High frequency neuronavigated repetitive transcranial magnetic stimulation in post-stroke shoulder pain: A double-blinded, randomized controlled study.

OBJECTIVE: This study aimed to determine the effect of 5Hz neuronavigated repetitive transcranial magnetic stimulation (rTMS) to the affected primary motor cortex (M1) on pain, the effect of pain on activities of daily living, disability, mood, neurophysiological parameters and passive shoulder joint range of motion in patients with post-stroke shoulder pain. DESIGN: Twenty two patients were randomized into an experimental group (rTMS, n=7) who received daily rTMS 5Hz 1000 pulses, five times/week for three weeks (15 sessions) to the affected M1 and a control group (n=11) who received sham stimulation. Outcome measures were Numeric Rating Scale (NRS), Brief Pain Inventory (BPI), Disabilities of the arm, shoulder, and hand questionnaire (Quick DASH), Hospital Depression Anxiety Scale (HADS), joint range of motion (ROM) measurements, neurophysiological parameters. Selected outcome measures were performed before treatment (T0), after the 5th session (T1) of rTMS treatment, after the 10th session (T2), after the 15th session (T3), and four weeks after the end of the treatment (T4). In the analysis of the outcomes, within-group comparisons were performed by using the Wilcoxon or Friedman test and between-group comparisons were performed by using the Mann-Whitney U test. RESULTS: There was no statistically significant difference between and within groups in terms of change- and followup scores in the NRS measurements (p>0.05). BPI scale was found to be lower in rTMS group at T0 and T3 (p= 0.010). Quick-DASH scores at T4 were found to be significantly lower in rTMS group (p= 0.032). However, no difference was found within each group over time (p>0.05) and there was no statistical difference between the groups in terms of change scores (T3-T0 and T4-T0) (p>0.05) for BPI and Quick-DASH. In rTMS group, there was a statistically significant difference in shoulder external rotation at T3 compared to the baseline (T0) (p=0.039). However, the magnitude of external rotation change (T3-T0) with the treatment was comparable in the groups. No statistically significant change occurred in both treatment groups in other range of motion measurements. CONCLUSION: High frequency neuronavigated rTMS to the affected M1 did not show any significant beneficial effect on pain, activities of daily living, disability, anxiety and depression, neurophysiological measurements and passive ROM over sham stimulation.

Anti-spastic effect of contralesional dorsal premotor cortex stimulation in stroke patients with moderate-to-severe spastic paresis: a randomized, controlled pilot trial.

OBJECTIVE: This study aimed at investigating the effect of a single-session repetitive transcranial magnetic stimulation (rTMS) of the contralesional dorsal premotor cortex on poststroke upper-limb spasticity. MATERIAL AND METHODS: The study consisted of the following three independent parallel arms: inhibitory rTMS (n = 12), excitatory rTMS (n = 12), and sham stimulation (n = 13). The primary and secondary outcome measures were the Modified Ashworth Scale (MAS) and F/M amplitude ratio, respectively. A clinically meaningful difference was defined as a reduction in at least one MAS score. RESULTS: There was a statistically significant change in MAS score within only the excitatory rTMS group over time [median (interquartile range) of - 1.0 (- 1.0 to - 0.5), p = 0.004]. However, groups were comparable in terms of median changes in MAS scores (p > 0.05). The proportions of patients achieving at least one MAS score reduction (9/12 in the excitatory rTMS group, 5/12 in the inhibitory rTMS group, and 5/13 in the control group) were also comparable (p = 0.135). For the F/M amplitude ratio, main time effect, main intervention effect, and time-intervention interaction effect were not statistically significant (p > 0.05). CONCLUSIONS: Modulation of the contralesional dorsal premotor cortex with a single-session of excitatory or inhibitory rTMS does not appear to have an immediate anti-spastic effect beyond sham/placebo. The implication of this small study remains unclear and further studies into excitatory rTMS for the treatment of moderate-to-severe spastic paresis in poststroke patients should be undertaken. CLINICAL TRIAL REGISTRATION NO: NCT04063995 (clinicaltrials.gov).

Evaluation of YouTube videos as sources of information about complex regional pain syndrome.

