Comparison of the activation and mechanical properties of scapulothoracic muscles in young tennis players with and without scapular dyskinesis: an observational comparative study.

BACKGROUND: In tennis athletes with scapular dyskinesis, the activation of the scapulothoracic muscles during serve is not known. Also, the mechanical properties (tone, elasticity, and stiffness) of the scapulothoracic muscles of the tennis athletes with scapular dyskinesis are likely to change. The study aimed to evaluate the activation of the scapulothoracic muscles while performing tennis serve and to determine the changes in the mechanical properties of the same muscles in young tennis athletes with scapular dyskinesis. METHODS: Seventeen tennis athletes with scapular dyskinesis aged between 11 and 18 years (the scapular dyskinesis group) and age- and gender-matched 17 asymptomatic tennis athletes (the control group) were included in the study. Activation of scapulothoracic muscles (descending-transverse-ascending trapezius and serratus anterior) in the 3 phases (preparation, acceleration, and follow-through) of the serve was evaluated using surface electromyography, and the mechanical properties of the same muscles were measured at rest by myotonometry. RESULTS: Ascending trapezius activation in the follow-through phase was lower in the scapular dyskinesis group compared with the control group (mean difference 95% confidence interval: -22.8 [-41.2 to -4.5]) (P = .017). The tone and stiffness of the transverse trapezius (P = .043 and P = .017, respectively) were higher, whereas the same parameters of the ascending trapezius were lower (P = .008 and P = .010, respectively) in the scapular dyskinesis group compared with the control group. CONCLUSIONS: Activation of the ascending trapezius and the tone and stiffness of the transverse-ascending trapezius were altered in tennis athletes with scapular dyskinesis. Implementations to improve these changes can be included in the rehabilitation or training programs of young tennis athletes with scapular dyskinesis.

Demographic and clinical characteristics of inpatient stroke patients in Turkey.

Objectives: This study aims to assess the stroke rehabilitation facilities provided by university hospitals (UHs) and training and research hospitals (TRHs) and to evaluate the geographical disparities in stroke rehabilitation. Patients and methods: Between April 2013 and April 2014 a total of 1,529 stroke patients (817 males, 712 females; mean age: 61.7±14.0 years; range, 12 to 91 years) who were admitted to the physical medicine and rehabilitation clinics in 20 tertiary care centers were retrospectively analyzed. Demographic, regional and clinical characteristics, details of rehabilitation period, functional status, and complications were collected. Results: The median duration of stroke was five (range, 1 to 360) months. The ratio of the patients treated in the TRH in the Marmara region was 77%, but only 25% of the patients were living in the Marmara region. Duration of hospitalization was longer in the TRHs with a median of 28 days compared to those of UHs (median: 22 days) (p<0.0001). More than half of the patients (55%) were rehabilitated in the Marmara region. Time after stroke was the highest in the Southeast region with a median of 12 (range, 1 to 230) months and the lowest in the Aegean region with a median of four (range, 1 to 84) months. Conclusion: This study provides an insight into the situation of stroke rehabilitation settings and characteristics of stroke patients in Turkey. A standard method of patient evaluation and a registry system may provide data about the efficacy of stroke rehabilitation and may help to focus on the problems that hinder a better outcome.

Evaluation of bone health in patients with mucopolysaccharidosis.

INTRODUCTION: This study aimed to evaluate the relationship between clinical findings, height and weight standard deviation scores, 25-hydroxyvitamin D3 (25(OH)D3) level, and dual-energy X-ray absorptiometry (DXA) results in patients diagnosed with mucopolysaccharidosis (MPS), where effective current treatments such as enzyme replacement therapy (ERT) can be accessed. MATERIALS AND METHODS: 25(OH)D3 level was measured in 126 patients with MPS (17 with MPS I, 14 with MPS II, 18 with MPS III, 33 with MPS IVA, and 44 with MPS VI; 24-524 months). DXA was performed in 45 of these patients (8 with MPS I, 4 with MPS II, 4 with MPS III, 12 with MPS IVA, and 17 with MPS VI; 62-197 months; all patients were under 18 when DXA was performed) to assess bone mineral density (BMD) of the lumbar spine. RESULTS: In total, 67.5% patients had a short stature, and 50% of them were underweight for their age. Of the patients, 13.5% were immobile, 28.6% had 25(OH)D3 deficiency, and 30.2% had an insufficient level of 25(OH)D3. BMD z score of 45 patients was - 2.5 ± 1.7. In 40% patients, it was < - 2. However, after correction for height-for-age z score (HAZ), HAZ-adjusted BMD z score was - 0.1 ± 0.9. In 2.2% patients, it was < - 2. CONCLUSION: The low BMD z score prevalence reported with DXA was misleadingly higher in children with MPS and short stature. To prevent exposure to unnecessary antiresorptive treatments in these children, the effect of severe short stature and bone geometry on DXA measurements should be considered; further studies on bone health are warranted.

