Early detection of median nerve syndrome at the carpal tunnel with high-resolution 18 MHz ultrasonography in systemic sclerosis patients

OBJECTIVES

To investigate carpal tunnel syndrome (CTS) with ultrasound (US) in asymptomatic SSc patients and to seek out the relationship between CTS and SSc clinical variables

METHODS

In 64 SSc patients (55 women and 9 men, mean age 57±14 years) and in 30 healthy controls, area (MNA), transverse (MNT) and anteroposterior (MNAP) diameters of MN at carpal tunnel were studied with US (My Lab 25 XVG US Esaote 18 MHz). MN flattening ratio (MNFR) was calculated. Duration of disease, subset (limited, diffuse), phase of skin involvement (oedematous, atrophic, fibrotic), modified Rodnan skin score (mRSS) and friction tendon rub were also recorded.

RESULTS

MNA (p<0.001), MNT (p<0.005) and MNFR (p<0.005) were significantly higher in the SSc patients than in controls, while no difference in MNAP was found. There was no correlation between median nerve (MN) and SSc clinical features (only lower MNAP correlated inversely with longer disease duration; Spearman coefficient -0.2).

CONCLUSIONS

MN involvement is frequently present in all phases of asymptomatic SSc patients, independently to clinical variables.

Phantom limb related phenomena and their rehabilitation after lower limb amputation

This paper reviewed the various hypotheses on phantom limb and phantom limb pain as well as all the related rehabilitation techniques to control these symptoms. The uncertainty in their pathophysiology strongly affects all the rehabilitation approaches so far used, as no single parameter has been found to predict or control phantom limb pain as well as no single factor can be quoted as an indicator of rehabilitation success for lower limb amputation. Within a comprehensive rehabilitation plan, behavioral interventions, stimulation techniques, feedback, physical therapies designed to possibly reverse the maladaptive memory traces and enhance its extinction have been described. Although substantially not clinically useful, pharmacological and surgical interventions also have been briefly considered. A reassessment of the actual strategies used is suggested with a role for rehabilitation not only after the amputation but also in the pre-emptive control of the pre-existing painful condition. In this process, rehabilitation should take into account many parameters, not always related to the traditional role of rehabilitation. Pain assessment before and after amputation, its natural history and clinical picture such as its quality, variations, level of the amputation, dominance, time interval between amputation and rehabilitation, as well as all the other phantom limb related phenomena should be considered and treated.

Central motor control failure in fibromyalgia: a surface electromyography study

Background

Fibromyalgia (FM) is characterised by diffuse musculoskeletal pain and stiffness at multiple sites, tender points in characteristic locations, and the frequent presence of symptoms such as fatigue. The aim of this study was to assess whether the myoelectrical manifestations of fatigue in patients affected by FM are central or peripheral in origin.

Methods

Eight female patients aged 55.6 ± 13.6 years (FM group) and eight healthy female volunteers aged 50.3 ± 9.3 years (MCG) were studied by means of non-invasive surface electromyography (s-EMG) involving a linear array of 16 electrodes placed on the skin overlying the biceps brachii muscle, with muscle fatigue being evoked by means of voluntary and involuntary (electrically elicited) contractions. Maximal voluntary contractions (MVCs), motor unit action potential conduction velocity distributions (mean ± SD and skewness), and the mean power frequency of the spectrum (MNF) were estimated in order to assess whether there were any significant differences between the two groups and contraction types.

Results

The motor pattern of recruitment during voluntary contractions was altered in the FM patients, who also showed fewer myoelectrical manifestations of fatigue (normalised conduction velocity rate of changes: -0.074 ± 0.052%/s in FM vs -0.196 ± 0.133%/s in MCG; normalised MNF rate of changes: -0.29 ± 0.16%/s in FM vs -0.66 ± 0.34%/s in MCG). Mean conduction velocity distribution and skewnesses values were higher (p < 0.01) in the FM group. There were no between-group differences in the results obtained from the electrically elicited contractions.

Conclusion

The apparent paradox of fewer myoelectrical manifestations of fatigue in FM is the electrophysiological expression of muscle remodelling in terms of the prevalence of slow conducting fatigue-resistant type I fibres. As the only between-group differences concerned voluntary contractions, they are probably more related to central motor control failure than muscle membrane alterations, which suggests pathological muscle fibre remodelling related to altered suprasegmental control.

Phantom limb pain relief by contralateral myofascial injection with local anaesthetic in a placebo-controlled study: preliminary results

OBJECTIVE

To ascertain the existence of contralateral painful muscle areas mirroring phantom pain and to evaluate the short-term effects of anaesthetic vs saline, injected contra notlaterally to control phantom and phantom limb pain.

