Pattern of startle reflex to somatosensory stimuli changes after spinal cord injury.

INTRODUCTION: Spinal cord injury (SCI) may cause functional changes at various levels in central and peripheral nervous systems. One of these changes is increased excitability above the lesion such as enhanced auditory startle responses (ASR). Startle response may also be obtained after somatosensory stimulus (startle reflex to somatosensory stimuli, SSS). In this study, we investigated changes of both ASR and SSS in SCI. METHOD: We examined ASR and SSS in 14 patients with SCI and 18 age-matched healthy volunteers. SSS responses were recorded from orbicularis oculi (O.oc), sternocleidomastoid (SCM) and biceps brachii (BB) muscles by electrical stimulation of median nerve at the wrist. ASR was evoked by binaural auditory stimuli and recorded from O.oc, masseter, SCM and BB muscles. Probability, latency, amplitude and duration of responses were compared between two groups for each muscle. RESULTS: Presence of response over O.oc after somatosensory stimuli was decreased in patients compared to controls (P = 0.004). There were no differences in SSS responses of other muscles. ASR latency was shorter in masseter, SCM and BB in patients with SCI, but only BB had significantly reduced latency (P = 0.033). The duration of O.oc response was longer and the amplitude of SCM was larger in patients with SCI (P = 0.037 and P = 0.015, respectively). CONCLUSION: ASR is enhanced after SCI whereas SSS of eye muscles is hypoactive and pattern of SSS after median stimulation changes in SCI.

Validation of Duruöz Hand Index in patients with tetraplegia.

STUDY DESIGN: Cross-sectional, clinical measurement. PURPOSE: To investigate the validity of the Duruöz Hand Index (DHI) in the assessment of hand function in patients with tetraplegia. METHODS: A total of 40 patients with tetraplegia participated. Patients' upper extremities were assessed on the level of 'body function and structure' [The American Spinal Cord Injury Association (ASIA) Impairment Scale (AIS) 2000 revised criteria, upper extremity motor score (UEMS), neurologic level of injury and visual analogue scale of hand function (VAS-HF)], 'activity' [DHI and Quadriplegia index of function-short form (QIF-SF)] and 'body function and structure, activity and participation' [Health Survey Short Form-36 (SF-36)] according to International Classification of Function. RESULTS: The DHI showed significant correlations with UEMS, AIS, QIF-SF, VAS-HF, physical functioning and physical compound summary scores of SF-36. CONCLUSIONS: The DHI was found a valid method in the assessment of hand functions in patients with tetraplegia. LEVEL OF EVIDENCE: Diagnostic III.

Ultrasound-guided greater occipital nerve block: an efficient technique in chronic refractory migraine without aura?

