Estimating the most accurate sonographic measurement in the diagnosis of carpal tunnel syndrome: Which is the best?

OBJECTIVES: This study aims to identify the most accurate method or ultrasonographic measurement for the diagnosis of carpal tunnel syndrome (CTS). PATIENTS AND METHODS: Between October 2010 and April 2011, a total of 160 hands of 87 patients (4 males, 83 females; mean age 54.5 years; range, 26 to 84 years) with clinically and electrodiagnostically proven CTS and 80 hands of 40 controls (3 males, 37 females; mean age 53.7 years; range, 32 to 77 years) were evaluated by sonographic examination. The diameters and cross-sectional areas (CSA) of the median nerve and longitudinal diameters of the median nerve were measured at the inlet, proximal carpal tunnel, and outlet of the carpal tunnel. Volar bulging and thickness of the retinaculum were also measured. RESULTS: The most optimal combination for the diagnosis of CTS was proximal CSA, volar bulging, and the proximal transverse diameter. The combination of proximal CSA with volar bulging increased the sensitivity and specificity of sonographic measurements. CONCLUSION: Based on our study results, ultrasonography can be used as a practical modality to distinguish CTS patients from asymptomatic controls.

Peripheral nerve injuries: Long term follow-up results of rehabilitation.

BACKGROUND: Peripheral nerve injury (PNI) is a common problem in the world resulting with severe disability. Etiological data is different in studies because of the study period, patient population, economic status, and workplace safety policies of the different countries. OBJECTIVE: To define epidemiological and etiological data of our patients with peripheral nerve injury and to identify factors influencing efficacy of rehabilitation methods and recovery. METHODS: Patients were compared by means of electromyography and muscle strength changes. Influence of orthotics use, disease interval and type of physical therapy (electrical stimulation or EMG biofeedback) was assessed. RESULTS: There was no significant difference between groups. But we found weak correlation between EMG and motor changes. There was no difference in EMG and motor score changes in terms of orthotics use and type of physical therapy. When the patients were grouped according to EMG changes, we found significant difference by disease interval. Disease interval was longest in patients with no change in EMG. When the patients were grouped according to motor score changes, there was no significant difference by disease interval. CONCLUSION: Etiology of the patients didn't affect long term results in peripheral nerve injury. The results of this study might help rehabilitation teams to guide their follow-up.

A case of recurrent complex regional pain syndrome accompanying Raynaud's disease: a prospective coincidence?

Complex regional pain syndrome (CPRS) and Raynaud's disease are disorders characterized by vasomotor disturbances associating with abnormal autonomic nervous system. We present a case of CRPS involving a history of recurrence and no initiating event. Raynaud's disease accompanying CRPS was diagnosed clinically in the patient. We propose that a sympathetic dysfunction underlies the pathophysiologies of both disorders and may be responsible for the coexistence of these two distinct entities. Recurrence and unknown etiology of CRPS might account for temporary alterations in sympathetic function.

Effects of steroid with repetitive procaine HCl injection in the management of carpal tunnel syndrome: an ultrasonographic study.

BACKGROUND AND AIM: With the use of musculoskeletal ultrasonography (MSUS), morphological changes in the median nerve have been recently reported in patients with carpal tunnel syndrome (CTS). On the other hand, the literature still lacks the information whether those changes are further altered with steroid and local anesthetic injection which is a widely used treatment in this group of patients. Therefore, the aim of our study was to explore in-vivo the effects of steroid with repetitive procaine HCl injection on the median nerve of patients with CTS. MATERIALS AND METHOD: This prospective clinical trial followed-up patients for 2 months. 22 patients (37 median nerves) with clinical and electrophysiological evidence of CTS were included in the study. All patients received both 40 mg of triamcinolone acetonide once and 4 ml of 1% procaine HCl twice a week for 2 weeks with the same technique. Clinical, functional, electrophysiological and ultrasonographic evaluations were performed at the study onset, and 2 months after the last injection. RESULTS: Electrophysiological, ultrasonographic findings (median nerve anterior-posterior diameter, transverse diameter and cross sectional area in the proximal carpal tunnel and volar bulging,) VAS scores, Boston carpal tunnel symptom and function assessment scale improved significantly (P<0.05). CONCLUSION: Steroid injection with repetitive procaine HCl injection effectively reduced the symptoms of CTS, improved the Boston carpal tunnel symptom and function assessment scale and also electrophysiological and ultrasonographic findings. Long term effects remain to be studied. Indisputably, the use of MSUS seems to be promising in this regard.

