Neurophysiological Findings in Critical COVID-19 Patients With Peripheral Nervous System Manifestations.

INTRODUCTION: Coronavirus disease 2019 patients hospitalized in intensive care units develop neuromuscular manifestations. However, to our knowledge, a study describing the neurophysiological findings in these patients has not been reported. The objective of this study was to diagnose the cause of neuromuscular deficit in severe coronavirus disease 2019 patients, through neurophysiological examination. METHODS: This is a retrospective, observational case series. Data were collected from April 13, 2020, to May 31, 2020. Twenty-two coronavirus disease 2019 patients with generalized neuromuscular deficit during intensive care unit hospitalization were studied. Neurophysiological examinations included motor and sensory peripheral nerve conductions, needle electromyography, F waves, and repetitive nerve stimulation. RESULTS: The subjects were 14 men (63.6%) and eight women, ranged from 35 to 74 years old (58.0, interquartile ranges 50.7-66.2). Intensive care unit hospitalization time ranged from 14 to 82 days (median 37.5, interquartile ranges 22.7-55.0). Through neurophysiological examination, myopathy was diagnosed in 17 patients (77.3%) and polyneuropathy in four (18.2%). Focal neuropathies were diagnosed in 12 patients (54.6%), with a total of 19 affected nerves. Common peroneal nerve lesions at the fibular head (68.4%) and ulnar nerve lesions at the elbow level (21.1%) were the most frequent locations. No significant differences were established between neurophysiological findings and clinical or analytical data. CONCLUSIONS: In critical coronavirus disease 2019 patients with neuromuscular complaints, neurophysiological examination provides an accurate diagnosis-useful to select treatment measures and establish the prognosis of recovery. Neurophysiological findings are similar to those described for critical illness neuromuscular disease, with myopathy being the most frequent diagnosis.

Prediction of Outcome in Women With Carpal Tunnel Syndrome Who Receive Manual Physical Therapy Interventions: A Validation Study.

Study Design Secondary analysis of a randomized trial. Background A clinical prediction rule to identify patients with carpal tunnel syndrome (CTS) most likely to respond to manual physical therapy has been published but requires further testing to determine its validity. Objective To assess the validity of a clinical prediction rule proposed for the management of patients with CTS in a different group of patients with a variety of treating clinicians. Methods A preplanned secondary analysis of a randomized controlled trial investigating the efficacy of manual physical therapies, including desensitization maneuvers of the central nervous system, in 120 women suffering from CTS was performed. Patients were randomized to receive 3 sessions of manual physical therapy (n = 60) or surgical release/decompression of the carpal tunnel (n = 60). Self-perceived improvement with a global rating of change was recorded at 6- and 12-month follow-ups. Pain intensity (mean pain and worst pain on a 0-to-10 numeric pain-rating scale) and scores on the Boston Carpal Tunnel Questionnaire (functional status and symptom severity subscales) were assessed at baseline and at 1, 3, 6, and 12 months. A baseline assessment of status on the clinical prediction rule was performed (positive status on the clinical prediction rule was defined as meeting at least 2 of the following criteria: pressure pain threshold of less than 137 kPa over the affected C5-6 joint; heat pain threshold of less than 39.6°C over the affected carpal tunnel; and general health score [Medical Outcomes Study 36-Item Short-Form Health Survey] of greater than 66 points). Linear mixed models with repeated measures were used to examine the validity of the rule. Results Participants with a positive status on the rule who received manual physical therapy did not experience greater improvements compared to those with a negative status on the rule for mean pain (P = .65), worst pain (P = .86), function (P = .99), or symptom severity (P = .85). Further, the clinical prediction rule performed no better than chance in identifying the individuals with CTS most likely to respond to manual physical therapy or surgery (mean pain, P = .87; worst pain, P = .91; function, P = .60; severity, P = .66). No differences in self-perceived improvement were observed at either 6 (P = .68) or 12 (P = .36) months, according to the rule. Conclusion The results of this study did not support the validity of the previously developed clinical prediction rule for manual physical therapy in women with CTS. Level of Evidence Prognosis, level 1b. J Orthop Sports Phys Ther 2016;46(6):443-451. Epub 23 Mar 2016. doi:10.2519/jospt.2016.6348.

Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial.

UNLABELLED: This randomized clinical trial investigated the effectiveness of surgery compared with physical therapy consisting of manual therapies including desensitization maneuvers in carpal tunnel syndrome (CTS). The setting was a public hospital and 2 physical therapy practices in Madrid, Spain. One hundred twenty women with CTS were enrolled between February 2013 and January 2014, with 1-year follow-up completed in January 2015. Interventions consisted of 3 sessions of manual therapies including desensitization maneuvers of the central nervous system (physical therapy group, n = 60) or decompression/release of the carpal tunnel (surgical group, n = 60). The primary outcome was pain intensity (mean pain and the worst pain), and secondary outcomes included functional status and symptoms severity subscales of the Boston Carpal Tunnel Questionnaire and the self-perceived improvement. They were assessed at baseline and 1, 3, 6, and 12 months by a blinded assessor. Analysis was by intention to treat. At 12 months, 111 (92%) women completed the follow-up (55/60 physical therapy, 56/60 surgery). Adjusted analyses showed an advantage (all, P < .01) for physical therapy at 1 and 3 months in mean pain (Δ -2.0 [95% confidence interval (CI) -2.8 to -1.2]/-1.3 [95% CI -2.1 to -.6]), the worst pain (Δ -2.9 [-4.0 to -2.0]/-2.0 [-3.0 to -.9]), and function (Δ -.8 [-1.0 to -.6]/-.3 [-.5 to -.1]), respectively. Changes in pain and function were similar between the groups at 6 and 12 months. The 2 groups had similar improvements in the symptoms severity subscale of the Boston Carpal Tunnel Questionnaire at all follow-ups. In women with CTS, physical therapy may result in similar outcomes on pain and function to surgery. TRIAL REGISTRATION: http://www.clinicaltrials.gov, ClinicalTrials.gov, NCT01789645. PERSPECTIVE: This study found that surgery and physical manual therapies including desensitization maneuvers of the central nervous system were similarly effective at medium-term and long-term follow-ups for improving pain and function but that physical therapy led to better outcomes in the short term.

Catechol-O-methyltransferase Val158Met polymorphism is associated with pain and disability, but not widespread pressure pain sensitivity, in women with carpal Tunnel syndrome.

BACKGROUND: The genetic influence of Val158Met polymorphisms, one of the potential genetic determinants for nociceptive processing, has not been previously investigated in women with carpal tunnel syndrome (CTS). OBJECTIVES: To investigate the association between the Val158Met polymorphism with CTS and to assess the relationship between the Val158Met polymorphism and the clinical outcomes and widespread pressure pain hypersensitivity in women with CTS. STUDY DESIGN: Case control study. SETTING: Neurology department at an urban hospital. METHOD: One hundred nine (n = 109) women (mean age: 47 ± 9 years) with a clinical and electrodiagnostic diagnosis of CTS and 109 matched healthy women participated. After amplifying the Val158Met polymorphism by polymerase chain reactions, rs4680 genotype frequencies and allele distributions were calculated. We classified individuals according to their Val158Met polymorphism: Val/Val, Val/Met, Met/Met. The intensity of the pain was assessed with a numeric rating scale (0-10) and disability was determined with the Boston Carpal Tunnel Questionnaire. Pressure pain thresholds were bilaterally assessed over median, radial, and ulnar nerve trunks; C5-C6 facet joints; and carpal tunnel and tibialis anterior muscles.Institutional Review Board: The study project was approved by the local human research committee (HUFA-12/14). All participants signed an informed consent prior to their inclusion in the study. RESULTS: The distribution of the 3 Val158Met genotypes (Val/Val, Val/Met, Met/Met) and alleles was not significantly different between women with CTS and healthy women (Chi-Square = 0.498; P = 0.780). Women with CTS carrying the Met/Met genotype showed higher levels of pain and disability than those with the Val/Met genotype (P < 0.01) and with the Val/Val genotype (P < 0.001). No differences in the years with pain (P = 0.954), age (P = 0.740), depression (P = 0.530), severity of CTS (P = 0.744) or presence of unilateral-bilateral symptoms (P = 0.279) existed depending on the rs4680 Val158Met genotype. No significant differences in widespread pressure pain sensitivity were observed in any of the points depending on the rs4680 Val158Met genotype (P > 0.315). LIMITATIONS: We only recruited women from a specialized department. CONCLUSION: Current results indicated that the Val158Met polymorphism seems not to be a risk factor for the development of CTS; however, it was associated with increased perception of pain and higher disability scores.

