Serdar Kesikburun

Platelet-Rich Plasma Injections in the Treatment of Chronic Rotator Cuff Tendinopathy A Randomized Controlled Trial With 1-Year Follow-up

Background: Rotator cuff tendinopathy (RCT) is a significant source of disability and loss of work. Platelet-rich plasma (PRP) has been suggested to be beneficial in the treatment of RCT. Purpose: To investigate the effect of PRP injections on pain and shoulder functions in patients with chronic RCT. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 40 patients, 18 to 70 years of age, with (1) a history of shoulder pain for >3 months during overhead-throwing activities, (2) MRI findings of RCT or partial tendon ruptures, and (3) a minimum 50% reduction in shoulder pain with subacromial injections of an anesthetic were included in this placebo-controlled, double-blind randomized clinical trial. Patients were randomized into a PRP group (n = 20) or placebo group (n = 20). Patients received an ultrasound-guided injection into the subacromial space that contained either 5 mL of PRP prepared from autologous venous blood or 5 mL of saline solution. All patients underwent a 6-week standard exercise program. Outcome measures (Western Ontario Rotator Cuff Index [WORC], Shoulder Pain and Disability Index [SPADI], 100-mm visual analog scale [VAS] of shoulder pain with the Neer test, and shoulder range of motion) were assessed at baseline and at 3, 6, 12, and 24 weeks and 1 year after injection. Results: Comparison of the patients revealed no significant difference between the groups in WORC, SPADI, and VAS scores at 1-year follow-up (P = .174, P = .314, and P = .904, respectively). Similar results were found at other assessment points. Within each group, the WORC, SPADI, and VAS scores showed significant improvements compared with baseline at all time points (P < .001). In the range of motion measures, there were no significant group × time interactions. Conclusion: At 1-year follow-up, a PRP injection was found to be no more effective in improving quality of life, pain, disability, and shoulder range of motion than placebo in patients with chronic RCT who were treated with an exercise program.

The effect of repetitive transcranial magnetic stimulation on refractory neuropathic pain in spinal cord injury.

Abstract Objective To investigate the analgesic effect of repetitive transcranial magnetic stimulation (rTMS) on intractable neuropathic pain in patients with spinal cord injury (SCI). Design A single center, prospective, randomized, double-blinded, controlled study. Setting SCI rehabilitation unit of university rehabilitation center. Participants Seventeen patients with SCI and chronic neuropathic pain who met the inclusion criteria recruited between April 2010 and January 2012. Interventions Ten daily treatment sessions of real or sham rTMS (30 trains of 10-Hz stimuli for a duration of 5 seconds; a total of 1500 pulses at intensity equal to 110% of the resting motor threshold) was applied over vertex using a figure-of-8-shaped coil. Outcome measures Pain was assessed with visual analog scale (VAS) at baseline and 10 days, 6 weeks and 6 months after the treatment. Patients’ satisfactions obtained using a 5-point Likert scale at 6 months. Results Both real and sham rTMS provided a significant reduction in the VAS scores (real rTMS group, P = 0.004; sham rTMS group, P = 0.020). Post hoc analysis revealed the significant difference was at 10 days and 6 weeks compared to baseline in the real rTMS group and only at 10 days compared to baseline in the sham rTMS group. Comparison of VAS scores and patient satisfaction did not show any significant difference at each assessment point (P > 0.05). Conclusion Our results demonstrated analgesic effect of rTMS on intractable neuropathic pain in SCI was not superior to placebo. However, middle-term (over 6 weeks) pain relief by rTMS is encouraging and suggests the need for future studies with a larger sample size.

