Iranian clinical practice guideline for amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegeneration involving motor neurons. The 3-5 years that patients have to live is marked by day-to-day loss of motor and sometimes cognitive abilities. Enormous amounts of healthcare services and resources are necessary to support patients and their caregivers during this relatively short but burdensome journey. Organization and management of these resources need to best meet patients' expectations and health system efficiency mandates. This can only occur in the setting of multidisciplinary ALS clinics which are known as the gold standard of ALS care worldwide. To introduce this standard to the care of Iranian ALS patients, which is an inevitable quality milestone, a national ALS clinical practice guideline is the necessary first step. The National ALS guideline will serve as the knowledge base for the development of local clinical pathways to guide patient journeys in multidisciplinary ALS clinics. To this end, we gathered a team of national neuromuscular experts as well as experts in related specialties necessary for delivering multidisciplinary care to ALS patients to develop the Iranian ALS clinical practice guideline. Clinical questions were prepared in the Patient, Intervention, Comparison, and Outcome (PICO) format to serve as a guide for the literature search. Considering the lack of adequate national/local studies at this time, a consensus-based approach was taken to evaluate the quality of the retrieved evidence and summarize recommendations.

The effect of dextrose prolotherapy versus placebo/other non-surgical treatments on pain in chronic plantar fasciitis: a systematic review and meta-analysis of clinical trials.

BACKGROUND: Prolotherapy is the injection of a small volume of sclerosing or irritant solutions into an injured tissue. We aimed to investigate the effect of dextrose prolotherapy (DPT) versus placebo/other non-surgical treatments on pain in chronic plantar fasciitis. METHODS: We searched seven electronic databases (PubMed/MEDLINE, Web of Science, EMBASE, Scopus, ProQuest, CENTRAL, PEDro) from inception to December 31, 2021 with no language restriction for publications comparing the effect of DPT with placebo/other non-surgical treatments in patients with chronic plantar fasciitis. Our primary outcome was pain and the secondary outcomes were foot function and plantar fascia thickness. The risk of bias was assessed using the Cochrane Collaboration's tool. RESULTS: Overall, eight studies with a total of 449 patients were included in the meta-analysis. All the included studies reported short-term pain. A large effect size (dppc2 = -0.97, 95% confidence interval [CI] -1.84 to -0.10) was observed favoring the use of DPT to reduce pain in patients with chronic plantar fasciitis in the short-term. The results for foot function improvement (dppc2 = -1.28, 95% CI -2.49 to -0.07) and plantar fascia thickness reduction (dppc2 = -1.02, 95% CI -1.99 to -0.05) in the short-term were also in favor of DPT. CONCLUSIONS: Since almost all the included studies had high risk of bias and multiple trials lacked long-term follow-ups, further high-quality research is required to determine the long-term effects of DPT vs placebo/other non-surgical interventions.

Effects of weight loss after bariatric surgery on the median and ulnar nerves conduction studies.

BACKGROUND: The aim of the present study was to compare the nerve conduction study (NCS) of median and ulnar nerves before and after bariatric surgery. METHODS: This prospective cross-sectional study included 32 patients with BMI≥35 who were candidate for Sleeve gastrectomy. NCS of median and ulnar nerves were evaluated before and 3 months after surgery. In CTS cases, Boston Carpal Tunnel Questionnaire (BCTQ) was completed. RESULTS: Eligible participants were 32 patients aged between 19 and 64 years. 20 patients including 34 hands had CTS. Severity of CTS and BCTQ scores were significantly different after surgery. Moreover, sensory amplitude, and motor NCV for both median and ulnar nerves in hands without CTS as well as sensory amplitude of ulnar nerve in hands with CTS were significantly different after bariatric surgery (P value < 0.05). CONCLUSIONS: The results of this study suggest that three months after the bariatric surgery, the clinical and electrophysiological severity of CTS shows a significant improvement. ETHICAL CODE OF STUDY: IR.IUMS.FMD.REC.1396.15008.

Validity and reliability of the Persian version of self-administered foot evaluation questionnaire (SAFE-Q) in people with foot orthopedic problems.