Clinical, physical, and neurophysiological impairments associated with decreased function in women with carpal tunnel syndrome.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To examine the associations between clinical (pain), physical (cervical range of motion [ROM] and pinch grip force), and neurophysiological (pressure pain thresholds) outcomes and self-reported function and disability in women with carpal tunnel syndrome (CTS). BACKGROUND: The association of physical and physiological variables with self-rated function and disability in patients with CTS has not been fully determined. A better understanding of the association between potentially modifiable risk factors, such as limited cervical ROM, could assist clinicians in optimizing therapeutic programs for this group of patients. METHODS: One hundred fifty-four women with CTS were recruited. Demographic information and data on duration of symptoms, pain intensity, depression, cervical ROM, pinch grip force, and pressure pain thresholds over the neck, hand, and leg were collected. Self-reported function and disability were measured with the functional status subscale of the Boston Carpal Tunnel Questionnaire. Correlation and regression analyses were performed to determine associations between variables. RESULTS: There were significant positive correlations between the functional status subscale score and pain intensity (r = 0.36, P<.001), depression (r = 0.32, P<.001), and duration of symptoms (r = 0.23, P = .005). Significant negative correlations were also observed between the functional status subscale score and pinch grip force of the index finger (r = -0.25, P = .002) and little finger (r = -0.28, P<.001), ROM in cervical flexion (r = -0.22, P = .003) and lateral flexion away from the side of CTS (r = -0.24, P = .002) and toward the side of CTS (r = -0.16, P = .045), and pressure pain threshold over C5-6 (r = -0.34, P<.001), the carpal tunnel (r = -0.35, P<.001), and the tibialis anterior muscle (r = -0.26, P<.001). Stepwise regression analyses revealed that pain intensity, thumb and little finger pinch grip force, severity of depression, and cervical ROM in lateral flexion away from the side of CTS explained 38.2% of the variance in functional status (R2 = 0.411, adjusted R2 = 0.382, F = 15.42, P<.001). CONCLUSION This study found that a number of modifiable factors are associated with self-reported function in women with CTS. Future longitudinal studies will help to determine the clinical implications of these findings.

Bilateral deficits in fine motor control and pinch grip force are not associated with electrodiagnostic findings in women with carpal tunnel syndrome.

