Consensus recommendations for botulinum toxin injections in the spasticity management of children with cerebral palsy during COVID-19 outbreak

Spasticity is the most common motor disturbance in cerebral palsy (CP). Lockdown in the COVID-19 outbreak has profoundly changed daily routines, and similarly caused the suspension of spasticity treatment plans. Besides, the delay in botulinum toxin (BoNT) injection, which is important in the management of focal spasticity, led to some problems in children. This consensus report includes BoNT injection recommendations in the management of spasticity during the COVID-19 pandemic in children with CP. In order to develop the consensus report, physical medicine and rehabilitation (PMR) specialists experienced in the field of pediatric rehabilitation and BoNT injections were invited by Pediatric Rehabilitation Association. Items were prepared and adapted to the Delphi technique by PMR specialists. Then they were asked to the physicians experienced in BoNT injections (PMR specialist, pediatric orthopedists, and pediatric neurologists) or COVID-19 (pediatric infectious disease, adult infectious disease). In conclusion, the experts agree that conservative management approaches for spasticity may be the initial steps before BoNT injections. BoNT injections can be administered to children with CP with appropriate indications and with necessary precautions during the pandemic.

The validity and reliability of the Turkish version of the functional mobility scale in patients with cerebral palsy.

Objectives: The aim of this study was to investigate the validity and reliability of the Turkish version of the Functional Mobility Scale (FMS) in patients with cerebral palsy. Patients and methods: The validity and reliability study was conducted with 100 cerebral palsy patients (66 males, 34 females; mean age: 6.4±2.7 years; range, 2 to 18 years) between July 2015 and July 2018. The translation of the FMS was performed according to international standards. For test-retest reliability, 54 patients were reevaluated one week after the initial test with the Turkish version of the FMS, and Cohen's weighted kappa values were analyzed. The validity of the scale was assessed by correlating the FMS with the Gross Motor Function Classification System and the Gillette Functional Assessment Questionnaire Walking Scale. Twenty patients were evaluated by two researchers for interobserver reliability. Results: The kappa coefficients for test-retest reliability were 0.90 for FMS 5 m, 0.92 for FMS 50 m, and 0.91 for FMS 500 m. An evaluation of the validity revealed a significant correlation between FMS and the Gross Motor Function Classification System for all distances (r=-0.95, r=-0.96, and r=-0.92 for 5, 50, and 500 m, respectively; p <0.001), as well as the Gillette Functional Assessment Questionnaire Walking Scale (r=-0.95, r=-0.94, and r=-0.91 for 5, 50, and 500 meters, respectively; p <0.001). The kappa coefficients related to interobserver reliability were 0.73 for 5 m, 0.69 for FMS 50 m, and 0.81 for FMS 500 m. Conclusion: The Turkish version of the FMS can be considered a valid and reliable instrument for the assessment of cerebral palsy patients.

Efficacy of paraffin bath therapy in hand osteoarthritis: a single-blinded randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of paraffin bath therapy on pain, function, and muscle strength in patients with hand osteoarthritis. DESIGN: Prospective single-blinded randomized controlled trial. SETTING: Department of physical medicine and rehabilitation in a university hospital. PARTICIPANTS: Patients with bilateral hand osteoarthritis (N=56). INTERVENTIONS: Patients were randomized into 2 groups with a random number table by using block randomization with 4 patients in a block. Group 1 (n=29) had paraffin bath therapy (5 times per week, for 3-week duration) for both hands. Group 2 (n=27) was the control group. All patients were informed about joint-protection techniques, and paracetamol intake was recorded. MAIN OUTCOME MEASURES: The primary outcome measures were pain (at last 48h) at rest and during activities of daily living (ADL), assessed with a visual analog scale (0-10cm) at 12 weeks. The secondary outcome measures were the Australian Canadian Osteoarthritis Hand Index (AUSCAN) and the Dreiser Functional Index (DFI), used for subjective functional evaluation, loss of range of motion (ROM), grip and pinch strength, painful and tender joint counts, and paracetamol intake. A researcher blind to group allocation recorded the measures for both hands at baseline, 3 weeks, and 12 weeks at the hospital setting. RESULTS: At baseline, there were no significant differences between groups in any of the parameters (P>.05). After treatment, the paraffin group exhibited significant improvement in pain at rest and during ADL, ROM of the right hand, and pain and stiffness dimensions of the AUSCAN (P<.05). There was no significant improvement in functional dimension of the AUSCAN and the DFI (P>.05). The control group showed a significant deterioration in right hand grip and bilateral lateral pinch and right chuck pinch strength (P<.05), but there was no significant change in the other outcome measures. When the 2 groups were compared, pain at rest, both at 3 and 12 weeks, and the number of painful and tender joints at 12 weeks significantly decreased in the paraffin group (P<.05). Bilateral hand-grip strength and the left lateral and chuck pinch strength of the paraffin group were significantly higher than the control group at 12 weeks (P<.05). CONCLUSIONS: Paraffin bath therapy seemed to be effective both in reducing pain and tenderness and maintaining muscle strength in hand osteoarthritis. It may be regarded as a beneficial short-term therapy option, which is effective for a 12-week period.

