A correlation between clinical severity and functional state with nerve conduction studies findings in patients with carpal tunnel syndrome: a systematic review

Carpal Tunnel Syndrome is the most common compressive neuropathy in the general population, and it may lead to disabling symptoms and significant functional limitation. This systematic review covered Pubmed, Medline, Embase, Cochrane, CINAHL, LILACS, and SCIELO databases, with no time or language delimitations. The PICO strategy defined the search strategy with keywords extracted from the Medical Subjects Headings, and the quality of the studies was evaluated by the Agency for Healthcare Research and Quality (AHRQ) scale. Overall, 857 studies were identified, of which only 10 fulfilled the inclusion criteria. Despite the good results shown, a noticeable heterogeneity was observed among the studies included, associated with methodological discrepancy and to limited sample size in a few of them. Four studies showed no correlation between electrophysiological findings and clinical symptoms and signs, whereas three could demonstrate such association and other three studies had equivocal results. Other studies are necessary, with better methodological standards and more homogeneous and precise evaluations, so as to improve the level of scientific evidence.A síndrome do Túnel do Carpo é a neuropatia compressiva mais frequente na população geral que pode levar a sintomas incapacitantes e significativa limitação funcional. Uma revisão sistemática foi realizada nas bases de dados Pubmed, Medline, Embase, Cochrane, CINAHL, LILACS e SCIELO, sem delimitação de tempo ou idioma. Utilizou-se da estratégia PICO para a pesquisa, palavras-chave extraídas dos Descritores de Ciências da Saúde (Decs) e a qualidade dos estudos foi avaliada através da escala Agency for Healthcare Research and Quality (AHRQ). Identificaram-se 857 estudos dos quais, somente 10 obedeceram aos critérios de inclusão. Apesar dos bons resultados apresentados, verificou-se uma expressiva heterogeneidade existente entre os estudos incluídos, associado à discrepância metodológica, e um limitado tamanho amostral em alguns deles. São necessários estudos com melhor padrão metodológico, bem como avaliações mais homogêneas e precisas, a fim de melhorar o nível de evidência científica

Thalidomide-induced sensory polyneuropathy and electrophysiological study of the sural nerve as a screening diagnosis: a case report

Polineuropatia é uma condição clínica freqüente com sintomatologia debilitante e o tratamento depende fundamentalmente da etiologia. Inúmeras são as causas possíveis deste tipo de distúrbio e o diagnóstico etiológico nem sempre é fácil. Neste relato de caso descrevemos um caso de um paciente com mieloma múltiplo que evoluiu com polineuropatia puramente sensitiva, comprovada por estudo eletrofisiológico, induzida por talidomida.Polyneuropathy is a common clinical condition with debilitating symptoms whose treatment depends on etiology. There are numerous possible causes of this type of disorder and the etiological diagnosis is not always easy. In this case report we describe a case of a patient with multiple myeloma who developed purely sensory polyneuropathy, confirmed by electrophysiological study, induced by thalidomide

