RCAAP Repository

Compression stockings are commonly used for prophylaxis of deep venous thromboembolism after surgery and its effectiveness is well established. Peroneal nerve palsy is the most common entrapment neuropathy of the lower extremity. It can result from multiple causes but direct external compression of fibula head seems to be the main one. The authors report a 20-year-old female patient, who was submitted to a liver transplantation and after 25 days on Intensive Care Unit, rolled-down compression stockings were removed, and a linear impression mark below knee with bilateral foot drop was observed. The electrodiagnostic testing confirmed the diagnosis of a severe sensory-motor polyneuropathy. The aim of this report was to emphasize the importance of early recognition of the symptoms of peripheral nerve injury, especially in critical ill patients with multiple risk factors, who might have a worst outcome and permanent damage.

Botulinum toxin application on post burn hypertrophic scars has had a growing international interest. Despite this, up to this day, there are no scientific publications or case reports in Portugal on the usual data bases. We present the first case published in Portugal, as well as the protocol in use and the objective and patient-reported results. The positive results achieved are in line with the existing literature. This technique should thus be considered in selected patients, constituting an added value in the rehabilitation of hyperthrophic scars sequelae.

The ability to walk upright is a defining characteristic of man.Walking is a complex process where body segments need to move in a coordinated manner. The lower bodyextremity must have the ability to support body weight during the stance phase of the locomotion cycle, rotateand coordinate the joints to achieve forward progression, adjust limb length during the swing phase of gait, andfurther smooth the trajectory of the centre of mass for energy conservation.Some of the therapeutic strategies adopted in paediatrics ortotraumatologic and/or neuromuscular pathology,involve walking with a blocked knee, for example knee arthrodesis, transfemoral amputation or kneedisarticulation with a non-articulated prosthesis, or a Knee-Ankle-Foot Orthosis (KAFO), that generally doesn’tarticulate. Patients who walk with a knee blocked in full extension clear the foot during swing phase by adoptingcompensatory movements and such compensations result in decreased efficiency and increased energeticconsumption.KAFOs are prescribed for individuals who, due to significant weakness of the knee extensor musculature or deformity, need a mechanical control of the knee during stance, trough blockage in extension. More recently, theintroduction of Stance-Control Knee-Ankle-Foot Orthoses (SCKAFO) has been designed to allow swing phasefreedom for the knee joint while automatically providing stance phase stability. However, commercially availablesolutions are not available to the paediatric population, and this stage is essential for the development andacquisition of a definitive corporal scheme and activation of motor patterns.The aim of this paper is to highlight the importance of lower limb orthoses with articulated knee, for thepaediatric population. The authors have split this article into three sections: the first section reviews the gait cycle,describing the changes resulting from the blocked knee in extension; the second section presents lower limborthoses available with assistance during the support phase, setting out its faults; in the third section, by way ofconclusion, the authors propose guidelines for future research solutions adaptable to the paediatric population.Keywords: Child; Knee Joint ; Knee Prosthesis; Walking

Simultaneous bilateral anterior tibial tuberosity avulsion fracture is a very uncommon injury and rarely reported in adolescents. Since the first reported case by Borch-Madsen in 1955 only 23 cases have been published. We report the case of a 14-year-old boy who had a simultaneous bilateral anterior tibial tuberosity avulsion fracture during a gym class, while running. The patient was submitted to surgical repair with anatomical reduction of the fractures and fixation with a cannulated screw. The patient underwent an intensive rehabilitation program for 4 months, without any significant complications. The outcome was very favorable with complete return, without restrictions to daily living activities.

Introduction:  Congenital pseudarthrosis of the clavicle (CPC) presents as a congenital painless swelling over the mid-third of the clavicle, mostly on the right side and females, that persists over lifetime with no functional limitations.Purpose: Present a 12 years follow-up case of CPC and literature review.Clinical Case: A full-term newborn boy, with uncomplicated pregnancy and vaginal delivery, presented with a firm bony protuberance (1x1cm), in the mid-third of the right clavicle without functional limitations and no other physical examination abnormality. The X-ray identified a bony defect in the mid-third of the right clavicle with smooth, regular, intact/sclerotic cortex and without any evidence of callus formation. The diagnosis of CPC was performed.Over the twelve follow-up years, he kept asymptomatic, without functional limitations and normal physical and skeletal development. Over time, the X-rays showed the same bone defect with the same characteristics. At fourth years old, surgery was proposed for aesthetic reasons but parents refused.Conclusions:  Although rare, CPC can be easily diagnosed through characteristic physical examination findings and radiographic hallmarks. It is essential to exclude other differential diagnosis, like clavicular fracture or rare bone diseases, and be able to reassure parents, explaining the benign nature of this condition.

