versão impressa ISSN 1413-3555
Rev. bras. fisioter. vol.16 no.2 São Carlos mar./abr. 2012 Epub 01-Mar-2012
Terapia de constrição com indução do movimento e terapia de uso forçado modificadas em pacientes pós-acidente vascular encefálico são eficientes em promover melhora do equilíbrio e da marcha
Amanda C. FuzaroI; Carlos T. GuerreiroI; Fernanda C. GalettiI; Renata B. V. M. JucáI; João E. de AraujoII
ILaboratory of Neuropsychobiology and Motor Behavior, Department of Biomechanics, Medicine and Rehabilitation of the Locomotor System, Medical School, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
IICourse of Physical Therapy, Laboratory of Neuropsychobiology and Motor Behavior, Department of Biomechanics, Medicine and Rehabilitation of the Locomotor System, Medical School, USP, Ribeirão Preto, SP, Brazil
BACKGROUND: Previous studies show that chronic hemiparetic patients after stroke, presents inabilities to perform movements in paretic hemibody. This inability is induced by positive reinforcement of unsuccessful attempts, a concept called learned non-use. Forced use therapy (FUT) and constraint induced movement therapy (CIMT) were developed with the goal of reversing the learned non-use. These approaches have been proposed for the rehabilitation of the paretic upper limb (PUL). It is unknown what would be the possible effects of these approaches in the rehabilitation of gait and balance.
OBJECTIVES: To evaluate the effect of Modified FUT (mFUT) and Modified CIMT (mCIMT) on the gait and balance during four weeks of treatment and 3 months follow-up.
METHODS: This study included thirty-seven hemiparetic post-stroke subjects that were randomly allocated into two groups based on the treatment protocol. The non-paretic UL was immobilized for a period of 23 hours per day, five days a week. Participants were evaluated at Baseline, 1st, 2nd, 3rd and 4th weeks, and three months after randomization. For the evaluation we used: The Stroke Impact Scale (SIS), Berg Balance Scale (BBS) and Fugl-Meyer Motor Assessment (FM). Gait was analyzed by the 10-meter walk test (T10) and Timed Up & Go test (TUG).
RESULTS: Both groups revealed a better health status (SIS), better balance, better use of lower limb (BBS and FM) and greater speed in gait (T10 and TUG), during the weeks of treatment and months of follow-up, compared to the baseline.
CONCLUSION: The results show mFUT and mCIMT are effective in the rehabilitation of balance and gait. Trial Registration ACTRN12611000411943.
Keywords: forced use therapy; constrain induced movement therapy; stroke; gait rehabilitation; walking speed; physical therapy.
CONTEXTUALIZAÇÃO: Pacientes hemiparéticos crônicos, após acidente vascular encefálico (AVE), apresentam incapacidade para executar movimentos no hemicorpo parético. Essa incapacidade é reforçada positivamente por tentativas fracassadas de movimento, conceito chamado desuso aprendido. A terapia de uso forçado (FUT) e a terapia de constrição com indução do movimento (CIMT) foram desenvolvidas objetivando a reversão do desuso aprendido do membro superior parético. Não se encontrou na literatura quais seriam os possíveis efeitos dessas técnicas na reabilitação da marcha e do equilíbrio.
OBJETIVOS: Avaliar o efeito da FUT e da CIMT modificadas (mFUT e mCIMT) na marcha e no equilíbrio durante quatro semanas de tratamento e três meses de seguimento.
MÉTODOS: Este estudo incluiu 37 sujeitos hemiparéticos pós-AVE, divididos em dois grupos com base no protocolo de tratamento. A imobilização do membro superior não-parético foi feita por 23 horas ao dia, cinco dias por semana. Os sujeitos foram avaliados no início, durante quatro semanas de tratamento e três meses de acompanhamento. Para a avaliação, utilizou-se a Escala de Impacto do AVE (SIS), Berg Balance Scale (BBS) e Fugl-Meyer Motor Assesment (FM). Para a marcha, utilizou-se o teste de caminhada de 10 metros (T10) e Timed Up & Go test (TUG).
RESULTADOS: Ambos os grupos revelaram um melhor estado de saúde (SIS), melhor equilíbrio, com melhor utilização dos membros inferiores (BBS e FM) e maior velocidade na marcha (T10 e TUG) durante tratamento e seguimento em comparação com o início.
