Pseudodystrophy. A conversion disorder mimicking reflex sympathetic dystrophy.

The authors suggest some criteria by which pseudodystrophy and reflex sympathetic dystrophy, although sharing some similar clinical features, can be distinguished as two different conditions, each requiring its own approach and management. The most important distinction is found on bone scintigraphy. In reflex sympathetic dystrophy the bone scan shows a typical increased tracer uptake (at least during stages I and II); in pseudodystrophy there is a normal or decreased tracer uptake in the affected region. Moreover the vascularization is increased in reflex sympathetic dystrophy stage I, whereas in pseudodystrophy hypovascularization is found from the beginning. The clinical features, as well as the results of technical investigations, psychological evaluation and treatment of 4 patients with pseudodystrophy are presented. The importance of distinguishing this condition from reflex sympathetic dystrophy is stressed.

Effect of physical therapy on limited joint mobility in the diabetic foot. A pilot study.

Eleven patients with limited joint mobility and neuropathy were enrolled in a physical therapy program of passive joint mobilization at a rate of two sessions per week. Treatment resulted in a significant improvement in joint mobility after 10 sessions. Further improvement after 20 sessions did not reach the level of statistical significance, although near-normal joint mobility was attained. After completion of therapy, there was a progressive deterioration in joint mobility. No serious adverse effects were noted during treatment. This study provides some evidence that use of physical therapy may result in significant, although temporary, improvement in the mobility of the ankle and foot joints in diabetic patients with limited joint mobility and neuropathy. As limited joint mobility has been associated with the development of abnormally high pressures under the feet, which in turn may contribute to plantar ulceration in the susceptible neuropathic foot, the results indicate that physical therapy may be useful in the prevention of plantar ulceration in diabetic patients with limited joint mobility and neuropathy, although this must be verified by additional research.

What is reflex sympathetic dystrophy?

In the literature there is no unanimity with respect to the diagnosis of reflex sympathetic dystrophy (RSD). Frequently, the diagnosis is established on mere clinical grounds. In our opinion, however, bone scintigraphy is of major importance for the diagnosis. Using this examination, true RSD can be clearly differentiated from other conditions which are incorrectly diagnosed and treated as RSD. If the bone scan is not suggestive of RSD, the clinical picture, radiological examination and vascular scan may lead to the correct diagnosis. This may be a pseudodystrophy, in which a hypovascularization is found right from the start, while in true RSD there is initially a hypervascularization. Other conditions which may be confused with RSD are causalgia, neurotic compulsive postures, hysterical conversion, malingering and even self-mutilation. In the spontaneous course of RSD three phases can be distinguished. Stage I is the warm or hypertrophic phase, stage II the cold or atrophic phase. Per definition the third phase corresponds to stabilization or, in rare instances, to healing. By means of the vascular scan the correct stage can be determined, and the results of treatment evaluated. Finally it should be noted that in children the condition is completely different from true RSD, as it concerns a pseudodystrophy or disuse-related dystrophy. This condition may also be seen in adults and adolescents, usually females. The bone scan is always negative. In this way bone scintigraphy constitutes the means to answer the question as to what RSD is and what it is not. An algorithm for the differential diagnosis is presented.

Cryptotetany--place of EMG-recording.

Ninety-two cryptotetany tests were performed with simultaneous EMG-recording in the M. Interosseus dorsalis I and the M. Opponens pollicis. It was found that, in 21 cases out of 92 (22.8%), exclusively in the M. Interosseus dorsalis I, and in 11 cases out of 92 (11.9%), exclusively in the M. Opponens pollicis, multiplet activity was detected for at least 2 minutes. From this study it appears that, in performing the cryptotetany test, the M. Opponens pollicis is certainly not be preferred to the M. Interosseus dorsalis as the only place of recording. It appears, on the contrary, that simultaneous recording in the M. Interosseus dorsalis I and the M. Opponens pollicis is to be preferred to a recording exclusively in the M. Interosseus dorsalis I. In this way, a not unsignificant number of false negative cryptotetany tests can be avoided.

Hypogonadism as a cause of recurrent muscle injury in a high level soccer player. A case report.

