[Perioperative Diagnostics of Peripheral Nerve Lesions and Compression Syndromes: Position Paper of the German-Speaking Group for Microsurgery of Peripheral Nerves and Vessels]. / Diagnostik von peripheren Nerven bei Läsionen und Kompressionssyndromen: Positionspaper der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie ­ (DAM).

The treatment of peripheral nerve pathologies requires a rapid and precise diagnosis. However, the correct identification of nerve pathologies is often difficult and valuable time is lost in the process. In this position paper of the German-Speaking Group for Microsurgery of Peripheral Nerves and Vessels (DAM), we describe the current evidence for various perioperative diagnostics for the detection of traumatic peripheral nerve lesions or compression syndromes. In detail, we evaluated the importance of clinical examinations, electrophysiology, nerve ultrasound and magnetic resonance neurography. Additionally, we surveyed our members for their diagnostic approach in this regard. The statements are based on a consensus workshop on the 42nd meeting of the DAM in Graz, Austria.

Contribution of individual spa therapies in the treatment of chronic pain.

OBJECTIVES: The aim of the present study was to evaluate the contribution of individual spa therapies administered during a period of 3 weeks on measures of well being and pain in a sample of patients with chronic back pain. DESIGN: One hundred fifty-three patients with chronic back pain undergoing inpatient spa therapy in Bad Tatzmannsdorf, Austria, participated in the study. According to the prescription of their spa physician, patients underwent two or more of the following treatments: mud packs, carbon dioxide baths, massages, exercise therapies, spinal traction, and electrotherapy. The outcome measures were general pain, back pain, negative mood, and health satisfaction. Regression analyses were conducted to predict the 4 outcome measures at the end of spa therapy and at 6 weeks' follow-up for all therapies applied. The pretreatment outcome measure, age, and sex were controlled for by entering them into the analysis. RESULTS: Patients showed significant improvements in all 4 outcome measures. The prediction of improvement was generally small: only 1% to 11% of the change of the outcome measures could be explained by the type and number of therapies received. On a short-term basis, mud packs and exercise were found to be associated with a greater improvement in mood, whereas a greater frequency of massage therapy and carbon dioxide baths was associated with a smaller improvement in health satisfaction. On a long-term basis, exercise therapy and spinal traction were associated with a greater reduction in back pain. CONCLUSIONS: The results indicate that, in addition to the individual therapies, other factors relating to spa therapy as a whole must contribute to overall treatment outcome. In addition, the results support the efficacy of exercise therapy for chronic back pain.

Complex regional pain syndrome.

PURPOSE: This paper provides a review of the current concepts of complex regional pain syndrome (CRPS) and current diagnostic criteria are presented. Etiology and pathophysiological mechanisms of painful disorders, previously addressed as reflex sympathetic dystrophy (RSD) remain doubtful. ISSUES: The supposition of a sympathetic hyperactivity in the development of this syndrome could not be confirmed. Up to now no diagnostic test that would be specific for the diagnosis of CRPS is available. The diagnosis relies on clinical findings and the exclusion of conditions that could account for the degree of pain and dysfunction. Pain relief and functional restoration are the primary goals of all therapeutic intervention and should start as early as possible.

Mutations at Ser331 in the HSN type I gene SPTLC1 are associated with a distinct syndromic phenotype.

Mutations in the serine palmitoyltransferase subunit 1 (SPTLC1) gene are the most common cause of hereditary sensory neuropathy type 1 (HSN1). Here we report the clinical and molecular consequences of a particular mutation (p.S331Y) in SPTLC1 affecting a patient with severe, diffuse muscle wasting and hypotonia, prominent distal sensory disturbances, joint hypermobility, bilateral cataracts and considerable growth retardation. Normal plasma sphingolipids were unchanged but 1-deoxy-sphingolipids were significantly elevated. In contrast to other HSN patients reported so far, our findings strongly indicate that mutations at amino acid position Ser331 of the SPTLC1 gene lead to a distinct syndrome.

