Are rehabilitation outcomes after severe anoxic brain injury different from severe traumatic brain injury? A matched case-control study.

Many reports have investigated rehabilitation outcomes after a traumatic brain injury (TBI); however, comparably less is known about whether they differ from outcomes of an anoxic brain injury (ABI). Thus, we aimed to compare the rehabilitation outcomes of patients with ABI with control patients who have TBI. Forty participants with ABI and 40 participants with TBI were included in this retrospective study. Participants with ABI were matched with participants with TBI who had similar clinical characteristics such as age, initial Functional Independence Measurement (FIM) score, and duration of coma. FIM and Functional Ambulation Classification (FAC) scores on rehabilitation admission and on rehabilitation discharge were recorded. The FIM score in the ABI group was 41.7±28.5 on rehabilitation admission and increased to 57.1±31.4 on rehabilitation discharge. The FIM score in the TBI group was 40.8±24.0 on rehabilitation admission and increased to 65.9±35.3 on rehabilitation discharge. There was no statistically significant difference in the FIM scores on rehabilitation discharge between groups. Initial FAC was similar in both groups and there was no statistically significant difference in the FAC scores on rehabilitation discharge. The multiple linear regression analysis showed that intensive care unit length of stay had an inverse relationship with the FAC change. We did not find significant differences in the rehabilitation outcomes of participants with ABI compared with participants with TBI. Considering the lack of information in the literature on ABI rehabilitation, this study may be important to guide rehabilitation teams.

A Different Presentation of Mal De Meleda: New Skin Lesions in a Residual Limb after Traumatic Amputation.

Mal de Meleda is a rare autosomal recessive skin disease which is known as keratoderma palmoplantaris transgradiens. Here we report a case of Mal de Meleda who had skin lesions in the residual limb and pseudoainhum in the thigh after traumatic lower leg amputation. A 71-year-old female was admitted to our tertiary hospital for prosthetic rehabilitation. On the physical examination, thickening of the skin on palms, left sole and residual limb was present. The patient reported that she had these skin lesions since infancy and she realized new skin lesions after amputation in the residual limb. We requested dermatology consultation and she was diagnosed as Mal de Meleda. To our knowledge, this is the first Mal de Meleda case in the literature with new lesions at the residual limb. Although exact pathophysiological mechanisms are not well known in Mal de Meleda, prosthesis use might have accelerated disease process in our patient.

Determinants of disease-specific health-related quality of life in Turkish stroke survivors.

Stroke is a worldwide cause of morbidity and mortality that affects health-related quality of life. In this study, our objective was to identify determinants of disease-specific health-related quality of life in Turkish stroke survivors. A total of 114 consecutive patients who experienced a stroke at least 6 months earlier were studied. Health-related quality of life was measured using Stroke-specific Quality of Life (SS-QoL) consisting of 12 domains. Demographic and clinical data were collected, including age, sex, marital status, years of education, time since stroke, whether the patient received rehabilitation before enrollment, stroke etiology, whether the dominant hand was affected or not, presence of vision defect, neglect, aphasia, and dysarthria. The patients were assessed by the functional independence measure (FIM) and the Mini-Mental State Examination. A multiple linear regression analysis was carried out using a stepwise method to determine the predictors of 12 domains and the total score of the SS-QoL. The domains of work, social roles, mobility, and self-care had the lowest SS-QoL scores, whereas the highest scores were for the domains of personality, thinking, language, and vision. The total SS-QoL score was explained by the total FIM and Mini-Mental State Examination. Among the 12 domains, the mobility domain was explained the best (R=0.50) by motor FIM, previously received rehabilitation, and age, followed by the language domain (R=0.37) explained by the presence of aphasia and dysarthria, and previously received rehabilitation. The domains of mood (R=0.13) and upper extremity (R=0.19) were explained the worst. The results indicated that functional independence, age, cognitive status, and receiving a rehabilitation program were the primary determinants of the SS-QoL.

The relationship between prosthesis use, phantom pain and psychiatric symptoms in male traumatic limb amputees.

