The effect of transcranial direct current stimulation on balance, gait function and quality of life in patients with stroke.

Transcranial direct current stimulation (tDCS) has been used in various neurological diseases due to its positive effects on cortical excitability. The aim of our study is to examine the effects of tDCS in stroke and 28 patients with stroke were randomly divided into two groups as intervention and control groups. Balance was evaluated with the Timed Up and Go Test and Berg Balance Scale. Walking functions were evaluated using the 10-meter Walk Test and the 6 Minutes Walk Test, lower extremity function was evaluated by Fugl Meyer Lower Extremity Scale, quality of life by Stroke-Specific Quality of Life Scale (SS-QOL). A task-oriented physiotherapy and rehabilitation program was applied to both groups. In addition to the task-oriented program, anodal tDCS was applied in the intervention group and carried out with a current of 2 mA, 5 days a week, 20 min, for a total of 4 weeks. In the control group, after the flow was opened for 30 s and the patient felt a tingling sensation, it was turned off without the patient noticing. As a result, significant improvement was obtained in all parameters in both groups (p < 0.05). At the difference values of both groups, only SS-QOL mobility subgroup was significant and other parameters were not significant. Considering all these results, it can be seen that tDAS applied in addition to the task-oriented training program in individuals with stroke makes a positive contribution to the patients' balance, walking function and quality of life. We think that tDAS may be a feasible and safe additional approach in this patient group.

Sarcopenia is a possible risk factor for amputation after peripheral arterial interventions.

OBJECTIVES: Sarcopenia has been demonstrated to be related to unfavorable clinical outcomes in patients with vascular diseases. The purpose of this study is to evaluate the relationship between sarcopenia and clinical results in patients with peripheral arterial disease who underwent endovascular therapy (EVT). METHODS: This single-center retrospective study involved patients with PAD who underwent peripheral EVT at Ankara City Hospital, between January 2018 and December 2021. Two groups of patients were created: sarcopenic and non-sarcopenic patients according to computed tomography angiography muscle measurements. Primary outcome measures were major and minor amputation and survival. Mortality, amputation, and clinical characteristics were compared between the two patient groups. Hazard ratios (HRs) for amputation were calculated for each risk factor via univariate and multivariate analyses. Secondary outcomes included length of hospital stay and post-procedural complications. RESULTS: The mean follow-up period was 29.9 ± 9 months for all patients. A total number of 100 patients (mean age 63.5 ± 9.2 years) were involved in the study cohort. A significant association was identified between mortality and sarcopenia (p < .001). The mortality rate in the group with sarcopenia was significantly higher than the other group; 65.7% (23 patients) versus (20%, 13 patients) (p < .001). The major amputation rate in the group with sarcopenia was 57.1%, the major amputation rate in the group without sarcopenia was calculated as 15.4%, revealing that the major amputation rate was detected to be significantly higher in the sarcopenia group (p < .001). Multivariate regression analyses showed that only sarcopenia (HR, 0.52; 95% CI, 0.21-1.27; p = 0.15) was independently associated with major amputation in patients with PAD after EVT. Kaplan-Meier analysis revealed a statistically significant difference between the survival curves of sarcopenia and non-sarcopenia patients (p < .001). CONCLUSIONS: Sarcopenia seems to be a possible risk factor associated with amputation in patients with PAD who undergo EVT. The results of this study imply that sarcopenia is a possible risk factor for overall survival in patients with PAD.

Efficacy of ultrasound versus short wave diathermy in the treatment of chronic low back pain in patients with lumbar disk herniation: a prospective randomized control study.

