2017 update of the Turkish League Against Rheumatism (TLAR) evidence-based recommendations for the management of knee osteoarthritis.

In a Turkish League Against Rheumatism (TLAR) project, evidence-based recommendations for the management of knee osteoarthritis (OA) was developed for the first time in our country in 2012 (TLAR-2012). In accordance with developing medical knowledge and scientific evidence, recommendations were updated. The committee was composed of 22 physical medicine and rehabilitation specialists (4 have rheumatology subspeciality also) and an orthopaedic surgeon. Systematic literature search were applied on Pubmed, Embase, Cochrane and Turkish Medical Index for the dates between January the 1st 2012 and January the 29th of 2015. The articles were assessed for quality and classified according to hierarchy for the level of evidence, and the selected ones sent to committee members electronically. They were asked to develop new recommendations. In the meeting in 2015, the format of the recommendations was decided to be patient-based and considering the grade and the severity of the disease. By the discussion of the each item under the light of new evidences, the final recommendations were developed. Each item was voted electronically on a 10-cm visual analogue scale (VAS) and the strength of recommendation (SoR) was calculated. In the light of evidences, totally 11 titles of recommendations were developed; the first 7 were applicable to each patient in every stages of the disease, remaining were for defined specific clinical situations. The mean SoR value of the recommendations was between 7.44 and 9.93. TLAR-2012 recommendations were updated in a new format. We think that, present recommendations will be beneficial for the physicians who manage, as well as the patients who suffer from the disease.

Correlations among enthesitis, clinical, radiographic and quality of life parameters in patients with ankylosing spondylitis.

OBJECTIVES: To investigate the relationship between enthesitis and disease activity, functional status, fatigue, joint mobility, radiological damage, laboratory parameter and quality of life in patients with ankylosing spondylitis (AS). METHODS: A total of 421 patients with AS (323 male and 98 female) who were included in the Turkish League Against Rheumatism Registry were enrolled in the study. The Bath AS Disease Activity Index (BASDAI), fatigue, the Bath AS Functional Index (BASFI), the Bath AS Metrology Index (BASMI), the Maastricht AS Enthesitis Score (MASES), AS quality of life (ASQoL), the Bath AS Radiology Index (BASRI) and erythrocyte sedimentation rate (ESR) were evaluated. RESULTS: Enthesitis was detected in 27.3% of patients. There were positive correlations between MASES and BASDAI, BASFI and fatigue (p < 0.05). MASES was not correlated with BASRI, BASMI, ASQoL and ESR. The mean MASES score was 1.1 ± 2.4. The most frequent regions of enthesopathies were right iliac crest, spinous process of L5 and proximal to the insertion of left achilles tendon, respectively. CONCLUSIONS: Enthesitis was found to be associated with higher disease activity, higher fatigue, worse functional status and lower disease duration. As enthesitis was correlated with BASDAI, we conclude that enthesitis can reflect the disease activity in patients with AS.

Muscle energy technique versus corticosteroid injection for management of chronic lateral epicondylitis: randomized controlled trial with 1-year follow-up.

OBJECTIVE: To determine the short- and long-term effectiveness of the muscle energy technique (MET) compared with corticosteroid injections (CSIs) for chronic lateral epicondylitis (LE). DESIGN: Randomized controlled trial with 1 year of follow-up. SETTING: Outpatient clinic of a university's department of physical medicine and rehabilitation. PARTICIPANTS: Patients with chronic LE (N=82; 45 women, 37 men). INTERVENTIONS: Eight sessions of MET, or a single CSI was applied. MAIN OUTCOME MEASURES: Grip strength, pain intensity, and functional status were assessed using the pain-free grip strength (PFGS), a visual analog scale (VAS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, respectively. Measurements were performed before beginning treatment and at 6, 26, and 52 weeks afterward. RESULTS: When the baseline PFGS, VAS, and DASH scores were compared with the scores at the 52-week follow-up, statistically significant improvements were observed in both groups over time. The patients who received a CSI showed significantly better effects at 6 weeks according to the PFGS and VAS scores, but declined thereafter. At the 26- and 52-week follow-ups, the patients who received the MET were statistically significantly better in terms of grip strength and pain scores. At 52 weeks, the mean PFGS score in the MET group was significantly higher (75.08±26.19 vs 62.24±21.83; P=.007) and the mean VAS score was significantly lower (3.28±2.86 vs 4.95±2.36; P=.001) than those of the CSI group. Although improvements in the DASH scores were more pronounced in the MET group, the differences in DASH scores between the groups were not statistically significant. CONCLUSIONS: This study showed that while both MET and CSI improved measures of strength, pain, and function compared with baseline, subjects receiving MET had better scores at 52 weeks for PFGS and the VAS for pain. We conclude that MET appears to be an effective intervention in the treatment of LE.