INTRODUCTION: Foot problems are one of the main causes of seeing a doctor. According to the World Health Organization's definition of health, the healthcare system must consider patients' quality of life as an important entity. In this regard, many tools have been developed to evaluate patients' opinions about their health status. The purpose of the present study is to evaluate the validity and reliability of the Persian version of the Foot Self-Assessment Questionnaire (SAFE-Q) in patients with foot orthopedic problems. METHOD: 215 people aged 17-60 years with orthopedic foot problems were included in this cross-sectional study. The Spearman correlation coefficient of SAFE-Q questionnaires versus Foot Function Index (FFI) questionnaire was evaluated for the convergent validity. Forty-three people randomly completed SAFE-Q again one week later. Intraclass correlation coefficient (ICC) and Cronbach's alpha was calculated to evaluate the test-retest reliability and internal consistency of the SAFE-Q, respectively. RESULTS: A strong relationship was found between the SAFE-Q total score and other scales with FFI questionnaire (r = 0.52 to 0.87). ICC test-retest reliability and Cronbach's alpha were 0.981 and 0.98 for SAFE-Q, respectively. CONCLUSION: The results indicate that the Persian version of the SAFE-Q questionnaire has acceptable validity and reliability and can be used to assess the health status and quality of life of Persian speakers with orthopedic foot problems.

Neuropathic Pain Symptom Inventory (NPSI) Questionnaire-Persian Version Can Differentiate Neuropathic from Non-Neuropathic Pain.

BACKGROUND: Neuropathic pain (NP) is a common condition that impacts life negatively. This type of pain responds poorly to treatment. Neuropathic Pain Symptom Inventory (NPSI) is a common instrument used for the assessment of NP response to the treatment. AIM: The current study aims to validate the Persian version of NPSI (PV-NPSI). METHODS: The current study has been conducted on 162 patients experiencing pain from neuropathic ornon-neuropathic origin. The Persian version of NPSI was proposed through standard protocol and responded to by patients twice: at baseline within an interval of 3 hours and then again within 1 month. Its correlation with the patient global impression of change (PGIC) and the clinical global impression of change (CGIC) was assessed. In addition, the validity and reliability of the PV-NPSI was evaluated. RESULTS: The reliability Cronbach's alpha of PV-NPSI was 0.834 and test-retest intraclass-coefficient was calculated as 0.983 (95% confidence interval [CI]: 0.977-0.988; p < .001). In addition, the measured coefficient sensitivity to change based on PGIC and CGIC was 0.859 for both. Receiver operating characteristic (ROC) curve for the diagnosis of NP revealed area under curve (AUC) of 0.936 (p < .001; 95%CI: 0.894-0.978). CONCLUSIONS: Based on the current study's findings, the PV-NPSI is a reliable and valid means for the differentiation of NP from the other types of pain in patients with several musculoskeletal pain complaints, but we cannot determine a cutoff point for it. Also, this questionnaire can be efficiently used for the assessment of response to NP treatment.

Ultrasound-Guided vs. Blind Coccygeal Corticosteroid Injections for Chronic Coccydynia: A Randomized, Clinical Trial.

Background: Corticosteroid injection is frequently used for chronic coccydynia management. Ultrasonography can be used to improve the accuracy of the injection. This study aims to assess the clinical outcome of ultrasound-guided compared to blind coccygeal injection in chronic coccydynia. Methods: Thirty patients with chronic coccydynia were randomized into two groups and received a coccygeal corticosteroid injection at maximum tenderness point: 15 patients with and 15 patients without ultrasound guidance. The patient's pain was evaluated with the visual analog scale (VAS) at 1-, 4-, 8-, and 24-week postinjection. Furthermore, the Dallas Pain Questionnaire was assessed before injection; also, four and eight weeks after treatment. The quality of life of patients was evaluated before an assessment and four weeks after the intervention by the SF-36 questionnaire. Results: The VAS score decreased significantly 24-week after the intervention in both ultrasound-guided and blinded groups (P < .001), without any significant difference between the groups (P = .964). Similarly, the Dallas pain scale had a significant decrease at eight weeks after intervention in both groups (P < .001) with no significant difference between the groups (P = .972). Although there was a significant improvement in the patient's quality of life in each group eight weeks after the intervention, it was not significantly different between the two groups. Neither of the treatment groups had any adverse effects associated with the injection. Conclusion: There were no significant differences in the clinical outcome of coccygeal ultrasound-guided vs. blind steroid injection for chronic coccydynia.

