Intervenções para reabilitação motora em pacientes com amputação abaixo do joelho por doença arterial periférica ou diabetes melito - revisão sistemática Cochrane
Data
2022-05-24
Autores
Aledi, Luciane Basilio [UNIFESP]
Orientadores
Miranda Junior, Fausto [UNIFESP]
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: Amputação é descrita como a remoção de uma parte do corpo por trauma, doença ou cirurgia. Amputações causadas por doenças vasculares são cada vez mais frequentes, associada ao envelhecimento da população, com maior incidência de diabetes e doença arterial obstrutiva periférica (DAOP). Intervenções para reabilitação motora podem funcionar como precursores para o processo de reabilitação e uso de prótese em pacientes com amputação abaixo do joelho por doença vascular. Reabilitação efetiva pode permitir aos amputados melhorar a mobilidade, dar oportunidade de readquirir as atividades com perda funcional mínima e melhorar a qualidade de vida dessa população. Treinamento de força muscular tradicional (TFMT) é a técnica mais usada para reabilitação motora objetivando o aumento de força muscular. Intervenções como imaginação motora (IM), ambientes virtuais (AV) e facilitação neuromuscular proprioceptiva (FNP) podem melhorar a reabilitação e visto que podem ser realizadas no domicílio do paciente, os custos do processo de reabilitação podem diminuir. Devido ao aumento da prevalência, impacto econômico e o longo processo de reabilitação em pacientes com amputações por doença vascular uma revisão investigando a efetividade das intervenções de reabilitação motora em pacientes com amputação abaixo do joelho por doença vascular é necessária. Objetivo: Acessar e comparar a efetividade das intervenções para reabilitação motora em pacientes com amputação abaixo do joelho (transtibial) devido à doença arterial obstrutiva periférica ou diabetes. Métodos: Revisão sistemática de ensaios clínicos randomizados e “quasi”-randomizados. A pesquisa foi realizada nas bases de dados Cochrane Vascular Specialized Register, CENTRAL, MEDLINE, EMBASE, AMED e CINAHL, na Plataforma Internacional de Registro de Ensaios Clínicos da Organização Mundial da Saúde, no registro de ensaios clínicos do ClinicalTrials.gov e complementado através da verificação através de busca manual de revistas, livros e resumos de conferências relevantes. Não houve restrições de idioma e data de publicação. Foram incluídos ensaios clínicos randomizados comparando qualquer intervenção para reabilitação motora com treinamento de força muscular tradicional (TFMT) + cuidados usuais (CU) ou comparando intervenções para reabilitação motora entre si. Os desfechos de interesse foram uso de prótese, eventos adversos, avaliação da mobilidade, qualidade de vida e dor fantasma no membro. Dois revisores independentes realizaram a seleção dos estudos, extração de dados e avaliação de risco de viés para os estudos incluídos, seguindo as recomendações da Cochrane Collaboration. Resultados: Foram incluídos três ensaios clínicos randomizados (ECR) com um total de 61 pacientes. Um ECR (8 pacientes) avaliou imaginação motora (combinado com prática de caminhada) versus prática de caminhada; um estudo comparou dois protocolos diferentes de marcha (1 ECR, 22 pacientes) e outro ECR (31 pacientes) comparou sessões de telessaúde com intervenção de mudança de comportamento de atividade física (combinado com controle de atenção por telessaúde) versus sessões de telessaúde com intervenção de mudança de comportamento de atividade física. Não houve diferença clara nos parâmetros de avaliação da mobilidade comparando-se a imaginação motora (combinada com prática de caminhada) com a prática de caminhada. Ambos os protocolos de marcha (o focado no nível de deficiência e o focado no nível de tarefa) apresentaram uma possível melhora na avaliação da mobilidade no pós-tratamento em relação ao início do tratamento. Comparando-se sessões de telessaúde com intervenção de mudança de comportamento de atividade física (combinado com controle de atenção por telessaúde) versus sessões de telessaúde com intervenção de mudança de comportamento de atividade física não houve diferença entre os grupos no período de realização da intervenção em relação ao início do tratamento nos parâmetros de avaliação da mobilidade, qualidade de vida e eventos adversos. Conclusões: há escassez de estudos na área de reabilitação motora em amputação por doença vascular. Foram identificadas evidências de baixa certeza que sugerem que protocolos de treinamento de marcha podem resultar em melhora nos parâmetros de avaliação da mobilidade e que a imaginação motora não melhora parâmetros de avaliação da mobilidade. Evidências de muito baixa certeza sugerem que sessões de telessaúde de intervenção de mudança de comportamento de atividade física não melhoram a avaliação da mobilidade, qualidade de vida ou eventos adversos em pessoas com amputação abaixo do joelho devido a doença arterial periférica ou diabetes melito. Visto que a certeza das evidências foi baixa a muito baixa, continua incerto se essas intervenções podem melhorar o uso de próteses, mobilidade, mortalidade, qualidade de vida e dor fantasma. Estudos de alta qualidade envolvendo intervenções para reabilitação motora em amputações abaixo do joelho por doença vascular podem ser importantes.
