Neuropatía motora multifocal: ¿cómo diagnosticar un caballo de Troya? / Multifocal motor neuropathy: how to diagnose a trojan horse?

Introducción: La neuropatía motora multifocal con bloqueos de la conducción (NMMBC) es una enfermedad crónica inmunomediada, con un compromiso exclusivo de los nervios motores. Es importante diferenciarla de otras enfermedades que cursan con afectación motora, debido a que ésta es una enfermedad tratable. Cuadro clínico: Paciente varón de 56 años, con compromiso motor progresivo en el miembro superior del lado derecho desde el año 2016. El examen neurofisiológico demostró la presencia de múltiples bloqueos de la conducción nerviosa. Los anticuerpos antigangliósidos fueron negativos. Se indicó tratamiento con inmunoglobulina endovenosa en varios ciclos, con mejoría progresiva del cuadro. Discusión: Se discute el plan diagnóstico clínico y electrofisiológico, los diagnósticos diferenciales, las hipótesis fisiopatológicas y el tratamiento de esta enfermedad de rara ocurrencia

Introduction: Multifocal motor neuropathy with conduction blocks (NMMBC) is a chronic immunemediated disease that exclusively involves the motor nerves. It is important to differentiate it from other diseases that present with motor involvement, because this is a treatable disease. Clinical picture: A 56-year-old male patient, with progressive motor involvement in the right upper limb since 2016. A neurophysiological examination revealed multiple nerve conduction blocks. Antiganglioside antibodies were negative. Treatment with intravenous immunoglobulin was indicated for several cycles with progressive improvement of the condition. Discussion: Clinical and electrophysiological diagnostic plans, differential diagnoses, pathophysiological hypotheses, and treatment of this rare disease are discussed

Efeito da mobilização neural no tratamento da dor em indivíduos com cervicobraquialgia: uma revisão sistemática / Effect of neural mobilization on the treatment of pain in individuals with cervicobrachialgia: a systematic review

: A cervicobraquialgia (CB) é caracterizada por uma dor com origem em diferentes níveis estruturais da coluna cervical baixa (C3- C7), com irradiação bilateral ou unilateral para o membro superior. Considerando as causas e consequências advindas da CB, novas modalidades de tratamento têm sido propostas na tentativa de promover intervenções efetivas. Entre os procedimentos fisioterapêuticos encontram-se as técnicas de terapia manual como liberação miofascial, quiropraxia, mobilização articular, estabilização segmentar e a mobilização neural (MN) que procura restabelecer a função do tecido neural, sua condução elétrica, elasticidade, movimento e fluxo axoplasmático. Sendo assim, o objetivo do estudo foi avaliar sistematicamente as evidências sobre o efeito da MN no tratamento da dor em indivíduos com CB. A busca bibliográfica foi realizada no período entre Novembro de 2018 a Junho de 2019, sem limite de ano de publicação, nas bases de dados: PEDro, PubMed, Biblioteca Virtual em Saúde (Lilacs, Scielo e Medline) e Cochrane Library. A análise foi restrita aos ensaios clínicos randomizados. Para a análise etodológica dos artigos aptos a inclusão, foi utilizada a escala PEDro. Foi encontrado um total de 38 artigos. Após remoção de duplicatas, 14 artigos foram elegidos por resumo, 8 artigos foram recuperados para leitura completa e analisados quanto a sua adequação, dos quais 3 foram excluídos por não cumprirem os critérios de elegibilidade, ao fim 5 artigos foram incluídos na revisão. Houve redução significativa da dor, em pacientes tratados com MN. Considerando os resultados obtidos nesta revisão, foi possível concluir que a MN demonstra ser eficaz na redução da dor presente na CB. Embora os estudos mostrem que os resultados da MN como tratamento da CB são significativamente inferiores ao efeito do Ibuprofeno, deve-se ter em consideração as consequências a longo prazo para a saúde sobre a utilização de anti- inflamatórios orais.(AU)

Cervicobrachialgia (CB) is characterized by pain originating from different structural levels of the lower cervical spine (C3-C7), w ith bilateral or unilateral irradiation to the upper limb. Considering the causes and consequences of CB, new treatment modalities have been proposed in an attempt to promote effective interventions. Among the physical therapy procedures are manual therapy techniques such as myofascial release, chiropractic, joint mobilization, segmental stabilization and neural mobilization (NM) that seeks to restore the function of neural tissue, its electrical conduction, elasticity, movement and ax oplasmic flow . Thus, the objective of the study w as to evaluate systematically evaluate the evidence on the effect of NM on pain management in individuals w ith CB. The bibliographic search w as performed from November 2018 to June 2019, w ithout limit of year of publication, in the databases: PEDro, PubMed, Virtual Health Library (Lilacs, Scielo and Medline) and Cochrane Library. The analysis w as restricted to randomized controlled trials. For the methodological analysis of the articles eligible for inc lusion, the PEDro scale w as used. A total of 38 articles w ere found. After removal of duplicates, 14 articles w ere elected by abstract, 8 articles w ere retrieved for full reading and analyzed for suitability, of w hich 3 w ere excluded for not meeting eligibility c riteria, at the end 5 articles w ere included in the review . There was a significant pain reduction in patients treated w ith NM. Considering the results obtained in this review , it w as concluded that NM demonstrates to be effective in reducing pain present in CB. Although studies show that the results of NM as a treatment for CB are significantly low er than the effect of ibuprofen, consideration should be given to the long-term health consequences about the utilization of oral anti-inflammatory drugs.(AU)

Determining the utility of minimum F-wave latency alterations in the electrodiagnosis of ulnar neuropathy at the elbow / Determinação da utilidade das alterações mínimas da latência da onda F no eletrodiagnóstico da neuropatia ulnar do cotovelo

ABSTRACT Background: Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy. There is little information about the application of F-wave studies for evaluation of UNE. Objective: The aim of this study was to evaluate the diagnostic value of minimum F-wave (F-min) latency alterations by comparing this with nerve conduction analyses in UNE-suspected patients. Methods: Ninety-four UNE-suspected patients were admitted to this study. Sensory and motor nerve conduction and F-wave analyses on the median and ulnar nerves were performed on both upper extremities. Results: A total of 188 upper extremities of 94 patients were examined. Their mean age was 41.4±12.9 years, and 69 patients were female (73.4%). The mean ulnar-nerve across-elbow motor conduction velocity (MCV) in the affected arms was significantly slower than the velocity in healthy arms. The mean ulnar-nerve F-min latencies were significantly longer in the affected arms. Fifty-one patients were electrophysiologically diagnosed as presenting UNE (54.2%). Significantly slower mean ulnar-nerve across-elbow MCV, longer mean ulnar-nerve F-min latency and longer distal onset latency were detected in UNE-positive arms. Lastly, patients who were symptomatic but had normal nerve conduction were evaluated separately. Only the mean ulnar F-min latency was significantly longer in this group, compared with the healthy arms. Conclusion: Our study confirmed the utility of F-min latency measurements in the electrodiagnosis of UNE. F-wave latency differences can help in making an early diagnosis to provide better treatment options.

