RCAAP Repository

Objetivos Cada vez mais doentes com traqueostomia (DTQ) têm alta de Unidades de Cuidados Intensivos antes da descanulação; o melhor modelo de prestação destes cuidados são as equipas inter/multidisciplinares. O presente trabalho faz uma revisão da literatura acerca deste tema e apresenta um estudo numa Unidade de Doentes Agudos (UDA) hospitalar, co-coordenada por Fisiatra.Materiais e Métodos Estudo observacional retrospetivo da análise da atividade assistencial no internamento em UDA (maio/2011-2013). Recolhida informação dos processos clínicos de 40 DTQ, relativa às variáveis: proveniência, idade, diagnóstico de entrada, patologia médica/cirúrgica, duração de TQ e de internamento hospitalar, percentagem de descanulações, destino após alta. Análise da significância estatística da evolução funcional de toda a amostra e comparativa dos doentes descanulados vs não descanulados. Na revisão da literatura usou-se a base de dados eletrónica MEDLINE. Efetuou-se paralelismo entre os dados da UDA e os da literatura.Resultados 40 DTQ foram internados na UDA. A idade média dos doentes foi 59.6 anos. Descanularam-se 77.5% dos doentes, 100% com sucesso. O tempo médio de descanulação foi 35 dias e o total de internamento foi 60.9 dias. A diferença de medianas de evolução funcional à data de entrada e alta foi significativa (p<0.001), tendo os doentes descanulados tido uma evolução funcional superior à dos não descanulados (p=0.023). A idade média, os tempos de descanulação e de internamento dos doentes da UDA estão no limite superior do descrito nos artigos, o que se poderá dever a elevados índices de gravidade e mais comorbilidades dos doentes da UDA, assim como prestação de reabilitação intensiva enquanto necessária.Conclusões A criação de equipas inter/multidisciplinares que prestem cuidados a DTQ é o melhor modelo de prestação destes cuidados. A UDA apresentada representa uma experiência crescente na prestação deste tipo de cuidados. Os doentes descanulados na UDA registaram evolução funcional mais favorável do que os não descanulados. A idade média e tempos de descanulação e de internamento estão no limite superior do descrito nos artigos encontrados, provavelmente por mais comorbilidades, índices de gravidade superiores e prestação de reabilitação intensiva independentemente do tempo de internamento previsto. A UDA poderá ser inovadora evidenciando nova área de atuação da MFR. Palavras-chave:Traqueostomia, Traqueotomia, Equipa interdisciplinar / multidisciplinar.

Introduction: Stroke is one of the main causes of morbidity and mortality, representing the neurological pathology most frequently admitted to Internal Medicine (IM) departments. Rehabilitation is essential in optimizing the functionality of these patients.Material and Methods: Retrospective study of patients admitted to an IM department from January to December 2017 with a clinical diagnosis of stroke. The sample was characterized for sociodemographic and clinical variables. Functional variation during hospitalization was evaluated using the Barthel index. Statistical analysis was performed using the SPSS® software, version 23.0, considering a pvalue !0.05 as significant.Results: A total of 189 patients were included, which presented a median age of 78 years, a slightly female predominance (51.3%) and multiple comorbidities, such as hypertension (68.8%), dyslipidemia (47.6%) and diabetes mellitus (35.5%). The majority (77.8%) had imagiological translation, with 82.5% being of ischemic aetiology. The mortality rate was 10.1%. In 70.9% of cases, a Physical Medicine and Rehabilitation (PMR) assessment was requested. A statistically significant association was identified between the performance of rehabilitation and the in-hospital functionality variation (p=0.000).Conclusion: In this study, stroke occurred predominantly in a geriatric population, it was mostly due to ischemic aetiology and was associated with multiple comorbidities. The vast majority of patients were referred to PMR, with most of them presenting gain or maintenance of in-hospital functionality with rehabilitation performance. Thus, this study demonstrates the important role of PMR in minimizing functional deficits after stroke, allowing functionality improvement and facilitating socio-familiar integration.

