\nField of expertise<\/strong>
\nPhysical medicine and rehabilitation (physiatrics)
\nInstitution<\/strong>
\nUniversity of S\u00e3o Paulo (USP)
\nEducational background<\/strong>
\nDegree in Medicine from the Pontifical Catholic University of S\u00e3o Paulo (1974), PhD from USP (1990)
\nPublished works<\/strong>
\n284 articles and 20 books (coauthor or editor)
\n<\/div>\n
How has the pandemic changed your life?<\/strong> What are the challenges of rehabilitating people who’ve had Covid-19?<\/strong> What effects have you observed?<\/strong> Is this condition reversible?<\/strong> How do you follow up with patients?<\/strong> In public administration, at times it’s better to wait and structure a program that has more substance. Small attempts won’t survive<\/p><\/blockquote>\n What are they afraid of?<\/strong> Can Covid-19 be seen as a chronic disease?<\/strong> How do you tell a person who’s had a stroke or spinal cord injury that despite their best efforts they won’t be able to recover all their usual movement?<\/strong> What are the limits of rehabilitation?<\/strong> How is your research going?<\/strong>
\nEveryone is suffering. I love my family, but we have to keep our distance. This health tragedy has exposed our weaknesses, but it’s also opened up opportunities. Today I talk to my research partners in the United States and England with an ease that I didn’t have before; I don’t know why. The communication platforms were there, but it was difficult to find the time. We’re trained to have an answer for everything, but I suddenly saw that my colleagues were scared; I was terrified. But we\u2019ve learned to understand our patients’ pain from afar, through the internet. I\u2019ve found that this format allows us to bring the patient’s son or daughter into the treatment, which had often been the family’s wish, but the opportunity had been lacking.<\/p>\n
\nWhen the pandemic started, the first thing we did\u2014in a project supported by FAPESP\u2014was to look for possibilities for expanding medical care. In late February 2020, one of the discussions at the congress of the International Society of Physical and Rehabilitation Medicine in Atlanta, in the United States, was precisely the challenge of respiratory epidemics. It was clear that the situation could get worse, based on reports from colleagues in China who were already confronting Covid-19. In March, when cases began to multiply in Brazil, the effects of Covid-19 were already a bit better known. We began to see what would need to be done to meet this new demand at the basic, intermediate, and high-complexity care facilities. We expanded the patient attendance models, so that no one would be left out. As of today [early April 2021], we at the HC [Hospital das Cl\u00ednicas of the USP school of medicine] have attended 4,000 patients, with around 3,000 survivors, and we\u2019re still following up with 823 patients after discharge. Of this total, 60% had comorbidities such as hypertension, diabetes, and obesity, but comorbidities alone do not explain all the long-term sequelae. The vast majority of patients who left hospitals alive are not yet able to return to their former activities. Rehabilitation is critical because the effects of Covid-19 are devastating.<\/p>\n
\nIn addition to the already known symptoms, such as loss of smell and taste, we’ve frequently observed intense fatigue, headaches, joint pain, insomnia, depression, and difficulty with swallowing, communication, and movement. With ultrasound, we saw major changes in the structure of muscles in the legs and arms. It’s a severe form of sarcopenia [muscle loss due to age, disease, or long periods of immobilization] like we’ve never seen before.<\/p>\n
\nI hope so. Rehabilitation helps a lot. In February this year we published an innovative approach in the journal Clinics<\/em>, associating the use of medication with robotic exercises, high frequency ultrasound, and FES\u2014functional electrical stimulation\u2014which we use in a completely new way and which makes the stimulus quite tolerable for the patient. In our rehabilitation hospitals we achieved a good recovery in three to four weeks, which is a great result for people who were hospitalized for three to five months in intensive care units. Exercise has a direct impact on neural control and on reducing anxiety and depression.<\/p>\n
\nThe HC created an integrated, multidisciplinary assessment of post-Covid patients, with teams from cardiology, pulmonology, endocrinology, pediatrics, otolaryngology, psychiatry, and our team, from rehabilitation. During a single visit the patient sees several specialists, with breaks so they won’t get tired, and a standardized system for recording information. We already know that people who’ve had Covid-19 really need rehabilitation. They are very alarmed; and scared.<\/p>\n
\nAt first, it’s about having Covid-19. Then they’re afraid of dying. When they leave the hospital they’re afraid of returning, and having to relive through something that was very difficult. You call and the patient says he’s fine. \u201cBut are you walking? Does it still hurt?\u201d \u201cA little bit,\u201d he says. We push on: \u201cAre you able to eat well?\u201d “No, I still prefer eating soup.” When we say that he needs to come to the hospital, he asks: \u201cBut I’m not going to be admitted, am I?” It’s a fear of the future, of illness, of the unknown. The psychiatry team has been working brilliantly on this, which includes using an app developed at HC that’s provided really good support for guiding patients through self-treatment at home.<\/p>\n
\nToday it’s being classified as a chronic disease, what’s called “long Covid.” The long-term duration of symptoms affects a subgroup of patients, who will require attention and care for an extended period. That’s what scares us: how is our healthcare system going to handle it? If we’re not able to handle it now, what will it be like in four or five years?<\/p>\n
\nThat’s my deepest concern. Who am I to say to a patient: \u201cYou’re all done, it’s no use anymore.” And there’s another side: who are we, as a health system, to keep putting resources into a treatment that’s not working? I have two patients dealing with the same type of stroke, but one of them responds to a treatment and the other doesn’t. In the latter case, is it because he’s hit a functional limitation or because it isn’t the right treatment for him? In a research project with colleagues from Harvard University [United States], with funding from FAPESP, we’re studying biomarkers to find answers to these questions.<\/p>\n
\nIt all depends on neuroplasticity [the nervous system’s ability to readjust to new conditions]. Each patient’s previous history impinges on the possibility of functional recovery. Early treatment is another important variable. One of our research goals is to identify the best stimulus and the best intensity level capable of actually impacting the central nervous system without causing fatigue. As part of public policy in this area, we provide stimulus for accessible gyms and guidance for the major sports centers in the city, but there’s still a long way to go.<\/p>\n
\nWe have a Research Support Center that brings together medicine and engineering from S\u00e3o Carlos and Poli [Polytechnic School], which are both part of USP. We’re searching for materials and automation systems that will open new possibilities for exoskeletons. Today, exoskeletons work like armor and function for training patients in rehabilitation centers, but we need to create a system that’s friendlier and easier to use outside of rehabilitation centers\u2014something that can be used to stand upright and help cover short distances. One study sponsored by FAPESP, coordinated by Arturo Forner Cordero from Poli, and Adriano Siqueira, from the S\u00e3o Carlos School of Engineering, is aimed at expanding the possibilities for the use and functionality of exoskeletons in the rehabilitation process [see<\/em> Pesquisa FAPESP issue n\u00ba 301<\/em><\/a>]. Adriano had the idea of developing a half-exoskeleton to train hemiplegics, people who’ve had a stroke. The prototype is ready for the clinical testing phase. We need to involve materials engineering, because what’s currently out there doesn’t meet our needs. Nobody is going to walk with 26 kilos on their back. Arturo’s study, along these same lines, is going well and should be ready by the end of the year; it also received funding from CNPq [the National Council for Scientific and Technological Development]. Now it’s time to talk to Brazilian industry about the possibilities of producing these new devices.<\/p>\n
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