Primary Motor Area Activity in Phantom Limb Imagery of Traumatic Unilateral Lower Limb Amputees With Phantom Limb Pain.

Introduction: Estimates of the worldwide increase in amputees raises the awareness to solve long-standing problems. Understanding the functional brain modifications after a lower limb amputation (LLA) is one of the first steps towards proposing new rehabilitation approaches. Functional modifications in the central nervous system due the amputation could be involved in prosthesis use failures and Phantom Limb Pain (PLP), increasing costs and overwhelming the health services. Objective: This study analyses orphan primary motor area (M1-Orphan) hemodynamic and metabolic behaviour, which previously controlled the limb that was amputated, in comparison with the M1-Preserved, responsible for the intact limb (IL) during phantom limb imagery moving during Mirror Therapy (MT), compared to Isolated Intact Limb Movement Task (I-ILMT). Methodology: A case-control study with unilateral traumatic LLA with moderate PLP who measured [oxy-Hb] and [deoxy-Hb] in the M1 area by Functional Near InfraredSpectroscopy (fNIRS) during the real (I-ILMT) and MT task. Results: Sixty-five patients, with 67.69% of men, young (40.32 ± 12.91), 65.63% amputated due motorcycle accidents, 4.71 ± 7.38 years ago, predominantly above the knee (57.14%). The M1 activation in the orphan cortex did not differ from the activation in the intact cortex during MT (P > .05). Conclusion: The perception of the Phantom limb moving or intact limb moving is metabolically equivalent in M1, even in the absence of a limb. In other words, the amputation does not alter the brain metabolism in control of phantom movement.

Distinct patterns of metabolic motor cortex activity for phantom and residual limb pain in people with amputations: A functional near-infrared spectroscopy study.

BACKGROUND: Phantom pain limb (PLP) has gained more attention due to the large number of people with amputations around the world and growing knowledge of the pain process, although its mechanisms are not completely understood. OBJECTIVES: The aim of this study was to understand, in patients with amputations, the association between PLP and residual limb pain (RLP), and the brain metabolic response in cortical motor circuits, using functional near-infrared spectroscopy (fNIRS). METHODS: Sixty participants were recruited from the rehabilitation program in São Paulo, Brazil. Included patients were aged over 18 years, with traumatic unilateral lower-limb amputation, with PLP for at least 3 months after full recovery from amputation surgery. PLP and RLP levels were measured using visual analogue scales. fNIRS was performed during motor execution and motor mirror tasks for 20 s. In order to highlight possible variables related to variation in pain measures, univariate linear regression analyses were performed for both experimental conditions, resulting in four fNIRS variables (two hemispheres x two experimental conditions). Later, in order to test the topographic specificity of the models, eight multivariate regression analyses were performed (two pain scales x two experimental conditions x two hemispheres), including the primary motor cortex (PMC) related channel as an independent variable as well as five other channels related to the premotor area, supplementary area, and somatosensory cortex. All models were controlled for age, sex, ethnicity, and education. RESULTS: We found that: i) there is an asymmetric metabolic activation during motor execution and mirror task between hemispheres (with a predominance that is ipsilateral to the amputated limb), ii) increased metabolic response in the PMC ipsilateral to the amputation is associated with increased PLP (during both experimental tasks), while increased metabolic response in the contralateral PMC is associated with increased RLP (during the mirror motor task only); ii) increased metabolic activity of the ipsilateral premotor region is associated with increased PLP during the motor mirror task; iii) RLP was only associated with higher metabolic activity in the contralateral PMC and lower metabolic activity in the ipsilateral inferior frontal region during motor mirror task, but PLP was associated with higher metabolic activity during both tasks. CONCLUSION: These results suggest there is both task and region specificity for the association between the brain metabolic response and the two different types of post-amputation pain. The metabolic predominance that is ipsilateral to the amputated limb during both tasks was associated with higher levels of PLP, suggesting a cortical motor network activity imbalance due to potential interhemispheric compensatory mechanisms. The present work contributes to the understanding of the underlying topographical patterns in the motor-related circuits associated with pain after amputations.

