Deniz Palamar

Comparison of High-Power Pain Threshold Ultrasound Therapy With Local Injection in the Treatment of Active Myofascial Trigger Points of the Upper Trapezius Muscle

OBJECTIVE To compare the effects of high-power pain threshold ultrasound (HPPTUS) therapy and local anesthetic injection on pain and active cervical lateral bending in patients with active myofascial trigger points (MTrPs) of the upper trapezius muscle. DESIGN Randomized single-blinded controlled trial. SETTING Physical medicine and rehabilitation department of university hospital. PARTICIPANTS Subjects (N=49) who had active MTrPs of the upper trapezius muscle. INTERVENTIONS HPPTUS or trigger point injection (TrP). MAIN OUTCOME MEASURES Visual analog scale, range of motion (ROM) of the cervical spine, and total length of treatments. RESULTS All patients in both groups improved significantly in terms of pain and ROM, but there was no statistically significant difference between groups. Mean numbers of therapy sessions were 1 and 1.5 in the local injection and HPPTUS groups, respectively. CONCLUSIONS We failed to show differences between the HPPTUS technique and TrP injection in the treatment of active MTrPs of the upper trapezius muscle. The HPPTUS technique can be used as an effective alternative to TrP injection in the treatment of myofascial pain syndrome.

Musculoskeletal Sonography in Physical and Rehabilitation Medicine: Results of the First Worldwide Survey Study

OBJECTIVES To explore the current status of musculoskeletal ultrasound (MSUS) in the realm of physical medicine and rehabilitation (PMR), and to determine the effects of a 1-day MSUS course on the awareness of physiatrists. DESIGN Survey. SETTING International Society of Physical and Rehabilitation Medicine Congress, 2009, Istanbul. PARTICIPANTS Physiatrists attending the congress (n=276) and the MSUS course (n=30). INTERVENTION Not applicable. MAIN OUTCOME MEASURES The survey contained 17 multiple-choice and open-ended questions concerning personal background, perceptions regarding MSUS, and current use of MSUS. Additionally, a group of physicians who attended the 1-day MSUS course before the congress were evaluated twice (before and after the course) to assess the change in their awareness. RESULTS Data from 306 physiatrists (with a mean experience of 10.5+/-8.1 y in the field of PMR) were evaluated. Among the participants, 57.8% were using MSUS in their diagnostic algorithms, 90.4% were thinking that physiatrists should perform sonography themselves, and 75.1% declared that they would perform sonography if they had a device. The ratio of subjects who rated MSUS to be essential for their clinical practice increased from 35.7% to 58.6% after the MSUS course (P>.05). CONCLUSIONS Physiatrists strongly believe that they should perform MSUS themselves, lack of education and lack of device seem to be important issues to be addressed, and even a 1-day course significantly changes awareness of MSUS.

A quantitative skin impedance test to diagnose spinal cord injury

The purpose of this study was to develop a quantitative skin impedance test that could be used to diagnose spinal cord injury (SCI) if any, especially in unconscious and/or non-cooperative SCI patients. To achieve this goal, initially skin impedance of the sensory key points of the dermatomes (between C3 and S1 bilaterally) was measured in 15 traumatic SCI patients (13 paraplegics and 2 tetraplegics) and 15 control subjects. In order to classify impedance values and to observe whether there would be a significant difference between patient and subject impedances, an artificial neural network (ANN) with back-propagation algorithm was employed. Validation results of the ANN showed promising performance. It could classify traumatic SCI patients with a success rate of 73%. By assessing the experimental protocols and the validation results, the proposed method seemed to be a simple, objective, quantitative, non-invasive and non-expensive way of assessing SCI in such patients.

Lateral Pectoral Nerve Injury Mimicking Cervical Radiculopathy.

