[Hand Therapy in the Treatment of Patients with CRPS]. / Die Handtherapie in der Behandlung des CRPS.

In the modern treatment of CRPS a multidisciplinary concept is firmly established (MMPT, multimodal pain therapy). Besides medical therapy and psychotherapy, physio- and occupational therapy count as basic treatment options. Although physio- and occupational therapy (in the following called hand therapy) are the most important basic treatments, the therapy is hardly standardised and there are few scientific investigations concerning their application. Therefore the purpose of this paper is to present the applied hand therapeutic techniques with regard to function/performance, application and effectiveness, and to derive a suitable treatment algorithm. The techniques used in hand therapy are presented and reviewed in regard to their effectiveness by means of a literature search. It turns out that exercise therapy, manual therapy, graded motor imaging, CO2 baths and occupational therapy have a proven benefit for the patients. Although for many of the treatments reliable evidence-based data are lacking a treatment algorithm was established but there is a strong need for further investigations concerning the therapeutic effectiveness in the treatment of CRPS.

Perceptions of water, sanitation and health: a case study from the Mekong Delta, Vietnam.

In the Mekong Delta in the south of Vietnam about 5.7 million people lack access to safe drinking water and 10 million people in rural areas live without adequate sanitation. Between May and August, 2007 a survey was carried out in An Bin, a peri-urban ward in the Mekong Delta, to gain insight into water, sanitation and health as well as to health-related hygiene behaviour. The study employed a combination of quantitative (standardized questionnaire) and qualitative (focus group discussions, semi-structured interviews) methods. The most important features in the choice of drinking water sources are matters of hygiene and the taste of the water. The majority (74%) of the 120 households surveyed indicated their ownership of a sanitation facility, but the fish pond toilet (64%) which is predominantly utilized is considered to be unimproved sanitation. The local peri-urban population link water and hygiene to health, but sanitation instead to environmental pollution. This and other outcomes lead to the assumption that people have a basic knowledge of proper hygiene behaviour. However, hygiene measures such as hand washing are put into practice in an untimely manner, most likely due to a misconception of risks and/or a lack of background knowledge of cause-effect relationships as well as ingrained habits.

Arousal, EEG spectral power and pulse transit time in UARS and mild OSAS subjects.

OBJECTIVES: Upper airway resistance syndrome (UARS) and obstructive sleep apnea syndrome (OSAS) are associated with arousals and autonomic activation. Pulse transit time (PTT) has been used to recognize transient arousals. We examined the accuracy of PTT to recognize arousals, and the relationship between PTT deflection and visual and non-visual arousals. METHODS: Ten UARS and 10 mild OSAS subjects were studied via polysomnography including measurement of esophageal pressure. Electroencephalogram (EEG) spectral power was obtained from central leads. Seven types of events were identified, depending upon the presence or absence of: a sleep-related respiratory event (SRRE), i.e. apnea, hypopnea, and abnormal breathing effort; a PTT signal; or a visually scored arousal (>1.5s). RESULTS: One thousand four hundred forty-six events were identified in 20 subjects. Fifty-nine percent of all SRREs were associated with a PTT signal and a visual EEG arousal. Nineteen percent of SRREs had no EEG arousals at their termination, and 7.4% had no associated PTT signal. Delta power was significantly increased when non-visual EEG arousals were scored. The time delay for PTT was determined by the presence or absence of EEG arousal. The sensitivity of PTT to recognize EEG arousal was 90.4% and the specificity was 16.8%. The sensitivity and specificity of PTT to recognize SRRE was 90.7 and 21.9%, respectively. CONCLUSIONS: These results preclude the use of PTT by itself. SRREs induce an activation with positive PTT response but without arousal in 14% of cases. This PTT response, however, is much slower than that occurring with arousal. UARS and mild OSAS do not respond in the same way to SRREs, particularly during rapid eye movement sleep.

Uvulopalatopharyngoplasty, maxillomandibular advancement, and the velopharynx.