Resultados da imaginação motora no fortalecimento muscular em membro inferior de uma pessoa com sequela pós acidente vascular cerebral: estudo de caso / Results of motor imagination in muscle strengthening of the lower limb in hemiplegia after stroke: case report

A Imaginação Motora (IM) é a representação mental de um ato motor sem a execução real do movimento, e ativa as mesmas áreas cerebrais do movimento real, mesmo na presença de paralisia, perda de membro ou visão, podendo ser utilizado no processo de conservação e estimulação de engramas cerebrais no processo de recuperação motora de um membro paralisado. Método: Homem, 34 anos, hemiplegia direita pós Acidente Vascular Cerebral (AVC) isquêmico. Realizou exercícios com profissional de Educação Física, duas vezes/semana, 50 minutos/sessão, durante 19 semanas, além do programa convencional de reabilitação multidisciplinar. A intervenção baseou-se na IM para flexão e extensão do joelho do lado paralisado, seguida da tentativa do mesmo movimento ativo. Resultados: Amplitude de movimento ativa (ADM_A) dos flexores do joelho direito iniciou em 217° com carga mínima do equipamento (5 kg). Em seguida, o profissional solicitava ao paciente que imaginasse que estava realizando o movimento e depois tentasse realizá-lo. Após 19 semanas, a ADM_A foi de 112°. Conclusão: Ganhos em ADM_A de 8,48° para a flexão de joelho do hemicorpo paralisado representa uma diferença mínima clinicamente importante em pacientes pós-AVC. A IM aumenta a demanda cognitiva nas áreas motoras cerebrais, aumentando a plasticidade, resultando em ganhos motores que impactam no prognóstico de capacidade e funcionalidade, justificando seu uso como método de treinamento na recuperação pós-AVC. A IM associada ao treinamento de força na reabilitação contribui para a recuperação de sequelas pós-AVC.

Motor Imagination (MI) is the mental representation of a motor act without the actual execution of the movement. It activates the same brain areas as real movement, even in the presence of paralysis, missing limb or vision, and can be used in the process of conserving and stimulating brain engrams in the process of motor recovery of a paralyzed limb. Method: We report a 34-year-old patient with right hemiplegia due to ischemic stroke. He performed exercises with a Physical Educator professional, twice a week, 50 minutes/session, for 19 weeks, in addition to the conventional multidisciplinary rehabilitation program. The intervention was based on MI for flexion and extension of the knee on the paralyzed side, followed by the attempt of the same active movement. Results: Active range of motion (ROM_A) of the right knee flexors started at 217° with the minimum equipment load (11 lbs). Then, the professional asked the patient to imagine that he was performing the movement and then try to perform it. After 19 weeks, ROM_A was 112° Conclusion: The ROM_A gain of 8.48° for knee flexion of the paralyzed hemibody represents a clinically important minimal difference in post-stroke patients. MI increases the cognitive demand on the brain's motor networks, increasing plasticity, resulting in motor gains that impact the prognosis of capacity and functionality, justifying its use as a training method in post-stroke recovery. MI associated with strength training in rehabilitation contributes to the recovery of post stroke sequelae.

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.

Predictors of the Health-Related Quality of Life (HRQOL) in SF-36 in Knee Osteoarthritis Patients: A Multimodal Model With Moderators and Mediators.

