RCAAP Repository

Objective: Characterize children with limb deficiency observed at Hospital Pediátrico de Coimbra betweenJanuary 2005 and July 2009.Compare prosthetic prescription and functioning in children with congenital and acquired limb deficiency.Methods: Retrospective study based on informatic reports of the 36 patients as well as complete clinical processesof the 12 children with upper limb deficiency.Results: Thirty six patients, 21 with congenital and 15 with acquired limb deficiency. Transtibial amputation wasthe most frequent acquired amputation and upper limb longitidinal deficiency was the congenital deficiencymost representative. Acquired amputations were most frequently caused by trauma. Twelve patients had upper limb deficiency. The most frequent was transverse below the elbow reductiondeficiency. The rejection to use a prosthetic device is higher on the congenital group. The children who still areprosthetic users, mainly use active devices. Children with upper limb reduction deficiency perform well on dailyactivities, even the prosthetic non-users.Conclusions: Congenital limb deficiencies outnumber acquired amputations, being unknown its precise cause.The cause and level of acquired amputations in our population are similar to those described in other studies.Nevertheless, upper limb congenital defect was not the most frequent.Even though the prescription of active devices in children with upper limb defect is related with the currentprosthetic use, the prostheses are useful for specific activities, rather than for daily activities in general.Keywords: Amputation; Congenital deficiency; Rehabilitation; Prostheses.

.

The sacroiliac joints (SI) dysfunction is a condition when the normal joint biomechanics is affected, thereby leading to a restricted or excessive motion. Although it is a relatively common pathology, it is often underdiagnosed. This study aims to characterize this entity, particularly regarding the anatomy, biomechanics and physiopathology, as well as to describe the most relevant clinical features and treatment. For this purpose, we performed a narrative review of the literature published until May 2016 in medical databases. SI is the strongest and most stable diarthroses that support body weight. The torsional forces exerted on the SI are significant and are controlled by ligaments around them, particularly the sacrospinous and sacrotuberous ligaments. Both the ischiotibial and abdominal muscles appear to have a considerable lever effect, forcing the iliac to a posterior rotation. Clinical history and objective evaluation (eg, trunk flexion pattern and specific maneuvers) are fundamental for diagnosis and to exclude other potential differential diagnoses, such as discopathy and lumbar facet dysfunction. Treatment involves a multimodal approach that should include patient education, pharmacological treatment, physical agents, manual, muscle energy and stabilization techniques, and prolotherapy.

Introduction: Prolonged orotracheal intubation may induce dysphagia and lead to dehydration, malnutrition, aspiration pneumonia and death. A case study was developed to evaluate the presence of post-prolonged orotracheal intubation dysphagia and the  importance of early diagnosis to avoid complications.Material and Methods: For 12 months, between September 2016 and August 2017, patients submitted to prolonged orotracheal intubation were evaluated, with “STOP Dysphagia” protocol, between 24-72 hours and 6-8 weeks post-extubation,. The gender, age, comorbidities, admission diagnosis, severity indices at 24 hours APACHE II and SAPS II, time of prolonged orotracheal intubation, degree of dysphagia and complications were recorded. Patients with pathology involving swallowing physiology, unable to use the oral cavity for feeding or non-colaborative, were excludedResults: Fifty patients were evaluated, aged 20-83 years. The mean time of prolonged orotracheal intubation was 173 hours and 43 hours till evaluation. Twenty one (42%) patients had no dysphagia, 15 (30%) needed nectar, 5 (10%) honey, 7 (14%) pudding and 2 (4%) nasogastric intubation. A statistically significant difference was found between the presence of dysphagia and age (p=0.006) and severity indexes (APACHE II p=0.016, SAPS II p=0.014) and a moderate correlation between dysphagia severity and age (p=0.427 p=0.002)), APACHE-II (p=0.458 (p=0.001)) and SAPS II (p=0.428 (p=0.002)). No significant statistic correlation was found between prolonged orotracheal intubation and time of orotracheal intubation (p=0.385). Forty-one patients were reassessed 6-8 weeks after the first evaluation and only one still had dysphagia.Discussion: Post-prolonged orotracheal intubation dysphagia is a frequent complication and the early diagnosis allow to take adequate care and prevent complications. It has a good short-term prognosis with tendency to full resolution.Conclusion: Post-prolonged orotracheal intubation dysphagia must be excluded before oral feeding, to allow preventive measures and to avoid complications.

