Effects on Muscle Dynamics Reprogramming (RDM) in Spinal Cord Sequelae

Carmen Silvia da Silva Martini¹, Francisco Miguel Pinto² & Luiz Roberto de Andrade Marchesini^3*

¹Faculty of Physical Education and Physiotherapy, Federal University of Manaus, Brazil
²Federal University of the State of Rio de Janeiro, Brazil
³Institute of Public and Private Teachers, Brazil

*Correspondence to: Dr. Luiz Roberto de Andrade Marchesini, Institute of Public and Private Teachers, Brazil.

Copyright © 2018 Dr. Luiz Roberto de Andrade Marchesini, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction
Rehabilitation by muscular dynamic reprogramming (RDM) comes from self-therapy induced by corrective postures and microflexions (lying, sitting, and standing), inserted in articular points, called “body codes” identified in the postural examination. This process facilitates the central nervous system to decode the new movements, reorganizing the nervous tensions and compressions by the movements themselves, stabilizing the loss of motor capacity, sensitivity, motor control [1].

The RDM was created by the physiotherapist, Dr. Francisco Miguel Pinto in the 90’s, researching a type of treatment that would support not only the spine but also the dynamics of other joints and muscles, soothing pain, postural changes and that would stimulates the neurological system, increasing motor control and selfrecognition of body limits, as well as overcoming them, through the proprioceptive system [1,2].

The RDM works from child to the third age, in a progressive, continuous and evolutionary way for the body self-control (the patient in control). One of the characteristics that distinguishes the RDM method is to teach, with a progressive therapeutic pedagogy, the patients to know themselves and to recognize their changes with resistive micromovements in each EP that presents variable densities, and thus, to rehabilitate the movements of the body, reconstructing its scheme by conditioning, avoiding the return of the problem and eliminating or controlling every aspect of the postural reconstruction process [2].

The spinal cord injury (LM) is characterized by serious complications that can be devastating to the human being in terms of physical, psychological and social injuries. It can promote injury to the structures of the spinal canal, especially to the spinal cord, causing motor, sensory, autonomic and psychoaffective alterations. The alterations may be due to the affection manifested, mainly due to the paralysis or paresis of the limbs, altered muscle tone, superficial and deep reflexes, alterations or loss of different sensitivities, among others [3,4], preventing the individual from performing their daily activities of daily living, through complete or partial interruption of sensory and / or motor paths [4].

Nowadays, the incidence of LM is 30 to 40 cases per 10000 individuals, with approximately 10,000 new cases per year exclusively in the USA, where 48% of individuals evolve to death, in which 80% at the site of the accident and 4 to 15% after hospital admission. And in Brazil, it is estimated to occur about 40 new cases per million of population, resulting in 6-8 thousand cases a year, raising health care costs (FREITAS, 2016).

Therefore, the purpose of the study was to verify the effects of muscle dynamics reprogramming (RDM) on the spinal cord sequelae.

Material and Method

This is a descriptive and exploratory experimental study, with a quantitative and qualitative approach, developed in a patient diagnosed with lower limb paraplegia and cervical arthrodesis, performed by PRONEURO (Multiprofessional Nucleus of Neurofunctional Rehabilitation), which is developed in the Laboratory of Neurosciences and Behavior Studies of the Faculty of Physical Education and Physiotherapy of the Federal University of Amazonas, approved by the Ethics Committee for Human Research CAAE31075814.0.0000.5020.

The sample consisted of one (1) male patient, 56 years old, with a diagnosis of spinal cord injury (wheelchair user), with cervical arthrodesis, who attended 2 times a week, 45 minutes each session, totaling 21 sessions.

The procedures consisted of filling in the assessment file, presenting the study to the patient, informing about the objectives and processes to be adopted, being invited to participate in the study then signing the Informed Consent Form (TCLE).

Next, the patient was evaluated utilizing the Static and Dynamic Posture Evaluation Form from the Muscular Dynamics Reprogramming Method (RDM), also by the Borg CR10 Scale and by the OASIS: AID / AIVD information set, before and after the sessions of rehabilitation [5].

Regarding the instruments, the static posture evaluation is based on patient identification, in posterior, frontal, and right and left lateral views; identification of postural deviation; profession, medications, hypertension, family sickness, and muscle strengthening and relaxation. As for the dynamic evaluation, the degree of flexion, extension, adduction, abduction of body segments, rotation of head and trunk and, by balance in orthostatic position on one lower limb (MMII) and the other flexed near the trunk.

