Neşe Özgirgin

Sentence comprehension in Turkish Broca's aphasia: An integration problem

Background: Comprehension of semantically reversible sentences is often impaired in Brocas aphasia. When the arguments in such sentences are in derived order, they are more difficult to comprehend than when they are not. Most studies on this topic are of English, a morphologically poor language; only a few experiments have examined sentence comprehension in case-marking languages. These studies tested sentences in which word order was varied while case was kept constant. Their results suggest that case does not improve comprehension of derived order sentences. The present study is on the comprehension of semantically reversible sentences in Turkish Brocas aphasia. Turkish, with its flexible word order and rich case morphology, is well suited to this investigation because there is an interaction between word order and case, which is known to influence sentence production in this aphasia type (Yarbay Duman, Aygen, & Bastiaanse, 2008). Aims: The purpose of this study was to investigate the influence of word order and case information on the auditory comprehension of semantically reversible sentences in Turkish Brocas aphasia to find out whether an interaction between word order and case, similar to the one found in production, can be observed in sentence comprehension. Methods & Procedures: A comprehension test with five reversible sentence types (base order active sentences, sentences with object scrambling, subject relatives, object relatives, and passives) was developed. Sentences in base and derived word order varied in their use of case. Sentences with base case (subject = nominative; object = accusative) and non-base case were included to evaluate the interplay between word order and case separately. Outcomes & Results: The results showed that both word order and case influenced sentence comprehension. Clauses were comprehended best when there was both base (unambiguous) case and base word order information (base order active sentences). Performance dropped if there was base case information but derived word order (object scrambling and subject relatives). When there was neither base case information nor base word order (object relatives and passives), clauses were comprehended least well. Conclusions: The sentence comprehension deficit in Turkish Brocas aphasia is due to a problem in assigning thematic roles to the noun phrases by integrating syntactic word order and case information. Such an integration problem is in line with previous findings on sentence production in Turkish and the Integration Problem Hypothesis (IPH: Yarbay Duman, 2009).

Effects of Mirror Therapy in Stroke Patients With Complex Regional Pain Syndrome Type 1: A Randomized Controlled Study

OBJECTIVE To investigate the effects of mirror therapy on upper limb motor functions, spasticity, and pain intensity in patients with hemiplegia accompanied by complex regional pain syndrome type 1. DESIGN Randomized controlled trial. SETTING Training and research hospital. PARTICIPANTS Adult patients with first-time stroke and simultaneous complex regional pain syndrome type 1 of the upper extremity at the dystrophic stage (N=30). INTERVENTIONS Both groups received a patient-specific conventional stroke rehabilitation program for 4 weeks, 5 d/wk, for 2 to 4 h/d. The mirror therapy group received an additional mirror therapy program for 30 min/d. MAIN OUTCOME MEASURES We evaluated the scores of the Brunnstrom recovery stages of the arm and hand for motor recovery, wrist and hand subsections of the Fugl-Meyer Assessment (FMA) and motor items of the FIM-motor for functional status, Modified Ashworth Scale (MAS) for spasticity, and visual analog scale (VAS) for pain severity. RESULTS After 4 weeks of rehabilitation, both groups had significant improvements in the FIM-motor and VAS scores compared with baseline scores. However, the scores improved more in the mirror therapy group than the control group (P<.001 and P=.03, respectively). Besides, the patients in the mirror therapy arm showed significant improvement in the Brunnstrom recovery stages and FMA scores (P<.05). No significant difference was found for MAS scores. CONCLUSIONS In patients with stroke and simultaneous complex regional pain syndrome type 1, addition of mirror therapy to a conventional stroke rehabilitation program provides more improvement in motor functions of the upper limb and pain perception than conventional therapy without mirror therapy.