CONCLUSÃO: Os resultados mostram que a mFUT e a mCIMT são eficazes para a reabilitação do equilíbrio e da marcha. Registro de Ensaios Clínicos ACTRN12611000411943.
Palavras-chave: terapia de uso forçado; terapia de constrição com indução de movimento; reabilitação de marcha; velocidade de marcha; fisioterapia.
Stroke is one of the major causes of death and disability in adults worldwide1. In Brazil is the main cause of death, responsible for the highest mortality rates by age group in Latin America2,3. The majority of survivors show some degree of recovery, but more than 50% still present some sensory or motor deficits and, only 30% of these patients can return to work during the first year post-stroke4,5. Because stroke affects posture and functional movements, paresis is present in upper and lower limbs (UL and LL) or hemibody6. The decline in motor function is also correlated to balance7. More than 80% of the survivors have paresis of the UL8, and 30%-60% of these patients cannot use the paretic UL (PUL) which compromises their independence and quality of life9.
Maintained posture is an important and complex task for the human body, which involves constant and coherent adjustments in order to maintain the body segments aligned10. Trunk stability is a key element for body balance and coordinated use of limbs during functional and gait activities11. Hemiparetic patients have asymmetry during static motor activation for either sitting or standing postures as well as for dynamic functional movements such as gait12,13.
The hemiparetic patient has a lower speed during gait, asymmetry during orthostatic posture and functional movements14, longer periods of weight bearing on the non-paretic LL, and increase in double support time15. This type of gait requires more energy compared to healthy individuals16 due to the displacement of the body's center of gravity, which raises the metabolic demands and increase fatigue17. The center of gravity is shifted towards the non-paretic LL because of the decreased weight distribution in the paretic LL18,19. Any task involving simple limb coordination becomes difficult to perform20. This asymmetry is observed in static sitting and standing postures as well as during functional movements, being associated to balance impairment and gait disorganization21. Reorganizing the gait patterns is one of the main objectives proposed by the rehabilitation programs and highly expected by the patients22. About 60% of the post-stroke patients recover from severe gait impairments after a period of 3 months. However, these patients may present a certain degree of deficiency in their balance23 and only 40% of them recover their normal gait speed15.
Physical therapy techniques are used for rehabilitation of post-stroke patients24-26. An intensive motor rehabilitation facilitates recovery and promotes changes in the neuromuscular system by training repeated tasks27. One of the techniques using such a concept is the Constraint-Induced Movement Therapy (CIMT)28. The original protocol used restriction of the non-paretic upper limb (NPUL) for 90% of waking hours and a 6-hour daily training for two weeks4. The Forced-Use Therapy (FUT) is a technique that preceded the CIMT, consisting of restricting NPUL without training20. Use of CIMT or FUT without these classic parameters should be classified as modified CIMT or FUT (mCIMT or mFUT). In both therapies, the main target is the motor rehabilitation of the PUL. There are no published studies providing with clear evidence that these therapies produce positive effects on LL, gait or balance.
By knowing that stroke causes alterations in the center of balance as well as in UL and LL, and that these alterations affect the performance of any task involving simple limb coordination20, and seeking to find alternatives to rehabilitation, the following questions were asked: Can mFUT and/or mCIMT promote changes in the LL? Can a restriction of NPUL promote changes in the motor strategies of hemiparetic patients and influence their balance and gait? What would be the most important, to simply prevent the non-use of the NPUL (FUT) or to induce the movement through specific stimulations (CIMT)?
Thirty-seven participants (19 males and 18 females) took part in this study. The subjects were randomized into the two groups of treatment. For randomization, we use sealed envelopes containing the indication for one of the treatment groups and each participant could freely choose a sealed envelope. The inclusion criteria were: good cognition, absence of joint stiffness, preserved range of motion, ability to walk independently, and able to perform active extension for wrist and metacarpophalangeal joints at 20 and 10 degrees of active extension, respectively. The exclusion criteria were: cardiac arrhythmias, non-controlled blood pressure, and severe respiratory and cardiovascular problems. Medications for stroke treatment and hypertension were allowed (Figure 1).
