Zafer Hasçelik

A Comparison of the Benefits of Sonography and Electrophysiologic Measurements as Predictors of Symptom Severity and Functional Status in Patients With Carpal Tunnel Syndrome

OBJECTIVES To clarify whether sonography or electrophysiologic testing is a better predictor of symptom severity and functional status in carpal tunnel syndrome (CTS) and to assess the diagnostic value of sonography in patients with idiopathic CTS. DESIGN Cross-sectional. SETTING University hospital physical medicine and rehabilitation clinic. PARTICIPANTS Thirty-four hands with CTS and 38 normative hands were evaluated. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The Boston Carpal Tunnel Questionnaire, which comprised symptom severity and functional status scale, was applied to CTS patients. Bilateral upper-extremity nerve conduction studies of median and ulnar nerves and sonographic imaging of the median nerve were performed in all participants. Sonographic evaluation was performed by a physician blinded to the physical and electrophysiologic findings of the subjects. RESULTS Cross-sectional areas (CSAs) of the median nerve at the carpal tunnel entrance and proximal carpal tunnel were 12.5+/-2.6 and 10.6+/-2.6 versus 15.6+/-4.2 and 11.5+/-3.2 in CTS patients versus controls, respectively. Increased CSA of the median nerve at the carpal tunnel entrance (P<.002) and at the proximal carpal tunnel (P<.000) were detected in the hands with CTS. Flattening ratios did not differ in a statistically significant manner between the groups (P>.05). The best predictor of symptom severity was median nerve sensory distal latency and that of functional status was median nerve motor distal latency. The optimum cutoff value for median nerve CSA was 11.2mm(2) at the carpal tunnel entrance and 11.9mm(2) at the proximal carpal tunnel. Sensitivity, specificity, and positive and negative predictive values at the proximal carpal tunnel (88%, 66%, 71%, 80%, respectively) were higher than those at the carpal tunnel entrance (68%, 62%, 65%, 66%, respectively). CONCLUSIONS The best predictors of symptom severity and functional status in idiopathic CTS seem to be the electrophysiologic assessments rather than sonographic measurements. On the other hand, sonography may be helpful in the diagnosis of idiopathic CTS.

Quantification of the weakness and fatigue in thoracic outlet syndrome with isokinetic measurements

Objectives: Patients with thoracic outlet syndrome (TOS) complain of many subjective symptoms that are difficult to measure and quantify. In this study we have tried to assess the weakness (muscle strength) and fatigue (endurance) of these patients with an objective measurement method, isokinetic muscle testing. Methods: Twenty three TOS patients and 15 age matched healthy controls were enrolled in the study. Detailed histories of the patients were taken and the patients underwent complete physical examinations. Cervical radiographies, Doppler ultrasonography, electromyography, and isokinetic measurements were carried out. The isokinetic measurements were carried using the Biodex System 3 dynamometer during concentric shoulder flexions and extensions at velocities of 60°/s, 180°/s, and 240°/s. Results: Although the muscle strengths of both groups seemed to be similar, the fatigue ratios of TOS patients at 60°/s and 180°/s were found to be higher compared with those of healthy controls (p = 0.029, p = 0.007). Conclusions: TOS patients were found to have muscular performance similar to controls, but their upper extremities developed fatigue more easily than those of healthy individuals.

The role of quantitative ultrasound in predicting osteoporosis defined by dual X-ray absorptiometry

Abstract The aim of this study was to establish whether quantitative ultrasound (QUS) parameters could identify patients classified as osteoporotic and osteopenic on the basis of dual energy X-ray absorptiometry (DEXA). One hundred and twenty-three patients (39 male, 84 female) with osteoporosis and suspected of having osteoporosis were included in this study. Broadband ultrasound attenuation (BUA) and speed of sound (SOS) were measured and bone mineral densities (BMD) of the lumbar spine and left hip was measured by DEXA. Subjects were classified into three groups (normal, osteopenic and osteoporotic) on the basis of BMD T-scores measured by DEXA. QUS parameters of the osteoporotic group were significantly lower than those of osteopenic and normal groups; there was no difference in QUS parameters between the normal and osteopenic groups. Correlations of both right and left SOS and BUA with the spine and femoral neck BMD were moderate (r=0.343–0.539, P < 0.001). There was also reasonable correlation between DEXA and QUS T-scores (r=0.364–0.510, P < 0.001). QUS had a sensitivity of 21% and a specificity of 95% for diagnosing osteoporosis. We concluded that, although DEXA and QUS parameters were significantly correlated, QUS parameters can not predict osteopenia as defined by DEXA, and sensitivities and specificities of QUS parameters were not sufficiently high for QUS to be used as an alternative to DEXA.

