RCAAP Repository

Heterotopic ossifications (HO) are bony formations in non-skeletal tissue that may occur in traumatic and/or neurological disorders. The diagnosis is based on clinical signs and symptoms, completed with lab tests and imagiologic tests. The most common used drugs to prevent and treat this entity are the bisfosphonates and the NSAID’s. Rehabilitation has an important role in optimizing the function of the affected areas. In this work the authors present the case report of a 54 year old male that suffered a traffic accident in 23/8/2010 with TBI and severe toraco-abdominal trauma. Physical examination in 8/11/2010 showed severe pain (VAS 8) on the mobilization of the left shoulder. Painful right knee (VAS 8) with 30o flexion, -20o extension. Walking was only possible with the help of a third person. The exams revealed 2 large and metabolically active HO, one on the left shoulder and the other on the right knee. Under physiatrist’s responsibility, he started Rehabilitation management and medication with oral corticoid, NSAID and bisphosfonate. After the treatment the patient was discharged in 28/1/2011, independent in the ADL and walking, with mild pain (VAS 3) and limitation of the movements of the left shoulder. Keywords: Ossification; Heterotopic; Rehabilitation; Wounds and Injuries.

The authors reviewed the literature focusing on the use of anti-inflammatory agents and massage in osteoarthritis, aiming at updating the major aspects of the medical management of this pathology.We conducted a review of the literature in PubMed between October 2012 and January 2013, using the MeSH terms “Administration, Topical”, “Anti-Inflammatory Agents, Non-Steroidal”, “Osteoarthritis” and “Massage” of English articles without time limit. Subsequently, “related citations” of the items found were added, and the articles considered relevant to the work selected, considering the subject.The authors concluded that massage, topical NSAIDs, or a combination of both appear to be safe and potentially effective options that may have a role in a rehabilitation program and contribute to the reduction of antiinflammatory and analgesic oral intake in the osteoarthritis treatment.

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Frey syndrome is mostly seen after parotidectomies and is an underdiagnosed surgical complication that may cause social inhibition and quality of life (QoL) deterioration. We report a case complemented with a literature review regarding the use of botulinum toxin on Frey syndrome. We consulted the patient’s file and photographed the Minor tests. We searched PubMed using the keywords: Frey syndrome; gustatory sweating; botulinum toxin. A 43-year-old woman, diagnosed with a pleomorphic adenoma of the left parotid gland treated by parotidectomy was referred to our Physical and Rehabilitation Medicine department due to symptoms suggestive of Frey syndrome: flushing and sweating on the left parotid region during meals with impact on socialization and QoL. Minor test confirmed the diagnosis. The patient underwent intradermic infiltration of 46U of onabotulinum toxin A (Botox®) across the positive area on Minor test that matched the patient’s complaints. Three weeks post-procedure, the patient denied hyperhidrosis (demonstrated on Minor test) and mentioned overall improvement on QoL. Treatment is symptomatic and should be offered to those patients whose symptoms cause a negative impact on QoL. Botulinum toxin infiltration is currently the gold standard treatment, since it is a safe, effective and reliable procedure. The Minor test is essential to optimise botulinum toxin dosage, thus reducing the possibility of occurring adverse effects.