OBJECTIVES: The purpose of this study was to identify psychiatric symptoms by comparing male patients with traumatic leg amputations (LAs) with healthy controls and to determine the association between these psychiatric symptoms and phantom pain and prosthesis use characteristics. METHODS: One hundred four volunteers, 51 LA patients (group 1) and 53 healthy controls (group 2) were included. Demographic data including age, height, weight, time since amputation, duration of prosthesis use, and Satisfaction with Prosthesis Questionnaire scores were recorded. Phantom pain was measured a visual analog scale (VAS). Psychiatric symptoms were measured using the Symptom Checklist-90-R, Beck Depression Inventory, Pittsburgh Sleep Quality Index, Rosenberg Self-Esteem Scale, and State-Trait Anxiety Inventory. Correlations were determined between time since amputation, duration of prosthesis use and satisfaction with prosthesis questionnaire scores and psychiatric scale scores. RESULTS: Amputee patients had higher phobic anxiety, state anxiety, trait anxiety and sleep disturbance scores (p<0.05) than the controls. No difference was determined in terms of psychiatric symptoms between the phantom pain and no phantom pain groups (p>0.05). There were significant negative correlations between time since amputation, duration of prosthesis use, duration of daily prosthesis use, and satisfaction with prosthesis questionnaire scores and psychiatric symptoms. CONCLUSIONS: Apart from anxiety (state, trait or phobic) and disturbed sleep, other psychiatric symptoms in amputee patients undergoing lengthy prosthetic rehabilitation may not differ from those of healthy controls. The presence and severity of phantom pain appear to be unrelated to general psychiatric symptomatology. Length of time since amputation, length of prosthesis use, daily length of prosthesis use and prosthesis satisfaction are negatively correlated with general psychiatric symptoms. These characteristics must be borne in mind in psychiatric and prosthetic rehabilitation.

Quality of life and functionality after lower limb amputations: comparison between uni- vs. bilateral amputee patients.

BACKGROUND: It is difficult for the lower limb amputee patients to adapt to their new lifestyles. OBJECTIVE: To compare the life quality and functionality of patients with bilateral vs. unilateral lower extremity amputations. STUDY DESIGN: Cross-sectional study. METHODS: Fifteen bilateral and 15 unilateral lower extremity amputee patients were enrolled. Demographics, cause and level of amputations, frequency and duration of prosthesis use were evaluated. SF-36, Satisfaction with Prosthesis Questionnaire (SAT-PRO), Amputee Body Image Scale. (ABIS), Houghton Scale (HS), six-minute walk test (6MWT), and 10-metre walk test (10 MWT) were performed. RESULTS: Physical function, physical and emotional role scores of SF-36 were significantly lower in the bilateral amputee group in comparison with the unilateral group. SAT-PRO and ABIS total scores were similar between the groups. There was a positive correlation between the frequency of prosthetic use and SF-36 subgroups (except pain). The unilateral amputee group had significantly better scores than the bilateral amputee group in terms of HS, 6MWT and 10 MWT. CONCLUSION: Physical capacity of bilateral lower extremity amputee patients is lower than the unilateral amputee patients; satisfaction with prosthesis and body image are not related with the amputation level; and the life quality and satisfaction with prostheses are increased in parallel with the use of the prostheses. Clinical relevance Although differences exist between the groups, in terms of quality of life and functionality, patients can reach an acceptable life standard with good rehabilitation and a suitable prosthesis.

Effects of botulinum toxin-A on the muscle architecture of stroke patients: the first ultrasonographic study.

OBJECTIVE: The aim of this study was to explore in vivo the effects of botulinum toxin-A treatment on the muscle architecture of patients with stroke, using musculoskeletal ultrasonography. METHODS: This prospective clinical trial included 26 adult stroke sufferers with a mean age of 55 years (standard deviation 14). Pennation angles between the fascicle path and the deep aponeurosis of the muscle, fascicle length, muscle thickness and muscle compressibility were scanned at the bulkiest part of the medial gastrocnemius on both limbs. Sonographic evaluations were performed initially before botulinum toxin-A injection and repeated on day 10 and after 2 months. RESULTS: On the hemiplegic sides, anterior pennation angle and muscle thickness decreased (p = 0.014, p = 0.010, respectively), fascicle length increased (p = 0.025) and muscle compressibility did not change after 2 months of treatment compared with the baseline values. CONCLUSION: The results confirm that muscle structure changes due to botulinum toxin-A. Long-term effects of botulinum toxin-A, timing for disappearance of the toxin effects, or evaluations for repeat injections, remain to be studied. The use of musculoskeletal ultrasonography appears to be promising in this regard. :

The effects of electrical stimulation combined with continuous passive motion versus isometric exercise on symptoms, functional capacity, quality of life and balance in knee osteoarthritis: randomized clinical trial.