All patients were recruited from the Neurovascular Outpatient Clinic at the Ribeirão Preto School of Medicine, after being evaluated by the medical staff and later referred to the rehabilitation department. These subjects were submitted to a motor assessment, with the execution of free movement of both UL, and gait test for 20 yards. All subjects had grade 5 in muscle strength in their LL on a force scale of 0-5. The participants were also tested for a cognitive assessment, using the Mini Mental State Examination29. The subjects that showed a good free range of motion and scored <15 points for the illiterate, or <22 for 1 to 11 years of education or even education <27 with more than 11 years were eligible to participate in the study and were analyzed in relation to their inclusion and exclusion criteria29. The patients who met the inclusion criteria signed the informed consent form were enrolled in this study. The study protocol was approved by the Human Research Ethics Committee of Clinics Hospital at the Ribeirão Preto School of Medicine, Universidade de São Paulo, Ribeirão Preto, SP, Brazil (protocol number 5995/2006). It was registered in the Brazilian National Information System on Ethics on Human Research (CAAE-0119.0.004.000-06) and prospectively registered in the Australian New Zealand Clinical Trials Registry (ACTRN12611000411943).
During the study, subjects declared that they were not participating in any other rehabilitation protocol.
Immobilization, mobilization, and stretching of the NPUL
Immobilization was performed by means of a tubular mesh involving the NPUL in abduction, rotating the shoulder internally, allowing elbow flexion above 90º (Figure 2).
This immobilization was maintained for 23 hours during five days a week over a period of four weeks. The tubular mesh was removed every day by the researchers for cleaning, mobilization, and stretching the UL. On Saturdays, the caregiver or family members were instructed to remove the tubular mesh of the participants, at the same hour the physical therapy sessions. Throughout the weekend, the patient was then free to move both UL normally. The NPUL mobilization was performed by using traction techniques and joint circular movements, with 30 repetitions for each joint. All muscle groups of the UL were stretched. A total of three repetition consisted of keeping the extension pressure for 45 seconds were performed. This procedure enabled the patient to have unrestricted movements for at least 60 minutes. Then, another immobilization was prepared using a new tubular mesh.
Motor stimulation of PUL
Subjects in the mCIMT attended an exercise-training program for 5 days a week. The program was applied only to the PUL. Each session lasted 50 minutes on average of and during this period the NPUL was maintained free next to the body. Bimanual activity was only permitted in special tasks, i.e. manipulation tasks with paper clip, but the PUL should be the main conductor of activity. Each session included a 5-10 minutes warm-up periods, scapula mobilization, flexion exercises that were combined with shoulder abduction, elbow extension and wrist extension flexion movements. In addition trunk extension and rotation associated with UL movements, and functional activities such as unlocking a door, among other tasks were performed30-33. All exercises were performed using three series of 10 repetitions and the rest interval was determined for each subject in order to avoid fatigue and excessive tiredness. LL was not stimulated in both groups. Exercises were performed with subjects sitting on a chair with standard dimensions at a maximum range and with some resistance by the physical therapist, whenever possible. For the functional activities we used a support table.
Motor evaluation was performed on a weekly basis (except for the admission scale) during the 4-week treatment period and every 30 days after treatment for three months. There were eight assessment time-points of evaluations: initial (baseline), three weekly (1st, 2nd, and 3rd weeks), post-treatment (4th week), and monthly follow-ups over three months period (1st, 2nd, and 3rd follow up). The physical therapist responsible for evaluating all the subjects was blinded to the treatment groups.
The Stroke Impact Scale (SIS) version 3.034 was used on baseline, 4th week and all subsequent follow-ups. SIS integrates significant dimensions of function and quality of life by self-report. The version used has 59 questions and evaluates 8 domains (strength, hand function, performance and independence in activities of daily living, mobility, communication, emotion, memory and thoughts) with a maximum score of 295 points35. In our study, we used only the items that assessed the performance of activities of daily living, LL strength and locomotion (walking and transfers), resulting in a maximum score of 80 points.
Balance was evaluated by Berg Balance Scale (BBS)31 and LL function by Fugl-Meyer Assessment of Motor Recovery (FM)36-38. The BBS assesses balance performance by using 14 items. Each item has an ordinal scale of five alternatives ranging from 0 to 4 points, with a maximum score is 56 points39,40. The FM evaluates the sensorimotor recovery of UL and LL post-stroke. The maximum scores are 66 and 34 points for upper and LL, respectively, which defines a normal motor function36,38. We used only the LL section of this instrument.
Gait analysis was performed by the 10-meter walking test (T10)41,42 and Time Up & Go test (TUG)43,44. The T10 evaluates the time to walk a distance of 10 meters45. The participants were instructed to conduct the test quickly and safely. In our study, the execution time of each evaluation test was performed twice and we averaged the results. The TUG measures the time need to rise from a chair and walk a distance of 3 meters, return and sit down, without any assistance46,47. For both tests, the data of the start were normalized in percentage, corresponding to 100% of the time to perform the test. Assessments of all weeks and all follow up time points were also normalized into percentages, regarding the percentage of the beginning of the test. All evaluations were recorded on video through a Sony digital camera for further and more detailed analysis.
