamento aeróbio melhorou o comprometimento sensório-motor, equilíbrio, agilidade e qualidade de vida relacionada à saúde dos participantes de ambos os grupos, como alterações nos padrões eletromiográficos dos músculos na locomoção dos participantes de ambos os grupos. Não houve efeito do treinamento aeróbio para os parâmetros cinemáticos das articulações analisadas. Houve a fraca relação entre os parâmetros EMG e as variáveis funcionais. Os participantes foram beneficiados pela prática do treinamento aeróbio que propiciou a melhora da funcionalidade dos participantes, independente do meio o qual foi realizado / Stroke is the leading cause of adult disability in the world. Clearly, walking retraining is a major goal in a rehabilitation program for person with stroke. Our study was designed to evaluate the effect of a training program involving both treadmill and aquatic walking to reduce the disability due to poor walking performance in chronic stroke persons. Twelve participants were randomly assigned to treadmill group and aquatic group for the 9 week program (3 days/week) progressive graded, high-intensity aerobic treadmill exercise or aquatic exercise. Data from functional assessments were selected according to levels of the International Classification of Functioning, Disability and Health: Fulg-Meyer scale to body function, Brazilian Berg balance scale, Timed and up & go test and The Postural Assessment Scale for Stroke Patients to activity and Medical Outcomes Study short-form 36-item questionnaire (SF-36) to participation. Biomechanical data were the lower limb kinematic variables (peak and minimal angle and maximal range) and surface electromyogram signals was recorded from tibialis anterior, lateral gastrocnemius, rectus femoris, vastus lateralis, biceps femoris and semitendinosus bilaterally during gait. A five-way analysis of variance was performed to test for differences among groups, phases, muscles, sides and gait phases. Multiple linear regression models were ran to examine the relationships between functional assessment and the electromyography variables. The aerobic training improved the functional variables in both groups. The electromyography variables showed influence of the training program in both groups. Weak relationship exists between functional assessment and the electromyography variables. The aerobic training programs in chronic hemiparetic stroke were beneficial and improving functional status in stroke person for both groups

In order for stroke subjects to gain functional recovery of their hemiparetic limbs, facilitation techniques such as the repetitive facilitation exercise, or RFE, have been developed. Currently, there is a lack of understanding of the neural mechanisms associated with these types of facilitation techniques. To better understand the neural mechanisms associated with the RFE a functional magnetic resonance imaging (fMRI) study should be conducted. This thesis presents experimental results testing the feasibility of implementing an fMRI-compatible actuator to facilitate a myotatic reflex in synchronization with the subject’s intention to move their hemiparetic limb. Preliminary data from a healthy individual demonstrated the feasibility of overlapping the long latency component of the afferent myotatic reflex, created by electrical stimulation, with descending nerve impulses, created using transcranial magnetic stimulation, in a time window of 15ms. In addition, a pneumatic actuation time delay due to long transmission line was evaluated. The pneumatic actuator met the timing precision requirement for the rehabilitation device for varying transmission line lengths. Therefore a pneumatic actuation system was chosen for the rehabilitation device. This thesis will also presents on the design of an fMRI-compatible pneumatic actuator device to excite a stretch reflex response. Initial, experimental results with the device demonstrated that the designed pneumatic device can control the timing of the muscle response with a fixed signal within the required 15ms window required for cortical facilitation, which was found in the previous feasibility study. However, the device was unable to create a long latency reflex observable at the muscle. Finally, this thesis presents on the capability of the device in creating subthreshold long latency response with precision to overlap with a subthreshold descending nerve impulse, created using transcranial magnetic stimulation. The overlap of the two responses was evaluated by comparing the amplitude of the muscle response with and without the stretch reflex, created by the fMRI-compatible pneumatic actuator device. Varying time delays were analyzed.