The aim of this study was to evaluate effects of electrical stimulation combined with continuous passive motion (CPM-ES) versus isometric exercise on symptoms, functional capacity, quality of life, muscle strength, knee and thigh circle measurements, and balance in knee osteoarthritis (OA). This is a randomized clinical trial. The study was done in Gulhane Military Medical Academy (GMMA) Rehabilitation Center. Forty patients with knee OA were included in this study. Participants were randomly assigned to two groups: 20 patients placed in Group 1 were treated with conventional physical therapy and CPM-ES combination; 20 patients in Group 2 were treated with conventional physical therapy and isometric exercise. Therapies were applied 3 weeks, 5 days per week. The following main outcome measures were done: values of pain (VAS was used), WOMAC, SF-36, knee and thigh circle measurements, isokinetic tests, dynamic and static balance tests were determined at baseline and after the treatment. There were no statistically significant differences in the tested variables between the groups for post-treatment values. Dynamic and static balance test improved statistically strongly significantly in both groups. The findings of this study demonstrate that knee OA patients could improve their balance function in both static and dynamic conditions after CPM-ES combination or isometric exercise therapy. The improvement might prevent knee OA patients from falling down and increase their sense of security during physical activities.

Which treatment approach is better for hemiplegic shoulder pain in stroke patients: intra-articular steroid or suprascapular nerve block? A randomized controlled trial.

OBJECTIVE: To determine which injection technique was effective for patients with hemiplegic shoulder pain. DESIGN: Randomized prospective double-blind study. SETTING: Brain Injury Rehabilitation Unit. INTERVENTION: Patients with hemiplegic shoulder pain were recruited over a 12-month period and all were hospitalized in our clinic. Intra-articular steroid injection or suprascapular nerve block was performed on all patients. MAIN MEASURES: Range of motion values at the moment that pain started (range of motion A) and passive maximum range of motion values (range of motion B) were recorded. Pain intensity levels (visual analogue scale) at these two range of motion values (pain A and pain B) were also taken. Evaluations were made before the injection, and 1 hour, one week and one month after the injection. RESULTS: Twenty-six patients were enrolled in the study, the mean age was 61.53 ± 10.30 years. The mean time since injury was 8.69 ± 15.71 months. The aetiology was ischaemic in 16 (61%) patients. Intra-articular steroid injection was performed in 11 (42 %) patients, and suprascapular nerve block in 15 (57%) patients. Range of motion A and range of motion B were changed statistically in repeated measures. There were important differences in repeated measures of pain intensity levels at these two range of motion values (P < 0.05). However, no significant differences were determined in all measurements between intra-articular steroid injection and suprascapular nerve block groups (P > 0.05). CONCLUSIONS: Our results showed that neither injection technique was superior to the other. Both injection procedures are safe and have a similar effect in stroke patients with hemiplegic shoulder pain.

Manual lymphatic drainage in management of edema in a case with CRPS: why the(y) wait?

Complex regional pain syndrome (CRPS) is a disorder characterized by pain, edema, skin color changes and autonomic abnormalities. Its treatment is quite difficult and in most of the patients effective results cannot be reached. Manual lymphatic drainage is a very rare method for managing limb edema in CRPS. In this case report, the dramatic response of an excessive edema to lymphatic drainage was discussed in a CRPS patient.

Autonomic dysreflexia as a complication of a fecal management system in a man with tetraplegia.

BACKGROUND/OBJECTIVE: To present a case of autonomic dysreflexia caused by the use of a fecal management system in a patient with tetraplegia. DESIGN: Case report. SETTING: Military rehabilitation center. RESULTS: A man with tetraplegia had a fecal management system inserted to divert stool away from his sacral pressure ulcer to reduce contamination and infection risk. Two days later, he developed severe autonomic dysreflexia that improved after removal of the system. CONCLUSIONS: Autonomic dysreflexia, a life-threatening complication, has not been reported before as a side effect of a fecal management system. These systems should be used with caution in patients with high-level spinal cord injury.