RESUMO Introdução: A neuropatia ulnar do cotovelo (NUC) é a segunda neuropatia por encarceramento mais comum. Existem poucas informações sobre a aplicação dos estudos da onda F para avaliação da NUC. Objetivo: O objetivo deste estudo foi avaliar o valor diagnóstico das alterações mínimas de latência da onda F (F-min), comparando-as com análises de condução nervosa em pacientes com suspeita de NUC. Métodos: Noventa e quatro pacientes com suspeita de NUC foram admitidos neste estudo. A condução nervosa sensitiva e motora e as análises da onda F nos nervos mediano e ulnar foram realizadas em ambas as extremidades superiores. Resultados: Um total de 188 membros superiores de 94 pacientes foi examinado. A média de idade foi 41,4±12,9 anos e 69 pacientes eram do sexo feminino (73,4%). A velocidade de condução motora média do nervo ulnar através do cotovelo (VCM) nos braços afetados foi significativamente mais lenta do que a velocidade em braços saudáveis. As latências médias F-min do nervo ulnar foram significativamente mais longas nos braços afetados. Cinquenta e um pacientes foram diagnosticados eletrofisiologicamente como apresentando NUC (54,2%). Pacientes com presença de NUC tiveram, de forma significativa, detecção de VCM mais lenta no nervo ulnar ao nível do cotovelo, presença de latência mais longa da onda F-mínima no nervo ulnar, bem como latência de início distal mais longa. Por fim, os pacientes sintomáticos, e com condução nervosa normal, foram avaliados separadamente. Apenas a latência da onda F mínima média do nervo ulnar foi significativamente maior neste grupo, em comparação com os braços saudáveis. Conclusão: Nosso estudo confirmou a utilidade das medidas de latência da onda F-mínima no eletrodiagnóstico da NUC. As diferenças de latência da onda F podem ajudar a fazer um diagnóstico precoce para fornecer melhores opções de tratamento.

Electrophysiological evaluation of carpal tunnel syndrome female patients after vitamin D replacement / Avaliação eletrofisiológica de pacientes do sexo feminino com síndrome do túnel do carpo após reposição de vitamina D

Abstract Objective: The effects of vitamin D on the central and peripheral nervous system continue to be investigated today. In the present study, we aimed to evaluate pain and electrophysiologic response in patients with carpal tunnel syndrome (CTS) who have undergone replacement therapy due to vitamin D deficiency. Methods: Fifty female patients diagnosed with mild and moderate CTS and accompanied by vitamin D deficiency were included in this study. Nerve conduction study (NCS) was performed before and after vitamin D replacement, and the patient's pain was evaluated with Visual Analogue Scale (VAS). Results: When NCS were compared before and after treatment, there was a statistically significant improvement in the median distal sensory onset latency (DSOL) and sensory conduction velocity (CV) and motor distal latencies (DML) values (p=0.001; p<0.001; p=0.001, respectively). At the same time, there was a decrease in the VAS values in patients (p<0.001). When the two groups were compared there was an improvement in DSOL and sensory CV in both groups, but in DML only in moderate CTS group. Conclusion: In this study, it was shown that mild and moderate CTS patients had an improvement in pain and electrophysiological parameters after vitamin D replacement. Replacing vitamin D in early stages of CTS may be beneficial.

Resumo Objetivo: Os efeitos da vitamina D no sistema nervoso central e periférico continuam sendo investigados atualmente. Neste estudo, objetivamos avaliar a dor e a resposta eletrofisiológica em pacientes com síndrome do túnel do carpo (STC) submetidos a terapia de reposição devido à deficiência de vitamina D. Métodos: Cinquenta pacientes do sexo feminino diagnosticadas com STC leve e moderada e acompanhadas de deficiência de vitamina D foram incluídas neste estudo. O estudo da condução nervosa (ECN) foi realizado antes e após a reposição da vitamina D, e a dor do paciente foi avaliada com a Escala Visual Analógica (EVA). Resultados: Quando a ECN foi comparada antes e após o tratamento, houve uma melhora estatisticamente significativa na latência mediana do início sensorial distal (DSOL) e nos valores de velocidade de condução sensorial (VC) e latência distal motora (LDM) (p=0,001; p<0,001; p=0,001, respectivamente). Ao mesmo tempo, houve uma diminuição dos valores da EVA nos pacientes (p<0,001). Quando os dois grupos foram comparados, houve uma melhora no DSOL e no VC sensorial em ambos, mas no LDM apenas no grupo STC moderado. Conclusão: Neste estudo, foi demonstrado que pacientes com STC leve e moderada apresentaram melhora da dor e parâmetros eletrofisiológicos após a reposição de vitamina D. A substituição da vitamina D nos estágios iniciais da STC pode ser benéfica.

