A esquizofrenia é uma das 25 principais causas de incapacidade em todo o mundo. Indivíduos que desenvolvem a doença apresentam prejuízos cognitivos relevantes ao longo vida. A combinação de tratamentos farmacológico e psicossocial é eficaz na melhora das dimensões psicopatológicas da esquizofrenia, porém a maioria dos pacientes apresenta importantes déficits cognitivos, principalmente em funções executivas (FE) com impacto na funcionalidade, impossibilitando uma vida independente. O método Occupational Goal Intervention (OGI) é eficaz na melhora de FE, porém não foi testado em pacientes com esquizofrenia resistente (ER). Realizamos estudo piloto cujos resultados foram descritos na dissertação de mestrado e publicados no periódico Psychiatry Research. O presente trabalho inclui o estudo completo com follow-up de 6 meses. Objetivos: Trata-se de um ensaio clínico comparando a intervenção de Terapia Ocupacional (TO), baseada no método OGI para a reabilitação de FE, com um grupo-controle de indivíduos com ER. Método: O estudo desenvolveu-se em 3 tempos: baseline, pós-tratamento e follow-up. Cinquenta e quatro pacientes com diagnóstico de ER foram randomizados e distribuídos em dois grupos: experimental e controle (placebo). O grupo experimental recebeu 30 sessões de TO com o método OGI e o grupo controle (GC) recebeu 30 sessões de atividades artesanais de livre escolha, sem intervenção ativa do terapeuta (placebo). As medidas de desfecho primário foram avaliadas pela BADS, e as de desfecho secundário pela DAFS-BR e ILSS-BR O impacto sobre a cognição foi avaliado por uma bateria neuropsicológica padrão, que mediu as seguintes funções: atenção, fluência verbal, FE, memória e o QI estimado. As escalas PANSS e o CGI foram utilizadas para monitorar a gravidade dos sintomas psicopatológicos. A eficácia foi avaliada nos três tempos do estudo por meio da análise linear de efeitos mistos e obtido o tamanho de efeito por meio d de Cohen. Resultados: Observou-se melhora significativa com tamanhos de efeito de médios a altos na BADS total (d=0,73), com pequena redução no follow-up (d=0,69).Na DAFS-BR total os tamanhos de efeito foram médios (d=0,58) porém não se sustentou no follow-up (d=0,39). Os resultados de tamanhos de efeito na ILSS-BR total foi alto (d=1,09) e com aumento de melhora clínica no follow-up (d=1,19). Não foram observadas mudanças nas funções cognitivas avaliadas pela bateria neuropsicológica. Conclusão: o método OGI mostrou-se eficaz na melhora da maioria das FE relacionadas à capacidade de controle inibitório, planejamento, resolução de problemas e flexibilidade mental de pacientes com ER quando comparado ao placebo, melhora esta que foi mantida 6 meses de seguimento / Schizophrenia is one of the top 25 causes of disability worldwide. Individuals who develop the disease have relevant cognitive impairments over a long period of time. The combination of pharmacological and psychosocial treatments is effective in improving the psychopathological dimensions of schizophrenia, but the majority of patients present significant cognitive deficits, especially in executive functions (EF) with an impact on functionality, making life independent. The Occupational Goal Intervention (OGI) method is effective in improving EF but has not been tested in patients with resistant schizophrenia (RE). We conducted a pilot study whose results were described in the master\'s thesis and published in the journal Psychiatry Research. The present study includes the complete 6-month follow-up study. Objectives: This is a clinical trial comparing Occupational Therapy (OT), based on the OGI method for the rehabilitation of EF, with a control group of individuals with RE. Method: The study was developed in 3 stages: baseline, post-treatment, and follow-up. Fifty-four patients diagnosed with RE were randomized and divided into two groups: experimental and control (placebo). The experimental group received 30 OT sessions with the OGI method and the control group received 30 sessions of free-choice craft activities without active therapist intervention (placebo). Primary outcome measures were evaluated by the BADS and secondary endpoints by DAFS-BR and ILSS-BR. The impact on cognition was assessed by a standard neuropsychological battery, which measured the following functions: attention, verbal fluency, EF, memory, and estimated IQ. PANSS scales and CGI were used to monitor the severity of psychopathological symptoms. Efficacy was assessed in the three study times by means of the linear analysis of mixed effects and the effect size obtained by means d of Cohen. Results: A significant improvement was observed with mean to high effect sizes in the total BADS (d = 0.73), with a small reduction in follow-up (d = 0.69). In DAFS-BR total effect sizes were medium (d = 0.58) but did not sustained at the follow-up (d = 0.39). The results of effect sizes in the total ILSS-BR were high (d = 1.09) and with an increase in clinical followup at follow-up (d = 1.19). No changes were observed in the cognitive functions evaluated by the neuropsychological battery. Conclusion: the OGI method proved to be effective in improving the majority of EF related to inhibitory control capacity, planning, problem-solving, and mental flexibility of RE patients when compared to placebo, which was maintained 6 months after follow-up