Background: Amputation is described as the removal of a body part by trauma, medical illness or surgery. Amputations caused by vascular diseases (dysvascular amputations) are increasingly frequent, most commonly due to peripheral arterial disease (PAD), associated with an aging population and increased incidence of diabetes and atherosclerotic disease. Interventions for motor rehabilitation might work as a precursor to enhance the rehabilitation process and prosthetic use in patients with dysvascular amputations below the knee. Effective rehabilitation can improve mobility, allow patients the opportunity to take up activities again with minimum functional loss and may enhance the quality of life of this population. Traditional strength training (TST) is the most used technique for lower-extremity amputation rehabilitation, aiming to increase muscular strength. Interventions such as motor imaging (MI), virtual environments (VEs) and proprioceptive neuromuscular facilitation (PNF) might improve rehabilitation and once these interventions can be performed at home, the overall expense of the rehabilitation process may decrease. Due to the elevated prevalence, economic impact and long-term rehabilitation process in people with dysvascular amputations, a review investigating the effectiveness of motor rehabilitation interventions in patients with dysvascular below-knee amputations is warranted. Objective: To assess and compare the effectiveness of interventions for motor rehabilitation in people with below-knee amputations (transtibial amputations) resulting from peripheral arterial disease or diabetes (dysvascular causes). Method: Systematic review of randomized and quasi-randomized clinical trials. The search was conducted in Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED and CINAHL databases, the World Health Organization International Clinical Trials Registry Platform, the ClinicalTrials.gov trials register and complemented by checking through manual search of relevant journals, books and conference abstracts. There were no language and date of publication restrictions. Randomized clinical trials comparing any intervention for motor rehabilitation with traditional strength training (TST) plus usual care (UC) or comparing interventions for motor rehabilitation against each other were included. Outcomes of interest were prosthesis use, adverse events, mobility assessment, mortality, quality of life and phantom limb pain. Two review authors independently reviewed studies retrieved by the search strategies, assessed selected studies for complete analysis and performed study selection, data extraction and risk of bias assessment for included studies, following the Cochrane Collaboration recommendations. Results: Were included three randomized controlled trials (RCTs) with a combined total of 61 participants. One RCT (8 participants) evaluated Motor Imaging (MI) combined with physical practice of walking versus physical practice of walking; one study compared two different gait training protocols (1 RCT, 22 participants) and the other study (1 RCT, 31 participants) compared telehealth sessions of physical activity behavior-change intervention (combined with attention control sessions) versus telehealth sessions of physical activity behavior-change intervention. There was no clear difference in mobility assessment comparing MI (combined with physical practice of walking) with physical practice of walking. The gait training protocols focused on impairment level and the gait training protocol focused on task level showed a slight improvement within each group from baseline to post-treatment for mobility assessment and there was probably no difference on adverse events comparing the two different gait training protocols. Comparing the telehealth sessions of physical activity behavior-change intervention (combined with attention control sessions) with telehealth sessions of physical activity behavior-change intervention there was no evidence of difference in both groups from baseline to the intervention period in mobility assessment, adverse events and quality of life. Conclusions: Overall, there is a paucity of research in the field of motor rehabilitation in dysvascular amputation. Gait training protocols focused on impairment level and focused on task level improve mobility assessment with low‐certainty evidence. Motor Imaging combined with physical practice of walking versus physical practice of walking showed no clear difference in mobility assessment (low‐certainty evidence). Telehealth sessions of physical activity behavior-change intervention (combined with attention control sessions) and Telehealth sessions of physical activity behavior-change intervention showed, with very low‐certainty evidence, no clear difference in both groups from baseline to the intervention period in mobility assessment, adverse events and quality of life. Due to a lack of high-certainty evidence, it remains unclear whether these interventions may improve the prosthesis use, adverse events, mobility assessment, mortality, quality of life and phantom limb pain. Further well‐designed studies that address interventions for motor rehabilitation in dysvascular below-knee amputation may be important.