We used Kruskal-Wallis One Way Analysis of Variance on Ranks for within-group comparisons between weeks and follow ups, with Dunn´s post-hoc test. Possible between-groups differences we tested by Mann-Whitney rank sum tests. The significance level chosen was α=0.05.
The 37 participants were randomly allocated into the mFUT or mCIMT groups, to check if only forced use or intense stimulation of the PUL would be able to provide changes in the balance and gait. Sides of hemi-paresis, mean stroke duration and mean age are described in Table 1.
The subjects have a typical helicopod hemiparetic gait and a good balance on the BBS, up 41 points at baseline evaluation39.
From a total of 418 potential participants listed, 195 did not meet the criteria for inclusion and/or exclusion was dismissed after medical assessment, 20 refused immediately, another 32 reported problems, i.e. difficulties with public transportation to attend the treatment sessions. After this initial assessment we selected 72 potential subjects.
In mCIMT the 36 subjects that started, 10 reported not support the tubular mesh or indicated personal and/or family problems and abandoned in the first week. During the second week there were more 7 dropouts, these subjects were not accounted in the analysis. After completion and along the follow up, 6 subjects did not return for reevaluation. For the mFUT, 36 were assessed at baseline, 12 did not stand the tubular mesh and were excluded in the first week. Along the protocol, 6 more were discharged and were not accounted for the analysis. Along the follow up periods, 4 participants did not return, but were included in the analysis until the time they were assessed.
The analysis of the SIS values at baseline showed a significant increase in the 4th week and in all follow up periods, compared to the start for the mCIMT (H=34.41). For the mFUT this increased was observed in the 1st follow up (H=10.134). No differences were found between 4th week of treatment all remaining follow up periods compared to baseline. The between-group comparison showed that mCIMT at baseline had a significantly lower score than the mFUT (T=420.50). However, in assessing the 4th week follow up the mCIMT showed a significantly higher score than mFUT (T=271.00). Thus, increase in the SIS values reveal a neuro-behaviour improvement in the 4th week, which was maintained during all follow up periods for the mCIMT. For the mFUT, the baseline score of the SIS is only significantly higher on first follow up without maintenance in the next assessments.
By analyzing the BBS scale in relation to baseline, the mFUT showed a significant increase in the score after the 4th week and all follow up periods (H=19.60). For the mCIMT, this increase occurred in the 2nd week follow up, which was maintained during the 3rd and 4th weeks and all follow up periods and were higher when compared to the 1st week (H=89.74). The comparison showed that mCIMT group at baseline had a lower score than the mFUT, however this difference disappeared after the 1st week (T=473.50).
FM scale had higher scores in the mFUT (H=20.84) and mCIMT (H=79.99) after the 3rd week and all follow up periods. The mCIMT showed a higher score after the 3rd and 4th weeks and all follow up periods compared to the 1st week (H=79.99). The comparison showed that group mCIMT had a lower score than the mFUT at baseline (T=140.50) and after the 1st week (T=169.50). However mCIMT in 3rd and 4th weeks (T=305.00; T=318.50) and in the 1st and 2nd follow-ups (T=344.50; T=331.50) showed higher scores than the mFUT. These three scales reveal improved level of independence, decreased disability, and improved static and dynamic balance in both groups.
Similarly T10 test showed an increase in gait speed for the mFUT. Data show a decrease in time needed to complete the task during all weeks as well as maintenance of the effects over all follow up periods compared to baseline (H=29.78). The mCIMT showed a decrease in time needed to complete the task in the 2nd, 3rd and 4th week and during all follow up periods. In this group, also the 5th week and 3rd follow-up shows a decrease in time when compared to 1st week (H=57.56). The comparison revealed a decrease in task completion time for the group mCIMT in the 3rd and 4th week (T=423.00; T=450.00) and all follow up periods (T=221.00; T=209.50; T=209.00). Compared to start, the TUG test showed that the mFUT had a decrease in time needed to complete the task from all weeks and during all follow up periods (H=33.52). A reduction time to complete the task for the mCIMT was evidenced from the 2nd, 3rd, and 4th week and during all follow up periods (H=60.84). The between-group comparison revealed a higher decrease in task completion time for the group mCIMT in the 4th week (T=423.00) and all follow up periods (T=225.5; T=188.00; T=91.00) (Table 2, Figure 3).