O estudo teve como objetivo geral investigar a vida cotidiana das pessoas em sofrimento psíquico dos CAPS II do ponto de vista das áreas ocupacionais de autocuidado, de produtividade e de lazer. Este estudo foi composto pelas amostras de quarenta participantes: vinte usuários e um familiar de cada usuário de serviços de saúde mental, denominados de Centros de Atenção Psicossocial do tipo II do Departamento/Direção Regional de Saúde de Piracicaba (DRS-X). Dessa forma, configura-se como uma pesquisa descritiva, exploratória, de natureza qualiquantitativa com predominância na abordagem qualitativa. Como fundamentação teórica de suporte para o desenvolvimento da pesquisa, foi utilizado como base o referencial da Reabilitação Psicossocial e o referencial filosófico da Teoria sobre o Cotidiano de Agnes Heller. A partir dessa ótica, emergiram três eixos temáticos referentes às áreas ocupacionais do autocuidado, produtividade e lazer, que foram analisados por meio do Discurso do Sujeito Coletivo (DSC), que é uma abordagem proposta por Lefèvre e Lefèvre, a fim de auxiliar na análise das entrevistas semiestruturadas dos dados. Verificou-se, a partir dos DSCs, que se exige a necessidade urgente de uma reestruturação dos CAPS II e um novo direcionamento para a forma do cuidado em saúde mental. Foi possível comprovar que, de fato, as áreas ocupacionais de autocuidado, produtivas e de lazer dos usuários dos CAPS II ainda são pouco estimuladas por familiares e profissionais dos próprios serviços, necessitando, assim, de uma transformação e um novo olhar para o cuidado em saúde mental. De modo geral, os usuários experienciam o sofrimento psíquico em idade produtiva, apresentando dificuldades para se relacionar com outras pessoas e dar sequência em seus estudos. Têm dificuldades para se manter em empregos formais e, em sua maioria, necessitam do auxílio de familiares para a realização de diferentes atividades cotidianas, fator esse que implica o empoderamento de sua autonomia. Ainda há uma urgente necessidade de ampliação de espaços territoriais para que esses usuários possam ser reinseridos no contexto social. A interface entre o conhecimento científico e empírico permitiu uma aproximação com os usuários e seus familiares, a partir de seus discursos, reforçando ser esse um campo fértil para reflexões das práticas em saúde mental, por meio das relações humanas. No entanto, esta pesquisa oferece contribuições e informações úteis para a (re)organização de ações e políticas de saúde mental e até mesmo políticas públicas, pois a forma como as pessoas compreendem a vida cotidiana dos usuários em sofrimento psíquico propicia a identificação de elementos que podem orientar a busca de intervenções e ações no cuidado em saúde mental, contribuindo, assim, para a consolidação da reforma psiquiátrica / The study aimed to investigate the daily lives of people in psychological distress CAPS II from the standpoint of occupational areas of self-care, productivity and leisure. This study was composed of samples of forty participants: twenty members and a relative of each user of mental health services, called Psychosocial Care Centers Type II Department/Health Regional Directorate of Piracicaba (DRS-X). Thus, it appears as a descriptive, exploratory, qualitative-quantitative nature of the predominantly qualitative approach. As theoretical foundation of support for the development of research, was used as a basis the framework of Psychosocial Rehabilitation and the philosophical framework of the Theory of Daily Life of Agnes Heller. From this perspective, they emerged three themes relating to occupational areas of self-care, productivity and leisure, which were analyzed using the Collective Subject Discourse (CSD), which is an approach proposed by Lefèvre and Lefèvre, in order to assist in the analysis of semi-structured interviews the data. It was, from DSCs, which requires the urgent need for a restructuring of CAPS II and a new direction for the shape of mental health care. It was possible to prove that, in fact, occupational areas of self-care, productive and recreational users of CAPS II are still not encouraged by family and work of the service, requiring thus a transformation and a new look for care in mental health. In general, users experience psychological distress in productive age, presenting difficulties to relate to others and to follow up on their studies. They have difficulties to keep in formal jobs and, in most cases, require the assistance of family members to perform different daily activities, this factor which involves the empowerment of autonomy. There is still an urgent need for expansion of territorial spaces so that these users can be reintegrated in the social context. The interface between the scientific and empirical knowledge allowed close to the users and their families, from their discourse, reinforcing that this is a fertile ground for reflections of mental health practices through human relations. However, this research offers contributions and useful information for the new organization of actions and mental health policies and even public policy because the way people understand the daily life of psychological distress in users provides the identification elements can guide the search for interventions and actions in mental health care, thus contributing to the consolidation of the psychiatric reform

Introdução: O declínio cognitivo representa uma das principais causas de comprometimento funcional e da qualidade de vida do idoso. A busca por preditores de alterações cognitivas precoces ao diagnóstico de demência tem despertado cada vez mais o interesse dos pesquisadores. Tem-se como hipótese que menor desempenho de Atividades Avançadas de Vida Diária (AAVD) poderia ser marcador de declínio cognitivo futuro. As AAVD reúnem as atividades sociais, produtivas e de lazer, e estariam relacionadas ao topo da hierarquia da complexidade das atividades cotidianas, com melhores níveis funcionais e cognitivos. Objetivo: Analisar a associação entre o desempenho de atividades avançadas de vida diária por idosos paulistanos e a incidência de declínio cognitivo. Métodos: Estudo longitudinal com uma amostra de idosos não institucionalizados que participaram da segunda (2006) e terceira (2010) ondas do estudo de múltiplas coortes Saúde, Bem estar e Envelhecimento em São Paulo, Brasil. A amostra final contou com 819 idosos. O declínio cognitivo foi avaliado com o Miniexame do Estado mental abreviado. Foram consideradas 12 AAVD. Outras covariáveis abordaram as condições sociodemográficas, saúde, estilo de vida e incapacidade funcional dos participantes no início do seguimento. A análise estatística incluiu frequência, análises bivariadas e multivariadas, com o uso de Regressão Logística. O programa Stata 12.0 foi utilizado para a análise e a correção para os efeitos do desenho do estudo foi feita pelo comando survey para analisar os dados originados de uma amostra complexa. Resultados: Após quatro anos de