A systematic review on the effectiveness of medical training therapy for subacute and chronic low back pain.

Medical training therapy (MTT) to improve muscular strength and endurance follows evidence based guidelines and is increasingly recommended to patients suffering from subacute and chronic back pain (LBP). This study investigated whether MTT was effective in reducing pain and improving function in patients with subacute or chronic LBP. Data sources were MEDLINE, EMBASE, CINAHL, Pedro, Cochrane Central Register of Controlled Trials. We included RCTs that examined exercise or MTT in adult patients with LBP compared to placebo, no intervention or other interventions. Study outcomes had to include at least one of the following: pain intensity; functional status, absenteeism. Two independent reviewers performed quality assessment. Visual analogue scale ratings ranging from 0-10 MTT quantified the MTT aspects of the intervention. Studies with rating scores >7.5 were included. We identified only 2 studies that examined the effectiveness of MTT. Both trials, one was of high quality, found MTT to decrease pain and improve function significantly better than therapy of uncertain effectiveness. There is moderate evidence that would support the effectiveness of MTT in the treatment chronic LBP. Future high quality RCT will have to clarify whether MTT is effective and would be superior to other forms of therapeutic exercise.

Infrared thermal imaging in medicine.

This review describes the features of modern infrared imaging technology and the standardization protocols for thermal imaging in medicine. The technique essentially uses naturally emitted infrared radiation from the skin surface. Recent studies have investigated the influence of equipment and the methods of image recording. The credibility and acceptance of thermal imaging in medicine is subject to critical use of the technology and proper understanding of thermal physiology. Finally, we review established and evolving medical applications for thermal imaging, including inflammatory diseases, complex regional pain syndrome and Raynaud's phenomenon. Recent interest in the potential applications for fever screening is described, and some other areas of medicine where some research papers have included thermal imaging as an assessment modality. In certain applications thermal imaging is shown to provide objective measurement of temperature changes that are clinically significant.

Severity of chronic venous disorders and its relationship to the calf muscle pump.

BACKGROUND: To investigate the relationship between the calf muscle pump and the clinical severity of chronic venous disorders (CVD) and of venous function parameters. PATIENTS AND METHODS: 84 limbs in 44 patients underwent duplex scan and digital photoplethysmography (DPPG), the range of ankle movement was measured by digital goniometry and strength of calf muscles was determined by dynamometry. Limbs were allocated on the basis of clinical signs of CVD (according to the CEAP classification) into 4 groups: controls (no signs and symptoms of CVD): 34 limbs, C1/2: 24 limbs, C3/4: 16 limbs, C6: 10 limbs. RESULTS: A higher degree in clinical severity of CVD was related to shorter venous refilltime (VRT) and lower venous pump power (VPP) measured by DPPG. The strength of dorsiflexion was significantly reduced in group C6 compared to controls. There was a positive correlation between measurements of DPPG and the strength of dorsiflexion and also with total strength (p < 0.05). In limbs with pathological reflux (> 1 s) the strength of dorsiflexion, range of ankle plantarflexion movement and total range of ankle movement were significantly reduced compared to those without pathological reflux (p < 0,05). Strength of plantarflexion was significantly reduced in group C1/2 compared to control group (p < 0,05). CONCLUSIONS: Strength of dorsiflexion seems to be the main driving factor of normal venous flow and range of ankle movement is impaired in patients with pathological venous reflux. Further prospective studies should clarify if additional strengthening of ankle dorsiflexors should be included in well established venous training programs.

Predicting factors for severity of rheumatoid arthritis: a prospective multicenter cohort study of 172 patients over 3 years.

