Low-dose, low-volume chemonucleolysis. A biochemical study.

Thirty patients with persistent sciatica due to a single disc protrusion were injected with 0.5 ml (2.0 mg) or 2.0 ml (8.0 mg) of chymopapain. Serial 24-hour urine samples were collected 1 day preinjection and for 5 days postinjection for glycosaminoglycan analysis. There was a significant increase in urinary glycosaminoglycan in both groups following chemonucleolysis, but no significant difference was found between the two groups in the total excretion of glycosaminoglycan during the 5-day period. Low-dose, low-volume chemonucleolysis may be as effective as standard doses in releasing glycosaminoglycan from intervertebral discs.

A new non-invasive test for the detection of compartment syndromes.

Chronic exertional compartment syndrome (CECS) is currently diagnosed using invasive pressure measurements. We report the use of 99Tcm-methoxyisobutyl isonitrile (99Tcm-MIBI) scintigraphy as a new non-invasive method of diagnosis. Forty-six patients with suspected chronic compartment syndrome underwent graded treadmill exercise to reproduce the presenting symptoms. At peak exercise, 300 MBq of 99Tcm-MIBI were injected intravenously. Subsequent cross-sectional imaging provided by emission tomography demonstrated regional abnormalities in muscle perfusion in the calf. A repeat study was performed at rest the following day. All patients in whom there was a strong clinical suspicion of CECS were considered for invasive pressure measurements. Statistical analysis of the results for investigation of CECS using 99Tcm-MIBI versus pressure studies gave P = 0.06. A comparison of 99Tcm-MIBI versus outcome gave P < 0.0001. The sensitivity was 80% and the specificity 97% for 99Tcm-MIBI studies based on outcome. The positive predictive value was 89% and the negative predictive value 94%. Thus 99Tcm-MIBI can detect compartment syndromes with good positive and negative predictive values. It is relatively simple, cheap and less invasive than pressure measurements. This technique shows promise in the diagnosis of CECS.

Pulsed low-intensity ultrasound therapy for chronic lateral epicondylitis: a randomized controlled trial.

OBJECTIVES: Pulsed low-intensity ultrasound therapy (LIUS) has been found to be beneficial in accelerating fracture healing and has produced positive results in animal tendon repair. In the light of this we undertook a randomized, double-blind, placebo controlled trial to assess the effectiveness of LIUS vs placebo therapy daily for 12 weeks in patients with chronic lateral epicondylitis (LE). METHODS: Patients with LE of at least 6 weeks' duration were recruited from general practice, physiotherapy and rheumatology clinics, and had to have failed at least one first-line treatment including non steroidal anti-inflammatory drugs (NSAIDs) and corticosteroid injection. Participants were assigned either active LIUS or placebo. Treatment was self-administered daily for 20 min over a 12-week period. The primary end-point was a 50% improvement from baseline in elbow pain measured at 12 weeks using a patient-completed visual analogue scale. RESULTS: Fifty-five subjects aged 18-80 were recruited over a 9-month period. In the active group 64% (16/25) achieved at least 50% improvement from baseline in elbow pain at 12 weeks compared with 57% (13/23) in the placebo group (difference of 7%; 95% confidence interval -20 to 35%). However, this was not statistically significant (chi(2) = 0.28, P = 0.60). CONCLUSION: In this study LIUS was no more effective for a large treatment effect than placebo for recalcitrant LE. This is in keeping with other interventional studies for the condition.

Cutaneous reflex responses and their central nervous pathways studied in man.