BACKGROUND: The effectiveness of greater occipital nerve block (GONB) in patients with primary headache syndromes is controversial. Few studies have been evaluated the usefulness of GONB in patients with migraine without aura (MWOA). OBJECTIVE: To compare the effectiveness of ultrasound-guided GONB using bupivacaine 0.5% and placebo on clinical improvement in patients with refractory MWOA in a randomized, double-blinded clinical trial. STUDY DESIGN: A prospective, randomized, placebo-controlled, double-blind pilot trial. SETTING: Physical medicine and rehabilitation and neurology departments of a University Hospital. METHODS: Thirty-two patients with a diagnosis of MWOA according to the International Classification of Headache Disorders-II criteria were included in the study. Twenty-three patients (2 men, 21 women) completed the study. They were randomly assigned to receive either GONB with local anesthetic (bupivacaine 0.5% 1.5 mL) or greater occipital nerve (GON) injection with normal saline (0.9% 1.5 mL). Ultrasound-guided GONB was performed to more accurately locate the nerve. All procedures were performed using a 7 - 13 MHz high-resolution linear ultrasound transducer. The treatment group was comprised of 11 patients and the placebo group was comprised of 12 patients. The primary outcome measure was the change in the headache severity score during the one-month post-intervention period. Headache severity was assessed with a visual analogue scale (VAS) from 0 (no pain) to 10 (intense pain). RESULTS: In both groups, a decrease in headache intensity on the injection side was observed during the first post-injection week and continued until the second week. After the second week, the improvement continued in the treatment group, and the VAS score reached 0.97 at the end of the fourth week. In the placebo group after the second week, the VAS values increased again and nearly reached the pre-injection levels. The decrease in the monthly average pain intensity score on the injected side was statistically significant in the treatment group (P = 0.003), but not in the placebo group (P = 0.110). No statistically significant difference in the monthly average pain intensity score was observed on the uninjected side in either group (treatment group, P = 0.994; placebo group, P = 0.987). No serious side effect was observed after the treatment in either group. Only one patient had a self-limited vaso-vagal syncope during the procedure. LIMITATIONS: This trial included a relatively small sample. This may have been the result of the inclusion of only those patients who correctly completed their pain diaries. Another major limitation is the short follow-up duration. Patients were followed for one month after the injection, thus relatively long-term effects of the injection have not been observed. CONCLUSIONS: Ultrasound guided GONB with 1.5 mL of 0.5% bupivacaine for the treatment of migraine patients is a safe, simple, and effective technique without severe adverse effects. To increase the effectiveness of the injection, and to implement the isolated GONB, ultrasonography guidance could be suggested.

Trigemino-cervical reflex in spinal cord injury.

Abnormal enhancement of polysynaptic brainstem reflexes has been previously reported in patients with spinal cord injury (SCI). We aimed to investigate trigemino-cervical reflex (TCR) in SCI since it may reflect alterations in the connections of trigeminal proprioceptive system and cervical motoneurons. Consecutive 14 patients with SCI and 16 healthy subjects were included in this study. All patients were in the chronic phase. TCR was recorded over sternocleidomastoid (SCM) and splenius capitis (SC) muscles by stimulation of infraorbital nerve. We measured onset latency, amplitudes and durations of responses and compared between groups. We obtained stable responses over both muscles after one sided stimulation in healthy volunteers whereas probability of TCR was decreased in patients over both SCM (78.6% vs. 100%, p=0.050) and SC (71.4% vs. 100%, p=0.022). The absence of TCR was related to use of oral baclofen (≥50mg/day). However, when present, responses of SCI group had higher amplitudes and were more persistent. We demonstrated that TCR probability was similar to healthy subjects in SCI patients who used no or low dose oral baclofen. But it had higher amplitudes and longer durations. It was not obtained in only two patients who used oral baclofen more than 50mg/day.

Skin thickness on bony prominences measured by ultrasonography in patients with spinal cord injury.

OBJECTIVE: The detailed assessment of soft tissues over bony prominences and identification of methods of predicting pressure sores would improve the quality of care for patients with spinal cord injury (SCI). Comparing skin thicknesses on bony prominences in patients with SCI to those in healthy individuals will represent, to our knowledge, the first study aimed at determining whether differences in skin thicknesses between these groups can be detected by ultrasound. DESIGN: In both patients and controls, skin thicknesses on the sites at risk for pressure ulcers - sacrum, greater trochanter, and ischium - were evaluated using high-frequency ultrasound. The waist was also evaluated by the same method for control as it was considered to be a pressure-free region. PARTICIPANTS: Thirty-two patients with complete thoracic SCI and 34 able-bodied individuals. RESULTS: The skin was significantly thinner over the sacrum and ischial tuberosity in individuals with SCI compared with healthy individuals. No significant differences were observed in skin thicknesses over the greater trochanter or the waist between the two groups. CONCLUSIONS: Protecting skin integrity in patients with paraplegia is challenging due to many contributing factors, such as prolonged pressure, frictional/shearing forces, and poor nutrition. Thinning of the skin can increase the risk of soft tissue damage, leading to pressure ulcers. The significant differences in skin thickness at the sacrum and ischium provide the basis for establishing the early signs of pressure damage. Measuring skin thickness by ultrasound is a reliable non-invasive method that could be a promising tool for predicting pressure ulcers.

