Birol Balaban

Gait Disturbances in Patients With Stroke

Poststroke hemiplegic gait is a mixture of deviations and compensatory motion dictated by residual functions, and thus each patient must be examined and his/her unique gait pattern identified and documented. Quantitative 3‐dimensional gait analysis is the best way to understand the complex multifactorial gait dysfunction in hemiparetic patients. The goals of the present work are to (1) review the temporospatial, kinematic, kinetic, and electromyographic deviations from normal gait that commonly occur after stroke and are of clinical significance, along with the most likely causes of these deviations, and (2) differentiate the departures from normal gait parameters that arise as a direct consequence of poststroke motor problems and those that arise as learned or adaptive compensations for poststroke motor problems.

Narrative ReviewGait Disturbances in Patients With Stroke

Poststroke hemiplegic gait is a mixture of deviations and compensatory motion dictated by residual functions, and thus each patient must be examined and his/her unique gait pattern identified and documented. Quantitative 3‐dimensional gait analysis is the best way to understand the complex multifactorial gait dysfunction in hemiparetic patients. The goals of the present work are to (1) review the temporospatial, kinematic, kinetic, and electromyographic deviations from normal gait that commonly occur after stroke and are of clinical significance, along with the most likely causes of these deviations, and (2) differentiate the departures from normal gait parameters that arise as a direct consequence of poststroke motor problems and those that arise as learned or adaptive compensations for poststroke motor problems.

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.

Sacroiliitis in familial Mediterranean fever and seronegative spondyloarthropathy: importance of differential diagnosis

Familial Mediterranean fever (FMF) is a multisystemic autosomal recessive disease, occasionally accompanied by sacroiliitis. Transient and non-erosive arthritis of the large joints is the most frequent articular involvement. Amyloidosis is also the most significant complication of FMF, leading to end stage renal disease. Here we present three cases of FMF with sacroiliitis and review the literature for spinal arthritic involvement of FMF. All cases were referred to our clinic with a diagnosis of seronegative spondyloarthropathy and with low back pain sourced by sacroiliitis. They also had homozygous M694V gene mutations and negative HLA B27 antigens. Molecular analysis of the gene mutation is recommended during the evaluation of uncertain cases in order to clarify diagnostic discrimination. We suggest that FMF with sacroiliitis, which is rare in rheumatological practice, should be considered in the differential diagnosis of seronegative spondyloarthropathy or other rheumatologic diseases causing spinal involvement.

Ochronotic spondyloarthropathy: spinal involvement resembling ankylosing spondylitis

Ochronotic spondyloarthropathy is a rare metabolic disease with the musculoskeletal manifestations of alkaptonuria. Ochronotic arthropathy patients may have spinal abnormalities similar to ankylosing spondylitis (AS). The proof of sacroiliac involvement or bamboo spine appearance is not sufficient either for diagnosis of ankylosing spondilitis or exclusion of ochronosis. In this report, the case of a 54-year-old woman having ochronosis, with clinically more recognizable axial arthropathy resembling AS, is presented, and the history, clinical presentation, diagnostic techniques, and distinctive diagnosis are reviewed.

The effects of onabotulinum toxin A injection into rectus femoris muscle in hemiplegic stroke patients with stiff-knee gait: a placebo-controlled, nonrandomized trial.

Objective This study aimed to compare the efficacy of onabotulinum toxin A (onabot) injection into the rectus femoris muscle with that of placebo in the treatment of hemiplegic stroke patients presenting with stiff-knee gait. Design Twenty-five chronic hemiparetic stroke patients presenting with a stiff-knee gait were included in this study. Fifteen patients received 100–125 U of onabot, and 10 patients received placebo into the rectus femoris muscle. Three-dimensional gait analysis, energy expenditure, 10-m and 6-min walk tests, and spasticity level of the rectus femoris were evaluated at baseline and 2 mos posttreatment. Results The mean age of patients who received onabot was 53.86 ± 14.74 yrs and of those who received placebo was 59.00 ± 8.11 yrs. At study onset, groups were similar with respect to all parameters (P > 0.05). We observed significant improvement in knee flexion (7 degrees average) during swing and a reduction in energy cost of 0.8-J/kg per meter response to injection of 100–125 U of onabot into the rectus femoris muscle. Onabot treatment significantly reduced muscle tone and improved knee kinematics, energy expenditure during walking, and functional assessments at 2 mos (P < 0.05); however, placebo had no effects on these parameters. Moreover, maximum knee flexion at swing and energy expenditure in the onabot group was significantly better than placebo at 2 mos (P < 0.05). Conclusions Our results showed the superiority of onabot over placebo in increasing knee flexion during swing phase and decreasing energy expenditure. The application of onabot into the rectus femoris muscle in stroke patients who presented with stiff-knee gait may be a treatment option to provide independent, safe, and less tiring ambulation.