We have to consider an important finding in our study. It is possible to rehabilitate the gait of post-stroke patients with chronic hemiparesis by using either mCIMT or mFUT. These techniques influence the movement of the contralateral arm and induce an increase in range of motion and directly modifies the coordination between arms and legs during the gait cycle. These changes produce positive changes in balance and walking in patients affected by hemiparesis.
Taub and Wolf48 used CIMT for NPUL constriction during 90% of time that patients are awakened. Our study used a similar protocol but with a longer duration of restriction. In association with this restrictive movement, the Taub motor stimulations are performed for 6 hours a day during 14 days consecutively49,50. As in Brazil most of physical therapy sessions last an average of 1 hour, we adapted the motor stimulation to one hour.
Several authors have modified the original treatment protocol as well as the material used for restriction50-54 and also the daily and total periods of immobilization32,33. The most commonly used materials for the movement restriction are gloves52, arm slings54, and UL orthoses50,53.
In our study, we have used a tubular mesh, which allowed immobilization of the NPUL to the trunk, which was another adjustment to the Brazilian reality, since it is an affordable material. Our daily motor stimulation time corresponded to the patterns of a common physical therapy session performed in Brazil. Similarly, restricting the NPUL for five days a week facilitated the physical therapists' work. Moreover, it is possible that restricting the NPUL to the body might be a differential modification of the original technique, which can explain both functional improvement and increased gait speed in the subjects who had participated in our study.
Hemiparetic patients do not use their PUL spontaneously, but they achieve high score in the functional tests55,56. Because of our inclusion criteria, the included participants had already both reasonable functioning and good general health status. However, our study showed that the need to use the PUL because of the immobilization of the NPUL produced additional benefits to these patients57.
There is a greater interaction between the LL during gait. However the coordination between UL and LL seems to be task-dependent58. Such an interaction between limbs during the gait can be altered by hemiparesia, since the NPUL has to exert more balance to compensate the poor balance on the paretic side59.
Hemiparetic patients have difficulty in bearing their body weight through the paretic LL and in positioning the center of mass between the supporting base60,61. It is possible that their center of mass and equilibrium is located only in the NPUL. In our study, restriction of the NPUL to the trunk interfered with such an equilibrium, thus demanding a re-organization of the body center of mass. Thus, we can justify the improvement obtained in BBS and FM scales because they are correlated to the level of patient's independence, decrease in LL disability, and improve in static and dynamic balance.
Disability in UL causes a reduction in its range of motion during gait and decreases both frequency and arm/leg phase interaction. These features produce a slower gait due to lack of coordination between arms and legs59. In our study, we changed the behavioral pattern regarding the non-use of the PUL balance during gait, favoring gains in LL. Like mCIMT and mFUT, this approach causes an increase in the range of motion of the PUL, which improves the synchronism between the limbs and increases the speed during gait59. The gait speed has been used as a parameter of coordination between the limbs44.
Both mCITM and mFUT interfere with the movement of a PUL. These treatment approaches increase the range of motion during gait, and modify the coordination between arms and legs, thus producing positive changes in balance and locomotion59. Our treatment protocol generated a greater balance in the PUL while the NPUL was immobilized to the trunk. The TUG and T10 showed are higher speed in gait rehabilitation corroborating this concept.
The mFUT group measured by the scales SIS, BBS and FM had a lower early motor impairment than subjects allocated to the mCIMT group, but during the study this difference disappeared. This difference did not impact on the results, since no between-group differences were observed from the second assessment on. In this way, from this time-point the groups were considered similar and their evolution from this time-point was comparable. This improved performance was evident in the FM assessment after the 3rd week showing a better motor pattern when compared to the mFUT. These results are consistent with other studies that show that an intensive rehabilitation is important for motor learning20,27.
All participants from this study had completed conventional physical therapy treatments at different times after stroke. At the time of discontinuation of these treatments at different physical rehabilitation services, the subjects could no longer reach functional evolution. As we did not have their baseline functional data of these subjects, it was not possible to compare their conventional physical therapy to our two treatment groups. However, our results show that participants who do not have more functional changes can have additional benefits from the proposed treatment approaches tested in our study.
