Agreement between clinical screening procedures for neuropathy in the feet

Introduction: The correlation between monofilament testing, symptom surveys, and electrodiagnostic studies for the diagnosis of axonal polyneuropathy has not been well studied. This investigation was done to assess the agreement between these procedures in a non‐random sample of volunteers. Methods: The procedures evaluated included electrodiagnostic tests of the sural nerve, monofilament testing of the great toe, a symptom survey, and a body diagram. Kappa coefficients and sensitivity and specificity, using nerve conduction as a “gold standard,” were used to determine the agreement between various combinations of procedures. Results: Poor agreement (kappa values −0.12–0.44) and sensitivity (sensitivity <30%) were found for all combinations of symptoms and monofilament results in comparison with sural peak latency and amplitude. Conclusions: Overall, the results demonstrated a low discriminatory power for the screening procedures for identifying persons with impaired sural nerve function. The results highlight the need for further development and evaluation of screening methods for distal neuropathy in population‐based studies. Muscle Nerve, 2012Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/91168/1/23238_ftp.pd

A case report of a patient with upper extremity symptoms: differentiating radicular and referred pain

<p>Abstract</p> <p>Background</p> <p>Similar upper extremity symptoms can present with varied physiologic etiologies. However, due to the multifaceted nature of musculoskeletal conditions, a definitive diagnosis using physical examination and advanced testing is not always possible. This report discusses the diagnosis and case management of a patient with two episodes of similar upper extremity symptoms of different etiologies.</p> <p>Case Presentation</p> <p>On two separate occasions a forty-four year old female patient presented to a chiropractic office with a chief complaint of insidious right-sided upper extremity symptoms. During each episode she reported similar pain and parasthesias from her neck and shoulder to her lateral forearm and hand.</p> <p>During the first episode the patient was diagnosed with a cervical radiculopathy. Conservative treatment, including manual cervical traction, spinal manipulation and neuromobilization, was initiated and resolved the symptoms.</p> <p>Approximately eighteen months later the patient again experienced a severe acute flare-up of the upper extremity symptoms. Although the subjective complaint was similar, it was determined that the pain generator of this episode was an active trigger point of the infraspinatus muscle. A diagnosis of myofascial referred pain was made and a protocol of manual trigger point therapy and functional postural rehabilitative exercises improved the condition.</p> <p>Conclusion</p> <p>In this case a thorough physical evaluation was able to differentiate between radicular and referred pain. By accurately identifying the pain generating structures, the appropriate rehabilitative protocol was prescribed and led to a successful outcome for each condition. Conservative manual therapy and rehabilitative exercises may be an effective treatment for certain cases of cervical radiculopathy and myofascial referred pain.</p

The effect of local corticosteroid injection on F-wave conduction velocity and sympathetic skin response in carpal tunnel syndrome

The aim of this study was to evaluate the efficacy of steroid injection for the treatment of the carpal tunnel syndrome (CTS), with F-wave parameters and sympathetic skin response (SSR). Seventeen hands of 10 women patients were treated with local steroid injection with 2-month follow-up. All patients underwent single injection into the carpal tunnel. Response to injection was measured nerve conduction studies (NCSs), median nerve F waves, and SSR before and after treatment. To determine the normal values, 42 hands of 21 healthy women were also studied. There was a significant improvement of sensory and motor nerve conduction values when compared to baseline values (P < 0.01). At the end of follow-up period, the median sensory distal latency and the sensory latency differences between the median and the ulnar nerve were improved 35 and 65%, respectively. The maximum, mean F-wave amplitudes and chronodispersion showed a slight improvement with respect to baseline values and controls, but statistical significance was not achieved after treatment. Although no statistically significant improvements were observed in SSR parameters, slightly decreased amplitudes and increased habituation of SSR were noted at the end of the treatment. The present study shows that the local steroid injection results in improvement in NCSs values, but the F-wave parameters were not effectual in short-term outcome of CTS treatment. These findings suggest that the sensory latency differences between the median and the ulnar wrist-to-digit 4 are better parameters in the median nerve recovery after treatment than the median sensory distal latency. Furthermore, the SSR does not seem to be a sensitive method in follow-up of CTS treatment

