RCAAP Repository

Introduction: Presentation of a prospective study of a 14 patients series with adhesive capsulitis of the shoulder, undergoing an ultrasound guided capsular hydrodistension, as part of a multimodal physiatric therapeutic approach.Material and Methods: This article presents a nine months prospective study. All patients were diagnosed with stage II adhesive capsulitis, and were submitted to an ultrasound guided capsular distension of the shoulder. Subsequently, they underwent a specific adhesive capsulitis conventional rehabilitation protocol. The outcome measures analyzed were pain through the visual numeric scale of pain (VNS), passive range of motion (ROM), and function using the UCLA (University of California and Los Angeles) Shoulder scale. These parameters were evaluated before capsular distension, immediately after the distension, at six months and at nine months of follow-up.Results: In all 14 patients there was demonstrated pain reduction, with a mean pre-distension VNS of 6.4/10, a six months post-distension VNS of 4.5/10 and a nine months post-distension VNS of 4.3/10. The mean pre-distension lateral elevation was 117.9º, immediately passing to 151.4º right after the intervention, maintaining the articular amplitude of 163.6º at the ninth month of evaluation. The mean pre-distension external rotation was 30.4º, immediately passing to 54.6º after distension, maintaining 54.3º at the end of the follow up period. The adduction/ internal rotation was evaluated in terms of vertebral level gain. Before the intervention, the articular amplitudes in adduction/internal rotation variated between the gluteal region and T12. We observed an immediate gain of 4.1 vertebral levels right after the distension, which increased to 5.6 levels at the end of the nine months follow-up. Concerning the functional scale, the mean score before the distension was 13.8/35 in the UCLA shoulder scale. At the sixth month of follow up it was 25.6/35 and at the ninth month of evaluation it was 25.5/35.Conclusion: In this study, ultrasound guided capsular hydrodistension associated to a specific rehabilitation program demonstrated clinical and statistical benefit in the treatment of adhesive capsulitis, regarding pain, ROM and function, at a short, medium and long term follow-up. More studies are necessary to evaluate the real valor of the ultrasound guided capsular distension in the therapeutic approach of this pathology.

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Background: Overweight and its consequences are associated with increased cardiovascular morbidity andmortality. Weight loss significantly contributes to improvement in overall cardiac risk factor profile both inprimary and secondary prevention of coronary heart disease.Objective: To identify predictors of weight change during a hospital-based phase II cardiac rehabilitation programin coronary patients.Methods: Prospective cohort study of 118 patients who completed a phase II cardiac rehabilitation program (CRP)within 3 months after acute coronary syndrome (ACS) recruited between September 2008 and December 2009.Data regarding anthropometric, clinical, laboratorial and functional response was collected at baseline andprogram completion. Psychosocial profile and quality of life were assessed using Patient Health Questionnaire(PHQ-9) and Short-Form 36 (SF-36), respectively. Univariate linear regression was used to identify predictors ofweight change during CRP.Results: We analyzed 118 patients who completed a mean of 14,92(4,32) exercise sessions. They were mostly men108(91,5%) and had low-levels of education. Mean weight loss and mean Body Mass Index (BMI) reduction was0,73(2,56)Kg and 0,27(0,93)Kg/m2 respectively. Body composition showed 1,13(2,91) percent reduction in fat massand 0,45(1,16) percent increase in lean body mass. Independent predictors of weight loss were level of education(b=0,25; p<0,001), smoking status at program entrance (quitters: b=-0,35; p<0,001; persistent smokers b=-0,27;p<0,05), depressive symptoms (b=-0,10; p=0,001; major depression: b=-1,55; p<0,001) and total energyexpenditure during training session (b=0,20; p<0,05).Conclusion: Weight reduction is a reflection of compliance to both dietary and physical activity recommendationsin secondary prevention programs, hence its dependency on level of education, smoking status and estimatedenergy expenditure during physical activity. Weight change is also negatively influenced by psychological factors,mainly depression. Identifying factors associated with poorer weight response might allow earlier, individuallytailored interventions such as more aggressive low-calorie high-expenditure combinations and psychobehaviouralinterventions. Further studies are needed to evaluate the impact of such interventions.Keywords: predictors, weight change, cardiac rehabilitation.

