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Ciuffreda G, Bueno-Gracia E, Albarova-Corral I, Montaner-Cuello A, Pérez-Rey J, Pardos-Aguilella P, Malo-Urriés M, Estébanez-de-Miguel E. In Vivo Effects of Joint Movement on Nerve Mechanical Properties Assessed with Shear-Wave Elastography: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2024; 14:343. [PMID: 38337859 PMCID: PMC10855485 DOI: 10.3390/diagnostics14030343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/02/2024] [Accepted: 02/02/2024] [Indexed: 02/12/2024] Open
Abstract
Peripheral nerves are subjected to mechanical tension during limb movements and body postures. Nerve response to tensile stress can be assessed in vivo with shear-wave elastography (SWE). Greater tensile loads can lead to greater stiffness, which can be quantified using SWE. Therefore, this study aimed to conduct a systematic review and meta-analysis to perform an overview of the effect of joint movements on nerve mechanical properties in healthy nerves. The initial search (July 2023) yielded 501 records from six databases (PubMed, Embase, Scopus, Web of Science, Cochrane, and Science Direct). A total of 16 studies were included and assessed with a modified version of the Downs and Black checklist. Our results suggest an overall tendency for stiffness increase according to a pattern of neural tensioning. The main findings from the meta-analysis showed a significant increase in nerve stiffness for the median nerve with wrist extension (SMD [95%CI]: 3.16 [1.20, 5.12]), the ulnar nerve with elbow flexion (SMD [95%CI]: 2.91 [1.88, 3.95]), the sciatic nerve with ankle dorsiflexion (SMD [95%CI]: 1.13 [0.79, 1.47]), and the tibial nerve with both hip flexion (SMD [95%CI]: 2.14 [1.76, 2.51]) and ankle dorsiflexion (SMD [95%CI]: 1.52 [1.02, 2.02]). The effect of joint movement on nerve stiffness also depends on the nerve segment, the amount of movement of the joint mobilized, and the position of other joints comprised in the entirety of the nerve length. However, due to the limited number of studies, many aspects of nerve behavior together with the effect of using different ultrasound equipment or transducers for nerve stiffness evaluation still need to be fully investigated.
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Affiliation(s)
- Gianluca Ciuffreda
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain; (E.B.-G.); (I.A.-C.); (A.M.-C.); (J.P.-R.); (P.P.-A.); (M.M.-U.)
| | - Elena Bueno-Gracia
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain; (E.B.-G.); (I.A.-C.); (A.M.-C.); (J.P.-R.); (P.P.-A.); (M.M.-U.)
- PhysiUZerapy: Health Sciences Research Group, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain
| | - Isabel Albarova-Corral
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain; (E.B.-G.); (I.A.-C.); (A.M.-C.); (J.P.-R.); (P.P.-A.); (M.M.-U.)
- PhysiUZerapy: Health Sciences Research Group, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain
| | - Alberto Montaner-Cuello
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain; (E.B.-G.); (I.A.-C.); (A.M.-C.); (J.P.-R.); (P.P.-A.); (M.M.-U.)
- PhysiUZerapy: Health Sciences Research Group, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain
| | - Jorge Pérez-Rey
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain; (E.B.-G.); (I.A.-C.); (A.M.-C.); (J.P.-R.); (P.P.-A.); (M.M.-U.)
- PhysiUZerapy: Health Sciences Research Group, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain
| | - Pilar Pardos-Aguilella
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain; (E.B.-G.); (I.A.-C.); (A.M.-C.); (J.P.-R.); (P.P.-A.); (M.M.-U.)
- PhysiUZerapy: Health Sciences Research Group, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain
| | - Miguel Malo-Urriés
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain; (E.B.-G.); (I.A.-C.); (A.M.-C.); (J.P.-R.); (P.P.-A.); (M.M.-U.)
- PhysiUZerapy: Health Sciences Research Group, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain
| | - Elena Estébanez-de-Miguel
- Department of Physiatry and Nursing, Faculty of Health Sciences, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain; (E.B.-G.); (I.A.-C.); (A.M.-C.); (J.P.-R.); (P.P.-A.); (M.M.-U.)
- PhysiUZerapy: Health Sciences Research Group, University of Zaragoza, Calle Domingo Miral S/N, 50009 Zaragoza, Spain
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Impaired median nerve mobility in patients with carpal tunnel syndrome: a systematic review and meta-analysis. Eur Radiol 2023; 33:2378-2385. [PMID: 36394604 DOI: 10.1007/s00330-022-09262-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES This systematic review and meta-analysis investigated the mobility of the median nerve (MN) in carpal tunnel syndrome (CTS) patients compared to healthy people. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed and the electronic databases including PubMed, Scopus, EMBASE, and Cochrane Library were searched up to April 2022. All published observational studies comparing the excursion of MN between participants with and without CTS were included. The quality of research was assessed by the Newcastle-Ottawa Scale tool. The primary outcome was the excursion of the MN under dynamic examination, representing nerve mobility quantified by the standardized mean difference (SMD) for random effect meta-analysis. RESULTS Fourteen studies were included in the qualitative review, and twelve entered the meta-analysis involving a total of 375 CTS patients and 296 healthy controls. The forest plot revealed that the mobility of the MN significantly decreased in the CTS group compared to the non-CTS control (SMD = -1.47, 95% CI: -1.91, -1.03, p < 0.001, heterogeneity 82%). In subgroup analysis, both transverse and longitudinal methods for nerve excursion showed less nerve mobility in CTS than in non-CTS. CONCLUSIONS This meta-analysis showed that the patients with CTS exhibited less mobility of the MN than those without CTS, suggesting MN mobility as a potential CTS marker. KEY POINTS • The patients with CTS revealed less mobility of the median nerve than those without CTS. • The mobility of the median nerve could be regarded as a potential CTS marker.
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Kok XLF, Newton JT, Jones EM, Cunningham SJ. Social support and pre-operative anxiety in patients undergoing elective surgical procedures: A systematic review and meta-analysis. J Health Psychol 2023; 28:309-327. [PMID: 36047037 PMCID: PMC10026156 DOI: 10.1177/13591053221116969] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pre-operative anxiety may adversely affect post-operative recovery and treatment satisfaction. This systematic review assessed the impact of social support on pre-operative anxiety in elective surgery patients. MEDLINE via Ovid, Embase, PsycINFO, Web of Science, CINAHL Plus, Emcare and LILACS were searched for publications (1950-2021). Fourteen studies were included for descriptive analysis and five for meta-analysis. The pooled estimate in the meta-analysis was r = -0.372 (95% CI: -0.578 to -0.122). Stronger social support was weakly associated with reduced pre-operative anxiety, but the quality of available evidence was low. The findings suggest potential benefit in enhancing utilisation of support networks before elective surgery.
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Padua L, Cuccagna C, Giovannini S, Coraci D, Pelosi L, Loreti C, Bernabei R, Hobson-Webb LD. Carpal tunnel syndrome: updated evidence and new questions. Lancet Neurol 2023; 22:255-267. [PMID: 36525982 DOI: 10.1016/s1474-4422(22)00432-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/12/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022]
Abstract
Carpal tunnel syndrome is the most common entrapment neuropathy, affecting quality of life for many people. Although it is a well recognised condition, new insights into epidemiology, diagnosis, and treatment have emerged in the past 6 years. The availability of disease-modifying treatments for rare systemic disorders associated with carpal tunnel syndrome (eg, amyloidosis) should alert clinicians to these diagnostic possibilities. Besides clinical evaluation and electrophysiology, the role of ultrasonography as a diagnostic tool has been confirmed and new ultrasound techniques have been applied, the clinical use and feasibility of which require further investigation. Surgical and non-surgical interventions are beneficial for the treatment of carpal tunnel syndrome and several treatment options are now available, giving clinicians the possibility to choose the best approach for every patient. New diagnostic and therapeutic techniques require further validation.
