Nezehat UNLUER - Academia.edu (original) (raw)

Papers by Nezehat UNLUER

Research paper thumbnail of The relationship between trunk control, spinal posture, and spinal mobility in patients with multiple sclerosis: a cross-sectional study

Turkish journal of medical sciences, Feb 15, 2024

Background/aim: Trunk control, which plays a key role in balance and mobility, decreases in patie... more Background/aim: Trunk control, which plays a key role in balance and mobility, decreases in patients with multiple sclerosis (PwMS) and many parameters such as sensory, motor, and musculoskeletal systems affect trunk control. The aim of this study was to compare trunk control, spinal mobility, and spinal posture in PwMS with healthy controls and investigate the relationship between trunk control with spinal posture and spinal mobility in PwMS. Materials and methods: The study was completed with 38 PwMS and 38 healthy controls with matched age and sex. Trunk control was evaluated with the Trunk Impairment Scale (TIS). Spinal posture and mobility were evaluated in sagittal and frontal planes using an IDIAG M360 Spinal Mouse. Spinal posture was evaluated in upright, maximum flexion, extension, left and right lateral flexion positions, and spinal mobility was evaluated from upright to flexion, extension, right and left flexion positions in sagittal and frontal planes. Results: TIS scores, thoracic mobility angles (from upright to flexion and left lateral flexion), lumbar mobility angles (from upright to extension and right lateral flexion) and lumbar posture angle (maximum right lateral flexion) were lower, and thoracic posture angles (upright and maximum extension) were higher in PwMS than healthy controls (p < 0.05). No significant difference was found between other spinal postures and mobility values. In addition, there was only a negative relationship between thoracic spinal mobility from upright to extension and trunk control in PwMS (r =-0.349; p = 0.032). Conclusion: These findings indicate the importance of early detection of trunk disturbances in PwMS. Thus, even in the early stages of multiple sclerosis, detailed trunk assessment will guide the implementation of comprehensive exercise programs.

Research paper thumbnail of Investigation of parameters related to lower extremity muscle strength and proprioception in Patients with Multiple Sclerosis: a cross-sectional study

Multiple Sclerosis and Related Disorders

Research paper thumbnail of Investigation of the Relationship Between Trunk Motor Control and Balance, Functional Mobility, and Gait Capacity in Patients with Multiple Sclerosis

Turkish Journal Of Neurology, Oct 4, 2021

The functions of the trunk are critical for balance, functional mobility, and gait capacity. Trun... more The functions of the trunk are critical for balance, functional mobility, and gait capacity. Trunk impairment, balance, functional mobility, and gait capacity are affected in patients with multiple sclerosis (PwMS). This study examines the relationship between trunk motor control and balance, functional mobility, and gait capacity in PwMS with mild to moderate disability. Materials and Methods: The study was conducted in 54 PwMS with an age range of 18-65 years. The disability level was determined by the expanded disability status scale. Trunk motor control was assessed using the trunk impairment scale (TIS). Balance was measured with the Mini-BESTest and single-leg stance test. Functional mobility was measured with the timed up and go test (TUG). Gait capacity was measured with the two-minute walk test. Results: The total points of the TIS were correlated with the Mini-BESTest, single-leg stance test (dominant and non-dominant), TUG, and two-minute walk test in PwMS (r=0.652/p<0.001, r=0.389 p=0.004, r=0.458 p<0.001, r=-0.534 p<0.001, r=0.471 p<0.001, respectively). Conclusion: Our study demonstrated that trunk motor control was related to balance and functional mobility and gait capacity in PwMS with mild to moderate disability. These results suggest that a more detailed assessment of the trunk is essential to plan an effective rehabilitation program for the protection and development of balance, functional mobility, and gait capacity in PwMS with mild to moderate disability.

Research paper thumbnail of Erken ve Orta Evredeki Parkinson Hastalarında Omuz Postürü ve Dengenin İncelenmesi: Bir Pilot Çalışma

DergiPark (Istanbul University), Jun 24, 2021

Bu çalışmanın amacı, erken ve orta evredeki Parkinson hastalarında (PH) omuz postürü ve dengeyi i... more Bu çalışmanın amacı, erken ve orta evredeki Parkinson hastalarında (PH) omuz postürü ve dengeyi incelemekti. Yöntem: Çalışmaya erken ve orta evredeki PH (n=14) ve sağlıklı kontrol grubu (n=14) dahil edildi. Katılımcılar Haziran-Aralık 2019 tarihleri arasında değerlendirildi. Çalışmamızda postür değerlendirilmesi, Android sisteme sahip cihazla PostureScreen Mobile uygulaması kullanılarak yapıldı. Denge, gözler açık ve kapalı olarak Biodex-BioSway™ Denge Sistemi ile değerlendirildi. Bulgular: PostureScreen Mobile uygulamasında PH'da postüral değişikliklerin kontrol grubuna göre daha fazla olduğu görüldü (p<0,05). Erken ve orta evredeki PH'nın kontrol grubuna göre gözler açık ve kapalı dengenin azalmış olduğu görüldü (p<0,05). PH'da gözler açık toplam salınım ile omuz ve başın yer değişiklikleri arasında mükemmel ve çok iyi derece arasında korelasyon ilişkileri bulundu (p<0.05). Gözler kapalı toplam salınım ile omuz ve başın yer değişiklikleri arasında mükemmel ve iyi derece arasında korelasyon ilişkileri bulundu (p<0.05). Gözler kapalı toplam salınım ile anteriorda başın yer değişimi arasında ilişki bulunamadı (p>0.05). Sonuç: Bu çalışmada, erken ve orta evredeki PH'da tremorun başladığı taraftaki omuzda postüral değişikliklerin kontrol grubuna göre daha fazla olduğu ve PH'da dengenin azalmış olduğu görüldü. PH'da omuz ve baş postürü ile denge arasında ilişki olduğu görüldü. Kliniklerde erken ve orta evredeki PH'da omuz ve baş postürünün dengeyi etkileyebileceğini ve yaralanmalara daha açık hale getirebileceğini göz önünde bulundurarak asimetrik postürü önlemeye yönelik müdahalelere rehabilitasyon programının erken döneminden itibaren dahil edilmesi gerektiğini düşünmekteyiz.