In addition, OASIS (Center for Health Services and Policy Research, 1997) has fourteen (14) items that investigate how to dress up, ability to dress the lower body, showering, toileting, transfer, transportation (driving a car, picking up taxis, buses, etc.), laundry (washing your clothes and / or taking them to the laundry), housekeeping, going to shopping and the ability to use a telephone (answer, enter), where each item can be punctuated from 0 to 5, plus a letter “D” for unknown if it does not respond, determining that the lower the score the better the result.

Regarding the RDM program, the technique is applied in an individualized way, respecting the bodily state of each patient without promoting lesions, because it teaches patient to know themselves and recognize their changes. The elements used are epcs (special proprioceptive foams) in the form of rollers (77 cm) and hexagonal polymers (23 cm), in anti-allergic material in green, blue and yellow colors, in combined densities, postural modifier, calyx palmar, corrective, folding pillow and plain mattress.

In this methodology the head requires a more efficient connection of the sensory motor system to identify the flexions, extensions and rotations performed by the feet and thus respond to the movement and the posture desired in a precise, deep and controlled manner. Between these two body regions, heads and feet, is where acts perception and adaptation of the whole body against gravity. This process occurs through self-therapy induced by corrective stances (it is the initial phase of the placement of EP - Propriopercetive Elements, made of special polymers with rectangular, cylindrical and quadrangular wedge shapes), see figure 1. [1].

The posture is the first maneuver of the RDM method. This procedure has, in the context of its maneuvers to start the strategies for application of the method, standard postures that need a plane of rigid resistance or regular stiffness. Its use follows the following patterns of posture to initiate the insertion of the EP in each region of the body. Dorsal decubitus, lateral decubitus, ventral decubitus and seated for micro movements. See Figure 2 for the dorsal decubitus pattern.

In this case study, we used the posture, sitting to maintain the stimulus pattern at each point of the posture. Seated in the wheelchair the patient was positioned with the insertion of the EP in each region of the body, because it is necessary to adapt the pattern to the limits of the patient in each phase of the treatment, to perform the micro movements. See Figure 3.

In the PE insertion phase, the micro-flexions are performed (it is the phase where the patient performs the pressure movement in the body region where each PE is inserted). All EPs are micro movement facilitators and proprioceptive stimulators in contact with the skin. See Figure 4.

Case Report
Patient Marco Aurélio (fictitious name), male, 56 years old, married, occupational safety technician, and diagnosed with spinal cord injury for 1 year and 5 months. In the history of the current illness, the patient reported that he came home very tired and went straight to the bathroom. Sometime later, he woke up disoriented in a hospital and did not know what had happened with him. His relatives reported that he had slept in the toilet and that he fell on the floor hitting his forehead and was taken to the emergency room. Still, they stated that with the fall, the patient broke his nose, the cervical spine (C5 and C6) and underwent a fixation surgery (arthrodesis).

Upon arriving at the clinic the patient was in a wheelchair pushed by his relative presenting an aspect of sadness, bent posture, anxious and afraid to move, feeling pain and making it difficult to transfer the wheelchair to the stage.

Regarding the history of the previous disease, the patient presented complementary tests that indicated the diagnosis of spinal cord injury, with cervical spine arthrodesis (C5 / C6) and controlled systemic hypertension. In regards to the social history and family history, he reports that there was no similar accident, and reported that he used analgesic, but did not do physiotherapeutic rehabilitation.

After the anamnesis, a physical examination was performed to verify that the vital signs had the following values:

During physical examination, it was noticed that the muscle tone, assessed by the muscular belly on palpation, was normotonic in the upper limbs (MMSS) and lower limb hypotonic (MMII); muscle strength was presented in different degrees for the MMSS and MMII muscles, according to the Oxford scale, shown in Table 2 and 3 below.

Next, the patient underwent a physical therapy rehabilitation program, utilizing muscle dynamics reprogramming technique (RDM), for a total of 21 sessions of 45 minutes each. At the end of the sessions, a new evaluation was performed, with the same protocols, totalling two evaluations at the end of the study, showing a positive evolution of the patient.

In what comprises the rehabilitation program, it was developed in two phases as follows:

During the treatment sessions, regarding evidences, it was observed that the patient was exhibiting improvement in the increased range of motion (AM) after the amounts of EPC which were used, as example 1 EPC: folding pillow and wedge to, 1 epc: wedge (between the 6th and 10th session), as well as in the sensitivity and reacquisition of strength.

Also, that the sensorimotor perceptions evolved in terms of lower limb movements (MMII), which at first presented only outline in muscle contraction and it had to be aided in full execution of the movement (dorsiflexion) and started to perform the movement with more control.

