O objetivo deste trabalho foi estudar o efeito da radioterapia na profilaxia da ossificação heterotópica (OH) em pacientes com lesão medular traumática. Foram estudados 19 pacientes (15 homens e quatro mulheres), média de idade de 30,4 ± 10,8 anos (19 a 58 anos), com lesão medular traumática. A causa mais freqüente da lesão medular foi acidente de trânsito (42,1%), seguida por queda (26,3%), ferimento por projétil de arma de fogo (21%), mergulho (5,3%) e queda de objeto sobre as costas (5,3%). Dez pacientes eram tetraplégicos (52,6%) e nove (47,4%) eram paraplégicos. Apresentavam lesão medular completa (Frankel A) 14 pacientes (73,7%) e cinco pacientes (25,3%) tinham lesão incompleta (Frankel B). Todos os pacientes incluídos no estudo realizaram cintilografia óssea inicial até um mês após o traumatismo raquimedular e apresentaram diagnóstico negativo para OH. Os pacientes foram divididos em dois grupos: nove pacientes receberam radioterapia em dose única de 8 Gy nos quadris (Grupo Estudo) e 10 pacientes compuseram o Grupo Controle. Após seis meses de seguimento clínico e radiológico, um paciente do Grupo Estudo (11%) e cinco pacientes do Grupo Controle (50%) apresentaram OH. A distribuição da freqüência do desenvolvimento da OH nos dois grupos não mostrou diferença estatística significante, apesar da menor incidência de OH no grupo submetido à radioterapia (Grupo Estudo). Concluiu-se que, com o número de pacientes estudados, não foi possível comprovar a eficácia da radioterapia na prevenção da ossificação heterotópica, ainda que haja uma forte tendência para a correlação estatística / The goal of this study was to evaluate the effect of radiotherapy on the prophylaxis of heterotopic ossification (HO) after spinal cord injury (SCI). Nineteen SCI patients were studied (15 men and four women). The mean age was 30.4 ± 10.8 years (range 19 to 58 years). The most frequent causes of lesion were traffic accident (42.1%), fall (26.3%), shot gun (21%), diving (5.3%) and objects falling on the vertebral column (5.3%). Ten patients were tetraplegics (52.6%) and nine were paraplegics. Fourteen patients (73.7%) had complete lesion (Frankel A) and five had incomplete lesion (Frankel B). All patients realized initial scintigraphy until one month after SCI and showed negative results for HO. The patients were randomized in two groups: nine patients received single dose irradiation with 8 Gy on the hips (Study Group) and 10 patients were the Control Group. After six months of clinical and radiological follow up, one patient of the Study Group (11%) and five patients of Control Group (50%) showed HO. The frequency distribution of the development of HO in both groups showed no significant statistical difference, although there was lower incidence of HO in the radiotherapy group. We concluded that, with the number of patients studied, it was no possible to prove the efficacy of radiotherapy to prevent HO, although had a strong tendency for the statistical correlation

Orientador: Alberto Cliquet Júnior / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-18T12:33:02Z (GMT). No. of bitstreams: 1 Medeiros_RodrigoCastrode_M.pdf: 1107012 bytes, checksum: 8c4a2b98916bf061db40e20d0c7d01a6 (MD5) Previous issue date: 2011 / Resumo: Nas últimas décadas, a reabilitação nos lesado-medulares vem evoluindo através do uso da estimulação elétrica funcional (EEF). Apesar dos inegáveis ganhos cardiovasculares, psicológicos e na densidade mineral óssea advindos desta técnica, o ortostatismo e a deambulação destes pacientes sob estímulo elétrico ainda dependem do suporte fornecido pelos membros superiores. A literatura pertinente aos estudos biomecânicos sobre EEF para ortostatismo em paraplégicos está baseada em teoremas matemáticos fundamentados na física mecânica referente aos braços de alavanca musculoesqueléticos. Contudo, percebe-se uma falha conceitual nestes teoremas a medida que desconsideram os princípios de regulação do reflexo postural observados nos indivíduos sem alterações neurológicas. Nos indivíduos saudáveis, o princípio da conservação de energia exige que, na posição ortostática, a cabeça e tronco estejam alinhados sobre a pelve e centrados em relação aos pés. Para obtenção de uma postura adequada, o organismo utiliza primariamente o reflexo postural espinopélvico, através do qual as curvaturas sagitais da coluna são adaptadas à posição da pelve e dos quadris. O objetivo deste estudo é descrever os aspectos