Sensibilidad y especificidad de tres métodos complementarios para el diagnóstico de síndrome de túnel carpiano / Sensitivity and specificity of three complementary methods in the diagnosis of carpal tunnel syndrome

Resumen: Introducción: Actualmente, no existe un estándar de referencia aceptado universalmente para el diagnóstico del síndrome de túnel carpiano, por lo que se le considera una patología de «clase latente¼, es decir, que carece de alguna prueba diagnóstica que dé certeza absoluta de la presencia de la enfermedad. Métodos: Estudio prospectivo, observacional y analítico en el cual se evaluaron los tres métodos diagnósticos utilizados para el síndrome de túnel carpiano (examen clínico, ecografía y electromiografía). En él, se establecieron valores de normalidad para cada método diagnóstico. Resultados: Se evaluó un total de 50 personas (14 hombres y 36 mujeres). El examen clínico presentó correlación positiva y significativa con el diámetro del nervio mediano afectado (ecografía) (R = 0.694 y p = 0.032). Los valores del área bajo la curva (AUC, por sus siglas en inglés) para la velocidad de conducción del nervio mediano (VCNM), velocidad de conducción de nervio cubital (VCNC) y latencia distal motora (LDM) por electromiografía fueron de 0.60, 0.519 y < 0.50, respectivamente, lo cual determinó que el valor diagnóstico de las características por electromiografía es malo. Conclusión: Nuestro trabajo establece al examen clínico como una herramienta de buena calidad, siendo el método más sensible para el diagnóstico de síndrome de túnel carpiano. Si existiera la necesidad de realizar una confirmación diagnóstica, la ecografía mostró ser un estudio altamente satisfactorio, el cual genera menos estrés, dolor e invasión al paciente, disminuyendo, a su vez, el gasto de salud y agilizando el proceso.

Abstract: Introduction: Currently there is no universally accepted standard of reference for the diagnosis of carpal tunnel syndrome so it is considered a «latent class¼ pathology, that is, it lacks any diagnostic tests that absolutely certain the presence of disease. Methods: Prospective, observational and analytical study evaluating the three diagnostic methods used for carpal tunnel syndrome (clinical examination, ultrasound and electromyography). Normality values were set for each diagnostic method. Results: 50 people (14 men and 36 women) were evaluated. The clinical examination showed a positive and significant correlation with the diameter of the affected median nerve (ecography) (R = 0.694, p = 0.032). The values of the under the curve area (UCA) for median nerve conduction speed (MNCS), cubital nerve conduction speed (CNCS), and distal latency (DL) by electromyography were 0.60, 0.519 and less than 0.50 respectively. This states that the diagnostic value of electromyography characteristics is bad. Conclusion: Our work establishes clinical examination as a good quality tool being the most sensitive method for diagnosing carpal tunnel syndrome. If there was a need for diagnostic confirmation, the ultrasound proved to be a highly satisfactory study generating less stress, pain and invasion to the patient, decreasing health expenditure and speeding up the process.

Dexmedetomidine attenuates P2X4 and NLRP3 expression in the spine of rats with diabetic neuropathic pain

Abstract Purpose: To evaluate the effects of Dexmedetomidine (Dex) on spinal pathology and inflammatory factor in a rat model of Diabetic neuropathic pain (DNP). Methods: The rats were divided into 3 groups (eight in each group): normal group (N group), diabetic neuropathic pain model group (DNP group), and DNP model with dexmedetomidine (Dex group). The rat model of diabetes was established with intraperitoneal streptozotocin (STZ) injections. Nerve cell ultrastructure was evaluated with transmission electron microscopy (TEM). The mechanical withdrawal threshold (MWT) and motor nerve conduction velocity (MNCV) tests documented that DNP rat model was characterized by a decreased pain threshold and nerve conduction velocity. Results: Dex restored the phenotype of neurocytes, reduced the extent of demyelination and improved MWT and MNCV of DNP-treated rats (P=0.01, P=0.038, respectively). The expression of three pain-and inflammation-associated factors (P2X4, NLRP3, and IL-IP) was significantly upregulated at the protein level in DNP rats, and this change was reversed by Dex administration (P=0.0022, P=0.0092, P=0.0028, respectively). Conclusion: The P2X4/NLRP3 signaling pathway is implicated in the development and presence of DNP in vivo, and Dex protects from this disorder.

Riché-Cannieu Anastomosis: Structure, Function, and Clinical Significance / Anastomose de Riché-Cannieu: estrutura, função e significância clínica

Abstract Objective To define the anatomy pattern and the incidence of Riché-Cannieu anastomosis, that is, median and ulnar communication in the palmar aspect of the hand. Materials Methods A total of 80 anatomical dissections were performed on 60 hands of 30 cadavers from 1979 to 1982, and on 20 hands from 2012 to 2015. All of these procedures were performed at the Department of Anatomy of our institution. The incidence of Riché-Cannieu anastomosis and the innervation of the thenar muscles were studied. Results Riché-Cannieu anastomosis was identified in every dissected hand (100%). The extramuscular Riché-Cannieu anastomosis was recorded in 57 hands, and the intramuscular, in 19 hands. The association of extra- and intramuscular Riché-Cannieu anastomoses occurred in four hands. The ulnar component always originated from the deep branch. The anastomotic branch arising from the median nerve originated from the motor thenar branch (recurrent branch) of the median nerve in most of the observations. The median-ulnar double innervation only to the deep head of the flexor pollicis brevis was identified in 29 of 80 hands. The double innervation only of the superficial head of the flexor pollicis brevis was found in 13 hands. In 12 hands, the deep head of the flexor pollicis brevis was absent. The double innervation of the superficial and deep heads of the flexor pollicis brevis occurred in 14 hands. The oblique head of the adductor pollicis received double innervation in 12 hands. The deep head of the flexor pollicis brevis and the oblique head of adductor pollicis were doubly-innervated in nine hands. The transverse head of the adductor pollicis received double innervation in two hands. Double innervation of the deep head of the flexor pollicis brevis and the transverse head of the adductor pollicis were found in one hand. Conclusion According to the present study, Riché-Cannieu anastomosis should be considered a normal anatomical neural connection, not an anatomical variation. Knowledge of this anastomosis is essential because the presence of such neural communication may result in confusing clinical, surgical, and electromyographic findings in cases of median or ulnar damage or entrapment.