Background: As the internet usage becomes easily accessible, the patients are more frequently searching about diseases and medical/non-medical treatments. Considering that complex regional pain syndrome (CRPS) is a debilitating disease, it is important to check the information that patients are accessing. Therefore, this study aimed to investigate the reliability, sufficiency, and accuracy of the YouTube videos about CRPS. Methods: This study is a descriptive research which is derived by searching videos using the keyword 'complex regional pain syndrome' on YouTube. Relevance-based sequencing was used to sort the videos. Sources and video parameters were documented. To evaluate the accuracy, reliability and content quality of the videos, Global Quality Score, Journal of American Medical Association Benchmark Criteria and Modified DISCERN Questionnaire scales were used. Results: A total of 167 videos were included in this study. The majority of the videos originated from USA (80.2%, n = 134). The median number of views was 639 and the viewing rate was 73.3. Most of the videos had partially sufficient data and the interaction index viewing rate parameters for videos with high content quality were greater than videos with low content quality (P = 0.010, P = 0.014). Conclusions: Our results showed that videos about CRPS on YouTube mostly had partially sufficient data and include intermediate-high quality contents. Moreover, high-content quality videos had higher viewing rates, interaction indexes, number of likes, longer durations, as well as better reliability and accuracy scores. Videos with high quality and reliable content are needed to reduce misinformation about CRPS.

Inter-rater reliability of the Australian Spasticity Assessment Scale in poststroke spasticity.

To investigate the inter-rater reliability of the Australian Spasticity Assessment Scale (ASAS) in adult stroke patients with spasticity, two experienced clinicians rated the elbow flexor, wrist flexor, and ankle plantar flexor spasticity by using the ASAS in 85 persons with stroke. Unweighted and weighted (linear and quadratic) kappa statistics were used to calculate the inter-rater reliability for each muscle group. Unweighted kappa coefficients for elbow flexors (n = 83), wrist flexors (n = 80), and ankle plantar flexors (n = 77) were 0.67, 0.60, and 0.55, respectively. Linear and quadratic weighted kappa coefficients, respectively, were 0.77 and 0.87 for elbow flexors, 0.72 and 0.82 for wrist flexors, and 0.72 and 0.85 for ankle plantar flexors. The raters never disagreed by more than a single score in the rating of elbow flexors. On the contrary, the raters disagreed by more than a single score in three patients in the rating of ankle plantar flexors and in one patient in the rating of wrist flexors. The results suggested that inter-rater reliability of the ASAS differed according to the spastic muscle group assessed and the statistical method used. The strength of the agreement on the ASAS, an ordinal scale, ranged from good to very good when the weighted kappa values were considered.

Effect of muscle selection for botulinum neurotoxin treatment on spasticity in patients with post-stroke elbow flexor muscle over-activity: an observational prospective study.

PURPOSE/AIM: To investigate the effect of muscle selection for botulinum neurotoxin A (BoNT-A) treatment on spasticity in patients with post-stroke elbow flexor muscle over-activity. MATERIALS AND METHODS: Chronic stroke patients with a deforming spastic paresis in the upper limb (elbow flexion with forearm pronation) who were injected BoNT-A into at least one of elbow flexor muscles (brachialis, brachioradialis, and biceps brachii) were included in this prospective observational study. The main outcome measure was spasticity angle by Tardieu Scale recorded at pre-treatment and week 4 after treatment. RESULTS: Three muscle selection groups with sufficient sample size for statistical analysis were able to be created; brachialis (n = 14), biceps brachii (n = 21), and brachialis plus brachioradialis (n = 11). Although there was a significant improvement in spasticity angle within all groups over time (p < 0.05), the change in spasticity angle was not different between the groups (p > 0.05 for each pairwise comparison). However, the magnitude of the change in spasticity angle was larger in the groups in which brachialis was preferred. CONCLUSIONS: In stroke patients with a spontaneous spastic posture of elbow flexion and forearm pronation, targeting brachialis for BoNT-A injection seems more effective in reducing the severity of spasticity. CLINICAL TRIAL REGISTRATION NO: NCT04036981.

Effect of static knee joint flexion on vastus medialis obliquus fiber angle in patellofemoral pain syndrome: An ultrasonographic study.

