Preâmbulo ao manual: O exercício, a prática regular da atividade física, a recreação, o lazer e o desporto têm-se revelado, nos últimos tempos, como excelentes e poderosos instrumentos para a reabilitação, a inclusão social e consciencialização da sociedade para o acesso e a participação cívica e ativa das pessoas com paralisia cerebral. Verifica-se que as pessoas com paralisia cerebral tendem a ter estilos de vida menos ativos que as pessoas sem deficiência e, por consequência, a serem menos saudáveis, terem menos bem-estar e qualidade de vida. Contribuem para esta situação a existência de diversos tipos de condicionantes, das quais destacamos as atitudes negativas e a falta de programas estruturados de exercício e desporto facilitadores da sua participação com os outros na comunidade e que respondam às suas necessidades específicas6-7. O presente manual visa contribuir para a alteração desta situação, fornecendo aos profissionais de exercício e de desporto informação pertinente para a existência de uma prescrição e o desenvolvimento de programas mais eficazes para as pessoas com paralisia cerebral, envolvendo a família, e criando mais oportunidades de participação na atividade física seja ela formal ou informal, de âmbito recreativo, lazer ou desportivo, em contexto familiar, comunitário ou institucional. Leonor Moniz Pereira

Proton density (PD) and diffusion tensor imaging (DTI) are imaging techniques that enable the acquisition of data from living subjects that can be used in the fine-tuning of subject-specific models’ architectural parameters. The aim of this study was to determine the in vivo 3D architectural parameters (volume, pennation angle, fiber length and physiological cross-sectional area) of the gastrocnemius medialis, gastrocnemius lateralis, soleus and tibialis anterior muscles using proton density and diffusion tensor imaging data before and after an exhaustive one-legged jump exercise. These methods were used in the in vivo 3D data acquisition of six young and physically active female subjects’ lower legs, followed by a fiber-tracking algorithm and analysis tools. No significant differences were found in the muscles’ architecture after the exercise, with the following exceptions: the anatomical cross-section area of the gastrocnemius medialis increased (p-value 0.001, effect size 0.18) after exercise; the fiber lengths of the gastrocnemius medialis, lateralis and soleus muscles were higher after exercise (p-value 0.002, 0.001 and 0.001, respectively, and effect size 2.03, 1.29 and 0.85, respectively); and the soleus mean pennation angle decreased after exercise (p-value 0.0015, effect size 2.31). These changes (or lack thereof) could be attributed to the extended acquisition time of the MRI scans to minimize noise: by increasing the acquisition time, the effect of the exercise may have been partially lost due to muscle recovery.

A major concern of Biomechanics research is the evaluation of the mechanical load and power that the human body develops and endorses when performing high to moderate sport activities. With the purpose of increasing performance and reducing the risk of injury, substantial advances were accomplished to pursuit this goal, either on the laboratory techniques as well as modelling and simulation. Traditionally, the main focus was the assessment of kinematics, kinetics and electromyography data to describe the main mechanics and neuromuscular behaviour, when performing a certain movement. The use of methodologies that enable the quantification of the effect of a particular joint moment of force in the entire body or the contribution of an individual muscle force to accelerate the centre of mass of the body is quite relevant in biomechanical analysis. This is particularly important when dealing with explosive movements such as those that occur in sports activities, or in the clinical field when dealing with abnormal movement. At the same time, the advances in imaging technology allows us the use of some of those techniques to gather subject-specific information, particularly the muscle architectural parameters that are crucial to the production of force, such as muscle volume, muscle physiological cross-section area and muscle pennation angle. In the course of this dissertation, we investigated the use and/or combination of different methodologies to study the effect of mechanical load in the lower limb musculoskeletal system during a cyclic stretch-shortening exercise. We aimed at using an integrated approach to better characterize the behaviour of the musculoskeletal system when subjected to this type of mechanical load.

Introduction: The ankle-foot orthosis is the most common non-invasive therapeutic intervention used to correct gait deviations, especially in children with Cerebral Palsy (CP). Several studies demonstrated that its use improved spatio-temporal and kinematic outcomes. However, biomechanical reports can be complex and may need experience to correctly interpret the results. Gait deviation indices, such as the Gait Profile Score (GPS) intend to summarize some clinically meaningful parameters and clarify in which way an ankle-foot orthosis impacts gait in children with CP. Research question: The aim of this study was to assess if GPS reflects the effect of AFO use on a sample of children with CP while walking.

Background: Cerebral Palsy is a complex pathology that describes a group of motor disorders with different presentations and functional levels. Three-dimensional gait analysis is used in the assessment of CP children to assist in clinical decision-making and assessing outcomes in the rehabilitation process. Due to the CP intra-subject gait variability, it’s crucial to access the repeated gait measurements to evaluate the response to therapeutic interventions in the rehabilitation process. Aim of the study: The objective of this study was to determine the intra-subject measurement reliabilities of the kinematic parameters of children with hemiplegic and diplegic types of cerebral palsy.

Cerebral palsy (CP) is a common cause of motor disability, and pedobarography is a useful, non-invasive, portable, and accessible tool; it is easy to use in a clinical setting; and can provide plenty of information about a foot–soil interaction and gait deviations. The reliability of this method in children with CP is lacking. The aim of this study is to investigate test-retest reliability and minimal detectable change (MDC) of plantar pressure insole variables in children with CP. Eight children performed two trials 8 ± 2.5 days apart, using foot insoles to collect plantar pressure data. Whole and segmented foot measurements were analyzed using intraclass correlation coefficients (ICC). The variability of the data was measured by calculating the standard error of measurement (SEM) and the MDC/ICC values demonstrated high test-retest reliability for most variables, ranging from good to excellent (ICC ≥ 0.60). The SEM and the MDC values were considered low for the different variables. The variability observed between sessions may be attributed to the heterogeneous sub-diagnosis of CP.

