RCAAP Repository

Criança 11 anos, admitida em Centro de Reabilitação com o diagnóstico de Mal de Pott, condicionando paraplegia, que apresentava deformidade óssea da coluna dorsal e radiologicamente apresentava colapso vertebralcom destruição dos corpos vertebrais de D5- D8 e marcada angulação cifóticacom hipersinal da medula espinhal de D3- D8 a traduzir mielopatia. O Mal de Pott permanece uma realidade, sobretudo em doentes provenientes dos países africanos sendo otratamento dirigido e a reabilitação fundamentais para minimizar o impacto da doença e melhorar a qualidade de vida.

Introduction: Our aim was to assess fampridine impact on upper limbs (UL) function in multiple sclerosis (MS) patients.Material and Methods: A prospective, unicentric, open-label, non-controlled and non-randomized clinical study in patients diagnosed with MS, EDSS between 4 and 7, clinic with involvement of the upper limbs and under treatment with fampridine. For right (RUL) and left (LUL) upper limbs functional assessment, the 9-Hole-Peg-Test (9-HPT) scale was used immediately before (Pre-RUL and Pre-LUL) and after (Post-RUL and Post-LUL) starting treatment. Statistical analysis was performed using SPSS, with statistical significance set to p<0.05.Results: From a total of 23 patients, 15 were included. The averages of the time (in seconds) of the evaluations were: pre-RUL 86.12 and post-RUL 50.95; pre-LUL 53.98 and post-LUL 45.08, with statistically significant value for the RUL (p=0.003, dominant upper limb.Conclusion: The results suggested the potential of fampridine in improving upper limbs function, in addition to the gains already confirmed in gait.

Purpose: Tracheotomy is a temporary or permanent procedure for treatment of upper respiratory tract failure, neurologic pathology, and trauma. It also presents some disadvantages: cervical dysmorphia, need for cannula cleaning/replacement, oral communication difficulties, absence of nasal function and tracheomalacia risk. Accordingly, as soon as possible, tracheotomy closure is needed in patient ́s rehabilitation. Cannula removal should only be considered if upper airway obstruction has solved, respiratory secretions are minimal and there is no need for mechanical ventilation. Predictors of success: ability to produce cough and absence of aspiration phenomena. Cannula withdrawal requires care, particularly after prolonged use. A standardized protocol optimizes performance and minimizes risks. PMR, in partnership with other specialties and health professionals, has a key role to play in this procedure. We present the protocol used in tracheotomy closure in our PMR institution. Material and methods: Literature search about tracheotomy management and closure protocols Results: Protocol (steps to follow-resume): - Deflate the cuff - Change to an uncuffed tracheostomy tube with smaller diameter - Partial cannula closure - Complete tube closure - Cannula removal and stoma closure Important remarks: - Set responsible physician - Evaluate the need of protocol adaptation with nursing team - Inform the patient and collect consent - Teach patient/caregivers how to act in case of sudden dyspnea - Monitor O2 saturation/patient surveillance - Each step must last a minimum of 12 hours. Conclusions: The PMR team skills and knowledge are essential in the tracheotomy closure comprehensive approach. A protocol improves its management. Scientific information is scarce and valid studies are needed in this field. PMR should contribute to improve the services provided to these patients. Keywords: Tracheotomy/rehabilitation; Airway Management.

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Hiccups are sudden and involuntary contractions of the diaphragm and intercostal muscles, which causes sudden inspiration followed by abrupt closure of the glottis, generating a characteristic sound. There is a large panoply of pharmacological and non-pharmacological interventions that have been attempted to treat persistent or intractable hiccups. However none of the interventions showed sustained and consensual scientific evidence. Some studies have suggested favorable effects of acupuncture on eliminating persistent hiccups. In this article we report a clinical case in which acupuncture was used to eliminate persistent hiccups following brainstem stroke.

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The complex regional pain syndrome (CRPS) is characterized by disproportionate pain concerning noxious stimuli,as well as sensory, vasomotor, trophic or motor disorders in the affected limb. It´s related to major trauma andsoft tissue minor injury, clinically presenting from joint stiffness and pain, to loss of function.The Physical Medicine and Rehabilitation (PRM) approach is crucial in functional recovery.The authors describe the case of a 32-year-old male with a knee pain that began 4 years ago. He was sent a yearago, after several knee arthroscopies without significant diagnostic findings, presenting quadriceps atrophy, kneeoedema and hyperesthesia, which lead to walking with crutches and professional inability. The patient wassubmitted to a program including joint mobilization and muscle strengthening as well as analgesicelectrotheraphy. After the contribution of bone scintigraphy for the diagnosis of CRPS, calcitonin was introducedand a reinforcement of the program was made through additional muscle strengthening, physical agents andpsychological support. An increase in muscle strength, pain relief in walking (VAS) and professional reintegrationwere accomplished.In CRPS, early intervention of PRM is decisive in keeping functional use of the affected limb through pain relief,range of movement and muscle strength preservation, as shown in this case.Keywords: Complex Regional Pain Syndromes; physical therapy; knee; pain.

