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H. Mazin. Bellarmine University.

The Bordeaux asylum surgeon Eugène Azam (1822-99) described the case of Félida generic serophene 100 mg with amex, a seamstress buy discount serophene 50 mg on line, during the 1870s order genuine serophene line. Her primary personality was ‘present’ for the birth of her many children but it appears that it was the secondary personality who became pregnant! Some authors have reported on as much as 100 ‘recent cases’ and others have discovered it in 3. Reporting of individuals with 100 or many more ‘personalities’ have excited some commentators to suggest that there is a competition afoot! A significant proportion of cases report hearing voices that have an internal origin. Among the characteristics of the alternate personality are various mood states, various attitudes toward the primary personality, the same or opposite sex, or different chronological ages. Pierre Janet described the mechanism dissociation - elements of consciousness split off to assume an autonomous existence which analysts invoke for this and many other hysterical phenomena, such as amnesia and fugue states. Hypnosis has its enthusiasts as a diagnostic or therapeutic instrument in these cases,(Maldonado & Spiegel, 2003, p. The alternate personality tends to be blamed for promiscuity, self-mutilation, etc. Many psychiatrists hold that the disorder is iatrogenic and culturally dependent, whilst others believe that it is induced by media coverage. Merskey (1992) described the diagnosis as a ‘misdirection of effort which hinders the resolution of serious psychological problems in the lives of patients’. He retains the right to diagnose occasional changes in temperament (constitutional tendency to react to stimuli in a particular way; component of personality that is heritable, developmentally stable, based on emotion, and immune to social/cultural influence) or apparent personality style as dissociative in nature. Some authors decry the fact that many years passed before the condition was 1597 diagnosed. In dissociative (psychogenic) amnesia the person cannot recall important personal information, usually of a traumatic or stressful nature, and the amnesia is too extensive to be explained by ordinary forgetting. Freeman (1993) wrote that ‘it is probably impossible to distinguish [hysterical] amnesias from conscious malingering unless the patient confesses’. In dissociative 1599 (psychogenic – as distinct from that due to depression or epilepsy) fugue there is sudden, unexpected travel away from home or work, accompanied by inability to recall ones past and confusion about personal identity or the assumption of a new identity. Twilight (dreamy) states are characterised by disorientation for time and place and impaired short term memory, as if dreaming. Therapy (psychological, amytal, or hypnosis) is aimed at helping the patient to recall what happened leading up to the fugue. Brief fugues often resolve spontaneously whereas chronic cases may prove to beyond help. Other culturally determined fugues may include possession states in India, amok in Indonesia, latah in Malaysia, bebainan in Indonesia, and ataque de nervios in Latin America. Leading from these thoughts, it has been suggested, speculatively, that the automaticity of certain dissociative disorders might follow from the separation of self-identification/explicit memory from routine activity/implicit memory. The differential diagnosis of wandering includes psychogenic fugue (long journey, behaviour normal, amnesia – may be patchy – for episode, +/- assumption of new identity, may last for days), postictal fugue (less purposeful and briefer), depression, acute stress disorder, malingering, dementia, delirium, alcoholic ‘black-out’, head injury, and hypoglycaemia. Conversion The term ‘conversion’ assumes transformation of unconscious psychic conflict into a physical symptom. This is difficult ‘prove’ unless there is demonstrable temporal proximity between psychosocial stress and symptom onset or if similar circumstances previously led to ‘conversion’ in the same patient. Conversion disorder is commoner in females (married women in Lahore in one study: Chaudhry ea, 2005) than in males and usually, but not exclusively, commences in late childhood or early adulthood. More severe forms of sexual and/or physical abuse in childhood are reported more often by conversion disorder patients. Culturally sanctioned behaviour or experience would include ladies swooning in years gone by or ‘seizures’ during religious ceremonies. Conversion disorder appears to be more common in rural, less