Purpose The study aimed to examine associations between the 36-item short form health survey (SF-36) in clinical and neurophysiological measures to identify its predictors in patients with knee osteoarthritis (KOA) in a rehabilitation program. Methods We analyzed data from our cohort study (DEFINE cohort). We analyzed data from our KOA arm, with 107 patients, including clinical assessments, demographic data, pain scales, motor function (Timed Up and Go Test (TUG), 10 meters walk test, and 6-minute walk), balance (BBS), sleepiness (ESS), and Transcranial Magnetic Stimulation (TMS) and Electroencephalography (EEG). Results Our results showed 83.19% of patients were female with an average age of 68.6 years and an average number of days of pain was 96 days; around 31.86% were using more than five medications per day. Regarding the multimodal model to explain SF-36, the main variables relevant to the quality of life (QoL) were related to emotional aspects, such as anxiety and depression. Moreover, our study added findings with polymorphism (OPRM1/rs1799971) predicting mental aspects. Cognitive variables were important in predicting the mental health, emotional, and social support dimensions of the SF-36. In the physical domain, pain-related variables predominantly predicted QoL in these relationships. The domain of vitality significantly predicted all dimensions studied, except for mental and general health. Conclusion The results help in understanding the aspects that contribute to QoL and are discussed considering the general literature on physical rehabilitation and specific to this clinical group. Furthermore, the statistical methods allowed us to explore and effectively understand the dimensions related to QoL.

Long-term functioning status of COVID-19 survivors: a prospective observational evaluation of a cohort of patients surviving hospitalisation.

OBJECTIVES: The study investigated the long-term functional status of hospitalised COVID-19 survivors to explore and document their functional situation. DESIGN: This prospective observational study assessed 801 COVID-19 survivors at 3-11 months after hospital discharge. It analyses participants' sociodemographic background, COVID-19 clinical manifestations, and clinical and functional evaluations. SETTING: Tertiary-level university hospital in São Paulo, Brazil. PARTICIPANTS: Study participants are COVID-19 survivors admitted to hospital care for at least 24 hours to treat acute SARS-CoV-2 infection. OUTCOME MEASURES: Epworth Sleepiness Scale, EuroQoL-5 Dimensions-5 Levels, Functional Assessment of Chronic Illness Therapy-Fatigue, Functional Independence Measure, Functional Oral Intake Scale, Handgrip Strength, Insomnia Severity Index, Medical Research Council (MRC) Dyspnea Scale, MRC sum score, Modified Borg Dyspnea Scale, pain Visual Analogue Scale, Post-COVID-19 Functional Status, Timed Up and Go, WHO Disability Assessment Schedule 2.0, 1-Minute Sit to Stand Test. RESULTS: Many participants required invasive mechanical ventilation (41.57%, 333 of 801). Mean age was 55.35±14.58 years. With a mean of 6.56 (SD: 1.58; 95% CI: 6.45 to 6.67) months after hospital discharge, 70.86% (567 of 800) reported limited daily activities, which were severe in 5.62% (45 of 800). They also reported pain and discomfort (64.50%, 516 of 800), breathlessness (64.66%, 514 of 795), and anxiety and depression (57.27%, 457 of 798). Daytime sleepiness and insomnia evaluations showed subthreshold results. Most (92.85%, 727 of 783) participants reported unrestricted oral intake. Data indicated no generalised fatigue (mean score: 39.18, SD: 9.77; 95% CI: 38.50 to 39.86). Assessments showed poor handgrip strength (52.20%, 379 of 726) and abnormal Timed Up and Go results (mean 13.07 s, SD: 6.49). The invasive mechanical ventilation group seemed to have a better handgrip strength however. We found no clear trends of change in their functional status during months passed since hospital discharge. CONCLUSIONS: Muscle weakness, pain, anxiety, depression, breathlessness, reduced mobility, insomnia and daytime sleepiness were the most prevalent long-term conditions identified among previously hospitalised COVID-19 survivors.

Characterisation of Phantom Limb Pain in Traumatic Lower-Limb Amputees.