seguimento a incidência de declínio cognitivo foi de 7.9 por cento . A análise múltipla evidenciou que os indivíduos com maior número de AAVD no início do estudo apresentavam menor risco de declínio cognitivo ao final do seguimento OR 0.83 [0.71; 0.96]. Outras características foram associadas à incidência de declínio cognitivo no modelo final: 75 anos e mais OR 4.54 [IC 2.52; 8.17], possuir dificuldades nas atividades instrumentais e básicas de vida diária OR 2.54 [1.32; 4.87]. Possuir 8 anos e mais de estudo mostrou-se como fator protetor ao declínio cognitivo OR 0.16 [IC 0.05; 0.52] Conclusões: O desempenho de maior número de AAVD mostrou-se como fator protetor à incidência de declínio cognitivo, independentemente de condições sociodemográficas, condições gerais de saúde, funcionalidade e estilo de vida. / Introduction: Cognitive decline is one of the major causes of impairment of function and quality of life of the elderly. The search for prevention and of early diagnosis of cognitive impairment has attracted increasing interest from researchers. It has been hypothesized that lower performance on Advanced Activities of Daily Living (AADL) could be a marker of future cognitive decline. The AADL cluster the social, productive and leisure activities, and are related to the top of the hierarchy of the daily activities complexity, with better functional and cognitive levels. Objective: Examine the association between the performance of advanced activities of daily living for elderly from São Paulo and the incidence of cognitive impairment. Methods: Longitudinal study with a sample of non-institutionalized elderly who attended the second (2006) and third (2010) waves of the SABE cohort study in São Paulo, Brazil. The final sample consisted of 819 elderly. Cognitive decline was assessed with the Mini-Mental State abridged. 12 AADL were considered. Other covariates have addressed the sociodemographic conditions, health, life style and functional disability of the participants at baseline. The statistical analysis included frequency, bivariate and multivariate analyzes, using logistic regression. Stata 12.0 software was used for the analysis and correction for the effects of study design was done by the \"survey\" command to analyze the data obtained from a complex sample. Results: After four years of follow-up the incidence of cognitive impairment was 7.9 per cent . Multiple regression analysis showed that individuals with the highest number of AADL at baseline had a lower risk of cognitive impairment at the end of follow-up OR 0.83 [0.71; 0.96]. Other variables were associated with incidence of cognitive impairment in the final model: 75 years and over OR 4:54 [2:52 IC; 8:17], difficulties in instrumental and basic activities of daily living OR 2:54 [1:32; 4.87]. To have 8 years and more of study OR 0.16 [IC 0.05; 0.52] was a protective factor of cognitive decline. Conclusions: The performance of a larger number of AADL appeared as a protective factor to the incidence of cognitive impairment, regardless of sociodemographic conditions, general health status and functionality.

INTRODUÇÃO: Embora os quadros demenciais sejam caracterizados, principalmente, por comprometimentos cognitivos e funcionais, muitos pacientes apresentam alterações comportamentais ou sintomas neuropsiquiátricos (SNPs) em alguma fase de sua história clínica. De acordo com a literatura atual, os SNPs são muito frequentes, podendo ocorrer em até 90% dos casos de demência. Dentre os SNPs mais comuns, estão incluídos: agressividade, apatia, agitação, perambulação, desinibição, ansiedade, humor deprimido e sintomas psicóticos (alucinações e delírios). Diretrizes internacionais têm sugerido que os tratamentos não-farmacológicos devem ser a primeira opção na abordagem dos SNPs. Recentemente, os estudos têm mostrado que as intervenções não-farmacológicas são tão eficazes quanto os tratamentos farmacológicos, no entanto, sem ocasionar os efeitos colaterais e riscos das medicações. Uma abordagem não-farmacológica promissora é o uso de atividades. Um método de Terapia Ocupacional, denominado Tailored Activity Program (TAP - Programa Personalizado de Atividades - versão domiciliar) foi desenvolvido com o objetivo de reduzir e prevenir SNPs em idosos com demência moderada a grave e, de acordo com os estudos, tem se mostrado eficaz. No Brasil, existem poucos estudos sobre abordagens nãofarmacológicas no tratamento de SNPs em indivíduos com demência. OBJETIVOS: Realizar a tradução e adaptação transcultural do método TAP para a língua portuguesa, bem como sua adequação para o uso ambulatorial. Avaliar a eficácia do método TAP (versão ambulatorial brasileira) no tratamento de SNPs de indivíduos com demência moderada a grave e na redução da sobrecarga dos seus cuidadores. MÉTODO: Trata-se de um ensaio clínico aleatorizado, controlado, duplamente encoberto, para o tratamento de SNPs em idosos com demência moderada a grave, através da versão traduzida e adaptada do método TAP para uso ambulatorial. O grupo experimental recebeu oito sessões baseadas no método TAP, em regime ambulatorial, e o grupo controle recebeu oito sessões baseadas em um programa psicoeducativo com orientações sobre demência. As medidas de desfecho consistiram na avaliação de SNPs dos indivíduos com demência, por meio do The Neuropsychiatric Inventory-Clinician rating scale (NPI-C), e da avaliação da sobrecarga dos seus cuidadores, por meio da Escala Zarit. Todos os participantes foram avaliados nos momentos pré (T0) e pós-intervenção (T1). RESULTADOS: Foram incluídos 54 indivíduos com demência, que foram alocados para as condições experimental (n= 28) e controle (n= 26). Observou-se melhora estatisticamente significante no grupo experimental nos seguintes SNPs: delírios (p=0,05), agitação (p=0,001), agressividade (p=0,007), depressão (p=0,008), ansiedade (p=0,006), euforia (p=0,007), apatia (p=0,02), desinibição (p=0,03), irritabilidade (p=0,03), distúrbio motor (p=0,007) e vocalizações aberrantes (p=0,03). Por sua vez, não foi observada melhora nos seguintes SNPs: alucinações (p=0,06), distúrbios do sono (p=0,06) e distúrbios do apetite (p=0,5). O método TAP para