Common Mistakes in the Dual-Energy X-ray Absorptiometry (DXA) in Turkey. A Retrospective Descriptive Multicenter Study.

BACKGROUND: Osteoporosis is a widespread metabolic bone disease representing a global public health problem currently affecting more than two hundred million people worldwide. The World Health Organization states that dual-energy X-ray absorptiometry (DXA) is the best densitometric technique for assessing bone mineral density (BMD). DXA provides an accurate diagnosis of osteoporosis, a good estimation of fracture risk, and is a useful tool for monitoring patients undergoing treatment. Common mistakes in BMD testing can be divided into four principal categories: 1) indication errors, 2) lack of quality control and calibration, 3) analysis and interpretation errors, and 4) inappropriate acquisition techniques. The aim of this retrospective multicenter descriptive study is to identify the common errors in the application of the DXA technique in Turkey. METHODS: All DXA scans performed during the observation period were included in the study if the measurements of both, the lumbar spine and proximal femur were recorded. Forearm measurement, total body measurements, and measurements performed on children were excluded. Each examination was surveyed by 30 consultants from 20 different centers each informed and trained in the principles of and the standards for DXA scanning before the study. RESULTS: A total of 3,212 DXA scan results from 20 different centers in 15 different Turkish cities were collected. The percentage of the discovered erroneous measurements varied from 10.5% to 65.5% in the lumbar spine and from 21.3% to 74.2% in the proximal femur. The overall error rate was found to be 31.8% (n = 1021) for the lumbar spine and 49.0% (n = 1576) for the proximal femur. CONCLUSION: In Turkey, DXA measurements of BMD have been in use for over 20 years, and examination processes continue to improve. There is no educational standard for operator training, and a lack of knowledge can lead to significant errors in the acquisition, analysis, and interpretation.

Effects of Exergames on Balance, Functional Mobility, and Quality of Life of Geriatrics Versus Home Exercise Programme: Randomized Controlled Study.

AIM: To compare the effects of exergames (EGs) using the Xbox Kinect™ device and home exercise (HE) on balance, functional mobility, and quality of life of individuals aged 65 years or older. METHOD: One hundred participants who met the inclusion criteria were randomized to the EG or HE group. The EG group took part in a 6-week programme using the Xbox360Kinect™ device, and the HE group took part in a 6-week balance exercise programme at home 5 days a week. The Berg Balance Scale (BBS) was used to assess balance, the Timed Up and Go (TUG) test was used to evaluate functional walking, and the Short Form 36 (SF-36) was used to assess quality of life. RESULTS: Forty-eight participants in the EG group and 42 participants in the HE group completed the study. The groups were similar in terms of age, sex, and pretreatment values of BBS, TUG, and SF-36. Although the BBS scores of both groups improved significantly (all p<0.05), the post-treatment scores of the EG group were better than those of the HE group. The TUG scores improved only in the EG group (p<0.05). The increase in the BBS scores and decrease in the TUG test scores were significant only in the EG group (all p<0.05). A significant improvement was also observed in the quality of life parameters of physical functioning, social role functioning, physical role restriction, general health perceptions, and physical component scores in the post-exercise evaluations of the EG group. The participants commented that they found the EG programme very entertaining. CONCLUSION: The EG can be considered a safe, entertaining and sustainable alternative to HE programmes, and it may have positive effects on balance, functional walking and quality of life in geriatric subjects.

Hand splinting for poststroke spasticity: a randomized controlled trial.

PURPOSE: To determine the effect of volar and dorsal splinting on the spasticity of the wrist flexor muscles in patients who had stroke. METHOD: Thirty-nine subjects were prospectively randomized to use a dorsal or volar splint or no splint (control group). All the patients underwent home-based exercise program, and the experimental groups used either dorsal or volar hand splints according to their distribution. The primary outcome measure was spasticity assessed clinically by the Modified Ashworth Scale (MAS) and electrophysiologically by H latency and Hmax:Mmax ratio of flexor carpi radialis. Secondary outcome measure was passive range of motion (PROM) of wrist extension. RESULTS: Spasticity parameters (MAS, H latency, Hmax:Mmax ratio) and wrist PROM were not significantly different among the groups. CONCLUSIONS: This study failed to demonstrate any statistically significant difference in spasticity or in wrist PROM of both the volar and dorsal splint groups. These splints could be recommended as part of an integrative approach without expecting a major clinical effect rather than as an alternative to other treatment.

The effect(s) of a six-week home-based exercise program on the respiratory muscle and functional status in ankylosing spondylitis.

