Different Methods of Physical Therapy for Stroke
Condition: Joint Loose Bodies
MeSH terms: Joint Loose Bodies
Study type: Interventional

Summary: 
      It is estimated that worldwide, about 15 million people are affected by vascular accident
      (CVA) per year, and in Brazil, the stroke is a major cause of death and disability,
      generating too much economic and social impact by generating motor sequelae , sensory and
      cognitive arising from blockage or rupture of blood vessels. Among the motor sequelae is the
      hemiparesis, which affects about 80% of cases with consequent impairment of the quality of
      life of individuals. However, physical therapy has shown to facilitate return of the function
      of these individuals, while minimizing the sensorimotor deficits for promoting neuronal
      plasticity through the motor relearning. Among the features of physical therapy are the
      conventional physical therapy techniques, Therapy and Restriction of Movement Induction
      (TRIM) and the Mental Practice. In view of this, the objective of the study is to compare the
      application of conventional physiotherapy protocols and TRIM and / or mental practice on the
      morphometric features, functionality and quality of life of post-stroke hemiparetic subjects
      in the chronic phase. 60 volunteers will be selected, of both sexes, aged between 45 and 80
      years with a clinical diagnosis of stroke, with hemiparesis in the chronic phase were divided
      into four groups (N = 15): control group (CG), TRIM Group (GT), Mental Practice group (GPM)
      and group TRIM + Mental Practice (GTPM) to perform specific exercises for each group for
      three times a week, totaling 24 sessions. Volunteers will be evaluated in four times through
      the Fugl-Meyer Assessment scale (FMA) adapted and Motor Ability Test of the Upper Limb
      (THMMS) and to assess the Quality of Life will be used Quality Scale Specific Life Vascular
      Accident brainstem (EQVE-AVE) and oxidative stress analysis by collecting blood and
      electromyography for muscular activity. After the research data will be tabulated on an Excel
      spreadsheet to perform intergroup and intragroup comparisons between the four evaluation
      times, which will be used for data analysis the BioEstat® 5.2 program, the choice of tests
      for analysis dependent on the statistical distribution types found and the homogeneity of
      their variances.
    

Detailed description: 
      The sample is composed of 60 volunteers of both sexes, with a clinical diagnosis of stroke
      (CVA) with injury over six months time that characterizes the chronic stage of the disease
      and present hemiparesis in upper limb.

      PROCEDURES AND DATA COLLECTION

      The research will be divided into the following steps:

      STAGE 1: The search will begin with an invitation to volunteers to participate in the study,
      through posters and verbal invitation. Then, a pre-selection candidates by applying MMSE will
      be performed, Jaeger card and Whisper test in order to evaluate the existence of cognitive
      impairment, visual and auditory respectively. If they can make up the sample, volunteers will
      be selected as meeting the inclusion and exclusion criteria, and researchers will deliver
      two-way the IC explaining how occur the research objectives of the Office and application of
      the Protocol and deliver two-way also statement of photographs and footage authorization for
      display permit photos and footage. It is noteworthy that both routes of the term and
      Declaration will be signed on every page by volunteers, which will be a copy of each document
      with the same.

      Prior to the procedures and data collection, the researchers will be trained in the
      application of all instruments of evaluation and handling of resources to be used in the
      treatment of volunteers.

      2nd STAGE: Volunteers will be evaluated through the scale application of FMA and THMMS in
      order to analyze the functionality and ability of MS and QOL will be assessed by EQVE-stroke
      as described in materials in this methodology.

      The amplitude of the paretic upper limb movement will also be assessed by goniometry
      scapulohumeral humeral joint, shoulder, elbow, wrist, thumb interphalangeal and where use of
      a universal manual goniometer and another smaller toward the measuring fingers. The first
      measure goniometric be obtained after the patient's arrival in treatment- place in the
      pre-treatment. The following measures will be during treatment (12 ° session) and the
      immediate and late stages after the treatment. To perform such a procedure will be asked to
      volunteers who remain supine on a stretcher, followed by the sitting position in a chair, the
      latter should position the upper limb aligned to the trunk and forearm to be evaluated on a
      small table, a neutral pronation and supination with the elbow held in 90 ° of flexion.

      3rd STAGE: Next muscle electromyographic activity will be measured by electromyography
      apparatus of Miotec ®.

      Volunteers will conduct the test in a well-lit room with adequate ventilation and environment
      without noise, which will be placed in the sitting position with arm supported on fixed
      surface and so will surface electrodes connected on the paretic upper limb having as guidance
      for positioning electrodes muscular motor points previously located by an electrical
      stimulator and coupled with a conductive gel, so as to promote a more stable transitions and
      tendon insertions in order to quantitatively analyze the information sent nerve member.