Introduction: Chemical synoviorthesis (CS) is a procedure frequently utilized/used in the management of patients with active arthritis in a limited number of joints. This technique involves the intraarticular administration of a therapeutic agent, such as long-acting corticosteroid. Its use in children is described since 1979. Currently, it is recommended in the oligoarticular form of juvenile idiopathic arthritis (JIA) and also used in the other forms of JIA when refractory arthritis to conservative treatment is present.Purpose: To assess the efficacy and safety of chemical synoviorthesis in patients with JIA, which had not responded to systemic therapy. Material: Twenty-six patients (6 males, mean age 13.4 years) who met the ILAR criteria for JIA (2 systemic JIA, 20 oligoarthritis, 1 RF-positive polyarticular JIA, 2 RF-negative polyarticular JIA and 1 psoriatic arthritis) were included in the study. Thirty-seven synoviorthesis were performed from January 2006 to December 2009, using triamcinolone acetonide (35) or hexacetonide(2). Methods: A retrospective review of patient’s data was performed using a protocol which included demographic information, disease characteristics, evolution and follow-up after synoviorthesis. Microsoft Excel 2003 and SPSS Statistics 17.0 for Windows were used for data organization and analysis. Results: Mean disease evolution was 27.4 months and mean follow up time was 6.3 years. Relapse occurred in 6 cases. In the oligoarthritis subgroup, 92,9% of the treated joints showed no inflammatory activity in 24 months versus 62,5% in the other subgroups of JIA. Fifteen patients were considered to be in clinical remission, with a tendency for the oligoarthritis subgroup (X2(1) =5.38, p=0,020). Complications of the procedure occurred in 2 cases (subcutaneous atrophy). Conclusion: We found a positive association between the oligoarthritis subgroup of JIA and clinical remission, despite small sample size. Chemical synoviorthesis is a safe and effective procedure for treatment of arthritis in pediatric patients with JIA, especially in oligoarticular form, strongly suggesting its application as first line therapy in oligoarthritis JIA. Keywords: Arthritis, Juvenile Rheumatoid; Injections, Intra-Articular; Triamcinolone Acetonide.

Introdução: A paralisia cerebral é uma patologia que surge na idade pediátrica e implica necessidades de reabilitação ao longo da vida. O exercício físico, nomeadamente o aquático, ganhou importância no processo de reabilitação das crianças e adolescentes com paralisia cerebral. Contudo, os seus verdadeiros efeitos não foram ainda definidos. Métodos: Pesquisou-se a expressão (“cerebral palsy” AND “aquatic”) OR (“children” AND “aquatic exercise”) nas bases de dados PubMed, PEDro e Cochrane e analisaram-se os dados relativos à população, intervenção terapêutica, controlo e resultados em 13 artigos. Resultados: 102 crianças/adolescentes com paralisia cerebral foram submetidos a um programa de exercício aquático. As amostras variaram entre um e 46 elementos com 5 a 21 anos de idade; todos eles apresentavam um padrão espástico de paralisia cerebral, sendo a forma de apresentação variável. Todos os artigos incluíram no programa de exercício aquático atividades para desenvolver a resistência aeróbia; alguns deles incluíram ainda atividades de fortalecimento muscular e/ou de outras variantes da aptidão física. As intervenções duraram 30 a 60 minutos (1-3 vezes/semana) num período de 6 semanas a 8 meses. Nenhum dos artigos procedeu à randomização da amostra e apenas quatro compararam grupos com intervenções distintas. A metodologia de avaliação dos resultados foi diversa, abrangendo as repercussões do programa de exercício aquático na funcionalidade. Discussão: As particularidades do meio aquático conferem uma vantagem para a reabilitação de crianças e adolescentes com paralisia cerebral tendo em conta o espectro de apresentação da doença. Apesar das evidências de eficácia e segurança do exercício aquático na reabilitação de crianças e adolescentes com paralisia cerebral serem ainda limitadas, este tipo de exercício enquadra-se como uma boa alternativa para melhorar os níveis de aptidão física, parâmetro fundamental no processo de reabilitação desta população. A diversidade das arquiteturas dos estudos já realizados não permite aglutinar evidências quanto à eficácia do exercício aquático na reabilitação de crianças e adolescentes com paralisia cerebral mas permite avançar com sugestões para tentar ultrapassar esta limitação. Conclusões: O exercício aquático revela-se uma opção válida para as crianças e adolescentes com paralisia cerebral alcançarem alguns dos benefícios de uma vida ativa, otimizarem a sua funcionalidade e melhorarem a sua qualidade de vida. Os próximos estudos sobre programas de exercício aquático na reabilitação da paralisia cerebral deverão, entre outros aspetos, recrutar indivíduos pela classificação no Sistema de Classificação da Função Motora Global, utilizar escalas de avaliação consensuais e tecer considerações sobre barreiras à participação, adequação do programa de reabilitação e segurança do ambiente aquático. Palavras-chave: Exercício; Reabilitação; Criança; Adolescente; Paralisia Cerebral. 

