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Locomotor Training with Partial Body Weight Support in Spinal Cord Injury Rehabilitation: Literature Review

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Locomotor Training with Partial Body Weight Support in Spinal Cord Injury Rehabilitation: Literature Review doi: ISSN 0103-5150 Fisioter. Mov., Curitiba, v. 26, n. 4, p.página 907-920, set./dez. 2013 Licenciado sob uma Licença Creative Commons [T] Treino locomotor com suporte parcial de peso corporal na reabilitação da lesão medular: revisão da literatura [I] Locomotor training with partial body weight support in spinal cord injury rehabilitation: literature review [A] Cristina Maria Rocha Dutra[a], Cynthia Maria Rocha Dutra[b], Auristela Duarte de Lima Moser[c], Elisangela Ferretti Manffra[c] [a] Mestranda do Programa de Pós-Graduação em Tecnologia em Saúde da Pontiícia Universidade Católica do Paraná (PUCPR), Curitiba, PR - Brasil, e-mail: [email protected] [b] Professora mestre da Universidade Tuiuti do PR - Curitiba, Paraná, Brasil, e-mail: [email protected] [c] Professoras doutoras do Programa de Pós-Graduação em Tecnologia em Saúde da Pontiícia Universidade Católica do Paraná, Curitiba, P - Brasil, e-mails: [email protected], [email protected] [R] Resumo Introdução: O treino locomotor com suporte de peso corporal (TLSP) é utilizado há aproximadamente 20 anos no campo da reabilitação em pacientes que sofrem de patologias neurológicas. O TLSP favorece melhoras osteomusculares, cardiovasculares e psicológicas, pois desenvolve ao máximo o potencial residual do orga- nismo, proporcionando a reintegração na convivência familiar, proissional e social. Objetivo: Identiicar as principais modalidades de TLSP e seus parâmetros de avaliação com a inalidade de contribuir com o esta- belecimento de evidências coniáveis para as práticas reabilitativas de pessoas com lesão medular. Materiais e métodos: Foram analisados artigos originais, publicados entre 2000 e 2011, que envolvessem treino de marcha após a lesão medular, com ou sem suporte parcial de peso corporal, e tecnologias na assistência do treino, como biofeedback e estimulação elétrica funcional, entre outras. Resultados: A maioria dos participan- tes dos estudos era do sexo masculino; os níveis de lesão variavam de C3 a L3; ASIA teve pontuações de A a D; os tempos de lesão variaram entre 0,3 meses a 33 anos. Também se veriicou que não há consenso em relação ao protocolo de TLSP. Conclusão: O treino locomotor com suporte de peso corporal mostra-se viável na reabi- litação de pacientes que sofrem de uma patologia neurológica como a lesão medular. Independentemente do Fisioter Mov. 2013 set/dez;26(4):página 907-20 Dutra CMR, Dutra CMR, Moser ADL, Manffra EF 908 protocolo de treino utilizado, os beneícios referentes ao aumento da força muscular, manutenção ou aumento da densidade óssea, diminuição da frequência cardíaca e aumento do condicionamento ísico estão presentes [P] Palavras-chave: Suporte de carga. Marcha. Lesão medular. [B] Abstract Introduction: The locomotor training with bodyweight support (LTBWS) has been used for approximately twenty years in the field of rehabilitation in patients who suffer from neurological pathologies. The LTBWS favors these improvements muscle, cardiovascular and osteo-psychological, because maximum residual potential develops the body, providing reintegration into the familial, social and professional. Objective: Identify the main methods of as- sessment and their parameters LTBWS with the purpose of contributing to the establishment of reliable evidence for the rehabilitation practice of people with spinal cord. Materials and methods: Original articles were analyzed, published between 2000 and 2011, involving gait training after spinal cord, with or without partial body weight sup- port, and training assistance technologies such as functional electrical stimulation and biofeedback among others. Results: The majority of the participants of the studies was male; injury levels ranged from C3 to L3, ASIA had scores from A to D; injury times ranged from 0.3 months 33 years. Also it was noted that there is no consensus regarding LTBWS Protocol. Conclusion: The locomotor training with bodyweight support shows up, viable in the rehabilita- tion of patients who suffer from a neurological pathology such as the spinal cord, regardless of training protocol used the benefits relating to increases in muscular strength, maintaining or increasing bone density, decreased heart rate, increase in physical conditioning are present. [K] Keywords: Weight-bearing. Gait. Spinal cord injury. Introdução O GCP é responsável por produzir o padrão cíclico da marcha mesmo após a LM, pois se encontra na me- O treino locomotor com suporte de peso corporal dula espinal (6, 7). A ativação do GCP durante o trei- (TLSP) tem sido proposto como uma alternativa para namento na esteira poderia favorecer os processos a reabilitação de pessoas com lesão medular (LM), de plasticidade neural, regulando a interação entre com o intuito de desenvolver ao máximo o potencial o GCP e a atividade relexa periférica. O treino esti- residual do organismo e auxiliar a reintegração na mula a atividade neuronal e ativa os centros espinais convivência familiar, proissional e social. de