BACKGROUND: Ankylosing spondylitis (AS) is a chronic, inflammatory rheumatic disease. Involvement of costovertebral and costotransverse joints results in rigidity of the chest wall and inability to expand the chest fully on inspiration. Also significant reduction in exercise capacity in the AS patients was reported. OBJECTIVES: To determine the effects of a 6-week home-based exercise program on the respiratory muscle and energy cost in AS. METHODS: Twenty-two AS patients were included. Chest expansion, tragus-wall distance, modified Schober test, maximal inspiratory pressure, maximal expiratory pressure, 6-minute walking distance, physiologic cost index and functional status Bath Ankylosing Spondylitis Functional Index of patients were measured at baseline and repeated at the end of an open 6-week home-based exercise program. Breathing exercises and upper extremity exercises were taught to all the patients. The patients were then asked to practice these exercises at home individually for 6 weeks. RESULTS: Chest expansion, maximal inspiratory pressure, and maximal expiratory pressure values and Bath Ankylosing Spondylitis Functional Index scores of patients significantly increased after 6 weeks (P < 0.001). Six-minute walking distance and physiologic cost index values did not change at the end of the 6 weeks (P > 0.05). CONCLUSIONS: A home-based exercise program can have an effect on some measures respiratory muscle and functional status. Greater emphasis should be placed on maintaining cardiorespiratory fitness as well as spinal mobility to encourage patients with AS.

Evaluation of the effects of neural therapy in patients diagnosed with fibromyalgia.

OBJECTIVES: This study aims to compare the effects of neural therapy and exercise on pain, quality of life, depression, anxiety, and functioning status in patients diagnosed with fibromyalgia syndrome (FMS). PATIENTS AND METHODS: This multi-center study included a total of 72 patients (60 females, 12 males; mean age: 39.2±9.5 years; range, 22 to 53 years) who were diagnosed with FMS according to the 1990 American College of Rheumatology (ACR) criteria between January 2015 and June 2015. The patients were randomly divided into two groups: the first group (n=30) received an exercise program (strengthening, stretching, relaxation, and aerobic exercises, three days a week), and the second group (n=42) received a total of six sessions of neural therapy as one session a week in addition to the same exercise program. Pain severity was assessed with the Visual Analog Scale (VAS), emotional state with the Beck Depression Scale (BDS) and Beck Anxiety Inventory (BAI), quality of life with Short Form-36 (SF-36), and functioning status with the Fibromyalgia Impact Questionnaire (FIQ). The patients were evaluated at the end of treatment (week 6) and one month after the end of treatment. RESULTS: The mean disease duration was 34.3±9.3 months, the mean VAS score was 7.3±2.2, and the mean FIQ score was 58.4±13.2. There were significant improvements in the VAS, FIQ, SF-36, BDS, and BAI scores after the treatment in both groups (p<0.05). Post-treatment BDS and VAS scores were significantly lower in the neural therapy group (p=0.038; p=0.049; p<0.05). There was no significant difference in any parameter one month after the treatment between the groups (p>0.05). CONCLUSION: When neural therapy is combined with exercise in FMS patients, it may be advantageous in terms of pain and depression, compared to exercise alone.

Nurse's Knowledge of Neuropathic Pain.

The aim of our study was to determine the levels of information and awareness of the nurses who work on neuropathic pain in the departments of physical medicine and rehabilitation, neurology and neurosurgery. A total of 60 nurses (20 per each department) who work in the physical medicine and rehabilitation, neurology and neurosurgery departments of Beyhekim State Hospital of Konya in Turkey took part in the study. The level of information and awareness of the nurses on neuropathic pain were assessed via a questionnaire prepared by specialists in the light of recent literature. The questionnaire was composed of 30 questions including the definition, symptoms, treatment and management of neuropathic pain. None of 60 nurses participating in the study were given any previous in-service training on neuropathic pain. According to the assessments, 80% of nurses (48) were found not to have sufficient knowledge about definition of neuropathic pain; 83.3% (50) about diseases causing neuropathic pain; 83.3% (50) about symptoms of neuropathic pain; and 90% (54) about management of neuropathic pain. The findings obtained from the nurses of these three departments showed no statistically significant relation. Our findings indicated that the knowledge of participants' about neuropathic pain who work in these three departments seriously lack of information. Informing nurses about neuropathic pain during in-service training will be an important step towards improving the quality of services provided.

Somatosensory evoked potentials of hand muscles in stroke and their modification by botulinum toxin: a preliminary study.

