Ismail Safaz

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.

Quality of life and functionality after lower limb amputations: comparison between uni- vs. bilateral amputee patients

Background: It is difficult for the lower limb amputee patients to adapt to their new lifestyles. Objective: To compare the life quality and functionality of patients with bilateral vs. unilateral lower extremity amputations. Study Design: Cross-sectional study. Methods: Fifteen bilateral and 15 unilateral lower extremity amputee patients were enrolled. Demographics, cause and level of amputations, frequency and duration of prosthesis use were evaluated. SF-36, Satisfaction with Prosthesis Questionnaire (SAT-PRO), Amputee Body Image Scale. (ABIS), Houghton Scale (HS), six-minute walk test (6MWT), and 10-metre walk test (10 MWT) were performed. Results: Physical function, physical and emotional role scores of SF-36 were significantly lower in the bilateral amputee group in comparison with the unilateral group. SAT-PRO and ABIS total scores were similar between the groups. There was a positive correlation between the frequency of prosthetic use and SF-36 subgroups (except pain). The unilateral amputee group had significantly better scores than the bilateral amputee group in terms of HS, 6MWT and 10 MWT. Conclusion: Physical capacity of bilateral lower extremity amputee patients is lower than the unilateral amputee patients; satisfaction with prosthesis and body image are not related with the amputation level; and the life quality and satisfaction with prostheses are increased in parallel with the use of the prostheses. Clinical relevance Although differences exist between the groups, in terms of quality of life and functionality, patients can reach an acceptable life standard with good rehabilitation and a suitable prosthesis.

Which treatment approach is better for hemiplegic shoulder pain in stroke patients: intra-articular steroid or suprascapular nerve block? A randomized controlled trial

Objective: To determine which injection technique was effective for patients with hemiplegic shoulder pain. Design: Randomized prospective double-blind study. Setting: Brain Injury Rehabilitation Unit. Intervention: Patients with hemiplegic shoulder pain were recruited over a 12-month period and all were hospitalized in our clinic. Intra-articular steroid injection or suprascapular nerve block was performed on all patients. Main measures: Range of motion values at the moment that pain started (range of motion A) and passive maximum range of motion values (range of motion B) were recorded. Pain intensity levels (visual analogue scale) at these two range of motion values (pain A and pain B) were also taken. Evaluations were made before the injection, and 1 hour, one week and one month after the injection. Results: Twenty-six patients were enrolled in the study, the mean age was 61.53 ± 10.30 years. The mean time since injury was 8.69 ± 15.71 months. The aetiology was ischaemic in 16 (61%) patients. Intra-articular steroid injection was performed in 11 (42 %) patients, and suprascapular nerve block in 15 (57%) patients. Range of motion A and range of motion B were changed statistically in repeated measures. There were important differences in repeated measures of pain intensity levels at these two range of motion values (P < 0.05). However, no significant differences were determined in all measurements between intra-articular steroid injection and suprascapular nerve block groups (P > 0.05). Conclusions: Our results showed that neither injection technique was superior to the other. Both injection procedures are safe and have a similar effect in stroke patients with hemiplegic shoulder pain.

Sonographic evaluation of the sciatic nerve in patients with lower-limb amputations

Hypertrophy of the sciatic nerve after lower‐limb amputation in patients with sarcomas has been previously reported by magnetic resonance imaging; however, sonographic evaluation of the sciatic nerve after lower‐limb amputation due to nonmalignant causes has not been done before. Therefore, the aim of this study was to perform imaging of the sciatic nerve in lower‐limb amputees and to find out whether sonographic findings were related to clinical characteristics. Twenty‐three males with lower‐limb amputations due to traumatic injuries were enrolled. Sonographic evaluations were performed using a linear array probe (Aloka UST‐5524‐7.5 MHZ). Sciatic nerve diameters were measured bilaterally at the same level, and the values of the normal limbs were taken as controls. Sciatic nerve width and thickness values were found to be greater on the amputated sides than the normal sides (P = 0.001). The thickness values were greater in above‐knee amputees than below‐knee amputees (P = 0.05). Subjects with a neuroma also had thicker sciatic nerves (P = 0.04). The diameters were found not to change between subjects with different liners (P > 0.05), but they were correlated with time after amputation (r = 0.6, P = 0.006; r = 0.4, P = 0.05, respectively). Our results clearly show that the sciatic nerves were wider and thicker on the amputated sides. Amputation level, duration, and the presence of a neuroma seem to affect the eventual diameters of the nerves. Muscle Nerve, 2010

