RCAAP Repository

introdução: Embora as guidelines atuais recomendem o exercício como tratamento de primeira linha na doença arterial periférica, quer a sua disponibilidade quer a sua utilização continuam a ser limitadas. O objetivo deste trabalho consiste em fazer uma revisão sobre as características ótimas de um programa de exercício na doença arterial periférica.Métodos: Foi realizada uma revisão bibliográfica sistematizada. Foram utilizadas as bases de dados PubMed e Cochrane Library sob os termos de pesquisa: “exercise” AND “peripheral arterial disease” e “rehabilitation” AND “peripheral arterial disease”. Foram incluídos os consensos, guidelines, meta-análises e artigos de revisão encontrados desde janeiro de 2010 até dezembro de 2016.Resultados: Foram identificados 35 artigos. Estão descritos inúmeros programas de exercício nos mais diversos estudos. Parece existir superioridade nos programas de exercício supervisionados, com duração superior a três meses e uma frequência de três vezes por semana. É proposto treino aeróbio intermitente com duração mínima de 30 minutos. Ainda existe controvérsia relativa à intensidade mais adequada e ao ritmo de progressão do programa de exercício. O treadmill é a modalidade mais estudada, no entanto, outras modalidades alternativas têm ganho interesse crescente.Conclusão: Apesar de existir ainda alguma controvérsia relativa à superioridade de determinados parâmetros na prescrição de exercício, existem outros bastante consensuais, nomeadamente no que diz respeito a supervisão do programa, duração e frequência das sessões de exercício.

Introdução: A maioria das complicações relacionadas com o aparelho extensor numa artroplastia total do joelho (ATJ) prendem-se com a instabilidade patelo-femoral. O objetivo deste artigo é ilustrar o desafio que pode ser para o Fisiatra a orientação de um doente com luxação recidivante da rótula após ATJ.Caso Clínico: Doente de 70 anos, do sexo feminino, seguida em consulta de Medicina Física e Reabilitação por status pós-ATJ direita (bi-compartimental) complicada com luxação recidivante da rótula. Depois de um episódio de queda, sofreu fratura proximal da tíbia com descolamento do componente tibial, tendo sido submetida a revisão cirúrgica e posterior plano de reabilitação individualizado. Foi intervencionada mais quatro vezes por luxação recidivante da rótula e luxação da própria prótese.Discussão: A etiologia da instabilidade rotuliana após artroplastia total do joelho é muitas vezes multifatorial, sendo a principal causa os erros técnicos cirúrgicos que podem levar a um mau posicionamento dos componentes protésicos. A maioria das opções de tratamento passa por uma revisão cirúrgica seguida de um plano de reabilitação.Conclusão: A instabilidade patelo-femoral é uma complicação relevante em doentes submetidos a artroplastia total do joelho, podendo a mesma ser evitada por múltiplas estratégias cirúrgicas e não-cirúrgicas.

The Temporomandibular Joint Disfunction (TMJD) reaches to a variety of clinical conditions associated to pain and disorders of the temporomandibular joint (TMJ) and masticatory muscles, which are of controversial aetiology. Despite of the excellent vital prognosis, the TMJD could impose substantial decreases in the life quality. The recent recommendations concerning to treatment, advice an initial conservative approach, which includes almost consensually the important role of Physical and Rehabilitation Medicine (PRM). The authors present a bibliographic overview of the scientific evidence concerning the success of the PRM in the TMJD. Keywords: Temporomandibular Joint Disfunction (TMJD), Physical and Rehabilitation Medicine (PRM)

Currently survival has increased in patients with congenital heart disease due to advances in medicine. However, most of these patients still does not perform regular physical activity, not due to their underlying disease, but because fears of themselves, family members and teachers related to the disease. Also cardiac rehabilitation programs with well-known benefits in adults are still little performed in children and adolescents and it is not known the methodology and results at the level of functional abilities and psychological condition of these patients. The authors reviewed the literature searching for the current evidence of cardiac rehabilitation programs for children and adolescents with congenital heart disease and current recommendations for practice of physical activity.Most studies report the beneficial effects of multidisciplinary cardiac rehabilitation programs, including psychological and nutritional counselling, to decrease the number of new hospitalizations and improve functional capacity and quality of life of these patients. At the same time, there are many articles that point out that physical exercise and participation in competitive sports in most cases is possible and safe, if the patient follow the necessary recommendations to their pathology in particular and the advices given for their attending physician in relation to this particular subject.