The goals of total knee arthroplasty are to minimize knee pain, promote articular stability during gait and maximize the range of motion. The prevalence of knee stiffness after arthroplasty can reach 25%. The scientific community points out, as main risk factors for its appearance, a smaller preoperative range of motion, the lack of collaboration of the patient in a rehabilitation program, patella ínfera and the use of coumarinic anticoagulation. The improvement of knee range of motion rarely occurs after six months of arthroplasty, even under an appropriate rehabilitation program. In case of postoperative stiffness, the most effective option for current gain of range includes joint manipulation under anesthesia. Arthroscopic or open arthrolysis has modest results in the gain of range of motion as well as revision arthroplasty. However, the latter proves to be effective in individual cases of stiffness with flexion contracture.

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Introduction: This article aims to expose the current scientific evidence concerning adjuvant therapeutic options of botulinum toxin in the control of spasticity.Methods: A narrative review of the literature published in the Medscape, Cochrane Library and PubMed databases until December 2020 was performed. The terms used in the research were: “botulinum toxin”, “spasticity” and “adjunct therapy”. A total of 137 articles emerged from the research. Case reports, articles of dubious methodological rigor and articles not specifically referring to the objective of the study were excluded. Meta-analysis studies, systematic and narrative reviews as well as controlled and randomized clinical trials were included. After applying the mentioned criteria, 23 articles were selected.Results: The scientific evidence of the different therapeutic options identified was divided into the following categories: physiotherapy/kinesitherapy (stretching, functional training and other interventions), orthoses, plastered immobilizations, functional bands, modified constraint-induced movement therapy and physical agents (electrostimulation, ultrasound, extracorporeal shock waves and vibration). Comparative studies between therapeutic modalities after the application of BoNT-A were also identified.In general, a shortage of evidence for the effectiveness of the various modalities mentioned and, in some cases, evidence of lack of benefit from certain associations was found. Even so, clinical trials with promising interventions were identified, namely the ones that targeted physiotherapy with an association of techniques, electrostimulation, and shock waves therapy. The authors also identified comparative studies that seem to indicate the superiority of electrostimulation and functional bands in relation to stretches, the superiority of shock waves therapy in relation to electrostimulation and the superiority of plastered immobilizations compared to stretches.Conclusion: Prescribing physical therapy with functional training, electrostimulation, shock waves therapy and occasionally using orthoses for intermittent use, may be the most advantageous strategies after the application of BoNT- A. Ultrasound, body vibration and stretching (mainly if applied alone) seem to be less useful. The choice of the specific adjuvant therapy is limited by the available scientific evidence, and the must meet the patient’s, caregivers’ and rehabilitation resources’ particularities.