educated, non-Western societies, and may be influenced by lack of opportunity for protest. In people with normal vision this will produce involuntary (opticokinetic) nystagmus. Cases of so-called functional dysphonia have been said to have difficulty 1602 expressing their true feelings! When a supine patient flexes a thigh to lift the leg there is a downward contralateral leg movement that can be felt by the examiner’s hand held under the heel. A patient with psychogenic hemiparesis will show Hoover’s sign (lack of downward movement of the ‘unaffected’ leg when the patient tries to raise the ‘paralysed’ leg). Rutter and Hersov (1985) followed up children diagnosed as having conversion hysteria for 4-11 years and almost half were shown to have an organic disorder! Among the many conditions misdiagnosed as hysteria over the years are temporal lobe epilepsy and basal ganglia A-V malformations. In hysterical aphonia there is no vocal cord paralysis (only voluntary cord adduction is impaired) and the patient may be able to cough or hum. Many conversion disorder patients are subsequently found to have somatisation and other neurotic disorders. Also, Chaudhry ea (2005) followed up 107cases (83% female, mean age at start of 23. Stone ea (2005) conducted a systematic review of the literature and found that there has been a 4% rate of misdiagnosis of conversion symptoms since 1970. Hysterical overlay This term is often employed by psychiatrists to infer an inconsistent miscellany of symptoms, signs and behaviours reminiscent of classical hysterical syndromes but here occurring as a reaction to real organic disorder. It is not sufficient to diagnose conversion or dissociation simply on the basis of the non-finding of an organic disorder – positive evidence of a hysterical illness must be sought. Hysteria, in either its conversion or dissociation guises, is rare after 40 years of age, most cases starting before 35 years. Hysteria with onset in middle or old age may be a harbinger of another primary condition. Hysterical psychosis Some patients, who often have hysterical personality traits, were said to become abruptly and transiently psychotic when under stress. There could also be delusions, paranoid thinking, bizarre depersonalisation, and grossly unusual behaviour. Hirsch and Hollender (1969) suggested that the modern equivalent is borderline personality disorder with brief psychotic episodes. Familial cases may have an earlier onset (not 1606 all cases are familial), affect an excess of males, and be frequently comorbid with tics and 1607 developmental disorders, as well as anxiety, mood and disruptive disorders. With isolation the person is only aware of the affectless idea, the affect and impulse from the idea being repressed. In undoing, a compulsive act is done to prevent or undo consequences imagined to follow thoughts or impulses.

The patient is usually awake or presents mild partial brachiofacial sensitive loss (mainly tactile and drowsiness or agitation cheap 100 mg serophene amex, particularly with a right discriminative modalities) discount serophene 25mg online, transient conjugate ipsilat- infarct buy cheap serophene 25mg line. Cognitive signs are always present: in the case eral eye and head deviation and aphasia (aphemia or of a left lesion, aphasia, and most of the time global, Broca aphasia) frequently associated with buccolin- ideomotor apraxia. In the case of a right lesion, gual apraxia in the case of left infarcts and various contralateral multimodal hemineglect (visual, motor, degrees of multimodal hemineglect, anosognosia, 122 sensitive, visual, spatial, auditive), anosognosia (denial anosodiaphoria, confusion and monotone language of illness), anosodiaphoria (indifference to illness), in right lesions. Ischemia in their glect, transcortical motor aphasia and behavioral dis- territory can therefore produce severe deficits with a turbances (with involvement of the supplementary very small-volume lesion. Sensory hemisyndromes affecting mainly minor, except in the case of deafferentation of the cortex the contralateral leg are also described. Clinical function, mutism, anterograde amnesia, grasping, signs include proportional hemiparesis, hemihypesthe- and behavioral disturbances are particularly frequent sia, dysarthria, hypophonia, and occasionally abnormal in ischemia of the deep perforating arteries and the movements in the case of involvement of basal ganglia. Involvement of the corpus callosum can produce The centrum ovale receives its blood supply from the callosal disconnection syndrome, secondary to medullary perforating arteries coming principally interruption of the connection