The changing face of neurological rehabilitation

INTRODUÇÃO: A reabilitação neurológica e a contribuição da fisioterapia mudaram consideravelmente nas últimas décadas, uma vez que o desenvolvimento científico e tecnológico permitiu uma maior compreensão dos mecanismos de reorganização cerebral e dos mecanismos envolvidos no controle e desempenho motores, em suas dificuldades e adaptações. OBJETIVO: Este artigo apresenta uma perspectiva histórica da segunda metade do século passado. DISCUSSÃO: Pesquisas científicas atuais e a subseqüente reavaliação do efeito funcional dos problemas que aparecem pela lesão do neurônio motor superior estão levando à mudança de foco das intervenções clínicas, com ênfase na otimização motora através de exercícios de tarefas orientadas, de ganho de força e de treino de desempenho físico. Achados em modelos animais e humanos sugerem que, para que a reabilitação seja eficiente em otimizar a reorganização neural e a recuperação funcional, uma ênfase maior deve ser colocada em tarefas úteis que sejam desafios interessantes com um treino que promove o aprendizado. As questões da intensidade do treino de tarefas e da extensão do estresse cardiovascular durante a atividade física também são discutidos. Embora exista muito que se aprender em achados de pesquisa clínica, a prática clínica da reabilitação continua ser altamente variada, dependendo largamente do método preferido pelo terapeuta individual, e com predomínio dos métodos terapêuticos desenvolvidos meio século atrás. Fisioterapeutas necessitam assumir a responsabilidade do uso de técnicas baseadas em evidências, ou pelo menos usar métodos de intervenção e medidas objetivas de resultados que sejam cientificamente aceitáveis.

Omeprazole for treatment of chronic erosive esophagitis in children: a multicenter study of efficacy, safety, tolerability and dose requirements. International Pediatric Omeprazole Study Group.

OBJECTIVES: To determine the efficacy, safety, and tolerability of omeprazole in children and to determine the doses required to heal chronic, severe esophagitis. STUDY DESIGN: Open multicenter study in children aged 1 to 16 years with erosive reflux esophagitis. The healing dose of omeprazole used was that with which the duration of acid reflux was <6% of a 24-hour intraesophageal pH study. Follow-up endoscopy was performed after 3 months of treatment with the healing dose. RESULTS: At entry, two thirds of 57 patients who completed the study had esophagitis grade 3 or 4 (scale 0-4); some 50% had neurologic impairment or repaired esophageal atresia. Of the 57 patients, 54 healed; 3 did not heal and left the study, and 3 healed with a second course. Doses required for healing were 0.7 to 3.5 mg/kg/d: 0.7 mg/kg/d in 44% of patients and 1.4 mg/kg/d in another 28%. Healing dose correlated with grade of esophagitis but not with age or underlying disease. Reflux symptoms improved dramatically in almost all of the 57 patients, including the unhealed patients. CONCLUSIONS: Omeprazole is well tolerated, highly effective, and safe for treatment of erosive esophagitis and symptoms of gastroesophageal reflux in children, including children in whom antireflux surgery or other medical therapy has failed. On a per-kilogram basis, the doses of omeprazole required to heal erosive esophagitis are much greater than those required for adults.

Nutritional status of children with cystic fibrosis measured by total body potassium as a marker of body cell mass: lack of sensitivity of anthropometric measures.

OBJECTIVE: To investigate measures aimed at defining the nutritional status of cystic fibrosis (CF) populations, this study compared standard anthropometric measurements and total body potassium (TBK) as indicators of malnutrition. METHODS: Height, weight, and TBK measurements of 226 children with CF from Royal Children's Hospital, Brisbane, Australia, were analyzed. Z scores for height for age, weight for age, and weight for height were analyzed by means of the National Centre for Health Statistics reference. TBK was measured by means of whole body counting and compared with predicted TBK for age. Two criteria were evaluated with respect to malnutrition: (1) a z score < -2.0 and (2) a TBK for age <80% of predicted. RESULTS: Males and females with CF had lower mean height-for-age and weight-for-age z scores than the National Centre for Health Statistics reference (P <.01), but mean weight-for-height z score was not significantly different. There were no significant gender differences. According to anthropometry, only 7.5% of this population were underweight and 7.6% were stunted. However, with TBK as an indicator of nutritional status, 29.9% of males and 22.0% of females were malnourished. CONCLUSION: There are large differences in the percentage of patients with CF identified as malnourished depending on whether anthropometry or body composition data are used as the nutritional indicator. At an individual level, weight-based indicators are not sensitive indicators of suboptimal nutritional status in CF, significantly underestimating the extent of malnutrition. Current recommendations in which anthropometry is used as the indicator of malnutrition in CF should be revised.