Research paper thumbnail of Morphological and mechanical properties of plantar fascia and intrinsic foot muscles in individuals with and without flat foot

Journal of orthopaedic surgery, Sep 1, 2018

Many musculoskeletal disorders are associated with over-pronated foot and decreased medial longit... more Many musculoskeletal disorders are associated with over-pronated foot and decreased medial longitudinal arch (MLA) height. Foot intrinsic muscles and plantar fascia (PF) are the primary structures that support MLA. An important reason for the over-pronated foot and the reduction in the MLA height may be the morphological characteristics of the foot intrinsic muscles and PF as well as changes in their mechanical properties. The aim of the present study is to investigate the morphologic structure and mechanical properties of PF, flexor hallucis brevis (FHB), flexor digitorum brevis (FDB), and abductor hallucis (AbH) muscles in individuals with flat foot and to compare the results with those of healthy individuals. Methods: The study included 80 participants, 40 with flat foot and 40 with normal foot posture. The foot posture of the participants was assessed using the Foot Posture Index. PF, FHB, FDB, and AbH thickness and stiffness were measured with an ultrasonography device using a linear ultrasonography probe. Results: Individuals with flat foot had higher AbH thickness compared to individuals with normal foot posture (p < 0.001), whereas both groups were similar in terms of PF (p ¼ 0.188), FHB (p ¼ 0.627), and FDB (p ¼ 0.212) thickness. Stiffness values of the assessed tissues were similar in both groups (p > 0.05). Conclusion: AbH thickness was higher in individuals with flat foot; however, PF, FHB, and FDB thickness were similar in both groups. In addition, our results suggest that foot posture is not related to the stiffness of the assessed tissues.

Research paper thumbnail of Thickness, cross-sectional area, and stiffness of intrinsic foot muscles affect performance in single-leg stance balance tests in healthy sedentary young females

Journal of Biomechanics, 2020

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Research paper thumbnail of Adherence to Home Exercise Program in Patients with Low Back Pain

Objectives: The purpose of this study was to evaluate the exercise adherence of the patients acco... more Objectives: The purpose of this study was to evaluate the exercise adherence of the patients according to the recommended home exercise program and to determine which exercises were performed more accurately. Materials and Methods: One hundred twenty-one consecutive patients who applied to the Physical Medicine and Rehabilitation Department of Hacettepe University Hospital due to low back pain and who were recommended home exercise program were included in the study. The traditional exercise approaches were applied. On the 10th day following the introduction of the home program, the patients were invited for first control to assess the accuracy of the practice of the exercises. The accuracy of each exercise was analyzed by the physiotherapists (Likert type scoring system from 0 to 4). After 1 month, the patients were called for the second check of the correctness of the application of exercises. The same assessment was repeated. Results: While the number of patients was 121 at the beginning, the number of patients in the first control decreased to 73, the number of patients in the second control decreased to 21 after 1 month. A statistically significant increase was found for only isometric strengthening exercises in terms of the difference in the accurate application of exercises between second and first assessment (p <0.05). Conclusion: It is thought that it would be beneficial to carry out further studies to examine the effects of combined interventions to ensure adherence to the home exercise program.

Research paper thumbnail of An investigation of knee position sense, balance, and dual task performance in different phases of menstrual cycle in females with multiple sclerosis: a pilot study

Multiple sclerosis and related disorders, Sep 1, 2020

Background: Sex hormones have been thought to play an important role in disease progression and i... more Background: Sex hormones have been thought to play an important role in disease progression and inflammatory activity in females with multiple sclerosis. The aim of this study was to investigate knee position sense, balance, and dual task performance in different phases of menstrual cycle in females with multiple sclerosis. Methods: The study included 14 females diagnosed with MS and 13 healthy females with regular menstrual cycles who did not use oral contraceptives. The disability level was determined using the Expanded Disability Status Scale. The mental state was assessed using the Mini-Mental State Examination. Knee position sense was evaluated with an Acumar dual digital inclinometer (Acu360, Acumar, Lafayette, IN, USA). The balance was measured with the Biodex Balance System (Biodex Medical Systems, Shirley, NY, USA). Time taken to complete the Timed Up and Go test (TUG) under 3 conditions (TUG without task, TUG with counting backward from 100 by 3s or listing the names starting with the letter "A" [TUG cognitive ], and TUG while carrying three glasses of water on a tray [TUG motor ]) was measured. Measurements were conducted in the early follicular, ovulation, and luteal phases. Results: As a result, it was found that knee position sense, dynamic balance, and dual task performance decreased in the early follicular phase in both the group of females with multiple sclerosis and the control group (p<0.05). The change of dynamic balance and gait performance in the three phases of the menstrual cycle were different between the groups (p<0.05). Conclusion: As a result, it was found that knee position sense, dynamic balance, and dual task performance in females with multiple sclerosis changed throughout the menstrual cycle. The change in dynamic balance and gait performance differed from the control group during the menstrual cycle. Therefore, we think that each phase of the menstrual cycle should be taken into consideration in the follow-up of physiotherapy evaluations in females with multiple sclerosis.

Research paper thumbnail of A Comparison of Prenatal, Natal, and Postnatal Histories in Children with Cerebral Palsy with and without Swallowing Disorder

Erciyes Medical Journal

In children with suspected cerebral palsy (CP) after birth who are followed up, the possibility o... more In children with suspected cerebral palsy (CP) after birth who are followed up, the possibility of swallowing disorder should also be considered from the early stages and should be evaluated on a regular basis. The aim of the study was to compare the prenatal, natal, and postnatal histories in children with CP with and without swallowing disorder. Materials and Methods: Children with CP who were between 2 and 16 years old and who were currently subjected to oral feeding were evaluated. The demographic characteristics and natal histories of the children were noted by asking their caregivers. The 3-ounce water swallow test was used in swallowing evaluation. Results: On the basis of the results of the water swallow test, 46 children were divided into two groups: those who had no swallowing disorder (n=15) and those who had swallowing disorder (n=31). The groups were similar in terms of histories between the prenatal period and natal period (p>0.05). Postnatal histories, including gagging after sucking, weight loss, chewing problem, and head control, were different between groups (p=0.024, p=0.001, p=0.001, and p=0.047, respectively). Conclusion: It is important to evaluate the postnatal symptoms and motor development of children with CP who have swallowing disorders during follow-up.