INTRODUCTION: In patients with patellofemoral pain syndrome, the vastus medialis obliquus muscle fiber angle measured by ultrasound at knee extension was found to be different from that in healthy individuals. An important feature of patellofemoral pain syndrome is the increase in pain severity during activities that require knee flexion. OBJECTIVE: To investigate whether there was an ultrasonographic change in the vastus medialis obliquus fiber angle by flexing the knee joint in patients with patellofemoral pain syndrome compared to healthy pain-free individuals. DESIGN: A cross-sectional clinical study. SETTING: An outpatient clinic of a tertiary care hospital. PARTICIPANTS: Forty-seven patients with patellofemoral pain syndrome (median age of 40 years) and 43 healthy volunteers (median age of 39 years) were included in the study. INTERVENTIONS: No intervention. MAIN OUTCOME MEASURES: Vastus medialis obliquus fiber angle measured by ultrasonography at three different positions of knee joint including extension, 30° of flexion, and 45° of flexion. RESULTS: There was no significant change in the vastus medialis obliquus fiber angle with knee flexion in both groups (p > .05 for each group). However, the median vastus medialis obliquus fiber angle values in the group with patellofemoral pain syndrome were significantly lower at all knee joint angles than those in the comparison group (p < .05 at all knee joint angles). CONCLUSIONS: Although the vastus medialis obliquus fiber angle does not change with static knee flexion, the lower angle of the vastus medialis obliquus fiber in those with patellofemoral pain syndrome implicitly suggests that vastus medialis obliquus dysfunction may exist.

Caregiver burden in cerebral palsy: Validity and reliability of the Turkish version of caregiver difficulties scale.

BACKGROUND: This study aims to translate the caregiver difficulties scale (CDS) into Turkish language and to reveal its reliability and validity in Turkish informal family caregivers of children with cerebral palsy (CP). METHODS: This study included 130 participants (39.9 ± 7.8 years; range 24-58 years; 106 females and 24 males). Demographic properties of participants, relationship with the care recipient, income, caregiving time, CP type and diseases of the child (e.g., epilepsy, hydrocephalus and congenital heart disease) and the caregiver were recorded. The CDS, caregiver well-being scale (CWBS), World Health Organization Quality of Life (WHOQOL-BREF) and Beck depression inventory (BDI) were used for data collection. The internal consistency of the CDS was assessed using the calculation of Cronbach's alpha coefficient. A test-retest interval of 2 weeks was used to assess the reliability. The intercorrelation of variables was evaluated using the Spearman correlation coefficient. The receiver operating characteristic (ROC) analysis was performed to find the predictive power of CDS scores for depression. RESULTS: A total of 130 family caregivers of children with CP completed the test/retest procedures. The Cronbach alpha coefficients were found as 0.878 for the test and 0.852 for the retest. Intraclass correlation coefficient (ICC) value was found between 0.83 and 0.90 for test-retest reliability of the CDS. In addition, the CDS showed a significantly strong correlation with CWBS-activities of living subscale and WHOQOL-BREF psychological, physical and environment domains, as well as a significantly moderate correlation with CWBS basic needs subscale, BDI and WHOQOL-BREF general health and social domains. CDS scores that are >46 resulted in a sensitivity of 81.48% and a specificity of 73.79% for moderate-severe depression. CONCLUSION: The Turkish version of the CDS is a valid and reliable measure for caregiver burden of family caregivers of children with CP.

Effects of High-Frequency Neuronavigated Repetitive Transcranial Magnetic Stimulation in Fibromyalgia Syndrome: A Double-Blinded, Randomized Controlled Study.

OBJECTIVE: The primary aim of the study was to investigate the effect of 10-Hz repetitive transcranial magnetic stimulation to the left dorsolateral prefrontal cortex on pain in fibromyalgia. Secondary aims were to determine its effects on stiffness, fatigue, quality of life, depression/anxiety, and cognitive functions. DESIGN: Twenty participants were randomized into two groups. Group A received 10-Hz repetitive transcranial magnetic stimulation to left dorsolateral prefrontal cortex and group B received sham stimulation. Visual analog scale for pain, visual analog scale-stiffness, Fibromyalgia Impact Questionnaire, and Fatigue Severity Scale were assessed at the baseline, 2nd, and 6th weeks, whereas Hospital Anxiety Depression Scale and Addenbrooke's cognitive examination were assessed at the baseline and 6th week. RESULTS: There was no significant difference in visual analog scale-pain and Fatigue Severity Scale within and between groups over time (P > 0.05). In group A, significant improvement was found in visual analog scale-stiffness and fibromyalgia impact questionnaire at the 2nd week in comparison to the baseline (P < 0.05). However, no significant difference was detected in comparison with group B. There was no significant change in Hospital Anxiety Depression Scale scores between and within groups. All cognitive measures were similar in terms of differences from baseline between the groups (P > 0.05). CONCLUSIONS: High-frequency repetitive transcranial magnetic stimulation to the left dorsolateral prefrontal cortex did not show any significant beneficial effect on pain, stiffness, fatigue, quality of life, mood, and cognitive state over sham stimulation.

