[Comparison of manual lymph drainage with physical therapy in complex regional pain syndrome, type I. A comparative randomized controlled therapy study]. / Manuelle Lymphdrainage im Vergleich zur Physiotherapie bei Complex Regional Pain Syndrom Typ I. Randomisierte kontrollierte Therapievergleichsstudie.

Sympathetic blockage and physiotherapy are among the most effective treatment approaches for the complex regional pain syndrome (CRPS). It is important to institute the treatment as early as possible in order to avoid major functional limitations of the affected limb. Unfortunately, there is a paucity of vigorously applied randomised or placebo-controlled trials for these therapeutic approaches. A prospective randomised study of 35 outpatient clinic patients with type I complex regional pain syndrome of the lower extremities lasting less than 6 months is described. One of two treatments, exercise alone or exercise in combination with manual lymph drainage, was applied for six weeks, three times a week, to the affected limb. Clinical and subjective parameters for pain, swelling, temperature, and range of motion were evaluated. Manual lymph drainage was chosen as adequate therapy for oedema reduction, whereas exercise was applied as standard therapy for contracture prophylaxis in reflex sympathetic dystrophy. Both groups were asked not to use analgesics but received extensive instructions for avoiding pain. Significant improvements in clinical parameters were observed in both groups, but no significant effect between treatment groups was found. Pain measurement alone with a verbal rating scale showed a tendency towards greater pain reduction in the group receiving lymph drainage. The results indicate that, during the first 6 months of complex regional pain syndrome type I, manual lymph drainage provides no additional benefit when applied in conjunction with an intensive exercise program.

The role of the biarticular agonist and cocontracting antagonist pair in isometric muscle fatigue.

Isometric knee extensions until exhaustion at 30%, 50%, and 70% of maximum voluntary contraction were performed by 18 healthy subjects. During muscle fatigue, surface electromyographic activity was recorded from the knee-extensors vastus lateralis, vastus medialis, and rectus femoris, and the coactive antagonistic biceps femoris. The electromyographic parameter median frequency (MF) served as a measure of fatigue. Coefficients of regression of the MF fatigue changes were analyzed statistically. MF fatigue occurred within the coactive biceps femoris and was significantly more pronounced than in the quadriceps. When the MF fatigue shifts of the coactive biceps femoris were compared with each of the three investigated parts of the quadriceps separately, MF fatigue shifts were similar in shape for the biarticular coactive biceps femoris and the biarticular rectus femoris, but differed significantly between the biceps femoris and the two monoarticular muscles, vastus medialis and vastus lateralis. As both the biarticular agonist and coactive antagonist muscles fatigued at a higher rate than the two monoarticular muscles, it seems likely that this biarticular agonist/antagonist pair determines the time to the limit of endurance.

EMG fatigue patterns accompanying isometric fatiguing knee-extensions are different in mono- and bi-articular muscles.

OBJECTIVES AND METHODS: Isometric, fatiguing knee-extensions at 30%, 50% and 70% maximum voluntary contraction (MVC) were performed by 18 healthy human subjects. Surface electromyographic (SEMG) activity was recorded from the mono-articular vastus medialis (VM) and vastus lateralis (VL) muscles, and the bi-articular rectus femoris muscle (RF). To make the bi-articular muscle work under (1) constant and (2) similar working conditions as the two mono-articulars do, the hip was fixed in a flexed position. The root mean square (RMS) SEMG recorded during fatigue was standardized to the respective values of MVC. The mean coefficients of regression of the RMS and median frequency (MF) changes were then analyzed by multivariate analysis of variance. RESULTS: The load effect upon the muscle fatigue changes, as measured by increase in RMS EMG, differed between the bi-articular muscle and the two mono-articulars, in that the parameter dropped with maximum load for the bi-articular, whilst it remained stable or even increased for the mono-articulars. This might suggest that the mono- and bi-articular muscles have different roles in fatigue tasks where the bi-articulars function purely as mono-articulars. By contrast, such a clear dichotomy between the bi-articular RF and the two mono-articulars, VM and VL, was lacking for the fatigue parameter of MF. CONCLUSIONS: As these findings were confined to the changes in RMS EMG, different neuronal coding mechanisms for the mono- and bi-articular muscles in the central nervous system may be inferred.

Ultrasound treatment for treating the carpal tunnel syndrome: randomised "sham" controlled trial.