Resumo Objetivo Definir a anatomia e a incidência da anastomose de Riché-Cannieu, ou seja, a comunicação entre os nervos medianos e ulnar na palma da mão. Materiais e Métodos Foram dissecadas 60 mãos de 30 cadáveres frescos de adultos, entre 1979 a 1982, e 20 mãos entre 2011 e 2015, num total de 80 mãos, no Departamento de Anatomia da nossa instituição. A incidência da anastomose de Riché-Cannieu e a inervação dos músculos da região do tênar foram estudadas. Resultados A anastomose de Riché-Cannieu foi identificada em todas as mãos dissecadas (100%). A anastomose de Riché-Cannieu extramuscular foi registrada em 57 mãos, e a intramuscular, em 19, e a associação das anastomoses extra e intramuscular, em 4 mãos. O componente ulnar da anastomose de Riché-Cannieu foi sempre do seu ramo profundo. O ramo anastomótico oriundo do nervo originava-se do ramo recorrente do nervo mediano na maioria das observações. A dupla inervação mediano-ulnar apenas da cabeça profunda do músculo flexor curto do polegar foi identificada em 29 de 80 mãos. Observou-se dupla inervação apenas da cabeça superficial do músculo flexor curto do polegar em 13 mãos. Foi observada dupla inervação das cabeças superficial e profunda do flexor curto do polegar em 14 mãos. A cabeça oblíqua do adutor do polegar recebeu inervação dupla em 12 mãos. A cabeça profunda do músculo flexor curto do polegar e a cabeça oblíqua do adutor do polegar foram inervadas duplamente em nove mãos. A cabeça transversa do adutor do polegar recebeu inervação dupla em duas mãos. A inervação dupla da cabeça profunda do flexor curto do polegar e da cabeça transversa do adutor do polegar foi observada em uma mão. Conclusão De acordo com o presente estudo, a anastomose de Riché-Cannieu deve ser considerada uma conexão nervosa normal, e não uma variação anatômica. O conhecimento dessa anastomose é essencial, pois a presença dessa comunicação neural pode resultar em achados clínicos, cirúrgicos e eletromiográficos confusos em casos de lesões ou síndromes compressivas dos nervos mediano ou ulnar.

Potencial de ação duplo e alterações ecográficas do nervo mediano em doentes com síndrome do túnel cárpico / Double peak action potential and ultrasonography nerve evaluation in patients with carpal tunnel syndrome

Introdução: A síndrome do túnel cárpico (STC) é sustentada pela presença de lentificação do potencial de ação do nervo mediano no estudo ortodrómico de condução nervosa sensitiva em comparação com o nervo radial (EC-MR). Uma técnica modificada de registo simultâneo de ambos os nervos (EC-MRsimul) pode ser utilizada, detetando a lentificação do nervo mediano através da presença de potencial de ação sensitivo duplo (PAS-D). O objetivo deste estudo é correlacionar o PAS-D com os achados de EC-MR e com o edema perineural em doentes com diagnóstico de STC. Métodos: Indivíduos saudáveis e doentes com STC há menos de 12 meses foram submetidos a avaliação eletrofisiológica, incluindo o EC-MR e o EC-MRsimul. Foi também realizada ultrassonografia para registo da área seccional do nervo mediano (AS-NM) no punho e antebraço e, respetivo índice punho-antebraço (I-PA). Resultados: Foram recrutados 38 doentes com idade média de 54,8 ± 15,3 anos com STC e 18 indivíduos saudáveis. A diferença de latência distal entre o nervo mediano e radial foi superior nos doentes (0,80 ± 0,30ms vs. 0,15 ± 0,20ms; p=0,015). O EC­MRsimul demonstrou a presença de PAS-D nos indivíduos sintomáticos. A AS­NM no punho foi também superior nos doentes (8,9 ± 0,9mm2 vs. 6,6 ± 0,7mm2; p<0.003), tendo sido identificado um quisto sinovial e um neurinoma. O edema perineural traduzido pela AS-SM correlacionou-se positivamente com a diferença de latência interpico no EC-MR e com a presença de PAS-D. Conclusão: O PAS-D está associado à presença de lentificação da condução e ao edema perineural do nervo mediano no contexto de STC ou devido a lesões ocupantes de espaço. (AU)

Introduction: Carpal tunnel syndrome (CTS) is characterized by median nerve action potential slowing, which can be shown in comparative orthodromic sensory nerve conduction studies between median and radial nerve (NCS-MR). A modified technique with simultaneous recording of both nerves (NCS-MRsimul) can also be used to detect median nerve slowing through the presence of double peak action potential (DPp). The study aims to correlate the presence of DPp with NCS-MR findings and with perineural edema in patients diagnosed with STC. Methods: Healthy individuals and patients with CTS for less than 12 months underwent NCS-MR and MRsimul. An ultrasonography evaluation was also performed to record the medial nerve sectional area (SA-MN) on the wrist and forearm, and the wrist-to-forearm ratio (WFR) was calculated. Results: We recruited 38 patients with CTS whose mean age was 54.8 ± 15.3 years and 18 healthy individuals. Distal latency difference between the median and radial nerves was higher in patients with CTS (0.80 ± 0.30 ms vs. 0.15 ± 0.20 ms, p = 0.015). NCS-MRsimul showed DPp in symptomatic individuals. SA-MN in the wrist was also higher in patients with CTS (8.9 ± 0.9 mm2 vs. 6.6 ± 0.7 mm2 , p <0.003). Ultrasonography evaluation identified a synovial cyst and a neurinoma. Perineural edema traduced by higher SA-MN and WFR correlated positively with interpeak latency difference in NCS-MR and with the presence of DPp. Conclusions: DPp was associated with median nerve sensory action potential slowing and with perineural edema due to either CTS or to space-occupying lesions. (AU)

Does the type of electrode affect the electromyoneurographic parameters in rats?

Abstract Purpose: To evaluate if the type of electrode (needle vs. surface) affects the electromyoneurography parameters in rats. Methods: Twenty male rats were anesthetized, then compound muscle action potential were recorded using a Neuropack S1 MEB- 9400©. All animals were submitted to two electroneuromyography analysis: first with surface electrode and then by needle electrode. We evaluated the latency, amplitude, duration and area of the negative peak of the gastrocnemius and cranial tibial muscles. Results: There were no significant differences between the groups in the mean of duration, latency, amplitude or area of the negative peak in gastrocnemius and cranial tibial muscles. Conclusion: The type of electrode does not affect the electroneuromyography parameters.

Is phrenic nerve conduction affected in patients with difficult-to-treat asthma? / A neurocondução do nervo frênico está alterada na asma de difícil controle?

ABSTRACT Objective The aim of this study was to obtain data on phrenic neuroconduction and electromyography of the diaphragm muscle in difficult-to-treat asthmatic patients and compare the results to those obtained in controls. Methods The study consisted of 20 difficult-to-treat asthmatic patients compared with 27 controls. Spirometry, maximal inspiratory and expiratory pressure, chest X-ray, phrenic neuroconduction and diaphragm electromyography data were obtained. Results The phrenic compound motor action potential area was reduced, compared with controls, and all the patients had normal diaphragm electromyography. Conclusion It is possible that a reduced phrenic compound motor action potential area, without electromyography abnormalities, could be related to diaphragm muscle fiber abnormalities due to overload activity.