radiográficos do perfil sagital obtidos em pacientes paraplégicos em postura bipedal através da estimulação elétrica funcional dos quadríceps complementados com apoio bimanual. Dez pacientes paraplégicos que participam do ambulatório de reabilitação foram selecionados. Após serem submetidos a radiografias panorâmicas em perfil, foram analisados as médias e os desvios-padrão dos vários parâmetros geométricos descritos na literatura referentes ao equilíbrio sagital em indivíduos saudáveis. Os valores obtidos para cifose torácica e lordose lombar foram semelhantes a dos pacientes saudáveis descritos na literatura. Os parâmetros pélvicos revelaram inversão do tilt pélvico, aumento do slop sacral e diminuição do ângulo sacrofemoral. Nos parâmetros espinopélvicos, foram observados aumentos nas distâncias horizontais entre as vértebras e a bacia e/ou quadris. Estes aspectos traduzem a presença de uma importante anteversão da bacia associada à flexão dos quadris com consequente translação anterior da linha de prumo da coluna expressada através de um intenso desequilíbrio sagital anterior. Para quem deseja optimizara postura bipedal dos paraplégicos sob EEF, este estudo inédito lança uma nova e importante visão sobre a compreensão das alterações ergonômicas presentes no balanço sagital. Tal fato possivelmente servirá de base para o desenvolvimento de novas configurações de EEF / Abstract: In recent decades, the rehabilitation of injured spinal cord-has been evolving through the use of functional electrical stimulation (FES). Despite the undeniable gains cardiovascular, psychological and bone mineral density resulting from this technique, the standing and ambulation of these patients still depend on electrical stimulation of the support provided by the upper limbs. The literature pertaining to the biomechanical studies on FES for standing in paraplegics is based on mathematical theorems based on the physical mechanics related to musculoskeletal lever arms. However, we find a conceptual flaw in these theorems as they disregard the principles of regulation of postural reflex observed in subjects without neurological damage. In healthy subjects, the principle of conservation of energy requires that, in standing position, head and torso are aligned in the pelvis and centered over the feet. To obtain a proper posture, the body uses primarily espinopélvico postural reflex, whereby the sagittal curvatures of the spine are adapted to the position of the pelvis and hips. The aim of this study is to describe the radiographic features of the sagittal profile obtained in bipedal posture in paraplegic patients by functional electrical stimulation of the quadriceps supplemented with bimanual support. Ten paraplegic patients participating in outpatient rehabilitation were selected. After being subjected to panoramic radiography in profile, we analyzed the means and standard deviations of various geometrical parameters described in the literature for the sagittal balance in healthy subjects. The values obtained for thoracic kyphosis and lumbar lordosis were similar to healthy patients in the literature. The parameters revealed pelvic tilt reversal of pelvic, sacral and increase the slop angle reduction sacrofemoral. The spinopelic parameters increases were observed in the horizontal distances in relation to vertebrae and pelvis and/or hips. These aspects reflect the presence of a significant anteversion of the pelvis associated with hip flexion with subsequent anterior translation of the plumb line of the column expressed through an intense anterior sagittal imbalance. For those who want to optimize the bipedal posture of paraplegic patients under FES, this new study sheds new and important insight into the understanding of these ergonomic changes in sagittal balance. This fact possibly serve as the basis for the development of new configurations of FES / Mestrado / Fisiopatologia Cirúrgica / Mestre em Cirurgia