Factitious disorders encountered in patients with the diagnosis of reflex sympathetic dystrophy

Reflex sympathetic dystrophy (RSD) may be a misdiagnosis or at least not descriptive enough in patients with atypical hand posture and atypical edema. Seven patients with the previous diagnosis of RSD were investigated further because of inconsistent clinical picture with the underlying pathology and bizarre course of the disease. Four patients had clenched fist and three had factitious edema. These seven patients underwent psychological examination, and MMPI was applied to all. In two of these no psychological disorder was obtained according to DSM-IV. One patient could not adapt to MMPI. In two anxiety disorders, in one depression, and in one patient conversion disorder was diagnosed. We suggest that these patients are not motivated enough to improve their conditions and expectations of such patients may show some differences depending on the environment.

Early rehabilitation outcome in patients with middle cerebral artery stroke

Although important data on the prognosis and rehabilitation outcome in stroke patients have been reported, data on functional recovery according to stroke subtypes are limited. This retrospective study aimed to evaluate functional outcome in patients with middle cerebral artery (MCA) stroke-the most common subtype of ischemic stroke. The records of stroke patients that underwent the rehabilitation program at our brain injury rehabilitation service between January 2007 and December 2008 were reviewed, and those with MCA stroke were included in the study. Patient demographic and clinical data, and Barthel Index (BI) and Functional Independence Measure (FIM) scores at admission and discharge were collected. The study included 80 MCA stroke patients with a mean age of 63.54 years. FIM and BI scores improved significantly post rehabilitation (P<0.05). Age was negatively correlated with both BI and FIM scores at admission and discharge. Length of stay was not correlated with improvement in BI or FIM scores during hospitalization. The patients that had ≤1 month of inpatient rehabilitation had similar outcomes as those that had >1 month of inpatient rehabilitation (P>0.05). Length of time after stroke onset was not correlated with BI or FIM scores at admission. Regardless of initial functional status, prediction of discharge functional status was misleading. Physiatrists should keep in mind that functional improvement does not always increase with duration of inpatient therapy.

Familial mediterranean fever unusually coexisted in an ankylosing spondylitis patient. MEFV mutation has any role

Dear editor, Ankylosing spondylitis (AS) and familial mediterranean fever (FMF) are two clinical conditions aVecting people of almost same age group. In AS, sacroiliitis is the hallmark, but peripheral joints can also be aVected. On the other hand, articular involvement is the second most common manifestation of FMF. In FMF, although peripheral joints are aVected mostly, sacroiliac joints can be involved and it can be accompanied by seronegative spondyloarthropathy (SNSA). The shared feature of AS and FMF is sacroiliitis. The higher rate of coincidence of sacroiliitis with FMF in comparison with the healthy population was found to be statistically signiWcant [1]. This Wnding has led the sacroiliitis to be accepted as one of joint involvements of FMF [1–3]. Although sacroiliitis can occur in course of both conditions, it is not known yet exactly if there is any pathogenic relation between FMF and AS. Almost all of the FMF-related SNSA are HLAB27 negative [1–4]. There were only Wve patients who had both FMF and HLAB27 positive AS in the literature. These patients were considered as being more severe form of FMF-related SNSA because of the presence of HLAB27. It was also proposed that the presence of HLAB27 could predispose the occurring of AS in these FMF-related SNSA patients [1, 4, 5]. In review of literature, we perceived that, in all of these HLAB27 positive patients, AS was diagnosed after a period of time from the onset of FMF or simultaneously in one. In our opinion, this might have led the authors to put forward this consideration. Herein we represent an unusual case of HLAB27 positive AS that was accompanied with FMF 8 years after the diagnosis of AS, having M680I mutation in MEFV gene. A 27-year-old man with low back pain for 10 years that was accompanied with abdominal pain, fever, polyarthralgia recurring periodically for last 2 years was presented. He had been feeling stiVness and pain in his low back and occasionally left hip at morning that was relieving with motion and daily activities slowly within about 2 h. His Wrst episode of abdominal pain, accompanying with polyarthralgia (especially low back, left hip and knee) had occurred 2 years ago and he had been hospitalized with the possible diagnosis of appendicitis but resolved spontaneously in 12 h and had been discharged. After two additional episodes occurred with intervals of approximately 3 months, he was diagnosed with FMF and began to receive colchicine. Regular colchicine treatment reduced not only the frequency but also intensities of complaints during episodes. Physical examination revealed restricted lumbar motions (Schober: 3 cm), Patrick–Fabere and sacroiliac compression tests were positive bilaterally. There was swelling in left ankle, pain in both of the wrists, both of the knees and left shoulder. Laboratory investigations revealed that HLAB27 was positive. Erythrocyte sedimentation rate was 14 mm/h. Whole blood counts were normal. The urine contained no protein. Radiographs of painful peripheral joints were normal. Sacroiliac plain radiography revealed marginal irregularities, increased in density and sclerosis at especially iliac sides of sacroiliac joints. Bone scan showed increased I. Duman (&) · B. Balaban · I. Tugcu · K. Dincer Department of Physical Medicine and Rehabilitation, Gulhane Military Medical Academy, 06018 Etlik-Ankara, Turkey e-mail: iltekinduman@yahoo.com

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.