Estágio profissional de intervenção em fisioterapia neurológica com pacientes adultos após aciente vascular cerebral

Mestrado em Fisioterapia NeurológicaIntrodução: A Fisioterapia Neurológica é uma área de intervenção essencial na medida em que existem cada vez mais doentes com sequelas resultantes de lesões do sistema nervoso central a necessitar de cuidados de fisioterapia, nomeadamente doentes com Acidente Vascular Cerebral já que as taxas de incidência são altas e a mortalidade tem vindo a decrescer com os avanços da medicina. Por outro lado, os conhecimentos atuais da área da neurociência permitem que a intervenção do fisioterapeuta seja baseada na evidência. Objetivos: Aprofundar conhecimentos, capacidades e competências em Fisioterapia Neurológica em pacientes adultos; intervindo essencialmente, em pacientes com sequelas de Acidente Vascular Cerebral, desenvolvendo o modelo de raciocínio clínico e investigando a efetividade do conceito de Bobath na funcionalidade de pacientes pós Acidente Vascular Cerebral. Metodologia: O estágio articulou a vertente de investigação, a dimensão pedagógica e a prática clínica; decorreu no Hospital Curry Cabral (Centro Hospitalar Lisboa Central) com pacientes adultos a realizar fisioterapia, em regime de internamento ou ambulatório, devido a patologia neurológica e mais especificamente com pacientes com sequelas de AVC; teve a duração de 200h. Foram selecionadas três escalas de funcionalidade (o Indicador de Barthel Modificado, a Medida de Independência Funcional e a Motor Assessement Scale) para a avaliação dos casos clínicos acompanhados e a abordagem em fisioterapia foi baseada no Conceito de Bobath. Resultados: Este estágio favoreceu a aquisição e consolidação de conhecimentos na área da Fisioterapia Neurológica, nomeadamente sobre o Conceito de Bobath e a avaliação da funcionalidade. São apresentados três casos clínicos de pacientes com sequelas de AVC que permitiram treinar a aplicação das escalas de funcionalidade, desenvolver o raciocínio clínico, aplicar as estratégias selecionadas e refletir sobre a eficácia da intervenção. Discussão: Embora não exista evidência robusta da superioridade do Conceito de Bobath em relação a outras abordagens, a sua filosofia facilita a avaliação e a tomada de decisão numa perspetiva holística sem menosprezar a individualidade de cada paciente. Das três escalas de funcionalidade aplicadas a Motor Assessement Scale é a única a levar em consideração a qualidade do movimento, o que a torna mais sensível a pequenas evoluções facilitando a mensuração adequada dos objetivos da intervenção. Conclusão: A realização deste estágio foi um período de aprendizagem importante e uma experiência enriquecedora no aspeto clínico, científico e académico.ABSTRACT - Introduction: Neurological Physiotherapy is an essential intervention area as there are more and more patients with sequelae resulting from injuries to the central nervous system requiring physiotherapy care, namely patients with stroke as the incidence rates are high and mortality has been decreasing with medical advances. On the other hand, current knowledge in the field of neuroscience allows the intervention of the physiotherapist to be based on evidence Objectives: To deepen knowledge, skills, and competencies in Neurological Physiotherapy in adult patients; essentially intervening in patients with sequelae of stroke, developing the model of clinical reasoning and investigating the effectiveness of the Bobath Concept in the functionality of patients after stroke. Methodology: The internship articulated the research aspect, the pedagogical dimension, and the clinical practice; it took place at Hospital Curry Cabral (Centro Hospitalar Lisboa Central) with adult patients undergoing physical therapy, inpatient or outpatient, due to neurological pathology and more specifically with patients with stroke sequelae; lasted 200 hours. Three scales of functionality were selected (the Barthel modified indicator the Functional Independence Measure and the Motor Assessment Scale) for the evaluation of the clinical cases followed and the approach in physiotherapy was based on the Bobath Concept. Results: This internship allowed the acquisition and consolidation of knowledge in the area of Neurological Physiotherapy, namely on the Bobath Concept and the evaluation of functionality. Three clinical cases of patients with stroke sequelae are presented, which allowed to train the application of the selected functionality scales, develop clinical reasoning and reflect on the effectiveness of the intervention. Discussion: While there is no robust evidence of the superiority of the Bobath Concept over other approaches, its philosophy facilitates assessment and decision-making from a holistic perspective without underestimating the individuality of each patient. Of the three scales of functionality applied the Motor Assessment Scale, is the only one to consider the quality of the movement, which makes it more sensitive to small developments, facilitating the adequate measurement of the intervention goals. Conclusion: This internship was an important learning period and an enriching experience in the clinical, scientific, and academic aspects.N/