Pain in patients with multiple sclerosis.

Objectives: This study aims to identify the factors associated with pain and neuropathic pain (NP) in patients with multiple sclerosis (MS) and to determine the relationship between pain and NP with disability, functionality, activities of daily living, fatigue, mood, and quality of life (QoL). Patients and methods: Between July 2017 and October 2017, a total of 100 adult patients with MS (18 males, 82 females; mean age: 35.3±9.9 years; range, 19 to 71 years) were included. All patients were evaluated in terms of pain and NP. Patients with and without pain, and patients with and without NP were compared in terms of sociodemographic characteristics, disease data, disability, functionality, daily living activities, fatigue severity, mood, and QoL using various scales. Results: A total of 62% of the patients had pain. Pain was found to be associated with low education level (p=0.014), increased fatigue (p<0.001), depressive mood (p<0.001) and lower QoL (p<0.001). A total of 29.03% of patients with pain had NP. Patients with NP had a greater pain intensity (p<0.001) and fatigue (p=0.002) and lower QoL (p=0.011). The number of patients who received the correct treatment for their symptoms was low. Conclusion: Pain and NP should be better investigated and treated by physicians, as these symptoms are common in MS and adversely affect the QoL and social relations of affected patients and reduce their productivity.

Correlation of clinical signs and magnetic resonance imaging findings in patients with lumbar spondylosis.

Objectives: The purpose of the study was to contribute further to this debated topic by investigating the correlation of magnetic resonance imaging (MRI) findings with the clinical picture in lumbar spondylosis patients. Patients and methods: This multicenter retrospective study (as part of the epidemiological project of the TLAR-OASG [Turkish League Against Rheumatism-Osteoarthritis Study Group]) included 514 patients (101 males, 413 females; mean age: 63.6±10.8 years; range, 40 to 85 years) who were diagnosed as lumbar spondylosis by clinical examination and direct X-ray between December 2016 and June 2018. Demographic characteristics of patients, Visual Analog Scale for pain, presence of radiating pain, Roland-Morris disability questionnaire, straight leg raise test, deep tendon reflexes, neurogenic intermittent claudication symptoms, any decrease of muscle strength, and abnormality of sensation were recorded. Lumbar MRI findings of the patients were recorded as positive or negative in terms of disc herniation, intervertebral disc degeneration, root compression, osteophytes, spinal stenosis. Statistical analysis was done to assess the correlation between the clinical symptoms, physical examination, and MRI findings. Results: Correlation analysis of the MRI results and the clinical findings showed a significant correlation between straight leg raise test and root compression (p<0.001, r=0.328) and a significant correlation between neurogenic intermittent claudication and spinal stenosis (p<0.001, r=0.376). Roland-Morris disability questionnaire had a significant correlation with all MRI findings (p<0.05, r<0.200). Conclusion: The results of this study corroborate the notion that diligent patient history and physical examination are more valuable than MRI findings, even though a higher incidence of abnormal MRI findings have been obtained in patients with disability and dermatomal radiating pain.

The effects of fibromyalgia syndrome on female sexuality: a controlled study.

