Efeitos da adição da restrição de tronco à terapia por contensão induzida modificada em ambiente domiciliar: um ensaio clínico aleatorizado

Abstract

People with hemiparesis excessively use trunk compensatory movements to perform the movements of reaching and grasping with their paretic upper limb (UL). Trunk restraint associated with constraint-induced movement therapy (CIMT) could improve the UL kinematics. This randomized clinical trial tested the hypothesis that home-based modified CIMT, plus trunk restraints were superior to modified CMIT alone in improving function, strength, kinematics, and quality of life with chronic stroke subjects. In addition, the influences of previous UL dominance on the results were also investigated. The subjects were randomly assigned into experimental (EG) or control (CG) groups. To observe the influences of previous UL dominance, the participants were further divided into a dominant group (paretic UL was previously the dominant) and a non-dominant group (paretic UL was not previously the dominant). The EG undertook three hours/day of CIMT plus trunk restraints to prevent trunk displacements, five days/week over two weeks, while the controls only undertook the same doses of CIMT. At baseline, immediately after the interventions, and four and 12 weeks after the cessation of the interventions, outcome measures were collected by researchers blinded to group allocations. The interventions were delivered in the individuals homes by trained physical therapists and the protocol included shaping, task practice, and the transfer packages. Outcomes included measures of UL function and dexterity during unimanual activities (Motor Activity Log - MAL-Brazil, and Wolf Motor Function Test - WMFT-Brazil) and bilateral activities (Bilateral Activity Assessment Scale - BAAS); strength; reaching kinematics; and quality of life. Statistical analyses were carried out by an independent investigator. Intention-to-treat analyses were employed. Twenty-two subjects participated with a mean age of 59.2±8.6 years and a mean time since the onset of the stroke of 80.8±49.1 months. They had moderate impairments, as determined by mean Fugl Meyer scores of 47.7±8.0. Repeated measure ANOVAS revealed no interaction effects for any of the outcome measures. However, main effects of the interventions were observed for the MAL amount of use and quality of movement, and the BAAS. These gains were maintained during both follow-ups. When previous UL dominance was considered, the maintenance of the gains regarding the MAL scores was observed only for the dominant group. The findings showed that the addition of trunk restraint did not result in further benefits. Improvements in the paretic UL performance were reported, which are important parameters to be considered during rehabilitation. In addition, carry-over effects of the unilateral gains to bilateral tasks were observed. The dominance prior to stroke positively interfered the maintenance of the unimanual gains. The findings that the group who had their non-dominant UL affected returned to the use of their dominant non-paretic UL during daily activities, suggested that close follow-ups are necessary for these individuals to avoid unwanted tissue adaptations and disuse of their paretic UL. The absence of kinematic changes reinforces that CIMT has the potential to promote functional gains without reinforcing compensatory movement patterns.