Introduction: Low back pain is a major cause of chronic pain and one of the most frequent reasons for referral to Physical and Rehabilitation Medicine (PRM)’s consultation. Chronic back pain can lead to significant functional disability and is a common cause of work absenteeism. The main purpose of this study was to evaluate the efficacy of mesotherapy in relieving chronic low back pain and to investigate if that relief has functional impact on the daily life of patients.Methods: A quasi experimental pre post study was conducted on a PRM Department, assessing all patients with chronic low back pain who underwent mesotherapy in the period from March to November of 2014, applying the questionnaires “Brief Pain Inventory” (BPI) and the “Roland Morris Disability Questionnaire” (RMDQ) before and after the four cycles of treatment with mesotherapy with antiinflammatory, local anesthetics and muscle relaxants.Results: We included 26 patients, 80.8% women and 19.2% men, with a mean age of 54.8 years. The most common diagnosis was non-specific low back pain (34.6%). Analyzing BPI, there was a decline of 2.6 points in pain severity scale after mesotherapy, statistically significant finding (p = 0.000). For evaluation of functional impact of pain, assessed by the BPI, there was a decrease of 1.7 points, statistically significant result (p = 0.000). In RMDQ there was a decrease of 4.5 points after mesotherapy (p = 0.000).Conclusion: Although there are few articles in the literature, mesotherapy seems to lead to the relief of low back pain, which provides a better quality of life for patients. Therefore, mesotherapy may be a valid alternative to the conventional approach of low back pain.

Non-traumatic cerebral hemorrhages are less common than acute ischaemic vascular lesions but are associated with higher mortality rates and years of life lost due to disability. They may lead to a diversity of neurological deficits, being the intervention of Physical Medicine and Rehabilitation (PMR) essential for clinical and functional improvement.59 years-old female patient, non-hypertense, previously independent in activities of daily living and cognitively intact. The patient was admitted to the Emergency Department after a sudden severe headache. On admission, the patient presented a left homonymous hemianopsia and hemiparesia. Computed tomography revealed a voluminous parenchymal cortico-subcortical right temporo-fronto- parietal hemorrhage. The patient underwent emerging decompressive craniectomy. During hospitalization, the patient had a positive clinical and functional evolution, and was transferred on the 66th day of hospitalization to the PMR ward. After 17 days, the patient presented an indolent deterioration of the state of consciousness, with progressive somnolence and prostration, making unfeasible to participate in the rehabilitation program. Given the worsening of the neurological status, neuro-imaging study was repeated and a large expansive lesion with necrotic- cystic enhancement pattern, of probable neoplastic etiology (primary glial or secondary series) was depicted.The evaluation, interpretation and orientation of cases of nontraumatic intracerebral hemorrhage with fluctuation of neurological status and/or stagnation of functional evolution in the subacute and chronic phase appears as a diagnostic challenge. It is essential to increase the perception that intracerebral hemorrhage without defined etiology may be due to primary or secondary brain neoplasms, which require early and directed evaluation and guidance.

Objectives: This paper is intended to analyze several, considered relevant, studies in order to draw up a leafletthat includes joint protection measures and an exercise scheme, for the patient with rheumatoid arthritis (RA).Material and Methods: The authors performed a literature review on joint protection programs and handexercises for patients with RA; the authors selected five studies that had a higher study design quality andadequate outcomes: pain, inflammation, muscle strength and function.Results: The reviewed studies shown beneficial effects of several exercise and joint protection programs in termsof pain, stiffness, grip strength and upper limb function. The beneficial effects of these programs remain longterm.Just providing information is not enough - demonstration and repetition is required.Conclusions: The programs that combine measures of joint health, range of motion exercises and musclestrengthening, with increasing repetitions are more effective and better tolerated. Based on the data drawn fromthe various studies, the authors developed a leaflet for patients with RA, as a part of a comprehensiverehabilitation program.Keywords: Rheumatoid Arthritis; Hand; Exercise Therapy; Patient Education; Health Behavior.

