Lower Urinary Tract Symptoms in a prospective cohort of COVID-19 survivors

PURPOSE

To analyze the prevalence of lower urinary tract symptoms (LUTS) in patients who survived moderate and severe forms of COVID-19 and the risk factors for LUTS six months after hospitalization.

MATERIALS AND METHODS

In this prospective cohort study, patients were evaluated six months after hospitalization due to COVID-19. LUTS were assessed using the International Prostate Symptom Score. General health was assessed through the Hospital Anxiety and Depression Scale and the EQ5D-L5 scale, which evaluates mobility, ability to perform daily activities, pain and discomfort and completed a self-perception health evaluation.

RESULTS

Of 255 participants, 54.1% were men and the median age was 57.3 [44.3 - 66.6] years. Pre-existing comorbidities included diabetes (35.7%), hypertension (54.5%), obesity (30.2%) and physical inactivity (65.5%). One hundred and twenty-four patients (48.6%) had a hospital stay >15 days, 181 (71.0%) were admitted to an ICU and 124 (48.6%) needed mechanical ventilation. Median IPSS was 6 [3-11] and did not differ between genders. Moderate to severe LUTS affected 108 (42.4%) patients (40.6% men and 44.4% women; p=0.610). Nocturia (58.4%) and frequency (45.9%) were the most prevalent symptoms and urgency was the only symptom that affected men (29.0%) and women (44.4%) differently (p=0.013). LUTS impacted the quality of life of 60 (23.5%) patients with women more severely affected (p=0.004). Diabetes, hypertension, and self-perception of worse general health were associated with LUTS.

CONCLUSIONS

LUTS are highly prevalent and bothersome six months after hospitalization due to COVID-19. Assessment of LUTS may help ensure appropriate diagnosis and treatment in these patients.

The role of clinical and demographic predictors for understanding the cognitive impairment in Spinal Cord Injury (SCI) patients

STUDY DESIGN

Using a cross-sectional design, we extracted sociodemographic and clinical data from 488 Spinal Cord Injury (SCI) patients during their initial assessment before receiving intensive rehabilitation treatment.

OBJECTIVES

The primary objectives of this study were to ascertain the prevalence of cognitive impairment in the study sample and specify the key clinical and demographic predictors of cognitive functioning in SCI patients.

SETTING

Lucy Montoro Rehabilitation Institute (LMRI), University of Sao Paulo, Sao Paulo, Brazil.

METHODS

We utilized independent univariate and multivariate regression models with the Montreal Cognitive Assessment (MoCA) scale, adapted for individuals with visual impairment. Moreover, we consider scores from the execution tasks (visuospatial/executive) as the dependent variable.

RESULTS

Our findings demonstrate that approximately 80% of the evaluated study sample exhibited cognitive impairment. Through the multivariate regression models, we show that several factors, including age, education, depression levels, and the use of analgesics and/or opioids, are significant predictors of total cognitive scores. These factors are independent of the clinical features associated with SCI, such as age, sex, education, and time since the injury.

CONCLUSIONS

The results indicate a high prevalence of significant cognitive impairment within the sample, with age, education, depression levels, and the use of analgesics and/or opioids emerging as the primary predictors of total cognitive scores, independent of the clinical features correlated to SCI. These findings hold significant implications for both clinical research and practice, offering valuable guidance for comprehensive management throughout hospitalization and rehabilitation.

Health-related quality of life and functionality in primary caregiver of surviving pediatric COVID-19

Objectives

To prospectively assess health-related quality of life (HRQoL), global functionality, and disability in primary caregivers of surviving children and adolescents after COVID-19.

Methods

A longitudinal observational study was carried out on primary caregivers of surviving pediatric post-COVID-19 patients (n = 51) and subjects without COVID-19 (n = 60). EuroQol five-dimension five-level questionnaire (EQ-5D-5L) and 12-question WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) were answered for both groups. The univariate regression analysis was carried out using SPSS (v 20) and significance was established at 5%.

