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Arash Babaei-Ghazani,1 Bijan Forogh,1 Gholam Reza Raissi,1 Tannaz Ahadi,1 Bina Eftekharsadat,2 Naseh Yousefi,1 Shahram Rahimi-Dehgolan,3 Katayoun Moradi1 1Neuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation, Iran University of Medical Sciences (IUMS), Tehran, Iran; 2Physical Medicine and Rehabilitation Research Center, Department of Physical Medicine and Rehabilitation, Tabriz University of Medical Sciences, Tabriz, Iran; 3Physical Medicine and Rehabilitation Department, IKHC Center, Tehran University of Medical Sciences (TUMS), Tehran, IranCorrespondence: Shahram Rahimi-DehgolanPhysical Medicine and Rehabilitation Department, IKHC Center, Tehran University of Medical Sciences (TUMS), Tehran, IranEmail shahram.rahimi.dehgolan@gmail.comKatayoun MoradiNeuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation, Iran University of Medical Sciences (IUMS), Tehran, IranEmail katayoun-moradi69@gmail.comPurpose: To compare two common approaches for ultrasonography (US)-guided injection.Patients and Methods: Sixty patients with mild-to-moderate CTS were included in this double-blind randomized controlled trial (RCT). They received a single shot of corticosteroid injection through either the US-guided in-plane approach: radial or ulnar side. Participants were evaluated using Boston Carpal Tunnel Questionnaire (BCTQ) and visual analogue scale (VAS) for pain, as well as electrodiagnosis (EDX) and US parameters before the intervention, and within 12 weeks of follow-up.Results: In both groups, all outcomes, except for the electrodiagnostic measures, significantly improved within the follow-up. Pain-VAS and both subscales of BCTQ questionnaire, as our main subjective outcomes, revealed dramatic improvement, with the largest amount of changes in VAS (70%; comparing to baseline value), and about 37% for both of BQSS and BQFS scales, all indicating superiority of radial to ulnar in-plane approach. During the first follow-up, we did not detect any remarkable preference between the groups in either subjective or electrodiagnostic variables. However, there was a significant difference at next follow-up time-points in terms of VAS for pain and BQFS favoring radial approach (Table 3). Furthermore, US-measured parameters including nerve-circumference and CSA improved only in the radial in-plane group.Conclusion: The current data proved that radial in-plane approach for CTS injection could be at least as effective as the more common ulnar in-plane method. Even the pain-relief effect was longer for the radial in-plane approach. Also, patients’ functional status and objective variables all revealed better outcomes via the new approach.Keywords: electromyography, corticosteroid injection, Boston Carpal Tunnel Questionnaire, BCTQ, carpal tunnel syndrome, CTS

Seyed Ahmad Raeissadat,1,2 Seyed Mansoor Rayegani,2 Bijan Forogh,3 Porya Hassan Abadi,4 Mahsa Moridnia,5 Shahram Rahimi Dehgolan6 1Clinical Development Research Center of Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences,Tehran, Iran 2Shohada-e-Tajrish Hospital, Physical Medicine and Rehabilitation Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; 3College of Medical and Dental Sciences, Birmingham Medical School, Birmingham, UK; 4Physical Medicine and Rehabilitation Department, Iran University of Medical Sciences, 5Shahid Beheshti University of Medical Sciences, Deputy of Education, 6Physical Medicine and Rehabilitation Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Purpose: Knee osteoarthritis (OA) is a common disease, imposing a great burden through pain and decreased function. There are many therapeutic modalities including non-pharmacologic choices and oral, topical, and intra-articular medications. New studies have shown promising results for ozone application in knee OA. Our aim was to compare the effects of ozone therapy versus hyaluronic acid (HA) intra-articular injection in knee OA patients.Methods: In this randomized clinical trial, a total of 174 patients with more than 3 months of chronic pain or swelling in the knee joints along with consistent imaging findings were enrolled and randomly allocated into two groups of HA and ozone, which were planned to undergo 3 weekly injections of HA (Hyalgan®) and 10 mL of a 30 µg/mL ozone solution, respectively. Patients were evaluated at baseline and 6 months after the last injection for pain, stiffness, and function using the visual analog scale (VAS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. Results: No major adverse events were detected in this study. Total WOMAC score decreased from 40.8±9.8 to 20.4±4.9 (p

BACKGROUND: The vulnerability of the youth to acquired immune deficiency syndrome (AIDS) and smoking is one of the most important public health issues around the world. Adequate knowledge about AIDS and smoking is a powerful tool for promoting positive attitudes and safe behaviors. OBJECTIVE: This study aimed to determine the effect of self-care education on AIDS and smoking on the level of adolescents' knowledge and health attitude. MATERIALS AND METHODS: This experimental study was conducted in the academic year of 2017–2018, and the participants were selected using randomized cluster sampling. These participants included 220 female students of the third grade of middle school in Isfahan (105 in the intervention group and 115 in the control group). Data were collected using a demographic questionnaire; a researcher-made questionnaire on knowledge about AIDS, knowledge about smoking, and attitudes toward smoking; and a standard questionnaire on students' attitude toward AIDS. After completing the pretest, the intervention group performed two training sessions and completed the posttest 1 month later. One month after completing the pretest, the control group completed the posttest and did not receive an intervention. Finally, the data were analyzed using descriptive statistics, statistical tests, and statistical software SPSS version 22. RESULTS: The results showed that despite the similarity between the two groups at the beginning of the study, after self-care education, the knowledge level of AIDS (P < 0.001) and attitude toward AIDS (P < 0.001) and the knowledge level of smoking (P < 0.001) and attitude toward smoking (P < 0.001) in the intervention group were significantly higher than the control group. In intragroup analysis, it was also observed that the difference between the scores before and after was only significant in the intervention group. CONCLUSION: It seems that education can promote the level of knowledge and attitude of adolescents toward AIDS.

Background: Extracorporeal shockwave therapy (ESWT) and ultrasound-guided percutaneous lavage (UGPL or barbotage) are among those used to treat the pain of rotator cuff calcific tendinopathy (RCCT). This meta-analysis was done to review the effect ESWT and UGPL in reducing the pain of RCCT., Methods: A comprehensive search was done based on the PRISMA. PubMed, Web of Science, Scopus, Cochrane Library and Google Scholar were reviewed for articles published by Feb 1, 2024, on ESWT vs. UGPL. The main keywords searched are as follows: "rotator cuff calcific tendinopathy", "tendinitis", " ESWT", " ultrasound-guided percutaneous lavage", " RCCT ″, " UGPL", " extracorporeal shock wave therapy" and titles or abstracts may contain one or a mix of these elements. This study was registered at PROSPERO with code" CRD42022385068". STATA version 13 was applied to analyze., Results: In general, 779 patients from 22 studies were analyzed. The mean age was 51.85 ± 3.41 years. The patients were referred after 18.69 months of suffering from tendinopathy symptoms. Right-sided and supraspinatus locations were affected more. ESWT has been effective in a decrease of calcium deposit (-1.70 SMD after 1 week for ESWT, -0.96 SMD after 12 weeks for ESWT and -1.20 SMD after 12 weeks UPGL). ESWT has been effective in decreasing VAS by -4.32 SMD after 1 week while UPGL showed -0.23 SMD reductions in VAS After 1 week but in time >1 week, UPGL showed better effect by more reduction in VAS. ESWT has been effective in an increase of CMS by 1.60 SMD after 4-6 weeks, by 1.79 SMD after 12 weeks, by 2.44 SMD after 24 weeks, and 2.53 SMD after 48 weeks., Conclusion: Based on the results, ultrasound-guided lavage is more effective in reducing pain than ESWT, and this effect becomes more evident in the long term. In terms of CMS score, over time, the efficiency of ESWT becomes more visible. In long-term follow-up, UPGL had a better effect on the calcium deposit reduction., Competing Interests: None., (© 2024 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.)