Urinary neopterin excretion and dihydropteridine reductase activity in rheumatoid arthritis

Abstract Neopterin and biopterin are two products of the pteridine pathway. Even though their roles and interrelationships have not been exactly clarified, neopterin is known as a biomarker of cell-mediated immunity. In this case, the highly elevated neopterin levels are parallel to the slightly elevated biopterin levels. On the otherhand, the reduced form of biopterin-tetrahydrobiopterin is an essential cofactor of aromatic monoxygenases that leads to synthesis of tyrosine, tryptophan and dopamine neurotransmitters and its concentration in body fluids and tissues is maintained by the enzyme dihydropteridine reductase (DHPR). Increased numbers of activated lymphocytes can be found in peripheral blood, in the synovial fluid and synovial membranes or patients with rheumatoid arthritis (RA). Since the present study was undertaken to evaluate the role of the pteridine pathway in RA, we measured urine neopterin levels and dried blood DHPR activities in 36 patients with RA and in 20 healthy volunteers, in parallel with other clinical parameters. We found that neopterin excretion was significantly increased in RA patients compared with controls. The means were 433±216, 153±43 and 111±34 μmol/mol creatinine for patients in active stage, in remission and controls, respectively. Our results suggest that urine neopterin levels were strongly dependent on the stage and activity of RA. Either as an effect of the disease itself or of drug administration, slightly reduced DHPR activities were detected (3.484± 0.304 for control, 2.974±0.255 in active stage RA, and 3.048±0.302 red cytochrome C/min/5 mm disc in remission).

Muscle performance in fibromyalgia syndrome.

Abstract The objective of the study was to examine the muscle performance, isokinetic muscle strength, muscle endurance ratio, and submaximal aerobic performance in fibromyalgia syndrome (FMS) patients, to evaluate the relation between muscle performance, pain severity, clinical findings, and physical activity level, and to compare the results with healthy control subjects. Twenty-four FMS patients and 15 control subjects participated in this study. Data were obtained about the symptoms, location and onset of pain, treatment, and associated symptoms. Patients and controls underwent an examination of isokinetic muscle strength of right quadriceps on a Cybex dynamometer, and submaximal aerobic performance tests (PWC-170) were done for all subjects. Maximal voluntary muscle strength of the quadriceps was significantly lower in patients compared with the control group. Endurance ratios showing the work capacity were not statistically different between two groups. Submaximal aerobic performance scores were higher in the control group. There was not a relation between the decreased muscle performance and clinical findings, including pain severity, number of tender points, and duration of the symptoms of FMS patients. We found a reduced quadriceps muscle strength and submaximal aerobic performance in patients with FMS, indicating that patients have impaired muscle function.

Relation between foot arch index and ankle strength in elite gymnasts: a preliminary study.

Background: Gymnasts usually start intensive training from early childhood. The impact of such strenuous training on the musculoskeletal system is not clear. Objectives: To evaluate the relation between muscle strength of the ankle joint and foot structure in gymnasts. Methods: The study population comprised 20 high level male gymnasts and 17 non-athletic healthy male controls. Arch indices were measured using a podoscope. Ankle plantar/dorsiflexion and eversion/inversion strengths were measured using a Biodex 3 dynamometer within the protocol of concentric/concentric five repetitions at 30°/s velocity. Results: The mean arch index of the right and left foot of the gymnasts and the controls were respectively: 31.4 (29.1), 34.01 (34.65); 60.01 (30.3), 63.75 (32.27). Both the arch indices and the ankle dorsiflexion strengths were lower in the gymnasts. Although no correlation was found between strength and arch index in the control group, a significant correlation was observed between eversion strengths and arch indices of the gymnasts (r  =  0.41, p  =  0.02). Conclusions: Whether or not the findings indicate sport specific adaptation or less training of the ankle dorsiflexors, prospective data are required to elucidate the tendency for pes cavus in gymnasts, for whom stabilisation of the foot is a priority.

99mTc-citrate versus 67Ga-citrate for the scintigraphic visualization of inflammatory lesions.