Sonographic evaluation of the sciatic nerve in patients with lower-limb amputations.

Hypertrophy of the sciatic nerve after lower-limb amputation in patients with sarcomas has been previously reported by magnetic resonance imaging; however, sonographic evaluation of the sciatic nerve after lower-limb amputation due to nonmalignant causes has not been done before. Therefore, the aim of this study was to perform imaging of the sciatic nerve in lower-limb amputees and to find out whether sonographic findings were related to clinical characteristics. Twenty-three males with lower-limb amputations due to traumatic injuries were enrolled. Sonographic evaluations were performed using a linear array probe (Aloka UST-5524-7.5 MHZ). Sciatic nerve diameters were measured bilaterally at the same level, and the values of the normal limbs were taken as controls. Sciatic nerve width and thickness values were found to be greater on the amputated sides than the normal sides (P = 0.001). The thickness values were greater in above-knee amputees than below-knee amputees (P = 0.05). Subjects with a neuroma also had thicker sciatic nerves (P = 0.04). The diameters were found not to change between subjects with different liners (P > 0.05), but they were correlated with time after amputation (r = 0.6, P = 0.006; r = 0.4, P = 0.05, respectively). Our results clearly show that the sciatic nerves were wider and thicker on the amputated sides. Amputation level, duration, and the presence of a neuroma seem to affect the eventual diameters of the nerves.

The efficacy of serial casting after botulinum toxin type A injection in improving equinovarus deformity in patients with chronic stroke.

INTRODUCTION: Spasticity is an important early complication of stroke, which may lead to shortening of gastrocnemius and soleus muscles and contracture in the Achilles tendon and soft tissues of the ankle. Botulinum toxin A (BTX-A) is a promising drug for the management of focal spasticity. Serial casting is another alternative method for reducing contractures due to spasticity. The present study aimed to determine if serial casting after BTX-A injection could help to limit the development of calf contracture in chronic hemiplegic patients. METHOD: The records of patients with stroke that were treated in the brain injury rehabilitation clinic between January 2007 and December 2008 were screened. In all, 10 patients that underwent a serial casting programme for 24 days following BTX-A injection were included in the study. Goniometric scores for ankle ROM, Physician Rating Scale (PRS) and Functional Independence Measurement (FIM) scores were recorded. RESULTS: Mean age of the patients was 33.2 years. Mean time interval after stroke onset was 35.0 months. Improvements in ROM were quite significant after serial casting. Moreover, FIM and PRS scores improved significantly. CONCLUSION: Serial casting may be an appropriate intervention following BTX-A injection to prevent equinovarus deformity and improve the quality of walking in chronic stroke patients. The role of casting and splinting are important topics that require further research.

The effects of balneotherapy on disease activity, functional status, pulmonary function and quality of life in patients with ankylosing spondylitis.

OBJECTIVE: This study aimed to determine the effects of balneotherapy on disease activity, functional status, metrology index, pulmonary function and quality of life in patients with ankylosing spondylitis (AS). MATERIALS AND METHODS: The study included 28 patients (27 male and 1 female) diagnosed with AS according to modified New York criteria. The patients were treated with balneotherapy for 3 weeks (30 min/day, 5 days/week). The patients were evaluated using the global index, Bath ankylosing spondylitis disease activity index (BASDAI), disease functional index (BASFI), metrology index (BASMI), chest expansion measures, pulmonary function testing, and the medical outcomes study-short form-36 Health Survey (SF-36) (measure of quality of life) before balneotherapy and 1 month after treatment. RESULTS: Post balneotherapy BASDAI and global index decreased, BASMI parameters improved, chest expansion increased, and some SF-36 parameters improved; however, none of these changes were statistically significant (P > 0.05), except for the decrease in BASMI total score (P < 0.05). Before balneotherapy 6 patients had restrictive pulmonary disorder, according to pulmonary function test results. Pulmonary function test results in 3 (50%) patients were normalized following balneotherapy; however, as for the other index, balneotherapy did not significantly affect pulmonary function test results. CONCLUSION: The AS patients' symptoms, clinical findings, pulmonary function test results, and quality of life showed a trend to improve following balneotherapy, although without reaching significant differences. Comprehensive randomized controlled spa intervention studies with longer follow-up periods may be helpful in further delineating the therapeutic efficacy of balneotherapy in AS patients.