BACKGROUND: Lumbar disk herniation (LDH) is a cause of chronic low back pain (CLBP) treated using physical therapy (PT), including exercise and physical modalities such as ultrasound (US) and short wave diathermy (SWD). Despite the use of US and SWD, there is inconclusive evidence on their efficacy. The aim of this study was to investigate the efficacy of US and SWD in the treatment of CLBP in patients with LDH. METHODS: A prospective randomized control clinical study. Individuals with radicular CLBP and LDH on magnetic resonance imaging, presenting to the Physical and Rehabilitation Medicine Department were randomized into 3 treatment groups. All participants received 10 sessions of hotpack, transcutaneous nerve stimulation (TENS) and therapeutic exercises. In addition, Group 1 received 10 sessions of therapeutic US (1 MHz, 1.5W/cm2, 10 min), Group 2 SWD (27.12 MHz, wavelength 11.06 m, induction technique, 20 min) to the lower back. Group 3 (control group) received hotpack, TENS and therapeutic exercises alone. Visual analogue scale (VAS) for LBP, Modified Oswestry Disability Index (MODI) and Short Form 36 (SF-36) were evaluated pre and post treatment and at one and three months follow up. RESULTS: In all groups, VAS for LBP and MODI improved with treatment and at the one and three month follow up (p < 0.001). In Groups 1 and 2, MODI scores continued to reduce at 1 and 3 months (p < 0.001 and p = 0.012 respectively). SF-36 physical, social function and pain parameters reduced in all groups (p < 0.05). Role limitation due to physical and emotional problems, emotional well-being, vitality and mental health improved in Groups 1 and 2 (p < 0.05). CONCLUSIONS: Deep heating agents can be used as part of the physical therapy for CLBP in those with LDH with positive mid-term effects. TRIAL REGISTRATION: NCT03835182, 02/04/2019.

Electrochemically pre-lithiated SiO2@C nanocomposite anodes for improved performance in lithium-ion batteries.

Silica (SiO2)-based materials are a promising alternative anode material due to their high specific capacity, abundance, safety, and environmental friendliness. However, the significant volume expansion and the formation of a solid electrolyte interphase (SEI) with electrolytes cause active lithium loss and result in poor Coulombic efficiency of SiO2-based materials, which hinder their commercial applications. Therefore, pre-lithiation, a method of embedding extra lithium ions in the electrodes prior to cycling, is an effective approach to replenish the largely irreversible lithium loss during cycling and overcomes these challenges. In this study, carbon-coated silica (SiO2@C) nano composite was synthesized via a sol-gel method and the beneficial impacts of using pre-lithiated SiO2@C electrodes in coin cells were investigated. It is shown that the carbon coating onto the surface of the SiO2particles and the pre-lithiation method led to a distinct improvement in the overall capacity and Coulombic efficiency of the cells due to the pre-formed SEI and the presence of a lithium reservoir within the anode. Furthermore, the anodes exhibited excellent cycling stability and good rate capability up to 2 A g-1.

Multiple dissecting intracranial and extracranial aneurysms in rheumatoid arthritis: a rare case.

A 52 year old female with a history of rheumatoid arthritis (RA) and persistently raised levels of serum rheumatoid factor and cyclic citrunillated peptide, presented with dissecting aneurysms at the right internal carotid artery, and intact aneurysms at the supraclinoid segment and opening of the right opthalmic artery. Coil embolization was performed. The patient developed an ischaemic stroke two days later.Intra and extra-cranial large vessel aneurysms in RA have rarely been reported in the literature. RA patients with persistent systemic inflammation are at increased risk of developing vascular complications and ischaemic stroke. Here, high levels of tissue-deposited immune complexes may have resulted in cerebral artery vasculopathy. Risk stratification for the development of vascular complications, including cranial aneurysms and ischaemic stroke, in RA patients with poorly controlled systemic inflammation, is important; especially when we consider the neurological sequelae associated with dissecting cerebral aneurysms, cerebral infarction and surgical intervention.

Scapula winging secondary to prone plank exercise: a case report.

