Elif Akalin

Treatment of Carpal Tunnel Syndrome with Nerve and Tendon Gliding Exercises

Akalin E, El Ö, Peker Ö, Şenocak Ö, Tamci Ş, Gülbahar S, Çakmur R, Öncel S: Treatment of carpal tunnel syndrome with nerve and tendon gliding exercises. Am J Phys Med Rehabil 2002;81:108–113. ObjectiveTo assess the effect of nerve and tendon gliding exercises in carpal tunnel syndrome. DesignThe study was a prospective, randomized, before-and-after treatment trial. A total of 28 patients with the diagnosis of carpal tunnel syndrome in 36 hands were randomly assigned to two groups. A custom made neutral volar wrist splint was given to group 1 and group 2. The patients were instructed to wear the splints all night and during the day as much as possible for 4 wk. The patients in group 2 were also instructed to perform series of nerve and tendon gliding exercises in addition to the splint treatment. Patients were evaluated with clinical parameters, a functional status scale, and a symptom severity scale. ResultsAt the end of treatment, statistically significant improvement was obtained in all parameters in both groups. The improvement in group 2 was slightly greater, but the difference between the groups was not significant, except for the lateral pinch strength value. Patient satisfaction was investigated during the follow-up period, ranging from 5 to 11 mo, with a mean of 8 mo. A total of 72% of the patients in group 1 and 93% of the patients in group 2 reported good or excellent results. The difference between the two groups was not statistically significant. ConclusionAlthough the results in group 2 were better than group 1, the difference was not statistically significant. Further investigations are required to establish the role of nerve and tendon gliding exercises in the treatment of carpal tunnel syndrome.

Hypermobility syndrome increases the risk for low bone mass

Few studies on the benign joint hypermobility syndrome suggest a tendency toward osteopenia, but there are conflicting results. We assessed bone mineral density in pre-menopausal women with hypermobility. Twenty-five consecutive Caucasian women diagnosed with benign hypermobility syndrome by Beighton score and 23 age- and sex-matched controls were included in the study. Age, menarch age, number of pregnancies, duration of lactation, physical activity and calcium intake were questioned according to European Vertebral Osteoporosis Study Group (EVOS) form. All subjects were pre-menopausal and none of them were on treatment with any drugs effecting bone metabolism or had any other systemic disease. No statistically significant difference was found for body mass index, menarch age, number of pregnancies, duration of lactation, calcium intake, calcium score and physical activity score between the two groups. Total femoral and trochanteric bone mineral density and t and z scores were significantly lower in hypermobile patients compared to the control group. Ward’s triangle and femoral neck z scores were also found to be significantly low in hypermobile patients (p<0.05). Significant negative correlations were found between the Beighton scores and trochanteric BMD, t and z scores (r=−0.29, r=−0.30, and r=−0.32) in hypermobility patients. Low bone mass was more frequently found among subjects with hypermobility (p=0.03). Hypermobility was found to increase the risk for low bone mass by 1.8 times (95% confidence interval 1.01–3.38). Our study suggests that pre-menopausal women with joint hypermobility have lower bone mineral density when compared to the controls and hypermobility increases the risk for low bone mass.

Lung parenchyma changes in ankylosing spondylitis: demonstration with high resolution CT and correlation with disease duration.

OBJECTIVE To analyze the spectrum of the lung parenchyma changes in ankylosing spondylitis (AS) with high resolution computed tomography (HRCT) and correlate the findings with disease duration. MATERIAL AND METHODS Twenty patients (18 male, 2 female) with the diagnosis of AS according to New York criteria were included in the study. None of the patients had history of tuberculosis, prolonged inorganic dust exposure and hospitalization for pneumonia. Seven of the patients were smokers, three patients were ex-smokers, and 10 patients were nonsmokers. The patients were assigned to three groups depending on disease duration. Group 1: patients with disease duration <or=5 years (N: four patients), group 2: patients with disease duration >or=6 years but <or=10 years (N: four patients), group 3: patients with disease duration >or=11 years (N: 12 patients). HRCT and pulmonary function tests (PFT) were performed in all patients. RESULTS HRCT demonstrated pathology in 17 patients (85%). Two patients in group 1, 4 patients in group 2 and 11 patients in group 3 had pulmonary parenchyma changes. Emphysema (9/20), septal thickening (9/20) and pleural thickening (9/20) were the most common changes followed by nodule (8/20) and subpleural band formation (7/20). Three patients had apical fibrosis (AF). Septal and pleural thickening (both 4/10) were the most common changes when only nonsmokers were considered. Among nine patients with emphysema three were nonsmokers. CONCLUSION There is a wide spectrum in pulmonary parenchyma changes in AS. These changes begin in early stages of the disease and increase with disease duration. Although smoking complicates the spectrum of changes in pulmonary parenchyma, they are predominately in the form of interstitial inflammation.