.

.

Introduction: Our objective was the identification and characterization of the bacterial spectrum and of its susceptibility to antibiotics in patients treated in a Spinal Cord Injury Unit. The determination of the role played in the infections by the vesical emptying method and the medullar injury, as classified by the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI).Material and Methods: We retrospectively analyzed 79 patients who had been hospitalized in a Spinal Cord Injury Unit between 1/09/2014 and 1/09/2015. One hundred and fifty-eight urine samples were collected and sent for bacteriological examination. The urine samples were collected only in cases where there was clinical suspicion of a UTI. The variables taken into account were: gender, age, ISCNCSCI classification, antibiotic therapy applied, microorganisms isolated in the urine cultures, the method employed to bladder emptying at the time of the infection, and the profile of resistance to antibiotics.Results: We found that 75.9% of patients contracted at least one UTI in our Spinal Cord Injury Unit, with a higher frequency detected among those subjected to a urinary catheterization technique. Patients undergoing continuous catheterization presented a higher number of UTIs than those on intermittent catheterization. The most common bacteria isolated were Klebsiella pneumoniae (43%) and Escherichia coli (22.8%). We determined that 71.5% of the isolated bacteria were multidrug-resistant. The highest rates of resistance (82%) were found among patients undergoing continuous catheterization (p < 0.05).Conclusion: Klebsiella pneumoniae was the most frequent bacterial cause of UTIs in our unit. Our results are consistent with scientific reports describing increasingly higher levels of bacterial resistance to drugs, as well as a higher rate of multi-resistant infections within the population with SCI. Intermittent catheterization is preferable, since most UTIs were reported among patients undergoing continuous catheterization. AIS D patients, and those with spontaneous urination, exhibited a lower rate of infection. These results are food for thought on the antimicrobial resistance of bacteria and on the need for the development of alternative strategies to prevent UTIs.

Background: Surf has been growing exponentially in Portugal. However, in Portugal, there are no publishedstudies about this issue. The few published researches (international) show that the most common acute injuriesare lacerations and contusions to the head, neck and lower extremity. Most of them result from direct collisionwith their own board.Objectives: The purpose of the study was to know the Portuguese reality about Surfing-related Acute Injuries,understand their pattern and risk factors and define injury prevention strategies.Methods: Cross-sectional study that included 151 surfers (convenience sample) of both genders, aged 18 years ormore, and that have been active surfers at 2009. The questionnaire was developed by the author. It was used SPSSprogram.Results: 246 acute injuries were reported: lacerations (46.4%), contusions (10.1%), sprains/strains (8.2%) andfractures (8.2%). They were to the head (31.3%) and lower limb (31.3%). 53.3% resulted from the collision withtheir own board, 20.2% occurred during the entering/exiting water, 65.9% in sand bottom, with small waves(427%) and with shortboards (81%). Surfers that practice in large waves have a higher risk for significant injuries.The calculated risk injury was 2.4 per 1000 surfing episodes.Conclusions: It is quite possible that most of the injuries can be prevented using protective equipment, changesin the equipment and self-protection strategies. It is important that these data are published and known and topromote a culture (and even a “fashion “) of prevention. More studies are needed for a better evaluation of Surfing Injuries.Keywords: Sports; Athletic injuries.

A actividade física na população idosa é uma realidade crescente. A consolidação desta realidade torna imperativa a opção por tratamentos cirúrgicos da anca que permitam a manutenção da maior funcionalidade. Estes doentes devem efectuar um período de reabilitação gradual, após a cirurgia, que lhes permitam realizar as actividades que eram comuns antes desta, nomeadamente a condução automóvel, actividades desportivas e relações sexuais. O médico assistente deve aconselhar sobre as actividades permitidas na fase pós-operatória para prevenir uma possível luxação da prótese. O sucesso da reabilitação na artroplastia da anca depende principalmente do próprio doente, sendo o papel da equipa multidisciplinar fundamental para o orientar em todo este processo.