Muscle strength and bone mineral density in mine victims with transtibial amputation.

The aims of this study were to: (i) Determine if there were significant bone mineral density and muscle strength differences between intact and amputated limbs, and (ii) investigate the possible relationship between local bone loss and muscle strength in transtibial amputees. Fifteen male veterans with traumatic unilateral transtibial amputations who ranged in age from 18-45 years were included in this prospective study. Lower limb muscle strength was measured with an isokinetic dynamometer. Dual energy X-ray absorptiometry was used to determine bone mineral density of the femur and tibia. The bone mineral density values of the femur and tibia were found significantly decreased on the amputated side. Significant decreases (p < 0.001) in strength of the quadriceps and hamstrings were observed in the amputated limb. There was a weak correlation between quadriceps strength and total femur bone mineral density (p = 0.048, r = 0.518) on the amputated limb. Transtibial amputees are prone to bone mineral loss and muscle strength decrease on the amputated side. Our results also indicate that muscle strength itself might not be of decisive importance for bone mass in transtibial amputees.

Evaluation of the patellar tendon in transtibial amputees: a preliminary sonographic study.

This study aimed to provide sonographic imaging of the patellar tendon (PT) - one of the main weight bearing structures for prosthetic use - in transtibial amputees. Thirteen males, who had been under follow-up for unilateral traumatic transtibial amputations, were enrolled. After physical examination of the limb, pain was evaluated by visual analogue scale and Leeds Assessment of Neuropathic Symptoms and Signs. Sonographic evaluations were performed by using a linear array probe (Aloka UST-5524-7.5 MHz) on both sides. Measurements pertaining to the contralateral limbs were taken as controls. In three subjects (23.1%), two with a silicone liner and one with a pelite liner, cortical irregularities were detected at the tibial insertion of the PT on the amputated sides. PTs were found to be thicker on the amputated sides when compared with those of the contralateral sides (p = 0.03), and this increase in thickness correlated with disease duration (r = 0.67, p = 0.01). Overall, our preliminary results imply that after transtibial amputation, PTs of the amputated sides tend to become thicker by time. These findings need to be complemented with future studies. In this regard, sonography seems to be promising for imaging the soft tissue problems of the stump.

Brunnstrom recovery stage and motricity index for the evaluation of upper extremity in stroke: analysis for correlation and responsiveness.

The aim of this study was to find out first whether Brunnstrom recovery stage (BRS) and motricity index (MI) were correlated with each other and second to observe whether the two assessment tools were sensitive to changes regarding the rehabilitation outcome. Forty-six stroke patients who were admitted to the Stroke Rehabilitation Unit at our Rehabilitation Centre were recruited. All measurements were made within the first 72 h of admission and on the last day of discharge. A physiotherapist performed all MI evaluations and a physiatrist blind to the results performed all BRS evaluations. Both upper extremity (UE) and hand BRS scores were found to be positively correlated with those of UE-MI; moreover, correlations between the discharge values were stronger than those between the admission values. The responsiveness of both the total scores of the BRS and UE-MI were strong (effect size d = 0.97, Wilcoxon Z=5.33, P<0.001 for the UE-BRS; d=0.81, Z=5.09, P<0.001 for the hand BRS; d=0.91, Z=5.45, P<0.001 for the UE-MI). BRS and MI scores were found to be increased on discharge when compared with those of admission and the differences in between were statistically significant (P<0.001). BRS and MI seem to be well correlated and responsive concerning the evaluation of UEs in early stage stroke patients. Being convenient tests, they may easily be applied repetitively for close follow-up during rehabilitation.

Primary paraspinal hydatid cyst treated with puncture, aspiration, injection and re-aspiration (PAIR) technique: a case report.

Hydatid disease is a parasitic tapeworm infection that usually involves liver and lungs. Primary skeletal muscle hydatid cyst without liver and lung involvement is rare. En bloc resection without inducing rupture and spreading the daughter cyst is recommended treatment strategy and accepted to be curative for intramuscular hydatid cyst. We report a case of primary hydatid cyst of the erector spinae muscle which was treated successfully with ultrasonography guided puncture, aspiration, injection of 95% ethanol and re-aspiration (PAIR) technique.