FISIOTERAPIA ASSOCIADA À YOGA E MUSICOTERAPIA NA DOENÇA DE PARKINSON: ENSAIO CLÍNICO

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FISIOTERAPIA ASSOCIADA À YOGA E

MUSICOTERAPIA NA DOENÇA DE PARKINSON:

ENSAIO CLÍNICO

PHYSIOTHERAPY ASSOCIATED WITH YOGA AND MUSICOTHERAPY IN

PARKINSON'S DISEASE: CLINICAL TRIAL

Ana Sofia Kauling de Sousa1_{, Karolini Lima Lopes}1_{, Samuel Geraldi Fragnani}1_{, Tatyana Nery}1_{, Emílio Werner}2_{, Poliana Penasso} Bezerra1

RESUMO

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ABSTRACT

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Tabela 1 – Programa de intervenção: yoga e musicoterapia

YOGA

Respiração

Percepção da respiração, em decúbito dorsal ou sentado sobre tatame de EVA, durante a inspiração e expiração, realizada pelo nariz e pela boca. Mãos posicionadas abertas,

palma para cima, em seguida sobre tórax e abdomen. Durante todas as posições, o controle da respiração é

mantido.

Posição da pinça sentada (ﬂexão para

frente) iniciante

Sentado sobre tatame de EVA, membros inferiores estendidos (ou levemente ﬂexionados). Se necessário, uma faixa era utilizada passando por trás dos pés, levar o tronco para frente. As costas permanecem eretas e os ombros

abaixados. Olhar direcionado ao dedão do pé.

Posição sentada em ângulo com uma

perna

Sentado sobre tatame de EVA, um membro inferior estendido e o outro com o joelho ﬂexionado cruzando o pé sobre o membro inferior estendido. O cotovelo empurra contra a parte exterior do joelho contralateral e a mão do outro lado

é colocada no chão, ao lado do corpo. Olhar por cima do ombro.

Posição da meia ponte

Deitado no tatame de EVA, sola do pé e palma da mão mantem contato com o chão, eleva-se o quadril.

Posição gato/vaca

Posição de quatro apoios sobre tatame de EVA, realiza ﬂexão e extensão da coluna lombar, direcionando o olhar para cima

e para baixo.

Posição do bebê

A partir da posição ajoelhada sobre tatame de EVA, o quadril é trazido para baixo até os calcanhares, enquanto os

membros superiores se estendem para a frente no chão.

Posição da montanha

Em pé, coluna reta, com os pés paralelos e dedões dos pés se tocando. Olhar para frente. Inicialmente com membros

superiores ao lado do corpo, progredindo entrelaçando os dedos e alongando os membros superiores para cima. Realizado inicialmente na posição sentada em uma cadeira,

evoluindo para de pé.

Alongamento lateral estendido

Com os membros inferiores afastados, flexionar um deles. O outro pé, de trás, deve estar perpendicular ao da frente. O cotovelo do braço da frente fica apoiado sobre a coxa do mesmo lado. O outro braço se eleva, estirado, em direção ao teto. O peito fica virado para a frente e o olhar voltado para a mão que se eleva. Realizado inicialmente na posição sentada em uma cadeira, enfatizando o movimento do tronco

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Posição do guerreiro iniciante

Membro inferior dianteiro ﬂexionado, pé direcionado para frente. Membro inferior de trás alongado, com o pé perpendicular ao da frente. Corpo virado para frente. Membros superiores elevados e estirados, mãos juntas. Olhar

em direção das mãos. Realizado inicialmente na posição sentada em uma cadeira, enfatizando o movimento do tronco

e membros superiores, evoluindo para de pé.

Posição da Cadeira

Joelhos ﬂexionados no limite dos dedos dos pés, com as coxas as mais paralelas possível do chão. O tronco é movido

à frente com os membros superiores elevados. Realizado inicialmente na posição sentada em uma cadeira, enfatizando o movimento do tronco e membros superiores, evoluindo para

de pé.