Research paper thumbnail of Investigation of the relationship between trunk position sense and balance, functional mobility, fear of falling, and disease stage in Parkinson’s disease

Irish Journal of Medical Science (1971 -)

Research paper thumbnail of What has changed in patients with multiple sclerosis after the pandemic? Fatigue, Physical Activity, Sleep Quality, and Anxiety Levels

DergiPark (Istanbul University), Dec 31, 2021

Amaç: Bu çalışmanın amacı, COVID-19 salgını sırasında Multipl Sklerozlu (MS) hastalarda yorgunluk... more Amaç: Bu çalışmanın amacı, COVID-19 salgını sırasında Multipl Sklerozlu (MS) hastalarda yorgunluk, fiziksel aktivite, uyku kalitesi ve anksiyete düzeylerini COVID-19 öncesine göre karşılaştırmaktı. Gereç ve Yöntemler: Bu kesitsel çalışmada rutin olarak takip ettiğimiz 48 MS hastasına e-posta ile ulaşıldı. Katılımcılardan sosyodemografik veri formu, Yorgunluk Şiddet Ölçeği (YŞÖ), Uluslararası Fiziksel Aktivite Anketi (UFAA), Pittsburgh Uyku Kalitesi İndeksi (PUKİ) ve Hastane Anksiyete ve Depresyon Ölçeği'nin (HADÖ) anksiyete bölümünü içeren çevrimiçi bir anketi doldurmaları istendi. Ayrıca hastaların sosyal izolasyon süreleri ve bu dönemde kimlerle yaşadıkları kaydedildi. Çalışma Türkiye'de 5-15 Mayıs 2020 tarihleri arasında tamamlandı. Bulgular: Yaşları 21-58 arasında olan 30 MS hastası çalışmaya katılmak için gönüllü oldu. COVID-19 pandemi döneminde fiziksel aktivite ve uyku kalitesinin azaldığını ve yorgunluğun arttığını bulduk (p <0,05). Ancak anksiyete düzeyinde anlamlı fark bulunmadı (p> 0,05). Sonuç: Kesitsel tipteki bu çalışmanın sonuçları, fiziksel aktivite, uyku kalitesi ve yorgunluğun pandemi öncesi değerlere göre daha olumsuz olduğunu, ancak anksiyete durumunda herhangi bir değişiklik olmadığını göstermektedir.

Research paper thumbnail of An Investigation of temporomandibular pain, headache, and fatigue in relation with long-term mask use during the COVID-19 pandemic period

Research paper thumbnail of Core stability-based balance training and kinesio taping for balance, trunk control, fear of falling and walking capacity in patients with multiple sclerosis: A randomized single-blinded study

Multiple Sclerosis and Related Disorders

Research paper thumbnail of Erken ve Orta Evredeki Parkinson Hastalarında Omuz Postürü ve Dengenin İncelenmesi: Bir Pilot Çalışma

DergiPark (Istanbul University), Jun 24, 2021

Bu çalışmanın amacı, erken ve orta evredeki Parkinson hastalarında (PH) omuz postürü ve dengeyi i... more Bu çalışmanın amacı, erken ve orta evredeki Parkinson hastalarında (PH) omuz postürü ve dengeyi incelemekti. Yöntem: Çalışmaya erken ve orta evredeki PH (n=14) ve sağlıklı kontrol grubu (n=14) dahil edildi. Katılımcılar Haziran-Aralık 2019 tarihleri arasında değerlendirildi. Çalışmamızda postür değerlendirilmesi, Android sisteme sahip cihazla PostureScreen Mobile uygulaması kullanılarak yapıldı. Denge, gözler açık ve kapalı olarak Biodex-BioSway™ Denge Sistemi ile değerlendirildi. Bulgular: PostureScreen Mobile uygulamasında PH'da postüral değişikliklerin kontrol grubuna göre daha fazla olduğu görüldü (p<0,05). Erken ve orta evredeki PH'nın kontrol grubuna göre gözler açık ve kapalı dengenin azalmış olduğu görüldü (p<0,05). PH'da gözler açık toplam salınım ile omuz ve başın yer değişiklikleri arasında mükemmel ve çok iyi derece arasında korelasyon ilişkileri bulundu (p<0.05). Gözler kapalı toplam salınım ile omuz ve başın yer değişiklikleri arasında mükemmel ve iyi derece arasında korelasyon ilişkileri bulundu (p<0.05). Gözler kapalı toplam salınım ile anteriorda başın yer değişimi arasında ilişki bulunamadı (p>0.05). Sonuç: Bu çalışmada, erken ve orta evredeki PH'da tremorun başladığı taraftaki omuzda postüral değişikliklerin kontrol grubuna göre daha fazla olduğu ve PH'da dengenin azalmış olduğu görüldü. PH'da omuz ve baş postürü ile denge arasında ilişki olduğu görüldü. Kliniklerde erken ve orta evredeki PH'da omuz ve baş postürünün dengeyi etkileyebileceğini ve yaralanmalara daha açık hale getirebileceğini göz önünde bulundurarak asimetrik postürü önlemeye yönelik müdahalelere rehabilitasyon programının erken döneminden itibaren dahil edilmesi gerektiğini düşünmekteyiz.

Research paper thumbnail of An investigation of biomechanics, muscle performance, and disability level of craniocervical region of individuals with temporomandibular disorder

Cranio : the journal of craniomandibular practice, 2021

OBJECTIVE To investigate biomechanics, muscle performance, and disability of the craniocervical r... more OBJECTIVE To investigate biomechanics, muscle performance, and disability of the craniocervical region in temporomandibular disorder (TMD) patients and compare them with controls. METHODS Craniocervical posture was evaluated using lateral photography and radiography. Range of motion, muscle performance, disability, and TMD severity were assessed using an inclinometer, Functional Strength Testing of Cervical Spine, Neck Disability Index, and Fonseca Anamnestic Index, respectively. RESULTS Compared to the control group, the TMD group demonstrated higher cervical flexion angle (p=0.005) and neck disability (p<0.001) as well as lower cervical extension (p=0.040), right cervical rotation (p=0.005), left cervical rotation (p<0.001), and tragus-C7-horizontal (p=0.048) angles, and reduced muscle performances (p≤0.001). Most patients had higher than normal craniocervical angle (p<0.001). Muscle performance in each cervical motion (p<0.005) and disability (p<0.001) were associa...