A Three months Electrodiagnostic Follow-Up of Patients Suspected of having Ulnar Nerve Involvement at Elbow Level with Normal Conventional Electrodiagnostic Study at First Evaluation.

Background: Compression of ulnar nerve at the elbow is the second most common peripheral neuropathy of the upper extremity. Objective: Due to the lack of the gold diagnostic standard for ulnar nerve involvement at elbow level (UNE) and the lack of sufficient study in this field, we decided to evaluate patients with symptoms of this disease who have normal conventional electrodiagnostic study (EDX) in first evaluation. Materials and Methods: In this cross-sectional study, 18 persons were selected from patients who were referred to the clinic of Physical Medicine and Rehabilitation. If conventional EDX was normal, compound nerve action potential (CNAP) test (peak latency and amplitude) was carried out. Patients with normal conventional EDX but abnormal ulnar CNAP included to our study. After 3 months, if they had not been treated for ulnar neuropathy, they were reexamined by conventional EDX plus ulnar CNAP measurement. Results: In total, 18 patients (11 females, 7 males) aged 28-58 years old (mean = 40.11) were analyzed in this study. After 3 months, 14 patients (77.8%) demonstrated parameter changes consistent with UNE in conventional EDX. Conclusion: Based on the results of this study, ulnar CNAP has diagnostic value in patients with symptoms of UNE who have normal routine EDX. Therefore, ulnar CNAP should be taken into account for early diagnosis of ulnar neuropathy when routine electrodiagnostic tests are normal.

Effects of Meaningful Action Observation Therapy on Occupational Performance, Upper Limb Function, and Corticospinal Excitability Poststroke: A Double-Blind Randomized Control Trial.

Introduction: Action observation therapy (AOT) is a mirror neuron-based approach that has been recently used in poststroke rehabilitation. The main goal of this study was to investigate the effectiveness of AOT of occupations and tasks that are meaningful for chronic stroke patients on occupational performance, upper-extremity function, and corticospinal changes. Method: A randomized control trial was designed to compare between experimental (n = 13) and control groups (n = 14). In both groups, the execution of meaningful tasks was practiced, but the videos of those tasks were just shown to the experiment group. Instead, patients in the control group watched nature videos as a placebo. Clinical outcomes were evaluated using the Canadian Occupational Performance Measure (COPM), Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), and Box-Block Test (BBT) on 3 occasions: baseline, post (at 4 weeks), and follow-up (at 8 weeks). The assessments of central motor conduction time (CMCT) for abductor policis brevis (APB) and extensor indicis (EI) were only recorded at baseline and posttreatment. Both assessors of clinical and neurophysiological outcomes were blinded to the allocation of subjects. Result: Finally, the results of outcomes in 24 patients who completed the study were analyzed. In both groups, significant improvements after treatment were seen for most outcomes (p ≤ 0.05). These changes were persistent until follow-up. There were significant differences in COPM performance (p = 0.03) and satisfaction (p = 0.001) between the experimental and control groups. In contrast, other clinical assessments such as FMA, ARAT, and BBT did not show significant differences between the two treatments (p ≥ 0.05). The results of CMCT related to APB showed a more significant change in the experiment group compared to the control group (p = 0.022). There was no difference in change detected between the two groups for CMCT related to EI after treatments. Conclusion: Observation and execution of meaningful activities can enhance the effects of simply practicing those activities on occupational performance/satisfaction and corticospinal excitability poststroke.

The Effects of Vestibular Rehabilitation on Poststroke Fatigue: A Randomized Controlled Trial Study.