INTRODUCTION: Fibromyalgia may have negative effects on sexual function in women. AIMS: To evaluate the sexuality of women with fibromyalgia and healthy control subjects, and to investigate the relation between sexuality and clinical parameters of fibromyalgia. MAIN OUTCOME MEASURES: Female Sexual Function Index (FSFI), Tender Points Count (TPC), Beck Depression Inventory (BDI), Fibromyalgia Impact Questionnaire (FIQ), and Visual Analog Scale (VAS). METHODS: Clinical evaluation and surveys were done with 126 women with fibromyalgia and 132 healthy women. RESULTS: Patients with fibromyalgia had higher BDI scores and lower frequency of sexual intercourse than control subjects. The mean FSFI scores (total and all domains) were significantly lower in patients with fibromyalgia than control subjects. Mean FSFI scores (total and most domains) were significantly lower in patients with fibromyalgia who had BDI score≥17 than those who had BDI score<17. In women with fibromyalgia, a significant negative correlation was noted between total FSFI score, and both FIQ and BDI scores. CONCLUSIONS: Fibromyalgia has negative effects on female sexual function that are aggravated by depression.

Evaluation of sexual dysfunction in women with rheumatoid arthritis: a controlled study.

OBJECTIVE: To evaluate sexual function in women with rheumatoid arthritis (RA) and compare them with healthy controls. MATERIALS AND METHODS: Ninety-five patients with RA and 108 healthy controls were included in the study. Depression levels and sexual functions of all participants were evaluated by the Beck Depression Inventory (BDI) and Index of Female Sexual Function (IFSF), respectively. Morning stiffness in women with RA, pain (Visual Analog Scale--VAS), disability rate (Health Assessment Questionnaire--HAQ), and disease activity score (DAS-28) were defined. RESULTS: Total IFSF and mean of IFSF subgroup scores and significance of sexual life score were lower in patients with RA than controls, whereas mean BDI score was higher. The mean of the total IFSF scores was significantly lower in patients with RA with BDI≥17 than that of patients with BDI<17. The mean of the total IFSF score decreased as disease severity increased. There was a strong negative correlation between total IFSF and DAS-28 scores, a moderate negative correlation between total IFSF score and HAQ, BDI, VAS score, age, and morning stiffness, and weak negative correlation between total IFSF and body mass index. CONCLUSION: RA is observed to have negative effects on sexual functions of women. Presence of depressive symptoms with RA and increased disease severity increase the degree of sexual dysfunction. Women patients with RA should also be asked about their sexual lives while being evaluated.

The relationship between tender point count and disease severity in patients with primary fibromyalgia.

Objective of this study is to asses the relationship between tender point count (TPC) and the severity of disease in patients with primary fibromyalgia (FM). One hundred and seven female patients with FM diagnosis according to ACR criteria were included to the study. Main outcome measures were fibromyalgia impact questionnaire (FIQ), Beck depression inventory (BDI), visual analog scale (VAS) and tender point assessment. Mean TPC was 14.66 ± 2.50 and mean VAS was 6.6 ± 1.2 cm. Mean total FIQ score and BDI was 62.75 ± 15.57 and 16.17 ± 7.12, respectively. TPC was correlated positively with FIQ and VAS scores. There was no correlation between TPC and age and duration of symptoms. In conclusion, TPC is a simple and noninvasive examination finding that can supply information about the disease severity and the depression in FM.

The clinical, functional, and radiological features of hand osteoarthritis: TLAR-osteoarthritis multi-center cohort study.