A bronquiolite aguda é a infecção viral do tracto respiratório inferior mais frequente dos recém-nascidos. O vírus sincicial respiratório é o agente habitualmente identificado. Estima-se que cerca de 30% das crianças com menos de 2 anos de idade tenham pelo menos 1 episódio de bronquiolite na vida. No hemisfério norte, ocorre sobretudo entre os meses de Novembro a Março e é caracterizada por uma inflamação aguda, edema e necrose epitelial que aumenta a secreção mucosa e o broncoespasmo. A regressão espontânea é a regra, podendo o tratamento ser efectuado a nível de ambulatório. No entanto, o número de hospitalizações associadas à bronquiolite tem vindo a aumentar nas últimas décadas. O seu tratamento engloba broncodilatadores, corticóides, antivíricos, antibióticos e oxigenoterapia. A Cinesiterapia Respiratória, amplamente utilizada nos países francófonos e latinos, é contestada nos países anglo-saxonicos e é hoje objecto de grande controvérsia. A linha de actuação divergente parece resultar da utilização de técnicas cinesiológicas diferentes e da ausência de estudos clínicos de qualidade. Da revisão realizada conclui-se que técnicas de vibração e percussão não acrescem benefício ao tratamento de crianças sem comorbilidades, não ventiladas com esta patologia. Métodos que envolvam a aceleração do fluxo expiratório ou a expiração lenta e prolongada poderão estar indicados consoante a avaliação clínica. Mais estudos com metodologia adequada e amostras representativas serão de extrema importância para a clarificação do risco-benefício da cinesiterapia respiratória nesta afecção. Palavras-chave: bronquiolite, cinesiterapia respiratória, fisioterapia torácica.

Painful hemiplegic shoulder may appear from two weeks to four months after stroke. Painful hemiplegic shoulder has a high incidence rate and frequently a multifactorial etiology. Painful hemiplegic shoulder treatment represents a challenge to clinical practice, and sometimes with poor therapeutic response, that may compromise the results of rehabilitation programs.The structured approach can help a better therapeutic response and contribute to the success of rehabilitation program and patient quality of life. This work aims to systematize the therapeutic approach of this entity, according to the existing scientific evidence.

Um dos principais objetivos da reabilitação após a instalação de lesão medular consiste na reeducação funcional da marcha. Esta abordagem pode estar associada à reconfiguração dos reflexos espinhais e interneurónios, permitindo potenciar a neuroplasticidade que leva à recuperação da capacidade para a marcha. Os impulsos aferentes da carga e posição da anca são cruciais na geração de um padrão de marcha e consequentemente no treino funcional da marcha. Os sistemas robóticos são uma abordagem introduzida recentemente, com o objetivo da recuperação da capacidade de marcha em doentes com lesão medular incompleta, permitindo um treino consistente, com maior intensidade, num ambiente seguro. A evolução funcional é avaliada através de testes e escalas adequadas para a lesão medular. A utilização dos sistemas robóticos implica um conhecimento vasto acerca das indicações, benefícios, limitações e medidas de segurança necessárias para cada dispositivo e cada doente. São vários os tipos de sistemas robotizados, atualmente disponíveis para utilização na reabilitação da marcha. Não obstante, os autores pretendem através deste artigo, expor as principais vantagens e limitações, de dois sistemas robóticos, o Lokomat® e o EKSO GT®, bem como realizar uma revisão sumária da neurofisiologia e avaliação de fatores de prognóstico para realizar marcha após uma lesão medular.

Objectives: To review the literature on lumbar hyperlordosis with a focus on developing a definition, addressingthe etiopathogenesis, the diagnosis and enunciating an etiologic classification. For each form, particularities,pathophysiology, clinics and treatment are described, within a rehabilitation framework.Material and Methods: Physical Medicine and Rehabilitation (PMR) reference textbooks and electronic databaseswere searched, using the terms “lumbar hyperlordosis”, “hyperlordosis”, “lumbar lordosis” and “lordosis”. Thesearch was limited to review articles published in English or French, in which the term was included in the title,abstract and/or the keywords and in which the abstract and the full article were available. After the selection ofinformation, support literature consisted in 4 chapters of textbooks and 40 scientific articles.Results: Lumbar lordosis is a curve on the sagittal plane of the lumbar spine with an anterior apex and can bemeasured in lateral view radiograph using Cobb’s method. The Scoliosis Research Society (SRS) stipulated asphysiological angles the range between 31º and 79º.The diagnosis of lumbar hyperlordosis is established when a curve with an angle greater than the physiologicalis identified. This pathology is frequently asymptomatic, although it can be manifested as low back pain andreduction of the flexibility of the lumbar spine. Lumbar hyperlordosis, according to SRS, can be classified aspostural (the most frequent form), congenital (due to anomalies of the vertebral embryonic development), postlaminectomy(iatrogenic), neuromuscular (resulting from muscle tone and strength imbalances), secondary to hipflexion contracture and associated with other causes. The forms associated with spondylolysis (common inadolescents that practice sports with repetitive lumbar hyperextension) and spondylolisthesis (attributed tomultiple etiologies) were included in the classification by several authors.The management of PMR in the treatment of lumbar hyperlordosis can involve general measures, kinesiotherapyand the use of braces; some cases have surgical indication.Conclusions: Lumbar hyperlordosis is a spine static change of simple diagnosis, based on a physical exam andradiological confirmation. PMR intervention has a major role in detecting this pathology and enhancing itstherapeutic options, thereby improving patients’ quality of life.Keywords: Lordosis; Lumbar Vertebrae; Rehabilitation.