of physical informa- from leptomeningeal arteries. Small infarcts (less than tion from the right hemisphere to cognitive center in 1. Therefore, it is restricted to the deficits are often less proportional than in pontine left hand, which presents ideomotor apraxia, agra- or internal capsule lacunes. A rare but specific visual field defect less severe, with a classic subacute two-phase pre- is a homonymous defect in the upper and lower sentation or even asymptomatic. The two vertebral arteries leave the and repetition but anomia, jargon speech and seman- subclavian arteries, pass through transverse foramina tic paraphasic errors) with left infarct. The manifestations of acute internal carotid occlusion are quite variable, depending on the collateral status Clinical clues to differentiate posterior from and preexisting carotid stenosis. Consciousness is usually more posterior circulation stroke and should be recognized. In contrast, a progressive atherosclerotic occlusion Similarly, headache is more frequent in the posterior is usually less severe, with a classic subacute two- circulation, is typically ipsilateral to the infarct, and phase presentation. Chapter 8: Common stroke syndromes On exam, a disconjugate gaze strongly suggests a eyelid, and hemifacial anhydrosis. It may occur as a fixed misalign- ipsilateral dorsolateral brainstem, upper cervical, or ment of the ocular axis, such as in vertical skew thalamic lesion, but may also occur due to a carotid deviation of the eyes as part of the ocular tilt reaction. If the eyes are deviated toward the hemiparesis, nerves and fascicles that produce ipsilateral signs and i. If somnolence, early anisocoria or vertical A vertical gaze paresis (upwards, downwards, or gaze palsy are present, posterior circulation stroke is both) points to a dorsal mesencephalic lesion and may more probable than carotid territory stroke. The latter structure may also Section 3: Diagnostics and syndromes receive direct (long circumferential) branches from the case, the patient develops paresthesia in the shoulder, vertebral artery. Three classic clinical syndromes are neck stiffness up to opisthotonos, no motor recognized in their territory: the medial medullary responses, small and unreactive pupils, ataxic then stroke (or Déjerine syndrome); the dorsolateral medul- superficial respiratory pattern, Cushing’s triad lary stroke (or Wallenberg syndrome); and the hemi- (hypertension, bradycardia, apnea) and finally cardio- medullary stroke (or Babinski-Nageotte syndrome). With transtentorial herniation, The medial medullary stroke is a rare stroke lethargy and coma are accompanied by central hyper- syndrome and classically includes contralateral hemi- ventilation, upward gaze paralysis, unreactive, mid- paresis sparing the face (corticospinal tract), contra- position pupils and decerebration. The laterodorsal medullary stroke syndrome, leading to contralateral motor and all- is the most common of those three syndromes and modalities sensory deficits, ipsilateral tongue, phar- is named the Wallenberg syndrome, after Adolf ynx and vocal cord weakness and facial thermoalgesic Wallenberg (1862–1946), a German neurologist. Wallenberg syndrome and an infarct in the inferior Dorsolateral medullary stroke (or Wallenberg syn- cerebellum stroke can be seen in isolation or together, drome) is the most common brainstem syndrome the latter being usually the case if the vertebral artery of vertebral artery involvement. It is frequently misdiagnosed as the correct diagnosis is the presence of an unusual Wallenberg syndrome, but the main clinical distinc- nystagmus, which will be purely horizontal or direc- tions are the hearing loss and the peripheral-type tion-changing, and preservation of the vestibulo-ocular facial palsy. Occasionally, horizontal ipsilateral gaze reflex with the head thrust (Halmagyi) maneuver. Nystagmus (middle are nonspecific, such as paresthesias, dysarthria, and/or superior cerebellar peduncle, superior cerebel- (“herald”) hemiparesis or dizziness. Rapid identification of signs have been described, such as ipsilateral chorei- basilar artery ischemia can help to provide aggressive form abnormal movements or palatal myoclonus therapy by i. Severe pontine strokes are characterized by a locked-in syndrome that involves quadriplegia, bilateral face palsy, and horizontal gaze palsy. The anteromedial terri- Distal basilar territory stroke usually leads to mid- tory receives its blood supply from the paramedian brain ischemia and is therefore characterized by arteries, the anterolateral territory from the short ocular manifestations, such as disorders of reflex circumferential