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   2016| January-March  | Volume 43 | Issue 1  
    Online since February 24, 2016

 
 
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ORIGINAL ARTICLES
Manual therapy intervention in the treatment of patients with carpal tunnel syndrome: median nerve mobilization versus medical treatment
Faten I Mohamed, Amal A Hassan, Rasha A Abdel-Magied, Reem N Wageh
January-March 2016, 43(1):27-34
DOI:10.4103/1110-161X.177424  
Background Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. Median nerve mobilization is a manual therapy intervention used for treating CTS. Aim The aim of the present study was to investigate the effectiveness of median nerve mobilization in relieving manifestations of CTS when compared with conventional medical treatment. Patients and methods A total of 28 CTS patients were divided into two groups: patients in group I (n = 18) underwent median nerve mobilization, and those in group II (n = 10) underwent conventional medical treatment. Median nerve mobilization consisted of 18 treatments (three/week for 6 weeks). Patients were assessed for hand sensitivity, paresthesia, strength, pain, night awakening, thenar eminence atrophy, and were subjected to Phalen's test, Tinel's sign, Boston Carpal Tunnel Questionnaire's Symptom Severity Scale (BCTQ-SSS) and Functional Status Scale (BCTQ-FSS), and sensory and motor conduction studies for median nerve at baseline and at 6 weeks after treatment. Results At baseline versus at 6 weeks, pain, sensation, paresthesia, tingling, Tinel's signs, and Phalen's test outcomes were significantly improved in both groups; wrist flexion and extension improved only in group I. The difference between group I and group II after 6 weeks was significant as regards tingling, pain, wrist flexion, and extension. BCTQ-SSS and BCTQ-FSS scores improved after 6 weeks compared with baseline in patients in group I, whereas in group II the improvement was observed in BCTQ-FSS; the difference between the groups was significant. Sensory nerve conduction velocity, sensory distal latency, sensory amplitude, distal motor latency, and motor amplitude were significantly improved after 6 weeks in group I. In addition, there was a change in the grade of CTS, whereas in group II there was improvement only in sensory nerve conduction velocity; the difference between the groups was not significant. Conclusion CTS improves after median nerve mobilization, which is better than conventional medical treatment. It provides support for the use of manual therapy in conservative management of CTS with satisfactory results.
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Hemophilic arthropathy: clinical, radiologic, and functional evaluation: a single-center experience in a limited resource country
Hayam M Abdel Ghany, Hoda M.A. Hassab, Khaled I El-Noueam
January-March 2016, 43(1):35-40
DOI:10.4103/1110-161X.177425  
Introduction Hemophilia A and B are clinically indistinguishable and are heterogeneous disorders. The severity of bleeding symptoms correlates with the coagulant activity of the deficient factor. Joint bleeding initially leads to independent adverse changes in both the synovial tissue and the articular cartilage. Aim The aim of the present work was to evaluate hemophilic joints clinically, radiologically, and functionally in patients with hemophilic arthropathy. Materials and methods The study was carried out on 30 boys suffering from hemophilic arthropathy; the mean age was 10.6 ± 2.95 years. All patients were subjected to thorough history taking and local physical examination of the 'target joint'. Functional Independence Score in Hemophilia (FISH) and the Pettersson scoring system were assessed for all patients. Results The age at first hemarthrosis decreased with the severity of hemophilia, whereas the number of bleeds/year and the number of joints affected increased with the severity, and the results were statistically significant. A statistically significant positive correlation was found between the Pettersson score and both the age of the patients and the number of bleeds/year. However, a negative correlation was found with factor activity level. In contrast, the FISH score had a significant positive correlation with factor activity level. Conclusion A significant decrease in the functional ability was demonstrated on the basis of the severity of hemophilia. Both the FISH and Pettersson scoring systems are of great importance in assessing patients with hemophilic arthropathy.
  2,870 392 1
Needle electromyography in carpal tunnel syndrome: is it valuable or predictable?
Wafaa S El-Emary, Marwa M Hassan
January-March 2016, 43(1):41-46
DOI:10.4103/1110-161X.177426  
Context Needle electromyography (EMG) examination is not crucial in establishing the diagnosis of carpal tunnel syndrome (CTS). However, the presence of axonal loss in needle EMG helps clinicians determine a treatment strategy such as surgery. Aim of the work The aim of this study was to investigate whether needle EMG in CTS patients is essentially needed or could be predicted using other nerve conduction study (NCS) parameters. Materials and methods This study included 100 patients with clinical and NCS-proven CTS, as well as 50 age-matched and sex-matched controls. All individuals were evaluated using electrodiagnostic techniques, including median distal latency, compound muscle action potential (CMAP), forearm motor nerve conduction velocity, median peak latency, sensory nerve action potentials, and sensory nerve conduction velocity. All CTS patients underwent EMG examination of the abductor pollicis brevis muscle, and the presence or absence of spontaneous EMG activity was recorded. Results Comparison of the NCS parameters between CTS patients with and without spontaneous EMG activity revealed that the main determinant parameters for spontaneous activity were CMAPs, sensory nerve action potentials, and forearm motor nerve conduction velocities. However, logistic regression analysis showed that CMAP was the most powerful predictor of the presence of spontaneous activity (P = 0.000, odds ratio = 12.154). Conclusion It can be concluded that median nerve CMAP amplitudes are the most powerful predictors of the occurrence of spontaneous EMG activity. However, EMG examination is still valuable in some CTS patients and NCS cannot completely replace needle EMG examination in these patients.
