Does prior local corticosteroid injection prejudice the outcome of subsequent carpal tunnel decompression?

UNLABELLED: It has been suggested that treatment of carpal tunnel syndrome by local corticosteroid injection may prejudice the outcome of subsequent surgery. We identified patients who had proceeded directly to carpal tunnel surgery and patients who had initially been treated with one or more injections and then subsequently underwent carpal tunnel surgery on the same hand. Outcomes of surgery were evaluated using pre- and post-operative Boston carpal tunnel syndrome scales and an ordinal scale for overall satisfaction. Multivariate models were created to study the effect of pre-operation injection on the surgical outcome while controlling for demographic and clinical variables. A total of 942 patients were included; 85% of the direct group and 84% of the prior-injection group reported themselves either completely cured or much improved after surgery. Post-operative symptom severity and functional status scores showed no significant difference between the direct-to-surgery and prior-injection groups. Prior local steroid injection does not prejudice the outcome of surgery. LEVEL OF EVIDENCE: IV.

Treatment for spasticity in amyotrophic lateral sclerosis/motor neuron disease.

BACKGROUND: Spasticity commonly affects patients with motor neuron disease. It is likely to contribute to worsening muscle dysfunction, increased difficulty with activities of daily living and deteriorating quality of life. OBJECTIVES: The objective of this review is to systematically review treatments for spasticity in amyotrophic lateral sclerosis, also known as motor neuron disease. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group trials register (January 2003 and January 2005), MEDLINE (January 1966 to February 2005), EMBASE (January 1980 to February 2005), CINAHL (January 1982 to February 2005), AMED (January 1985 to February 2005) and LILACS (January 1982 to January 2003). We reviewed the bibliographies of the randomized controlled trials identified, and contacted authors and experts in the field. SELECTION CRITERIA: We included quasi-randomized or randomized controlled trials of participants with probable or definite amyotrophic lateral sclerosis according to the El Escorial diagnostic criteria (or a revised version) or the Airlie House revision. We would have included trials of physical therapy, modalities, prescription medications, non-prescription medications, chemical neurolysis, surgical interventions, and alternative therapies. Our primary outcome measure was reduction in spasticity at three months or greater as measured by the Ashworth (or modified Ashworth) spasticity scale. Our secondary outcome measures were: validated measures based on history, physical examination, physiological measures, measures of function, measures of quality of life, serious adverse events, and measures of cost. DATA COLLECTION AND ANALYSIS: We identified only one randomized controlled trial that met our inclusion criteria. Two authors extracted the data. We also contacted the author of the paper and obtained information not available in the published article. MAIN RESULTS: The included study was a trial of moderate intensity, endurance type exercise versus 'usual activities' in 25 patients with amyotrophic lateral sclerosis. At three months patients performing the 15 minute twice daily exercises had significantly less spasticity overall (mean reduction of -0.43, 95% CI -1.03 to +0.17 in the treatment group versus an increase of +0.25, 95% CI -0.46 to +0.96 in control) but the mean change between groups was not significant (-0.68, 95% CI -1.62 to +0.26), as measured by the Ashworth scale. AUTHORS' CONCLUSIONS: The single trial performed was too small to determine whether individualised moderate intensity endurance type exercises for the trunk and limbs are beneficial or harmful. No other medical, surgical or alternative treatment and therapy has been evaluated in a randomized fashion in this patient population. More research is needed.

Home versus center based physical activity programs in older adults.

BACKGROUND: Physical inactivity is a leading cause of preventable death and morbidity in developed countries. In addition physical activity can potentially be an effective treatment for various medical conditions (e.g. cardiovascular disease, osteoarthritis). Many types of physical activity programs exist ranging from simple home exercise programs to intense highly supervised hospital (center) based programs. OBJECTIVES: To assess the effectiveness of 'home based' versus 'center based' physical activity programs on the health of older adults. SEARCH STRATEGY: The reviewers searched the Cochrane Central Register of Controlled Trials (CENTRAL) (1991-present), MEDLINE (1966-Sept 2002), EMBASE (1988 to Sept 2002), CINAHL (1982-Sept 2002), Health Star (1975-Sept 2002), Dissertation Abstracts (1980 to Sept 2002), Sport Discus (1975-Sept 2002) and Science Citation Index (1975-Sept 2002), reference lists of relevant articles and contacted principal authors where possible. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials of different physical activity interventions in older adults (50 years or older) comparing a 'home based' to a 'center based' exercise program. Study participants had to have either a recognised cardiovascular risk factor, or existing cardiovascular disease, or chronic obstructive airways disease (COPD) or osteoarthritis. Cardiac and post-operative programs within one year of the event were excluded. DATA COLLECTION AND ANALYSIS: Three reviewers selected and appraised the identified studies independently. Data from studies that then met the inclusion/exclusion criteria were extracted by two additional reviewers. MAIN RESULTS: Six trials including 224 participants who received a 'home based' exercise program and 148 who received a 'center based' exercise program were included in this review. Five studies were of medium quality and one poor. A meta-analysis was not undertaken given the heterogeneity of these studies. CARDIOVASCULAR. The largest trial (accounting for approximately 60% of the participants) looked at sedentary older adults. Three trials looked at patients with peripheral vascular disease (intermittent claudication). In patients with peripheral vascular disease center based programs were superior to home at improving distance walked and time to claudication pain at up to 6 months. However the risk of a training effect may be high. There are no longer term studies in this population. Notably home based programs appeared to have a significantly higher adherence rate than center based programs. However this was based primarily on the one study (with the highest quality rating of the studies found) of sedentary older adults. This showed an adherence rate of 68% in the home based program at two year follow-up compared with a 36% adherence in the center based group. There was essentially no difference in terms of treadmill performance or cardiovascular risk factors between groups. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD). Two trials looked at older adults with COPD. In patients with COPD the evidence is conflicting. One study showed similar changes in various physiological measures at 3 months that persisted in the home based group up to 18 months but not in the center based group. The other study showed significantly better improvements in physiological measures in the center based group after 8 weeks but again the possibility of a training effect is high. OSTEOARTHRITIS. No studies were found. None of the studies dealt with measures of cost, or health service utilization. AUTHORS' CONCLUSIONS: In the short-term, center based programs are superior to home based programs in patients with PVD. There is a high possibility of a training effect however as the center based groups were trained primarily on treadmills (and the home based were not) and the outcome measures were treadmill based. There is conflicting evidence which is better in patients with COPD. Home based programs appear to be superior to center based programs in terms of the adherence to exercise (especially in the long-term).