Vitamin B12 deficiency causes several neurological manifestations such as myelopathy, polyneuropathy, optic neuropathy and dementia. The most common etiology for vitamin B12 deficiency is pernicious anemia; however, other causes include strict vegan, post-gastrectomy and Crohn’s disease. Vitamin B12 deficiency-induced myelopathy (subacute combined degeneration) is characterized by affecting the posterior and lateral columns of the spinal cord, which may lead to severe and irreversible damage. Diagnosis is established by clinical features, serum cobalamin and homocysteine levels, urinary methylmalonic acid measurements and magnetic resonance imaging. Treatment is based on vitamin B12 injections and recovery depends on the severity and duration of the deficiency. Typically it requires Physical and Rehabilitation Medicine for patients suffering from lasting deficits. In this case report, authors show promising clinical and functional results after the administration of cobalamim and after following a rehabilitation program.

Objetivo: Apresentar um modelo conceptual de história clínica em Medicina Física e de Reabilitação, tendo por base o seu papel de promoção da funcionalidade física e cognitiva.Material e Métodos: Foi realizada uma revisão da literatura, partindo de pesquisa na base de dados PubMed e consultando fontes adicionais de informação.Resultados: Verificou-se que o conteúdo da história clínica é relativamente consensual entre autores, porém a estrutura à qual esta obedece não está homogeneamente descrita. Neste artigo é apresentado um modelo de história clínica elaborado com base na literatura revista.Conclusão: A história clínica é um elemento fundamental na abordagem de qualquer doente. Apesar de existir uma estrutura comum, as particularidades de cada especialidade exigem uma adequação deste modelo, de forma a orientar a colheita de dados para os seus objetivos específicos. No caso da especialidade de Medicina Física e de Reabilitação, a avaliação funcional e contextual do doente assume particular importância, sendo determinante para o estabelecimento da estratégia de reabilitação.

Introduction: Introduce the animal assisted therapy ( AAT) into the therapeutic sessions and see if it will be a facilitator in achieving the defined goals.Material and Methods: We selected 3 children, followed in Physical Medicine and Rehabilitation (PMR) consultation and in treatment at the PMR service: C1 of 15 months (m), with occupational therapy sessions since 4m, due to delay of psychomotor development (DPMD); C2 of 31m, with speech therapy sessions since 14m, due to delay of language development; C3 of 27m, with occupational therapy and speech therapy sessions since 9m, due to DPMD. Individual and specific objectives were defined. The SGS-II was applied as an evaluation instrument at the beginning (T0) and at the end of the study (3 months later - T1), to evaluate C1 and C3, and to assess C2 were used specific articulation tests (applied at T0 and T1). The instructor designed the activities, together with the child ́s therapist, and guided the animal in session. The dog possessed obedience training and professional experience. Parents signed informed consent. The sessions were held once a week (45 minutes each), being filmed for later discussion of the case.Results: According to the SGS-II parameters evaluated at T0 and T1, we found that C1 presented a development corresponding to a mean age of 8m in T0 and 12m in T1, with an improvement in the speech and language parameter (result corresponding to an expected development of a 3m child in T0 and 15m in T1) and in the manipulative capacity (obtaining a development corresponding to a child of 8m in T0 and 15m in T1). C2 revealed in T1 a capacity for sentence construction (not observed in T0), improvement of the orofacial praxis and increase the time of attention/accomplishment of tasks. In C3, there was no change in the quoted values in the evaluation scale used. However, after viewing the session videos, we observed an increment in attention times, organization of simple tasks, comprehension of simple orders and improvement in number of vocalizations. Conclusion: The AAT emerges as a complement to the therapeutic sessions, enhancing the work developed by the technicians, facilitating the achievement of more expressive results in the specific cases of children with difficulties in interaction with the therapist. The dog becomes a motivating and optimizing vector of results. We consider the results obtained positive, given the short time elapsed from the program. Even in C3, where, despite the unchanged result of the evaluation scale used, it was found, after analyzing the parameters observed during the review of the session videos, an overall improvement in all of them.