Introduction: Patients with neuromuscular disease may present as a complication of their respiratory disease a chronic hypoventilation syndrome due to the neuromuscular inability of their respiratory system. Exposure during the flight to a hypoxic environment may originate an acute decompensation in these patients. Nevertheless, the only absolute contraindications to flying are active pneumothorax, bronchogenic cysts and severe pulmonary hypertension.Purpose: Set guidelines for the individualized assessment of patients with neuromuscular diseases prior to flight, benefit of oxygen supplementation and need for assistive equipments.Material and Methods: Review of current literature on the topic of medical management of air travel in patients with respiratory disease being given special attention to the implications in patients with neuromuscular diseases. A search was held in meta-search engines TRIPdatabase, SUMsearch and in the bibliographic database Medline/PubMed.Results: The physician is responsible to assess the patient’s fitness to fly and possible benefit of supplemental oxygen and other assistive equipments. For decision making, the physician will perform a clinical evaluation and, if necessary, an additional functional assessment, comparing the results with the current recommendations. Clinical evaluation includes history taking, measurement of peripheral saturations and, if justified by history, blood gas evaluation and/or spirometry. The functional assessment includes the 50-meter walking test, hypoxemia prediction equations and simulation tests of hypoxia at altitude.Conclusion: Flying is necessary in many socio-professional contexts. The physician (often the Physiatrist) must be aware of the flight effects on patients with neuromuscular diseases, knowing how to assess and decide based on current recommendations for air travel medicine.

Neuralgic Amyotrophy (NA) is an uncommon disorder, of unknown etiology,  typically characterized by abrupt onset of shoulder and upper extremity pain followed by progressive neurologic deficits. An immune/autoimmune process seems to have more support in development of NA. NA is a clinical diagnosis, however, further diagnostic studies can confirm clinical suspicion and help exclude other causes. The treatment consists predominantly in pain control and rehabilitation.            Patients with NA, can be evaluated by a wide range of clinical specialists in the early stage of disease before a correct diagnosis be made. This is a result of different phenotypes that this disorder exhibits, that complicate the diagnosis.  It is important for clinicians to beware of the classic  clinical manifestations that usually  follow a characteristic clinical course of abrupt onset of shoulder girdle pain followed by progressive neurologic deficits as muscle weakness, amyotrophy and sensory  abnormalities.            We report the case of a 32-year-old man who had a severe bilateral  and atypical shoulder involvement, that made the most probably diagnostic not so evident.