Research paper thumbnail of An Investigation of the Stiffness and Thickness of Abdominal Muscles in Early/Mild Stage Multiple Sclerosis Patients: A Primary Study

Research paper thumbnail of Yenidoğan ve İnfantta Multifrekans Timpanometri Bulguları

Ozet Amac: Bu calismada 0-28 hafta arasindaki yenidogan ve infant grubunda Transient Oto-akustik ... more Ozet Amac: Bu calismada 0-28 hafta arasindaki yenidogan ve infant grubunda Transient Oto-akustik Emisyon (TEOAE) ve Multifrekans Timpanometri (MFT) arasindaki iliskinin degerlendirilmesi amaclanmistir. Gerec ve Yontem: Bu calismaya Hacettepe Universitesi Tip Fakultesi Kulak Burun Bogaz Anabilim Dali Odyoloji ve Konusma Bozukluklari Unitesinde isitme taramasi yapilan ve 0-28 hafta arasi 245 kulak sag ve sol olarak ayni gun degerlendirmeye alindi. Bebeklere otoskopik muayene yapildiktan sonra impedansmetrik degerlendirme ve TEOAE olcumu yapildi. Analizler yapilirken SPSS 13,0 istatistik programi kullanildi. Calisma icin Etik Kuruldan onay alindi . Sonuclar: TEOAE ’dan gecen bebeklerde her iki kulakta 226-678 ve 1000 Hz prob tonda timpanometrik tepe basinc degerleri acisindan anlamli fark bulunmazken, sol kulakta statik admitans degerleri acisindan anlamli fark elde edildi. TEOAE’dan kalan bebeklerde ise sadece sol kulakta timpanometrik tepe basinc degerlerinde anlamli fark bulundu. T...

Research paper thumbnail of Multifrequency Tympanometry Findings In Newborns And Infants

Ozet Amac: Bu calismada 0-28 hafta arasindaki yenidogan ve infant grubunda Transient Oto-akustik ... more Ozet Amac: Bu calismada 0-28 hafta arasindaki yenidogan ve infant grubunda Transient Oto-akustik Emisyon (TEOAE) ve Multifrekans Timpanometri (MFT) arasindaki iliskinin degerlendirilmesi amaclanmistir. Gerec ve Yontem: Bu calismaya Hacettepe Universitesi Tip Fakultesi Kulak Burun Bogaz Anabilim Dali Odyoloji ve Konusma Bozukluklari Unitesinde isitme taramasi yapilan ve 0-28 hafta arasi 245 kulak sag ve sol olarak ayni gun degerlendirmeye alindi. Bebeklere otoskopik muayene yapildiktan sonra impedansmetrik degerlendirme ve TEOAE olcumu yapildi. Analizler yapilirken SPSS 13,0 istatistik programi kullanildi. Calisma icin Etik Kuruldan onay alindi . Sonuclar: TEOAE ’dan gecen bebeklerde her iki kulakta 226-678 ve 1000 Hz prob tonda timpanometrik tepe basinc degerleri acisindan anlamli fark bulunmazken, sol kulakta statik admitans degerleri acisindan anlamli fark elde edildi. TEOAE’dan kalan bebeklerde ise sadece sol kulakta timpanometrik tepe basinc degerlerinde anlamli fark bulundu. T...

Research paper thumbnail of Investigation of the Relationship Between Trunk Motor Control and Balance, Functional Mobility, and Gait Capacity in Patients with Multiple Sclerosis

Turkish Journal Of Neurology, 2021

The functions of the trunk are critical for balance, functional mobility, and gait capacity. Trun... more The functions of the trunk are critical for balance, functional mobility, and gait capacity. Trunk impairment, balance, functional mobility, and gait capacity are affected in patients with multiple sclerosis (PwMS). This study examines the relationship between trunk motor control and balance, functional mobility, and gait capacity in PwMS with mild to moderate disability. Materials and Methods: The study was conducted in 54 PwMS with an age range of 18-65 years. The disability level was determined by the expanded disability status scale. Trunk motor control was assessed using the trunk impairment scale (TIS). Balance was measured with the Mini-BESTest and single-leg stance test. Functional mobility was measured with the timed up and go test (TUG). Gait capacity was measured with the two-minute walk test. Results: The total points of the TIS were correlated with the Mini-BESTest, single-leg stance test (dominant and non-dominant), TUG, and two-minute walk test in PwMS (r=0.652/p<0.001, r=0.389 p=0.004, r=0.458 p<0.001, r=-0.534 p<0.001, r=0.471 p<0.001, respectively). Conclusion: Our study demonstrated that trunk motor control was related to balance and functional mobility and gait capacity in PwMS with mild to moderate disability. These results suggest that a more detailed assessment of the trunk is essential to plan an effective rehabilitation program for the protection and development of balance, functional mobility, and gait capacity in PwMS with mild to moderate disability.

Research paper thumbnail of An investigation of neck pain in older adults, and its relation with shoulder position sense and upper extremity function

Somatosensory & Motor Research, 2021

Abstract Purpose Neck pain is a musculoskeletal problem increasing with age. The disorders that o... more Abstract Purpose Neck pain is a musculoskeletal problem increasing with age. The disorders that occurs in the neck region may also affect the upper extremity due to its close anatomical relationships. The aim of this study was to determine whether neck pain affects shoulder position sense and upper extremity function in the older adults. Methods This cross-sectional study was carried out in nursing homes. The older adults over 65 years of age with chronic neck pain for the last 6 months were included. Pain intensity was evaluated with a Visual Analog Scale. Acumar dual digital inclinometer was used for the evaluation of shoulder position sense. 9-Hole Peg Test was used for the measure of upper extremity function. Results It was found dominant side shoulder position sense and the function of both upper extremities were different between the three groups (p < 0.05). Pain was correlated with dominant and non-dominant 60ᵒ flexion shoulder position sense and 60ᵒ abduction shoulder position sense (p < 0.05). Additionally, a relationship was found only between pain and non-dominant side upper extremity function (p < 0.05). Conclusion In conclusion, we found that in older adults with neck pain, position sense and function decreased in upper extremities. The findings from this study support that detailed evaluation of anatomically related regions as well as the cervical region where pain is felt is important in creating a more effective rehabilitation program.