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Affiliation(s)
- Luca Padua
- Department of Geriatrics and Orthopaedics, Università Cattolica del Sacro Cuore, Rome, Italy; UOC Neuroriabilitazione Alta Intensità, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy.
| | - Cristina Cuccagna
- UOC Neuroriabilitazione Alta Intensità, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Silvia Giovannini
- Department of Geriatrics and Orthopaedics, Università Cattolica del Sacro Cuore, Rome, Italy; UOS Riabilitazione Post-Acuzie, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Daniele Coraci
- Department of Neuroscience, Section of Rehabilitation, University of Padova, Padua, Italy
| | - Luciana Pelosi
- Departments of Neurology and Neurophysiology, Bay of Plenty District Health Board, Tauranga Hospital, Tauranga, New Zealand
| | - Claudia Loreti
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Roberto Bernabei
- Department of Geriatrics and Orthopaedics, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Lisa D Hobson-Webb
- Department of Neurology, Neuromuscular Division, Duke University, Durham, NC, USA
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Clinical outcomes following neurolysis and porcine collagen extracellular matrix wrapping of scarred nerves in revision carpal tunnel decompression. J Plast Reconstr Aesthet Surg 2022; 75:2802-2808. [PMID: 35597709 DOI: 10.1016/j.bjps.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 03/03/2022] [Accepted: 04/12/2022] [Indexed: 12/31/2022]
Abstract
Scar tether after primary nerve decompression can impair physiological nerve glide and vascularity of the nerve. Revision decompression in the setting of neurostenalgia should address the scarred mesoneurium in order to prevent further entrapment and tether. This study reports on the clinical outcomes of 12 patients with neurostenalgia following carpal tunnel decompression (CTD), treated with revision CTD and a porcine submucosa extracellular matrix nerve wrap (PECM) (Axoguard® nerve protector, Axogen Inc., Alachua, FL). Eleven patients had one primary decompression procedure prior to revision surgery; one patient previously had two operations for CTD. There was a significant reduction in visual analogue pain scores (VAS) and improvement in patients' satisfaction rating and symptom resolution. Patient-reported outcome measures were recorded using the Impact of Hand Nerve Disorders (I-HaND) Scale (Version 2), which demonstrated a significant reduction in hand disability. There were no complications attributable to the procedure and no re-revision procedures necessary at the latest follow-up.
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Abstract
ABSTRACT In this dynamic protocol, ultrasound evaluation of the wrist and hand is described using various maneuvers for relevant conditions. Scanning videos are coupled with real-time patient examination videos. The authors believe that this practical guide - prepared by the international consensus of several experts - will help musculoskeletal physicians perform a better and uniform/standard examination approach.
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Spatial variation in mechanical properties along the sciatic and tibial nerves: an ultrasound shear wave elastography study. J Biomech 2022; 136:111075. [DOI: 10.1016/j.jbiomech.2022.111075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/17/2022] [Accepted: 03/29/2022] [Indexed: 11/16/2022]
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Tullie S, Wiberg A, Furniss D, Schmid A. T2-weighted MRI defines critical compression in the distal carpal tunnel that is relieved after decompressive surgery. J Plast Reconstr Aesthet Surg 2022; 75:2251-2258. [PMID: 35341704 PMCID: PMC7613040 DOI: 10.1016/j.bjps.2022.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 02/07/2022] [Accepted: 02/15/2022] [Indexed: 11/25/2022]
Abstract
Introduction Despite Carpal Tunnel Syndrome (CTS) being the most common entrapment neuropathy, its pathophysiology remains debated. Sub-synovial connective tissues (SSCT) within the carpal tunnel are thought to play a role but are poorly characterised. MRI analysis offers potentially novel insights into SSCT characteristics. Methods A pilot study of T2-weighted MRI was performed in healthy controls (n=7), and in CTS patients (n=16) pre- and 6 months post-surgical decompression. Image analysis was performed to quantify SSCT cross-sectional area, SSCT signal intensity ratio, and wrist index (depth/width) at distal, middle and proximal wrist landmarks. Results Median SSCT signal intensity was lower in the distal carpal tunnel of CTS patients pre-operatively (0.96) compared to controls (1.13; P = 0.008) and normalised post-operatively (1.13, P = 0.001). Median wrist index was also lower in CTS patients pre-operatively (0.60) compared to controls (0.67, P = 0.022), and again normalised post-operatively (0.74, P =0.001). This was attributed to changes in carpal depth in the antero-posterior axis with decompression surgery. Conclusion This pilot study successfully demonstrated MRI assessment of SSCT in patients with CTS. The decreased SSCT signal intensities suggest predominant changes at the distal tunnel, potentially indicating reduced SSCT perfusion pre-surgery which normalised post-surgery. Our preliminary findings merit further investigation in a larger cohort.
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Affiliation(s)
- S Tullie
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, United Kingdom
| | - A Wiberg
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, United Kingdom; Department of Plastic and Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
| | - D Furniss
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, United Kingdom; Department of Plastic and Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom.
| | - A Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, West Wing Level 6, Headley Way, Oxford OX3 9DU, United Kingdom.
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Jun YK, Kim JW, Kim BG, Lee KL, Jung YJ, Kim W, Park HS, Lee DH, Koh SJ. Helicobacter pylori infection is not associated with portal hypertension-related gastrointestinal complications: A meta-analysis. PLoS One 2022; 17:e0261448. [PMID: 35061730 PMCID: PMC8782498 DOI: 10.1371/journal.pone.0261448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/02/2021] [Indexed: 11/18/2022] Open
Abstract
Despite the importance of Helicobacter pylori infection and portal hypertension (PH)-associated gastrointestinal (GI) diseases, such as esophageal varices and portal hypertensive gastropathy (PHG), the impact of H. pylori infection on PH-related GI complications has not yet been elucidated. This meta-analysis investigated the association between H. pylori infection and the risk of PH-related GI complications. An electronic search for original articles published before May 2020 was performed using PubMed, EMBASE, and the Cochrane Library. Independent reviewers conducted the article screening and data extraction. We used the generic inverse variance method for the meta-analysis, and Begg's rank correlation test and Egger's regression test to assess publication bias. A total of 1,148 cases of H. pylori infection and 1,231 uninfected controls were included from 13 studies. H. pylori infection had no significant association with esophageal varices [relative risk (RR) = 0.96, 95% confidence interval (CI) = 0.87-1.06 for all selected studies; RR = 0.95, 95% CI = 0.84-1.07 for cohort studies; odds ratio (OR) = 0.96, 95% CI = 0.60-1.54 for case-control studies]. Although H. pylori infection was significantly associated with PHG in case-control studies [OR = 1.86, 95% CI = 1.17-2.96], no significant differences were found in the cohort studies [RR = 0.98, 95% CI = 0.91-1.05] or all studies combined [RR = 1.18, 95% CI = 0.93-1.52]. In conclusion, H. pylori infection was not associated with the risk of PH-related GI complications. Clinicians should carefully treat cirrhotic patients with PH-related GI complications, regardless of H. pylori infection.
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Affiliation(s)
- Yu Kyung Jun
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Laboratory of Intestinal Mucosa and Skin Immunology, SMG-SNU Boramae medical Center, Seoul, Korea
| | - Ji Won Kim
- Laboratory of Intestinal Mucosa and Skin Immunology, SMG-SNU Boramae medical Center, Seoul, Korea
- Department of Internal medicine, Division of Gastroenterology, SMG-SNU Boramae medical Center, Seoul, Korea
| | - Byeong Gwan Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Kook Lae Lee
- Department of Internal medicine, Division of Gastroenterology, SMG-SNU Boramae medical Center, Seoul, Korea
| | - Yong Jin Jung
- Department of Internal medicine, Division of Gastroenterology, SMG-SNU Boramae medical Center, Seoul, Korea
| | - Won Kim
- Department of Internal medicine, Division of Gastroenterology, SMG-SNU Boramae medical Center, Seoul, Korea
| | - Hyun Sun Park
- Laboratory of Intestinal Mucosa and Skin Immunology, SMG-SNU Boramae medical Center, Seoul, Korea
- Department of Dermatology, SMG-SNU Boramae medical Center, Seoul, Korea
| | - Dong Hyeon Lee
- Department of Internal medicine, Division of Gastroenterology, SMG-SNU Boramae medical Center, Seoul, Korea
| | - Seong-Joon Koh
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Laboratory of Intestinal Mucosa and Skin Immunology, SMG-SNU Boramae medical Center, Seoul, Korea
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Abstract
Tensioning techniqueswere the first neurodynamic techniques used therapeutically in the management of people with neuropathies. This article aims to provide a balanced evidence-informed view on the effects of optimal tensile loading on peripheral nerves and the use of tensioning techniques. Whilst the early use of neurodynamics was centered within a mechanical paradigm, research into the working mechanisms of tensioning techniques revealed neuroimmune, neurophysiological, and neurochemical effects. In-vitro and ex-vivo research confirms that tensile loading is required for mechanical adaptation of healthy and healing neurons and nerves. Moreover, elimination of tensile load can have detrimental effects on the nervous system. Beneficial effects of tensile loading and tensioning techniques, contributing to restored homeostasis at the entrapment site, dorsal root ganglia and spinal cord, include neuronal cell differentiation, neurite outgrowth and orientation, increased endogenous opioid receptors, reduced fibrosis and intraneural scar formation, improved nerve regeneration and remyelination, increased muscle power and locomotion, less mechanical and thermal hyperalgesia and allodynia, and improved conditioned pain modulation. However, animal and cellular models also show that ‘excessive’ tensile forces have negative effects on the nervous system. Although robust and designed to withstand mechanical load, the nervous system is equally a delicate system. Mechanical loads that can be easily handled by a healthy nervous system, may be sufficient to aggravate clinical symptoms in patients. This paper aims to contribute to a more balanced view regarding the use of neurodynamics and more specifically tensioning techniques.