Rheumatoid arthritis may take an unfavourable course leading to rapid functional decline in a certain percentage of patients. Early identification of these patients is desirable. The aim of this study was to evaluate clinical and laboratory parameters for their value in the prediction of bad outcome. A total of 172 patients with early arthritis were followed for 3 years. Higher initial values for erythrocyte sedimentation rate, IgG and IgM rheumatoid factor, serum concentration of cartilage oligomeric matrix protein, Health Assessment Questionnaire score, Larsen score of feet, disease activity score, and swollen and tender joint count predicted worse outcome. An association with the presence of IgA rheumatoid factor or anti-cyclic-citrullinated peptide could not be established. We conclude that prognosis in an individual with rheumatoid arthritis depends on many factors. The determination of independent prognostic factors for progression of rheumatoid arthritis is a valuable tool in early arthritis to select patients for more aggressive therapy.

Radon therapy for the treatment of rheumatic diseases--review and meta-analysis of controlled clinical trials.

OBJECTIVE: The aim of this study was to analyze the effect of radon therapy on pain in rheumatic diseases. METHODS: MEDLINE and MedKur databases were searched for the terms radon plus therapy, rheum, arthritis, and osteo. Radon therapy centers and experts in the field were contacted, proceedings hand-searched, and bibliographies checked for references of potential importance. Included were all prospective randomized controlled clinical trials that compared clinical effects of radon therapy with other interventions in patients with rheumatic diseases and studied pain intensity. Information concerning patients, interventions, results, and methodology were extracted in a standardized manner by all authors independently and summarized descriptively. Reports on pain reduction were pooled for meta-analysis. RESULTS: Five clinical trials with a total of 338 patients and comparing the effect on pain of radon baths (three trials) or radon speleotherapy (two trials) with control intervention in degenerative spinal disease (two trials), rheumatoid arthritis (one trial) and ankylosing spondylitis (two trials) met the inclusion criteria. In meta-analysis, the pooled data showed no difference immediately after treatment (P=0.13) but significantly better pain reduction in the radon group than the control group at 3 months (P=0.02) and 6 months (P=0.002) after treatment. CONCLUSIONS: The existing trials suggest a positive effect of radon therapy on pain in rheumatic diseases. With respect to the potential clinical effect and given the increasing public interest in radon therapy, there is an urgent need for further randomized controlled clinical investigations with long-term follow-up.

Standardization of infrared imaging.

To provide an atlas and database for the temperature distribution of the skin in normal human subjects aged from 10 years to 75 years. The technique used in digital infrared thermal imaging which has been in use since 1960. Despite, many different applications and published studies, a normal database is not available. It is particularly needed for forensic and hospital clinic use.

Double-blind, randomised, placebo controlled low level laser therapy study in patients with primary Raynaud's phenomenon.

BACKGROUND: No causal treatment of primary Raynaud's phenomenon is available due to its unclear aetiology. Low level laser therapy (LLLT) is applied in a multitude of medical conditions often without sufficient evidence of efficacy and established mechanisms. To asses the effect of this therapy in patients with primary Raynaud's phenomenon a randomised, double blind, placebo controlled cross over study was designed. PATIENTS AND METHODS: Absolute and relative frequency and intensity of vasospastic attacks during three weeks of either LLLT or placebo therapy and results of infrared thermography before onset and at the end of both therapy sequences were evaluated in 15 patients with primary Raynaud's phenomenon. RESULTS: Frequency of Raynaud's attacks was not significantly affected by low level laser therapy. Compared to placebo a significantly lower intensity of attacks during laser irradiation was observed, but no transfer effect occurred. Additionally the mean temperature gradient after cold exposure was reduced after laser irradiation, while the number of fingers showing prolonged rewarming was unaffected. CONCLUSION: Though further studies are necessary to confirm these results we could demonstrate for the first time in a double blind placebo controlled clinical trial that low laser therapy is a potential candidate for an effective therapy of Raynaud's phenomenon, although effects seem to be of short duration.

Thermal imaging in acute herpes zoster or post-zoster neuralgia.

