Ultrasound versus palpation-guided corticosteroid injection for de Quervain disease: A randomized controlled trial

INTRODUCTION

Corticosteroid injection effectively treats de Quervain disease, and due to the high prevalence of the intracompartmental septum in the first extensor compartment, ultrasound guidance improves injection accuracy.

OBJECTIVE

To compare the effectiveness, adverse events, and the recurrence rate between ultrasound-guided and palpation-guided injection in patients with de Quervain disease.

DESIGN

Prospective, single-blind, randomized controlled trial.

SETTING

Rehabilitation department of a private teaching hospital.

PARTICIPANTS

We enrolled 49 patients, ≥20 years of age, clinically diagnosed with de Quervain disease based on their medical history and physical examination.

INTERVENTIONS

Patients were randomized into two groups: ultrasound-guided and palpation-guided injection. Both groups received a mixture of 10 mg triamcinolone acetonide (10 mg/1 mL) and 0.3 mL 1% lidocaine.

MAIN OUTCOME MEASURES

The primary outcome measure was the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score at 1 week. The secondary outcome measures were visual analog scale for pain (pain VAS) score, patient satisfaction, and adverse events or complications from the interventions at 1 week, 3 months, and 6 months.

RESULTS

Both groups showed improvement over time in QuickDASH scores and pain VAS (p < .001); however, no statistically significant differences were noted between the groups for either QuickDASH scores (p = .22) or pain VAS (p = .30). In addition, no statistically significant differences were found between the groups in terms of patient satisfaction (p = .76) and adverse events (p = .47, .33, .58) at the 1-week, 3-month, and 6-month follow-ups.

CONCLUSIONS

Both ultrasound-guided and palpation-guided injections effectively treated de Quervain disease. During a 6-month follow-up, there were no statistically significant differences between the groups in pain relief, upper limb function, or patient satisfaction. However, the palpation-guided group showed a tendency for more recurrence and skin side effects.

Efficacy of Combination Therapy (Hydrodilatation and Subdeltoid Bursa Injection With Corticosteroid, Mobilization, and Physical Therapy) vs Physical Therapy Alone for Treating Frozen Shoulder: A Randomized Single-Blind Controlled Trial, Phase I

OBJECTIVE

To compare the efficacy of combination therapy (hydrodilatation and subdeltoid bursa injection with corticosteroid, mobilization, and physical therapy [PT]) with that of PT alone for treating frozen shoulder.

DESIGN

A prospective, 2-arm parallel, single-blinded, randomized controlled trial.

SETTING

Rehabilitation clinic of a private academic hospital.

PARTICIPANTS

Patients (n=70) with frozen shoulder (freezing stage).

INTERVENTIONS

Participants (n=35) in the combination group underwent hydrodilatation and subdeltoid bursa injection with corticosteroid twice, mobilization, and usual-care PT for 8 weeks; participants (n=35) in the PT group received only the usual-care PT for 8 weeks.

MAIN OUTCOME MEASURES

The Shoulder Pain and Disability Index (SPADI) was the primary outcome measure. The secondary outcome measures were pain scores on a visual analog scale, range of motion (ROM), the Shoulder Disability Questionnaire (SDQ), quality of life (evaluated using the 36-item Short-Form Health Survey [SF-36]), and self-assessment of the treatment effect.

RESULTS

Compared with the PT group, the combination group had significantly better pain (during activity), SPADI, SDQ, active and passive ROM, and self-assessment scores (all P<.001) as well as scores on some parts of the SF-36 (physical function and bodily pain, P<.05). Between-group differences were significant at the 1-, 2-, 4-, and 6-month follow-ups.

CONCLUSIONS

A combination of hydrodilatation (with corticosteroid), bursal corticosteroid injection, and joint mobilization with PT was superior to PT alone for treating frozen shoulder, and the effects persisted for at least 6 months.

Ultrasonographic imaging findings of the shoulder in patients with Parkinson disease

BACKGROUND

Shoulder disorders, including frozen shoulder, bursitis, and rotator cuff lesions, are common musculoskeletal problems in patients with Parkinson disease (PD). Because musculoskeletal ultrasound (US) can clearly image shoulder joints, we aimed to evaluate shoulder joints using US in patients with PD and healthy participants and correlation between US and PD severity.