Abstract:The lateral pectoral nerve (LPN) is commonly injured along with the brachial plexus, but its isolated lesions are rare. Here, we present a case of an isolated LPN lesion confused with cervical radiculopathy. A 41-year-old man was admitted to our clinic because of weakness in his right arm. Previous magnetic resonance imaging (MRI) examination revealed right posterolateral protrusion at the C6-7 level. At the initial assessment, atrophy of the right pectoralis major muscle was evident, and mild weakness of the right shoulder adductor, internal rotator, and flexor muscles was observed. Therefore, electrodiagnostic evaluation was performed, and a diagnosis of isolated LPN injury was made. Nerve injury was thought to have been caused by weightlifting exercises and traction injury. Lateral pectoral nerve injury can mimic cervical radiculopathy, and MRI examination alone may lead to misdiagnosis. Repeated physical examinations during the evaluation and treatment phase will identify the muscle atrophy that occurs 1 or more months after the injury.

Regression of a symptomatic thoracic disc herniation with a calcified intervertebral disc component

There were only a few cases describing spontaneous regression of calcified thoracic disc herniation in the literature. We present a 38-year-old male office worker who had left paramedian-foraminal extruded disc at T7–T8 with calcifications of the T7–T8 and T8–T9 intervertebral discs. This case was unique in that the non-calcified extruded disc material regressed almost completely in 5 months while the calcified intervertebral discs remained the same during the process of regression. This report stresses that regression of the herniated material of the thoracic discs with subsidence of the symptoms is still possible even if the disc material is calcified.

The clinical importance of the thyroid nodules during anti-tumor necrosis factor therapy in patients with axial spondyloarthritis

The clinical importance of the thyroid nodules in patients with axial spondyloarthritis (ax-SpA) rests with the need to exclude thyroid malignancy. The aim of this study is to assess the risk of thyroid malignancy in ax-SpA patients receiving anti-TNF therapy. From September 2015 until December 2015, 70 patients diagnosed with ax-SpA were included in the research. Forty of the patients had received anti-TNF therapy, and 30 of the patients were anti-TNF naive. All cases were screened for the presence of nodules in the thyroid gland with ultrasound. Of the patients that received anti-TNF therapy, 15 (37.5%); and of the anti-TNF naive patients, 11 (36.7%) had thyroid nodule(s). Four patients from the anti-TNF group underwent fine needle aspiration biopsy of the nodules, and two of them were diagnosed with papillary thyroid carcinoma. None of the nodules in anti-TNF naive patients required biopsy. When compared to the normal population, the standardized incidence ratio (SIR) was found to be increased in both male (SIR 2.03, 95% CI 1.9 to 18) and female (SIR 2.7, 95% CI 2.6 to 24) cases. It is not yet established whether the development of cancer during the treatment process is the effect of the treatment or if it is a part of the natural course of the disease or if it is coincidental. We saw a mild increase in thyroid malignancies in ax-SpA patients who received anti-TNF therapy. Therefore, we believe that the thyroid gland should also be taken into consideration while screening for malignancy before anti-TNF therapy.

Comparison of the Data Classification Approaches to Diagnose Spinal Cord Injury

In our previous study, we have demonstrated that analyzing the skin impedances measured along the key points of the dermatomes might be a useful supplementary technique to enhance the diagnosis of spinal cord injury (SCI), especially for unconscious and noncooperative patients. Initially, in order to distinguish between the skin impedances of control group and patients, artificial neural networks (ANNs) were used as the main data classification approach. However, in the present study, we have proposed two more data classification approaches, that is, support vector machine (SVM) and hierarchical cluster tree analysis (HCTA), which improved the classification rate and also the overall performance. A comparison of the performance of these three methods in classifying traumatic SCI patients and controls was presented. The classification results indicated that dendrogram analysis based on HCTA algorithm and SVM achieved higher recognition accuracies compared to ANN. HCTA and SVM algorithms improved the classification rate and also the overall performance of SCI diagnosis.

Letter to the editor involving the article ‘Piriformis muscle syndrome: A cross-sectional imaging study in 116 patients and evaluation of therapeutic outcome’

Key Points• Lack of use of local injection test to confirm the diagnosis may lead to miss the diagnosis of PMS of myofascial origin.• Piriformis muscle syndrome should be diagnosed on the basis of clinical symptoms, specific physical examinations, and positive response to local injection.• Sciatic nerve entrapment is not a must in the diagnosis of PMS and PMS is mostly myofascial in origin.