Introduction: Low back pain is the most prevalent musculoskeletal disorder, affecting 40%-80% of individuals worldwide, representing a major disability factor in quality of life and enormous costs for the society. The present review aims to reflect on scientific evidence that evaluates the role of botulinum toxin (BT) as a treatment of low back pain.Methods: The present study is a systematic review. The authors reviewed the literature indexed in the databases Medline (via PubMed), Web of Science and CENTRAL. To achieve study purposes, only randomized clinical trials (RCT) were included, with at least 2 months of follow-up, appropriate sample size and in line with the standards of the Delphi List.Results: In the evidence contemplated, BT therapy proved to be superior in pain control and in the improvement of functional capacity when compared with placebo. On the other hand, the treatment of BT + physiotherapy showed more effectiveness versus 1) placebo + physiotherapy and versus 2) therapy of infiltrations with corticosteroid and local anesthetic (triamcinolone and lidocaine) + physiotherapy, regarding pain control of low back pain.Conclusion: Even though the approached studies indicate the important role of BT in low back pain management, the consolidation of these conclusions need scientific evidence with higher quality, larger randomized clinical trials, standardization of the evaluated outcomes and detailed intervention protocols. BT therapy, integrated in a multimodal approach, may be a relevant asset in the management of low back pain.

Introduction: FRAXTM (Fracture Risk Assessment Tool) is a tool used to calculate the risk of osteoporotic fracture within the next 10 years, by analyzing certain parameters entered by the clinician. One of these parameters is the Body Mass Index (BMI) and so the measurement of height and weight of the patient is a fundamental procedure as possible influences on the calculated result may affect the therapeutic decision. Objectives: The authors attempted to identify, in a sample of patients, the percentage of individuals that provide data on weight and height, and to assess its reliability and analyze the possible impact of the use of data provided to calculate the risk of fracture using the FRAXTM tool. Population and Methods: Cross sectional, non-randomized study. 91 women over 65 years of age (convenience sample) were included. The risk of major and femoral neck fracture was calculated using FRAXTM, applying data supplied by patients (estimated) and the values of weight and height measured by the authors (actual values). Statistically significant differences between the values obtained were sought, and the effects of those differences in therapeutic decisions were evaluated. The SPSS program v15.0 was used for data processing. Results: Eight women (8,79%) did not provide their weight and / or height. For the remainder, there was an agreement on the estimated and real weight, but a disagreement with regard to height (p <0.001). The actual BMI was higher than the estimated BMI (p = 0.001). The real risk of fracture (major and femoral neck) was lower than the estimated risk of fracture. The indication for drug therapy was slightly lower when the measured data was used. Conclusions: Most women provided data on their weight and height. Although the weight was correctly assessed, height was overestimated. The FRAXTM results obtained using these data underestimated BMI and overestimated the risk of fracture. Statistically, these results did not influence therapeutic decisions. The authors believe, therefore, that anthropometric data should be objectified whenever possible. Keywords: Osteoporotic Fractures; Fractures, Bone; Algorithms. 

Introduction: Dupuytren’s disease is a benign proliferative connective tissue disorder that involves the hand’s palmar fascia. The first clinical signs reported by the patients are thickening near the MCP. The small finger is the most affected. Dupuytren’s disease is more common in men over 40 years old. Diabetes mellitus, alcohol use, smoking and HIV have all been associated with a higher risk of Dupuytren’s disease. Surgical intervention is the gold standard on Dupuytren’s treatment and is indicated in cases of advanced disease. Postoperative rehabilitation should start between 3 and 5 days with early range of motion and palmar shift.Purpose: Characterize the post-operative population with Dupuytren’s disease and evaluate gains with the intervention of rehabilitation.Method: Retrospective and descriptive longitudinal study using the clinical data of surgically treated patients with Dupuytren’s disease evaluated and treated according with a protocol of occupational therapy at our department. Results: From a total of 50 surgically treated patients, between January 2014 and August 2015, 92% were men. The average age was 64.22 years. Risk factors association was predominantly diabetes mellitus (22%), smoking (8%) and moderate to severe alcoholic habits (6%). A percentage of 54% were intervened in the right hand, and the majority of the patients were intervened in the 5th finger (38%). Forty two patients (84%) attended the sessions twice a week. Thirteen patients abandoned the treatment before the end. The treatment had an average length of 70.14 days (SD 42.5). In comparison between the beginning and the end of the rehabilitation program there were a significantly difference in the range of motion of the extension and flexion of the MCP (p = 0.00, p = 0.03) and PIP (p = 0.00, p = 0.01). Other statistical significant relations were not foundDiscussion and Conclusion: Surgery followed by a structured rehabilitation program in Dupuytren’s disease allows an improvement in range of motion.