METHODS

This is a prospective case-control study. 50 patients with PD and 50 healthy subjects from the outpatient department were administered US for bilateral shoulders. For data analysis, we chose the more severely affected side in the PD group for matching with the corresponding shoulder in the control group according to age, sex, and body mass index. Pain and disability were measured using the Visual Analogue Scale (VAS) for pain, Shoulder Pain and Disability Index (SPADI), and the Shoulder Disability Questionnaire (SDQ).

RESULTS

The PD group had higher VAS pain scores during activity (p = 0.003) and rest (p < 0.001), as well as the SPADI and SDQ scores (p < 0.001). In US findings, biceps long head tendon sheath effusion (p = 0.001), humeral head cortical irregularity (p = 0.012), and abnormality in the supraspinatus tendon (p = 0.003) were significantly greater in the PD group. Intra-group analysis in the PD group demonstrated a significant difference in passive flexion (p = 0.019) and supraspinatus tendinopathy (p = 0.033) on US examination during different disease stages.

CONCLUSIONS

Patients with PD had more supraspinatus tendinopathy on US findings than control subjects. The lesion was significantly associated with disease severity.

CLINICAL TRIAL NUMBER

NCT02702232.

Comparison of corticosteroid injection, physiotherapy and combined treatment for patients with chronic subacromial bursitis - A randomised controlled trial

OBJECTIVE

To investigate whether combination of corticosteroid subdeltoid injections and physiotherapy was more effective than either treatment alone in chronic subacromial bursitis.

DESIGN

Prospective, three-arm randomised controlled trial.

SETTING

Rehabilitation department of an academic hospital.

SUBJECTS

Patients with chronic subacromial bursitis.

INTERVENTIONS

Patients were divided into corticosteroid injection (N = 36), physiotherapy (N = 40) and combined (N = 35) groups. Two corticosteroid subdeltoid injections in corticosteroid group, 8-week physical therapy emphasising on therapeutic exercise in physiotherapy group, and combined both treatments in combined group.

MAIN OUTCOME MEASURES

The primary outcome measures were pain visual analogue scale and Shoulder Pain and Disability Index at 8 weeks after finishing treatment. The secondary outcome measures were active range of motion, Shoulder Disability Questionnaire, Western Ontario Rotator Cuff Index, patient's evaluation of treatment effect, and symptom recurrence.

RESULTS

Group comparison showed significant statistical difference in shoulder flexion (P < 0.003) and patient's evaluation of treatment effect (P < 0.001). The time and group interactions comparison revealed significant statistical differences in pain score (P < 0.024), external rotation (P < 0.044) and patient's evaluation of treatment effect (P < 0.001). The above statistics were in favour of the corticosteroid and combined groups rather than physiotherapy group. The percentage of recurrence was 36.1, 7.5 and 17.1 in the corticosteroid, physiotherapy and combined groups, respectively (P < 0.001).

CONCLUSION

Corticosteroid subdeltoid injection, or combined with physiotherapy, was superior to physiotherapy alone, but the recurrence rate was least in the physiotherapy group.

Comparison of the effects of ultrasound- guided needle puncture, radial shock wave therapy, and combined treatments on calcific tendinitis of the shoulder: A single-blind randomized controlled trial

BACKGROUND

Calcific tendinitis of the shoulder is a common disorder resulting in restricted motion and pain.

OBJECTIVE

This study compared the effects of ultrasound-guided fine-needle puncture (USNP), radial shock wave therapy (RSWT), and the combination of both treatments (COMB) on calcific tendinitis of the shoulder.

METHODS

We enrolled 62 patients who had unilateral shoulder pain for more than 3 months. The patients were randomly divided into three groups: USNP, RSWT, and COMB. All USNP needle punctures were guided with ultrasound (US), and RSWT was delivered at 2 Hz (2000 shock waves; 0.26 mJ/mm2) once a week for 3 weeks. The COMB group received three weekly rounds of RSWT after a single US-guided needle puncture. The primary outcome was the pain visual analog scale (VAS), and secondary outcomes were the Constant scores, 36-Item Short-Form Health Survey, and range of motion.

RESULTS

A within-group comparison at 3 months revealed significant improvements in the pain VAS (p< 0.05, during activity) and Constant (p< 0.05) scores, but between-group comparisons revealed no statistically significant differences in the pain VAS (p> 0.05) or Constant (p= 0.089) scores. Only improvement differences in role-emotional (SF-36; p= 0.01) and active external rotation (p= 0.035) were determined over time, which favored the USNP and COMB groups.

