RCAAP Repository

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Introduction: Subacromial balloon arthroplasty is a promising new arthroscopic solution for massive to irreparable rotator cuff tears, consisting of insertion of a biodegradable device into the subacromial space. Despite the growing interest in this procedure since it was introduced in 2012, details concerning postoperative rehabilitation are yet very scarce.Our objective was to develop a rehabilitation protocol following subacromial balloon insertion without rotator cuff tear repair based on literature review.Methods: To develop the protocol, we reviewed the available literature in Scopus, Web of Science and PubMed until 2020, and collected experts’ opinion in PRM and Orthopedics departments of our institution.Results: We found 9 studies including information on postoperative rehabilitation. Duration of rehabilitation was 12 weeks. Main goals were: regaining range of motion, strength, and scapulotoracic balance. Shoulder immobilization was required for 1 to 4 weeks. Range of motion started in the first days, with variable progression. Strengthening began by the third/fourth weeks. Overhead activity was usually allowed after 6 weeks.Conclusion: According to these findings, we elaborated a 12-week rehabilitation program divided into 4-week blocks, focused on flexibility and early strengthening of scapular depressors and stabilizers to promote the lowering of the humeral head achieved by the balloon implantation. The ultimate goal is to recover independence in activities of daily living. The protocol presented in this article addresses the lack of proper details on the subacromial balloon arthroplasty postoperative rehabilitation process. In the future, prospective studies are warranted to provide evidence of the effectiveness of this comprehensive program.

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The purpose of this case report is to highlight the role of botulinum toxin type A in the treatment of spasticity and its benefits improving quality of life, taking into account the clinical evolution of a patient with Leigh syndrome.Leigh syndrome is a subacute necrotizing encephalomyelopathy, a progressive neurodegenerative disorder with onset usually before 12 months of age and with no specific treatment. Spasticity is one of the possible symptoms that can precipitate several complications.This case report shows the effects of botulinum toxin type A in controlling severe focal spasticity during patient’s growth in an attempt to manage pain and minimize orthopedic deformities. Although there was no objective measure available, the clinical evolution and the information given by the patient and his family confirm an improvement in quality of life.

The complex process of awarding technical aids in Portugal is discussed, namely the prosthesis to the amputee. The excellency of the process of arthroplasties is presented for the patients with osteoarthritis and it is questioned if the State should not proceed in a similar way with the amputees.

Introduction: Osteomyelitis may lead to severe complications, such as bone necrosis, which can result in segmental bone defects. Nowadays, this is a very rare complication due to the proper antibiotic therapy and surgical management.Case Report: We describe the case of a six-year-old child referred to our institution with a massive humeral osteolysis due to a complication from a right arm pan-osteomyelitis, without previous surgical intervention. Physical examination revealed a deformable arm due to bone support absence. However, some movements of elbow flexion/extension and shoulder elevation were still preserved.Discussion: This paper describes a very rare case of an extensive bone segmental osteolysis due to osteomyelitis, which is interesting not only for its rarity and peculiar imaging and clinical presentation, but also for the fact that the child preserves some arm movements, using compensation/ recruitment mechanisms.

Bibliografic revision about definition, types, history, epidemiology of Myofascial Syndrome. Triggers points definition and difference to Tender spots. Classification, causes, factors, histopatology, physiology and diagnoses of trigger points. Differential diagnoses with fibromyalgia. Treatment in the different stages and plan of action. Keywords: pain, myofascial, trigger point

The primary autonomic failure is a degenerative disease of the nervous system, of unknown etiology. Among the various possible clinical manifestations by impairment of the autonomic nervous system, highlight the genito–urinary dysfunction that is often over looked. The authors present a case of a woman 67 years diagnosed with primary autonomic failure, whose neurogenic bladder was diagnosed late. The aim of this work is to reflect on the diagnosis and treatment of this condition.

Muscle injury is one of the most frequent pathological processes in athletes. Early diagnosis and proper approach optimizes recovery and minimizes downtime.The healing process and muscle regeneration consists of a complex cellular and immune response with several phases and multiple biochemical processes involved: inflammatory phase, regeneration phase and remodeling phase.The treatment of muscle injury should be serial and take into account the biological stage in which healing is found.Pharmacological treatment of muscle injury is a controversial issue. Current therapeutic options attempt to interfere with the various stages of the healing process, either by stimulating cell regeneration or by inhibiting the formation of fibrosis. Currently either oral drugs or injectables have limited scientific evidence to be applied routinely.This article aims to describe the phases of muscle healing in detail, to detail the approach and treatment of rehabilitation indicated in each phase and to present the evidence of several therapeutic options. For this, a review of the literature published until July of 2018 was carried out in the main medical databases.