Background: Scapular winging occurs when the muscles responsible for the stabilization of the scapula (serratus anterior, trapezius, rhomboid major and minor) are paralyzed due to any reason. The most frequently observed neurological aetiology is serratus anterior muscle dysfunction due to long thoracic nerve palsy. The cause of long thoracic nerve palsy may be traumatic or atraumatic. It has been previously reported that a wide variety of sports can cause long thoracic nerve palsy.Clinical presentation: In this article, we report a case of unilateral winging of the scapula due to injury to the long thoracic nerve which occurred secondary to performing prone plank exercises; the likes of which has not previously been described in the literature and which may have occurred due to the exercise being performed incorrectly. In this patient, nerve recovery became evident one month following conservative treatment and cessation of plank exercises.Conclusion: Long thoracic nerve injury may have occurred due to increased and incorrect scapula loading during plank exercises. In order to prevent compression neuropathies caused by load transfer imbalance, attention should be paid to correct positioning whilst performing core stabilization exercises such as the prone plank.

Ultrasonographic and electrophysiological outcomes of carpal tunnel syndrome treated with low-level laser therapy: A double-blind, prospective, randomized, sham-controlled study.

Objectives: The aim of this study was to investigate the therapeutic effects of low-level laser therapy (LLLT) on clinical, ultrasonographic (US), and electrophysiological findings in carpal tunnel syndrome (CTS). Patients and methods: Between January 2015 and August 2015, 42 patients (7 males, 35 females; mean age: 50.4±8.7 years; range, 32 to 65 years) with mild-to-moderate CTS were randomly assigned to one of two groups: active LLLT (therapy group, n=22) 0.8 J/painful point and sham LLLT groups (n=20). Both groups wore neutral wrist orthoses. The patients were evaluated before and after 15 sessions of therapy (670 nm, 4 J/session over the carpal tunnel). Follow-up parameters included the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) Symptom Severity Scale (SSS), Functional Status Scale (FSS), nerve conduction studies and US evaluation of the median nerve cross-sectional area (CSA), vascularization (via power Doppler), flattening ratio (FR), and palmar bowing of the flexor retinaculum. Results: Nocturnal paresthesia improved in both groups; however, pain and patients with a positive Phalen's test reduced only in the therapy group (p=0.031). The FSS and SSS scores also improved only in the therapy group (p<0.001). Electrophysiologically, median sensory nerve conduction velocities showed a significant improvement only in the therapy group (p=0.002). The CSA, FR, and vascularization of the median nerve showed a significant improvement in the therapy group alone (p<0.001, p=0.048, and p=0.021, respectively). Conclusion: Improvements in the signs and symptoms of CTS and hand function, the improvements in sensory nerve conduction studies, and reduction in median nerve CSA, FR and vascularity in the LLLT group can be attributed to the anti-inflammatory and analgesic effects of LLLT. This study provides new US data demonstrating efficacy of LLLT along with a clinical and electrophysiological improvement. The LLLT seems to be an easily applied, non-invasive treatment option.

Sympathetic skin responses and electromyographic reaction times in chronic autoimmune thyroiditis: An overlooked electrodiagnostic study.

Objectives: This study aims to evaluate peripheral nerve functions, sympathetic skin responses (SSRs), and electromyographic (EMG) reaction times in hypothyroid patients and to compare them to healthy individuals. Patients and methods: Between January 2007 and September 2007, a total of 54 patients with Hashimoto's thyroiditis including 35 euthyroid (3 males, 32 females; mean age: 45.2±10.2 years; range, 35 to 60 years) and 19 with subclinical hypothyroidism (2 males, 17 females; mean age: 43.2±12.6 years; range, 40 to 65 years) were included in the study. The control group consisted of 35 healthy individuals (5 males, 30 females; mean age: 39.1±9.3 years; range, 29 to 52 years). Nerve conduction studies (NCSs), SSRs of the hand and foot obtained by stimulation of the contralateral median nerve, and EMG reaction times of the extensor indicis proprius muscle were performed in all subjects. Results: There was no significant difference in peripheral NCSs and SSRs between patients and the control group. However, reaction times were longer in the AIT patients compared to the healthy individuals suggesting alterations in cognitive function related to the primary disease process in AIT. Conclusion: Electrodiagnosis of autonomic nervous system involvement and cognitive impairment can be challenging in AIT. However, EMG reaction times and SSRs are practical and useful tools that are often overlooked. On the other hand, SSRs may be combined with more quantitative tests, such as sudomotor axon reflex testing, to allow us to better determine the extent of involvement of the autonomic nervous system in AIT.