CONCLUSIONS

Although no significant differences were observed among the groups in the treatment of calcific tendinitis of the shoulder, more satisfactory outcomes were noted in the USNP and COMB groups than in the RSWT group. Larger samples, longer follow-up times, and other treatment protocols are suggested for future studies.

The effect of giving verbal feedback during neck stabilisation exercise as an addition to physical therapy in patients with chronic neck pain: A randomised controlled trial

OBJECTIVES

To study the addition of feedback-guided neck strength home exercise to physical therapy as an enhanced rehabilitation programme in the treatment of patients with chronic neck pain.

DESIGN

A prospective randomised controlled trial.

SETTING

Rehabilitation department of an academic hospital.

SUBJECTS

Patients with chronic neck pain.

INTERVENTIONS

The patients in both groups received supervised physical therapy sessions 3 times a week for 12 weeks. Patients in Group A (N = 38) used the neck strengthening exerciser device for 20 min daily at home for 6 weeks and patients in Group B (N = 20) performed 20 min of daily regular neck exercise at home for 6 weeks.

OUTCOME MEASURES

Neck disability index, pain visual analogue scale, active range of motion of the neck, Patient Global Assessment and patient evaluation of treatment effect. All subjects were assessed at baseline as well as at 6- and 12-week follow-ups.

RESULTS

At the 6-week follow-up, Group A exhibited significantly greater improvements (P < 0.05) in pain Visual Analogue Scale (Group A: 2.97 ± 1.57; Group B: 4.20 ± 1.82), neck disability index (Group A: 13.95 ± 8.07; Group B: 20.07 ± 9.14) and active cervical extension (Group A: 65.26 ± 12.76; Group B: 51.45 ± 11.78). At 12-week follow-up, Group A also exhibited significantly greater active cervical extension (Group A: 67.74 ± 11.94; Group B: 53.85 ± 14.09; P < 0.05).

CONCLUSION

Adding neck strengthening exerciser home training to physical therapy was demonstrated to be more effective than physical therapy alone for patients with chronic neck pain.

Comparison of the corticosteroid injection and hyaluronate in the treatment of chronic subacromial bursitis: A randomized controlled trial

OBJECTIVE

To analyse the effectiveness of corticosteroid (CS) and hyaluronic acid (HA) subacromial - subdeltoid (SASD) injection compared with normal saline (NS) in patients with chronic subacromial bursitis (CSB).

DESIGN

A prospective three-arm double-blinded randomised controlled trial.

SETTING

Rehabilitation department of two teaching hospitals.

SUBJECTS

Patients with CSB (N = 186) divided into CS (N = 68), HA (N = 60), and NS (N = 58) groups.

INTERVENTIONS

Three SASD injections under ultrasound guidance: group A, 20 mg of triamcinolone; group B, 2.5 mL of HA; and group C, 2.5 mL of NS.

OUTCOME MEASURES

The primary outcome measures were the pain visual analogue scale (VAS) score at eight weeks. The secondary outcomes were scores on the Shoulder Pain and Disability Index (SPADI) and Shoulder Disability Questionnaire.

RESULTS

At eight weeks, the pain VAS scores during activity were 2.56 ± 2.29, 3.65 ± 2.50, and 4.71 ± 2.83 in the CS, HA, and NS groups, respectively (CS vs NS, P < 0.001; HA vs NS, P = 0.013; CS vs HA, P = 0.010). SPADI scores were 40.83 ± 21.75, 36.92 ± 22.78, and 33.35 ± 23.38 in the CS, HA, and NS groups, respectively (CS vs NS, P < 0.001; HA vs NS, P = 0.197; CS vs HA, P = 0.004).

CONCLUSION

Ultrasound-guided corticosteroid injection into the subacromial - subdeltoid bursa was proven to be effective and superior to hyaluronic acid and normal saline injection for treating CSB. Hyaluronic acid injection was only marginally more effective than normal saline injection.Trial Registration: ClinicalTrials.gov: NCT02702206.

