RCAAP Repository

Lance-Adams syndrome, or chronic posthypoxic myoclonus, is a rare complication of successful cardiopulmonary resuscitation often associated with cerebellar ataxia. The authors report a 41-year-old patient who presented with clinical features of dysarthria, tetraplegia, severe myoclonus, dysdiadochokinesia and cerebellar ataxia after respiratory arrest in the context of chemotherapy treatment. These symptoms resulted in marked functional consequences with inability to stand or perform activities of daily living. Hypoxic encephalopathy with Lance-Adams syndrome was assumed. Implementation of pharmacological treatment coupled with an intensive interdisciplinary rehabilitation program produced marked symptomatic and functional improvements which permitted autonomous activities of daily living and supervised locomotion after 7 months. The aim of this report was to emphasize the importance of the correct diagnosis and proper management of Lance-Adams syndrome leading to the improvement of the patients’ functional outcomes.

Introduction: many available instruments for the evaluation of balance, fall risk and fear of fallingmeasure simple indoors activities and present a “ceiling effect” in community dwelling elderly. The “ActivitiesspecificBalance Confidence (ABC) Scale” was designed to evaluate balance more thoroughly in several activitiesof daily living with different levels of difficulty.Objectives: translate to Portuguese and culturally adapt to Portugal the “Activities-specific Balance Confidence(ABC) Scale” and to assess its’ reliability.Methods: translation and cultural adaptation of the instrument. Evaluation of an elderly Portuguese populationto assess the instrument’s intra and interobserver reliability and internal consistency.Results: Results showed great homogeneity in most of the compared data, either intra or interobserver. They also showhigh internal consistency. These reliability levels were preserved even when any of the 16 questions of thequestionnaire was removed, with values that were almost identical to those of the complete questionnaireConclusions: The Portuguese version showed good intra and interobserver reliability and internal consistency in the evaluation of balance self-perception for several activities of daily living in an elderly Portuguese population. Further studieswill be required to assess the usefulness of this instrument for the evaluation of fall risk and the effect oftherapeutic interventions in this population.Keywords: Activities of Daily Living; Postural Balance; Questionnaires.

Introduction: The automobile driving ability should be properly evaluated. The fitness to drive assessment is a medical competence involving medical, legislation and technology expertise. This should include a careful objective exam and performance tasks, which can be conveniently followed-up with a test in a driving simulator. In Portugal there is only a driving simulator for these effects. This study aims to characterize and promote the work done in the Mobility Centre of a Rehabilitation Medicine Centre in the context of assessing fitness to drive in individuals with disabilities.Material and Methods: There was carried out the characterization of the individuals evaluated in the current simulator (June 1, 2007 to December 31, 2013), particularly with regard to demographic characteristics, primary diagnosis, disability(ies) and evaluation result. Changes proposed after the fitness to drive assessment were studied too.Results: There were 1.145 evaluations, referring to 1.061 different individuals. The average age of the patients was 45 ± 16 years, 73% were males and 83% had a driving license. The most frequent primary diagnosis and motor disability were, respectively, spinal cord injury (32%) and hemiplegia/hemiparesis (32%). The patients were fit without adaptations (18%) or with adaptations (54%), or unfit (10%). The fitness was considered conditional in 17% of cases, suggesting further assessments. From the 749 individuals considered fit (conditional or not) for driving an adapted car, 30% and 18% needed 3 and 2 distinct adaptations, respectively. 1.947 adjustments were suggested in total, among which the most frequent was the automatic gearbox (34%).Conclusions: Any doctor can request a fitness to drive assessment by a multidisciplinary team (physiatrist and occupational therapist) with the particularity of conducting a test on a driving simulator. Driving is a complex task that requires attention and the proper use of physical, sensory and cognitive abilities. The fitness to drive assessment is essential whenever there are doubts about the individual’s competence, being the inclusion of a driving simulator test an important asset.