Background: Amputation is described as the removal of a body part by trauma, medical illness or surgery. Amputations caused by vascular diseases (dysvascular amputations) are increasingly frequent, most commonly due to peripheral arterial disease (PAD), associated with an aging population and increased incidence of diabetes and atherosclerotic disease. Interventions for motor rehabilitation might work as a precursor to enhance the rehabilitation process and prosthetic use in patients with dysvascular amputations below the knee. Effective rehabilitation can improve mobility, allow patients the opportunity to take up activities again with minimum functional loss and may enhance the quality of life of this population. Traditional strength training (TST) is the most used technique for lower-extremity amputation rehabilitation, aiming to increase muscular strength. Interventions such as motor imaging (MI), virtual environments (VEs) and proprioceptive neuromuscular facilitation (PNF) might improve rehabilitation and once these interventions can be performed at home, the overall expense of the rehabilitation process may decrease. Due to the elevated prevalence, economic impact and long-term rehabilitation process in people with dysvascular amputations, a review investigating the effectiveness of motor rehabilitation interventions in patients with dysvascular below-knee amputations is warranted. Objective: To assess and compare the effectiveness of interventions for motor rehabilitation in people with below-knee amputations (transtibial amputations) resulting from peripheral arterial disease or diabetes (dysvascular causes). Method: Systematic review of randomized and quasi-randomized clinical trials. The search was conducted in Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED and CINAHL databases, the World Health Organization International Clinical Trials Registry Platform, the ClinicalTrials.gov trials register and complemented by checking through manual search of relevant journals, books and conference abstracts. There were no language and date of publication restrictions. Randomized clinical trials comparing any intervention for motor rehabilitation with traditional strength training (TST) plus usual care (UC) or comparing interventions for motor rehabilitation against each other were included. Outcomes of interest were prosthesis use, adverse events, mobility assessment, mortality, quality of life and phantom limb pain. Two review authors independently reviewed studies retrieved by the search strategies, assessed selected studies for complete analysis and performed study selection, data extraction and risk of bias assessment for included studies, following the Cochrane Collaboration recommendations. Results: Were included three randomized controlled trials (RCTs) with a combined total of 61 participants. One RCT (8 participants) evaluated Motor Imaging (MI) combined with physical practice of walking versus physical practice of walking; one study compared two different gait training protocols (1 RCT, 22 participants) and the other study (1 RCT, 31 participants) compared telehealth sessions of physical activity behavior-change intervention (combined with attention control sessions) versus telehealth sessions of physical activity behavior-change intervention. There was no clear difference in mobility assessment comparing MI (combined with physical practice of walking) with physical practice of walking. The gait training protocols focused on impairment level and the gait training protocol focused on task level showed a slight improvement within each group from baseline to post-treatment for mobility assessment and there was probably no difference on adverse events comparing the two different gait training protocols. Comparing the telehealth sessions of physical activity behavior-change intervention (combined with attention control sessions) with telehealth sessions of physical activity behavior-change intervention there was no evidence of difference in both groups from baseline to the intervention period in mobility assessment, adverse events and quality of life. Conclusions: Overall, there is a paucity of research in the field of motor rehabilitation in dysvascular amputation. Gait training protocols focused on impairment level and focused on task level improve mobility assessment with low‐certainty evidence. Motor Imaging combined with physical practice of walking versus physical practice of walking showed no clear difference in mobility assessment (low‐certainty evidence). Telehealth sessions of physical activity behavior-change intervention (combined with attention control sessions) and Telehealth sessions of physical activity behavior-change intervention showed, with very low‐certainty evidence, no clear difference in both groups from baseline to the intervention period in mobility assessment, adverse events and quality of life. Due to a lack of high-certainty evidence, it remains unclear whether these interventions may improve the prosthesis use, adverse events, mobility assessment, mortality, quality of life and phantom limb pain. Further well‐designed studies that address interventions for motor rehabilitation in dysvascular below-knee amputation may be important.