Recommendations for psoriatic arthritis management: A joint position paper of the Taiwan Rheumatology Association and the Taiwanese Association for Psoriasis and Skin Immunology

In Taiwan, the incidence and prevalence of psoriatic arthritis (PsA) have risen significantly in recent years. Moreover, data from the Taiwan National Health Insurance Research Database (NHIRD) show that more than 85% of PsA patients are treated with just non-steroidal anti-inflammatory drugs (NSAIDs) and/or conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). Taiwanese clinicians have also expressed concerns regarding uncertainties in the diagnosis of PsA and the delayed, interrupted, and/or tapered use of biologics, as well as differences in therapeutic preferences between and within dermatologists and rheumatologists. To address these issues, the Taiwan Rheumatology Association and the Taiwanese Association for Psoriasis and Skin Immunology jointly convened a committee of 28 clinicians from the fields of rheumatology, dermatology, orthopedics, and rehabilitation, to develop evidence-based consensus recommendations for the practical management of PsA in Taiwan. A total of six overarching principles and 13 recommendations were developed and approved, as well as a treatment algorithm with four separate tracks for axial PsA, peripheral PsA, enthesitis, and dactylitis. Psoriasis (PsO) management was not discussed here, as the Taiwanese Dermatological Association has recently published a comprehensive consensus statement on the management of PsO. Together, these recommendations provide an up-to-date, evidence-based framework for PsA care in Taiwan.

Taiwan Rheumatology Association consensus recommendations for the management of axial spondyloarthritis

Aim

To establish guidelines for the clinical management of axial spondyloarthritis that take into account local issues and clinical practice concerns for Taiwan.

Method

Overarching principles and recommendations were established by consensus among a panel of rheumatology and rehabilitation experts, based on analysis of the most up‐to‐date clinical evidence and the clinical experience of panelists. All Overarching Principles and Recommendations were graded according to the standards developed by the Oxford Centre for Evidence Based Medicine, and further evaluated and modified using the Delphi method.

Results

The guidelines specifically address issues such as local medical considerations, National Health Insurance reimbursement, and management of extra‐articular manifestations.

Conclusion

It is hoped that this will help to optimize clinical management outcomes for axial spondyloarthritis in Taiwan.

Comparison of the effect of Western-made unloading knee brace with physical therapy in Asian patients with medial compartment knee osteoarthritis-A preliminary report

PURPOSE

To compare the effect of unloading knee brace with physical therapy (PT) in Asian patients with osteoarthritis (OA) of the knee.

METHOD

This is a non-random, two-group comparative study. Patients with medial compartment knee OA (n = 41) were assigned to either the brace group (n = 20) or PT group (n = 21). Patients in the brace group were fitted with an unloading knee brace for three months and the PT group received a 60-min session of physiotherapy over the affected knee, three times a week, for three months. The primary outcome measures were the pain visual analogue scale (VAS) and the Western Ontario McMaster University Osteoarthritis Index (WOMAC); the second outcome measures were the 36-item Short-Form Health Survey (SF-36) and patient's satisfaction. The patients were evaluated at baseline, and at one month and three months.

RESULTS

Group comparison showed no significant difference regarding pain VAS, WOMAC, SF-36, and patient's satisfaction, except stiffness in WOMAC (P = .006) and social functioning in SF-36 (P = .007). Time and group interaction revealed significant differences only in general health (P = .007) and mental health (P = .006) of SF-36. Within-group comparison found that pain VAS and WOMAC decreased significantly at one months and three months in both groups.

CONCLUSION

The effect of brace fitting in patients with knee OA was similar to that of physical therapy. A Western-made unloading knee brace is acceptable in some Asian people with knee OA.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02712710.

Effects of Botulinum Toxin Landmark-Guided Intra-articular Injection in Subjects With Knee Osteoarthritis

BACKGROUND

Increasing evidence has suggested that botulinum toxin A (BoNT/A) can inhibit the release of selected neuropeptide transmitters from primary sensory neurons. Thus, intra-articular (IA) injection therapies with BoNT/A may reduce pain in patients with knee osteoarthritis (OA).

OBJECTIVE

To investigate the effects of landmark-guided IA injection of BoNT/A on patients with knee OA.

DESIGN

A prospective randomized controlled trial.

SETTING

A rehabilitation clinic of a private teaching hospital.

PATIENTS

A total of 46 patients with symptomatic knee OA (mostly Kellgren-Lawrence grade 2-3).