uso ambulatorial também se mostrou clinicamente eficaz na redução da sobrecarga nos cuidadores do grupo experimental (p=0,01). CONCLUSÃO: Este ensaio clínico é o primeiro estudo controlado sobre a eficácia de uma intervenção de Terapia Ocupacional baseada na versão ambulatorial do método TAP para aliviar os SNPs em pacientes com demência moderada a grave. Os resultados mostraram que o uso de atividades prescritas de maneira personalizada, aliada ao treinamento do cuidador, pode ser uma abordagem clinicamente eficaz na redução de SNPs e da sobrecarga de cuidadores de indivíduos com demência / INTRODUCTION: Although dementia is characterized mainly by cognitive and functional deficits, many patients present behavioral changes or neuropsychiatric symptoms (NPS) at some stage of their clinical evolution. According to the current literature, NPS are very frequent and may occur in up to 90% of dementia cases. The most common NPS are aggression, apathy, agitation, wandering, disinhibition, anxiety, depressed mood and psychotic symptoms (hallucinations and delusions). International guidelines have suggested that non-pharmacological treatments should be the first option in clinical approaching to NPS. Recently, studies have shown that nonpharmacological interventions are as effective as pharmacological treatments, however without the side effects and risks of medications. A promising nonpharmacological approach is the use of activities. An Occupational Therapy method, called Tailored Activity Program (TAP), was developed with the objective of reducing and preventing NPS in the elderly with moderate to severe dementia and, according to published studies, has shown to be effective. In Brazil, there are few studies on non-pharmacological approaches in the treatment of NPSs in individuals with dementia. OBJECTIVES: To perform the translation and transcultural adaptation of the TAP method to Brazilian Portuguese, as well as its adequacy for outpatient use. To evaluate the efficacy of the TAP (Brazilian outpatient version) method in the treatment of NPS in individuals with moderate to severe dementia and in the burden reduction of their caregivers. METHOD: This is a randomized, double-blind, controlled clinical trial for the treatment of NPS in elderly with moderate to severe dementia., using the transcultural translation and adaptation of the outpatient TAP method. The experimental group received eight sessions based on the TAP method, on an outpatient basis, and the control group received eight sessions based on a psychoeducational program with orientations about dementia. Outcome measures consisted of assessing the NPS of individuals with dementia, through the Neuropsychiatric Inventory-Clinician rating scale (NPI-C), and assessing the burden on their caregivers, using the Zarit Scale. All the participants were evaluated at pre (T0) and post-intervention (T1). RESULTS: We included 54 individuals with dementia, who were allocated to the experimental (n=28) and control (n=26) groups. There was improvement of the following NPS in the experimental group: delusions (p=0.05), agitation (p=0.001), aggressiveness (p=0.007), depression (p=0.008), anxiety (p=0.006), euphoria (p=0.007), apathy (p=0.02), disinhibition (p=0.03), irritability (p=0.03), motor disturbance (p=0.007) and aberrant vocalization (p=0.03). No improvement was observed in the following NPS: hallucinations (p=0.06), sleep disturbances (p=0.06) and appetite disorders (p=0.5). The TAP method for outpatient use was also clinically effective in reducing burden in the caregivers of the experimental group (p=0.01). CONCLUSION: This clinical trial is the first controlled study of the efficacy of an Occupational Therapy intervention based on the outpatient version of the TAP method to relieve NPS in patients with moderate to severe dementia. The results showed that the use of personalized prescribed activities, coupled with the caregiver training, may be a clinically effective approach to reduce NPS and caregiver burden of individuals with dementia

Introdução. Incapacidade funcional está relacionada à dificuldade em realizar as atividades de vida diária de forma independente comprometendo sobremaneira a qualidade de vida da pessoa idosa. Requer adaptação do idoso, reorganização familiar e, muitas vezes, a presença de um cuidador. Reconhecer seu processo de instalação pode auxiliar no estabelecimento de medidas preventivas e adequação dos serviços sociais e de saúde. Objetivo: Construir escala hierárquica de dificuldades referidas no desempenho funcional de AVDs (incapacidades) em uma população de idosos do Município de São Paulo. Metodologia: Utilizando-se o método de escalonamento de Guttman, foram desenvolvidas escalas hierárquicas de incapacidades com a população idosa do Município de São Paulo utilizando a base de dados do Estudo SABE. Com a base de dados de 2000 a escala foi comparada à outra construída aproximadamente dez anos antes buscando verificar mudanças ocorridas no período e, com a base de dados de 2006 foi construída uma escala hierárquica da incidência de incapacidades nesse grupo onde foi aplicada uma escala de escores para classificação do nível funcional. Resultados: Verificou-se que a proporção de incapacidades aumentou em um período de dez anos. Para o seguimento de 2006 encontrou-se a seguinte ordem hierárquica crescente de dificuldades: comer (5,7 por cento ), higiene pessoal (6,3 por cento ), usar o banheiro (7,2 por cento ), locomover-se (7,8 por cento ), tomar banho (10,1 por cento ), vestir a parte de cima da roupa (11,9 por cento ), ser continente (fecal) (13,8 por cento ), administrar as próprias finanças (20,3 por cento ), tomar o próprio medicamento (21,2 por cento ), mobilizar-se (22,8 por cento ), usar o telefone (24,2 por cento ), vestir a parte de baixo (25,6 por cento ), fazer compras (30,5 por cento ), ser continente (urinário)(40,5 por cento ) e utilizar transporte (43,8 por cento ). Nos dois períodos, percebeu-se que os homens apresentaram maiores proporções de incapacidades, apesar de as mulheres as acumularem mais e que as dificuldades aumentaram com o avançar da idade. Conclusões: Foram verificadas