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Affiliation(s)
- Richard Ellis
- School of Clinical Sciences, Active Living and Rehabilitation: Aotearoa, Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand.,Department of Physiotherapy, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Giacomo Carta
- Department of Clinical and Biological Sciences, University of Torino, Orbassano, Italy.,Neuroscience Institute Cavalieri Ottolenghi (Nico), University of Torino, Orbassano, Italy.,ASST Nord Milano, Sesto San Giovanni Hospital, Milan, Italy
| | - Ricardo J Andrade
- Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia.,School of Health Sciences and Social Work, Griffith University, Queensland, USA
| | - Michel W Coppieters
- Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia.,Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Effects of a preoperative neuromobilization program offered to individuals with carpal tunnel syndrome awaiting carpal tunnel decompression surgery: A pilot randomized controlled study. J Hand Ther 2021; 34:37-46. [PMID: 32151500 DOI: 10.1016/j.jht.2019.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 10/31/2019] [Accepted: 12/31/2019] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Pilot randomized controlled trial with parallel groups. INTRODUCTION Engaging individuals with carpal tunnel syndrome (CTS) awaiting carpal tunnel decompression surgery in a preoperative rehabilitation program may mitigate pain and sensorimotor impairments, enhance functional abilities before surgery, and improve postoperative outcomes. PURPOSE OF THE STUDY To assess the feasibility and the efficacy of a novel preoperative neuromobilization exercise program (NEP). METHODS Thirty individuals with CTS were randomly allocated into a four-week home-based neuromobilization exercise group or a standard care group while awaiting surgery. Outcome measures included feasibility (ie, recruitment, attrition, adherence, satisfaction, and safety) and efficacy metrics (ie, median nerve integrity and neurodynamics, tip pinch grip, pain, and upper limb functional abilities) collected before (ie, at the baseline and about four weeks later) and four weeks after surgery. RESULTS Thirty individuals with CTS were recruited (recruitment rate = 11.8%) and 25 completed the study (attrition rate = 16.7%). Adherence (94%) and satisfaction with the program (eg, enjoy the exercises and likeliness to repeat the NEP (≥4.2/5) were high and no serious adverse event was reported. NEP-related immediate pre- and post-surgery beneficial effects on pain interference were documented (P = .05, η2 = .10), whereas an overall increased neurodynamics (P = .04, η2 = .11) and decreased pain severity (P = .01, η2 = .21) were observed. DISCUSSION Engaging in the proposed NEP has limited beneficial effect as a stand-alone intervention on pre- and post-surgery outcomes for individuals with CTS. Expanding the program's content and attribute by adding other components including desensitization maneuvers and novel therapies promoting corticospinal plasticity is recommended. CONCLUSION A preoperative NEP completed by individuals with CTS awaiting surgery is feasible, acceptable, and safe. However, given the limited beneficial effectsof the program, revision of its content and attributes is recommended before proceeding to large-scale trials.
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Wang JC, Hsu PC, Wang KA, Chang KV. Ultrasound-Guided Triamcinolone Acetonide Hydrodissection for Carpal Tunnel Syndrome: A Randomized Controlled Trial. Front Med (Lausanne) 2021; 8:742724. [PMID: 34589506 PMCID: PMC8475784 DOI: 10.3389/fmed.2021.742724] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/19/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Despite the wide use of corticosteroid hydrodissection for carpal tunnel syndrome (CTS), there is insufficient evidence to confirm its efficacy. This study aimed to compare the effectiveness of corticosteroid hydrodissection vs. corticosteroid perineural injection alone on clinical and electrophysiological parameters in patients with CTS. Method: This prospective randomized controlled trial (RCT) was conducted in a tertiary care center with a follow-up period of 12 weeks. Subjects were randomly assigned to either ultrasound-guided hydrodissection with a mixture of 1 mL of triamcinolone acetonide (10 mg/mL), 1 mL of 2% lidocaine, and 8 mL normal saline or ultrasound-guided perineural injection with 1 mL of triamcinolone acetonide (40 mg/mL) and 1 mL of 2% lidocaine. The primary outcome measure was the symptom severity subscale (SSS) of Boston Carpal Tunnel Questionnaire (BCTQ) scores at baseline and at 6 and 12 weeks' post-treatment. The secondary outcomes included the functional status subscale (FSS) of BCTQ and the distal motor latency and sensory nerve conduction velocity of the median nerve. The effect of interventions on the designated outcome was analyzed using a 3 × 2 repeated measures analysis of variance. The within-subject and among-subject factors were differences in time (before the intervention, and 6 and 12 weeks after injection) and intervention types (with or without hydrodissection), respectively. Results: Sixty-four patients diagnosed with CTS were enrolled. Both groups experienced improvement in the SSS and FSS of BCTQ and median nerve distal motor latency and sensory nerve conduction velocity. However, group-by-time interactions were not significant in any outcome measurements. No serious adverse events were reported in either group, except for two patients in the hydrodissection group who reported minor post-injection pain on the first day after the intervention, which resolved spontaneously without the need for additional treatments. Conclusion: Hydrodissection did not provide an additional benefit compared to corticosteroid perineural injection alone. More prospective studies are needed to investigate the long-term effectiveness of corticosteroid hydrodissection, as well as its influence on median nerve mobility.
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Affiliation(s)
- Jia-Chi Wang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Cheng Hsu
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kevin A Wang
- Division of General Surgery, Department of Surgery, Shin-Kong Memorial Hospital, Taipei, Taiwan.,School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch and National Taiwan University College of Medicine, Taipei, Taiwan.,Center for Regional Anesthesia and Pain Medicine, Wang-Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Schmid AB, Fundaun J, Tampin B. [Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management : German version]. Schmerz 2021; 35:419-433. [PMID: 34505948 DOI: 10.1007/s00482-021-00584-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potenzial mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.
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Affiliation(s)
- Annina B Schmid
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford University, West Wing Level 6, OX3 9DU, Oxford, Großbritannien.
| | - Joel Fundaun
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, Oxford University, West Wing Level 6, OX3 9DU, Oxford, Großbritannien.,High Country Physical Therapy, Laramie, WY, USA
| | - Brigitte Tampin
- Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Westaustralien, Australien.,School of Physiotherapy and Exercise Science, Curtin University, Westaustralien, Australien.,Fakultät Wirtschafts- und Sozialwissenschaften, Hochschule Osnabrück, Osnabrück, Deutschland
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Hosseini-Farid M, Schrier VJMM, Starlinger J, Amadio PC. Carpal Tunnel Syndrome Treatment and the Subsequent Alterations in Median Nerve Transverse Mobility. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1555-1568. [PMID: 33073880 PMCID: PMC8053734 DOI: 10.1002/jum.15535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The mobility (transverse movement) of the median nerve (MN) is decreased in patients with carpal tunnel syndrome and can be measured noninvasively by ultrasound. To date, there are few prognostic features to help predict the outcome of 2 commonly performed treatments: surgical carpal tunnel release and corticosteroid injection. This study aimed to assess the changes in nerve mobility after the intervention and to correlate this with treatment and the disease severity. METHODS A total of 181 patients with carpal tunnel syndrome with different electrophysiologic severities were recruited and assessed by dynamic ultrasound scanning of the MN before and after treatment. The dynamic ultrasound images were collected while the patients performed finger and wrist flexion. RESULTS For both injection and carpal tunnel release, the nerve displacement increased with wrist flexion, from a mean ± SD of 7.0 ± 2.4 to 7.9 ± 2.7 mm (P < .005). Patients who underwent surgery showed greater improvement (P < .005) in nerve mobility compared to those who underwent injection. We also observed that the increase in nerve mobility was predominantly in patients with more nerve damage at baseline. CONCLUSIONS This study shows that the dynamic behavior of the MN changes in response to treatment and lays a foundation for future studies to assess the prognostic potential of nerve mobility measurement.