RESUMO Objetivo O objetivo do presente estudo foi obter dados da neurocondução do frênico e exame com agulha do diafragma em pacientes com asma de difícil controlee comparar com um grupo normal. Métodos O estudo consiste em realizar radiografia de tórax, espirometria, pressão máxima inspiratória e expiratória, neurocondução do nervo frênico e eletromiografia do músculo diafragma em 20 pacientes asmáticos de difícil controle e comparar com 27 controles. Resultados Encontramos redução da área do potencial de ação muscular composto do nervo frênico e a eletromiografia do musculo diafragma estava normal em todos os pacientes. Conclusão É possível que a redução da área do potencial de ação muscular composto do nervo frênico nos pacientes com asma de difícil controle associado a eletromiografia normal do músculo diafragma esteja relacionada as alterações da fibra muscular do mesmo devido à sobrecarga de atividade.

A correlation between clinical severity and functional state with nerve conduction studies findings in patients with carpal tunnel syndrome: a systematic review / Correlação entre gravidade clínica e estado funcional com achados eletroneuromiograficos, em pacientes com síndrome do túnel do carpo: uma revisão sistemática

Carpal Tunnel Syndrome is the most common compressive neuropathy in the general population, and it may lead to disabling symptoms and significant functional limitation. This systematic review covered Pubmed, Medline, Embase, Cochrane, CINAHL, LILACS, and SCIELO databases, with no time or language delimitations. The PICO strategy defined the search strategy with keywords extracted from the Medical Subjects Headings, and the quality of the studies was evaluated by the Agency for Healthcare Research and Quality (AHRQ) scale. Overall, 857 studies were identified, of which only 10 fulfilled the inclusion criteria. Despite the good results shown, a noticeable heterogeneity was observed among the studies included, associated with methodological discrepancy and to limited sample size in a few of them. Four studies showed no correlation between electrophysiological findings and clinical symptoms and signs, whereas three could demonstrate such association and other three studies had equivocal results. Other studies are necessary, with better methodological standards and more homogeneous and precise evaluations, so as to improve the level of scientific evidence

A síndrome do Túnel do Carpo é a neuropatia compressiva mais frequente na população geral que pode levar a sintomas incapacitantes e significativa limitação funcional. Uma revisão sistemática foi realizada nas bases de dados Pubmed, Medline, Embase, Cochrane, CINAHL, LILACS e SCIELO, sem delimitação de tempo ou idioma. Utilizou-se da estratégia PICO para a pesquisa, palavras-chave extraídas dos Descritores de Ciências da Saúde (Decs) e a qualidade dos estudos foi avaliada através da escala Agency for Healthcare Research and Quality (AHRQ). Identificaram-se 857 estudos dos quais, somente 10 obedeceram aos critérios de inclusão. Apesar dos bons resultados apresentados, verificou-se uma expressiva heterogeneidade existente entre os estudos incluídos, associado à discrepância metodológica, e um limitado tamanho amostral em alguns deles. São necessários estudos com melhor padrão metodológico, bem como avaliações mais homogêneas e precisas, a fim de melhorar o nível de evidência científica

Phrenic nerve conduction studies: normative data and technical aspects / Aspectos técnicos e normatização da neurocondução do nervo frênico

ABSTRACT Objective: The aim of the present study was to define normative data of phrenic nerve conduction parameters of a healthy population. Methods: Phrenic nerve conduction studies were performed in 27 healthy volunteers. Results: The normative limits for expiratory phrenic nerve compound muscle action potential were: amplitude (0.47 mv - 0.83 mv), latency (5.74 ms - 7.10 ms), area (6.20 ms/mv - 7.20 ms/mv) and duration (18.30 ms - 20.96 ms). Inspiratory normative limits were: amplitude (0.67 mv - 1.11 mv), latency (5.90 ms - 6.34 ms), area (5.62 ms/mv - 6.72 ms/mv) and duration (13.77 ms - 15.37 ms). Conclusion: The best point of phrenic nerve stimulus in the neck varies among individuals between the medial and lateral border of the clavicular head of the sternocleidomastoid muscle and stimulation of both sites, then choosing the best phrenic nerve response, seems to be the appropriate procedure.

RESUMO Objetivo: O objetivo do presente estudo foi definir os dados normativos de condução do nervo frênico de uma população saudável. Métodos: Foram realizados estudos de condução do nervo frênico em 27 voluntários saudáveis. Resultados: Os limites normais do potencial de ação muscular composto do nervo frênico durante a expiração foram: amplitude (0.47 mv - 0.83 mv), latência (5.74 ms - 7.10 ms), área (6.20 ms/mv - 7.20 ms/mv) e duração (18.30 ms - 20.96 ms). E durante a inspiração os limites normais foram: amplitude (0.67 mv - 1.11 mv), latência (5.90 ms - 6.34 ms), área (5.62 ms/mv - 6.72 ms/mv) e duração (13.77 ms - 15.37 ms). Conclusão: O melhor ponto de estímulo do nervo frênico no pescoço varia entre a borda medial e lateral da cabeça clavicular do músculo esternocleidomastóideo. Estimular ambos os locais e escolher a melhor resposta do nervo frênico parece ser o procedimento mais adequado.

Descripción electrofisiològica del síndrome de túnel carpiano según edad en pacientes adultos / Electrophysiological severity of carpal tunnel syndrome according to age in adult patients

Background: Carpal tunnel syndrome (CTS) represents 90% of entrapment neuropathies. Severity may be greater in older patients. Aim: To describe the electrophysiological findings in adult patients with CTS and determine if severity is related to age. Material and Methods: Descriptive and retrospective study of electrophysiological findings in patients over 18 years of age with clinical suspicion of CTS, studied between January 2011 and December 2015. Neurophysiological severity was classified in 3 grades, comparing them by age, gender and laterality. Results: Of 1156 patients subjected to electrophysiological studies due to a clinical suspicion of CTS, 690 (60%) had electrophysiological features of the disease. In 274 patients (24%) the compromise was mild, in 162 (14%) it was moderate and in 254 (22%) it was severe. There was a positive association between age and CTS severity (p < 0.01). Severity was significantly greater in males than females (p < 0.01). Bilateral CTS was present in 471 patients (68%), which was associated with increased age and severity (p < 0.01). Conclusions: Electrophysiological severity in CTS increases with age. Other factors associated with higher severity are male gender and bilateral disease.

