Extracorporeal shock wave therapy and ultrasound therapy improve pain and function in patients with carpal tunnel syndrome. A randomized controlled trial.

BACKGROUND: Ultrasound (US) therapy improves symptoms in carpal tunnel syndrome (CTS) patients. Extracorporeal shock wave therapy (ESWT) uses acoustic energy to determine its clinical effects, as US-therapy does. AIM: The aim of this study was to compare the short-term efficacy of US and ESWT on mild and moderate CTS. STUDY DESIGN: Randomized controlled trial. SETTING: University outpatient service. POPULATION: Twenty-five patients with mild to moderate CTS, for a total of 42 wrists. METHODS: patients were randomized to receive US, cryo-US or ESWT, and were evaluated for pain and function before treatment started, at the end of treatment, and four and 12 weeks after the end of the treatment. RESULTS: Significant improvement was noted in all groups for pain (P<0.05) and functionality (P<0.05). Patients in ESWT group show greater pain improvement at 12-weeks follow-up when compared with both US and cryo-US groups (P<0.05). CONCLUSION: Patients affected by CTS might benefit from the application of US, cryo-US or ESWT. Benefits persist 3 months after the end of treatment. CLINICAL REHABIL IMPACT: Clinicians might consider the possibility of a short-term non-surgical management for mild-to-moderate CTS.

Clinical application of shock wave therapy (SWT) in musculoskeletal disorders.

Currently the application of shock wave therapy (SWT) in musculoskeletal disorders has been primarily used in the treatment of tendinopathies (proximal plantar fasciopathy, lateral elbow tendinopathy, calcific tendinopathy of the shoulder, and patellar tendinopathy, etc.) and bone defects (delayed- and non-union of bone fractures, avascular necrosis of femoral head, etc.). Although the mechanism of their therapeutic effects are still unknown, the majority of published papers have shown positive and beneficial effects of using SWT as a treatment for musculoskeletal disorders, with a success rate ranging from 65% to 91%, while the complications are low or negligible. The purpose of this paper is to inform the reader about the published data on the clinical application of SWT in the treatment of musculoskeletal disorders. In this paper, with the help of a literature review, indications and success rates for SWT in the treatment of musculoskeletal disorders are outlined, while adequate SWT parameters (e.g., rate of impulses, energy flux density, etc.) are defined according to the present state of knowledge.

Patient-oriented rehabilitation in the management of chronic mechanical neck pain: a randomized controlled trial.

BACKGROUND: Management of chronic mechanical neck pain (CMNP) still represents a challenge. A patient-oriented (Pa-O) therapeutic approach could be considered as the one in which therapies are scheduled at the start of each therapeutic session according to the patient's current physical status, and differs from a prescription-oriented (Pr-O) therapeutic approach, in which therapies are prescribed at the first medical referral and are not adjusted at any time during the treatment period. AIM: To determine if a Pa-O approach may be more beneficial for CMNP patients when compared to a Pr-O one. DESIGN: Randomized controlled trial. POPULATION: 220 CMNP outpatients randomized to either Pa-O group (N.=114) or Pr-O group (N.=106). METHODS: Each group received 10 therapeutic sessions over 3 weeks. Primary outcome measures were pain assessment, evaluated by Visual-Analog-Scale (VAS), and disability level, evaluated by the Neck Pain and Disability Scale (NPDS-I). Secondary outcome measures included patients' response to treatment and treatment failures. Measurements were carried out at baseline (T0) and 1 month after treatment ended (T1). Data were analysed according to the intention-to-treat principle. RESULTS: Patients in both groups displayed at T1 a significant reduction in VAS and NPDS-I scores. The relative changes at T1 were greater in Pa-O group when compared with Pr-O group both for VAS (61.5% versus 48.8%; P<0.005) and for NPDS-I scores (48.4% versus 36.8%; P<0.05). CONCLUSION: A Pa-O approach may be more beneficial in terms of pain and disability improvement in the short-term follow-up in suffers from CMNP. However, the occurrence of a performance-bias due to the increased level of attention from physicians to patients in Pa-O group, cannot be ruled-out. CLINICAL REHABILITATION IMPACT: A Pa-O approach should be considered for CMNP also in an outpatient facility.

The ischiatic region: normal and MRI anatomy.

