Thais Raquel Martins Filippo

Concentration of cytokines in patients with osteoarthritis of the knee and fibromyalgia

Introduction Fibromyalgia and osteoarthritis may present a relationship with the concentration of cytokines. The aim of this study was to compare the serum concentrations of IL-12p70, tumor necrosis factor, IL-10, IL-6, IL-1β, and IL-8 in patients with knee osteoarthritis and fibromyalgia. Materials and methods The study included 53 women (71.2±7.6 years old) diagnosed with knee osteoarthritis with moderate-to-severe pain (visual analog scale >4) for at least 3 months. Sixty women (54.1±8.1 years old) diagnosed with fibromyalgia according to the American College of Rheumatology criteria and with moderate-to-severe pain (visual analog scale >4) also participated in this study. For the dosage of cytokines, blood was collected in the morning: 5 mL from the cubital vein. The material was centrifuged at 4°C, separated into 100 μL aliquots and stored at −80°C until processing. Serum concentrations of the studied cytokines were assessed using the BD Cytometric Bead Array method. Data were analyzed with Student’s t-test and the Mann–Whitney U test. Results We found higher levels of IL-6, IL-10, and IL-1β in fibromyalgia patients. After adjustment of age as a covariate, there was no statistically significant difference in the concentration of any cytokine between fibromyalgia and knee osteoarthritis patients. Conclusion Patients with knee osteoarthritis and fibromyalgia with the same duration and intensity of pain demonstrate similar concentrations of cytokines. Aging may play a role in cytokine profile, a finding not so extensively addressed in the literature and one that should be further investigated.

Pressure pain thresholds in patients with chronic nonspecific low back pain

BACKGROUND The lumbar back and hip muscles are important for a normal functioning of the human spine and they are considered to be of etiological significance in chronic nonspecific low back pain (nCLBP). Inactivity and a lower level of physical activity in patients with nCLBP may change muscle characteristics and may be associated with pain and disability. Pressure algometry has been found to be non-invasive, efficient and reliable in the exploration of physio-pathological mechanisms involved in muscle pain syndromes. The subjective characteristic of the pressure pain thresholds (PPTs) cannot be avoided once it is the very objective of the measurement, i.e. the minimum pain perceptible by the person, is a subjective factor. Most studies have revealed gender differences between PPTs, with females showing lower thresholds. OBJECTIVE to determine whether demographic variables and PPTs, are related pain intensity and a disability in patients with nCLBP. METHODS One hundred and twenty-four patients with nCLBP were included in the study. The Visual Analogue Scale (VAS) and the Roland-Morris Questionnaire for Low Back Pain (RM) were used to evaluate the intensity of pain and degree of disability. The PPT was performed from L1 up to S2 dermatomes, at the muscles over the Gluteus medius, minimus and maximus, including a point located at the level of the piriformis, at the Quadratus lumborum, at the Iliopsoas and points of reference located at the level of the L1 up to L5 ligaments. The pain intensity was assessed by visual analogue scale (VAS) and the lumbar function by Roland Morris questionnaire (RM). Multiple linear regression models were used for both the VAS and the RM. RESULTS No significant differences were found between the PPTs measured at either left or right limb. The mean VAS value was 7.3 (± 1.5) and the RM score was 14.2 (± 5.3). The PPT-values showed significant negative correlations to the VAS and the RM. The highest correlation between the mean VAS and PPT-values were found at the level of the Gluteus medius (r= -0.34, p< 0.001), which was the only measurement correlated to the intensity of pain (r2 = 0.11, p< 0.001). The RM was correlated to the BMI, the level of education and the PPT values at the level of the Iliopsoas muscle and the L4-L5 supraspinous ligament. CONCLUSIONS This study showed that most PPT values are correlated to the VAS and the RM. Nevertheless, the variability explained by PPT values and demographic characteristics was low for pain intensity and function.

Proximal tibia fracture in a patient with incomplete spinal cord injury associated with robotic treadmill training.