Effects of Lippia sidoides essential oil, thymol, p-cymene, myrcene and caryophyllene on rat sciatic nerve excitability

Lippia sidoides Cham is a typical herb species of Northeast Brazil with widespread use in folk medicine. The major constituents of the essential oil of L. sidoides (EOLs) are thymol, p-cymene, myrcene, and caryophyllene. Several studies have shown that the EOLs and its constituents have pharmacological effects, including antibacterial, anti-inflammatory, antioxidant and neuroprotective activity. Therefore, this work aimed to investigate the effects of the EOLs and their main constituents on rat sciatic nerve excitability. The sciatic nerves of adult Wistar rats were dissected and mounted in a moist chamber. Nerves were stimulated by square wave pulses, with an amplitude of 40 V, duration of 100 μs to 0.2 Hz. Both EOLs and thymol inhibited compound action potential (CAP) in a concentration-dependent manner. Half maximal inhibitory concentration for CAP peak-to-peak amplitude blockade were 67.85 and 40 µg/mL for EOLs and thymol, respectively. CAP peak-to-peak amplitude was significantly reduced by concentrations ≥60 µg/mL for EOLs and ≥30 µg/mL for thymol. EOLs and thymol in the concentration of 60 µg/mL significantly increased chronaxie and rheobase. The conduction velocities of 1st and 2nd CAP components were also concentration-dependently reduced by EOLs and thymol in the range of 30-100 µg/mL. Differently from EOLs and thymol, p-cymene, myrcene and caryophyllene did not reduce CAP in the higher concentrations of 10 mM. These data demonstrated that EOLs and thymol inhibited neuronal excitability and were promising agents for the development of new drugs for therapeutic use.

Efecto inmediato de la crioterapia sobre la excitabilidad refleja en personas con espasticidad post-ECV / Immediate effect of cryotherapy on the spastic reflex excitability in people with spasticity post-stroke

Introducción: Existe controversia sobre los efectos terapéuticos de la crioterapia en el músculo espástico y las implicaciones clínicas que fundamentan su uso como coadyuvante en el proceso de rehabilitación. Objetivo: Evaluar el efecto inmediato de la aplicación del paquete de hielo sobre la excitabilidad refleja en la musculatura plantiflexora espástica en personas post-ECV. Métodolos: Estudio experimental de mediciones repetidas con asignación aleatoria a dos grupos de intervención: Grupo Experimental (n=10) y Grupo Control (n=5). Se registró latencia (ms), duración (ms) y amplitud (mV) de las ondas M y H y el índice de amplitud Hmáximo/Mmáximo (%) antes y después de la crioterapia o reposo. Los participantes fueron quince individuos de ambos géneros con hemiparesia espástica post-ECV, edad media de 60,7±10,7años, mediana tiempo de evolución 36 meses (RIC17-49). No hubo diferencias significativas en las características basales entre los grupos de intervención. Resultados: La crioterapia induce un aumento estadísticamente significativo en la latencia de la onda H (32,9±3,3 vs. 34,9±3,6ms, p<0,001) y M (8,0±1,9 vs. 9,4±2,4ms, p<0,05) y en la duración de la onda M (6,3±1,3 vs. 9,8±2,2ms, p<0,001) y H (7,2±1,6 vs. 9,9± 2,0ms, p<0,001). No se determinaron cambios significativos en la amplitud, ni en el índice Hmáx/Mmáx. Conclusiones: Nuestros hallazgos sugieren que el enfriamiento puede ser útil para el tratamiento de la espasticidad, pues retrasa la respuesta muscular evocada por estimulación eléctrica directa y refleja. A su vez, prolonga el período refractario del potencial de acción, por lo cual se requeriría más tiempo para activar las fibras musculares.

Introduction: There is controversy about the therapeutic effects of cryotherapy on spasticity and clinical implications underlying its use as an adjunct in the rehabilitation process. Objective: To evaluate the immediate effect of the application of ice pack on the H-reflex excitability in spastic muscles post-stroke people. Methods: A randomized experimental study of repeated measurements, with two intervention groups, was performed: Experimental group (n=10) and control group (n=5). Latency (ms) duration (ms) and amplitude (mV) of M and H waves and the amplitude index Hmáximo / Mmáximo (%) were recorded before and after cryotherapy or rest. The participants were fifteen subjects with spastic hemiparesis post-stroke were screened, mean age 60.7±10.7 years, median of injury duration 36 months (IQR17-49). There were no significant differences in baseline characteristics between the intervention groups. Results: Cryotherapy induces a statistically significant increase in the H wave latency (32.9±3.3 vs. 34.9± 3.6ms, p<0,001) and M wave (8.0±1.9 vs. 2.4ms±9.4, p<0.05); as well as, increase was observed in the duration of the M wave (6.3±1.3 vs. 9.8±2.2ms, p<0.001) and H (7.2±1.6 vs. 9.9±2.0ms, p<0.001). No significant changes in the amplitude or the Hmax/Mmax ratio were determined. There were no differences between the H-reflex or the M-wave variables recorded before and after in the control group. Conclusions: Our findings suggest that cooling may be useful for the treatment of spasticity, due to it delays muscle response evoked by direct and reflects electrical stimulation. Simultaneously, cooling prolongs the refractory period of the action potential, whereby more time is required to activate the muscle fibers.

Alteración de las fibras finas A-delta por entrampamiento del nervio mediano en la muñeca utilizando el período silente cutáneo / The impairment of A-delta fibers in median nerve compression at the wrist, using the cutaneous silent period

El síndrome del túnel carpiano (STC) es una neuropatía por entrampamiento a nivel de la muñeca que cursa con dolor, parestesias y disestesias dolorosas. El diagnóstico electrofisiológico se basa en el estudio de la neuroconducción de las fibras gruesas. Nuestra hipótesis consiste en la existencia del compromiso de las fibras nerviosas finas y que este compromiso se correlaciona con el grado de gravedad. Se evaluaron retrospectivamente 69 manos correspondientes a 47 pacientes, varones y mujeres (edad media 53.8, rango 22-87 años) y como grupo contro, 21 manos correspondientes a los lados asintomáticos de estos casos. Se realizaron estudios de neuroconducción motora, sensitiva y ondas F para clasificar a las manos según el grado de gravedad. Se realizó el período silente cutáneo (PSC) en todas las manos. Se evaluaron latencias medias y duraciones medias del PSC. Las latencias medias se hallaron significativamente prolongadas en las manos con neuropatía (84.3 ± 16.3 mseg) con respecto a las manos sin neuropatía (74.8 ± 11.6 mseg), p < 0.05. Las latencias medias se hallaron más prolongadas en las manos con neuropatía de mayor gravedad (p < 0.05). En los 3 pacientes con neuropatía grado más grave no se halló el PSC. Se demostró el compromiso de las fibras finas A-delta en los pacientes con STC, con mayor compromiso a mayor severidad. El PSC puede usarse como complemento de los estudios de neuroconducción motora y sensitiva.

