Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part I: Management, Diagnosis, and Follow-up.

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome after acute stroke and may become chronic after the acute period and continues to affect all aspects of the patient's life. Patients with stroke may encounter any of the medical branches in the emergency room or outpatient clinic, and as in our country, there may not be specialists specific for dysphagia, such as speech-language pathologists (SLP), in every hospital. This study aimed to raise awareness and create a common opinion of medical specialists for stroke patients with dysphagia. This recommendation paper has been written by a multidisciplinary team and offers 45 recommendations for stroke patients with dysphagia. It was created using the eight-step Delphi round via e-mail. This study is mostly specific to Turkey. However, since it contains detailed recommendations from the perspective of various disciplines associated with stroke, this consensus-based recommendation paper is not only a useful guide to address clinical questions in practice for the clinical management of dysphagia in terms of management, diagnosis, and follow-up, but also includes detailed comments for these topics.

Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part II: Rehabilitation.

Dysphagia is one of the most common and important complications of stroke. It is an independent marker of poor outcome following acute stroke and it continues to be effective for many years. This consensus-based guideline is not only a good address to clinical questions in practice for the clinical management of dysphagia including management, diagnosis, follow-up, and rehabilitation methods, but also includes detailed algorithms for these topics. The recommendation paper has been written by a multidisciplinary team and offers 117 recommendations for stroke patients with dysphagia. While focusing on management principles, diagnosis, and follow-up in the 1st part (45 items), rehabilitation details were evaluated in the 2nd part (72 items).

Rehabilitation outcomes in patients with early and two-stage reconstruction of flexor tendon injuries.

[Purpose] The primary aim of this study was to assess rehabilitation outcomes for early and two-stage repair of hand flexor tendon injuries. The secondary purpose of this study was to compare the findings between treatment groups. [Subjects and Methods] Twenty-three patients were included in this study. Early repair (n=14) and two-stage repair (n=9) groups were included in a rehabilitation program that used hand splints. This retrospective evaluated patients according to their demographic characteristics, including age, gender, injured hand, dominant hand, cause of injury, zone of injury, number of affected fingers, and accompanying injuries. Pain, range of motion, and grip strength were evaluated using a visual analog scale, goniometer, and dynamometer, respectively. [Results] Both groups showed significant improvements in pain and finger flexion after treatment compared with baseline measurements. However, no significant differences were observed between the two treatment groups. Similar results were obtained for grip strength and pinch grip, whereas gross grip was better in the early tendon repair group. [Conclusion] Early and two-stage reconstruction of patients with flexor tendon injuries can be performed with similarly favorable responses and effective rehabilitation programs.

Treatment of fibromyalgia among patients with mastalgia and fibromyalgia improved mastalgia.

OBJECTIVES: The aim of this study is to examine the effect of fibromyalgia (FM) treatment on mastalgia by performing fibromyalgia screening in patients who applied for mastalgia and whose underlying cause could not be found. METHODS: Patients who applied to Kocaeli University General Surgery Outpatient Clinic between November 2017 and November 2020 with breast pain were included (n=120). Patients without cancer, systemic disease, previous breast surgery, and breast mass larger than 3 cm (n=30) were referred to the Physical Therapy and Rehabilitation Outpatient Clinic. A total of 13 patients (43%) were diagnosed with FMS. Twelve of them were given selective serotonin-noradrenaline reuptake inhibitor (duloxetine) treatment for 3 months. Turkish version of the Short Form - 36 (SF-36) quality of life scores, Visual Analog Scale (VAS), Cardiff breast pain score before and after treatment were compared. The remaining 17 patients were followed as only mastalgia. RESULTS: Patients with fibromyalgia and mastalgia had similar demographic results. At the end of the 3rd month, the complaints of breast pain completely regressed in all of the patients. Statistically significant changes were detected in VAS score, the number of trigger points, and SF-36 quality of life scores, Cardiff breast pain score after duloxetine treatment. CONCLUSION: In the presence of unexplained mastalgia, fibromyalgia should be kept in mind. Duloxetine treatment improved the breast pain and quality of life in patients with mastalgia and fibromyalgia.

Best Practice Recommendations for Geriatric Dysphagia Management with 5 Ws and 1H.