Wheelchair-bound paraplegics are in an unnatural, almost all-day sitting position. This is physiologically disadvantageous as it may cause increased abdominal pressure, renal dysfunction, pressure sores, muscle atrophy and osteoporosis. Thus it would be beneficial, physiologically and psychologically, for a paraplegic to be able to stand for temporary periods of time. As a result of the muscle atrophy and functional degeneration that follows a spinal cord injury, it is essential for paraplegics to undergo a muscle restrengthening program, using Functional Neuromuscular Stimulation (FNS), before standing up under FNS control can be attempted. Six healthy spinal cord injured subjects with spinal lesions between CS and T9 (two tetraplegics and four paraplegics) exercised their quadriceps muscles at home using a portable two-channel FNS muscle stimulator. The muscles were exercised against an increasing load to maximise the training effect. Inclined standing exercise, under FNS control, was performed in the Inclistand. The subjects' general state of health and fitness were assessed, namely their responses during a maximal arm ergometry exercise test, arm muscle function, lung function, blood biochemistry and their dietary habits. Subjects have shown improvement in quadriceps muscle strength, fatigue resistance and muscle bulk to varying degrees - according to their individual circumstances. The tetraplegics responded in a different manner to that of the paraplegics. The muscle strength increased significantly by a mean (+SD) of 97,8 + 59,6% and 171,2 + 118,1% for the four paraplegics, left and right leg respectively. There was a mean improvement of 16% in fatigue resistance in the left leg (p=0,08), while the mean response of the right leg varied. Quadriceps muscle bulk increased by 4,43 + 3,4% (left) and 2,7 + 2,1% (right) (0,05<p<0,l). The amount of subcutaneous fat around the mid-thigh decreased significantly by 4,73 + 1,4% (left) and 3,43 + 1,1% (right leg). The group was in a state of general well-being, with the exception of one subject whose serum cholesterol concentration fell within the high risk category. This study therefore showed that the FNS was sucessful in improving the quadriceps muscle strength, bulk and fatigue response of the SCI people in our research group. The valuable experience gained from this FNS study will be used to improve the present program.

Following a spinal cord injury (SCI), participation in regular exercise can enhance physical capacity and performance in activities of daily living. With this in mind, the use of subjective ratings of perceived exertion (RPE) may provide an easy-to-administer alternative to traditional methods of regulating exercise intensity (e.g. heart rate and power output (PO)). A physically active lifestyle is also associated with a reduced risk of cardiovascular disease, in part because exercise exerts anti-inflammatory effects. Examining the plasma response of inflammation-mediating chemical messengers, known as cytokines, to traditional and novel exercise modalities may help maximise the anti-inflammatory potential of regular exercise. Participants with a cervical level SCI successfully self-regulated a 20 min bout of moderate intensity wheelchair propulsion (Chapter three). No differences in physiological or PO responses were observed during the imposed-intensity and self-regulated wheelchair propulsion in the trained population group. In a non-SCI group of novice wheelchair-users, a differentiated RPE specific to the exercising muscle mass (RPEP) was the dominant perceptual signal during submaximal wheelchair propulsion (Chapter four). The novice group successfully self-regulated a 12 min bout of moderate intensity wheelchair propulsion, comprising of a discontinuous 3 x 4 min protocol, using differentiated RPEP. In contrast, a more accurate self-regulation of light intensity wheelchair propulsion was observed when employing traditional overall RPE compared to RPEP. Following strenuous wheelchair propulsion, plasma concentrations of the inflammation-mediating cytokine interleukin-6 (IL-6) were significantly elevated in non-SCI and thoracic level SCI participants (Chapter five). Impaired sympathetic nervous system (SNS) function was associated with a reduced IL-6 response in participants with a cervical level SCI. The plasma IL-6 response to 30 min moderate intensity (60% VO2peak) arm-crank ergometry (ACE) was associated with an elevation in the anti-inflammatory cytokine IL-1 receptor antagonist (IL-1ra) independent of SNS activation (Chapter six). Light intensity ACE resulted in a small, significant plasma IL-6 response but no IL-1ra response. The addition of functional electrical stimulation-evoked lower-limb cycling to concurrent hand cycling, termed hybrid exercise, resulted in a greater plasma IL-6 response compared to moderate intensity hand cycling alone in participants with a thoracic level SCI (Chapter seven).