An uncommon case of primary biliary cirrhosis and Hashimoto thyroiditis followed by the concurrent onset of multiple sclerosis and Sjögren syndrome.

A 51-year-old woman with a diagnosis of primary biliary cirrhosis and Hashimoto thyroiditis followed by concurrent onset of multiple sclerosis and Sjögren syndrome for seven years was admitted. The patient was treated with pulse steroid and cyclophosphamide combined with a physical therapy program. This is a case of four autoimmune diseases coexisting in a single patient, a finding which has not previously been described in the literature. This combination of autoimmune diseases should be kept in mind in patients with the relevant symptoms and signs of each to provide early diagnosis and appropriate treatment.

Physical therapy versus radial extracorporeal shock wave therapy in the treatment of carpal tunnel syndrome: A randomized-controlled study.

Objectives: This study aims to compare the efficacy of physical therapy (PT) and radial extracorporeal shock wave therapy (rESWT) in the treatment of carpal tunnel syndrome (CTS). Patients and methods: Between May 2020 and July 2020, a total of 125 wrists of 95 patients (22 males, 73 females; mean age: 54.3±11.3 years; range, 19 to 69 years) with mild-to-moderate CTS were allocated into three groups and evaluated. The control group (Group 1, n=42) was treated with splinting and an exercise program. Group 2 (n=42) was treated with a total of three sessions of rESWT, splinting and an exercise program. Group 3 (n=41) was treated with a total of 15 sessions of PT modalities, splinting, and an exercise program. Each patient was evaluated before, three weeks and 12 weeks after treatment using a Visual Analog Scale (VAS), the Boston Carpal Tunnel Questionnaire (BCTQ), the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale, and electrodiagnostic testing. Results: The reduction in VAS, BCTQ, LANSS, and improvement in sensory nerve conduction velocity were significantly greater at three and 12 weeks of follow-up in Groups 2 and 3, compared to Group 1 (p<0.001). A greater improvement was observed in all clinical parameters in Group 2, compared to Group 3 (p<0.001). Conclusion: This is the first study to compare the treatment outcomes of PT and rESWT in the treatment of CTS. The results of this study show that both PT and rESWT are effective in the treatment of CTS; however, rESWT yields superior treatment effects compared to conventional PT. The practicalities of administering rESWT and its efficacy in the treatment of CTS may make it the treatment of choice.

Compliance with Long-Term Use of Orthoses Following Spinal Cord Injury.

Background: Prescription of orthoses and assistive devices that facilitate physical function is a major component of the rehabilitation process in spinal cord injury (SCI). Objective: To evaluate the long-term use of orthoses prescribed during inpatient rehabilitation in people with SCI and investigate the factors related to discarding the device. Materials and Methods: Medical records of 202 SCI patients who were included in an inpatient rehabilitation program of a tertiary research hospital were reviewed retrospectively. Patients' demographic data, neurological level of spinal cord injury functional state and use of assistive devices for ambulation (orthoses, walkers, etc.) at discharge were recorded. At follow-up, study participants were contacted by telephone and queried regarding the frequency and duration of use of orthoses; if the individual had discontinued using the orthoses, the reasons for discarding the device were sought. Results: The majority of the study participants (62.7%) had been prescribed a knee-ankle-foot orthosis during their inpatient stay. At follow-up, the regular use of orthoses was ongoing in 67.6% of the participants, and nonuse was determined in 32.4%. The most common cited reasons for discarding the device were difficulty in donning and doffing, functional improvement, and mechanical problems of the orthoses. Conclusions: A significant number of patients had discarded their orthoses at the long-term follow-up and the main reasons for discarding the devices were orthotic factors. Timely reevaluation of the patient and orthosis modification according to patients' needs is necessary to achieve long-term compliance.

