Comparison of mobilization with supervised exercise for patients with subacromial impingement syndrome.

OBJECTIVES: This study aims to investigate the effects of joint mobilization with supervised exercise in patients with subacromial impingement syndrome (SAIS). PATIENTS AND METHODS: This prospective, randomized-controlled study included a total of 40 patients (18 males, 22 females; mean age 43.52 years; range, 27 to 67 years) with SAIS of more than six weeks between June 2014 and June 2015. The patients were randomly allocated into two groups: Group 1 (n=20) received joint mobilization and neuromuscular electrical stimulation and Group 2 (n=20) received a supervised exercise program and neuromuscular electrical stimulation. The outcome measures included the range of motion, pain intensity, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form-patient self-report section, Short Form-36, and Global Rating of Change Questionnaire. Pain was evaluated using the visual analog scale (VAS). RESULTS: In both groups, the mean VAS scores significantly decreased and the range of motion significantly increased after treatment (p<0.05). Both joint mobilization and supervised exercise combined with neuromuscular electrical stimulation led to a significant improvement in function in patients with SAIS (p<0.05), although it did not significantly differ between the groups (p>0.05). Patient satisfaction with treatment was similar in both groups (p=0.28). CONCLUSION: Based on our study results, mobilization and supervised exercise yield comparable outcomes in patients with SAIS.

Associations between the severity of disability level and fear of movement and pain beliefs in patients with chronic low back pain.

BACKGROUND AND OBJECTIVES: Low back pain (LBP) is one of the leading forms of chronic pain and is among the leading causes of pain and disability. In this study, we investigated the associations between the severity of disability and fear of movement and pain beliefs as well as the impact of the fear of movement and pain beliefs on the quality of life in patients with chronic LBP. METHODS: A total of 89 patients (42.29 ± 16.05 years) with chronic low back pain were included in the study. The instruments used in the assessments include the Visual Analogue Scale (VAS), the Oswestry Disability Index (ODI), the Tampa Kinesiophobia Scale (TKS), the Pain Belief Questionnaire (PBQ), and the SF 36-Short Form. Patients were assigned into three groups by disability severity based on ODI scores. Statistical analysis was performed using SPSS 15. RESULTS: No statistically significant intergroup differences were found in TKS and PBQ scores (p> 0.05). A positive correlation was found between TKS scores, age (r: 0.227/p< 0.05), PBQ organic (r: -0.250/p< 0.05) scores. CONCLUSIONS: Our study revealed high levels of kinesiophobia and similar pain beliefs, independent of the severity level of disability. We believe that cognitive-behavioral therapy that may reduce fear-avoidance behaviors and convert negative pain beliefs into positive ones should be added to rehabilitation procedures for LBP.

Medical complications experienced by first-time ischemic stroke patients during inpatient, tertiary level stroke rehabilitation.

[Purpose] The aim of this study was to assess the medical complications in first-time ischemic stroke patients, to identify the factors related to occurrence of complications. [Subjects and Methods] First-time ischemic stroke patients (n=81) admitted to a tertiary level inpatient rehabilitation center during a 5 year period were included in the study. The attending physiatrist noted the presence of specific medical complications and complications that required transfer to the acute care facility from patient records. The Oxfordshire Community Stroke Project classification was used to define the clinical subtypes of the ischemic stroke patients. The Charlson comorbidity index was used to evaluate co-morbid conditions. Functional disability was assessed using the Functional Independence Measure at admission and discharge. [Results] We found that 88.9% of the patients had at least one complication. The five most common complications were urinary tract infection (48.1%), shoulder pain (37.0%), insomnia (37.0%), depression (32.1%), and musculoskeletal pain other than shoulder pain (32.1%) and 11.1% of patients were transferred to acute care facility during rehabilitation period. Functional Independence Measure scores both at admission and discharge were significantly lower in patients with at least one complication than in patients with no complications. [Conclusion] Medical complications are common among patients undergoing stroke rehabilitation. Close interdisciplinary collaboration between physiatrists and other medical specialities is necessary for optimal management.

Comparison of the long-term effectiveness of progressive neuromuscular facilitation and continuous passive motion therapies after total knee arthroplasty.

[Purpose] The aim of this longitudinal study was to examine the long term functional effectiveness of proprioceptive neuromuscular facilitation (PNF) after total knee arthroplasty. [Subjects and Methods] We included 30 patients and they were randomly assigned to two groups. In addition to the standard rehabilitation program the PNF group received proprioceptive neuromuscular facilitation therapy and the CPM group received continuous passive motion therapy. The outcome measures included range of motion using a goniometer, pain scores using a numeric pain rating scale, days to reach functional benchmarks, the Beck depression scale and isokinetic torque and isometric strength measurements. [Results] There were no significant differences between the two groups in terms of baseline demographic data, clinical findings and length of stay. Days to reach range of motion benchmarks were similar in the two groups. Pain at the 8th week was slightly higher in the PNF group. With the exception of walking with a walker, days to reach functional benchmarks were statistically significantly fewer in patients of the PNF group despite similar isokinetic measurements. Administration of PNF resulted in earlier functional gains in patients after total knee arthroplasty. These functional accomplishments were more pronounced in the PNF group despite it having isokinetic torque measurements similar to those of the CPM group. [Conclusion] PNF techniques can positively affect functional outcomes over the long term.