Objetivos: É objetivo do estudo a avaliação do impacto da Fampridina na marcha, equilíbrio, nível funcional e perceção da capacidade de marcha em doentes com Esclerose Múltipla.Material e Métodos: Estudo prospetivo, aberto, não controlado e não randomizado, em doentes com Esclerose Múltipla e EDSS entre 4,0-7,0 sob tratamento com Fampridina. Foram usados para a avaliação do impacto da Fampridina: Multiple Sclerosis Walking Scale 12 (MSWS-12), Timed 25-Foot Walk (T25FW), Timed Up and Go (TUG) e Escala de Equilíbrio de Berg (EEB). A análise estatística foi efetuada com um nível de significância estatística de p<0,05.Resultados: Um total de 15 doentes (88,24%) foram considerados respondedores. O aumento do equilíbrio, velocidade da marcha e na perceção da capacidade para a marcha foram estatisticamente significativos com melhoria média de 19,08% (± 31,11) no T25FW (p=0,022), 19,20% (±26,13) na EEB (p=0,012), 35,97% (±34,93) no TUG (p=0,022) e 12,99% (±12,90) na MSWS-12 (p=0,016). Há uma correlação forte e estatisticamente significativa entre TUG e T25FW (r= 0,668, p= 0,017).Conclusões: Os resultados preliminares mostram a potencialidade da Fampridina no aumento da velocidade da marcha, equilíbrio e perceção da capacidade da marcha em doentes com Esclerose Múltipla. São necessários estudos para caracterizar os preditores de eficácia de resposta e avaliação do potencial do fármaco noutros níveis funcionais.

Introduction: Stroke is the pathology with the highest mortality in Portugal. This study aims to analyze the functional evolution and the assess satisfaction with quality of life of stroke cases hospitalized in PRM acute hospital unit.Methods: This study is a retrospective cohort, analyzing data between 2017 and 2019, referring to inpatients in the PRM department. 106 patients whose diagnosis on admission was stroke were evaluated (divided into ischemic stroke (IS) and hemorrhagic stroke (HS) groups). Participants were characterized in terms of different variables, namely the characterization of functional status at admission (FIM). Also the quality of life using the Satisfaction with Life Scale (SWLS) was assessed. Finally, multiple linear regression models were performed in order to determine which factors had an impact on functional improvement in stroke cases.Results: Of the 106 patients, 76 were IS (72%) and 30 were HS (28%). The HS group had younger patients compared to the IS group (67.57 ± 11.41 vs 58.33 ± 11.33, p<0.001). There were no statistically significant differences between the IS and HS groups in terms of length of stay (pre-PRM length of stay: 13.66 ± 15.01 vs 11.53 ± 12.414, p=0.495; length of stay in PMR: 21 .74 ± 15.46 vs 22.10 ± 19.77, p=0.920; total length of stay: 35.39 ± 22.15 vs 33.63 ± 23.66, p=0.918), functional status at admission (68 .19 ± 17.25 vs 73.42 ± 16.50, p=0.198). However, there is a difference between the IS and HS groups regarding the functional status at clinical discharge (79.64 ± 19.67 vs 98.10 ± 20.04, p<0.001), as well as in the degree of improvement during the hospital stay (11.38 ± 7.08 vs 26.88 ± 14.40, p<0.001). A positive correlation of functional status at clinical discharge with the diagnosis of HS (β = 13.35, p=2.442) and with age (β = -0.268, p= 0.006). Finally, differences were found between the IS and HS groups in terms of satisfaction with quality of life (20.01 ± 5.33 vs 23.88 ± 6.07, p= 0.016).Conclusion: The results of this study reflect the importance of considering different variables of stroke cases in PRM units.

otal shoulder arthroplasty with reverse prosthesis based on Grammont’s initial model of 1985 has been gaining increasing popularity. Initially designed as a solution for cuff-tear arthropathy, its current indications have been broadened to include advanced gleno-umeral pathology caused by rheumatic, traumatic or osteonecrotic processes. Rehabilitation following this kind of surgery has its own particularities, such as the design of the prosthetic components, the biomechanical changes of the shoulder joint, and the different surgical techniques. Due to the demanding needs of postoperative care for this type of arthroplasty, the Department of Physical Medicine and Rehabilitation of Centro Hospitalar de Entre Douro e Vouga (Santa Maria da Feira, Portugal) has elaborated a rehabilitation protocol for the patients that are submitted to this intervention. It involves a series of pre and postoperative functional evaluations and a rehabilitation program that is based on three general guiding principles: articular protection, promotion of deltoid function, and therapeutic individualization. This protocol also serves the goal of keeping an updated physiatric prescription through serial functional evaluation and of promotion of communication between the several elements of the multidisciplinary team that are involved in the rehabilitation process.Keywords: Arthroplasty; Replacement; Shoulder Joint; Joint Prosthesis; Rehabilitation/standards; Prosthesis Design.