Results

The median duration between COVID-19 diagnosis in children and adolescents and longitudinal follow-up visits was 4.4 months (0.8-10.7). The median age of children and adolescents caregivers with laboratory-confirmed COVID-19 was similar to primary caregivers of subjects without laboratory-confirmed COVID-19 [43.2 (31.6-60.9) vs. 41.5 (21.6-54.8) years, p = 0.08], as well as similar female sex (p = 1.00), level of schooling (p = 0.11), social assistance program (p = 0.28), family income/month U$ (p = 0.25) and the number of household's members in the residence (p = 0.68). The frequency of slight to extreme problems (level ≥ 2) of the pain/discomfort domain according to EQ-5D-5L score was significantly higher in the former group [74% vs. 52.5%, p = 0.03, OR = 2.57 (1.14-5.96)]. The frequency of disability according to WHODAS 2.0 total score was similar to those without disability and unknown (p = 0.79); however, with a very high disability in both groups (72.5% and 78.3%). Further analysis of primary caregivers of children and adolescents with post-COVID-19 condition (PCC) [n = 12/51 (23%)] compared to those without PCC [n = 39/51(77%)] revealed no differences between demographic data, EQ-5D-5L and WHODAS 2.0 scores in both groups (p > 0.05).

Conclusion

We longitudinally demonstrated that pain/discomfort were predominantly reported in approximately 75% of primary caregiver of COVID-19 patients, with high disability in approximately three-quarters of both caregiver groups. These data emphasized the prospective and systematic caregiver burden evaluation relevance of pediatric COVID-19.

Neuroplasticity changes in knee osteoarthritis (KOA) indexed by event-related desynchronization/synchronization during a motor inhibition task

PURPOSE

Event-related desynchronisation (ERD) and event-related synchronisation (ERS) reflect pain perception and integration of the nociceptive sensory inputs. This may contribute to the understanding of how neurophysiological markers of Knee Osteoarthritis (KOA) patients can differ from control individuals, which would improve aspects such as prediction and prognosis. We performed a cross-sectional analysis of our cohort study (DEFINE cohort), KOA arm, with 71 patients, compared with 65 control participants. The study aimed to examine possible differences between ERD and ERS in control participants compared to Knee Osteoarthritis (KOA) patients when adjusting for important covariates.

MATERIALS AND METHODS

We performed independent multivariate regression models considering as dependent variables the power value related to ERD and ERS for four different sensorimotor tasks (Motor Execution, Motor Imagery, Active Observation and Passive Observation) and four sensorimotor oscillations (Alpha, Beta, Low Beta, and High Beta), each model, controlled by age and sex.

RESULTS

We demonstrate that the differences between KOA and healthy subjects are frequency specific, as most differences are in the beta bandwidth range. Also, we observed that subjects in the KOA group had significantly higher ERD and ERS. This may be correlated to the amount of lack of brain organisation and a subsequent attempt at compensation induced by KOA.

CONCLUSIONS

Our findings strengthen the notion that subjects with KOA have a higher degree of brain plasticity changes that are also likely correlated to the degree of compensation and behavioural dysfunction.

The Institute of Physical Medicine and Rehabilitation, Hospital das Clínicas University of São Paulo School of Medicine comprehensive rehabilitation program for elderly people with knee osteoarthritis

Background

Knee osteoarthritis (OA) is a leading cause of disability in the elderly population. Chronic disabling pain is associated with maladaptive neuroplastic changes in brain networks, commonly associated with central sensitization. The main clinical features of nociplastic pain conditions include combined peripheral and central sensitization, and it is crucial to recognize this type of pain, as it responds to different therapies than nociceptive and neuropathic pain.

Objective

To report the effect of the Institute of Physical Medicine and Rehabilitation (IMREA) comprehensive rehabilitation program to reduce pain and to improve functioning in elderly people with knee OA, under the DEFINE cohort.

Methods

This is a retrospective observational cohort of 96 patients with knee OA, recruited from October 2018 to December 2019. All patients were evaluated by a trained multidisciplinary team using the Kellgren Lawrence classification, bilateral knee ultrasonography, the visual analog scale (VAS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain, rigidity and difficulty scores, the Timed Up and Go Test (TUG), 10-m and 6-min walking test (10 and 6 MWT), Berg Balance Scale, isokinetic dynamometry for knee extension and flexion strength, and pain pressure thresholds. The rehabilitation program included paraspinous lidocaine blocks, focal extracorporeal shockwaves combined with radial pressure waves and functional electrical stimulation according to individual needs. The baseline was compred with the treatment results with a paired t-test.