Reliability and Validity of the Turkish Version of the ABILHAND-Kids Survey in Children with Cerebral Palsy.

OBJECTIVES: The aim of the present study is to develop a Turkish version of the ABILHAND-Kids Survey, which evaluates upper extremity function in children with cerebral palsy (CP), and to carry out a validity and reliability study of the survey for Turkish CP patients. MATERIALS AND METHODS: Between November 2016 and March 2017, a total of 109 pediatric CP patients (62 males, 47 females; mean age 9.3±2.9 years; range, 6 to 15 years) followed in our outpatient clinic were included. The demographic characteristics and type of CP of the patients were recorded. A functional evaluation was made using the ABILHAND-Kids and Manual Ability Classification System (MACS) surveys. The reliability of the surveys was tested based on internal consistency (Cronbach's α) and test-retest (intraclass correlation coefficient [ICC]) methods. The validity of the approach was evaluated using converted scores from an ABILHAND-Kids Rasch analysis and a correlation of the MACS levels. RESULTS: The ICC value for the test/retest reliability was 0.98 and internal consistency was 0.94. A strong negative correlation was found between the Turkish version of the ABILHAND-Kids and MACS surveys (r=-0.849; p<0.001). A Rasch analysis indicated good item fit, unidimensionality, and model fit. CONCLUSION: The Turkish version of the ABILHAND-Kids survey is a reliable and valid scale for the assessment of manual ability in Turkish children with CP.

Updated approach for the management of osteoporosis in Turkey: a consensus report.

As a result of the current demographics, increased projections of osteoporosis (OP) and prevalence of the disease in Turkey, a panel of multidisciplinary experts developed a thorough review to assist clinicians in identifying OP and associated fracture risk patients, diagnosing the disease with the appropriate available diagnostic methods, classifying the disease, and initiating appropriate treatment. The panel expects to increase the awareness of this prevalent disease, decrease consequences of OP with corresponding cost savings and, ultimately, decrease the overall burden of OP and related fractures in Turkey. BACKGROUND: OP is not officially accepted as a chronic disease in Turkey despite the high prevalence and predicted increase in the following years. However, there are areas where the country is performing well, such as having a country-specific fracture risk assessment model, DXA access, and the uptake of FRAX. Additional efforts are required to decrease the existing treatment gap estimating 75-90% of patients do not receive pharmacological intervention for secondary prevention, and the diagnosis rate is around 25%. METHODS: A selected panel of Turkish experts in fields related to osteoporosis was provided with a series of relevant questions to address prior to the multi-day conference. Within this conference, each narrative was discussed and edited by the entire group, through numerous drafts and rounds of discussion until a consensus was achieved. Represented in the panel were a number of societies including The Turkish Osteoporosis Society, The Society of Endocrinology and Metabolism of Turkey (SEMT), and The Turkish Society of Physical Medicine and Rehabilitation. RESULTS: Standardized general guidelines to identify OP and related fractures and at-risk population in Turkey, which will enable clinicians to accurately and effectively diagnose the disease, treat the appropriate patients with available pharmacological and non-pharmacological treatments and decrease the burden of the disease. CONCLUSIONS: This manuscript provides a review of the current state of OP and related fractures in Turkey. Moreover, this manuscript reviews current international guidelines and national studies and proposes a number of helpful country-specific classifications that can be used by healthcare providers caring for the at-risk population. Additionally, the panel proposes practical recommendations that should be implemented nationally in order to decrease the burden of OP and related fractures and effectively preventing the burden in future generations.