DESIGN

Double-blinded cross-over study.

SETTING

Inpatients; rehabilitation institute.

PARTICIPANTS

Eight lower limb amputees with phantom limb pain in the past 6 months.

INTERVENTIONS

Either 1 ml of 0.25% bupivacaine or 0.9% saline injected alternately in each point with a 28-gauge needle, with 72 h between injections. Main outcome measurePhantom sensation modification and the intensity of phantom limb pain (visual analogue scale) before and after injections.

RESULTS

Although present, painful muscle areas in the healthy limb do not mirror the topographical distribution of phantom limb pain. Sixty minutes after the injection, a statistically significant greater relief of phantom limb pain was observed after using local anaesthetic than when using saline injection (p = 0.003). Bupivacaine consistently reduced/abolished the phantom sensation in 6 out of 8 patients. These effects on phantom sensation were not observed after saline injections.

CONCLUSION

Contralateral injections of 1 ml 0.25% bupivacaine in myofascial hyperalgesic areas attenuated phantom limb pain and affected phantom limb sensation. The clinical importance of this treatment method requires further investigation.

Symptoms and signs in fibromyalgia syndrome

Fibromyalgia syndrome (FM) is a common chronic pain condition that affects at least 2% of the adult population. Chronic widespread pain is the defining feature of FM, but patients may also exhibit a range of other symptoms, including sleep disturbance, fatigue, irritable bowel syndrome, headaches, and mood disorders. The etiology of FM is not completely understood and the syndrome is influenced by factors such as stress, medical illness, and a variety of pain conditions. Establishing diagnosis may be difficult because of the multifaceted nature of the syndrome and overlap with other chronically painful conditions. A unifying hypothesis is that FM results from sensitization of the central nervous system; this new concept could justify the variety of characteristics of the syndrome. FM symptoms can be musculoskeletal, non-musculoskeletal, or a combination of both; and many patients will also experience a host of associated symptoms or conditions. The ACR classification criteria focus only on pain and disregard other important symptoms; but three key features, pain, fatigue and sleep disturbance, are present in virtually every patient with FM. Several other associated syndromes, including circulatory, nervous, digestive, urinary and reproductive systems are probably a part of the so called central sensitivity or sensitization syndrome. A minority subgroup of patients (30-40%) has a significant psychological disturbance. Psychological factors are an important determinant of any type of pain, and psychological comorbidity is frequent in FM. Psychiatric disorders most commonly described are mood disorders, but psychiatric illness is not a necessary factor in the etiopathogenesis of FM.

The evaluation of the fibromyalgia patients

Fibromyalgia (FM) is a rheumatic disease characterized by musculoskeletal pain, chronic diffuse tension and/or stiffness in joints and muscles, easy fatigue, sleep and emotional disturbances, and pressure pain sensitivity in at least 11 of 18 tender points. At present, there are no instrumental tests or specific diagnostic markers for FM; in fact, many of the existing indicators are significant for research purposes only. Many differential diagnoses may be excluded by an extensive clinical examination and patient history. Considering overlap of FM with other medical conditions, the treating physicians should be vigilant: chest-X-rays and abdominal ultrasonography are the first steps of general evaluation for all the patients with suspected FM. Functional neuroimaging methods have revealed a large number of supraspinal effects in FM, a disorder mediated by mechanisms that are essentially unknown. Many treatments are used in FM patients, but evaluating their therapeutic effects in FM is difficult because the syndrome is so multifaceted. To address the identification of core outcome domains, the Initiative on IMMPACT and OMERACT workshop convened a meeting to develop consensus recommendations for chronic pain clinical trials.

Etiopathogenetic mechanisms of fibromyalgia syndrome

Fibromyalgia syndrome (FMS) is a common chronic condition of widespread pain with causal mechanisms that are largely unknown. It is characterized by moderate to severe musculoskeletal pain and allodynia, but its pathogenesis appears confined to the nociceptive structures of the central nervous system. FMS is often triggered by negative environmental influences, especially if they occur in childhood. In a fetus, these environmental triggers may influence the development of the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal axis (HPA). Increasing evidence supports the comorbidity of psychological conditions including depression, panic disorders, anxiety, and post-traumatic stress disorder (PTSD). Recent evidence suggests that genetic factors may play a role in the pathogenesis of FMS. Central sensitization has long been associated with FMS pain. It describes enhanced excitability of dorsal horn neurons, which leads to transmission of altered nociceptive information to the brain. Understanding of pathogenetic pathways in FMS has advanced beyond observing patient responses to neurophysiologically targeted therapies and basic research.