OBJECTIVE: To assess the efficacy of ultrasound treatment for mild to moderate idiopathic carpal tunnel syndrome. DESIGN: Randomised, double blind, "sham" controlled trial with assessments at baseline, after 2 weeks' and 7 weeks' treatment, and at a follow up assessment 6 months later (8 months after baseline evaluation). SETTING: Outpatient clinic of a university department of physical medicine and rehabilitation in Vienna. SUBJECTS: 45 patients with mild to moderate bilateral carpal tunnel syndrome as verified by electroneurography. INTERVENTION: 20 sessions of ultrasound (active) treatment (1 MHz, 1.0 W/cm2, pulsed mode 1:4, 15 minutes per session) applied to the area over the carpal tunnel of one wrist, and indistinguishable sham ultrasound treatment applied to the other. The first 10 treatments were performed daily (5 sessions/week); 10 further treatments were twice weekly for 5 weeks. MAIN OUTCOME MEASURES: Score of subjective symptom ratings assessed by visual analogue scale; electroneurographic measures (for example, motor distal latency and sensory antidromic nerve conduction velocity). RESULTS: Improvement was significantly more pronounced in actively treated than in sham treated wrists for both subjective symptoms (P < 0.001, paired t test) and electroneurographic variables (motor distal latency P < 0.001, paired t test; sensory antidromic nerve conduction velocity P < 0.001, paired t test). Effects were sustained at 6 months' follow up. CONCLUSION: Results suggest there are satisfying short to medium term effects due to ultrasound treatment in patients with mild to moderate idiopathic carpal tunnel syndrome. Findings need to be confirmed, and ultrasound treatment will have to be compared with standard conservative and invasive treatment options.

[Acupuncture in the treatment of a posttraumatic pain syndrome]. / Akupunktura v likuvanni pisliatravmatychnoho bol'ovoho syndromu.

Overall, fourteen patients with reflex sympathetic dystrophy (Sudeck's disease) presenting with pain syndrome were examined. The diagnosis was made on the basis of clinical symptomatology and was confirmed by thermographic and scintigraphic investigations. The patients were divided into two groups and they were administered double blind classical and sham acupuncture treatments, under the exposure to which treatments the pains began to subside in the above patients, with their general wellbeing having gotten improved.

Five phase bone scintigraphy supports the pathophysiological concept of a subclinical inflammatory process in reflex sympathetic dystrophy.

This study evaluates quantitative and qualitative patterns of bone scintigraphy and correlates them to laboratory findings and clinical signs to reveal possible inflammatory reactions in RSD. Activity ratios between the affected hand/foot and the contralateral side were calculated in 99mTc DPD-bone scintigraphy for five phases (arterial: 0-30 sec, early blood pool: 0.5-5 min. late blood pool: 5-15 min, 3 hrs early bone, 24 hrs late bone phase) and the presence of five scintigraphic signs in the bone phases was assessed. Activity ratios of all phases correlated with ESR those in the early and late bone phase correlated with alpha 2 globulin and beta globulin concentrations and those in the arterial, the early and late blood pool phase with the gamma globulin concentrations, respectively. Clinical features such as pain, swelling, physical force, temperature differences and the duration of symptoms did not correlate to the activity ratios. However, three signs in the bone phase were negatively correlated to albumin concentrations. Positive correlations were found for alpha 2, gamma globulin concentrations, ESR, neutrophil cell counts and individual uptake patterns. We conclude that the quantitative analysis of five phase bone scintigraphy in RSD reveals different aspects of tracer kinetics and provides different pathophysiological information. Lateralization of regional hyperemia, increased micro vascular permeability and bone metabolism in RSD parallels shifts in protein concentrations and blood cell counts that are suggestive of a subacute inflammatory process, even in patients with no overt signs of inflammation.

Pattern recognition in five-phase bone scintigraphy: diagnostic patterns of reflex sympathetic dystrophy in adults.

The objective of this study was to assess qualitative and quantitative patterns of tracer accumulation to increase the diagnostic utility of bone scintigraphy in reflex sympathetic dystrophy (RSD). Of 120 patients with high clinical suspicion for RSD, 96 were confirmed as having RSD during follow-up, while the remaining 24 were used as controls. Clinical parameters were measured and correlated to five activity ratios (0-30 s, 0.5-5 min, 5-15 min, 3 h, 24 h) and five scintigraphic signs. Monitoring three dynamic phases revealed different tracer kinetics of potential diagnostic utility; however, the 24-h bone phase offered no additional diagnostic contribution and can be omitted. Quantification provided objective parameters for the duration of symptoms, pain and impairment of movement but not for surface temperature differences, swelling and impairment of physical force. It is of limited use for diagnosis except for the exclusion of disease. Discriminant analysis revealed the combination of three signs (diffuse uptake in carpus/tarsus+diffuse uptake in all small joints+increased activity ratio in the late blood pool phase) to be the pattern with the highest diagnostic accuracy independent of localisation, sex, age and precipitating factors. It is concluded that the scintigraphic confirmation of RSD is based on lateralisation in the late blood pool phase and the described pattern in the early bone phase.

