Berrin Gündüz

The effect of low-frequency TENS in the treatment of neuropathic pain in patients with spinal cord injury

Study design:Prospective, randomized and controlled study.Objectives:The aim of the study was to investigate the effect of low-frequency transcutaneous electrical nerve stimulation (LF-TENS) in the treatment of neuropathic pain in patients with spinal cord injury (SCI).Methods:A total of 33 SCI patients with neuropathic pain were included in the study. History, duration, localization and characteristics of pain were recorded. Visual analog scale (VAS) was used to investigate the effect of LF-TENS four times during the day. Patients were randomly assigned to study and control groups. The study group was treated with 30 min of LF-TENS daily for 10 days while the placebo group with 30 min of sham TENS.Results:The mean age of the patients was 36.55±10.36 years. Out of 33 patients, 7 were tetraplegic and 26 were paraplegic. Twenty-three patients had complete SCI while 10 patients had incomplete injuries. Two groups were similar with respect to age, gender, duration, level and severity of injury. In the LF-TENS treatment group, a statistically significant reduction of the VAS values was observed, however, such an effect was not evident in the control group.Conclusion:This study revealed that in treatment of neuropathic pain of SCI patients, LF-TENS may be effective.Perspective:This article presents LF-TENS may effectively complement pharmacological treatment in patients with SCI and neuropathic pain.

Effects of different bladder management methods on the quality of life in patients with traumatic spinal cord injury.

Study design:Multi-center, cross-sectional study.Objectives:To investigate the effects of different bladder management methods on the quality of life (QoL) in patients with spinal cord injury (SCI).Setting:Turkey.Methods:Consecutive SCI patients (n=195, 74.4% males), for whom at least 6 months had elapsed since the injury, were included and evaluated in five groups: normal spontaneous micturition (NSM), micturition with assisted maneuvers (MAM), aseptic intermittent catheterization by patient (IC-P), aseptic IC by an attendant/caregiver (IC-A) and indwelling catheterization. The King’s Health Questionnaire was used to evaluate the patients’ QoL.Results:The bladder management groups were similar regarding age, time elapsed since injury, education level, marital and occupational status. There was no difference among the groups in general health perception, personal relationships and sleep/energy domain scores. While the NSM group had generally the lowest scores, that is, better QoL, the IC-A group had the highest scores, that is, poorer QoL, in most of the domains. When the patients were grouped according to the frequency of urinary incontinence or American Spinal Injury Association Impairment Scale grades, no difference was found in the domain scores of the groups except the symptom severity domain scores. No significant difference was found between paraplegic and tetraplegic patients in the King’s Health Questionnaire domains.Conclusion:The QoL was notably affected in SCI patients in IC-A group and negative effects on emotional status, physical and social activity limitations were observed, as well.

The effect of local injections in hemiplegic shoulder pain: a prospective, randomized, controlled study.

Lakse E, Gunduz B, Erhan B, Celik EC: The effect of local injections in hemiplegic shoulder pain: a prospective, randomized, controlled study. Objective:The aim of this study was to evaluate the effects of corticosteroid injections on hemiplegic shoulder pain and range of motion. Design:Fifty-two stroke patients with shoulder pain were evaluated. Thirty-eight patients who fulfilled the criteria were assigned randomly into either injection or control groups. Transcutaneous electrical nerve stimulation and therapeutic exercise program were applied to both groups for 15 sessions. The patients in the injection group were administered either intra-articular or subacromial injections of corticosteroid and local anesthetic according to their pathology. The evaluations were performed before treatment and at the first and fourth weeks of treatment. Primary follow-up parameters were passive shoulder range of motion and verbal analog scale for shoulder pain; secondary follow-up parameters were modified Barthel index, Brunnstrom upper-extremity score, and modified Ashworth scale. Results:In both groups, shoulder range of motion and shoulder pain scores showed significant improvement. When the two groups were compared, the improvement was more significant in the injection group. Barthel scores improved in both groups, and no difference was found between the groups. Brunnstrom upper-extremity and modified Ashworth scores revealed nonsignificant changes in both groups. Conclusions:Adding corticosteroid injection to conventional treatment in hemiplegic shoulder pain improved shoulder range of motion and decreased pain scores before treatment to the first and fourth weeks of treatment. Injection in hemiplegic shoulder pain is recommended in appropriate patients.

Sex hormone levels and functional outcomes: a controlled study of patients with spinal cord injury compared with healthy subjects.