Research paper thumbnail of The relationship between trunk control, spinal posture, and spinal mobility in patients with multiple sclerosis: a cross-sectional study

Turkish journal of medical sciences, Feb 15, 2024

Background/aim: Trunk control, which plays a key role in balance and mobility, decreases in patie... more Background/aim: Trunk control, which plays a key role in balance and mobility, decreases in patients with multiple sclerosis (PwMS) and many parameters such as sensory, motor, and musculoskeletal systems affect trunk control. The aim of this study was to compare trunk control, spinal mobility, and spinal posture in PwMS with healthy controls and investigate the relationship between trunk control with spinal posture and spinal mobility in PwMS. Materials and methods: The study was completed with 38 PwMS and 38 healthy controls with matched age and sex. Trunk control was evaluated with the Trunk Impairment Scale (TIS). Spinal posture and mobility were evaluated in sagittal and frontal planes using an IDIAG M360 Spinal Mouse. Spinal posture was evaluated in upright, maximum flexion, extension, left and right lateral flexion positions, and spinal mobility was evaluated from upright to flexion, extension, right and left flexion positions in sagittal and frontal planes. Results: TIS scores, thoracic mobility angles (from upright to flexion and left lateral flexion), lumbar mobility angles (from upright to extension and right lateral flexion) and lumbar posture angle (maximum right lateral flexion) were lower, and thoracic posture angles (upright and maximum extension) were higher in PwMS than healthy controls (p < 0.05). No significant difference was found between other spinal postures and mobility values. In addition, there was only a negative relationship between thoracic spinal mobility from upright to extension and trunk control in PwMS (r =-0.349; p = 0.032). Conclusion: These findings indicate the importance of early detection of trunk disturbances in PwMS. Thus, even in the early stages of multiple sclerosis, detailed trunk assessment will guide the implementation of comprehensive exercise programs.

Research paper thumbnail of Investigation of parameters related to lower extremity muscle strength and proprioception in Patients with Multiple Sclerosis: a cross-sectional study

Multiple Sclerosis and Related Disorders

Research paper thumbnail of Investigation of the Relationship Between Trunk Motor Control and Balance, Functional Mobility, and Gait Capacity in Patients with Multiple Sclerosis

Turkish Journal Of Neurology, Oct 4, 2021

The functions of the trunk are critical for balance, functional mobility, and gait capacity. Trun... more The functions of the trunk are critical for balance, functional mobility, and gait capacity. Trunk impairment, balance, functional mobility, and gait capacity are affected in patients with multiple sclerosis (PwMS). This study examines the relationship between trunk motor control and balance, functional mobility, and gait capacity in PwMS with mild to moderate disability. Materials and Methods: The study was conducted in 54 PwMS with an age range of 18-65 years. The disability level was determined by the expanded disability status scale. Trunk motor control was assessed using the trunk impairment scale (TIS). Balance was measured with the Mini-BESTest and single-leg stance test. Functional mobility was measured with the timed up and go test (TUG). Gait capacity was measured with the two-minute walk test. Results: The total points of the TIS were correlated with the Mini-BESTest, single-leg stance test (dominant and non-dominant), TUG, and two-minute walk test in PwMS (r=0.652/p<0.001, r=0.389 p=0.004, r=0.458 p<0.001, r=-0.534 p<0.001, r=0.471 p<0.001, respectively). Conclusion: Our study demonstrated that trunk motor control was related to balance and functional mobility and gait capacity in PwMS with mild to moderate disability. These results suggest that a more detailed assessment of the trunk is essential to plan an effective rehabilitation program for the protection and development of balance, functional mobility, and gait capacity in PwMS with mild to moderate disability.

Research paper thumbnail of Erken ve Orta Evredeki Parkinson Hastalarında Omuz Postürü ve Dengenin İncelenmesi: Bir Pilot Çalışma

DergiPark (Istanbul University), Jun 24, 2021

Bu çalışmanın amacı, erken ve orta evredeki Parkinson hastalarında (PH) omuz postürü ve dengeyi i... more Bu çalışmanın amacı, erken ve orta evredeki Parkinson hastalarında (PH) omuz postürü ve dengeyi incelemekti. Yöntem: Çalışmaya erken ve orta evredeki PH (n=14) ve sağlıklı kontrol grubu (n=14) dahil edildi. Katılımcılar Haziran-Aralık 2019 tarihleri arasında değerlendirildi. Çalışmamızda postür değerlendirilmesi, Android sisteme sahip cihazla PostureScreen Mobile uygulaması kullanılarak yapıldı. Denge, gözler açık ve kapalı olarak Biodex-BioSway™ Denge Sistemi ile değerlendirildi. Bulgular: PostureScreen Mobile uygulamasında PH'da postüral değişikliklerin kontrol grubuna göre daha fazla olduğu görüldü (p<0,05). Erken ve orta evredeki PH'nın kontrol grubuna göre gözler açık ve kapalı dengenin azalmış olduğu görüldü (p<0,05). PH'da gözler açık toplam salınım ile omuz ve başın yer değişiklikleri arasında mükemmel ve çok iyi derece arasında korelasyon ilişkileri bulundu (p<0.05). Gözler kapalı toplam salınım ile omuz ve başın yer değişiklikleri arasında mükemmel ve iyi derece arasında korelasyon ilişkileri bulundu (p<0.05). Gözler kapalı toplam salınım ile anteriorda başın yer değişimi arasında ilişki bulunamadı (p>0.05). Sonuç: Bu çalışmada, erken ve orta evredeki PH'da tremorun başladığı taraftaki omuzda postüral değişikliklerin kontrol grubuna göre daha fazla olduğu ve PH'da dengenin azalmış olduğu görüldü. PH'da omuz ve baş postürü ile denge arasında ilişki olduğu görüldü. Kliniklerde erken ve orta evredeki PH'da omuz ve baş postürünün dengeyi etkileyebileceğini ve yaralanmalara daha açık hale getirebileceğini göz önünde bulundurarak asimetrik postürü önlemeye yönelik müdahalelere rehabilitasyon programının erken döneminden itibaren dahil edilmesi gerektiğini düşünmekteyiz.