METHODS

The patients were randomly assigned to 1 of the following groups: BoNT/A group (BoNT/A injection; n = 21) or control group (education only; n = 20). The patients in the BoNT/A group received an IA injection of 100 units of BoNT/A into the affected knee.

MAIN OUTCOME MEASURES

The short-term (1 week posttreatment) and long-term (6 months posttreatment) effects were evaluated using a pain visual analogue scale (VAS) and questionnaires concerning functional status, including the Lequesne and Western Ontario and McMaster Universities (WOMAC) indexes.

RESULTS

The between-group comparison revealed significant differences with regard to the pain VAS score at 1 week (P < .001) and at 6 months (P = .001) posttreatment. Similar findings for the between-group comparison were observed for the WOMAC and Lequesne indexes at 6 months (P < .05) posttreatment. The pain VAS score in the BoNT/A group significantly decreased from 5.05 ± 1.12 (pretreatment) to 2.89 ± 1.04 at 1 week (P < .001) and 3.45 ± 1.70 at 6 months posttreatment (P < .001) but not in the control group (P = .476).

CONCLUSIONS

The IA injection of BoNT/A provided pain relief and improved functional abilities in patients with knee OA in both the short- and long-term follow-up.

LEVEL OF EVIDENCE

I.

Immediate and long-term efficacy of laterally-wedged insoles on persons with bilateral medial knee osteoarthritis during walking

Background

The current study aimed to investigate the immediate and long-term effects of laterally-wedged (LW) insoles on the knee loadings, the knee abductor moment (KAM) in particular, and the compensatory changes at other lower limb joints in patients with bilateral medial knee osteoarthritis during level walking with and without LW insoles.

Methods

Older adults with bilateral medial knee OA (age 66 ± 5.3 years; height 156 ± 4.9 cm; mass 60 ± 5.1 kg; leg length 83.72 ± 3.64 cm) were studied using computerized gait analysis initially (Baseline) and 6 weeks after using LW insoles (Follow-up) during barefoot walking and walking with LW insoles (7° of lateral inclination, with medial arch support). The three-dimensional angles and internal moments at the lower limb joints, as well as the ground reaction forces, were obtained using a motion analysis system and two forceplates. Key features of all the variables were compared using paired t tests for immediate effects (barefoot vs. LW) and for long-term effects (Baseline vs. Follow-up). The symptomatic severity (WOMAC Index) was also evaluated (Baseline vs. Follow-up).

Results

The KAM with LW insoles at Baseline was significantly reduced when compared to the barefoot condition (p < 0.05), suggesting that the LW insoles were effective in reducing unfavorable loadings at the knee immediately upon wearing the insoles. After 6 weeks of wearing LW insoles (Follow-up), no significant changes were found in most of the biomechanical variables, including KAM (p > 0.05), when compared to Baseline with LW insoles. However, a specific gait adaptation with reduced knee loading was revealed when walking without LW insoles, i.e., for the barefoot condition (p < 0.05).

Conclusions

After long-term use of LW insoles, the pain and physical function were improved with decreased peak KAM. A specific gait adaptation with reduced KAM was also found when walking without LW insoles. These results indicate a positive long-term effect in persons with bilateral medial knee OA, both as an orthosis to assist walking, and as a treatment intervention to facilitate gait adaptations in favor of reduced KAM.

Aerobic capacity and its correlates in patients with ankylosing spondylitis

AIM

To evaluate aerobic capacity in patients with ankylosing spondylitis (AS) and determine possible relationships between aerobic capacity, pulmonary function, and disease-related variables.

METHOD

Forty-two patients with AS and 42 healthy controls were recruited in the study. Descriptive data, disease-related variables (grip strength, lumbosacral mobility, occiput-to-wall distance, chest expansion, finger-to-floor distance, Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Global Score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and hemoglobin), and chest and thoracic spine x-rays were collected in each patient with AS. All subjects took standard pulmonary function and exercise tolerance tests, and forced vital capacity (FVC) and aerobic capacity were recorded.

RESULTS

Both aerobic capacity and FVC in patients with AS were significantly lower than those in normal subjects (P < 0.05). AS patients with BASFI scores of < 3 or BASDI scores of < 4 had a higher aerobic capacity. There was significant correlation between aerobic capacity, vital capacity, chest expansion, Schober's test, cervical range of motion, and BASFI in patients with AS. Neither aerobic capacity nor vital capacity correlated with disease duration, ESR, CRP, and hemoglobin.