The efficacy of conservative treatment in patients with full-thickness rotator cuff tears.

Rotator cuff tears are a common cause of shoulder pain and disability. Although many studies have reported about the surgical results of full-thickness tears of the rotator cuff, there are few studies about the efficacy of conservative treatment. The aim of this study was to investigate the efficacy of conservative treatment in patients with full-thickness rotator cuff tears by using objective and subjective measurements. Twenty patients with full-thickness rotator cuff tears were included in the study. Outcome measures were range of motion, pain and function according to the shoulder index of the American Shoulder and Elbow Surgeons (ASES), Constant score, Short-Form 36 Health Survey (SF-36), isokinetic shoulder strength, and patient response. Patients were assessed at baseline and after 6 months. In addition, patients were contacted by telephone at 1 year and at 3 years for functional assessment according to ASES, and patient response. The treatment protocol included activity modification, oral nonsteroidal antiinflammatory medications, physical modalities, and a specific exercise program. Statistically significant improvements were obtained in range of motion, pain and function scores according to ASES, Constant score, SF-36 scores, and isokinetic strength (P < 0.05). At the 6-month evaluation, 11 patients (55%) reported that they were "much better", and 9 patients (45%) "better". Conservative treatment of full-thickness rotator cuff tears yields satisfactory results both subjectively and objectively.

Botulinum toxin A injection for spasticity in diplegic-type cerebral palsy.

Botulinum toxin type A can be both safe and effective in relieving spasticity in pediatric patients with cerebral palsy. In our prospective study, we evaluated the functional effect of botulinum toxin A in spastic diplegic-type cerebral palsy. Patients were examined on enrollment and at 1, 3, and 6 months after injection. Passive dorsiflexion of the ankle joint was measured using a goniometer as an angle of possible maximal dorsiflexion with the knee extended and flexed. Spasticity was graded using the Modified Ashworth Scale. Selective motor control at the ankle was assessed, and observational gait analysis was done. The functional status of the patients was determined by using the gross motor classification system. Botulinum toxin A was injected into the gastrocnemius muscle in all patients, and in four patients with concomitant jump knee gait, a hamstring muscle injection was added. Fourteen patients were included in the study. The mean age was 58.81 +/- 15.34 months. Following injection, spasticity was clinically decreased and statistically significant improvement was noticed in all clinical parameters after 1, 3, and 6 months of injection. The improvement in the clinical parameters decreased after 6 months but not to the baseline. One patient was Level II, four patients were Level III, and six patients were Level IV according to the Gross Motor Function Classification System at baseline. Improvement in the gross motor classification system is continued after 6 months in 12 children. The main goal of spasticity treatment in cerebral palsy is functional improvement. In our study, most of our patients had functional improvement according to the gross motor function classification system and did not change at 6 months.

Interobserver reliability of the Turkish version of the expanded and revised gross motor function classification system.

PURPOSE: Cerebral palsy (CP) is the most common disability in childhood. The gross motor function classification system (GMFCS) has become an important tool to assess motor function in CP patient. In 2007, the expanded and revised (E&R) version of GMFCS which includes age band for youth 12-18 years of age was developed. The aim of this study was to evaluate reliability of Turkish version of expanded and revised GMCS. METHODS: We assessed interobserver reliability between two physical medicine and rehabilitation specialists in 136 children with CP and test-retest reliability within a subgroup of 48 patients. Percent agreement, intraclass correlation coefficient (ICC) and µ statistics were used to evaluate reliability. RESULT: The ICC between two physicians was 0.97 and the total agreement was 89%. This result indicates excellent agreement. The overall weighted µ was 0.86. High test-retest reliability was found (ICC: 0.94 95% confidence interval) and the total agreement was 75% for test-retest reliability. CONCLUSION: The Turkish version of the E&R GMFCS is shown to be reliable and valid for assessment of Turkish CP children.