Study design:One case report of proximal tibia fracture in a patient with incomplete spinal cord injury (SCI) associated with robotic treadmill training.Objective:To raise the awareness that bone densitometry may be recommended before starting the robotic treadmill therapy, as well as the active vigilance of symptoms after therapy.Setting:Institute of Physical and Rehabilitation Medicine, Lucy Montoro Institute for Rehabilitation, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil.Case report:The patient, female gender, with a fracture of vertebra T12 and arthrodesis from T9 to L1 (American Spinal Injury Association Classification (ASIA-C)). Training on Lokomat consisted of five 30-min weekly sessions, under the supervision of a qualified professional. At the beginning of the 19th session, the patient complained of pain in the anterior region of the left knee. Lokomat and any other body support therapy were discontinued. Magnetic resonance imaging (MRI) evidenced a transverse, oblique, metaphyseal proximal anterior and medial tibial fracture.Conclusion:Fractures are among the chronic complications of a SCI, affecting 34% and many times arising from minimal traumas. Lokomat resembles physiological walking, and more studies show its benefits. Many studies encourage the use of robotic devices for the rehabilitation of lower limbs, but there are still several unanswered questions. However, there are not enough studies to show whether there is a higher risk of fracture incidence in patients with osteopenia or osteoporosis who trained on the Lokomat.

Postural Control of Healthy Elderly Individuals Compared to Elderly Individuals with Stroke Sequelae.

A stroke and aging process can modify the postural control. We aimed to compare the postural control of health elderly individuals to that of individuals with stroke sequelae. This cross-sectional transversal study was made with individuals capable of walking without any assistance and that were considered clinically stable. The study had 18 individuals in the group with stroke sequelae (SG) and 34 in the healthy elderly control group (CG). The participants were evaluated for the timed up and go test (TUG) and force platform. The SG showed the worst results in relation to the time of execution of the TUG and the force platform evaluation. The displacement of center of pressure was worse for both groups in the eyes-closed situation, especially in the anteroposterior direction for the CG. The GS showed worse results in the static and dynamic postural control. The healthy elderly showed more dependence on sight to maintain their static balance and there was no difference in the balance tests in relation to the side affected by the stroke.

Aplicação das escalas Fugl-Meyer Assessment (FMA) e Wolf Motor Function Test (WMFT) na recuperação funcional do membro superior em pacientes pós-acidente vascular encefálico crônico: revisão de literatura

