"Idiopathic" Shoulder Pain and Dysfunction from Carpal Tunnel Syndrome and Cubital Tunnel Syndrome.

As a referral center for chronic pain, we see many patients with "idiopathic" shoulder pain and limited range of motion. The combination of mild or subclinical carpal tunnel syndrome and cubital tunnel syndrome may be an underrecognized etiology of symptoms in such patients. Here, we report our treatment algorithm and results for such patients. METHODS: Of patients with a chief complaint of shoulder pain, we identified 56 consecutive patients who had pain or tingling with median nerve compression at the proximal wrist crease and positive Tinel's around the cubital tunnel. They were first provided a night-time wrist orthosis. If still symptomatic, nerve blocks were given to median and ulnar nerves under ultrasound guidance. If symptoms recurred after nerve blocks, nerve conduction studies and surgical release of affected nerves were performed. RESULTS: Six patients had 60% or more pain relief with orthosis (mean 4.7 ± 0.8 (SD) to 2.2 ± 0.8). Twenty-three patients had nerve blocks and had persistent pain relief (6.0 ± 1.7 to 2.1 ± 1.9) and significant shoulder motion improvement. Twenty-seven patients only had temporal relief and required surgery but postoperatively had persistent pain relief (6.2 ± 2.0 to 1.2 ± 1.0) and improved shoulder motion. qDASH improved from 33.4 ± 20.1 preoperatively to 12.2 ± 7.4 postoperatively. CONCLUSIONS: All patients had substantial improvement in shoulder pain and motion with compressive neuropathy treatments. Targeted physical examination can identify these patients, who can have significant improvement with appropriate diagnosis and treatment. The study sheds light on an underrecognized cause of shoulder dysfunction.

Histopathological explanation of the MRI target sign in extra-axial schwannomas.

BACKGROUND: To better understand the nature of magnetic resonance imaging (MRI) findings in schwannomas, especially in the "target sign" of these findings, the histopathological investigation was performed. METHODS: The MRI findings were correlated with histopathological features in 22 samples of schwannomas, which were mostly resected from the extremities. The histopathological analyses included alcian blue staining and immunohistochemical staining for S-100 protein, proliferating cell nuclear antigen (PCNA) and epithelial membrane antigen (EMA). RESULTS: Seven of the 22 samples of schwannomas of the extremities exhibited target signs including a peripheral zone of homogeneously high signal intensity and a central zone of heterogeneous signal intensity in T2-weighted images. Gadolinium-enhanced T1-weighted images demonstrated a central heterogeneous enhancement and a peripheral ring of homogeneously low signal intensity. Histopathologically, S-100 and PCNA were positive only in the central heterogeneous signal area. In contrast, EMA was only stained on the degenerative epi/perineurium in the peripheral zone. CONCLUSION: In schwannomas of the extremities showing target sign in T2-weighted images, histopathologically, the peripheral areas were suggested to be mucinous degeneration of the epineurium or perineurium, while the central areas were composed of truly neoplastic cells.

Regeneration of a Completely Transected Sciatic Nerve with Use of a Bioabsorbable Nerve Conduit Filled with Collagen with a 14-Year Follow-up: A Case Report.

CASE: A 65-year-old man with a completely transected left sciatic nerve at the buttock received an implant with a bioabsorbable nerve conduit over a 20-mm gap. The conduit was filled with collagen to facilitate nerve regeneration. At 4 years after implantation, reinnervation potentials were detected in the muscles, and there was sensory recovery in the reinnervated areas. Thereafter, motor and sensory function recovered gradually over a 14-year period. CONCLUSION: Mixed nerve regeneration after conduit-based reconstruction was demonstrated objectively. Although it took >4 years for motor and sensory functions to be regained, the nerve connection between the buttock and the foot was restored.

Feasibility study of a combined treatment of electromyography-triggered neuromuscular stimulation and mirror therapy in stroke patients: a randomized crossover trial.

BACKGROUND: Mirror therapy (MT) and electromyography-triggered neuromuscular stimulation (ETMS) are both effective treatments for impaired upper limbs following stroke. A combination of these two treatments (ETMS-MT) may result in greater gain than either treatment alone. OBJECTIVES: The feasibility and possible effects of ETMS-MT upon upper extremity function were investigated in stroke patients. METHODS: Thirteen post-acute stroke patients were randomly assigned to an immediate ETMS-MT group or a delayed ETMS-MT group and then underwent an 8-week training program. The immediate ETMS-MT group received ETMS-MT in addition to physical and occupational therapy (PT+OT) for 4 weeks. They then received only PT+OT for the next 4 weeks. In the delayed ETMS-MT group, interventions were provided in the reverse order. The main outcome measure was the Fugl-Meyer Assessment (FMA). RESULTS: The immediate ETMS-MT group showed significantly greater gain in FMA in the first 4 weeks. The delayed ETMS-MT group showed significantly greater gain in active range of motion during the latter 4 weeks. No adverse effects were reported following ETMS-MT. CONCLUSION: ETMS-MT might be as effective as independent MT or ETMS without causing any side effects. Future research should focus upon the direct comparisons between independent and combined interventions.

Effects of peripheral sensory nerve stimulation plus task-oriented training on upper extremity function in patients with subacute stroke: a pilot randomized crossover trial.