INTRODUCTION: There is no diagnosis for phantom limb pain (PLP), and its investigation is based on anamnesis, which is subject to several biases. Therefore, it is important to describe and standardize the diagnostic methodology for PLP. OBJECTIVE: To characterise PLP and, secondarily, to determine predictors for its diagnosis. Methodology. This is a cross-sectional study involving patients with unilateral traumatic lower-limb amputation aged over 18 years. Those with clinical decompensation or evidence of disease, trauma, or surgery in the central or peripheral nervous system were excluded. Sociodemographic and rehabilitative data were collected; PLP was characterised using the visual analogue scale (VAS), pain descriptors, and weekly frequency. RESULTS: A total of 55 eligible patients participated in the study; most were male, young, above-knee amputees in the preprosthetic phase of the rehabilitation. The median PLP VAS was 60 (50-79.3) mm characterised by 13 (6-20) different descriptors in the same patient, which coexist, alternate, and add up to a frequency of 3.94 (2.5-4.38) times per week. The most frequent descriptor was movement of the phantom limb (70.91%). Tingling, numbness, flushing, itchiness, spasm, tremor, and throbbing are statistically significant PLP descriptor numbers per patient predicted by above-knee amputation, prosthetic phase, higher education level, and greater PLP intensity by VAS (p < 0.05). CONCLUSION: PLP is not a single symptom, but a set with different sensations and perceptions that need directed and guided anamnesis for proper diagnosis.

Attitudinal barriers from the perspective of people with physical disabilities / Avaliação das atitudes frente a incapacidades na perspectiva de pessoas com deficiências físicas

Objective: To quantify attitudes toward disabilities, perceived by persons with disabilities (PWDs) treated at a university hospital in Brazil, as well as to determine whether PWD-perceived attitudinal barriers correlate with various factors. Methods This was a cross-sectional, observational study of PWDs who completed the Attitudes to Disability Scale for persons with physical disabilities (ADS-D), which quantifies the perceived attitudinal barrier, the Hospital Anxiety and Depression Scale and the Functional Independence Measure (FIM). The data were correlated with sex, income, depression, FIM score, type of disability and time since the onset of disability. Results: We evaluated 68 patients - 50.0% with a spinal cord injury, 38.2% with one or more amputated limbs and 11.8% with hemiplegia - of whom 66.2% were male, with a mean age of 39.33 ± 12.89 years, a mean of 10.95 ± 4.25 years of schooling, a median time since the onset of disability of 20.5 months (range, 10.5­33.5 months) and a median FIM score of 110.5 (range, 94­116.5). Of the 68 patients, 55.9% perceived their income to be below the national average, and depression was observed in 11.76%. The mean ADS-D total score (61.29 ± 8.75) did not correlate with sex, functionality, type of disability or time since the onset of disability. The perceived magnitude of the attitudinal barrier correlated with income (ß-coefficient: −3.91; p = 0.001) and depression (ß = −1.74; p < 0.0001). Conclusion: Attitudinal barriers are influenced by income as a facilitator of inclusion and by depression as a barrier to inclusion.

Objetivo: Quantificar as atitudes frente a incapacidades, percebidas pelas pessoas com deficiências (PCDs) atendidas em hospital universitário no Brasil, assim como determinar se as barreiras atitudinais percebidas se correlacionam com outros fatores. Métodos: Este é um estudo observacional transversal, onde a amostra de PCDs completou a Escala de Atitudes Frente a Incapacidades para Pessoas com Incapacidades Físicas (ADS-D), que quantifica a barreira atitudinal percebida, a Escala Hospitalar de Ansiedade e Depressão e a Medida de Independência Funcional (MIF). Os dados foram correlacionados com sexo, renda, depressão, valor da MIF, tipo de deficiência e tempo de deficiência. Resultados: Foram avaliados 68 pacientes ­ 50,0% com lesão medular, 38,2% com amputações e 11,8% com hemiplegia ­ dos quais 66,2% eram do sexo masculino, com média de idade de 39,33 (±12,89) anos, média de 10,95 (±4,25) anos de estudo, mediana de 20,5 meses (intervalo de 10,5-33,5 meses) de tempo de deficiência, mediana de valor da MIF de 110,5 (intervalo de 94-116,5). Dos 68 pacientes, 55,9% declararam renda abaixo da média nacional e depressão foi observada em 11,76%. A média da ADS-D total (61,29 ± 8,75) não foi associada ao sexo, nível funcional, tipo ou tempo de deficiência. Renda (ß-coefficient: -3,91; p: 0,001) e sintomas depressivos (ß = -1,74; p < 0,0001) se correlacionaram com a magnitude da barreira atitudinal percebida. Conclusão: As barreiras atitudinais são influenciadas pela renda, como facilitador de inclusão, e pela depressão, como entrave à inclusão.

