RCAAP Repository

Introduction: The disease caused by coronavirus 19 (COVID-19) is an international health emergency and has reached pandemic proportions worldwide. Since March 2020, the Portuguese government implemented measures to prevent the spread of the virus, including almost total temporary suspension of outpatient rehabilitation treatments. Patients with chronic spinal cord injury have an increased risk of developing severe forms of COVID-19 infection. However, they need rehabilitation treatment to control and prevent complications. The aim of this study was to evaluate the impact of the first wave of the COVID-19 pandemic on the clinical evolution of patients with chronic spinal cord injury, regarding pain, spasticity and functionality.Material and Methods: This is a cross-sectional observational study. A telephonic questionnaire was applied to a group of patients with chronic spinal cord injury. The results allowed the comparison of symptoms and functionality before the pandemic and six months after its onset.Results: After exclusion criteria were applied, the sample included a total of 65 participants. All patients who were previously undergoing physiotherapy treatments had to suspend them. Six months after the beginning of the Pandemic in Portugal, 24.6% of the patients reported worsening of pain complaints; 26.2% noted increased spasticity and 21.5% had decreased functionality. In this sample, 12.3% of the patients reported new pressure ulcers or worsening of the previous ones.Patients with cervical spinal cord injury had increased spasticity compared to patients with dorsal or lumbar injury (p=0.003). On the other hand, patients with lumbar spinal cord injury had more frequent worsening of pain complaints (p=0.029). Patients with incomplete motor injury had greater pain worsening when compared to patients with complete injury (p=0.007).Conclusion: The COVID-19 pandemic is having an important impact on the treatment of patients with chronic spinal cord injury, leading to worsening of pain complaints, increased spasticity and decreased functionality. Spasticity worsened more in patients with cervical spinal cord injury while pain worsened more significantly in patients with lumbar injury and incomplete motor injury.

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Currently, the challenge of upper limb replantation after amputation became an achievable reality, thoroughly improved in last decades and in constant evolution.The surgical option for replantation should take into account not only the exclusive analysis of the feasibility of replantation, but specially the potential of long term hand's functional recovery.We report a case of an 18-year-old man, smoker, transferred from Barreiro's Hospital, victim of occupational accident with right distal forearm cut. This resulted in amputation.The warm ischemia time was 4 hours and he underwent Orthopaedics and Plastic and Reconstructive Surgery (PRC) combined surgery for replantation.Subsequently, he was referenced earlier to Physical Medicine and Rehabilitation (PRM), to perform a sequential program of rehabilitation.The aim of this work is to emphasize the importance of an early, thorough and extensive rehabilitation program as a key of functional recovery and long-term prognosis in these lesions and its role in preventing complications.Keywords: Amputation, Traumatic; Forearm Injuries; Replantation; Rehabilitation.

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Introduction: Lateral epicondylitis is a common cause of chronic elbow pain, often related to repeated muscle activity. Although there are several therapeutic options available, there is no consensus regarding treatment approach to the refractory condition.Case Report: Male, 38–years-old, referred to the attending physician with pain in the right lateral epicondyle. Ultrasonography revealed aspects compatible with tendinopathy and extensor digitorum communis partial tendon rupture near the epicondyle. The patient underwent a rehabilitation program in a community centre but, due to lack of pain control, was referred for hospital Physical Medicine and Rehabilitation consultation. In this consultation the patient presented pain on the numerical scale (NS) 8/10 and QuickDASH 68.2 / 100. He underwent 4 mesotherapy sessions, but due to persistent complaints, 20 U of onabotulinumtoxin A were administered in the extensor carpi radialis and the extensor digitorum muscles guided by ultrasound. The patient maintained follow-up during 5 months, being discharged with NS 1/10 and QuickDASH 4.5 / 100.Discussion: This case illustrates the possibility of successfully applying onabotulinumtoxin A in the treatment of epicondylitis. Studies have shown that administration of 20-60 U of botulinum toxin is effective in reducing pain. Thus, botulinum toxin represents a promising therapeutic option in the treatment of refractory epicondylitis.

IntroductionTraumatic brain injuries (TBI) are a very important cause of children morbidity and disability, with a negativeimpact on their life quality. Outcomes vary with the severity of injury, child age at injury, premorbid child characteristics, family factors and the families' socioeconomic status.AimTo evaluate the social inclusion of children following a traumatic brain injury after hospital discharge.Patients and MethodsThe authors made a retrospective study of the inpatients of a specific unit of the Pediatric Development andRehabilitation Service, dedicated to the care of children that, at admission, were in coma or in a minimalresponsive state. Medical records were reviewed corresponding to children admitted to this unit between 1996and 2007 and their social inclusion was evaluated.ConclusionChildren following traumatic brain injuries face serious difficulties when they return to their familiar environmentin terms of skills, behaviour, communication and education. They could also be a physical, emotional and financialburden to their families and society. Prevention measures and oriented rehabilitation programs are essential toassure a better outcome for children with TBI.

The authors present a case report of neurogenic thoracic outlet syndrome associated with a postural syndrome, in a female patient with right shoulder pain and right hand finger cramps, progressive functional limitation in shoulder abduction more than 90º and manual tweezers. At the physical examination a postural malalignement of the rachis was evident, as well as thenar and hypothenar significant atrophy. Several diagnoses were considered, such as cervical radiculopathy, brachial plexitis, carpal tunnel syndrome/ Guyon syndrome, writer’s cramp and Hirayama disease. Only electromyography and nerve conduction studies were suggestive of the neurogenic thoracic outlet syndrome, as cervical spine, chest x-rays, cervical and brachial plexus nuclear magnetic resonance have not revealed significant alterations. Conservative treatment was provided by Physical Medicine and Rehabilitation, with improved pain symptoms and with significant functional gains. A brief and related review of the literature is also performed, framing the syndrome in the Occupational Medicine.

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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.