AIM: The aim of this study was to describe the anatomy correlated to the normal magnetic resonance imaging (MRI) images of the proximal thigh region and the ischial tuberosity. METHODS: MRI coronal and axial sequences were obtained from 20 asymptomatic volunteers (10 male and 10 female) aged 20 to 38 years (mean age: 28 years), and then they were compared with 2 anatomical dissections and 7 cryosections of 6 cadaver thighs. RESULTS: The anatomical specimens were directly correlated with MRI scans. From the comparison it could be seen how the axial MRI sequences well outlined the sciatic nerve, usually observed oval in shape with moderate signal intensity, and thus easily detectable from other surrounding organs. Other structures were also identified by axial images: the ischial tuberosity, the proximal origin of the hamstring muscles arising from the ischium and the related bursae, the gluteus maximus and its bursa, the quadratus femoris and its inconstant bursa, a triangular adipose body and vessels. Coronal scans also showed well the hamstring muscles, both in length and thickness. CONCLUSIONS: Both MRI images and cadaver dissections showed the ischial tuberosity as an interesting intersection area that could be delimited as follows: on the dorsal border the gluteus maximus and its bursa, on the dorso-medial side the hamstring muscle origin, and on the antero-lateral side the quadratus femoris muscle with its inconstant bursa and the ischial tuberosity. These anatomical and MRI descriptions are very useful to give a contribution to the right explanation of sciatic symptoms caused by those sports specifically overloading the hamstring muscles. Frequently, in fact, in these athletes a sciatic syndrome arise drawing the physician's attention to the lumbosacral joint or to the sciatic nerve course near the piriformis muscle. Another very important site where the sciatic symptoms can rise, indeed, could also be found in the hamstring muscle region, where the nerve run under the gluteus maximus beside the ischiatic bone. Athletes who manifest notorious muscle overload in this anatomical region usually show sciatic pain symptoms that are not to be related with pathologies of the lumbosacral junction nor to relationships of the sciatic nerve with the piriformis muscle but rather to relationships that this nerve acquires with either gluteal muscles as well as with muscles of the underneath ischiatic region.

Analgesic efficacy of a lecithin-vehiculated diclofenac epolamine gel in shoulder periarthritis and lateral epicondylitis: a placebo-controlled, multicenter, randomized, double-blind clinical trial.

Diclofenac epolamine (2-hydroxyethyl-pyrrolidine) (DHEP) is a diclofenac salt endowed with enhanced cutaneous permeation. To optimize its absorption after topical application, a lecithin-enriched DHEP 1.3% gel has been developed (DHEP lecithin gel) and investigated in patients with shoulder periarthritis and lateral epicondylitis in a placebo-controlled, multicenter double-blind clinical trial. One hundred fifty-eight patients were randomized to a 10-day treatment with DHEP lecithin gel or placebo (5 g t.i.d. applied on the painful area). The efficacy criteria were pain measured by visual analog scale (VAS) while performing a specific standardized movement, intake of rescue medication (paracetamol), and the disabilities of the arm, shoulder and hand (DASH) questionnaire. VAS scores indicated a consistently higher analgesic activity of DHEP lecithin gel. At day 3, pain was reduced by -20.1 +/- 20.2 and -9.9 +/- 12.7 mm in the DHEP lecithin gel- and placebo-treated patients, respectively (p < 0.001); at day 6 of treatment, DHEP lecithin gel induced a pain reduction of -33.2 +/- 26.1 mm, while the reduction achieved with placebo was only -21.2 +/- 18.8 mm (p < 0.001). The mean changes in DASH questionnaire indicated that DHEP lecithin gel was more effective than placebo in improving patient well-being and reducing difficulties in performing the activities most severely impaired by rheumatism, while no difference was observed between the two treatments in consumption of rescue medication. In conclusion, these results indicate that DHEP lecithin gel is a topically effective analgesic product in patients with shoulder periarthritis or lateral epicondylitis and provide further evidence on the use of topical nonsteroidal anti-inflammatory drugs as an optimal approach to the treatment of localized musculoskeletal disorders.

Radial shock wave therapy for lateral epicondylitis: a prospective randomised controlled single-blind study.

AIM: Despite the lateral epicondylitis or tennis elbow is a common cause of pain in orthopaedic and sports medicine, the results of the different modalities of conservative treatment are still contradictory. The pourpose of this study was to evaluate the efficacy of radial shock wave therapy (RSWT) in the treatment of tennis elbow. METHODS: In a prospective randomized controlled single-blind study, of 75 eligible patients, 62 with tennis elbow were randomly assigned to study group and control group. There were 31 patients in the study group and 31 patients in the control group. Both groups had received a treatment a week for 4 weeks; the study group had received 2000 impulses of RSWT and the control group 20 impulses of RSWT. All patients were evaluated 3 times: before treatment, at the end of treatment and to 6 months follow-up. The evaluation consisted of assessments of pain, pain-free grip strength test, and functional impairment. RESULTS: Statistical analysis of visual analogue scale (VAS), disabilities of the arm, shoulder, and hand (DASH) questionnaire and pain-free grip strength test scores has shown, both after treatment and to the follow-up at 6 months, significant difference comparing study group versus control group (P <0.001). Statistical analysis within the groups, showed always statistically significant values for the study group. Also the control group showed statistically significant differences for some analyzed parameters. Nevertheless such differences resulted to be more statistics that not clinics as it showed the percentage of satisfied patients in the study group (87% post-treatment; 84% follow-up) in comparison with that of the control group (10% post-treatment; 3% follow-up), and the number needed to treat (NNT) that is of 1.15 at post-treatment and of 1.25 to the 6 months follow-up. CONCLUSION: The use of RSWT allowed a decrease of pain, and functional impairment, and an increase of the pain-free grip strength test, in patients with tennis elbow. The RSWT is safe and effective and must be considered as possible therapy for the treatment of patients with tennis elbow.