1. Cutaneous reflex responses have been recorded in human first dorsal interosseous and extensor digitorum brevis muscles following electrical stimulation of the digital nerves of the index finger and second toe respectively.2. Recordings have been made in normal subjects and in patients with central nervous lesions.3. Cutaneous reflex responses in first dorsal interosseous were triphasic, consisting of initial short latency excitation, followed by inhibition, followed by prominent long latency excitation. Cutaneous reflex responses in extensor digitorum brevis were biphasic, consisting of short and long latency periods of excitation.4. Estimated central delay for the initial excitatory components of the cutaneous reflex in first dorsal interosseous and extensor digitorum brevis muscles ranged from 2.4 to 6.2 ms (mean 4.6 ms) and 0.6 to 4.1 ms (mean 2.3 ms) respectively.5. Differences in latency between short and long latency excitatory components of the cutaneous reflexes recorded in first dorsal interosseous and extensor digitorum brevis muscles ranged from 16 to 18 ms (mean 17.3 ms) and 27 to 32 ms (mean 29.3 ms) respectively.6. Differences in time delay between short and long latency excitation in first dorsal interosseous and extensor digitorum brevis muscles when compared in individual subjects ranged from 9 to 14 ms (mean 12 ms). These values lay within 0-7 ms (mean 4 ms) of estimates in each subject of conduction time along central pathways between T12 and C7 spinal segments.7. Differences in latency between short and long latency excitatory components of the cutaneous reflex recorded in first dorsal interosseous were 3.5-8.5 ms longer than the estimated minimum time for impulse conduction along a pathway travelling through the dorsal columns to cerebral cortex and returning by way of the corticospinal tract.8. The long latency excitatory component of the cutaneous reflex in first dorsal interosseous muscle is reduced and often delayed in patients with dorsal column lesions.9. The long latency excitatory and short latency inhibitory components of the cutaneous reflex in first dorsal interosseous muscle are absent in patients with damage to motor cortex.10. The long latency excitatory component of the cutaneous reflex in first dorsal interosseous muscle is reduced in amplitude and often delayed in patients with motoneurone disease causing damage to the corticospinal tract. The timing of short latency excitatory and inhibitory components is unchanged.11. It is concluded that the short latency excitatory and inhibitory components of the cutaneous reflex response of first dorsal interosseous muscle have a spinal pathway and that the interneurones mediating the inhibitory component are under descending extrapyramidal control from systems whose inputs are deranged by damage to motor cortex.12. It is concluded that the long latency excitatory component of the cutaneous reflex response of first dorsal interosseous muscle is of supraspinal origin requiring transmission of afferent impulses through the dorsal columns, a relay in the sensori-motor cortex and then descending transmission to the lower motoneurone pool by way of the corticospinal tract.

Digital vasculitis associated with joint sepsis in rheumatoid arthritis.

Digital vasculitis complicating RA is not infrequent and is usually benign but may herald the onset of systemic vasculitis. A case is reported of a man with longstanding seropositive RA who developed digital vasculitis in association with septicaemia and multiple joint sepsis. Awareness that the onset of digital vasculitis in RA may be related to infection is important. This is especially so since aggressive immunosuppressive therapy is often used in patients with systemic vasculitis.

Mechanism of action of intradiscal chymopapain in the treatment of sciatica: a clinical, biochemical, and radiological study.

Seventeen patients with intractable sciatica due to prolapse of a lumbar disc, treated by intradiscal injection of chymopapain (chemonucleolysis) were studied. Analysis of serial 24 hour urine collections showed a significant increase in urinary glycosaminoglycan after chemonucleolysis. This was not detected in four patients undergoing routine discography. Enzymic analysis of urinary glycosaminoglycan after chemonucleolysis suggested that the increase in levels was largely due to an increase in the amounts of chondroitin sulphate present, probably resulting from proteoglycan breakdown in the intervertebral disc. Eight of the patients treated by chemonucleolysis underwent serial computed tomography (CT). One month after the injection the only change seen was a loss of definition of the disc prolapse, which could be interpreted as a loss of turgidity in the disc as a result of proteoglycan breakdown by chymopapain. By six months the CT of those patients whose symptoms had improved showed that the degree of disc prolapse was usually less marked and the disc margin more clearly defined, suggesting that by this stage anatomical remodelling had occurred.

Balance evaluation in hemiparetic stroke patients using lateral forces applied to the hip.

A technique for assessing balance that involves applying predictable controlled forces to the hips is described. Impairments in hemiparetic stroke patients' balance were documented by comparing their hip movements during and after a push with those of control subjects of similar age. Stroke patients swayed further and took longer to stabilize hip position than did the control subjects. The disturbance to stroke patients' balance caused by the termination of lateral force caused them more difficulty than did the onset of the force. Differences between stroke patients' involved and noninvolved sides were more pronounced on release from a push than at its onset. The implications of the findings for the assessment and treatment of balance after stroke are discussed.

Current practice of prophylactic anticoagulation in Guillain-Barré syndrome.

OBJECTIVE: To document the incidence of venous thromboembolism in Guillain-Barré syndrome and current practice of anticoagulating these patients. DESIGN: Retrospective study. SETTING: Acute neurology and rehabilitation wards in a teaching hospital. SUBJECTS: Seventy-three patients with Guillain-Barré syndrome admitted to Addenbrooke's Hospital from 1995 to 1999. RESULTS: Out of 73 patients, 50 were anticoagulated (68%) for 5-490 days with mean of 72 days. Anticoagulation was discontinued in 28 patients when they could walk independently and in six who were still wheelchair dependent. Five patients developed clinical deep venous thrombosis (DVT) (7%), three of them had pulmonary emboli. Venous thrombosis occurred in the first two months after onset in four patients. Two patients were not anticoagulated when they developed their DVT and the other three were on enoxaparin; one of these three had a pulmonary embolism and died. CONCLUSION: Despite prophylactic anticoagulants being used in the majority of patients admitted with major problems of mobility, 6% (3 out of 50) still developed clinically detected DVT and two developed pulmonary embolism. While this incidence is considerably lower than data reported before routine anticoagulation became a standard practice, these data reinforce the need for anticoagulation and suggest that full anticoagulation might be needed to reduce the incidence of thromboembolic complications further.