Electrodiagnostic evaluation of carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is the most common nerve entrapment. Electrodiagnostic (EDX) studies are a valid and reliable means of confirming the diagnosis. This monograph addresses the various EDX techniques used to evaluate the median nerve at the wrist. It also demonstrates the limitations of EDX studies with a focus on the sensitivity and specificity of EDX testing for CTS. The need to use reference values for populations such as diabetics and active workers, where normative values differ from conventional cutoffs used to confirm suspected CTS, is presented. The value of needle electromyography (EMG) is examined. Muscle Nerve, 2011Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/87013/1/22208_ftp.pd

Splinting or surgery for carpal tunnel syndrome? Design of a randomized controlled trial [ISRCTN18853827]

BACKGROUND: Carpal tunnel syndrome is a common disorder, which can be treated with surgery or conservative options. However, there is insufficient evidence and no consensus among physicians with regard to the preferred treatment for carpal tunnel syndrome. Therefore, a randomized controlled trial is conducted to compare the short- and long-term efficacy of surgery and splinting in patients with carpal tunnel syndrome. An attempt is also made to avoid the (methodological) limitations encountered in earlier trials on the efficacy of various treatment options for carpal tunnel syndrome. METHODS: Patients of 18 years and older, with clinically and electrophysiologically confirmed idiopathic carpal tunnel syndrome, are recruited by neurologists in 13 hospitals. Patients included in the study are randomly allocated to either open carpal tunnel release or wrist splinting during the night for at least 6 weeks. The primary outcomes are general improvement, waking up at night and severity of symptoms (main complaint, night and daytime pain, paraesthesia and hypoesthesia). Outcomes are assessed up to 18 months after randomization

Myasthenia gravis

Myasthenia gravis (MG) is a rare, autoimmune neuromuscular junction disorder. Contemporary prevalence rates approach 1/5,000. MG presents with painless, fluctuating, fatigable weakness involving specific muscle groups. Ocular weakness with asymmetric ptosis and binocular diplopia is the most typical initial presentation, while early or isolated oropharyngeal or limb weakness is less common. The course is variable, and most patients with initial ocular weakness develop bulbar or limb weakness within three years of initial symptom onset. MG results from antibody-mediated, T cell-dependent immunologic attack on the endplate region of the postsynaptic membrane. In patients with fatigable muscle weakness, the diagnosis of MG is supported by: 1. pharmacologic testing with edrophonium chloride that elicits unequivocal improvement in strength; 2. electrophysiologic testing with repetitive nerve stimulation (RNS) studies and/or single-fiber electromyography (SFEMG) that demonstrates a primary postsynaptic neuromuscular junctional disorder; and 3. serologic demonstration of acetylcholine receptor (AChR) or muscle-specific tyrosine kinase (MuSK) antibodies. Differential diagnosis includes congenital myasthenic syndromes, Lambert Eaton syndrome, botulism, organophosphate intoxication, mitochondrial disorders involving progressive external ophthalmoplegia, acute inflammatory demyelinating polyradiculoneuropathy (AIDP), motor neuron disease, and brainstem ischemia. Treatment must be individualized, and may include symptomatic treatment with cholinesterase inhibitors and immune modulation with corticosteroids, azathioprine, cyclosporine, and mycophenolate mofetil. Rapid, temporary improvement may be achieved for myasthenic crises and exacerbations with plasma exchange (PEX) or intravenous immunoglobulin (IVIg). Owing to improved diagnostic testing, immunotherapy, and intensive care, the contemporary prognosis is favorable with less than five percent mortality and nearly normal life expectancy