Necmettin Yildiz

Efficacy of exercise and ultrasound in patients with lumbar spinal stenosis: a prospective randomized controlled trial:

Objective: To assess the effectiveness of therapeutic exercises alone and in combination with a single physical agent — ultrasound — in patients with lumbar spinal stenosis. Design: Randomized, prospective, controlled trial. Setting: Department of Physical Medicine and Rehabilitation, University Hospital. Subjects: Forty-five patients presenting with symptoms of neurological claudication and magnetic resonance image-proven lumbar spinal stenosis were assigned to one of three groups: ultrasound plus exercise group (group 1, n =15), sham ultrasound plus exercise group (group 2, n= 15) and no exercise — no treatment group (control group, n = 15). Interventions: Stretching and strengthening exercises for lumbar, abdominal, leg muscles as well as low-intensity cycling exercises were given as therapeutic exercises. Ultrasound was applied with 1 mHz, 1.5 W/cm2 intensity, in continuous mode on the back muscle for 10 minutes in group 1 while ultrasound on/off mode was applied in group 2. Main outcome measures: Before and after a three-week period, all subjects were evaluated by pain, disability, functional capacity and consumption of analgesic. Results: Thirty-two of the participants were women and 13 were men, with an average age of 53.2 ± 12.68 years (range 25—82 years). After a three-week treatment period, leg pain decreased in group 1 (—1.47 ± 3.02) and group 2 (—2.47 ± 3.75) compared with the control group (P<0.05). Disability score decreased in group 1 (—3.94 ± 7.20) and group 2 (—7.80 ± 10.26) compared with control group (P<0.05). We did not find any statistically significant difference between groups 1 and 2 (P>0.05). The amount of analgesic consumption is significantly less in the group with ultrasound application compared to that in the control group (P<0.05). Conclusion: The results of our study suggest that therapeutic exercises are effective for pain and disability in patients with lumbar spinal stenosis and that addition of ultrasound to exercise therapy lowers the analgesic intake substantially.

Comparing the efficacy of mature mud pack and hot pack treatments for knee osteoarthritis

OBJECTIVE The objective of this study is to compare the efficacy of mature mud pack and hot pack therapies on patients with knee osteoarthritis. DESIGN This study was designed as a prospective, randomized-controlled, and single-blinded clinical trial. Twenty-seven patients with clinical and radiologic evidence of knee osteoarthritis were randomly assigned into two groups and were treated with mature mud packs (n 15) or hot packs (n=12). Patients were evaluated for pain [based on the visual analog scale (VAS)], function (WOMAC, 6 min walking distance), quality of life [Short Form-36 (SF-36)], and serum levels of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and insulin-like growth factor-1 (IGF-1) at baseline, post-treatment, and 3 and 6~months after treatment. RESULTS The mud pack group shows a significant improvement in VAS, pain, stifness, and physical function domains of WOMAC. The difference between groups of pain and physical activity domains is significant at post-treatment in favor of mud pack. For a 6 min walking distance, mud pack shows significant improvement, and the difference is significant between groups in favor of mud pack at post-treatment and 3 and 6 months after treatment. Mud pack shows significant improvement in the pain subscale of SF-36 at the third month continuing until the sixth month after the treatment. Significant improvements are found for the social function, vitality/energy, physical role disability, and general health subscales of SF-36 in favor of the mud pack compared with the hot pack group at post-treatment. A significant increase is detected for IGF-1 in the mud pack group 3 months after treatment compared with the baseline, and the difference is significant between groups 3 months after the treatment. CONCLUSION Mud pack is a favorable option compared with hotpack for pain relief and for the improvement of functional conditions in treating patients with knee osteoarthritis.

Effects of different bladder management methods on the quality of life in patients with traumatic spinal cord injury.

Study design:Multi-center, cross-sectional study.Objectives:To investigate the effects of different bladder management methods on the quality of life (QoL) in patients with spinal cord injury (SCI).Setting:Turkey.Methods:Consecutive SCI patients (n=195, 74.4% males), for whom at least 6 months had elapsed since the injury, were included and evaluated in five groups: normal spontaneous micturition (NSM), micturition with assisted maneuvers (MAM), aseptic intermittent catheterization by patient (IC-P), aseptic IC by an attendant/caregiver (IC-A) and indwelling catheterization. The King’s Health Questionnaire was used to evaluate the patients’ QoL.Results:The bladder management groups were similar regarding age, time elapsed since injury, education level, marital and occupational status. There was no difference among the groups in general health perception, personal relationships and sleep/energy domain scores. While the NSM group had generally the lowest scores, that is, better QoL, the IC-A group had the highest scores, that is, poorer QoL, in most of the domains. When the patients were grouped according to the frequency of urinary incontinence or American Spinal Injury Association Impairment Scale grades, no difference was found in the domain scores of the groups except the symptom severity domain scores. No significant difference was found between paraplegic and tetraplegic patients in the King’s Health Questionnaire domains.Conclusion:The QoL was notably affected in SCI patients in IC-A group and negative effects on emotional status, physical and social activity limitations were observed, as well.