Research paper thumbnail of Morphological and mechanical properties of plantar fascia and intrinsic foot muscles in individuals with and without flat foot

Journal of orthopaedic surgery, Sep 1, 2018

Many musculoskeletal disorders are associated with over-pronated foot and decreased medial longit... more Many musculoskeletal disorders are associated with over-pronated foot and decreased medial longitudinal arch (MLA) height. Foot intrinsic muscles and plantar fascia (PF) are the primary structures that support MLA. An important reason for the over-pronated foot and the reduction in the MLA height may be the morphological characteristics of the foot intrinsic muscles and PF as well as changes in their mechanical properties. The aim of the present study is to investigate the morphologic structure and mechanical properties of PF, flexor hallucis brevis (FHB), flexor digitorum brevis (FDB), and abductor hallucis (AbH) muscles in individuals with flat foot and to compare the results with those of healthy individuals. Methods: The study included 80 participants, 40 with flat foot and 40 with normal foot posture. The foot posture of the participants was assessed using the Foot Posture Index. PF, FHB, FDB, and AbH thickness and stiffness were measured with an ultrasonography device using a linear ultrasonography probe. Results: Individuals with flat foot had higher AbH thickness compared to individuals with normal foot posture (p < 0.001), whereas both groups were similar in terms of PF (p ¼ 0.188), FHB (p ¼ 0.627), and FDB (p ¼ 0.212) thickness. Stiffness values of the assessed tissues were similar in both groups (p > 0.05). Conclusion: AbH thickness was higher in individuals with flat foot; however, PF, FHB, and FDB thickness were similar in both groups. In addition, our results suggest that foot posture is not related to the stiffness of the assessed tissues.

Research paper thumbnail of Thickness, cross-sectional area, and stiffness of intrinsic foot muscles affect performance in single-leg stance balance tests in healthy sedentary young females

Journal of Biomechanics, 2020

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Research paper thumbnail of Adherence to Home Exercise Program in Patients with Low Back Pain

Objectives: The purpose of this study was to evaluate the exercise adherence of the patients acco... more Objectives: The purpose of this study was to evaluate the exercise adherence of the patients according to the recommended home exercise program and to determine which exercises were performed more accurately. Materials and Methods: One hundred twenty-one consecutive patients who applied to the Physical Medicine and Rehabilitation Department of Hacettepe University Hospital due to low back pain and who were recommended home exercise program were included in the study. The traditional exercise approaches were applied. On the 10th day following the introduction of the home program, the patients were invited for first control to assess the accuracy of the practice of the exercises. The accuracy of each exercise was analyzed by the physiotherapists (Likert type scoring system from 0 to 4). After 1 month, the patients were called for the second check of the correctness of the application of exercises. The same assessment was repeated. Results: While the number of patients was 121 at the beginning, the number of patients in the first control decreased to 73, the number of patients in the second control decreased to 21 after 1 month. A statistically significant increase was found for only isometric strengthening exercises in terms of the difference in the accurate application of exercises between second and first assessment (p <0.05). Conclusion: It is thought that it would be beneficial to carry out further studies to examine the effects of combined interventions to ensure adherence to the home exercise program.

Research paper thumbnail of An investigation of knee position sense, balance, and dual task performance in different phases of menstrual cycle in females with multiple sclerosis: a pilot study

Multiple sclerosis and related disorders, Sep 1, 2020

Background: Sex hormones have been thought to play an important role in disease progression and i... more Background: Sex hormones have been thought to play an important role in disease progression and inflammatory activity in females with multiple sclerosis. The aim of this study was to investigate knee position sense, balance, and dual task performance in different phases of menstrual cycle in females with multiple sclerosis. Methods: The study included 14 females diagnosed with MS and 13 healthy females with regular menstrual cycles who did not use oral contraceptives. The disability level was determined using the Expanded Disability Status Scale. The mental state was assessed using the Mini-Mental State Examination. Knee position sense was evaluated with an Acumar dual digital inclinometer (Acu360, Acumar, Lafayette, IN, USA). The balance was measured with the Biodex Balance System (Biodex Medical Systems, Shirley, NY, USA). Time taken to complete the Timed Up and Go test (TUG) under 3 conditions (TUG without task, TUG with counting backward from 100 by 3s or listing the names starting with the letter "A" [TUG cognitive ], and TUG while carrying three glasses of water on a tray [TUG motor ]) was measured. Measurements were conducted in the early follicular, ovulation, and luteal phases. Results: As a result, it was found that knee position sense, dynamic balance, and dual task performance decreased in the early follicular phase in both the group of females with multiple sclerosis and the control group (p<0.05). The change of dynamic balance and gait performance in the three phases of the menstrual cycle were different between the groups (p<0.05). Conclusion: As a result, it was found that knee position sense, dynamic balance, and dual task performance in females with multiple sclerosis changed throughout the menstrual cycle. The change in dynamic balance and gait performance differed from the control group during the menstrual cycle. Therefore, we think that each phase of the menstrual cycle should be taken into consideration in the follow-up of physiotherapy evaluations in females with multiple sclerosis.

Research paper thumbnail of A Comparison of Prenatal, Natal, and Postnatal Histories in Children with Cerebral Palsy with and without Swallowing Disorder

Erciyes Medical Journal

In children with suspected cerebral palsy (CP) after birth who are followed up, the possibility o... more In children with suspected cerebral palsy (CP) after birth who are followed up, the possibility of swallowing disorder should also be considered from the early stages and should be evaluated on a regular basis. The aim of the study was to compare the prenatal, natal, and postnatal histories in children with CP with and without swallowing disorder. Materials and Methods: Children with CP who were between 2 and 16 years old and who were currently subjected to oral feeding were evaluated. The demographic characteristics and natal histories of the children were noted by asking their caregivers. The 3-ounce water swallow test was used in swallowing evaluation. Results: On the basis of the results of the water swallow test, 46 children were divided into two groups: those who had no swallowing disorder (n=15) and those who had swallowing disorder (n=31). The groups were similar in terms of histories between the prenatal period and natal period (p>0.05). Postnatal histories, including gagging after sucking, weight loss, chewing problem, and head control, were different between groups (p=0.024, p=0.001, p=0.001, and p=0.047, respectively). Conclusion: It is important to evaluate the postnatal symptoms and motor development of children with CP who have swallowing disorders during follow-up.