Predictive factors of response in radial Extracorporeal Shock-waves Therapy for Myofascial and Articular Pain: A retrospective cohort study.

BACKGROUND: Myofascial Pain Syndrome causes disability in daily life activities and despite all efforts, it continues to be a challenge, perpetuating suffering, overloading services and costs. New treatment options need to be tested. OBJECTIVE: We aimed to quantify the rESWT short-term analgesic effect and identify the predictors of success through comparing results achieved in MPS and Articular Pain (AP). METHOD: Retrospective cohort study of 1,580 patients with Myofascial Pain Syndrome or Articular Pain underwent two weekly radial Extracorporeal Shock-wave Therapy sessions. The pain intensity was measured by Visual Analog Scale before and one week after the end of the treatment (3 weeks). RESULTS: The therapy decreases pain by 62.50% (p< 0.0001), with a high success rate (91.59%) and a low worsening of baseline conditions rate (2.1%). The best recommendation is for patients with intense myofascial pain (Visual Analog Scale ⩾ 70 mm), using high shock-wave frequency (⩾ 15 Hz). CONCLUSIONS: Two rESWT sessions promote pain relief, with a high success rate and low rates of treatment abandonment and worsening. The best results are obtained in myofascial pain patients with high pain intensity, treated with high-frequency dosage.

Developing a rigid frame wheelchair in Brazil.

PURPOSE: Describing the development process of a rigid frame wheelchair using user-centered and open innovation approaches, as envisaged by the WHO Wheelchair Guidelines. METHODS: Unstructured interviews and group discussions with conveniently sampled active wheelchair users oriented the initial brief, product design and selection. The initially approved prototype was subject to ISO 7176 tests, leading to further product adjustments. The long-term follow-up was inclusive of a new group of purposively selected active wheelchair users and measured user satisfaction and safety, as well as user mobility and wheelchair fitting. Data on user satisfaction, safety and effectiveness was produced using QUEST 2.0 and WHO Wheelchair Service Training Package's forms and checklists in Portuguese. RESULTS: Iterative design and selection led to a prototype that was found appropriate by multiple stakeholders. ISO testing ensured its safety and durability. Follow-up trials included 40 active wheelchair users, who used the studied wheelchair for at least two months. They were 80% male, on average 36.3 years old, and had received their rigid frame wheelchair approximately 4.7 years after disability onset. 92.5% of them had SCI, 7.5% had bilateral transfemoral amputations. Users' assessments showed satisfaction with products (4.4) and services (4.1). Users spent an average of 4.2 h/day sat in their wheelchairs. 7.5% and 20% of users reported pressure sores and falls, respectively. CONCLUSION: A user-centered, open innovation approach led to the development of a good quality, affordable, and acceptable rigid frame wheelchair model that increased the range of manual wheelchairs available through the Brazilian public healthcare system.Implications for rehabilitationThe feedback of rehabilitation professionals with respect to new products' features is fundamental in order to understand how these devices will be adequately serviced and delivered to users.Engaging users of assistive products and rehabilitation professionals in developing new and innovative products facilitates the iteration and selection of the best project alternatives and saves considerable time and resources.Rehabilitation professionals are in the best position to work with user of assistive products and other stakeholders, such as the industry and research and development centres, to identify the impact of new assistive products in users' functionality, acknowledging their conditions and environments and exploring their potential.Working with users and other stakeholders from different backgrounds and areas of expertise makes the moto "Nothing about us, without us" real. Working towards improving functionality often requires developers to challenge the usual top-down development process in order to adopt a user-centered perspective.