      The investigators will be asked to volunteer to perform three isometric contractions for four
      seconds each with two intervals between contractions two minutes, and asked each contraction
      the patient to reach its maximum strength. The muscles to be analyzed will be the flexors of
      fingers flexors wrist flexor ulnar elbow flexors, shoulder flexors and internal rotators of
      the shoulder, the answers will be measured and displayed on a computer screen that will be
      BIOPAC ® system.

      4th STAGE: As for the functional range of the MS paretic will be measured by the functional
      reach test, adapted to the sitting position, in which the individual will be sitting without
      armrest in the chair for the upper limb, positioned laterally to the wall, with shoulder 15
      cm away from this without touching it at any time, with feet parallel in a comfortable
      position, keeping the shoulder near the wall flexed to 90 °. A tape measure is fixed parallel
      to the floor, positioned at the height of the acromion. The volunteer will then be instructed
      to lean forward as much as possible; the displacement to be measured on the tape with three
      attempts functional range, then obtaining the average of the three.

      5th STEP: Then, for the collection of handgrip strength in paretic MS will be used hydraulic
      dynamometer handgrip Jamar® where with volunteers in the sitting position in the bed,
      standing with the shoulder in neutral position, elbows and wrist in 90 ° neutral position,
      the therapist will support the dynamometer. Volunteers will be instructed to perform three
      handgrip maneuvers reaching maximum voluntary contraction with each hand, with one-minute
      interval between one operation and another. After the collection will be the simple
      arithmetic average entrees the three measures collected.

      These procedures in the study will take place in four stages: before the start of treatment
      that correspond to the pre-treatment; after the 12th session that correspond to intermediate
      treatment; immediately after the 24th session, which will correspond to the immediate
      post-treatment; and the total intervention time equal to 24 sessions, which will be
      distributed in three weekly sessions held on alternate days (Monday, Wednesday and Friday).
      After evaluating the functionality evaluation of oxidative stress. Initially it will be
      collected blood with a sterile needle through the lancing on the medial side of the digital
      pulp of the fourth finger of the left hand, which will be pre-cleaned with 70% alcohol. The
      collection of blood drop will be made with a razor through five light taps of this blade with
      the drop microscopy. After this, at room temperature (23 ° C), the blade will be kept in
      place protected from contact with the blood of nine minutes for the realization of the
      collected blood clotting process. At the end of this period, the morphology of these clots is
      microscopically observed under a 40X magnification.

      Morphological evaluation of oxidative stress in plasm blood be evaluated according to the
      test known as Optical Microscopy for cell analysis in vitro or HLB test, also known under the
      designation of Dry layer oxidative test, which will be referred to as microscopic morphology
      oxidative stress in plasm (EEW).

      The EEW provides indirect information on to oxidative stress, among others, using the
      following grading system the percentage of the discontinuous area of clot present in
      microscope slide: grade I (normal oxidative stress rate, with total area of discontinuous
      extracellular matrix (ME) less than 10%), grade II (mild stress, with ME discontinuity area
      between 10 to 20%), grade III (moderate stress with ME discontinuity the area between 20
      30%), grade IV (severe stress, with ME discontinuity area between 30 to 40%) and the grade V
      (very severe stress, with the ME discontinuity area above 40%).

      The respective assigned qualitative graduation will be logged into a spreadsheet for further
      analysis statistics. As a measure of standardization, the observation of morphological
      patterns of different clots will be performed by one of the researchers associated with
      assessment by OxyScanner the so-called program developed and marketed by Aldea Global
      Soluciones® (SFA), which give a copy of the software.

      This evaluation will be done in four stages, which will use throughout the process coats,
      disposable gloves and masks, and will be held by only one of the researchers, in order to
      avoid bias in the research.
    

Intervention name(s): THERAPY CONTROL AND MOVEMENT OF INDUCTION
Intervention type(s): Other
Intervention description(s): Volunteers conventional physiotherapy group will stretching, strengthening and / or mobilization and functional training of the affected muscles with 3 sets of 10 repetitions for 60 minutes.
The restriction therapy group and induction motion the volunteers will wear a brace on the top healthy member to be restricted in each session during the exercises for this group for a period of 60 minutes, encouraging tasks involving activities of daily living and / or daily. In group practice mental, the volunteers listen to a CD that in the first two minutes, will promote progressive relaxation where imaginary in a calm and quiet place followed by 13 minutes of listening to the restriction therapy exercise protocol and motion induction. The association group practices and mental restriction therapy, volunteer listens to the CD for 15 minutes following the same procedures mentioned in group practice mental, followed by exercises functional activities for 45 minutes in the paretic limb.
Other intervention name(s): PRACTICING MENTAL THERAPY; CONVENTIONAL PHYSICAL THERAPY
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Investigator)
Primary purpose: Treatment
Keywords: hemiparesis; STROKE; neural plasticity; PHYSICAL THERAPY