O estudo foi realizado com pessoas do sexo masculino e que viveram a experiência de sofrer um trauma que acarretou a lesão da medula espinal. Teve como objetivos: - compreender os significados que a pessoa atribui a sua experiência de ser lesado medular; - compreender a maneira como a dimensão atribuída ao significado de ser lesado medular se manifesta nas ações da pessoa; - desenvolver um modelo teórico representativo da experiência da pessoa que sofreu uma lesão traumática na medula espinal. Utilizou-se como referencial teórico o Interacionismo Simbólico e como referencial metodológico, a Teoria Fundamentada nos Dados. A estratégia para a obtenção dos dados foi a entrevista. Dos resultados emergiram dois fenômenos - Sobrevivendo ao Acidente e Vivendo uma Nova Realidade. Destes, identificou-se a categoria central - Re dimensionando limitações e possibilidades. A compreensão da experiência da pessoa que adquire uma lesão da medula espinal possibilitou reconhecer como as vivências, que ocorrem após a constatação da deficiência física, são percebidas por esses indivíduos, e como redimensionam os significados que vão atribuindo às situações diferentes que passam a vivenciar. O modelo teórico mostra que a experiência de ter se tornado um paraplégico ou um tetraplégico, é permeada pela vivência de limitações, e dependências, sentimentos e reações que vão sendo dimensionados e redimensionados à medida que vai re elaborando significados e valores, e desenvolvendo ações que lhe apontam possibilidades, as quais toma posse mediante as escolhas que faz para dar continuidade ou sentido à vida preservada, porém modificada / A study conducted with adult males who had undergone the experience of suffering trauma causing spinal cord injury (SCI). The aim was to: - understand the meaning patients gave to their experience of being an SCI bearer; - understand how the dimensions attributed to being a SCI bearer manifested itself in the person\'s behavior; - develop a theoretical model representative of the experience of the person who suffered SCI. The study used as a theoretical reference Symbolic Interactionism and used the Grounded Theory methodology. Data was collected through interviews. Two phenomena emerged from the findings: \"Surviving the Accident\" and \"Living a New Reality\". Of these the central category was identified as Re defining limits and possibilities. Understanding of the experience of SCI bearers made it possible to recognize how the events that occurred after the diagnosis of the physical deficiency is perceived by the persons and how they redefine the meaning attributed to the different situations they came to experience after suffering the acquired physical deficiency. The theoretical model reveals that the experience of having become a paraplegic or tetraplegic involved a lot of coping with limitations and dependency, emotions and reactions that go on being defined and redefined as the individual restructured values and developed actions that led to possibilities of overcoming, which were adopted through the choices made, so as to give continuity of meaning to the life that remained, although in its modified state

Vesicle trafficking provides the solution to the 'sorting problem' - how the eukaryotic cell maintains the distinct identities, and thus functional properties, of its membrane-bound organelles. During vesicle trafficking, proteins are selectively sorted into membrane bound transport intermediates by vesicle adaptors, which include those of the highly conserved adaptor protein (AP) complex family. Each AP complex has a distinct subcellular localisation and functions in the sorting of a specific subset of transmembrane cargo proteins. Adaptor protein complex 4 (AP-4) is one of the more recently identified AP complexes, whose function has largely remained elusive. In humans, AP-4 deficiency causes a severe neurological disorder, suggesting an important role in neuronal development and homeostasis. However, the pathomechanisms that underly the neuronal pathology in AP-4 deficiency are currently unknown. AP-4 is proposed to function in protein sorting at the trans-Golgi network (TGN), so AP-4 deficiency can be thought of as a disease of missorting. The aim of this study was to apply unbiased global proteomic approaches to define the composition of AP-4 vesicles and to identify physiological