BACKGROUND: Dysphagia is a geriatric syndrome. Changes in the whole body that occur with aging also affect swallowing functions and cause presbyphagia. This condition may progress to oropharyngeal and/or esophageal dysphagia in the presence of secondary causes that increase in incidence with aging. However, no study has been published that provides recommendations for use in clinical practice that addresses in detail all aspects of the management of dysphagia in geriatric individuals. This study aimed to answer almost all potential questions and problems in the management of geriatric dysphagia in clinical practice. METHODS: A multidisciplinary team created this recommendation guide using the seven-step and three-round modified Delphi method via e-mail. The study included 39 experts from 29 centers in 14 cities. RESULTS: Based on the 5W and 1H method, we developed 216 detailed recommendations for older adults from the perspective of different disciplines dealing with older people. CONCLUSION: This consensus-based recommendation is a useful guide to address practical clinical questions in the diagnosis, rehabilitation, and follow-up for the management of geriatric dysphagia and also contains detailed commentary on these issues.

The Effect of Whole Body Vibration Treatment on Upper Extremity Functions Compromised by Stroke.

INTRODUCTION: In patients with neurological disorders Whole Body Vibration (WBV) has been reported to improve motor function. Our aim was to assess the effects of WBV on upper extremity function in adult stroke patients. METHODS: Forty-three post-stroke patients were randomly assigned to two groups: treatment group and control group. The demographic characteristics and Modified Ashworth Scale (MAS) were recorded in all patients. The plegic upper extremity range of motions (ROM) and motor functions were evaluated by goniometric measurement and Jebsen-Taylor Hand Function Test (JTHFT). All patients participated in a conventional rehabilitation program for three weeks while the treatment group also received WBV over the same period. All evaluations were performed before and after therapy. RESULTS: The median (range) age of all patients was 51.0±13.7 (18-66) years. The groups numbered 26 and 17 patients for the treatment and control groups respectively. No significant differences were found between the two groups in the pre-treatment evaluation based on the JTHFT all scores (p>0.05). Significant improvement was found in the elbow extension ROM degree (p=0.019) for the treatment group. A statistically significant improvement was observed in all parameters of JTHFT in the treatment group after the intervention, whereas only page turning, removing small objects, removing large light objects and removing large heavy objects showed a statistically significant improvement in controls (p<0.05). CONCLUSION: Statistically significant differences were observed between the treatment and control groups after intervention. WBV treatment is effective for the improvement of ROM and upper extremity functions in stroke patients.

Hemophilia-Specific Quality of Life Index (Haemo-QoL and Haem-A-QoL questionnaires) of children and adults: result of a single center from Turkey.

The aim of this study is to describe the health status, health care received, and their impact on the quality of life in patients with hemophilia. Patients with severe factor VIII or IX deficiency without inhibitors or other chronic disease were enrolled. Turkish version of the Hemophilia-Specific Quality of Life Index (Haemo-QoL) questionnaire was administered to the pediatric patients aged 4 to 16 years and Haem-A-QoL to the adult patients. Joints were evaluated according to the World Federation of Hemophilia (WFH) orthopedic joint scores.Thirty-nine children/adolescents and 31 adult patients were enrolled. Mean Haemo-QoL scores were 39.6 +/- 15.0 for the children and mean Haem-A-QoL 47.4 +/- 14.1 for the adult patients, respectively. Internal consistency reliability was generally sufficient. Total Cronbach's alpha coefficient was >.70 (range .77-.96) in all the age groups. Mean total WFH orthopedic joint scores were 1.83 +/- 2.7, 4.9 +/- 4.96, and 6.94 +/- 6.15 in 4-7, 8-12, and 13-16-year-old groups, respectively. They were more impaired in the adult patients (16.23 +/-14.12). These results show that the Turkish version of the Haemo-QoL and Haem-A-QoL are reliable instruments to measure the quality of life in the pediatric and adult patients with severe hemophilia. When compared to the Haemo-QoL scores of an international multicenter West European study of children, quality of life in the Turkish patients were more impaired in the subscales of physical health, feeling, view, school and sport, and treatment as well as more impaired WFH joint scores. The authors recommend primary factor prophylaxis and encouraging the patients to learn home treatment to improve joint scores and quality of life.

The Effect of Whole Body Vibration Treatment on Balance and Gait in Patients with Stroke.

INTRODUCTION: In patients with neurological disorders Whole Body Vibration (WBV) has been reported to improve motor function. Our aim was to assess the effects of WBV on both balance and walking performance in adult stroke patients. METHODS: Forty three post-stroke patients were randomly divided into two groups. One would receive WBV therapy (WBV group) while the control group would not. All patients participated in a conventional rehabilitation program for three weeks while the vibration group also received WBV over the same period. Patients balance and walking performance were evaluated using the Berg Balance Scale (BBS), Timed Up and Go Test (TUG) and computerized gait analysis. All evaluations were performed before and after therapy. RESULTS: The median (range) age of all patients was 51.00 (18-66) years. The groups numbered 26 and 17 patients for the WBV and control groups respectively. After intervention, significant improvements were found in the WBV group for BBS score (p=0.004), TUG score (p=0.035), step length (p=0.004) and walking speed (p=0.031) when compared to the controls. CONCLUSION: WBV is effective for the improvement of balance and gait performance in stroke patients.