Results

The study sample is composed of 96 participants, mostly females (n = 81, 84.38%), with bilateral osteoarthritis (n = 91, 94.79%), and a mean age of 68.89 (SD 9.73) years. Functional improvement was observed in TUG (p = 0.019), 6-mwt (p = 0.033), right knee flexion strength (p < 0.0001), WOMAC rigidity and difficulty domains (p < 0.0001). Pain was reduced from baseline as measured by WOMAC pain domain (p < 0.0001), VAS for both knees (p < 0.0001), and SF-36 pain domain (p < 0.0001). Pressure pain threshold was modified above the patella (p = 0.005 and p = 0.002 for right and left knees, respectively), at the patellar tendons (p = 0.015 and p = 0.010 for right and left patellar tendons, respectively), left S2 dermatome (p = 0.017), and L1-L2 (p = 0.008).

Conclusions

The IMREA comprehensive rehabilitation program improved functioning and reduced disabling pain in elderly people with knee OA. We highlight the relevance and discuss the implementation of our intervention protocol. Although this is an open cohort study, it is important to note the significant improvement with this clinical protocol.

Transcranial direct current stimulation combined with robotic training in incomplete spinal cord injury: a randomized, sham-controlled clinical trial

STUDY DESIGN

A randomized, sham-controlled clinical trial.

OBJECTIVE

To test the effects of tDCS, combined with robotic training, on gait disability in SCI. Our hypothesis was that participants who received active tDCS would experience greater walking gains, as indexed by the WISCI-II, than those who received sham tDCS.

SETTING

University of São Paulo, Brazil.

METHODS

This randomized, double-blind study comprised 43 participants with incomplete SCI who underwent 30 sessions of active (n = 21) or sham (n = 22) tDCS (20 min, 2 mA) before every Lokomat session of 30 min (3 times a week over 12 weeks or 5 times a week over 6 weeks). The main outcome was the improvement in WISCI-II. Participants were assessed at baseline, after 15 and 30 sessions of Lokomat, and after three months of treatment.

RESULTS

There was a significant difference in the percentage of participants that improved in WISCI-II at the 30-session, compared with baseline: 33.3% in the sham group and 70.0% in the active group (p = 0.046; OR: 3.7; 95% CI: 1.0-13.5). At the follow-up, the improvement compared with baseline in the sham group was 35.0% vs. 68.4% for the active group (p = 0.046; OR: 3.7; 95% CI: 1.0-13.5). There was no significant difference at the 15-session.

CONCLUSION

Thirty sessions of active tDCS is associated with a significant improvement in walking, compared to sham. Moreover, 15 sessions had no significant effect. The improvement in WISCI-II can be related to different aspects of motor learning, including motor recovery and compensation.

Specific Electroencephalographic Signatures for Pain and Descending Pain Inhibitory System in Spinal Cord Injury

OBJECTIVES

The pain related to Spinal Cord Injury (SCI) is difficult to treat and it is associated with significant morbidity. One aspect to improve therapeutics is to explore markers of pain and its correlates in SCI.

METHODS

In this cross-sectional neurophysiological analysis of a randomized, double-blind controlled trial, thirty-nine patients with SCI were included. We analyzed conditioned pain modulation (CPM) efficiency as the index of the descending pain inhibitory system, EEG variables, and clinical pain levels as measured by the Visual Analogue Scale. Regression analyses were performed to assess the relationship among EEG variables, pain levels, and CPM.

RESULTS

We included 39 SCI patients, 74% reported SCI-related pain. We found that (1)less alpha and beta power are related to pain presence, (2)less alpha and beta power are associated with higher pain levels among patients with pain, (3)patients with pain have decreased peak alpha-theta frequency compared to no-pain group, (4)more relative theta power are related to the presence of low CPM efficiency, (5)higher relative theta power is associated with lower CPM efficiency.

CONCLUSIONS

Our results confirm and provide additional data on the relationship between decreased alpha and beta frequencies and higher pain levels. One important finding, though, was a specific and different EEG signature for the descending inhibitory pain system, as we showed that increased theta EEG power is related to decreased CPM efficiency; suggesting that, although low CPM efficiency plays a major role in pain in these participants, it does seem to be associated with a specific oscillatory brain rhythm different from clinical pain. These findings have significant implications for future research on EEG-based biomarkers of pain in post-SCI and new interventions as neurofeedback to manage pain in this population.

Protective and Risk Factors for Phantom Limb Pain and Residual Limb Pain Severity

INTRODUCTION

The exact mechanisms underlying the development and maintenance of phantom limb pain (PLP) are still unclear. This study aimed to identify the factors affecting pain intensity in patients with chronic, lower limb, traumatic PLP.

METHODS

This is a cross-sectional analysis of patients with PLP. We assessed amputation-related and pain-related clinical and demographic variables. We used univariate and multivariate models to evaluate the associated factors modulating PLP and residual limb pain (RLP) intensity.