Impact of the Training on the Compliance and Persistence of Weekly Bisphosphonate Treatment in Postmenopausal Osteoporosis: A Randomized Controlled Study

Long-term patient adherence to osteoporosis treatment is poor despite proven efficacy. In this study, we aimed to assess the impact of active patient training on treatment compliance and persistence in patients with postmenopausal osteoporosis. In the present national, multicenter, randomized controlled study, postmenopausal osteoporosis patients (45-75 years) who were on weekly bisphosphonate treatment were randomized to active training (AT) and passive training (PT) groups and followed-up by 4 visits after the initial visit at 3 months interval during 12 months of the treatment. Both groups received a bisphosphonate usage guide and osteoporosis training booklets. Additionally, AT group received four phone calls (at 2nd, 5th, 8th, and 11th months) and participated to four interactive social/training meetings held in groups of 10 patients (at 3rd, 6th, 9th, and 12th months). The primary evaluation criteria were self-reported persistence and compliance to the treatment and the secondary evaluation criteria was quality life of the patients assessed by 41-item Quality of Life European Foundation for Osteoporosis (QUALEFFO-41) questionnaire.. Of 448 patients (mean age 62.4±7.7 years), 226 were randomized to AT group and 222 were randomized to PT group. Among the study visits, the most common reason for not receiving treatment regularly was forgetfulness (54.9% for visit 2, 44.3% for visit 3, 51.6% for visit 4, and 43.8% for visit 5), the majority of the patients always used their drugs regularly on recommended days and dosages (63.8% for visit 2, 60.9% for visit 3, 72.1% for visit 4, and 70.8% for visit 5), and most of the patients were highly satisfied with the treatment (63.4% for visit 2, 68.9% for visit 3, 72.4% for visit 4, and 65.2% for visit 5) and wanted to continue to the treatment (96.5% for visit 2, 96.5% for visit 3, 96.9% for visit 4, and 94.4% for visit 5). QUALEFFO scores of the patients in visit 1 significantly improved in visit 5 (37.7±25.4 vs. 34.0±14.6, p<0.001); however, the difference was not significant between AT and PT groups both in visit 1 and visit 5. In conclusion, in addition to active training, passive training provided at the 1st visit did not improve the persistence and compliance of the patients for bisphosphonate treatment.

Blood mean platelet volume and platelet lymphocyte ratio as new predictors of hip osteoarthritis severity.

Abstract Osteoarthritis (OA) is a low grade systemic inflammatory disease in which many inflammatory mediators are known to be elevated in the peripheric blood. Blood platelet lymphocyte ratio (PLR) and mean platelet volume (MPV) are accepted as novel markers in many of the systemic inflammatory disorders, but have not been investigated in synovitis-free radiographic OA yet. The aim of this study was to evaluate the levels of blood PLR and MPV in radiographic hip OA. A total of 880 patients were evaluated retrospectively and after certain exclusion criteria, 237 of them who have primary hip OA were included. Age, sex, height, weight, body mass index, neutrophil, lymphocyte and platelet counts, erythrocyte sedimentation rate (ESR), PLR, and MPV levels were recorded, Kellgren–Lawrence (KL) grading of the hip joints were performed. Patients were then divided into 2 groups as KL grades 1 to 2 (mild–moderate) and KL grades 3 to 4 (severe) hip OA. Mean age, mean neutrophil, lymphocyte and platelet counts, mean MPV, mean PLR, and mean ESR were statistically significantly different between mild/moderate hip OA group and severe hip OA group. In univariate analysis, older age and higher MPV, PLR, and ESR were severely associated with severe hip OA. In multiple logistic regression analysis, MPV, PLR, and ESR emerged as independent predictors of severe hip OA. The results of the present study, for the first time in the literature, suggest blood PLR and MPV as novel inflammatory markers predicting the radiographic severity of hip OA in the daily practice.

Sleep disordered breathing in children with cerebral palsy

OBJECTIVES The purpose of this study was to investigate the frequency of Sleep Disordered Breathing (SDB) in children with Cerebral Palsy (CP), and determine whether a relationship between SDB and age, gender, weight status, type of CP, motor function level, and spasticity can be established. METHODS The study included 94 children with CP and 94 healthy children with normal development, between the ages two and 18. SDB was assessed using the Sleep-Related Breathing Disorder (SRBD) scale of the Pediatric Sleep Questionnaire (PSQ). RESULTS No statistically significant difference was found with respect to age and gender between the study and the control groups. It was found that 9.6% of the patients with CP had snoring, 12.8% had sleepiness, 37.2% had attention deficiency-hyperactivity, and 18.1% had SRBD. SRBD was statistically significantly higher in patients with CP compared with the control group. No significant relationship was detected between SRBD and age, gender, weight status, type of CP, motor function level, spasticity, and epilepsy. CONCLUSIONS Our result confirm that SDB is more common in children with CP than typically developing children. Thus, SDB problems should be identified in routine clinical practice in patients with CP, by using the SRBD scale of the PSQ.