Objectives: This study aims to evaluate the clinical, functional, and radiological features of hand osteoarthritis (OA) and to examine their relationships in different geographic samples of the Turkish population. Patients and methods: Between April 2017 and January 2019, a total of 520 patients (49 males, 471 females; mean age: 63.6±9.8 years) with hand OA were included in the study from 26 centers across Turkey by the Turkish League Against Rheumatism (TLAR). The demographic characteristics, grip strengths with Jamar dynamometer, duration of hand pain (month), the severity of hand pain (Visual Analog Scale [VAS]), and morning stiffness were evaluated. The functional disability was evaluated with Duruöz Hand Index (DHI). The Kellgren-Lawrence (KL) OA scoring system was used to assess the radiological stage of hand OA. Results: The DHI had significant correlations with VAS-pain (r=0.367, p<0.001), duration of pain (r=0.143, p=0.001) and bilateral handgrip strengths (r=-0.228, p=0.001; r=-0.303, p<0.001). Although DHI scores were similar between the groups in terms of the presence of hand deformity (p=0.125) or Heberden's nodes (p=0.640), the mean DHI scores were significantly higher in patients with Bouchard's nodes (p=0.015). The total number of nodes had no significant correlations with the VAS-pain and DHI score (p>0.05). The differences between the groups of radiological hand OA grades in terms of age (p=0.007), VAS-pain (p<0.001), duration of pain (p<0.001), and DHI (p<0.001) were significant. There were no significant differences between radiological hand OA grades according to the duration of the stiffness, grip strength, and BMI (p>0.05 for all). Conclusion: In our population, the patients with hand OA had pain, functional disability, and weak grip strength. The functional impairment was significantly correlated with the severity of the pain, and the functional status was worse in high radiological hand OA grades.

A placebo-controlled, multicenter, randomized, double-blind, flexible-dose, two-way crossover study to evaluate the efficacy and safety of sildenafil in men with traumatic spinal cord injury and erectile dysfunction.

BACKGROUND/OBJECTIVE: To show the efficacy, safety, and tolerability of sildenafil in men with erectile dysfunction (ED) associated with complete or incomplete spinal cord injury (SCI) and to assess its effects on quality of life (QoL) using the Life-Satisfaction Check List. METHODS: This was a placebo-controlled, multicenter, randomized, double-blind, flexible-dose, 2-way crossover study with a 2-week washout period between each phase. Patients with ED attributable to SCI (Sexual Health Inventory-Male score < or =21) received 50 to 100 mg sildenafil (n = 24) or placebo (n = 26). RESULTS: Compared with placebo, sildenafil produced higher levels of successful sexual stimulation, intercourse success, satisfaction with sexual life and sexual relationship, erectile function, overall sexual satisfaction, and an improved Erectile Dysfunction Inventory of Treatment Satisfaction score, with no clinically relevant effects on vital signs. Sildenafil seemed more effective in patients with incomplete SCI than in those with complete SCI, producing significant improvements, compared with placebo, in a number of measures only in patients with incomplete SCI. All patients who expressed a preference selected sildenafil over placebo, although the drug had no effect on patient QoL. Sildenafil was well tolerated, with a profile comparable to that of placebo. CONCLUSIONS: Compared with placebo, treatment with oral sildenafil safely and effectively improved erectile function in patients with ED attributable to SCI, especially in those with incomplete injury, and was the agent of choice in those who expressed a preference.

Prevalence of Rheumatoid Arthritis and Spondyloarthritis in Turkey: A Nationwide Study.

OBJECTIVES: This study aims to estimate the prevalence of rheumatoid arthritis (RA) and spondyloarthritis (SpA) in Turkey using the same telephone questionnaire developed for screening RA and SpA in France and used in Serbia and Lithuania. MATERIAL AND METHODS: The study was performed in two steps. In step I, the French questionnaire was translated into Turkish and validated through a group of 200 patients (80 males, 120 females; mean age 44.0±13.1 years; range 19 to 75 years) followed up at the rheumatology departments of University Hospitals in Antalya and Ankara. In step II, the validated Turkish questionnaire was administered face-to-face to randomly selected 4,012 subjects (1,670 males, 2,342 females; mean age 41.5±16.8 years; range 16 to 97 years) by trained general practitioners across the country, in 25 prov- inces for case detection. The subjects who were suspected of having RA or SpA in accordance with the questionnaire were invited to the nearest university hospital for rheumatologic examination in order to confirm the diagnosis. RESULTS: In step II, a total of 25 subjects (2 males, 23 females) were diagnosed as RA. The standardized RA prevalence for the general population of Turkey was calculated as 0.56% (95% confidence interval [CI]; 0.33-0.79), 0.10% (95% CI; -0.05-0.25) for males and 0.89% (95% CI; 0.51-1.27) for females. A total of 18 subjects (3 males, 15 females) were diagnosed as SpA. The standardized SpA prevalence for the general population of Turkey was 0.46% (95% CI; 0.25-0.67), 0.17% (95% CI; -0.03-0.37) for males and 0.65% (95% CI; 0.32-0.98) for females. The prevalence of RA was highest in the Northern region (2.00%) and the prevalence of SpA was highest in the Central region (1.49%). CONCLUSION: The prevalences of RA and SpA in Turkey are close to each other and there are significant inter-regional variations in prevalences of both RA and SpA.