Research paper thumbnail of Investigation of the relationship between trunk position sense and balance, functional mobility, fear of falling, and disease stage in Parkinson’s disease

Irish Journal of Medical Science (1971 -)

Research paper thumbnail of What has changed in patients with multiple sclerosis after the pandemic? Fatigue, Physical Activity, Sleep Quality, and Anxiety Levels

DergiPark (Istanbul University), Dec 31, 2021

Amaç: Bu çalışmanın amacı, COVID-19 salgını sırasında Multipl Sklerozlu (MS) hastalarda yorgunluk... more Amaç: Bu çalışmanın amacı, COVID-19 salgını sırasında Multipl Sklerozlu (MS) hastalarda yorgunluk, fiziksel aktivite, uyku kalitesi ve anksiyete düzeylerini COVID-19 öncesine göre karşılaştırmaktı. Gereç ve Yöntemler: Bu kesitsel çalışmada rutin olarak takip ettiğimiz 48 MS hastasına e-posta ile ulaşıldı. Katılımcılardan sosyodemografik veri formu, Yorgunluk Şiddet Ölçeği (YŞÖ), Uluslararası Fiziksel Aktivite Anketi (UFAA), Pittsburgh Uyku Kalitesi İndeksi (PUKİ) ve Hastane Anksiyete ve Depresyon Ölçeği'nin (HADÖ) anksiyete bölümünü içeren çevrimiçi bir anketi doldurmaları istendi. Ayrıca hastaların sosyal izolasyon süreleri ve bu dönemde kimlerle yaşadıkları kaydedildi. Çalışma Türkiye'de 5-15 Mayıs 2020 tarihleri arasında tamamlandı. Bulgular: Yaşları 21-58 arasında olan 30 MS hastası çalışmaya katılmak için gönüllü oldu. COVID-19 pandemi döneminde fiziksel aktivite ve uyku kalitesinin azaldığını ve yorgunluğun arttığını bulduk (p <0,05). Ancak anksiyete düzeyinde anlamlı fark bulunmadı (p> 0,05). Sonuç: Kesitsel tipteki bu çalışmanın sonuçları, fiziksel aktivite, uyku kalitesi ve yorgunluğun pandemi öncesi değerlere göre daha olumsuz olduğunu, ancak anksiyete durumunda herhangi bir değişiklik olmadığını göstermektedir.

Research paper thumbnail of An Investigation of temporomandibular pain, headache, and fatigue in relation with long-term mask use during the COVID-19 pandemic period

Research paper thumbnail of Core stability-based balance training and kinesio taping for balance, trunk control, fear of falling and walking capacity in patients with multiple sclerosis: A randomized single-blinded study

Multiple Sclerosis and Related Disorders

Research paper thumbnail of Erken ve Orta Evredeki Parkinson Hastalarında Omuz Postürü ve Dengenin İncelenmesi: Bir Pilot Çalışma

DergiPark (Istanbul University), Jun 24, 2021

Bu çalışmanın amacı, erken ve orta evredeki Parkinson hastalarında (PH) omuz postürü ve dengeyi i... more Bu çalışmanın amacı, erken ve orta evredeki Parkinson hastalarında (PH) omuz postürü ve dengeyi incelemekti. Yöntem: Çalışmaya erken ve orta evredeki PH (n=14) ve sağlıklı kontrol grubu (n=14) dahil edildi. Katılımcılar Haziran-Aralık 2019 tarihleri arasında değerlendirildi. Çalışmamızda postür değerlendirilmesi, Android sisteme sahip cihazla PostureScreen Mobile uygulaması kullanılarak yapıldı. Denge, gözler açık ve kapalı olarak Biodex-BioSway™ Denge Sistemi ile değerlendirildi. Bulgular: PostureScreen Mobile uygulamasında PH'da postüral değişikliklerin kontrol grubuna göre daha fazla olduğu görüldü (p<0,05). Erken ve orta evredeki PH'nın kontrol grubuna göre gözler açık ve kapalı dengenin azalmış olduğu görüldü (p<0,05). PH'da gözler açık toplam salınım ile omuz ve başın yer değişiklikleri arasında mükemmel ve çok iyi derece arasında korelasyon ilişkileri bulundu (p<0.05). Gözler kapalı toplam salınım ile omuz ve başın yer değişiklikleri arasında mükemmel ve iyi derece arasında korelasyon ilişkileri bulundu (p<0.05). Gözler kapalı toplam salınım ile anteriorda başın yer değişimi arasında ilişki bulunamadı (p>0.05). Sonuç: Bu çalışmada, erken ve orta evredeki PH'da tremorun başladığı taraftaki omuzda postüral değişikliklerin kontrol grubuna göre daha fazla olduğu ve PH'da dengenin azalmış olduğu görüldü. PH'da omuz ve baş postürü ile denge arasında ilişki olduğu görüldü. Kliniklerde erken ve orta evredeki PH'da omuz ve baş postürünün dengeyi etkileyebileceğini ve yaralanmalara daha açık hale getirebileceğini göz önünde bulundurarak asimetrik postürü önlemeye yönelik müdahalelere rehabilitasyon programının erken döneminden itibaren dahil edilmesi gerektiğini düşünmekteyiz.

Research paper thumbnail of An investigation of biomechanics, muscle performance, and disability level of craniocervical region of individuals with temporomandibular disorder

Cranio : the journal of craniomandibular practice, 2021

OBJECTIVE To investigate biomechanics, muscle performance, and disability of the craniocervical r... more OBJECTIVE To investigate biomechanics, muscle performance, and disability of the craniocervical region in temporomandibular disorder (TMD) patients and compare them with controls. METHODS Craniocervical posture was evaluated using lateral photography and radiography. Range of motion, muscle performance, disability, and TMD severity were assessed using an inclinometer, Functional Strength Testing of Cervical Spine, Neck Disability Index, and Fonseca Anamnestic Index, respectively. RESULTS Compared to the control group, the TMD group demonstrated higher cervical flexion angle (p=0.005) and neck disability (p<0.001) as well as lower cervical extension (p=0.040), right cervical rotation (p=0.005), left cervical rotation (p<0.001), and tragus-C7-horizontal (p=0.048) angles, and reduced muscle performances (p≤0.001). Most patients had higher than normal craniocervical angle (p<0.001). Muscle performance in each cervical motion (p<0.005) and disability (p<0.001) were associa...