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Congenital scoliosis remains a challenge for the PMR clinician. It results from an anomaly in the vertebral development leading to its presentation in younger ages, when compared to idiopathic scoliosis. Congenital curves tend to be rigid and resistant to conservative treatment, that considering the remaining growth potential, may result in severe spine deformities. The authors reviewed the published literature concerning congenital scoliosis, aiming at the update of the fundamental aspects in diagnosis and treatment. Vertebral anomalies are classified in segmentation, formation, and mixt defects. Formation defects can be complete or partial, leadind to a hemivertebra ou a wedge vertebra. Among segmentation defects are the unsegmented bars and the vertebral bloc, in the complete absence of disc. The patient evaluation consists in a complete medical history, including prenatal, birth and neonatal antecedents, family history, development milestones and system revision. Physical examination includes spine, cutaneous, thoracic, genital and limb inspection and neurologic examination. The recognition of associated anomalies is important, namely intraspinal, genito-urinary and cardiovascular, among others. Early diagnosis and adequate follow-up are the key elements to avoid progression and complications. X-ray allows the diagnosis of vertebral malformations, measurement of scoliotic curve progression and the determination of growth potential. Evolution depends on the affected area, type of anomaly, age at diagnosis, balance and curve pattern. The presence of an unsegmented unilateral bar has a bad prognosis, whereas a vertebral bloc has the best prognosis. Even though orthotic treatment remains controverse, the possibility of delay in the progression of the scoliotic curve, allowing surgery in a later age, justify its use as a treatment option, in selected cases. The treatment of scoliotic short, rigid and progressive curves is surgical. PMR plays an important role in the diagnosis, treatment management and interface with other specialties, considering the specificity of individual treatment and hazard complications. Keywords: Scoliosis; Spine abnormalities; Diagnosis; Treatment.

Objectives: To evaluate the relationship between age and functional outcome in patients with sequelae of Traumatic Spinal Cord Injury (TSCI).Material and Methods: Retrospective study, with a 88 patients sample that were admitted as inpatients in Physical Medicine and Rehabilitation (PMR) Department of Hospital de Braga, between the years 2007 and 2011, with sequelae of TSCI. Clinical files were consulted and two age groups (<65 and ≥ 65 years) were compared. The Functional Independence Measure (FIM) was used to quantify the functional outcome by calculating the variation between the values at admission and discharge, in 68 of the 88 patients. For gait evaluation were used Modified Functional Ambulation Classification (MFAC) and the Walking Index for Spinal Cord Injury II (WISCI-II).Results: There were 65(73,9%) patients with <65 years and 23(26,2%) were ≥ 65 years. The mean age was 50 years. Fall was the most prevalent cause of TSCI. Cervical injuries were more frequent, as well as incomplete lesions. The average hospital stay was 95 days. The mean MIF score was 66.32 points (<65 = 67.2, ≥ 65 = 63.38) at admission and 97.09 points (<65 = 100.89, ≥ 65 = 83.4) at discharge . The mean MIF variation was 30.19 points (<65 = 33.36, ≥ 65 = 19). The mean MFAC was 0.33 and 1.57 points, and the mean WISCI-II was 1,60 and 8,55 points, at admission and discharge, respectively. There was a statistically significant relationship between age at the time of the accident and the FIM variation.Conclusions: In this sample there was a predominance of males and age at the time of the accident less than 65 years. There was an influence of age on functional outcome in patients with TSCI during hospitalization in a PRM Department, and patients aged ≥ 65 years showed a lower functional outcome, highlighting the importance of age on functional recovery after TCSI.