CONCLUSIONS

Significantly reduced aerobic capacity and FVC were observed in patients with AS, and there was significant correlation between aerobic capacity, vital capacity, chest expansion, and BASFI.

Efficacy and side effects of diclofenac patch in treatment of patients with myofascial pain syndrome of the upper trapezius

Locally administered nonsteroidal anti-inflammatory drugs have been widely used in acute soft-tissue damage and articular musculoskeletal pain. This double-blind, placebo-controlled, randomized study was designed to evaluate the efficacy and safety of a topical diclofenac sodium patch in the relief of pain and inflammation as a result of myofascial pain syndrome (MPS) in the upper trapezius. After sample size calculations indicated that 147 patients would be needed to detect a 25% difference between drug and control, 153 patients with MPS were recruited and randomized to receive either a diclofenac sodium patch or control (menthol) patch. Visual analog scale (VAS), cervical active range of motion, pressure pain threshold of the myofascial trigger point (MTrP), patient global assessment, Neck Disability Index, and the occurrence of adverse events were assessed on Day 0 (baseline), Day 4, and Day 8. Use of the diclofenac sodium patch elicited favorable responses for the VAS, cervical active range of motion, and Neck Disability Index by the end of the treatment course (P<0.05), and was consistently superior to the control patch at all time intervals. No significant differences were observed for the pressure pain threshold of the MTrP for either patch. Tolerability assessment similarly showed the diclofenac patch to be comparatively superior. When assessed at the end of the study, 20 diclofenac patch patients, but only four control patients, considered the tolerability of treatment to be "very good." Significant differences in adverse reactions were observed between the diclofenac and control patches, with the control patch more likely to produce overall skin irritation. This study demonstrate that the diclofenac sodium patch was superior to the control patch in terms of reducing pain and improving functional outcomes, and did not result in significant adverse effects.

Injection in the cervical facet joint for shoulder pain with myofascial trigger points in the upper trapezius muscle

The goal of this double-blinded, randomized, controlled study was to confirm the effectiveness of the cervical facet joint injection in treating shoulder pain with the myofascial trigger point in the upper trapezius muscle secondary to cervical facet lesion. Eighty-nine patients with chronic unilateral shoulder pain due to myofascial trigger points in the upper trapezius muscle received an injection to the C4-5 facet joint in the experimental group and to the corresponding unilateral multifidi muscle in the control group. Subjective pain intensity and pressure pain threshold of the myofascial trigger point were assessed, and the prevalence of endplate noise in the myofascial trigger point region was measured in 28 patients before, immediately after, and 1 month after the injection. Half of the patients in the experimental group, but none of the control patients, reported being completely pain free 1 month after the injection. Both the decrease in the pain intensity and the increase in pressure pain threshold were significantly more in the experimental group than in the control group either immediately or 1 month after the injection. There was no significant difference in the change of endplate noise prevalence between the 2 groups. This study demonstrates that intra-articular or peri-articular injection into the cervical facet joint region can effectively inactivate the upper trapezius myofascial trigger point secondary to the facet lesion.

Unilateral brachial plexus injury as a complication of thoracoscopic sympathectomy for hyperhidrosis: a case report

Unilateral brachial plexus injury is a rare complication of thoracoscopic sympathectomy, which is generally considered to be a simple and safe procedure. We report on a 26-year-old man who developed weakness and numbness of the right arm after thoracoscopic sympathectomy for hyperhidrosis. Electromyographic study revealed evidence of denervation in the upper trunk of the right brachial plexus. A nerve conduction study on the right axillary nerve revealed a reduced compound muscle action potential amplitude at the right deltoid muscle. We suggest that this complication was caused by stretch and/or compression when the arm was hyperabducted during the operation. The outcome was excellent, with almost complete recovery 3 months later. The complication can be prevented by minimizing operation time and avoiding hyperabduction of the arm. The prognosis for postoperative brachial plexopathy is usually good with conservative management.

Effect of intramuscular botulinum toxin injection on upper limb spasticity in stroke patients

OBJECTIVE

To evaluate the therapeutic effect of intramuscular injection of botulinum toxin on spasticity of the upper limb, with emphasis on its influence over limb function.