Beta-fibrilose encefálica e cardíaca em idosos autopsiados

INTRODUCTION: Amyloidosis in elderly individuals can be an independent alteration and a characteristic of aging. However, the clinical, pathophysiologic, and biochemical characteristics of amyloidosis related to age remain uncertain. OBJECTIVE: The purpose of this study was to determine the extent to which the heart and/or the brain of individuals aged 60 years or over exhibits amyloid deposits. MATERIALS AND METHODS: The autopsy findings of individuals who were at least 60 years old were studied. The autopsies took place between the years of 1976 and 2000. A total of 10 cases were selected that had hearts without cardiopathies, had negative serology for Chagas' disease, and had brains without morphological changes related to encephalopathies. Slides with fragments of heart and brain were processed and analyzed using polarized and common light microscopy. RESULTS: Of the 10 cases, 4 were positive for amyloidosis. All had positive findings in the brain, and 1 case also had positive findings in the heart. Among the positive cases, 50% were of people aged 60 to 69 years. There appeared to be a relationship between the presence of amyloid deposits and the ratio of brain and body weight, with the ratio in the positive cases being smaller than in the negative cases. CONCLUSIONS: The analysis of amyloid deposits in the brains and hearts of elderly individuals shows that such deposits may lead to a systemic attack of senility, common to natural aging. It is not certain that beta-amyloid deposits would alone bring such drastic repercussions to the individual. Some additional disorders of the organism could cause the breakdown of the natural balance related to the accumulation of these proteins, leading the way to the pathological contexts of amyloidosis.RESUMO INTRODUÇÃO: A amiloidose em idosos pode ser uma alteração independente e própria do envelhecimento. Entretanto, as características clínicas, fisiopatológicas e bioquímicas da Amiloidose relacionada à idade ainda permanecem incertas. OBJETIVO: Verificar se o coração e o encéfalo de indivíduos acima de 60 anos apresentavam depósito amilóide. MATERIAL E MÉTODOS: Foram estudados laudos consecutivos de autópsias de indivíduos acima de 60 anos realizadas entre 1976 e 2000, que apresentavam corações sem cardiopatias, com sorologia negativa para Doença de Chagas e encéfalos sem alterações morfológicas de encefalopatias, chegando a um n de 10 casos. Lâminas de fragmentos do coração e de encéfalo foram processadas e analisadas em microscopia de luz comum e polarizada. RESULTADOS: Dos 10 casos, 3 apresentaram depósito amilóide no encéfalo e 1 no encéfalo e no coração. Em 50% dos casos, os indivíduos tinham entre 60 e 69 anos. A relação entre o peso encefálico e o peso corporal mostrou ter uma associação significativa com os casos positivos, sendo esta menor em relação aos negativos. CONCLUSÃO: A análise conjunta de depósitos amilóides em encéfalo e coração de indivíduos idosos talvez direcione para um acometimento sistêmico comum ao envelhecimento natural. Alguma alteração adicional do organismo poderia determinar a quebra de um equilíbrio natural sobre o acúmulo dessas proteínas, levando dessa forma aos contextos patológicos da amiloidose

The contribution of concentric electrode-evoked potentials and nociceptive withdrawal reflex to the routine neurophysiological assessment of neuropathic pain:cross-sectional study

BACKGROUND AND OBJECTIVES:Conventional electrodiagnostic studies (EDX) are frequently used to support the diagnosis of peripheral neuropathic pain. However, routine EDX has poor diagnostic yield for identifying small fiber neuropathy, which may be cause of neuropathic pain in some patients. This study aimed to assess the gain in diagnostic yield brought by adding pain-related evoked potentials with concentric electrode (CN-PREP) and nociceptive withdrawal reflex (NWR) assessments to EDX.METHODS:Transversal observational accuracy study which included patients referred to routine EDX in a tertiary-care hospital who reported chronic neuropathic pain in their lower limbs. Besides routine EDX, subjects underwent CN-PREP and NWR assessments. Diagnostic yield and tolerability were examined and compared between test studies.RESULTS:The study enrolled 100 patients (54% female), with 57 ± 12 years. EDX was altered in 47% of all patients. The addition of CN-PREP alone, and NWR combined with CN-PREP increased diagnostic yield to 69% and 72%, respectively. CN-PREP proved to be well tolerable, while NWR was associated with higher test-related pain intensity and discontinuation rate (9% vs. 0%). Considering EDX as the reference test, CN-PREP sensitivity was 85.1% and specificity 58.5%.CONCLUSION:Combining CN-PREP with the routine EDX for patients with neuropathic pain is feasible and results in increased diagnostic yield. Conversely, the addition of NWR to the aforementioned tests provides little improvement to this yield and is less tolerable to the patient. Further studies are needed to determine the actual sensitivity and specificity of CN-PREP when compared to the gold-standard for small fiber neuropathy diagnosis, i.e. intraepidermal nerve fiber density assessment