It is estimated that 45-75% of chronic adult stroke patients have difficulty in using the hemiparetic upper limb (MS) in their daily life activities (DLAs). Functional scales are used in the practice of rehabilitation, in the search for diagnoses and prognoses, and in evaluating response to treatment. The Wolf Motor Function Test (WMFT) and Fugl-Meyer Assessment (FMA) scales are the instruments most commonly mentioned in the literature. Objective: The aim of this study was to review the use of the WMFT and FMA scales in the recovery of upper limb function in patients after chronic stroke. Method: We searched the MedLine database (PubMed) for articles published from 2000 to 2013. The PICO method was adopted as the search strategy. The descriptors used for the search were: (stroke OR cerebrovascular disorders OR intracranial arteriosclerosis OR thrombosis intracranial embolism) AND (Fugl-Meyer assessment OR wolf motor function test). Therapy/narrow was used as a search filter. Results: We found 181 studies, 89 of which were excluded because they did not meet the inclusion criteria or did not have a topic relevant to the review search. After selection by title and by abstract, 92 articles were fully read. Of these articles, 47 were excluded because they did not fulfil the search objective. All in all, 45 articles were reviewed. FMA is the tool most used and it was found that 80% of the studies applied this scale to evaluate responses to the different therapies. In these studies, the intervention most used was the Constrained Induced Therapy (CIT) (25%), followed by Robotics Therapy (22.2%). Although the WMFT was initially developed to assess the effects of CIT, nowadays this scale is used, after the application of other techniques, to assess the functional recovery of patients with stroke sequelae. In our survey, 44.4% of the studies used WMFT; of these, 35% assessed the effects of CIT, 15% assessed robotic therapy for the upper limbs, and 65% for different therapies. Conclusion: For randomized controlled trials, the FMA scale was more used to assess functional recovery in the upper limbs of chronic stroke patients, even after application of robotics therapy. However, we found that it is not the most appropriate scale to assess the same outcomes after CIT use. WMFT is the scale most widely used for functional assessment after application of CIT; it is more sensitive than FMA for bilateral therapy, and is highly applicable in virtual reality therapy.Estima-se que de 45 a 75% dos adultos que sofreram um Acidente Vascular Encefalico (AVE) tem dificuldade de utilizar o membro superior (MS) hemiparetico nas atividades de vida diaria (AVD’s) na fase cronica. Escalas funcionais sao utilizadas na pratica da reabilitacao e em pesquisas para diagnosticos, prognosticos e resposta a tratamentos. As escalas Wolf Motor Function Test (WMFT) e Fugl-Meyer Assessment (FMA) sao instrumentos muito citados na literatura. Objetivo: O objetivo deste estudo foi verificar a aplicacao das escalas WMFT e FMA na recuperacao funcional do membro superior em pacientes pos AVE cronico. Metodo: Foi realizada uma revisao de literatura com busca nas bases de dados do MedLine (PubMed) de artigos publicados de 2000 a 2013. Adotou-se como estrategia de pesquisa o metodo (P.I.C.O.). Os descritores utilizados para a pesquisa foram: (stroke OR cerebrovascular disorders OR intracranial arteriosclerosis OR intracranial embolism and thrombosis) AND (fugl-meyer assessment OR wolf motor function test). Foi utilizado therapy narrow como filtro de busca. Resultados: Foram encontrados 181 estudos, 89 foram eliminados por nao preencherem os criterios de inclusao ou por nao apresentarem tema relevante a pesquisa. Apos a selecao por titulo e resumo, 92 artigos foram lidos na integra. Destes, 47 foram excluidos por nao contemplarem o objetivo da presente pesquisa. No total, 45 artigos foram revisados. Houve predominio da utilizacao da ferramenta FMA e verificouse que 80% dos estudos aplicaram esta escala para avaliar respostas a diferentes tipos de terapias. Nestes estudos, a intervencao mais utilizada foi a Terapia de Contensao Induzida (TCI) (25%), seguida pela Terapia Robotica (22,2%). Apesar do WMFT ter sido inicialmente desenvolvido para avaliar os efeitos da TCI, nos dias de hoje verifica-se sua utilizacao para avaliar a recuperacao funcional de pacientes com sequelas de AVE apos aplicacao de outras tecnicas. Em nossa pesquisa, 44,4% dos estudos utilizaram o WMFT, destes, 35% avaliaram os efeitos da TCI, 15% da terapia robotica de MS e 65% usaram diferentes terapias. Conclusao: Em estudos controlados randomizados, a FMA foi a escala mais utilizada para avaliar a recuperacao funcional do MS em pacientes com AVE cronico, inclusive apos aplicacao de terapia robotica. Porem, verificamos que ela nao e a escala mais indicada para avaliar os mesmos desfechos apos utilizacao da TCI. Entretanto, a WMFT foi a escala mais utilizada para avaliacao funcional apos aplicacao da TCI e mostrou-se mais sensivel que a FMA na terapia bilateral, alem de alta aplicabilidade na terapia de realidade virtual.

Modelo de reabilitação hospitalar após acidente vascular cerebral em país em desenvolvimento

44 ABSTRACT Intensive rehabilitation services with standardized treatment for stroke survivors are desirable once they contribute to the patients’ functional improvement even in facilities with restricted financial resources. Objective: To verify whether the stroke program at our public inpatient Rehabilitation Center contributes to improvements in functional outcome. Method: This is a retrospective cross-sectional study of the first and last 100 neurological patients (2009-2010 and 2014-2015) admitted at the Lucy Montoro Rehabilitation Network (Morumbi Unit). For this study, the patients were analyzed at admission and at discharge by the modified Rankin Scale (mRS). After testing for normality, an unpaired t-test was on the patients’ clinical and demographic characteristics. Intragroup analysis was performed by the nonparametric Wilcoxon test. The intergroup analysis used the Mann-Whitney nonparametric test. Functional outcome scores ≤ 3 at discharge were considered favorable. Results: The modified Rankin Scores (mRS) were assessed just before the initiation of the therapies and at the patients’ discharge. Median mRS score at admission was 4 compared to 3 at discharge (p=0.0001), after 4 to 6 weeks in the stroke program. Conclusions: Short term, standardized intensive rehabilitation program with multidisciplinary therapies, in which the patient remains hospitalized, promote functional improvements of patients with stroke sequelae.