Among the MMIIs, the patient had more difficulty in performing the movement on the right limb (MD) and that from about the 10^th session on the therapist only assisted in the dorsal flexion of MMIID with a slight touch, while the left one the patient performed the movement in its fullness.

Results
In the scope of this study, different results were verified in the static postural evaluation, as indicated in Table 5 below. In this study, it was possible to observe that there was an improvement in the patient’s posture, where it was found that all the evaluated items obtained a decrease after the intervention by the RDM, pointing to the decrease of the angle of the scoliosis and the increase of the amplitude of movement (AM) in the cervical region.

Within dynamic results, were identified differences of the movements performed and the AM between the 1^st and 2^nd evaluation, as described in Table 6 below. These results reveal that improvement in body functionality was obtained.

Regarding the level of pain, the 1^st and 2^nd evaluation, as described in Table 7 below. According to this, it is clear that the pain in these body regions were suppressed.

In what concerns the evaluation of the individual and patient’s individual daily life activity, there was evolution in 13 of the 14 items, as indicated in Chart 1 below, as well as the improvement of the patient, decreasing the score from 42 to 25, according to Table 8 below. However, it is possible to perceive that the patient has evolved positively in the individual and individual activity of daily life.

Discussion
During this study, it was established the existence of two articles that discussed muscular dynamics reprogramming (RDM), addressing postural balance, reducing back pain and reducing pain in industrial workers.

Regarding the sensorimotor deficits caused by the spinal cord injury, this is the first experimental study that was performed, therefore there is no other article comparing to the RDM.

Consequently, we have chosen to compare the results obtained with other researchers who discuss similar and sensorimotor techniques, which may support the results of this study.

According to Neves et al. (2014) the study performed with 18 athletes (age = 23.2 ± 3.15 years) distributed in 2 groups, in capsule-ligament lesions that can generate mechanical instability and varied symptomatology, during 6 weeks using a sensorimotor program that promoted improvement in the postural control in dynamic tasks in the time of stabilization after receiving a jump [6].

Somatic sensation makes the primary reception in the parietal cortex, where the lower limb is located (MMII) and, with the organization of dermatomes of the periphery, there is replacement by a somatotopia in the cortex emphasizing the acuity of the sensation [7]. The brain receives information from all its parts, as well as sends the commands to produce the movements, allowing the control and awareness of the sensations [8].

Vieira and Cistia (2016) studied cerebral palsy (CP) with the objective of evaluating the evolution of the training of dynamic postural balance through varied proprioceptive strategies in an experimental manner as the “case study” type with the participation of a teenager at a fifteen years old age group. The final results showed evolution and increase in postural adjustments, both compensatory and anticipatory in the control of dynamic postural balance in stable and unstable surfaces [9].

Sensory reeducation allows reversal of errors on sensory reproduction, gauging new representation of the affected parts for reorganization of the sensory “map” [8].

Oliveira et al. (2018) clarifies that the reduction of proprioceptive acuity promotes the individual functional deficits, being essential the muscular control in the participation of the protective response during a movement. Also, that the proprioceptive exercises reestablish the deficits originated from musculoskeletal lesions [10].

Leao et al. (2017) studied individuals with spinal cord injury at thoracic level presenting impairments in their functionality and quality of life, using virtual reality as a therapeutic resource, aiming to increase balance and range of motion through simulation of sports and daily activities. It showed the effectiveness of the technique for the improvement of balance and quality of life, allowing greater safety for the accomplishment of the activities in the postures of sedestation and standing [11].

However, it is understood that the sensory-motor stimulation is essential for the rehabilitation of the individual spinal cord sequelae, and that through this it is intended to promote more functionality in the individual’s daily life activities, enabling a better quality of life for the individual and for the family, as well as for social welfare.

Conclusion
The scope of this new technique in rehabilitation instigates this population because it values its potential, favoring the reacquisition of its sensory-motor perceptions since, there is an active participation in the therapy without causing injuries.

Nevertheless, we can understand that it is possible to find barriers that will limit the functionality of the paraplegic patient, within social and family environment, that may stop the continuity of the therapy and act retroactively on its functionality.

Therefore, in this single and first case, it is possible to infer that rehabilitation with RDM promoted improvement in the individual and individual activities of the patient’s daily life, to gain more range of motion and to improve their sensorimotor perceptions.

But, as any new technique and with a single individual, it is recommended further investigation in order to produce more evidence, quantitatively and qualitatively, of the evolution on patients with spinal cord injury.

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