Marijuana use and epilepsy: prevalence in patients of a tertiary care epilepsy center.

The authors sought to determine the prevalence of marijuana use in patients with epilepsy by performing a telephone survey in a tertiary care epilepsy center. Twenty-one percent of subjects had used marijuana in the past year with the majority of active users reporting beneficial effects on seizures. Twenty-four percent of all subjects believed marijuana was an effective therapy for epilepsy. Despite limited evidence of efficacy, many patients with epilepsy believe marijuana is an effective therapy for epilepsy and are actively using it.

Treatment for spasticity in amyotrophic lateral sclerosis/motor neuron disease.

BACKGROUND: Spasticity commonly affects patients with motor neuron disease and it is likely to contribute to worsening muscle dysfunction, increased difficulty with activities of daily living and deteriorating quality of life. OBJECTIVES: The objective of this review is to systematically review all types of treatments for spasticity in amyotrophic lateral sclerosis, also known as motor neuron disease. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group specialised trials register (searched January 2003), MEDLINE (January 1966 to January 2003), EMBASE (January 1980 to January 2003), CINAHL (January 1982 to January 2003), AMED (January 1985 to January 2003) and LILACS (January 1982 to January 2003) for randomized controlled trials. We reviewed the bibliographies of the randomized trials identified, and contacted trial authors and known experts in the field. SELECTION CRITERIA: We included quasi-randomized or randomized controlled trials of participants with probable or definite amyotrophic lateral sclerosis according to the El Escorial diagnostic criteria (or a revised version) or the Airlie House revision. We would have included trials of physical therapy, modalities, prescription medications, non-prescription medications, chemical neurolysis, surgical interventions, alternative therapies. Our primary outcome measure was reduction in spasticity at three months or greater as measured by Ashworth (or modified Ashworth) spasticity scale. Our secondary outcome measures were: validated measures based on history, physical examination, physiological measures, measures of function, measures of quality of life, serious adverse events, and measures of cost. DATA COLLECTION AND ANALYSIS: We identified only one randomized controlled trial that met the inclusion criteria for this review. Two authors extracted the data. We also contacted the author of the paper and obtained further information not available in the published article. MAIN RESULTS: The included study was a trial of moderate intensity, endurance type exercise versus 'usual activities' in 25 patients with amyotrophic lateral sclerosis. At three months patients performing the 15 minute twice daily exercises had significantly less spasticity (mean reduction of 0.43 Ashworth grades versus an increase of 0.25 in controls), as measured by the Ashworth scale. REVIEWER'S CONCLUSIONS: Individualized, moderate intensity, endurance type exercises for the trunk and limbs may help to reduce spasticity in motor neuron disease. No other medical, surgical or alternative treatment and therapy has been evaluated in a randomized fashion in this patient population.

Impact of plasma exchange on indices of demyelination in chronic inflammatory demyelinating polyradiculoneuropathy.

We studied the impact of plasma exchange (PE) on indices of primary demyelination in patients of the Canadian multicenter trial of PE in chronic inflammatory demyelinating polyneuropathy (CIDP). Individual motor nerves (median, ulnar, peroneal, tibial) were studied: distal motor latencies (DMLs), proximal and distal compound muscle action potential (M-wave) amplitudes, negative peak areas and durations, and motor conduction velocities (CVs). Proximal M-wave amplitudes in individual motor territories, particularly in the ulnar nerve (from below elbow, above elbow, and axillary stimulating sites) demonstrated significant improvement with PE, but not sham exchange. Proximal ulnar M-wave areas also had significant improvement with PE. Trends toward improvement of individual nerve motor CVs, M-wave durations, and DMLs did not achieve statistical significance. Proximal M-wave amplitudes, particularly in the ulnar motor territory, and proximal M-wave areas (providing a measure of conduction block) were the most sensitive indices of improvement conferred by PE in CIDP. In individual patients, these indices may help judge the efficacy of therapy.

The effect of temperature on nerve conduction parameters in carpal tunnel syndrome.

Correction factors exist to allow for the dramatic effect that temperature has on nerve conduction study parameters. However, these are based on normal nerves in normal individuals and may not be appropriate in the diseased nerve setting. Our clinical study showed that in carpal tunnel syndrome, the median nerve reacts differently to temperature changes compared with normal ulnar controls. Furthermore, statistically significant differences exist between the rates of change with increasing temperature in motor and sensory nerves.

Anterior interosseous nerve syndrome presenting with pronator teres weakness: a case report.

Anterior interosseous nerve syndrome (AINS) has been well described. A key muscle to examine clinically and on electromyography is the pronator teres, as this can differentiate between forearm and more proximal entrapment sites. We present a case of AINS with marked weakness and denervation of pronator teres. At operation the anterior interosseous nerve gave rise to the nerve to pronator teres and was entrapped by a fibrous band from the deep head of pronator teres.