Long-Term Effectiveness of Combined Intermittent Pneumatic Compression Plus Low-Level Laser Therapy in Patients with Postmastectomy Lymphedema: A Randomized Controlled Trial.

Background: Upper limb lymphedema may be revealed after breast cancer and its treatment. Among different treatment approaches, intermittent pneumatic compression (IPC) therapy and low-level laser therapy (LLLT) are reported as effective modalities in the treatment of postmastectomy upper limb lymphedema (PML). The aim of the current study is to investigate the long-term effectiveness of combined IPC plus LLLT versus IPC therapy alone in patients with PML. Methods and Results: The patients were allocated into two groups in this single-blinded, controlled clinical trial. Group I received combined treatment with IPC plus LLLT (n = 21) and group II received only IPC (n = 21). IPC treatment was given 5 sessions per week for 4 weeks (20 sessions). LLLT was also performed 5 sessions per week for 4 weeks (20 sessions). Clinical evaluations were performed before and after the treatment at the 3, 6, and 12-month follow-up visits. According to within-group analysis, statistically significant improvements in the circumference difference (Cdiff) and grip strength were observed in both groups (for Cdiff, p = 0.018 and p = 0.032, respectively; for grip strength, p = 0.001 and p = 0.046, respectively). Visual analog scale values for arm pain and shoulder pain during motion were decreased only in group I. Conclusion: Both interventions have positive effects on lymphedema, grip strength, and pain. Long-term effects of combined therapy, especially on pain, are slightly superior to the pneumatic compression alone.

Proximal muscle strength as a predictor of vitamin D insufficiency in elderly.

OBJECTIVES: This study aims to evaluate the association of serum vitamin D level with proximal muscle strength, tone, elasticity, and stiffness in elderly. PATIENTS AND METHODS: Between September 2017 and January 2018, a total of 109 participants (21 males, 88 females; mean age: 71.2±4.6 years; range, 65 to 85 years) were included in the study. The proximal muscle strength was evaluated by MicroFET® 3 device. The muscle tone, elasticity, and stiffness were measured using the MyotonPRO® digital palpation device. Serum 25-hydroxyvitamin D [25(OH)D] level was tested by high-performance liquid chromatography. A receiver operating characteristic (ROC) curve was performed to evaluate the potential role of MicroFET® 3-measured proximal muscle strength in the quantification of vitamin D status. RESULTS: Vitamin D sufficient participants had a higher proximal muscle strength (p<0.001). Quadriceps and hamstring elasticity at the non-dominant site were significantly higher in vitamin D sufficient group (p<0.05). The ROC analysis indicated that the deltoid muscle strength had the potential of determining vitamin D insufficiency with moderate accuracy (area under the curve=0.744; 95% confidence interval: 0.643-0.845; p<0.001). CONCLUSION: Proximal muscle strength, elasticity, and physical performance are associated with vitamin D status. Proximal muscle strength measured by a hand-held dynamometer can be used as a predictor of hypovitaminosis D in elderly.

Morquio A syndrome and effect of enzyme replacement therapy in different age groups of Turkish patients: a case series.

BACKGROUND: This case series includes longitudinal clinical data of ten patients with Morquio A syndrome from south and southeastern parts of Turkey, which were retrospectively collected from medical records. All patients received enzyme replacement therapy (ERT). Clinical data collected included physical appearance, anthropometric data, neurological and psychological examinations, cardiovascular evaluation, pulmonary function tests, eye and ear-nose-throat examinations, endurance in the 6-min walk test and/or 3-min stair climb test, joint range of motion, and skeletal investigations (X-rays, bone mineral density). RESULTS: At the time of ERT initiation, two patients were infants (1.8 and 2.1 years), five were children (3.4-7.1 years), and three were adults (16.5-39.5 years). Patients had up to 4 years follow-up. Most patients had classical Morquio A, based on genotypic and phenotypic data. Endurance was considerably reduced in all patients, but remained relatively stable or increased over time in most cases after treatment initiation. Length/height fell below normal growth curves, except in the two infants who started ERT at ≤ 2.1 years of age. All patients had skeletal and/or joint abnormalities when ERT was started. Follow-up data did not suggest improvements in skeletal abnormalities, except in one of the younger infants. Nine patients had corneal clouding, which resolved after treatment initiation in the two infants, but not in the other patients. Hepatomegaly was reported in seven patients and resolved with treatment in five of them. Other frequent findings at treatment initiation were coarse facial features (N = 9), hearing loss (N = 6), and cardiac abnormalities (N = 6). Cardiac disease deteriorated over time in three patients, but did not progress in the others. CONCLUSIONS: Overall, this case series with Morquio A patients confirms clinical trial data showing long-term stabilization of endurance after treatment initiation across ages and suggest that very early initiation of ERT optimizes growth outcomes.

