Misuse of gabapentinoids (pregabalin and gabapentin) in patients with neuropathic pain related to spinal cord injury.

OBJECTIVE: To investigate the misuse of gabapentinoids (pregabalin and gabapentin) in patients with neuropathic pain related to spinal cord injury. STUDY DESIGN: Cross-sectional study. SETTING: Outpatient clinic in a physical therapy and rehabilitation hospital. PARTICIPANTS: 127 patients, aged 18-70 years, who had neuropathic pain related to spinal cord injury (SCI) and disease duration of at least 12 months. OUTCOME MEASURES: Gabapentinoid use disorder of the patients was determined based on the DSM-5 diagnostic criteria for substance-related disorders. Patients were divided into 2 groups as those with drug misuse and those without drug misuse. Demographic and clinical information of the patients were compared between the groups. Factors associated with drug misuse were analyzed. RESULTS: The misuse rate was 81.9% in patients using pregabalin and 69.69% in patients using gabapentin. Duration of disease and the Leeds assessment of neuropathic symptoms and signs (LANSS) score were statistically significantly higher in the drug misuse group. A statistically significant difference was found between the groups in terms of marital status, education and income level, and smoking and alcohol use. A statistically significant relationship was observed between drug misuse and duration of disease and LANSS score. CONCLUSION: Misuse of gabapentinoids is prevalent in patients with neuropathic pain related to spinal cord injury. The duration of disease and the severity of NP are associated with misuse. Clinicians should exercise caution when prescribing gabapentinoids to patients with SCI.

Muscle architecture and clinical parameters in stroke patients: An ultrasonographic study.

PURPOSE: To compare the lower extremity muscle architecture on both the affected side and healthy sides using ultrasound (US) imaging and examine the relationship between these measurements and clinical parameters in stroke patients. METHODS: A cross-sectional analysis of 125 stroke patients (64 M, 61 F) was performed in this study. Timed up and go (TUG) test was used to evaluate balance, Fugl-Meyer assessment of lower extremity (FMA-LE) was used to evaluate motor function, functional independence measurement (FIM) was used to evaluate functional status. Muscle thicknesses (MT) of rectus femoris (RF), vastus intermedius (VI), vastus medialis (VM), vastus lateralis (VL), soleus, medial gastrocnemius (GC) muscles, the PA and the FL of GC were obtained using ultrasound (US) imaging. RESULTS: The muscle thickness, PA and FL of the affected side decreased significantly compared to the healthy side (p = .0001) in stroke patients. Another clear result was that soleus and GC muscle thicknesses and PA of GC muscle were found to be associated with balance, motor function, and functional status. CONCLUSION: The properties of muscles evaluated with US may provide recommendations for clinical assessments and also potentially contribute to clinicians designing a rehabilitation intervention program for stroke patients.

Post-stroke complex regional pain syndrome and related factors: Experiences from a tertiary rehabilitation center.

OBJECTIVE: In this study, it is aimed to determine the risk factors associated with CRPS after stroke and the clinical parameters of the patients and the treatment agents used for CPRS METHOD: 213 hemiplegic patients with CRPS diagnosed in Group 1 and 213 hemiplegic patients without CRPS in group 2 (control group) were included in the study designed retrospectively. Demographic data of the patients, Brunnstrom stage, Modified Ashworth scale, Barthel index were recorded from patients files. Associated risk faktors with CRPS such as Shoulder subluxation, adhesive capsulitis, fracture, deep vein thrombosis, spasticity, neglect, visual field defect, heterotopic ossification, entrapment neuropathies, brachial plexus damage, pressure wound, lower respiratory tract infection (LRTI), urinary tract infection, epilepsy, and depression were questioned. In addition, clinical findings, medical treatments, and physical therapy agents used were recorded. RESULTS: The average age of the participants was 67.9 ± 10.3 in group 1 and 66.1 ± 9.9 in group 2. According to the multivariate logistic regression analysis, the presence of the duration of hemiplegi, the duration of hospitalization, shoulder subluxation, soft tissue lesion, adhesive capsulitis, spasticity, entrapment neuropathy, brachial plexus injury, protein energy malnutrition, LRTI, urinary infection, depression, coronary artery disease were significantly increased the development of CRPS (p<0.05). As a clinical parameter, edema was present in 95.3% of the patients, while trophic change was the lowest in 1.9%. While sensory reeducation was used in all patients in physical therapy, ganglion blockade was the lowest with 0.9% of patients. In medical treatment, the use of oral paracetamol was 28.2%, while the use of gabapentin was the last with 8.9%. CONCLUSIONS: In our study, the risk factors of CRPS after hemiplegia, which are as important as its treatment, as well as its diagnosis and prevention, are shown.

