Evren Yasar

The effect of hinged ankle-foot orthosis on gait and energy expenditure in spastic hemiplegic cerebral palsy.

Purpose. To assess the effectiveness of a hinged ankle-foot orthoses on gait impairments and energy expenditure in children with hemiplegic cerebral palsy (CP) whom orthoses were indicated to control equines. Method. Eleven children (seven males, four females) who had a diagnosis of hemiplegic cerebral palsy were included in the study. Each child underwent gait analysis and energy consumption studies with and without ankle-foot orthosis (AFO). The AFOs were all custom-made for the individual child and had plantarflexion stop at 0° with no dorsoflexion stop. The Vicon 512 Motion analysis system was used for gait analysis. Walking energy expenditure measurements were done with breath by breath method using an open-circuit indirect calorimeter (Vmax 29c, Sensormedics, USA). All tests were carried out on the same day with enough resting period. Results. AFO application, as compared with the barefoot condition improved walking speed, stride length and single support time. Double support time was decreased significantly with AFOs and no change in cadance. Ankle dorsiflexion at initial contact, midstance and midswing showed significiant increase. Knee flexion at initial contact was decreased and no significant change in maximum knee extension at stance and maximum knee flexion at swing was obtained. The oxygen consumption was significantly reduced during AFO walking. Conclusion. The hinged AFO is useful in controlling dynamic equinus deformity and reducing the energy expenditure of gait in children with hemiplegic spastic cerebral palsy.

Sexual problems in male ankylosing spondylitis patients: relationship with functionality, disease activity, quality of life, and emotional status

This study has focused on sexual problems of male ankylosing spondylitis (AS) patients. Initially, patients’ perceptions about the effects of disease on sexual intercourse were assessed. Secondly, we investigated the factors that relate to the disease and affect sexual intercourse negatively. Thirdly, we compared data from the patients whose sexual intercourse were affected negatively with of those whose sexual intercourse were unaffected. This is a cross-sectional and double-centered study. A total of 53 married or sexually active male patients, who were certainly diagnosed with AS according to modified New York criteria, were assessed. Twenty seven patients (50.94%) expressed that their sexual life was affected negatively by the AS in general (affected patients), and 26 patients (49.06%) expressed no negative effect (unaffected patients). Both affected and unaffected patients were compared with each other with regard to educational level, joint involvement, functionality, disease activity, quality of life, and depression status. Mean BASFI, BASDAI scores were worse in the affected group, and the difference was statistically significant (p = 0.012, p = 0.039, respectively). There were statistically significant differences between the groups with regard to lumbar column and hip involvement (p = 0.035, p = 0.021; respectively). The physical functioning, role limitations due to physical problems, vitality/energy/fatigue, general mental health, and general health perception subscale scores of SF-36 were worse in the affected group, and the differences were statistically significant (p = 0.027, p = 0.023, p = 0,013, p = 0.005, p = 0.045, respectively). Affected patients’ Beck Depression Inventory scores were worse than those of unaffected patients, and the difference between the groups was statistically significant (p = 0.039). Sexual problems are common in AS patients and might usually be associated with joint involvement, decreased functionality, increased disease activity, decreased health quality, and depression. Therefore, while examining AS patients and managing their treatments, special attention must be given to all domains of life instead of only physical problems.

Sciatic nerve compression due to femoral neck osteochondroma : MDCT and MR findings

A 34-year-old man presented with a 15-month history of pain along the left sciatic nerve. Radiographs and computed tomography (CT) revealed an exostosis on the postero-inferior aspect of the left femoral neck. Ultrasonographic examination of left upper thigh and a pelvic magnetic resonance (MR) imaging showed an enlarged sciatic nerve adjacent to the exostosis. Although peroneal and ulnar neuropathies due to the compression by exostosis are reported frequently, imaging findings of sciatic nerve involvement were not well documented in the literature. Multidetector CT and MR findings of a sciatic nerve compression caused by a femoral neck exostosis were presented.