arteries (or anterolateral arteries) and voluntary vertical gaze, skew deviation, disorder and the dorsolateral territory from the long circum- of convergence with pseudosixth palsy in the presence ferential arteries (or posterolateral arteries) as well as of hyperconvergence, Collier sign (upper eyelid from the cerebellar arteries. In ventral paramedian retraction), and small pupils with diminished reaction lesions, hemiparesis is the most severe. In anterolat- to light because of interruption of the afferent limb of eral lesions, the motor deficit is mild and can pre- the pupillary reflex. Small midbrain lesions may result dominate in the leg (crural dominant hemiparesis), in nuclear or fascicular third nerve palsies. Nuclear reflecting the topographical orientation of the fibers palsy is recognizable by bilateral upgaze paresis and (leg – lateral, arm – medial) [12]. Other classic midbrain syndromes Involvement of the tegmentum implies more sensory, can be found in Table 8. Different eponym syndromes have been Common sites of atherothrombotic stenosis are the described in the literature, corresponding to circum- origin of vertebral arteries (which can lead to artery- scribed lesions and precise deficits (see Table 8. Embolic clots may and symptoms, especially if atherosclerosis of the ver- arise from vertebral or basilar atherosclerosis or from 127 tebral or basilar artery is the cause. Motor symptoms are infrequent and minor [19] and are mostly related to laterothalamic edema affecting the posterior internal capsule or to ischemia of the cerebral peduncles. In the latter situ- ation, a patient may present severe contralateral hemiplegia, hypesthesia and hemianopsia, mimicking Figure 8. Therefore it can mimic nosia), palinopsia, amusia, Balint syndrome (asimul- cortical and subcortical strokes in the anterior or tanognosia or incapacity to see a scene as a whole, posterior circulation and is also called “the great ocular apraxia or poor hand–eye coordination and imitator”. Its vascularization is subdivided into four optic ataxia or apraxia of gaze), metamorphosia, and territories correlated with the organization of the prosopagnosia [16]. For example, Percheron reported that the The thalamus paramedian arteries may arise from a unique P1 seg- The thalamus is a centrally situated structure with ment or from a vascular arcade connecting both P1 129 extensive reciprocal connections with the cortex, basal segments. It described by Foix and Hillemand, is flexed, pronated is absent in about a third of the population, in which and the thumb is buried beneath the other fingers case the paramedian arteries vascularize its territory. Behavioral disturbances are infrequent in infero- Infarction results in anterograde amnesia (mostly lateral stroke and include soft executive dysfunction reversible if unilateral), automatic-voluntary dissoci- and affective changes, resembling those found after ation with facial paresis for emotional movement, cerebellar stroke [21]. The inferior and middle rami include temporospatial disorientation, euphoria, mis- irrigate parts of the midbrain and the pons, while judgment, lack of spontaneity, apathy, emotional the superior ramus irrigates a variable extent of thal- unconcern, and a unique behavioral pattern, named amus but mostly the dorsomedial nucleus, the intra- palipsychism [21]. With a left lesion, bucco- decreased level of consciousness with or without fluc- facial or limb apraxia and thalamic aphasia can occur tuations, vertical gaze abnormalities and cognitive with reduced fluency, anomia, phonological and impairment, which become more obvious after the semantic paraphasia, perseveration, impaired com- resolution of the somnolence. Bilateral involvement is prehension, acalculia with preservation of reading evidently more severe. Visual-spatial disturbances are present mostly of personality changes with disinhibited behav- with a right lesion. The principal branches supply disturbances is recognized as a “thalamic dementia”. With unilateral infarction, a left–right asym- and lateral pulvinar, as well as the laterodorsal metry is obvious in language versus visual-spatial nucleus. The aphasia, named adynamic aphasia tralateral hemihypesthesia, involving one or several [20], is characterized by a reduced verbal fluency, with sensory modalities. It may be associated with chor- perseveration and paraphasic errors but with a rela- eoathetoid movements, hemiataxia, slight transient tively preserved syntax, comprehension and repetition. They to result from interruption of the dentatorubrothala- supply the pulvinar, part of the lateral and medial mic pathway.