Posição de lótus (meditação)

Sentado sobre tatame de EVA, com as costas eretas, coloca-se o pé esquerdo sobre a coxa direita, e vice-versa. Membros superiores estendidos, mãos sobre os joelhos, palmas viradas para o alto. Dedos indicador e polegar juntos, posicionados em “chin mudra” (atitude de sabedoria ou de consciência). Manter a coluna vertebral ereta, esticando-a para cima. Posição do cadáver

(relaxamento profundo)

Deitado sobre tatame de EVA, corpo completamente relaxado, palmas das mãos viradas para o alto. Pés virados para fora.

Olhos fechados.

MUSICOTERAPIA

Exercícios de voz Exercícios de voz associado a movimentos da mímica facial (sorrir, bochechar ar, beijo, face de surpresa, tristeza e raiva)

Canto Cantar um repertório baseado nas preferências do grupo

Ritmo

Realizar movimentos corporais livres e especíﬁcos enquanto cantam uma determinada música, seguindo o ritmo imposto pelo musicoterapeuta. Com a marcha enfatizava-se passos

largos, postura ereta e balanço dos membros superiores.

Tabela 2 – Programa de intervenção: ﬁsioterapia

Alongamento Muscular

Movimentos ativos de alongamento das cadeias musculares anteriores e posteriores de tronco e membros.

Fortalecimento Muscular

Supino em decúbito ventral com as mãos apoiadas sobre uma bola suíça, tronco em 45º, joelhos apoiados no tatame, com

contração isométrica de abdome.

Agachamento até 90º com as costas apoiadas na bola (apoiada na parede) e membros inferiores paralelos alinhados ao quadril, com

contração isométrica de abdome.

Em decúbito ventral com abdome sobre a bola suíça, joelhos apoiados no tatame, realizar adução das escápulas com halteres,

com contração isométrica de abdome. Em decúbito dorsal sobre o tatame, pés apoiados no chão, realizar elevação de quadril com contração isométrica de glúteos

e abdome.

Sentado sobre a bola suíça, elevação frontal de braços até 90º com halteres, com contração isométrica de abdome.

Fortalecimento Muscular

Flexão e dorsiflexão de tornozelo sobre um step, com contração isométrica de abdome, mãos apoiadas no dorso de uma cadeira. Em pé, realizar flexão e extensão de cotovelo com halteres. Em decúbito dorsal, joelhos flexionados, pés apoiados no chão,

realizar ﬂexão abdominal.

Em decúbito dorsal, joelhos flexionados, pés apoiados no chão. Ombros e cotovelos fletidos à 90º. Realizar flexão e extensão de cotovelos segurando um halter com as duas mãos direcionando-o

à testa.

Atividades Funcionais

Exercício de transferência de levantar-se e sentar-se sem a utilização das mãos; exercício enfatizando a rotação de tronco realizado nas posições sentado e em pé com o uso de bolas e

bastões.

Exercícios de passar a bola em roda falando substantivos iniciados com determinadas letras do alfabeto ou o nome da pessoa ao

lado; memorizar e imitar uma atividade doméstica ou animal citada anteriormente pelo idoso posicionado ao lado e acrescentar

mais uma.

Marcha sobre superfície instável (colchonete); passadas laterais com deslocamento para direita e para esquerda; percorrer

circuitos que exigiam a deambulação em linha reta e em curvas, com e sem obstáculos, com tarefa cognitiva e motora (contagens, memorizações, identiﬁcando dias da semana, mês e ano, cantando uma música, retirando objetos de uma sacola e nomeando-os), com pistas visuais e auditivas, em circuitos cada

vez mais complexos.