The efficacy of serial casting after botulinum toxin type A injection in improving equinovarus deformity in patients with chronic stroke

Introduction: Spasticity is an important early complication of stroke, which may lead to shortening of gastrocnemius and soleus muscles and contracture in the Achilles tendon and soft tissues of the ankle. Botulinum toxin A (BTX-A) is a promising drug for the management of focal spasticity. Serial casting is another alternative method for reducing contractures due to spasticity. The present study aimed to determine if serial casting after BTX-A injection could help to limit the development of calf contracture in chronic hemiplegic patients. Method: The records of patients with stroke that were treated in the brain injury rehabilitation clinic between January 2007 and December 2008 were screened. In all, 10 patients that underwent a serial casting programme for 24 days following BTX-A injection were included in the study. Goniometric scores for ankle ROM, Physician Rating Scale (PRS) and Functional Independence Measurement (FIM) scores were recorded. Results: Mean age of the patients was 33.2 years. Mean time interval after stroke onset was 35.0 months. Improvements in ROM were quite significant after serial casting. Moreover, FIM and PRS scores improved significantly. Conclusion: Serial casting may be an appropriate intervention following BTX-A injection to prevent equinovarus deformity and improve the quality of walking in chronic stroke patients. The role of casting and splinting are important topics that require further research.

Muscle Strength and Bone Mineral Density in Mine Victims with Transtibial Amputation

The aims of this study were to: (i) Determine if there were significant bone mineral density and muscle strength differences between intact and amputated limbs, and (ii) investigate the possible relationship between local bone loss and muscle strength in transtibial amputees. Fifteen male veterans with traumatic unilateral transtibial amputations who ranged in age from 18–45 years were included in this prospective study. Lower limb muscle strength was measured with an isokinetic dynamometer. Dual energy X-ray absorptiometry was used to determine bone mineral density of the femur and tibia. The bone mineral density values of the femur and tibia were found significantly decreased on the amputated side. Significant decreases (p < 0.001) in strength of the quadriceps and hamstrings were observed in the amputated limb. There was a weak correlation between quadriceps strength and total femur bone mineral density (p = 0.048, r = 0.518) on the amputated limb. Transtibial amputees are prone to bone mineral loss and muscle strength decrease on the amputated side. Our results also indicate that muscle strength itself might not be of decisive importance for bone mass in transtibial amputees.

The relationship between prosthesis use, phantom pain and psychiatric symptoms in male traumatic limb amputees

OBJECTIVES The purpose of this study was to identify psychiatric symptoms by comparing male patients with traumatic leg amputations (LAs) with healthy controls and to determine the association between these psychiatric symptoms and phantom pain and prosthesis use characteristics. METHODS One hundred four volunteers, 51 LA patients (group 1) and 53 healthy controls (group 2) were included. Demographic data including age, height, weight, time since amputation, duration of prosthesis use, and Satisfaction with Prosthesis Questionnaire scores were recorded. Phantom pain was measured a visual analog scale (VAS). Psychiatric symptoms were measured using the Symptom Checklist-90-R, Beck Depression Inventory, Pittsburgh Sleep Quality Index, Rosenberg Self-Esteem Scale, and State-Trait Anxiety Inventory. Correlations were determined between time since amputation, duration of prosthesis use and satisfaction with prosthesis questionnaire scores and psychiatric scale scores. RESULTS Amputee patients had higher phobic anxiety, state anxiety, trait anxiety and sleep disturbance scores (p<0.05) than the controls. No difference was determined in terms of psychiatric symptoms between the phantom pain and no phantom pain groups (p>0.05). There were significant negative correlations between time since amputation, duration of prosthesis use, duration of daily prosthesis use, and satisfaction with prosthesis questionnaire scores and psychiatric symptoms. CONCLUSIONS Apart from anxiety (state, trait or phobic) and disturbed sleep, other psychiatric symptoms in amputee patients undergoing lengthy prosthetic rehabilitation may not differ from those of healthy controls. The presence and severity of phantom pain appear to be unrelated to general psychiatric symptomatology. Length of time since amputation, length of prosthesis use, daily length of prosthesis use and prosthesis satisfaction are negatively correlated with general psychiatric symptoms. These characteristics must be borne in mind in psychiatric and prosthetic rehabilitation.