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Aspirin and clopidogrel compared years with acute ischaemic stroke: Canadian Alteplase with clopidogrel alone after recent ischaemic stroke or for Stroke Effectiveness Study generic serophene 25mg mastercard. J Neurol Neurosurg transient ischaemic attack in high-risk patients Psychiatry 2006; 77(7):826–9 buy serophene 25 mg without prescription. Anticoagulants ultrasound monitoring in stroke patients treated with for acute ischaemic stroke discount serophene 100 mg with amex. Thrombolysis with Alteplase treatment in acute cardioembolic stroke: a meta- for acute ischaemic stroke in the Safe Implementation analysis of randomized controlled trials. Detrimental effect of blood pressure reduction in the first 24 hours of acute stroke 17. Glucose-potassium-insulin infusions in recanalization in the first hours after ischemic stroke. Treatment of post-stroke antithrombolytic therapy for ischaemic stroke: the hypertension. N Engl J Med 2005; Groups: The American Academy of Neurology affirms 352(8):777–85. Glucose and insulin therapy in acute acute ischaemic stroke in the Safe Implementation stroke; why delay further? Alteplase infusion followed by subcutaneous insulin treatment in compared with placebo within 3 to 4. Both high and temperature in acute stroke patients is an often blood pressure and low blood pressure were inde- neglected matter although it may have an important pendent prognostic factors for poor outcome. This chapter will summarize consideration that prolongation of the elevated blood the current knowledge regarding the management of pressure may be caused by more severe stroke as the above. However, in most of these studies The association between elevated blood pressure and antihypertensive agents were administrated several recanalization was evaluated in 149 patients after weeks after stroke onset. The authors concluded that namic and metabolic impact of pharmacologically when there is need for or no contraindication against increased systemic blood pressure on the ischemic early antihypertensive therapy, candesartan is a safe core and penumbra was evaluated in rats. Three months after treatment tions including 319 subjects, the small size of the trials began, the active treatment group had a significantly and the inconclusive results limit conclusion as to the lower mortality compared to the placebo group. According to region, but raises the risks of hemorrhagic trans- the American guidelines [21] it is generally agreed formation, cerebral edema, recurrence of stroke and hypertensive encephalopathy. There is an indication to treat blood pressure blood pressure in the acute phase of ischemic stroke only if it is above 220 mmHg systolic or if the mean 244 was found and more research is needed to identify the blood pressure is higher than 120 mmHg. No data are effective strategies for blood pressure management in available to guide selection of medication for the Chapter 17: Management of acute ischemic stroke and its complications lowering of blood pressure in the setting of acute hyperglycemia) or could not be fully classified due ischemic stroke. The recommended medication and to missing data in the oral glucose tolerance test. Several ongoing clinical trials such as pendent of age, stroke type and stroke size. How- these conditions, including impaired vascular tone ever, it is not clear whether hyperglycemia itself and flow, disruption to endothelial function, changes affects stroke outcome or reflects, as a marker, the at the cellular level, intracellular acidosis and severity of the event due to the activation of stress increased aggregation and coagulability. Pretreatment with insulin was found to limit the Among the factors found to contribute to the ischemia. Glucose level is an important risk factor for morbid- In one systematic study [24b] it was shown that ity and mortality after stroke, but it is unclear glucose pathology is seen in up to 80% of acute whether hyperglycemia itself affects stroke out- patients, many of them showing a high probability comes or reflects the severity of the event as a of previously unrecognized diabetes. The study was conducted among 933 hyper- pre-thrombolysis patients, an even more aggres- glycemic acute stroke patients who received glucose- sive approach may be advisable. In the treatment group significantly lowered glucose and blood pressure values were documented; however, Hyperthermia no clinical benefit was found among the treated Several animal studies [35, 36] demonstrated the cor- patients. The time window for treating post-stroke relation of elevated temperature and poor outcome in hyperglycemia still remains uncertain. Similar results were found in variety of methods of insulin administration, includ- human observations. Patients with hyperglycemia temperature was recorded every 2 hours for 72 hours (glucose > 6. Hypothermia was A randomized, multicenter, blinded pilot trial, introduced more than 50 years ago as a protective Treatment of Hyperglycemia in Ischemic Stroke measure for the brain [39]. The aggressive-treatment group was associ- hours after brain injury was not found to be effective ated with somewhat better clinical outcomes, which [41]. Other applications for which therapeutic hypo- were not statistically significant. According to the American high doses ranging between 3900 and 6000 mg daily guidelines [21], even lower serum glucose levels, pos- [42,43], caused only very mild reduction in body sibly between 140 and 185 mg/dl, should trigger temperature, ranging from 