Sonographic diagnosis of anatomical variations associated with carpal tunnel syndrome.

Bifid median nerve is an anatomic variation that occurs in about 18% of patients with symptoms suggestive of carpal tunnel syndrome and in about 15% of symptom-free subjects. Reversed palmaris longus is a rare anatomic muscular variation. The simultaneous presence of a bifid median nerve and a reversed palmaris longus has been very rarely described, usually during surgical exploration or in cadavers. We present two cases where ultrasound showed the presence of both abnormalities, allowing a correct diagnosis and influencing the treatment plan.

High ultrasound variability in chronic immune-mediated neuropathies. Review of the literature and personal observations.

Chronic immune-mediated neuropathies show high clinical variability. Diagnosis is based on clinical and neurophysiological studies, but recently ultrasound (US) of peripheral nerves has been shown to provide useful morphological information. US has already been shown to crucially influence diagnosis and clinical care in entrapment neuropathies, in traumatic nerve lesions and in tumors. The role of US in the evaluation of polyneuropathies is still not clearly defined, but increasing attention has recently been focused on the immune-mediated neuropathies and specific US measures (namely the intra- and inter-nerve cross-sectional area variability) have been developed. The aim of the current paper is to make a review of the available nerve US studies and provide data from personal observations in the most common chronic immune-mediated neuropathies.

Ultrasound as a useful tool in the diagnosis and management of traumatic nerve lesions.

OBJECTIVE: The possibility of depicting through ultrasound (US) the nerve and its surroundings should be very useful in traumatic nerve lesion (TNL) management. Our study aimed at evaluating the contribution of US as complementary tool in a neurophysiological laboratory for the diagnosis and management of TNL. METHODS: A total of 112 nerves from 98 consecutive patients with clinical suspicion of TNL were considered. Two independent and blinded clinicians, different from the examiners performing electrodiagnosis and US, classified clinical, neurophysiological and US findings and classified the contribution of US as follows: 'contributive' and 'non-contributive' if US confirmed the clinical and neurophysiological diagnosis or if US findings were unremarkable. RESULTS: US was 'contributive' (strongly modified the diagnostic and therapeutic path) in 58% of cases (n: 65) providing information on therapeutic approach (immediate or delayed surgery), diagnosis and follow-up. US specifically contributed to the (1) assessment of nerve continuity/discontinuity, hence neurotmesis/axonotmesis; (2) identification of aetiology; and (3) demonstration of multiple sites of damage. US was contributive mainly in cases with neurophysiological evidence of complete axonal damage. CONCLUSIONS: US should be used, when available, in all patients in whom TNL is suspected as it provides a more comprehensive diagnosis than neurophysiologic studies alone. Anatomical information is often crucial for choosing the most appropriate therapeutic strategies (and for surgical planning). SIGNIFICANCE: US can improve the outcome of TNL.

Balance and walking involvement in facioscapulohumeral dystrophy: a pilot study on the effects of custom lower limb orthoses.

BACKGROUND: Autosomal dominant facioscapulohumeral dystrophy (FSHD), the third most common muscular dystrophy, is characterised by asymmetric and highly variable muscle weakness. In FSHD patients, the coupling of the ankle muscles impairment with the knee, hip and abdominal muscles impairment, causes complex alterations of balance and walking with deterioration of quality of life (QoL). AIM: The aim of this pilot study is to evaluate the effects of custom orthoses (foot orthosis-FO and ankle foot orthosis-AFO) on balance, walking and QoL of FSHD patients through a multidimensional approach. DESIGN: Pilot study. SETTING: Outpatient Rehabilitation Department of Don Gnocchi Foundation. POPULATION: Fifteen patients with facioscapulohumeral muscular dystrophy were studied. METHODS: On 15 FSHD patients clinical evaluation (Manual Muscle Test-MMT, Clinical Severity Score), performance tests (10 meter Walking test-10mWT and 2 minute Walking Test-2minWT), instrumental assessment (stabilometric evaluation), disability (Rivermead Mobility Index- RMI, Berg Balance Scale-BBS) and patient-oriented (Medical Outcome Study 36-item Short Form-SF-36, North American Spine Society-NASS and Visual Analogue Scale-VAS) measures were performed. Patients were evaluated first, wearing their shoes and then wearing their shoes plus orthoses. This evaluation was performed 1 month after wearing the orthoses. RESULTS: The shoes plus orthoses evaluation, performed after one month in which the patients daily wore the custom lower limb orthoses, showed a significant improvement of walking performance (10-mWT p<0.01), balance (Romberg Index p<0.05; Medio-Lateral Velocity p<0.05) and QoL (PCS p<0.01). CONCLUSION: This pilot study shows that in FSHD patients' custom lower limb orthoses (foot-orthoses and ankle-foot-orthoses); evaluated by using a multidimensional approach, improve walking, balance and QoL. CLINICAL REHABILITATION IMPACT: These preliminary results suggest that custom lower limb orthoses could reduce the risk of falling with a positive effect on our patients' safety. Our results should encourage the scientific community to do efficacy study on this hot topic.

Balance and walking in facioscapulohumeral muscular dystrophy: multiperspective assessment.

BACKGROUND: In the Facioscapulohumeral muscular dystrophy (FSHD), the association of ankle muscle impairment with knee, hip and abdominal weakness causes complex alterations of static (postural) and dynamic (walking) balance, increasing the risk of recurrent falls. Stereophotogrammetric system and body-worn gyroscopes were used to focus on locomotor capacity and upper body movements in FSHD patients respectively. No data have been reported about static balance (plantar pressure and stabilometric parameters) and dynamic balance (spatio-temporal parameters during walking) in patients with FSHD. Moreover it is not known if the balance involvement influences disability and quality of life (QoL) of these patients. AIM: The aim of this study is to quantitatively assess static and dynamic balance in FSHD patients and their influence on disability and QoL. DESIGN: Case control-study. SETTING: Outpatient Rehabilitation Department. POPULATION: Sixteen FSHD patients were compared with 16 matched healthy subjects. METHODS: A baropodometric platform was used to measure plantar pressure and centre of pressure in stance (static evaluation), and spatio-temporal parameters during walking (dynamic evaluation). These quantitative results in FSHD patients were also correlated with validated clinical (Clinical Severity Scale), performance (10m and 2 min Walking Test), disability (Berg Balance Scale, Rivermead Mobility Index) and quality of life (QoL) measures (SF-36, NASS). RESULTS: The patients moved the plantar pressure forward from hindfoot to forefoot. Static balance was significantly reduced in patients compared with healthy subjects. Dynamic evaluation of walking showed a significant reduction of velocity and step length in the patients, and a significant increase in step width. Dynamic and static parameters were significantly related to a reduction of 10 mWT performance while only dynamic parameters were strongly related to disability and QoL. CONCLUSION: FSHD patients present an abnormal static and dynamic balance and they show compensation strategies to avoid falling . The involvement of the dynamic balance worsens the physical aspects of QoL and induces disability. The involvement of static balance induces a reduction of the performance in brief distances. CLINICAL REHABILITATION IMPACT: The balance training should be considered in the rehabilitation program of FSHD patients; the compensation strategies adopted by these patients should be considered in the ankle foot orthosis treatment. The static and dynamic balance assessment in FSHD patients can be used in natural history studies.