Botulinum toxin for pain

Botulinum toxin (BTX) injection is being increasingly used 'off label' in the management of chronic pain. Data support the hypothesis of a direct analgesic effect of BTX, different to that exerted on muscle. Although the pain-reducing effect of BTX is mainly due to its ability to block acetylcholine release at the synapse, other effects on the nervous system are also thought to be involved. BTX affects cholinergic transmission in both the somatic and the autonomic nervous systems. Proposed mechanisms of action of BTX for pain relief of trigger points, muscular spasms, fibromyalgia and myofascial pain include direct action on muscle and indirect effects via action at the neuromuscular junction. Invitro and invivo data have shown that BTX has specific antinociceptive activity relating to its effects on inflammation, axonal transport, ganglion inhibition, and spinal and suprasegmental level inhibition. Our review of the mechanisms of action, efficacy, administration techniques and therapeutic dosage of BTX for the management of chronic pain in a variety of conditions shows that although muscular tone and movement disorders remain the most important therapeutic applications for BTX, research suggests that BTX can also provide benefits related to effects on cholinergic control of the vascular system, autonomic function, and cholinergic control of nociceptive and antinociceptive systems. Furthermore, it appears that BTX may influence the peripheral and central nervous systems. The therapeutic potential of BTX depends mainly on the ability to deliver the toxin to the target structures, cholinergic or otherwise. Evidence suggests that BTX can be administered at standard dosages in pain disorders, where the objective is alteration of muscle tone. For conditions requiring an analgesic effect, the optimal therapeutic dosage of BTX remains to be defined.

The therapeutic efficacy of somatic acupuncture is not increased by auriculotherapy: A randomised, blind control study in cervical myofascial pain

Auriculotherapy (ear acupuncture) is a therapeutic technique in which points on the auricle are stimulated with needles. Usually it is combined with somatic acupuncture because of possible synergy, although the efficacy of this pairing has neither been confirmed nor disproved. The aim of this study was to verify: (1) if somatic acupuncture can reduce myofascial cervical pain; (2) if concomitant auriculotherapy improves the efficacy of somatic acupuncture. A group of 62 patients affected by cervical myofascial pain was randomly divided into two groups of 31. Group A (6 males and 25 females) underwent eight sessions of somatic acupuncture. Group B (7 males and 24 females) underwent eight sessions of somatic acupuncture in the same way as group A, paired with auriculotherapy. Pain was scored using the McGill Pain Questionnaire before and at the end of treatment, and 1 and 3 months later. The results showed that both somatic acupuncture and somatic plus ear acupuncture have a positive effect in reducing pain. The pain intensity score was 40.70 +/- 17.78 in group A before therapy and 13.32 +/- 9.62 after therapy; in group B it was 38.90 +/- 15.31 and 13.43 +/- 10.96. Somatic plus auriculotherapy was therefore not statistically significantly superior to somatic therapy alone in the treatment of cervical myofascial pain.

Proton magnetic resonance spectroscopy reveals central neuroaxonal impairment in systemic sclerosis

OBJECTIVE

. Involvement of the central nervous system (CNS) in systemic sclerosis (SSc) is rare. Proton magnetic resonance spectroscopy (1H-MRS) assesses in vivo cerebral metabolites. We investigated the biochemical modifications of the CNS in SSc.

METHODS

N-acetylaspartate/creatine ratio (NAA/Cr) and choline/creatine ratio (Cho/Cr) at right centrum semiovale (RCS) and at right basal ganglia (RBG) were evaluated by 1H-MRS in 12 patients with limited (lSSc) and 8 patients with diffuse SSc (dSSc) and 20 control subjects.

RESULTS

With 1H-MRS, a significant reduction of NAA/Cr ratio at RBG (p < 0.02) and at RCS (p < 0.002) was detected in SSc patients. Cho/Cr ratio was increased (p < 0.02) in the RCS, but not in RBG. In patients with lSSc, a significant reduction of NAA/Cr was detected in RCS but not in RBG.

CONCLUSION

Evidence of neuroaxonal damage strongly suggests the existence of CNS involvement in SSc.