Our study is based on functional scales, which can be considered a limitation factor regarding the full understanding of the motor acquisitions. however the scales were efficient in demonstrating both clinical and functional improvements. In addition, many patients could not participate in the study due to our very specific inclusion criteria, which can make the application of these instruments difficult in clinics and physical therapy rehabilitation centers on a daily basis.
In this study, we have shown for the first time that mCIMT and mFUT produce changes in the motor performance of LL. We also shown that mCIMT generates an improvement of the motor behavior pattern and produced higher scores on functional scales than mFUT, this finding confirms the need of a specific approach by neuro-functional physical therapy.
To FAPESP for a Master Scholarship (reference number 2007/05710-5).
1. Dirnagl U, Iadecola C, Moskowitz MA. Pathobiology of ischemic stroke: an integrated view. Trends Neurosci. 1999;22(9):391-7. [ Links ]
2. Pontes-Neto OM, Silva GS, Feitosa MR, de Figueiredo NL, Fiorot JA Jr, Rocha TN, et al. Stroke awareness in Brazil: alarming results in a community-based study. Stroke. 2008;39(2):292-6. [ Links ]
3. Bonita R, Mendis S, Truelsen T, Bogousslavsky J, Toole J, Yatsu F. The global stroke initiative. Lancet Neurol. 2004;3(7):391-3. [ Links ]
4. Myint JM, Yuen GF, Yu TK, Kng CP, Wong AM, Chow KK, et al. A study of constraint-induced movement therapy in subacute stroke patients in Hong Kong. Clin Rehabil. 2008;22(2):112-24. [ Links ]
5. WHO publishes definitive atlas on global heart disease and stroke epidemic. Indian J Med Sci. 2004;58(9):405-6. [ Links ]
6. Macko RF, Smith GV, Dobrovolny CL, Sorkin JD, Goldberg AP, Silver KH. Treadmill training improves fitness reserve in chronic stroke patients. Arch Phys Med Rehabil. 2001;82(7):879-84. [ Links ]
7. Mercier L, Audet T, Hébert R, Rochette A, Dubois MF. Impact of motor, cognitive, and perceptual disorders on ability to perform activities of daily living after stroke. Stroke. 2001;32(11):2602-8. [ Links ]
8. Hlustik P, Mayer M. Paretic hand in stroke: from motor cortical plasticity research to rehabilitation. Cogn Behav Neurol. 2006;19(1):34-40. [ Links ]
9. Rathore SS, Hinn AR, Cooper LS, Tyroler HA, Rosamond WD. Characterization of incident stroke signs and symptoms: findings from the atherosclerosis risk in communities study. Stroke. 2002;33(11):2718-21. [ Links ]
10. Barela JA, Jeka JJ, Clark JE. Postural control in children. Coupling to dynamic somatosensory information. Exp Brain Res. 2003;150(4):434-42. [ Links ]
11. Horak FB. Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age Ageing. 2006;35 (Suppl 2):ii7-11. [ Links ]
12. Hesse S, Reiter F, Jahnke M, Dawson M, Sarkodie-Gyan T, Mauritz KH. Asymmetry of gait initiation in hemiparetic stroke subjects. Arch Phys Med Rehabil. 1997;78(7):719-24. [ Links ]
13. Aruin AS, Hanke T, Chaudhuri G, Harvey R, Rao N. Compelled weightbearing in persons with hemiparesis following stroke: the effect of a lift insert and goal-directed balance exercise. J Rehabil Res Dev. 2000;37(1):65-72. [ Links ]
14. Goldie PA, Matyas TA, Evans OM. Gait after stroke: initial deficit and changes in temporal patterns for each gait phase. Arch Phys Med Rehabil. 2001;82(8):1057-65. [ Links ]
15. Harris JE, Eng JJ, Marigold DS, Tokuno CD, Louis CL. Relationship of balance and mobility to fall incidence in people with chronic stroke. Phys Ther. 2005;85(2):150-8. [ Links ]
16. Ivey FM, Hafer-Macko CE, Macko RF. Exercise rehabilitation after stroke. NeuroRx. 2006;3(4):439-50. [ Links ]
17. Lucarelli PR, Greve JM. Alteration of the load-response mechanism of the knee joint during hemiparetic gait following stroke analyzed by 3-dimensional kinematic. Clinics (Sao Paulo). 2006;61(4):295-300. [ Links ]