Musculoskeletal Sonography in Physical and Rehabilitation Medicine: Results of the First Worldwide Survey Study

OBJECTIVES To explore the current status of musculoskeletal ultrasound (MSUS) in the realm of physical medicine and rehabilitation (PMR), and to determine the effects of a 1-day MSUS course on the awareness of physiatrists. DESIGN Survey. SETTING International Society of Physical and Rehabilitation Medicine Congress, 2009, Istanbul. PARTICIPANTS Physiatrists attending the congress (n=276) and the MSUS course (n=30). INTERVENTION Not applicable. MAIN OUTCOME MEASURES The survey contained 17 multiple-choice and open-ended questions concerning personal background, perceptions regarding MSUS, and current use of MSUS. Additionally, a group of physicians who attended the 1-day MSUS course before the congress were evaluated twice (before and after the course) to assess the change in their awareness. RESULTS Data from 306 physiatrists (with a mean experience of 10.5+/-8.1 y in the field of PMR) were evaluated. Among the participants, 57.8% were using MSUS in their diagnostic algorithms, 90.4% were thinking that physiatrists should perform sonography themselves, and 75.1% declared that they would perform sonography if they had a device. The ratio of subjects who rated MSUS to be essential for their clinical practice increased from 35.7% to 58.6% after the MSUS course (P>.05). CONCLUSIONS Physiatrists strongly believe that they should perform MSUS themselves, lack of education and lack of device seem to be important issues to be addressed, and even a 1-day course significantly changes awareness of MSUS.

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.

Assessment of Spasticity With Sonoelastography Following Stroke: A Feasibility Study

To investigate the feasibility of sonoelastography to show muscle stiffness in poststroke spasticity, as well as the relationship between sonoelastography findings and muscle architecture features and clinical spasticity scores in the spastic gastrocnemius.

Botulinum toxin injection for bruxism associated with brain injury: case report.

Bruxism is involuntary grinding of the teeth and can occur as a complication of brain injury. If untreated, bruxism can lead to severe occlusal trauma. Herein, we present a patient with traumatic brain injury and nocturnal bruxism that was treated with botulinum toxin injection. A 21 yr old male patient with traumatic brain injury from a car accident was admitted to our inpatient rehabilitation unit. He had a history of coma for 2 wk in the intensive care unit. The initial cranial computed tomography scan indicated a superior thalamic hemorrhage. On admission to our department 3 mo postinjury, his mental status was good and he was able to walk without assistance, but he had mild ataxia. He complained about severe teeth grinding at night, which began 2 mo postinjury. Botulinum toxin-A was injected into the masseter muscles (20 U in each muscle) and temporalis muscles (15 U in each muscle) bilaterally. A decrease in bruxism was reported within 3 d. Clinical improvement persisted at assessment 4 mo posttreatment. Botulinum toxin injection can be used as an effective treatment for bruxism associated with brain injury.

Ultrasound-guided steroid injection in the treatment of stump neuroma: Pilot study

BACKGROUND Stump neuroma is a major cause of postamputation pain. Ultrasound is a practical way of imaging stump neuromas and can be employed for guiding therapeutic injections. OBJECTIVE The aim of this pilot study was to investigate the effectiveness of ultrasound-guided steroid injection in the treatment of stump neuroma. METHODS The amputee patients with stump neuroma who underwent a single ultrasound guided steroid injection in amputee rehabilitation unit of our hospital were reviewed. The pain logs employing a 11-point pain scale for each evaluation time (before the procedure, one day, one week, 2 weeks, 4 weeks, 6 weeks after procedure) and a subsequent phone call approximately six months after procedure were used as the source of information in the study. Mean changes in pain levels (pain in rest and pain with prosthesis) over time were evaluated. The patients that had 50% decrease in pain scores were regarded as having treated successfully. Time after amputation and duration of pain symptom were compared between successfully (Group A) and unsuccessfully (Group B) treated patients. RESULTS All patients (mean age, 29.7 ± 5.5 year) in the study were male (n=14). 12 patients were transtibial amputee (85.7%) and 2 patients were transfemoral amputee (14.3%). Both mean pain scores improved significantly in repeated measures (pain in rest F=25.35, p< 0.01; pain with prosthesis F=81,45, p <0,01). A total of 7 patients (50%) were regarded as having treated successfully. Time after amputation and duration of pain symptom were significantly longer in Group B. (p< 0.05, Group A: 16.8 ± 14.3 months after amputation, 3.5 ± 4.1 months pain duration; Group B: 80.2 ± 74.2 months after amputation, 52.8 ± 57.6 months pain duration). CONCLUSIONS Steroid injection may have positive effect in the treatment of postamputation neuroma. The patients with shorter pain and amputation duration may respond well to the injection.