Carpal tunnel síndrome (CTS) is an entrapment neuropathy of the median nerve at the wrist, that leads to pain, paresthesia and painful dysesthesia. The electrophysiological diagnosis is based upon nerve conduction studies which evaluate thick nerve fibers. Our hypothesis is that there is an additional dysfunction of small fibers in CTS, which correlates with the degree of severity of the neuropathy. A retrospective study of 69 hands that belonged to 47 patients of both sexes (mean age 53.8, years, range 22-87) was performed, and, as a control group, 21 hands which corresponded to the asymptomatic side of those patients were evaluated. Motor and sensory conduction studies, as well as F-waves were performed to classify the neuropathy according to the degree of severity. Cutaneous silent period (CSP) was elicited in all hands. Mean onset latencies and durations of CSP were evaluated. Mean onset latencies were significantly prolonged in neuropathic hands (84.3 ± 16.3 msec) compared to asymptomatic hands (74.8 ± 11.6 msec) (p < 0.05). Mean latencies of the CSP were even prolonged (p < 0.05) in hands affected by a more severe neuropathy. In the 3 hands with most severe neuropathy, a CSP could not be elicited. In CTS an impairment of A-delta fibers was recorded through the CSP. The more severe the neuropathy is, the more impairment of A-delta fibers can be found. CSP may be assessed as a complement of motor and sensory nerve conduction studies in this neuropathy.

Sensory disturbance and polyneuropathy in rheumatoid arthritis patients with foot deformity / Perturbações sensitivas e polineuropatia em pacientes com artrite reumatoide com deformidade do pé

Abstract Introduction Our aim in this study was to present the results of sensory evaluation tests and electrophysiological evaluations in rheumatoid arthritis (RA) patients with foot deformity and to determine their relation with general health status and lower extremity functionality. Materials and methods Fifty-one patients with RA diagnosis and foot deformity were included in the study. Demographic and disease characteristics of the patients were recorded, and a detailed neurological examination was performed. Superficial sensation, pain, heat, vibration, and two-point discrimination sensation were evaluated in each foot, and their sum was used to determine the sensory deficits index (SDI) of 0–10. The presence of polyneuropathy was evaluated with electrophysiological methods. The Health Assessment Questionnaire and mobility and walking subscales of the Arthritis Impact Measurement Scales-2 were used to assess general health status and lower extremity functionality, respectively. According to the sensory examination and electromyography results, patients were compared in terms of their general health status and lower extremity functional status. Results Sensory disturbance was detected in 39 patients (74%) during the examination; however, 27 patients (52.9%) had polyneuropathy determined electrophysiologically. In patients with sensory deficits, statistically significant deterioration was detected in general health and foot functionality, including mobility and walking, when compared to patients with a normal sensory evaluation. Conclusions Even in the presence of normal electrophysiological tests, sensory dysfunction alone seems to be associated with severe disability in general health status and foot functionality when compared to patients with a normal sensory examination.

Resumo Introdução O objetivo deste estudo foi apresentar os resultados dos testes de avaliação sensitiva e do exame eletrofisiológico em pacientes com artrite reumatoide (AR) com deformidade do pé e determinar a sua relação com o estado geral de saúde e o aspecto funcional dos membros inferiores. Materiais e métodos Foram incluídos no estudo 51 pacientes com diagnóstico de AR e deformidade do pé. Foram registradas as características demográficas e da doença de cada indivíduo e foi feito um exame neurológico detalhado. Foi avaliada a sensibilidade superficial, dolorosa, térmica e vibratória e aplicado o teste de discriminação de dois pontos em cada um dos pés. A soma dos escores foi usada para determinar o índice de déficits sensitivos (IDS) de 0‐10. A presença de polineuropatia foi avaliada com métodos eletrofisiológicos. Foram usados o Health Assessment Questionnaire e as subescalas mobilidade e deambulação da Arthritis Impact Measurement Scales‐2 para avaliar o estado geral de saúde e o aspecto funcional de membros inferiores, respectivamente. De acordo com os resultados dos exames de eletromiografia e de sensibilidade, os pacientes foram comparados em relação ao seu estado geral de saúde e estado funcional de membros inferiores. Resultados Foram detectados distúrbios sensitivos em 39 pacientes (74%) durante o exame; contudo, 27 (52,9%) tinham polineuropatia determinada eletrofisiologicamente. Em pacientes com déficits sensitivos, foi detectada deterioração estatisticamente significativa no estado geral de saúde e no aspecto funcional do pé, inclusive na mobilidade e deambulação, quando comparados com os pacientes com uma avaliação sensitiva normal. Conclusão Mesmo na presença de testes eletrofisiológicos normais, a disfunção sensitiva isolada parece estar associada a incapacidade grave no estado geral de saúde e ao aspecto funcional do pé em comparação com pacientes com um exame sensitivo normal.

Clinical and neurophysiological features of the hereditary neuropathy with liability to pressure palsy due to the 17p11. 2 deletion / Aspectos clínicos e neurofisiológicos de pacientes com a neuropatia hereditária com a susceptibilidade à pressão associada à deleção 17p11. 2

ABSTRACT The hereditary neuropathy with liability to pressure palsies (HNPP) is an autossomal dominant disorder manifesting recurrent mononeuropathies. Objective Evaluate its clinical and nerve conduction studies (NCS) characteristics, searching for diagnostic particularities. Method We reviewed the neurological manifestations of 39 and the NCS of 33 patients. Results Family history was absent in 16/39 (41%). The onset complaints were weakness in 24, pain in 6, sensory deficit in 5 and paresthesias in 4. Pain was seen in 3 other patients. The following neuropathy patterns were found: multiple mononeuropathy (26), mononeuropathy (7), chronic sensorimotor polyneuropathy (4), chronic sensory polyneuropathy (1) and unilateral brachial plexopathy (1). NCS showed a sensorimotor neuropathy with focal conduction slowing in 31, two had mononeuropathy and another brachial plexopathy. Conclusion HNPP presentation is variable and may include pain. The most frequent pattern is of an asymmetrical sensory and motor neuropathy with focal slowing at specific topographies on NCS.