Ef” cacy of two forms of electrical stimulation in increasing quadriceps strength: a randomized controlled trial

Objective: To investigate whether electrical stimulation is effective in improving quadriceps strength in healthy subjects and to compare interferential and low-frequency current in terms of the effects on quadriceps strength and perceived discomfort. Design: Randomized, controlled study. Setting: Physical Medicine and Rehabilitation Department in a university hospital. Subjects: Thirty medical faculty students, divided into three groups, participated in the study. Interventions: Group A received electrical stimulation with bipolar interferential current while group B received electrical stimulation with lowfrequency current (symmetrical biphasic). Group C served as the control group. Electrical stimulation was given for 15 minutes, ”ve days a week for three weeks, at a maximally tolerated intensity with the knee fully extended in the sitting position. Main outcome measures: Before and after the study, quadriceps strength was measured with a Cybex dynamometer isokinetically at the angular velocities of 60°/s and 120°/s. The perceived discomfort experienced with each type of electrical stimulation was quantified by the use of a visual analogue scale (VAS). Results: Statistically significant increase in isokinetic strength was observed after training in group A and group B. Increase in strength did not differ between the stimulation groups. No significant change in strength occurred in group C. Perceived discomfort by the stimulation groups was not significantly different. Conclusion: Both interferential and low-frequency currents can be used in strength training with the parameters used in this study.

Clinical and functional outcomes and proprioception after a modified accelerated rehabilitation program following anterior cruciate ligament reconstruction with patellar tendon autograft

OBJECTIVES The aim of this study was to evaluate the clinical and functional outcomes and proprioceptive function in patients who received a modified accelerated rehabilitation program after anterior cruciate ligament (ACL) reconstruction with a patellar tendon (PT) graft. METHODS The study included 38 patients (33 men, 5 women; mean age 27.6 ± 6.4 years; range 18 to 45 years) who underwent ACL reconstruction with a PT graft and participated in a modified accelerated rehabilitation program. Only six patients were athletes. Isokinetic strengths of concentric knee extension and flexion were measured with the Cybex isokinetic dynamometer, and static balance was tested with the Sport-KAT device. For proprioceptive assessment, active repositioning was measured at knee flexions of 40°, 20°, and 5° with an isokinetic dynamometer. Activity levels and subjective functional results were evaluated with the Tegner activity scale and Lysholm knee score, respectively. For objective functional testing, single leg hop, triple leg hop, and one-legged crossover hop tests were used. Knee stability was assessed with the Lachman test and anterior drawer test and knee range of motion was measured. The mean follow-up period was 16.2 ± 9.8 months. RESULTS There was no graft failure during the follow-up. Twenty patients (52.6%) had hypoesthesia at the donor site and 15 patients (39.5%) had anterior knee pain. Before surgery, all the patients had positive results in the Lachman and anterior drawer tests. After surgery, the Lachman test was negative in 32 patients (84.2%), while six patients (15.8%) had grade 1 laxity. The mean Lysholm knee score showed a significant increase postoperatively (p<0.001). The mean preoperative and postoperative Tegner activity scores were not significantly different (p>0.05). There were no significant differences in the range of motion between operated and uninjured extremities (p>0.05). The two extremities were similar in proprioception and balance (p>0.05). Isokinetic quadriceps muscle strength was significantly decreased in the operated extremity only in extension at 60°/sec angular velocity (p<0.05). Other muscle strength measurements were similar in both extremities. The ratios of flexion/extension muscle strength were significantly greater in the involved extremity at all angular velocities (p<0.05). The mean performance scores of three functional tests were more than 85% of the uninvolved extremity. All the patients returned to preinjury daily activities or sports activities in 6 to 12 months postoperatively. CONCLUSION We had satisfactory clinical, proprioceptive, and functional results in achieving dynamic and static stability of the knee with the modified accelerated rehabilitation program after ACL reconstruction with a PT graft.

Dermatomal and mixed nerve somatosensory evoked potentials in the diagnosis of neurogenic thoracic outlet syndrome

To evaluate the diagnostic utility of dermatomal and mixed nerve somatosensory evoked potentials (SEPs) in patients with thoracic outlet syndrome (TOS) and to compare their value with routine electrodiagnostic methods, we studied a group of 44 patients with neurogenic TOS and 30 healthy controls. In addition to bilateral median and ulnar SEPs, evoked potentials were recorded after stimulation of C6 and C8 dermatomes from the first and fifth digits, respectively. The patients were classified into 3 groups according to the nature of their clinical condition. The abnormality rate for both ulnar and C8 dermatomal SEPs was 100% in a small group of patients with severe neurological signs like atrophy. In groups of patients with lesser degrees of neurogenic damage, abnormality rates for ulnar and C8 dermatomal SEPs on affected limb(s) were 67 and 50%, respectively. Same abnormality rates were 25 and 18% in patients with only subjective symptoms. In patients with objective neurological signs, the major increase in sensitivity was with electromyography (EMG). Abnormalities of routine nerve conduction studies and F-wave latency were observed in patients with severe neurogenic damage. We concluded that the most useful tests in the diagnosis of neurogenic TOS are needle EMG and ulnar SEPs.