mudanças no padrão de instalação e aumento das proporções de incapacidade em quase uma década. A escala hierárquica possibilitou a determinação de níveis de incapacidade / Introduction: Functional disability is related to the difficulty to perform daily life activities independently, which seriously jeopardizes elderly peoples quality of life. It requires adaptation, family reorganization and, in many cases, the presence of a caregiver. Recognizing these needs may help establish prevention measures and adequacy to social and health care services. Objective: To build a hierarchy scale on the aforementioned difficulties in the functional performance of DLAs (disabilities) in a population of elderly people in the municipality of São Paulo. Methodology: By using Guttman scaling method, hierarchy scales of disabilities were developed with the elderly population of the municipality of São Paulo with the database of SABE Study. With the 2000 database at hand, the scale was compared to another one built nearly ten years earlier seeking to find changes occurred in this period and, with the 2006 database a hierarchy scale of the occurrence of disabilities was built for this group of people, where a scale of scores was applied to rank the functional level. Results: It was found that the proportion of disabilities increased in a ten-year period. For the 2006 segment, the study found the following order of increasing difficulty: eating (5.7 per cent ), personal hygiene (6.3 per cent ), using the toilet (7.2 per cent ), walking (7.8 per cent ), bathing (10.1 per cent ), dressing the top of clothing (11.9 per cent ), being able to keep their fecal continence (13.8 per cent ), managing their own finances (20.3 per cent ), taking their own medicine properly (21.2 per cent ), moving (22.8 per cent ), using the phone (24.2 per cent ), dressing the bottom of clothing (25.6 per cent ), shopping (30.5 per cent ), being able to keep their urinary continence (40.5 per cent ) and using means of transportation (43.8 per cent ). In both periods, men were reported to show greater proportions of disabilities, despite the fact that women accumulate more of them and that their difficulties grow as age progresses. Conclusions: Changes on the pattern of installation and an increase on the proportion of disabilities were found in the course of nearly a decade. The hierarchy scale allowed the determination of the levels of disability

Orientadores: Mary Angela Parpinelli, Rodolfo de Carvalho Pacagnella / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-11-09T13:12:49Z (GMT). No. of bitstreams: 1 Silveira_Carla_D.pdf: 15249519 bytes, checksum: e7a71ee5b4f10c300a70ac60a77915bf (MD5) Previous issue date: 2015 / Resumo: Introdução: A gravidez, parto e puerpério, com ou sem morbidades associadas, podem gerar consequências negativas sobre a saúde, a qualidade de vida e a funcionalidade das mulheres, a curto e a longo prazo. Pouco se sabe a respeito dessas consequências após as seis semanas de puerpério. A Organização Mundial de Saúde (OMS) criou um instrumento de avaliação de incapacidades (WHODAS 2.0) abrangendo as dimensões física, mental e social dos indivíduos, sendo expresso em seis domínios de vida: cognição, locomoção, autocuidado, relacionamento com as pessoas, atividades de vida, e participação. WHODAS 2.0 não estava adaptado e nem validado para o português do Brasil, e ainda não tinha sido utilizado em mulheres após uma gravidez e após episódio de morbidade materna grave (MMG). Objetivos: traduzir e adaptar o instrumento para o português do Brasil, realizar a análise de suas propriedades psicométricas em mulheres em idade reprodutiva, e a avaliação de seu desempenho em identificar as alterações de funcionalidade naquelas que tiveram algum episódio de MMG. Método: Realizou-se a adaptação transcultural a partir dos procedimentos de tradução do instrumento original para o português, seguida por retro tradução do português para o inglês. Constituiu-se então uma coorte de 638 mulheres que estiveram internadas durante o ciclo grávido-puerperal no Hospital da Mulher da Universidade Estadual de Campinas, no período de julho de 2008 a junho de 2012, e que responderam ao WHODAS 2.0. Foram estudadas variáveis sociodemográficas, obstétricas, neonatais e tempo transcorrido do evento de MMG. A consistência interna foi avaliada pelo ? de Cronbach, a estrutura por análise fatorial exploratória (EFA) e análise fatorial confirmatória (CFA), e as relações entre os domínios através do coeficiente de correlação de Pearson. Utilizando-se a mesma coorte de mulheres, divididas segundo o antecedente de MMG, analisaram-se as associações entre as médias e medianas dos escores do instrumento com as variáveis maternas e do recém-nascido. O teste de Mann-Whitney e a análise multivariada pelo modelo linear generalizado foram utilizados para os escores gerais e dos domínios específicos do instrumento. Resultados: Após o pré-teste, realizou-se adequação para o português mais coloquial e as versões mostraram-se semelhantes quanto ao significado geral e referencial. O ? de Cronbach foi superior a 0,79 para as mulheres que responderam 32 e 36 questões. As análises fatoriais, exploratória e confirmatória para 32 questões apresentaram, nos seis domínios, variância total de 54,7% (KMO 0,934 p<0.001) e de 53,47% (KMO 0.934 p< 0.001), respectivamente. O escore médio geral e dos domínios referentes a locomoção, atividades de vida e participação apresentaram aumento significativo nas mulheres com antecedente de MMG. Excluindo MMG, a paridade ? 