RESULTS

We included 71 unilateral traumatic lower limb amputees. Results showed that (1) amputation-related perceptions were experienced by a large majority of the patients with chronic PLP (sensations: 90.1%, n = 64; residual pain: 81.7%, n = 58); (2) PLP intensity has 2 significant protective factors (phantom limb movement and having effective treatment for PLP previously) and 2 significant risk factors (phantom limb sensation intensity and age); and (3) on the other hand, for RLP, risk factors are different: presence of pain before amputation and level of amputation (in addition to the same protective factors).

CONCLUSION

These results suggest different neurobiological mechanisms to explain PLP and RLP intensity. While PLP risk factors seem to be related to maladaptive plasticity, since phantom sensation and older age are associated with more pain, RLP risk factors seem to have components leading to neuropathic pain, such as the amount of neural lesion and previous history of chronic pain. Interestingly, the phantom movement appears to be protective for both phenomena.

Abandonment of assistive products: assessing abandonment levels and factors that impact on it

PURPOSE

To investigate the levels and factors that influence the abandonment of assistive products by users of a local reference rehabilitation center.

METHODS

This observational study involved users who received services and assistive products provided by our center of rehabilitation. Users were identified using the records of the center and their responses about the abandonment were collected through face-to-face interviews.

RESULTS

The abandonment level of assistive products was 19.38%. 83.5% of the users use at least one of the assistive products they have received. Rigid and folding frame wheelchairs, with and without postural support devices, as well as shower wheelchairs, presented the lowest abandonment levels, followed by canes and lower limb orthoses. Upper limb orthoses, Knee Ankle Foot Orthosis(KAFO), walkers, crutches and lower and upper limb prostheses all presented higher abandonment levels.

CONCLUSION

The simultaneous use of mutiple assistive products, users perception on the importance of using them, and completing the rehabilitation treatment were found to impact on the short and long-term use of products. The study offers inputs to decision making and planning for assistive technology provision in developing countries with regard to expected demand and service delivery. Implications for Rehabilitation Data about the abandonment of assistive products in Sao Paulo, Brazil, could assist informing decision making on provision and servicing of these products in similar settings. The strong correlation found between abandonment levels and the simultaneous use of multiple devices should be taken into account by health professionals when prescribing assistive products and providing guidance to users. The need for follow up on the use of assistive products after discharge from rehabilitation treatment becomes strikingly clear, as data show that completing treatment is significantly relevant when evaluating abandonment levels. As assistive products users' perception about the importance of using these devices is shown to be significant in explaining abandonment, it is mandatory that health and rehabilitation professionals take it into account when providing guidance and training users.

Neurophysiologic Correlates of Post-stroke Mood and Emotional Control

OBJECTIVE

Emotional disturbance is a common complication of stroke significantly affecting functional recovery and quality of life. Identifying relevant neurophysiologic markers associated with post-stroke emotional disturbance may lead to a better understanding of this disabling condition, guiding the diagnosis, development of new interventions and the assessments of treatment response.

METHODS

Thirty-five subjects with chronic stroke were enrolled in this study. The emotion sub-domain of Stroke Impact Scale (SIS-Emotion) was used to assess post-stroke mood and emotional control. The relation between SIS-Emotion and neurophysiologic measures was assessed by using covariance mapping and univariate linear regression. Multivariate analyses were conducted to identify and adjust for potential confounders. Neurophysiologic measures included power asymmetry and coherence assessed by electroencephalography (EEG); and motor threshold, intracortical inhibition (ICI) and intracortical facilitation (ICF) measured by transcranial magnetic stimulation (TMS).

RESULTS

Lower scores on SIS-Emotion was associated with (1) frontal EEG power asymmetry in alpha and beta bands, (2) central EEG power asymmetry in alpha and theta bands, and (3) lower inter-hemispheric coherence over frontal and central areas in alpha band. SIS-Emotion also correlated with higher ICF and MT in the unlesioned hemisphere as measured by TMS.

CONCLUSIONS

To our knowledge, this is the first study using EEG and TMS to index neurophysiologic changes associated with post-stroke mood and emotional control. Our results suggest that inter-hemispheric imbalance measured by EEG power and coherence, as well as an increased ICF in the unlesioned hemisphere measured by TMS might be relevant markers associated with post-stroke mood and emotional control which can guide future studies investigating new diagnostic and treatment modalities in stroke rehabilitation.