Association of ideomotor apraxia with lesion site, etiology, neglect, and functional independence in patients with first ever stroke.

BACKGROUND: Ideomotor apraxia (IMA) is characterized by the inability to correctly imitate hand gestures and voluntarily pantomime tool use. The relationship between IMA and characteristics of stroke has not been totally elucidated. OBJECTIVE: This study aimed to find out associations between presence of IMA and stroke etiology, site of the lesions, neglect, and temporal and functional parameters of stroke in patients with first ever stroke. METHODS: Thirty-nine patients with first ever stroke were included. Patients with severe cognitive deficits were excluded. Assessment tools included Ideomotor Apraxia Test, Functional Independence Measure (FIM), Brunnstrom recovery stages, Mini Mental Test (MMT), and star cancellation test. Etiology (hemorrhagic or ischemic) and site of stroke was assessed through brain imaging methods. Location and size of ischemic lesion was determined by using the Oxfordshire Community Stroke Project system. RESULTS: IMA was identified in 35.9% of the patients. Patients with IMA had significantly lower FIM scores both on admission and discharge (P = 0.001, P = 0.001). Presence of IMA was significantly associated with the presence of neglect (P = 0.004), total anterior circulation ischemia (TACI) (P < 0.001), and lower MMT scores (P < 0.001). Lesion site, patient age, time since onset, and stroke etiology had no impact on the presence of IMA. CONCLUSION: IMA was in concordance with poor cognitive and functional state and was not limited to left hemisphere lesions. The study revealed strong associations between IMA, neglect, and TACI. Every patient with stroke should be evaluated for the presence of IMA on admission to rehabilitation unit.

Evalution of Mulligan's technique for adhesive capsulitis of the shoulder.

OBJECTIVE: To evaluate Mulligan's technique for relieving pain and improving functional capacity of the shoulder in patients with adhesive capsulitis in the stiffness phase. DESIGN: Randomized controlled study. METHODS: A total of 40 subjects were randomly allocated into 2 groups: (i) group 1 (n = 20) were treated with hot pack, transcutaneous electrical nerve stimulation, and passive stretching exercises; (ii) group 2 (n = 20) were treated with hot pack, transcutaneous electrical nerve stimulation and Mulligan's technique. Mulligan's technique combines the sustained application of a manual "gliding" force to a joint, with the aim of repositioning bone positional faults while enabling concurrent physiological (osteo-kinematic) motion of the joint. All cases were evaluated using visual analogue scales for pain, passive and active range of motion, Constant score, Shoulder Disability Questionnaire, and patient and therapist satisfaction at baseline, after completion of treatment sessions and at the end of 3 months of follow-up. RESULTS: Marked improvement was noted in both groups after completion of treatment sessions and at the third month of follow-up compared with baseline. The improvements in outcome measures, namely pain, range of motion, shoulder scores, and patient and physiotherapist satisfaction, were significantly greater in subjects in group 2, who were treated with Mulligan's technique. CONCLUSION: Mulligan's technique and passive stretching exercises are both effective in reducing pain, and restoring range of motion and function. However, compared with stretching exercises, Mulligan's technique led to better improvements in terms of pain, range of motion, shoulder scores, and patient and physiotherapist satisfaction.

Is magnesium citrate treatment effective on pain, clinical parameters and functional status in patients with fibromyalgia?

The aims of this study were to investigate the relationship between magnesium levels and fibromyalgia symptoms and to determine the effect of magnesium citrate treatment on these symptoms. Sixty premenopausal women diagnosed with fibromyalgia according to the ACR criteria and 20 healthy women whose age and weight matched the premenopausal women were evaluated. Pain intensity, pain threshold, the number of tender points, the tender point index, the fibromyalgia impact questionnaire (FIQ), the Beck depression and Beck anxiety scores and patient symptoms were evaluated in all the women. Serum and erythrocyte magnesium levels were also measured. The patients were divided into three groups. The magnesium citrate (300 mg/day) was given to the first group (n = 20), amitriptyline (10 mg/day) was given to the second group (n = 20), and magnesium citrate (300 mg/day) + amitriptyline (10 mg/day) treatment was given to the third group (n = 20). All parameters were reevaluated after the 8 weeks of treatment. The serum and erythrocyte magnesium levels were significantly lower in patients with fibromyalgia than in the controls. Also there was a negative correlation between the magnesium levels and fibromyalgia symptoms. The number of tender points, tender point index, FIQ and Beck depression scores decreased significantly with the magnesium citrate treatment. The combined amitriptyline + magnesium citrate treatment proved effective on all parameters except numbness. Low magnesium levels in the erythrocyte might be an etiologic factor on fibromyalgia symptoms. The magnesium citrate treatment was only effective tender points and the intensity of fibromyalgia. However, it was effective on all parameters when used in combination with amitriptyline.