[Differential diagnosis of diseases of the Achilles tendon. A clinico-sonographic concept]. / Differentialdiagnose von erkrankungen der Achillessehne.

Ultrasound of the Achilles tendon is a suitable means of differentiating various diseases of the tendon and the surrounding tissue. Different forms of degenerative disease (tendinitis, peritendinitis or bursitis, fibroosteitis, and Haglund's disease) can be discriminated from rheumatic and metabolic diseases. Congenital and developmental abnormalities can also be detected. Tendon degeneration mainly occurs in the ventral part of the medial third of the tendon ("critical zone"). Immature tissue in this area leads to temporary [correction of temorary] instability of the tendon with a high risk of rupture ("vulnerable phase"). With sonography, lesions of the Achilles tendon are visible early in the course of the disease.

Impaired hemorheology in patients with postmastectomy lymphedema.

Lymphedema of the arm is one of the most disabling and serious complications of breast cancer. Apart from tumor infiltration or fibrosis of lymphatic pathways, little is known about factors favoring the development of lymphedema. In the present study, we investigated the impact of rheologic parameters, e.g. red cell aggregation (EA) and plasma viscosity (PV), and of capillary morphology and capillary flow in patients with breast cancer with (n = 18) and without (n = 18) lymphedema. Patients with lymphedema showed a significant increase of red cell aggregation (p < 0.001) that indicates a systemic component of lymphedema and might offer a possibility of prevention and therapy of this condition. A hitherto unclassified protein factor favoring red cell aggregation and lymphedema might be postulated.

[Description of a patient profile of ambulatory physical medicine facilities]. / Eine Beschreibung eines Patientenprofils ambulanter physikalisch-medizinischer Einrichtungen.

UNLABELLED: Beside objective diagnosis, the subjective feelings, of patients is of great importance in the field of physical medicine and rehabilitation. Evaluation of demographic data and quality of life of patients referred to an outpatient clinic of physical medicine and rehabilitation. DESIGN: Prospective, multi-center cross sectional study. Evaluation of impairment of the activities of daily living by a questionnaire based on the "Functional Assessment Screening Questionnaire" and the "Oswestry low back pain disability questionnaire" and of the perceived pain by a 100 nm visual analog scale (VAS). 1404 consecutive patients were included, 89% completed the questionnaire (n = 1250). Women 57.6%, men 42.3%, age 54.1 years. 67.6% of all diagnoses were related to the spine (36.7% cervical spine, 32.8% lumbar spine, 30.5% whole spine). 13.8% to joints of the lower and 8.4% to joints of the upper extremities. Intensity of pain was rated: 79.7 mm on the VAS (38.9% of all patients claimed to perceive pain all time). Patients referred to an outpatient facility of physical medicine are impaired in their activities of daily living and their well-being by pain. Further outcome studies of physical medicine outpatient treatment will be based on questionnaires developed in this present study.

[Therapy relevant aspects of anatomy, pathophysiology and diagnosis of urinary incontinence in women]. / Therapierelevante Aspekte der Anatomie, Pathophysiologie und Diagnostik der weiblichen Harninkontinenz.

Many aspects of the pathogenesis of urinary incontinence are poorly understood. Most studies show good results for physical therapy for instance for pelvic floor exercises and biofeedback. Unfortunately most of these studies lack an objective diagnostic and neurophysiological assessment. This could be one reason for the strongly divergent therapeutical success rates reported (30 to 90%). We recommend the use of objective parameters, for instance the PAD test with standardized bladder volume and a neurophysiological and short urodynamic assessment as well as subjective parameters [satisfaction with the outcome of treatment measured with the VAS (visual analog scale), documentation of the changes in ADL (activities of daily living)] in future therapeutical studies. A more precise assessment of the pathological cause of the impairment will help to develop optimal therapeutic procedures. Because of poor documentation in the past the analysis of therapeutic failures and the decision if mono-or complex physiotherapy is more appropriate has not been possible. This aspect will become even more important as the cost-effectiveness of treatments becomes a more important issue.