Exercícios orientados (domicílio)

Exercício ativo-livre: agachamento ou exercício de transferência de levantar-se e sentar-se sem a utilização das mãos; Atividade cognitiva: caça-palavra ou memória ou ligue pontos ou leitura;

Caminhada: livre ou ouvindo música

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Gênero

feminino 4 (33.3%) 8 (66.6%)

masculino 8 (66.6%) 4 (33.3%)

Idade (anos) 62.50±7.68 60.83±6.08 p=0.68; IC95% -7.24 a 10.58

Estadiamento (HY)

escore 1 4 (33.3%) 4 (33.3%)

escore 2 2 (16.6%) 0

escore 3 6 (50%) 8 (66.6%)

Clínica (UPDRS) 36.5±11.51 29.66±12.07 p=0.34; IC95% -8.34 a 22.01

Cognição (MEEM) 26.00±2.19 24.33±2.88 p=0.28; IC95% -1.62 a 4.95

Tabela 3. Dados demográﬁcos dos pacientes com Doença de Parkinson

Nota: HY: Hoehn & Yard; UPDRS: Uniﬁed Parkinson´s Disease Rating Scale; MEEM: Mini-Exame do Estado Mental. Os dados estão dispostos em: média ±desvio padrão e percentual.

(7)

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Tabela 4 – Comportamento dos grupos referente as variáveis cognição, mobilidade e funcionalidade nos momentos inicial e ﬁnal.

GRUPO CONTROLE GRUPO EXPERIMENTAL Grupo Momento Grupo vs

Momento

Momento inicial Momento ﬁnal Momento inicial Momento ﬁnal

Cognição (MEEM) 26.00±2.19 (23.70 a 28.30) 26.00±2.00 (23.90 a 28.10) 24.33±2.88 (21.32 a 27.35) 26.33±1.63 (24.62 a 28.05) p=0.59; ڦ2_ۃ=0.03 p=0.04; ڦ2_ۃ=0.33* p=0.04; ڦ2_ۃ=0.33** Equilíbrio (EEB) 46.67±5.13 (41.29 a 52.05) 51.83±2.14 (49.59 a 54.08) 49.00±2.76 (46.11 a 51.89) 52.50±2.17 (50.22 a 54.78) p=0.40; ڦ2_ۃ=0.07 p=0.00; ڦ2_ۃ=0.747* p=0.321; ڦ2_ۃ=0.098 Mobilidade Funcional (TUG) 14.00±3.79 (10.02 a 17.98) 13.17±2.86 (10.17 a 16.17) 13.00±0.89 (12.06 a 13.94) 8.50±2.26 (6.13 a 10.87) p=0.079; ڦ2_ۃ=0.276 p=0.00; ڦ2_ۃ=0.725* p=0.005; ڦ2_ۃ=0.555** Tarefa motora associada(TUGmot) 15.17±3.60 (11.39 a 18.95) 14.00±3.58 (10.25 a 17.75) 14.67±1.37 (13.23 a 16.10) 11.67±1.37 (10.23 a 13.10) p=0.387; ڦ2_ۃ=0.076 p=0.00; ڦ2_ۃ=0.98* p=0.00; ڦ2_ۃ=0.924** Tarefa cognitiva associada(TUGcog) 20.83±8.21 (12.22 a 29.45) 28.00±21.93 (4.99 a 51.01) 17.27±5.28 (11.73 a 22.8) 11.50±2.35 (9.04 a 13.96) p=0.081; ڦ2_ۃ=0.273 p=0.884; ڦ2_ۃ=0.002 p=0.195; ڦ2_ۃ=0.162 Independência funcional (PAS) 35.67±9.93 (25.24 a 46.09) 36.50±9.57 (26.46 a 46.54) 34.67±10.60 (23.55 a 45.79) 39.17±6.08 (32.79 a 45.55) p=0.876; ڦ2_ۃ=0.003 p=0.02; ڦ2_ۃ=0.415* p=0.097; ڦ2_ۃ=0.251

Nota: MEEM: Mini-Exame do Estado Mental; EEFB: Escala de Equilíbrio Funcional de Berg; TUG: Timed Up and Go; TUGmot: Timed Up and Go associado à tarefa motora; TUGcog: Timed Up and Go associado à tarefa cognitiva; PAS: escala de atividade de Parkinson. * Efeito significativo em relação ao momento **Interação significativa “grupo” vs “momento” frente à ANOVA two-way (medidas repetidas). Os dados estão dispostos em: média ±desvio padrão (intervalo de confiança de

(8)

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