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Introduction: Osteoarthritis is a common and debilitating disease, associated with loss of quality of life and important healthcare costs. It usually presents with pain, stiffness, diminished range of motion and loss of functional capacity. The treatment is multimodal, envolving oral/topic medication, patient education, physiotherapy; in refractory cases with moderate to severe pain the interventional procedures are a valid option. Intrarticular injection is a procedure for decades, and nowadays the componentes usually injected are: corticosteroids, hyaluronates and platelet rich plasma. The objective of this paper is to find the evidence available to date related to the interventional treatment of the osteoarthritis of the knee, comparing the three options available and mentioned previously.Methods: Narrative revision of the literature published on the following medical databases: Medscape, Cochrane Library and PubMed.Results: There is evidence of positive results with the three options in analysis; the safety profile is favorable. Corticosteroids are a safe and eficient option, mainly on inflamatory periods/flare, providing good short term pain relief. Hyaluronates also show efficacy, with possible benefit up to 24 weeks, with a potentially unfavorable profile of cost/effectiveness. Platelet rich plasma, more recent, presents a promising profile of efficacy on pain and quality of life, with potential benefit up to 12 months.Discussion: The interventional treatment of the osteoarthritis of the knee is widely used, in the meanwhile, there are no formal guidelines to date. Other issue is the fact that the concept of osteoarthritis deserves, probably, a revision, since it is an extremely heterogeneous and hard to define disease. In this sense, a detailed semiology and objective examination are of utmost importance, since the focus of the clinician should be the identification of the source of pain, leading to a correct line of thought that allows a selection of the best approach possible that guarantees a good symptomatic control The majority of the studies analysed present a suboptimal methodological quality, which compromises the result analysis and eventual conclusions.Conclusion: Osteoarthritis of the knee is a worldwide health issue, that tends to increase accordingly to the evolution of the demographic pyramid. Intrarticular injections are a safe and valid option, that must be considered following a detailed clinical examinations and, given the objective, staging and functional prognosis the most valid option should be selected. More investigation is necessary, studies with better methodological profiles and longer follow-up times, so that more robust conclusions can be achieved.

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Criança 11 anos, admitida em Centro de Reabilitação com o diagnóstico de Mal de Pott, condicionando paraplegia, que apresentava deformidade óssea da coluna dorsal e radiologicamente apresentava colapso vertebralcom destruição dos corpos vertebrais de D5- D8 e marcada angulação cifóticacom hipersinal da medula espinhal de D3- D8 a traduzir mielopatia. O Mal de Pott permanece uma realidade, sobretudo em doentes provenientes dos países africanos sendo otratamento dirigido e a reabilitação fundamentais para minimizar o impacto da doença e melhorar a qualidade de vida.

Introduction: Our aim was to assess fampridine impact on upper limbs (UL) function in multiple sclerosis (MS) patients.Material and Methods: A prospective, unicentric, open-label, non-controlled and non-randomized clinical study in patients diagnosed with MS, EDSS between 4 and 7, clinic with involvement of the upper limbs and under treatment with fampridine. For right (RUL) and left (LUL) upper limbs functional assessment, the 9-Hole-Peg-Test (9-HPT) scale was used immediately before (Pre-RUL and Pre-LUL) and after (Post-RUL and Post-LUL) starting treatment. Statistical analysis was performed using SPSS, with statistical significance set to p<0.05.Results: From a total of 23 patients, 15 were included. The averages of the time (in seconds) of the evaluations were: pre-RUL 86.12 and post-RUL 50.95; pre-LUL 53.98 and post-LUL 45.08, with statistically significant value for the RUL (p=0.003, dominant upper limb.Conclusion: The results suggested the potential of fampridine in improving upper limbs function, in addition to the gains already confirmed in gait.