Introduction: Falls are one of the greatest health problems in the elderly, causing high mortality, morbidity, disability and premature institutionalization. The Activities-specific Balance Confidence (ABC) Scale evaluates balance in a broad set of activities. It was translated and adapted for several other languages and settings, including the Portugal-Portuguese “Escala CEEA”. This instrument lacks high risk of falling and normal mobility cut-off points. Objectives: To determine cut-off points for high risk of falling and normal mobility of the “Escala CEEA”. Methods: 90 evaluations of 50 individuals aged 65 years or older, referring balance impairment and/or history of falls. Evaluations comprised the “Escala CEEA” and the timed “up & go” (TUG) test. The TUG cut-off point of 13,5 seconds was used to determine the “Escala CEEA” cut-off point for high risk of falling. The TUG cut-off point of 12 seconds was used to determine the “Escala CEEA” scale cut-off point for normal mobility in women. In each case, “Escala CEEA” sensibility and specificity were analysed and the area under the curve (AUC) was determined. Results: The best “Escala CEEA” cut-off point corresponding to the TUG test cut-off point of 13,5 seconds was 695. The best “Escala CEEA” cut-off point corresponding to the TUG test cut-off point of 12 seconds was 795. Conclusions: Balance evaluation instruments cut-off points are clinically useful in the identification of community- dwelling elderly in high risk of falling or of losing their normal mobility. The best “Escala CEEA” cut-off point for high risk of falling was 700 (gross score), with a sensibility of 71,8% and a specificity of 73,7%. For elderly women between 65 and 85 years of age, the best “Escala CEEA” cut-off point for normal mobility was 800 (gross score), with a sensibility of 70,1% and a specificity of 72,2%. Keywords: Activities of Daily Living; Elderly; Postural Balance; Questionnaires. 

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Multifocal osteonecrosis, defined by the involvement of 3 or more anatomic sites, is unusual, being observed in only 3% to 11% of patients diagnosed with osteonecrosis. Guillain– Barré syndrome is an acute onset, usually monophasic immune-mediated disorder of the peripheral nervous system.The aim of this article is to report a clinical case of multifocal osteonecrosis and Guillain–Barré syndrome with review of the literature.We present a case of a 40-year-old male, with neurological symptoms who presented to the Emergency Department one week after a flu like syndrome. Myelitis was firstly suspected and corticosteroids were started. Diagnosis of Guillain–Barré syndrome was later confirmed and he underwent treatment with immunoglobulins. One year later, the patient developed bilateral hips and shoulders arthralgia. The diagnosis of multifocal osteonecrosis was established by magnetic resonance imaging. Total right hip arthroplasty was performed and a left one was planned. The patient underwent a rehabilitation program aiming pain relief and function improvement with a good outcome.In the last ten years literature review, there were no reports of the association between Guillain–Barré syndrome and multifocal osteonecrosis.

Introduction: The disease caused by coronavirus 19 (COVID-19) is an international health emergency and has reached pandemic proportions worldwide. Since March 2020, the Portuguese government implemented measures to prevent the spread of the virus, including almost total temporary suspension of outpatient rehabilitation treatments. Patients with chronic spinal cord injury have an increased risk of developing severe forms of COVID-19 infection. However, they need rehabilitation treatment to control and prevent complications. The aim of this study was to evaluate the impact of the first wave of the COVID-19 pandemic on the clinical evolution of patients with chronic spinal cord injury, regarding pain, spasticity and functionality.Material and Methods: This is a cross-sectional observational study. A telephonic questionnaire was applied to a group of patients with chronic spinal cord injury. The results allowed the comparison of symptoms and functionality before the pandemic and six months after its onset.Results: After exclusion criteria were applied, the sample included a total of 65 participants. All patients who were previously undergoing physiotherapy treatments had to suspend them. Six months after the beginning of the Pandemic in Portugal, 24.6% of the patients reported worsening of pain complaints; 26.2% noted increased spasticity and 21.5% had decreased functionality. In this sample, 12.3% of the patients reported new pressure ulcers or worsening of the previous ones.Patients with cervical spinal cord injury had increased spasticity compared to patients with dorsal or lumbar injury (p=0.003). On the other hand, patients with lumbar spinal cord injury had more frequent worsening of pain complaints (p=0.029). Patients with incomplete motor injury had greater pain worsening when compared to patients with complete injury (p=0.007).Conclusion: The COVID-19 pandemic is having an important impact on the treatment of patients with chronic spinal cord injury, leading to worsening of pain complaints, increased spasticity and decreased functionality. Spasticity worsened more in patients with cervical spinal cord injury while pain worsened more significantly in patients with lumbar injury and incomplete motor injury.