BACKGROUND/AIMS: Asymmetry of normal skin temperature patterns has been reported in patients with herpetic disorders. The aim of the study was to describe the temperature distribution in patients suffering from acute herpes zoster or post-herpetic neuralgia. METHODS: Biographic data, including age, gender and time of onset of the skin lesions, were recorded. The distribution of pain was investigated by pain mapping, and the intensity of pain and dysesthesia was quantified by a visual analogue scale. Infrared thermal images of the affected body regions were performed in all possible views using either an Agema 870 or a NEC San-ei Thermotracer. RESULTS: The mean temperature difference between the affected and the unaffected sides of the body in all patients was 0.52+/-0.30 degrees C. Higher temperatures were detected in early cases with a disease duration of 1-9 days (mean temperature difference: 0.62+/-0.36 degrees C) than in patients with pain scores greater than 79 (mean temperature difference: 0.48+/-0.33 degrees C). Only 6 of 57 patients presented with a temperature difference between the affected side and contralateral side of less than 0.2 degrees C. CONCLUSION: Thermal asymmetry of the skin is a common finding in patients with acute herpes. However, the thermal patterns seem to correlate better with the duration of the disease than with the intensity of pain.

[Medicinal baths for treatment of generalized fibromyalgia]. / Medizinalbader zur therapie der generalisierten fibromyalgie.

OBJECTIVE: We studied whether whirl baths with plain water or with water containing pine oil or valerian have a different influence on pain, disturbed sleep or tender point count. METHODS: A randomized, comparative and investigator-blinded study was performed. Out-patients with generalized fibromyalgia were randomized into three treatment groups. INTERVENTIONS: Therapy consisted of either whirl bath with plain water or with the addition of pine oil or valerian. The baths were carried out 10 times, three times a week. MAIN OUTCOME MEASURES: General pain, change of pain intensity during the day, general well-being and occurrence of disturbed sleep were recorded before and after the therapy. The number of tender points was assessed by digital palpation, the pain threshold on the shinbone and the middle part of the deltoid muscle was measured by the dolorimeter of A. Fischer. The same instrument was used for recording pain threshold and pain tolerance of both trapezius muscles. The tissue compliance of these muscles was measured as well. RESULTS: 30 out of 39 patients included in the study were evaluated statistically. After treatment with valerian bath (n = 12) well-being and sleep were significantly improved and also the tender point count decreased significantly. Pine oil added to the bath water (n = 7) resulted in a significant improvement of well-being, but unfortunately also in a significant decrease of pain threshold of the shinbone and the right deltoid muscle. Whirl bath in plain water (n = 11) reduced general and maximum pain intensity significantly. CONCLUSIONS: Our cautious conclusion of this study is - with respect to the small number of treated patients - that different effects of whirl baths with or without medicinal bath oils can be detected in fibromyalgia patients. Plain water baths modify the pain intensity, medicinal baths improve well-being and sleep.

Diagnosis of Raynaud's phenomenon by thermography.

BACKGROUND/AIMS: The aim was to clarify whether cold fingers before a moderate cold stress test can predict a prolonged delay (more than 20 min) in rewarming, as diagnostic for Raynaud's phenomenon. METHODS: A retrospective study was conducted on 71 patients suspected of suffering from Raynaud's phenomenon. The thermal gradient from the metacarpophalangeal joints to the finger tips was calculated for each finger and cold fingers were defined by a temperature difference of more than -0.5°2C. RESULTS: Combining the frequencies of cold fingers with a diagnosis Raynaud's phenomenon resulted in a sensitivity of 78.4%, a specificity of 72.4% and diagnostic accuracy of 74.0%. CONCLUSION: Based on a positive predictive value of 58.5%, it was concluded, that a prolonged delay of rewarming after a cold stress test cannot be predicted sufficiently by the presence of cold fingers alone, and that a cold stress test is necessary to confirm the diagnosis objectively.

[Electrotherapy]. / Elektrotherapie.