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Affiliation(s)
- Mohammad Hosseini-Farid
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- College of Computing and Engineering, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Verena J M M Schrier
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Julia Starlinger
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Orthopedics and Trauma Surgery, Medical University Vienna, Vienna, Austria
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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15
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Hosseini-Farid M, Schrier VJMM, Starlinger J, Zhao C, Amadio PC. Carpal tunnel syndrome treatment and the subsequent alterations in tendon and connective tissue dynamics. Clin Biomech (Bristol, Avon) 2021; 88:105440. [PMID: 34329857 PMCID: PMC8490321 DOI: 10.1016/j.clinbiomech.2021.105440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Carpal tunnel syndrome patients demonstrate diminished motion of the median nerve and fibrotic changes in the subsynovial connective tissue within the carpal tunnel. Currently, there are few prognostic factors to help predict the outcome of commonly performed treatments including surgical carpal tunnel release and corticosteroid injections. This study aimed to non-invasively assess the changes in the dynamic response of the subsynovial tissue relative to tendon motion after the intervention and to correlate this with disease severity. METHODS A total of 145 patients with carpal tunnel syndrome were recruited into this study. Clinical and demographic data, electrophysiological severity and dynamic ultrasound images were collected before and after treatment, either by injection or surgery. The relative motion of the subsynovial tissue with the underlying middle finger flexor digitorum superficialis tendon was measured using a speckle tracking algorithm and was expressed as a shear index (SI). Baseline and follow-up data, the association between change in SI and severity, and the role of treatment modality were analyzed and statistically compared. FINDINGS Overall, there was a significant increase (more relative motion) after treatment in the mean shear index from 79.9% (±15.4% SD) to 82.9% (±14.8% SD) (p = 0.03). Secondary analyses showed that this change was mostly present in those with mild disease severity undergoing surgery (p = 0.01). INTERPRETATION This study shows that the relative subsynovial tissue movement increases in patients after intervention. The present study lays a foundation for future studies to non-invasively assess the role of carpal tunnel dynamics in response to treatment.
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Affiliation(s)
- Mohammad Hosseini-Farid
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States; College of Computing and Engineering, Nova Southeastern University, Fort Lauderdale, FL, United States
| | - Verena J M M Schrier
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States; Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Julia Starlinger
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States; Medical University Vienna, Department of Orthopedics and Trauma Surgery, Vienna, Austria
| | - Chunfeng Zhao
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, United States.
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16
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Festen RT, Schrier VJMM, Amadio PC. Automated Segmentation of the Median Nerve in the Carpal Tunnel using U-Net. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1964-1969. [PMID: 33931286 PMCID: PMC8169596 DOI: 10.1016/j.ultrasmedbio.2021.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 03/05/2021] [Accepted: 03/19/2021] [Indexed: 05/25/2023]
Abstract
Nerve area and motion in carpal tunnel syndrome (CTS) are currently under investigation in terms of prognostic potential. Therefore, there is increasing interest in non-invasive measurement of the nerve using ultrasound. Manual segmentation is time consuming and subject to inter-rater variation, providing an opportunity for automation. Dynamic ultrasound images (n = 5560) of carpal tunnels from 99 clinically diagnosed CTS patients were used to train a U-Net-shaped neural network. The best results from the U-Net were achieved with a location primer as initial region of interest for the segmentations during finger flexion (Dice coefficient = 0.88). This is comparable to the manual Dice measure of 0.92 and higher than the resulting automated Dice measure of wrist flexion (0.81). Although there is a dependency on image quality, a trained U-Net can reliably be used in the assessment of ultrasound-acquired median nerve size and mobility, considerably decreasing manual effort.
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Affiliation(s)
- Raymond T Festen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Verena J M M Schrier
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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17
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Sahebalam M, Ghayyem Hassankhani G, Azhari A, Moradi A. Do carpal Tunnel Hands Have Different Shape Compare to Normal Hands? THE ARCHIVES OF BONE AND JOINT SURGERY 2021; 9:180-188. [PMID: 34026935 DOI: 10.22038/abjs.2020.41835.2131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Given the fact that the carpal tunnel syndrome (CTS) happens as a consequence of the median nerve entrapment, besides other known factors, the shape and anthropometric characteristics of the carpal tunnel, wrist, and hand could be considered as a predisposing risk factor for idiopathic CTS. The aim of this study was to evaluate the morphology and radiologic scales in CTS hands. Methods In this prospective study, patients who underwent upper extremity electrodiagnostic studies were enrolled for hand morphologic and radiographic indexes. Patients were divided into CTS suffering and CTS symptom-free groups according to nerve conduction velocity (NCV) findings. A true posteroanterior radiograph of the hands was pas performed for each participant. Metacarpal length to wrist length index (carpal ratio), metacarpal length to metacarpal width index, third to first metacarpal length, hand length index, and hand volume index were measured in both groups. Results Significant differences were seen between the two groups regarding the body mass index (P< 0.001), metacarpal length divided by metacarpal width index (P=0.08), first metacarpal length divided by third metacarpal length (P=0.002), wrist circumference divided by distal flexor wrist crease to the tip of the third finger (P< 0.001), distal flexor wrist crease to the tip of the third finger divided by hand volume (P=0.05), and distal flexor wrist crease to the tip of the third finger divided by wrist circumference (P< 0.001). Multivariable analysis of hand indices were statically significant for the first metacarpal length divided by third metacarpal length (P=0.00), wrist circumference divided by distal flexor wrist crease to the tip of the third finger (P=0.138), and distal flexor wrist crease to the tip of the third finger divided by wrist circumference (P=0.117). However, first metacarpal length divided by third metacarpal length and third metacarpal length divided by palm height were associated with higher CTS occurrences. Receiver operating characteristic curve analysis demonstrated cutoff points which were possible to estimate only for first metacarpal length divided by third metacarpal length and wrist circumference divided by distal flexor wrist crease to the tip of the third finger. Conclusion Based on our findings, CTS hand is characterized by shorter fingers compared to thumb and wrist (metacarpal length to wrist length and hand length indexes), wider (metacarpal length to metacarpal width index), and bulkier (hand volume index) compared to non-CTS hands. The severity of CTS was correlated with a higher carpal ratio. In conclusion, CTS hands are bulkier with wider palms and shorter fingers compared to thumb. In this study, the thumb to the third metacarpal length was proved to be the best index for diagnosis of "CTS hand".
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Affiliation(s)
- Mohamad Sahebalam
- Orthopedic Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Amin Azhari
- Orthopedic Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Moradi
- Orthopedic Research Center, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
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18
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Lin MT, Liu IC, Syu WT, Kuo PL, Wu CH. Effect of Perineural Injection with Different Dextrose Volumes on Median Nerve Size, Elasticity and Mobility in Hands with Carpal Tunnel Syndrome. DIAGNOSTICS (BASEL, SWITZERLAND) 2021; 11:diagnostics11050849. [PMID: 34065073 PMCID: PMC8150286 DOI: 10.3390/diagnostics11050849] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/06/2021] [Accepted: 05/06/2021] [Indexed: 11/16/2022]
Abstract
This study aimed to investigate the effect of different injectate volumes on ultrasonographic parameters and the correlation to clinical outcomes under perineural dextrose injection (PDI). In this post hoc analysis of the randomized, double-blinded, three-arm trial, ultrasound-guided PDI with either 1 mL, 2 mL, and 4 mL 5% dextrose water was administered, respectively, in 14, 14, and 17 patients. Ultrasound outcomes included mobility, shear-wave elastography (SWE), and cross-sectional area (CSA) of the median nerve; clinical outcomes were Visual Analog Scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) score. Outcomes were measured before injection, and after injection at the 1st, 4th, 12th, and 24th week. For ultrasound outcomes, CSA decreased significantly from baseline data at all follow-up time-points in the 2 mL group (p = 0.005) and the 4 mL group (p = 0.015). The mean change of mobility from baseline showed a greater improvement on the 4 mL group than the other groups at the 1st week post-injection. For clinical outcomes, negative correlation between the VAS and mobility at the 1st (p = 0.046) and 4th week (p = 0.031) post-injection in the 4 mL group were observed. In conclusion, PDI with higher volume yielded better nerve mobility and decreased CSA of median nerve, but no changes of nerve elasticity.