Physical disability, psychological status, and health-related quality of life in older hemodialysis patients and age-matched controls.

We aimed at comparing the elderly adults and normal subjects with regard to their disability, psychological status, and quality of life (QOL). One hundred and twenty-five dialysis patients and 61 controls were recruited in the study. Depression and anxiety symptoms of the patients were evaluated with the Psychological Symptom Screening List (SCL 90-R). For evaluating the disability, the Rivermead mobility index (RMI) was utilized. For evaluating the QOL, we used the short form-36 (SF-36) scale. The Rivermead mobility index of the patients (9.6 +/- 3.4) was found. When compared with controls, dialysis patients had higher levels of disability (p = 0.0001). Depression and anxiety symptom scores of these patients were also significantly higher than that of the controls (p < 0.05). There was a correlation between the disability and depression symptom scores (r: 0.171, p = 0.037). Both physical and mental capacity scores of the dialysis patients were lower than those of the controls (p < 0.05 and p < 0.05) QOL scores for elderly hemodialysis patients were found to be lower. Their disability was higher, making them dependable on others during their daily lives. Specific exercise programs should be developed for these patients. Even the smallest effort in this regard will result in improvements in physical functioning while bringing them significant benefits.

Efficacy of vitamin D replacement therapy on patients with chronic nonspecific widespread musculoskeletal pain with vitamin D deficiency.

AIM: The objective of this study is the evaluation of the effect of vitamin D replacement treatment on musculoskeletal symptoms and quality of life in patients with chronic widespread musculoskeletal pain (CWP) including fibromyalgia (FM) and vitamin D deficiency. METHOD: Patients with nonspecific CWP and vitamin D deficiency (25-OH D3 < 25 ng/mL) were included into the study. Replacement treatments of 50 000 IU/week oral vitamin D3 for 3 months were given to the patients. Patients were assessed pre- and post-treatment in terms of serum levels of Ca, P, alkaline phosphatase, 25-OH D3, severity of pain (visual analogue scale [VAS]-pain), severity of asthenia (VAS-asthenia), Beck Depression Inventory (BDI), quality of life scale (Short Form [SF]-36), tender point count (TPC), severity of waking unrefreshed, headache, tenderness on tibia, meeting the criteria of FM, and level of patient satisfaction. RESULTS: Fifty-eight patients with a mean age of 36.9 ± 9.2 years were included into the study. 25-OH D3 levels of patients elevated from 10.6 ± 5.1 ng/mL to 46.5 ± 24.0 ng/mL after replacement treatment (P < 0.001). Marked decrease in VAS-pain, VAS-asthenia, severity of waking unrefreshed, TPC, and BDI and an evident increase in subgroups of SF-36 were established in patients after treatment (P < 0.001). The number of FM+ patients was 30 (52%) before treatment and regressed to 20 (34%) after treatment (P = 0.013); 85% of patients stated satisfaction with the treatment. CONCLUSIONS: Vitamin D replacement treatment in patients with nonspecific CWP has provided improvements in musculoskeletal symptoms, level of depression and quality of life of patients. Patients with CWP should be investigated for vitamin D deficiency.