Background: Borg’s Rating of Perceived Exertion (RPE) is a simple and convenient method for monitoring exercise intensity. However, it’s based on subjective feeling of exertion and fatigue during exercise, and possible factors that influence perception are highly variable inter and intra-individually. Objective: To evaluate the predictors of a higher RPE at the beginning of a cardiac rehabilitation program (CRP). Methods: Patients enrolled in a cardiac rehabilitation program after an acute coronary event between September 2008 and October 2010. Psychosocial profile at admission was characterized using Hospital Anxiety and Depression Scale (HADS) and the Medical Outcomes Study Short Form – 36 (SF-36). Functional status was estimated using both physical components of the SF-36 and exercise intensity in metabolic equivalents (MET) achieved at baseline exercise stress testing (EST). We used peak exercise perception score (PEPS=RPE/MET) to determine level of fatigue indexed to exercise intensity level during the first exercise training session. Results: One-hundred seventy five patients were analysed, 160(91,4%) were male, mean age [mean(SD): 53(9)] years and had low level of education [P50(P25-P75):6(4.-11)]. Treatment after the acute coronary event consisted of percutaneous coronary revascularization in 144 (82,3%), coronary artery bypass graft surgery in 19 (10,9%) and 12 (6,9%) patients received only medical treatment. Mean exercise capacity was 10 (2,0) MET at baseline EST and the perception of overall physical ability in daily activities scored 46,2 (8,1) in summary physical component of SF36. During initial exercise training sessions, we found a 2,27(0,6) increase in RPE per 1 MET increase in exercise intensity. Univariate determinants of exercise perception were gender (b=-0.23; p=0.003), years of education (b=- 0.32; p<0.001), maximum volume ventilation (MVV) (b=-0.29 per 10% of MVV increase; p<0.001), functional status at admission [SF-36v2 physical domains (b=-0.34; p<0.001); peak MET level at EST (b=-0.32; p<0.001)] and psychosocial profile at admission [HADS≥8 (b=0.18; p=0.02); SF-36 summary mental component (b=- 0.20;p=0.009)]. Age and sex-adjusted multivariate analysis identified level of education (b=-0.24; p=0.001), MVV (b=-0.19 per 10% of MVV increase; p=0.008), SF-36v2 physical domains (b=-0.19; p=0.011), MET level at EST (b=- 0.20; p=0.009), as predictor variables. Conclusions: Effort perception is multifactorial depending upon a complex interplay between psychosocial and physical capacities. Indentifying their main determinants may allow for more individualized interventions in CRP resulting in a better functional recovery, social participation and quality of life. Keywords: Coronary Heart Disease; Cardiac Rehabilitation; Physical Exertion.

In literature it is largely established the role of physical inactivity as a major risk factor to coronary heart disease. A Cardiac Rehabilitation Program improves functional capacity of the patient with cardiac disease as well as educates for the control of their cardiovascular risk factors. Aim: To evaluate the functional capacity of patients with coronary heart disease who underwent a Cardiac Rehabilitation Program over a 12-month follow-up and its relationship with changes in physical activity habits. Methods: We conducted a prospective cohort study that included patients with coronary heart disease consecutively referred for Cardiac Rehabilitation Program exercise based between January 2008 and December 2009. We evaluated the patients at three moments: baseline (first visit of Phase II), 3 and 12 months. We analyzed physical activity performed at home through the International Physical Activity Questionnaire and assessed time and Metabolic Equivalents (MET) achieved during exercise tests performed. Results: From a total of 329 patients 73 were excluded for not completing the phase II of the PRC due to loss of data during follow-up period. We studied 256 patients (76.2% male, mean age: 61,1 (10,6) years). At the end of phase II, there was a statistically significant improvement in the studied parameters, namely the average amount of physical activity performed in IPAQ scores (70.5%; p <0.0001), time (18,9%; p <0,0001 / 23,7; p =0,002) and MET (20,4%; p <0,0001) on exercise testing. This difference remained statistically significant after 12 months of follow- up. Conclusion: This study emphasizes the importance of Cardiac Rehabilitation programs in secondary prevention of cardiovascular disease and the need to implement strategies in order to maximize the long term effects. Keywords: Heart Diseases/rehabilitation; Recovery of Function. 

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Purpose: Given the global scope of disability, it is important that tools used to measure disability are not biasedby the language or literacy of the respondents. Yet it is impossible to accurately translate tools into the world’s7000 languages. The Language Independent Functional Evaluation (L.I.F.E.) is a video animated functionalassessment that bypasses language and literacy. This study assesses the face validity and content validity of theL.I.F.E.Methods: Rehabilitation professionals and non-rehabilitation students wrote descriptions of the 30 graphicanimations representing functional stages for 11 activities portrayed in the L.I.F.E. The relationship betweendescriptions and the principle L.I.F.E. designer’s description was rated by consensus of three reviewers on a 4-pointagreement scale.Results: Exact agreement was obtained for 82% of 600 responses provided by 12 rehabilitation professionals and8 students. Complete misunderstanding of the concept occurred in only 6% of cases. Most of these were in therealms of bowel, bladder, and mobility. There was no difference in understanding between the professionals(content validity) and students (face validity).Conclusions: The face and content validity of the L.I.F.E. are good enough for users to trust that the test portraysintended functions. This paves the way for easier measurement of functional ability regardless of language orliteracy.Keywords: Disability Evaluation, Language Tests, Physical Therapy Modalities.