Increased gastric juice epidermal growth factor after non-steroidal anti-inflammatory drug ingestion.

Epidermal growth factor (EGF), present in saliva and gastric juice, is a potent mitogen and an important element of mucosal defence. Changes in salivary and gastric juice epidermal growth factor in response to non-steroidal anti-inflammatory drug (NSAIDs) ingestion were measured to assess the role of EGF in gastric mucosal adaptation to NSAIDs. Patients with arthritis underwent endoscopy with collection of saliva and gastric juice for EGF measurement, before and two weeks after continuous NSAID ingestion. During this period patients also received either the prostaglandin analogue misoprostol or placebo in addition to their NSAID. In the misoprostol group (n = 5) there was no observed mucosal damage and no change in either salivary or gastric juice EGF. In the placebo group (n = 10) three patients developed erosions. Salivary EGF did not change (mean (SEM) 3.02 (0.54) ng/ml v 2.80 (0.41) ng/ml) but gastric juice EGF increased from 0.42 (0.12) ng/ml to 0.69 (0.14) ng/ml (p < 0.05). This increased EGF could contribute to the increased cellular proliferation observed during NSAID ingestion and may represent an important mechanism underlying gastric mucosal adaptation.

Demonstration of popliteal artery entrapment on leg muscle scintigraphy with 99mTc MIBI and single photon emission tomography.

Popliteal artery entrapment is difficult to diagnose even at surgery. Early diagnosis is important as the prognosis is better if detected before the onset of complications. There is no sensitive method for the evaluation of this condition. We describe three cases detected by a new technique using 99mTc methoxy isobutyl isonitrile (MIBI) with single photon emission tomography. The scintigraphic features of entrapment and the advantage of MIBI leg scintigraphy over other methods are discussed.

Changing patterns of postural hip muscle activity during recovery from stroke.

OBJECTIVE: To describe the recovery of neurophysiological responses to perturbation of standing balance after stroke. METHODS: Surface electromyography (EMG) from hip abductors and adductors and ground reaction forces (GRF) were measured in response to 20 sideways pushes applied to the pelvis by a linear motor. Each subject's data from pushes in each direction were averaged and the presence of a muscle EMG response was assessed visually. SUBJECTS: Thirteen acute hemiplegic patients were tested as soon as they could stand after stroke (median six weeks) and serially during recovery. RESULTS: Four patterns of hip muscle activity were seen: (1) no response at all, (2) no response in hemiparetic muscles but compensation by contralateral muscles, (3) an appropriate, if delayed, response in the hemiparetic abductor but not adductor muscles, and (4) a relatively normal pattern in both hemiparetic muscles. Nine of 13 patients showed a change in pattern of hip muscle activity during recovery. All patients who initially resisted the sideways pushes solely with muscles of the unaffected leg later regained use of the hemiparetic hip abductors. CONCLUSIONS: The pattern of hip muscle activation changed towards normal during recovery from stroke in most patients. Use of compensatory strategies early after stroke in these subjects did not prevent return of normal patterns of muscle activation later.

Ground reaction force after a sideways push as a measure of balance in recovery from stroke.

OBJECTIVE: To investigate if measuring ground reaction force after a sideways push at the hips gives a measure of standing balance in stroke subjects. METHODS: Fifteen control subjects and 13 right hemiparetic subjects who were able to stand independently stood with their feet on a single forceplate. Horizontal sideways pushes of 3% body weight were delivered to each side of the pelvis with the subjects held firmly in a semi-rigid belt. Measurements were made of lateral pelvic displacement (sway) and the lateral sheer component of ground reaction force (GRF). RESULTS: Right hemiparetic subjects showed significantly greater sway after a sideways push (p < 0.01) and later onset of GRF (p < 0.01) when pushed to their weak side compared with control subjects. There was also a positive correlation between sway after a sideways push and the onset latency of GRF in both strokes (0.41) and controls (0.61). The hemiparetic subjects swayed more (p < 0.01) when pushed to their weak side compared with their stronger side and their GRF latency was longer, but this latter measurement failed to reach statistical significance. No difference was seen between sides in sway or GRF latency in controls. CONCLUSIONS: The latency of GRF onset after a push at the hips in controls and in stroke subjects is related to sway and both measurements increase after a stroke. This test offers a method of measuring balance after a stroke, and serial testing of an individual after a stroke may prove a useful measure of an individual's recovery of balance.