Rehabilitation Medicine Management of Spasticity

Spasticity is a poorly recognized but common symptom, present in a wide range of neurological conditions. It can have a major impact on those affected, much of which is potentially preventable. This chapter provides an excellent paradigm to incorporate many of the key elements fundamental to the management of chronic conditions and it is of relevance to those who work in spasticity rehabilitation

Safety and Effectiveness of Low-Level Laser Therapy in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis

Low Level Laser Therapy was introduced as an alternative non-invasive treatment for osteoarthritis, but its effectiveness is still controversial. The main objective of this article was to determine the safety and efficacy of LLLT in patients with knee osteoarthritis. In order to gather evidence, main medical databases as well as relevant websites were browsed without time limit. We searched with appropriate keywords and strategies. After quality assessment of studies, study data were extracted by two reviewers. Standard mean difference proposed through Inverse Variance was used in the meta-analysis using the random-effects model. Twelve values were used for the evaluation of heterogeneity. A total of 823 studies, 14 RCTs were selected after final review. There was a significant difference between LLLT and Placebo in pain at rest (p=0.02), pain at activity (p=0.01), total pain (p=0.03), WOMAC function (p=0.01), WOMAC stiffness (p=0.02) and WOMAC total (p<0.0001) in favor of the LLLT. There was no significant difference between LLLT and Placebo in WOMAC pain (p=0.09) and range of motion (p=0.1). In spite of some positive findings, this meta-analysis lacked data on how LLLT effectiveness is affected with important factors: wavelength, energy density, treatment duration, numbers of sessions the treatment, severity of KOA and site of application

Validity and Reliability of the Persian Version of the Chronic Pain Grade Questionnaire in Patients with Musculoskeletal Pain

Introduction: Chronic pain which is a pain that remains or repeats for more than 3 to 6 months affects one in every 10 people in the world. Rising direct and indirect costs of chronic pain show the importance of researches which help to find better ways of pain management. Testing the validity and reliability of pain measurement tools in different populations can help this kind of researches. The chronic pain grade questionnaire is devised by Vonkorff and his colleagues. This seven-item instrument gives a score which empowers chronic pain patients to be characterized into one of four hierarchical categories according to pain severity or interference. The goal of this research was to test the validity and reliability of the Persian version of the chronic pain grade questionnaire. Methods: As a cross-sectional study after downloading the questionnaire from the internet and translating from English to Persian by researchers and backward translation by a native researcher, it was answered by 204 patients with musculoskeletal pain. These patients were referred to the physical medicine and rehabilitation clinic in Modarres Hospital and were registered using convenience sampling method. Patients were aged between 18 and 87; suffering from musculoskeletal pain (including primary and secondary pains) for at least the last 6 months. Fifty patients were reevaluated after two weeks. Results: As a result of testing reliability, Cronbach’s alpha was 0.89 and the Guttman split-half coefficient was around 0.82 and Test re-test coefficient using Spearman’s correlation coefficient was 0.89. Only a single component was extracted for the questionnaire, as a result of factor analysis. This component defines 59.8% of the variance. Conclusions: In summary, construct validity and reliability of the Persian version of the chronic pain grade questionnaire are approved, therefore it would be applicable to people with musculoskeletal pain in the Iranian population

Effectiveness of Low-Level Laser Therapy compared to Ultrasound in Patients With Carpal Tunnel Syndrome: A Systematic Review and Meta-analysis

Introduction: Carpal tunnel syndrome (CTS) is the most common type of peripheral entrapment neuropathy that occurs in the wrist area in a space called the carpal tunnel. Low-level laser therapy (LLLT) and ultrasound are among the most common methods of physical modalities for treating CTS; the effectiveness of these two methods and superiority of one over the other is not agreed among experts.Methods: In present systematic review and meta-analysis study, the most important databases including PubMed, Cochrane Library, Scopus, Centre for Reviews and Dissemination, Science Direct, Trip Medical Database, and Google Scholar were searched using appropriate keywords and specific strategies without time limitation to collect data. The collected data was analyzed using meta-analytic method and random effects model. The heterogeneity among studies was examined using I2. The data was analyzed using Review Manager Software.Results: From among 108 related studies, 49 cases were entered in the first stage. After the final examination, 6 studies were selected for meta-analysis. The total number of patients in these six studies was 403; 204 subjects were in the LLLT group and 199 subjects were in the ultrasound group. The results of meta-analyses showed that there was no significant difference between these two therapeutic methods in terms of pain relief, symptom severity scale (SSS), functional status scale (FSS), motor latency, sensory latency, handgrip strength, and motor amplitude.Conclusion: Based on meta-analyses, there was no significant difference between two LLLT and ultrasound methods; in other words, they had similar effectiveness in improving the condition of patients with CTS. However, the authors believed that arriving at conclusions in this area requires high-quality and large size studies.