Evaluation of the patellar tendon in transtibial amputees: A preliminary sonographic study

This study aimed to provide sonographic imaging of the patellar tendon (PT) – one of the main weight bearing structures for prosthetic use – in transtibial amputees. Thirteen males, who had been under follow-up for unilateral traumatic transtibial amputations, were enrolled. After physical examination of the limb, pain was evaluated by visual analogue scale and Leeds Assessment of Neuropathic Symptoms and Signs. Sonographic evaluations were performed by using a linear array probe (Aloka UST-5524-7.5 MHz) on both sides. Measurements pertaining to the contralateral limbs were taken as controls. In three subjects (23.1%), two with a silicone liner and one with a pelite liner, cortical irregularities were detected at the tibial insertion of the PT on the amputated sides. PTs were found to be thicker on the amputated sides when compared with those of the contralateral sides (p = 0.03), and this increase in thickness correlated with disease duration (r = 0.67, p = 0.01). Overall, our preliminary results imply that after transtibial amputation, PTs of the amputated sides tend to become thicker by time. These findings need to be complemented with future studies. In this regard, sonography seems to be promising for imaging the soft tissue problems of the stump.

Autonomic dysreflexia as a complication of a fecal management system in a man with tetraplegia.

Abstract Background/Objective: To present a case of autonomic dysreflexia caused by the use of a fecal management system in a patient with tetraplegia. Design: Case report. Setting: Military rehabilitation center. Results: A man with tetraplegia had a fecal management system inserted to divert stool away from his sacral pressure ulcer to reduce contamination and infection risk. Two days later, he developed severe autonomic dysreflexia that improved after removal of the system. Conclusions: Autonomic dysreflexia, a life-threatening complication, has not been reported before as a side effect of a fecal management system. These systems should be used with caution in patients with highlevel spinal cord injury.

Quality of Life in Patients with Lower Limb Amputation: Does It Affect Post-amputation Pain, Functional Status, Emotional Status and Perception of Body Image?

Abstract Objective: Comparison of quality of life [QOL] and emotional status in male patients with traumatic lower limb amputation [LLA] and controls and evaluation of the relationship between these outcomes and post-amputation pain, functional status and perception of body image. Methods: Thirty male patients aged between 20 and 45 years, with traumatic LLA and 30 healthy normal controls were enrolled. The Nottingham Health Profile [NHP], Beck Depression Inventory [BDI], Beck Anxiety Inventory [BAI], visual analog scale [VAS], Locomotor Capabilities Index [LCI] and Amputee Body Image Scale [ABIS] were used. Results: There were significantly higher NHP, BDI and BAI scores in patients with LLA than control subjects [p < 0.05]. In patients with LLA, all subgroups of NHP were positively correlated with BDI, BAI and ABIS scores [p < 0.05]. The NHP energy and physical disability subgroups scores were negatively correlated with LCI scores. The positive correlation was found between the NHP pain subgroup score and post-amputation pain VAS score [p < 0.05]. There was no correlation between NHP scores and age and time since amputation [p > 0.05]. The positive correlation was found between BDI, BAI and ABIS score [p < 0.05]. Conclusion: It was found that QOL and emotional status deteriorated in male patients with LLA. According to the results of this study, depression, anxiety and body image disturbances may be the determinants of QOL. Having lower functional status were higher post-amputation pain were associated with the poor QOL for some domain. Emotional status of LLA patients may be linked to perception of body image.