Halil Ünalan

The Sensitivity and Specificity of the Slump and the Straight Leg Raising Tests in Patients With Lumbar Disc Herniation

Background:An accurate and specific diagnosis prevents the recurrences of low back pain and chronic spinal pain. The physical examination is the most useful tool to diagnosis. The examiner must aim to determine the exact tissue that pain arises from to make the specific diagnosis. Lumbar disc herniation is 1 disease that physical examination, symptoms, and findings on imaging technique do not always correlate with each other. The Straight Leg Raising (SLR) test has been used as the primary test to diagnosis lumbar disc herniations and found to have high correlation with findings on operation since its sensitivity is high in only disc herniations leading to root compression that may eventually need operation. More sensitive test, like the Slump, might be used in herniations in which the SLR is negative. The Slump test is really a variant of the SLR and the Lasègues tests performed in the seated position and is a progressive series of maneuvers designed to place the sciatic nerve roots under increasing tension. At each step in the procedure, the patient informs the examiner what is being felt and whether radicular pain is produced. As a result, the Slump test applies traction to the nerve roots by incorporating spinal and hip joint flexion into the leg raising and would warn the examiner of the presence of nerve root compression when there is a negative SLR test. Objectives:This study measured the sensitivity and specificity of the Slump test and compare it with the SLR test in patients with and without lumbar disc herniations. Methods:A prospective case control study of 75 patients with complaints suggestive of lumbar disc herniation was carried out in the outpatient clinics of the neurosurgery department of a state teaching hospital. Seventy-five referred or self-admitted patients with low back, leg, or low back and leg pain who had results of magnetic resonance imaging (MRI) of the lumbar spine were included in the study. Thirty-eight patients had signs of herniation demonstrated by MRI. Control patients (n = 37) had no disc bulges or herniations on MRI. Both the Slump and SLR tests were performed during the assessment of all the patients by the second author. The MRI results were assessed and recorded by the first author. Results:The Slump test was found to be more sensitive (0.84) than the SLR (0.52) in the patients with lumbar disc herniations. However, the SLR was found to be a slightly more specific test (0.89) than the Slump test (0.83). Conclusion:The Slump test might be used more frequently as a sensitive physical examination tool in patients with symptoms of lumbar disc herniations. In contrast, owing to its higher specificity, the SLR test may especially help identify patients who have herniations with root compression requiring surgery.

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.

Effect of Treatment on Trigger Points

Patients with muscle pain complaints commonly are seen by clinicians treating pain, especially pain of musculoskeletal origin. Myofascial trigger points merit special attention because its diagnosis requires examinations skills and its treatment requires specific techniques. If undiagnosed, the patients tend to be overinvestigated and undertreated, leading to chronic pain syndrome. Patients with myofascial pain syndrome present primarily with painful muscle(s) and restricted range of motion of the relevant joint. Palpable painful taut bands are named trigger points and are the main and pathognomonic finding on physical examination. Eliciting local twitch response and referred pain requires experience and examination skills. It may be useful to classify the patient as having acute or chronic, and as having primary or secondary, myofascial pain so the decision on the details of treatment can be curtailed to the needs of each patient. Effective treatment modalities are local heat and cold, stretching exercises, spray-and-stretch, needling, local injection, and high-power pain threshold ultrasound.

Skin thickness on bony prominences measured by ultrasonography in patients with spinal cord injury

Abstract Objective The detailed assessment of soft tissues over bony prominences and identification of methods of predicting pressure sores would improve the quality of care for patients with spinal cord injury (SCI). Comparing skin thicknesses on bony prominences in patients with SCI to those in healthy individuals will represent, to our knowledge, the first study aimed at determining whether differences in skin thicknesses between these groups can be detected by ultrasound. Design In both patients and controls, skin thicknesses on the sites at risk for pressure ulcers – sacrum, greater trochanter, and ischium – were evaluated using high-frequency ultrasound. The waist was also evaluated by the same method for control as it was considered to be a pressure-free region. Participants Thirty-two patients with complete thoracic SCI and 34 able-bodied individuals. Results The skin was significantly thinner over the sacrum and ischial tuberosity in individuals with SCI compared with healthy individuals. No significant differences were observed in skin thicknesses over the greater trochanter or the waist between the two groups. Conclusions Protecting skin integrity in patients with paraplegia is challenging due to many contributing factors, such as prolonged pressure, frictional/shearing forces, and poor nutrition. Thinning of the skin can increase the risk of soft tissue damage, leading to pressure ulcers. The significant differences in skin thickness at the sacrum and ischium provide the basis for establishing the early signs of pressure damage. Measuring skin thickness by ultrasound is a reliable non-invasive method that could be a promising tool for predicting pressure ulcers.