A dor lombar crónica determina um elevado nível de incapacidade sendo atualmente um problema de Saúde Pública que afeta uma grande percentagem da população ativa na Europa. A fadiga, embora subjetiva e complexa, parece ser um dos principais sintomas dos doentes com dor lombar crónica. A prevalência e a patogenia da fadiga não estão completamente esclarecidas, porém sabe-se que a fadiga interfere de forma decisiva na percepção de bem-estar e na qualidade de vida. Este estudo pretende avaliar a prevalência da fadiga em doentes com dor lombar crónica não específica e o seu impacto na funcionalidade.Estudo clínico, transversal não-randomizado, em 30 adultos portugueses com dor lombar crónica que incluiu a aplicação dos seguintes instrumentos: Questionário de Caracterização Individual, Escala Visual Analógica para Dor, Escala de Impacto da Fadiga e Questionário de Roland e Morris.Verificou-se uma duração longa da dor (média de 10.6 anos) e valor moderado a alto de incapacidade na população estudada. Constatou-se uma relação estatisticamente significativa entre intensidade da dor e fadiga (p≤0.05) e entre fadiga e incapacidade (p≤0.001).A fadiga é um sintoma prevalente nos doentes com dor lombar crónica e está associada à intensidade da dor e à incapacidade. Este facto realça a necessidade de uma abordagem clínica do elemento nociceptivo, entendido como gerador de limitação à atividade e à participação. Sublinha também a necessidade de um programa de reabilitação funcional que identifique e aborde de forma objectiva as variáveis dor, fadiga e função.

.

Objectives: In patients with Traumatic Brain Injury (TBI), the increase of the pre-admission inpatient Length Of Stay (LOS) (hospital acute care inpatient LOS in other specialties, before the admission in Physiatry) and the Physiatry ward inpatient LOS can not justify its inclusion or maintenance in inpatient rehabilitation. Therefore, it may not be cost-effective comparatively to ambulatory models. The main objective of this study was to evaluate the impact of the pre-admission and the Physiatry ward inpatient LOS in functionality gains obtained by patients with TBI. Material and Methods: Population: Patients admitted for TBI in the Physical Medicine and Rehabilitation (PMR) ward between 1/1/1996 and 31/12/2010 (n = 79). Inclusion criteria: TBI; pre-admission inpatient LOS < 6 months; PMR ward inpatient LOS >7 days. Exclusion criteria: neurologic and musculoskeletal impairments before the TBI; complications that would affect the rehabilitation program. Study sample n=64. The variation of several functionality parameters (dependent variables) were analysed based on the PMR ward admission and discharge records. The analyses used generalized linear statistical models: logistic regression, multiple linear regression and logistic ordinal regression, in the variables with binary, interval or ordinal scales, respectively. The independent variables of the model were gender, age and the pre-admission and PMR ward inpatient LOS. To test if there was improvement after inpatient rehabilitation in the PMR ward, the t parametric test for paired samples was applied. Results: Gender (female: 32.81%, male: 67.19%); mean age (34.73±14.64 years); mean LOS (pre-admission: 68.03±36.71 days, PMR ward: 46.55±29.23 days). The PMR ward inpatient LOS led to statistically significant gains (p < 6.54x10-2) in all the dependent variables. The Pre-Admission Inpatient LOS (PAILOS) had a nonlinear statistically significant influence in the PMR ward inpatient LOS (estimate PAILOS: 1.18, estimate PAILOS2: -5.92x10-3, p PAILOS: 9.17x10-3, p PAILOS2: 1.52x10-2). The reduction of the pre-admission inpatient LOS was associated with a more favourable evolution in 20 functionality variables, 10 of which with statistically significant influence (p < 0.12). The increase of the PMR ward inpatient LOS was significantly associated with greater gains in the FIM and Barthel scales (p < 4.31x10-3). Conclusions: The pre-admission inpatient LOS has a nonlinear influence on the PMR ward LOS and constitutes a parameter of functional outcome in rehabilitation. Its reduction is cost-effective in the TBI rehabilitation. Therefore, it is recommend to be taken into consideration when selecting patients to inpatient rehabilitation. The inpatient rehabilitation program leads to significant functionality gains and a higher duration is associated with greater gains. Keywords: Traumatic Brain Injury; Length of Stay; Physiatry; Cost-Benefit Analysis Rehabilitation.