Transcranial Direct Current Stimulation Combined with Aerobic Exercise to Optimize Analgesic Responses in Fibromyalgia: A Randomized Placebo-Controlled Clinical Trial

Fibromyalgia is a chronic pain syndrome that is associated with maladaptive plasticity in neural central circuits. One of the neural circuits that are involved in pain in fibromyalgia is the primary motor cortex. We tested a combination intervention that aimed to modulate the motor system: transcranial direct current stimulation (tDCS) of the primary motor cortex (M1) and aerobic exercise (AE). In this phase II, sham-controlled randomized clinical trial, 45 subjects were assigned to 1 of 3 groups: tDCS + AE, AE only, and tDCS only. The following outcomes were assessed: intensity of pain, level of anxiety, quality of life, mood, pressure pain threshold, and cortical plasticity, as indexed by transcranial magnetic stimulation. There was a significant effect for the group-time interaction for intensity of pain, demonstrating that tDCS/AE was superior to AE [F (13, 364) = 2.25, p = 0.007] and tDCS [F (13, 364) = 2.33, p = 0.0056] alone. Post-hoc adjusted analysis showed a difference between tDCS/AE and tDCS group after the first week of stimulation and after 1 month intervention period (p = 0.02 and p = 0.03, respectively). Further, after treatment there was a significant difference between groups in anxiety and mood levels. The combination treatment effected the greatest response. The three groups had no differences regarding responses in motor cortex plasticity, as assessed by TMS. The combination of tDCS with aerobic exercise is superior compared with each individual intervention (cohen's d effect sizes > 0.55). The combination intervention had a significant effect on pain, anxiety and mood. Based on the similar effects on cortical plasticity outcomes, the combination intervention might have affected other neural circuits, such as those that control the affective-emotional aspects of pain.

TRIAL REGISTRATION

(www.ClinicalTrials.gov), identifier NTC02358902.

Time variation of some selected topics in bioethical publications

OBJECTIVE

To analyse the time variation of topics in bioethical publications as a proxy of the relative importance.

METHODS

We searched the Medline database for bioethics publications using the words "ethics or bioethics", and for 360 specific topics publications, associating Medical Subject Heading topic descriptors to those words. We calculated the ratio of bioethics publications to the total publications of Medline, and the ratio of each topic publications to the total bioethics publications, for five-year intervals, from 1970 to 2004. We calculated the time variation of ratios, dividing the difference between the highest and lowest ratio of each topic by its highest ratio. Four topics were described, selected to illustrate different patterns of variation: "Induced Abortion", "Conflict of Interest", "Acquired Immunodeficiency Syndrome", "Medical Education."

RESULTS

The ratio of bioethics publications to total Medline publications increased from 0.003 to 0.012. The variation of the topic's ratios was higher than 0.7 for 68% of the topics. The Induced Abortion ratios decreased from 0.12 to 0.02. Conflict of Interest ratios increased from zero to 0.07. The Acquired Immunodeficiency Syndrome ratios were nearly zero in the first three intervals, had a peak of 0.06 during 1985-9, followed by a decrease to 0.01. Medical Education ratios varied few, from 0.04 to 0.03.

CONCLUSIONS

There was an increase of bioethical publications in the Medline database. The topics in bioethics literature have an important time variation. Some factors were suggested to explain this variation: current legal cases, resolution of the issue, saturation of a discussion and epidemiologic importance.

Computerized pedobarography in the characterization of ankle-foot instabilities of haemophilic patients

Among the most common clinical manifestations of haemophilia are joint haemorrhages. This study aimed to verify whether repetitive ankle haemarthrosis is associated with instability of the rear foot. We evaluated haemophilic patients with repetitive bleeding in the ankles, 39 of type A and four of type B, whose mean age was 16.1 years. All presented a functional gait, without the need for motion assistance devices. The number of rear-foot and ankle haemarthrosis episodes during the 6 months prior to the study was verified from the medical records of each patient. After verifying the alignment of the rear foot of the patients, we evaluated the subjects through computerized pedobarography with the f-scan system, emphasizing the study of the trajectory of the centre of pressure (COP) with each step taken. All patients received functional orthoses according to the results of these examinations, and were re-evaluated 1 week and 6 months after being fitted. The number of haemarthrosis episodes at the rear foot and the ankle was compared with the occurrence of joint bleeding within the previous 6 months. In the first examination, the COP trajectory showed that all the 43 patients studied had some sort of instability. Six months later, a significant reduction in the frequency of spontaneous bleeding events (P<0.001) concerning the rear foot and the ankle was observed. This method of evaluation was useful to identify joint instabilities, allowing the best prescription of orthoses to improve stability in the rear foot and the ankle.