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Affiliation(s)
- Meng-Ting Lin
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu 300, Taiwan;
| | - I-Chun Liu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 100, Taiwan; (I.-C.L.); (P.-L.K.)
| | - Wei-Ting Syu
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei 100, Taiwan;
| | - Po-Ling Kuo
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 100, Taiwan; (I.-C.L.); (P.-L.K.)
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei 100, Taiwan;
- Department of Electrical Engineering, National Taiwan University, Taipei 100, Taiwan
| | - Chueh-Hung Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu 300, Taiwan;
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei 100, Taiwan; (I.-C.L.); (P.-L.K.)
- Correspondence:
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Thoomes E, Ellis R, Dilley A, Falla D, Thoomes-de Graaf M. Excursion of the median nerve during a contra-lateral cervical lateral glide movement in people with and without cervical radiculopathy. Musculoskelet Sci Pract 2021; 52:102349. [PMID: 33618231 DOI: 10.1016/j.msksp.2021.102349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 02/03/2021] [Accepted: 02/06/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND A segmental, contra-lateral cervical lateral glide (CCLG) mobilization technique is effective for patients with cervical radiculopathy (CR). The CCLG technique induces median nerve sliding in healthy individuals, but this has not been assessed in patients with CR. OBJECTIVE This study aimed to 1) assess longitudinal excursion of the median nerve in patients with CR and asymptomatic participants during a CCLG movement, 2) reassess nerve excursions following an intervention at a 3-month follow-up in patients with CR and 3) correlate changes in nerve excursions with changes in clinical signs and symptoms. DESIGN Case-control study. METHODS During a computer-controlled mechanically induced CCLG, executed by the Occiflex™, longitudinal median nerve excursion was assessed at the wrist and elbow with ultrasound imaging (T0) in 20 patients with CR and 20 matched controls. Patients were re-assessed at a 3-month follow-up (T1), following conservative treatment including neurodynamic mobilization. RESULTS There was a significant difference between patients and controls in the excursion of the median nerve at both the wrist (Mdn = 0.50 mm; IQR = 0.13-1.30; 2.10 mm (IQR = 1.42-2.80, p < 0.05)) and elbow (Mdn = 1.21 mm (IQR = 0.85-1.94); 3.49 mm (IQR = 2.45-4.24, p < 0.05)) respectively at T0. There was also a significant increase in median nerve excursion at both sites between T0 and T1 in those with CR (Mdn = 1.96, 2.63 respectively). Wilcoxon Signed-Ranks Test indicated median pre-test ranks (Mdn = 0.5, 1.21; Z = - 3.82, p < 0.01; Z = -3.78, p < 0.01 respectively) and median post-test ranks. There was a strong correlation between improvement in median nerve excursion at the elbow at T1 and improvement in pain intensity (r = 0.7, p < 0.001) and functional limitations (r = 0.6, p < 0.01). CONCLUSION Longitudinal median nerve excursion differs significantly between patients with CR and asymptomatic volunteers at baseline, but this difference is no longer present after 3 months of conservative physiotherapy management. Improvement in nerve excursion correlates with improvement in clinical signs and symptoms.
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Affiliation(s)
- Erik Thoomes
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Edgbaston, United Kingdom; Fysio-Experts, Research Department, Hazerswoude, the Netherlands.
| | - Richard Ellis
- Department of Physiotherapy, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand; Active Living and Rehabilitation: Aotearoa New Zealand, Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - Andrew Dilley
- Department of Neuroscience, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Deborah Falla
- Centre of Precision Rehabilitation for Spinal Pain (CPR Spine), School of Sport, Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of Birmingham, Edgbaston, United Kingdom
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Mezian K, SobotovÁ K, Kuliha M, Chang KV, CeÉ J, AngerovÁ Y, ÖzÇakar L. Ultrasound-guided perineural vs. peritendinous corticosteroid injections in carpal tunnel syndrome: a randomized controlled trial. Eur J Phys Rehabil Med 2021; 57:775-782. [PMID: 33733720 DOI: 10.23736/s1973-9087.21.06682-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Corticosteroid injections are proven to be effective in the management of carpal tunnel syndrome (CTS); however, the optimal injection site still remains unclear. AIM To compare the efficacy of perineural vs. peritendinous target sites for corticosteroid injection in CTS. DESIGN A Randomized, Single-Blind, Controlled Trial. SETTING Outpatients, tertiary care center. POPULATION Forty-six patients were equally randomized into two intervention groups as Group A (18 F and 5 M, mean age;50.0 ± 15.9 years, mean symptom duration;5.9 ± 3.3 months) and Group B (19 F, 4 M patients, mean age;54.3 ± 15.0 years, mean symptom duration;5.9 ± 4.7 months). METHODS Methylprednisolone acetate (40 mg) and 1 mL of 1% trimecaine hydrochloride was injected next to the median nerve (Group A) or among flexor tendons away from the nerve (Group B) under ultrasound (US) guidance. The visual analogue scale was used as the primary outcome measure, and the symptom severity scale and functional status scale of the Boston Carpal Tunnel Questionnaire were used as the secondary subjective outcome measures. Twopoint discrimination, grip strength, cross-sectional area, and distal motor latency were assessed as objective outcome measures. The data were collected at baseline and at 2, 6 and 12 weeks after the injection. RESULTS Both groups showed improvement in subjective and objective measures at 2 weeks following the injection - also maintained up to 12 weeks during the follow-up (p<0.05). However, no difference was observed between the two groups (p<0.05). No serious adverse effects were observed in either group. CONCLUSIONS Both intervention techniques seem to be effective and safe in the conservative treatment of CTS. CLINICAL REHABILITATION IMPACT Based on this study results, it might be noteworthy that physicians can opt for perineural or peritendinous injections without compromising the treatment efficacy and safety. Herewith, US guidance is, for sure, necessary for performing safe and accurate injections.
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Affiliation(s)
- Kamal Mezian
- Department of Rehabilitation Medicine, First Faculty of Medicine and General University Hospital in Prague, Charles University, Prague, Czech Republic -
| | - Karolína SobotovÁ
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | | | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei City, Taiwan. 5 Department of Neurosurgery, J. E. Purkyně University, Masaryk Hospital, Ústí nad Labem, Czech Republic
| | - Jiří CeÉ
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
| | - Yvona AngerovÁ
- Department of Rehabilitation Medicine, First Faculty of Medicine and General University Hospital in Prague, Charles University, Prague, Czech Republic
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Lin MT, Liao CL, Hsiao MY, Hsueh HW, Chao CC, Wu CH. Volume Matters in Ultrasound-Guided Perineural Dextrose Injection for Carpal Tunnel Syndrome: A Randomized, Double-Blinded, Three-Arm Trial. Front Pharmacol 2020; 11:625830. [PMID: 33391002 PMCID: PMC7773892 DOI: 10.3389/fphar.2020.625830] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/26/2020] [Indexed: 12/17/2022] Open
Abstract
Ultrasound-guided perineural dextrose injection (PDI) has been reported effective for carpal tunnel syndrome (CTS). Higher volume of injectate may reduce adhesion of median nerve from other tissues, but volume-dependent effects of PDI in CTS remain unknown. We aimed to investigate whether PDI with different injectate volumes had different effects for CTS participants. In this randomized, double-blinded, three-arm trial, 63 wrists diagnosed with CTS were randomized into three groups that received ultrasound-guided PDI with either 1, 2 or 4 ml of 5% dextrose water. All participants finished this study. Primary outcome as visual analog scale (VAS) and secondary outcomes including Boston Carpal Tunnel Questionnaire (BCTQ), Disability of the Arm, Shoulder and Hand score (QuickDASH), electrophysiological studies and cross-sectional area (CSA) of the median nerve at carpal tunnel inlet were assessed before and after PDI at the 1st, 4th, 12th and 24th weeks. For within-group analysis, all three groups (21 participants, each) revealed significant improvement from baseline in VAS, BCTQ and QuickDASH at the 1st, 4th, 12th and 24th weeks. For between-group analysis, 4 ml-group yielded better VAS reduction at the 4th and 12th weeks as well as improvement of BCTQ and QuickDASH at the 1st, 4th, and 12th weeks, compared to other groups. No significant between-group differences were observed in electrophysiological studies or median nerve CSA at any follow-up time points. There were no severe complications in this trial, and transient minor adverse effects occurred equally in the three groups. In conclusion, ultrasound-guided PDI with 4 ml of 5% dextrose provided better efficacy than with 1 and 2 ml based on symptom relief and functional improvement for CTS at the 1st, 4th, and 12th week post-injection, with no reports of severe adverse effects. There was no significant difference between the three groups at the 24th-week post-injection follow-up. Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT03598322.