controle da locomoção. Dessa forma, as repostas Os trabalhos iniciais de TLSP foram de Lois Finch e sinápticas e celulares dos circuitos de controle do Hugues Barbeau (1), sendo o pesquisador canadense GCP poderiam ser mais lexíveis ou moduladas de Hugues Barbeau (2) o pioneiro no uso de TLSP. A fun- forma mais adequada na esteira do que no solo (8). damentação teórica para o desenvolvimento do TLSP O TLSP em pacientes com lesão medular incom- advém dos trabalhos que estudaram a recuperação pleta pode ser um importante aliado na reabilitação da locomoção em gatos com LM (2, 3). Gatos adultos motora, principalmente por meio da plasticidade com LM completa, incapazes de movimentar suas neural (9), o que proporciona o aprendizado de um patas traseiras logo após a lesão, quando colocados novo padrão de marcha. Esse aprendizado depende na esteira e estimulados a andar com o suporte de de inputs sensoriais especíicos, associados com o peso, conseguiram dar passos com suas patas trasei- desempenho de uma tarefa motora e a prática repe- ras após sete meses de TLSP. titiva dessa tarefa (10). Uma possível explicação neuroisiológica para es- O aprendizado motor traz melhoras da biomecânica sas respostas motoras seria que o movimento contí- dos Membros inferiores (MMII), como pelve e tornoze- nuo da esteira e a repetição das passadas poderiam lo, por meio do aumento da amplitude de movimento estimular os circuitos neurais de controle da loco- das articulações envolvidas e na força dos MMII, garan- moção, que compõem o chamado gerador central de tindo mais estabilidade durante a marcha (11). Essas padrões (GCP) de nível medular (4, 5). mudanças periféricas contribuem com a melhora do Fisioter Mov. 2013 set/dez;26(4):página 907-20 Treino locomotor com suporte parcial de peso corporal na reabilitação da lesão medular 909 controle motor, que se relete no aumento da velocidade principais modalidades de TLSP e seus parâmetros de (12) e da independência da marcha (13). avaliação, com a inalidade de contribuir com o esta- Além dos ganhos motores, muitos estudos apon- belecimento de evidências coniáveis para as práticas tam para o potencial do TLSP em proporcionar ganho reabilitativas de pessoas com lesão medular. de capacidade aeróbica (14), redução do risco de do- enças cardiovasculares (15), melhora da autoimagem, autoestima, satisfação com a vida (16) e manutenção Materiais e métodos da densidade mineral óssea pelo efeito mecânico a partir da contração muscular (17-19), o que contribui A busca de informações foi realizada nas bases para o aumento da força nos MMII (20). Destaca-se, Wiley Online Library, ScienceDirect, SciELO, BioMed ainda, a manutenção e o aumento da resistência para Central, MEDLINE, LILACS e Google Acadêmico. Os a prática de atividade ísica (21). Foi observado que o idiomas selecionados foram português e inglês e as uso regular do TLSP proporciona beneícios à condi- palavras-chave utilizadas foram: body weight-suppor- ção cardiovascular, tanto central (coração) (22) como ted, treadmill training, spinal cord injury, gait training, na temperatura periférica (vasos) (23), reduzindo robotic-assisted — treino locomotor, suporte parcial fatores de risco para doenças cardiovasculares (20) de peso, lesão medular, treino de marcha e terapia e aumentando a regulação da FC e da PA (21, 24), robótica assistida. bem como na qualidade e ganho de independência Foram revisados somente artigos originais que funcional (25). O TLSP em pacientes com lesão me- envolvessem treino de marcha após a lesão medular, dular incompleta é fundamental para a recuperação com ou sem suporte parcial de peso corporal, e tec- ísica, principalmente por meio da plasticidade neural nologias na assistência do treino, como biofeedback (9) e com o uso de células-tronco (26). e estimulação elétrica funcional, entre outras. Apesar da aplicação do TLSP na reabilitação da LM Foram descartados os trabalhos que visassem trei- ter sido proposta e estudada há mais de 20 anos, ainda no locomotor em patologias não decorrentes de lesão não se tem um consenso sobre os parâmetros da sua medular e artigos que não explicitassem a modalida- aplicação e sobre todos os efeitos que ele pode pro- de de avaliação. A janela de tempo pesquisada foi de duzir. Isso porque existem diferenças metodológicas 2000 a 2011. Após a realização da busca nas bases de na aplicação do treino e nas análises realizadas. Por dados foram lidos os abstracts e eliminadas as dupli- exemplo, os movimentos passivos necessários ao TLSP cações. Dos trabalhos selecionados, foram extraídas podem ser realizados por um técnico ou roboticamente informações a respeito dos seguintes tópicos: treino assistidos por uma órtese robótica (27). O TLSP poder locomotor com suporte parcial de peso corporal, treino ser associado a técnicas como a realidade virtual ou a de marcha, eletromiograia e lesão medular. estimulação elétrica funcional (2, 28). Os protocolos utilizam diferentes velocidades, faixas de descarga de peso e durações, como velocidade de 2.7 km/h, 80% Resultados de descarga de peso corporal, duração do treino de 10 minutos (25) ou velocidade de 0.6 km/h, 60% de des- A síntese elaborada baseou-se em 43 referências carga de peso e 60 minutos de duração de treino (23).
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