OBJECTIVE: To determine the effect of botulinum toxin A on spasticity and somatosensory evoked potentials of hand muscles in patients who have undergone cerebrovascular accident. DESIGN: Preliminary, prospective, before-after study design. PATIENTS: Six subjects prospectively followed after application of botulinum toxin A in the rehabilitation department of a university hospital. METHODS: All patients underwent botulinum toxin A injection to the upper extremity muscles in varying combinations and carried out a home-based exercise programme. Primary outcome measure was median somatosensory evoked potential of hand muscles (N20). Secondary outcome measures were: spasticity assessed clinically by Modified Ashworth Scales (MAS); functional ability analysis assessed by Physician's Rating Scale (PRS); and functional difficulties reported by patients or their care-givers by patient disability and care-giver burden rating scale (PD & CBRS). RESULTS: MAS, PRS and PD & CBRS improved with botulinum toxin A treatment. In the affected limb, N20 potentials were impaired compared with those in the unaffected side. With botulinum toxin A treatment, although improvement in overall N20-P25 amplitudes was significant, as a result of limited sample size, post hoc pair-wise comparisons with Bonferroni correction failed to yield any significant pairs. CONCLUSION: The improvement in the median somatosensory evoked potentials following botulinum toxin A treatment suggests that central somatosensory patterns in hemiplegia can be modified by peripheral inputs.

Functional outcomes of multilevel botulinum toxin and comprehensive rehabilitation in cerebral palsy.

The objective of this study was to measure the effect of lower extremity multilevel botulinum toxin A injections and comprehensive rehabilitation on spasticity and to determine the functional gains in ambulatory children with cerebral palsy. Sixteen ambulatory children with spastic cerebral palsy (9 hemiplegic, 7 diplegic), aged between 3 and 8 years, who were able to walk with or without assistance (Gross Motor Functional Classification System I-III) were recruited to the study. Botulinum toxin A injections were applied to a total of 23 extremities, followed by a comprehensive rehabilitation program. Walking distance and walking speed (evaluated by the Six-Minute Walk Test) were significantly improved after treatment. Similarly, scores on the Observational Gait Scale (assessed by video gait analysis) increased significantly. Improvements in muscle length, spasticity, and selectivity were recorded. Reduced muscle spasticity after botulinum toxin A injections in children with cerebral palsy, with a comprehensive rehabilitation program, enabled clinically relevant improvements in functional ability.

Biering-Sorensen test scores in coal miners.

OBJECTIVES: Biering-Sorensen test is an isometric back endurance test. Biering-Sorensen test scores have varied in different cultural and occupational groups. The aims of this study were to collect normative data on Biering-Sorensen holding times, to determine the discriminative ability of the Biering-Sorensen test in Turkish coal miners, and to examine the association between Biering-Sorensen test result and functional disability. METHODS: One hundred and fifty male coal miners participated in this study. Trunk extensor muscle strength was measured using the Biering-Sorensen test. Oswestry disability index was used to measure the functional disability level of low back pain. RESULTS: The mean Biering-Sorensen holding time for the total subject group was 107.3+/-22.5s. The mean time of Biering-Sorensen test of the subjects with and without low back pain were 99.9+/-19.8 and 128.6+/-15.2 s, respectively. The difference between the subjects with and without low back pain was statistically significant (p<0.001). There was a statistically significant negative correlation between Oswestry functional disability score and Biering-Sorensen holding time (r=-0.824, p<0.001). CONCLUSIONS: Turkish coal miners have low mean back extensor endurance holding times. Biering-Sorensen test had a good discriminative ability in our study group. Trunk muscle strength has a significant effect on the disability level of low back pain. Thus trunk muscle endurance training exercise therapy may be effective for the reduction of disability in patients with low back pain.

Polypharmacy in the elderly: a multicenter study.

OBJECTIVE: The aim of this study was to evaluate the polypharmacy issue and its correlations with socioeconomic variables in Turkish elderly patients. DESIGN: Cross-sectional SETTING: Outpatient clinics of the medical schools, departments of physical medicine and rehabilitation from 12 provinces. PARTICIPANTS: A total of 1430 elderly in different geographical regions of Turkey during January 2007 to January 2008 were included. MEASUREMENTS: Patients were interviewed using a questionnaire that included demographic characteristics, current medical diagnosis, and pharmaceuticals that are used by elderly. Demographical parameters were gender, age, marital status, number of children, level of education, province, and status of retirement. RESULTS: The mean number of drugs was found to be higher in the females. There was a significant difference among age groups, marital status groups, and the number of children categories. The distribution of the number of drugs among education levels did not differ significantly, whereas the distribution of the number of drugs between the status of retirement and presence of chronic disease differed significantly. CONCLUSIONS: Polypharmacy is correlated with various factors including age, sex, marital status, number of children, status of retirement, and presence of chronic medical conditions but not educational status in our study group.