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Currently, the challenge of upper limb replantation after amputation became an achievable reality, thoroughly improved in last decades and in constant evolution.The surgical option for replantation should take into account not only the exclusive analysis of the feasibility of replantation, but specially the potential of long term hand's functional recovery.We report a case of an 18-year-old man, smoker, transferred from Barreiro's Hospital, victim of occupational accident with right distal forearm cut. This resulted in amputation.The warm ischemia time was 4 hours and he underwent Orthopaedics and Plastic and Reconstructive Surgery (PRC) combined surgery for replantation.Subsequently, he was referenced earlier to Physical Medicine and Rehabilitation (PRM), to perform a sequential program of rehabilitation.The aim of this work is to emphasize the importance of an early, thorough and extensive rehabilitation program as a key of functional recovery and long-term prognosis in these lesions and its role in preventing complications.Keywords: Amputation, Traumatic; Forearm Injuries; Replantation; Rehabilitation.

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Introduction: Lateral epicondylitis is a common cause of chronic elbow pain, often related to repeated muscle activity. Although there are several therapeutic options available, there is no consensus regarding treatment approach to the refractory condition.Case Report: Male, 38–years-old, referred to the attending physician with pain in the right lateral epicondyle. Ultrasonography revealed aspects compatible with tendinopathy and extensor digitorum communis partial tendon rupture near the epicondyle. The patient underwent a rehabilitation program in a community centre but, due to lack of pain control, was referred for hospital Physical Medicine and Rehabilitation consultation. In this consultation the patient presented pain on the numerical scale (NS) 8/10 and QuickDASH 68.2 / 100. He underwent 4 mesotherapy sessions, but due to persistent complaints, 20 U of onabotulinumtoxin A were administered in the extensor carpi radialis and the extensor digitorum muscles guided by ultrasound. The patient maintained follow-up during 5 months, being discharged with NS 1/10 and QuickDASH 4.5 / 100.Discussion: This case illustrates the possibility of successfully applying onabotulinumtoxin A in the treatment of epicondylitis. Studies have shown that administration of 20-60 U of botulinum toxin is effective in reducing pain. Thus, botulinum toxin represents a promising therapeutic option in the treatment of refractory epicondylitis.

IntroductionTraumatic brain injuries (TBI) are a very important cause of children morbidity and disability, with a negativeimpact on their life quality. Outcomes vary with the severity of injury, child age at injury, premorbid child characteristics, family factors and the families' socioeconomic status.AimTo evaluate the social inclusion of children following a traumatic brain injury after hospital discharge.Patients and MethodsThe authors made a retrospective study of the inpatients of a specific unit of the Pediatric Development andRehabilitation Service, dedicated to the care of children that, at admission, were in coma or in a minimalresponsive state. Medical records were reviewed corresponding to children admitted to this unit between 1996and 2007 and their social inclusion was evaluated.ConclusionChildren following traumatic brain injuries face serious difficulties when they return to their familiar environmentin terms of skills, behaviour, communication and education. They could also be a physical, emotional and financialburden to their families and society. Prevention measures and oriented rehabilitation programs are essential toassure a better outcome for children with TBI.

The authors present a case report of neurogenic thoracic outlet syndrome associated with a postural syndrome, in a female patient with right shoulder pain and right hand finger cramps, progressive functional limitation in shoulder abduction more than 90º and manual tweezers. At the physical examination a postural malalignement of the rachis was evident, as well as thenar and hypothenar significant atrophy. Several diagnoses were considered, such as cervical radiculopathy, brachial plexitis, carpal tunnel syndrome/ Guyon syndrome, writer’s cramp and Hirayama disease. Only electromyography and nerve conduction studies were suggestive of the neurogenic thoracic outlet syndrome, as cervical spine, chest x-rays, cervical and brachial plexus nuclear magnetic resonance have not revealed significant alterations. Conservative treatment was provided by Physical Medicine and Rehabilitation, with improved pain symptoms and with significant functional gains. A brief and related review of the literature is also performed, framing the syndrome in the Occupational Medicine.

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