Electrophysiological and clinical evaluation of the effects of transcutaneous electrical nerve stimulation on the spasticity in the hemiplegic stroke patients

To investigate whether transcutaneous electrical nerve stimulation (TENS) mitigates the spasticity of hemiplegic stroke patients, as assessed by electrophysiological variables, and the effects, if any, on the clinical appearance of spasticity. [Subjects and Methods] Twenty-seven subjects who had acute hemiplegia and 24 healthy people as the control group, were enrolled in this study. Some of the acute cerebrovascular disease patients could walk. Subjects who did not have spasticity, who were taking antispasticity medicine, or had a previous episode of cerebrovascular disease were excluded. The walking speed of the patients was recorded before and after TENS. EMG examinations were performed on the healthy controls and in the affected side of the patients. A 30-minute single session of TENS was applied to lower extremity. At 10 minutes after TENS, the EMG examinations were repeated. [Results] A statistically significant decrease in the spasticity variables, and increased walking speed were found post-TENS. The lower M amplitude and higher H reflex amplitude, H/M maximum amplitude ratio, H slope, and H slope/M slope ratio on the spastic side were found to be statistically significant. [Conclusion] TENS application for hemiplegic patients with spastic lower extremities due to cerebrovascular disease resulted in marked improvement in clinical scales of spasticity and significant changes in the electrophysiological variables.

Low bone density in achondroplasia

To the editor, A 39-year-old female achondroplastic patient was admitted to our outpatient clinic for her back and lower extremity pain. Her height and weight were 125 cm and 38 kg, respectively (Fig. 1). She had a body mass index of 24.3 kg/m. She had undergone leg lengthening on bilateral tibias when she was 12. On physical examination, she had bilateral paravertebral muscle spasm at her back. She also had painful hip internal rotation and knee flexion on both sides with bilateral positive Clarke’s sign. Her physical examination was otherwise noncontributory. X-ray examination revealed early degenerative changes, especially at the hip joints and strikingly osteopenia. On detailed questioning, it was understood that she had been advised to receive 300,000 IU vitamin D3 (the form of vitamin D available in our country) once a year and to exercise regularly for low bone density 2 years ago. The past two bone mineral density (BMD) measurements, performed by a single technician using dual-energy X-ray absorptiometry (DEXA) on a Lunar DPX-IQ scanner in our center, were analyzed, and a new BMD measurement was performed under similar conditions with the ones referred above (Table 1, Fig. 2). The laboratory tests was as follows: serum total calcium, 9.3 mg/dl (8.2–10.6); inorganic phosphate, 3.2 mg/dl (2.5–4.5); alkaline phosphatase (ALP), 47 U/l (30–126); type 1 collagen C terminal telopeptide (CTX), 0.253 (25–573); osteocalcin, 3.46 ng/ml (3.1–13.7); parathormone, 34.23 pg/ml (15–65), and vitamin D3, 20.1 ng/ml (>30). Risk factor examination for low bone density yielded no results. Low bone density was considered as a consequence of altered bone metabolism due to achondroplasia. She was prescribed 300,000 IU oral vitamin D3 and recommended to continue on her exercises. She was also included in a physical therapy program for her symptoms due to degenerative changes. Achondroplasia is the most common form of skeletal dysplasias. A spontan or inherited mutation in the fibroblast growth factor receptor 3 (FGFR3) gene on the fourth chromosome brings out the disease [1]. The primary defect is abnormal endochondral ossification [2]. It has a number of wellknown neuromusculoskeletal manifestations [3]. Recently, Arita et al. reported low bone density, diagnosed with spinal BMD analysis and panoramic radiographic measurements, in 5 of 11 achondroplastic patients for the first time in the literature [4]. To the best of our knowledge, our report is the second one referring the relationship between

Sacral Insufficiency Fracture in a Hemiplegic Patient.