Effect of Dry Needling Injection and Kinesiotaping on Pain and Quality of Life in Patients with Mechanical Neck Pain.

BACKGROUND: Dry needling (DN) is a commonly used technique by clinicians for the treatment of mechanical neck pain (MNP) by targeting trigger points and nontrigger point structures. It is a skilled intervention that uses a thin ?liform needle to penetrate the skin and stimulate underlying trigger points, muscular and connective tissues without the use of injectate. Another popular treatment technique used in the management of musculoskeletal pathologies is kinesiotaping (KT). Although its popular, there is minimal scientific evidence supporting KT for neck pain. Although there are a few studies regarding KT for neck pain in literature, there is a lack of randomized, controlled studies evaluating KT for neck pain. OBJECTIVES: To evaluate the effect of KT on posterior cervical spine and DN into a posterior paracervical muscle of patients with MNP. STUDY DESIGN: Randomized clinical study. SETTING: Physical medicine and rehabilitation center. METHODS: Seventy-two patients (17 men, 55 women) were randomly assigned to DN or KT treatment groups. Numeric Rating Scale (NPS-11), Neck Disability Index (NDI), range of motion (ROM), Short Form-36 Quality of Life Scale, and Beck Depression Inventory (BDI) were assessed before the intervention and one month postintervention. RESULTS: Before treatment, there was no difference between groups in NPS-11, NDI, and BDI scores; however, ROM of the DN group was greater than ROM of the KT group (P < 0.05). After treatment, significant improvement was observed in all variables for both of the groups, except ROM in the DN group (P < 0.05). The KT group showed greater ROM compared with the DN group (P < 0.05). The pre- and posttreatment results showed that the KT group was significantly superior for the differences on ROM and NDI (P < 0.05); however, each group showed better results after treatment (P < 0.05). LIMITATIONS: First, we did not include a control or placebo group. Second, patients were followed up for only 4 weeks. Third, we used a sample of convenience from one clinic, which may not be representative of the entire population of individuals with MNP. CONCLUSIONS: In this study, both methods were found to be effective on pain, mood, and quality of life, and KT was found to be superior to DN in MNP in terms of increasing ROM and decreasing disability. KEY WORDS: Dry needling, kinesiotaping, mechanical neck pain, quality of life.

Ultrasonographic measurements of the metacarpophalangeal and talar cartilage thicknesses: A reliability study in healthy subjects.

BACKGROUND: Assessment of the joint cartilage using ultrasound imaging is important. OBJECTIVE: Our aim was to investigate the reliabilities of ultrasonographic measurements for talus dome (TCT) and metacarpal cartilage thicknesses (MCT). METHODS: Twenty healthy volunteers were recruited in the study. Every day, five physiatrists measured eight joint cartilage thicknesses. They repeated all the measurements in five consecutive days. RESULTS: Intra-observer intraclass correlation coefficient (ICC) values were "excellent" for all MCTs, except for the 3rd left MCT on the 1st day, 4th left MCT on the 1st day and 4th right MCT on the 3rd day which were "good". They were "excellent" for the TCT measurements, except for the left side on the 3rd day and the right side on the 4th day which were "good". Inter-observer ICC values pertaining to the 2nd MCT measurements were "excellent" for all sonographers. Third and 4th MCT measurements (at least one side) were "excellent" for four and three sonographers, respectively. On the other hand, while TCT measurements were "excellent" for 4 sonographers. CONCLUSIONS: Our results have shown that sonographic measurements of MCT and TCT have good to excellent reliabilities in healthy adults. These findings support the use of ultrasound for cartilage assessment in various diseases.

Ultrasonographic diagnosis of heterotopic ossification and secondary nerve entrapments in a patient with spinal cord injury.