Purpose: Tracheotomy is a temporary or permanent procedure for treatment of upper respiratory tract failure, neurologic pathology, and trauma. It also presents some disadvantages: cervical dysmorphia, need for cannula cleaning/replacement, oral communication difficulties, absence of nasal function and tracheomalacia risk. Accordingly, as soon as possible, tracheotomy closure is needed in patient ́s rehabilitation. Cannula removal should only be considered if upper airway obstruction has solved, respiratory secretions are minimal and there is no need for mechanical ventilation. Predictors of success: ability to produce cough and absence of aspiration phenomena. Cannula withdrawal requires care, particularly after prolonged use. A standardized protocol optimizes performance and minimizes risks. PMR, in partnership with other specialties and health professionals, has a key role to play in this procedure. We present the protocol used in tracheotomy closure in our PMR institution. Material and methods: Literature search about tracheotomy management and closure protocols Results: Protocol (steps to follow-resume): - Deflate the cuff - Change to an uncuffed tracheostomy tube with smaller diameter - Partial cannula closure - Complete tube closure - Cannula removal and stoma closure Important remarks: - Set responsible physician - Evaluate the need of protocol adaptation with nursing team - Inform the patient and collect consent - Teach patient/caregivers how to act in case of sudden dyspnea - Monitor O2 saturation/patient surveillance - Each step must last a minimum of 12 hours. Conclusions: The PMR team skills and knowledge are essential in the tracheotomy closure comprehensive approach. A protocol improves its management. Scientific information is scarce and valid studies are needed in this field. PMR should contribute to improve the services provided to these patients. Keywords: Tracheotomy/rehabilitation; Airway Management.

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Hiccups are sudden and involuntary contractions of the diaphragm and intercostal muscles, which causes sudden inspiration followed by abrupt closure of the glottis, generating a characteristic sound. There is a large panoply of pharmacological and non-pharmacological interventions that have been attempted to treat persistent or intractable hiccups. However none of the interventions showed sustained and consensual scientific evidence. Some studies have suggested favorable effects of acupuncture on eliminating persistent hiccups. In this article we report a clinical case in which acupuncture was used to eliminate persistent hiccups following brainstem stroke.

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The complex regional pain syndrome (CRPS) is characterized by disproportionate pain concerning noxious stimuli,as well as sensory, vasomotor, trophic or motor disorders in the affected limb. It´s related to major trauma andsoft tissue minor injury, clinically presenting from joint stiffness and pain, to loss of function.The Physical Medicine and Rehabilitation (PRM) approach is crucial in functional recovery.The authors describe the case of a 32-year-old male with a knee pain that began 4 years ago. He was sent a yearago, after several knee arthroscopies without significant diagnostic findings, presenting quadriceps atrophy, kneeoedema and hyperesthesia, which lead to walking with crutches and professional inability. The patient wassubmitted to a program including joint mobilization and muscle strengthening as well as analgesicelectrotheraphy. After the contribution of bone scintigraphy for the diagnosis of CRPS, calcitonin was introducedand a reinforcement of the program was made through additional muscle strengthening, physical agents andpsychological support. An increase in muscle strength, pain relief in walking (VAS) and professional reintegrationwere accomplished.In CRPS, early intervention of PRM is decisive in keeping functional use of the affected limb through pain relief,range of movement and muscle strength preservation, as shown in this case.Keywords: Complex Regional Pain Syndromes; physical therapy; knee; pain.

Vitamin B12 deficiency causes several neurological manifestations such as myelopathy, polyneuropathy, optic neuropathy and dementia. The most common etiology for vitamin B12 deficiency is pernicious anemia; however, other causes include strict vegan, post-gastrectomy and Crohn’s disease. Vitamin B12 deficiency-induced myelopathy (subacute combined degeneration) is characterized by affecting the posterior and lateral columns of the spinal cord, which may lead to severe and irreversible damage. Diagnosis is established by clinical features, serum cobalamin and homocysteine levels, urinary methylmalonic acid measurements and magnetic resonance imaging. Treatment is based on vitamin B12 injections and recovery depends on the severity and duration of the deficiency. Typically it requires Physical and Rehabilitation Medicine for patients suffering from lasting deficits. In this case report, authors show promising clinical and functional results after the administration of cobalamim and after following a rehabilitation program.