The effect of foot orthoses in rheumatoid arthritis

OBJECTIVE

To evaluate the effectiveness of foot orthoses using the foot function index (FFI) in a group of patients with rheumatoid arthritis (RA) during a period of 6 months.

METHODS

Thirty-six rheumatoid subjects with foot pain were examined and appropriate foot orthoses were prescribed according to each patient's needs. All the patients were evaluated 30, 90 and 180 days after the baseline visit. FFI values, daily time of wearing the orthoses and adverse effects were noted at each appointment. The Stanford Health Assessment Questionnaire (HAQ) was used at the initial visit to evaluate the influence of physical condition on FFI response.

RESULTS

With the use of foot orthoses, FFI values decreased in all subscales (pain, disability and activity limitation). This reduction was noted in the first month and was maintained throughout the trial. Those using EVA (ethyl-vinyl acetate; n = 28) orthoses presented results similar to those for the total group. Patients wearing made-to-measure orthoses (n = 8) exhibited higher initial FFI values and worse evolution during the trial, significant for pain and disability but not for activity limitation. Minor adverse reactions were noted; none required interruption of treatment. There was no relation between HAQ and FFI evolution.

CONCLUSIONS

Foot orthoses were effective as an adjuvant in the management of rheumatoid foot. They significantly reduced pain, disability and activity limitation, as measured by the FFI, with minor adverse effects.

Analysis of the results of functional electrical stimulation on hemiplegic patients?? upper extremities using the Minnesota manual dexterity test

To study the influence of functional electric stimulation (FES) on grip acquisition and on the change of grip processing speed, 38 hemiplegic patients took part in the rehabilitation program of the Division of Rehabilitation Medicine of the Hospital das Clinicas, School of Medicine, University of Sao Paulo. Half of the patients received FES on their wrist and finger extensor muscles. The patients in this study were evaluated initially, then after 3 months and after 6 months using the Minnesota manual dexterity test. We concluded that the time necessary for use of FES to generate a significant improvement in the grip speed in hemiplegic patients is 6 months, using twice-weekly administration of stimulation.

Effect of alendronate on bone mineral density in spinal cord injury patients: a pilot study

STUDY DESIGN

Prospective, randomised controlled trial.

OBJECTIVE

To evaluate the effect of alendronate on bone mineral density in chronic spinal cord injury (SCI) patients.

SETTING

University-based rehabilitation centre in São Paulo, Brazil.

METHODS

A total of 19 chronic SCI patients were evaluated, divided into a control group and an experimental group. Control group patients received 1000 mg of calcium daily, and experimental group patients received 1000 mg of calcium plus 10 mg of alendronate daily. The study duration was 6 months. In all, 12 densitometric parameters were analysed using whole-body dual-energy X-ray absorptiometry at baseline and after 6 months.

RESULTS

The experimental group presented increases in nine densitometric parameters, although statistical significance was attained in only two of those parameters. In the control group, an increase was observed in only one parameter, whereas the remaining 11 presented either no alteration or a decrease.

CONCLUSION

The use of alendronate had a positive effect on bone mineral density in SCI patients and therefore represents a potential tool for prevention and treatment of osteoporosis in this population.

Non-operative treatment of flexion contracture of the knee in haemophilia

For the non-operative treatment of flexion contracture of the haemophilic knee we have used serial casting and wedging in 58 patients, and extension/de-subluxation orthoses in 13 patients. On average it was possible to achieve -5 degrees of extension by 4 weeks, with only a little improvement in the following 4 weeks. The short--to medium-term results using either the extension/de-subluxation hinges or serial casting were similar. Both methods have been shown to result in significant improvement in joint contracture.