0. Despite the current recom- The clinical benefit of this reduction is not well estab- mendation, a more aggressive approach is advised, lished. The use of external cooling aids [44], such as especially in pre-thrombolysis patients. Many ques- cooling blankets, cold infusions and cold washing, tions surrounding the role of glucose lowering ther- aiming at a body temperature of 33 C for 48 to 72 apy remain unanswered [32]. What level of blood hours in patients with severe middle cerebral artery glucose is best for intervention? How long should the insulin Similar results, of decreasing acute post-ischemic Chapter 17: Management of acute ischemic stroke and its complications cerebral edema, were found in a small pilot study Summary of endovascular induced hypothermia [45]. The use Optimal management of hypertension following of an endovascular cooling device which was inserted stroke has not been yet established. A U-shaped rela- into the inferior vena cave was evaluated among tionship between baseline systolic blood pressure and patients with moderate to severe anterior circulation both early death and late death or dependency has territory ischemic stroke in a randomized trial. Stroke patients with impaired consciousness results suggest that this approach is feasible and that showed higher mortality rates with increasing blood moderate hypothermia can be induced in patients pressure. However, the current data do not support the pressure reduction as a secondary prevention of use of induced hypothermia for treatment of patients stroke is well established, but only a few trials have with acute stroke. However, these few peutic potential, hypothermia as a treatment for trials demonstrate a beneficial effect of lowering acute stroke has been investigated in only a few very blood pressure. According to the is still thought of as experimental, and evidence of American guidelines, indication to treat blood pres- efficacy from clinical trials is needed [47]. Glucose level is febrile or non-febrile patients with antipyretics is an important risk factor for morbidity and mortality not proven. In pre-thrombolysis In summary, hypertension, hyperglycemia and patients, an even more aggressive approach may be hyperthermia are common conditions following acute advisable. All three have a major and independent Hyperthermia within the first 24 hours from impact on the severity of outcome. Occasionally, the stroke onset was associated with larger infarct volume benefit of this impact is no less than that of more and worse outcome. Mild induced hypothermia “heroic” strategies such as intravenous and intra- was found to improve neurological outcome and arterial thrombolysis. Despite the lack of consensus reduce mortality following cardiac arrest due to on the data and optimal management, one should ventricular fibrillation, but the current data (few very carefully monitor these three “hyper links” and treat small studies) do not support the use of induced them appropriately.

Mechanical factors such as postural changes (lumbar hyperex- netic feld and electrical stimulation treatment on the projection of tension) probably also contribute to the musculoskeletal symptoms pain generic serophene 25 mg on-line. The second group (control buy serophene 100mg on-line, 22 patients) purchase serophene in india, re- lumbar discs are contributing causes, the major cause for the pain ceived only the basic medication (non-steroid anti-infammations and is usually due to exaggerated lordosis (sway back) which results in myorelaxants). Results: The pain intensity of the patients in the frst spasm of the lumbar muscles. Tender and tight muscles around the group was reduced after 7–10 days of treatment (70% patients) com- spinal column can typically be found on examination. Kinesio-tap- pared to the control group, where pain reduction after 14–16 days of ing technique facilitates circulation and motion due to elevation of treatment (44. Conclusion: The addition of the skin and subcutaneous tissue, decreases infammation and pain. Ma- non-medication therapy (combination of acupuncture, low-frequent terial and Methods: It was designed as prospective clinical trial. The variable magnetic feld and electrical stimulation) to the treatment of aim was to evaluate the effcacy of kinesio-taping for the treatment acute discogenic pain resulted in earlier remission. The kinesio-taping was applied to the lumber region of the patients who was clinically diagnosed with low back pain associated 213 pregnancy. The application of kinesio-tape to the lomber ative pain arise from central sensitization includes allodynia and region in pregnancy who presented with low back pain may be a hyperalgesia. Morphine and anti-infammatory drugs are common safe treatment option to relieve pain and improving quality of life. Von Frey flament test was at 1h, 2 h, 4 h, 24 h after the treatment at primary and secondary area. Introduction/Background: Myofascial pain syndrome is a regional The rats showed twitching refexes on the skin when they sensitized pain condition that was caused by trigger points in muscle or muscle mechanical stimulations as nociceptive stimulations. In recent years, Kinesio tap- sia from the post-operative day 1 to post-operative day 6. However, ing has been used to support injured muscle and joints, and relieve the data showed no effect on allodynia. In this study, the question of whether the kinesio-taping will alleviate post-operative hyperalgesia and that is a local effect. Material and Methods: Prospec- tive, randomized, single-blinded, clinical trial