A Escala Modificada de Ashworth consiste no padrão outro de avaliação de tônus muscular, possuindo boa confiabilidade inter e intra-avaliadores(63). Ela consiste em uma escala de 6 pontos que avalia a resistência ao movimento passivo, nos quais escores mais altos correspondem a espasticidade ou aumento do tônus, enquanto escores mais baixos indicam tônus muscular normal(64).
Estudos utilizando a TE associada a outras técnicas (estimulação
elétrica funcional, reabilitação convencional) apresentaram melhorias
significativamente maiores nas funções motoras e espasticidade do MS distal do que proximal, comparada aos grupos controle(32, 65, 66).
2.5 Terapia do Espelho
A TE é uma das técnicas de reabilitação potencialmente benéficas para a recuperação sensório-motora do MS de pacientes após AVC e é baseada na teoria da plasticidade cerebral e reorganização funcional cortical(12, 21, 67, 68). A TE foi primeiramente introduzida por Ramachandran, em 1996, para tratar a
dor no membro fantasma após a amputação(15), e este estudo tornou-se a base
para futuras pesquisas sobre a neuroplasticidade do SNC. Desde então, a TE vem sendo aplicada para o tratamento do AVC, lesões do sistema nervoso periférico, distrofia simpático reflexa e desordens de coordenação motora(7, 12, 65).
Somente no final da década de 1990, Altschuler et al. (1999)(14)
introduziram a TE na reabilitação de pacientes hemiparéticos após AVC, apresentando melhorias na amplitude de movimento, velocidade, destreza,
força muscular e recuperação funcional do braço parético(69). A partir de então,
a TE tem sido utilizada para melhorar a função do MS, principalmente em
indivíduos após AVC crônico(7). A maioria das pesquisas mostram a eficácia da
TE na melhora da função do MS(68), entretanto, se essa melhora é devido a TE
ou apenas a sua associação com outras abordagens terapêuticas, ainda não é claro, já que a maioria dos estudos associam a TE com outras modalidades terapêuticas(5).
A TE é aplicada por meio de um espelho que é posicionado entre os MSs do indivíduo de modo sagital. Com a intenção de reeducar o cérebro e
20 promover uma ilusão visual e sinestésica, o indivíduo realiza uma série de movimentos com o membro saudável que são refletidos pelo espelho e
interpretados como se fossem realizados pelo membro afetado(15). Assim,
cria-se uma ilusão convincente de que os movimentos do braço afetado atrás do
espelho parecem ser feitos de forma tão eficaz quanto o braço não afetado(70).
Esta ilusão visual pode ser utilizada para melhorar o desempenho motor e a percepção do membro afetado(19, 68).
Sugere-se que os efeitos da TE podem estar relacionados à ativação de neurônios espelho, os quais são ativados quando um indivíduo observa outro realizando movimentos, e durante a prática mental de tarefas motoras(17), (19). Neurônios espelho são células nervosas com propriedades visual-motoras, que
foram descobertas na área F5 do cérebro do macaco(71, 72). Esse tipo específico
de neurônios, também presente no cérebro humano, são ativados quando uma ação está em andamento ou quando a ação é observada, sendo realizada por outros(73).
Embora pesquisas clínicas indiquem a eficácia da TE, as alterações neurais subjacentes associadas à ela ainda são pouco compreendidas. Pesquisas sugerem que o feedback do espelho modifica o funcionamento do córtex motor primário do hemisfério que controla o braço atrás do espelho
(hemisfério lesionado)(74). Após a TE, há um declínio na ativação do hemisfério
contralesional e movimentos de equilíbrio de ativação em direção ao hemisfério
lesionado(5). Assim, a TE induz uma reorganização das áreas pré-motoras
bilaterais para estabelecer comunicação funcional com o córtex motor primário contralateral; há uma comunicação calosa aumentada do hemisfério lesionado para o sadio, equilibrando a inibição inter-hemisférica; o cerebelo também pode demonstrar ativação para melhorar o controle motor e a aprendizagem motora(18).
Uma interconexão funcional, essencial para o movimento do membro parético, também é estabelecida entre o córtex somatossensorial e motor
ipsilesional após sessão única de TE(37). Além disso, é observada uma
excitabilidade aumentada das vias corticoespinhais correspondentes ao lado do corpo afetado, há uma ativação da área motora primária, córtex somatossensorial primário, área motora suplementar e área pré-motora do
21 Em um estudo de magnetoencefalografia, a presença do espelho mudou o padrão de ativação inicialmente assimétrico em pacientes com AVC para um padrão mais simétrico, indicando que a assimetria de ativação entre os
hemisférios cerebrais pode ser normalizada pela TE(20). Além das áreas
motoras, a TE também estimula áreas como o córtex pré-frontal dorsolateral relacionado à cognição, aumenta a atividade no córtex precuneus e cingulado posterior, áreas associadas à consciência corporal e atenção espacial(67).