Clinical evaluation during the acute exacerbation of knee osteoarthritis: the impact of diagnostic ultrasonography.

We aimed to investigate (1) the probable correlation between clinical and ultrasonographic findings in chronic painful primary knee OA patients referred with acute flare-ups and (2) the impact of diagnostic ultrasonography (US) to determine the real source of pain in these patients. We included 100 patients consecutively who were admitted to our outpatient unit with a pain complaint on a single knee with the diagnosis of primary knee OA according to the ACR criteria. The control group consisted of the patients with pain-free knees at least during the last month, who were already included in the study group. The sonographic evaluation of the knee was performed by a physician who was blinded to the clinical evaluation and/or the physical and radiological evaluations. In the present study, sonographic findings were significantly more observed on the painful knees (p < 0.001). The most commonly encountered findings on the symptomatic knees were the suprapatellar effusion (55 %), the baker cyst (25 %), and the pes anserine bursitis. The distribution of the findings on the asymptomatic knees was as follows: 22 %, the suprapatellar effusion and 5 %, the Baker cyst. Effusion was detected in 55 % of the painful knees of our patients with knee OA. This finding was statistically significant compared to the painless knees of the subjects included. The results of our study also showed that there was a significant relation between the Kellgren-Lawrence grading and the frequency of suprapatellar effusion on US examination (p = 0.026). It was concluded that in chronic, primary, painful knee osteoarthritis, US is a valuable diagnostic method in the confirmation of synovitis and/or the inflammatory episode in spite of the absence of obvious clinical parameters. In advanced osteoarthritis, when we consider that the inflammatory episodes are expected findings, the early confirmation of the inflammation on US may be particularly valuable in the clinical setting.

Assessment of quality of life and depression in spouses of patients with ankylosing spondylitis.

The objective of this study is to investigate the quality of life and the rates of depression in spouses/partners of patients with AS compared with spouses/partners of healthy controls". Twenty-five persons with AS and their 25 spouses (21 women and 4 men) and 25 healthy controls were recruited consecutively. All the subjects completed 36-item Short Form Health Survey (SF-36) questionnaire forms and 17-item Hamilton Depression Rating Scale (HAM-D17). Mean age was 35 ± 6.47 years in spouse group (SG) and 36.26 ± 5.93 in control group (CG). In SG and CG, the SF-36 subscale scores were compared using Mann-Whitney U test. Social functioning, mental health, emotional role, and general health were significantly (P < 0.05) lower in SG compared with CG. The average score of social functioning was found to be 65.41 in spouses of patients compared with healthy controls (90.75). Depression scores were significantly (P < 0.001) higher in SG compared with CG. Among SF-36 subgroups in spouses, general health perception had a negatively significant correlation with depression scores (P < 0.05) and duration of ankylosing spondylitis (P < 0.05). A positively significant correlation has been identified between bodily pain and depression scores in spouses (P < 0.05). Therefore, female partners of male patients were found to be more depressive. Being a spouse of a patient with AS significantly interferes with quality of life and increases the depression frequency.

Comparison of high-power pain threshold ultrasound therapy with local injection in the treatment of active myofascial trigger points of the upper trapezius muscle.

OBJECTIVE: To compare the effects of high-power pain threshold ultrasound (HPPTUS) therapy and local anesthetic injection on pain and active cervical lateral bending in patients with active myofascial trigger points (MTrPs) of the upper trapezius muscle. DESIGN: Randomized single-blinded controlled trial. SETTING: Physical medicine and rehabilitation department of university hospital. PARTICIPANTS: Subjects (N=49) who had active MTrPs of the upper trapezius muscle. INTERVENTIONS: HPPTUS or trigger point injection (TrP). MAIN OUTCOME MEASURES: Visual analog scale, range of motion (ROM) of the cervical spine, and total length of treatments. RESULTS: All patients in both groups improved significantly in terms of pain and ROM, but there was no statistically significant difference between groups. Mean numbers of therapy sessions were 1 and 1.5 in the local injection and HPPTUS groups, respectively. CONCLUSIONS: We failed to show differences between the HPPTUS technique and TrP injection in the treatment of active MTrPs of the upper trapezius muscle. The HPPTUS technique can be used as an effective alternative to TrP injection in the treatment of myofascial pain syndrome.