Deconditioning in chronic low back pain: might there be a relationship between fitness and magnetic resonance imaging findings?

The presence of persistent low back pain leads to avoidance of daily activities, contributes to further exercise intolerance and subsequent further loss of functional capacity. We sought to search for the relationship between lumbar magnetic resonance imaging findings and deconditioning in a homogeneous subset of patients with low back pain. We studied 20 sedentary, nonsmoking patients with chronic low back pain using symptom-limited cardiopulmonary exercise testing using treadmill breath-by-breath analysis using modified Bruce protocol. Lumbar facet and disc degeneration involving L1-S1 levels were assessed using 1.5 Tesla MRI. The total number of levels involved was positively correlated with age (r = 0.478, P = 0.033). The Pfirrmann grading of lumbar disc degeneration was positively correlated with Weishaupt grading of facet degeneration (r = 0.502, P = 0.024); however, VO(2) peak was only negatively correlated with facet degeneration (r = -0.5, P = 0.025). Facet joint-mediated pain is a significant problem in all patients suffering from chronic low back pain. Since in this study, aerobic fitness level was negatively correlated with facet degeneration, we suggest that degeneration of facet joints might better reflect the chronicity of low back pain when compared to intervertebral disc degeneration.

Health-related quality of life in patients with myofascial pain syndrome.

Health-related quality of life is being emphasized because people who are living with a chronic illness are demanding that the qualities of their lives are enhanced. Health-related quality of life defines the effects of diseases or symptoms including musculoskeletal conditions on functioning and a sense of well being. This review highlights the results of quality-of-life measurements in patients with myofascial pain syndrome while providing a comparison with various musculoskeletal disorders, emphasizing the domains that are affected for each specific disease. Also, myofascial pain studies that included quality-of-life measurement as an outcome variable are considered.

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.

Degeneration of the lumbar spine and dual-energy X-ray absorptiometry measurements in patients without osteoporosis.

AIM: The aim of this study was to evaluate the effects of degenerative findings on the accuracy of readings obtained by dual-energy X-ray absorptiometry (DXA) in patients without osteoporosis. METHODS: Twenty-four female patients who had undergone both DXA and lumbar magnetic resonance imaging were included in the study. CONCLUSION: This study has demonstrated that degenerative radiologic changes, especially in the osteophyte area, affect bone mineral density measurements, so degeneration should be considered in the evaluation of this measurement.

Predictors of functional outcome in first-ever ischemic stroke: a special interest to ischemic subtypes, comorbidity and age.

OBJECTIVES: Most cardiovascular abnormalities are associated not only with increased risk of certain ischemic stroke subtypes but also with markedly greater disability in stroke patients. We aimed to investigate the associations between age, comorbidity, cardiovascular problems, site and size of ischemic lesions and functional outcome in inpatient first-ever ischemic stroke patients. SUBJECTS: A total of 129 first-ever ischemic stroke admissions to a university affiliated rehabilitation centre were involved. METHODS: Demographic data, brain computerized tomography or magnetic resonance imaging reports of the patients were recorded. Cardiovascular parameters consisted of electrocardiographic, echocardiographic and carotid Doppler ultrasonographic findings. Location and size of ischemic lesions was determined by using the Oxfordshire Community Stroke Project classification. Charlson Comorbidity index adjusted for ischemic stroke was used to assess associated health problems. Functional recovery was defined as the improvements made on Functional Independence Measure. RESULTS: Our data indicated that the presence of chronic atrial fibrillation and carotid stenosis had significant associations with total anterior circulation infarcts. Multivariate analyses revealed that age, Charlson Comorbidity index adjusted for ischemic stroke, total anterior circulation infarcts, Functional Independence Measure on admission were associated with rehabilitation outcomes. CONCLUSIONS: Advanced age, high comorbidity, large anterior circulation infarcts and poor functional level on admission were independent indicators of unfavorable functional outcome. Hemodynamic comorbidities had significant impact on localization and extend of ischemic lesions.

Determinants of length of stay in stroke patients: a geriatric rehabilitation unit experience.