Maintenance of musculoskeletal function in people with haemophilia

Bleeding affecting muscles and joints is the most common manifestation of haemophilia. In the long term, prevention of musculoskeletal abnormality in haemophilic patients is cost effective. Early diagnosis and proper treatment is fundamental to prevent disability. Prevention can be divided into secondary and tertiary levels. Secondary prevention concentrates on how to handle a haemophilic child, and on the education of the family so that they develop a safe and healthy lifestyle and awareness of the importance of early diagnosis and treatment. Tertiary prevention deals with minimizing the musculoskeletal consequences of muscle and joint bleeding. Coagulation factor replacement, appropriate care of the bleeding site and early physical therapy helps to prevent complications and yields the best results. Recurrent episodes of joint bleeding can lead to chronic synovitis. Initially synovitis demands conservative treatment. However, conservative methods are often not successful. Chronic synovitis is the most important cause of joint degeneration and the aim of rehabilitation is to achieve functional status using special casting techniques, orthoses or preventative surgery. Surgical, radioisotope or chemical synovectomy may be used. Technical requirements and availability of haemostatic cover limit the use of surgical and radioisotope synovectomy. The author has found chemical synovectomy with rifampicin to be an easier and more effective procedure than surgery. Problems related to joint deformities, muscle atrophy and chronicle pain demand comprehensive care. They are the main factors affecting the maintenance of musculoskeletal function and the social integration of people with haemophilia.

Rehabilitation in haemophilia--options in the developing world

Musculoskeletal care is provided in many different settings by many different providers. Physicians are better prepared to treat acute diseases, acute manifestations and have problems in following chronic patients and to preventing losses of functional independence. Haematoma affecting muscles and joints is the most common musculoskeletal finding in haemophilic patients. Proper treatment is fundamental to prevent disability. Treatment aims at restoring the original muscle trophism and strength because joint stability is dependent on the uniform distribution of muscle power over different joint surfaces. Physical rehabilitation continues until complete anatomical and functional recovery is achieved. Coordination and proprioceptive stimulation complement the exercises to recover original muscle strength. Recurrent haemorrhages usually progress to chronic synovitis, the leading cause of motor disability and joint degeneration in haemophilic patients. Moreover, chronic synovitis is a predisposing factor for repetitive episodes of haemarthrosis, a leading cause of joint deformities and severe muscle atrophy. At this point, an efficient treatment alternative should be put into effect to restrain bleeding and prevent synovitis-related joint degeneration, which is synovectomy. Synovectomy is an effective alternative, less costly and easier to perform. Rifampicin synovectomy is advantageous because it is safe, not aggressive to the patient, can be repeated if necessary, and it does not prevent the use of either radiotherapy or surgery after, if necessary. Once the sequelae have set in, treatment tends to be conservative, and it aims at giving the patient functional independence for gait and other activities. The most common limb deformities seen in these patients are knee and elbow flexion, but the patient should also be assessed for compensatory scoliosis, hyperlordosis and lower limb length discrepancies. Chronic joint pain is a rather common complaint in this patient population with early arthrosis, and special drugs and physical treatment must be put into action. Rehabilitation is often inexpensive and very efficient.

[Early physical conditioning of patients surgically treated for myocardial revascularization. Influence on the functional capacity]

PURPOSE

To evaluate the early physical conditioning (PC) effect [initiated 15 days after the myocardial revascularization surgery (MRS)] in the functional capacity.

METHODS

Twenty-two male patients (mean-age of 52y-o), divided in two groups (A and B, 11 patients each), were studied. Group A started PC 3 months after MRS (phase III), with a training intensity of about 70% of the maximum heart rate reserve, during three months, three sessions per week with one hour duration. Group B started PC 15 days after the MRS (fase II), with a training intensity up to five metabolic unities, three times a week, 1 hour and 15 duration. The post-MRS period of three months was designated as the time I (beginning of fase III) and six months as time 2. Stress test, Kraus-Weber flexibility test, coxo-femural flexibility test (flexion, elevation and abduction) and scapule-umeral flexibility test (flexion, extension and abduction) were applied.

RESULTS

The maximum oxygen uptake and the total work increased significantly from time 1 to time 2 in both groups, but there was no significant difference between the two groups, either in time 1 or 2. Flexibility in the Kraus-Weber test and in the scapule-umeral flexibility test when in flexion, were significantly greater in group B than A, in both times (1 and 2). Other flexibility variables studied show no significant difference, neither between the studied groups nor in the times 1 and 2 of evaluation.

CONCLUSION

Early PC after MRS increased the value of two variables that measure flexibility. However, it has not increased other flexibilities variables and the aerobic capacity.

Assessment of functional capacity during gait using a reciprocal propulsion orthosis (ARGO)--a comparative study with a conventional mechanical orthosis

One subject (male, 24 years) with an incomplete motor and sensitive SCI, neurological level C6-C7 was submitted to a comparative study during gait using an advanced reciprocating gait othosis (ARGO) and a conventional mechanical orthosis (CMO) and respiratory and metabolic variables were compared at peak effort and in the second minute of recovery. We found that the ARGO, as with the CMO, not guarantee gait independence but the ARGO does enable a more functional gait pattern with a more efficient ventilation. The ratio of CO2/O2 showed that ARGO enable aerobic conditions of work and the energy expenditure using is significantly lower than CMO.