Background and Objective: Reduction manipulation using self-reduction procedures such as Stimson, Milch, and Boss-Holtzach should be easy and effective and also require less force, pain medication, and outside assistance. This technique should not cause damage to arteries, nerves, or shoulder joint components. Self-reduction is straightforward and can be done in clinics, making it ideal for people who suffer from shoulder joint dislocation frequently. The goal of this study is to compare the effectiveness of supervised self-reduction procedures vs. physician-assisted treatments in the treatment of anterior shoulder dislocations., Method: We conducted a comprehensive search on PubMed, Scopus, Web of Science, and Cochrane up to March 22, 2023, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Relevant articles were reviewed, with a focus on studies comparing supervised self-reduction techniques to physician-assisted techniques in cases of anterior shoulder dislocation., Results: Four papers in all were included in the meta-analysis. One prospective trial, one case-control study, one randomized clinical trial, and one retrospective trial made up these studies. The studies involved 283 patients in the physician-assisted group and 180 patients in the supervised self-reduction group. They were carried out in four European countries: Italy, Germany, Portugal, and Spain. The success rate of supervised self-reduction techniques was significantly higher, with an odds ratio of 2.71 (95% CI 1.25-5.58, p-value = 0.01). Based on the Visual Analog Scale (VAS) score, the physician-assisted group reported significantly higher maximum pain, with a mean difference of 1.98 (95% CI 1.24-2.72, p-value < 0.01). The self-reduction approaches exhibit shorter reduction time in comparison to physician-assisted groups. In addition, the self-reduction groups do not document any complications. Based on the GRADE system, the level of assurance in the evidence was high., Conclusion: Supervised self-reduction techniques outperform in terms of success rate and reduction-related maximum pain. These techniques could be used as an effective first-line treatment for anterior shoulder dislocation, potentially reducing the need for analgesics and emergency room visits., (© 2024. The Author(s).)

Objective: The objective of this study was to assess the evidence for the impact of dry needling (DN) on hip pain and function., Methods: Medline/PubMed, Embase, Scopus, Web of Science and Cochrane CENTRAL databases were searched systematically through June 2022 for randomized clinical trials (RCTs) investigating the impact of DN on hip pain and function. Version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to assess risk of bias. Descriptive analysis was conducted to explain the outcomes and adverse events of DN in hip joint diseases. Meta-analysis was not feasible due to significant heterogeneity., Results: A total of seven eligible studies (including 273 patients) were included out of 2152 screened records. Five studies were in participants with hip osteoarthritis (OA; n  = 3), greater trochanteric pain syndrome (GTPS; n  = 1) or piriformis syndrome ( n  = 1); the other two studies were conducted in healthy athletes ( n  = 2). Two articles assessed changes in participants' short-term visual analog scale (VAS) scores (<1 week), one of which showed that DN significantly reduced pain ( P  < 0.05). One-week VAS scores were analyzed in three studies, all of which demonstrated reduced scores following DN ( P  < 0.05). Hip range of motion (ROM) and muscle force were also improved following DN. No serious side effects were reported., Conclusion: DN may be safe and effective at relieving hip pain and improving hip function. DN performs significantly better than several different types of control intervention (including sham DN, no treatment, corticosteroid injections and laser). Strong evidence (high degree of certainty around the results) is lacking, and future studies should ideally use longer follow-up periods and larger sample sizes., Review Registration Number: CRD42022297845 (PROSPERO)., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Background: Neck pain (NP) is a condition influenced by multiple factors. It places a significant burden on individuals suffering from NP and on social and economic systems. On a global scale, low back pain (LBP) stands out as a significant contributor to years lost to disability, and this burden is on the rise due to population growth and aging., Methods: The Global Burden of Disease database was used to collect data on the prevalence, incidence, and years lived with disability (YLD) of NP and LBP between 1990 and 2019. Various factors, including age group, gender, Iran, and its 31 provinces, were used to classify the data., Results: Iran accounted for 0.86 million incident cases of NP in 2019, with age-standardized incident rate per 100 000 population of 934.1. Tehran has the maximum age-standardized prevalence, incidence, and YLD. Iran accounted for the age-standardized incidence rate for LBP per 100 000 population of 3492.9, and it reduced to -8.35% from 1990. Mazandaran exhibits the highest levels of prevalence, incidence, and YLD for LBP in 2019. In Iran, the point prevalence of NP in 2019 was higher in females and increased with age up to 50-54 years for females and 70-74 years for males. However, there is only a slight difference between females and males in Iran regarding LBP prevalence., Conclusions: In this study, the authors report the prevalence, incidence, YLD, and age-standardized rates for NP and LBP in the world's general population and Iran's population based on its sub-nations in 1990 and 2019., Competing Interests: The authors have no conflicts of interest to disclose.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Objective: Chronic ankle instability (CAI) is one of the most common sports injuries, and whole-body vibration (WBV) training has been used lately as a potential rehabilitation modality for these patients. The authors conducted a systematic review and meta-analysis to assess whether WBV training positively affects patients with CAI., Materials and Methods: The authors systematically searched four databases, including MEDLINE (PubMed), Scopus, Web of Science, and Cochrane Central Register of Controlled Trials, for randomized and non-randomized trials evaluating the effects of WBV on individuals with CAI. The authors used Cochrane RoB2 to assess the risk of bias in randomized trials. A meta-analysis was conducted if three or more studies measured the same outcome. Effect estimates were pooled using a random-effects model., Results: Results were retrieved from seven articles encompassing 288 participants who had CAI. The reach distance of the Star Excursion Balance Test (SEBT) was regarded as the study's main finding. The authors saw a significant training effect on certain planes of motion on dynamic balance. The findings showed that the post-intervention measurements in the WBV group compared to control groups showed improvements in the posterolateral, posteromedial, and medial directions, respectively. There were also promising results on improvements in muscle activity, strength, and proprioception sense measurements with a great diversity in the reported parameters., Conclusion: The authors observed a significant WBV training effect on dynamic balance over posterolateral, posteromedial, and medial reach distances. These findings suggest future studies on the effects of WBV on muscle activity, strength, and proprioception in addition to dynamic and static balance., Competing Interests: The authors have no conflicts of interest to declare.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Parkinson's disease (PD) is a neurodegenerative disorder with different motor and neurocognitive symptoms. Tremor is a well-known symptom of this disease. Increasing evidence suggested that the cerebellum may substantially contribute to tremors as a clinical symptom of PD. However, the theoretical foundations behind these observations are not yet fully understood., Methods: In this study, a computational model is proposed to consider the role of the cerebellum and to show the effectiveness of cerebellar transcranial alternating current stimulation (tACS) on the rest tremor in participants with PD. The proposed model consists of the cortex, cerebellum, spinal circuit-muscular system (SC-MS), and basal ganglia blocks as the most critical parts of the brain, which are involved in generating rest tremors. The cortex, cerebellum, and SC-MS blocks were modeled using Van der Pol oscillators that interacted through synchronization procedures. Basal ganglia are considered as a regulator of the coupling weights defined between oscillators. In order to evaluate the global behavior of the model, we applied tACS on the cerebellum of fifteen PD patients for 15 min at each patient's peak frequency of their rest tremors. A tri-axial accelerometer recorded rest tremors before, during, and after the tACS., Results and Discussion: The simulation of the model provides a suggestion for the possible role of the cerebellum on rest tremors and how cerebellar tACS can affect these tremors. Results of human experiments also showed that the online and offline effects of cerebellar tACS could lead to the reduction of rest tremors significantly by about %76 and %68, respectively. Our findings suggest that the cerebellar tACS could serve as a reliable, therapeutic technique to suppress the PD tremor., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Rahimi, Towhidkhah, Baghdadi, Forogh, Saadat, Soleimani and Habibi.)