Bilateral peroneal nerve palsy secondary to prolonged sitting in an adolescent patient.

Peroneal nerve palsy most commonly occurs due to focal compression of the peroneal nerve at the level of the fibular head and causes foot drop and variable sensory loss. Mononeuropathies infrequently occur in childhood, bilateral peroneal palsy is very rare. In this article, we report the case of a 14-year-old boy with bilateral peroneal nerve entrapment which developed secondary to a prolonged sitting posture. We discuss the clinical assessment, diagnosis, and treatment of this rare case of bilateral peroneal palsy following prolonged immobility in light of the current literature.

Scapular Winging Secondary to Iatrogenic Spinal Accessory Nerve Lesions.

Motor innervation of trapezius and sternocleidomastoid (SCM) muscles is provided solely by the spinal accessory nerve (SAN). SAN palsy most often occurs as a result of iatrogenic injury to the nerve. A patient, who had undergone neck dissection for thyroid cancer, presented with pain and reduced range of motion of the shoulders. Electroneuromyography revealed denervation of the trapezii and SCM muscles secondary to SAN injury. The patient was treated with a course of physical therapy (PT). This case reminds us that a SAN lesion should be considered in the differential diagnosis of a patient presenting with shoulder pain following surgery of the neck. Even though unilateral SAN injury can eventually lead to atrophy of the trapezius, muscle asymmetry may not be obvious, especially in bilateral iatrogenic SAN injuries. In our experience, these patients benefit from PT. However, evidence to support the use of PT in the treatment of shoulder dysfunction secondary to SAN injury is insufficient; the optimum type and timing of PT requires further investigation. Development of best-practice guidelines in terms of management is necessary. Key Words: Spinal accessory nerve, Electroneuromyography, Scapular winging.

Prognostic value of magnetic resonance imaging in the evaluation of physical therapy outcomes in patients with adhesive capsulitis.

OBJECTIVES: This study aims to investigate whether the treatment outcomes of patients with a clinical diagnosis of adhesive capsulitis (AC) and magnetic resonance imaging (MRI) findings consistent with AC undergoing physical therapy (PT) differs to those with AC in the absence of these MRI findings. PATIENTS AND METHODS: Between January 2012 and October 2012, a total of 30 patients (8 males, 22 females; mean age 55.6±12.1 years; range, 35 to 85 years) with a clinical diagnosis of AC underwent MRI of the index shoulder. The MRI scans were evaluated for findings associated with AC: intensity of the inferior glenohumeral ligament (IGHL) and rotator interval (RI). All patients received a total of 15 sessions of PT: hot pack, transcutaneous electrical nerve stimulation, ultrasound, and shoulder exercises. The patients were assessed for shoulder range of motion (ROM) using the Visual Analog Scale (VAS) for shoulder pain, Quick Disabilities of the Arm Shoulder and Hand (Q-DASH), and Health Assessment Questionnaire (HAQ) prior to and following completion of PT. RESULTS: Of the patients, 21 had no MRI findings consistent with AC (Group 1), nine patients had changes in the IGHL and/or RI characteristic of AC (Group 2). In both groups, there was a significant improvement in active and passive shoulder ROM and VAS scores for shoulder pain at rest (Group 1: p<0.001, Group 2: p=0.017) with movement (Group 1: p<0.001, Group 2: p=0.007) and at night (Group 1: p<0.001, Group 2: p=0.012) following PT. However, there was no significant inter-group difference in scores. Similar findings were recorded for Q-DASH and HAQ. CONCLUSION: Based on these study findings, the presence of characteristic MRI findings of AC with a clinical diagnosis do not predict clinical response to physical therapy.