Myoelectric manifestations of fatigue during exposure to hypobaric hypoxia for 12 days

Lack of oxygen, as occurs at high altitude (HA), leads to a number of adaptive processes in muscle, but their precise nature is unclear. To better understand mechanisms of adaptations of the neuromuscular system to HA, we collected surface electromyographic (EMG) signals during a 12-day stay at 5,050 m above sea level (SL). The aim was to investigate the effect of hypobaric hypoxia on muscle-fiber membrane and motor-unit control properties. Surface EMG signals were recorded from the dominant biceps brachii muscle of six subjects at HA and 3 months after their return to SL. Supramaximal electrical stimuli (25 HZ) were delivered and voluntary isometric contractions at 40 and 80% of maximal voluntary torque were performed in 10 experimental sessions at HA and in 3 at SL. Maximal isometric torque was not altered at HA. Surface EMG spectral frequencies at the beginning of the voluntary contractions were greater at HA than SL. The rates of change of spectral frequencies and conduction velocity during the voluntary contractions were significantly larger at HA than SL. No differences in EMG variables were observed in the electrically elicited contractions. The maximal torque and surface EMG variables did not depend on the day of measure at HA. It was concluded that acute exposure to hypobaric hypoxia does not significantly affect the muscle-fiber membrane properties but does impact motor-unit control properties. This provides new insights in the understanding of motor control in extreme conditions of oxygen reduction, with relevance for sport and rehabilitation medicine, and may also explain the pathophysiological adaptations of the neuromuscular system occurring in such disorders as chronic obstructive pulmonary disease.

Blink reflex discloses CNS dysfunction in neurologically asymptomatic patients with systemic sclerosis

OBJECTIVE

To investigate trigeminal-nerve, brain-stem, and brain function, in order to disclose a possible nervous system involvement in neurologically asymptomatic systemic sclerosis (SSc) patients.

METHODS

Using a standard electromyographic (EMG) technique, we recorded the early (R1) and late (R2) components of the blink reflex in 35 SSc patients with no history or signs of cranial-nerve impairment and 20 control subjects. SSc patients were classified as limited or diffuse SSc and also evaluated for disease duration, autoantibody pattern (ANA, ACA, Scl70) and skin score (by Rodnan modified method).

RESULTS

Whereas no SSc patients had an abnormal R1, six (18%) had delayed R2 responses. We found no correlation between R2 latency and clinical or laboratory data.

CONCLUSIONS

Whereas previous studies reported both R1 and R2 abnormalities (reasonably due to trigeminal neuropathy) in symptomatic SSc patients, we found selective abnormalities of the R2 components in asymptomatic patients. The selective R2 abnormality is secondary to a central dysfunction, either because of a direct impairment of the polysynaptic circuits in the medulla, or because of a decreased cortico-reticular drive on these circuits. The lack of overt trigeminal symptoms in our patients favours a suprasegmental dysfunction, possibly due to microvascular lesions disseminated in the subcortical white matter.

Surface EMG alterations induced by underwater recording

BACKGROUND AND PURPOSE

This study aims to verify if amplitude and spectral characteristics of surface EMG signal are modified due to recording in a wet environment.

METHODS

Isometric contractions of the biceps brachii muscle of ten subjects were performed in several different set-up combinations, both in dry (D) and in water from hydrotherapy pools (PW), with (PWM) or without moving the pool water and with (T) or without water-resistant adhesive taping.

RESULTS

In PW condition the amplitude of the recorded signal is reduced to 5-10% of the corresponding signal recorded in D condition. In PWM the power spectrum is drastically reduced and altered by the water movement that introduces an increase of spectral power in the frequency range 0-20 Hz. The use of T modality allows to record signals with both amplitude and spectral frequencies comparable with those obtained in the D conditions.

DISCUSSION AND CONCLUSION

This work demonstrates the need for water resistant taping when EMG signals are recorded in water. Signals recorded without such a protective film are strongly affected in their amplitude and frequency characteristics by the conductivity and the movement of water.

The autonomic nervous system in systemic sclerosis. A review

The autonomic nervous system is an underestimated target of systemic sclerosis alterations. In this review we analyzed the major manifestations of its involvement, reconsidering the main theories of its pathogenesis.

[Peripheral neuropathy rehabilitation. Indications for a diagnostic-rehabilitation approach]

The increased incidence of occupational neurological disorders has led, in recent years, to the development of new specialties in neurorehabilitation for the recovery of deficits of central nervous system (CNS) lesions. This same development has not occurred for damage to the peripheral nervous system (PNS), the treatment of which is still based on empirically applied rehabilitation techniques. This is due to the fact that the peripheral neuropathies comprise a vast groups of disorders caused by a huge variety of etiological agents; in order to identify their exact cause and thus be able to differentiate rehabilitation techniques it is necessary to classify them. The aim of this study is to summarize the main rehabilitation strategies, pharmacological treatments and surgical techniques used most effectively in the management of peripheral neuropathies in order to develop a therapeutic rehabilitation strategy for each of the different forms and lay the bases for the development of specific guidelines.