Neoplastic brachial plexopathy detected by ultrasonography in a patient with chronic cervicobrachialgia.

OBJECTIVE: We report here a case of neoplastic brachial plexopathy detected by musculoskeletal ultrasonography in a patient with chronic cervicobrachialgia. METHODS/RESULTS: A 71-year-old man presented at Gülhane Military Medical Academy, Turkish Armed Forces Rehabilitation Center, Ankara, Turkey with a one-year history of cervicobrachial pain radiating to the left arm and numbness in the medial aspect of the left arm and hand. He could not tolerate magnetic resonance imaging because his pain was exacerbated by cervical extension. Radiographs of his chest and cervical spine were normal. Ultrasound examination of the left brachial plexus revealed segmental fusiform swelling, suggestive for a compressing lesion. Magnetic resonance imaging of the brachial plexus performed under general anaesthesia revealed a left apical lung tumour (Pancoast) infiltrating the brachial plexus. CONCLUSION: Clinicians should consider neoplastic brachial plexopathy, which is an uncommon diagnosis, when evaluating patients with unrelenting and severe cervicobrachialgia. Musculoskeletal ultrasonography can be beneficial for examining brachial plexus lesions.

Accuracy of ultrasound-guided suprascapular nerve block measured with neurostimulation.

Although the use of ultrasound (US) to perform suprascapular nerve block (SsNB) is rapidly gaining popularity, information about its accuracy is still lacking. The aim of this study was to investigate the proximity of the needle to suprascapular nerve under US guidance by means of neurostimulation current intensity in SsNB. The patients who were referred for SSnB due to shoulder pain were included in the study. The patients were placed in sitting position, and when the operator decided that the needle was in the correct place under US guidance, the time duration until that time and the current amplitude in that location were recorded. Current intensity was obtained by gradually increasing the amplitude until patient feels parestesia over the shoulder area or contractions of the supraspinatus or infraspinatus muscles. Out of 27 patients, in five patients current intensity was between 0.1 and 0.8 mA (successful) and time duration was 2.52 ± 1.67 min in this group; in 19 patients, current intensity was between 0.9 and 1.4 mA (semi-successful) and time duration was 1.86 ± 1.02 min in this group; in three patients, current intensity was ≥ 1.5 mA (unsuccessful) and time duration was 2.41 ± 1.02 min in this group. Our results show that the needle could not reach sufficient proximity to the suprascapular nerve with only US guidance by means of NS current intensity.

Consistency between physical medicine and rehabilitation specialists and a radiologist in interpretation of lumbosacral radiographs.

OBJECTIVE: To investigate intra- and inter-observer reliability among physical medicine and rehabilitation specialists and a radiologist in interpretation of plain lumbar spine X-ray films in patients with low back pain. METHODS: Three assessors (A: a resident of PM&R, B: an experienced PM&R specialist, C: an experienced radiologist) read the standard lumbosacral plain radiographs of 79 patients with 2-3 month time interval. Each assessor recorded the presence or absence of abnormalities on the radiograph according to a standardized assessment form. RESULTS: For assessors B and C, all kappa values were > 0.40. Transitional vertebrae abnormalities reached to the highest agreement ratio. The intrarater agreement showed higher kappas than the interrater agreement. The radiologists had the highest intrarater agreement, closely followed by the experienced PM&R specialist. Agreement among three assessors was substantial in sacralisation, lumbarisation and facet joint pathologies. CONCLUSION: We usually obtained a good intrarater agreement, especially for the experienced PM&R specialist and the radiologist indicating that experience increases diagnostic consistency. Besides the systematic differences in radiographic interpretation between the assessors, institutional specific conditions (esp. patient profile and regularities) may cause the phycians to pay more attention to a specific group of pathologies.

Manual lymphatic drainage in management of edema in a case with CRPS: why the(y) wait?

Complex regional pain syndrome (CRPS) is a disorder characterized by pain, edema, skin color changes and autonomic abnormalities. Its treatment is quite difficult and in most of the patients effective results cannot be reached. Manual lymphatic drainage is a very rare method for managing limb edema in CRPS. In this case report, the dramatic response of an excessive edema to lymphatic drainage was discussed in a CRPS patient.

The effects of electrical stimulation combined with continuous passive motion versus isometric exercise on symptoms, functional capacity, quality of life and balance in knee osteoarthritis: randomized clinical trial.