Background: A major complication caused by stroke is poststroke fatigue (PSF), and by causing limitations in doing activities of daily living (ADL), it can lower the quality of life. Objective: The present study is an attempt to examine the effects of vestibular rehabilitation on BADL (Basic Activities of Daily Living), fatigue, depression, and Lawton Instrumental Activities of Daily Living (IADL) in patients with stroke. Method: Patients with a history of stroke took part voluntarily in a single-blind clinical trial. The participants were allocated to control and experimental groups randomly. The experimental group attended 24 sessions of vestibular rehabilitation protocol, while the control group received the standard rehabilitation (including three sessions per week each for around 60 min). To measure fatigue, the Fatigue Impact Scale (FIS) and the Fatigue Assessment Scale (FAS) were used. Depression, BADL, and IADL were measured using the Beck Depression Inventory-II (BDI-II), Barthel Index (BI), and Lawton Instrumental Activities of Daily Living, respectively. All changes were measured from the baseline after the intervention. Results: Significant improvement was found in the experimental group compared to the control group (p < 0.05) in FIS (physical, cognition, and social subscales), FAS, BDI-II, BADL, and IADL. Moreover, the results showed small to medium and large effect sizes for the physical subscale of FIS and FAS scores based on Cohen's d, respectively; however, no significant difference was found in terms of cognition and social subscales of FIS, BDI-II, BADL, and IADL scores. Conclusion: It is possible to improve fatigue, depression, and independence in BADL and IADL using vestibular rehabilitation. Thus, it is an effective intervention in case of stroke, which is also well tolerated.

Comparison of the Effect of Ultrasound-Guided Injection of Botulinum Toxin Type A and Corticosteroid in the Treatment of Chronic Plantar Fasciitis: A Randomized Controlled Trial.

OBJECTIVE: The aim of the study was to compare the efficacy of ultrasound-guided injection of botulinum toxin type A with corticosteroid in patients with chronic plantar fasciitis (PF). DESIGN: This randomized controlled trial was conducted on 35 patients with chronic plantar fasciitis. Participants were randomly allocated into two groups: one group received methylprednisolone in to the plantar fascia ( n = 18) and the other group received botulinum toxin type A injection into the flexor digitorum brevis and quadratus plantae ( n = 17). All injections were performed under ultrasound guidance. Patients were evaluated using the Visual Analog Scale, Foot and Ankle Ability Measures, and plantar fascia thickness before the intervention, 3 wks, 12 wks, and 6 mos after the treatment. RESULTS: In both groups, patients' pain and function improved significantly up to 3 wks after injection. In the botulinum toxin type A group, morning Visual Analog Scale improved significantly at 12 wks after intervention and the improvement was sustained for another 3 mos. In the botulinum toxin type A group, Foot and Ankle Ability Measures-sports subscale improved in all evaluated points, whereas in the corticosteroid group, the improvement was significant only when comparing follow-ups values to baseline. CONCLUSIONS: Both ultrasound-guided botulinum toxin type A and corticosteroid injection were effective in the treatment of plantar fasciitis. Our study showed that the effects of botulinum toxin type A injection last longer than those of steroid injection.

Acupuncture-like versus conventional transcutaneous electrical nerve stimulation in the management of active myofascial trigger points: A randomized controlled trial.

PURPOSE: Myofascial pain syndrome (MPS) is one of the most common causes of chronic musculoskeletal pain. The transcutaneous electrical nerve stimulation (TENS) is a non-expensive, safe, feasible modality, used recently for the treatment of MPS with promising but limited results. The purpose of this study was to determine the efficacy of acupuncture-like TENS (AL-TENS) vs conventional TENS (C-TENS) in the treatment of active myofascial trigger points. METHODS: This randomized controlled trial study was carried out with 60 consecutive patients with active trapezius trigger points referred to Physical Medicine and Rehabilitation Clinic. Participants randomly assigned to receive AL-TENS, C-TENS or sham TENS (S-TENS). The Visual Analogue Scale (VAS), Pressure Pain Thresholds (PPTs), and neck range of motion (ROM) were measured at baseline, after the first treatment sessions, after the final treatment session, and 3 months after the end of the last treatment session. Patients function was evaluated by Disabilities of the Arm, Shoulder, and Hand (DASH) at baseline, after the final treatment sessions, and 3 months after the end of intervention. RESULTS: The interaction effect of time and group was significantly different when evaluating VAS (df = 4.65, F = 2.50, p = 0.038) and DASH (df = 2.63, F = 7.25, p < 0.001) in favor of active groups, as well as neck total lateral bending in favor of AL-TENS group compared other two groups (df = 4.16, F = 5.23, p = 0.001). Both VAS and DASH improved significantly at all follow-ups in AL-TENS and C-TENS groups. Of note, significant immediate improvement in all outcomes was observed only with AL-TENS. CONCLUSIONS: According to the present study, both AL-TENS and C-TENS were superior to placebo in pain reduction and functional improvement. Although both TENS techniques have similar efficiency on pain reduction, functional and pain perception improvement, the AL-TENS was the superior approach when evaluating neck lateral bending ROM.