The GUSS test as a good indicator to evaluate dysphagia in healthy older people: a multicenter reliability and validity study.

PURPOSE: Dysphagia is known to be a disorder of the swallowing function, and is a growing health problem in aging populations. Swallowing screening tests have mostly been studied in comorbidities such as stroke associated with old age. There is no simple, quick and easy screening test to best determine the risk of oropharyngeal dysphagia in geriatric guidelines. We aimed to evaluate whether the Gugging Swallowing Screen (GUSS) test is an effective method for evaluating swallowing difficulty in healthy older people. METHODS: This cross-sectional and multicenter study was conducted at 13 hospitals between September 2017 and February 2019. The study included 1163 participants aged ≥65 years and who had no secondary dysphagia. Reliability was evaluated for data quality, scaling assumptions, acceptability, reliability, and validity as well as cutoff points, specificity and sensitivity. RESULTS: The age distribution of 773 (66.5%) patients was between 65 and 74 years and 347 (29.8%) of them were male and 767 (66%) patients were female. The average total GUSS score was 18.57 ± 1.41. The Cronbach's alpha was 0.968. There was a moderate statistically significant negative correlation between the total GUSS and 10-item Eating Assessment Tool scores as well as between the total GUSS score and quality of life. The cutoff point of the total GUSS score was 18.50, sensitivity was 95.5% and specificity was 94.4%. CONCLUSIONS: The GUSS test is a valid and reliable test to identify possible oropharyngeal dysphagia risk in healthy older people who had no secondary dysphagia. It is suitable as a screen test for clinical practice.

Comparison of biochemical parameters of blood and urine in spinal cord injury patients and association with urinary stone formation.

OBJECTIVE: The aim of this study was to compare the biochemical parameters of the urine and blood in spinal cord injury (SCI) patients and healthy subjects. METHODS: Thirty male patients with SCI were enrolled. Biochemical features of the urine and blood of the SCI patients were compared to healthy subjects. Extracted stones were analyzed by X-ray diffraction. RESULTS: A total of 30 patients with SCI (mean age of 28.77 ± 7.3 years) and 10 healthy subjects (mean age of 27.6 + 6.2 years) were included. Among the patients with SCI; 12 of them (40%) had urinary stones and 18 of them (60%) did not. Urinary stone was localized in the kidneys and bladder in 25% and 75% of the subjects, respectively. The mean duration of cord injury at diagnosis of urinary stone was 9.2 ± 6 months. Urine cultures obtained on admission were negative for the control group, while the microorganism isolation rate was 73.3% in the SCI group. The urinary excretion of citrate and Mg were lower in the patient group compared with control group (p= 0.008, p= 0.001, respectively). As for the diffraction analysis of eight stones; five (62.5%) of the stones were calcium oxalate, two (25%) of them were calcium phosphate, and one (12.5%) was magnesium ammonium phosphate. CONCLUSION: Both infection and metabolic changes play an important role in stones formation in SCI patients. The urinary excretion of citrate and Mg was decreased and urinary PH was increased in SCI patients.

Psychiatric approach in the treatment of reflex sympathetic dystrophy in an adolescent girl: a case report.

Reflex sympathetic dystrophy (RSD) is an unusual diagnosis in the pediatric age group. It is a syndrome characterized by pain in one or more extremities with a significant morbidity in childhood. Patients with RSD have frequently undergone many unnecessary investigations such that the diagnosis and treatment may be considerably delayed. The pathophysiology remains unclear; however, a number of psychological problems were frequently suggested to play a role in this disorder. We describe a 13-year-old girl diagnosed as pediatric RSD who was admitted to a child and adolescent psychiatry unit with a history of severe pain in the right hand, increasing disability and symptoms of nervousness and withdrawal from social activities. In this report, we discuss psychogenic factors underlying the disorder of an adolescent girl and psychiatric approach as a part of a multimodal treatment of pediatric RSD.

Sympathetic skin responses in hemiplegic patients with and without complex regional pain syndrome.