18. Morioka S, Miyamoto S, Abe M. Relationship between the center of gravity point in spontaneous standing and the middle point calculated from the center of gravity shifting distance to the non-paralytic and paralytic sides in hemiplegics after stroke. Journal of Physical Therapy Science. 2003;15(2):99-103. [ Links ]
19. Laufer Y, Dickstein R, Resnik S, Marcovitz E. Weight-bearing shifts of hemiparetic and healthy adults upon stepping on stairs of various heights. Clin Rehabil. 2000;14(2):125-9. [ Links ]
20. Cauraugh JH, Summers JJ. Neural plasticity and bilateral movements: a rehabilitation approach for chronic stroke. Progress Neurobiol. 2005;75(5):309-20. [ Links ]
21. Mercer VS, Freburger JK, Chang SH, Purser JL. Measurement of paretic-lower-extremity loading and weight transfer after stroke. Phys Ther. 2009;89(7):653-64. [ Links ]
22. Patterson KK, Gage WH, Brooks D, Black SE, McIlroy WE. Changes in gait symmetry and velocity after stroke: a cross-sectional study from weeks to years after stroke. Neurorehabil Neural Repair. 2010;24(9):783-90. [ Links ]
23. Mercier C, Bourbonnais D, Bilodeau S, Lemay JF, Cross P. Description of a new motor re-education programme for the paretic lower limb aimed at improving the mobility of stroke patients. Clin Rehabil. 1999;13(3):199-206. [ Links ]
24. Sackley CM, Lincoln NB. Physiotherapy treatment for stroke patients: a survey of current practice. Physiother Theory Pract. 1996;12(2):87-96. [ Links ]
25. Davidson I, Waters K. Physiotherapists working with stroke patients: a national survey. Physiotherapy. 2000;86(2):69-80. [ Links ]
26. Pollock A, Baer G, Langhorne P, Pomeroy V. Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke: a systematic review. Clin Rehabil. 2007;21(5):395-410. [ Links ]
27. Schaechter JD. Motor rehabilitation and brain plasticity after hemiparetic stroke. Progr Neurobiol. 2004;73(1):61-72. [ Links ]
28. Liepert J, Miltner WH, Bauder H, Sommer M, Dettmers C, Taub E, et al. Motor cortex plasticity during constraint-induced movement therapy in stroke patients. Neurosci Lett. 1998;250(1):5-8. [ Links ]
29. De Marchis GM, Foderaro G, Jemora J, Zanchi F, Altobianchi A, Biglia E, et al. Mild cognitive impairment in medical inpatients: the Mini-Mental State Examination is a promising screening tool. Dement Geriatr Cogn Disord. 2010;29(3):259-64. [ Links ]
30. Taub E, Miller NE, Novack TA, Cook EW 3rd, Fleming WC, Nepomuceno CS, et al. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil. 1993;74(4):347-54. [ Links ]
31. Taub E, Uswatte G, Pidikiti R. Constraint-Induced Movement Therapy: a new family of techniques with broad application to physical rehabilitation-a clinical review. J Rehabil Res Dev. 1999;36(3):237-51. [ Links ]
32. Hakkennes S, Keating JL. Constraint-induced movement therapy following stroke: a systematic review of randomised controlled trials. Aust J Physiother. 2005;51(4):221-31. [ Links ]
33. Uswatte G, Taub E, Morris D, Vignolo M, McCulloch K. Reliability and validity of the upper-extremity Motor Activity Log-14 for measuring real world arm use. Stroke. 2005;36(11):2493-6. [ Links ]
34. Duncan PW, Lai SM, Bode RK, Perera S, DeRosa J. Stroke Impact Scale-16: A brief assessment of physical function. Neurology. 2003;60(2):291-6. [ Links ]
35. Berg KO, Maki BE, Williams JI, Holliday PJ, Wood-Dauphinee SL. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil. 1992;73(11):1073-80. [ Links ]
36. Fugl-Meyer AR, Jääskö L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7(1):13-31. [ Links ]
37. Duncan P, Richards L, Wallace D, Stoker-Yates J, Pohl P, Luchies C, et al. A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke. Stroke. 1998;29(10):2055-60. [ Links ]
38. Richards CL, Malouin F, Bravo G, Dumas F, Wood-Dauphinee S. The role of technology in task-oriented training in persons with subacute stroke: a randomized controlled trial. Neurorehabil Neural Repair. 2004;18(4):199-211. [ Links ]