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Affiliation(s)
- Meng-Ting Lin
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Chun-Li Liao
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Ming-Yen Hsiao
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsueh-Wen Hsueh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chi-Chao Chao
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chueh-Hung Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of General Medicine, National Taiwan University Hospital Biomedical Park Branch, Hsinchu, Taiwan
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22
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Schrier VJMM, Evers S, Geske JR, Kremers WK, Villarraga HR, Selles RW, Hovius SER, Gelfman R, Amadio PC. Relative Motion of the Connective Tissue in Carpal Tunnel Syndrome: The Relation with Disease Severity and Clinical Outcome. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:2236-2244. [PMID: 32600671 PMCID: PMC7429249 DOI: 10.1016/j.ultrasmedbio.2020.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 05/07/2023]
Abstract
Excursion of the median nerve and the surrounding subsynovial connective tissue (SSCT) is diminished in patients with carpal tunnel syndrome (CTS). This study sought to determine if SSCT excursion could be utilized to predict surgical outcome. Idiopathic CTS patients were reviewed with ultrasound and electrodiagnostic tests at baseline. A speckle tracking algorithm was used to determine SSCT relative to tendon motion (shear index). Analysis of variance tests were used to compare SSCT motion with disease severity at baseline. Adjusted linear regressions were used to test the association with patient-reported outcome. A total of 90 CTS patients were analyzed and found to have an average shear index of 79% (95% confidence interval: 76.3%-81.6%). SSCT motion was lower in CTS patients with increasing electrophysiological severity (p = 0.0475). There was no significant association of pre-operative SSCT motion with symptomatic improvement (p = 0.268). Overall, SSCT motion is decreased in CTS patients, but exhibits limited correlation with clinical severity.
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Affiliation(s)
- Verena J M M Schrier
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stefanie Evers
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jennifer R Geske
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Walter K Kremers
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Hector R Villarraga
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Ruud W Selles
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Steven E R Hovius
- Department of Plastic and Reconstructive Surgery, Radboudumc University Hospital, Nijmegen, The Netherlands
| | - Russell Gelfman
- Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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23
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Paquette P, Higgins J, Gagnon DH. Peripheral and Central Adaptations After a Median Nerve Neuromobilization Program Completed by Individuals With Carpal Tunnel Syndrome: An Exploratory Mechanistic Study Using Musculoskeletal Ultrasound Imaging and Transcranial Magnetic Stimulation. J Manipulative Physiol Ther 2020; 43:566-578. [PMID: 32861518 DOI: 10.1016/j.jmpt.2019.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 10/11/2019] [Accepted: 10/22/2019] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Neuromobilization exercises are increasingly advocated in the conservative management of individuals with carpal tunnel syndrome (CTS), as they may mitigate CTS-related signs and symptoms via potential peripheral (ie, musculoskeletal) and central (ie, neurophysiological) adaptations. However, the mechanisms underlying these adaptations have not been studied extensively. Hence, this exploratory and mechanistic study aims to evaluate the potential peripheral and central adaptations that may result in individuals with CTS who have completed a neuromobilization program. METHODS Fourteen individuals with CTS were evaluated before and 1 week after the completion of a 4-week neuromobilization program that incorporated median nerve sliding exercises. Pain and upper limb functional abilities were assessed using standardized questionnaires. The biological integrity and mechanical properties of the median nerve and the corticospinal excitability were quantified using musculoskeletal ultrasound imaging and transcranial magnetic stimulation, respectively. RESULTS Upon completion of the program, participants reported both large and moderate improvements in pain (P ≤ .03) and upper limb functional abilities (P = .02), respectively. The biological integrity and mechanical properties of the median nerve remained unchanged (P ≥ .22), whereas a small significant increase in corticospinal excitability (P = .04) was observed. CONCLUSION The proposed neuromobilization program appears promising to improve pain and upper limb functional abilities in individuals with CTS. These improvements may be preferentially mediated via central, rather than peripheral, adaptations. Future studies, especially with a larger sample size, longer intervention duration, and additional measurement times, are needed to strengthen current evidence.
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Affiliation(s)
- Philippe Paquette
- School of Rehabilitation, Université de Montréal, Montréal, Québec, Canada.
| | - Johanne Higgins
- School of Rehabilitation, Université de Montréal, Montréal, Québec, Canada
| | - Dany H Gagnon
- School of Rehabilitation, Université de Montréal, Montréal, Québec, Canada
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Schmid AB, Fundaun J, Tampin B. Entrapment neuropathies: a contemporary approach to pathophysiology, clinical assessment, and management. Pain Rep 2020; 5:e829. [PMID: 32766466 PMCID: PMC7382548 DOI: 10.1097/pr9.0000000000000829] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 05/04/2020] [Accepted: 05/30/2020] [Indexed: 12/18/2022] Open
Abstract
Entrapment neuropathies such as carpal tunnel syndrome, radiculopathies, or radicular pain are the most common peripheral neuropathies and also the most common cause for neuropathic pain. Despite their high prevalence, they often remain challenging to diagnose and manage in a clinical setting. Summarising the evidence from both preclinical and clinical studies, this review provides an update on the aetiology and pathophysiology of entrapment neuropathies. Potential mechanisms are put in perspective with clinical findings. The contemporary assessment is discussed and diagnostic pitfalls highlighted. The evidence for the noninvasive and surgical management of common entrapment neuropathies is summarised and future areas of research are identified.
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Affiliation(s)
- Annina B. Schmid
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, United Kingdom
| | - Joel Fundaun
- Nuffield Department of Clinical Neurosciences, Oxford University, Oxford, United Kingdom
- High Country Physical Therapy, Laramie, WY, USA
| | - Brigitte Tampin
- Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Physiotherapy and Exercise Science, Curtin University, Western Australia, Australia
- Faculty of Business Management and Social Sciences, Hochschule Osnabrück, University of Applied Sciences, Osnabrück, Germany
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25
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Schrier VJMM, Lin J, Gregory A, Thoreson AR, Alizad A, Amadio PC, Fatemi M. Shear wave elastography of the median nerve: A mechanical study. Muscle Nerve 2020; 61:826-833. [PMID: 32170959 DOI: 10.1002/mus.26863] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 02/03/2020] [Accepted: 03/10/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Shear wave elastography (SWE) shows promise in peripheral neuropathy evaluation but has potential limitations due to tissue size and heterogeneity. We tested SWE sensitivity to elasticity change and the effect of probe position in a median nerve cadaver model. METHODS Ten specimens were used to measure median nerve elasticity under increasing loads using SWE and indentation. Measurements were compared using repeated-measures analysis of variance. RESULTS Indentation and SWE-based longitudinal nerve elasticity increased with tensile loading (P < .01), showing a similar relationship. Acquisition in a transverse plane showed lower values compared with longitudinal measurements, mostly under higher loads (P = .03), as did postdissection elasticity (P = .02). Elasticity did not change when measured proximal to the carpal tunnel. CONCLUSIONS Longitudinal SWE is sensitive to changes in median nerve elasticity. Measuring elasticity of peripheral nerves noninvasively could elucidate intra-neural pathology related to compression neuropathies, and proof to be of added value as a diagnostic or prognostic tool.