The Effect of High-Power Pain Threshold Ultrasound Therapy on the Electrical Activity of Trigger Points and Local Twitch Response on Electromyography: A Preliminary Study

Objectives: We aimed to compare the effects of the high-power pain threshold ultrasound [HPPTUS] technique and needling on the spontaneous electrical activity [SEA] of trigger points [TrPs], local twitch response [LTR], and clinical improvement in myofascial pain syndrome. Methods: Twenty female patients presenting with acute TrPs on their upper trapezius muscles were included in this study. The patients were randomly assigned into two groups. The cases in the study group underwent HPPTUS technique and active stretching of the muscle. The cases in the control group underwent dry needling done by five adjacent electromyography [EMG] needle penetrations on the TrP [dry needling and analysis done concurrently] and did active stretching. Number of points where SEA observed were recorded. Visual analog scale [VAS], range of motion [ROM] measurement during contralateral flexion of the cervical spine, and the number of LTR were recorded. Results: Significant improvements were measured in both groups in terms of pain level and cervical ROM [P < 0.05]. There were no statistically significant changes in the number of recorded SEA of both groups at the end of the treatment. However, significant reduction in the number of LTR in the HPPTUS group was found [P = 0.015]. When the two groups were compared regarding level, patients in the study group reported significantly more reduction in pain [P = 0.009]. However, there was no difference in the cervical ROM improvement between two groups [P = 0.136]. Conclusions: The HPPTUS technique combined with exercise was found to be more effective in reducing the LTRs when compared with dry needling combined with exercise.

Trigemino-cervical reflex in spinal cord injury

Abnormal enhancement of polysynaptic brainstem reflexes has been previously reported in patients with spinal cord injury (SCI). We aimed to investigate trigemino-cervical reflex (TCR) in SCI since it may reflect alterations in the connections of trigeminal proprioceptive system and cervical motoneurons. Consecutive 14 patients with SCI and 16 healthy subjects were included in this study. All patients were in the chronic phase. TCR was recorded over sternocleidomastoid (SCM) and splenius capitis (SC) muscles by stimulation of infraorbital nerve. We measured onset latency, amplitudes and durations of responses and compared between groups. We obtained stable responses over both muscles after one sided stimulation in healthy volunteers whereas probability of TCR was decreased in patients over both SCM (78.6% vs. 100%, p=0.050) and SC (71.4% vs. 100%, p=0.022). The absence of TCR was related to use of oral baclofen (≥50mg/day). However, when present, responses of SCI group had higher amplitudes and were more persistent. We demonstrated that TCR probability was similar to healthy subjects in SCI patients who used no or low dose oral baclofen. But it had higher amplitudes and longer durations. It was not obtained in only two patients who used oral baclofen more than 50mg/day.

A 14-year-old girl with Smith-McCort dysplasia misdiagnosed as seronegative juvenile idiopathic arthritis

Dear Editor, Spondylo-epi-metaphyseal dysplasias (SEMDs) are a heterogeneous group of disorders with differing modes of inheritance, all of which are defined by the combination of vertebral, epiphyseal and metaphyseal abnormalities. The specific diagnosis is based on the specificity of the skeletal manifestations or the presence of characteristic extraskeletal features. Dyggve-Melchior-Clausen syndrome (DMC) and Smith-McCort dysplasia (SMC) are rare autosomal recessive SEMDs. SMC (OMIM: 607326), which is a rare variant of DMC syndrome without evidence of mental retardation, has been shown to be allelic to DMC syndrome. Smith-McCort dysplasia is a progressive, autosomalrecessive SEMD that may be misdiagnosed in clinical practice as juvenile idiopathic arthritis (JIA). The clinical importance of this rare disorder may be attributed to its clinical similarity to JIA, which has a very different prognosis and treatment regimen. Typical dysplastic skeletal abnormalities, which occur mainly in the spine and iliac bones, and the absence of synovial inflammation enable the differential diagnosis of SMC from JIA. We present the case of a 14-year-old girl with SMC who was misdiagnosed as having JIA. A 14-year-old girl was admitted to our hospital with pain in the bilateral hip and leg that had hindered her normal walking for 3 months. Evaluation of the clinical history revealed that the pain had started from both hips and spread to the legs, and had gradually reduced her ability to walk. She reported that she could not stand or walk without support for the previous 2.5 months. The history of the patient revealed no evidence of swelling, redness or warmth of the joints during this time period. Approximately 3.5 months prior to presentation at our hospital with these complaints, she had consulted an orthopedic surgeon, who had recommended bilateral total hip arthroplasty. In the meantime, she was admitted to our hospital and was evaluated at the Departments of Pediatrics and Rheumatology, _Istanbul University Cerrahpasa Medical Faculty, Turkey. After a diagnosis of a seronegative rheumatoid arthritis, treatment was initiated with a regimen of prednisolone 5 mg once daily, methotrexate 15 mg/ week, calcium–vitamin D once daily, and folic acid once daily, twice a week in the Department of Rheumatology. These treatments did not produce any change in her pain or walking ability. The patient is the fifth child in a family in which the parents are non-consanguineous. She had no history of severe disease or disability, apart from slow growth and developmental delay. Neurological examination was normal, and the patient was still receiving primary education. She had short and fusiform hand fingers. Increased anteroposterior chest diameter and kyphoscoliosis were present, and the proximal portions of the upper and lower limbs were short. She had pain and limitation regarding range of motion in the knee and hip joints bilaterally. She also had bilateral valgus deformity of the knee and ankle joint. The right and left leg lengths were 63 and 67 cm, respectively. The patient’s serum 25-hydroxyvitamin D, parathyroid hormone, thyroxine, thyroid stimulating hormone, acute phase response proteins, serum protein electrophoresis, and bone, liver, and kidney profiles were all normal. Urine amino acids were normal and there was no excretion of mucopolysaccharides. Spinal radiography revealed platyspondyly in almost all the vertebral bodies (Fig. 1), and pelvis radiography revealed lacy iliac bones and dysplasia of the acetabulum and femoral heads bilaterally (Fig. 2). In a cervical magnetic resonance imaging, there was odontoid hypoplasia, platyspondyly at multiple levels, irregularities of the end-plates, and characteristic double-humped appearance due to a wedge-shaped ossification defect. The bone mineral density (BMD) of the patient was measured using dual-energy X-ray absorptiometry (DEXA; Hologic QDR-4500, Bedford, International Journal of Rheumatic Diseases 2012; 15: e55–e57