The objective was to identify the predictors of length of stay--the impact of age, comorbidity, and stroke subtype- on the outcome of geriatric stroke patients. One hundred and seventy stroke patients (129 first-ever ischemic, 25 hemorrhagic, and 16 ischemic second strokes) were included in the study. The Oxfordshire Community Stroke Project classification for clinical subtypes of ischemic stroke patients and the Charlson comorbidity index were used to evaluate comorbidity. The Functional Independence Measure (FIM) scores were noted on admission and at discharge. Comparison of the patients below and over 65 years revealed that elderly patients had higher comorbidity scores, were more likely to be prematurely discharged, and were less likely to be successfully rehabilitated despite similar FIM scores on admission. Excluding premature discharges, FIM scores on admission emerged as the only predictor of length of stay. Age, stroke type, lesion characteristics, and comorbidities are not significant associates of prolonged length of stay. Results and limitations inherent to our study and similar stroke studies are discussed within the context of rehabilitation differences among rehabilitation centers and countries.

Comparing hot pack, short-wave diathermy, ultrasound, and TENS on isokinetic strength, pain, and functional status of women with osteoarthritic knees: a single-blind, randomized, controlled trial.

OBJECTIVE: To investigate the therapeutic effects of physical agents administered before isokinetic exercise in women with knee osteoarthritis. DESIGN: One hundred patients with bilateral knee osteoarthritis were randomized into five groups of 20 patients each: group 1 received short-wave diathermy + hot packs and isokinetic exercise; group 2 received transcutaneous electrical nerve stimulation + hot packs and isokinetic exercise; group 3 received ultrasound + hot packs and isokinetic exercise; group 4 received hot packs and isokinetic exercise; and group 5 served as controls and received only isokinetic exercise. RESULTS: Pain and disability index scores were significantly reduced in each group. Patients in the study groups had significantly greater reductions in their visual analog scale scores and scores on the Lequesne index than did patients in the control group (group 5). They also showed greater increases than did controls in muscular strength at all angular velocities. In most parameters, improvements were greatest in groups 1 and 2 compared with groups 3 and 4. CONCLUSIONS: Using physical agents before isokinetic exercises in women with knee osteoarthritis leads to augmented exercise performance, reduced pain, and improved function. Hot pack with a transcutaneous electrical nerve stimulator or short-wave diathermy has the best outcome.

Treatment of immobilization hypercalciuria using weekly alendronate in two quadriplegic patients.

Metabolic and urinary problems encountered in spinal cord injury patients are multifaced. We report two patients with high-level spinal cord injuries who have developed hypercalciuria after admission to the rehabilitation unit. To establish a clean intermittent self-catheterization programme, the hypercalciuria was treated successfully with alendronate. Twenty-four-hour urinary calcium excretion decreased significantly after medical treatment for hypercalciuria. Since high-level quadriplegic patients may not be mobilized in the acute phase of the rehabilitation, use of alendronate for preventing hypercalciuria and maintaining a successful clean intermittent self-catheterization programme can be considered as a supportive/complementary measure.

Unrecognized peripheral nerve lesions in a traumatic brain injury patient.

Patients with traumatic brain injury constitute a diagnostic challenge since peripheral nerve injuries may be overlooked due to cognitive dysfunction and priority given to life-sustaining measures. Electromyography may be helpful in the differential diagnosis of weakness and atrophy. Problems specific for the traumatic brain injury patients, namely heterotopic ossification, hypertrophic callus formation and myositis ossificans should be considered by the physician. We report a 15-year-old patient involved in a pedestrian motor vehicle accident with traumatic brain injury. He had weakness and atrophy of the left upper extremity. Electromyographic examination revealed axillary nerve injury and carpal tunnel syndrome. Differential diagnosis of atrophy and weakness in traumatic brain injury patients is discussed.

Intraoperative monitoring of a patient with craniovertebral junction meningioma.

Intraoperative monitoring is considered as a useful tool to prevent neurological damage during different neurosurgical procedures. Somatosensory evoked potentials (SEP) allow simultaneous assessment of several cortical and sub cortical centers. In this case presentation, we report intraoperative monitoring of an elderly patient with craniovertebral junction meningioma. Tibial SEP responses were elicited by stimulation of the tibial nerve; the recordings were visually analyzed for the presence of the main peaks P40-N50, peak to peak amplitudes, peak latencies and compared to baseline recordings throughout the procedure. During decompression from the medial aspect of the medulla SEP responses were lost for a brief period of time. Surgeons achieved total tumor removal and the patient left the operating room without any neurological deficit.

A challenging case of syndrome of inappropriate secretion of antidiuretic hormone in an elderly patient secondary to quetiapine.

Hyponatremia secondary to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is an uncommon complication of treatment with centrally acting drugs including selective serotonin reuptake inhibitors (SSRIs) and antipsychotic medications. Antipsychotics are commonly used for the treatment of behavioral and psychiatric symptoms in elderly patients with dementia, and the use of those agents is increasing. Here, we report an elderly man who developed hyponatremia after treatment with medications for depression and agitation.