Ganglionopatia como manifestação inicial de neoplasia pulmonar: relato de caso

Ganglionopathy is a rare condition defined by an injury to the sensory neurons in the dorsal root ganglion. This disease belongs to a group of peripheral polyneuropathies with an exclusively sensory and axonal pattern and its diagnoses can be made by an electromyoneurographic study. The association between ganglionopathy and other underlying pathologies, such as some types of cancer, autoimmune diseases, and celiac disease is often mentioned in published studies. The purpose of this report was to describe the case of a patient suffering from ganglionopathy including a detailed discussion of the electromyoneurographic study that led the attending physician to a diagnosis of neoplastic lung disease. The conclusion therefore was that it is important for the neurophysiology specialist to keep in mind the possible causes of ganglionopathy and, through this diagnosis, to help the attending physician in making an early and full workup of the patient.A ganglionopatia é uma entidade rara que consiste na afecção dos neurônios sensitivos da raiz dorsal, fazendo parte do grupo das polineuropatias periféricas do tipo exclusivamente sensitivo com comprometimento axonal e tendo seu diagnóstico feito através de estudo eletroneuromiográfico. A associação entre a ganglionopatia e outras patologias como neoplasias, doenças autoimunes, doença celíaca, entre outras é amplamente citada na literatura. O objetivo deste trabalho é descrever o caso clínico de um paciente com diagnóstico de neoplasia pulmonar cuja manifestação inicial foi a ganglionopatia, incluindo a descrição detalhada do exame eletroneuromiográfico que auxiliou no processo diagnóstico do médico assistente. Concluímos ser importante que o médico neurofisiologista tenha em mente as possíveis causas da ganglionopatia e saiba apontar o médico assistente para que a investigação possa ser realizada de maneira completa e precoce

Prevalence of Carpal Tunnel syndrome in wheel-chair users due to medullary lesion

Medullary lesions create numerous functional limitations directly related to the loss of nervous functions. However, the mechanics associated with the use of a wheelchair impose a load on the upper limbs that seems to be linked to secondary lesions in the tendinous and nervous structures. Objective: This study seeks to evaluate the appearance of signs of electromyographic impairments of the median nerve around the carpal tunnel in individuals who use wheelchairs due to medullary lesion. Method: Following a transversal design, all the individuals with medullary lesion in the rehabilitation program at the HC-FMUSP Institute of Physical Medicine and Rehabilitation in the year 2010 were submitted to a study of nervous conduction and electromyography. Those findings were correlated with biodemographic and clinical variables, as well as to characteristics of the use of wheelchairs. Results: Twenty-eight (28) individuals were evaluated, with an average age of 41.4 years (60.7% males). Most patients moved the wheelchair for less than four hours and would move it less than 500 meters a day. An absence of painful symptoms was found in 67.9%, while only 7.1% presenting positive Phalen and/or Tinel test. Half of the sample presented the neurophysiological diagnostic of carpal tunnel syndrome (CTS), which had a statistically significant association with age (p = 0.024), but not with the time and distance moving the wheelchair daily, the use of protection or adaptation of the wheelchair, of pain in upper limbs, or the presence of positive signs of CTS in the physical exam. Conclusion: We concluded that the electromyographic signs of CTS are very prevalent in these individuals, which suggests more situations of risk for the integrity of their upper limbs and demands the development of a more efficient biomechanical strategy for prevention.A lesão medular acarreta inúmeras limitações funcionais diretamente relacionadas à perda das funções nervosas. Todavia, a mecânica associada ao uso de cadeiras de rodas impõe uma sobrecarga aos membros superiores que parece estar associada ao aparecimento de lesões secundárias em estruturas tendíneas e nervosas. Objetivo: Avaliar o surgimento de sinais eletromiográficos de comprometimento do nervo mediano na altura do túnel do carpo em indivíduos usuários de cadeiras de rodas devido à lesão medular. Método: Seguindo um desenho transversal, todos os indivíduos com lesão medular sob programa de reabilitação no Instituto de Medicina Física e Reabilitação do HC-FMUSP no ano 2010 foram submetidos a estudo de condução nervosa e eletromiografia. Esses achados foram correlacionados com variáveis biodemográficas e clínicas, bem como características do uso de cadeiras de rodas. Resultados: Foram avaliados 28 indivíduos, com média de idade de 41,4 anos (60,7% homens). A maioria dos pacientes tocava a cadeira de rodas por um tempo inferior a quatro horas e percorria uma distância tocando a cadeira de rodas inferior a 500 metros por dia. A ausência de sintomas dolorosos ocorreu em 67,9%, enquanto apenas 7,1% apresentavam o teste de Phalen e/ou Tinel positivos. Metade da amostra apresentava o diagnóstico neurofisiológico de síndrome do túnel do carpo (STC), que apresentou associação estatisticamente significante com a idade (p = 0,024), mas não com tempo e distância percorrida tocando a cadeira de rodas diariamente, uso de proteção ou adaptação na cadeira de rodas, sintomatologia dolorosa em membros superiores ou presença de sinais positivos para STC ao exame físico. Conclusão: Os sinais eletromiográficos de STC são muito prevalentes nesses indivíduos, o que sugere maiores situações de risco para a integridade dos membros superiores e exige o desenvolvimento de estratégias biomecanicamente mais eficazes para a prevenção