introdução: Embora as guidelines atuais recomendem o exercício como tratamento de primeira linha na doença arterial periférica, quer a sua disponibilidade quer a sua utilização continuam a ser limitadas. O objetivo deste trabalho consiste em fazer uma revisão sobre as características ótimas de um programa de exercício na doença arterial periférica.Métodos: Foi realizada uma revisão bibliográfica sistematizada. Foram utilizadas as bases de dados PubMed e Cochrane Library sob os termos de pesquisa: “exercise” AND “peripheral arterial disease” e “rehabilitation” AND “peripheral arterial disease”. Foram incluídos os consensos, guidelines, meta-análises e artigos de revisão encontrados desde janeiro de 2010 até dezembro de 2016.Resultados: Foram identificados 35 artigos. Estão descritos inúmeros programas de exercício nos mais diversos estudos. Parece existir superioridade nos programas de exercício supervisionados, com duração superior a três meses e uma frequência de três vezes por semana. É proposto treino aeróbio intermitente com duração mínima de 30 minutos. Ainda existe controvérsia relativa à intensidade mais adequada e ao ritmo de progressão do programa de exercício. O treadmill é a modalidade mais estudada, no entanto, outras modalidades alternativas têm ganho interesse crescente.Conclusão: Apesar de existir ainda alguma controvérsia relativa à superioridade de determinados parâmetros na prescrição de exercício, existem outros bastante consensuais, nomeadamente no que diz respeito a supervisão do programa, duração e frequência das sessões de exercício.

Introdução: A maioria das complicações relacionadas com o aparelho extensor numa artroplastia total do joelho (ATJ) prendem-se com a instabilidade patelo-femoral. O objetivo deste artigo é ilustrar o desafio que pode ser para o Fisiatra a orientação de um doente com luxação recidivante da rótula após ATJ.Caso Clínico: Doente de 70 anos, do sexo feminino, seguida em consulta de Medicina Física e Reabilitação por status pós-ATJ direita (bi-compartimental) complicada com luxação recidivante da rótula. Depois de um episódio de queda, sofreu fratura proximal da tíbia com descolamento do componente tibial, tendo sido submetida a revisão cirúrgica e posterior plano de reabilitação individualizado. Foi intervencionada mais quatro vezes por luxação recidivante da rótula e luxação da própria prótese.Discussão: A etiologia da instabilidade rotuliana após artroplastia total do joelho é muitas vezes multifatorial, sendo a principal causa os erros técnicos cirúrgicos que podem levar a um mau posicionamento dos componentes protésicos. A maioria das opções de tratamento passa por uma revisão cirúrgica seguida de um plano de reabilitação.Conclusão: A instabilidade patelo-femoral é uma complicação relevante em doentes submetidos a artroplastia total do joelho, podendo a mesma ser evitada por múltiplas estratégias cirúrgicas e não-cirúrgicas.

The Temporomandibular Joint Disfunction (TMJD) reaches to a variety of clinical conditions associated to pain and disorders of the temporomandibular joint (TMJ) and masticatory muscles, which are of controversial aetiology. Despite of the excellent vital prognosis, the TMJD could impose substantial decreases in the life quality. The recent recommendations concerning to treatment, advice an initial conservative approach, which includes almost consensually the important role of Physical and Rehabilitation Medicine (PRM). The authors present a bibliographic overview of the scientific evidence concerning the success of the PRM in the TMJD. Keywords: Temporomandibular Joint Disfunction (TMJD), Physical and Rehabilitation Medicine (PRM)

Currently survival has increased in patients with congenital heart disease due to advances in medicine. However, most of these patients still does not perform regular physical activity, not due to their underlying disease, but because fears of themselves, family members and teachers related to the disease. Also cardiac rehabilitation programs with well-known benefits in adults are still little performed in children and adolescents and it is not known the methodology and results at the level of functional abilities and psychological condition of these patients. The authors reviewed the literature searching for the current evidence of cardiac rehabilitation programs for children and adolescents with congenital heart disease and current recommendations for practice of physical activity.Most studies report the beneficial effects of multidisciplinary cardiac rehabilitation programs, including psychological and nutritional counselling, to decrease the number of new hospitalizations and improve functional capacity and quality of life of these patients. At the same time, there are many articles that point out that physical exercise and participation in competitive sports in most cases is possible and safe, if the patient follow the necessary recommendations to their pathology in particular and the advices given for their attending physician in relation to this particular subject.

