Browsing articles tagged with "Rehabilitación Neurológica Archives - Updates en Rehabilitación"

Entrenamiento de fuerza y ejercicio aeróbico en enfermedades musculares.

DM2 Histopathology

Distrofia miotónica- histopatología

Se ha publicado una actualización de la Cochrane sobre el entrenamiento de fuerza y ejercicio aeróbico en enfermedades musculares.
Se incluyen dos ensayos sobre el entrenamiento de fuerza en personas con distrofia muscular facioescapulohumeral y distrofia miotónica (101 participantes), dos ensayos de entrenamiento de fuerza combinado con ejercicios aeróbicos en personas con miopatía mitocondrial (18 participantes) y distrofia miotónica tipo I (35 participantes) y una prueba de ejercicio aeróbico en pacientes con polimiositis y dermatomiositis (14 participantes).
Estos ensayos mostraron que el entrenamiento de fuerza de intensidad moderada en personas con distrofia miotónica o con distrofia muscular facioescapulohumeral, y con ejercicios aeróbicos en pacientes con dermatomiositis o polimiositis parece no provocar daño muscular.
El entrenamiento de fuerza combinado con ejercicio aeróbico parece ser seguro en la distrofia miotónica tipo I y puede ser eficaz en el aumento de la resistencia en las personas con miopatía mitocondrial.
La evidencia sugiere que el entrenamiento de fuerza no es perjudicial en personas con distrofia facioescapulohumeral, distrofia miotónica, trastornos mitocondriales y dermatomiositis y polimiositis, pero más investigación es necesaria para determinar el beneficio potencial.

Podéis leer el artículo en: Strength training and aerobic exercise training for muscle disease


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Strength training or aerobic exercise programmes might optimise muscle and cardiorespiratory function and prevent additional disuse atrophy and deconditioning in people with a muscle disease. This is an update of a review first published in 2004.Objectives:
To examine the safety and efficacy of strength training and aerobic exercise training in people with a muscle disease.Search strategy:
We searched the Cochrane Neuromuscular Disease Group Specialized Register (July 2012), CENTRAL (2012 Issue 3 of 4), MEDLINE (January 1946 to July 2012), EMBASE (January 1974 to July 2012), EMBASE Classic (1947 to 1973) and CINAHL (January 1982 to July 2012).Selection criteria:
Randomised or quasi-randomised controlled trials comparing strength training or aerobic exercise programmes, or both, to no training, and lasting at least six weeks, in people with a well-described diagnosis of a muscle disease.We did not use the reporting of specific outcomes as a study selection criterion.

Data collection and analysis:
Two authors independently assessed trial quality and extracted the data obtained from the full text-articles and from the original investigators. We collected adverse event data from included studies.

Main results:
We included five trials (170 participants). The first trial compared the effect of strength training versus no training in 36 people with myotonic dystrophy. The second trial compared aerobic exercise training versus no training in 14 people with polymyositis and dermatomyositis. The third trial compared strength training versus no training in a factorial trial that also compared albuterol with placebo, in 65 people with facioscapulohumeral muscular dystrophy (FSHD). The fourth trial compared combined strength training and aerobic exercise versus no training in 18 people with mitochondrial myopathy. The fifth trial compared combined strength training and aerobic exercise versus no training in 35 people with myotonic dystrophy type 1.

In both myotonic dystrophy trials and the dermatomyositis and polymyositis trial there were no significant differences between training and non-training groups for primary and secondary outcome measures. The risk of bias of the strength training trial in myotonic dystrophy and the aerobic exercise trial in polymyositis and dermatomyositis was judged as uncertain, and for the combined strength training and aerobic exercise trial, the risk of bias was judged as adequate. In the FSHD trial, for which the risk of bias was judged as adequate, a +1.17 kg difference (95% confidence interval (CI) 0.18 to 2.16) in dynamic strength of elbow flexors in favour of the training group reached statistical significance. In the mitochondrial myopathy trial, there were no significant differences in dynamic strength measures between training and non-training groups. Exercise duration and distance cycled in a submaximal endurance test increased significantly in the training group compared to the control group. The differences in mean time and mean distance cycled till exhaustion between groups were 23.70 min (95% CI 2.63 to 44.77) and 9.70 km (95% CI 1.51 to 17.89), respectively. The risk of bias was judged as uncertain. In all trials, no adverse events were reported.

Authors’ conclusions:
Moderate-intensity strength training in myotonic dystrophy and FSHD and aerobic exercise training in dermatomyositis and polymyositis and myotonic dystrophy type I appear to do no harm, but there is insufficient evidence to conclude that they offer benefit. In mitochondrial myopathy, aerobic exercise combined with strength training appears to be safe and may be effective in increasing submaximal endurance capacity. Limitations in the design of studies in other muscle diseases prevent more general conclusions in these disorders.