OBJECTIVE: To investigate the feasibility of peripheral sensory nerve stimulation combined with task-oriented training in patients with stroke during inpatient rehabilitation. DESIGN: A pilot randomized crossover trial. SETTING: Two rehabilitation hospitals. SUBJECTS: Twenty-two patients with subacute stroke. INTERVENTIONS: Participants were randomly assigned to two groups and underwent two weeks of training in addition to conventional inpatient rehabilitation. The immediate group underwent peripheral sensory nerve stimulation combined with task-oriented training in the first week, followed by another week with task-oriented training alone. The delayed group underwent the same training in reverse order. MAIN MEASURES: Outcome measures were the level of fatigue and Wolf Motor Function Test. Patients were assessed at baseline, one and two weeks. RESULTS: All participants completed the study with no adverse events. There was no significant difference in level of fatigue between each treatment. From baseline to one week, the immediate group showed larger improvements than the delayed groups in the Wolf Motor Function Test (decrease in mean time (± SD) from 41.9 ± 16.2 seconds to 30.6 ± 11.4 seconds versus from 46.8 ± 19.4 seconds to 42.9 ± 14.7 seconds, respectively) but the difference did not reach significance after Bonferroni correction (P = 0.041). Within-group comparison showed significant improvements in the Wolf Motor Function Test mean time after the peripheral sensory nerve stimulation combined with task-oriented training periods in each group (P < 0.01). CONCLUSION: Peripheral sensory nerve stimulation is feasible in clinical settings and may enhance the effects of task-oriented training in patients with subacute stroke.

Frequency analysis of electroencephalogram recorded from a bottlenose dolphin (Tursiops truncatus) with a novel method during transportation by truck.

In order to obtain information regarding the correlation between an electroencephalogram (EEG) and the state of a dolphin, we developed a noninvasive recording method of EEG of a bottlenose dolphin (Tursiops truncatus) and an extraction method of true-EEG (EEG) from recorded-EEG (R-EEG) based on a human EEG recording method, and then carried out frequency analysis during transportation by truck. The frequency detected in the EEG of dolphin during apparent awakening was divided conveniently into three bands (5-15, 15-25, and 25-40 Hz) based on spectrum profiles. Analyses of the relationship between power ratio and movement of the dolphin revealed that the power ratio of dolphin in a situation when it was being quiet was evenly distributed among the three bands. These results suggested that the EEG of a dolphin could be detected accurately by this method, and that the frequency analysis of the detected EEG seemed to provide useful information for understanding the central nerve activity of these animals.

Regeneration of peripheral motor nerve gaps with a polyglycolic acid-collagen tube: technical case report.

OBJECTIVE: After previous success in regenerating canine peripheral nerves over 80 mm gaps using a bioabsorbable nerve guide tube, we have extended this method to the treatment of patients experiencing various types of nerve injury. This report describes the treatment of two cases of motor nerve disorder. METHODS: The bioabsorbable nerve tube was a cylindrically woven polyglycolic acid (PGA) tube filled with collagen. A peripheral motor nerve defect (the frontalis branch of the facial nerve) was reconstructed using this PGA-collagen tube in two patients who experienced posttraumatic unilateral eyebrow ptosis for 3 months. RESULTS: Five months after surgery, both patients regained their ability to voluntarily lift their eyebrows symmetrically. Electrophysiological examination at 5 months revealed recovery of compound muscle action potential and disappearance of distal latency on the affected side. CONCLUSION: This is the first clinical report of motor nerve recovery achieved using the PGA-collagen nerve guide tube. The results suggest that use of a PGA-collagen tube is a promising option for the repair of motor nerve defects.

Surgical relief of causalgia with an artificial nerve guide tube: Successful surgical treatment of causalgia (Complex Regional Pain Syndrome Type II) by in situ tissue engineering with a polyglycolic acid-collagen tube.

Two patients with causalgia associated with allodynia and finger contracture were treated surgically with a bioresorbable nerve guide tube made from polygycolic acid and collagen: the injured segment of the digital nerve was resected and the resulting gap (25 and 36mm) was bridged with the tube. In both cases, a neuroma was found on the injured nerve and many sprouting branches were. After reconstruction, the causalgia and allodynia disappeared and movement of the fingers recovered during the following 6 months. Functional recovery was objectively identified for 1 year and 9 months. Both patients regained full use of their finger and were free of discomfort for up to 24 and 18 months, respectively. Since the first description of causalgia in 1864, there has been no definitive treatment for this intractable burning pain. Our experience shows that at least some types of causalgia can be resolved successfully by surgery.

Regeneration of peripheral nerve gaps with a polyglycolic acid-collagen tube.

OBJECTIVE: The aim of this study was to report by means of objective methods on the effectiveness of a nerve reconstruction procedure using a bioresorbable tube in two patients. Our previous successes in regenerating canine peripheral nerves across long distances (80-mm gaps) using a bioabsorbable tube have led us to investigate the value of such a tube for the treatment of human patients with chronic nerve injuries. METHODS: The device was made from a cylindrically woven polyglycolic acid tube filled with a collagen sponge. It was designed to be resorbed after nerve regeneration. Peripheral sensory nerve defects in two patients with neuroma and pain were reconstructed using this tube. Patient 1 (a 62-year-old man) had a 20-mm defect of the proper digital nerve, and Patient 2 (a 56-year-old woman) had a 65-mm defect of the superficial peroneal nerve. RESULTS: After surgery, both patients recovered from the unpleasant sensations and intolerable pain. In Patient 1, functional recovery was objectively identified at 2 months, and conduction velocity of the nerve recovered to 49.1 m/s. In Patient 2, conduction velocity of the nerve was determined to be 16.9 m/s at 5 months. Current perception threshold testing indicated that sensory nerve function had been recovered by 65 days after surgery. CONCLUSION: This work represents the first precise clinical evaluation, performed under objective evaluation criteria, of sensory recovery achieved using a nerve tube, suggesting that the use of a polyglycolic acid-collagen tube has the potential to become a viable alternative to conventional autografting for the repair of peripheral nerve defects.