Citric acid was labeled with 99mTc with an efficiency of > 99%. The biodistribution of 99mTc-citrate was studied in mice with turpentine-induced abscesses in comparison to 67Ga-citrate. The max. abscess/muscle concentration ratios were 4.61 +/- 1.92 (3 h) for 99mTc-citrate and 4.76 +/- 2.04 (4 h) for 67Ga-citrate. Arthritis was induced in 10 rabbits by intra-articular injection of ovalbumin Scintigrams obtained 4 days later and at 3 h post-injection of 99mTc-citrate showed increased activity involving the synovium. The max. arthritic/contralateral knee ratio was 3.19 +/- 1.29 (3 h) and 6.47 +/- 3.71 (24 h) for 99mTc- and 67Ga-citrate, respectively. The blood clearance curve of 99mTc-citrate in rabbits was biexponential with a fast (T1/2 = 36 min) and a slow (T1/2 = 18 h) component, compared to mono-exponential clearance of 67Ga-citrate (T1/2 = 23 h). In 10 patients with rheumatoid arthritis whole-body scintigrams and spot images of involved joints indicated localization of the tracer in inflamed tissues. The mean target-to-soft tissue ratios were 3.04 +/- 0.81 and 4.95 +/- 2.56 for 99mTc-citrate and 99mTc-MDP, respectively. Renal clearance of radioactivity was evident from the scintigrams. Our results demonstrated that 99mTc-citrate is effective as a radiopharmaceutical for the visualization of inflammatory lesions and may be preferred to 67Ga-citrate due to the ideal physical characteristics of the radionuclide, easy preparation, low cost, early accumulation and the preference for the renal route of excretion.

Evaluation of Tc-99m(V) DMSA for imaging inflammatory lesions: An experimental study

The present study evaluated99mTc(V) DMSA as an agent for the visualization of inflammatory lesions in comparison to99mTc(HI) DMSA and99mTc-HIG. All three radiopharmaceuticals were prepared with commercial kits.99mTc(V) DMSA was prepared at neutral pH by the addition of first bicarbonate and then pertechnetate to the kit contents. The labeling efficiency was 99% as determined by ITLC. Abscesses were induced by i.m. injection of 50 μl turpentine into the right thighs of 36 Swiss albino mice. Six days later 3.7 MBq of each radiopharmaceutical was i.v. administered to 12 mice. The mice were sacrificed at 1,3,6 and 24 h later. Scintigrams were obtained with a gamma camera. The abscesses were better visualized on scintigrams with99mTc(V) DMSA compared to99mTc(III) DMSA, starting at 1 h. The animals were dissected and the organs were removed, weighed and the radioactivity determined with a gamma counter. The abscess to other tissue ratios were higher with99mTc(V) DMSA than the other radiopharmaceuticals. The max. abscess/muscle ratios were 9.46 ± 3.20 (24 h), 4.19 ± 1.39 (6 h) and 5.98 ± 1.17 (24 h) and max. abscess/blood ratios were 6.22 ± 1.41, 4.09 ± 0.84 and 0.914 ± 0.351 all at 24 h for99mTc(V) DMSA,99mTc(III) DMSA and99mTc-HIG, respectively.Experimental arthritis was produced in 6 New Zealand white rabbits by intra-articular injection of ovalbumin. Four days later 37 MBq of99mTc(V) DMSA and99mTc-HIG were each i.v. administered to 3 rabbits. Scintigrams obtained at 1, 3, 6, and 24 h clearly demonstrated arthritic joints. ROFs over arthritic joints were compared to contralateral normal joints (A/C). The max. A/C ratios were 2.10 ± 0.31 (3 h) and 2.92 ± 0.99 (24 h) for99mTc(V) DMSA and99mTc-HIG, respectively.Our results indicated the feasibility of imaging inflammatory lesions with99mTc(V) DMSA.

Musculoskeletal sonography use in physiatry: a single-center one-year analysis.

Özçakar L, Malas FÜ, Kara G, Kaymak B, Hasçelik Z: Musculoskeletal sonography use in physiatry: A single-center one-year analysis. Objective:To document the musculoskeletal ultrasonography experience in a physiatry clinic for 1 yr and to find out whether its use decreased time, cost, and radiation exposure with regard to musculoskeletal imaging. Design:All patients who underwent musculoskeletal ultrasonography examination (n = 309) in our physiatry department during the whole year of 2007 were enrolled. The same physiatrist, experienced in musculoskeletal ultrasonography, performed all of the evaluations by using 5–10 MHz and 8–16 MHz linear probes (Diasus Dynamic Imaging Ltd., Scotland, UK). At the end of the year, each patient was retrospectively considered on an individual basis, and the answers to the following three questions were recorded in case he/she had not been evaluated by musculoskeletal ultrasonography: (1) How long would the patient have waited (i.e., for further radiologic appointments)? (2) What would the extra cost have been? (3) What would the radiation exposure have been? Cumulative numbers were calculated for the whole year concerning time, cost, and radiation dose. Results:According to the calculations, the total waiting period was estimated as 7620 days if musculoskeletal ultrasonography had not been used for imaging. Similarly, the total cost and the radiation dose were estimated to be &U20AC;8128 (

The frequency of fibromyalgia in sport professionals

16,256 US) and 20 Sievert (2000 cGy), respectively. Conclusions:Musculoskeletal ultrasonography provides a significant amount of gain regarding time and cost in physiatry clinics. We call the attention of physiatrists to this issue and advocate that a standardized international approach to musculoskeletal ultrasonography training and assessment is definitely awaited.