Introduction: Low back pain is a major cause of chronic pain and one of the most frequent reasons for referral to Physical and Rehabilitation Medicine (PRM)’s consultation. Chronic back pain can lead to significant functional disability and is a common cause of work absenteeism. The main purpose of this study was to evaluate the efficacy of mesotherapy in relieving chronic low back pain and to investigate if that relief has functional impact on the daily life of patients.Methods: A quasi experimental pre post study was conducted on a PRM Department, assessing all patients with chronic low back pain who underwent mesotherapy in the period from March to November of 2014, applying the questionnaires “Brief Pain Inventory” (BPI) and the “Roland Morris Disability Questionnaire” (RMDQ) before and after the four cycles of treatment with mesotherapy with antiinflammatory, local anesthetics and muscle relaxants.Results: We included 26 patients, 80.8% women and 19.2% men, with a mean age of 54.8 years. The most common diagnosis was non-specific low back pain (34.6%). Analyzing BPI, there was a decline of 2.6 points in pain severity scale after mesotherapy, statistically significant finding (p = 0.000). For evaluation of functional impact of pain, assessed by the BPI, there was a decrease of 1.7 points, statistically significant result (p = 0.000). In RMDQ there was a decrease of 4.5 points after mesotherapy (p = 0.000).Conclusion: Although there are few articles in the literature, mesotherapy seems to lead to the relief of low back pain, which provides a better quality of life for patients. Therefore, mesotherapy may be a valid alternative to the conventional approach of low back pain.

Non-traumatic cerebral hemorrhages are less common than acute ischaemic vascular lesions but are associated with higher mortality rates and years of life lost due to disability. They may lead to a diversity of neurological deficits, being the intervention of Physical Medicine and Rehabilitation (PMR) essential for clinical and functional improvement.59 years-old female patient, non-hypertense, previously independent in activities of daily living and cognitively intact. The patient was admitted to the Emergency Department after a sudden severe headache. On admission, the patient presented a left homonymous hemianopsia and hemiparesia. Computed tomography revealed a voluminous parenchymal cortico-subcortical right temporo-fronto- parietal hemorrhage. The patient underwent emerging decompressive craniectomy. During hospitalization, the patient had a positive clinical and functional evolution, and was transferred on the 66th day of hospitalization to the PMR ward. After 17 days, the patient presented an indolent deterioration of the state of consciousness, with progressive somnolence and prostration, making unfeasible to participate in the rehabilitation program. Given the worsening of the neurological status, neuro-imaging study was repeated and a large expansive lesion with necrotic- cystic enhancement pattern, of probable neoplastic etiology (primary glial or secondary series) was depicted.The evaluation, interpretation and orientation of cases of nontraumatic intracerebral hemorrhage with fluctuation of neurological status and/or stagnation of functional evolution in the subacute and chronic phase appears as a diagnostic challenge. It is essential to increase the perception that intracerebral hemorrhage without defined etiology may be due to primary or secondary brain neoplasms, which require early and directed evaluation and guidance.

Objectives: This paper is intended to analyze several, considered relevant, studies in order to draw up a leafletthat includes joint protection measures and an exercise scheme, for the patient with rheumatoid arthritis (RA).Material and Methods: The authors performed a literature review on joint protection programs and handexercises for patients with RA; the authors selected five studies that had a higher study design quality andadequate outcomes: pain, inflammation, muscle strength and function.Results: The reviewed studies shown beneficial effects of several exercise and joint protection programs in termsof pain, stiffness, grip strength and upper limb function. The beneficial effects of these programs remain longterm.Just providing information is not enough - demonstration and repetition is required.Conclusions: The programs that combine measures of joint health, range of motion exercises and musclestrengthening, with increasing repetitions are more effective and better tolerated. Based on the data drawn fromthe various studies, the authors developed a leaflet for patients with RA, as a part of a comprehensiverehabilitation program.Keywords: Rheumatoid Arthritis; Hand; Exercise Therapy; Patient Education; Health Behavior.