Effect of treatment on trigger points.

Patients with muscle pain complaints commonly are seen by clinicians treating pain, especially pain of musculoskeletal origin. Myofascial trigger points merit special attention because its diagnosis requires examinations skills and its treatment requires specific techniques. If undiagnosed, the patients tend to be overinvestigated and undertreated, leading to chronic pain syndrome. Patients with myofascial pain syndrome present primarily with painful muscle(s) and restricted range of motion of the relevant joint. Palpable painful taut bands are named trigger points and are the main and pathognomonic finding on physical examination. Eliciting local twitch response and referred pain requires experience and examination skills. It may be useful to classify the patient as having acute or chronic, and as having primary or secondary, myofascial pain so the decision on the details of treatment can be curtailed to the needs of each patient. Effective treatment modalities are local heat and cold, stretching exercises, spray-and-stretch, needling, local injection, and high-power pain threshold ultrasound.

The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation.

BACKGROUND: An accurate and specific diagnosis prevents the recurrences of low back pain and chronic spinal pain. The physical examination is the most useful tool to diagnosis. The examiner must aim to determine the exact tissue that pain arises from to make the specific diagnosis. Lumbar disc herniation is 1 disease that physical examination, symptoms, and findings on imaging technique do not always correlate with each other. The Straight Leg Raising (SLR) test has been used as the primary test to diagnosis lumbar disc herniations and found to have high correlation with findings on operation since its sensitivity is high in only disc herniations leading to root compression that may eventually need operation. More sensitive test, like the Slump, might be used in herniations in which the SLR is negative. The Slump test is really a variant of the SLR and the Lasègue's tests performed in the seated position and is a progressive series of maneuvers designed to place the sciatic nerve roots under increasing tension. At each step in the procedure, the patient informs the examiner what is being felt and whether radicular pain is produced. As a result, the Slump test applies traction to the nerve roots by incorporating spinal and hip joint flexion into the leg raising and would warn the examiner of the presence of nerve root compression when there is a negative SLR test. OBJECTIVES: This study measured the sensitivity and specificity of the Slump test and compare it with the SLR test in patients with and without lumbar disc herniations. METHODS: A prospective case control study of 75 patients with complaints suggestive of lumbar disc herniation was carried out in the outpatient clinics of the neurosurgery department of a state teaching hospital. Seventy-five referred or self-admitted patients with low back, leg, or low back and leg pain who had results of magnetic resonance imaging (MRI) of the lumbar spine were included in the study. Thirty-eight patients had signs of herniation demonstrated by MRI. Control patients (n = 37) had no disc bulges or herniations on MRI. Both the Slump and SLR tests were performed during the assessment of all the patients by the second author. The MRI results were assessed and recorded by the first author. RESULTS: The Slump test was found to be more sensitive (0.84) than the SLR (0.52) in the patients with lumbar disc herniations. However, the SLR was found to be a slightly more specific test (0.89) than the Slump test (0.83). CONCLUSION: The Slump test might be used more frequently as a sensitive physical examination tool in patients with symptoms of lumbar disc herniations. In contrast, owing to its higher specificity, the SLR test may especially help identify patients who have herniations with root compression requiring surgery.

In vitro investigation of heat transfer in calf spinal cord during polymethylmethacrylate application for vertebral body reconstruction.