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.

Basal Metabolic Rate and Autonomic Nervous System Dysfunction in Men With Spinal Cord Injury

Objectives: The purpose of this study was to determine the relationship between autonomic nervous system dysfunction and basal metabolic rate (BMR), and the effect of spasticity on basal metabolic rate.

Effect of autonomic dysfunction on p-wave dispersion in patients with chronic spinal cord injury.

Yasar E, Yilmaz B, Yasar AS, Goktepe AS, Alaca R, Mohur H: Effect of autonomic dysfunction on P-wave dispersion in patients with chronic spinal cord injury. Objective:To provide information about the effect of autonomic dysfunction on P-wave dispersion, as a predictor of atrial fibrillation, in patients with spinal cord injury. Design:Thirty patients with chronic traumatic spinal cord injury and 27 healthy controls were included in this study. The initial assessment of the patients included routine physical examination and evaluation of 12-lead electrocardiography. In the patient group, blood pressure and electrocardiography recordings were obtained during urodynamic assessment. The measurements of the P-wave duration were performed manually by two blinded investigators. P-wave dispersion was calculated as the difference between maximum P-wave duration and minimum P-wave duration. P-wave dispersion values of resting electrocardiography recordings in control and study groups were compared. In the patient group, subgroup analyses were also performed according to the injury level and severity and existence of autonomic dysfunction in examinations. Results:P-wave dispersion values were greater in patients with spinal cord injury than in healthy controls. There was statistically significant difference between P-wave dispersion values of the patients with and without autonomic dysfunction. P-wave dispersion values at initial sensation of vesical filling were greater than those of the resting state in the patients without autonomic dysfunction. Conclusions:Our findings indicate that P-wave dispersion increases significantly in chronic spinal cord injured patients with autonomic dysfunction. This finding suggests a tendency for atrial fibrillation occurrence in patients with spinal cord injury, which may cause further cerebrovascular complications in this special subset of patients by creating a thromboembolic milieu.

Ultrasound-guided steroid injection in the treatment of stump neuroma: Pilot study

BACKGROUND Stump neuroma is a major cause of postamputation pain. Ultrasound is a practical way of imaging stump neuromas and can be employed for guiding therapeutic injections. OBJECTIVE The aim of this pilot study was to investigate the effectiveness of ultrasound-guided steroid injection in the treatment of stump neuroma. METHODS The amputee patients with stump neuroma who underwent a single ultrasound guided steroid injection in amputee rehabilitation unit of our hospital were reviewed. The pain logs employing a 11-point pain scale for each evaluation time (before the procedure, one day, one week, 2 weeks, 4 weeks, 6 weeks after procedure) and a subsequent phone call approximately six months after procedure were used as the source of information in the study. Mean changes in pain levels (pain in rest and pain with prosthesis) over time were evaluated. The patients that had 50% decrease in pain scores were regarded as having treated successfully. Time after amputation and duration of pain symptom were compared between successfully (Group A) and unsuccessfully (Group B) treated patients. RESULTS All patients (mean age, 29.7 ± 5.5 year) in the study were male (n=14). 12 patients were transtibial amputee (85.7%) and 2 patients were transfemoral amputee (14.3%). Both mean pain scores improved significantly in repeated measures (pain in rest F=25.35, p< 0.01; pain with prosthesis F=81,45, p <0,01). A total of 7 patients (50%) were regarded as having treated successfully. Time after amputation and duration of pain symptom were significantly longer in Group B. (p< 0.05, Group A: 16.8 ± 14.3 months after amputation, 3.5 ± 4.1 months pain duration; Group B: 80.2 ± 74.2 months after amputation, 52.8 ± 57.6 months pain duration). CONCLUSIONS Steroid injection may have positive effect in the treatment of postamputation neuroma. The patients with shorter pain and amputation duration may respond well to the injection.

Pellegrini-stieda disease in a patient with cauda equina syndrome.