Limb-length inequality (LLI) is commonly associated with compensatory gait abnormalities, resulting in secondarysyndromes. The correction of LLI with insoles is widely used, although there are few studies demonstratingobjective benefits. These where evaluated through Gait Analysis and Baropodography, in a patient with posttraumaticLLI.The authors report the case of a male patient, aged 27, motorcycle accident survivor, with multi-level fractures inright lower limb (RLL), who was surgically treated. The RLL was radiographically 9 mm shorter. 3D gait analysisand computorized baropodography were performed in the gait laboratory with and without LLI compensation.In orthostatic position, the following were observed: relative rise of left pelvis; flexion of the hips and knees,ankle dorsiflexion (magnitudes on the left greater than on the right). The spacio-temporal gait parameters werewithin normal ranges.The static baropodography showed pressures concentrating at forefoot on RLL.The dynamic baropodography revealed abnormal progression of the center of pressure on the right, starting atthe head of the 5th metatarsal, backards to the mid-foot, then forward, towards the 1st toe.The vertical component of ground reaction forces analysis showed: absence of both peaks during right stance,normal on the left; flatter curve of ankle dorsiflexion moment on the RLL; ankle power comparatively reducedon RLL.The asymmetries were markedly reduced by wearing an 8 mm insole in the right shoe.The gait laboratory measured the positive immediate effects of an orthotic intervention with a more than likelyimportant role in preventing long-term complications.Keywords: Leg Length Inequality; Insoles; Gait.

There are no predictable hormonal or gynecologic changes that impair pregnancy following a spinal cord injury in women. Female fertility generally remains intact postinjury. When desired, these women should be able to choose motherhood, integrated into the whole rehabilitation program and as a part of social integration.The main medical problems associated with pregnancy in spinal cord injured women are urinary tract infections, neurogenic bladder and bowel management, anemia, deep venous thrombosis, pressure ulcers, spasticity, hypotension, premature labor and, in some cases, respiratory problems and autonomic dysreflexia.Labor and delivery present specific changes due to motor and sensory alterations that can be different according to the level and type of injury. There is a considerable risk of autonomic dysreflexia in women with lesions at or above T6, which should be avoided with epidural anesthesia.Pregnant women with spinal cord injury should attend multidisciplinary antenatal care, in a tertiary hospital, so that complications are promptly recognized and treated. Therefore, the women can have a secure pregnancy that culminates in the birth of healthy children.

Objetivo: determinar a incidência de disreflexia autonómica nos doentes com lesão medular durante o período de internamento; identificar a causas desencadeantes mais comuns; determinar que variáveis poderão influenciar a incidência de disreflexia autonómica.Métodos: Foi conduzido um estudo retrospetivo num serviço de Medicina Física e de Reabilitação, tendo sido selecionados todos os doentes com lesão medular com nível sensitivo acima de T6 internados entre Janeiro de 2011 e Dezembro de 2013. A informação sobre o número de episódios de disreflexia autonómica, as características demográficas, as causas de disreflexia e a necessidade de utilizar medicação anti-hipertensora foi retirada dos registos clínicos dos pacientes incluídos.Procedeu-se à análise estatística recorrendo ao statistical package for social sciences (SPSS). Resultados: 12,7% dos pacientes incluídos desenvolveram pelo menos 1 episódio de disreflexia autonómica durante o período de internamento; 71,4% dos episódios de disreflexia autonómica ocorreram em doentes com lesão medular completa (AIS A); todos os episódios ocorreram em pacientes em que a causa da lesão medular foi o traumatismo vértebro-medular e com lesão medular com nível sensitivo cervical.Os principais fatores desencadeantes de disreflexia autonómica foram de origem genitourinária (48%) ou gastrointestinal (44,2%). Houve necessidade de administrar medicação anti-hipertensora em 26,5% dos episódios.Conclusão: A disreflexia autonómica parece ser um complicação relativamente comum nos doentes com lesão medular. É importante estar alerta para a possibilidade desta complicação, uma vez que o correto tratamento passa pelo reconhecimento atempado, pela imediata eliminação dos fatores desencadeantes e pela administração de tratamento farmacológico se necessário. 

Groin pain is a frequent athletic injury with a multitude of etiologies, being ilioinguinal and iliohypogastric nerve pain one of the most frequent causes.We present a case of a trail running athlete with a groin pain in the ilioinguinal and iliohypogastric nerve territory that was refractory to conventional treatment. Three months after the initial symptoms, he was submitted to incobotulinum toxin injection in the iliopsoas muscle fibers that were adjacent to the nerves, in the inguinal area. The symptoms quickly disappeared, pointing the iliopsoas muscle as a possible cause of ilioinguinal and iliohypogastric nerve impingement and providing new insights into this pathology.