Electrotherapy is defined as the sum of therapeutic modalities of physical medicine capable to change the threshold of elicitation of nerve or muscle. Classification due to applied pulse frequencies, way of action of transcutaneous nerve stimulation (= TENS) and of iontophoresis is described. Pain syndromes, muscle atrophy by loss of activity and support of wound healing are named as accepted indications for electrotherapy. The difficulties of electrical stimulation of paretic muscles and the problem, whether different indications for certain forms of electrotherapy exist or not, is discussed.

Chemically-induced chronic nerve compression in rabbits--a new experimental model for the carpal tunnel syndrome.

In order to create an experimental model for the carpal tunnel syndrome without the use of the commonly applied foreign bodies (silicone or rubber tubes, tourniquets etc.), the present study tried to induce a chemically provoked compression of the median nerve in rabbits. In 9 female rabbits 1 ml of Aethoxskerol 3% (Hydrox-polyethoxy dodecan) was instilled into the carpal tunnel around the median nerve after visualisation of the nerve. The other foreleg served as the control and was treated with the same amount of saline solution. Electroneurophysiologic parameters were registered preoperatively, 1 month and 6 months post surgery and histomorphologic investigations by light and electron microscopy were performed after 6 months. 6 months after treatment with Aethoxysklerol, a statistically significant lengthening of the distal latency period as well as a significant reduction of the compound potential amplitude could be observed. In accordance with these findings, morphological investigation revealed the presence of extensive granulation tissue around the median nerve together with signs of demyelination. Our results indicate that we were able to produce the development of extensive granulation tissue in the carpal tunnel of rabbits with subsequent compression of the median nerve which was confirmed by histomorphologic investigation as well as by measurement of nerve conductive velocity.

[Isokinetic measurements of the stretch strength of the femoral quadriceps muscle in surfers in comparison to healthy, untrained persons]. / Isokinetische Messungen der Streckkraft des M. quadriceps femoris bei Surfsportlern im Vergleich zu gesunden untrainierten Personen.

The strength of the quadriceps muscle of twelve male surfers who practice their sport for more than 10 years was compared with results of 15 male untrained persons. The concentric peak torque of knee extensors was measured every 10 degrees in a range from 90 to 20 degrees isometrically and dynamically with a constant angle velocity of 10 degrees/sec. The difference in torque between the left and the right leg is not significant, but there is a slight dominance in favour of the standing leg. The body weight related strength of the surfers was 3.2 Nm/kg indicating a higher strength characteristic compared to 2.7 Nm/kg of untrained subjects. Moreover the strength values of our group of athletes were above the value of 3 Nm/kg, which is referred to in the literature as representing a good training status. In view of these results it can be concluded that a long-lasting specific training like surfing will change the strength characteristics of the quadriceps muscles, although none of the surfers had undertaken an extensive strength training for the lower extremity.

[The effect of meniscectomy on the strength of the femoral quadriceps muscle after more than 3 years]. / Einfluss der Menisektomie auf die Kraft des M. quadriceps femoris nach mehr als drei Jahren.

This paper investigates the strength of the quadriceps extensor femoris following partial meniscectomy by means of arthrotomy. Measurements were carried out on 30 patients using a velocity-controlled dynamometer. Follow-up ranged from three to twelve years. On clinical examination 17 patients revealed atrophy of the quadriceps, amounting to 1 cm in 12 patients and up to 2 cm in 5 patients. The average difference in muscular strength between the operated leg and the non-operated one totalled 11% in the cases of 1 cm atrophy and 19% in the 2 cm cases. Those patients who presented with no atrophy on the operated leg had an average loss of 4% in muscular strength, which is within the normal range. In addition, an interrelationship was established between measurements carried out at different angular velocities and the extent of quadriceps atrophy. The high percentage of patients showing a weakness of the quadriceps extensor femoris after a long follow-up period is most likely due to the severing of proprioceptors during surgery and to inadequate or lacking postoperative physiotherapy.

[Is mere surgical division of the transverse carpal ligament in treatment of carpal tunnel syndrome adequate?]. / Ist die blosse chirurgische Spaltung des Ligamentum carpi transversum zur Behandlung des Carpaltunnel-Syndroms ausreichend?