Residual Deficits of Knee Flexors and Plantar Flexors Predict Normalized Walking Performance in Patients with Poststroke Hemiplegia.

OBJECTIVES: The aim of the study was to investigate the relation of lower limb muscle strength with normalized walking value, gait speed, and balance in patients with poststroke hemiplegia. METHODS: Functional ambulatory unilateral hemiplegic patients were included in the study. Functionality of the lower limb was tested by Fugl-Meyer lower extremity motor subscale. Six-minute walk test (6MWT), 10-meter walk test, and Berg Balance Scale were performed to evaluate functional walking capacity, gait speed, and balance, respectively. Normalized 6MWT value was calculated by using a formula. Maximum isometric strengths of 8 muscle groups of both limbs were measured using a handheld dynamometry and residual deficits of the paretic side muscles were calculated. RESULTS: The study population was comprised of 61 hemiplegic patients (mean age: 54.6 ± 11.7 years and mean duration after stroke: 23.4 ± 18.1 months). Mean normalized walking distance on 6MWT was 44.4% of expected. The residual deficits of the affected lower extremity muscles were negatively correlated with normalized 6MWT: hip flexors (r = -.651), hip extensors (r = -.621), hip abductors (r = -.657), hip adductors (r = -.630), knee flexors (r = -.738), knee extensors (r = -.659), ankle dorsiflexors (r = -.776), and ankle plantar flexors (r = -.773). Lower extremity residual deficits also showed moderate-strong negative correlations with Berg Balance Scores and gait speed. Multiple linear regression analyses showed that the residual deficits of the ankle plantar flexors and knee flexors are the major independent determinants of normalized 6MWT results (R: .791 R2: 625). CONCLUSIONS: Residual deficits of lower extremity muscles-particularly of ankle dorsiflexors, plantar flexors, and knee flexors-are related to walking performance, gait speed and balance. Besides, knee flexors and plantar flexors are predictors of normalized 6MWT.

Osteosarcopenia among postmenopausal women and handgrip strength as a practical method for predicting the risk.

BACKGROUND: Osteosarcopenia is a recently described geriatric syndrome. Studies concerning its role on physical function are relatively few. AIM: To evaluate the prevalence of osteosarcopenia and to analyze its relationship with physical function among postmenopausal women. METHODS: Demographic and clinical data, fracture risk, and osteosarcopenia risk factors of 140 postmenopausal women were evaluated between April 2018 and September 2018. Body composition and bone mineral density were measured by dual-energy X-ray absorbtiometry. Handgrip strength and physical performance test results were recorded. Sarcopenia was diagnosed according to the European Working Group on Sarcopenia in Older People, whereas osteopenia/osteoporosis was diagnosed according to the World Health Organisation criteria. RESULTS: The mean age of the patients was 64.1 ± 8.9 years. Among the patients, 64.3% (n = 90) were found to be osteosarcopenic. Insufficient protein and calcium intake and low physical activity level were found to be the most frequent risk factors. When further analysis was done according to the osteosarcopenia, sarcopenia-only, and osteoporosis-only groups, osteosarcopenia group revealed the lowest body mass index, skeletal mass index, handgrip strength values, and physical performance test results. The handgrip strength was found to be a determinant of osteosarcopenia and each 1-unit decrease in handgrip strength increased the risk of osteosarcopenia by 1.162 times (95% CI 1.086-1.25). CONCLUSIONS: The prevalence of osteosarcopenia is high among postmenopausal women. It is recommended to be aware of osteosarcopenia while managing osteoporotic patients, to use handgrip strength as a simple screening method, and to consider sarcopenia treatment as an important component of osteoporosis prevention and treatment.

Functionality of patients with post-stroke hemiplegia: Does serum folate level matter?