DESIGN

An open-label, noncontrolled trial with a duration of 12 wk was designed to determine the safety and efficacy of intramuscular botulinum toxin A injection in the treatment of 16 patients with stroke with spastic hemiparesis. Electromyographically guided intramuscular botulinum toxin A injections were applied to the spastic limbs. A detailed scale system was used for the evaluation of muscle tone and functional changes induced by botulinum toxin A treatment.

RESULTS

No major side effect secondary to botulinum toxin A injection was reported. Statistically significant (P < 0.05) improvements of muscle tone, joint range of motion, hand muscle strength, and muscular pain were seen after the injection. The improvements lasted up to 8-12 wk after the treatment. However, there was no significant functional improvement except in two of the patients.

CONCLUSIONS

Botulinum toxin A injection may help relieve upper limb spasticity and pain in patients with stroke. Its effect on function is probably determined by case selection.

Bilateral femoral neuropathy after vaginal hysterectomy

A case of bilateral femoral neuropathy as a complication of vaginal hysterectomy is presented. A 45-year-old woman developed weakness of both quadriceps, absence of bilateral knee jerks, and numbness over bilateral anteromedial thighs and medial lower legs after a vaginal hysterectomy. Electromyographic examination revealed evidence of denervation in the bilateral quadriceps. A nerve conduction study showed prolonged distal latencies and markedly reduced amplitude of the compound muscle action potentials in bilateral femoral nerves. It is suggested that this complication is caused by a microvascular and/or local mechanical injury of the femoral nerve, which is compressed beneath the tough inguinal ligament in a sustained posture with the hip joint in an extreme abduction and external rotation position. The prognosis was excellent with almost complete recovery within 10 weeks. The complication may be preventable by minimizing operating time, changing the patient's posture, and limiting the degree of flexion, abduction, and external rotation of the hip.

Isokinetic and isometric testing of knee musculature in young female patients with patellofemoral pain syndrome

By using a Cybex II+ isokinetic dynamometer, we performed isokinetic and isometric tests of the knee musculature in 29 female patients (aged 17-45 years) with patellofemoral pain syndrome (PFPS) and the same number of age- and weight-matched female controls. The pain was unilateral in 11 patients and bilateral in 18. The isokinetic testing was set at speeds of 60 degrees, 120 degrees and 180 degrees/sec; the isometric testing was set at 30 degrees and 60 degrees of knee flexion. The results showed that the lowest torque values occurred on the affected side of the unilateral group, followed by both sides of the bilateral group, the sound side of the unilateral group, and the control group, sequentially. The highest rate of abnormal torque values for all PFPS patients occurred in the quadriceps at 60 degrees/sec of isokinetic contraction: 33%. In this study, five (17%) patients showed abnormal torque curves and 10 (34%) patients complained of pain or soreness at either the lowest speed of isokinetic testing or during the isometric testing of the quadriceps muscles. The bilateral torque difference was highest in the unilateral group.(ABSTRACT TRUNCATED AT 250 WORDS)

Isokinetic and isometric testing of knee musculature in patients with rheumatoid arthritis with mild knee involvement

This study sought to determine if weakness and poor endurance of quadriceps and hamstring muscles are present in rheumatoid arthritis (RA) patients with minimally involved knees; determine if there is an abnormal hamstring/quadriceps ratio or abnormal torque curves in RA patients; and begin to evaluate the feasibility of isokinetic (IK) exercise in RA patients. Sixteen RA patients with minimally involved knees and 16 matched control subjects were tested bilaterally with a Cybex II dynamometer. Torque values in the RA group were significantly less (78% for isokinetic and 81% for isometric). The hamstring/quadriceps torque ratio was significantly higher in the RA patients than in the controls: 66.8% vs 61.7%. There was no significant difference in endurance between the two groups. In the RA patients the angle at which peak torque occurred shifted later in the range of motion (37.4 degrees) compared with the control subjects (28.7 degrees). Except for IK torque of hamstring muscles in the control group, there was no significant difference in the torque values between the right and left sides in RA patients or control subjects. The findings suggested that even in RA patients with minimally involved joints, muscle weakness was present; exercise of quadriceps should be emphasized since in RA patients quadriceps were weaker than hamstrings; and isokinetic testing is feasible in selected patients with RA.