2 foi a única variável associada com aumento do escore médio geral e para o domínio de relacionamento com as pessoas. Conclusões: o instrumento WHODAS 2.0, adaptado ao português do Brasil, mostrou-se de fácil aplicação e compreensão. Apresentou boas propriedades psicométricas, e identificou que a MMG e a maior paridade foram independentemente associadas com a redução da funcionalidade em mulheres após uma gravidez, e a longo prazo / Abstract: Introduction: Pregnancy, delivery and postpartum period, with or without associated morbidities, may generate negative consequences on the health, quality of life and functioning of women. Little is known on these consequences after six weeks of postpartum period. The World Health Organization Disability Assessment Schedule (WHODAS 2.0) was built to assess individuals in their physical, mental and social areas, expressed in six domains: cognition, mobility, self-care, relationships, getting along, life activities and social participation. WHODAS had not yet been adapted nor validated for the Brazilian Portuguese and was not yet used for women after a pregnancy and after an episode of severe maternal morbidity (SMM). Objectives: to translate and cross-culturally adapt the Brazilian Portuguese version of the instrument, to assess its psychometric properties and its performance among women in the reproductive period. Method: A cross-cultural adaptation was performed using procedures of translation of the original instrument into Portuguese, followed by a back translation into English. A cohort of 638 women who were admitted during pregnancy at the Women's Hospital of the University of Campinas from July 2008 to June 2012 was then settled and they answered the WHODAS 2.0. Socio demographic, obstetric and neonatal variables, plus the time elapsed from the SMM episode were reported. The internal consistency of the instrument was assessed with ? of Cronbach, its structure by exploratory factorial analysis (EFA) and confirmatory factorial analysis (CFA), and its content and the relationships among the domains were evaluated with the Pearson's correlation coefficient. Using the same cohort of women now split according to the past history of SMM, associations between means and medians of WHODAS scores with maternal, neonatal and the six domains variables were analyzed with Mann-Whitney test and multivariate analysis with generalized linear models. Results: After the pretest, an adequation to more colloquial Portuguese was performed in the instrument and this version showed to be similar regarding its general and referential meaning. The Cronbach' ? was higher than 0.79 for the 32 and 36 questions. The exploratory and confirmatory factorial analyses for the six domains, divided in seven factors showed a total variance of 54.7% (KMO 0.934 p<0.001) and of 53.47% (KMO 0.934 p< 0.001), respectively. The mean of WHODAS general score for the total sample and some domains showed significant increase for the group with morbidity. Except to the SMM, parity ? 2 was the only other significantly associated to higher scores. Conclusions: the WHODAS 2.0 instrument adapted to the Brazilian Portuguese showed to be easily applicable and understandable. It also showed to have good psychometric properties and identified that SMM and higher parity were independently associated with a long term functioning impairment among women after a pregnancy / Doutorado / Saúde Materna e Perinatal / Doutora em Ciências da Saúde

Objetivo: Caracterizar a adequação das ações do programa de controle da hanseníase no momento do pós-alta nos municípios de Sobral e Fortaleza, Ceará, no plano de políticas públicas, organização da rede de atenção à saúde, limitação funcional e de atividades e participação social das pessoas atingidas. Metodologia: Pesquisa transversal descritiva realizada no período de agosto de 2006 a setembro de 2007. Incluiu 304 residentes afetados pela hanseníase dos dois municípios uma amostra de 10% dos que receberam alta entre 2003 e 2005. Além da construção do cenário técnico-político do pós-alta, foram realizados nos participantes exame físico dermatoneurológico, avaliação simplificada das funções neurais, caracterização sociodemográfica, caracterização da limitação de atividade e consciência de risco e caracterização da restrição à participação social. Resultados: A população era em sua maioria masculina, parda, com baixas condições socioeconômicas e com profissões/ocupações que ampliavam a vulnerabilidade para incapacidades físicas. Aqueles com marcante progressão do grau de incapacidade física eram, em sua maioria, multibacilares (87% em Sobral; 62,6% em Fortaleza). O acesso à atenção pós-alta foi frágil em relação a intervenções como cirurgias e atenção psicológica. Os estados reacionais contemplaram em grande parte a busca e oferta de atenção neste período. Aproximadamente 30% das pessoas em acompanhamento pós-alta tiveram necessidade de encaminhamentos adicionais. Esse acompanhamento não seguiu parâmetros de referência. Existiu baixa percepção de risco dos participantes (escore 0: 60,1% em Fortaleza; 56,5% em Sobral); não houve relação definida entre escala SALSA e idade ou EHF. A maioria não apresentou nenhuma restrição significativa à participação; aqueles com restrição configuravam-se principalmente no plano relativo aos aspectos do trabalho. Do ponto de vista técnico-político foram observados importantes avanços no país nas questões do pós-alta. Conclusões: Foram identificadas lacunas em termos da operacionalização da atenção às pessoas atingidas no momento do pós-alta em ambos os municípios. A análise integrada e ampliada dessa pesquisa possibilitou a verificação da fragilidade das ações voltadas ao momento do pós-alta nos municípios estudados. A abordagem das pessoas atingidas pela hanseníase mantém-se como um importante desafio para o SUS. / Objective: To characterize the performance of actions of the Hansens Disease Control Programs in Sobral and Fortaleza municipalities, Ceará State, regarding health policy planning, organization of health care networks, activity and functional limitation and safety awareness, and social participation in affected people after release from treatment. Methods: Descriptive and cross-sectional study performed from August 2006 to September 2007. In total, 304 affected residents of both municipalities were included a sample of 10% of cases released from treatment between 2003 and 2005. Besides the analysis of technical and political scenarios, the following data were collected: dermatological and neurological examination, simplified assessment of neural deficits, socio-demographic characterization, assessment of activity limitation and safety awareness, and characterization of social participation. Results: The majority of the