OBJECTIVES: This study aims to investigate the possible effects of folate on the functional outcomes of patients with post-stroke hemiplegia. PATIENTS AND METHODS: Between January 2012 and March 2015, a total of 80 patients with hemiplegia (51 males, 29 females; mean age 60.3±13.2 years; range, 19 to 95 years) at least three months post-stroke were included in this study. Serum folate levels (ng/mL), Brunnstrom recovery stages of the lower limb, and Functional Ambulation Category (FAC) scores were recorded. All patients were divided into two groups according to the Brunnstrom stages (Category I; Stage 1-3 and Category II; Stage 4-6) and FAC scores (non-functional ambulatory; score 0-2, functional ambulatory; score 3-5). RESULTS: The mean serum folate level of the patient group was 6.8±2.8 ng/mL. Serum folate levels differed significantly between the Brunnstrom categories with lower levels in patients with poorer motor recovery (Category I) (p=0.047). Folate levels were also lower in non- functional ambulatory patients than those in patients with functional ambulation (p=0.046). CONCLUSION: Lower serum folate levels are associated with poorer ambulation potential and impaired lower limb motor recovery in patients with post-stroke hemiplegia.

Comparative short-term effectiveness of ibuprofen gel and cream phonophoresis in patients with knee osteoarthritis.

The objective of the present study was to compare the effectiveness of gel and cream ibuprofen phonophoresis in patients with knee osteoarthritis. A single-blinded, randomized, comparative design was applied. Patients diagnosed with knee osteoarthritis according to the American College of Rheumatology criteria were included in the study. After obtaining written informed consent, patients were randomized into ibuprofen gel and cream phonophoresis groups. Each patient was treated five sessions per week for 2 weeks (ten sessions). Main outcome measures were 100 mm visual analogue scale (VAS) for pain and the disease-specific questionnaire; Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Sixty-one knee osteoarthritis patients with a mean age of 57.9 ± 9.7 years were included in the study. Baseline VAS and WOMAC scores were similar between gel (n = 30) and cream (n = 31) phonophoresis groups (p > 0.05 for both). Following the treatment, both groups showed improvement compared to baseline measures including VAS pain and WOMAC scores. In the gel phonophoresis group, the improvement in VAS score was higher than that observed in the cream phonophoresis group (p < 0.001). Similarly, the improvement in WOMAC total score was also higher in the gel phonophoresis group (p < 0.001). Ibuprofen phonophoresis is clinically effective in patients with knee osteoarthritis. Phonophoresis using the gel form of ibuprofen is associated with more clinical improvement than that using the cream form of the same molecule.

Which Predicts Quadriceps Muscle Strength in Knee Osteoarthritis: Biological Markers or Clinical Variables?

OBJECTIVES: This study aims to evaluate the relationship between biological markers and quadriceps muscle strength, the correlation of clinical variables with quadriceps muscle strength, and the results according to the radiological severity in patients with knee osteoarthritis. PATIENTS AND METHODS: A total of 152 patients (22 males, 130 females; mean age 57.3±7.5 years; range 40 to 70 years) with primary knee osteoarthritis were included in the study. We evaluated biological markers of C-telopeptide of type I collagen, C-telopeptide of type II collagen, leptin, and osteocalcin along with 25-hydroxy vitamin D. We measured quadriceps muscle strength both by manual muscle tester and computerized isokinetic dynamometer. We evaluated pain and functional status of the patients by visual analog scale and Western Ontario and McMaster Universities Osteoarthritis Index. We analyzed the correlation between biological markers and quadriceps muscle strength along with clinical variables. We classified the strength of correlations as no-very weak, weak-moderate, moderate-strong, and excellent. RESULTS: Of the patients, 76.9% (n=117) were obese. Quadriceps muscle strength measures were significantly lower in females than that in males. There was no-very weak correlation between biological marker levels and quadriceps muscle strength. However, weak-moderate correlations were found between clinical variables (pain and Western Ontario and McMaster Universities Osteoarthritis Index scores) and quadriceps muscle strength measures. CONCLUSION: Among the measured biological markers, none had any influence on quadriceps muscle strength in patients with knee osteoarthritis. However, pain and functional status of the patients might affect quadriceps muscle strength.

Lumbosacral morphology in lumbar disc herniation: a "chicken and egg" issue.

