Fatih Tok

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.

Medical complications, physical function and communication skills in patients with traumatic brain injury: a single centre 5-year experience.

Objective: The aim of this retrospective study was to review the medical complications of patients with traumatic brain injury (TBI) who were followed in 2000–2006. Methods and procedures: The demographic data, functional and cognitive status of 116 persons with TBI were noted. The presence of communication problems, swallowing disturbances, urinary and faecal incontinence, pressure ulcer, deep venous thrombosis (DVT), post-traumatic seizure (PTS) and heterotopic ossification (HO) were recorded at first admission and follow-up. Main outcome and results: This study detected aphasia in 19.0%, dysarthria in 30.2%, dysphagia in 17.2%, pressure ulcers in 6.9% and DVT in 2.6% the our patients with TBI. Urinary and faecal incontinence on admission were 32.7% and 26.7%, respectively. Patients with incontinence had poorer cognitive function than those with normal continence. HO rate was 18.1% and the ambulation levels of patients with HO were worse than those without HO. PTS was seen in 13.8% of the patients on admission and this ratio increased to 21.6% during the follow-up. In these patients, the aetiological risk factors for PTS were gunshot and fall injuries. Conclusions: Considering the wide spectrum of complications, this study advocates that these persons with TBI should be followed promptly by a multidisciplinary team.

Ultrasound-guided vs. blind steroid injections in carpal tunnel syndrome: A single-blind randomized prospective study.

ObjectiveThe aim of this study was to compare the efficacy and the safety of ultrasound (US)–guided vs. blind steroid injections in patients with carpal tunnel syndrome (CTS). DesignThis prospective randomized single-blind clinical trial included 46 patients with CTS (46 affected median nerves). The subjects were randomized—to either the US-guided or the blind injection group—before they received 40 mg of methylprednisolone. They were evaluated using the Boston Carpal Tunnel Questionnaire symptom/function at baseline and at 6 wks and 12 wks after injection, and the side effects were noted. ResultsThe symptom severity and functional status scores improved significantly in both groups at 6 wks after treatment, and these improvements persisted at 12 wks after treatment (all P < 0.05). The improvement in symptom severity scores in the US-guided group at 12 wks was higher than in the palpation-guided group (P < 0.05). Average time to symptom relief was shorter in the US-guided group (P < 0.05). There was no significant difference between the two groups in terms of side effects (P > 0.05). ConclusionsAlthough both US-guided and blind steroid injections were effective in reducing the symptoms of CTS and improving the function, an earlier onset/better improvement of symptom relief suggests that US-guided steroid injection may be more effective than are blind injections in CTS.

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.

Musculoskeletal ultrasonography in physical and rehabilitation medicine

Musculoskeletal ultrasound has gained a significant place in the diagnosis and management of various musculoskeletal disorders due to its several advantages (being convenient, inexpensive, non-invasive, repeatable, providing dynamic imaging and not requiring any exposure to radiation). It has also become a valuable tool in the daily clinical practice of physical and rehabilitation medicine physicians; the musculoskeletal ultrasound probe having become synonymous with the physicians stethoscope. In this paper, aside from drawing attention to this growing issue in the agenda of PRM physicians, we will touch upon its basic technical features and certain aspects as regards muscle, tendon, ligament, nerve, joint lesions and ultrasound guided interventions.

Triamcinolone acetonide vs procaine hydrochloride injection in the management of carpal tunnel syndrome: randomized placebo-controlled study.

OBJECTIVE The aim of this trial was to compare the efficacy of triamcinolone acetonide and procaine HCl with that of placebo in the treatment of carpal tunnel syndrome. DESIGN This prospective, randomized placebo-controlled trial included 57 patients (90 median nerves). Ninety median nerves were randomly assigned to 1 of 3 groups: group 1 was injected with 1 ml 0.09% saline, group 2 was injected with 40 mg triamcinolone acetonide, and group 3 was injected with 4 ml 1% procaine HCl. Clinical and electrophysiological evaluations were performed at study onset, and at 2 and 6 months post-treatment. RESULTS At study onset no significant differences were observed between groups with respect to clinical and electrophysiological parameters. Clinical and electrophysiological evaluations was improved significantly in groups 2 and 3 at post-treatment (p<0.05). No significant changes were observed in group 1 (p>0.05). Moreover, groups 2 and 3 had better scores than group 1 at 2 and 6 months post-treatment(p<0.05). There was no difference between groups 2 and 3 in terms of change scores of any terms at post-treatment (p>0.05). CONCLUSION Triamcinolone acetonide and procaine HCl injections are effective regarding short- and long-term outcomes compared with placebo injections, and procaine HCl injection was as effective as steroid injection.