Dystonias: rehabilitation

Articles in the MedLine (PubMed) database and other research sources were reviewed, with no time limit. The search strategy used was based on structured questions in the PICO format from the initials: Patient, Intervention, Control and Outcome. The descriptors used were: dystonia and (benzodiazepines or baclofen or tizanidine or clodinine): dystonia and (anticholinergics or haloperidol or lisuride); dystonia and (botulinum toxin); dystonia cervical and (speech therapy or speech pathologist or botulinum toxin); focal dystonia and (botulinum toxin); dystonia and (sensory stimulation or sensory rehabilitation); dystonia and (biofeedback or electromyography biofeedback); dystonia and (transcranial magnetic stimulation); (dystonic disorders or dystonia) and (self help devices or assistive technology or assistive technologies or rehabilitation); dystonia and (activity daily living); dystonias and (neurosurgery not intrathecal baclofen).Foram revisados artigos nas bases de dados do MedLine (PubMed) e outras fontes de pesquisa, sem limite de tempo. A estratégia de busca utilizada baseou-se em perguntas estruturadas na forma P.I.C.O. (das iniciais "Paciente", "Intervençao", "Controle", "Outcome"). Foram utilizados como descritores: dystonia and (benzodiazepines or baclofen or tizanidine or clodinine): dystonia and (anticholinergics or haloperidol or lisuride); dystonia and (botulinum toxin); dystonia cervical and (speech therapy or speech pathologist or botulinum toxin); focal dystonia and (botulinum toxin); dystonia and (sensory stimulation or sensory rehabilitation); dystonia and (biofeedback or electromyography biofeedback); dystonia and (transcranial magnetic stimulation); (dystonic disorders or dystonia) and (self help devices or assistive technology or assistive technologies or rehabilitation); dystonia and (activity daily living); dystonias and (neurosurgery not intrathecal baclofen)

Use of concentric planar electrode for evaluation of patients with lower limbs pain and neuropathic characteristics