Pupillocynetic activity of substance P in systemic sclerosis

OBJECTIVE

In systemic sclerosis (SSc), dysfunctions of peripheral nervous system (PNS) have been observed. Substance P (SP) instillation in human eye induces a cholinergic-independent pupil myosis. Pupil basal diameters (PBD) and pupil responsiveness to SP, expressed as area under the curve (AUC), were studied by pupillometry to assess SP-ergic fiber state and function in SSc.

METHODS

Forty SSc patients [24 with limited (lSSc), 16 with diffuse (dSSc) disease] and 40 controls underwent pupillometric evaluation. After evaluation of PBD, SP 10-3 M was instilled in one eye and placebo in the contralateral eye. Antinuclear (ANA), anticentromere (ACA), and anti-Scl-70 autoantibodies were correlated with PBD and AUC.

RESULTS

PBD was significantly lower in SSc patients versus controls (p < 0.001). PBD was minor in lSSc versus both dSSc and controls (p < 0.05), but no difference was found between dSSc and controls. In SSc, SP 10-3 M induced greater myosis compared to controls (p < 0.001). SP 10-3 M-induced myosis was higher in lSSc versus both dSSc and controls (p < 0.05). ACA significantly correlated with decreased values of PBD and AUC (p < 0.001).

CONCLUSION

Our results show that PBD is reduced in patients with SSc and that SP induces a more intense myosis in SSc than controls. Moreover, in lSSc PBD is lower and SP increases the myosis in lSSc compared to dSSc and controls. This suggests a peculiar dysfunction of PNS in patients with the limited subset of SSc.

Can continuous physical training counteract aging effect on myoelectric fatigue? A surface electromyography study application

OBJECTIVES

To compare the myoelectric onset of muscle fatigue in physically active trained young skiers with respect to elderly skiers and to test whether continuous training can counteract the selective loss of type II muscle fibers usually observed with aging.

DESIGN

An observational, cross-sectional study of the myoelectric onset of muscle fatigue in the left tibialis anterior muscles.

SETTING

Surface electromyography recorded with portable devices at a downhill ski rescue lodge in the Italian Alps.

PARTICIPANTS

Fifty-four physically trained, active skiers (43 men, 11 women; age range, 24-85y).

INTERVENTIONS

Questionnaire on physical activity and 2 sustained isometric voluntary contractions at 20% and 2 at 80% of the maximal voluntary contraction level.

MAIN OUTCOME MEASURES

Isometric contractions and mean and median spectral frequencies calculated to monitor the myoelectric manifestations of muscle fatigue.

RESULTS

Fatigue indices did not differ significantly between younger and older subjects and, thus, did not show a correlation between myoelectric manifestations of muscle fatigue and age in physically active subjects.

CONCLUSION

It appears possible that aging skeletal muscles subjected to continuous exercise develop an adaptive response that counteracts the selective loss of type II muscle fibers usually observed in the muscles of elderly sedentary subjects. Our results suggest that physical activity could be considered in the elderly within a broad rehabilitative framework in which appropriate and even tailored physical training could be planned to counteract the physiologic effects of aging on muscle fiber distribution.

[Role of depression in the functional recovery and cost of stay in patients with acute cerebrovascular lesions]

BACKGROUND AND PURPOSE

The constant increase in health costs in recent years has led to the introduction of instruments such as DRG--diagnosis-related groups--with the declared aim of best rationalizing in-hospital costs. As part of this rationalisation it has become necessary to identify the causes of prolonged admissions in health-care structures. As far as concerns the rehabilitation of cerebrovascular diseases, attention has been centred on the presence of post-stroke depression. Our study was aimed at analysing the effect of depression on the time spent in hospital and whether the depression also affected on the patient's potential for functional recovery.

METHODS

Patients with acute cerebrovascular lesions admitted to our center for rehabilitation were enrolled in this study. Depressive syndromes and functional deficits were evaluated at admission and discharge.

RESULTS AND CONCLUSIONS

The most depressed patients were those who spent a longer time in hospital, but they were also those who had a greater functional deficit. The depression did not affect the efficacy and efficiency of the rehabilitation treatment. The time spent in hospital did, however, correlate with the clinical condition of the patient at admission and the age of the lesion.