Comparison of ultrasound and ketoprofen phonophoresis in the treatment of carpal tunnel syndrome.

OBJECTIVE The aim of this study was to compare the efficacy of ultrasound (US) and ketoprofen phonophoresis (PH) in the treatment of carpal tunnel syndrome (CTS). DESIGN This study was a prospective, randomised, controlled, double-blinded clinical trial with follow-up at 8 weeks. Fiftyone patients (76 median nerves) with clinical and electrophysiologic evidence of mild or moderate CTS were included in the study. They were randomly assigned to one of three groups; group 1 received sham US and splinting, group 2 received US and splinting, and group 3 received ketoprofen phonophoresis and splinting. Patients were evaluated by use of electrophysiological variables such as median motor distal latency (mMDL), median sensory distal latency (mSDL), functional status scale (FSS), symptom severity scale (SSS) and visual analog scale (VAS). Electrophysiological variables and scales were evaluated at the beginning, end of therapy (2nd week) and 8th week. RESULTS All the randomised patients were included in the intention-to-treat (ITT) analysis. The per protocol (PP) analysis included only those patients who complied with the study protocol. After completing 2 weeks of treatment, seven out of 51 randomized patients did not finish the study protocol due to non-compliance to splinting, illness and lost to follow-up. Those patients were excluded from PP analysis. Participants were similar in all clinical, electrophysiological and demographic respects (p>0.05). An improvement was found in all parameters (VAS, FSS, SSS, mMDL and mSDL) for all groups at the end of the treatment and 8th week. It was found that pain score was significantly lower in group 3 compared to other treatment groups at 8th week according to ITT and PP analysis (p= 0.002, p=0.004 and p=0.001, p=0.001). CONCLUSION Ketoprofen PH as adjuvant therapy on splinting is effective with respect to reduction of pain. Adding US therapy to the splinting is not superior to the splinting alone in patients with CTS.

Neurogenic bladder in patients with traumatic spinal cord injury: treatment and follow-up

Study design:Multi-center, cross-sectional study.Objectives:Our aim was to evaluate the treatment methods and follow-up of neurogenic bladder in patients with traumatic spinal cord injury retrospectively using a questionnaire.Setting:Turkey.Methods:Three hundred and thirty-seven patients who had spinal cord injury for at least 2 years were enrolled from six centers in the neurogenic bladder study group. They were asked to fill-out a questionnaire about treatments they received and techniques they used for bladder management.Results:The study included 246 male and 91 female patients with a mean age of 42±14 years. Intermittent catheterization (IC) was performed in 77.9% of the patients, 3.8% had indwelling catheters, 13.8% had normal spontaneous micturition, 2.6% performed voiding maneuvers, 1.3% used diapers and 0.6% used condom catheters. No gender difference was found regarding the techniques used in bladder rehabilitation (P>0.05). Overall, 63.2% of patients used anticholinergic drugs; anticholinergic drug use was similar between genders (P>0.05). The most common anticholinergic drug used was oxybutynin (40.3%), followed by trospium (32.6%), tolterodine (19.3%) darifenacin (3.3%), propiverine (3.3%) and solifenacin (1.1%). The specialties of the physicians who first prescribed the anticholinergic drug were physiatrists (76.2%), urologists (22.1%) and neurologists (1.7%). Only four patients had previously received injections of botulinum-toxin-A into the detrusor muscle and three of them stated that their symptoms showed improvement. Most of the patients (77%) had regular follow-up examinations, including urine cultures, urinary system ultrasound and urodynamic tests, when necessary; the reasons for not having regular control visits were living distant from hospital (15.3%) and monetary problems (7.7%). Of the patients, 42.7% did not experience urinary tract infections (UTI), 36.4% had bacteriuria but no UTI episodes with fever, 15.9% had 1-2 clinical UTI episodes per year and 5% had ⩾3 clinical UTIs. The clinical characteristics of patients with and without UTI (at least one symptomatic UTI during 1 year) were similar (P>0.05). The frequency of symptomatic UTI was similar in patients using different bladder management techniques (P>0.05).Conclusion:The most frequently used technique for bladder rehabilitation in patients with SCI was IC (77.9%). In all, 63.2% of patients used anticholinergic drugs, oxybutynin being the most commonly used drug. Also, 77% of patients had regular control visits for neurogenic bladder; 42.7% did not experience any UTIs.