Clinical and functional outcomes and proprioception after a modified accelerated rehabilitation program following anterior cruciate ligament reconstruction with patellar tendon autograft.

OBJECTIVES: The aim of this study was to evaluate the clinical and functional outcomes and proprioceptive function in patients who received a modified accelerated rehabilitation program after anterior cruciate ligament (ACL) reconstruction with a patellar tendon (PT) graft. METHODS: The study included 38 patients (33 men, 5 women; mean age 27.6 ± 6.4 years; range 18 to 45 years) who underwent ACL reconstruction with a PT graft and participated in a modified accelerated rehabilitation program. Only six patients were athletes. Isokinetic strengths of concentric knee extension and flexion were measured with the Cybex isokinetic dynamometer, and static balance was tested with the Sport-KAT device. For proprioceptive assessment, active repositioning was measured at knee flexions of 40°, 20°, and 5° with an isokinetic dynamometer. Activity levels and subjective functional results were evaluated with the Tegner activity scale and Lysholm knee score, respectively. For objective functional testing, single leg hop, triple leg hop, and one-legged crossover hop tests were used. Knee stability was assessed with the Lachman test and anterior drawer test and knee range of motion was measured. The mean follow-up period was 16.2 ± 9.8 months. RESULTS: There was no graft failure during the follow-up. Twenty patients (52.6%) had hypoesthesia at the donor site and 15 patients (39.5%) had anterior knee pain. Before surgery, all the patients had positive results in the Lachman and anterior drawer tests. After surgery, the Lachman test was negative in 32 patients (84.2%), while six patients (15.8%) had grade 1 laxity. The mean Lysholm knee score showed a significant increase postoperatively (p<0.001). The mean preoperative and postoperative Tegner activity scores were not significantly different (p>0.05). There were no significant differences in the range of motion between operated and uninjured extremities (p>0.05). The two extremities were similar in proprioception and balance (p>0.05). Isokinetic quadriceps muscle strength was significantly decreased in the operated extremity only in extension at 60°/sec angular velocity (p<0.05). Other muscle strength measurements were similar in both extremities. The ratios of flexion/extension muscle strength were significantly greater in the involved extremity at all angular velocities (p<0.05). The mean performance scores of three functional tests were more than 85% of the uninvolved extremity. All the patients returned to preinjury daily activities or sports activities in 6 to 12 months postoperatively. CONCLUSION: We had satisfactory clinical, proprioceptive, and functional results in achieving dynamic and static stability of the knee with the modified accelerated rehabilitation program after ACL reconstruction with a PT graft.

Effects of muscle strengthening versus aerobic exercise program in fibromyalgia.

The purpose of this study was to compare the effects of aerobic training with a muscle-strengthening program in patients with fibromyalgia. Thirty women with fibromyalgia were randomized to either an aerobic exercise (AE) program or a strengthening exercise (SE) program for 8 weeks. Outcome measures included the intensity of fibromyalgia-related symptoms, tender point count, fitness (6-min walk distance), hospital anxiety and depression (HAD) scale, and short-form health survey (SF-36). There were significant improvements in both groups regarding pain, sleep, fatigue, tender point count, and fitness after treatment. HAD-depression scores improved significantly in both groups while no significant change occurred in HAD-anxiety scores. Bodily pain subscale of SF-36 and physical component summary improved significantly in the AE group, whereas seven subscales of SF-36, physical component summary, and mental component summary improved significantly in the SE group. When the groups were compared after treatment, there were no significant differences in pain, sleep, fatigue, tender point count, fitness, HAD scores, and SF-36 scores. AE and SE are similarly effective at improving symptoms, tender point count, fitness, depression, and quality of life in fibromyalgia.

Flexible flatfoot and related factors in primary school children: a report of a screening study.