Introduction: Plantar Fasciitis (PF) represents the most common cause of plantar heel pain. An initial conservative trial is recommended. Objectives: To characterize demographic and symptomatic factors, previous therapy, results with laser monotherapy. Material and Methods: Observational retrospective study (12 months period). The treatment consisted of infrared laser (AsGa 904nm; energy density 20J/cm2; peak potency 200mW). Descriptive and comparative statistical analysis was made (level of significance 0,05). Results: Thirty-two patients with PF were followed-up, mean age 54,28 years (24-86; SD 13,95), 66% female, mean body mass index 30,18Kg/m2 (17,91-41,13; SD 5,19), 75% unilateral, mean time of symptoms onset 6,28 months (0,2-24; SD 6,82), 21 with previous pharmacotherapy and 12 with other PRM treatment modalities. Mean initial pain level (Numeric pain scale) was 7,31 (5-10; SD 1,38). Of the 26 patients treated (6 follow-up losses), 24 (92,3%) reported improvement. The average number of sessions was 28,5 (11-60; SD 14,01). The mean end pain level was 0,75 (0-5; SD 2,37), with an average pain level reduction of 89,7% (28,6%-100%; SD 0,16). The level of pain intensity at onset was superior in patients with higher body mass index (p=0,002). There were not found other statistical significant relations.Conclusions: PF was characterized by a significant pain level (moderate to severe). Obesity was a risk factor for the initial pain intensity. Rate reduction in pain level intensity was very satisfactory. Infrared Low level laser therapy is a good therapeutic option, justifying the need for further evaluation through randomized controlled prospective studies. Keywords: Laser Therapy; Fasciitis, Plantar; Pain; Physical Therapy Modalities. 

Introduction: Acute spinal cord ischemia syndrome or spinal cord infarction is a rare condition, accounting for 1- 2% of all stroke admissions. Several mechanisms can cause impaired perfusion of the spinal cord, and in a few cases no etiology can be found. We present two case reports with acute spinal cord ischemia syndrome admitted at a Rehabilitation Department, and compare their clinical features with current literature studies.Case Report: The first case was a 55-year-old woman with a C8 incomplete tetraplegia AIS C, after medullar infarction of unknown etiology. The second case was a 58-year-old man who developed a sudden neurologic status of a C6 incomplete tetraplegia AIS C, after a heart attack. In both cases the spine magnetic resonance identified a medullar lesion of ischemic characteristics. After rehabilitation treatment they presented a good functional and neurologic development. At discharge, both patients were independent, at daily life activities, and walked with gait devices.Discussion: Acute spinal cord ischemia syndrome has a wide variety of clinical syndromes, depending on the lesion level and the vascular territory affected. The two presented cases are suggestive of an anterior spinal artery syndrome, and are in concordance with the latest literature findings. The recent studies agree that the main prognostic factor is the impairment status at admission, determined by the American Spinal Injury Association Impairment Scale. Regarding the outcome, they reveal a good functional and neurologic recovery when the patient is submitted to an individual and holistic rehabilitation program.

Introduction: Regular physical activity reduces the risk of mortality and morbidity in patients with coronary disease, regardless of other lifestyle modifications. Reassignment to effort and encouragement to practice regular physical activity are key components of cardiac rehabilitation programs (CRP). The goal of this study is to characterize the physical activity levels of patients with coronary disease after have completed the effort reconditioning program (ERP) of the CRP.Material and Methods: Demographic data and clinical history were obtained of the SClinic computing platform. To assess the level of weekly physical activity of the patients, the International Physical Activity Questionnaire (IPAQ) was applied either in person or by phone. From the calculation of the METs made in different types of exercise throughout the week, it was possible to attribute to each patient a value called “total activity score” that allows the categorization of the sample into groups, sedentary, moderately active and active.Results: Fifty-five patients (71% males, mean age 53 years) were included in the study. 62% of the patients surveyed maintained regular physical activity, with 26% being classified as active and 36% moderately active. It has been found that there is a statistically significant difference in the level of weekly physical activity practiced when comparing patients over 55 years of age and with less than 55 years of age (p<0.05), presenting these last higher levels of physical activity. Patients who have completed cardiac rehabilitation treatment longer ago (more than 1 year) appear to be more likely to be sedentary than patients who have recently completed the rehabilitation program.Conclusion: PRE is an integral part of CRP, and it is expected that patients will acquire habits of exercise and/or physical activity through this intervention. It has been found that younger patients maintain a more sustained practice of physical activity.

.

