Neuropathic pain in an elderly population of an urban area of iran with a special focus on carpal tunnel syndrome : epidemiological aspects, clinical characteristics, and non-surgical therapy

Background: People are getting older, and aging problems and disorders are increasing fast. Knowing the rates, causes, symptomatology, treatment, relief, and prognosis of associated disorders can help and facilitate the elderly, their families, primary health care providers, and health policymakers. Chronic pain in the elderly is a common complaint and its prevalence differs in society and depends on many factors, including type, severity, and localization but also comorbidities, socio-economic factors, and genetics. Pain is in two main categories, nociceptive and neuropathic. Nociceptive pain usually occurs after end-organ damage or derangement such as musculoskeletal problems, osteoarthritis, or trauma. Neuropathic pain arises from central or peripheral nervous system injuries. One of the most common types of peripheral neuropathic pain is hand pain caused by the carpal tunnel syndrome (CTS). Hand pain and CTS are common among the elderly, especially in women. The etiology usually remains uncertain until the late stages of the disorder, when intrinsic hand muscles become weak or atrophy, when it is too late to manage the CTS adequately. Thus, it is important to be aware of its clinical symptoms, signs, and provocation maneuvers, but also to have a noninvasive diagnostic tool when CTS is suspected. Also, it is important to have a solution for mild and moderate types of CTS to prevent surgery in older adults, especially in those with frailer constitutions. Objectives: We evaluated the prevalence of pain, with special focus on neuropathic pain and CTS, in a large population-based study in Tehran, the capital of Iran. We chose CTS as being the most common symptom of focal neuropathy and evaluated the median nerve by noninvasive, high-resolution ultrasonography. We investigated and diagnosed CTS and determined its severity. Following the results of our diagnostic study, we performed interventional treatment studies on patients diagnosed with CTS. To find the optimum steroid dose site, we examined three different doses of steroid in a mixture injected in the tunnel near the affected nerve medianus with an adhesion removal technique called hydro dissection. Finally, we compared different methods of injection in our last study to examine a hypothesis about nonsurgical flexor retinaculum release. Methods and material: More than 5,000 patients were investigated randomly by a multistage cluster sample. Participants were then interviewed using a sociodemographic checklist, a standard pain questionnaire, and general health through GHQ-28. In the 2nd study, demographics were noted along with the clinical presentation of CTS, and the median nerve anatomy was assessed by ultrasound and electrodiagnostic tests. The median nerve cross-sectional area (CSA) at the tunnel inlet and four different areas over the median nerve were measured and analyzed. In the 3rd paper with an intervention, we designed a prospective three group, randomized, double-blind trial to evaluate 40, 80, and 0 mg triamcinolone in a mixture of 3 mL containing 1 cc of lidocaine 2%. Outcome measures included the Boston Carpal Tunnel Questionnaire, VAS (visual analog scale), median nerve conduction criteria, and the ultrasound median CSA. All data were recorded at the baseline, 14 days, 1 month, and 6 months after the injection. In the 4th study, the design was similar to the 3rd one, though we had only two groups and the injecting mixture was 40 mg of triamcinolone and 1 cc of lidocaine 2%. The location of the injection was different with one group injected in the flexor retinaculum and the other near the nerve. All data were recorded as in the 3rd study but only at baseline, and 6 weeks after injection. Results: We found a 13.7% prevalence of chronic neuropathic pain and 30% of chronic nociceptive pain, overall chronic of 31.7% and overall acute of 39.1% which, in combination, add up to 70.8%. The major comorbidities were osteoporosis, diabetes, disability, and stroke. In the 2nd study with 203 CTS and 103 control subjects, CSA at the tunnel inlet with a threshold of 8.5 mm2 had a sensitivity and specificity of 96.9% and 93.6% respectively. In the 3rd study with 161 patients, we did not find any statistically significant differences between groups, i.e., all groups with a steroid dose had similar results. In the last study with 50 eligible subjects randomized into two groups, there was a significant improvement in Boston scores (p-value 0.023), VAS (p-value 0.026), and ultrasonographic measure (p-value 0.004), in favor of intra-flexor retinaculum steroid injection compared to near the nerve. Conclusions: Neuropathic pain prevalence is relatively high; 13.7% among Iranian elderly people, and the overall pain is very high around 70 %. It should be addressed by health policymakers, primary care physicians, and caregivers. High-resolution ultrasonography is a noninvasive diagnostic tool with about 95% sensitivity and specificity in detecting CTS in the elderly and should be introduced as a screening tool by primary physicians engaged in elderly care. The use of plain lidocaine was beneficial in managing CTS in elderly patients, and we did not find any superiority for the steroids. Finally, in case of no contraindication for steroids, we prefer the intra-flexor retinaculum injection. Larger studies should be performed in future studies in this field to confirm our results

Normal Values and Reproducibilitiy of Electric Current Perception Threshold in Sensory Fibers