The aim of this study was to analyze the longitudinal arch morphology and related factors in primary school children. Five hundred and seventy-nine primary school children were enrolled in the study. Generalized joint laxity, foot progression angle, frontal hindfoot alignment, and longitudinal arch height in dynamic position were evaluated. The footprints were recorded by Harris and Beath footprint mat and arch index of Staheli was calculated. The mean age was 9.23 +/- 1.66 years. Four hundred and fifty-six children (82.8%) were evaluated as normal and mild flexible flatfoot, and 95 children (17.2%) were evaluated as moderate and severe flexible flatfoot. The mean arch indices of the feet was 0.74 +/- 0.25. The percentage of flexible flatfoot in hypermobile and non-hypermobile children was found 27.6 and 13.4%, respectively. There was a statistically significant difference in dynamic arch evaluation between hypermobile and non-hypermobile children. There was a significant negative correlation between arch index and age, and a significant negative correlation between hypermobility score and age. Our study confirms that the flexible flatfoot and the hypermobility are developmental profiles.

The reliability and validity of the Turkish version of the Western Ontario Rotator Cuff Index.

To adapt the Western Ontario Rotator Cuff (WORC) index for use in Turkey and to investigate its reliability and validity; the Turkish version of the WORC was developed according to the guidelines in the literature. Seventy-two patients with rotator cuff disease were administered the questionnaire and were also evaluated by using the University of California Los Angeles (UCLA) shoulder rating scale, Constant score, and Short Form (SF)-36 to test validity. The WORC questionnaire was repeated in 35 patients after a mean interval of 2.9 days (range 2-7 days) to evaluate test-retest reliability. Cronbach's alpha was calculated as 0.92 for the total questionnaire. The intraclass correlation coefficients were very high and ranged between 0.96 and 0.98 for each section. There was a significant negative correlation between the Turkish version of WORC and UCLA (r = -0.598, P < 0.01), Constant score (r = -0.630, P < 0.01), and all subscales of SF-36 (P < 0.01). The Turkish version of the WORC index is a reliable and valid instrument for use in clinical trials in patients with rotator cuff disorders.

Functional outcome in patients with zone V flexor tendon injuries.

INTRODUCTION: Zone V flexor tendon injuries may involve major nerves and arteries as well as the wrist and finger flexors. Although these injuries are not infrequent, few studies have reported functional outcomes. The purpose of this study was to evaluate the functional outcome in patients with flexor tendon repairs in zone V. MATERIALS AND METHODS: Eighteen patients with repaired zone V flexor tendon injuries were followed up for an average of 20 months. The postoperative rehabilitation program consisted of a combined regime of modified Kleinert and modified Duran techniques. Outcome parameters were hand function according to the Buck-Gramcko assessment system, grip and key pinch strength values, and return to work status. RESULTS: Functional results were excellent in 92.8% of the digits, good in 1.4%, and poor in 5.8%. Grip strength recovered to an average of 77% and pinch strength to 74% of the uninjured hand. Two tendon ruptures occurred in a patient, and tenolysis was required in 3 patients. Of 15 patients who were employed at the time of injury, 13 returned to their original occupations. CONCLUSION: Satisfactory functional results can be obtained when proper surgical technique is coupled with careful postoperative management in patients with zone V flexor tendon injuries.

Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises.

OBJECTIVE: To assess the effect of nerve and tendon gliding exercises in carpal tunnel syndrome. DESIGN: The study was a prospective, randomized, before-and-after treatment trial. A total of 28 patients with the diagnosis of carpal tunnel syndrome in 36 hands were randomly assigned to two groups. A custom made neutral volar wrist splint was given to group 1 and group 2. The patients were instructed to wear the splints all night and during the day as much as possible for 4 wk. The patients in group 2 were also instructed to perform series of nerve and tendon gliding exercises in addition to the splint treatment. Patients were evaluated with clinical parameters, a functional status scale, and a symptom severity scale. RESULTS: At the end of treatment, statistically significant improvement was obtained in all parameters in both groups. The improvement in group 2 was slightly greater, but the difference between the groups was not significant, except for the lateral pinch strength value. Patient satisfaction was investigated during the follow-up period, ranging from 5 to 11 mo, with a mean of 8 mo. A total of 72% of the patients in group 1 and 93% of the patients in group 2 reported good or excellent results. The difference between the two groups was not statistically significant. CONCLUSION: Although the results in group 2 were better than group 1, the difference was not statistically significant. Further investigations are required to establish the role of nerve and tendon gliding exercises in the treatment of carpal tunnel syndrome.