Celik B, Sahin A, Caglar N, Erhan B, Gunduz B, Gultekin O, Karabulut M: Sex hormone levels and functional outcomes: a controlled study of patients with spinal cord injury compared with healthy subjects. Am J Phys Med Rehabil 2007;86:784–790. Objectives:To investigate testosterone and free testosterone levels in male patients after spinal cord injury (SCI) in comparison with healthy subjects, the effects of free testosterone on Functional Independence Measure (FIM) instrument, and their relationship between time since injury, spinal cord injury levels, and testosterone levels. Design:Prospective case series during 2004–2005. Male patients with SCI (n = 44) and a control group (n = 42) from healthy volunteers with similar age and body mass index were included in the study. Plasma luteinizing hormone (LH) was measured along with testosterone and free testosterone in the same blood sample. The FIM instrument was administered at the admission to hospital and at discharge. Results:Serum LH levels were significantly higher in both patient subgroups than in the control group (P < 0.01 and 0.03). Free testosterone levels were lower in the subgroup with time since injury ≤12 mos than in the other patient subgroup and the control group (P = 0.01 and 0.02). No significance was found between androgen status and FIM change. Conclusions:Our findings suggest that a negative androgen status might be notable especially in the first year after spinal cord injury. However, the androgen status does not correlate with functional outcome in patients coming for rehabilitation after spinal cord injury.

Neurogenic bladder in patients with traumatic spinal cord injury: treatment and follow-up

Study design:Multi-center, cross-sectional study.Objectives:Our aim was to evaluate the treatment methods and follow-up of neurogenic bladder in patients with traumatic spinal cord injury retrospectively using a questionnaire.Setting:Turkey.Methods:Three hundred and thirty-seven patients who had spinal cord injury for at least 2 years were enrolled from six centers in the neurogenic bladder study group. They were asked to fill-out a questionnaire about treatments they received and techniques they used for bladder management.Results:The study included 246 male and 91 female patients with a mean age of 42±14 years. Intermittent catheterization (IC) was performed in 77.9% of the patients, 3.8% had indwelling catheters, 13.8% had normal spontaneous micturition, 2.6% performed voiding maneuvers, 1.3% used diapers and 0.6% used condom catheters. No gender difference was found regarding the techniques used in bladder rehabilitation (P>0.05). Overall, 63.2% of patients used anticholinergic drugs; anticholinergic drug use was similar between genders (P>0.05). The most common anticholinergic drug used was oxybutynin (40.3%), followed by trospium (32.6%), tolterodine (19.3%) darifenacin (3.3%), propiverine (3.3%) and solifenacin (1.1%). The specialties of the physicians who first prescribed the anticholinergic drug were physiatrists (76.2%), urologists (22.1%) and neurologists (1.7%). Only four patients had previously received injections of botulinum-toxin-A into the detrusor muscle and three of them stated that their symptoms showed improvement. Most of the patients (77%) had regular follow-up examinations, including urine cultures, urinary system ultrasound and urodynamic tests, when necessary; the reasons for not having regular control visits were living distant from hospital (15.3%) and monetary problems (7.7%). Of the patients, 42.7% did not experience urinary tract infections (UTI), 36.4% had bacteriuria but no UTI episodes with fever, 15.9% had 1-2 clinical UTI episodes per year and 5% had ⩾3 clinical UTIs. The clinical characteristics of patients with and without UTI (at least one symptomatic UTI during 1 year) were similar (P>0.05). The frequency of symptomatic UTI was similar in patients using different bladder management techniques (P>0.05).Conclusion:The most frequently used technique for bladder rehabilitation in patients with SCI was IC (77.9%). In all, 63.2% of patients used anticholinergic drugs, oxybutynin being the most commonly used drug. Also, 77% of patients had regular control visits for neurogenic bladder; 42.7% did not experience any UTIs.

Intermittent catheterization in patients with traumatic spinal cord injury: obstacles, worries, level of satisfaction

Objectives:The aim of this study is to examine the obstacles in people with traumatic spinal cord injury (SCI) face performing intermittent catheterization (IC), also their worries and level of satisfaction.Methods:Two hundred sixty-nine patients performing IC for at least 3 months were asked to fill-out a questionnaire about their opinions on IC.Results:In total, 69.5% of patients performed IC themselves, 10.4% had performed by their mothers, 7.8% by another caregiver and 7.4% by their spouse. For the 72 (26%) patients unable to apply IC, reasons were insufficient hand function (56.1%), being unable to sit appropriately (35.4%) and spasticity (8.5%). In all, 70% of male patients had insufficient hand function, 20% could not sit and 10% had spasticity while 56.3% of female patients could not sit, 37.5% had insufficient hand function and 63% had spasticity. Difference between sexes was found to be statistically significant (P<0.05). Worries patients had when starting IC were fear of being dependent on IC (50.2%), accidentally injuring self (43.8%), embarrassment (43.2%), causing an infection (40.2%), bleeding (32.7%), fear of feeling pain (30.2%) and hygiene (24.7%). More women felt embarrassment; other items were similar in both sexes. In all, 46.9% of patients had urinary incontinence in intervals.Conclusion:In total, 69.5% of patients performed IC themselves. Men’s most common obstacle was insufficient hand function while women’s was being unable to sit appropriately. Patients’ most common worries were being dependent on IC for life. In all, 46.9% had incontinence in intervals; 47.9% said IC improved their life quality; and 97.4% preferred IC over continuous catheterization.