Background: : Dry needling (DN) is recommended as a therapeutic modality for various neuromusculoskeletal disorders. No study has been performed on the impact of DN on arthrogenic muscle inhibition (AMI) after anterior cruciate ligament reconstruction (ACLR). This study protocol is aimed to investigate the impacts of DN on AMI of quadriceps femoris, corticomotor, and spinal reflex excitability in patients with ACLR., Methods: : A double-blind, between-subject, randomized, controlled trial will be conducted to measure changes in AMI after DN. Twenty-four subjects with ACLR will be recruited to receive a DN or a sham DN, providing that they met the inclusion criteria. Three sessions of DN on the quadriceps femoris will be applied during a one-week period. The primary outcome measures are the active motor threshold, motor evoked potential, and H max - M max ratio. The secondary outcomes are the International Knee Documentation Committee subjective knee form questionnaire score and maximum quadriceps isometric torque. Data will be collected at baseline, immediately after the first session, after the third session, and at the one-month follow-up visit., Discussion: : The results of this study will provide preliminary evidence regarding the effects of DN on AMI of quadriceps femoris in patients with ACLR.

Introduction: Foot problems are one of the main causes of seeing a doctor. According to the World Health Organization's definition of health, the healthcare system must consider patients' quality of life as an important entity. In this regard, many tools have been developed to evaluate patients' opinions about their health status. The purpose of the present study is to evaluate the validity and reliability of the Persian version of the Foot Self-Assessment Questionnaire (SAFE-Q) in patients with foot orthopedic problems., Method: 215 people aged 17-60 years with orthopedic foot problems were included in this cross-sectional study. The Spearman correlation coefficient of SAFE-Q questionnaires versus Foot Function Index (FFI) questionnaire was evaluated for the convergent validity. Forty-three people randomly completed SAFE-Q again one week later. Intraclass correlation coefficient (ICC) and Cronbach's alpha was calculated to evaluate the test-retest reliability and internal consistency of the SAFE-Q, respectively., Results: A strong relationship was found between the SAFE-Q total score and other scales with FFI questionnaire (r = 0.52 to 0.87). ICC test-retest reliability and Cronbach's alpha were 0.981 and 0.98 for SAFE-Q, respectively., Conclusion: The results indicate that the Persian version of the SAFE-Q questionnaire has acceptable validity and reliability and can be used to assess the health status and quality of life of Persian speakers with orthopedic foot problems., (Copyright © 2022. Published by Elsevier B.V.)

Design: Chronic plantar fasciitis (PF) is a common cause of chronic heel pain, with different conventional treatment options. In this randomized clinical trial, the effect of ultrasound-guided injection of dextrose versus corticosteroid in chronic PF was evaluated and compared., Methods: A total of 44 patients suffering from chronic PF who visited the physical medicine and rehabilitation clinic were enrolled in the study. Two table-randomized groups were formed. They received an ultrasonography-guided, single injection of either 40 mg methylprednisolone or 20% dextrose. Numeric Rating Scale (NRS), Foot and Ankle Ability Measure questionnaire with 2 subscales, Activities of Daily Living (FAAM-A) and Sports (FAAM-S), along with ultrasonographic parameters were evaluated before and at 2 and 12 weeks after the injection. Results. A total of 40 participants completed the study. Both interventions significantly improved pain and function at 2 and 12 weeks postinjection. After 2 weeks, compared with the dextrose prolotherapy, the corticosteroid group had significantly lower daytime and morning NRS scores (2.55 vs 4.1, P = .012, and 2.75 vs 4.65, P = .004), higher FAAM-S (66.84 vs 54.19; P = .047), and lower plantar fascia thickness at insertion and 1 cm distal to the insertion zone (3.89 vs 4.29 mm, P = .004, and 3.13 vs 3.48 mm, P = .002), whereas FAAM-A was similar in both groups ( P = .219). After 12 weeks, all study variables were statistically similar between corticosteroid and dextrose prolotherapy groups. No injection-related side effects were recorded in either group., Conclusion: Both methods are effective. Compared with dextrose prolotherapy, our results show that corticosteroid injection may have superior therapeutic effects early after injection, accompanied by a similar outcome at 12 weeks postinjection., Levels of Evidence: Level II.

Background: Laparoscopic surgeons who regularly perform endoscopy are more likely to develop musculoskeletal disorders than other internal medicine specialists, a difference that attributed to repetitive movements, poor postures, and sub-optimal equipment design., Objective: This study aimed to design, build, and evaluate an endoscope holder for reducing the static load applied by the weight of the endoscope, in order to reduce musculoskeletal disorders risk factors in the surgeon's hand, shoulder and back issues regions., Methods: A new endoscope holder was designed according to ergonomic design principles. The designed holder was evaluated by surface electromyography (sEMG) and discomfort assessment including 15 laparoscopic surgeons. The results were analyzed with centrality statistics and compared with the independent t-test using SPSS version 22., Results: The evaluation of the new endoscope holder shows a statistical significant decrease in the average electrical activity of biceps brachii, triceps brachii, lateral deltoid, T9 Thoracic erector spinae, L4 Lumbar erector spinae, and external oblique after using the holder (p < 0.05)., Conclusion: The results shows that using the new endoscope holder is associated with a lower level of discomfort, as well as a lower induced muscle activity. The results also highlight the need to upgrade the holder to offer rotability in all directions (perpendicular to the ground) which will be included in the next design.

Aim: The main assessment of this study is to analyze the efficiency of ultrasound-guided dextrose prolotherapy against corticosteroid injections for the treatment of carpal tunnel syndrome. Materials & methods:  A total of 54 patients with carpal tunnel syndrome were included. Patients who were assigned into the prolotherapy group were injected with 5cc 5% dextrose water under ultrasound guidance. Patients in the corticosteroid group received ultrasound-guided 1 ml triamcinolone 40 mg/ml injection. Results: The inter-group analysis revealed that dextrose prolotherapy has a similar efficacy as corticosteroid for improving pain intensity, functional limitation in daily life, electrophysiologic parameters and ultrasonographic outcomes. No remarkable difference was found between the two treatments until 3 months of follow-up. Conclusion: Dextrose 5% has similar efficacy as triamcinolone for improving pain intensity, functional limitation in daily life, electrophysiologic parameters and ultrasonographic outcomes.