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Introduction: After an ischemic cardiac event patients often face the increased risk of developing ObstructivePeripheral Arterial Disease (OPAD) symptoms as a manifestation of vascular disease, with additional impact overfunctional capacity and quality of life. Frequently, intermittent claudication (IC) symptoms appear for the firsttime during supervised exercise sessions in the context of a cardiac rehabilitation program (CRP) addressed tocoronary disease (CD), influencing the rehabilitative process. It’s therefore important to implement specific strategies to diagnose and treat OPAD on Cardiovascular Prevention and Rehabilitation Units (CVPRU),incorporated on the established CRP.Methods: Prospective study aiming to determine the real prevalence of OPAD and its association with modifiable Cardiovascular Risk Factors in patients with CD referred to the Cardiovascular Prevention and Rehabilitation Unitin Centro Hospitalar do Porto/Hospital de Santo António during the year 2009.Results: Doppler ultrasound with Ankle-Brachial Index (ABI) was performed on 141 patients with CD admitted toa CRP in the CVPRU: 115(81,5%) male and 26 (18,5%) female. OPAD diagnosis (ABI <0,9) was confirmed in 21patients (17 male and 4 women), corresponding to a 14,8% prevalence. In 11 patients (7,8%; 52,3% of thepatients with OPAD) IC appeared for the first time during the CRP. There was a significant correlation between OPAD and smoking habits (p<0,002), present in 17 of the 21 patients); sedentary habits (p<0,002), also present in17 patients and Hypertension (p<0,01) diagnosed in 15 patients.Conclusion: OPAD elevated prevalence and its clinical variability indicates the need to include the ABI in theevaluation of patients with CD. It’s important to implement on CVPRU measures to prevent and treat the severalmanifestations of atherosclerotic disease.Keywords: Coronary Disease, Peripheral Vascular Disease, Ankle Brachial Index, Rehabilitation.

Introduction: This study aims to calculate the percentage of young adults among patients admitted with stroke diagnosis in one Rehabilitation Centre service and study the effect of some parameters on the efficiency of their rehabilitation program in the post-acute phase.Material and Methods: Retrospective, analytical study, drawn up from information contained in the patients admitted in one Rehabilitation Centre service database. Inclusion criteria: hospitalization by cerebrovascular disease diagnosis, namely ischemic or hemorrhagic stroke; first stroke episode and end of hospitalization between January 1, 2007 and December 31, 2012. Exclusion criteria: absence of the event date and readmission. Young adult category was defined for age between 18 and 45 years. It was analyzed the impact of time between event and admission to the rehabilitation centre, type of stroke and laterality on injury inpatient rehabilitation program efficiency in young adults. Z test and t test were used for comparison of proportions and means, respectively.Results: Among patients admitted to the rehabilitation centre because stroke, the annual percentage of young adults ranged from 5% (2010) and 23.3% (2011). The average efficiency of the inpatient rehabilitation program for young adults decreased with increasing number of days that mediated the event and the admission date to the Rehabilitation Centre. The effectiveness of rehabilitation programs in young adults who have suffered an ischemic stroke (versus hemorrhagic) was slightly better, but without statistical significance. Conclusions: The results, while not necessarily representative of the national reality, reveal the relevance of addressing the issue of stroke in young adults with the greatest attention. In young adults, the rehabilitation program efficiency in an inpatient rehabilitation centre decreases with the delay between the stroke event and the Rehabilitation Centre admission.