Efficacy of Proprioceptive Exercises in Patients with Subacromial Impingement Syndrome: A Single-Blinded Randomized Controlled Study.

ObjectiveThe objective of this study was to evaluate the effectiveness of proprioceptive exercises on shoulder proprioception, range of motion, pain, muscle strength, and function in patients with subacromial impingement syndrome. DesignSixty-one patients with subacromial impingement syndrome participated in this prospective, single-blind randomized controlled trial. All patients were randomly divided into two groups: control group (conventional physiotherapy, n = 30) and intervention group (proprioceptive exercise and conventional physiotherapy, n = 31). The primary outcome measures were sense of kinesthesia and active and passive repositioning for proprioception at 0 degrees and 10 degrees external rotation at 12 wks. The secondary outcome measures were pain at rest, at night, and during activities of daily living with the visual analog scale (0–10 cm), the Western Ontario Rotator Cuff index, the American Shoulder and Elbow Surgeons index, range of motion, and isometric muscle strength at both 6 and 12 wks. ResultsAfter treatment, significant improvement was found in range of motion, pain, isometric muscle strength, kinesthesia at 0 degrees external rotation, and functional tests in both groups. The intervention group showed a significant improvement in kinesthesia at 10 degrees external rotation and active and passive repositioning at 10 degrees external rotation. When groups were compared, there were no statistically significant differences in any of the parameters at 12 wks. ConclusionsAlthough proprioceptive exercises may provide better proprioceptive acuity, no additional positive effect on other clinical parameters was observed.

Task-based learning programme for clinical years of medical education.

CONTEXT Task-based learning (TBL) is an educational strategy recommended for the later years of the medical education programme. The TBL programme was adopted for clinical years in the 2000-2001 academic year in Dokuz Eylul University School of Medicine (DEUSM). OBJECTIVE The aim of this paper is to describe the TBL programme of DEUSM. METHODS DEUSM outlined 50 clinical tasks for fourth-year students and 37 for fifth-year students. The tasks were grouped into four and five blocks. Interdisciplinary practicals, lectures and patient visits were organised in each tasks schedule. The tasks were the focus of learning and each discipline contributed its own learning opportunities to the attached tasks. Formative and summative methods were used to evaluate the programme. CONCLUSION Based on the experience and feedback provided by the students and trainers, the authors considered TBL an applicable and advisable approach for the clinical years of medical education.

Technetium-99m human immunoglobulin scintigraphy in patients with adhesive capsulitis : A correlative study with bone scintigraphy

Adhesive capsulitis (AC) is a disorder that is characterized by shoulder pain and progressive limitation of both active and passive shoulder motion. Although the underlying pathological mechanisms of the disease are not well understood, the inflammatory reactions depending on the stage have been demonstrated histologically. The purpose of the study is to investigate the inflammatory changes that can be demonstrated with Tc-99m HIG in AC, and to determine the presence of correlations between scintigraphic findings and the clinical assessment. Twenty-one patients (12 females and 9 males) with a mean age of 50.57±8.49 were included in the study. AC was diagnosed according to recognized criteria. The planar X-ray images of the affected shoulders of all patients were normal. The patients were evaluated with the Constant Scoring System, and the functional and pain assessment parts of the American Shoulder and Elbow Surgeons’ Form (ASES). Three phase bone scans and Tc-99m HIG scintigraphy were performed at least two days apart. Bone scan and Tc-99m HIG scintigraphy were evaluated visually and HIG uptake was evaluated in comparison with the contralateral normal shoulder. Bone scan demonstrated hypervascularity in 9 of the 21 patients (43%), whereas increased osteoblastic activity was detected in 19 (90%) in the affected shoulder. Tc-99m HIG uptake was positive in 12 (57%), and negative in 9 (43%) patiens. All patients with increased Tc-99m HIG accumulation in the affected shoulder, also had increased osteoblastic activity on Tc-99m bone scintigraphy. A significant correlation was found between HIG uptake and constant, functional and pain scores. The difference between these scores was also statistically significant in patients with HIG positive and negative uptake. This study indicates that there is a good correlation between Tc-99m HIG scan findings and clinical scores. Tc-99m HIG accumulation in the affected shoulder may be related to continuing inflammatory reaction to AC. Tc-99m HIG scan may be a noninvasive, complementary method for demonstrating continuing inflammatory changes and may help in staging the disease.

The droopy shoulder syndrome.

Abstract Droopy shoulder syndrome (DSS) is characterized by a depression of the shoulders that stretches the brachial plexus, thus causing pain without any signs of neurological impairment. We describe ten patients with DSS; all had been treated for different diagnoses before. Contrary to previous reports, three patients had unilateral involvement, and five had accompanying disease of the cervical-shoulder region. All patients responded well to conservative treatment in 2–10 weeks. DSS must be kept in mind in the differential diagnosis of pain in the cervical-shoulder region, to prevent unnecessary medication.