The aim of this study was to evaluate effects of electrical stimulation combined with continuous passive motion (CPM-ES) versus isometric exercise on symptoms, functional capacity, quality of life, muscle strength, knee and thigh circle measurements, and balance in knee osteoarthritis (OA). This is a randomized clinical trial. The study was done in Gulhane Military Medical Academy (GMMA) Rehabilitation Center. Forty patients with knee OA were included in this study. Participants were randomly assigned to two groups: 20 patients placed in Group 1 were treated with conventional physical therapy and CPM-ES combination; 20 patients in Group 2 were treated with conventional physical therapy and isometric exercise. Therapies were applied 3 weeks, 5 days per week. The following main outcome measures were done: values of pain (VAS was used), WOMAC, SF-36, knee and thigh circle measurements, isokinetic tests, dynamic and static balance tests were determined at baseline and after the treatment. There were no statistically significant differences in the tested variables between the groups for post-treatment values. Dynamic and static balance test improved statistically strongly significantly in both groups. The findings of this study demonstrate that knee OA patients could improve their balance function in both static and dynamic conditions after CPM-ES combination or isometric exercise therapy. The improvement might prevent knee OA patients from falling down and increase their sense of security during physical activities.

The effects of balneotherapy on disease activity, functional status, pulmonary function and quality of life in patients with ankylosing spondylitis.

OBJECTIVE: This study aimed to determine the effects of balneotherapy on disease activity, functional status, metrology index, pulmonary function and quality of life in patients with ankylosing spondylitis (AS). MATERIALS AND METHODS: The study included 28 patients (27 male and 1 female) diagnosed with AS according to modified New York criteria. The patients were treated with balneotherapy for 3 weeks (30 min/day, 5 days/week). The patients were evaluated using the global index, Bath ankylosing spondylitis disease activity index (BASDAI), disease functional index (BASFI), metrology index (BASMI), chest expansion measures, pulmonary function testing, and the medical outcomes study-short form-36 Health Survey (SF-36) (measure of quality of life) before balneotherapy and 1 month after treatment. RESULTS: Post balneotherapy BASDAI and global index decreased, BASMI parameters improved, chest expansion increased, and some SF-36 parameters improved; however, none of these changes were statistically significant (P > 0.05), except for the decrease in BASMI total score (P < 0.05). Before balneotherapy 6 patients had restrictive pulmonary disorder, according to pulmonary function test results. Pulmonary function test results in 3 (50%) patients were normalized following balneotherapy; however, as for the other index, balneotherapy did not significantly affect pulmonary function test results. CONCLUSION: The AS patients' symptoms, clinical findings, pulmonary function test results, and quality of life showed a trend to improve following balneotherapy, although without reaching significant differences. Comprehensive randomized controlled spa intervention studies with longer follow-up periods may be helpful in further delineating the therapeutic efficacy of balneotherapy in AS patients.

Work disability in ankylosing spondylitis: differences among working and work-disabled patients.

Ankylosing spondylitis (AS) is a systemic chronic inflammatory disease primarily affecting the axial skeleton. Work disability can be one of the major consequences of AS, and the knowledge about the burden of AS to the patient and society is not well-established yet. The objective of this study was to investigate work disability among patients with AS in the national service and to put forward the related factors and differences among disabled and nondisabled groups. A total of 121 male AS patients were included in the study. Patient demographics and duration of disease were noted, and employment status and disability were questioned. Measures of functionality, axial mobility, health-related quality of life, and depression were used. It was found that 38 patients (31.4%) continued their work lives with no change, 54 patients (44.6%) changed to a lighter job, and 29 patients (24%) were retired due to AS. Differences in age at onset of the disease, time since the diagnosis, C-reactive protein (CRP) levels, and hip involvement were statistically significant. The mean retirement age of the patients was 36 +/- 4.2 years. Frequency of hip involvement was higher in the work-disabled group. Spine was evidently affected more seriously, and CRP values were higher in the work-disabled group. Older age at onset, longer time since the diagnosis, longer diagnosis delay, and some physical impairments like decrease in spinal mobility and hip involvement may preclude AS patients from leading a productive work life.

The comparison of ultrasonographic and scintigraphic findings of early arthritis in revealing rheumatoid arthritis according to criteria of American College of Rheumatology.