Introdução: A instabilidade autonómica paroxística com distonia é uma complicação incomum de várias lesões do sistema nervoso central (SNC) ainda pouco compreendida, apesar do quadro clínico exuberante. Está associada a morbilidade e mortalidade significativas e aumento do tempo de internamento interferindo nos processos de reabilitação com resultados funcionais desfavoráveis. Por ser difícil de diferenciar de outras condições que põem a vida em risco é necessário que os médicos estejam alertados para esta síndrome. A persistente disfunção autonómica pode resultar em lesão cerebral secundária, podendo ser fatal.Caso Clínico: Cinco anos, sexo masculino, vítima de paragem cardiorrespiratória prolongada por quase afogamento, resultando numa encefalopatia anóxica grave com sequelas neuromotoras e cognitivo-perceptivas severas. Um mês depois foi internado num centro de reabilitação, em estado de mínima consciência, iniciando episódios de distonia em postura de descerebração associados a taquicardia, diaforese e choro persistente, desencadeados por diferentes estímulos. Estes episódios de difícil controlo, foram um desafio clínico interferindo grandemente no processo de reabilitação.Discussão: Esta entidade permanece pouco presente na prática clínica estando associada a morbilidade e mortalidade significativas, recurso exagerado de exames complementares de diagnóstico e terapêutica inadequada, interferindo na reabilitação destes doentes. O seu rápido reconhecimento e tratamento são cruciais para prevenir lesões cerebrais secundárias.

Purpose: Shoulder range of motion measurement is not only of diagnostic significance but is also relevant for monitoring response to therapeutic interventions. Smartphones incorporate accelerometers which enable easy multiaxial and multiangle measurements but their reliability compared to the classic goniometer remains to be established. The authors aim to ascertain the intra-rater reliability between manual and smartphone-based digital goniometry in measuring active flexion (AF) and external rotation (ER) in both standing (St) and supine (Su) positions. Methods: A convenience sample of 16 healthy volunteers was selected. Measures were taken by an independent rater at two different times, a week apart. We randomized both participant’s order and measurement sequence. The rater was trained according to a predetermined measurement protocol and blinded to intermediate measurements. We evaluated agreement between methods using the intraclass correlation coefficient (ICC), visual inspection of Bland-Altman plots and calculation of the limits of agreement. Results: The intra-rater correlation was good regarding the ER-StICC 0,87 (IC 95%: 0,66-0,95), the ER-SuICC 0,92 (IC 95%: 0,80-0,97)) and the AF-StICC 0,92 (IC 95%: 0,78-0,97). The score was lower in the AF-SuICC 0,81 (IC 95%: 0,55-0,93). Conclusions: There was a good intra-rater reliability between classic and digital goniometer in ER (regardless of positioning) and in standing AF. The smartphone based digital goniometer might be an easy tool to assist physical examination in healthy individuals, but its accuracy and applicability to clinical settings needs further evaluation.  Keywords: Arthrometry, Articular; Shoulder; Patient Positioning; Observer Variation;

.

Objective: 1)To characterize a spinal cord injured (SCI) population who underwent an inpatient comprehensive rehabilitation program at the Medical Rehabilitation Centre of the Central Region of Portugal – Rovisco Pais (CMRRC-RP); 2)To quantify the functional gains of this population using the SCIM; 3) To evaluate the possible correlation between SCIM III values and the motor score (MS) of the American Spinal Injury Association Impairment Scale (AIS); 4) Contribute to validate the Portuguese version of the SCIM scale. Material and Methods: Observational study using admission and discharge data including etiology, level and completeness of SCI, MS according to the AIS, SCIM III values of all SCI patients admitted to the CMRRC-RP in the time period between January 1st and December 31st 2010. Admission and discharge total and sub-total SCIM scores were compared. Variables such as age, gender, length of stay as an inpatient, etiology, level and completeness of injury were analyzed. The correlation between MS and SCIM score (totals and subgroups) was calculated to determine the applicability of thePortuguese version of the SCIM scale. Results: 47 of the 72 admissions met the inclusion criteria. Median Self Care, median Respiratory & Sphincter Management and median Mobility SCIM Subgroups, showed a significant functional improvement from admission to discharge. The major improvement was observed in the self-care item. AIS Upper Limb MS correlated highly with the SCIM Self Care, AIS Lower Limb MS correlated highly with SCIM Mobility and AIS total MS correlated highly with SCIM total score. Conclusion: TThe Portuguese version of SCIM was found to be useful and practical in assessing functional gains in SCI individuals submitted to a comprehensive rehabilitation management program in the CMRRC-RP. Keywords: Spinal Cord Injuries; Disability Evaluation; Recovery of Function; Rehabilitation Centers.