[Groin pain in athletes: role of magnetic resonance]. / La pubalgia negli atleti: ruolo della Risonanza Magnetica.

INTRODUCTION: Aim of our work was to evaluate the diagnostic role and potentials of Magnetic Resonance Imaging (MRI) in the study of groin pain in athletes and in the differential diagnosis among the pathological conditions that cause this syndrome. MATERIAL AND METHODS: MRI examinations were performed with a 1.5 T superconductive magnet, and a 0.2 T permanent magnet. Spin-Echo (SE) T1-w, PD, SE T2-w, Gradient-Echo (GE) T2-w and fat saturation sequences were used, on axial, sagittal and coronal scan planes. We performed MRI on twenty-five athletes (22 men and 3 women; age range 17 to 32 years) with chronic groin pain of questionable origin who had been complaining of it for at least 6 months. In 22 cases, radiographs were available; Computed Tomography (CT) had been performed in 3 cases and Ultrasound (US) in 7 cases. Nine patients were submitted to MRI after the symptoms had disappeared. RESULTS: In all patients, MRI provided an accurate depiction of pubic bone alterations and of adjacent myotendinous structures. In 14 cases, osteitis pubis was diagnosed, which was bilateral in 2 cases only (muscular asymmetry of the rectus abdominis was found in 4 of these patients); 4 patients had myotendinous posttraumatic changes (1 hematoma of the psoas muscle and 3 injuries of the abductor muscles of the thigh); 4 patients presented isolated dysmetria of rectus abdominis muscles, with unilateral involvement of the sacroiliac joint in 1 patient; 3 patients had inguinal hernia, surgically confirmed in all cases. DISCUSSION: Osteitis pubis, intended as reactive intraspongiuos edema of the pubic bones, is the most frequent cause of groin pain in athletes. In the early diagnostic phases, both plain films and CT may be negative or not specific. On the other hand, MRI has always proved to be a valuable diagnostic technique in detecting the osteitic change as an area of low signal intensity on T1-w images and of high and homogeneous signal intensity on T2-w scans without fat suppression. Dysmetria of the straight muscles of the abdomen, which may be associated, is always well depicted by MRI on axial planes. Both posttraumatic and dysmetric changes of the muscular structures adjacent to the pubis are well documented by US and MRI. The latter, however, thanks to its multiplanar capabilities, allows better spatial assessment of the alteration, especially if located at peri-insertional level. Possible associated diseases such as the involvement of the sacroiliac joints are also well shown by MRI. Inguinal hernias are easily demonstrated by MRI, which allows the direct visualization of the hernial sac within the inguinal canal. CONCLUSIONS: In our experience, only MRI can permit an accurate and early diagnosis of the different sport-related pubic conditions. MRI is also a valuable tool in monitoring the alterations with reference to their response to treatment, which may also help bring the athletes back to their activities.

Sports injuries in the pelvis and hip: diagnostic imaging.

We discuss the role of imaging techniques in examining the athletes with sports injuries involving the pelvis and the hip. Pelvis and hip pain is of difficult clinical clarification because of the various athletic injuries which may affect the bone or soft tissues at different anatomic sites. Moreover, the symptoms of pelvis and hip injuries are similar in most cases and they are often diffuse and atypical. Diagnostic imaging can play an essential role because treatment success depends on a correct diagnosis and these techniques can actually differentiate the most frequent causes of pelvis and hip sports injuries such as groin strain, osteitis pubis, ischial intersection syndrome, snapping hip, stress fractures, hernias and avulsion fractures. Finally, we discuss the role of magnetic resonance imaging in detecting the causes of hip pain other than sports injuries, such as avascular necrosis, reflex sympathetic dystrophy syndrome, herniation pit, acetabular labrum injuries. To conclude, diagnostic imaging techniques currently permit the direct and noninvasive depiction of pelvis and hip conditions. Particularly, magnetic resonance imaging is very helpful in detecting injury site, extent and characteristics; it can also predict the time period an athlete will be disabled and help define the best treatment planning.