A dor neuropática é definida como uma condição associada a uma lesão ou doença que afeta o sistema somatosensorial (SSS). A lesão do SSS é frequentemente determinada por estudos eletrodiagnósticos convencionais (EDX) em casos de dor neuropática periférica. No entanto, o EDX não pode detectar neuropatia de pequenas fibras, que podem ser a causa de lesões do SSS em alguns pacientes. Realizamos um estudo prospectivo avaliando o ganho na faixa diagnóstica provocado pelo uso de dois testes neurofisiológicos adicionais: potenciais evocados relacionados a dor obtidos por um eletrodo concêntrico (CN-PREP) e o reflexo nociceptivo de flexão (NFR) quando adicionado ao EDX. Foram incluídos pacientes com histórico de dor crônica nos membros inferiores e um escore positivo do questionário Douleur Neuropathique (DN4), encaminhados para EDX de rotina. Além do EDX, os pacientes foram submetidos ao CN-PREP e medições do NFR. Foram incluídos 100 pacientes (54 mulheres , 57± 12 anos) com suspeita de (provável) dor neuropática. O EDX foi alterado em 47% dos pacientes, enquanto a adição do CN-PREP aumentou a faixa diagnóstica para 69%. A adição de NFR ao EDX e CN-PREP aumentou a positividade para 72,0%, enquanto o restante dos pacientes tiveram resultados normais para os três testes. Considerando o EDX como teste de referência, a sensibilidade do CN-PREP foi de 85,1% e a especificidade 58,5%. O CN-PREP mostrou-se tolerável para os pacientes, enquanto o NFR foi associado a um maior desconforto. Mostramos que os CN-PREPs podem ser adicionados à avaliação neurofisiológica de rotina de pacientes com suspeita de dor neuropática, o que aumenta a positividade diagnóstica. Resta saber qual é a sensibilidade real e a especificidade dos CN-PREPs neste cenário quando comparados aos padrões de ouro de avaliação de fibras de pequeno porte, como a densidade de fibra nervosa intraepidérmica e potenciais evocados a laser, para que a taxa de falsa positividade de tal estratégia possa ser determinadaNeuropathic pain is defined as a condition associated with an injury or disease that affects the somatosensory system (SSS). SSS lesion is frequently determined by conventional electrodiagnostic studies (EDX) in cases of peripheral neuropathic pain. However, EDX cannot detect small fiber neuropathy, which may be cause of SSS lesions in some patients. We have conducted a prospective study assessing the gain in diagnostic range brought about by the use of two additional neurophysiological tests: pain related evoked potentials obtained by a concentric electrode (CN-PREP), and the nociceptive flexion reflex (NFR) when added to EDX. We included patients with a history of chronic pain in the lower limbs and a positive Douleur Neuropathique questionnaire score addressed for routine EDX. In addition to EDX, patients underwent evoked potential with concentric electrode (CN-PREP) and measurements of nociceptive flexion reflexes. 100 patients (54 female , 57±12 years) were included with suspected (probable) neuropathic pain. EDX was altered in 47% of patients, while the addition of CN-PREP increases diagnostic range to 69%. The addition of NFR to EDX and CN-PREP increased positivity to 72.0%, while the remaining had normal results for the three tests. Considering EDX as the reference test, CN-PREP sensitivity was 85.1% and specificity 58.5%. The CN-PREP proved to be tolerable for patients, while NFR was associated with more discomfort. We have shown that CN-PREPs can be added to the routine neurophysiological assessment of patients with suspected neuropathic pain, which increases diagnostic positivity. It remains to be determined the actual sensitivity and specificity of CN-PREPs in this scenario when compared to gold standards of small fiber assessment such as intraepidermal nerve fiber density and laser-evoked potentials, so that the false positive rate of such a strategy can be determine

Cerebral and cardiac amyloidosis in autopsied elderly individuals

INTRODUCTION: Amyloidosis in elderly individuals can be an independent alteration and a characteristic of aging. However, the clinical, pathophysiologic, and biochemical characteristics of amyloidosis related to age remain uncertain. OBJECTIVE: The purpose of this study was to determine the extent to which the heart and/or the brain of individuals aged 60 years or over exhibits amyloid deposits. MATERIALS AND METHODS: The autopsy findings of individuals who were at least 60 years old were studied. The autopsies took place between the years of 1976 and 2000. A total of 10 cases were selected that had hearts without cardiopathies, had negative serology for Chagas' disease, and had brains without morphological changes related to encephalopathies. Slides with fragments of heart and brain were processed and analyzed using polarized and common light microscopy. RESULTS: Of the 10 cases, 4 were positive for amyloidosis. All had positive findings in the brain, and 1 case also had positive findings in the heart. Among the positive cases, 50% were of people aged 60 to 69 years. There appeared to be a relationship between the presence of amyloid deposits and the ratio of brain and body weight, with the ratio in the positive cases being smaller than in the negative cases. CONCLUSIONS: The analysis of amyloid deposits in the brains and hearts of elderly individuals shows that such deposits may lead to a systemic attack of senility, common to natural aging. It is not certain that beta-amyloid deposits would alone bring such drastic repercussions to the individual. Some additional disorders of the organism could cause the breakdown of the natural balance related to the accumulation of these proteins, leading the way to the pathological contexts of amyloidosis