Relatório de estágio

Relatório de estágio - Mestrado em Ensino da MúsicaRésumé-Section I - En septembre 2012, l’auteur a été engagé comme professeur au Conservatoire à Rayonnement Départemental du Choletais en France et a pris la classe de cor constituée de 25 élèves en charge. Dans un premier temps, l’auteur présente le projet pédagogique établi pour cette classe. Il répond aux exigences liées à son cadre d’emploi et tient compte des con naissances académiques acquises lors de sa formation à l’École Supérieure de Musique de Lisbonne et à l’École Supérieure d’Éducation. Dans un second temps, lors d’une description et d’une analyse de la mise en place de ce projet pédagogique pour l’ensemble de la classe, il aborde les sujets de l’enseignement adapté aux élèves déficients, l’enseignement aux adultes et de la transversalité des enseignements. Finalement est analysé, sur la base de ce projet pédagogique, le cas d'un élève de chaque cycle d'enseignement classique.Résumé-Section II - Depuis l’abaissement de l’âge d’entrée en 1er cycle dans l’enseignement spécialisé de la musique décrété par le ministère de la Culture dans les schémas d’orientation pédagogique des 20 dernières années, les cors standards doubles utilisés jusqu’à présent représentent de par leur poids un obstacle à l’apprentissage. En 1981, suite à une formation de 3 ans comme thérapeute de technique Alexander, le corniste anglais Pip Eastop conçoit un pied-support qui lui permet de jouer du cor tout en respectant "le bon usage de soi". Cette étude se concentre sur ce pied-support et cherche à définir s’il est possible de le considérer comme un outil ergonomiquement valide pour l’acquisition des compétences fondamentales présentées en 1ère section. Sont présentés un historique de l'évolution du poids du cor, les solutions envisageables pour l'enseignement du cor, une étude empirique basée sur des questionnaires effectuée au sein de la classe de cor du Conservatoire à Rayonnement départemental du Choletais et pour conclure est abordée en discussion finale les conséquences de l'ergonomie sur l'enseignement spécialisé de la musique.Abstract-Section I - In September 2012, the author was taken on as a French horn teacher at the "Conservatoire à Rayonnement Départemental du Choletais" in France, taking over the corresponding class of 25 students. Firstly, the author presents the educational project designed specifically for this class. It meets the requirements of his job description, and reflects the academic knowledge acquired during his training at the "Escola Superior de Musica de Lisboa," as well as at the "Escola Superior da Educacao." Secondly, by describing and analysing the implementation of this educational project for the whole class, the author examines issues regarding the education of "special-needs" students, adult education and the transversatily of musical teaching syllabuses. Finally, based on the educational project, the author analyses the individual case of a student from each of the classical cycle.Abstract Section II - Since the lowering of the age of entry to the first cycle in special, musical education in a decree enacted over the past twenty years by the Ministry of Culture, the double- standard French horns used so far have been a barrier to learning, simply through their sheer weight. In 1981, after three years training as a therapist using the "Alexander Method," the English French horn player, Pip Eastop, designed a hornstick which enabled him to play while maintaining "the proper use of the self." This study focuses on the hornstick, and attempts to ascertain whether it is possible for the hornstick to be considered as an ergonomically-valid tool for the acquisition of the basic skills presented in the first section. The author presents the history of the evolution of the weight of the French horn, some possible solutions for teaching the French horn, as well as an empirical study based on questionnaires completed by members of the French horn classes at the "Conservatoire à Rayonnement Département du Choletais," before concluding by examining the ergonomic consequences on teaching methods.N/

Control of breathing in anuran amphibians

The primary role of the respiratory system is to ensure adequate tissue oxygenation, eliminate carbon dioxide and help to regulate acid-base status. To maintain this homeostasis, amphibians possess an array of receptors located at peripheral and central chemoreceptive sites that sense respiration-related variables in both internal and external environments. As in mammals, input from these receptors is integrated at central rhythmogenic and pattern-forming elements in the medulla in a manner that meets the demands determined by the environment within the constraints of the behavior and breathing pattern of the animal. Also as in mammals, while outputs from areas in the midbrain may modulate respiration directly, they do not play a significant role in the production of the normal respiratory rhythm. However, despite these similarities, the breathing patterns of the two classes are different: mammals maintain homeostasis of arterial blood gases through rhythmic and continuous breathing, whereas amphibians display an intermittent pattern of aerial respiration. While the latter is also often rhythmic, it allows a degree of fluctuation in key respiratory variables that has led some to suggest that control is not as tight in these animals. In this review we will focus specifically on recent advances in studies of the control of ventilation in anuran amphibians. This is the group of amphibians that has attracted the most recent attention from respiratory physiologists. (c) 2006 Elsevier B.V. All rights reserved

ATP in the locus coeruleus as a modulator of cardiorespiratory control in unanaesthetized male rats