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Affiliation(s)
- Verena J M M Schrier
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Mayo Clinic Minnesota, Rochester, Minnesota
| | - Jason Lin
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Mayo Clinic Minnesota, Rochester, Minnesota
| | - Adriana Gregory
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota
| | - Andrew R Thoreson
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Mayo Clinic Minnesota, Rochester, Minnesota
| | - Azra Alizad
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota
| | - Peter C Amadio
- Biomechanics Laboratory and Tendon and Soft Tissue Biology Laboratory, Mayo Clinic Minnesota, Rochester, Minnesota
| | - Mostafa Fatemi
- Department of Physiology and Biomedical Engineering, Mayo Clinic Minnesota, Rochester, Minnesota
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26
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Schrier VJMM, Evers S, Geske JR, Kremers WK, Villarraga HR, Kakar S, Selles RW, Hovius SER, Gelfman R, Amadio PC. Median Nerve Transverse Mobility and Outcome after Carpal Tunnel Release. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:2887-2897. [PMID: 31488311 PMCID: PMC6768738 DOI: 10.1016/j.ultrasmedbio.2019.06.422] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/18/2019] [Accepted: 06/24/2019] [Indexed: 05/13/2023]
Abstract
Nerve movement is decreased in patients with carpal tunnel syndrome and can be assessed with ultrasound. In addition to morphologic features, this study describes a novel approach in which nerve movement and the association with short-term patient-reported outcome are assessed. Ultrasound images at the carpal tunnel inlet were acquired during finger and wrist flexion. Linear regression models were used with the Boston Carpal Tunnel Questionnaire as main outcome. Eighty-five patients were included; 93% completed the 3-mo follow-up. Pre-surgical mean nerve area was 14.5 ± 4.2 mm2 and decreased to 13.3 ± 3.8 mm2 (p < 0.001). Displacement in dorsal direction with wrist flexion increased from 1.9 ± 1.3 to 2.4 ± 1.3 mm (p < 0.01). A pre-surgical larger nerve area was associated with more functional improvement (β = -0.024, p = 0.02), but baseline mobility was not. Change in excursion with finger flexion was associated with symptomatic improvement, but with a small effect (β = -0.05, p = 0.01). This indicates that there is limited prognostic potential for dynamic transverse ultrasound in carpal tunnel syndrome.
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Affiliation(s)
- Verena J M M Schrier
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stefanie Evers
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jennifer R Geske
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Walter K Kremers
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Hector R Villarraga
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Ruud W Selles
- Department of Plastic, Reconstructive and Hand Surgery, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Rehabilitation Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Steven E R Hovius
- Department of Plastic and Reconstructive Surgery, Radboudumc University Hospital, Nijmegen, The Netherlands
| | - Russell Gelfman
- Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter C Amadio
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Normalization of Spinal Cord Displacement With the Straight Leg Raise and Resolution of Sciatica in Patients With Lumbar Intervertebral Disc Herniation: A 1.5-year Follow-up Study. Spine (Phila Pa 1976) 2019; 44:1064-1077. [PMID: 30985566 DOI: 10.1097/brs.0000000000003047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A controlled radiologic follow-up study. OBJECTIVE The aim of this study was to ascertain whether changes in cord excursion with straight leg raise test (SLR) at 1.5-year follow-up time accompany changes in clinical symptoms. SUMMARY OF BACKGROUND DATA Lumbar intervertebral disc herniation (LIDH) is known to be a key cause of sciatica. Previously, we found that a significant limitation of neural displacement (66.6%) was evident with the SLR on the symptomatic side of patients with subacute single level posterolateral LIDH. METHODS Fourteen patients with significant sciatic symptoms due to a subacute single-level posterolateral LIDH were reassessed clinically and radiologically at 1.5 years follow-up with a 1.5T MRI scanner. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure and compared between SLRs and to data from baseline. Multivariate regression models and backward variable selection method were employed to identify variables more strongly associated with a decrease in low back pain (LBP) and radicular symptoms. RESULTS Compared with previously presented baseline values, the data showed a significant increase in neural sliding in all the quantified maneuvers (P ≤ 0.01), and particularly of 2.52 mm (P ≤ 0.001) with the symptomatic SLR.Increase in neural sliding correlated significantly with decrease of both radicular symptoms (Pearson = -0.719, P ≤ 0.001) and LBP (Pearson = -0.693, P ≤ 0.001). Multivariate regression models and backward variable selection method confirmed the improvement of neural sliding effects (P ≤ 0.004) as the main variable being associated with improvement of self-reported clinical symptoms. CONCLUSION To our knowledge, these are the first noninvasive data to objectively support the association between increase in magnitude of neural adaptive movement and resolution of both radicular and LBP symptoms in in vivo and structurally intact human subjects. LEVEL OF EVIDENCE 2.
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Tang CT, Cheng AL. Ultrasound Visualization of Radial Nerve Excursion During Acupuncture. Med Acupunct 2019; 31:185-188. [PMID: 31312289 DOI: 10.1089/acu.2019.1335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: Nerves are likely to be contacted by needles somewhat regularly during acupuncture treatments. However, the effects of this are not well-known or described. The aim of this article is to describe the effects of acupuncture needling to the radial nerve in a single healthy subject. Materials and Methods: In this experiment, conducted at an academic medical center (Washington University School of Medicine in St. Louis, St. Louis, MO), ultrasound-guided acupuncture needling was performed to the radial nerve of one of the authors (C.-T.T.) in the upper arm at acupoint LI 13. The main outcome measures sought were ultrasonic visualization of the nerve during acupuncture needling and the sensations experienced during acupuncture needling of the nerve. Results: The radial nerve was seen to "roll" out of the way when it was needled. Two De Qi responses were elicited en route to the nerve, but, during nerve contact and penetration, minimal-to-no sensation was experienced. Conclusions: Healthy nerves can show side-to-side excursion when needled, and providers and patients cannot know reliably whether or not a nerve has been contacted or penetrated based on the sensations the patient experiences.
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Affiliation(s)
- Chi-Tsai Tang
- Department of Orthopedic Surgery, Division of Physical Medicine and Rehabilitation, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Abby L Cheng
- Department of Orthopedic Surgery, Division of Physical Medicine and Rehabilitation, Washington University School of Medicine in St. Louis, St. Louis, MO
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29
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Whittaker JL, Ellis R, Hodges PW, OSullivan C, Hides J, Fernandez-Carnero S, Arias-Buria JL, Teyhen DS, Stokes MJ. Imaging with ultrasound in physical therapy: What is the PT's scope of practice? A competency-based educational model and training recommendations. Br J Sports Med 2019; 53:1447-1453. [PMID: 31023858 PMCID: PMC6900235 DOI: 10.1136/bjsports-2018-100193] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2019] [Indexed: 11/14/2022]
Abstract
Physical therapists employ ultrasound (US) imaging technology for a broad range of clinical and research purposes. Despite this, few physical therapy regulatory bodies guide the use of US imaging, and there are limited continuing education opportunities for physical therapists to become proficient in using US within their professional scope of practice. Here, we (i) outline the current status of US use by physical therapists; (ii) define and describe four broad categories of physical therapy US applications (ie, rehabilitation, diagnostic, intervention and research US); (iii) discuss how US use relates to the scope of high value physical therapy practice and (iv) propose a broad framework for a competency-based education model for training physical therapists in US. This paper only discusses US imaging—not ‘therapeutic’ US. Thus, ‘imaging’ is implicit anywhere the term ‘ultrasound’ is used.
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Affiliation(s)
- Jackie L Whittaker
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Richard Ellis
- Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Paul William Hodges
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Cliona OSullivan
- Department of Physiotherapy and Performance Science, University College Dublin, Dublin, Ireland
| | - Julie Hides
- School of Allied Health Sciences, Griffith University, Brisbane, Queensland, Australia
| | | | | | - Deydre S Teyhen
- Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Maria J Stokes
- School of Health Professions and Rehabilitation Sciences, University of Southampton, Southampton, UK
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30
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Wiberg A, Ng M, Schmid AB, Smillie RW, Baskozos G, Holmes MV, Künnapuu K, Mägi R, Bennett DL, Furniss D. A genome-wide association analysis identifies 16 novel susceptibility loci for carpal tunnel syndrome. Nat Commun 2019; 10:1030. [PMID: 30833571 PMCID: PMC6399342 DOI: 10.1038/s41467-019-08993-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 02/13/2019] [Indexed: 01/07/2023] Open
Abstract
Carpal tunnel syndrome (CTS) is a common and disabling condition of the hand caused by entrapment of the median nerve at the level of the wrist. It is the commonest entrapment neuropathy, with estimates of prevalence ranging between 5-10%. Here, we undertake a genome-wide association study (GWAS) of an entrapment neuropathy, using 12,312 CTS cases and 389,344 controls identified in UK Biobank. We discover 16 susceptibility loci for CTS with p < 5 × 10-8. We identify likely causal genes in the pathogenesis of CTS, including ADAMTS17, ADAMTS10 and EFEMP1, and using RNA sequencing demonstrate expression of these genes in surgically resected tenosynovium from CTS patients. We perform Mendelian randomisation and demonstrate a causal relationship between short stature and higher risk of CTS. We suggest that variants within genes implicated in growth and extracellular matrix architecture contribute to the genetic predisposition to CTS by altering the environment through which the median nerve transits.