International Society of Physical and Rehabilitation Medicine (ISPRM): strengthening Physical and Rehabilitation Medicine (PRM) worldwide

Objectives: Urinary incontinence (UI) is the involuntary leakage of urine. It is classified as stress UI, urgency UI or mixed UI and has different degree of severity affecting patients’ quality of life (QOL). The aim of this study is to evaluate the effects of rehabilitation in UI. Methods: Retrospective analysis based on clinical files of female patients sent by Gynecology and undergoing rehabilitation treatment for UI from January 2009 to June 2010. Variables were analyzed using SPSS® 17.0. Results: Total of 84 valid cases (5 excluded due to noncompliance - 8.2%) with an age average of 53 years. Of these, 59.5% had stress urinary incontinence, 39.3% mixed and 1.2% urgency. The average duration of UI prior to referral to Physical Medicine and Rehabilitation was 10 years. Surgery had previously been performed without success in 11.9%. Each person had on average 22 sessions of physiotherapy. At the end of treatment 53.6% didnt have urinary incontinence, 23.8% considered themselves subjectively improved and 22.6% had the same complaints. Patients with previous surgical treatment reported improvement in 70% of cases. The VAS (Visual Analogue Scale) average for impact on QOL after treatment reduced 50%. Treatment was reinstituted in 14.3% due to relapse of symptoms and 10.7% required surgical treatment.Conclusion: Although this is a retrospective analysis, with all its limitations, this study reinforces the importance of a multidisciplinary approach in cases of UI. We believe that rehabilitation has beneficial effects in perception of leakage and improving QOL of patients, even when surgical treatment has failed. Keywords: Urinary incontinence; Quality of life; Exercise Therapy; Pelvic Floor. 

Introduction: Shoulder range of motion measurement is not only of diagnostic significance but is also relevant for monitoring response to therapeutic interventions. Smartphones incorporate accelerometers which enable easy multiaxial and multiangle measurements but their reliability compared to the classic goniometer remains to be established. The authors aim to ascertain the intra-rater reliability between manual and smartphone-based digital goniometry in measuring active flexion and external rotation in both standing and supine positions.Methods: A convenience sample of 16 healthy volunteers was selected. Measures were taken by an independent rater at two different times, a week apart. We randomized both participant’s order and measurement sequence. The rater was trained according to a predetermined measurement protocol and blinded to intermediate measurements. We evaluated agreement between methods using the intraclass correlation coefficient, visual inspection of Bland-Altman plots and calculation of the limits of agreement.Results: The intra-rater correlation was good regarding the external rotation-standing intraclass correlation coefficient 0.87 (IC 95%: 0.66-0.95), the external rotation-supine intraclass correlation coefficient 0.92 (IC 95%: 0.80-0.97)) and the active flexion standing intraclass correlation coefficient 0.92 (IC 95%: 0.78-0.97). The score was lower in the active flexion supine intraclass correlation coefficient 0.81 (IC 95%: 0.55-0.93).Conclusion: There was a good intra-rater reliability between classic and digital goniometer in external rotation (regardless of positioning) and in standing active flexion. The smartphone based digital goniometer might be an easy tool to assist physical examination in healthy individuals, but its accuracy and applicability to clinical settings needs further evaluation.

The urodynamic study, like any invasive diagnostic or therapeutic procedure performed at the genitourinary level can lead to the development of urinary tract infection or bacteriuria, so it is recommended antibiotic prophylaxis. The growing resistance of microorganisms to antimicrobial agents is recognized worldwide as a serious threat to public health. It is therefore essential to take all possible measures to prevent infections associated with these procedures, as well as measures to prevent increased antimicrobial resistance. The various literature reviews on this topic were analyzed, as well as the European Association of Urology guidelines for urological infections, the American Urological Association best practice guide, and revisions made related to the pediatric population. From the literature analyzed, recommendations are made for prophylaxis of urinary tract infection and / or bacteriuria associated with urodynamic study in both adults and the pediatric population.