[Wobenzyme and diuretic therapy in lymphedema after breast operation]. / Wobenzym- und Diuretikatherapie beim Lymphödem nach Mammaoperation.

The authors of this clinical study report the results of a controlled clinical trial in randomized parallel groups (Wobenzym vs. diuretics) of 55 female patients suffering from brachial arm lymph edema subsequent to ablatio mammae. All patients received manual and machine lymph drainage as well as gymnastics as concomitant therapy. After 7 weeks of therapy the results of the volometric assessments of the arm, the circumference of the arm and the skinfold thickness showed significant improvements compared to diuretics. In addition, the patients receiving Wobenzym reported a significantly higher proportion of patients free of pain compared to the diuretics patients. Overall safety assessment results are satisfactory thus resulting in a superior benefit/risk relation of the Wobenzym group.

[Neural therapy in the light of recent data]. / Die Neuraltherapie im Licht neuerer Daten.

In German-speaking countries, local injection of anesthetic is a popular form of treatment, either as "neural therapy", a complementary method intended to stimulate adaptive body functions, or as pure analgesia. While the latter is unquestionably effective, neither the rationale nor the individual mechanisms, nor its therapeutic efficacy have been investigated scientifically. Recent data show that the analgesic effect does not depend on the injection of local anesthetic. It is conceivable that this form of treatment acts via a mechanism known as diffuse noxious inhibition control.

[Cryotherapy]. / Kryotherapie.

Cryotherapy is defined as cooling of definitive parts of the body by means of ice packs, ice cubes, ice water or ethylchloride sprays. It is used in the treatment of a range of conditions including spasticity and hypertonus of the muscles, soft tissue lesions, arthritises, edema and pain. The known physiological effects and clinical efficacy associated with cooling are considered. Further research i.e. randomized, controlled studies in the field of clinical application is high-lighted.

Ice freezes pain? A review of the clinical effectiveness of analgesic cold therapy.

Among the physical treatments to reduce pain, ice has had its place for many years. Experience tells us that ice has a strong short-term analgesic effect in many painful conditions, particularly those related to the musculoskeletal system. Serial applications may also be helpful. The scientific evidence from clinical trials is, however, fragmentary. This applies both for acute and serial cold-induced analgesia. The mechanisms by which cryotherapy might elevate pain threshold include an antinociceptive effect on the gate control system, a decrease in nerve conduction, reduction in muscle spasms, and prevention of edema after injury. It is concluded that ice may be useful for a variety of musculoskeletal pains, yet the evidence for its efficacy should be established more convincingly.

A review of the clinical effectiveness of exercise therapy for intermittent claudication.

BACKGROUND: Intermittent claudication is both frequent and disabling. Conservative treatment consists of the elimination of risk factors, particularly smoking, drug treatment, and physical exercises. This review represents an attempt to define how effectively exercise prolongs the walking ability of claudicants. METHODS: A computerized literature search was done to identify all controlled trials on the subject. In addition, other studies were admitted if they were in accordance with certain quality criteria. RESULTS: Without exception, these studies showed that exercise can prolong the pain-free walking distance of claudicants. Even though this message seems uniform and convincing, one should point out that all trials are burdened with methodological flaws. The variability of increase in walking ability demonstrated in these studies is impressive and cannot be fully explained. A multitude of possible mechanisms could be involved in bringing about the clinical effect; at present it is impossible to define their relative importance. CONCLUSIONS: The optimal exercise program should be supervised, performed regularly for at least 2 months, and of high intensity. Appropriate steps to guarantee patients' compliance must be taken. Even though many fundamental questions remain unanswered, it is justified to prescribe exercise therapy for intermittent claudication more generally than is realized in today's practice.

[Conservative therapy of backache. Part 5: TENS, acupuncture, biofeedback, traction, cryotherapy, massage and ultrasound]. / Konservative Therapie von Kreuzschmerzen. Teil 5 (Schluss): TENS, Akupunktur, Biofeedback, Traktion, Kryotherapie, Massagen und Ultraschall.

In addition to the major therapeutic modalities for use in back pain already discussed, a number of other forms of treatment are also available and in common use some of which at least have a solid scientific basis. Recent data suggest that subthreshold TENS is no effective treatment for low back pain. Whether this is also true of higher-dose TENS is not yet clear. Electro-acupuncture, in contrast, does appear to be effective, but not biofeedback or traction. Other commonly employed treatment modalities, such as cryotherapy, heat, massage or ultrasound cannot definitively be assessed at present, since controlled trials have not been carried out.