Efficacy of High-Power Laser in Alleviating Pain and Improving Function of Patients With Patellofemoral Pain Syndrome: A Single-Blind Randomized Controlled Trial

Introduction: In this study, a single-blind and randomized controlled trial (RCT) for assessing the effectiveness of high-power (up to 12 W) laser therapy (HPLT) on patients with patellofemoral pain syndrome (PFPS) was carried out.Methods: Forty-four patients were randomly assigned to two treatment groups by generating random numbers with MATLAB 2014b software, where odd and even numbers were attributed to sham laser group (group A) and actual laser group (group B), respectively. Group B patients underwent HPLT with total dose of 300 J/session for 5 consecutive sessions separated by a 2-day interval. On the other hand, sham laser was applied to group A patients. Both groups had the same exercise therapy programs during the study period (3 months). The exercise therapy program included isometric knee exercise for 3 sets per day and 10 times in each set, with duration of 10 seconds per time and straight leg raise for 15 seconds 10 times a day. The group codes of patients were not revealed to subjects and data analyzer until completion of the study. Kujala, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and visual analog scale (VAS) questionnaires were chosen as outcome measures. These questionnaires were completed at three points during the study; at the beginning of the study to obtain the pre-therapy conditions and one month and three months after the start of the study to evaluate post-therapy conditions.Results: Two main analyses were conducted: within-group and between-group analyses. Within-group analyses indicated significant improvements in respect to all measurements where pre-therapy and post-therapy comparisons were conducted in both groups (P < 0.05). On the other hand, between-group comparisons did not reveal any statistically significant functional difference between group A and group B regarding the evaluative criteria (P > 0.05) except for pain VAS (P < 0.05).Conclusion: This study indicated that short-term HPLT accompanied by appropriate exercise regimen significantly decreased pain in patients with PFPS. But it was not recommended as an efficient modality in functional improvement. Also, it was observed that, in the short-term period of study, HPLT was a safe modality

The Effect of Polarized Polychromatic Noncoherent Light (Bioptron) Therapy on Patients with Carpal Tunnel Syndrome

Introduction: To study the effects of Polarized Polychromatic Noncoherent Light (Bioptron) therapy on patients with carpal tunnel syndrome (CTS).Methods: This study was designed as a randomized clinical trial. Forty four patients with mild or moderate CTS (confirmed by clinical and electrodiagnostic studies) were assigned randomly into two groups (intervention and control goups). At the beginning of the study, both groups received wrist splinting for 8 weeks. Bioptron light was applied for the intervention group (eight sessions, for 3/weeks). Bioptron was applied perpendicularly to the wrist from a 10 centimeters distance. Pain severity and electrodiagnostic measurements were compared from before to 8 weeks after initiating each treatment.Results: Eight weeks after starting the treatments, the mean of pain severity based on Visual Analogue Scale (VAS) scores decreased significantly in both groups. Median Sensory Nerve Action Potential (SNAP) latency decreased significantly in both groups. However, other electrophysiological findings (median Compound Motor Action Potential (CMAP) latency and amplitude, also SNAP amplitude) did not change after the therapy in both groups. There was no meaningful difference between two groups regarding the changes in the pain severity.Conclusion: Bioptron with the above mentioned parameters led to therapeutic effects equal to splinting alone in patients with carpal tunnel syndrome. However, applying Bioptron with different therapeutic protocols and light parameters other than used in this study, perhaps longer duration of therapy and long term assessment may reveal different results favoring Bioptron therapy

The Effects of Low Intensity Laser on Clinical and Electrophysiological Parameters of Carpal Tunnel Syndrome

Introduction: Carpal Tunnel Syndrome (CTS) is the most common type of entrapment neuropathy. Conservative therapy is usually considered as the first step in the management of CTS. Low Level Laser Therapy (LLLT) is among the new physical modalities, which has shown therapeutic effects in CTS. The aim of the present study was to compare the effects of applying LASER and splinting together with splinting alone in patients with CTS.Methods: Fifty patients with mild and moderate CTS who met inclusion criteria were included in this study. The disease was confirmed by electrodiagnostic study (EDx) and clinical findings. Patients were randomly divided into 3 groups. Group A received LLLT and splinting. Group B received sham LLLT+ splinting and group C received only splints. Group A received LLLT (50 mw and 880nm with total dose of 6 joule/cm2). Clinical and EDx parameters were evaluated before and after treatment (3 weeks and 2 months later).Results: Electrophysiologic parameters and clinical findings including CTS provocative tests, Symptoms severity score (SSS), Functional Severity Score (FSS) and Visual Analogue Score (VAS) were improved in all three groups  at 3 weeks and 2 months after treatment. No significant changes were noticed between the three groups regarding clinical and EDX parameters.Conclusion: We found no superiority in applying Low Intensity Laser accompanying splinting to traditional treatment which means splinting alone in patients with CTS. However, future studies investigating LLLT with parameters other than the one used in this study may reveal different results in favor of LLLT