Introduction: Cardiac rehabilitation programs (CRP) are recommended (Class I, level of evidence A) in the entire spectrum of coronary disease , including after percutaneous coronary interventions . However, current evidence is unclear about the impact of CRP in patients with significant residual stenosis after PCI, thereby many cardiac rehabilitation program consider them inegible.Aim: We aimed to evaluate the influence of residual significant coronary stenosis (in other territories) in response to a multidimensional CRP.Methods and Materials: Retrospective analysis of 369 patients enrolled in a cardiac rehabilitation programs (phase II) who underwent successful PCI (residual stenosis <10% and final TIMI flow grade 3) after acute coronary syndrome (ACS). Patients were categorized according to the presence of significant anatomic stenosis (≥ 50%) in additional non-revascularized coronary territories (EST+). We collected data on socio-demographic characteristics, cardiovascular (CV) risk profile and ACS characteristics. The functional capacity [metabolic equivalents (MET) and total duration of the exercise stress test (min:sec)], the psychosocial profile (based on hospital anxiety and depression scale ) and quality of life (based on short-form-36 health survey) were assessed at the baseline and end of the CRP. Intragroup comparisons were performed using paired student’s t-test or Wilcoxon test, and the Mcnemar. For intergroup comparisons we used the t-student or Mann-Whitney test, and the Qui-square.Results: The groups did not differ in age, but there was a higher prevalence of women and lower proportion of active workers in the group EST+. The group EST+ had a worse CV risk profile and worse baseline functional capacity. There were no differences in the ACS characteristics, psychosocial profile and general perception of health status. Both groups showed significant improvement in functional capacity [1.5(1.61) MET versus +2.1(1.5), ρ<0.001], and not significantly different between groups (ρ = 0.91); significant improvement in both physical dimensions [(+3.6 (6.5) vs. +3.1 (6.7), ρ <0.001] and mental dimensions of the SF36, only in the group EST-. As for psychosocial profile, we found a significant reduction in anxiety only in the group EST-.Conclusion: The benefit of multidimensional PRC seems to be extended to patients with residual coronary disease. However, the heterogeneity of this group, suggests caution in interpreting these results and should be considered when deciding on the referral.

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Introduction: The benefits of land-based aerobic physical training in patients with cardiac pathology are well studied. However, there are patients who, for personal reasons or osteoarticular limitations, prefer to exercise in water, so it is important to understand the advantages, disadvantages and precautions to be taken when the rehabilitation plan is carried out in an aquatic environment.Methods: To carry out this narrative review, the following databases were accessed: MEDLINE, SCOPUS and Web of Science.Results:With the increase of the immersion depth, the heart fills and consequent systolic volume increases, but the heart rate (HR) decreases. Peak oxygen uptake (VO2peak) and HRpeak values are 84% and 95% lower in water compared to those observed out of water, respectively. Therefore, a reduction of 13% or 10 bpm in relation to the target HR values established out of water is recommended. Aquatic exercise induces an increase in heart rate variation and cardiac autonomic modulation, both of which have a positive impact on the prognosis of these patients.Conclusion: Physical exercise in water is safe, provides cardiovascular protection and improves the prognosis in low-risk cardiac patients who are in phase III of the cardiac rehabilitation program and who, for musculoskeletal or personal reasons, prefer to perform exercise in this context.

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Introduction: Evaluate the intra- and interrater reliability in the thigh circumference measurement using different anatomical references.Material and Methods: Twenty five volunteers without history of pathology or surgery in the dominant leg entered in the study. The measurements were performed by two independent evaluators, on two occasions with an interval of one week. The measurements and participants order were randomized. The results of the interim measures were concealed, being analyzed by a third investigator. The assessment protocol was previously defined. The intra- and inter-rater correlation was measured through the intraclass correlation coefficient (ICC). The limits of agreement were established in accordance with the method of Bland and Altman.Results: The intraclass agreement in intrarater reproducibility was high (SPPICC 0.96, KJLICC 0.95, ASISICC 0.96). In the interrater results the limits of agreement were: SPPICC 0.91 (IC 95%: 0.79–0.96), KJLICC 0.94 (IC 95%: 0.86–0.97), ASISICC 0,90 (IC 95%: 0.77–0.95).Conclusion: All methods presented high intra- and interrater reliability, which by the simplicity of the measurement method may favor the choice for upper pole of the patella in the absence of pathology in anatomical segment evaluated.