This record should be cited as: Voet NBM, van der Kooi EL, Riphagen II, Lindeman E, van Engelen BGM, Geurts ACH. Strength training and aerobic exercise training for muscle disease. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003907. DOI: 10.1002/14651858.CD003907.pub4
Assessed as up to date: July 2, 2012
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Estimulación magnética transcraneal y Rehabilitación Cognitiva sobre deficits de atención en el Ictus

Recientemente se han publicado varias revisiones de la Cochrane sobre el ictus, os las dejo a continuación:

Estimulación magnética transcraneal Ictus

1) En la primera de ellas se concluye que la evidencia actual no soporta el uso rutinario de la estimulación magnética transcraneal en el ictus.

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Cochrane Database Syst Rev. 2013 May 31;5:CD008862. doi: 10.1002/14651858.CD008862.pub2.
Repetitive transcranial magnetic stimulation for improving function after stroke.
Hao Z, Wang D, Zeng Y, Liu M.
Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, China, 610041.
It had been assumed that suppressing the undamaged contralesional motor cortex by repetitive low-frequency transcranial magnetic stimulation (rTMS) or increasing the excitability of the damaged hemisphere cortex by high-frequency rTMS will promote function recovery after stroke.
To assess the efficacy and safety of rTMS for improving function in people with stroke.
We searched the Cochrane Stroke Group Trials Register (April 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4), the Chinese Stroke Trials Register (April 2012), MEDLINE (1950 to May 2012), EMBASE (1980 to May 2012), Science Citation Index (1981 to April 2012), Conference Proceedings Citation Index-Science (1990 to April 2012), CINAHL (1982 to May 2012), AMED (1985 to May 2012), PEDro (April 2012), REHABDATA (April 2012) and CIRRIE Database of International Rehabilitation Research (April 2012). In addition, we searched five Chinese databases, ongoing trials registers and relevant reference lists.
We included randomised controlled trials comparing rTMS therapy with sham therapy or no therapy. We excluded trials that reported only laboratory parameters.
Two review authors independently selected trials, assessed trial quality and extracted the data. We resolved disagreements by discussion.
We included 19 trials involving a total of 588 participants in this review. Two heterogenous trials with a total of 183 participants showed that rTMS treatment was not associated with a significant increase in the Barthel Index score (mean difference (MD) 15.92, 95% CI -2.11 to 33.95). Four trials with a total of 73 participants were not found to have a statistically significant effect on motor function (standardised mean difference (SMD) 0.51, 95% CI -0.99 to 2.01). Subgroup analyses of different stimulation frequencies or duration of illness also showed no significant difference. Few mild adverse events were observed in the rTMS groups, with the most common events being transient or mild headaches (2.4%, 8/327) and local discomfort at the site of the stimulation.
Current evidence does not support the routine use of rTMS for the treatment of stroke. Further trials with larger sample sizes are needed to determine a suitable rTMS protocol and the long-term functional outcome.



2) En la siguiente revisión sobre Rehabilitación Cognitiva sobre déficits de atención en el ictus, los resultados sugieren que puede haber un efecto a corto plazo sobre la capacidad de atención, pero no hay estudios de calidad sobre la persistencia de los efectos y sobre la relación con las AVDs.

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Cochrane Database Syst Rev. 2013 May 31;5:CD002842. doi: 10.1002/14651858.CD002842.pub2.
Cognitive rehabilitation for attention deficits following stroke.
Loetscher T, Lincoln NB.
School of Psychology, Flinders University, Adelaide, Australia.
Many survivors of stroke complain about attentional impairments, such as diminished concentration and mental slowness. However, the effectiveness of cognitive rehabilitation for improving these impairments is uncertain.
To determine whether (1) people receiving attentional treatment show better outcomes in their attentional functions than those given no treatment or treatment as usual, and (2) people receiving attentional treatment techniques have a better functional recovery, in terms of independence in activities of daily living, mood and quality of life, than those given no treatment or treatment as usual.
We searched the Cochrane Stroke Group Trials Register (October 2012), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library October 2012), MEDLINE (1948 to October 2012), EMBASE (1947 to October 2012), CINAHL (1981 to October 2012), PsycINFO (1806 to October 2012), PsycBITE and REHABDATA (searched October 2012) and ongoing trials registers. We screened reference lists and tracked citations using Scopus.
We included randomised controlled trials (RCTs) of cognitive rehabilitation for impairments of attention for people with stroke. The primary outcome was measures of global attentional functions, and secondary outcomes were measures of attention domains, functional abilities, mood and quality of life.
Two review authors independently selected trials, extracted data and assessed trial quality.
We included six RCTs with 223 participants. All six RCTs compared cognitive rehabilitation with a usual care control. Meta-analyses demonstrated no statistically significant effect of cognitive rehabilitation for persisting effects on global measures of attention (two studies, 99 participants; standardised mean difference (SMD) 0.16, 95% confidence interval (CI) -0.23 to 0.56; P value = 0.41), standardised attention assessments (two studies, 99 participants; P value ≥ 0.08) or functional outcomes (two studies, 99 participants; P value ≥ 0.15). In contrast, a statistically significant effect was found in favour of cognitive rehabilitation when compared with control for immediate effects on measures of divided attention (four studies, 165 participants; SMD 0.67, 95% CI 0.35 to 0.98; P value < 0.0001) but no significant effects on global attention (two studies, 53 participants; P value = 0.06), other attentional domains (six studies, 223 participants; P value ≥ 0.16) or functional outcomes (three studies, 109 participants; P value ≥ 0.21).Thus there was limited evidence that cognitive rehabilitation may improve some aspects of attention in the short term, but there was insufficient evidence to support or refute the persisting effects of cognitive rehabilitation on attention, or on functional outcomes in either the short or long term.
The effectiveness of cognitive rehabilitation remains unconfirmed. The results suggest there may be a short-term effect on attentional abilities, but future studies need to assess the persisting effects and measure attentional skills in daily life. Trials also need to have higher methodological quality and better reporting.