Somatosensory dysfunction related neuropathic pain component affects disease activity, functional status and quality of life in ankylosing spondylitis.

AIM: To investigate the neuropathic pain (NP) component in ankylosing spondylitis (AS) and to assess the relations between NP and disease characteristics. METHODS: Eighty participants were included in this study. Demographic properties, duration of disease, laboratory values and clinical assessments (visual analog scale [VAS], Bath Ankylosing Spondylitis Disease Activity Index [BASDAI], Bath Ankylosing Spondylitis Functional Index [BASFI], Bath Ankylosing Spondylitis Metrology Index [BASMI], Short Form [SF]-36 questionnaire, Beck Depression Inventory [BDI]) were recorded. The NP component was assessed by both DN4 and PainDETECT questionnaires (PD-Q) and patients were classified into groups according to questionnaire scores. RESULTS: NP component was detected by the DN4 and PD-Q in 40% and 28.7% of our patients, respectively. Likely-NP group had significantly higher scores in VAS-pain, BASDAI, BASFI, BASMI and BDI compared with both uncertain-NP and unlikely-NP groups. There was no significant difference between the SF-36 scores of the likely-NP and uncertain-NP groups. Moreover, all SF-36 scores were significantly lower in the likely-NP group than in the unlikely-NP group. Based on DN4 scale, patients with NP had significantly higher erythrocyte sedimentation rate (ESR), VAS, BASDAI, BASFI, BASMI scores and significantly lower SF-36 (except social functioning) scores compared to patients without NP. Both painDETECT and DN4 scores of the patients were significantly positively correlated with ESR, VAS, BASDAI, BASFI, BASMI, BDI scores and negatively correlated with all SF-36 scores. CONCLUSIONS: Our results revealed that the presence of NP component in patients with AS is associated with various disease-related variables, including pain, high disease activity, reduced mobility of the axial skeleton, depression and poor quality of life.

YouTube as a Source of Information for Transcranial Magnetic Stimulation in Stroke: A Quality, Reliability and Accuracy Analysis.

BACKGROUND AND OBJECTIVES: Studies using YouTube data for various diseases are rapidly increasing. This study aimed to investigate the educational quality, reliability and accuracy of the YouTube videos concerning repetitive transcranial magnetic stimulation (rTMS) applications in patients with stroke. METHODS: This is a descriptive study. A video based search on YouTube was performed on April 18th, 2020 by using keyword 'stroke repetitive transcranial magnetic stimulation'. The videos were queried using the default settings on YouTube and the results were listed according to relevance. Video parameters and sources were recorded. Quality, reliability and accuracy of the videos were determined with Global Quality Score (GQS), Journal of American Medical Association (JAMA) Benchmark Criteria and Modified DISCERN Questionnaire, respectively. RESULTS: A total of 21 videos were included in the study. The median number of views for videos was 884 (range: 89-28589) and the median duration was 135 seconds. None of the videos had a negative interaction index. The median value was found to be 3 for all three measurements (GQS, JAMA, and DISCERN). Most of the videos were of intermediate quality (47.6%) and had partial sufficient data (61.9%). In the high-quality group, the number of views, dislikes, the duration of the videos, JAMA and DISCERN scores were higher than the low-quality group (p < 0.05). At the same time, viewing rates of the high-quality group were better than the low and the intermediate-quality group (p < 0.05). There was a significant positive correlation between GQS and number of the views, video duration, number of likes, number of dislikes, viewing rate and modified DISCERN questionnaire scores (p < 0.05). CONCLUSION: Our results showed that most of the rated videos were of intermediate quality and had partially sufficient data. It has also been found that high-quality videos have higher viewing rates, more dislikes, longer video durations as well as better reliability and accuracy scores. YouTube videos of higher quality and accuracy are needed to increase awareness of rTMS by stroke patients.

Validity and reliability of the Turkish version of caregiver self-assessment questionnaire.