Objective: The aim of the study was to compare the efficacy of ultrasound-guided injection of botulinum toxin type A with corticosteroid in patients with chronic plantar fasciitis (PF)., Design: This randomized controlled trial was conducted on 35 patients with chronic plantar fasciitis. Participants were randomly allocated into two groups: one group received methylprednisolone in to the plantar fascia ( n = 18) and the other group received botulinum toxin type A injection into the flexor digitorum brevis and quadratus plantae ( n = 17). All injections were performed under ultrasound guidance. Patients were evaluated using the Visual Analog Scale, Foot and Ankle Ability Measures, and plantar fascia thickness before the intervention, 3 wks, 12 wks, and 6 mos after the treatment., Results: In both groups, patients' pain and function improved significantly up to 3 wks after injection. In the botulinum toxin type A group, morning Visual Analog Scale improved significantly at 12 wks after intervention and the improvement was sustained for another 3 mos. In the botulinum toxin type A group, Foot and Ankle Ability Measures-sports subscale improved in all evaluated points, whereas in the corticosteroid group, the improvement was significant only when comparing follow-ups values to baseline., Conclusions: Both ultrasound-guided botulinum toxin type A and corticosteroid injection were effective in the treatment of plantar fasciitis. Our study showed that the effects of botulinum toxin type A injection last longer than those of steroid injection., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Extracorporeal shockwave therapy (ESWT) emerged recently for the treatment of musculoskeletal conditions owing to its regenerative and anti-inflammatory effects. In this study, the aim was to compare the efficacies of ESWT and steroid injection in patients with coccydynia., Design: Thirty-four patients with coccydynia were randomized into two groups. In the ESWT group, patients received radial shockwave for three weekly sessions. The second treatment group received an injection of steroid in the tip of the coccyx or sacrococcygeal junction. Outcome measures were visual analog scale, Short-Form Health Survey, and Dallas Pain Questionnaire. Visual analog scale was measured at baseline and 1 wk, 1 mo, 2 mos, and 6 mos after the intervention. Short-Form Health Survey and Dallas Pain Questionnaire were assessed before and 1 mo after treatment., Results: The visual analog scale score was significantly decreased in all follow-ups in both groups. There was also a significant decrease between 1 wk and three other posttreatment visits in the ESWT treatment group. Time and group interaction effect was significant on the visual analog scale (F2.64, 84.63 = 2.95, P = 0.043), in favor of ESWT. Concerning the Short-Form Health Survey and Dallas Pain Questionnaire, only some dimensions improved., Conclusions: ESWT is an effective intervention in patients with coccydynia and had more long-lasting efficacy than steroid in terms of pain relief over 6 mos of observation., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The scope of this study was to assess salivary and serum osteoprotegerin (OPG) levels in knee osteoarthritis (OA)., Methods: Serum and saliva OPG levels of 30 knee OA and 30 matched healthy controls in this cross-sectional study was assessed by ELISA. Knee pain was assessed by WOMAC. Data were analyzed by Student's t-test, Spearman correlation test and ROC., Results: The mean serum but not saliva OPG level was lower in knee OA than that of the healthy group. WOMAC negatively correlated with serum OPG (r = -0.501; P = 0.000). The serum OPG cutoff value was 237.5 pg/ml for the diagnosis of knee OA., Conclusions: As serum OPG was lower in knee OA and negatively correlated with WOMAC, it seems that detection of OPG in serum but not in saliva may be a probable marker to the diagnosis of knee OA., Key Messages: Osteoprotegerin decreases in knee osteoarthritis., (Copyright © 2021 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: The aim of this study was to compare the effects of repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) on pain and quality of life in patients with fibromyalgia., Methods: Thirty participants were randomized into two groups of 15 patients, to receive 3 sessions of either high-frequency (10 Hz) rTMS or 2 mA, 20 min anodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex (DLPFC) over 1 week. Pain was assessed using a Visual Analog Scale (VAS) before treatment, immediately after treatment, 6 and 12 weeks later. Quality of life was evaluated using the Revised Fibromyalgia Impact Questionnaire (FIQR) and psychiatric symptoms were measured using the Depression Anxiety Stress Scale-21 Item (DASS-21) before treatment, and 6 and 12 weeks after treatment., Results: For the VAS there was a significant time-group interaction, showing that the behavior of two groups differed regarding changes of VAS in favor of the RTMS group (df = 1.73, F = 4.80, p = <0.016). Time-group interaction effect on DASS-21 and FIQR was not significant. 66.6% of patients in rTMS group and 26.6% of patients in tDCS group experienced at least a 30% reduction of VAS from baseline to last follow-up (p = 0.028)., Discussion: With the methodology used in this study, both rTMS and tDCS were safe modalities and three sessions of rTMS over DLPFC had greater and longer lasting analgesic effects compared to tDCS in patients with FM. However, considering the limitations of this study, further studies are needed to explore the most effective modality., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Objective: Recently, ozone injection has been used to treat various musculoskeletal diseases. This study was performed to compare ultrasound-guided corticosteroid versus ozone injections in the treatment of carpal tunnel syndrome., Design: Forty patients with mild to moderate carpal tunnel syndrome were enrolled and randomly placed in one of the two groups of receiving a corticosteroid or ozone injection under ultrasound guidance. To determine the effectiveness of both injection techniques and compare their outcomes, visual analog scale and scores of Boston Carpal Tunnel Questionnaire, as well as ultrasound and electrodiagnostic criteria, were followed at 0, 6, and 12 wks after the injection., Results: Both groups showed improvement in visual analog scale and Boston Carpal Tunnel Questionnaire at week 6, and this improvement continued until the 12th week after the injections. However, electrodiagnostic values of sensory nerve action potentials and compound motor action potentials latency, and ultrasound carpal tunnel syndrome criteria showed significant improvement only among the subjects in the corticosteroid group at 6 and 12 wks after the injection (P < 0.05)., Conclusions: Ozone might be as effective as corticosteroid injection in reducing pain and improving the function. Objective improvements in electrodiagnostic and ultrasound criteria of carpal tunnel syndrome were shown only among patients after corticosteroid injection., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: This study was conducted to investigate the effect of Dalk and Ghamz on pain and disability in patients with nonspecific chronic neck pain., Patients and Methods: This study was conducted on 37 patients with nonspecific chronic neck pain. Dalk and Ghamz massage were performed once a week for four sessions and the neck pain was evaluated by visual analog scale (VAS). In addition, the neck disability index (NDI) was used to assess the disability related to neck disorder. Data were analyzed with the SPSS software., Results: Among 37 patients, 85.5% were female and 13.5% were male. A significant decrease in VAS score was observed during the study (F = 57.77, p < 0.001). The NDI score decreased from 27.27 ± 5.83 to 19.08 ± 7.71 (p < 0.001)., Conclusion: Dalk and Ghamz massage in patients with nonspecific neck pain could reduce pain and disability., (© 2020 S. Karger AG, Basel.)

Background: Stroke can cause balance disorders, which often lead to falls and fall-related injuries. The Mini-Balance Evaluation Systems Test (Mini-BESTest) is a balance test that has been recently translated into Persian. The reliability and validity of the Persian version of Mini-BESTest have not been assessed in patients with stroke., Objectives: To assess the reliability and validity of the Persian version of the Mini-BESTest in patients with stroke., Methods: A cross-sectional study was designed. Thirty patients with stroke participated in this study. Patients were tested using the Mini-BESTest according to the Persian instructions, and two raters independently rated each patient's performance. Each patient was matched with a healthy adult in the terms of age and gender. Healthy subjects were also tested for discriminative validity., Results: There was excellent correlation between two raters on the Persian version of the Mini-BESTest total scores (r Pearson  = 0.98, P < 0.001) and its sections (r Pearson  > 0.9). There was a significant difference between stroke patients and healthy subjects confirming the discriminative validity of the Persian version of the Mini-BESTest (19.4 ± 5.4 vs. 24.8 ± 2.3, P < 0.001)., Limitations: We only assessed stroke patients, and the results may not be generalized to other patients with balance deficits., Conclusions: The Persian version of the Mini-BESTest is a reliable and valid tool for balance evaluation of stroke patients.