Manejo no farmacológico la espasticidad en la Esclerosis Múltiple y Neuroestimulación en Parkinson

En ésta entrada de domingo os dejo dos artículos relacionados con la Neurorrehabilitación.  Simplemente os dejo un pequeño comentario y a continuación podéis os he añadido directamente el abstract y la referencia del artículo.

1) Se ha publicado una actualización de la Cochrane sobre las intervenciones no farmacológicas en la espasticidad en pacientes con Esclerosis Múltiple. Se han encontrado pruebas de baja calidad a favor de la terapia física en conjunción con otras intervenciones (p.ej toxina botulínica) y a favor de la estimulación magnética y terapia electromagnética.

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Amatya B, Khan F, La Mantia L, Demetrios M, Wade DT.
Non pharmacological interventions for spasticity in multiple sclerosis.
Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD009974. DOI: 10.1002/14651858.CD009974.pub2.BackgroundSpasticity is commonly experienced by people with multiple sclerosis (MS), and it contributes to overall disability in this population. A wide range of non pharmacological interventions are used in isolation or with pharmacological agents to treat spasticity in MS. Evidence for their effectiveness is yet to be determined.


To assess the effectiveness of various non pharmacological interventions for the treatment of spasticity in adults with MS.

Search methods

A literature search was performed using the Specialised Register of the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Review Group on using the Cochrane MS Group Trials Register which among other sources, contains CENTRAL, Medline, EMBASE, CINAHL, LILACS, PEDRO in June 2012. Manual searching in the relevant journals and screening of the reference lists of identified studies and reviews were carried out. Abstracts published in proceedings of conferences were also scrutinised.

Selection criteria

Randomised controlled trials (RCTs) that reported non pharmacological intervention/s for treatment of spasticity in adults with MS and compared them with some form of control intervention (such as sham/placebo interventions or lower level or different types of intervention, minimal intervention, waiting list controls or no treatment; interventions given in different settings), were included.

Data collection and analysis

Three review authors independently selected the studies, extracted data and assessed the methodological quality of the studies using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) tool for best-evidence synthesis. A meta-analysis was not possible due to methodological, clinical and statistical heterogeneity of included studies.

Main results

Nine RCTs (N = 341 participants, 301 included in analyses) investigated various types and intensities of non pharmacological interventions for treating spasticity in adults with MS. These interventions included: physical activity programmes (such as physiotherapy, structured exercise programme, sports climbing); transcranial magnetic stimulation (Intermittent Theta Burst Stimulation (iTBS), Repetitive Transcranial Magnetic Stimulation (rTMS)); electromagnetic therapy (pulsed electromagnetic therapy; magnetic pulsing device), Transcutaneous Electrical Nerve Stimulation (TENS); and Whole Body Vibration (WBV). All studies scored ‘low’ on the methodological quality assessment implying high risk of bias.

There is ‘low level’ evidence for physical activity programmes used in isolation or in combination with other interventions (pharmacological or non pharmacological), and for repetitive magnetic stimulation (iTBS/rTMS) with or without adjuvant exercise therapy in improving spasticity in adults with MS. No evidence of benefit exists to support the use of TENS, sports climbing and vibration therapy for treating spasticity in this population.

Authors’ conclusions

There is ‘low level’ evidence for non pharmacological interventions such as physical activities given in conjunction with other interventions, and for magnetic stimulation and electromagnetic therapies for beneficial effects on spasticity outcomes in people with MS. A wide range of non pharmacological interventions are used for the treatment of spasticity in MS, but more robust trials are needed to build evidence about these interventions.