Objective: This study aims to translate the Caregiver Self-Assessment Questionnaire (CSAQ) into Turkish language and to test its reliability and validity in Turkish informal family caregivers.Materials and methods: This is a cross-sectional and methodological study. Eighty family caregivers (54.53 ± 12.07 years; range 25 to 77 years; 65 females, 15 males) were included in the study. Demographic properties of the participants (age, sex, education, occupation, marital status), relationship with care recipient, caregiving time, main diseases of the patients were recorded. After that CSAQ, Caregiver Well-Being Scale (CWBS) and Hospital Anxiety Depression Scale (HADS) were used for data collection. A test-retest interval of seven-days was used to assess the reliability. Internal consistency between the items was assessed by Cronbach's alpha coefficient. For reliability; test-retest reliability, intraclass correlation coefficient, and paired sample t tests were used. Intercorrelation of variables was performed with Spearman's rho tests. A ROC curve and sensitivity and specificity analysis were performed to determine the ability of the CSAQ to predict depression or anxiety.Results: Totally 80 participants completed test/retest procedures. Content Validity Index values of the Items were sufficient and all items were included in the questionnaire. During exploratory factor analysis, 1 factor with eigenvalues greater than 1 were extracted, explaining 62.36% of the total variance. The corrected item total correlation coefficients for Item 2 and Item 5 were found to be <0.3. Therefore, these two items were omitted. Cronbach's α value was found as 0.90 (excellent level). Test-retest reliability (Intraclass correlation coefficient values range: 0.93-0.97) of the CSAQ was found to be excellent. Statistically negative moderate correlations were detected between CSAQ total score and CWBA basic needs and activities of living sub scores (rho = -0.605, rho = -0.523, p < 0.001), while positive strong correlations were detected between HADS depression and anxiety scores (rho = 0.610, rho = 0.651, p < 0.001). CSAQ score of 9 or greater resulted in a sensitivity of 0.56 and a specificity of 0.87 for depression and sensitivity of 0.84 and a specificity of 0.83 for anxiety. According to the scoring instructions of CSAQ with the positivity of any one of four criteria, we found sensitivity of 0.87 for depression and 0.96 for anxiety.Conclusion: The Turkish version of the CSAQ is a valid and reliable questionnaire for evaluating stress-levels of informal family caregivers.Implications for rehabilitationMeasures of caregivers' psychological status are of clinical value.The Caregiver Self-Assessment Questionnaire functions as a screening measure for symptoms of depression and anxiety.The Turkish version of the Caregiver Self-Assessment Questionnaire is a valid and reliable questionnaire for evaluating stress-levels of informal family caregivers.

Activities and participation after stroke: validity and reliability of the Turkish version of IMPACT-S questionnaire.

Objective: This study aims to translate the screener part of the The International Classification of Functioning, Disability and Health (ICF) Measure of Participation and ACTivities Questionnaire (IMPACT-S) into Turkish and to test its reliability and validity in Turkish patients with stroke.Materials and methods: Participants were recruited from the inpatient rehabilitation clinic of a university hospital. Eighty-six stroke patients (mean ages: 60.43 ± 12.62 years; range 20-82 years; 51 males and 35 females) were included in the study. Demographic properties of the patients (age, sex, education, occupation, and body mass index), the start of in-patient rehabilitation treatment, affected extremity, types of stroke, and comorbidities were recorded. After that IMPACT-S questionnaire and World Health Organization Disability Assessment Schedule-II (WHODAS-II) were used for data collection. A test-retest interval of 7 d was used to assess the reliability. Internal consistency between the items was assessed by Cronbach's alpha coefficient. For reliability; test-retest reliability, intraclass correlation coefficient (ICC), paired sample t-test were used. Intercorrelation of variables was performed with Spearman's rho tests.Results: Totally 86 patients completed test/retest procedures. Cronbach's alpha coefficient of the questionnaire was found to be 0.96. Both internal consistency (Cronbach's alpha score range: 0.65-0.98) and test-retest reliability (ICC values range: 0.86-0.97) of the IMPACT-S were found to be good. The correlations between all IMPACT-S subscales were moderate to strong (correlation range: 0.45-0.80). The correlation between the Activities and Participation scores (0.86) and IMPACT-S total score (0.96) were very strong. Statistically significant negative correlations were detected between all sub-scores of IMPACT-S and WHODAS-II, except for life activities/communication and life activities/knowledge. These findings show excellent concurrent validity. However, a lower-than-expected correlation between Major life areas (IMPACT-S) and Life activities (WHODAS-II) was observed.Conclusion: The Turkish version of the IMPACT-S is a valid and reliable questionnaire for evaluating activities and participation in patients with stroke.Implications for rehabilitationPatients with stroke experience difficulties across multiple participation domains, such as major life areas and community life.The screener part of the IMpact on Participation and ACTivities (IMPACT-S) questionnaire is the only measure that accurately reflects The International Classification of Functioning, Disability and Health (ICF) sections and appears a promising outcome measure in rehabilitation research.The Turkish version of the IMPACT-S was found to be valid and reliable for evaluating "Activities and Participation" in stroke patients.