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Introduction: COVID-19 has a wide clinical spectrum and, in severe cases, can lead to serious functional impairments. The role of Physical and Rehabilitation Medicine (PRM) in the subacute and chronic phases of this novel disease has become indisputable but remains unclear in the acute phase. Our aim was to describe the impact of a PRM intervention in acute COVID-19 patients.Methods: Observational retrospective study of the COVID- 19 patients admitted to the ICU and Internal Medicine wards and referred for inpatient intervention by the PRM department of an acute care Portuguese hospital during April and May of 2020. Recommendations from the Portuguese Society of PRM regarding rehabilitation of COVID-19 patients in the intensive care unit (ICU) were followed. Two assessments were performed by a PRM physician: prior to the intervention and at discharge. Demographic data, comorbidities, Medical Research Council Sum Score (MRC-SS), handgrip dynamometry and Chelsea Critical Care Physical Assessment Tool (CPAx) were recorded in electronic health records and were afterwards retrieved for analysis.Results: Twenty-two patients were eligible. Sixteen (72.7%) were male and six (27.3%) were female with a mean age of 65.36 ± 14.07 years old. Mean duration of hospitalization was 25.64 ± 10.25 days, with 18/22 patients being admitted to the ICU (mean of 11.39 days). At discharge, there was: a mean improvement of 16.96 points in MRC-SS; a difference in median handgrip dynamometry of 10.00 kg, (improvements in 21/22 patients); a difference in median CPAx total score of 24.00 points, (improvements in 21/22 patients); improvements in all CPAx subscores. All results were statistically significant (p<0.05). There were no adverse events in patients or infections in the PRM team.Conclusion: A PRM intervention in the acute COVID-19 inpatient is safe both for patients and PRM team. It seems to have a positive effect on physical and functional status of the patients, reflected by improvements in all of the parameters evaluated.

Introduction: Falls in the elderly are associated with considerable mortality, morbidity, loss of function and premature institutionalization. They represent the main risk factor for fractures. Exercise programs reduce the risk of falling in the elderly and may be cost-effective. Computerized Dynamic Posturography is a method used in the evaluation of postural control. Although it also allows balance training, this has been scarcely investigated. Objectives: To assess the risk of falling and its modification by means of a balance training program with Computerized Dynamic Posturography. Methods: 22 individuals, aged over 65 years, were evaluated. An initial evaluation was performed, including the “timed up and go” test, the Portuguese version of the Activities-specific Balance Confidence Scale and Computerized Dynamic Posturography. Balance training with Computerized Dynamic Posturography was then performed. Finally, all individuals were reevaluated by repeating some of the initial proceedings. The obtained values were compared trough the calculation of their evolution. The Shapiro-Wilk test was used to assess the normality of each variable in each evaluation and the Wilcoxon test was used to compare the results obtained in the first and second evaluations. Results: There was a significant evolution of the “timed up and go” test between evaluations. There was a significant evolution of the score of the Portuguese version of the Activities-specific Balance Confidence Scale. Computerized Dynamic Posturography testing showed a significant evolution of several test results: modified Clinical Test of Sensory Interaction on Balance, Limits of Stability, Sit to Stand and Walk Across. Conclusions: The individuals engaged in the study presented a significant and beneficial evolution of several parameters connected to the risk of falling. This evolution may entail clinical benefits, with a reduction in the risk of falling which may be due to the balance training program that was performed. Keywords: Aged; Postural Balance; Diagnosis, Computer-Assisted; Accidental Falls.

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