OBJECTIVE: To evaluate the presence of velopharyngeal insufficiency (VPI) symptoms and the associated changes of the velopharyngeal anatomy in patients who underwent maxillomandibular advancement (MMA) for persistent obstructive sleep apnea (OSA) after uvulopalatopharyngoplasty (UPPP). METHODS: Preoperative and postoperative cephalometric radiographs were analyzed to assess the anatomic changes of the velopharynx. In addition, a questionnaire survey was sent to the patients between 6 to 12 months after MMA. The questionnaires evaluated the presence and extent of VPI symptoms, including nasal regurgitation while eating or drinking as well as hypernasal speech. A 10-cm visual analog scale (VAS 0-10) was included to assess the impact of VPI symptoms on the patient's quality of life. In the patients who reported VPI symptoms, telephone interviews were conducted 1 year after the survey to evaluate the changes in VPI symptoms over time. RESULTS: Fifty-two of the 65 questionnaires were returned. Five patients (9.6%) reported nasal regurgitation of liquids when drinking hastily, with 2 patients reporting the occurrences as occasional and 3 patients reporting as rare. The impact of these symptoms on the patient's quality of life was minimal (VAS 0.6 +/- 0.4). Regurgitation of food or hypernasal speech was not reported. The telephone interviews 1 year later revealed that the symptoms have completely resolved in all 5 patients. Comparison of the preoperative and postoperative cephalometric radiographs demonstrated the pharyngeal depth increase was 48% of the amount of maxillary advancement and the functional pharyngeal length increased 53% of the maxillary advancement. The functional depth of the pharynx after MMA was significantly greater in the patients with VPI symptoms (P=.01). CONCLUSION: The results of this study suggest that patients who undergo MMA for persistent OSA after UPPP have a low risk of developing VPI. If symptoms occur postoperatively, they are mild and have minimal effect on the patient's quality of life; moreover, the symptoms usually resolve over time.

Variability of respiratory effort in relation to sleep stages in normal controls and upper airway resistance syndrome patients.

OBJECTIVE: Investigation of the role of sleep states on the respiratory effort of controls and subjects with upper airway resistance syndrome (UARS) using nasal cannula/pressure transducer system and esophageal manometry. PATIENTS AND METHODS: One night's monitoring of sleep and breathing, including the determination of peak end inspiratory esophageal pressure (respiratory effort) with esophageal manometry and flow limitation with nasal cannula. Analysis of the data, breath-by-breath, using visual inspection and a computerized program. Setting - a university sleep laboratory. Patients were nine men with UARS and nine control men matched for age, ethnicity, and body mass index. RESULTS: A modulation of respiratory effort by sleep state and stages is seen in all subjects, the lowest noted during REM sleep and the highest associated with Slow Wave Sleep. When total nocturnal breaths are investigated, a significant difference between peak end inspiratory esophageal pressure [(Pes)-considered as an index of respiratory effort] is noted between normal subjects and UARS. Two specific breathing patterns, seen primarily in UARS patients, are NREM sleep stage dependent. Crescendos (defined as more negative peak end inspiratory Pes with each successive abnormal breath) occur mostly during stages 1-2 NREM sleep, while segments consisting of regular and continuous, breath-after-breath, high respiratory efforts are associated with Slow Wave Sleep. Depending on sleep stage, visually scored arousal response displays differences in Pes negativity. The termination of the abnormal breathing pattern, always well defined with Pes, is not necessarily associated with a pattern of 'flow limitation' at the nasal cannula tracing, even when a visually scored EEG arousal is present. CONCLUSIONS: UARS patients have significantly more breaths, with more negative peak end inspiratory Pes, than do control subjects. The modulation of peak end inspiratory Pes (an index of respiratory effort) by sleep stage and state differs in UARS patients and control subjects. The nasal cannula/pressure transducer system may not detect all abnormal breathing pattern during sleep. As indicated by the visual sleep scoring, repetitive arousals may lead to more or less severe sleep fragmentation.