Background: Due to the limitations of pharmacological and surgical management of knee osteoarthritis (OA), several non-pharmacologic approaches including transcutaneous electrical nerve stimulation (TENS) and transcranial direct current stimulation (tDCS) have been introduced, with promising results., Objective: We aimed to investigate and compare the therapeutic effects of TENS and tDCS for the treatment of patients with knee OA., Methods: In this double-blinded randomized controlled trial, a total of 40 adult patients with knee OA were randomly allocated to either the TENS or the tDCS group. Patients in either group received 6 sessions of the TENS or tDCS for 2 weeks. Knee strengthening exercises were performed twice daily for the entire treatment period. Patients were evaluated using the visual analogue scale (VAS) and Western Ontario and McMaster Universities (WOMAC)., Results: Significant improvement was observed in all outcomes in both TENS and tDCS groups at each follow up compared to baseline although the early improvement (first follow-up) in the WOMAC index was not significant in the TENS group. Based on the within-subject analysis, the behavior of two treatment groups did not differ regarding the changes in the course of the VAS, WOMAC score and its subscales, i.e. stiffness, pain and function (p = 0.263, 0.051, 0.198, 0.075, and 0.146, respectively)., Conclusions: Based on the results of this study, the effect of tDCS and TENS was not significantly different on pain and function of patients with knee OA., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Background: This is an update of a Cochrane Review published in 2014. Chronic non-specific low back pain (LBP) has become one of the main causes of disability in the adult population around the world. Although therapeutic ultrasound is not recommended in recent clinical guidelines, it is frequently used by physiotherapists in the treatment of chronic LBP., Objectives: The objective of this review was to determine the effectiveness of therapeutic ultrasound in the management of chronic non-specific LBP. A secondary objective was to determine the most effective dosage and intensity of therapeutic ultrasound for chronic LBP., Search Methods: We performed electronic searches in CENTRAL, MEDLINE, Embase, CINAHL, PEDro, Index to Chiropractic Literature, and two trials registers to 7 January 2020. We checked the reference lists of eligible studies and relevant systematic reviews and performed forward citation searching., Selection Criteria: We included randomised controlled trials (RCTs) on therapeutic ultrasound for chronic non-specific LBP. We compared ultrasound (either alone or in combination with another treatment) with placebo or other interventions for chronic LBP., Data Collection and Analysis: Two review authors independently assessed the risk of bias of each trial and extracted the data. We performed a meta-analysis when sufficient clinical and statistical homogeneity existed. We determined the certainty of the evidence for each comparison using the GRADE approach., Main Results: We included 10 RCTs involving a total of 1025 participants with chronic LBP. The included studies were carried out in secondary care settings in Turkey, Iran, Saudi Arabia, Croatia, the UK, and the USA, and most applied therapeutic ultrasound in addition to another treatment, for six to 18 treatment sessions. The risk of bias was unclear in most studies. Eight studies (80%) had unclear or high risk of selection bias; no studies blinded care providers to the intervention; and only five studies (50%) blinded participants. There was a risk of selective reporting in eight studies (80%), and no studies adequately assessed compliance with the intervention. There was very low-certainty evidence (downgraded for imprecision, inconsistency, and limitations in design) of little to no difference between therapeutic ultrasound and placebo for short-term pain improvement (mean difference (MD) -7.12, 95% confidence interval (CI) -17.99 to 3.75; n = 121, 3 RCTs; 0-to-100-point visual analogue scale (VAS)). There was also moderate-certainty evidence (downgraded for imprecision) of little to no difference in the number of participants achieving a 30% reduction in pain in the short term (risk ratio 1.08, 95% CI 0.81 to 1.44; n = 225, 1 RCT). There was low-certainty evidence (downgraded for imprecision and limitations in design) that therapeutic ultrasound has a small effect on back-specific function compared with placebo in the short term (standardised mean difference -0.29, 95% CI -0.51 to -0.07 (MD -1.07, 95% CI -1.89 to -0.26; Roland Morris Disability Questionnaire); n = 325; 4 RCTs), but this effect does not appear to be clinically important. There was moderate-certainty evidence (downgraded for imprecision) of little to no difference between therapeutic ultrasound and placebo on well-being (MD -2.71, 95% CI -9.85 to 4.44; n = 267, 2 RCTs; general health subscale of the 36-item Short Form Health Survey (SF-36)). Two studies (n = 486) reported on overall improvement and satisfaction between groups, and both reported little to no difference between groups (low-certainty evidence, downgraded for serious imprecision). One study (n = 225) reported on adverse events and did not identify any adverse events related to the intervention (low-certainty evidence, downgraded for serious imprecision). No study reported on disability for this comparison. We do not know whether therapeutic ultrasound in addition to exercise results in better outcomes than exercise alone because the certainty of the evidence for all outcomes was very low (downgraded for imprecision and serious limitations in design). The estimate effect for pain was in favour of the ultrasound plus exercise group (MD -21.1, 95% CI -27.6 to -14.5; n = 70, 2 RCTs; 0-to-100-point VAS) at short term. Regarding back-specific function (MD - 0.41, 95% CI -3.14 to 2.32; n = 79, 2 RCTs; Oswestry Disability Questionnaire) and well-being (MD -2.50, 95% CI -9.53 to 4.53; n = 79, 2 RCTs; general health subscale of the SF-36), there was little to no difference between groups at short term. No studies reported on the number of participants achieving a 30% reduction in pain, patient satisfaction, disability, or adverse events for this comparison., Authors' Conclusions: The evidence from this systematic review is uncertain regarding the effect of therapeutic ultrasound on pain in individuals with chronic non-specific LBP. Whilst there is some evidence that therapeutic ultrasound may have a small effect on improving low back function in the short term compared to placebo, the certainty of evidence is very low. The true effect is likely to be substantially different. There are few high-quality randomised trials, and the available trials were very small. The current evidence does not support the use of therapeutic ultrasound in the management of chronic LBP., (Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

The purpose of this study was to investigate the effects of a total-contact insole with and without subthreshold mechanical random noise on the balance control in diabetic patients with mild-to-moderate peripheral neuropathy. Twenty diabetic patients with mild-to-moderate neuropathy was recruited to this study. A total-contact insole was prototyped and vibratory motors were embedded into it. The parameters of the center of pressure (amplitude, velocity, and phase plane portrait) were analyzed after 30-minute walks with the shoe only, the shoe with vibro-medical insole with and without vibrations in eyes open and closed condition. The center of pressure amplitude, velocity, and phase plane portrait in the anterior-posterior and medio-lateral directions were significantly decreased using a vibro-medical insole without vibration in the eyes open condition (p < 0.05), as compared to the shoe, and with vibro- medical insole with vibration in both eyes open and closed conditions (p < 0.05) compared to the shoe. A significant drop was observed in the center of pressure amplitude, velocity and phase plane portrait parameters when the vibro-medical insole with vibration was used compared to vibro- medical insole without vibration in eyes closed condition (p < 0.05). The use of vibro-medical insoles was found to improve the patient's balance control, as compared to the shoe. In the eyes closed condition, an improvement in the balance control was observed only with vibro-medical insole with vibration rather than vibro-medical insole without vibration or the shoe. Current finding suggest that a combination of the total-contact insole with vibration may improve the balance control remarkably in diabetic patients with mild-to-moderate neuropathy., Competing Interests: Declaration of Competing Interest The author(s) received no financial support for the research, authorship, and/or publication of this article., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background and Purpose: Hand tremor is a disturbing yet sometimes resistant symptom in persons with Parkinson disease (PD). Although many exercise regimens for these people have gained attention in recent years, the effect of resistance training and especially eccentric training on parkinsonian tremor is still uncertain. This study was conducted to investigate the precise effect of upper limb eccentric training on hand tremor in PD., Methods: In this randomized controlled trial, a consecutive sample of 21 persons with PD recruited from general hospitals went through 6 weeks of upper limb pure eccentric training as the intervention group (n = 11) or no additional exercise during this period as the control group (n = 10). Resting and postural tremor amplitudes were measured with the cellphone-based accelerometer., Results: Comparing hand tremor amplitudes before and after the trial showed a significant reduction in resting tremor amplitude in the intervention group after exercise sessions (p < 0.05) while detecting no changes in the control group during 6 weeks of study. Meanwhile, postural tremor amplitude remained unchanged in both groups.

