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Objective: To investigate whether a higher number of transcranial direct current stimulation (tDCS) sessions results in a greater improvement in upper limb function in chronic post-stroke patients. Materials and methods: A randomized, sham-controlled, double-blind clinical trial was conducted in 57 chronic post-stroke patients (≥ 3 months after their injuries). The patients were allocated to receive sessions of tDCS combined with physiotherapy and divided into three groups (anodal, cathodal, and sham). The Fugl-Meyer Assessment of Upper Extremity (FMA-UE) was used to assess the sensorimotor impairment of the patients’ upper limbs before (baseline) and after five and ten sessions. The percentage of patients who achieved a clinically significant improvement (> five points on the FMA-UE) was also analyzed. Results: The FMA-UE score increased after five and ten sessions in both the anodal and cathodal tDCS groups, respectively, compared to the baseline. However, in the sham group, the FMA-UE score increased only after ten sessions. When compared to the sham group, the mean difference from the baseline after five sessions was higher in the anodal tDCS group. The percentage of individuals who achieved greater clinical improvement was higher in the stimulation groups than in the sham group and after ten sessions when compared to five sessions. Conclusions: Our results suggest that five tDCS sessions are sufficient to augment the effect of standard physiotherapy on upper limb function recovery in chronic post-stroke patients, and ten sessions resulted in greater gains.

The ratio between slower and faster frequencies of brain activity may change after stroke. However, few studies have used quantitative electroencephalography (qEEG) index of ratios between slower and faster frequencies such as the delta/alpha ratio (DAR) and the power ratio index (PRI; delta + theta / alpha + beta ) for investigating the difference between the affected and unaffected hemisphere poststroke. Here, we proposed a new perspective for analyzing DAR and PRI within each hemisphere and investigated the motor impairment-related interhemispheric frequency oscillations. Forty-seven poststroke subjects and twelve healthy controls were included in the study. Severity of upper limb motor impairment was classified according to the Fugl–Meyer assessment in mild/moderate ( n = 25 ) and severe ( n = 22 ). The qEEG indexes (PRI and DAR) were computed for each hemisphere (intrahemispheric index) and for both hemispheres (cerebral index). Considering the cerebral index (DAR and PRI), our results showed a slowing in brain activity in poststroke patients when compared to healthy controls. Only the intrahemispheric PRI index was able to find significant interhemispheric differences of frequency oscillations. Despite being unable to detect interhemispheric differences, the DAR index seems to be more sensitive to detect motor impairment-related frequency oscillations. The intrahemispheric PRI index may provide insights into therapeutic approaches for interhemispheric asymmetry after stroke.

Transcranial direct current stimulation (tDCS) can enhance the effect of conventional therapies in post-stroke neurorehabilitation. The ability to predict an individual’s potential for tDCS-induced recovery may permit rehabilitation providers to make rational decisions about who will be a good candidate for tDCS therapy. We investigated the clinical and biological characteristics which might predict tDCS plus physical therapy effects on upper limb motor recovery in chronic stroke patients. A cohort of 80 chronic stroke individuals underwent ten to fifteen sessions of tDCS plus physical therapy. The sensorimotor function of the upper limb was assessed by means of the upper extremity section of the Fugl-Meyer scale (UE-FM), before and after treatment. A backward stepwise regression was used to assess the effect of age, sex, time since stroke, brain lesion side, and basal level of motor function on UE-FM improvement after treatment. Following the intervention, UE-FM significantly improved ( p < 0.05 ), and the magnitude of the change was clinically important (mean 6.2 points, 95% CI: 5.2–7.4). The baseline level of UE-FM was the only significant predictor ( R 2 = 0.90 , F 1 , 76 = 682.80 , p < 0.001 ) of tDCS response. These findings may help to guide clinical decisions according to the profile of each patient. Future studies should investigate whether stroke severity affects the effectiveness of tDCS combined with physical therapy.