Ultrasonographic and electrophysiologic evaluation of median and ulnar nerves in chronic stroke patients with upper extremity spasticity.

Objective: To evaluate the upper extremity nerves of stroke patients morphologically and electrophysiologically and to determine whether there is a relationship between clinical evaluations, ultrasonographic measurements, and electrodiagnostic findings. Methods: This cross-sectional study included 30 chronic stroke patients. After recording demographical data, clinical, ultrasonographic, and electrophysiological evaluations were performed. Clinical evaluations included Brunnstrom Recovery Stages (BRS), Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS), Motricity index (MI), Functional Independence Measurement (FIM), and Functional Ambulation Scale (FAS). For ultrasonographic measurements, median and ulnar nerves were scanned. Median and ulnar nerve conduction studies were performed bilaterally. Results: Mean ages of the patients were 62.2 ± 13.0 years (range 24-84 years; 22 males, 8 females). There was no significant difference in median/ulnar nerve ultrasonographic measurements between paretic and non-paretic sides (p > .05), whereas median nerve motor conduction velocity was significantly slower and median nerve F-wave latency was prolonged on the paretic side (p < .05). The median and ulnar nerve compound motor action potential (CMAP) amplitudes of paretic sides were positively correlated with lower extremity BRS and FAS scores. Median CMAP amplitudes were also positively correlated with FIM scores and ulnar CMAP amplitudes were positively correlated with motricity scores. Moreover, on the paretic side, there were positive correlations of median SNAP amplitudes with FIM and FAS scores (p < .05). Conclusions: Our results showed electrophysiological changes in peripheral nerves on the paretic upper extremities, however, no morphological change was determined. Further studies with larger number of patients and longer follow-up periods are needed to clarify the effect of stroke and spasticity on the peripheral nervous system.

The effect on upper extremity functions of cardiac electronic device placement on the dominant hand side.

BACKGROUND: Although cardiac implantable electronic device (CIED) implantation is considered to be minor surgery, almost 60% of the patients suffer from shoulder-related problems a short time after the procedure. The purpose of this study was to determine the possible effects of the preference of the dominant side for CIED implantation on the ipsilateral superior extremity functions. METHODS: The study included a total of 107 patients who had been living with a CIED for >6 months. Patients were separated into two groups according to the dominant hand and side of the CIED. The ipsilateral dominant-hand group comprised those with a CIED on the same side as the dominant hand and the contralateral dominant-hand group included patients with the CIED placed on the contralateral side to the dominant hand. Visual analogue scale (VAS) pain score, quick disability of the arm shoulder and hand questionnaire (QuickDASH) and maximum isometric grip strength tests were used to evaluate the upper extremity disabilities. RESULTS: No significant difference was determined between the groups in respect of VAS pain scores (P = 0.10), QuickDASH scores (P = 0.21), and limitations of the shoulder joint range of motion (P = 0.192). The maximum isometric grip strength was significantly different in the right hands between two groups (34 [16-95]-40 [24-85]) (P = 0.02). CONCLUSION: The present study shows that the joint range of motion limitation, pain, and disability of the upper extremity were no different in the affected arm compared to the healthy contralateral side with respect to the placement of the CIED on the dominant or non-dominant side.

Is high-frequency repetitive transcranial magnetic stimulation of the left primary motor cortex superior to the stimulation of the left dorsolateral prefrontal cortex in fibromyalgia syndrome?

OBJECTIVE: To investigate effectiveness of two different high-frequency repetitive transcranial magnetic stimulation (rTMS) protocols on pain, fatigue, quality of life (QoL) and depression in female patients with fibromyalgia. METHODS: Thirty patients were randomized into three groups. Fifteen sessions of 10 Hz (90% resting motor threshold-RMT, 1200 pulses) rTMS were applied to left primary motor cortex and left dorsolateral prefrontal cortex (DLPFC) in Group M1 (n:10) and Group DLPFC (n:10), respectively. Group sham (n = 10) received 15 sessions of sham rTMS over 3 weeks. Visual Analogue Scale, Fibromyalgia Impact Questionnaire, Fatigue Severity Scale, Short-form 36, and Beck Depression Inventory were assessed at baseline and at the end of the treatments by a blinded-experienced assessor. RESULTS: Significant improvements in pain, QoL, and depression scores were observed in three groups. However, improvements in depression, physical functioning, physical role functioning, and general health perceptions were greater in active rTMS groups than in sham group. Emotional role functioning was only improved in Group M1. The decrease in VAS scores was significantly greater in Group M1 when compared to sham group. Change in physical role functioning was significantly greater in Group DLPFC than in Group M1. CONCLUSIONS: Significant improvements in physical role functioning, physical functioning, depression, and general health perceptions were achieved in active rTMS groups. Further clinical studies on larger samples involving both sexes with longer follow-up durations are needed.