Effectiveness of Self-Action Observation Therapy as a Novel Method on Paretic Upper Limb and Cortical Excitability Post-Stroke: A Single-Subject Study.

Background: Action Observation Therapy (AOT) is a top-down approach that has been recently introduced in the rehabilitation of neurological disorders mainly after stroke. The main goal of this study was to investigate the effects and feasibility of a new technique in AOT procedure (called self-AOT) following periods of no treatment and routine AOT intervention on upper limb motor function, occupational performance and neurophysiological changes in a stroke patient. Methods: A single-subject A-B-A-C design was used and a 58-year-old woman with a 3-year history of left hemiplegia poststroke participated in this study. In the baseline (A1, A2) phases, the patient received no treatment. In the first intervention (B phase), she received a 4-week AOT, and in the second intervention (C phase), a 4 week of Self-AOT was practiced. In all phases, upper limb motor recovery as a target outcome was evaluated on 4 occasions using the Fugl-Meyer assessment. Upper limb function, dexterity and spasticity were assessed using Action Research Arm Test, Box-Block Test and Modified Modified Ashworth Scale respectively. Occupational Performance/Satisfaction was assessed with Canadian Occupational Performance Measure and to assess neuroplasticity, Motor Evoked Potential was recorded by Transcranial Magnetic Stimulation. Visual analysis, slope, and percentage of non-overlapping data were used for assessing the changes between phases. Results: Percentage of non-overlapping data and slopes indicated that motor recovery had clinically relevant improvements after both interventions compared to baselines. Other outcomes also showed improvements except for spasticity of wrist/elbow flexors and Motor Evoked Potential of opponens indicis. Conclusion: Self-AOT may be as effective as other procedures of AOT for improving upper limb motor function, occupational performance/satisfaction, and cortical excitability post-stroke.

Randomized clinical trial comparing of transcranial direct current stimulation (tDCS) and transcutaneous electrical nerve stimulation (TENS) in knee osteoarthritis.

BACKGROUND: Due to the limitations of pharmacological and surgical management of knee osteoarthritis (OA), several non-pharmacologic approaches including transcutaneous electrical nerve stimulation (TENS) and transcranial direct current stimulation (tDCS) have been introduced, with promising results. OBJECTIVE: We aimed to investigate and compare the therapeutic effects of TENS and tDCS for the treatment of patients with knee OA. METHODS: In this double-blinded randomized controlled trial, a total of 40 adult patients with knee OA were randomly allocated to either the TENS or the tDCS group. Patients in either group received 6 sessions of the TENS or tDCS for 2 weeks. Knee strengthening exercises were performed twice daily for the entire treatment period. Patients were evaluated using the visual analogue scale (VAS) and Western Ontario and McMaster Universities (WOMAC). RESULTS: Significant improvement was observed in all outcomes in both TENS and tDCS groups at each follow up compared to baseline although the early improvement (first follow-up) in the WOMAC index was not significant in the TENS group. Based on the within-subject analysis, the behavior of two treatment groups did not differ regarding the changes in the course of the VAS, WOMAC score and its subscales, i.e. stiffness, pain and function (p = 0.263, 0.051, 0.198, 0.075, and 0.146, respectively). CONCLUSIONS: Based on the results of this study, the effect of tDCS and TENS was not significantly different on pain and function of patients with knee OA.

Ultrasound-Guided Corticosteroid Injection in Carpal Tunnel Syndrome: Comparison Between Radial and Ulnar Approaches.

PURPOSE: To compare two common approaches for ultrasonography (US)-guided injection. PATIENTS AND METHODS: Sixty patients with mild-to-moderate CTS were included in this double-blind randomized controlled trial (RCT). They received a single shot of corticosteroid injection through either the US-guided in-plane approach: radial or ulnar side. Participants were evaluated using Boston Carpal Tunnel Questionnaire (BCTQ) and visual analogue scale (VAS) for pain, as well as electrodiagnosis (EDX) and US parameters before the intervention, and within 12 weeks of follow-up. RESULTS: In both groups, all outcomes, except for the electrodiagnostic measures, significantly improved within the follow-up. Pain-VAS and both subscales of BCTQ questionnaire, as our main subjective outcomes, revealed dramatic improvement, with the largest amount of changes in VAS (70%; comparing to baseline value), and about 37% for both of BQSS and BQFS scales, all indicating superiority of radial to ulnar in-plane approach. During the first follow-up, we did not detect any remarkable preference between the groups in either subjective or electrodiagnostic variables. However, there was a significant difference at next follow-up time-points in terms of VAS for pain and BQFS favoring radial approach (Table 3). Furthermore, US-measured parameters including nerve-circumference and CSA improved only in the radial in-plane group. CONCLUSION: The current data proved that radial in-plane approach for CTS injection could be at least as effective as the more common ulnar in-plane method. Even the pain-relief effect was longer for the radial in-plane approach. Also, patients' functional status and objective variables all revealed better outcomes via the new approach.