Introduction: The recovery of stroke patients is long and boring due to the repetitive nature of the exercises used and the length of treatment. Thus, we started using virtual reality as an alternative and, because of its advantages, health professionals are adapting video games for physical therapy. However, there are some limitations, such as the fact that games are designed for entertainment and not for therapeutic purposes. Objective: In order to mitigate gaps in assistive devices for physical therapy, this study describes the development and applicability of a computer support system for motor rehabilitation - Ikapp - in stroke victims. Methods: Twenty-seven stroke patients filled out a socioeconomic questionnaire, tested Ikapp during five minutes and answered a usability and satisfaction questionnaire about handling the tool. The chi-square test was used to analyze any association between sociodemographic factors and the features of the system. Results: The Ikapp system can be an excellent device to assist neurological rehabilitation of stroke patients, as participants questionnaires showed that 85.2% were satisfied in regard to motivation and inclusion of Ikapp in physiotherapy and 77.8% relative to ease of interaction with the tool. Conclusion: The Ikapp system proved to be an easy-to-use and accessible computer support system for patients with functional limitations. Resumo Introdução: A recuperação de indivíduos pós-Acidente Vascular Encefálico (AVE) tem se mostrado longa e monótona devido ao caráter repetitivo dos exercícios utilizados na clínica e aos anos de tratamento. Logo, tem-se utilizado a Realidade Virtual (RV) como uma alternativa e diante de suas vantagens, profissionais de saúde vêm adaptando vídeo games à fisioterapia. No entanto, existem algumas limitações, como a do fato de estes vídeo games terem sido desenvolvidos para diversão e não serem apropriados para uso terapêutico. Objetivo: Em busca de atenuar lacunas existentes em dispositivos adaptados à fisioterapia, este estudo descreve o desenvolvimento e a aplicabilidade de um sistema computacional de suporte a reabilitação motora - Ikapp - em pacientes pós-AVE. Métodos: 27 pacientes pós-AVE preencheram um questionário socioeconômico, testaram o Ikapp durante 5 min e responderam a um questionário de usabilidade e satisfação sobre o manuseio da ferramenta. Para analisar a associação de fatores sociodemográficos com funcionalidades do sistema, o teste qui quadrado (Exato de Fisher) foi utilizado. Resultados: O Ikapp pode ser uma excelente ferramenta de auxílio à reabilitação neurológica de pacientes pós-AVE, visto que seus testes evidenciaram 85,2% de satisfação no que diz respeito à motivação e inclusão no processo fisioterápico e 77,8% em relação à facilidade de interação com a ferramenta. Conclusão: O Ikapp mostrou ser um sistema computacional de fácil aplicação e acessível a pacientes com diferentes limitações funcionais.

Background and Objective Interactive systems for rehabilitation have been widely investigated for motivational purposes. However, more attention should be given to the manner in which user movements are recognized and categorized. This paper aims to evaluate the efficacy of using a clinically-related gesture recognition tool, based on the international biomechanical standards (ISB) for the reporting of human joint motion, for the development of an interactive augmented reality (AR) rehabilitation system —mirrARbilitation. Methods This work presents an AR rehabilitation system based on ISB standards, which enables the system to interact and to be configured according to therapeutic needs. The KinectTM skeleton tracking technology was exploited and a new movement recognition method was developed to recognize and classify biomechanical movements. Further, our mirrARbilitation system provides exercise instructions while simultaneously motivating the patient. The system was evaluated on a cohort of 33 patients, physiotherapists, and software developers when performing shoulder abduction therapy exercises. Tests were performed in three moments: (i) users performed the exercise until they feel tired without the help of the system, (ii) the same however using the mirrARbilitation for motivation and guidance, and (iii) users performed the exercise again without the system. Users performing the movement without the help of the system worked as baseline reference. Results We demonstrated that the percentage of correct exercises, measured by the movement analysis method we developed, improved from 69.02% to 93.73% when users interacted with the mirrARbilitation. The number of exercise repetitions also improved from 34.06 to 66.09 signifying that our system increased motivation of the users. The system also prevented the users from performing the exercises in a completely wrong manner. Finally, with the help of our system the users' worst result was performing 73.68% of the rehabilitation movements correctly. Besides the engagement, these results suggest that the use of biomechanical standards to recognize movements is valuable in guiding users during rehabilitation exercises. Conclusion The proposed system proved to be efficient by improving the user engagement and exercise performance outcomes. The results also suggest that the use of biomechanical standards to recognize movements is valuable in guiding users during rehabilitation exercises.