L'hémiparésie est une des déficiences fréquemment observée après un accident vasculaire cérébral (AVC). Elle s’accompagne d’une gestion anormale de la co-contraction musculaire et des déficits de production de force qui contribuent de manière significative à réduire la performance de la marche. Une réorganisation des stratégies musculaires est mise en place pour répondre aux contraintes de stabilité et de propulsion du centre de masse au cours de la marche. Cependant, la littérature reporte très peu de données sur les actions musculaires des membres, parétique et non-parétique, au cours de la marche. De plus, les patterns de co-contraction ont été évalués à partir des seules données EMG chez les patients post-AVC. Par ailleurs, les patients post-AVC présentent une fatigabilité plus importante que les individus sains. Alors que plusieurs facteurs sont impliqués dans la fatigue, le rôle de la co-contraction reste mal connu. L’objectif principal de ce travail était de caractériser les altérations des stratégies musculaires des membres inférieurs chez des patients hémiparétiques post-AVC au cours de la marche et lors de la fatigue induite par des contractions maximales volontaires concentriques isocinétiques. Ce travail introduit l'utilisation novatrice d'une modélisation neuromusculo-squelettique assistée par EMG pour estimer les forces musculaires générées autour des articulations du genou et de la cheville au cours de la marche chez des patients post-AVC. De plus, nous avons montré qu’une quantification de la co-contraction à partir des moments musculaires est préférable par rapport à des mesures EMG. Les résultats ont montré que les forces réduites développées par les fléchisseurs plantaires de la cheville et les extenseurs du genou du côté parétique seraient à l’origine des troubles de la marche hémiparétique. Les forces musculaires élevées produites par les quadriceps et les fléchisseurs du genou du côté nonparétique, ainsi que la force élevée générée par les fléchisseurs du genou du côté parétique, par rapport aux sujets sains, pendant la phase d’appui correspondrait à une réorganisation comportementale, permettant d’augmenter la stabilité et d’ajuster la propulsion du centre de masse. Cette réorganisation des patterns de coordination musculaire se manifeste également par des niveaux élevés de co-contraction (basée sur les moments musculaires) observés du côté parétique et non-parétique au cours de la marche. Il s’agit d’une stratégie d'adaptation permettant d’améliorer la stabilité articulaire. Cependant, la cocontraction plus élevée au cours de la marche peut contribuer à l’augmentation du coût énergétique chez les patients et entraîner une fatigue plus rapide. L’étude de la fatigue neuromusculaire chez les patients post-AVC a mis en évidence une fatigabilité moindre par rapport aux sujets sains en présence d’un niveau plus élevé de co-contraction (basée sur les données EMG). Le déclin de l’activité EMG agoniste lors de contractions concentriques répétées, s’est produit parallèlement à un déclin de l’activité EMG antagoniste diminuant la force d’opposition au mouvement et entraînant une moindre diminution du moment net. Ceci semble être un mécanisme potentiel par lequel la production du moment net est préservée chez les patients post-AVC qui sont intrinsèquement plus faibles. Les résultats de ce travail soulignent l’importance de développer des programmes de rééducation centrés sur le renforcement des fléchisseurs plantaires et des extenseurs du genou et sur la sélectivité du contrôle des mouvements tel que l’entraînement en puissance. / Hemiparesis is one of the most frequent deficits after stroke. It is accompanied by an abnormal muscle co-contraction pattern and an altered force production that significantly contribute to reduced gait performance. These alterations lead to a reorganization of muscle coordination patterns to ensure stability and adjust the propulsion of the center of mass during walking. However, less is known about muscle actions in the paretic and non-paretic lower limbs during walking. In addition, co-contraction patterns were evaluated from only EMG data in post-stroke patients. Furthermore, post-stroke patients manifest higher levels of fatigability than healthy individuals. While several factors are involved in fatigue, the role of co-contraction remains poorly understood. The main objective of this thesis was to characterize the alterations of the muscle strategies of the lower limbs in post-stroke hemiparetic patients during walking and during fatigue induced by isokinetic concentric maximal contractions. This thesis introduces the novel use of an EMG-driven modelling approach to measure muscle forces generated around the knee and ankle joints of the paretic and non-paretic lower limbs during gait in post-stroke patients. In addition, we have shown that quantification of co-contraction from muscle moments is preferable compared to EMG measurements. The results showed that the reduced forces exerted by the plantar-flexors and the knee-extensors on the paretic side, gives a possible explanation for hemiparetic gait abnormalities. Increased forces generated by the knee-flexor and knee-extensor muscles on the non-paretic side, as well as increased force generated by the knee flexors on the paretic side, compared to healthy subjects, during the stance phase would be a behavioral reorganization to better support body weight and properly adjust the forward center of mass. This reorganization of muscle coordination patterns is also reflected by the increased levels of co-contraction (based on muscle moments) observed on the paretic and non-paretic side during walking. This seems to be an adaptive, compensatory strategy to ensure postural stability. However, increased co-contraction during walking can contribute to an increased energy cost in patients and lead to a more rapid fatigue development. The study of neuromuscular fatigue in post-stroke patients showed less fatigability compared to healthy subjects, in the presence of a higher level of co-contraction (based on EMG data). Decreasing agonist EMG during repeated concetric contractions, occurred in parallel with decreasing antagonist EMG, reducing the relative opposing force and resulting in a less decline in net torque. This seems to be a potential mechanism by which net torque output is preserved in post-stroke patients who are inherently weaker. The results of these studies underline the importance of developing rehabilitation programs focused on the strengthening of plantar flexors and knee extensors and on the selectivity of movement control, such as power training.

Background and purpose . This pilot study examined SSRI's in association with partial body weight treadmill training (PBWTT) to improve locomotion post stroke. Serotonin is thought to play a role in recovery of motor function such as locomotion on a treadmill eliciting the central pattern generators (CPG's) identified from animal models. There would be benefits in knowing if serotonin combined with PBWTT influenced motor recovery. The purpose of the study was to determine if patients undergoing treatment with an SSRI would improve in locomotor function to a greater degree than patients not receiving an SSRI. Subjects and methods . Non clinically depressed post stroke patients (N = 4) and clinically depressed post stroke patients on SSRI's (N = 4) were assigned to two groups of convenience. Initial baseline performance was established at two evaluation points using functional gait tests, balance tests, and electomyographical analysis during performance of locomotion over an eight week period (Pre 1 & Pre 2). Intervention of PBWTT was introduced for eight weeks and subjects were evaluated again (Post 1). Subjects returned four weeks later for a follow up evaluation (Post 2). The intervention included training three days a week for eight weeks utilizing PBWTT. Data was analyzed using non parametric statistics. Results . All subjects improved in gait velocity, distance covered and assistance needs as it relates to the PBWTT. Functional gait, balance and gait characteristic improved in both groups with significant differences noted in the “timed up and go test” and Tinetti Assessment in the group undergoing treatment with SSRI's. Weight bearing squat scores improved in both groups with a greater significance at 0 and 30 degrees of knee flexion in the subjects under the influence of SSRI's. The limits of stability scores (LOS) and sensory organization test (SOT) improved in both groups without significant differences. Electromyographical data supported visual observations for improvement of gait deviations and improved on-off timing during the gait cycle in both groups. Conclusion . This study would indicate comparing SSRI therapy and specific functional movement learning for further study.