A 30-yr-old man with cauda equina syndrome resulting from a compression fracture of the L1 vertebra was enrolled in a rehabilitation program at the authors’ hospital, and on completion, he was able to walk with the aid of an ankle-foot orthosis and cane. One year later, at his clinical follow-up visit, the patient complained of pain and swelling in his left knee. Despite the absence of a history of knee trauma, patellar subluxation was observed by physical examination. The patient then underwent several orthopedic surgeries to improve this condition. After this surgical process, a kneeankle foot orthosis was prescribed to prevent any exacerbation of the knee lesion secondary to walking. Nonetheless, he again developed patellar subluxation 6 mos after his last surgery. There was no swelling of the knee or restriction of motion. Valgus stress test results were positive, and the medial knee was sensitive to palpation. Plain radiography showed a characteristic bony formation and calcification in the soft tissue next to the medial femoral condyle (Fig. 1). Pellegrini-Stieda disease was considered based on the characteristic x-ray findings and clinical course. Radiographically, Pellegrini-Stieda disease seems as an ossification arising from the epicondylar portion of the medial femoral condyle. Humoral, neural, and local factors including tissue hypoxia, hypercalcemia, changes in sympathetic nerve activity, prolonged immobilization, and mobilization with frequent periods of exercise after prolonged immobilization may result in neurogenic ectopic bone formation. Although Pellegrini-Stieda disease has rarely been reported in patients with spinal cord injury, this report highlights the need for its consideration in the diagnosis of such patients if knee symptoms are present.

Basics of bone metabolism and osteoporosis in common pediatric neuromuscular disabilities

Bone modeling is a process that starts with fetal life and continues during adolescence. Complex factors such as hormones, nutritional and environmental factors affect this process. In addition to these factors, physical conditioning and medications that have toxic effects on bony tissue should be carefully considered in patient follow-up. Osteoporosis is a significant problem in pediatric population because of ongoing growth and development of skeletal system. Two types of osteoporosis are primary and secondary types and children with neuromuscular disabilities constitute a major group with secondary osteoporosis. Low bone mass in patients with cerebral palsy, spina bifida, and Duchenne muscular dystrophy cause increased bone fragility in even slight traumas. Maximizing peak bone mass and prevention of bone loss are very important to reduce the fracture risk in neuromuscular diseases. This article aims to review the determinants of bone physiology and bone loss in children with cerebral palsy, spina bifida, and Duchenne muscular dystrophy.

Comparison of Intact Knee Cartilage Thickness in Patients with Traumatic Lower Extremity Amputation and Nonimpaired Individuals.

ObjectiveThe aim of this study was to assess the femoral articular cartilage thickness of the intact knee in patients with traumatic lower extremity amputation compared with nonimpaired individuals. DesignA total of 30 male patients with traumatic lower extremity amputation (mean [SD] age, 31.2 [6.3] yrs) and a random sample of 53 age-matched and body mass index–matched male nonimpaired individuals (mean [SD] age, 29.8 [6.3] yrs) participated in the study. Exclusion criteria were age younger than 18 yrs, history of significant knee injury, previous knee surgery, or rheumatic disease. The femoral articular cartilage thickness was measured using ultrasound at the midpoints of the medial condyle, the intercondylar notch, and the lateral condyle. Ultrasonographic cartilage measurement was performed on the intact side of the patients with amputation and on both sides of the nonimpaired individuals. ResultsThe femoral articular cartilage thickness of the intact knees of the patients with amputation was significantly decreased at the lateral and medial condyles compared with the nonimpaired individuals (P < 0.05). There was no significant difference in the measurements at the intercondylar notch between the patients with amputation and the nonimpaired individuals (P > 0.05). ConclusionsThere was a premature cartilage loss in the intact limb knee of the patients with traumatic amputation. This result supports the view that patients with traumatic lower extremity amputation are at increased risk for developing knee osteoarthritis in the intact limb.