using a repeated measures design. Subjects in group 2 (sham kinesio-taping) and group 3 (kinesio-taping) wore the tape 214 for 2 consecutive 3-day intervals, in addition to injection therapy. X-ray of the ankle 5 6 demonstrated a local heterotopic ossifcation area above the lateral Yorulmaz , A. We referred the patient to the orthopedic service for Yıldırım Beyazıt University Faculty of Medicine, Department of surgical removal. Discussion: The objective of this report was to Physical Medicine and Rehabilitation, Ankara, Turkey, 2Adana describe an unusual localization of heterotopic ossifcation that oc- Numune Training and Research Hospital-, Department of Physical curred without any predisposing factor. R International School, Director, Bioggio, Switzerland, 2Asso- ing fatigue, stiffness and sleep disturbances. Etiology and patho- ciazione di Posturologia Interdisciplinare Svizzera, Vice President, genic mechanisms are still unknown but it is suggested that envi- 3 Bioggio, Switzerland, M. R International School, Medical Direc- ronmental and genetic factors may play role in etiopathogenesis. We planned to examine the probable effect cal science used to measure the results. Results: Posturlogy allows medical sciences, and signs of all the cases were recorded. Fibromyalgia Im- used to scientifcally measure posturology, transforming it into Sci- pact Questionnaire, Visual Analog Scale, Beck Depression Inven- ence. By using posturology and posturometry in combination, this tory, Pittsburgh Sleep Quality Index and Horne-Ostberg Question- method allows medical sciences, to reach at the root of the prob- naire were applied to all cases. Ata4 of Bo’s abdominal acupuncture therapy in treating Shoulder-hand 1 syndrome after stroke. Methods: sixty-two participants with shoul- Golcuk Military Hospital, Physical Medicine and Rehabilitation, 2 der-hand syndrome after stroke were recruited and randomized to Kocaeli, Turkey, Kasimpasa Military Hospital, Physical and Re- 3 the treatment and control groups. The treatment group was given habilitation Medicine, Istanbul, Turkey, Bursa Military Hospital, Bo’s abdominal acupuncture therapy and regular rehabilitation ex- Orthopedic Surgery, Bursa, Turkey, 4Gulhane Military Medical ercise, while the control group was offered regular rehabilitation Academy- Haydarpasa Training Hospital, Physical and Rehabili- exercise alone. Results: The treatment group showed signifcant improve- people were diagnosed with fbromyalgia. Conclusion: Bo’s Abdominal acupuncture relation between hypermobility and pes planus (p<0. Conclusion: Hypermobility can be seen in 5–15% of healthy individuals without any symptoms or with chronic pain complaints. The pur- 1Niigata University Medical and Dental Hospital, Rehabilitation pose of our research was to determine the effect of physiotherapy Center, Niigata, Japan, 2Niigata University Medical and Dental on the autoregulation of cerebral circulation in patients with post- Hospital, Orthopedic surgery, Niigata, Japan concussion syndrome. Material and Methods: We observed 25 pa- tients with consequences of traumatic brain injury. Patients were divided into two purpose of this study was to evaluate the effcacy of a cognitive groups: the frst group were patients who received standard therapy. Sastradimaja1 Introduction/Background: The aim of this study is to investigate 1Hasan Sadikin Hospital, Physical Medicine and Rehabilitation, the frequency of hypermobility and to analyze the relationship with Bandung, Indonesia musculoskeletal disorders in healthy individuals between 18–25 years. The big- evaluated according to the Beighton and Brighton hypermobility gest portion of treatment expenses is due to its disabilities, therefore, criteria. This kind of exercise has were effective on reducing the severity of pain, fatigue, morning not been studied much and has become variable on its application. Material and Methods: This is an interventional study with approaches was compared to each other, aerobic exercise with Ki- pre- and post- intervention measurement. The study was conducted nesio taping treatment was more effective than only aerobic exer- in Dr. Hasan Sadikin General Hospital Bandung between Mar and cise treatment on reducing the severity of pain (p<0. Aly2 Surabaya, Indonesia 1Alexandria, Egypt, 2Faculty of Medicine- Alexandria University, Introduction/Background: Musculoskeletal diseases associated with Physical Medicine- Rheumatology & Rehabilitation, Alexandria, daily activities or occupation have reached the highest proportion Egypt of epidemiology in recent years. The aim of this study was to identify the prevalence of the habilitation of Haji Hospital, Surabaya. Seferoglu 1 arthritis, painful neuropathies, carpal tunnel syndrome, periarthritis of Ataturk University Medical Faculty, Physical Medicine and Reha- the shoulder and/or osteoporosis). Results: We found that aerobic exer- therapy is often preferred for a variety of symptoms. Nevertheless, cise and aerobic exercise with Kinesio taping treatment approaches there is no effective treatment. Stress is the worst detriment to health Trig- right iliac crest was found and partially resected with complete pain gers the “fght or fight” response. In our offce, direct compression of supra-gluteal system is constantly hyperactive. We suspected off the adrenaline system and activate parasympathetic system is to cluneal nerve entrapment so patient underwent medial superior eliminate the pain and stress. The autonomic and central nervous cluneal nerve exploration and release from thoracolumbar fascia.