Objective: Routine electrodiagnosis (EMG-NCS) has some shortcomings in the evaluation of peripheral nervous system, auch as autonomous nervous system evaluation, in pure sensory radiculopathies and acute hyperesthetic stages of neuropathies. Quantitative sensory testings such as current perception threshold (CPT) with electrical stimulations are suggested for above mentioned pathologies. Ttest results should be compared with a normal value of similar identical population. This study is conducted to determine normal value and reproducibility of CPT in the Iranian population. Materials & Methods: Fifty normal volunteers (32 men, 18 woman) in the range of 20-40 years without exclusion criteria (such as neuro- musculoskeletal disorders, diabetes mellitus and alcoholism) were recruited with simple randomized selection and CPT test was conducted on C8 (4th finger) and L5 (1st Toe)dermatomes. To determine test’s reproducibility, 6 persons (4 men, 2 women) were examined 3 times a day, 2 day per week. Collected data were analyzed to determine mean and standard deviation. Results: Normal values of CPT test was defined as one standard deviation from mean of our CPT data. These values are in C8 dermatome 2000 Hz: 2.04± 47 250 Hz: 0.75±0.25 5 Hz: 0.76±0.3 and for L5 dermatome 2000Hz: 2.83± 0.73 250 Hz: 1.24 ± 45 5Hz: 0.76± 0.3 To determine our results reproducibility and reliability, Alpha- cronbach (existed in SPSS software) was used and %98.5 & 99% were obtained for C8 & L5 dermatomes respectively. Conclusion: Our findings are about C8 & L5 dermatomes which could be used as a normal Values for such dermatomes. Regarding to its good correlation with international results we can use international references as a normal Valueswith consideration of each clinic’s reproducibility should be assessed individually

The Relationship Between Disability and Variables of Depression, Cognitive Status, and Morale Among Older People

Objectives: This study aimed to assess disability and its relationship with depression, cognitive status, and&nbsp;morale in older people. Methods & Materials: This descriptive-analytic research was conducted in a day-care rehabilitation center&nbsp;of Kahrizak charity foundation. A total of 90 older adults were selected by total enumeration sampling&nbsp;method. For the evaluation of study participants, we used The World Health Organization Disability Assessment&nbsp;2.0 (WHODAS II) (36 items). This questionnaire examines the person&rsquo;s disability in 6 domains of&nbsp;cognition, mobility, self-care, getting along, life activities, and social participation. The depression status&nbsp;was determined by Geriatric Depression Scale (GDS-15), cognitive status by Abbreviated Mental test&nbsp;(AMT), and morale of older people by Lawton&rsquo;s Philadelphia Geriatric Center Morale Scale. The Chisquare&nbsp;test, Independent t-test, Mann-Whitney U-test, Kruskal-Wallis, and the Spearman correlation&nbsp;coefficient were carried out to analyze the data. Results:&nbsp;The mean (SD) score of older adults&rsquo; disability was 20.61 (13.66) indicating a significant difference between&nbsp;men and women (P=0.001). The women&rsquo;s mean disability score was higher than that of men.&nbsp;With regard to 6 domains of disability, the highest disability was seen in domains of mobility, life activities,&nbsp;and participation. There were also significant differences between men and women with regard&nbsp;to the mean disability scores of mobility (P=0.001), life activities (P=0.001), and participation (P=0.005),&nbsp;i.e., the mean disability scores of women were higher than those of men. However, there were no differences&nbsp;between men and women with regard to domains of getting along, cognition, and self-care.&nbsp;Furthermore, there were no significant differences between various educational groups with regard to&nbsp;mean scores of disabilities. There were significant associations between disability scores and depression&nbsp;(P<0.001), cognitive status (P<0.001), and morale of older people (P<0.001). This association was direct&nbsp;in depression and reverse in cognitive status, and morale, i.e., with an increase in depression scores and&nbsp;a decrease in cognitive status and morale, the disability of older people increases. There were significant&nbsp;and reverse associations between disability and 3 subscales of spirit of agitation (P<0.001), attitudes to&nbsp;aging (P<0.001), and dissatisfaction with loneliness (P<0.001). Conclusion: Disability in older people had a significant relationship with their depression, cognitive status,&nbsp;and morale. Thus, the degree of their disability can be lowered by prevention and early treatment of depression,&nbsp;promotion of memory, delaying cognitive disorders, as well as providing morale enhancement&nbsp;programs, creating a positive attitude toward old age, and increasing life satisfaction in older people.&nbsp

Stroke Epidemiology and One-Month Fatality among an Urban Population in Iran

Objective Stroke is one of the most common causes of death and disability in Iran. This study evaluated stroke patient profiles with respect to rate, risk factors, and one-month fatality. Material and method A cross-sectional, hospital-based study on all stroke patients older than 45 years admitted to hospitals in the city of Qom throughout 2001. Results Four hundred and sixty patients older than 45 years were admitted as stroke. The annual stroke rate was estimated to 338/100 000 (95% confidence interval, 300–360) inhabitants older than 45 years. The annual rate of stroke was 384/100 000 (95% confidence interval, 381–386) when adjusted to the European population. Stroke subtypes were; ischaemic infarction 75%, intracranial haemorrhage 20·7%, subarachnoid haemorrhage 3%, and undetermined 1·3%. Main risk factors were hypertension in 74·6% and diabetes in 55·7%. Mortality rate was 24·6% within the first month. Conclusion Stroke incidence was higher than in Western countries. Hypertension and diabetes mellitus were considerably more frequent in our studied stroke patients than in other developing countries. Our findings need to be addressed in future health education programmes in Iran identifying patients at risk and focusing on more aggressive prevention programmes to lower stroke incidence. </jats:sec