Ultrasound‐Guided Diagnosis and Injection of the Lateral Femoral Cutaneous Nerve with an Anatomical Variation

Meralgia paresthetica (MP) is an entrapment neuropathy of the lateral femoral cutaneous nerve (LFCN). There are many variations in the course of the LFCN. A 55‐year‐old woman presented with pain and tingling sensations on the anterolateral aspect of her left thigh. Physical examination revealed hypoesthesia of the proximal anterolateral thigh on the left side. During the electrodiagnostic study, sensory nerve action potential of the LFCN could not be obtained on both sides. Through those clinical and electrophysiological findings, we prediagnosed the case as MP and planned to perform diagnostic nerve block. For the injection to perform, ultrasonography was used. During the ultrasonographic evaluation, the left LFCN was visualized lateral to the anterior superior iliac spine (ASIS). Then ultrasound‐guided nerve block with 2 cc lidocaine 2% for diagnostic purpose was performed in this region. Immediately after the injection, the patients complaints relieved completely, and hence the patient was diagnosed as having MP with an LFCN anatomical variation. Two months later her complaints persisted, and ultrasound‐guided LFCN injection with 2 mL of lidocaine 2% + 1 cc of betametazone was performed. One month after the second injection, her complaints were relieved markedly and she resumed her daily activities. In conclusion, the course of the LFCN is quite variable. We present a relatively rare anatomical variation of the LFCN, crossing lateral to the ASIS, diagnosed with ultrasonography. Ultrasonography can be performed to visualize the LFCN, especially a nerve with an anatomical variation.

Palpation tests versus impingement tests in Neer stage I and II subacromial impingement syndrome

We read with interest the article by Toprak et al. [9]. The authors detected that the diagnostic accuracy of impingement tests versus palpation tests in Neer stage I and II subacromial impingement syndrome cases. In this study, ultrasonography has been used as a reference test. However, also in asymptomatic individuals, rotator cuff tears can be observed sonographically [8, 10]. Rotator cuff lesions are a natural correlate of ageing, with a statistically significant linear increase after the fifth decade of life, and are often present with no clinical symptoms [5]. Likewise patients with shoulder pain, sonographic findings can be found on the contralateral side [4, 10]. This situation is valid for magnetic resonance imaging (MRI) that has been shown to be more accurate than ultrasonography [3]. It has also been shown that a significant number of asymptomatic shoulders may reveal abnormal internal signals and even complete ruptures of rotator cuff tendons, by MRI [2, 7]. Consequently, each method mainly evaluates the anatomopathologic conditions in the rotator cuff. Neer, who popularized subacromial impingement syndrome, stated that subacromial injection test (SIT) should be done, because impingement tests may be positive in other pathologies [6]. In the study of Calis et al. [1] that has been mentioned at this article, SIT has been used as the reference test for the diagnosis, not the MRI. SIT does not investigate the anatomopathologic condition in rotator cuff, but it depresses the pain generators in the subacromial area where the impingement occurs. In this way, the other pathologies like adhesive capsulitis, instability, myofascial pain syndrome, etc., can be excluded easily. In this study, although ultrasonography was accepted as the reference test, palpation tests were interestingly reported to be more positive than the sonographic findings. For example, both infraspinatus and subscapularis tendinosis were seen sonographically in 5 % of cases; on the other hand, the palpation tests of these tendons were found positive in 34.7 and 42 % of cases, respectively. Although there was no pain on the contralateral shoulder, the possible relationship between the sonographic features of this shoulder with the palpation tests was not given. As seen, the use of sonography as the reference test may cause many contradictions. Therefore, we can conclude that in such a complex joint as shoulder, diagnostic injection tests such as SIT should be used as the reference test for painful pathologies, not the diagnostic imaging techniques.