cargo proteins of the AP-4 pathway. Using 'Dynamic Organellar Maps' and comparative analysis of vesicle-enriched fractions from wild-type and AP-4-depleted cells, three ubiquitously expressed transmembrane cargo proteins, ATG9A, SERINC1 and SERINC3, were found to be mislocalised in AP-4-deficient cells. Two novel cytosolic AP-4 accessory proteins, RUSC1 and RUSC2, were also identified. Further proteomic analyses confirmed the interactions between these proteins. AP-4 deficiency was found to cause missorting of ATG9A in diverse cell types, including patient derived cells, as well as dysregulation of autophagy. RUSC2 facilitates the transport of AP-4-derived, ATG9A and SERINC-positive vesicles from the TGN to the cell periphery. These vesicles cluster in close association with autophagosomes, suggesting they are the 'ATG9 reservoir' required for autophagosome biogenesis. This study uncovers ATG9A trafficking as a ubiquitous function of the AP-4 pathway. Furthermore, it provides a potential molecular pathomechanism of AP-4 deficiency, through dysregulated spatial control of autophagy.

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No. of bitstreams: 2 Dissertação - Sémebber Silva Lino - 2018.pdf: 6051816 bytes, checksum: ea335e51b02781bbf65596b8422bac01 (MD5) license_rdf: 0 bytes, checksum: d41d8cd98f00b204e9800998ecf8427e (MD5) Previous issue date: 2018-02-23 / Extension or flexion movements of the body in a healthy individual are routine physical activity in daily life, necessary for its autonomy and independence.Injuries to the spinal cord and brain are the main causes of paraplegia, which makes it impossible for human locomotion with autonomy. The use of a wheelchair will help them into your daily horizontal mobility. But the possibility of using an orthotic device to allow it to increase the amplitude of the movements of extension or flexion will help in maintaining your bone density, improving your blood circulation and enlargement of muscle tone, involving tension in muscles, arteries and other tissues organic well as excessive involuntary reflex. Therefore, this study aims to present a mathematical model to describe the trajectory of nodes corresponding to the movable joints and upper extremity of a low cost orthosestic device, of the exoskeleton type, to be coupled in the wheelchair, using computer simulation to determine the variation of positions and velocities of these joints associated with the articulations of the hip and lower limbs of the paraplegic wheelchair user, when performing extension or flexion movements of the body segments, besides the simulation of a prototype developed in CAD. As for the main results of the research, first, there is the trajectory of the nodes with respect the mobile joints and upper end using the representation of Denavit-Hartenberg, generated graphically by numerical and computer simulation, in order to validate and make feasible the mechanical construction of the device. Then, as the variation of the positions and velocities of motor gasket associated with the user’s knee joint device, has its graphical representation plucked by multistep interactive Runge-Kuta 4th Order, using the Lagrange equations for numerical and computational simulation of the transmission system drive, with the application of a torque on the crank of the robotic mechanism proposed, thus confirming its usability, reliability and security. Finally, the development of a 3D virtual prototype device CAD. Therefore, the preparation and provision of this manual orthotic device developed to assist in the vertical mobility of the paraplegic with spinal cord injury, will improve physical, psychological health, functional independence and daily well-being, and helping them in their autonomy to support on the feet. / Os movimentos de extensão ou flexão corporal em um indivíduo saudável são atividades físicas rotineiras necessárias para sua autonomia e independência. As lesões da medula espinhal e do cérebro são as principais causas da paraplegia, que impossibilitam a locomoção humana com autonomia. O uso de uma cadeira de rodas os auxiliará em sua mobilidade horizontal diária. Mas a possibilidade de uso de um dispositivo ortético que lhe permita aumentar a amplitude dos movimentos de extensão ou flexão, contribuirá na manutenção da sua densidade óssea, melhorando sua circulação sanguínea e