OBJECTIVE: : The aim of this study was to analyze the differences in deficits in fine motor control and pinch grip force between patients with minimal, moderate/mild, or severe carpal tunnel syndrome (CTS) and healthy age- and hand dominance-matched controls. DESIGN: : A case-control study was conducted. The subtests of the Purdue Pegboard Test (one-hand and bilateral pin placements and assemblies) and pinch grip force between the thumb and the remaining four fingers of the hand were bilaterally evaluated in 66 women with minimal (n = 16), moderate (n = 16), or severe (n = 34) CTS and in 20 age- and hand-matched healthy women. The differences among the groups were analyzed using different mixed models of analysis of variance. RESULTS: : A two-way mixed analysis of variance revealed significant differences between groups, not depending on the presence of unilateral or bilateral symptoms (side), for the one-hand pin placement subtest: patients showed bilateral lower scores compared with controls (P < 0.001), without differences among those with minimal, moderate, or severe CTS (P = 0.946). The patients also exhibited lower scores in bilateral pin placement (P < 0.001) and assembly (P < 0.001) subtests, without differences among them. The three-way analysis of variance revealed significant differences among groups (P < 0.001) and fingers (P < 0.001), not depending on the presence of unilateral/bilateral symptoms (P = 0.684), for pinch grip force: patients showed bilateral lower pinch grip force in all fingers compared with healthy controls, without differences among those with minimal, moderate, or severe CTS. CONCLUSIONS: : The current study revealed similar bilateral deficits in fine motor control and pinch grip force in patients with minimal, moderate, or severe CTS, supporting that fine motor control deficits are a common feature of CTS not associated with electrodiagnostic findings.

Increased pain sensitivity is not associated with electrodiagnostic findings in women with carpal tunnel syndrome.

OBJECTIVE: To determine the differences in widespread pressure pain and thermal hypersensitivity in women with minimal, moderate, and severe carpal tunnel syndrome (CTS) and healthy controls. METHODS: A total of 72 women with CTS (19 with minimal, 18 with moderate, and 35 with severe) and 19 healthy age-matched women participated. Pressure pain thresholds were bilaterally assessed over the median, ulnar, and radial nerves, the C5 to C6 zygapophyseal joint, the carpal tunnel, and the tibialis anterior muscle. In addition, warm and cold detection thresholds and heat and cold pain thresholds were bilaterally assessed over the carpal tunnel and the thenar eminence. All outcome parameters were assessed by an assessor blinded to the participant's condition. RESULTS: No significant differences in pain parameters among patients with minimal, moderate, and severe CTS were found. The results showed that PPT were significantly decreased bilaterally over the median, ulnar, and radial nerve trunks, the carpal tunnel, C5 to C6 zygapophyseal joint, and the tibialis anterior muscle in patients with minimal, moderate, or severe CTS as compared with healthy controls (all, P<0.001). In addition, patients with CTS also showed lower heat pain threshold and reduced cold pain threshold compared with controls (P<0.001). No significant sensory differences between minimal, moderate, or severe CTS were found. CONCLUSIONS: The similar widespread pressure and thermal hypersensitivity in patients with minimal, moderate, or severe CTS and pain intensity suggests that increased pain sensitivity is not related to electrodiagnostic findings.

Women with carpal tunnel syndrome show restricted cervical range of motion.

STUDY DESIGN: A case control, blinded study. OBJECTIVES: To compare the amount of cervical range of motion in women with minimal, mild/moderate, and severe carpal tunnel syndrome (CTS) to that of healthy control participants. We also assessed the relationships between cervical range of motion and clinical variables related to the intensity and temporal profile of pain within each CTS group. BACKGROUND: It is plausible that the cervical spine may be involved in individuals with CTS. No study has investigated the relationship between cervical range of motion and symptoms associated with CTS severity. METHODS: Cervical range of motion was assessed in 71 women with CTS (18 with minimal, 18 with mild/moderate, and 35 with severe signs and symptoms) and in 20 similar, healthy women. Those with CTS were aged 35 to 59 years (mean ± SD, 45 ± 8 years) and those in the healthy group were aged 31 to 60 years (45 ± 8 years). An experienced therapist, blinded to the participants' conditions, used a cervical range-of-motion (CROM) device to assess cervical range of motion. Mixed-model analyses of variance (ANOVAs) were conducted to evaluate the differences in cervical range of motion among the 3 groups of patients with CTS and healthy controls. A corrected P value of less than .025 was used as threshold for significance (Bonferroni correction). RESULTS: The mixed-model ANOVAs revealed that the individuals with CTS exhibited restricted cervical range of motion compared to healthy controls (P<.001), with no significant differences among the groups with minimal, mild/moderate, or severe CTS (P>.356). A significant negative correlation between pain intensity and cervical spine lateral flexion away from the affected side was identified: the greater the mean pain intensity, the lesser the cervical lateral flexion away from the affected side. CONCLUSIONS: Women with minimal, mild/moderate, or severe CTS exhibited less cervical range of motion compared to women of a similar age, suggesting that restricted cervical range of motion may be a common feature in individuals with CTS, independent of severity subgroups, as defined by electrodiagnosis. Future research should investigate cervical range of motion as a possible consequence or causative factor of CTS and related symptoms.

Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.

The aim of the current study was to identify whether hyperexcitability of the central nervous system is a prognostic factor for individuals with carpal tunnel syndrome (CTS) likely to experience rapid and clinical self-reported improvement following a physical therapy program including soft tissue mobilization and nerve slider neurodynamic interventions. Women presenting with clinical and electrophysiological findings of CTS were involved in a prospective single-arm trial. Participants underwent a standardized examination and then a physical therapy session. The physical therapy sessions included both soft tissue mobilization directed at the anatomical sites of potential median nerve entrapment and a passive nerve slider neurodynamic technique targeted to the median nerve. Pressure pain thresholds (PPT) over the median, radial and ulnar nerves, C5-C6 zygapophyseal joint, carpal tunnel and tibialis anterior muscle were assessed bilaterally. Additionally, thermal detection and pain thresholds were measured over the carpal tunnel and thenar eminence bilaterally to evaluate central nervous system excitability. Subjects were classified as responders (having achieved a successful outcome) or non-responders based on self-perceived recovery. Variables were entered into a stepwise logistic regression model to determine the most accurate variables for determining prognosis. Data from 72 women were included in the analysis, of which 35 experienced a successful outcome (48.6%). Three variables including PPT over the C5-C6 joint affected side <137 kPa, HPT carpal tunnel affected side <39.6º and general health >66 points were identified. If 2 out of 3 variables were present (LR + 14.8), the likelihood of success increased from 48.6 to 93.3%. We identified 3 factors that may be associated with a rapid clinical response to both soft tissue mobilization and nerve slider neurodynamic techniques targeted to the median nerve in women presenting with CTS. Our results support that widespread central sensitization may not be present in women with CTS who are likely to achieve a successful outcome with physical therapy. Future studies are now necessary to validate these findings.

Pressure pain sensitivity topographical maps reveal bilateral hyperalgesia of the hands in patients with unilateral carpal tunnel syndrome.

OBJECTIVE: To assess topographical pressure pain sensitivity maps of the hand in patients with unilateral carpal tunnel syndrome (CTS) as compared with healthy subjects. METHODS: A total of 20 women with CTS (ages 32-52 years) and 20 healthy matched women (ages 32-51 years) were recruited. Pressure pain thresholds (PPTs) were measured bilaterally over 30 locations of the palm of each hand by an assessor blinded to the subjects' conditions. RESULTS: Patients showed lower PPTs in both hands in all of the measurement points as compared with controls (P < 0.001 for all). PPTs were lower in those points over the proximal phalanx of the fingers and the thenar eminency as compared with those points located over the distal phalanx of the fingers (P < 0.001). CTS patients showed lower PPT levels in dermatomes C6, C7, and C8 when compared with healthy controls (P < 0.001 for all), but without differences between dermatomes (P = 0.4). PPT was negatively correlated with both hand pain intensity and duration of symptoms (P < 0.001 for all). CONCLUSION: Our findings revealed bilateral generalized pressure pain hyperalgesia in unilateral CTS because lower PPT levels were found in all of the points. The pressure pain hyperalgesia was not uniformly distributed since PPTs were lower in points over the proximal phalanx of the fingers and the thenar eminency as compared with those points located over the distal phalanx of the fingers. The decrease in PPT levels was associated with the intensity and the duration of the pain symptoms, supporting a role of both peripheral and central sensitization mechanisms in this pain condition.