The effectiveness of triamcinolone acetonide vs. procaine hydrochloride injection in the management of carpal tunnel syndrome: a double-blind randomized clinical trial.

Objective: Corticosteroid injection into the carpal tunnel is frequently used for the treatment of carpal tunnel syndrome (CTS). Steroids are usually mixed with local anesthetics, which have positive effects that can aid the treatment of CTS by inhibiting the spontaneous discharge ability of excitable cells. The aim of this study was 3-fold: (1) to determine the efficacy of triamcinolone acetonide injection in the treatment of CTS, (2) to determine the efficacy of procaine hydrochloride (HCl) in the treatment of CTS, and (3) to compare the efficacy of triamcinolone acetonide and that of procaine HCl in the treatment of CTS. Design: This prospective, randomized, double-blind clinical trial included 99 patients (120 median nerves) with clinical and electrophysiologic evidence of CTS. The 120 median nerves were randomly assigned to one of three groups: group 1 received 40 mg of triamcinolone acetonide, group 2 received 4 ml of 1% procaine HCl, and group 3 received both 40 mg of triamcinolone acetonide and 4 ml of 1% procaine HCl. Clinical and electrophysiologic evaluations were performed at the study onset and at 2 and 6 mos after treatment. Results: At the study onset, there were no statistically significant differences between the groups with respect to distal motor latency, compound motor action potential, compound sensory action potential, sensory nerve conduction velocity, or visual analog scale score; however, distal motor latency, compound sensory action potential amplitude, sensory nerve conduction velocity, and visual analog scale scores improved significantly in each group 2 mos after treatment (P < 0.05), and these improvements persisted at 6 mos after treatment (P < 0.05). Significant differences were not observed between groups 1 and 2 or between groups 1 and 3 with respect to electrophysiologic findings at baseline or 2 or 6 mos after treatment (P > 0.05). Group 3 had better compound sensory action potential amplitude and sensory nerve conduction velocity scores than group 2 did at 6 mos (P < 0.05) and better visual analog scale scores than group 2 did at 2 and 6 mos (P < 0.05). Conclusions: Local procaine HCl injection and steroid injection effectively reduced the symptoms of CTS and equally improved electrophysiologic findings. As such, procaine HCl can be used in CTS patients in whom steroid use is contraindicated.

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.

Effects of botulinum toxin-A on the muscle architecture of stroke patients: the first ultrasonographic study.

OBJECTIVE The aim of this study was to explore in vivo the effects of botulinum toxin-A treatment on the muscle architecture of patients with stroke, using musculoskeletal ultrasonography. METHODS This prospective clinical trial included 26 adult stroke sufferers with a mean age of 55 years (standard deviation 14). Pennation angles between the fascicle path and the deep aponeurosis of the muscle, fascicle length, muscle thickness and muscle compressibility were scanned at the bulkiest part of the medial gastrocnemius on both limbs. Sonographic evaluations were performed initially before botulinum toxin-A injection and repeated on day 10 and after 2 months. RESULTS On the hemiplegic sides, anterior pennation angle and muscle thickness decreased (p = 0.014, p = 0.010, respectively), fascicle length increased (p = 0.025) and muscle compressibility did not change after 2 months of treatment compared with the baseline values. CONCLUSION The results confirm that muscle structure changes due to botulinum toxin-A. Long-term effects of botulinum toxin-A, timing for disappearance of the toxin effects, or evaluations for repeat injections, remain to be studied. The use of musculoskeletal ultrasonography appears to be promising in this regard. :

The utility of musculoskeletal ultrasound in rehabilitation settings.

Aside from its prompt use in musculoskeletal injuries (sports lesions, degenerative/inflammatory joint disorders, and peripheral nerve pathologies), ultrasonographic imaging can be used quite conveniently in various types of rehabilitation conditions as well. If used in a rehabilitation setting, ultrasound can significantly contribute to the diagnostic/therapeutic algorithm of rehabilitation patients. Accordingly, in this article, the authors focus on the diagnostic/interventional utility of ultrasound particularly for shoulder problems, overuse injuries of wheelchair users, heterotopic ossification, amputee follow-up, peripheral nerve and botulinum toxin injections, and diaphragm imaging/electromyography.