Low-back pain assessment based on the Brief ICF Core Sets: diagnostic relevance of motor performance and psychological tests.

OBJECTIVE: The Brief International Classification of Functioning, Disability and Health (ICF) Core Sets for chronic low-back pain (cLBP) have included the three body functional categories sensation of pain, muscle functions, and emotional functions. As the latter two categories represent umbrella terms, the objective of this research was to identify those clinical tests that most expediently substantiate these two categories. DESIGN: This case-control study included 32 consecutive cLBP patients and 19 nonathletic healthy controls (HC), matched in age, body mass index, and sex. All patients and HCs underwent a comprehensive standardized clinical examination, with objective muscle functions tests that measured trunk muscle strength, endurance, and postural performance. Assessment of the category emotional functions included the Symptom Checklist 90-Revised, the Beck depression inventory, the Fear-Avoidance Beliefs Questionnaire (FABQ-D), and body experience (Borg category ratio scales about exertion, tension, fear of harm, and (re-)/injury). RESULTS: Logistic regression analyses revealed back muscle endurance and somatization to explain 50% of the between-group variances. Furthermore, the variables of Sensory Organization Test (SOT) composite score and FABQ were best associated with disablement in cLBP. CONCLUSIONS: In the Brief ICF Core Set for cLBP, back muscle endurance tests best examined the category muscle functions, whereas somatization best examined that of emotional functions. Furthermore, both the SOT and the FABQ would, in addition to the aforementioned tests, optimize the functional diagnostic relevance of the two ICF categories for cLBP.

Reliability and validity of the Medical Research Council (MRC) scale and a modified scale for testing muscle strength in patients with radial palsy.

OBJECTIVE: To assess the inter-rater and intra-rater reliability and validity of the original and a modified Medical Research Council scale for testing muscle strength in radial palsy. DESIGN: Prospective, randomized validation study. PATIENTS: Thirty-one patients with peripheral paresis of radial innervated forearm muscles were included. METHODS: Wrist extension, finger extension and grip strength were evaluated by manual muscle testing. Dynamometric measurement of grip strength was performed. Pair-wise weighted kappa coefficients were calculated to determine inter-rater and intra-rater reliability. The 2 scores were compared using the signed-rank test. Spearman's correlation coefficients of the maximal relative force measurements with the median (over-raters) Medical Research Council and modified Medical Research Council scores were calculated to determine validity. RESULTS: Inter-rater agreement of the Medical Research Council scale (finger extension: 0.77; wrist extension: 0.78; grip strength: 0.78) and the modified Medical Research Council scale (finger extension: 0.81; wrist extension: 0.78; grip strength: 0.81) as well as intra-rater agreement of the Medical Research Council scale (finger extension: 0.86; wrist extension: 0.82; grip strength: 0.84) and the modified Medical Research Council scale (finger extension: 0.84, wrist extension: 0.81; grip strength: 0.88) showed almost perfect agreement. Spearman's correlation coefficients of the maximal relative force measurements with the median Medical Research Council and modified Medical Research Council score were both 0.78. CONCLUSION: Medical Research Council and modified Medical Research Council scales are measurements with substantial inter-rater and intra-rater reliability in evaluating forearm muscles.

Variations in the output power and surface heating effects of transducers in therapeutic ultrasound.