Research paper thumbnail of An Investigation of the Stiffness and Thickness of Abdominal Muscles in Early/Mild Stage Multiple Sclerosis Patients: A Primary Study

Research paper thumbnail of Yenidoğan ve İnfantta Multifrekans Timpanometri Bulguları

Ozet Amac: Bu calismada 0-28 hafta arasindaki yenidogan ve infant grubunda Transient Oto-akustik ... more Ozet Amac: Bu calismada 0-28 hafta arasindaki yenidogan ve infant grubunda Transient Oto-akustik Emisyon (TEOAE) ve Multifrekans Timpanometri (MFT) arasindaki iliskinin degerlendirilmesi amaclanmistir. Gerec ve Yontem: Bu calismaya Hacettepe Universitesi Tip Fakultesi Kulak Burun Bogaz Anabilim Dali Odyoloji ve Konusma Bozukluklari Unitesinde isitme taramasi yapilan ve 0-28 hafta arasi 245 kulak sag ve sol olarak ayni gun degerlendirmeye alindi. Bebeklere otoskopik muayene yapildiktan sonra impedansmetrik degerlendirme ve TEOAE olcumu yapildi. Analizler yapilirken SPSS 13,0 istatistik programi kullanildi. Calisma icin Etik Kuruldan onay alindi . Sonuclar: TEOAE ’dan gecen bebeklerde her iki kulakta 226-678 ve 1000 Hz prob tonda timpanometrik tepe basinc degerleri acisindan anlamli fark bulunmazken, sol kulakta statik admitans degerleri acisindan anlamli fark elde edildi. TEOAE’dan kalan bebeklerde ise sadece sol kulakta timpanometrik tepe basinc degerlerinde anlamli fark bulundu. T...

Research paper thumbnail of Multifrequency Tympanometry Findings In Newborns And Infants

Ozet Amac: Bu calismada 0-28 hafta arasindaki yenidogan ve infant grubunda Transient Oto-akustik ... more Ozet Amac: Bu calismada 0-28 hafta arasindaki yenidogan ve infant grubunda Transient Oto-akustik Emisyon (TEOAE) ve Multifrekans Timpanometri (MFT) arasindaki iliskinin degerlendirilmesi amaclanmistir. Gerec ve Yontem: Bu calismaya Hacettepe Universitesi Tip Fakultesi Kulak Burun Bogaz Anabilim Dali Odyoloji ve Konusma Bozukluklari Unitesinde isitme taramasi yapilan ve 0-28 hafta arasi 245 kulak sag ve sol olarak ayni gun degerlendirmeye alindi. Bebeklere otoskopik muayene yapildiktan sonra impedansmetrik degerlendirme ve TEOAE olcumu yapildi. Analizler yapilirken SPSS 13,0 istatistik programi kullanildi. Calisma icin Etik Kuruldan onay alindi . Sonuclar: TEOAE ’dan gecen bebeklerde her iki kulakta 226-678 ve 1000 Hz prob tonda timpanometrik tepe basinc degerleri acisindan anlamli fark bulunmazken, sol kulakta statik admitans degerleri acisindan anlamli fark elde edildi. TEOAE’dan kalan bebeklerde ise sadece sol kulakta timpanometrik tepe basinc degerlerinde anlamli fark bulundu. T...

Research paper thumbnail of Investigation of the Relationship Between Trunk Motor Control and Balance, Functional Mobility, and Gait Capacity in Patients with Multiple Sclerosis

Turkish Journal Of Neurology, 2021

The functions of the trunk are critical for balance, functional mobility, and gait capacity. Trun... more The functions of the trunk are critical for balance, functional mobility, and gait capacity. Trunk impairment, balance, functional mobility, and gait capacity are affected in patients with multiple sclerosis (PwMS). This study examines the relationship between trunk motor control and balance, functional mobility, and gait capacity in PwMS with mild to moderate disability. Materials and Methods: The study was conducted in 54 PwMS with an age range of 18-65 years. The disability level was determined by the expanded disability status scale. Trunk motor control was assessed using the trunk impairment scale (TIS). Balance was measured with the Mini-BESTest and single-leg stance test. Functional mobility was measured with the timed up and go test (TUG). Gait capacity was measured with the two-minute walk test. Results: The total points of the TIS were correlated with the Mini-BESTest, single-leg stance test (dominant and non-dominant), TUG, and two-minute walk test in PwMS (r=0.652/p<0.001, r=0.389 p=0.004, r=0.458 p<0.001, r=-0.534 p<0.001, r=0.471 p<0.001, respectively). Conclusion: Our study demonstrated that trunk motor control was related to balance and functional mobility and gait capacity in PwMS with mild to moderate disability. These results suggest that a more detailed assessment of the trunk is essential to plan an effective rehabilitation program for the protection and development of balance, functional mobility, and gait capacity in PwMS with mild to moderate disability.

Research paper thumbnail of An investigation of neck pain in older adults, and its relation with shoulder position sense and upper extremity function

Somatosensory & Motor Research, 2021

Abstract Purpose Neck pain is a musculoskeletal problem increasing with age. The disorders that o... more Abstract Purpose Neck pain is a musculoskeletal problem increasing with age. The disorders that occurs in the neck region may also affect the upper extremity due to its close anatomical relationships. The aim of this study was to determine whether neck pain affects shoulder position sense and upper extremity function in the older adults. Methods This cross-sectional study was carried out in nursing homes. The older adults over 65 years of age with chronic neck pain for the last 6 months were included. Pain intensity was evaluated with a Visual Analog Scale. Acumar dual digital inclinometer was used for the evaluation of shoulder position sense. 9-Hole Peg Test was used for the measure of upper extremity function. Results It was found dominant side shoulder position sense and the function of both upper extremities were different between the three groups (p < 0.05). Pain was correlated with dominant and non-dominant 60ᵒ flexion shoulder position sense and 60ᵒ abduction shoulder position sense (p < 0.05). Additionally, a relationship was found only between pain and non-dominant side upper extremity function (p < 0.05). Conclusion In conclusion, we found that in older adults with neck pain, position sense and function decreased in upper extremities. The findings from this study support that detailed evaluation of anatomically related regions as well as the cervical region where pain is felt is important in creating a more effective rehabilitation program.