Peripheral neuropathy is a common clinical problem, resulting from peripheral nerve injury. The toxic etiology is a less common cause, comparative with metabolic, inflammatory and hereditary. Included in this group the chemical, industrial and agricultural agents, heavy metals, and medication. In general, therapeutic approach of toxic neuropathies consists on removal of the causal agent, relieving pain, prevention and treatment of sequelae and therefore its important to refer to Physical Medicine and Rehabilitation. The authors present two clinical cases and a literature review of the pathophysiology, clinical management and treatment of toxic neuropathies. Keywords: Peripheral Nervous System Disease/chemically induced; Peripheral Nervous System Disease/ rehabilitation.

Spinal cord injury is a devastating health problem posing, along its course, huge challenges to the doctor and the patient. Few studies have addressed autonomic dysfunctions after spinal cord injury, particularly the diagnostic perspectives and therapeutic interventions. The joint committee of the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS) recommends the recognition and assessment of the following conditions as autonomic nervous system dysfunctions after spinal cord injury: Neurogenic Shock, Cardiovascular Dyfunctions (cardiac dysrhythmias and orthostatic hypotension), Autonomic Dysreflexia, Temperature Dysregulation and Sweating Disturbances. This article discusses the pathophysiology, diagnosis, and treatment of the different autonomic nervous system dysfunctions after spinal cord injury, in terms of the global rehabilitation of the spinal cord injured. Keywords: Autonomic Nervous System Diseases; Spinal Cord Injuries. 

Compression stockings are commonly used for prophylaxis of deep venous thromboembolism after surgery and its effectiveness is well established. Peroneal nerve palsy is the most common entrapment neuropathy of the lower extremity. It can result from multiple causes but direct external compression of fibula head seems to be the main one. The authors report a 20-year-old female patient, who was submitted to a liver transplantation and after 25 days on Intensive Care Unit, rolled-down compression stockings were removed, and a linear impression mark below knee with bilateral foot drop was observed. The electrodiagnostic testing confirmed the diagnosis of a severe sensory-motor polyneuropathy. The aim of this report was to emphasize the importance of early recognition of the symptoms of peripheral nerve injury, especially in critical ill patients with multiple risk factors, who might have a worst outcome and permanent damage.

Botulinum toxin application on post burn hypertrophic scars has had a growing international interest. Despite this, up to this day, there are no scientific publications or case reports in Portugal on the usual data bases. We present the first case published in Portugal, as well as the protocol in use and the objective and patient-reported results. The positive results achieved are in line with the existing literature. This technique should thus be considered in selected patients, constituting an added value in the rehabilitation of hyperthrophic scars sequelae.

The ability to walk upright is a defining characteristic of man.Walking is a complex process where body segments need to move in a coordinated manner. The lower bodyextremity must have the ability to support body weight during the stance phase of the locomotion cycle, rotateand coordinate the joints to achieve forward progression, adjust limb length during the swing phase of gait, andfurther smooth the trajectory of the centre of mass for energy conservation.Some of the therapeutic strategies adopted in paediatrics ortotraumatologic and/or neuromuscular pathology,involve walking with a blocked knee, for example knee arthrodesis, transfemoral amputation or kneedisarticulation with a non-articulated prosthesis, or a Knee-Ankle-Foot Orthosis (KAFO), that generally doesn’tarticulate. Patients who walk with a knee blocked in full extension clear the foot during swing phase by adoptingcompensatory movements and such compensations result in decreased efficiency and increased energeticconsumption.KAFOs are prescribed for individuals who, due to significant weakness of the knee extensor musculature or deformity, need a mechanical control of the knee during stance, trough blockage in extension. More recently, theintroduction of Stance-Control Knee-Ankle-Foot Orthoses (SCKAFO) has been designed to allow swing phasefreedom for the knee joint while automatically providing stance phase stability. However, commercially availablesolutions are not available to the paediatric population, and this stage is essential for the development andacquisition of a definitive corporal scheme and activation of motor patterns.The aim of this paper is to highlight the importance of lower limb orthoses with articulated knee, for thepaediatric population. The authors have split this article into three sections: the first section reviews the gait cycle,describing the changes resulting from the blocked knee in extension; the second section presents lower limborthoses available with assistance during the support phase, setting out its faults; in the third section, by way ofconclusion, the authors propose guidelines for future research solutions adaptable to the paediatric population.Keywords: Child; Knee Joint ; Knee Prosthesis; Walking

Simultaneous bilateral anterior tibial tuberosity avulsion fracture is a very uncommon injury and rarely reported in adolescents. Since the first reported case by Borch-Madsen in 1955 only 23 cases have been published. We report the case of a 14-year-old boy who had a simultaneous bilateral anterior tibial tuberosity avulsion fracture during a gym class, while running. The patient was submitted to surgical repair with anatomical reduction of the fractures and fixation with a cannulated screw. The patient underwent an intensive rehabilitation program for 4 months, without any significant complications. The outcome was very favorable with complete return, without restrictions to daily living activities.