A afasia cruzada caracteriza-se por um distúrbio adquirido da linguagem causado por uma lesão hemisférica cerebral direita em dextros, com uma prevalência de 1% - 2%.Os autores reportam o caso clínico de um homem de 69 anos de idade, dextro, com múltiplos fatores de risco cardiovascular.Assintomático até 28 de setembro de 2017, altura em que inicia quadro de alteração da linguagem e défice motor esquerdo, motivo pelo qual foi admitido no serviço de urgência onde efetuou estudo imagiológico cerebral que evidenciou lesões isquémicas hemisféricas direitas. Realizou trombólise endovenosa e trombectomia mecânica. Apresentou agravamento neurológico 24 horas após o início do quadro clínico, pelo que repetiu o estudo imagiológico que mostrou lesões isquémicas cortico-subcorticais fronto- temporo-parieto-insular direitas com envolvimento da região caudado-lenticulo-capsular.Admitido em Unidade de Acidente Vascular Cerebral e, posteriormente, no Serviço de Medicina Física e de Reabilitação. À avaliação inicial, além do défice motor esquerdo apresentava alterações da linguagem compatíveis com afasia global. Foi integrado num programa de reabilitação, com evolução lenta do quadro afásico e motor.O prognóstico da afasia cruzada relaciona-se com a localização e gravidade da lesão cerebral. Dada a gravidadeda lesão do doente será de esperar uma evolução lenta/estabilização do quadro clínico.

Objective: to determine if in a population of spinal cord injury above D11 patients the use of an abdominal binder(AB) improves or not respiratory function. Material and Methods: it was done a longitudinal retrospective study,and selected all inpatients that were in Spinal Cord Injury Department of Centro de Medicina de Reabilitação deAlcoitão – Portugal - with tetraplegia or paraplegia with neurological level above D11, between the 1st of Januaryand the 31st of March 2009, that have done functional respiratory tests with and without AB. We analyse thefollowing parameters: forced vital capacity (FVC), total lung capacity (TLC), residual volume (RV), inspiratorypressure (IP) and expiratory pressure (EP). It was used SPSS 11.5 and T-student test for statistical analysis. Results:AB use increased FVC (p=0,02) and EP (p=0,004), and decreased RV (p=0,00). Conclusions: this study foundevidence that AB use in patients with tetraplegia or paraplegia with neurological level above D11 improvespulmonary ventilatory function.Keywords: Spinal cord injuries; Abdominal binder; Abdomen; Respiration; Restraint, Physical.

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Actualmente a sobrevida tem aumentado em doentes com cardiopatias congénitas devido aos avanços da medicina. No entanto, a maioria ainda não realiza actividade física regular, não por impedimento devido à sua patologia de base, mas por receios dos próprios, familiares e professores. Além disso programas de reabilitação cardíaca com benefícios bem conhecidos nos adultos, ainda são pouco realizados em crianças e adolescentes, desconhecendo-se a sua metodologia e resultados a nível das capacidades funcionais e estado psicológico destes doentes. Os autores realizaram uma revisão da literatura sobre as evidências actuais dos programas de reabilitação cardíaca em crianças e adolescentes com cardiopatias congénitas e quais as recomendações actuais sobre a prática de exercício físico.A maioria dos estudos relata os efeitos benéficos de programas de reabilitação cardíaca multidisciplinares, incluindo orientação psicológica e nutricional, na diminuição do número de reinternamentos, melhoria das capacidades funcionais e qualidade de vida destes doentes. Concomitantemente, são inúmeros os artigos que salientam que a prática de exercício físico e participação em desportos de competição na maioria dos casos é possível e segura, desde que seguidas as recomendações necessárias para a patologia em concreto e tendo em conta o doente de forma individual, cabendo ao médico assistente dar todo o aconselhamento necessário em relação a este assunto em particular.

Musculoskeletal complaints take a place in the primary health care consultation grounds. Synthetic injectable corticosteroids (CCT) have been widely used as anti-inflammatory agents in several musculoskeletal disorders, both articular and soft tissues, allowing greater symptomatic control, greater range of motion and / or improved function. The effectiveness in its use depends not only on a correct medical diagnosis, but also on the selection of the most appropriate drug and on the technical execution of the procedure. Currently, there is little evidence to guide the selection of the most appropriate CCT. This review article offers an overview of the different CCT preparations that can be used in injectable procedures in musculoskeletal pathology, their indications and complications in order to assist the physician in choosing the best drug. The choice must be guided by the objective, the underlying musculoskeletal diagnosis and clinical experience. Complications resulting from its use are rare, but the doctor must be alert and understand its potential risks, in order to properly advise the patient.