In the period between 1985-1986 137 patients underwent simple nerve decompression by division of the carpal ligament as therapy for carpal tunnel syndrome. In a long-term follow-up it was possible to control the results of 61 cases. Beside two patients all showed an absolutely satisfying result, subjectively as well as electroneurophysiologically. Therefore we can recommend simple ligament division as a safe and quick method for the therapy of carpal tunnel syndrome.

[Scintigraphic monitoring of chondro-protective therapy of finger polyarthritis]. / Szintigraphische Kontrolle einer chondroprotektiven Therapie von Fingerpolyarthrosen.

A pilot study in patients with osteoarthritis of fingers was done to clarify the question, whether abnormal joints in bone scanning can predict degenerative changes in X-rays and if scintigraphy is of help in monitoring therapy with chondroprotective medications. 2 groups of 7 patients with symptomatic osteoarthritis of fingers were treated either with galvanic bath alone or in combination with Rumalon-injections for 6 weeks. After therapy the number of abnormal joints in bone scan and number of tender joints was found reduced in both groups, a decrease of the mean circumference of joints was only seen in the Rumalon-group. After 1 year an increase of degenerative signs in X-rays was demonstrated in both groups. But the number of tender joints was smaller in the Rumalon-group than in controls. For abnormal joints in bone scanning a high positive value was calculated regarding to signs of osteoarthritis in radiographs. But no major information in monitoring the chondroprotective efficacy of the medicament was given by bone scanning.

[Comparison of the effectiveness of acupuncture and physical therapy in ambulatory patients with gonarthrosis]. / Vergleich der Wirksamkeit von Akupunktur und Physikotherapie bei ambulanten Gonarthrose-patienten.

A comparative study between acupuncture and physical therapy in patients with gonarthrosis is reported. Patients treated with physical therapy showed 4 parameters significantly reduced after a treatment duration of 2 weeks, and 7 out of 10 parameters after 4 weeks of therapy. Acupuncture could better 2 parameters but only after 4 weeks of treatment. Although physical therapy was superior in most of the objective measurements, the subjective judgement by the patients of the efficacy of both treatments found no significant difference. In summary acupuncture is thought to be only an additional form of treatment in gonarthrosis.

Ultrastructural and autoradiographic investigations of cell cultures derived from tendons or ligamentous material from patients with fibromatous disorders.

Cell cultures were derived from tendons or ligamentous material from patients with carpal tunnel syndrome (CTS), Dupuytren's contracture (DP), tendopathia nodosa (TN) and hallux valgus (HV). The ultrastructure of the operation specimens as well as of the cell monolayers was investigated, using a floating sheet method in order to preserve both cell-to-cell contacts and the orientation of the monolayers. The histologic features of the tissues obtained in the operations were correlated with the ultrastructure of the cells in culture derived from these specimens. In DP, above all in the nodules, an activation of the capillary endothelium in the vicinity of myofibroblasts and mast cells was observed. In CTS the collagen fibrils varied extremely in diameter. In DP and TN biopsies a splicing process of helicoidly arranged fibrils could be seen. A disintegration of elastic fibers in the fibrillar and amorphous components was found in DP nodules, HV and TN tissues. Transitional forms between fibroblasts and myofibroblasts were observed not only in DP but also-though in a smaller percentage--in the cultures derived from the other patients. The cells showed organelles for active protein synthesis and transport. Autophagocytosis and the formation of multilamellated bodies took place in TN and HV cultures. In CTS, DP and TN cultures cells were connected via gap junctions. In some cultures, above all in those derived from CTS, monocilia were found. In CTS cultures the formation of intracellular collagen occurred. Growth parameters were rather low in HV cultures. PLmax (maximal pulse labelling index) values were higher in TN cultures than in DP and HV cultures. Plating efficiency (PE) values were higher in cultures derived from cell-rich and capillarized tissues than in biopsies with few cells.