Introdução:O síndrome isquémico agudo da medula espinhal (SIAME), ou enfarte medular, é uma entidade rara, com uma prevalência de 1-2% de todas as patologias isquémicas agudas do sistema nervoso central. Existem vários fatores que podem condicionar a perfusão sanguínea medular e em alguns casos a etiologia permanece desconhecida.Apresentamos dois casos clínicos, admitidos num internamento de Reabilitação, e comparamos o seu padrão e evolução clínica com os estudos mais recentes da literatura.Caso clínico:Uma melhor, de 55 anos, admitida por uma tetraplegia incompleta nível neurológico C8, por enfarte medular de etiologia desconhecida. O segundo caso aborda um homem, de 58 anos, que desenvolveu subitamente um quadro de tetraplegia incompleta nível neurológico C6, após um enfarte cardíaco. Em ambos os casos, a ressonância magnética identificou lesões compatíveis com isquémia medular. Após reabilitação, ambos apresentaram uma boa evolução clínica e funcional. À alta encontravam-se independentes nas atividades de vida diária e faziam marcha de forma autónoma com auxiliares.Discussão:O SIAME apresenta-se com variados padrões clínicos, dependendo do nível de lesão e do território vascular afetado. Os dois casos apresentam clínica sugestiva de enfarte da artéria espinhal anterior, e encontram-se em concordância com os achados mais recentes da literatura. Estes demonstram que o melhor fator de prognóstico é o grau de incapacidade à admissão, determinado pela classificação da American Spinal Injury Association. Em termos de recuperação, as análises de casos confirmam que doentes submetidos a um programa de reabilitação holístico e individual apresentam uma boa evolução funcional.

Introduction: Peripheral mononeuropathies are one of the leading causes of access to health care.Case Report: A 70-year-old woman felt non-specific pain in the popliteal region. After the exams, it was thought to be a radiculopathy. Therefore, the patient was medicated with muscle relaxants and anti-inflammatories without improvement of complaints, though. On examination, she had apparent pain during palpation of the semitendinosus and semimembranosus tendons. This way, it was decided to make an ultrasound scan of the popliteal region, being verified that the tibial nerve had an increased dimension in comparison to the contralateral one. The patient reported that, for the past two months, she had been using elastic stockings up to the knee region. A nerve block was performed with lidocaine, which led to a successful regression of the symptomatology.Discussion: Tibial nerve lesions tend to be uncommon as opposed to peroneal nerve lesions, since it is found in a relatively deep region.Conclusion: This case report highlights the importance of having a good clinical history combined with a detailed physical examination and the valuable details given by the ultrasound analysis at the time of the evaluation, in order to complement the data collected. Keywords: Peripheral Nerve Injuries/diagnostic imaging; Peripheral Nerve Injuries/therapy; Stockings, Compression; Tibial Nerve/injuries.

In cyclists, overuse injuries are quite common; the knee is one of the most frequently affected anatomical sites. Knee overuse injuries can be caused by several factors and are sometimes associated with changes in mode, intensity or duration of training. Knee pain is the main clinical manifestation. In decreasing order of frequency and according to its location, knee pain can be classified as anterior, lateral, medial and posterior knee pain. An adequate approach to these injuries includes the establishment of a correct anatomical and pathological diagnosis as well as the identification and correction of intrinsic or extrinsic predisposing factors. As these injuries have a significant functional impact, their prevention seems more relevant than their treatment. Keywords: Bicycling, Cumulative trauma; Athletic Injuries; Knee injuries.

The patellofemoral instability is pathology of the adolescent and young adult. An important contributory factor is trochlear dysplasia, which may cause patellar recurrent dislocation. Trochleoplasty pretends to recreate the patellofemoral biomechanical stability. The authors present a case report of a young woman, combat sports practitioner, with trochlear dysplasia and patellar recurrent dislocation. The patient did a trochleoplasty and was submitted to a rehabilitation programme, with good outcome. In this case report diagnosis, treatment and follow-up results are discussed. Keywords: Patellar Instability; Patellar Dislocation; Rehabilitation.