OBJECTIVE: The aim of this study was to analyze the relationship, if any, between lumbar disc herniation and lumbosacral morphology. METHODS: Intervertebral disc angles (IDA), lumbar lordosis angle (LLA), lumbosacral lordosis angle (LSLA), lumbosacral angle (LSA), and sacral tilt (ST) were measured on lumbar magnetic resonance imaging of 224 patients with LDH (n=151) and without LDH (n=73) and were then compared. RESULTS: Regarding LLA, LSLA, LSA and ST, there were no significant differences between the 2 groups. The smallest IDA of each level (except L2-L3) was detected at the same level with disc herniation. When the relationship between the grade of disc herniation and IDA was evaluated in patients with LDH, angles of L3-L4 and L4-L5 levels were significantly smaller in patients with extruded disc herniation (p=0.009 and p=0.013, respectively). CONCLUSION: Despite changes in IDA by grade and level of disc herniation, no relation was found between lumbosacral alignment and LDH.

Vitamin D profile of patients with spinal cord injury and post-stroke hemiplegia: All in the same boat.

BACKGROUND: Patients with spinal cord injury (SCI) and hemiplegia are at risk of fractures partly due to decreased bone mineral density with relation to the low levels of vitamin D. OBJECTIVE: The objective of this study is to evaluate the vitamin D profile of patients with SCI and post-stroke hemiplegia. METHODS: 25(OH)D levels of patients with SCI and hemiplegia were obtained from the electronic medical record database and compared with age- and sex-matched non-disabled controls. Furthermore, the effect of Functional Ambulation Category (FAC), American Spinal Injury Association (ASIA) level and Brunnstrom's recovery stage, on vitamin D insufficiency, was studied. RESULTS: The study sample consisted of 173 individuals (118 patients and 55 controls). Vitamin D levels and sufficiency rates of the neurologically disabled patients was significantly lower than that of controls (p= 0.000 and p= 0.000, respectively). However, there was no difference between patients with SCI and hemiplegia regarding the 25(OH)D levels and vitamin D insufficiency (p= 0.303 and p= 0.952, respectively). There were no statistically significant differences in vitamin D status by American Spinal Injury Association (ASIA) level and Brunnstrom's score. However, regression analysis revealed that vitamin D insufficiency rate of non-functionally ambulatory (FAC = 0-2) patients was higher than that of functionally ambulatory (FAC = 3-5) ones (p= 0.044). CONCLUSIONS: Vitamin D status of patients with neurological disabilities was lower than that of controls. Non-functionally ambulatory patients had higher vitamin D insufficiency rate than functionally ambulatory patients. Preventative measures including adequate supplementation of vitamin D should be directed to neurologically disabled subjects, particularly those with non-functional ambulation.

Does Lumbosacral Transitional Vertebra Have Any Influence on Sacral Tilt?

STUDY DESIGN: Retrospective case-control study. OBJECTIVE: To compare the sacral tilt (ST) angle between patients with and without lumbosacral transitional vertebra (LSTV). SUMMARY OF BACKGROUND DATA: Although LSTV is a common malformation of the lumbosacral region, data regarding the effect of LSTV on the tilt of sacrum is limited. METHODS: Anterioposterior and lateral lumbar radiographs of patients with low back pain performed between March 2013 and September 2013 were extracted from the medical electronic database. Among these radiographs, those belonging to patients with Castellvi types II, III, and IV LSTV were identified. The angle of ST was measured on lateral lumbar radiographs and compared with that of age- and sex-matched controls without LSTV. RESULTS: Of the 1588 radiographs extracted from the database, 96 (6.1%) were positive in terms of Castellvi types II, III and IV LSTV. 85 of them were found to be eligible for analysis. Patients with LSTV had significantly smaller ST angle than those without LSTV (p = 0.000). However, this angle did not differ among types (II, III and IV) of LSTV (p = 0.788). CONCLUSION: Results of this study revealed that patients with LSTV had less ST--that is to say more vertical sacrum-than those without this malformation. LEVEL OF EVIDENCE: 4.

Early rehabilitation of a child with intensive care unit acquired weakness secondary to membranoproliferative glomerulonephritis: A case report.

Intensive care unit acquired weakness presents with flaccid paralysis of the extremities and difficulty of weaning from the ventilator and it has occasionally been reported in children. We report the early rehabilitation of a 12-year-old girl with membranoproliferative glomerulonephritis who developed intensive care unit acquired weakness. She underwent an intensive rehabilitation procedure which included assistive range of motion, bed mobility, airway clearance and breathing techniques, neuromuscular electrical stimulation (NMES) to the quadriceps muscles and resistive therapeutic band exercises. Following the rehabilitation program, muscle strength (Medical Research Council sum score), ambulation (Functional Ambulation Category) and activity (Wee FIM) scores increased significantly.