Locus coeruleus (LC) noradrenergic neurons are chemosensitive to CO2 and pH in mammals and amphibians and are involved in the CO2-related drive to breathe. Purinergic neuromodulation in the LC is of particular interest because ATP acts as a neuromodulator in brainstem regions involved in cardiovascular and respiratory regulation, such as the LC. ATP acting on LC P2 receptors influences the release of noradrenaline. Thus, the goal of the present study was to investigate the role of LC purinergic neuromodulation of ventilatory and cardiovascular responses in normocapnic and hypercapnic conditions in unanaesthetized male Wistar rats. We assessed the purinergic modulation of cardiorespiratory systems by microinjecting an ATP P2X receptor agonist [,-methylene ATP (,-meATP), 0.5 or 1 nmol in 40 nl] and two non-selective P2 receptor antagonists [pyridoxalphosphate-6-azophenyl-2,4-disulfonic acid (PPADS), 0.5 or 1 nmol in 40 nl; and suramin, 1 nmol in 40 nl] into the LC. Pulmonary ventilation (measured by plethysmography), mean arterial pressure (MAP) and heart rate (HR) were determined before and after unilateral microinjection (40 nl) of ,-meATP, PPADS, suramin or 0.9% saline (vehicle) into the LC. These measurements were made during a 60 min exposure to normocapnic conditions or a 30 min exposure to 7% CO2. Subsequently, animals undergoing pharmacological treatment were subjected to a 30 min exposure to normocapnic conditions as a recovery period. In normocapnic conditions, ,-meATP did not affect any parameter, whereas PPADS decreased respiratory frequency and increased MAP and HR. Suramin increased MAP and HR but did not change ventilation. Moreover, hypercapnic conditions induced an increase in ventilation and a decrease in HR in all groups. In hypercapnic conditions, ,-meATP increased ventilation but did not change cardiovascular parameters, whereas PPADS increased MAP but did not alter ventilation, and suramin increased both ventilation and MAP. Thus, our data suggest that purinergic signalling, specifically through P2 receptors, in the LC plays an important role in cardiorespiratory control in normocapnic and hypercapnic conditions in unanaesthetized rats.Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq

The Locus Coeruleus and Central Chemosensitivity

The locus coeruleus (LC) lies in the dorsal pons and supplies noradrenergic (NA) input to many regions of the brain, including respiratory control areas. The LC may provide tonic input for basal respiratory drive and is involved in central chemosensitivity since focal acidosis of the region stimulates ventilation and ablation reduces CO2-induced increased ventilation. The output of LC is modulated by both serotonergic and glutamatergic inputs. A large percentage of LC neurons are intrinsically activated by hypercapnia. This percentage and the magnitude of their response are highest in young neonates and decrease dramatically after postnatal day P10. The cellular bases for intrinsic chemosensitivity of LC neurons are comprised of multiple factors, primary among them being reduced extracellular and intracellular pH, which inhibit inwardly rectifying and voltage-gated K+ channels, and activate L-type Ca2+ channels. Activation of KCa channels in LC neurons may limit their ultimate response to hypercapnia. Finally, the LC mediates central chemosensitivity and contains pH-sensitive neurons in amphibians, suggesting that the LC has a long-standing phylogenetic role in respiratory control

The Locus Coeruleus and Central Chemosensitivity

The locus coeruleus (LC) lies in the dorsal pons and supplies noradrenergic (NA) input to many regions of the brain, including respiratory control areas. The LC may provide tonic input for basal respiratory drive and is involved in central chemosensitivity since focal acidosis of the region stimulates ventilation and ablation reduces CO2-induced increased ventilation. The output of LC is modulated by both serotonergic and glutamatergic inputs. A large percentage of LC neurons are intrinsically activated by hypercapnia. This percentage and the magnitude of their response are highest in young neonates and decrease dramatically after postnatal day P10. The cellular bases for intrinsic chemosensitivity of LC neurons are comprised of multiple factors, primary among them being reduced extracellular and intracellular pH, which inhibit inwardly rectifying and voltage-gated K+ channels, and activate L-type Ca2+ channels. Activation of KCa channels in LC neurons may limit their ultimate response to hypercapnia. Finally, the LC mediates central chemosensitivity and contains pH-sensitive neurons in amphibians, suggesting that the LC has a long-standing phylogenetic role in respiratory control

Brain monoaminergic neurons and ventilatory control in vertebrates

Monoamines (noradrenaline (NA), adrenaline (AD), dopamine (DA) and serotonin (5-HT) are key neurotransmitters that are implicated in multiple physiological and pathological brain mechanisms, including control of respiration. The monoaminergic system is known to be widely distributed in the animal kingdom, which indicates a considerable degree of phylogenetic conservation of this system amongst vertebrates. Substantial progress has been made in uncovering the participation of the brain monoamines in the breathing regulation of mammals, since they are involved in the maturation of the respiratory network as well as in the modulation of its intrinsic and synaptic properties. On the other hand, for the non-mammalian vertebrates, most of the knowledge of central monoaminergic modulation in respiratory control, which is actually very little, has emerged from studies using anuran amphibians. This article reviews the available data on the role of brain monoaminergic systems in the control of ventilation in terrestrial vertebrates. Emphasis is given to the comparative aspects of the brain noradrenergic, adrenergic, dopaminergic and serotonergic neuronal groups in breathing regulation, after first briefly considering the distribution of monoaminergic neurons in the vertebrate brain. (C) 2008 Elsevier B.V. All rights reserved.Fundacao de Amparo a Pesquisa do Estado de Sao Paulo (FAPESP)Conselho Nacional de Desenvolvimento Cientifico e Tecnologico (CNPq