[Soft tissue rheumatism: therapeutic approach]

The authors review the conventional methods for the management of the soft tissue rheumatism. The success in relieving the patient's chief complaint, i.e. pain, depends on the choice of the appropriate measures that can be used without inconvenience to the patients.

[Osteomyoarticular injuries in a physical conditioning program]

From the follow-up of one hundred and thirty patients in a physical conditioning program during the period of one year, partially disabling lesions with preliminary complaints were observed at the beginning of the program in thirteen patients, and lesions during the development of the program were observed in nineteen patients. Within the first group, four patients had to quit the program, two temporarily and two definitively. In the second group, five patients had to interrupt the program for periods varying from twenty days to two months. In both groups, treatment involving physical agents, kinesiotherapy and drugs was proposed. Interruptions in the physical conditioning program for periods longer than three weeks imply in considerable reduction of the cardiovascular benefits. The clinician must be aware of the fact that sedentary patients have not only cardiovascular, but also musculoskeletal deconditioning. These patients must be evaluated by the physiatrist in order that the disabling lesions be avoided and treated.

[Chronotropic and pressoric response in myocardiopathy in patients with heart failure during ergometric test. Correlation of spirometry variables with effort]

PURPOSE

To correlate the variables heart rate (HR), blood pressure (BP) and double product (DP) during the ergometric test with the variables oxygen consumption (VO2) and pulmonary ventilation (VE) of spiroergometry.

METHODS

A study was carried out with 40 male patients suffering from cardiomyopathy with heart failure (functional class II-IV of NYHA)-of ischemic (IS), Chagas' disease (CH) and idiopathic (ID) etiology. These three groups were compared to a group of 10 normal individuals (N). The 4 groups were evaluated under 4 different conditions: rest (RES), anaerobic threshold (LA), power peak of exercise (P) and in the fourth minute recovery (REC). The investigation was carried out with the data obtained through spiroergometry (using a treadmill and spiroergometric equipment specific for the effort), as well as data related to HR, BP, DP, VO2 and VE.

RESULTS

There were significant differences observed in the ergometric evaluate of the HR, BP and DP responses in the IS, CH and ID groups as compared with the N group. There were significant difference observed in the spirometric evaluation to the VO2 and VE efforts in the IS, CH and ID groups as compared with the N group.

CONCLUSION

The HR, BP and DP variables studies, obtained by means of classic ergometry, unaided by direct methodology (spiroergometry) enabled them to infer valuable data for the control and evaluation of cardiomyopathies with IC, taking into consideration the low chronotropic and pressoric responses in the various phases of evaluation during this study, corresponding to the concomitant low performance of O2 consumption and pulmonary ventilation.

Evaluation of the physical fitness by the Bruno Balke protocol in sedentary and wheelchair trained paraplegic patients

The Bruno Balke test is one of the methods available to measure the oxygen intake in wheelchair users. The equation of the test is:intake O2 = 33+ (speed average-133) x 0.17 ml/kg x min. (-1). The average speed represents the acceleration and may be used to measure the level of physical fitness. In order to verify the efficiency of this kind of evaluation, we selected ten male, sedentary paraplegic patients, level D5-D12 in an ordinary rehabilitation program and ten paraplegic athletes. All of them were submitted to the Bruno Balke test. The results demonstrated that the average speed, the covered distance and the oxygen intake were significantly greater in athletes than in sedentary individuals.

[Functional electrical stimulation in the reciprocal locomotion of paraplegic patients]

The functional electrical stimulations is employed for standing-up posture and reciprocal locomotion in paraplegic patients. Five male paraplegic patients, level D5-D12 mean age 32.4 years, were treated with functional electrical stimulation, during two months. The quadriceps and fibular nerves were stimulated for 30 minutes, twice a day. After the training period, two patients were able to remain in the stand-up position and walk in parallel bars; one of them was able to use a walker. In other patients the technique was without effect for standing and walking. This method is not the solution for locomotion of paraplegics and more research is needed for the improvement of the results of functional electrical stimulation.

[Functional electric stimulation (FES) in cerebral palsy]

Our study concerns a patient with cerebral palsy, submitted to conventional occupational therapy and functional electrical stimulation. The results as to manual ability, spasticity, sensibility and synkinesis were satisfactory.