To compare the interhemispheric asymmetry of the motor cortex excitability of chronic stroke patients with healthy and to observe if the magnitude of this asymmetry is associated to sensory-motor impairment and stroke chronicity. This cross-sectional study was performed with chronic stroke and aged and sex-matched healthy individuals. The interhemispheric asymmetry index was calculated by the difference of rest motor threshold (rMT) of the brain hemispheres. The rMT was assessed by transcranial magnetic stimulation over the cortical representation of the first dorsal interosseous muscle. To investigate the relationship of the asymmetry with sensory-motor impairment and injury chronicity, the stroke patients were grouped according to the level of sensory-motor impairment (mild/moderate, moderate/severe, and severe) and different chronicity stages (> 3–12, 13–24, 25–60, and > 60 months since stroke). Fifty-six chronic stroke and twenty-six healthy were included. We found higher interhemispheric asymmetry in stroke patients (mean, 27.1 ± 20.9) compared to healthy (mean, 4.9 ± 4.7). The asymmetry was higher in patients with moderate/severe (mean, 35.4 ± 20.4) and severe (mean, 32.9 ± 22.7) impairment. No difference was found between patients with mild/moderate impairment (mean, 15.5 ± 12.5) and healthy. There were no differences of the interhemispheric asymmetry between patients with different times since stroke (> 3–12, mean, 32 ± 18.1; > 13–24, mean, 20.7 ± 16.2; > 25–60, mean, 29.6 ± 18.1; > 60 months, mean, 25.9 ± 17.5). Stroke patients showed higher interhemispheric asymmetry of the motor cortex excitability when compared to healthy, and the magnitude of this asymmetry seems to be correlated with the severity of sensory-motor impairment, but not with stroke chronicity. Higher interhemispheric asymmetry was found in stroke patients with greatest sensory-motor impairment.

CAPES A estimulação transcraniana por corrente contínua (tDCS, do inglês transcranial direct current stimulation) é uma ferramenta de neuromodulação com efeitos benéficos na recuperação motora do membro superior parético de pacientes pós acidente vascular encefálico (AVE). Apesar da evidência referente aos efeitos positivos da tDCS para recuperação neurofuncional de pacientes pós AVE, a variabilidade individual ao tratamento limita sua implementação na prática clínica. A presente tese apresenta dois artigos originais realizados a fim de auxiliar na compreensão da variabilidade da resposta terapêutica à tDCS em pacientes pós-AVE e assim guiar a tomada de decisão clínica. O estudo 1 se propôs se características clínicas e biológicas podem predizer os efeitos da tDCS na recuperação motora do membro superior parético de pacientes pós AVE. Por meio de uma análise de regressão que incluiu diferentes fatores que poderiam influenciar na resposta a tDCS. Este estudo demonstrou que apenas o comprometimento motor (mensurado pela escala de Fugl Meyer - EFM) foi um fator preditivo. Nesse contexto, esse achado pode guiar a decisão clínica de acordo com o perfil de cada paciente. O segundo estudo foi um ensaio clínico randomizado, sham controlado e duplo-cego realizado com pacientes pós-AVE, cujo objetivo foi investigar se o grau de recuperação sensória motora do membro superior parético de pacientes pós AVE diferentes níveis de comprometimento motor é dependente do protocolo de tDCS. Cinquenta e sete pacientes foram alocados em dois estratos de acordo com nível de comprometimento motor avaliado pela EFM: estrado leve a moderado (EFM> 19) e estrato grave (EFM19) and severe category (FMA

The aim of this study is to investigate the effects of transcranial direct current stimulation (tDCS) combined with cueing gait training (CGT) on functional mobility in patients with Parkinson´s disease (PD).A pilot double-blind controlled, randomized clinical trial was conducted with 22 patients with PD assigned to the experimental (anodal tDCS plus CGT) and control group (sham tDCS plus CGT). The primary outcome (functional mobility) was assessed by 10-m walk test, cadence, stride length, and Timed Up and Go test. Motor impairment, bradykinesia, balance, and quality of life were analyzed as secondary outcomes. Minimal clinically important differences (MCIDs) were observed when assessing outcome data.Both groups demonstrated similar gains in all outcome measures, except for the stride length. The number of participants who showed MCID was similar between groups.The CGT provided many benefits to functional mobility, motor impairment, bradykinesia, balance, and quality of life. However, these effect magnitudes were not influenced by stimulation, but tDCS seems to prolong the effects of cueing therapy on functional mobility.