We aimed to investigate the diagnostic significance of high frequency ultrasonography (USG), comparing the findings in USG, bone scintigraphy and clinical stuation. Fifty-one patients who had early symptoms of inflammatory arthritis, but not fulfilling the ACR diagnostic criteria for rheumatoid arthritis (RA) were included in this study. They were referred to USG and bone scintigraphy for examination of the synovial joints. After following at least 2 years with visits at every 3 months, those who fulfilled the ACR criteria for the diagnosis of RA were defined as reference group. The concordance levels were assessed with Kappa statistic among them. The diagnosis of inflammatory arthritis that was made with USG in early time showed average agreement with the diagnosis according to ACR criteria. However, there was statistically discordance between the diagnosis of inflammatory arthritis that was made with bone scintigraphy in early time and the diagnosis according to ACR criteria.

Inflammatory sacroiliitis in a man with spinal cord injury.

BACKGROUND: Inflammatory sacroiliitis associated with spinal cord injury (SCI) as an unusual cause of elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level has not been reported previously to our knowledge. OBJECTIVE: To represent a case of SCI associated with bilateral sacroiliitis causing ESR and CRP level elevation. METHODS: Case report of a man with T9 paraplegia. FINDINGS: ESR and CRP levels were high. Pelvic radiography was nearly normal, except for mildly blurred sacroiliac joints with normal margins. A 3-phase bone scan revealed bilateral sacroiliitis and heterotopic ossification at medial side of the left knee. Past history was significant for a recent urinary tract infection. Indomethacin and etidronate were prescribed. Significant decreases in ESR and CRP level were seen 1 month later. CONCLUSIONS: Sacroiliitis might be an unusual cause of elevated ESR and CRP levels in patients with SCI. Sensory and motor deficits may obscure the typical clinical presentation; therefore, imaging studies are essential for the diagnosis.

Sexual problems in male ankylosing spondylitis patients: relationship with functionality, disease activity, quality of life, and emotional status.

This study has focused on sexual problems of male ankylosing spondylitis (AS) patients. Initially, patients' perceptions about the effects of disease on sexual intercourse were assessed. Secondly, we investigated the factors that relate to the disease and affect sexual intercourse negatively. Thirdly, we compared data from the patients whose sexual intercourse were affected negatively with of those whose sexual intercourse were unaffected. This is a cross-sectional and double-centered study. A total of 53 married or sexually active male patients, who were certainly diagnosed with AS according to modified New York criteria, were assessed. Twenty seven patients (50.94%) expressed that their sexual life was affected negatively by the AS in general (affected patients), and 26 patients (49.06%) expressed no negative effect (unaffected patients). Both affected and unaffected patients were compared with each other with regard to educational level, joint involvement, functionality, disease activity, quality of life, and depression status. Mean BASFI, BASDAI scores were worse in the affected group, and the difference was statistically significant (p = 0.012, p = 0.039, respectively). There were statistically significant differences between the groups with regard to lumbar column and hip involvement (p = 0.035, p = 0.021; respectively). The physical functioning, role limitations due to physical problems, vitality/energy/fatigue, general mental health, and general health perception subscale scores of SF-36 were worse in the affected group, and the differences were statistically significant (p = 0.027, p = 0.023, p = 0,013, p = 0.005, p = 0.045, respectively). Affected patients' Beck Depression Inventory scores were worse than those of unaffected patients, and the difference between the groups was statistically significant (p = 0.039). Sexual problems are common in AS patients and might usually be associated with joint involvement, decreased functionality, increased disease activity, decreased health quality, and depression. Therefore, while examining AS patients and managing their treatments, special attention must be given to all domains of life instead of only physical problems.

Clinical presentations of chlamydial and non-chlamydial reactive arthritis.

The aim of this study was to investigate the triggering micro-organisms and the clinical as well as laboratory differences between Chlamydial and non-chlamydial reactive arthritis (ReA) in a prospective study on 98 patients with acute/subacute arthritis. An inciting organism was found in 42 patients. Eighteen of these were chlamydial. Fifty-seven percent of all ReA patients were carriers for HLA-B27, which increased to 67% in the chlamydial group. Chlamydial ReA patients had more urethritis (P<0.05) with a longer period between arthritis and inciting infection, significantly lower CRP levels, and involved joint counts (P<0.05). Additionally, sacroiliitis was more frequent besides extra-articular manifestations in chlamydial ReA group. This study shows that chlamydial ReA differs in some points from non-chlamydial ReA, which in turn may affect the evaluation of an arthritic patient. ReA due to chlamydia more frequently encompasses a monoarticular or oligoarticular clinical picture with predominant distal extremity involvement. Non-chlamydial ReA presents higher joint counts and may involve upper extremity joints.