A Randomized Clinical Trial on the Effect of Biofeedback on Pain and Quality of Life of Patients With Chronic Coccydynia.

INTRODUCTION: Pelvic floor muscles dysfunction is one of the most important etiologies of coccydynia; therefore, manual therapies have been proposed as the first line of treatment. The purpose of this study was to investigate the effect of biofeedback as a new approach in the treatment of coccydynia. METHODS: Thirty women were randomized into two groups. Both groups were injected with the corticosteroid. One group received pelvic floor muscle exercises plus biofeedback while the other group only performed exercises. The patient's pain was measured using the Visual Analog Scale (VAS) in the first visit and after 1, 2, and 6 months of follow-up as well as Dallas pain and SF-36 quality of life questionnaires before and 2 months after the treatment. RESULTS: Pain had improved significantly after 1, 2, and 6 months in both groups compared to the baseline. However, the amount of change was not different between the groups at any time interval. The results were the same for the Dallas pain scale and SF-36 quality of life questionnaire. CONCLUSION: Adding biofeedback to pelvic floor muscle exercises did not lead to any further improvement in the management of chronic coccydynia. Further studies with larger sample sizes may reveal the effect of biofeedback more clearly.

Prolotherapy vs Radial Extracorporeal Shock Wave Therapy in the Short-term Treatment of Lateral Epicondylosis: A Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to compare the efficacy of prolotherapy with hypertonic dextrose and radial shock wave therapy in chronic lateral epicondilosis. DESIGN: Prospective single-blind randomized clinical trial. SETTING: Physical medicine and rehabilitation clinic. SUBJECTS: Thirty-three patients with at least three months of signs and symptoms of lateral epicondilosis, as well as failure of at least one of the conservative treatments, randomly allocated into two groups. METHODS: Sixteen patients received three sessions of shock wave therapy, and 17 received one session prolotherapy. Severity of pain via visual analog scale (VAS), grip strength via Baseline Pneumatic Dynamometer, pressure pain threshold (PPT) by algometer and Disabilities of Arm, Shoulder, and Hand quick questionnaire (Quick DASH) were assessed at baseline, four weeks, and eight weeks after the intervention. RESULTS: Within-group analysis showed that in both groups, differences between all of the outcome measures were significant after four and also eight weeks. Between-group analysis after four and eight weeks showed that the VAS and Quick DASH had significantly more improvement in the shock wave group. However, the two groups were similar regarding grip strength and PPT. No complication was observed in the two groups. CONCLUSIONS: Based on the results of this study, a regiment of three sessions (weekly) of radial extracorporeal shock wave therapy is significantly more effective than one session of prolotherapy with 20% dextrose regarding pain and function in the management of chronic lateral epicondylosis in short-term follow-up.

Comparison Between Effectiveness of Ultrasound-Guided Corticosteroid Injection Above Versus Below the Median Nerve in Mild to Moderate Carpal Tunnel Syndrome: A Randomized Controlled Trial.

OBJECTIVE: In this study, the clinical effectiveness of ultrasound-guided corticosteroid injection "above" versus "below" the median nerve for treatment of patients with mild to moderate carpal tunnel syndrome was compared. DESIGN: This prospective randomized double-blind clinical trial included 44 patients with mild to moderate carpal tunnel syndrome. The subjects were randomly assigned to two groups to receive ultrasound-guided injection of 40 mg of triamcinolone either "above" or "below" the involved median nerve. Outcome measures were the Boston Carpal Tunnel Questionnaire, visual analog scale, electrophysiological tests, and ultrasonographic measurement of the median nerve cross-sectional area at baseline, 6, and 12 wks after the injection. RESULTS: All outcome measures improved significantly in both groups at 6 wks after intervention, and these improvements were persevered up to 12 wks of follow-up (all P values <0.05). However, there was no significant difference in measured outcomes between the two groups. No adverse effects were observed. CONCLUSIONS: Both above and under median nerve ultrasound-guided steroid injection techniques were effective in reducing the symptoms, improving the function, and improving electrodiagnostic and sonographic findings of carpal tunnel syndrome. However, the amount of improvement in the outcomes did not differ between groups, implying that none of technique has the superiority over another.