Resting energy expenditure, pulmonary inflammation, and genotype in the early course of cystic fibrosis.

To further investigate the early course of cystic fibrosis (CF), specifically to examine factors contributing to energy imbalance, we examined resting energy expenditure (REE) (by indirect calorimetry) per unit body weight and metabolically active body cell mass (by total body potassium), in relation to CF genotype (by genomic DNA analysis), CF pancreatic phenotype, and markers of pulmonary inflammation (from bronchoalveolar lavage fluid). Eighteen subjects with presymptomatic CF who were less than 2 years of age (n = 11, delta F508/ delta F508 genotype; n = 15, pancreatic insufficiency phenotype), identified by newborn screening, were compared with age-, sex-, and length-matched control subjects (n = 13). Those with the delta F508/ delta F508 genotype had significantly higher mean REE expressed per unit body weight (125%) and body cell mass (115%; p < 0.03). Those with other genotypes (n = 7) did not, as a group, have significantly different mean REEs, but individuals with known "severe" genotypes had REEs in the high range and those with a pancreatic-sufficient phenotype had significantly lower REE than those with a pancreatic-insufficient phenotype (p < 0.05), and REEs were in the normal range. Examination of bronchoalveolar lavage fluid revealed positive culture results (7/10) but variable colony counts, neutrophil percentages, and concentrations of interleukin-8 and interleukin-1 beta equally in both CF genotype groups. These markers of pulmonary inflammation were not correlated, individually or collectively, with REE or genotype. We conclude that genotypic variations in energy balance are detectable early in CF unrelated to lung inflammation. Subclinical defects in body composition and pulmonary integrity occur early in CF and, in combination with increased cellular metabolic activity, have important clinical implications with respect to early diagnosis and management.

Characterization of cassava vein mosaic virus: a distinct plant pararetrovirus.

Cassava vein mosaic virus (CVMV) was found to be widespread throughout the north-eastern region of Brazil. The complete sequence of CVMV was determined, and the genome was 8158 bp in size. A cytosolic initiator methionine tRNA (tRNA met1)-binding site that probably acts as a primer for minus-strand synthesis was present. The genome contained five open reading frames that potentially encode proteins with predicted molecular masses of 186 kDa, 9 kDa, 77 kDa, 24 kDa and 26 kDa. The putative 186 kDa protein had regions with similarity to the zinc finger-like RNA-binding domain that is a common element in the capsid proteins and similarity to the intercellular transport domain of the plant pararetroviruses. The predicted 77 kDa protein had regions with similarity to aspartic proteases, reverse transcriptase and RNase H of pararetroviruses. This gene order was confirmed by the amplification of similar PCR products from total DNA extracted from CVMV-infected cassava plants. The genomic organization of CVMV was different from the organization of either the caulimoviruses or badnaviruses. In comparisons of the regions with the reverse transcriptase motif, CVMV was grouped between the caulimoviruses and badnaviruses. It appears that CVMV is distinct from the other well-characterized plant pararetroviruses.

Measured versus predicted resting energy expenditure in infants: a need for reappraisal.

The reliability of commonly used predictive equations for estimating energy expenditure in infants in both health and disease was assessed by comparing resting energy expenditure (REE, measured by indirect calorimetry) in relation to weight, height, and body cell mass (by total body potassium analysis) with predictive equations (Harris-Benedict, Food and Agriculture Organization/World Health Organization/United Nations University (FAO/WHO/UNU), Schofield weight-only, and Schofield weight-and-height equations) in 36 healthy infants (age 0.43 +/- 0.27 years; 19 male) and in 9 infants with cystic fibrosis (age 0.41 +/- 0.30 years; 4 male). Mean +/- SD REE for healthy boys was 0.205 +/- 0.019 MJ kg-1 day-1 and for healthy girls 0.217 +/- 0.026 MJ kg-1 day-1. Infants with cystic fibrosis had a significantly higher REE (0.258 +/- 0.034 vs 0.210 +/- 0.024 MJ kg-1 day-1; p < 0.005). Compared with measured values, predicted REE values varied markedly among equations, overestimating REE in healthy infants (Harris-Benedict equation, 182% +/- 63% (SD) of measured values; FAO/WHO/UNU equation, 104% +/- 14%; Schofield weight-only equation, 107.5% +/- 14%; and Schofield weight-and-height equation, 106% +/- 11%) and underestimating REE in those with cystic fibrosis (84% to 88% for the FAO/WHO/UNU, Schofield weight-only, and Schofield weight-and-height equations) except the Harris-Benedict equation (152%). On regression analysis both weight and body cell mass were related significantly to REE (r2 = 0.87 and r2 = 0.61, respectively) for normal infants and (r2 = 0.92 and r2 = 0.94) for those with cystic fibrosis. Using a generalized linear model of variance, we saw a significant (p < 0.001) variability among all REE measures. Thus we could rely on none of the predictive equations to give an accurate estimate of REE, and hence energy and fluid requirements, in individual infants. We suggest that when accurate estimates are needed, measurement of REE in individual infants should be attempted, especially in disease states, and that the continued use of current formulas should be reexamined.