Pediatric Spine and Spinal Cord Injury in Istanbul: A Retrospective Analysis of 106 Patients

Abstract:This study provided a retrospective analysis of 106 pediatric patients 17 years of age or younger who incurred spinal cord injuries (SCIs) during the last decade in Istanbul. Data were retrieved from the medical records of the patients, who were admitted to Istanbul Universitys Cerrahpasa Medical Faculty and 70. Yil Physical Medicine and Rehabilitation Training Hospital from January 1992 to December 2002. The patients were evaluated with respect to demographic data, cause of injury, and level of injury as well as completeness of injury, radiologic findings, and mortality rate. The mean age of the patients was 12.67 ± 4.3 years, and the male-to-female ratio was 2:1. The most common cause of injury was motor vehicle accidents (41%), followed by falls from heights (33.6%), diving injuries (10.3%), and gunshot wounds (9.3%). The levels of injury, in descending order of frequency, were cervical (47.2%), thoracic (34.9%), and lumbar (12.3%). Complete and incomplete SCIs were seen in 55% and 45% of patients, respectively. SCIs without radiographic abnormalities were only seen in 1.9% of the patients in this series. The overall mortality rate was 9.4%. SCI caused by trauma is relatively uncommon in children, but the results may be catastrophic. This study aims to provide a statistical analysis of pediatric SCI cases admitted to our clinics and tries to estimate the situation in Turkey on the basis of the demographic features of Istanbul. The importance of preventive measures is also stressed.

Elbow problems in paraplegic spinal cord injured patients: frequency and related risk factors—a preliminary controlled study

Study design:Cross-sectional controlled study.Objectives:To evaluate the elbow joint with ultrasound in paraplegic patients, determine the related factors and compare it with healthy controls.Setting:A training and research rehabilitation hospital in Istanbul.Methods:A total of 30 paraplegic patients and 20 healthy controls were included in the study. Patients demographic data, pain in the elbow joint, level and duration of injury, ambulation status, type of wheelchair used, daily duration of wheelchair and other ambulation equipment usage, transfers being dependent or independent, daily number of push-ups were recorded. Elbow joints were evaluated with ultrasound for presence of fluid and thickness of the triceps tendon.Results:Mean triceps tendon thickness values of the right side were larger in spinal cord injury (SCI) patients when compared with those of healthy controls’. Joint effusion on the right elbow joint was also found to be more common in SCI patients than in normal subjects. Triceps tendon thickness measurements were not found to be correlated with demographic and clinical factors. Seven paraplegic patients (23%) reported that they have pain in the elbow.Conclusion:In this preliminary study, our results showed that right elbow effusion was more frequent and right triceps tendon was thicker in SCI patients when compared with healthy subjects.

Employment among spinal cord injured patients living in Turkey: a cross-sectional study

The aim of this study was to determine the rate of employment and to establish the factors affecting vocational status in spinal cord injured patients living in Turkey. One hundred and fifty-two traumatic spinal cord injured patients older than 18 years with injury duration of at least 1 year and living in the community were included in the study; homemakers were not taken into consideration. The demographic and clinical data were retrieved from the medical records. The patients were interviewed with a structured questionnaire about the employment status at the time of the injury and after the injury, seeking a job after the injury, possible causes for unemployment, educational activities after the injury, and being a member of a social association. Descriptive statistics, Mann–Whitney U test and Pearsons χ2 test were used to analyze the results. The rate of employment was 21% among this group of spinal cord injured patients. Female sex, young age at the time of the injury, longer time since injury, higher educational level, being educated after injury, and being a member of a social association have positive effects on vocational outcome; age at the time of the study and severity and level of the lesion did not affect employment. According to the results of this study, the employment rates after spinal cord injury are low in Turkey. There is a need to maximize the employment capacity. Social and educational activities after injury should be encouraged during rehabilitation.

Acute tetraplegia following laryngotracheal reconstruction surgery

Background: Paraplegia following thoracic spinal surgery or abdominal operations is usually attributed to spinal cord ischemia due to interruption of the segmental spinal vascular supply. Alternatively, the etiology of spinal cord ischemia following cervical surgery is less clear. Case Description: A 14-year-old male became acutely tetraplegic with a C4 sensory level and sphincteric dysfunction 12 h following surgery for tracheal stenosis due to prior intubation. Signs included loss of pain and temperature below the level of C4 with preservation of deep sensations (position and vibration) and mute plantar responses. The cervical magnetic resonance imaging revealed diffuse intramedullary cord swelling between C2-C7 and hyperintense signal changes in the anterior and posterior columns of the cord on T2-weighted images. Various etiologies for this finding included a cervical hyperextension or hyperflexion injury vs. anterior spinal artery syndrome. Conclusions: Postoperative treatment of spinal cord ischemia attributed to cervical and thoracoabdominal surgery is largely ineffective in reversing major neurological deficits. Therefore, it is critical to prevent ischemia during these procedures by the avoidance of coagulopathies, anemia, hypotension, and hyperflexion/hyperextension maneuvers.