Inclusão social no mercado de trabalho de pacientes amputados em processo de reabilitação / Social inclusion in the labor market of amputees in the process of rehabilitation

Objetivo: Conhecer o processo de inclusão social no mercado de trabalho, do paciente amputado, e identificar alterações socioeconômicas, após o processo de reabilitação, além de contribuir para o levantamento de dados socioeconômicos acerca da pessoa com deficiência. Método: Pesquisa retrospectiva, quantitativa e qualitativa, sob a perspectiva dialética. Os dados foram obtidos por meio do Protocolo de Avaliação Social Institucional e relatórios sociais dos pacientes amputados, que passaram pelo ambulatório, após alta do processo em um Centro de Reabilitação no município de São Paulo, no período de abril a setembro de 2016. Resultados: Os sujeitos da pesquisa (23) foram, em sua maioria do gênero masculino (20), em idade ativa (média simples de 39,5 anos), com nível de escolaridade no ensino médio (9). A maioria (21) absteve das atividades laborais. Após a instalação da deficiência, houve queda na renda familiar. Inicialmente, (17) usufruem de benefícios previdenciários, (1) benefício assistencial, e (4) estão em processo de solicitação de benefício. Durante o tratamento reabilitativo, houve redução dos benefícios previdenciários (de 17 para 15), aumento nos benefícios assistenciais (3), (1) aguarda concessão de benefício, e 3 obtiveram alta do INSS. Conclusão: Os resultados apontam que os pacientes amputados sofrem alterações socioeconômicas, após a instalação da deficiência, decorrentes à abstenção as atividades laborais e rebaixamento na renda, apontando para a importância da proteção previdenciária e assistencial. Fatores como idade, escolaridade e quantidade de internações favoreceram o retorno dos pacientes amputados no mercado de trabalho.

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.

Osteopenia and osteoporosis in people living with HIV: multiprofessional approach.

Increasing bone mineralization abnormalities observed among people living with HIV (PLWHIV) result from various factors relating to the host, the virus, and the antiretrovirals used. Today, HIV infection is considered to be a risk factor for bone mineralization disorders. The test most recommended for diagnosing osteoporosis is measurement of bone mineral density by means of dual energy X-ray absorptiometry at two sites. Osteoporosis treatment has the aims of bone mass improvement and fracture control. A combination of calcium and vitamin D supplementation may reduce the risk of fractures. Antiresorptive drugs act by blocking osteoclastic activity and reducing bone remodeling. On the other hand, bone-forming drugs stimulate osteoblastogenesis, thereby stimulating the formation of bone matrix. Mixed-action medications are those that are capable of both stimulating bone formation and inhibiting reabsorption. Antiresorptive drugs form the group of medications with the greatest quantity of scientific evidence confirming their efficacy in osteoporosis treatment. Physical activity is a health promotion strategy for the general population, but only preliminary data on its real value and benefit among PLWHIV are available, especially in relation to osteoporosis.