Background Transcranial direct current stimulation (tDCS) can optimize beneficial effects induced by motor practice in patients with neurological disorders. However, possibly because of homeostatic regulation, the conditioning effects of tDCS are often imprecise and variable, limiting its therapeutic application. Objective The aim of the study was to explore the magnitude and direction of the after effects induced by physical activity (PA) on tDCS-preconditioned cortical excitability (CE). Design First, a crossover experiment was performed with 12 subjects to determine whether a single session of low-, moderate-, and high-intensity PA on a treadmill modulates the motor CE measured by transcranial magnetic stimulation. In a second crossover experiment, we investigated long-lasting changes (until 90 mins) of the effects induced by PA (with intensities defined by the first experiment) on motor CE after the subject had been preconditioned by tDCS (using different polarities). Results and conclusions In experiment 1, we found that high- and moderate-intensity PA modulate the CE. Experiment 2 demonstrated that preconditioning the CE using tDCS homeostatically changes the direction and magnitude of after effects induced by subsequent PA plasticity caused by motor activity. In conclusion, the results suggest that the direction of after effects induced by the combination of physical exercise with tDCS on the CE is regulated within a physiologically defined range.

Motor threshold (MT) measured by transcranial magnetic stimulation (TMS) has diagnostic utility in central nervous system disorders. Its diagnostic sensitivity may be enhanced by identification of non-pathological factors which may influence this measure. The aim of this study was to provide a description of MT variability across physiological and non-pathological behaviour characteristics in a large cohort, including hemispheric asymmetries. In a cross-sectional study, age, handedness, physical activity level, body mass index, gender/menstrual cycle phase, glycemic index and degree of stress were collected from 115 healthy participants. The resting MT of the first dorsal interosseous muscle to TMS was recorded in both hemispheres and served as an indicator of the cortical excitability level. Repeated measures ANOVAs revealed higher MT values in the non-dominant hemisphere, elderly people, stressed individuals and women with amenorrhea. Other biological and behavioral individual characteristics did not influence cortical excitability. Although the degree of interhemispheric difference varied (range: 0.2 to 4.3), depending on biological and behavioral characteristics, this variation was not significant (0.1 ≤ p ≤ 0.8). In conclusion, MT varied considerably between subjects. The difference between the hemisphere excitability that was less influenced by external factors, may be an alternative method of TMS measure to identify pathological changes of cortical excitability.

Noninvasive brain stimulation has recently been used to augment motor training-induced plasticity. However, the exact time during which noninvasive brain stimulation can be combined with motor therapy to maximize neuroplasticity and behavioral changes is unknown. We conducted a randomized sham-controlled crossover trial to examine when (before, during, or after training) transcranial direct current stimulation (tDCS) should be applied to best reinforce motor training-induced plasticity in 12 healthy right-handed participants (mean age: 21.8±1.6) who underwent active or sham tDCS combined with motor training. Transcranial magnetic stimulation-elicited motor-evoked potentials from the right first dorsal interosseous muscle were recorded before (baseline) and immediately after each session. The training task comprised four practice trials - 3 min each (30 s pause between trials) - of repetitive finger movements (thumb abduction/adduction) with the right hand. Anodal tDCS (1 mA, 13 min, on the motor primary cortex) was applied before, during, and after the training. Compared with baseline motor-evoked potentials and the sham condition, tDCS that was applied before, but not during or after, the motor task enhanced corticospinal excitability. These data suggest that tDCS performed before - not during or after - promotes optimization of motor training-induced plasticity.