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Shall We Inject Superficial or Deep to the Plantar Fascia? An Ultrasound Study of the Treatment of Chronic Plantar Fasciitis.

We compared the effectiveness of ultrasound (US)-guided corticosteroid, injected superficial or deep to the fascia, in patients with plantar fasciitis. Thirty patients (24 females [75%] and 6 males [25%]) with unilateral chronic plantar fasciitis were divided into 2 groups according to the corticosteroid injection site: superficial (n = 15) or deep (n = 15) to the plantar fascia. Patient heel pain was measured using a Likert pain scale and the Foot Ankle Outcome Scale (FAOS) for foot disability, evaluated at baseline and repeated in the first and sixth weeks. The plantar fascia and heel pad thicknesses were assessed on US scans at baseline and the sixth week. The groups were similar in age, gender, and body mass index (p > .05 for all). Compared with the baseline values, the Likert pain scale (p < .001 for all) and FAOS subscale (p < .01 for all) scores had improved at the first and sixth week follow-up visits in both groups. Although the plantar fascia thickness had decreased significantly in both groups at the sixth week (p < .001 for both), the heel pad thickness remained unchanged (p > .05 for both). The difference in the FAOS subscales (pain, p = .002; activities of daily living, p = .003; sports/recreational activities, p = .008; quality of life, p = .009) and plantar fascia thickness (p = .049) showed better improvement in the deep than in the superficial injection group. US-guided corticosteroid injections are safe and effective in the short-term therapeutic outcome of chronic plantar fasciitis. Additionally, injection of corticosteroid deep to the fascia might result in greater reduction in plantar fascia thickness, pain, and disability and improved foot-related quality of life.

The importance of orthoses on activities of daily living in patients with unilateral lower limb amputations.

BACKGROUND: The role of the selected prothesis on activities of daily living (ADL). OBJECTIVE: To evaluate the impact of prothesis on ADL in patients with lower-limb amputations. METHODS: The data of 500 patients with unilateral lower limb amputation were recorded. The activity level was defined based on the Medicare Functional Classification Level. Old and new prescribed prosthesis were recorded. Nottingham Extended Activities of daily living activities Daily Living Scale was used to evaluate ADL. RESULTS: Amputation levels were transfemoral (TF) in 268 (53.6%), transtibial (TT) in 178 (35.6%), knee disarticulation (KD) in 54 (10.8%). In patients with TF and KD amputation active vacuum system, pin modular system, hydraulic system and mechanical modular prosthesis were replaced with the swing stance phase microprocessor-controlled prostheses. In patients with TT amputation pin modular system, hydraulic system and mechanical modular prosthesis were converted to active vacuum system prostheses. Prescribed new prosthesis has caused a statistically significant increase in all amputation levels in ADL of patients (p≤ 0.05). CONCLUSIONS: We observed that there was significant improvement in ADL when conventional prostheses replaced with advanced technology prostheses in unilateral lower extremity amputation patients.

Ultrasonographic Evaluation of the Radial Nerves in Patients with Unilateral Refractory Lateral Epicondylitis.

Objective: To evaluate the possible radial nerve entrapment of patients with unilateral refractory lateral epicondylitis (LE) by using ultrasound (US) and electroneuromyography. Design: Cross-sectional study. Setting: Three physical medicine and rehabilitation departments. Subjects: Consecutive 44 patients (15 M, 29 F) with unilateral refractory LE. Methods: All patients underwent detailed clinical, electrophysiological and ultrasonographic evaluations. Ultrasound imaging was used to evaluate thickness and presence of abnormal findings of the common extensor tendon (CET) and cross-sectional area (CSA) of the radial nerve (at spiral groove and before bifurcation) bilaterally. Unaffected sides of the patients were taken as controls. Results: When compared with the unaffected sides, CET thickness and radial nerve CSAs (at both levels) were higher, and abnormal US findings regarding LE (47.7% vs. 6.8%) were more common on the affected sides than nonaffected sides (all P < 0.001). Grip strength values were lower on the affected sides ( P < 0.001). Electrophysiological studies were all normal, and similar between the two sides (all P > 0.05). When subgroup analyses were performed after taking into account the hand dominance, affected and dominant sides were found to be the same in 31 and different in 13 patients. In subgroups, CETs and radial nerve CSAs at both levels were higher on the affected sides (all P < 0.01). Conclusions: Radial nerves and the CETs seem to be swollen on the affected sides, independent from the hand dominance of the patients with refractory LE. These results morphologically support the previous literature that attributes some of the chronic complaints of these patients actually to radial nerve entrapment.