ampliação do tônus muscular, envolvendo tensão em músculos, artérias ou outros tecidos orgânicos além de reflexos involuntários excessivos. Por conseguinte, este estudo objetiva apresentar um modelo matemático para descrever a trajetória dos nós correspondentes as juntas móveis e extremidade superior de um dispositivo ortético manual de baixo custo, do tipo exoesqueleto, a ser acoplado na cadeira de rodas do paraplégico, usando-se de simulação computacional para determinar a variação das posições e velocidades dessas juntas associadas às articulações do seu quadril e membros inferiores, ao realizar movimentos de extensão ou flexão dos segmentos corporais, além da simulação de um protótipo desenvolvido em CAD. Quanto aos principais resultados decorrentes da pesquisa, primeiramente, obteve-se a trajetória dos nós referentes às juntas móveis e extremidade superior utilizando-se da representação de Denavit-Hartenberg, gerada graficamente por simulação numérico- computacional, no intuito de validar e viabilizar a construção mecânica do dispositivo. Em seguida, a variação das posições e velocidades da junta motora associada à articulação do joelho do usuário do dispositivo, teve sua representação gráfica tangida pelo método interativo multipasso de Runge-Kuta de 4ª ordem, usando-se das equações de Lagrange para simulação numérico-computacional do acionamento do sistema de transmissão, com a aplicação de um torque na manivela do mecanismo robótico proposto, confirmando assim, a sua usabilidade, confiabilidade e segurança. Por último, o desenvolvimento de um protótipo virtual 3D em CAD do dispositivo. Portanto, a confecção e disponibilização desse dispositivo ortético desenvolvido para auxiliar na mobilidade vertical do paraplégico com lesão medular, melhorará sua saúde física, psicológica, independência funcional e bem-estar diário, auxiliando-o na autonomia para apoiar sobre os pés.

The intent of this study was to describe the effects of long term paraplegia and wheelchair use on upper limb function. Bilateral upper extremity isokinetic and grip strength, pain, and active range of motion were compared in 52 men with paraplegia (mean age 44 years: mean duration of spinal cord injury (SCI) 17 years) and 52 age and activity-level matched able-bodied men. The impact of upper limb pain on activities of daily living (ADL) performance was examined in the paraplegic sample. Strength was not significantly different between the two samples except for bilateral shoulder flexion (able-bodied stronger) and bilateral elbow extension (paraplegia stronger). Strength changed similarly with age in the two groups. The effect of duration of SCI on strength, excluding age, was significant for grip strength only. Duration of paraplegia and activity-level were better predictors of strength than age in 9 of 14 muscle groups, whereas in the able-bodied, age was the best strength predictor. Limited bilateral shoulder internal rotation and non-dominant external rotation were associated with paraplegia. Upper limb pain in the past week was associated with paraplegia (shoulder p<.001; elbow p<.00l; wrist/hand p<.00l). Reported pain prevalences for the paraplegic sample were: shoulder 39%, elbow 31%, wrist/hand 40%. The paraplegic subjects' pain intensity ratings revealed them to be experiencing mild to moderate levels of upper limb pain. Shoulder pain was associated with duration of injury, exclusive of age (p<.05). Measurement of the impact of upper limb pain On 18 activities of daily living (ADL) tasks revealed pain to be experienced by the majority of subjects with paraplegia (mobility tasks 60%; self-care tasks 5 8 % ; general activities tasks 60%). However, only 23-35% had made changes in their routines, and 6-16% had sought assistance with ADL due to upper limb pain. ++ / When age was excluded, it appeared that duration of SCI was more associated with pain during ADL, but this was significant only for pain during self-care tasks. The tasks most reported to cause upper limb pain were work/school, sleep, wheelchair transfers, outdoor wheeling, and driving. These results suggest that preventative and management steps are required to ensure continued independence and quality of life in this group over time. The effect of duration of SCI suggests that limitations in upper limb function may be seen in this population at relatively young ages.