High Power Pain Threshold Ultrasound Technique in the Treatment of Active Trigger Points

In our published study (2), we demonstrated the effectiveness of the high power pain threshold ultrasound technique method for the treatment of active TrPs. Besides the original method we used during the study [increasing the power to the pain level while holding the probe on the TrP and decreasing it to half intensity after three to five seconds], we have begun to use the more apparent practical way of applying ultrasound at a constant power of 1.5-2 w/cm2, holding the probe on the TrP for three to four seconds [again to the level of pain threshold], and when the pain becomes unbearable, switching to conventional stroking technique for 10 to 15 seconds. This cycle is repeated at least three times during one session. The response of theactiveTrPs tobothkindsof stimulation is dramatic. We find it effective on especially acute TrPs as a treatment method with lasting effectiveness. We should have used both methods on more than 1,000 patients during the last ten years; we had already been using the methods for a few yearsbeforeorganizing thestudy.Wehope that it will be used in the upcoming years as a new, effective, and exciting treatment method. Nevertheless, the mechanism of action of this and other stimulating methods remains unknown. We have also observed over the years that this technique elicits pain only when applied on

Experimental Study on Static Ultrasound [High-Power Pain Threshold Ultrasound] Application: Potential Adverse Effects on Rats

ABSTRACT Objectives: To investigate the probable tissue damage after the application of static ultrasound in the intensities, durations, and session numbers identical to the originally defined high-power pain threshold ultrasound technique that has been shown to be effective in the treatment of myofascial trigger points. Methods: Twenty-four male Wistar-albino rats were used in a controlled single-blinded experimental model. The animals were assigned into three groups and underwent the static ultrasound applications in intensities ranging from 0.5 watt/cm2 to 1.5 watt/cm2. Muscle, peripheral nerve, spinal cord, and bone tissue were pathologically assessed for the signs of any possible damage. Blood samples were analyzed for abnormal creatine kinase level. Results: Creatine kinase levels were normal in all the cases. Pathological analyses of the tissue samples taken from the nerve, muscle, spinal cord, and bone tissues revealed no abnormal findings. Conclusion: The static ultrasound technique applied in identical intensities and durations to the high-power pain threshold ultrasound technique used in the treatment of myofascial trigger points in an original experimental model did not lead to tissue damage.

Pattern of startle reflex to somatosensory stimuli changes after spinal cord injury

Introduction: Spinal cord injury (SCI) may cause functional changes at various levels in central and peripheral nervous systems. One of these changes is increased excitability above the lesion such as enhanced auditory startle responses (ASR). Startle response may also be obtained after somatosensory stimulus (startle reflex to somatosensory stimuli, SSS). In this study, we investigated changes of both ASR and SSS in SCI. Method: We examined ASR and SSS in 14 patients with SCI and 18 age-matched healthy volunteers. SSS responses were recorded from orbicularis oculi (O.oc), sternocleidomastoid (SCM) and biceps brachii (BB) muscles by electrical stimulation of median nerve at the wrist. ASR was evoked by binaural auditory stimuli and recorded from O.oc, masseter, SCM and BB muscles. Probability, latency, amplitude and duration of responses were compared between two groups for each muscle. Results: Presence of response over O.oc after somatosensory stimuli was decreased in patients compared to controls (P = 0.004). There were no differences in SSS responses of other muscles. ASR latency was shorter in masseter, SCM and BB in patients with SCI, but only BB had significantly reduced latency (P = 0.033). The duration of O.oc response was longer and the amplitude of SCM was larger in patients with SCI (P = 0.037 and P = 0.015, respectively). Conclusion: ASR is enhanced after SCI whereas SSS of eye muscles is hypoactive and pattern of SSS after median stimulation changes in SCI.