Objetivo: Apresentar um modelo conceptual de história clínica em Medicina Física e de Reabilitação, tendo por base o seu papel de promoção da funcionalidade física e cognitiva.Material e Métodos: Foi realizada uma revisão da literatura, partindo de pesquisa na base de dados PubMed e consultando fontes adicionais de informação.Resultados: Verificou-se que o conteúdo da história clínica é relativamente consensual entre autores, porém a estrutura à qual esta obedece não está homogeneamente descrita. Neste artigo é apresentado um modelo de história clínica elaborado com base na literatura revista.Conclusão: A história clínica é um elemento fundamental na abordagem de qualquer doente. Apesar de existir uma estrutura comum, as particularidades de cada especialidade exigem uma adequação deste modelo, de forma a orientar a colheita de dados para os seus objetivos específicos. No caso da especialidade de Medicina Física e de Reabilitação, a avaliação funcional e contextual do doente assume particular importância, sendo determinante para o estabelecimento da estratégia de reabilitação.

Introduction: Introduce the animal assisted therapy ( AAT) into the therapeutic sessions and see if it will be a facilitator in achieving the defined goals.Material and Methods: We selected 3 children, followed in Physical Medicine and Rehabilitation (PMR) consultation and in treatment at the PMR service: C1 of 15 months (m), with occupational therapy sessions since 4m, due to delay of psychomotor development (DPMD); C2 of 31m, with speech therapy sessions since 14m, due to delay of language development; C3 of 27m, with occupational therapy and speech therapy sessions since 9m, due to DPMD. Individual and specific objectives were defined. The SGS-II was applied as an evaluation instrument at the beginning (T0) and at the end of the study (3 months later - T1), to evaluate C1 and C3, and to assess C2 were used specific articulation tests (applied at T0 and T1). The instructor designed the activities, together with the child ́s therapist, and guided the animal in session. The dog possessed obedience training and professional experience. Parents signed informed consent. The sessions were held once a week (45 minutes each), being filmed for later discussion of the case.Results: According to the SGS-II parameters evaluated at T0 and T1, we found that C1 presented a development corresponding to a mean age of 8m in T0 and 12m in T1, with an improvement in the speech and language parameter (result corresponding to an expected development of a 3m child in T0 and 15m in T1) and in the manipulative capacity (obtaining a development corresponding to a child of 8m in T0 and 15m in T1). C2 revealed in T1 a capacity for sentence construction (not observed in T0), improvement of the orofacial praxis and increase the time of attention/accomplishment of tasks. In C3, there was no change in the quoted values in the evaluation scale used. However, after viewing the session videos, we observed an increment in attention times, organization of simple tasks, comprehension of simple orders and improvement in number of vocalizations. Conclusion: The AAT emerges as a complement to the therapeutic sessions, enhancing the work developed by the technicians, facilitating the achievement of more expressive results in the specific cases of children with difficulties in interaction with the therapist. The dog becomes a motivating and optimizing vector of results. We consider the results obtained positive, given the short time elapsed from the program. Even in C3, where, despite the unchanged result of the evaluation scale used, it was found, after analyzing the parameters observed during the review of the session videos, an overall improvement in all of them.

Peripheral neuropathy is a common clinical problem, resulting from peripheral nerve injury. The toxic etiology is a less common cause, comparative with metabolic, inflammatory and hereditary. Included in this group the chemical, industrial and agricultural agents, heavy metals, and medication. In general, therapeutic approach of toxic neuropathies consists on removal of the causal agent, relieving pain, prevention and treatment of sequelae and therefore its important to refer to Physical Medicine and Rehabilitation. The authors present two clinical cases and a literature review of the pathophysiology, clinical management and treatment of toxic neuropathies. Keywords: Peripheral Nervous System Disease/chemically induced; Peripheral Nervous System Disease/ rehabilitation.

Spinal cord injury is a devastating health problem posing, along its course, huge challenges to the doctor and the patient. Few studies have addressed autonomic dysfunctions after spinal cord injury, particularly the diagnostic perspectives and therapeutic interventions. The joint committee of the American Spinal Injury Association (ASIA) and the International Spinal Cord Society (ISCoS) recommends the recognition and assessment of the following conditions as autonomic nervous system dysfunctions after spinal cord injury: Neurogenic Shock, Cardiovascular Dyfunctions (cardiac dysrhythmias and orthostatic hypotension), Autonomic Dysreflexia, Temperature Dysregulation and Sweating Disturbances. This article discusses the pathophysiology, diagnosis, and treatment of the different autonomic nervous system dysfunctions after spinal cord injury, in terms of the global rehabilitation of the spinal cord injured. Keywords: Autonomic Nervous System Diseases; Spinal Cord Injuries.