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Musculoskeletal Conditions Complicating Stroke Rehabilitation: a Clinical and Ultrasound Study

Paolo Falsetti, Caterina Acciai, Francesco Carpinteri, Barbara Gallai, Rosanna Palilla, Lucia Lenzi, Italy

Objective: the aims of this study were to evaluate incidence and clinical predictors of musculoskeletal complications in patients with stroke in a neurorehabilitation setting, and to describe its clinical and ultrasound (US) features, and its impact on functional recovery. Methods: in all, 130 consecutive patients admitted in tertiary-level neurorehabilitation unit with diagnosis of ischemic or hemorrhagic stroke, were enrolled. All the patients with symptoms or signs of musculoskeletal pathology, underwent bedside musculoskeletal US. Results: musculoskeletal pathologies were diagnosed in 66/130 (51%), more frequently in females (p=0.005). In 88% US clarified diagnosis and/or modified therapeutic approach. Shoulder pain was observed in 40/130 (31%). US showed a shoulder subluxation in 82% and a frozen shoulder in 5% of painful shoulders. In all the cases of painful shoulder rotator cuff abnormalities was noted. Wrist-hand syndrome was observed in 25/130 (19%). US showed mild effusion in wrist joints and tendon sheaths and subcutaneous edema without significant vascularity. Neurogenic heterotopic ossification were observed in 2/130 (1,5%). US demonstrated the "zone phenomenon" or heterogeneously hypoechoic mass with low resistance vessels within the lesions. Contractures and spasticity were observed in 27/130 (21%). Relapsing osteoarthritis and acute arthritis were diagnosed in 23/130 (18%) and 10/130 (8%) respectively. Cortical stroke of nondominant side was associated with musculoskeletal complications (p=0.0249) while posterior circulation stroke showed a reduced incidence of musculoskeletal complications (p=0.0002). Musculoskeletal complications were significantly associated to hemispatial neglect (p=0.018) and depression (p=0.0004). Significant increase of erythrocyte sedimentation rate (p=0.0008) and lower hemoglobine concentrations (p=0.01) were noted in patients with musculoskeletal complications. Patients with musculoskeletal complications had lower Katz index scores in discharge (p<0.0026) and more length of hospital stay (p=0.0008). Conclusion: Musculoskeletal pathologies complicate the course of stroke in about half of patients admitted to rehabilitation, and they delay functional recovery. Patients with cortical stroke of nondominant side and hemispatial neglect are more prone to develop musculoskeletal complications. Bedside US is a cheap and sensitive diagnostic tool and it can aid clinicians to define diagnosis and to choose therapeutic approach.

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