Hypogonadotropic hypogonadism is a well known entity in highly trained female athletes. In male sportsmen, resting testosterone levels may be lowered especially in well endurance trained athletes and during high intensity training periods, frequently in combination with excessive weight reduction. However, only few reports illustrate a clinical pathology related to this state. In this report, where we present a case of a high level soccer player with recurrent muscle injuries over several years, hypogonadism was caused by sports activity together with an impaired testicular function (cryptorchidy). Clinical findings included testicular maldevelopment, decreased libido, infertility and a high incidence of muscle strains and delayed post-exercise soreness in mainly eccentric exercised muscle groups. Laboratory findings showed abnormally lowered resting testosterone values, most prominent during training periods, and an unfavourable testosterone/cortisol ratio during recuperation after exercise. With respect to treatment of the problem, neither any form of physical therapy nor rehabilitation program could give long lasting benefit. Using tamoxifen, an anti-oestrogenic drug, which stimulates LH and FSH production, we not only observed normal physiological resting testosterone values and a restoration of the testosterone/cortisol ratio after exercise, but our patient also experienced a higher sexual drive, well being and a spectacular decrease in the muscle injury rate. Although this patient was not a highly endurance trained athlete, we assume that a chronic anabolic/catabolic hormone imbalance may be of greater clinical importance in sports activity based on eccentric and explosive muscle work.

A retrospective study of the conservative treatment of tennis-elbow.

The files of 64 patients (70 tennis elbows) treated in our department because of tennis elbow complaints, were reviewed. The results showed injection with a corticosteroid preparation to be effective in alleviating the pain in the short term (91% improvement within 1 week), but the incidence of recurrence of symptoms to be high (51%) after an average period of 3 months). Physical therapy appeared to be less effective (47% improvement after an average of 6 weeks or 20 sessions), but recurrence of symptoms was far less frequent (5%).

[Peri-articular ossifications]. / Peri-articulaire ossificaties.

Restriction of motion of the joints due to peri-articular ossifications constitute a major problem in the rehabilitation of patients with transverse spinal cord lesion. The therapeutic possibilities as well as the preventive measurements are described and illustrated with a few case reports.

F-wave latencies of the deep peroneal nerve in diabetic polyneuropathy.

The F-wave latency of the deep peroneal nerve in function of leg length was determined in 66 normal persons and 25 diabetic patients with known polyneuropathy. The latencies were measured by stimulating the nerve at the ankle and recording the F-wave at the musculus extensor digitorum brevis using a needle electrode. The leg length was represented by the distance between the spina iliaca anterior superior and the lateral malleolus. The F-wave latencies obtained in diabetic patients were significantly higher than in controls (p less than 0.01). The method is suitable to detect polyneuropathy, especially in early cases where the conventional techniques (determination of the motor and/or sensory latencies and/or conduction velocities at the lower limbs) may still yield normal or borderline values. The upper limits of the normal values of the F-wave latencies in function of leg length is given by a non-linear curve, which can be represented by the equation: F-wave latency (msec) = 14.7 + 47.5 x (leg length in m)2. For practical purposes, the upper limit of the normal value for a given leg length can be readily determined from a latency-length curve.

[Mesotherapy in abarticular rheumatism]. / Mesotherapie bij abarticulair reuma.

Mesotherapy is a method of treatment in which subcutaneous infiltrations are given loco dolenti at short intervals of time. In this way a mixture of readily available drugs is administered. There are many indications for mesotherapy, although most applications are found in the field of the osteo-articular affections. As yet there is no scientific explanation for the effect of this therapy. Studies on this subject are currently being performed.

[Correlation between motor terminal latency time of the median nerve and the result of conservative treatment (cortisone injection) in carpal tunnel syndrome]. / Correlatie tussen de motorische terminale latentietijd (MTLT) van de nervus medianus en het resultaat van de conservatieve behandeling (cortisone inspuiting) bij het carpaal tunnel syndroom.

45 patients with carpal tunnel syndrome could be followed after an initial conservative treatment (local injection with Depomedrol 40 mg) either up to a surgical intervention (15 patients) or up to 14 to 48 months after the first injection (mean 23 months). Pregnant patients were excluded, as well as the patients with a distal motor latency (DML) greater than or equal to 7 msec (immediate surgical intervention). The age and sex distribution corresponds with the data reported in the literature: 7 males (15%) versus 38 females (85%), including 7 between 20 and 39 years (16%), 24 between 40 en 59 years (53%) and 14 between 60 and 80 years (31%). The side of the complaints also corresponds with the literature data: bilateral 16 (36%), right hand 23 (51%), left hand 6 (13%). In the 16 patients with a DML greater than 5,5 msec (normal value up to 4.3 msec) a rapid recurrence of the complaints after the injections necessitated a surgical intervention in 12 cases. In the 29 patients with a DML less than or equal to 5.5 msec who had been operated, the improvement of the complaints after the first injection lasted 2 months at most in 8 cases, as opposed to an average of 12.5 months (0 to 48 months) for the population as a whole.