A twelve week exercise program improves the psychological status, quality of life and work capacity in hemodialysis patients.

BACKGROUND: Patients with chronic renal failure (CRF) are restricted in physical, emotional and social dimensions of life due to their treatment and their comorbid medical conditions. We aimed to evaluate the effects of a 12-week exercise program on the functional capacity, functional mobility, walking capacity, quality of life and depression in patients with renal failure on hemodialysis (HD). METHODS: Twenty patients with renal failure on HD were included and 14 of them completed the study. The patients went through a 12-week exercise program of 90 min/day, 3 days a week. Exercise and walking capacity, functional mobility, psychological status and quality of life were evaluated pre- and post-training. RESULTS: Following the exercise, peak oxygen consumption, exercise duration and peak workload improved significantly (respectively, p=0.006, p=0.002 and p=0.002). There were significant improvements in the sit-to-stand-to-sit test and the 6- min walk test (p<0.001 and p=0.002). There was a significant reduction in the depression score (p<0.001). Both physical component scale (PCS) and mental component scale (MCS) of the Kidney Disease Quality of Life Short-Form 36 (SF-36) questionnaire showed significant increases (respectively, p=0.002 and p=0.004). CONCLUSION: The application of an appropriate exercise program would improve psychological status and quality of life, as well as work capacity in long-term maintenance HD patients.

A rare cause of dysphagia: compression of the esophagus by an anterior cervical osteophyte due to ankylosing spondylitis.

Ankylosing spondylitis (AS) is a chronic inflammatory rheumatological disease affecting the axial skeleton with various extra-articular complications. Dysphagia due to a giant anterior osteophyte of the cervical spine in AS is extremely rare. We present a 48-year-old male with AS suffering from progressive dysphagia to soft foods and liquids. Esophagography showed an anterior osteophyte at C5-C6 resulting in esophageal compression. The patient refused surgical resection of the osteophyte and received conservative therapy. However, after 6 months there was no improvement in dysphagia. This case illustrates that a large cervical osteophyte may be the cause of dysphagia in patients with AS and should be included in the diagnostic workup in early stages of the disease.

Full-length silicone insoles versus ultrasound-guided corticosteroid injection in the management of plantar fasciitis: a randomized clinical trial.

BACKGROUND: Plantar fasciitis often leads to disability. Optimal treatment for this clinical condition is still unknown. OBJECTIVE: To compare the effectiveness of wearing a full-length silicone insole with ultrasound-guided corticosteroid injection in the management of plantar fasciitis. STUDY DESIGN: Randomized clinical trial. METHODS: Forty-two patients with chronic unilateral plantar fasciitis were allocated randomly to have an ultrasound-guided corticosteroid injection or wear a full-length silicone insole. Data were collected before the procedure and 1 month after. The primary outcome measures included first-step heel pain via Visual Analogue Scale and Heel Tenderness Index. Other outcome measures were the Foot and Ankle Outcome Score and ultrasonographic thickness of the plantar fascia. RESULTS: After 1 month, a significant improvement was shown in Visual Analogue Scale, Heel Tenderness Index, Foot and Ankle Outcome Score, and ultrasonographic thickness of plantar fascia in both groups. Visual Analogue Scale scores, Foot and Ankle Outcome Score pain, Foot and Ankle Outcome Score for activities of daily living, Foot and Ankle Outcome Score for sport and recreation function, and plantar fascia thickness were better in injection group than in insole group (p < 0.05). CONCLUSIONS: Although both ultrasound-guided corticosteroid injection and wearing a full-length silicone insole were effective in the conservative treatment of plantar fasciitis, we recommend the use of silicone insoles as a first line of treatment for persons with plantar fasciitis.

The prevalence of fibromyalgia and its relation with headache characteristics in episodic migraine.