Objectives: Non-traumatic spinal cord injury (NTSCI) presents a significant challenge for treatment and rehabilitation and a thorough knowledge of this population may help to adjust service responses to need. We perform a retrospective analysis of first-admission NTSCI patients in a specialized spinal cord injury service in Portugal. Methods: Medical records of all NTSCI patients first admitted between 01/01/2007 and discharged up to 30/11/2009 were sought. Patients who presented with a time to injury window greater than 24 months and who had prior rehabilitation in another specialized service were excluded. Epidemiological and injury etiology variables were collected, as well as neurological and functional outcome measures (ASIA Impairment Classification, FIM, bladder control, ambulation, and complications). Statistical analysis of data was performed using SPSS for Windows® version 17.0. Results: A total of 69 patients met criteria for inclusion. There was a slight male predominance (55.1%) and the average age was 58 years. The most common NTSCI etiologies were tumors (20.3%), degenerative diseases (18.8%) and iatrogenesis (18.8%). Less prevalent causes included infectious, idiopathic, vascular and autoimmune diseases. Paraplegia occurred in 79.7% of cases and most of the study population had incomplete injuries (89.9%). Urinary tract infections (62.5%) and nociceptive and neuropathic pain (48.4%) were the most prevalent complications. There was a significant functional improvement after the rehabilitation program. Conclusions: Data obtained from this sample is consistent with the literature, suggesting an similar gender incidence, a predominant incomplete neurological injury and a favorable outcome with the rehabilitation program.Keywords: Spinal cord injuries; Rehabilitation.

Objectivos: Avaliar a repercussão da preservação ou substituição da rótula em doentes com gonartrose submetidos a artroplastia total do joelho (ATJ) na duração do internamento e evolução da funcionalidade após reabilitação em internamento num Serviço de Medicina Física e de Reabilitação (MFR). Material e Métodos: Estudo retrospectivo comparativo entre dois grupos de 10 doentes cada submetidos a ATJ com preservação (grupo A) ou substituição (grupo B) da rótula, ambos com próteses do mesmo modelo e conservação do ligamento cruzado posterior. Grupos pareados para raça, género, idade e índice de massa corporal (IMC). Critérios de inclusão: gonartrose primária, ATJ primária unilateral e reabilitação em internamento em MFR. Critérios de exclusão: gonartrose secundária, artroplastia prévia dos membros inferiores, cirurgia bilateral e complicações pós-operatórias. Foram analisados a duração do internamento em MFR e os ganhos nas escalas de funcionalidade, flexibilidade do joelho, força muscular e autonomia na marcha, necessidade de ajudas técnicas, transferências e actividades de vida diária (AVD). Avaliaram-se também a duração da reabilitação no Serviço de Ortopedia, intercorrências no Serviço de MFR, comorbilidades e medicação. Resultados: Não se verificaram diferenças estatisticamente significativas entre os dois grupos no índice de massa corporal (p=0.880). Os dois grupos registaram diferenças estatisticamente significativas na idade (p=0.044). Não se encontrou evidência estatística de diferenças entre os grupos A e B na duração de internamento em MFR (p=0.569) e nos ganhos nas escalas de funcionalidade (valores de p superiores a 0.21) e na flexibilidade (valores de p>0.17), força muscular (p=1) e autonomia na marcha, ajudas técnicas e AVD (valores de p>0.34). Para todos os parâmetros, nos 20 doentes, verificou-se evidência de diferenças estatisticamente significativas nos registos obtidos nos momentos de entrada e alta do Serviço de MFR (valores de p inferiores a 0.01). Conclusões: Na amostra em estudo, a opção entre a preservação ou substituição da rótula durante a ATJ primária unilateral parece não influenciar a duração do internamento e a evolução da funcionalidade após a reabilitação num Serviço de MFR. O programa de reabilitação em regime de internamento conduz a ganhos na funcionalidade e autonomia dos doentes. Palavras-chave: Osteoartrose, Joelho; Artroplastia de Substituição do Joelho; Rótula; Reabilitação. 

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