Pellegrini-Stieda disease in traumatic brain injury rehabilitation.

Pellegrini–Stieda disease (PSD) is posttraumatic ossification of the proximal attachment of the medial collateral ligament of the knee, diagnosed by radiography. Antecedent traumas include direct and indirect injury to the medial side of the knee. Repeated microtraumas, including therapeutic manipulation of a stiff joint and postsurgical rehabilitation, have also been reported. Because PSD is rarely diagnosed in neurologic rehabilitation patients, only one case of spinal cord injury having this disease was reported. We describe a traumatic brain injury patient with clinical and radiologic findings of PSD. Our aim in this report is to show that this entity can be seen in neurological rehabilitation patients during the course of exercise treatment and must be taken into account in differential diagnosis of knee pain, swelling, and range-of-motion limitation. A 22-yr-old man, with contusion lesions determined by cranial computerized tomography secondary to a motorcycle accident, attended our clinic for rehabilitation. The patient had a history of 3 mos of hospitalization in the intensive care unit and anesthesia clinic in another hospital for multiple traumas. The patient did not describe any known injury or trauma to the knee in the motorcycle accident. On examination, the patient was found to have rangeof-motion limitation with swelling and complaint of pain in his left knee. The patient had no history of systemic diseases such as gout, rheumatoid arthritis, systemic sclerosis, sarcoidosis, or hyperparathyroidism. On physical examination, the left knee was limited at 60 degrees of flexion, extension was at a normal range, and the knee joint was stable. Serum calcium, phosphate, and alkaline phosphatase levels were within normal ranges. The plain radiographs demonstrated a characteristic bony formation, calcification medial to the femoral condyle (Fig. 1). Because of the characteristic radiographic findings and the clinical course, the diagnosis of PSD was considered. PSD manifests radiographically, with ossification arising from the epicondylar portion of the medial femoral condyle. In the etiology of neurogenic ectopic bone formation, humoral, neural, and local factors, including tissue hypoxia, hypercalcemia, changes in sympathetic nerve activity, prolonged immobilization, and mobilization with frequent periods of exercising after prolonged immobilization, play a role. In traumatic brain injury patients, neurogenic heterotopic ossification can result in accelerated fracture healing. Reduced collagen degradation in polytraumas with traumatic brain injury causes enhanced osteogenesis. Radiographically, the ossification is seen as a thin crescent or curvilinear line of a few millimeters from the femoral condyle. This feature is crucial for ruling out other lesions including fracture of the femoral condyle, periostitis, and osteoma. In conclusion, PSD can be seen in neurologic rehabilitation patients during the course of exercise treatment, and it must be taken into account in the differential diagnosis of knee pain, swelling, and range-of-motion limitation.

Intermittent catheterization in patients with traumatic spinal cord injury: obstacles, worries, level of satisfaction

Objectives:The aim of this study is to examine the obstacles in people with traumatic spinal cord injury (SCI) face performing intermittent catheterization (IC), also their worries and level of satisfaction.Methods:Two hundred sixty-nine patients performing IC for at least 3 months were asked to fill-out a questionnaire about their opinions on IC.Results:In total, 69.5% of patients performed IC themselves, 10.4% had performed by their mothers, 7.8% by another caregiver and 7.4% by their spouse. For the 72 (26%) patients unable to apply IC, reasons were insufficient hand function (56.1%), being unable to sit appropriately (35.4%) and spasticity (8.5%). In all, 70% of male patients had insufficient hand function, 20% could not sit and 10% had spasticity while 56.3% of female patients could not sit, 37.5% had insufficient hand function and 63% had spasticity. Difference between sexes was found to be statistically significant (P<0.05). Worries patients had when starting IC were fear of being dependent on IC (50.2%), accidentally injuring self (43.8%), embarrassment (43.2%), causing an infection (40.2%), bleeding (32.7%), fear of feeling pain (30.2%) and hygiene (24.7%). More women felt embarrassment; other items were similar in both sexes. In all, 46.9% of patients had urinary incontinence in intervals.Conclusion:In total, 69.5% of patients performed IC themselves. Men’s most common obstacle was insufficient hand function while women’s was being unable to sit appropriately. Patients’ most common worries were being dependent on IC for life. In all, 46.9% had incontinence in intervals; 47.9% said IC improved their life quality; and 97.4% preferred IC over continuous catheterization.