Persons with paraplegia who use a manual wheelchair for mobility are at high risk for overuse injuries in the upper extremities. Years of shoulder overuse performing transfers, wheelchair propulsion, dressing, bathing, and household chores, (activities of daily living or ADL) leads to an increased incidence of cumulative trauma to the shoulders. Few studies have addressed the stressful task of wheelchair transfers among SCI individuals. The goal of this pilot study is to develop valid and reliable measurement technologies to quantify shoulder musculoskeletal stressors during wheelchair transfers and pressure relief tasks among individuals with SCI. Using a standard wheelchair, 10 participants were asked to perform 3 typical pairs of independent transfer tasks: wheelchair to/from bed, wheelchair to/from commode, and wheelchair to/from vehicle. Also, two pressure relief tasks (P/R) were performed sitting in a wheelchair, one using the armrest and one using the wheels. By observation, the transfers in descending order from the most demanding to the least demanding were as follows: vehicle, commode, and bed. During a P/R using the wheels there is a 40% greater max shoulder force and a 47% greater mean shoulder force than when using the armrest. The max shoulder force of over 1000 N is generated at the initial push off, during a P/R using the wheels, then the force drops 45% to an average of 558 N. The max shoulder force of 722 N at the initial push off, during a P/R using the Armrest, drops 48% and then averages 378 N. During a P/R using the wheels there is a 104% greater max shoulder torque and a 17% greater mean shoulder torque than when using the armrest. As in the initial large amount of shoulder force there is also a large amount of shoulder torque that drops 77% during a P/R using the wheels. The shoulder torque decreases 62% during a P/R using the armrest. Because of the greater distance the body's Center of Mass (COM) travels during the P/R using the armrest, 24% more work is done.

The overall aim of this study is to explore the subjective experiences of psychotherapeutic interventions and the sense-making process in a group of persons paralysed as a consequence of violence-related gunshot injury. An available and purposive sample of ten participants was selected from public and private hospitals in and around Johannesburg, and from the Association for the Physically Disabled in South Africa. Three females and seven males, between the ages of 26 and 43 years, took part in the research. The participants had all suffered penetrative damage to the spinal cord in the thoracic region as a result of violence related gunshot injury, and are therefore classified as having paraplegia The participants' gunshot injuries had been sustained in incidents ranging from attempted hijacking and armed robbery, to being caught in crime-related crossfire. In-depth interviews were conducted with the participants. A narrative approach was used to examine participants' unique stories, utilising a systematic form of narrative analysis. The thesis consists of three articles, namely 1) The subjective experience of psychotherapeutic interventions in the rehabilitation of persons paralysed as a result of violence-related gunshot injuries; 2) Making sense of paraplegia caused by violence-related gunshot injury; and 3) Therapeutic guidelines for the management of persons paralysed as a result of violence-related gunshot injuries. The findings of article 1 reveal that paraplegic persons had both positive and negative experiences during their hospital rehabilitation. Ultimately, however, positive experiences compensated for negative experiences. This suggests that in the absence of psychotherapeutic interventions, psychosocial adjustment may possibly not be facilitated. The second article indicates that although several barriers prevented participants from making sense of their trauma, meaningful relationships, spiritual growth and a greater appreciation of the value of life were still possible. in the final article guidelines were put forward that include meeting the holistic and adjustment needs of paraplegic persons. Future research is suggested and limitations acknowledged. / Thesis (Ph.D. (Psychology))--North-West University, Potchefstroom Campus, 2006.