The objective of this experimental study was to investigate the temperature variations within the spinal cord of calf cadavers during polymethlymethacrylate (PMMA) application for vertebral body reconstruction. Cervical spines including the cervical spinal cord of ten fresh cadavers were used. Corpectomy and laminectomy were performed and dura was exposed at the same level for proper placement of thermal sensors. Sensors were placed in multiple holes in the spinal cord at depths of 3, 6, 9 and 12 mm, respectively. Whether the thermal sensors were placed in the gray or white matter was determined by computerized tomography. The white and gray matters of the spinal cord exhibited different thermal properties. The white matter was more conductive and absorbed less heat than the gray matter. The heat sensor nearest to PMMA exhibited temperatures of 42-44 degrees C. The second heat sensor placed at 9 mm depth within the gray matter showed 44 degrees C. The third sensor, which was placed at 6 mm depth within the spinal cord recorded the same temperature as the first, i.e., nearest to PMMA sensor. The fourth heat sensor, which was at the farthest location from PMMA demonstrated 37-39 degrees C. The temperature distribution within the gray matter was inversely proportional to the distance from the heat source. The temperature at the dorsal white matter, which was distant from the heating source, remained nearly constant and was not elevated. Our data suggest that thermal injury to the spinal cord during PMMA application may be expected to be more significant in the gray matter when compared with other neural tissues.

High-power pain threshold ultrasound technique in the treatment of active myofascial trigger points: a randomized, double-blind, case-control study.

OBJECTIVE: To study what effects a high-power, pain-threshold, static ultrasound technique applied to acute myofascial trigger points of the upper trapezius has on pain and on active cervical lateral bending. DESIGN: Double-blind randomized trial. SETTING: Physical therapy unit of a private general hospital. PARTICIPANTS: Seventy-two adults with acute pain on 1 side of the neck, admitted to the outpatient unit during 1999 and 2000. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Visual analog scale and goniometric measurement of active lateral bending of the neck performed daily after treatment sessions and length of treatment (number of therapy sessions). RESULTS: High-power ultrasound applied to the trigger points before stretching the muscle was more effective (P<.05) than conventional ultrasound, and it also significantly (P<.001) decreased the length of therapy. CONCLUSIONS: High-power, pain-threshold, static ultrasound technique may be considered in the treatment of patients with acute myofascial pain syndrome, with the understanding that this technique demands more concentration and communication between the patient and the therapist.

Multicenter, randomized, double-blinded, placebo-controlled trial of thiocolchicoside in acute low back pain.

OBJECTIVE: To evaluate the efficacy of intramuscular injection of thiocolchicoside (4 mg-2 ml) compared to placebo administered twice daily for 5 days in patients suffering from acute low back pain. PATIENTS AND METHODS: Multicenter, randomized, double-blinded, placebo-controlled trial. The study was conducted between July 1998 and March 2000 in five centers. Hospitalized patients with acute low back pain were included. The primary evaluation criterion was spontaneous pain at rest assessed by visual analog scale (VAS). Hand-to-floor distance, muscle spasm intensity, patients' global evaluation and analgesic tablet (paracetamol) consumption were used as secondary evaluation criteria. RESULTS: One hundred and forty nine patients were included. Both groups showed improvement on spontaneous pain assessed by VAS at the end of day 1; however, improvement was statistically significant in thiocolchicoside group on day 3 (P < 0.001). Hand-to-floor distance and muscle spasm determined by palpation decreased significantly on day 5 in thiocolchicoside group (P < 0.0005 for both). According to the patients' global evaluation, 76.8% of patients in thiocolchicoside group evaluated the treatment as very good/good (P < 0.0005). Also a significant difference was observed in favor of the thiocolchicoside group in the total paracetamol consumption (P < 0.001). Treatment was well tolerated in both groups and none of the patients was withdrawn from the study due to an adverse effect. CONCLUSION: Twice daily administration of 4 mg thiocolchicoside for 5 days provides an efficient and safe treatment for patients with acute low back pain accompanied by muscle spasm.