Introduction Musculoskeletal pain is a common clinical condition and about 10% of the population have musculoskeletal disorder. Objective The aim of this study was to evaluate whether ischemic pressure and dry needling techniques are able to reduce the pain of patients with myofascial pain syndrome. Method 22 patients aged 20-75 years were randomized into 3 groups: ischemic pressure (IPG = 8), dry needling (DNG = 7) and control (CG = 7). Patients in the IPG and DNG were assessed before and after 10 intervention sessions, which occurred 3 times per week. The CG was assessed initially and reassessed three weeks later. The assessment of pain was done through Visual Analogic Scale (VAS) and quality of life through WHOQOL-BREF (5 domains: global, physical, psychological, social and environmental). Results There was no significant difference for clinical and demographic data of all groups at baseline, except for age (p = 0.042). The results of the VAS expressed that IPG had pain relief in most sessions, the same was not observed for DNG. Comparing the 2 groups was obtained difference in the 4th and 8th sessions. The results of the WHOQOL-BREF showed that the three groups had a significant increase in the psychological domain. The same was not true for global domains, physical, environmental and social. Conclusion Ischemic pressure and dry needling were able to reduce the pain of patients and also change their quality of life, specifically the psychological aspect.

Aims the aim of this study was to verify the effects of different intensities of locomotor exercise on corticospinal excitability. Methods 18 healthy subjects (27.6 ± 6.5 years,) participated in a design study of three different exercise protocols on a cycle ergometer: (i) 10 min at 75% Wmax (high intensity); (ii) 15min at 60% Wmax (moderate intensity) or (iii) 30 min at 45% Wmax (low intensity). The protocols of lower body cycling were assigned in random order in separate sessions. A control session was done with subjects at rest. Corticospinal excitability was assessed before (baseline) and every 5 min for 15min after the end of exercise/rest (time: 0, 5, 10 and 15) by measurement of the motor evoked potential (MEP) elicited by transcranial magnetic stimulation in the relaxed first-dorsal interosseus muscle. Results Compared to the resting session, a significant decrease (64%) in the motor evoked potential amplitudes was found only in the session of exercise of high intensity. This result seems depend on the level of physical activity of subject. No change was found after rest, low and moderate exercises. Conclusions These findings suggest that changes in the corticospinal excitability depend on exercise intensity and level of physical activity of subjects.

Introdução: a estimulação magnética transcraniana (EMT) é uma técnica de estimulação cortical não invasiva que vem sendo empregada na investigação da fisiopatologia de desordens neurológicas. De modo a permitir a efetividade do uso da EMT como uma ferramenta para o neurodiagnóstico, é importante investigar se fatores não relacionados com doenças podem estar associados com modificações das medidas fisiológicas avaliadas pela técnica. Objetivo: verificar se o gênero, fases do ciclo menstrual e uso de anticoncepcional influenciam nas medidas de excitabilidade cortical. Metodologia: através de um estudo transversal, 114 voluntários foram divididos nos grupos: homens; mulheres em idade reprodutiva (fase folicular e lútea) e mulheres na menopausa. A EMT foi usada para identificar o limiar motor de repouso (LMR) do músculo primeiro interósseo dorsal que serviu como indicador do nível de excitabilidade. Resultados: A ANOVA one way revelou que o LMR de mulheres na menopausa e dos homens são maiores do que a de mulheres em idade reprodutiva. Ao comparar homens com mulheres em diferentes fases do ciclo menstrual, foi visto que essa diferença só existe quando as mulheres estão em fase folicular. O teste t para amostras independentes não mostrou variações no LMR de mulheres que usa ou não anticoncepcional. Conclusão: foi constatado que a excitabilidade cortical é influenciada pela variação hormonal que ocorre em indivíduos saudáveis. O uso da variação de excitabilidade cortical como medida para neurodiagnóstico de algumas doenças devem considerar essas variações não relacionadas à doença para evitar erros de diagnóstico.