Assessment of post-stroke elbow flexor spasticity in different forearm positions.

Purpose/Aim: There have been conflicting results regarding which muscle contribute most to the elbow spastic flexion deformity. This study aimed to investigate whether flexor spasticity of the elbow changed according to the position of the forearm, and to determine the muscle or muscles that contributed most to the elbow spastic flexion deformity by clinical examination. METHODS: This study is a single group, observational and cross-sectional study. Sixty patients were assessed for elbow flexor spasticity in different forearm positions (pronation, neutral and supination) with Modified Tardieu Scale. The primary outcome measure was a domain of the Modified Tardieu Scale, the dynamic component of spasticity (spasticity angle). RESULTS: In general, there was a significant difference between forearm positions regarding spasticity angle (p < .001). In pairwise comparisons, median spasticity angles in pronation (70 degrees) and neutral position (60 degrees) were significantly higher than those in supination (57.5 degrees) (adjusted p < .001 and adjusted p = .003, respectively). However, median spasticity angle in pronation did not differ significantly from those in neutral position in favour of pronation (adjusted p = .274). CONCLUSIONS: The severity of spasticity changes according to the elbow position which suggests that the magnitude of contribution of each elbow flexor muscle to spastic elbow deformity is different. Reduction of spasticity from pronation to supination leads us to consider brachialis as the most spastic muscle. Since biceps was suggested to be the least spastic muscle in this study, and also to avoid spastic pronation deformity of the forearm, it should be rethought before performing chemodenervation into biceps muscle.

Comparison of different electrotherapy methods and exercise therapy in shoulder impingement syndrome: A prospective randomized controlled trial.

OBJECTIVE: The aim of this study was to assess and compare the effects of different electrotherapy methods and exercise therapy on pain, function and quality of life in shoulder impingement syndrome. METHODS: Eighty-three patients (66 females, 17 males; mean age: 48.2 ± 7.33 years) with shoulder impingement syndrome were selected and 79 of them were randomly allocated into four groups. Group 1 (n = 19, mean age: 47.89 ± 7.12 years) was given hot pack and exercises, Group 2 (n = 20, mean age: 47.70 ± 6.51 years) was given hot packs, exercises and interferential current, Group 3 (n = 20, mean age: 48.50 ± 8.34 years) was given hot packs, exercises and TENS and Group 4 (n = 20, mean age: 48.55 ± 7.89 years) was given hot packs, exercises and ultrasound three times a week for four weeks. Assessments were made before treatment, right after it and three months after that using the visual analog scale (VAS), Short Form-36 (SF-36) and the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measures. RESULTS: At the fourth week and third month assessments, all groups showed significant improvements in terms of pain, DASH and SF-36 physical component scores (p < 0.05). In intragroup comparisons, a significant difference between pre- and post-treatment results was found only in SF-36 mental component scores of Group 2. No significant difference was observed between the groups in any stage of the study period (p > 0.05). CONCLUSION: Application of ultrasound, interferential current and TENS in addition to exercise therapy in shoulder impingement syndrome treatment had similar improvements in terms of pain, function and physical component of quality of life. However, interferential current treatment showed significantly better outcomes for the mental component of quality of life. LEVEL OF EVIDENCE: Level I, Therapeutic study.

Investigation of the Relationship between Anterior Knee Pain and Chondromalacia Patellae and Patellofemoral Malalignment.