RESUMO A neuropatia hereditária com susceptibilidade à pressão (HNPP) é uma doença autossômica dominante que manifesta mononeuropatias recorrentes. Objetivo Avaliar as características clínicas e os estudos da condução nervosa (ECN) procurando particularidades diagnósticas. Método Revisamos as características clínicas de 39 e os ECN de 33 pacientes. Resultados História familiar ausente em 16/39 (41%). As manifestações iniciais foram: fraqueza em 24, dor em 6, déficit sensitivo em 5 e parestesias em 4. Dor foi referida por outros 3 pacientes. Os seguintes padrões de neuropatia foram observados: mononeuropatia múltipla (26), mononeuropatia (6), polineuropatia sensitivo-motora (4), polineuropatia sensitiva (1) e plexopatia braquial unilateral (1). Os ECN mostraram uma neuropatia sensitivo-motora com redução focal da velocidade de condução em 31, dois tinham mononeuropatia e outro plexopatia braquial. Conclusão A apresentação da HNPP é variável e pode incluir dor. O padrão mais frequente é o de uma neuropatia sensitivo-motora assimétrica com alentecimentos focais da condução em topografias específicas nos ECN.

Síndrome de Davidenkow: Una neuropatía periférica rara / Davidenkow syndrome. A rare peripheral neuropathy

En 1939 Davidenkow describió un tipo de atrofia diferente y rara con un patrón predominante en distribución escápulo-peroneal. Algunos investigadores caracterizaron el síndrome como una variante de la enfermedad de Charcot-Marie-Tooth; sin embargo, Davidenkow percibió que las manifestaciones clínicas y de laboratorio no corroboraban exactamente esta hipótesis. Describimos el caso de una mujer de 39 años, con cuadro clínico semejante al síndrome descrito por Davidenkow, presentando atrofia escápulo-peroneal. Sus primeros síntomas comenzaron cuando tenía 24 años, inicialmente con debilidad motora proximal en los miembros superiores. No tenía historia familiar de miopatía o neuropatía y se excluyeron otros síndromes que se podrían incluir entre los diagnósticos diferenciales mediante la realización de pruebas de mutación genética, además del examen físico y electromiografía. El amplio espectro de enfermedades neuromusculares a veces dificulta su diagnóstico y debe ser siempre considerado en el diagnóstico diferencial.

A different and rare type of atrophy with a predominant pattern in scapulo-peroneal distribution was described by Davidenkow in 1939. The syndrome was characterized by some researchers as a variant of Charcot-Marie-Tooth disease, however Davidenkow noticed that clinical and laboratorial manifestations did not corroborate exactly with this hypothesis. We describe a case of a female patient, 39 years-old, clinical picture similar to the syndrome described by Davidenkow, presenting scapulo-peroneal atrophy. Her first symptoms had appeared when she was 24, initially with proximal motor weakness in the upper limbs. This patient did not have family history of myopathy or neuropathy. Several tests were performed to exclude other syndromes that could be included in the differential diagnosis, by testing gene mutation, in addition to the physical examination and electromyography. The large spectrum of neuromuscular diseases makes difficult the diagnosis of Davidenkow’s syndrome which always should be considered in the differential diagnosis.

Evidencia de la aplicabilidad de la neuromonitorización intermitente en cirugía de tiroides / Evidence of the applicability of intermittent neuromonitoring in thyroid surgery

La tiroidectomía es la cirugía cervical más frecuente, con poca frecuencia de complicaciones. La frecuencia de lesión definitiva del nervio laríngeo recurrente es menor de 1 %, la de hipoparatiroidismo definitivo es de 1 a 2 % y la de hematoma cervical es de 0,5 %. La frecuencia de la lesión bilateral del nervio laríngeo recurrente que obliga a una traqueostomía, es inferior al 0,2 %. Desde hace más de una década aparecieron reportes del uso de la neuromonitorización intermitente, como una estrategia para disminuir aún más el riesgo de lesión del nervio laríngeo recurrente y del laríngeo superior. El objetivo de esta revisión es exponer la información disponible en pro o en contra del uso rutinario de la neuromonitorización intermitente en la cirugía de tiroides. En cinco de las seis revisiones sistemáticas, llegan a la conclusión de que no existen datos que demuestren que las lesiones definitivas del nervio laríngeo recurrente o el laríngeo superior, disminuyan con el uso rutinario de la neuromonitorización. La mayoría de los autores sugieren que los pacientes de alto riesgo de lesión del nervio serían los más beneficiados, pero la definición de alto riesgo es bastante heterogénea e indefinida. El uso del monitor ayuda poco en la toma de decisiones, específicamente cuando se pierde la señal, que es el objetivo con el cual se usa. Tampoco existen datos que demuestren que el uso del neuromonitor disminuya las demandas médico-legales.

Thyroidectomy is the most frequent surgical procedure performed on the neck and is associated with a low number of complications. The rate of definitive injury of the recurrent laryngeal nerve is lower than 1%, of definitive hypoparathyroidism is around 1-2%, and of neck hematoma is lower than 0.5%. The incidence of bilateral recurrent laryngeal nerve injury needing tracheostomy is lower than 0.2%. For more than a decade there have appeared reports suggesting that intermittent neuromonitoring is a strategy to decrease even more the risk of laryngeal nerve injuries. This review discusses the available evidence about the effectiveness of intermittent neuromonitoring in thyroidectomy. Five of six systematic reviews concluded that there is no evidence of a statistically significant decrease in the rate of laryngeal nerves injuries with the routine use of neuromonitoring. Most authors agree that the device will be useful in high risk patients, but definition of high risk is heterogeneous and unclear. Routine use of monitoring offers a minor advantage in decision making during surgery, especially when a loss of signal occurs. Besides, there is no evidence that neuromonitoring decreases the number of medico legal issues.