A 69-year-old hemiplegic woman was seen due to weakness and hip pain on her right side, and gait difficulty. Medical history revealed hypertension, thrombotic stroke (5 months ago), and pubic ramus fracture. On detailed questioning, she did not declare a fall after stroke. On physical examination, she had extensor spasticity (modified Ashworth Scale 1) and hyperactive deep tendon reflexes in her right lower limb. Brunnstrom’s stages (right side) of upper/lower extremity and hand were 1, 2, and 1, respectively. Hip joint range of motion was painful and limited on the right side. Right side of the sacrum was also painful with palpation. Visual Analog Scale (VAS) pain score was 6, Barthel Index was 10, and Functional Ambulation Classification Scale was 0. Pelvis anteroposterior radiograph and computed tomography (CT) demonstrated symphysis pubis fracture and increased radiolucency (Figure 1). Bone mineral density (BMD) measurements displayed severe osteoporosis; T-scores and BMD values of femur neck and L1-4 vertebra being 3.6 (0.539 g/cm) and 5.3 (0.533 g/cm), respectively. Magnetic resonance imaging (MRI) yielded bone marrow edema and linear sacral insufficiency fracture (SIF) on the right side of the sacrum (Figure 2). Laboratory parameters including complete blood count, erythrocyte sedimentation rate, liver/renal/thyroid function tests, intact parathyroid hormone, prolactin, cortisol, calcium, phosphor, alkaline phosphatase, total protein, and albumin levels were all normal. 25-OH vitamin D level was 7.8 ng/mL (N: 8–60). Following pain control (rest, nonsteroidal anti-inflammatory drug, transcutaneous electrical nerve stimulation), she was early mobilized. As for the osteoporosis treatment, vitamin D was supplemented. Thereafter, intravenous zoledronic acid 100 mL/5 mg/year and oral calcium plus vitamin D 1200 mg-800 IU/day were prescribed. After 2 months of rehabilitation program, Brunnstrom’s stages for the right upper/lower limb and hand were 1, 4, and 1, respectively. Barthel index was 40 and FAC was 2. There was also significant improvement in VAS pain score (2), and she was able to walk with tripod and foot up assistance.

Bilateral quadriceps and triceps tendon rupture in a hemodialysis patient

This paper presented a 58‐year‐old hemodialysis patient who had bilateral quadriceps and triceps tendon rupture, whereby the role of rehabilitation in functional parameters has been highlighted.

Does Vitamin D Affect Muscle Strength and Architecture? An Isokinetic and Ultrasonographic Study

BACKGROUND AND OBJECTIVES The objective of this study was to explore the association between 25- hydroxyvitamin D (25(OH)D) and muscle strength/architecture. METHODS AND STUDY DESIGN Thirty patients (27 women, 3 men) were allocated into Group I (n=15, mean age; 44.4±9.4 years) and Group II (n=15, mean age; 39.0±9.9 years) according to the median of 25(OH)D (<13.7 ng/mL vs >13.7 ng/mL, respectively). Peak torque/body weight of the knee flexor/extensor muscles at 60°/sec and 180°/sec and those of ankle flexor/ extensor muscles at 30°/sec and 90°/sec were evaluated by using a Biodex System 3 Pro Multijoint System isokinetic dynamometer. A 7-12 MHz linear array probe was used to evaluate thickness (MT), pennation angle (PA) and fascicle length (FL) of medial gastrocnemius and vastus lateralis muscles. RESULTS Mean of 25(OH)D was 9.4±2.5 ng/mL and 20.7±8.3 ng/mL in Groups I and II, respectively. Although all isokinetic strength parameters were lower in Group I, significant differences were found in knee flexion at 180°/sec (p=0.007), knee extension at 30°/sec (p=0.038) and 180°/sec (p=0.001), and ankle extension at 30°/sec (p=0.002) and 90°/sec (p=0.007). On the other hand, no significant difference was found between the groups regarding MT, PA and FL values (all p>0.05). CONCLUSION In light of our results, we can argue that 25(OH)D is associated with muscle strength but not with muscle architecture. Further studies concerning the long-term follow-up effects of 25(OH)D treatment on muscle strength are awaited.