Introduction: Cardiac rehabilitation programs (CRP) are recommended (Class I, level of evidence A) in the entire spectrum of coronary disease , including after percutaneous coronary interventions . However, current evidence is unclear about the impact of CRP in patients with significant residual stenosis after PCI, thereby many cardiac rehabilitation program consider them inegible.Aim: We aimed to evaluate the influence of residual significant coronary stenosis (in other territories) in response to a multidimensional CRP.Methods and Materials: Retrospective analysis of 369 patients enrolled in a cardiac rehabilitation programs (phase II) who underwent successful PCI (residual stenosis <10% and final TIMI flow grade 3) after acute coronary syndrome (ACS). Patients were categorized according to the presence of significant anatomic stenosis (≥ 50%) in additional non-revascularized coronary territories (EST+). We collected data on socio-demographic characteristics, cardiovascular (CV) risk profile and ACS characteristics. The functional capacity [metabolic equivalents (MET) and total duration of the exercise stress test (min:sec)], the psychosocial profile (based on hospital anxiety and depression scale ) and quality of life (based on short-form-36 health survey) were assessed at the baseline and end of the CRP. Intragroup comparisons were performed using paired student’s t-test or Wilcoxon test, and the Mcnemar. For intergroup comparisons we used the t-student or Mann-Whitney test, and the Qui-square.Results: The groups did not differ in age, but there was a higher prevalence of women and lower proportion of active workers in the group EST+. The group EST+ had a worse CV risk profile and worse baseline functional capacity. There were no differences in the ACS characteristics, psychosocial profile and general perception of health status. Both groups showed significant improvement in functional capacity [1.5(1.61) MET versus +2.1(1.5), ρ<0.001], and not significantly different between groups (ρ = 0.91); significant improvement in both physical dimensions [(+3.6 (6.5) vs. +3.1 (6.7), ρ <0.001] and mental dimensions of the SF36, only in the group EST-. As for psychosocial profile, we found a significant reduction in anxiety only in the group EST-.Conclusion: The benefit of multidimensional PRC seems to be extended to patients with residual coronary disease. However, the heterogeneity of this group, suggests caution in interpreting these results and should be considered when deciding on the referral.

Não aplicável.

Introduction: The benefits of land-based aerobic physical training in patients with cardiac pathology are well studied. However, there are patients who, for personal reasons or osteoarticular limitations, prefer to exercise in water, so it is important to understand the advantages, disadvantages and precautions to be taken when the rehabilitation plan is carried out in an aquatic environment.Methods: To carry out this narrative review, the following databases were accessed: MEDLINE, SCOPUS and Web of Science.Results:With the increase of the immersion depth, the heart fills and consequent systolic volume increases, but the heart rate (HR) decreases. Peak oxygen uptake (VO2peak) and HRpeak values are 84% and 95% lower in water compared to those observed out of water, respectively. Therefore, a reduction of 13% or 10 bpm in relation to the target HR values established out of water is recommended. Aquatic exercise induces an increase in heart rate variation and cardiac autonomic modulation, both of which have a positive impact on the prognosis of these patients.Conclusion: Physical exercise in water is safe, provides cardiovascular protection and improves the prognosis in low-risk cardiac patients who are in phase III of the cardiac rehabilitation program and who, for musculoskeletal or personal reasons, prefer to perform exercise in this context.

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Introduction: Evaluate the intra- and interrater reliability in the thigh circumference measurement using different anatomical references.Material and Methods: Twenty five volunteers without history of pathology or surgery in the dominant leg entered in the study. The measurements were performed by two independent evaluators, on two occasions with an interval of one week. The measurements and participants order were randomized. The results of the interim measures were concealed, being analyzed by a third investigator. The assessment protocol was previously defined. The intra- and inter-rater correlation was measured through the intraclass correlation coefficient (ICC). The limits of agreement were established in accordance with the method of Bland and Altman.Results: The intraclass agreement in intrarater reproducibility was high (SPPICC 0.96, KJLICC 0.95, ASISICC 0.96). In the interrater results the limits of agreement were: SPPICC 0.91 (IC 95%: 0.79–0.96), KJLICC 0.94 (IC 95%: 0.86–0.97), ASISICC 0,90 (IC 95%: 0.77–0.95).Conclusion: All methods presented high intra- and interrater reliability, which by the simplicity of the measurement method may favor the choice for upper pole of the patella in the absence of pathology in anatomical segment evaluated.