Cervicogenic somatic tinnitus is a subtype of subjective tinnitus and is defined as tinnitus in which forceful contractions of jaw and neck muscles modulate its psychoacoustic attributes. Various physical therapies have been proposed for the treatment of somatosensory tinnitus although there is no definitive cure for it. This report describes the use of acupuncture in the treatment of a 71-year-old woman with chronic neck pain who suffered from a left-sided tinnitus for 2 years as well. The tinnitus and neck pain severity was rated as 7 and 6, respectively, on a numeric rating scale of 10. On examination, she had restricted cervical range of motion and several myofascial trigger points in cervical muscles. Audiometric tests of the patient were normal. She received trigger point acupuncture of cervical muscles twice per week for 10 sessions. Her tinnitus completely disappeared after the third session and did not return during the 5-year follow-up. Her neck pain intensity also decreased to 1 on the numeric rating scale after 10 sessions. Based on the results of this study, direct trigger point acupuncture of cervical muscles may be beneficial in the treatment of somatic tinnitus with a long-duration effect., (Copyright © 2019. Published by Elsevier B.V.)

Purpose: Knee ligamentous trauma and the following pain is one of the most prevalent athletic injuries. Transcutaneous electrical nerve stimulation is one of the conservative approaches in controlling pain which is low cost, noninvasive, and safe with low complications. Our purpose was to study whether transcutaneous electrical nerve stimulation (TENS) could help athletes perform better during the first phase of rehabilitation (0-4 weeks) after anterior cruciate ligament (ACL) reconstruction surgery and until the follow-up., Methods: This randomized single blind (exercise instructor and assessor) clinical trial was performed on 70 male athletes, undergone ACL surgery. After the surgery, patients were randomly divided into two groups: the first group received semi-supervised exercise plus high-frequency TENSTENS for 35 min a day and the second group only performed exercises. Treatment duration continued for 20 sessions, 4 weeks. The visual analog scale (VAS) score (100 mm), International Knee Documentation Committee (IKDC) questionnaire and knee flexion Range of motion (ROM) were evaluated for all patients after the surgery (before commencing the rehabilitation program), after 4 weeks and 14 weeks from the surgery., Results: Mixed ANOVA was used to explore the interaction effects of time and group on outcome measures and post hoc additional tests were performed on the data. The VAS, IKDC questionnaire score and knee flexion ROM increased in both groups over time, but the amount of improvement did not differ between the two groups, implying no additional improvement in the group receiving TENS along with exercises., Conclusion: The findings of the present trial shows that adding TENS to a specific protocol of semi-supervised exercise in the first phase of rehabilitation after ACL reconstruction is not efficient on improving knee function and pain more than exercise alone. Implications for Rehabilitation Injury to the anterior cruciate ligament of the knee is a common injury specifically in athletes. Incorporating effective pain relieving strategies during the post anterior cruciate ligament reconstruction surgery rehabilitation could lead to improvement in regaining the range of motion and function of the knee which is of crucial importance after the surgery. Applying transcutaneous electrical nerve stimulation alongside a specific protocol of semi-supervised exercise in the first phase of rehabilitation after anterior cruciate ligament reconstruction did not have any additional effect to exercise alone.

Objective: Plantar fasciitis (PF) is one of the most common causes of heel pain. The affected area is often close to the attachment of plantar fascia to calcaneus bone. The purpose of this study was to compare the effects of ozone (O2-O3) injection to corticosteroid injection under ultrasound guidance for the treatment of chronic PF., Design: Randomized clinical trial., Setting: Academic University and Neuromusculoskeletal Research Center., Subjects: Thirty patients with chronic PF., Methods: The patients were randomly divided into two groups receiving methylprednisolone (15 subjects) vs ozone (O2-O3; 15 subjects). The following outcome measures were assessed before injection and then two weeks and 12 weeks after the injection in each group; morning and daily pain via visual analog scale, daily life and exercise activities via the Foot and Ankle Ability Measure, and plantar fascia thickness at insertion and 1 cm distal to its insertion into the calcaneus via ultrasound imaging., Results: Intragroup changes showed significant improvement in pain, functional parameters, and sonographic findings in both groups (P < 0.05). Pain reduction (both daily and morning) and daily activity improvement were better in the corticosteroid group two weeks after injection; however, at 12 weeks, the ozone (O2-O3) group had significantly more improvement (P = 0.003, P = 0.001, and P = 0.017, respectively)., Conclusions: Both methods were effective in the treatment of chronic PF. Steroid injection provided a more rapid and short-term therapeutic effect. However, ozone (O2-O3) injection led to a slow and longer-lasting treatment outcome. Ozone (O2-O3) injection can be an effective treatment, with slow onset and a longer durability in the treatment of chronic PF., (© 2018 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Knee osteoarthritis (OA) is a common skeletal impairment that can cause many limitations in normal life activities. Stem cell therapy has been studied for decades for its regenerative potency in various diseases. We investigated the safety and efficacy of intra-articular injection of placental mesenchymal stem cells (MSCs) in knee OA healing., Methods: In this double-blind, placebo-controlled clinical trial, 20 patients with symptomatic knee OA were randomly divided into two groups to receive intra-articular injection of either 0.5-0.6 × 10 8 allogenic placenta-derived MSCs or normal saline. The visual analogue scale, Knee OA Outcome Score (KOOS) questionnaire, knee flexion range of motion (ROM) and magnetic resonance arthrography were evaluated for 24 weeks post-treatment. Blood laboratory tests were performed before and 2 weeks after treatment., Results: Four patients in the MSC group showed mild effusion and increased local pain, which resolved safely within 48-72 h. In 2 weeks post-injection there was no serious adverse effect and all of the laboratory test results were unchanged. Early after treatment, there was a significant knee ROM improvement and pain reduction (effect size, 1.4). Significant improvements were seen in quality of life, activity of daily living, sport/recreational activity and decreased OA symptoms in the MSC-injected group until 8 weeks (P < 0.05). These clinical improvements were also noted in 24 weeks post-treatment but were not statistically significant. Chondral thickness was improved in about 10% of the total knee joint area in the intervention group in 24 weeks (effect size, 0.3). There was no significant healing in the medial/lateral meniscus or anterior cruciate ligament. There was no internal organ impairment at 24 weeks follow-up., Conclusion: Single intra-articular allogenic placental MSC injection in knee OA is safe and can result in clinical improvements in 24 weeks follow-up., Trial Registration Number: IRCT2015101823298N., (Copyright © 2018. Published by Elsevier Inc.)