A rare cause of forearm pain: anterior branch of the medial antebrachial cutaneous nerve injury: a case report

Introduction Medial antebrachial cutaneous nerve (MACN) neuropathy is reported to be caused by iatrogenic reasons. Although the cases describing the posterior branch of MACN neuropathy are abundant, only one case caused by lipoma has been found to describe the anterior branch of MACN neuropathy in the literature. As for the reason for the forearm pain, we report the only case describing isolated anterior branch of MACN neuropathy which has developed due to repeated minor trauma. Case presentation We report a 37-year-old woman patient with pain in her medial forearm and elbow following the shaking of a rug. Pain and symptoms of dysestesia in the distribution of the right MACN were found. Electrophysiological examination confirmed the normality of the main nerve trunks of the right upper limb and demonstrated abnormalities of the right MACN when compared with the left side. Sensory action potential (SAP) amplitude on the right anterior branch of the MACN was detected to be lower in proportion to the left. In the light of these findings, NSAI drug and physical therapy was performed. Dysestesia and pain were relieved and no recurrence was observed after a follow-up of 14 months. Conclusion MACN neuropathy should be taken into account for the differential diagnosis of the patients with complaints of pain and dysestesia in medial forearm and anteromedial aspect of the elbow.

The effects of repeated filling cystometries on cystometric variables in spinal cord-injured patients with overactive detrusor, who utilize different type of urine drainage methods.

Study design:Cross-sectional study.Objectives:Our aim was to compare the effects of repeated cystometric measurements in spinal cord injury (SCI) patients with neurogenic detrusor overactivity (NDO) who use indwelling catheters (IDC) or intermittent catheterization (IC).Setting:Turkey.Methods:A total of 20 SCI patients with NDO, 9 patients on IC and 11 on IDC for at least two consecutive months were included. After emptying the bladder, first involuntary detrusor contraction volume (1stIDCV), cystometric bladder capacity (CC), bladder compliance and maximum detrusor pressure (MPdet) were assessed by filling it with sterile physiological saline at room temperature at a continuous rate of 30 ml min−1. The bladder was re-emptied after the process and a second filling cystometry was performed in the same way.Results:When all study population were taken into account, 1stIDCV and CC measures were significantly increased in the second cystometry compared with the first cystometry (P=0.001 and P=0.022, respectively), whereas there was no statistically significant difference on bladder compliance and MPdet measures between the first and the repeated cystometry. There was no statistically significant difference on 1stIDCV, CC and bladder compliance measures between the first and the repeated cystometries for IC group, whereas there was statistically significant increase on these measures in the IDC group (P=0.003, P=0.008 and P=0.022, respectively). In addition there was no statistically significant difference on MPdet measures between the first and the repeated cystometries for both the urine drainage methods. When IC and IDC groups were compared according to mean values of differences in 1stIDCV, CC and bladder compliance measures between the two cystometries, the IDC group had a statistically significant increase in all parameters when compared with the IC group in the second cystometry performed (P=0.001, P=0.003 and P=0.048, respectively).Conclusion:Repeated cystometric measurements in SCI patients with NDO lead to an increase in 1stIDCV and CC. However, when the type of urine drainage method is taken into account, although repeated filling cystometry leads to an increase in 1stIDCV, MCC and bladder compliance in patients with IDC, it does not cause a difference in patients on IC.

Efficacy of low level laser therapy and intramuscular electrical stimulation on myofascial pain syndrome.

BACKGROUND Myofascial pain syndrome (MPS) which is an important cause of musculoskeletal pain has shown a dramatic increase in recent years. OBJECTIVES We aimed to evaluate the efficacy of intramuscular electrical stimulation therapy (IMS) and low-level-lasertherapy (LLLT) in patients with MPS. METHODS Patients were randomly divided into three groups. First group were treated with LLLT and stretching exercise. Second group were treated with IMS and stretching exercise. Third group were treated with only stretching exercise. The patients were evaluated through the pain intensity, pain threshold, cervical joint movement range and the neck disability index parameters. RESULTS An improvement was found in all parameters for all groups, except for the pain threshold within the control group at the end of the treatment and one month after the treatment. It was found that pain score was significantly lower in Group 1 and 2 at one month after the treatment compared to Group 3. Similarly, it was found that pain threshold score was significantly higher in Group 2 at one month after the treatment compared to Group 3. CONCLUSIONS In this study we observed that both LLLT and IMS treatments added on to stretching are effective in improving pain parameters in patients with MPS.