The objective of this study was to assess the prevalence of fibromyalgia (FM) in patients with episodic migraine and to evaluate the relationship between migraine characteristics and FM. One hundred and eighteen consecutive patients (mean age = 38 years, 75% women) fulfilling the International Classification of Headache Disorders-II criteria for migraine with (n = 22) and without (n = 96) aura from an outpatient headache clinic of a university hospital were evaluated. The diagnosis of FM was made based on the 1990 American College of Rheumatology classification criteria. Participants completed some self-administered questionnaires ascertaining sociodemographics, headache severity, frequency and duration, headache-related disability (Headache Impact Test [HIT-6]) and Migraine Disability Assessment Scale, widespread musculoskeletal pain (visual analog scale), depression (Beck depression inventory), anxiety (Beck anxiety inventory), sleep quality (Pittsburgh Sleep Quality Index), fatigue (Multidimensional Assessment of Fatigue), and quality of life (Short Form-36 Health Survey [SF-36]). In patients with FM, the tender point count and the Fibromyalgia Impact Questionnaire were employed. FM was diagnosed in 37 (31.4%) of the patients. FM comorbidity was equally distributed across patients with and without aura. Severity of migraine headache, HIT-6, and anxiety were especially associated with FM comorbidity. Patients suffering from migraine plus FM reported lower scores on all items of the SF-36. This study indicates that the assessment and management of coexisting FM should be taken into account in the assessment and management of migraine, particularly when headache is severe or patients suffer from widespread musculoskeletal pain.

The efficacy of electrical stimulation in reducing the post-stroke spasticity: a randomized controlled study.

PURPOSE: The purpose of this study is to evaluate the efficacy of surface electrical stimulation on the spasticity occurring in the wrist flexor muscles after a cerebrovascular event. METHOD: Hemiplegic patients with stage 2-3 spasticity in the wrist muscles based on the Ashworth scale were divided into two groups. Both groups were applied stretching. One group was additionally administered neuromuscular electrical stimulation (NMES) to the wrist extensors, in the form of pulsed current, 100 Hz, with a pulse duration of 0.1 msec, and a resting duration of 9 seconds, for 15 minutes to provide the maximum muscular contraction. The efficacy of the treatment was evaluated using the following: modified Ashworth scale (MAS), Fmax/Mmax ratio, Hmax/Mmax ratio, wrist extension range of motion (ROM). The daily activities were assessed by Functional Independence Measurement (FIM) and the motor recovery was evaluated by Brunnstrom motor staging. RESULTS: Both groups revealed a significant recovery after the treatment based on the MAS, the electrophysiological evaluation results, wrist ROM, FIM and Brunnstrom motor staging. The group receiving the combined treatment showed a better recovery in terms of MAS, wrist ROM, FIM and Brunnstrom motor staging compared to the group doing the stretching alone. CONCLUSIONS: The results of this study showed that NMES given together with stretching of the wrist extensor muscles was more effective than stretching of the wrist extensor muscles alone in reducing spasticity.

Efficacy of therapeutic ultrasound in the treatment of spasticity: a randomized controlled study.

The purpose of this study was to investigate the effect of ultrasound (US) on the spasticity occurring in the ankle plantar flexor muscles after a cerebrovascular event. According to the modified Ashworth scale (MAS), the hemiplegic patients with stage 2-3 spasticity on the ankle plantar flexor muscles were enrolled in the study and divided into two groups. Passive stretching exercise was applied to both groups. Additionally, 10-minute US was applied to one of the groups, using the mode of continuous wave of 1.5w/cm^{2} to the calf muscles before stretching. In order to monitor the efficacy of the treatment in the patients, MAS, Hmax/Mmax ratio, the ankle range of motion (ROM), Functional Independence Measure and Brunnstrom Motor Recovery Stage were evaluated. While a significant recovery was monitored in the MAS and ankle ROM measurements after treatment in both groups, no change was obtained in the other parameters. No significant difference was detected in any of the measurements between the groups. In this study, US treatment applied in combination with the ankle plantar flexor muscles passive stretching exercise was determined to have no effect on the stretching treatment in minimizing the spasticity.