Ultrasound-Guided Diagnosis and Treatment of Meralgia Paresthetica.

Meralgia paresthetica refers to the entrapment of the lateral femoral cutaneous nerve at the level of the inguinal ligament. The lateral femoral cutaneous nerve - a purely sensory nerve - arises from the L2 and L3 spinal nerve roots, travels downward lateral to the psoas muscle, and then crosses the iliacus muscle. Close to the anterior superior iliac spine, the nerve courses in contact with the lateral aspect of the inguinal ligament and eventually innervates the lateral thigh. The entrapment syndrome is usually idiopathic but can also ensue due to trauma/overuse, pelvic and retroperitoneal tumors, stretching of the nerve due to prolonged leg/trunk hyperextension, leg length discrepancies, prolonged standing, external compression by belts, weight gain, and tight clothing. The diagnosis of Meralgia paresthetica is usually clinical, i.e., based on the following symptoms: paresthesia, numbness, burning sensation, dysesthesia, and pain over the anterolateral aspects of the thigh. These complaints may be worsened by walking or prolonged standing and typically disappear after weight loss, abdominal muscle strengthening, or elimination of the underlying cause. Although there are several reports on the confirmatory role of electrodiagnostic studies in the diagnosis of Meralgia paresthetica, electromyographers would usually prefer/suggest not to perform nerve conduction studies in daily clinical practice. Herewith, due to its several advantages, ultrasound imaging has been proposed as an alternative diagnostic method in the recent literature. It not only confirms the entrapment morphologically, but also uncovers a likely underlying cause and provides immediate interventional guidance. The pertinent sonographic findings would be hypoechoic and swollen lateral femoral cutaneous nerve.

Ultrasonographic measurement of the femoral cartilage thickness in patients with transfemoral amputation.

OBJECTIVE: To compare the distal femoral cartilage thickness of the non-amputee sides in patients who had unilateral transfemoral amputation with those of healthy subjects by using ultrasound. METHODS: Thirty transfemoral amputees (27 male, 3 female) and 30 age-, sex-, and body mass index-matched healthy controls were included. Functional usage of the prosthesis was evaluated by using Houghton score. The cartilage thickness was measured from the following midpoints; medial femoral condyle (MFC), intercondylar area, and lateral femoral condyle. RESULTS: Thirty patients with unilateral transfemoral amputation (mean age; 38.6 ± 9.5 years) and 30 healthy controls (mean age; 38.4 ± 9.4 years) were included. Although femoral cartilage thicknesses were found to be lower for all measurements in the amputees, the difference reached significance only in the MFC (p= 0.031). In the patient group, cartilage thickness values did not correlate with age, duration of amputation, daily walking time, stump length or Houghton score. CONCLUSION: The distal femoral cartilage thickness seems to be decreased medially on the non-amputee sides of the transfemoral amputees when compared with the healthy subjects. Further studies concerning the follow-up designs, functional parameters and osteoarthritis scales are awaited.

Ultrasound-Guided Diagnosis and Treatment of Morton's Neuroma.

Morton's neuroma is the fibrous enlargement of the interdigital nerve branches, usually in the second and third interspace between the metatarsal heads where the lateral and medial plantar nerves often join. Specific symptoms are dull or sharp pain, numbness and/or tingling in the third and fourth digits, burning sensation, cramping, and a feeling of "walking on a stone" around the metatarsal heads. Numerous clinical tests for Morton's neuroma have been described, such as thumb index finger squeeze, and Mulder's click and foot squeeze tests. Ultrasound and magnetic resonance imaging can be used for confirmation, especially for differential diagnosis, exact localization, and number of neuromas. Further, performing dynamic imaging during the aforementioned tests is paramount and can readily be carried out with ultrasound. The treatment mainly comprises footwear modifications, radiofrequency ablation, physical therapy, local (corticosteroid and anesthetic) injections into the affected webspace, and surgery. Again the use of real-time ultrasound guidance during such interventions is noteworthy.