Introduction:  Congenital pseudarthrosis of the clavicle (CPC) presents as a congenital painless swelling over the mid-third of the clavicle, mostly on the right side and females, that persists over lifetime with no functional limitations.Purpose: Present a 12 years follow-up case of CPC and literature review.Clinical Case: A full-term newborn boy, with uncomplicated pregnancy and vaginal delivery, presented with a firm bony protuberance (1x1cm), in the mid-third of the right clavicle without functional limitations and no other physical examination abnormality. The X-ray identified a bony defect in the mid-third of the right clavicle with smooth, regular, intact/sclerotic cortex and without any evidence of callus formation. The diagnosis of CPC was performed.Over the twelve follow-up years, he kept asymptomatic, without functional limitations and normal physical and skeletal development. Over time, the X-rays showed the same bone defect with the same characteristics. At fourth years old, surgery was proposed for aesthetic reasons but parents refused.Conclusions:  Although rare, CPC can be easily diagnosed through characteristic physical examination findings and radiographic hallmarks. It is essential to exclude other differential diagnosis, like clavicular fracture or rare bone diseases, and be able to reassure parents, explaining the benign nature of this condition.

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Congenital scoliosis remains a challenge for the PMR clinician. It results from an anomaly in the vertebral development leading to its presentation in younger ages, when compared to idiopathic scoliosis. Congenital curves tend to be rigid and resistant to conservative treatment, that considering the remaining growth potential, may result in severe spine deformities. The authors reviewed the published literature concerning congenital scoliosis, aiming at the update of the fundamental aspects in diagnosis and treatment. Vertebral anomalies are classified in segmentation, formation, and mixt defects. Formation defects can be complete or partial, leadind to a hemivertebra ou a wedge vertebra. Among segmentation defects are the unsegmented bars and the vertebral bloc, in the complete absence of disc. The patient evaluation consists in a complete medical history, including prenatal, birth and neonatal antecedents, family history, development milestones and system revision. Physical examination includes spine, cutaneous, thoracic, genital and limb inspection and neurologic examination. The recognition of associated anomalies is important, namely intraspinal, genito-urinary and cardiovascular, among others. Early diagnosis and adequate follow-up are the key elements to avoid progression and complications. X-ray allows the diagnosis of vertebral malformations, measurement of scoliotic curve progression and the determination of growth potential. Evolution depends on the affected area, type of anomaly, age at diagnosis, balance and curve pattern. The presence of an unsegmented unilateral bar has a bad prognosis, whereas a vertebral bloc has the best prognosis. Even though orthotic treatment remains controverse, the possibility of delay in the progression of the scoliotic curve, allowing surgery in a later age, justify its use as a treatment option, in selected cases. The treatment of scoliotic short, rigid and progressive curves is surgical. PMR plays an important role in the diagnosis, treatment management and interface with other specialties, considering the specificity of individual treatment and hazard complications. Keywords: Scoliosis; Spine abnormalities; Diagnosis; Treatment.

Objectives: To evaluate the relationship between age and functional outcome in patients with sequelae of Traumatic Spinal Cord Injury (TSCI).Material and Methods: Retrospective study, with a 88 patients sample that were admitted as inpatients in Physical Medicine and Rehabilitation (PMR) Department of Hospital de Braga, between the years 2007 and 2011, with sequelae of TSCI. Clinical files were consulted and two age groups (<65 and ≥ 65 years) were compared. The Functional Independence Measure (FIM) was used to quantify the functional outcome by calculating the variation between the values at admission and discharge, in 68 of the 88 patients. For gait evaluation were used Modified Functional Ambulation Classification (MFAC) and the Walking Index for Spinal Cord Injury II (WISCI-II).Results: There were 65(73,9%) patients with <65 years and 23(26,2%) were ≥ 65 years. The mean age was 50 years. Fall was the most prevalent cause of TSCI. Cervical injuries were more frequent, as well as incomplete lesions. The average hospital stay was 95 days. The mean MIF score was 66.32 points (<65 = 67.2, ≥ 65 = 63.38) at admission and 97.09 points (<65 = 100.89, ≥ 65 = 83.4) at discharge . The mean MIF variation was 30.19 points (<65 = 33.36, ≥ 65 = 19). The mean MFAC was 0.33 and 1.57 points, and the mean WISCI-II was 1,60 and 8,55 points, at admission and discharge, respectively. There was a statistically significant relationship between age at the time of the accident and the FIM variation.Conclusions: In this sample there was a predominance of males and age at the time of the accident less than 65 years. There was an influence of age on functional outcome in patients with TSCI during hospitalization in a PRM Department, and patients aged ≥ 65 years showed a lower functional outcome, highlighting the importance of age on functional recovery after TCSI.