This pilot double-blind sham-controlled randomized trial aimed to determine if the addition of anodal tDCS on the affected hemisphere or cathodal tDCS on unaffected hemisphere to modified constraint-induced movement therapy (mCIMT) would be superior to constraints therapy alone in improving upper limb function in chronic stroke patients.Twenty-one patients with chronic stroke were randomly assigned to receive 12 sessions of either (i) anodal, (ii) cathodal or (iii) sham tDCS combined with mCIMT. Fugl-Meyer assessment (FMA), motor activity log scale (MAL), and handgrip strength were analyzed before, immediately, and 1 month (follow-up) after the treatment. Minimal clinically important difference (mCID) was defined as an increase of ≥5.25 in the upper limb FMA.An increase in the FMA scores between the baseline and post-intervention and follow-up for active tDCS group was observed, whereas no difference was observed in the sham group. At post-intervention and follow-up, when compared with the sham group, only the anodal tDCS group achieved an improvement in the FMA scores. ANOVA showed that all groups demonstrated similar improvement over time for MAL and handgrip strength. In the active tDCS groups, 7/7 (anodal tDCS) 5/7 (cathodal tDCS) of patients experienced mCID against 3/7 in the sham group.The results support the merit of association of mCIMT with brain stimulation to augment clinical gains in rehabilitation after stroke. However, the anodal tDCS seems to have greater impact than the cathodal tDCS in increasing the mCIMT effects on motor function of chronic stroke patients.The association of mCIMT with brain stimulation improves clinical gains in rehabilitation after stroke. The improvement in motor recovery (assessed by Fugl-Meyer scale) was only observed after anodal tDCS. The modulation of damaged hemisphere demonstrated greater improvements than the modulation of unaffected hemispheres.

Introduction Musculoskeletal pain is a common clinical condition and about 10% of the population have musculoskeletal disorder. Objective The aim of this study was to evaluate whether ischemic pressure and dry needling techniques are able to reduce the pain of patients with myofascial pain syndrome. Method 22 patients aged 20-75 years were randomized into 3 groups: ischemic pressure (IPG = 8), dry needling (DNG = 7) and control (CG = 7). Patients in the IPG and DNG were assessed before and after 10 intervention sessions, which occurred 3 times per week. The CG was assessed initially and reassessed three weeks later. The assessment of pain was done through Visual Analogic Scale (VAS) and quality of life through WHOQOL-BREF (5 domains: global, physical, psychological, social and environmental). Results There was no significant difference for clinical and demographic data of all groups at baseline, except for age (p = 0.042). The results of the VAS expressed that IPG had pain relief in most sessions, the same was not observed for DNG. Comparing the 2 groups was obtained difference in the 4th and 8th sessions. The results of the WHOQOL-BREF showed that the three groups had a significant increase in the psychological domain. The same was not true for global domains, physical, environmental and social. Conclusion Ischemic pressure and dry needling were able to reduce the pain of patients and also change their quality of life, specifically the psychological aspect. Introdução A dor musculoesquelética é uma condição clínica comum e cerca de 10% da população possui distúrbio do sistema musculoesquelético. Objetivo O objetivo deste estudo foi avaliar se a compressão isquêmica e o agulhamento seco são técnicas capazes de reduzir a dor de pacientes com síndrome miofascial. Método 22 pacientes com idade entre 20-75 anos foram randomizados em 3 grupos: compressão isquêmica (GCI = 8), agulhamento seco (GAS = 7) e controle (GC = 7). Os pacientes do GCI e GAS foram avaliados antes e após as 10 sessões terapêuticas, que ocorreram 3 vezes por semana. O GC foi avaliado inicialmente e reavaliado 3 semanas depois. Para mensuração da dor usou-se a Escala Visual Analógica (EVA) e da qualidade de vida o WHOQOL-BREF (5 domínios: global, físico, psicológico, social e meio ambiente). Resultados A análise dos dados clínicos e demográficos mostrou que não houve diferença entre os grupos, exceto para idade (p = 0,042). Os resultados da EVA expressaram que o GCI teve redução da dor na maioria das sessões, o mesmo não se observou para o GAS. Comparando os 2 grupos obteve-se diferença na 4ª e 8ª sessões. Os resultados do WHOQOL-BREF demonstraram que os 3 grupos tiveram um aumento significante no domínio psicológico. O mesmo não ocorreu para os domínios global, físico, meio ambiente e social. Conclusão A compressão isquêmica e o agulhamento seco foram capazes de reduzir a dor dos pacientes e também intervir na sua qualidade de vida, especificamente no aspecto psicológico.