Nutritional rehabilitation in cystic fibrosis: controlled studies of effects on nutritional growth retardation, body protein turnover, and course of pulmonary disease.

The effects of a sustained increase in energy and protein intake on weight gain, growth, body protein metabolism, and the course of pulmonary disease were studied in 10 undernourished patients with cystic fibrosis unable to maintain nutrition and growth by the oral route and with declining nutritional and pulmonary status in the year prior to study. A 1-year course of nutrient supplementation using a semielemental high-nitrogen formula was delivered by nocturnal intragastric feeding or as an orally administered supplement; progress was compared with that of 14 height-, sex- and FEV1-matched patients with cystic fibrosis receiving conventional therapy. Supplementation resulted in a catch-up weight gain and sustained improvement in linear growth, with fewer pulmonary infections per year than during the initial observation period. Better weight gain and linear growth than in the comparison group were observed, as well as a significant reversal of the trend for deteriorating lung function. Compared with data from healthy children, 15N-glycine kinetics demonstrated increased protein breakdown and negligible net protein deposition in the treatment group prior to supplementation. After supplementation, synthesis in excess of breakdown, with net protein accretion, occurred by 1 month of supplementation. By 6 to 12 months a significant reduction in the previously high rate of mean synthesis and breakdown was observed, with maintenance of net anabolism. These dynamic changes in whole-body protein turnover reflect a long-term improvement in energy and protein intake, which can favorably affect nutrition, growth, and the course of pulmonary disease in problem cases of cystic fibrosis.

Chemotherapy in giardiasis: clinical responses and in vitro drug sensitivity of human isolates in axenic culture.

To investigate drug sensitivities of human Giardia isolates, we developed a reproducible in vitro 3H-thymidine uptake assay to compare drug potencies. Among 13 Giardia intestinalis stocks obtained from the culture of trophozoites isolated from duodenal juice, considerable variation in susceptibility to a range of currently used drugs was found. The population doubling time of these stocks also varied widely. Clinical features in patients ranged in severity from mild chronic diarrhea to a celiac-like syndrome, with a similar variation in the degree of histologic change in the mucosa. Brush-border enzyme activities were universally reduced in children younger than 5 years of age. The two isolates with the highest ID50 values for furazolidone in vitro were from patients who had persistent symptoms after treatment with this drug; these patients subsequently responded to treatment with a nitroimidazole with greater in vitro potency. These studies suggest that biologic variants of G. intestinalis exist in humans and may in part account for the variable clinical manifestations and for some treatment failures.

Cauliflower mosaic virus in the nucleus of Nicotiana.

An isolate of cauliflower mosaic virus that occurs in nuclei of Nicotiana is reported. Affected nuclei become greatly enlarged and filled with virions without the electron-dense matrix material characteristic of cytoplasmic sites of virus assembly. Conventional cytoplasmic inclusions with embedded virus occurred in other cells of the same tissue.

Improved growth and clinical, nutritional, and respiratory changes in response to nutritional therapy in cystic fibrosis.

To investigate the role of nutritional factors in growth and in the clinical, nurtitional, and respiratory status in cystic fibrosis, we studied 12 problem CF patients from six months before to six months after a period of supplemental parenteral nutrition. During the initial six months' observation period on appropriate conventional therapy, the patients (aged 0.5 to 11 years) had inadequate growth and weight gain, a total of 21 active pulmonary infections, and, despite dietary supplements, inadequate ad libitum nutrient intakes. After nutritional therapy, providing a balanced consistent hypercaloric intake for 21 days, catch-up weight gain occurred by one month and continued at six months; catch-up in linear growth was observed by three months and continued at six months. In addition, significantly fewer pulmonary infections were observed in the six months' post-therapy (n = 3), sustained and significant improvements were noted in clinical score and plumonary function, and there was a marked improvement in well-being and ad libitum nutrient intake. We conclude that adequate nutritional support can favorably affect growth, clinical status, and the course of chronic pulmonary disease in problem cases of CF.