Neuroestimulación en Parkinson
La Neuroestimulación subtalácmica en Pacientes con Parkinson y alteraciones motoras precoces fue superior al tratamiento médico con respecto a la discapacidad motora, actividades de la vida diaria, las complicaciones inducidas por levodopa, y el tiempo con buena movilidad y sin discinesia.

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Neurostimulation for Parkinson’s Disease with Early Motor Complications
W.M.M. Schuepbach, J. Rau, K. Knudsen, J. Volkmann, P. Krack, L. Timmermann, T.D. Hälbig, H. Hesekamp, S.M. Navarro, N. Meier, D. Falk, M. Mehdorn, S. Paschen, M. Maarouf, M.T. Barbe, G.R. Fink, A. Kupsch, D. Gruber, G.-H. Schneider, E. Seigneuret, A. Kistner, P. Chaynes, F. Ory-Magne, C. Brefel Courbon, J. Vesper, A. Schnitzler, L. Wojtecki, J.-L. Houeto, B. Bataille, D. Maltête, P. Damier, S. Raoul, F. Sixel-Doering, D. Hellwig, A. Gharabaghi, R. Krüger, M.O. Pinsker, F. Amtage, J.-M. Régis, T. Witjas, S. Thobois, P. Mertens, M. Kloss, A. Hartmann, W.H. Oertel, B. Post, H. Speelman, Y. Agid, C. Schade-Brittinger, and G. Deuschl for the EARLYSTIM Study Group
N Engl J Med 2013; 368:610-622February 14, 2013DOI: 10.1056/NEJMoa1205158

Subthalamic stimulation reduces motor disability and improves quality of life in patients with advanced Parkinson’s disease who have severe levodopa-induced motor complications. We hypothesized that neurostimulation would be beneficial at an earlier stage of Parkinson’s disease.

In this 2-year trial, we randomly assigned 251 patients with Parkinson’s disease and early motor complications (mean age, 52 years; mean duration of disease, 7.5 years) to undergo neurostimulation plus medical therapy or medical therapy alone. The primary end point was quality of life, as assessed with the use of the Parkinson’s Disease Questionnaire (PDQ-39) summary index (with scores ranging from 0 to 100 and higher scores indicating worse function). Major secondary outcomes included parkinsonian motor disability, activities of daily living, levodopa-induced motor complications (as assessed with the use of the Unified Parkinson’s Disease Rating Scale, parts III, II, and IV, respectively), and time with good mobility and no dyskinesia.

For the primary outcome of quality of life, the mean score for the neurostimulation group improved by 7.8 points, and that for the medical-therapy group worsened by 0.2 points (between-group difference in mean change from baseline to 2 years, 8.0 points; P=0.002). Neurostimulation was superior to medical therapy with respect to motor disability (P<0.001), activities of daily living (P<0.001), levodopa-induced motor complications (P<0.001), and time with good mobility and no dyskinesia (P=0.01). Serious adverse events occurred in 54.8% of the patients in the neurostimulation group and in 44.1% of those in the medical-therapy group. Serious adverse events related to surgical implantation or the neurostimulation device occurred in 17.7% of patients. An expert panel confirmed that medical therapy was consistent with practice guidelines for 96.8% of the patients in the neurostimulation group and for 94.5% of those in the medical-therapy group.

Subthalamic stimulation was superior to medical therapy in patients with Parkinson’s disease and early motor complications. (Funded by the German Ministry of Research and others; EARLYSTIM number, NCT00354133.)


Mini-Updates 3 (Ictus)

Os dejo 3 nuevos artículos, en ésta ocasión sobre Rehabilitación Neurológica (concretamente sobre el ictus).


1) Inhibidores selectivos de la recaptación de serotonina (ISRS) para la recuperación del accidente cerebrovascular

Los ISRS parecen disminuir la dependencia, discapacidad, deterioro neurológico, ansiedad y depresión después de un accidente cerebrovascular, pero con heterogeneidad entre los ensayos y limitaciones metodológicas en una proporción sustancial de ellos. Son necesarios ensayos grandes, bien diseñados, para determinar si los ISRS deberían ser indicados de forma rutinaria a los pacientes con accidente cerebrovascular.

2) PLAN Score: Escala sencilla para realizar a pie de cama para predecir muerte y discapacidad grave tras el accidente cerebrovascular isquémico agudo. En los resultados iniciales también se observa relación con las puntuaciones favorables de la escala Rankin modificada

3) Ortesis funcional de hombro en el Ictus:

Neurolux Rehabilitación Ictus

La ortesis funcional tipo Neurolux
elección de las variables resultados se podrían mejorar)parece reducir la incidencia/progresión del Síndrome hombro-mano en pacientes hemipléjicos (aunque el tamaño muestral es pequeño y la elección de las variables resultados se podrían mejorar)