Evaluation of Acupuncture in the Treatment of Restless Legs Syndrome: A Randomized Controlled Trial.

The aim of this study was to examine the additive effect of medical acupuncture on controlling the symptoms of restless legs syndrome (RLS). A total of 46 randomly allocated patients diagnosed with RLS were assigned to receive either 10 sessions of acupuncture plus gabapentin (300 mg/d), or gabapentin (300 mg/d) alone (23 patients in each group) over 4 weeks in a single-blind study. The symptoms of patients were assessed by the Visual Analogue Scale (VAS), the International Restless Legs Syndrome Rating Scale (IRLSRS), and the Pittsburgh Sleep Quality Index (PSQI) at baseline, just after the therapeutic course and 8 weeks later. For all outcome measures, there was a significant time-group interaction, showing that the behavior of groups differed regarding changes in VAS, IRLSRS, and PSQI in favor of the experimental group. After therapeutic course termination and in 8 weeks follow up, VAS and IRLSRS had a significant improvement in both the experimental group and the control group, but PSQI improved significantly just in the experimental group. Based on the findings of the present study, acupuncture plus a low dose of gabapentin (300 mg/d) is clinically useful in the treatment of RLS during 8 weeks follow up, and also has an additive therapeutic effect over gabapentin alone in patients with RLS.

Efficacy of biofeedback on quality of life in stages I and II pelvic organ prolapse: A Pilot study.

OBJECTIVES: Pelvic organ prolapse (POP) is a prevalent disorder which seriously affects the sufferer's quality of life. The main goal of this study was to evaluate biofeedback impact on quality of life in women with mild to moderate POP. STUDY DESIGN: 40 females in stages I and II POP were allocated into 2 groups. One group received pelvic floor muscle exercise and lifestyle advice in addition to biofeedback twice a week for 4 weeks, while the other received a lifestyle advice sheet and pelvic floor muscle exercise without biofeedback. A valid Persian version of P-QOL questionnaire was applied to assess the patients̕ quality of life at baseline, 4 weeks and 12 weeks follow up. Pressure biofeedback and Physical examination were also performed in order to determine pelvic floor muscle strength and staging of the prolapse, respectively. Collected data were analyzed by mixed ANOVA test using SPSS 22. RESULTS: Biofeedback improved the quality of life in seven of nine P-QOL domains. However, it had no significant impact either on pelvic floor muscle strength or on the stage of the prolapse. CONCLUSION: Biofeedback could be considered as a non-invasive treatment leading to quality of life promotion in women with stages I and II POP.

Vasculitic Mononeuritis Multiplex May Be Misdiagnosed as Carpal Tunnel Syndrome.

Vasculitis is a group of disorders characterized by inflammation and destruction of blood vessels, resulting in ischemic injury to the involved tissue. Sometimes, peripheral neuropathy is one of the first symptoms of systemic vasculitis. Although the classic form of peripheral nervous system vasculitis is mononeuritis multiplex, it can also present as a mononeuritis. In this case report, the patient presented with progressive rapid onset numbness in her right hand for 2 months. She underwent carpal tunnel decompression surgery with initial diagnosis of acute carpal tunnel syndrome but failed to respond to the surgery, and two month later, she presented with foot drop. The final diagnosis was vasculitic mononeuritis multiplex. The present case report demonstrates the importance of identification of median mononeuritis as one of the first presentations of vasculitic disorders and distinction from acute carpal tunnel syndrome. The natural history of many of the systemic vasculitides is rapidly progressive, and they are likely to be fatal without early treatment. In this regard, timely diagnosis of vasculitis is critical because of the vital role of early immunosuppressive therapy in preventing multiorgan damage and decreasing mortality rate.