Background: Cerebral palsy (CP) is a complex pathology that describes a group of motor disorders with different presentations and functional levels. Three-dimensional gait analysis is widely used in the assessment of CP children to assist in clinical decision-making. Thus, it is crucial to assess the repeatability of gait measurements to evaluate the progress of the rehabilitation process. The purpose of the study is to evaluate the test-retest reliability of a six-degree-of-freedom (6DoF) marker set in key points of gait kinematics, kinetics, and time-distance parameters in children with CP. Methods: trials were performed on two different days within a period of 7.5 ± 1.4 days. Motion capture data was collected with 14 infrared, high-speed cameras at a frequency rate of 100 Hz, synchronized in time and space with two force plates. Intraclass correlation coefficients considering the two-way mixed model, and absolute agreement (ICC[A,k]) were calculated for anthropometric, time–distance, kinematic and kinetic parameters of both lower limbs. Results: the majority of gait parameters demonstrated a good ICC, and the lowest values were in the kinematic variables. Conclusions: This study indicates wide-ranging reliability values for lower limb joint angles and joint moments of force during gait, especially for frontal and transverse planes. Although the use of a 6DoF-CAST in CP children was shown to be a feasible method, the gait variation that can be observed between sessions in CP children seems to be related not only to the extrinsic factors but also to their different gait patterns and affected sides.

Diastasis recti abdominis (DRA) or increased inter-rectus distance (IRD) is characterized by the separation of the rectus abdominis muscles. It has its onset during pregnancy and the first weeks following childbirth. The reliability of the instruments used to assess this condition is unclear. There is scant knowledge on the prevalence and risk factors for development of the condition. There is little evidence on which exercises are most effective in reduction of DRA. The aims of our studies were to establish a reliable method for the assessment of the morphology of the abdominal wall, describe DRA prevalence, risk factors, and evaluate the acute response on the IRD induced by drawing-in and abdominal crunch exercises. The results of three methodological studies showed ultrasound imaging to be a reliable method for measuring IRD. The ultrasound transducer can be held relatively stationary in a clinical setting, to evaluate IRD. DRA is prevalent at 6 months postpartum, with a prevalence rate of 39%. The acute response on IRD produced by drawing-in exercise was a widening of the IRD in postpartum, while the abdominal crunch exercise induced an acute narrowing response of the IRD in pregnancy and in postpartum.

Background: Cerebral palsy (CP) is the most common cause of motor disability in children and can cause severe gait deviations. The sagittal gait patterns classification for children with bilateral CP is an important guideline for the planning of the rehabilitation process. Ankle foot orthoses should improve the biomechanical parameters of pathological gait in the sagittal plane. Methods: A systematic search of the literature was conducted to identify randomized controlled trials (RCT) and controlled clinical trials (CCT) which measured the effect of ankle-foot orthoses (AFO) on the gait of children with spastic bilateral CP, with kinetic, kinematic, and functional outcomes. Five databases (Pubmed, Scopus, ISI Web of SCIENCE, SciELO, and Cochrane Library) were searched before February 2020. The PEDro score was used to assess the methodological quality of the selected studies and alignment with the Cochrane approach was also reviewed. Prospero registration number: CRD42018102670. Results: We included 10 studies considering a total of 285 children with spastic bilateral CP. None of the studies had a PEDro score below 4/10, including five RCTs. We identified five different types of AFO (solid; dynamic; hinged; ground reaction; posterior leaf spring) used across all studies. Only two studies referred to a classification for gait patterns. Across the different outcomes, significant differences were found in walking speed, stride length and cadence, range of motion, ground force reaction and joint moments, as well as functional scores, while wearing AFO. Conclusions: Overall, the use of AFO in children with spastic bilateral CP minimizes the impact of pathological gait, consistently improving some kinematic, kinetic, and spatial-temporal parameters, and making their gait closer to that of typically developing children. Creating a standardized protocol for future studies involving AFO would facilitate the reporting of new scientific data and help clinicians use their clinical reasoning skills to recommend the best AFO for their patients.

Peripheral nerve injury remains a clinical challenge with severe physiological and functional consequences. Despite the existence of multiple possible therapeutic approaches, until now, there is no consensus regarding the advantages of each option or the best methodology in promoting nerve regeneration. Regenerative medicine is a promise to overcome this medical limitation, and in this work, chitosan nerve guide conduits and olfactory mucosa mesenchymal stem/stromal cells were applied in different therapeutic combinations to promote regeneration in sciatic nerves after neurotmesis injury. Over 20 weeks, the intervened animals were subjected to a regular functional assessment (determination of motor performance, nociception, and sciatic indexes), and after this period, they were evaluated kinematically and the sciatic nerves and cranial tibial muscles were evaluated stereologically and histomorphometrically, respectively. The results obtained allowed confirming the beneficial effects of using these therapeutic approaches. The use of chitosan NGCs and cells resulted in better motor performance, better sciatic indexes, and lower gait dysfunction after 20 weeks. The use of only NGGs demonstrated better nociceptive recoveries. The stereological evaluation of the sciatic nerve revealed identical values in the different parameters for all therapeutic groups. In the muscle histomorphometric evaluation, the groups treated with NGCs and cells showed results close to those of the group that received traditional sutures, the one with the best final values. The therapeutic combinations studied show promising outcomes and should be the target of new future works to overcome some irregularities found in the results and establish the combination of nerve guidance conduits and olfactory mucosa mesenchymal stem/stromal cells as viable options in the treatment of peripheral nerves after injury.