Is coxa valga a predictor for the severity of knee osteoarthritis? A cross-sectional study.

PURPOSE: In the present study, we aimed to evaluate the affect of the variations in hip anatomy and pelvic geometry on the severity of knee OA. METHODS: Idiopathic knee OA patients fulfilling the clinical criteria of American College of Rheumatology for OA were enrolled in the study. Several measurements regarding the hip and pelvis were performed on pelvic radiographs. Each knee was graded according to the Kellgren and Lawrence (KL) radiographic system (0-4) along with a categorization in accordance with the medial tibiofemoral joint space widths (JSW). RESULTS: The study group consisted of 111 subjects. The inner and outer pelvic diameters were getting wider as the JSW grade increased. Likewise, among the hip measurements, femoral head, neck and shaft diameters and hip axis lengths were linked with KL grade. There were significant differences in neck-shaft angle (NSA) between groups of JSW with a highest NSA in JSW grade 3. The optimal cut-off value for NSA in predicting the severity of knee OA was 134.4°. Furthermore, NSA beyond 134.4° was found to increase the risk of severe knee OA eightfold. CONCLUSIONS: Variations in pelvic geometry and hip anatomy are associated with the severity of knee OA. People with NSA of above 134.4° have eightfold increased risk of developing severe knee OA. Pelvic radiographies could be evaluated at younger ages-particularly in people with high genetic predispositions-to identify the individuals at high risk and in turn, to tailor the preventive measures to these subjects.

Comparative study of lumbosacral alignment in elderly versus young adults: data on patients with low back pain.

BACKGROUND: Sagittal spinal alignment is an important determinant for proper spinal function. Alterations in spinal alignment may serve as leading factor for diminished body biomechanics. Although increased age is suggested to be associated with changes in lumbosacral alignment, in turn body posture, this is still a current issue in geriatrics which requires further research. AIMS: The aim of this study was to compare the spinal alignment of elderly to that of young adults. METHODS: A total of 402 (243 female and 159 male) patients with low back pain were included in the study. The mean ages of young adults (n = 205) and elderly (n = 197) were 29.15 ± 6.46 and 71.97 ± 6.48 years, respectively. The electronic medical record database was used to obtain the lumbar radiographs of the individuals retrospectively. Lumbar lordosis angle (LLA), lumbosacral lordosis angle (LSLA), sacral tilt (ST) and lumbosacral angle (LSA) were measured on lateral standing lumbar radiographs. RESULTS: Lumbar lordosis angle of elderly was significantly smaller than that of young adults (36.22 ± 11.94 and 39.83 ± 10.01 respectively, p = 0.001). When the data was analyzed according to sex, females had wider LLA, ST and LSA than males, whilst males had wider LSLA than females. DISCUSSION: This study reflects an age-related loss of lumbar lordosis along with sex-dependent alterations in lumbar sagittal alignment CONCLUSIONS: Aging is related with the loss of lumbar curvature, particularly in men. Longitudinal studies on this issue are needed to confirm the results of this study.

Hemiplegic shoulder pain: a common clinical consequence of stroke.

Hemiplegic shoulder pain is common in stroke survivors, developing in up to 54% of patients. The underlying mechanisms include soft tissue lesions, impaired motor function and central nervous system-related phenomena. Hemiplegic shoulder pain has many underlying causes and is challenging to manage, requiring a team approach, including physicians, therapists and caregivers. The management strategy must target the underlying causes. Preventative measures, such as positioning and handling, can reduce the risk of developing hemiplegic shoulder pain. We have reviewed the literature on hemiplegic shoulder pain, and used this to categorise the underlying mechanisms, and to explore the best management strategies.

Parapagus (dicephalus, tetrabrachius, dipus) conjoined twins and their rehabilitation.

A case of female parapagus conjoined twins living as unseparated is presented in this report. The twins had two heads, four arms and two legs. As a result of their fusion, operative care had been considered to be unacceptable, and the family had refused to take care of them. At three years of age, they were referred to the Rehabilitation Department with the complaint of inability to walk. While designing the rehabilitation program, somatosensory evoked potential evaluation was performed and showed that twin 1 controlled the right leg and twin 2 controlled the left. The program consisted of coordinated pacing training by verbal commands, upper and lower extremity reeducation, and balance and coordination exercises. After two months of inpatient rehabilitation, they were able to walk independently with a specially designed walker. Currently, the twins are 11 years old with normal academic achievement, and they are able to walk, run and climb the stairs independently.