OBJECTIVE: The study aimed to investigate whether there is any association of anterior knee pain and knee function with chondromalacia stage and patellofemoral alignment in patients with anterior knee pain for over a month and with chondromalacia patellae (CMP) detected by magnetic resonance imaging (MRI). MATERIALS AND METHODS: We reviewed the medical records of 38 patients who underwent a knee MRI examination and were diagnosed with chondromalacia based on the MRI. Knee MRI images were evaluated by a radiologist for chondromalacia staging. Patients were divided into two groups as early stage (stage 1-2) and advanced stage (stage 3-4) chondromalacia. Patients' demographical data (age, sex, and occupation), clinical features, physical examination findings and patellofemoral pain severity scale, kujala patellofemoral scoring system, and functional index questionnaire scores were obtained from their medical records. Trochlear sulcus angle, sulcus depth, lateral patellofemoral angle, patellar translation, and Insall-Salvati index were measured using the MRI images. RESULTS: The mean patient age was higher in the advanced stage CMP group compared to the early stage CMP group (p=0.038). There was no statistically significant difference regarding other demographical data (p>0.05). MRI measurement parameters did not show difference between the groups (p>0.05). Patients in the advanced stage CMP group had higher patellofemoral pain severity score, lower kujala patellofemoral score, and lower functional index questionnaire score compared to the early stage CMP group. The differences were statistically significant (p=0.008, p=0.012, and p=0.026, respectively). CONCLUSION: As chondromalacia stage advances, the symptom severity worsens and knee functions decline; however, MRI measurements do not show difference between early and advanced stage CMP patients.

Effects of Kinect-based virtual reality game training on upper extremity motor recovery in chronic stroke.

BACKGROUND: Therapeutic benefits of Kinect-based virtual reality (VR) game training in rehabilitation encourage its use to improve motor function. OBJECTIVE: To assess the effects of Kinect-based VR training on motor recovery of the upper extremity and functional outcomes in patients with chronic stroke. METHODS: In this randomized controlled trial, group A received 20 sessions of physical therapy (PT) + 20 sessions of Kinect-based VR training and group B received only 20 sessions of PT. Clinical outcome measures were assessed at baseline and at the end of the treatments. Primary outcome measures that assess stroke patients' motor function included upper extremity (UE) Fugl-Meyer Assessment (FMA). Secondary outcome measures were Brunnstrom Recovery Stages (BRS), Modified Ashworth Scale (MAS), Box and Block test (BBT), Motricity index (MI), and active range of motion (AROM) measurement. RESULTS: Statistically significant improvements in game scores (p < 0.05) were observed in group A. In within-group analysis, there were statistically significant improvements in all clinical outcome measures except for the BRS-hand, MAS-distal, and MAS-hand in group A; MAS-(proximal, distal, hand) and BRS-(UE, hand) in group B compared with baseline values. Differences from baseline of FMA, MI, and AROM (except adduction of shoulder and extension of elbow) were greater in group A (p < 0.05). CONCLUSIONS: To conclude, our results suggest that the adjunct use of Kinect-based VR training may contribute to the improvement of UE motor function and AROM in chronic stroke patients. Further studies with a larger number of subjects with longer follow-up periods are needed to establish its effectiveness in neurorehabilitation.

Comparison of Efficiency Between Corticosteroid and Platelet Rich Plasma Injection Therapies in Patients With Knee Osteoarthritis.

OBJECTIVES: This study aims to assess whether platelet rich plasma (PRP) is an effective treatment for knee osteoarthritis, and compare its efficiency with corticosteroid treatment in terms of pain control, physical function, and quality of life. PATIENTS AND METHODS: The study included 50 patients (4 males, 46 females; mean age 61.6±6.9 years; range 50 to 75 years) who were diagnosed as grade 3 knee osteoarthritis. Patients were randomized into three groups as corticosteroid group (receiving one corticosteroid injection), single PRP group (receiving one PRP injection), and three PRP group (receiving three PRP injections with one week interval). All patients were given a home exercise program. Patients were evaluated with Visual Numeric Scale (VNS), Western Ontario and McMaster Universities Arthritis Osteoarthritis Index (WOMAC), Lequesne index and the Hospital Anxiety and Depression Scale before treatment, and at second and sixth months following the implementation of injections. RESULTS: In single and three PRP groups; VNS, WOMAC and Lequesne scores decreased significantly at second month follow-up; also, sixth month scores showed a slight increase but remained significantly lower than baseline. In corticosteroid group, all VNS, WOMAC, and Lequesne scores decreased at second month follow-up; however, at sixth month, rest, night VNS and WOMAC stiffness scores were increased while no significant difference was found with baseline. At sixth month; VNS movement, WOMAC pain, function, and the total and Lequesne scores were worse, but remained significantly lower than baseline. When groups were compared, three PRP group's second month VNS movement scores were significantly lower than the corticosteroid group. Sixth month VNS movement and WOMAC pain scores were significantly lower in single and three PRP groups compared to the corticosteroid group, with no significant difference between the PRP groups. CONCLUSION: Our findings revealed that PRP is a safe treatment option and efficient in osteoarthritis symptom control up to six months after application. Treatment response obtained with corticosteroid injection has a shorter duration than PRP treatment.