A maioria dos estudos sobre TE relatam o seu efeito (associado a outras modalidades terapêuticas) através de movimentos simétricos bilaterais, estimulando os pacientes verbalmente para que movam ambos os braços, da maneira que for possível(7, 14, 21, 61, 65, 68). Já, outros autores testaram diferentes condições de treinamento (unilateral ou bilateral, com ou sem espelho) a fim de investigar os efeitos de curto prazo durante a tarefa de alcance e não observaram diferenças em relação ao tempo de movimento entre as condições
bimanuais com ou sem espelho(24). De outra maneira, Rodrigues et al.
(2016)(75) observou melhora significativa na comparação do desempenho pré e
pós-treinamento apenas para tarefas bilaterais.
O valor agregado da TE é que o espelho substitui o feedback sobre o movimento do lado afetado por um feedback visual que cria a ilusão de que o lado parético se move com um padrão de movimento normal. No entanto, a partir do número relativamente pequeno de estudos e a falta de comparação direta, devido aos diferentes tipos de treinamento da TE, a forma de treinamento ideal ainda não está clara(24).
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28 4 ARTIGO
ACUTE EFFECT OF MIRROR THERAPY ON MOTOR CONTROL, MANUAL DEXTERITY AND SPASTICITY OF PARETIC UPPER EXTREMITY AFTER
CHRONIC STROKE
(Este artigo será submetido ao periódico Clinical Rehabilitation)
Ariane Bôlla Freire1, Elren Passos Monteiro2, Chen Chai Ling3, Rochelle Rocha Costa4, Caren Luciane Bernardi5
1Rehabilitation Sciences Graduate Program, Universidade Federal de Ciências
da Saúde de Porto Alegre (UFCSPA), Brazil
2,4Health Sciences Graduate Program, Universidade Federal de Ciências da
Saúde de Porto Alegre (UFCSPA), Brazil.
3Undergraduate in Physiotherapy course, Universidade Federal de Ciências da
Saúde de Porto Alegre (UFCSPA), Brazil
4School of Physical Education, Universidade Federal do Rio Grande do Sul, Brazil
5Departmentof Physiotherapy, Universidade Federal de Ciências da Saúde de
Porto Alegre (UFCSPA), Brazil.
Correspondent Author: Ariane Bôlla Freire, PT, MSc
Programa de Pós-Graduação em Ciências da Reabilitação
Universidade Federal de Ciências da Saúde de Porto Alegre – UFCSPA 245 Sarmento Leite Street - Porto Alegre, RS, Brazil - Zip code: 90050-170 Phone: +55-55-991731191
29 ABSTRACT
Objective: To investigate the acute effect of mirror therapy (MT) on motor control, manual dexterity and spasticity of the paretic upper extremity (UE) of individuals with chronic hemiparesis after stroke, during reaching task.
Design: Randomized cross-over single-blinded trial.
Subjects: Thirty-three patients post chronic stroke completed the study.
Intervention: Patients who first participated in the MT intervention performed a single session of MT, whereas in the control intervention a single session composed of the same exercises was performed, but without the mirror. After a month washout, the patients switched groups.
Main measure: The primary outcome measure was motor control. The secondary outcome measure was manual dexterity and UE spasticity.
Results: Among the kinematic outcomes, only the movement cycle time (MCT) presented statistical significance in both groups after interventions (ES=0.53; p<0.006). The manual dexterity (ES=0.03; p<0.016), spasticity of elbow flexors (ES=0.29; p<0.000), wrist flexors (ES=0.54; p<0.001) and horizontal shoulder adductor (ES=0.68; p<0.011) also improved after both interventions. Only the spasticity of wrist flexors demonstrated a difference between the interventions (p<0.046), suggesting that the magnitude of the spasticity reduction observed after MT was higher than that observed after the control intervention. Conclusions: These results demonstrate an effective improvement in MCT, manual dexterity and spasticity of paretic UE after both interventions, however, comparisons between groups did not reveal significant differences except for spasticity of the wrist flexors. Thus, this study indicates that isolated MT was no more effective than training of both UE in post chronic stroke subjects.
30 INTRODUCTION
Stroke is a leading global cause of incapacity(1).Although complex motor,
sensory and cognitive dysfunctions contribute in various proportions to the global disability, motor impairment is often the most striking deficit(1). Up to approximately 85% of stroke survivors experience paresis of the upper
extremity (UE) after the stroke(2). Patients with hemiparesis generally
demonstrate abnormal motor patterns in terms of muscle tone, coordination, disrupted joint recruitment and deficits in endpoint control, which is characterized by smaller movement amplitude, prolonged movement times and segmented movement trajectories, considerably reducing motor function of the affected limb(3).
An accurate and precise measurement of UE performance is essential for rehabilitation(4). Kinematic measures can better clarify the motor control strategies underlying the motor improvements of stroke patients(5), including movement trajectories (endpoint control), joint recruitment and inner joint coordination, variables frequently used to characterize the deficit, recovery and treatment effects of motor control strategies during reaching(6). Reaching has