Severe heterotopic ossification in the non-affected limbs of a hemiplegic patient with traumatic brain injury

Background/objective: Heterotopic ossification characterized by new bone formation in the periarticular regions of large joints in patients with neurologic injury most commonly occurs on the neurologically involved side. This study presents a very rare localization of heterotopic ossification that developed in the non-paretic limbs of a hemiplegic patient with traumatic brain injury (TBI). Case report: A 25-year-old left hemiplegic male with TBI due to a gunshot wound was admitted to the rehabilitation centre after a 2.5-month period of coma in the intensive care unit. He had limited range of motion accompanied by pain in the bilateral hip, bilateral elbow and right knee joints. Neurological examination revealed upper motor neuron lesions only on the left side in neurological exam. Plain radiographs of the involved joints revealed bilateral heterotopic ossification, which was more severe on the non-paretic side. Discussion: Clinicians should keep in mind that heterotopic ossification can occur in non-hemiplegic extremities as well as hemiplegic extremities in patients with TBI in whom the extent of neurologic damage cannot be definitely established.

Comparison of Intact Knee Cartilage Thickness in Patients with Traumatic Lower Extremity Amputation and Nonimpaired Individuals.

ObjectiveThe aim of this study was to assess the femoral articular cartilage thickness of the intact knee in patients with traumatic lower extremity amputation compared with nonimpaired individuals. DesignA total of 30 male patients with traumatic lower extremity amputation (mean [SD] age, 31.2 [6.3] yrs) and a random sample of 53 age-matched and body mass index–matched male nonimpaired individuals (mean [SD] age, 29.8 [6.3] yrs) participated in the study. Exclusion criteria were age younger than 18 yrs, history of significant knee injury, previous knee surgery, or rheumatic disease. The femoral articular cartilage thickness was measured using ultrasound at the midpoints of the medial condyle, the intercondylar notch, and the lateral condyle. Ultrasonographic cartilage measurement was performed on the intact side of the patients with amputation and on both sides of the nonimpaired individuals. ResultsThe femoral articular cartilage thickness of the intact knees of the patients with amputation was significantly decreased at the lateral and medial condyles compared with the nonimpaired individuals (P < 0.05). There was no significant difference in the measurements at the intercondylar notch between the patients with amputation and the nonimpaired individuals (P > 0.05). ConclusionsThere was a premature cartilage loss in the intact limb knee of the patients with traumatic amputation. This result supports the view that patients with traumatic lower extremity amputation are at increased risk for developing knee osteoarthritis in the intact limb.

Knee pain relief with genicular nerve blockage in two brain injured patients with heterotopic ossification.

Abstract Background: Heterotopic ossification (HO) is the ectopic bone formation in non-osseous tissues. This study aimed to present two patients with traumatic brain injury (TBI) who had HO in knee joint and pain relief after genicular nerve blockage. Case 1: A 14-year-old patient with TBI was admitted with bilateral knee pain and limited range of motion. Physical examination and x-ray graphics revealed calcification which was diagnosed as HO. Ultrasonography (US) guided genicular nerve blockage was performed to both knees with 2 ml lidocaine and 1 ml betamethasone. VAS of pain was decreased to 30 mm from 80 mm. At 6-month follow-up, VAS of pain was still 30 mm. Case 2: A 29-year-old patient with TBI was admitted for rehabilitation. He had right knee pain and his pain was 80 mm according to VAS. Investigation revealed HO. US guided genicular nerve blockage was performed to the right knee and pain was decreased to 20 mm. Discussion: US guided genicular nerve blockage can provide pain relief in HO and this technique may be effective and alternative for pain relief in patients with neurogenic knee HO to increase patient’s compliance.