BACKGROUND AND AIMS: To investigate whether there were changes in the sympathetic skin responses (SSR) in the limbs with complex regional pain syndrome (CRPS) type I in hemiplegic patients. SETTING: A physical medicine and rehabilitation center in Turkey. MATERIALS AND METHODS: Sympathetic skin responses were evaluated in 69 stroke patients (41 with CRPS and 28 without CRPS) and 20 healthy volunteers. SSR were recorded on the paretic and healthy hands after stimulation of the ipsilateral median nerve. Patients' ages ranged from 33 to 77 years, with a mean of 60.0+/-12.9 years. RESULTS: The SSR were obtained in all patients with CRPS, whereas SSR was absent in 9 of 28 patients with hemiplegia who did not have CRPS after stimulation of the plegic side and the difference was statistically significant (P=0.023). SSR amplitudes were increased at the hemiplegic limbs in patients affected by CRPS compared to individuals unaffected; this group difference was statistically significant (P=0.014). The mean amplitude of the SSR in the advanced stage of CRPS was greater than lower stage and the difference was statistically significant (P=0.035). CONCLUSION: Our results suggest that SSR can be obtained in stroke patients with CRPS even in the early stages of CRPS. SSR acquirability and amplitude increase as the stage of the disease advances. As an electrophysiologic technique, SSR may be used in the evaluation of the sympathetic function in hemiplegic patients and also in the diagnosis of CRPS and in monitoring of its treatment.

Management of acetabular fractures with modified posterior approach to spare external hip rotators.

INTRODUCTION: In the present study the quality of reduction and incidence of complications in hip external rotator sparing modified posterior approach was assessed in both simple and complex acetabular fractures. MATERIALS AND METHODS: This retrospective study includes 37 patients (38 hips) with a mean age of 42.1 years (range 21-60), that had been treated for displaced acetabular fractures from June 2007 through May 2011. They were reviewed at a mean of 3 years (20-67 months). RESULTS: The fractures were classified according to the Letournel-Judet classification. Anatomic reduction and stable fixation of the fracture with less than 2mm residual displacement was achieved in 28 of 38 hips. At the final follow up the patients were evaluated clinically according to Merle d'Aubigne and Postel scoring system which had been modified by Matta and radiologically based on the criteria described by Matta. The clinical results were excellent in 20, good in 8, fair in 8, and poor 2 hips. Complications included two superficial local wound infection and 10 heterotopic ossification with 7 of the cases having grade I heterotopic ossification. Avascular necrosis of the femoral head was not seen in any of the 38 hips. One patient with preoperative sciatic nerve palsy had complete recovery of neurologic function. There were no cases of deep vein thrombosis or pulmonary embolism. CONCLUSION: The functional outcome was satisfactory in most of the cases and comparable with other larger series. Using the limited part of Henry's sciatic nerve exposure skin incision - working in the plane between gluteus maximus and the tensor fascia lata as in the classical Gibson approach and two portal external rotator hip sparing approach resulted in good fracture reduction without approach related complications.

External rotator sparing with posterior acetabular fracture surgery: does it change outcome?

This study analyses the results of the treatment with external rotator sparing approach in acetabular fractures to determine whether muscle sparing has a positive impact on functional outcome. 20 patients with a mean age of 45.9 years (range: 26-64) that had been treated for displaced acetabular fractures were included in this series. Short Musculoskeletal Function Assessment (SMFA) questionnaire and hip muscle strength measurement were done at the 24-month of follow-up period. The radiographic results at the final followup were excellent in 9 hips (45%), good in 6 hips (30%), fair in 4 hips (20%), and poor in one hip (5%) according to the criteria developed by Matta. The average SMFA score for all of the patients was 18.3 (range: 0-55.4). The mean dysfunctional and bother indexes were 17.2 and 20.6, respectively. The overall muscle strength deficit was 11.8%. The greatest loss of strength was in internal rotation. In patients with better postoperative reduction quality of acetabular fracture, peak torque, and maximum work of hip flexion, extension and also internal rotation maximum work deficit were significantly lower (P < 0.05). Accurate initial reduction and longer postoperative muscle strengthening exercise programs seem critical to decrease postoperative hip muscle weakness after acetabular fractures.

Autonomic dysreflexia after intramuscular injection in traumatic tetraplegia: a case report.

Autonomic dysreflexia is a syndrome of massive imbalance of reflex sympathetic discharge occurring in patients with spinal cord lesion above the splanchnic outflow (T6). It is characterized by a sudden onset and severe increase in blood pressure and is potentially life threatening. The most common causes are bladder and rectum distention. In this case study, we report an autonomic dysreflexia case that developed after intramuscular injection in a 29-yr-old tetraplegic patient with C5 American Spinal Injury Association grade A lesion. After careful scrutiny of English literature, this clinical manifestation seems to be an unusual event.