Computer Game Assisted Task Specific Exercises in the Treatment of Motor and Cognitive Function and Quality of Life in Stroke: A Randomized Control Study.

OBJECTIVES: Computer game assisted task specific exercises (CGATSE) are rehabilitation gaming systems (RGS) used in stroke rehabilitation to facilitate patient performance of high intensity, task based, repetitive exercises aiming to enhance neuroplasticity. CGATSE maybe an appealing option in home based rehabilitation of stroke patients, especially during the COVID-19 pandemic. This study aimed to determine the effects of CGATSE on hemiplegic arm-hand function, cognitive function and quality of life in stroke. MATERIALS AND METHODS: Thirty stroke patients were randomized into two groups. All participants received twenty sessions of physical therapy. In addition, the therapy group undertook thirty minutes of CGATSE using the Rejoyce gaming system; while the control group undertook thirty minutes of occupational therapy (OT). Motor function was evaluated before and after treatment using the Fugl Meyer upper extremity (FMUE), Brunnstrom stages of stroke recovery (BSSR) arm and hand. The CGATSE group also completed the Rejoyce arm hand function test (RAHFT). Cognitive function was evaluated using the mini mental state examination, Montreal Cognitive Assessment (MoCA) and Stroke Specific Quality of Life (SS-QOL) scale. RESULTS: The FMUE, BSSR arm and SSQOL improved in both groups (p < 0.05). BSSR of the hand improved only in the CGATSE group (p = 0.024). RAHFT scores improved in the CGATSE group (p = 0.008). MoCA scores significantly improved in the control group (p = 0.008). CONCLUSIONS: CGATSE may be beneficial in providing continuation of care after stroke, especially during the Covid-19 pandemic when home based rehabilitation options are becoming increasingly important. Benefits of CGATSE in improving cognitive function is less clear. RGS aimed at improving motor function may be compared to gaming systems designed to target cognitive development and more detailed higher cortical function deficit tests can be used as outcome measures.

Sacroiliac Joint Dysfunction Treated Using Neural Therapy to the Temporomandibular Joint: A Case Report.

Temporomandibular joint disorders (TMJD) include temporomandibular joint dysfunction and bruxism. Sacroiliac joint dysfunction (SJD) is a frequent cause of non-discogenic low back pain. Studies suggest a relationship between TMJD and SJD; however, the link remains unclear. Neural therapy (NT) utilises local anaesthetic injections to treat pain by normalising a dysfunctional autonomic nervous system held responsible for initiating or propagating chronic pain. A 31-year-old female presented with a 1-year history of mechanical left-sided low back pain and sleep bruxism. Examination revealed crepitation of the left TMJ and a trigger point in the masseter muscle. Range of motion of the spine and hip joints were normal, Patrick and Geanslen tests were positive on the left side. Spine and standing flexion tests were also positive. Magnetic resonance imaging of the lumbar spine and sacroiliac joints were normal. A diagnosis of SJD was made, and the patient was treated using NT. Injections of lidocaine 0.5% to the left TMJ, the masseter muscle and intradermal segmental injections at the level of C4 were administered. The patient's back pain and TMJ tenderness reduced and continued so throughout the 3-month follow-up period. SJD may be related to TMJD, and NT may be used in its treatment.

Exercise, Manipulative Therapy, and Physical Modalities in the Treatment of Notalgia Paresthetica: A Case Report.

Objective: The purpose of this case report is to describe the care of a patient with notalgia paresthetica (NP). Clinical Features: A 61-year-old man presented with a 7-year history of upper back pain, concentrated in the right periscapular region. Physical examination revealed a hyperpigmented area in the right dorsal paravertebral and infrascapular region with local paraesthesia. After investigations, a diagnosis of NP was made. Intervention and Outcome: An exercise program including back and shoulder stretching and shoulder strengthening exercises, and transcutaneous electrical nerve stimulation resulting in a reduction of symptoms. Conclusion: In the case described here, the patient's symptoms regressed when treated conservatively with exercise and physical therapy modalities.