Objectives: Spinal cord injury (SCI) has several causes, not only iatrogenic, but also traumatic, vascular, neoplasic,infectious, degenerative, metabolic and congenital. The true relative contribution of each cause in the incidenceof this disease on a global scale is unknown. We found only one retrospective study (Bacher et al.) whichconsidered the incidence of iatrogenic SCI in a Rehabilitation Centre and characterized its population. The aimsof the present study were to quantify the incidence and characterize iatrogenic SCI of an inpatient population inthe Centro de Medicina de Reabilitação do Alcoitão (CMRA) and to compare the results with the mentionedstudy.Methods: Longitudinal retrospective study of patients admitted for the first time to the SCI department of CMRAin a 5 year period. Demographic and clinical data were collected from the clinical file of these patients. The sample included 16 patients. The incidence of iatrogenic SCI was determined between 1-1-2005 e 31-12-2008(n=11). For the characterization of iatrogenic SCI, inpatients from 1-7-2004 e 30-6-2009 were accepted (n=16).Results: We obtained an incidence of iatrogenic injury of 2,7%. The mean age was 58 years, with slight femalepredominance. The most frequent pre-iatrogenic diagnosis was degenerative spondylopathy (53,3%). In 50% theiatrogenic medical act was spinal surgery (62,5% lumbar surgery) being laminectomy the most common surgicalprocedure. Most cases were classified as paraplegia ASIA B (31,2%) or ASIA C (37,5%), with thoracic neurologicallevel in 56,2% of the patients. In 54,5%, the index event occurred immediately after the surgery. The study ofBacher et al. revealed a lower incidence of iatrogenic lesion (0,69%) and the majority of patients were classifiedas paraplegia ASIA A.Conclusion: The incidence of iatrogenic SCI is still not well understood. The comparison between the two studiesshowed important differences of incidence, but a relatively similar clinical description. More studies, specially witha multicenter design, are needed for a better characterization of iatrogenic SCI.Keywords: Spinal Cord Injuries; Iatrogenic Disease; Epidemiology.

Shoulder pain is a common symptom in general population and can be caused by several pathologies. Injectable local corticotherapy is a therapeutic option for shoulder pain patients promoting inflammation and pain reduction and providing functional recovery. The authors performed a literature review concerning corticosteroids infiltration in shoulder pain with focus on proceedings, techniques and drugs available and its efficacy compared to other treatment options. A bibliographic research was performed using PubMed with the terms “shoulder pain”, “corticosteroids” and “injections”. Articles considered relevant were selected according to subject suitability. The authors concluded that corticosteroids infiltration is a safe and effective option for shoulder pain management at short-term, if security norms are fulfilled.

Introdução: A doença de Dupuytren é uma patologia proliferativa benigna do tecido conjuntivo que envolve a fáscia palmar. A primeira manifestação clínica reportada pelo doente é o espessamento da pele junto à articulação MCF. O 5º dedo é o mais afetado, e a doença de Dupuytren atinge mais frequentemente homens com mais de 40 anos. A diabetes mellitus, a dependência do álcool e do tabaco e o HIV estão associados a um maior risco de desenvolvimento da doença. O tratamento gold standart passa pela intervenção cirúrgica que está indicado em casos de doença avançada. A reabilitação pós-operatória deve começar entre 3 a 5 dias após a cirurgia com exercícios de manutenção de amplitudes articulares e uma tala palmar.Objetivos: Caracterizar a população com doença de Dupuytren submetida a intervenção cirúrgica e avaliar os ganhos do programa de reabilitação pós-cirúrgico.Método: Estudo retrospetivo e longitudinal com consulta dos arquivos clínicos dos doentes com doença de Dupuytren tratados cirurgicamente, avaliados e seguidos no Serviço de Medicina Física e de Reabilitação de acordo com o programa de terapia ocupacional.Resultados: De um total de 50 doentes com doença de Dupuytren tratados cirurgicamente entre Janeiro de 2014 e Agosto de 2015, 92% eram homens. A média de idades era de 64.22 anos de idade. Os fatores de risco associados foram predominantemente diabetes mellitus (22%), tabagismo (8%) e hábitos alcoólicos moderados a acentuados (6%). 54% dos doentes foram operados à mão direita, e a maioria dos doentes foi operada ao 5.º raio (38%). 42 doentes (84%) frequentaram o programa de reabilitação 2 vezes por semana. 13 doentes abandonaram o tratamento não tendo efetuado consulta de reavaliação. A média dos tratamentos foi de 70.14 dias (DP 42.5). Em comparação com o início e o fim do programa de reabilitação houve uma diferença significativa tanto na extensão como na flexão da MCF (p=0.00, p=0.03), da IFP (p=0.00, p=0.01), e na dor (p=0.00). Não se encontraram outras relações estatisticamente significativas.Conclusão: A cirurgia seguida de um programa de reabilitação estruturado na doença de Dupuytren permite uma melhoria das amplitudes articulares e da dor.