population was male, coloured, of low socio-economic status and performing jobs with increased vulnerability for development of physical disabilities. The majority of patients presenting with a high degree of physical disability were multibacillary (87%, Sobral; 62.6%, Fortaleza). The access to specific health care after release from treatment was limited, especially to surgeries and psychological care. Most cases attended were due to Hansens disease reactions. About 30% of people followed up after release from treatment needed additional evaluations by other specialists. Guidelines were not used when following up patients. There was a low risk perception of study participants (score 0: 60.1%, Fortaleza; 56.5%, Sobral) and no clear relation between SALSA scale and age or EHF score. Most participants did not present any significant participation restriction; if restrictions were present, work-related aspects were most frequently involved. Considering operational and political aspects, a progress was observed in these questions after release from treatment. Conclusions: Problems were identified related to application of health care after release from treatment. The present comprehensive and integrated analysis detected the fragility of measures focusing on Hansens disease patients after release from treatment in both municipalities. The assessment of these people continues to be an important challenge for Brazils Unified Health System.

The number of old people is growing and will increase future demands on healthcare services for old people. Hip fracture is one of the diagnoses that increases with age and it has become a major problem, both for those suffering a fracture and for society due to the large numbers involved, the morbidity with complications such as falls, functional decline, and the high mortality rate among those affected. The main purposes of this thesis were, to study the impact of previous hip fractures on their life among the very old, to study in-patient falls, fall-related injuries and fall-risk factors, and to evaluate a multidisciplinary, multi-factorial intervention program designed to reduce in-patient falls and to enhance functional performance among old people who have sustained a femoral neck fracture. The impact of a hip fracture was examined in a cross-sectional population-based study, among the very old (Umeå 85+). After adjustment for potential covariates, participants with a history of hip fracture were found to be more dependent in the performance of Personal/Primary Activities of Daily Living (P-ADL) (p=0.024), walked less independently (p=0.040) and used a wheelchair more frequently (p=0.017). Most of the participants with earlier hip fractures who had moved to institutional care or begun using mobility aids, as compared to before the fracture, had started to do so permanently in connection with the fracture incident. In-patient falls, fall-related injuries and fall-risk factors were studied in 97 participants, aged 70 or more, treated for a femoral neck fracture. There were 60 postoperative falls occurring among 26/97 participants (27%). Thirty-two percent of the falls resulted in injuries, 25 % were minor, and 7 % were serious. Delirium after day seven, (Hazard Rate Ratio (HRR) with a 95% Confidence Interval (CI)), 4.62 (1.30-16.37), male sex 3.92 (1.58-9.73), and sleeping disturbances 3.49 (1.24-9.86), were associated with in-patient falls. Forty-five percent of the participants were delirious on the day they fell. The effects of a multidisciplinary, multi-factorial intervention program on in-hospital falls and injuries as well as the short- and long-term effects on living conditions, walking ability and performance of activities of daily living were evaluated in a randomised controlled trial among 199 participants with femoral neck fracture, aged ≥70 years. Participants were randomised to care in a geriatric ward (intervention, n=102) or to conventional postoperative routines (control, n=97). The intervention consisted of staff education, individualized care planning and rehabilitation, systematic assessment and treatment of fall-risk factors, active prevention, and detection and treatment of postoperative complications and an intervention follow up at four-months. The staff worked in teams to apply comprehensive geriatric assessment, management and rehabilitation. Twelve participants fell a total 18 times in the intervention group compared to 26 participants suffering a total 60 falls in the control group. Only one participant with dementia fell in the intervention group compared to 11 participants with dementia in the control group. The fall incidence rate was 6.29/1000 days vs. 16.28/1000 for the intervention and control groups respectively. The Incidence Rate Ratio (IRR) was 0.38 (95% CI: 0.20-0.76, p=0.006) for the total sample and 0.07 (95% CI: 0.01-0.57, p=0.013) among participants with dementia. No new fractures were incurred in the intervention group but there were four in the control group. In addition, despite shorter hospitalization, significantly more people from the intervention group had regained independence in P-ADL performance at the four- and twelve-month follow ups, Odds Ratios (OR), with 95% CI, were 2.51 (1.00-6.30) and 3.49 (1.31-9.23) respectively. More participants in the intervention group had also regained the ability to walk independently without walking aids indoors, at the end of the study period, 3.01 (1.18-7.61). In conclusion, hip fracture among the very old seems to be associated with poorer P-ADL performance and poorer mobility. Falls and injuries are common during in-patient rehabilitation after a femoral neck fracture, delirium and sleep disturbances and male gender are factors associated with in-patient falls. Having a team apply comprehensive geriatric assessments and rehabilitation, including the prevention, detection and treatment of fall-risk factors, can successfully prevent in-patient falls and fall-related injuries, even among participants with dementia, and can also enhance the performance of Activities of Daily Living (ADL) and mobility after a hip fracture, in both short- and long-term perspectives.