39. Blum L, Korner-Bitensky N. Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review. Phys Ther. 2008;88(5):559-66. [ Links ]
40. Berg K, Norman KE. Functional assessment of balance and gait. Clin Geriatr Med. 1996;12(4):705-23. [ Links ]
41. Goldie PA, Matyas TA, Evans OM. Deficit and change in gait velocity during rehabilitation after stroke. Arch Phys Med Rehabil. 1996;77(10):1074-82. [ Links ]
42. Bohannon RW. Gait performance of hemiparetic stroke patients: selected variables. Arch Phys Med Rehabil. 1987;68(11):777-81. [ Links ]
43. Ahmed S, Mayo NE, Higgins J, Salbach NM, Finch L, Wood-Dauphinée SL. The Stroke Rehabilitation Assessment of Movement (STREAM): a comparison with other measures used to evaluate effects of stroke and rehabilitation. Phys Ther. 2003;83(7):617-30. [ Links ]
44. Donker SF, Beek PJ, Wagenaar RC, Mulder T. Coordination between arm and leg movements during locomotion. J Mot Behav. 2001;33(1):86-102. [ Links ]
45. Oberg T, Karsznia A, Oberg K. Basic gait parameters: reference data for normal subjects, 10-79 years of age. J Rehabil Res Dev. 1993;30(2):210-23. [ Links ]
46. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-8. [ Links ]
47. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80(9):896-903. [ Links ]
48. Taub E, Wolf S. Constraint-induced movement techniques to facilitate upper extremity use in stroke patients. Top Stroke Rehabil. 1997;3(4):38-61. [ Links ]
49. Morris DM, Crago JE, DeLuca SC, Pidikiti RD, Taub E. Constraint-induced movement therapy for motor recovery after stroke. Neurorehabilitation. 1997;9(1):29-43. [ Links ]
50. Page SJ, Sisto S, Johnston MV, Levine P. Modified constraint-induced therapy after subacute stroke: a preliminary study. Neurorehabil Neural Repair. 2002;16(3):290-5. [ Links ]
51. Boake C, Noser EA, Ro T, Baraniuk S, Gaber M, Johnson R, et al. Constraint-induced movement therapy during early stroke rehabilitation. Neurorehabil Neural Repair. 2007;21(1):14-24. [ Links ]
52. BrogÅrdh C, Sjölund BH. Constraint-induced movement therapy in patients with stroke: a pilot study on effects of small group training and of extended mitt use. Clin Rehabil. 2006;20(3):218-27. [ Links ]
53. Lum PS, Taub E, Schwandt D, Postman M, Hardin P, Uswatte G. Automated Constraint-Induced Therapy Extension (AutoCITE) for movement deficits after stroke. J Rehabil Res Dev. 2004;41(3A):249-58. [ Links ]
54. Bohannon RW, Larkin PA. Lower extremity weight bearing under various standing conditions in independently ambulatory patients with hemiparesis. Phys Ther. 1985;65(9):1323-5. [ Links ]
55. Taub E, Crago JE, Burgio LD, Groomes TE, Cook EW 3rd, DeLuca SC, et al. An operant approach to rehabilitation medicine: overcoming learned nonuse by shaping. J Exp Anal Behav. 1994;61(2):281-93. [ Links ]
56. Hirschfeld H. Motor control every day motor tasks: guidance for neurological rehabilitation. Physiol Behav. 2007;92(1-2):161-6. [ Links ]
57. Bohannom RW. Muscle strength and muscle training after stroke. J Rehabil Med. 2007;39(1):14-20. [ Links ]
58. Dietz V, Fouad K, Bastiaanse CM. Neuronal coordination of arm leg movements during human locomotion. Euro J Neurosci. 2001;14(11):1906-14. [ Links ]
59. Ford MP, Wagenaar RC, Neweell KM. Arm constraint and walking in healthy adults. Gait Posture. 2007;26(1):135-41. [ Links ]
60. Shumway-Cook A, Anson D, Hailler S. Postural sway biofeedback: its effect on reestablishing stance stability in hemiplegic patients. Arch Phys Med Rehabil. 1988;69(6):395-400. [ Links ]
61. Wagenaar RC, van Emmerik RE. Resonant frequencies of arms and legs identify different walking patterns. J Biomech. 2000;33(7):853-61. [ Links ]
João E. de Araujo,
Laboratório de Neuropsicobiologia e Comportamento Motor, Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor
Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo
Av. dos Bandeirantes, 3900, CEP 14049-900,
Ribeirão Preto, SP, Brasil,