A new modification of KAFO for assistance in knee extension.

In this paper, a dynamic knee-ankle-foot orthosis (KAFO) extension assisted with elastic support, has been described which contributes to stance phase stability and swing phase freedom. The temporal distance factors including velocity, cadence, stride length, and clinical gait assessment score (CGAS) with bare foot and orthosis have been documented. The orthosis enables walking without fully immobilizing the knee.

Is osteoporosis generalized or localized to central skeleton in ankylosing spondylitis?

BACKGROUND: Osteoporosis at the lumbar spine and at the femur is a well-established complication in ankylosing spondylitis (AS), but the exact mechanism and the distribution of osteoporosis are not known absolutely. OBJECTIVE: To determine whether the osteoporosis is generalized or localized to central skeleton and to examine the relation between bone mineral density (BMD) and disease activity and radiologic progression in patients with AS. METHODS: In this study, 26 patients with AS and 33 healthy controls matched for age and sex were recruited to the study. Hip and forearm BMD were measured by dual energy X-ray absorptiometry (DEXA). Laboratory and clinical disease activity parameters were documented, and anteroposterior sacroiliac radiographs were taken to determine the radiologic progression. RESULTS: The urine deoxypyridinoline levels of the patients with AS were statistically significantly higher (P = 0.02) and the serum osteocalcin levels were significantly lower with respect to controls (P = 0.03). The femoral neck and femur BMD values and T scores were significantly lower in patients with AS compared with the controls (P = 0.019, 0.003, 0.01, and 0.01, respectively). The differences in BMD values and T scores of the distal 1/3 radius between 2 groups were not statistically significant. The relation between BMD and disease activity, and radiologic progression in patients with AS could not detected. CONCLUSION: Sparing of distal regions such as the as radius suggests that osteoporosis might be due to localized effects of inflammatory activity or immobility rather than a systemic effect. Both increased resorption and decreased formation might be involved in the pathogenesis of osteoporosis. Radius BMD may not be appropriate to evaluate bone loss in patients with AS.

Awareness of osteoporotic patients.

Osteoporosis has recently been recognized as a major public health problem by some governments and health care providers. Despite significant progress in knowledge about osteoporosis, public awareness is required for effective management if precautions are to be taken. The aim of this study was to evaluate the educational status of osteoporotic individuals, and their awareness about the disease and sources of information. We also aimed to compare the variables between the geographical regions of the country, since significant differences exist in socioeconomic status and lifestyle within the same cultural context. This multicenter study was carried out in eight cities located in six different geographical regions between September 2001 and January 2002. To our knowledge, this is the first multicenter study in Turkey evaluating the relationship between awareness of osteoporotic patients and other variables such as educational level and economic factors. Ten centers took part in this study and consecutive patients with either femoral or lumbar T-scores below -2.5 SD were enrolled into the study group. Bone mineral density was measured using dual energy X-ray absorptiometry (DXA). Patients were interviewed using a questionnaire on past medical history, education, awareness about their disease and risk factors for osteoporosis. A total of 540 women (93.8%) and 36 men (6.3%) were included in the study. Fifty-four percent of patients declared that they were aware of osteoporosis. With regard to sources of information, 56.8% of patients reported physicians as the main source of information. Awareness of the patients was negatively correlated with age (P=0.025, r=-0,94) but positively correlated with education (P=0.0001, r=0.327), level of physical activity (P=0.001, r=143), calcium intake (P=0.005, r=119) and modern clothing style (P=0.0001, r=309). Educational status of the patients was negatively correlated with BMI (P=0.0001, r=-283) and positively correlated with physical activity (P=0.0001, r=268), modern clothing style (P=0.0001, r=600) and smoking (P=0.0001, r=273). Regional comparison of female patients demonstrated that significant differences exist in terms of educational status, clothing style, smoking, level of physical activity, calcium intake, and knowledge about osteoporosis. As a result, education has profound effects on awareness about osteoporosis and many aspects of human behavior, such as calcium intake, physical activity, clothing style and smoking. Significant disparities may be observed between the geographical regions of the same country.