Rehabilitation after brain injury is often a process which is spread over several years and runs through different phases. After sub acute in-patient rehabilitation a community based post-acute rehabilitation can follow. In this late phase after injury the rehabilitation focuses on reintegration into the community through a return to work and participation in other occupations in society. The overall aim of this dissertation was to study the long-term outcome of brain injury, with a special emphasis on the return to everyday domestic and productive occupations and the connection these have to life satisfaction as a whole. The aim was also to describe and understand the lived experience of the consequences of brain injury in these areas. This dissertation comprises four studies on different aspects of the long-term outcome of those who have had a brain injury. In a sample of 56 people, the value of occupational therapy assessments as predictors of an eventual return to work was investigated. In a longitudinal follow-up study, the life satisfaction of the participants (n 36) was reported and its correlation to a return to work was evaluated. Interviews were conducted (n 10) to explore the main characteristics of the meaning of work after brain injury in ten respondents. And, finally, in the fourth study, 157 people reported their participation in community activities. The extent of the correspondence between the level of participation and life satisfaction was calculated. The findings showed that occupational therapy assessments were useful in predicting a return to work in the late phase of the recovery after brain injury. A combination of assessments on the level of body function with assessments on activity level appeared to comprise the best predictive model. In two different studies the reported life satisfaction was found to be significantly lower than the level of life satisfaction in a sample of healthy Swedes for almost all domains. When comparing life satisfaction at two points in time with an interval of three years between them in the longitudinal study, no significant improvement was found. There was no difference reported by the participants for their overall life satisfaction regardless of whether they were back at work or in education, or not. On the other hand, participation in daily occupations in a wider perspective was found to have a positive impact on satisfaction with life as a whole. However, half or more than half of the participants claimed that their participation was restricted except for the items self-care and mobility, where a higher degree of participation was reported. The meaning of work after the brain injury had changed: Work had taken on a new place in life and the importance of work had decreased. In contrast, the social dimension of work had expanded in importance. After the brain injury, the perception of the participants’ own competence and work identity had changed and the respondents described their striving to return to normality. To conclude, brain injury has a lasting effect on a person’s life, even many years after the injury; consequently there is need for rehabilitation in this late phase. Life satisfaction, which is often used as an overriding goal for rehabilitation, did not improve over time. This finding raises the question of whether life satisfaction is too broad a concept and/or insufficiently sensitive to improvements. There is need for further research in this area to clarify the factors that have an impact on life satisfaction.

This study investigated a series of independent unassisted and device-assisted transfers from a wheelchair to vehicle mock-up and vice versa while simultaneously capturing kinematic, kinetic and electromyographic (EMG) data of impaired volunteers. The study provides a venue for observation and evaluation of upper extremity (UE) joint stresses, muscular force and functional demands associated with transfers in persons with spinal cord injury (SCI) to ultimately prevent UE injury, minimize excessive stress, preserve functionality and limit pain. If people with SCI lose function of their UEs, due to pain and/or degeneration, they must then rely on others for everyday tasks. Five paraplegic males from the Tampa Bay area were recruited to take part in the study. Participants were asked to perform a series of transfers using 4 commercially available devices or mock-ups of that device as well as an unassisted transfer, which permitted the use of no assistive device. Three data types were captured: kinematic data using motion capture, kinetic data using force transducers which were integrated into the vehicle mock-up and EMG of 5 bilateral muscle groups. Data collection took approximately 4 hours per subject. Forces occurring during the unassisted transfers were found to be the highest. This is also supported by the EMG data. Performing level transfers lessened stresses at the UE versus non-level transfers. The highest moments of the UEs were found at the shoulders with high variability between subjects. It was also found that body mass index (BMI) had an affect on a subjects ability to perform transfers. Ultimately this study found that using an assistive device is better than not using an assistive device. This is proven by EMG and force data, which were both found to be less with the use of an assistive device as opposed to transferring independently with no assistance. Performing level transfers, maintaining ones body mass and staying active are all factors that will limit stresses at the UEs during wheelchair transfers to and from a vehicle.