Efetividade da acupuntura para alívio da dor e ganho funcional em espondilite anquilosante: ensaio clínico controlado e randomizado / Efficacy of acupuncture in pain relief and function improvement in Ankylosing Spondylitis: a randomized controlled trial

A espondilite anquilosante (EA) é uma doença inflamatória crônica que acarreta seqüelas osteomusculares, déficit funcional e dor. Apesar do crescente número de pacientes buscando acupuntura como opção terapêutica para analgesia, há poucos trabalhos verificando sua eficácia em ensaios controlados. O objetivo deste estudo é avaliar a eficácia da acupuntura para alívio da dor espinhal em pacientes com EA. Estudo piloto randomizado duplo-cego, placebo-controlado na Divisão de Medicina Física e Reabilitação do Hospital das Clínicas da Universidade de São Paulo. Dez portadores de dor espinhal secundária à EA foram estudados para se verificar o efeito de dez sessões de acupuntura clássica, duas vezes por semana, contra eletroacupuntura placebo. A avaliação da intervenção antes e após incluiu medida da dor espinhal, mobilidade espinhal (teste de Schober, distância dedos-chão, distância occipício-parede e expansibilidade torácica), inflamação (BASDAI, proteínas de fase aguda), avaliação subjetiva do paciente e função (BASFI). Acupuntura clássica não foi melhor que placebo nas medidas de saída. Contudo, o Effect Size para alívio da dor foi 2,04 para acupuntura e 1,09 para placebo, ambos considerados comparáveis aos tratamentos padrão para EA. Pelo teste do Sinal, ambas as intervenções mostraram resultado significante. Acupuntura não é melhor que placebo para o alívio da dor em pacientes com EA. A resposta relevante no grupo placebo fornece evidência do efeito benéfico da relação médico-paciente no alívio da dor em pacientes com EA. O estudo está registrado com o número ISRCTN02971192 em http://isrctn.org.

Reabilitação na hemipelvectomia traumática / Rehabilitation for traumatic hemipelvectomy

A hemipelvectomia traumática constitui um evento raro, catastófico, cujos mecanismos de lesão e prognóstico são bem descritos na literatura. O crescente número de acidentes motociclísticos têm elevado a prevalência desta amputação, definindo o grupo de vítimas como jovens do sexo masculino sem comorbidade. Acarreta múltiplas sequelas físicas, psicológicas e sociais. Através da reabilitação, o paciente poderá recuperar independência funcional. A protetização é de grande valia, uma vez que os pacientes são jovens com prognóstico de marcha. Neste relato é apresentado o caso de uma vítima de hemipelvectomia traumática do sexo feminino, que se tornou independente para as atividades da vida diária após processo de reabilitação, que incluiu prótese, com melhora da qualidade de vida observada sob diversos aspectos. A protetização adequada não devolveu à paciente todas as finções perdidas, mas se constituiu em um instrumento capaz de melhorar-lhe a qualidade de vida.

A importância do tratamento das síndromes dolorosas no traumatismo cranioencefálico / Treatment of painful syndromes in traumatic brain injury

Segundo o modelo do National Center for Medical Rehabilitation Research, a doença crônica (como traumatismo cranioencefálico) deve ser observada por meio de 5 eixos - a fisiopatologia, a deficiência observável (a hemiparesia), a limitação funcional (incapacidade para tarefa específica), incapacidade para a realização de atividades de vida diária, e limitação social. Levando em conta que tais aspectos sejam inter-relacionados, a abordagem interdisciplinar é o método de escolha da prática da Medicina de Reabilitação. O objetivo do presente relato é confirmar a interferência da dor na reabilitação do trumatismo cranioencefálico (TCE), cuja importância muitas vezes é minimizada, apesar de crescentes estudos acerca da etiopatogenia e tratamento da dor no TCE. Foi realizado acompanhamento de uma paciente vítima de TCE na Divisão de Medicina Física do Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo em 2002, para quem diversas modalidades analgésicas foram propostas, além da aplicação de questionário funcional e sobre a qualidade de vida, com melhora observada em todas as medidas. É necessária análise crítica dos instrumentos de medida de saúde, na medida em que neles se observa alta capacidade para detecção de habilidades motoras e baixa eficiência em detectar melhora da funcionalidade devido aos ganhos nos campos psicoafetivos e sociais, que são diretamente relacionados à experiência dolorosa.