Neuroplasticidade e recuperação funcional na reabilitação pós-acidente vascular encefálico

O conceito de reabilitacao no acidente vascular encefalico (AVE) atualmente e baseado em evidencias da neuroplasticidade, considerada responsavel pela recuperacao apos AVE. A escassez de informacoes na literatura e, principalmente, de metodos que avaliem especificamente a neuroplasticidade nao condiz com a sua importância funcional. A literatura aborda, geralmente, as avaliacoes funcionais dos membros apos o AVE e poucos estudos se concentram no comprometimento cerebral. Objetivo: Revisar a literatura para avaliar os programas de reabilitacao atuais em AVE e seu potencial para promover melhorias funcionais e plasticidade neuronal. Metodo: Foi realizada uma revisao de literatura com busca na base de dados do PubMed de artigos publicados de 2000 a 2015. Os descritores utilizados para a pesquisa foram: “Stroke/rehabilitation” OR “Stroke/therapy” AND “Neuronal Plasticity”. Resultados: Foram encontrados 86 estudos, 36 foram classificados como Therapy/Narrow, sendo 17 artigos excluidos por nao preencherem os criterios de inclusao ou por nao apresentarem tema relevante a pesquisa. Apos a selecao por titulo e resumo, 19 artigos foram lidos na integra. Destes, 6 foram excluidos por nao contemplarem o objetivo da presente pesquisa. No total, 13 artigos foram revisados. Dentre estes 13 artigos, os instrumentos de avaliacao variaram entre a ressonância magnetica funcional, estimulacao magnetica transcraniana e tomografia computadorizada por emissao de foton unico (SPECT). As intervencoes utilizadas foram especificas para os membros superiores, exceto por um artigo que teve a intervencao atraves da terapia de oxigenio hiperbarica. Conclusao: Poucos estudos avaliam a plasticidade neuronal na reabilitacao do AVE, e a maioria dos artigos apresentou melhorias tanto funcionais quanto na neuroplasticidade. Entretanto, maiores estudos devem investigar e correlacionar ambos os aspectos na reabilitacao dos pacientes com AVE

Poster 557 Neuroplasticity and Functional Improvement in Stroke Rehabilitation: A Neglected Knowledge Gap

charged with some type of oral feedings with 67.2% eating 3 meals per day. Patients who were discharged on some sort of oral feeding had a significantly longer IPR length of stay than those discharged NPO (t -2.91, P 0.014). The majority of patients (60%) with a FT were discharged to a subacute destination. At time of discharge from IPR, 58/64 (90.6%) patients still had a FT in place with 40/64 (62.5%) still requiring full or partial supplemental tube feedings. Conclusions: Patients admitted to IPR with neurogenic dysphagia and FT are able to make functional progress. Despite the functional gains noted and returning to oral feedings, the majority of the patients still required supplemental FT at time of discharge from IPR.

Poster 388 Hyperalgesia in Chronic Nonspecific Low Back Pain: Does it Matter?

Disclosures: M. Miedema, No Disclosures. Case Description: The patient presented with 6 weeks of gradual onset, constant sharp low back pain radiating into both legs without inciting trauma. Her symptoms worsened with weight bearing and were relieved with sitting. History was otherwise unremarkable and her examination was notable for positive dural tension signs. Radiograph of the lumbar spine revealed facet arthropathy at L5-S1. Initial lumbar MRI without contrast was obtained and showed severe L4-5 facet arthrosis, a high T2-weighted, multilocular lesion in the ventral epidural space at L4-5 creating moderate to severe central spinal canal narrowing and right L5 nerve compression within the right lateral recess. Subsequently, an MRI with contrast was obtained which again demonstrated the anterior epidural multilocular cystic mass with linear enhancement and confirmed the suspicion of a dissecting synovial cyst arising from the adjacent right L4-5 facet, and ruling out neoplasm. She was treated with a CT-guided rupture of the facet cyst and right L4-5 transforaminal epidural steroid injection. Setting: Outpatient spine rehabilitation clinic. Results or Clinical Course: At 3 weeks after facet cyst rupture the patient had significant improvement in her pain. Discussion: This is the first reported case, to our knowledge, of a ventral epidural multilocular lesion arising from a dissecting synovial cyst. Conclusions: Although uncommon, dissecting synovial cysts should be considered in the differential diagnosis of ventral epidural lesions in the setting of known facet arthropathy.