The Effects of Knee Orthosis with Two Degrees of Freedom Joint Design on Gait and Sit-to-Stand Task in Patients with Medial Knee Osteoarthritis

Objectives: Knee bracing as a conservative treatment option for patients with medial knee osteoarthritis (KOA) is of great interest to health practitioners and patients alike. Optimal orthotic knee joint structure is essential to achieve biomechanical and clinical effectiveness. Therefore, this study aimed to identify the effects of a knee orthosis with a new two-degrees-of-freedom (DOF) joint design on selected gait parameters and in a sit-to-stand task in patients with mild-to-moderate medial KOA. Methods: This study was conducted both at the Physical Medicine and Rehabilitation Clinic in Shahid Modarres Academic Hospital and the Biomechanical Laboratory of Rehabilitation Faculty of Iran University of medical Sciences in Tehran, Iran from September 2015 to October 2017. The gait performance of 16 patients was assessed without an orthosis, using a common one-DOF (DOF) knee orthosis and using the same knee orthosis with a two-DOF orthotic joint design. The interactive shearing force between limb and brace in the shell area during a sit-to-stand test was also identified. Repeated measures analysis of variance was used to analyse the data. Results: Compared with walking with no orthosis, both orthosis conditions reduced the external knee adduction moment significantly (P ≤0.05). A significant increase between the one-DOF and two-DOF conditions in terms of walking speed (P = 0.041 and P = 0.009, respectively) and stride length (P = 0.028 and P = 0.038, respectively) was observed. In a sit-to-stand test, wearing the orthosis significantly decreased knee transverse plane range of motion (P ≤0.05). There was a 41.31 ± 8.34 Newtons reduction in knee flexion constraint force. Conclusion: The two-DOF knee orthosis was more comfortable compared to the one-DOF knee orthosis during deep knee flexion. Otherwise, the one- DOF- and two-DOF-braces performed similarly. Keywords: Knee Osteoarthritis; Orthosis; Braces; Gait Analysis; Rotations; Kinematics; Kinetics; Patient Comfort

Cost-utility analysis and net monetary benefit of Platelet Rich Plasma (PRP), intra-articular injections in compared to Plasma Rich in Growth Factors (PRGF), Hyaluronic Acid (HA) and ozone in knee osteoarthritis in Iran

Abstract Purpose To evaluate the cost-effectiveness of Platelet Rich Plasma (PRP), Plasma Rich in Growth Factors (PRGF), Hyaluronic Acid (HA) and ozone as effective treatment approaches in knee osteoarthritis management from Iran Health care perspective. Methods A decision tree model was conducted to assess the cost-effectiveness of four common intra-articular treatment approaches in patients with mild and moderate knee osteoarthritis. The data on clinical effectiveness was obtained from a randomized controlled trial (RCT) conducted in Iran and used to estimate utility values. The direct medical costs were estimated according to tariffs for public medical centers and hospitals, approved by the Iran Ministry of Health and Medical Education in 2021. The incremental cost-effectiveness ratio (ICER) and the net monetary benefit (NMB) were used to evaluate the cost-utility analysis. Deterministic and probabilistic sensitivity analyses are performed to investigate the robustness of the results and account for the different sources of uncertainty. Results In this study, HA intra-articular injection-related costs ($581.67/patient) were defined as the highest cost, followed by PRGF ($328.10/patient), PRP (318.58/patient), and Ozone (103.20/patient). According to the utility value, PRP and PRGF (0.68) have the same and the most utility among Intra-articular injections in knee osteoarthritis management. However, the PRP injection method was identified as the most cost-effective intervention due to its high NMB and ICER estimates. Based on the Monte Carlo Simulation, PR intervention, compared to other ones, was introduced as the dominant strategy regarding knee OA management, with a WTP of $10,000 for 100% of cases. Conclusion The study result demonstrated that intra-articular injection of PRP, compare to other injections, is a cost-effective treatment option for patients with mild and moderate knee osteoarthritis. In addition, intra-articular injection of PRP was identified as the best injection, with the highest level of net monetary benefit, for knee OA management