OBJECTIVE: To determine the real emitted output power and maximum surface heating of commercial therapeutic ultrasound transducers emitting in air for various therapeutic regimens. DESIGN: Surface temperatures of ultrasound transducers with frequencies of .05 to 3 MHz were detected over 5 minutes by using a calibrated infrared thermographic camera; additionally, the indicated output power was checked with a radiation force balance. SETTING: University center for biomedical engineering and physics and medical school for physical medicine and rehabilitation. PARTICIPANTS: Not applicable. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Power variations and surface temperatures of clinical devices were analyzed to determine whether they comply with obligatory limits given in International Electrotechnical Commission standard 60601-2-5. RESULTS: Depending on the operation mode and the output power, surface temperatures ranged between 24.2 degrees to 80 degrees C within 5 minutes. Differences between measured and displayed power output (limit, +/-20%) ranged between -32% and 28%. CONCLUSIONS: The effectiveness of treatment is lowered if the value of emitted power is not known reliably. In the worst case, damage or irritation of the skin is possible, particularly in patients with sensory compromised skin. Damage may be caused by hot surfaces if the threshold level required to activate the device is lowered or if the device is defective. Improved thermal control units are necessary to prevent potential thermal hazards. Regular checks of transducer emission should be obligatory to ensure correct and precise function of the clinical devices.

[The role of gender medicine in rehabilitation]. / Rehabilitation unter geschlechtsspezifischen Aspekten.

This article provides a coherent view of gender differences in rehabilitation medicine from the biological, individual and social perspective. It reports the role of gender in pain, in rehabilitation of the musculosceletal system and in rehabilitation of patients with prostate cancer.

Relative slowing of the median antidromic sensory nerve conduction velocity to the ring finger in screening for carpal tunnel syndrome.

PURPOSE: This study analyzed the accuracy of the relative slowing of the antidromic sensory conduction velocity of the median nerve in comparison with the ulnar nerve, from the wrist to the ring finger, in the diagnosis of carpal tunnel syndrome (CTS). METHODS: Eighty-two patients had been referred consecutively to our department to confirm or exclude CTS. The antidromic sensory conduction velocities of the median nerve and the ulnar nerve from the wrist to the ring finger were determined. The difference between the 2 values was calculated to express the relative slowing of the median nerve compared with the ulnar nerve. Carpal tunnel syndrome was diagnosed when the patient had clinical symptoms compatible with CTS confirmed by an established electrophysiologic investigation. The accuracy of a relative slowing of 5 m/s, 10 m/s, and 15 m/s of the median antidromic sensory conduction velocity to the ring finger was determined to diagnose CTS. RESULTS: At a cut-off value of 5 m/s the sensitivity was 95%, the specificity was 63%, and the efficiency was 79%. At a cut-off value of 10 m/s the sensitivity was 90%, the specificity was 85%, and the efficiency was 88%. At a cut-off value of 15 m/s the sensitivity decreased to 83%, the specificity increased to 93%, and the efficiency was 88%. CONCLUSIONS: A high accuracy is achieved in the diagnosis of CTS by determining the relative slowing of the median antidromic sensory nerve conduction velocity from the wrist to the ring finger.

Chronaxie and accommodation index in the diagnosis of muscle denervation.

OBJECTIVE: To determine the sensitivity of the combined measurement of chronaxie and the accommodation index in the qualitative diagnosis of muscle denervation with needle electromyography and to compare quantitative diagnoses. DESIGN: Ninety-three neurogenic muscles diagnosed by needle electromyography were consecutively included for measurement of chronaxie and the accommodation index in this prospective study. The sensitivity of qualitative diagnosis was assessed for all muscles, separately for the acute and subacute-chronic denervation phase and for the complete and partial denervation. RESULTS: The combined measurement of chronaxie and the accommodation index showed a 90% sensitivity to needle electromyography for qualitative diagnosis of muscle denervation for all muscles. A 100% sensitivity was found for the acute denervation phase and for complete denervation. The subacute-chronic denervation phase revealed a 86% sensitivity, and partial denervation had a 88% sensitivity. The kappa coefficients did not show satisfactory agreement in quantitative diagnosis, and Bowker's test revealed a statistically significant underestimation of muscle denervation for measurement of chronaxie. CONCLUSION: The combined measurement of chronaxie and the accommodation index can be recommended for the screening of neurogenic lesions in the acute denervation phase.