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Affiliation(s)
- Akira Wiberg
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK.,Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK.,Department of Plastic and Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Michael Ng
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK
| | - Annina B Schmid
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Robert W Smillie
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK
| | - Georgios Baskozos
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Michael V Holmes
- Medical Research Council Population Health Research Unit at the University of Oxford, Oxford, OX3 7LF, UK.,Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK
| | - K Künnapuu
- Institute of Technology, University of Tartu, Nooruse 1, 50411, Tartu, Estonia
| | - R Mägi
- Estonian Genome Center, Institute of Genomics, University of Tartu, Riia 23 B, 51010, Tartu, Estonia
| | - David L Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
| | - Dominic Furniss
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Science, University of Oxford, Botnar Research Centre, Windmill Road, Oxford, OX3 7LD, UK. .,Department of Plastic and Reconstructive Surgery, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
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31
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Wolny T, Linek P. Is manual therapy based on neurodynamic techniques effective in the treatment of carpal tunnel syndrome? A randomized controlled trial. Clin Rehabil 2018; 33:408-417. [PMID: 30306805 DOI: 10.1177/0269215518805213] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE: The aim of this study was to evaluate the efficacy of manual therapy based on neurodynamic techniques in conservative treatment of carpal tunnel syndrome. DESIGN: Randomized controlled trial. SETTING: Several medical outpatient clinics in the south of Poland. PARTICIPANTS: The study included 103 patients with mild and moderate carpal tunnel syndrome (mean age = 53.95, SD = 9.5) years, who were randomly assigned to a neurodynamic techniques group (experimental group, n = 58) or a group without treatment (control group, n = 45). INTERVENTION: Neurodynamic techniques were used in the experimental group. Treatment was conducted twice weekly (20 sessions). Control group did not receive treatment. MAIN MEASURES: Nerve conduction study, pain, symptom severity and functional status of Boston Carpal Tunnel Questionnaire, and strength of cylindrical and pincer grips were assessed at baseline and immediately after treatment (nerve conduction study one month after treatment). RESULTS: Baseline assessment revealed no group differences in any assessed parameters ( P > 0.05). There were significant differences between groups after treatment, including nerve conduction (e.g. sensory conduction velocity: experimental group: 38.3 m/s, SD = 11.1 vs control group: 25.9 m/s, SD = 7.72, P < 0.01). Significant changes also occurred in pain (experimental group: 1.38, SD = 1.01 vs control group: 5.46, SD = 1.05, P < 0.01), symptom severity (experimental group: 1.08, SD = 0.46 vs control group: 2.87, SD = 0.68, P < 0.01), and functional status (experimental group: 1.96, SD = 0.64 vs control group: 2.87, SD = 1.12, P < 0.01). There were no group differences in strength ( P > 0.05). CONCLUSION: The use of neurodynamic techniques in conservative treatment for mild to moderate forms of carpal tunnel syndrome has significant therapeutic benefits.
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Affiliation(s)
- Tomasz Wolny
- Department of Kinesiotherapy and Special Methods in Physiotherapy, The Jerzy Kukuczka Academy of Physical Education in Katowice, Katowice, Poland
| | - Pawel Linek
- Department of Kinesiotherapy and Special Methods in Physiotherapy, The Jerzy Kukuczka Academy of Physical Education in Katowice, Katowice, Poland
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Ellis R, Rohan M, Fox J, Hitt J, Langevin H, Henry S. Ultrasound Elastographic Measurement of Sciatic Nerve Displacement and Shear Strain During Active and Passive Knee Extension. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2091-2103. [PMID: 29430675 DOI: 10.1002/jum.14560] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 11/22/2017] [Accepted: 11/24/2017] [Indexed: 06/08/2023]
Abstract
There is current need for objective measures of sciatic nerve mobility in patients with sciatic-type pain. The objective of the study was to assess the feasibility and reliability of ultrasound elastography to quantify sciatic nerve displacement and shear strain at the sciatic nerve-hamstring muscle interface during active and passive knee extension-flexion exercises performed while sitting in healthy people. Ultrasound elastography showed excellent intrarater within-session reliability for assessing sciatic nerve displacement and sciatic nerve-hamstring muscle interface shear strain during active knee extension-flexion exercises. These findings will inform similar future work conducted in patients with sciatic-type pain.
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Affiliation(s)
- Richard Ellis
- Department of Physiotherapy, School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland, New Zealand
- Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland, New Zealand
| | - Maheswaran Rohan
- Department of Biostatistics and Epidemiology, Faculty of Health and Environmental Sciences , Auckland University of Technology, Auckland, New Zealand
| | - James Fox
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Juvena Hitt
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - Helene Langevin
- Department of Neurological Sciences, University of Vermont College of Medicine, Burlington, Vermont, USA
- Osher Center for Integrative Medicine, Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharon Henry
- Department of Rehabilitation Science, University of Vermont College of Nursing and Health Science, Burlington, Vermont, USA
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Abstract
Entrapment neuropathies are the most prevalent type of peripheral neuropathy and often a challenge to diagnose and treat. To a large extent, our current knowledge is based on empirical concepts and early (often biomechanical) studies. This Viewpoint will challenge some of the current beliefs with recent advances in both basic and clinical neurosciences. J Orthop Sports Phys Ther 2018;48(2):58-62. doi:10.2519/jospt.2018.0603.
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Kasehagen B, Ellis R, Pope R, Russell N, Hing W. Assessing the Reliability of Ultrasound Imaging to Examine Peripheral Nerve Excursion: A Systematic Literature Review. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1-13. [PMID: 29100792 DOI: 10.1016/j.ultrasmedbio.2017.08.1886] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 08/22/2017] [Accepted: 08/28/2017] [Indexed: 06/07/2023]
Abstract
Ultrasound imaging (USI) is gaining popularity as a tool for assessing nerve excursion and is becoming an important tool for the assessment and management of entrapment neuropathies. This systematic review aimed to identify current methods and report on the reliability of using USI to examine nerve excursion and identify the level of evidence supporting the reliability of this technique. A systematic search of five electronic databases identified studies assessing the reliability of using USI to examine nerve excursion. Two independent reviewers critically appraised and assessed the methodological quality of the identified articles. Eighteen studies met the eligibility criteria. The majority of studies were of "moderate" or "high" methodological quality. The overall analysis indicated a "strong" level of evidence of moderate to high reliability of using USI to assess nerve excursion. Further reliability studies with consistency of reporting are required to further strengthen the level of evidence.
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Affiliation(s)
- Ben Kasehagen
- Bond Institute of Health and Sport, Faculty of Health Sciences and Medicine, Bond University, Robina, Gold Coast, Queensland, Australia.
| | - Richard Ellis
- Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Rodney Pope
- Bond Institute of Health and Sport, Faculty of Health Sciences and Medicine, Bond University, Robina, Gold Coast, Queensland, Australia
| | - Nicholas Russell
- Bond Institute of Health and Sport, Faculty of Health Sciences and Medicine, Bond University, Robina, Gold Coast, Queensland, Australia
| | - Wayne Hing
- Bond Institute of Health and Sport, Faculty of Health Sciences and Medicine, Bond University, Robina, Gold Coast, Queensland, Australia
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35
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Bland JDP. Hydrodissection for treatment of carpal tunnel syndrome. Muscle Nerve 2017; 57:4-5. [PMID: 28786115 DOI: 10.1002/mus.25759] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 07/22/2017] [Accepted: 08/05/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Jeremy D P Bland
- East Kent Hospitals University NHS Foundation Trust, Kent and Canterbury Hospital, Ethelbert Road, Canterbury, Kent CT1 3NG, United Kingdom
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