Complex Female Pelvic Pain: A Case Series From a Multidisciplinary Clinic in Urogynecology and Physiatry.

OBJECTIVE: The internal pelvic floor muscles that support the pelvic viscera lie within the external pelvic structures, which support posture and locomotion. The presence of pain in the hip, groin, leg, abdomen, and/or back in patients with pelvic pain suggests that external pelvic sites may act as pain generators that contribute to chronic pelvic pain (CPP). The aim of this study was to report musculoskeletal diagnoses resulting from including a physiatry evaluation as part of a Multidisciplinary Pelvic Pain Clinic for women with complex chronic pain. METHODS: This retrospective case series was conducted by chart review of all women attending the clinic from February 2016 through March 2018. Variable definitions were created for each demographic and clinical characteristic and used to guide a structured review of the chart. Descriptive statistical analysis was performed. RESULTS: Ninety-six percent of the 68 women (mean age, 51 years) had CPP of 6 months' duration or longer. Levator ani tenderness was present in 81% and obturator internus tenderness in 81%. Seventy-one percent of women had failed pelvic physical therapy. Musculoskeletal diagnoses included osteoarthritis, tendinopathies, enthesopathies, osteitis pubis, ischiofemoral impingement, Paget disease, and other systemic conditions. CONCLUSIONS: Musculoskeletal abnormalities were common in this highly selected cohort of complex CPP cases with external pelvic symptoms. The imaging findings and specific diagnoses allowed targeted therapy beyond generalized physical therapy for CPP. The expertise of urogynecologists and physical therapists who evaluate the internal pelvic muscles and viscera combined with the physiatrist's expertise in musculoskeletal assessment and imaging provides an expanded, collaborative approach for managing these patients.

Lack of utility of Semmes-Weinstein monofilament testing in suspected carpal tunnel syndrome.

OBJECTIVE: To investigate the value of Semmes-Weinstein monofilament (SWM) testing in patients with electrodiagnostically confirmed carpal tunnel syndrome in a group of patients with symptoms compatible with carpal tunnel syndrome. DESIGN: A total of 119 consecutive patients with symptoms compatible with carpal tunnel syndrome were assessed. Blinded comparison of two Semmes-Weinstein monofilament testing protocols with orthodromic midpalm electrodiagnostic testing was performed. The electrodiagnostic test was considered the standard to which the results of the Semmes-Weinstein monofilament testing were measured. RESULTS: Fifty three percent of our patients had electrodiagnostically confirmed carpal tunnel syndrome. Using a conservative Semmes-Weinstein monofilament testing protocol the sensitivity was 98% and the specificity was 15%. The positive predictive value was 56% and the negative predictive value was 88%. Using a liberal Semmes-Weinstein monofilament testing protocol the sensitivity was 13% and the specificity was 88%. The positive predictive value was 53% and the negative predictive value was 47%. CONCLUSION: Semmes-Weinstein monofilament testing was not shown to have utility in diagnosing electrodiagnostically confirmed carpal tunnel syndrome in our population of predominantly male veterans.

Value of the lumbrical-interosseous technique in carpal tunnel syndrome.

OBJECTIVE: To determine whether the second lumbrical-interosseous technique has comparable sensitivity with the median-ulnar transcarpal mixed nerve technique (palmdiff). DESIGN: A prospective series of consecutive patients with median distribution paresthesias were evaluated with electrodiagnostic testing. Outpatient veterans referred by a heterogeneous group of specialists and generalists to the Portland Veterans Affairs Medical Center electrodiagnostic laboratory. A total of 129 consecutive veterans referred for evaluation of median distribution paresthesias were assessed with two electrodiagnostic tests. RESULTS: The second lumbrical-interosseous technique performed with equal sensitivity (60.5%) to the palmdiff technique, with the added unique feature of its being uniformly obtainable. CONCLUSIONS: The second lumbrical-interosseous technique is characterized by performance equal to the palmdiff in categorizing carpal tunnel syndrome. It is also characterized by being nearly uniformly obtainable, even in severe carpal tunnel syndrome. These features suggest a wider role for the second lumbrical-interosseous technique than currently accepted.

Median sensory nonresponders in carpal tunnel syndrome workup.

OBJECTIVE: To determine an optimal strategy when, in the course of performing the Combined Sensory Index (CSI) or routine median sensory evaluation of carpal tunnel syndrome (CTS), an unobtainable median sensory response is encountered. DESIGN: Prospectively assessed collected data for optimal electrodiagnostic strategies in the setting of an absent median sensory response. SETTING: Electrodiagnostic laboratory of a Veterans Affairs medical center. PARTICIPANTS: Two hundred forty consecutive outpatient veterans referred to the laboratory with CTS-compatible symptoms were evaluated with the CSI. Of these, 62 were identified as having 1 or more unobtainable median CSI components. INTERVENTIONS: Performed tests to determine latencies across the palm and to the thumb and the ring finger; motor comparison studies of median thenar and ulnar hypothenar motor latencies and second lumbrical-interosseous latency differences. MAIN OUTCOME MEASURES: Prevalence of latency test absence, prevalence of electrophysiologically confirmed CTS, and CSI component response rate. RESULTS: When the transpalmar response was absent, subsequent median-ulnar to digit 4 testing and median-radial to digit 1 testing yielded responses in 6% and 8% of cases, respectively. When the median-ulnar to digit 4 response was absent, subsequent transpalmar and median-radial to digit 1 testing yielded responses in 39% and 32% of cases, respectively. The second lumbrical-interosseous comparison was always obtainable and the standard median thenar response was obtainable in 95% of cases; the motor comparison studies confirmed a median mononeuropathy in 98% and 85% of the cases, respectively. CONCLUSION: When initially a median CSI component is absent, subsequent median sensory studies are often unobtainable. Proceeding directly to motor comparison studies is efficient and provides the requisite electrodiagnostic information.

Superficial Heat and Cold.

In brief The wide array of superficial heat and cold modalities offers physicians many options for treating sports-related injuries. Appropriate application of heat and cold therapies can reduce the impact of an injury by relieving pain, reducing swelling, and encouraging rehabilitation.