Elastofibroma dorsi: A case report on an unobserved cause of back pain.

Elastofibroma dorsi (ED) is a rare, benign soft tissue tumor which often occurs in the subscapular region of elderly individuals and shows a female predominance. While many patients remain asymptomatic, ED can cause pain in the periscapular region. The clinical signs of ED are non-specific and variable which can result in misdiagnoses; it is often confused with rotator cuff and cervical spine pathologies. In this article, we present the case of a 78-year-old female patient with persistent back and shoulder pain. The patient was admitted to various clinics over a number of years for diagnostic investigations and treatment. However, the true etiology of back pain was never established and treatments were applied without any positive effect. Finally, when the patient presented to our clinic, a mass was detected in the right subscapular region. Thoracic computed tomography imaging was consistent with a diagnosis of ED. Due to the patient's persistent back pain, surgical excision of the tumor was performed. The pathology report confirmed the diagnosis. This case emphasizes the importance of a thorough examination in patients who may initially only have very subtle signs of the underlying pathology. This case also highlights the importance of re-visiting initial evaluations and differential diagnoses when faced with a difficult case of persistent back and shoulder pain so to avoid misdiagnoses and unnecessary treatments.

A Rare Benign Tumor With Diagnostic Difficulties: Synovial Chondromatosis.

In this article, we present a case of a 47-year-old male patient presenting with an insidious onset of hip pain and loss of range of motion. The patient was initially treated conservatively to no avail. Detailed investigations included magnetic resonance imaging of the left hip which revealed a synovitis. Blood results were unremarkable apart from moderately raised inflammatory markers. Differential diagnoses of both intra- and extra-articular hip pain were ruled out and the patient treated for a preliminary diagnosis of psoriatic arthritis for a total of six months. Persistent pain resulted in a re-visit of the diagnosis and further clinical evaluation. This time, an X-ray of the hip revealed calcification at the joint. A computed tomography followed and revealed synovial thickening and intra-articular calcification. A biopsy was consistent with primary synovial chondromatosis (SC). Open synovectomy was performed approximately one year after the onset of symptoms. This case emphasizes the importance of re-visiting initial evaluations and diagnoses when faced with a difficult case of persistent hip pain so to avoid misdiagnosis and unnecessary pharmacological treatment. In view of its rarity and diagnostic challenges, future work on SC should concentrate on gathering data which can be used to produce a diagnostic algorithm.

Post-stroke bilateral heterotopic ossification: An acute problem with long-lasting consequences.

Heterotopic ossification (HO) is a complication of injury to the central nervous system in which production of lamellar bone within the soft tissues occurs resulting in pain, reduced range of motion (ROM) and loss of functional capacity. Heterotopic ossification is rarely seen in stroke patients and mostly affects the paretic side. In this article, we present a case of established bilateral HO of the hips soon after stroke onset. A 77-year-old female patient with a five-month history of stroke presented to our rehabilitation clinic. Physical examination revealed sensorimotor aphasia, right-sided hemiplegia, bilateral painful limited ROM of the hips and left knee contracture. An anteroposterior X-ray of the pelvis revealed previously undiagnosed bilateral HO of the hips. The patient and her relatives declined operative interventions. The patient was discussed in the departmental meeting and it was agreed that she would not be able to partake in an active inpatient rehabilitation program. She was discharged with a home exercise plan. This case highlights the importance of HO, of both the paretic and non-paretic side, being included in the differential diagnosis of post-stroke patients presenting with joint pain and reduced ROM, both acutely and in the long-term. This may aid the timely diagnosis and management of HO, a pathology which has detrimental effects on functionality.