Osteoarthritis (OA) is a chronic multifactorial disease characterized by progressive joint degeneration. The purpose of this study was to compare the effects of ultrasound-guided corticosteroid injection with oxygen-ozone injection in patients with knee OA. This double-blind randomized clinical trial was performed on 62 patients with knee OA. The patients were randomly divided into two groups. In the first group 40 mg triamcinolone (1 cc) and in the second group 10 cc (15 μg/ml) oxygen-ozone (O 2 -O 3 ) were injected into the knee joint under ultrasound guidance. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis (WOMAC), knee flexion range of motion (ROM), effusion in ultrasound images of the suprapatellar recess, and visual analog scale (VAS), which were evaluated before injection, 1 week, 1 month, and 3 months after the treatment. Sixty-two patients (10 men and 52 women) were enrolled with mean age of 57.9 years. VAS improved in both groups (steroid P value = 0.001, oxygen-ozone P value > 0.001). The improvements seen in VAS and WOMAC scores 3 months after treatment were in favor of the oxygen-ozone group when compared to the steroid group (P = 0.041 vs P = 0.19). There was no significant difference between the two groups in ROM and joint effusion seen under ultrasound (ROM p = 0.880, effusion p = 0.362). However, in the oxygen-ozone-receiving group, joint effusion was decreased significantly (p < 0.001). Both steroid and oxygen-ozone injections are effective in patients with knee osteoarthritis. Our study showed that the effects of oxygen-ozone injection last longer than those of steroid injection to the knee joint.

Background and Design: Chronic nonspecific low back pain (CNSLBP) has major socioeconomic as well as personal impact in many industrialized and developing countries. Physiotherapy is a common intervention for this group of patients and using anti-pain physical modalities is a common part of the physical therapy. In a randomized controlled trial we investigated the immediate effect of the Diadynamic current in comparison to TENS on reducing the pain in patients suffering from non specific chronic low back pain., Methods: Thirty patients were randomized into the Diadynamic current and TENS groups. Electrical stimulation was applied for 10 min in the Diadynamic group and for 15 min in the TENS group for one session. Pain, on a 100 mm Visual Analog Scale, and Pressure Pain Threshold (PPT), using an Algometer, was measured before the treatment, after the current application, 20 min later and after 48 h., Results: Pain was decreased significantly after 20 min following the current application only in the TENS group, with no improvement at all measurement points in the group receiving Diadynamic current. PPT was increased immediately after current application in both groups but did not last until later measurements., Conclusion: Diadynamic current had no positive effect on prompt relief of pain in patients suffering from recurrent CNSLBP., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: In this study, the clinical effectiveness of ultrasound-guided corticosteroid injection "above" versus "below" the median nerve for treatment of patients with mild to moderate carpal tunnel syndrome was compared., Design: This prospective randomized double-blind clinical trial included 44 patients with mild to moderate carpal tunnel syndrome. The subjects were randomly assigned to two groups to receive ultrasound-guided injection of 40 mg of triamcinolone either "above" or "below" the involved median nerve. Outcome measures were the Boston Carpal Tunnel Questionnaire, visual analog scale, electrophysiological tests, and ultrasonographic measurement of the median nerve cross-sectional area at baseline, 6, and 12 wks after the injection., Results: All outcome measures improved significantly in both groups at 6 wks after intervention, and these improvements were persevered up to 12 wks of follow-up (all P values <0.05). However, there was no significant difference in measured outcomes between the two groups. No adverse effects were observed., Conclusions: Both above and under median nerve ultrasound-guided steroid injection techniques were effective in reducing the symptoms, improving the function, and improving electrodiagnostic and sonographic findings of carpal tunnel syndrome. However, the amount of improvement in the outcomes did not differ between groups, implying that none of technique has the superiority over another.

Objective: To review the literature and assess the comparative effectiveness of ultrasound-guided versus landmark-guided local corticosteroid injections in patients with carpal tunnel syndrome (CTS)., Data Sources: Cochrane Central Register of Controlled Trials, MEDLINE (PubMed), Embase (Ovid), and Web of Science (from inception to February 1, 2017)., Study Selection: Randomized controlled trials (RCTs) comparing ultrasound-guided injection with landmark-guided injection in patients with CTS were included., Data Extraction: Two authors independently screened abstracts and full texts. The outcomes of interest were Symptom Severity Scale (SSS) and Functional Status Scale (FSS) scores of the Boston Carpal Tunnel Questionnaire and 4 electrodiagnostic parameters, including compound muscle action potential (CMAP), sensory nerve action potential (SNAP), distal motor latency (DML), and distal sensory latency (DSL)., Data Synthesis: Overall, 569 abstracts were retrieved and checked for eligibility; finally, 3 RCTs were included (181 injected hands). Pooled analysis showed that ultrasound-guided injection was more effective in SSS improvement (mean difference [MD], -.46; 95% confidence interval [CI], -.59 to -.32; P<.00001), whereas no significant difference was observed between the 2 methods in terms of the FSS (MD, -.25; 95% CI, -.56 to .05; P=.10). There were also no statistically significant differences in improvements of CMAP (MD, 1.54; 95% CI, 0.01 to 3.07; P=.05), SNAP (MD, -0.02; 95% CI, -6.27 to 6.23; P>.99), DML (MD, .05; 95% CI, -.30 to .39; P=.80), or DSL (MD, .00; 95% CI, -.65 to .65; P>.99)., Conclusions: This review suggested that ultrasound-guided injection was more effective than landmark-guided injection in symptom severity improvement in patients with CTS; however, no significant differences were observed in functional status or electrodiagnostic improvements between the 2 methods., (Copyright © 2017 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Parkinson disease (PD) is one of the common causes of imbalance, and the balance assessment is necessary for treatment and rehabilitation of these patients. The Berg Balance Scale (BBS) has been the main instrument used to evaluate balance impairment. The purpose of this study is to investigate reliability and validity of the Persian translation of BBS in Parkinson disease., Methods: One hundred PD patients (with mean age of 56.8 ± 15.13 years) were included. Interrater reliability was measured with the Kappa statistics and interclass correlation coefficients., Results: The mean values of the BBS scored by the two evaluators were 47/85 ± 11/09 and 48/03 ± 10/90, respectively. The mean of Kappa coefficient between two examiners was 0.76, which was between 0.38 and 0.93 for various items. The total score recorded by both examiners, interclass correlation coefficient, was 0.99, which is excellent. Cronbach's alpha for Iranian version of BBS was 0.92, which shows the excellent reliability of the questionnaire (0.62-0.9 for all items)., Conclusion: The Persian version of the BBS has excellent interrater reliability and internal consistency for the assessment of PD patients.

Objective: This study intended to determine the extent to which Ultrasound could add to the effects of exercise and manual therapy in the rehabilitation treatment of primary adhesive capsulitis., Design: A pilot double blind randomized clinical trial was carried out on 50 patients suffering from primary adhesive capsulitis. Intervention included continuous 3 MHz, 1.5 w/cm 2 Ultrasound, applied for the first group and sham Ultrasound for the second group. In addition specific stretching and strengthening exercises as well as glenohumeral joint mobilization were delivered to both groups. Pain (VAS), functional ability (using Oxford Shoulder Score) and shoulder range of motion were assessed at the baseline, after 10 sessions of treatment, and at 3 months follow-up. An intention to treat Mixed ANOVA analysis was performed to explore the interaction effects of time and group on outcome measures., Results: No significant interaction effect of time and group was seen on pain, function and Range of Motion (p > 0.05), meaning that the amount of improvement in all outcome measures were alike in the two groups., Conclusion: Applying continuous Ultrasound along with a regimen of semi supervised exercise and mobilization in patients with primary adhesive capsulitis did not have any additional effect to the placebo Ultrasound, on outcome measures. Larger scale studies are needed to confirm the findings., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The aim of this study was to examine the additive effect of medical acupuncture on controlling the symptoms of restless legs syndrome (RLS). A total of 46 randomly allocated patients diagnosed with RLS were assigned to receive either 10 sessions of acupuncture plus gabapentin (300 mg/d), or gabapentin (300 mg/d) alone (23 patients in each group) over 4 weeks in a single-blind study. The symptoms of patients were assessed by the Visual Analogue Scale (VAS), the International Restless Legs Syndrome Rating Scale (IRLSRS), and the Pittsburgh Sleep Quality Index (PSQI) at baseline, just after the therapeutic course and 8 weeks later. For all outcome measures, there was a significant time-group interaction, showing that the behavior of groups differed regarding changes in VAS, IRLSRS, and PSQI in favor of the experimental group. After therapeutic course termination and in 8 weeks follow up, VAS and IRLSRS had a significant improvement in both the experimental group and the control group, but PSQI improved significantly just in the experimental group. Based on the findings of the present study, acupuncture plus a low dose of gabapentin (300 mg/d) is clinically useful in the treatment of RLS during 8 weeks follow up, and also has an additive therapeutic effect over gabapentin alone in patients with RLS., (Copyright © 2017. Published by Elsevier B.V.)

Introduction: Balance impairment is a common problem and a major cause of motor disability after stroke. Therefore, this study aimed to investigate whether low-frequency repetitive Transcranial Magnetic Stimulation (rTMS) improves the postural balance problems in stroke patients., Methods: This randomized double blind clinical trial with 12 weeks follow-up was conducted on stroke patients. Treatment was carried with 1 Hz rTMS in contralateral brain hemisphere over the primary motor area for 20 minutes (1200 pulses) for 5 consecutive days. Static postural stability, Medical Research Council (MRC), Berg Balance Scale (BBS), and Fugl-Meyer assessments were evaluated immediately, 3 weeks and 12 weeks after intervention., Results: A total of 26 patients were enrolled (age range=53 to 79 years; 61.5% were male) in this study. Administering rTMS produced a significant recovery based on BBS (df=86, 7; F=7.4; P=0.01), Fugl-Meyer Scale (df=86, 7; F=8.7; P<0.001), MRC score (df=87, 7; F=2.9; P=0.01), and static postural stability (df=87, 7; F=9.8; P<0.001) during the 12 weeks follow-up., Conclusion: According to the findings, rTMS as an adjuvant therapy may improve the static postural stability, falling risk, coordination, motor recovery, and muscle strength in patients with stroke., Competing Interests: Conflict of Interest All authors certify that this manuscript has neither been published in whole nor in part nor being considered for publication elsewhere. The authors have no conflicts of interest to declare.

Objectives: Pelvic organ prolapse (POP) is a prevalent disorder which seriously affects the sufferer's quality of life. The main goal of this study was to evaluate biofeedback impact on quality of life in women with mild to moderate POP., Study Design: 40 females in stages I and II POP were allocated into 2 groups. One group received pelvic floor muscle exercise and lifestyle advice in addition to biofeedback twice a week for 4 weeks, while the other received a lifestyle advice sheet and pelvic floor muscle exercise without biofeedback. A valid Persian version of P-QOL questionnaire was applied to assess the patients̕ quality of life at baseline, 4 weeks and 12 weeks follow up. Pressure biofeedback and Physical examination were also performed in order to determine pelvic floor muscle strength and staging of the prolapse, respectively. Collected data were analyzed by mixed ANOVA test using SPSS 22., Results: Biofeedback improved the quality of life in seven of nine P-QOL domains. However, it had no significant impact either on pelvic floor muscle strength or on the stage of the prolapse., Conclusion: Biofeedback could be considered as a non-invasive treatment leading to quality of life promotion in women with stages I and II POP., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Parkinson is a common and disabling disease that affects patient's and career's quality of life. Unfortunately, medications, such as dopaminergic and sedative-hypnotic drugs, as an effective treatment have unwilling side effects. Recently, Transcranial Direct Current Stimulation (tDCS) in conjunction with medication becomes popular as a complementary safe treatment and several studies have proved its effectiveness on controlling motor and specially non-motor aspects of Parkinson's disease. In this randomized double-blind parallel study, 23 patients with Parkinson's disease divided into two groups of real tDCS plus occupational therapy and sham tDCS plus occupational therapy and the effects of therapeutic sessions (eight sessions tDCS with 0.06 mA/cm 2 current, 20 min on dorsolateral prefrontal cortex) were evaluated on fatigue and daytime sleepiness just after therapeutic course and in 3-month follow-up. tDCS had a significant effect on fatigue and no effect on daytime sleepiness reduction in patients with Parkinson's disease. tDCS is an effective and safe complementary treatment on fatigue reduction in Parkinson's disease.

This study examined the effectiveness of radial extracorporeal shock wave therapy in the treatment of carpal tunnel syndrome (CTS). Forty patients with mild to moderate CTS were allocated to two groups: (i) shock wave + wrist splint and (ii) wrist splint. Patients used wrist splints followed by three sessions of low-energy shock wave therapy in the intervention group and wrist splints alone in the other group. The QuickDASH Questionnaire, visual analogue scale and nerve conduction studies were used to evaluate the patients before the study and at 3, 8 and 12 wk after the start of the treatment. At the end of the study, both groups saw the same clinical benefits. However, a significantly greater improvement in the median nerve distal sensory latency was noted in the shock wave group compared with the control group. We suggest that application of shock wave with alternative protocols may be effective in the treatment of CTS in future studies., (Copyright © 2016 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Purpose: To investigate the effect of low-frequency repetitive transcranial magnetic stimulation (rTMS) on lower extremity (LE) spasticity, motor function and motor neurone excitability in chronic stroke patients., Method: This study was a randomised sham-controlled cross-over trial with 1-week follow-up. A total of 20 post-stroke patients were randomised to receive active (n = 10) or sham (n = 10) rTMS. Fourteen of them (7 in each group) crossed over to the sham or active rTMS after a washout period of 1 month. Interventions consist of five consecutive daily sessions of active or sham rTMS to the unaffected lower extremity motor area (1000 pulses; 1 Hz; 90% of the tibialis anterior motor threshold). Outcome measures were modified modified ashworth scale (MMAS), the H-reflex, lower extremity section of Fugl-Mayer assessment (LE-FMA) and timed UP and GO (TUG) test. All outcomes were measured at three levels in each intervention period: pre- and post-intervention and 1-week follow-up., Results: Friedman's test revealed significant improvement in MMAS score only after active rTMS. This improvement lasted for one week after the active rTMS. Repeated measure analysis of variance (ANOVA) showed significant time*intervention interaction for LE-FMA. There are no differences between groups for the MMAS and LE-FMA. No significant change in Hmax/Mmax ratio and TUG test was noted., Conclusion: Low-frequency rTMS over the LE motor area can improve clinical measures of muscle spasticity and motor function. More studies are needed to clarify the changes underlying this improvement in spasticity. Implications for Rehabilitation Spasticity is a common disorder and one of the causes of long-term disability after stroke. Physical therapy modalities, oral medications, focal intervention and surgical procedures have been used for spasticity reduction. Beneficial effect of the repetitive transcranial magnetic stimulation (rTMS) for post-stroke upper extremity spasticity reduction and motor function improvement was demonstrated in previous studies. This study shows amelioration of lower extremity spasticity and motor function improvement after five daily sessions of inhibitory rTMS to the unaffected brain hemisphere which lasted for at least 1 week following the intervention.