  1,973 174 1
Magnetic resonance spectroscopy in evaluation of cerebral chemical changes in fibromyalgia patients
Abd Elsamad I Elhewala, Ahmad A Emerah, Amany A Elqresh, Ayman F Zeid
January-March 2016, 43(1):7-13
DOI:10.4103/1110-161X.177420  
Fibromyalgia (FM) is a clinical syndrome defined by the presence of chronic widespread musculoskeletal pain and the presence of at least 11 of 18 body tender points and these features are often accompanied by other symptoms such as fatigue, poor sleep quality, loss of memory, and mood disturbance. The aim of this work was to investigate the role of magnetic resonance spectroscopy (MRS) to detect the differences in cerebral chemical changes between FM patients and control participants. Thirty patients with primary FM (27 females and three males) were selected from the outpatient clinic of the Department of Rheumatology and Rehabilitation, Faculty of Medicine, Zagazig University Hospitals. Patients with primary FM fulfill the American College of Rheumatology criteria for diagnosis of FM. Ten persons were needed as healthy control participants with the same age and sex as the included patients. 1 H-MRS unit was used to assess N-acetyl aspartate (NAA), choline (Cho), creatine (Cr), and their ratios from both hippocampi. Our results showed the following: there was a significant difference in the level of l-hippocampal (NAA) and right hippocampus Cho and the levels of hippocampal glutamate/glutamine (Glx) in the patient group compared with the control group. There is a highly significant difference between the level of Rt and Lt hippocampal Glx in the same patient, highly significant difference in the level of Rt and Lt hippocampal NAA/Cr, NAA/Cho, and left hippocampal Cho/Cr ratios between cases and controls, and there was a negative correlation between the number of tender points and the level of Lt hippocampal Cr. Moreover, there was a significant difference between the number of tender points and the level of Rt hippocampal NAA and Lt hippocampal Ch/Cr ratios, highly significant difference between the level of Rt hippocampal NAA/Cho, NAA/Cr, and Lt NAA/Cr and number of tender points, and a highly significant difference between the level of Rt hippocampal NAA/Cho, Rt NAA/Cr, Lt NAA/Cr, and number of tender points (P < 0.001). There was a highly significant difference between the level of Rt hippocampal NAA/Cho, Lt hippocampal NAA/Cr, and visual analogue scale, and there was a significant difference between the level of Rt hippocampal NAA/Cho, Lt hippocampal NAA/Cr, and fibromyalgia impact questionnaire. Conclusion These findings outline the possible nature of FM as a systemic disorder that is mainly expressed through sensorineural dysfunction and abnormal neuroendocrine stress responses.
  1,216 126 -
Musculoskeletal ultrasonographic findings of the affected and unaffected shoulders in hemiplegic patients
Fatma Ali, Mona Hamdy, Rasha A Abdel-Magied, Mostafa M Elian
January-March 2016, 43(1):14-20
DOI:10.4103/1110-161X.177421  
Background There are many sonographic changes in affected and unaffected shoulders in patients with established hemiplegia. Aim The aim of this study was to evaluate the sonographic findings of hemiplegic shoulder in patients after acute stroke and the detection of the correlation between the physical or sonographic findings and early-onset hemiplegic shoulder pain. Patients and methods Shoulders of 30 patients with cerebrovascular stroke (six male and 24 female patients), 18 with right-sided and 12 with left-sided established hemiplegia, were tested. Wasting and weakness of the deltoid were recorded in the involved side. Musculoskeletal ultrasonography examination of both affected and unaffected shoulders of all patients was carried out. Two physicians classified the severity of the injury on a six-point rating scale, and Brunnström motor recovery stages and Brief Pain Inventory score were assessed. Results Biceps tendon calicification, tendinosis, and tear (73.3, 76.6, and 13.3%, respectively), deltoid calcification and tendinosis (33.3 and 33.3%, respectively), supraspinatus calcification and tear (53.3 and 26.7%, respectively), and the subacromial-subdeltoid bursitis (43.75%) were the most frequent abnormalities in the affected painful shoulder. No significant relationship (P = 0.1) was found between the US grades of the painful hemiplegic shoulder and the Brunnström motor recovery stages. Ultrasonographic grades of the unaffected shoulder correlated with the stroke duration (P = 0.001). The ultrasonographic rating scores of hemiplegic shoulders correlated with age, duration of stroke, shoulder pain duration, limitation of shoulder movement, the Brief Pain Inventory score and degree of spasticity (P = 0.04, 0.03, 0.001, 0.03, 0.046, and 0.001, respectively). Conclusion Hemiplegic stroke results in injury to the affected shoulder and the shoulder on the unaffected side. Musculoskeletal ultrasonography is an essential method in the evaluation of poststroke painful hemiplegic shoulder. However, the US grades did not correlate with the stages of motor recovery.
  1,145 147 -
Sensory changes in pediatric patients with spinal muscular atrophy: an electrophysiologic study
Hussien E Sultan, Wafaa S El-Emary
January-March 2016, 43(1):1-6
DOI:10.4103/1110-161X.177419  
Context Spinal muscular atrophy (SMA) is well known to be a pure motor neuron disease. However, it was reported that sensory neuron degeneration can also occur in pediatric SMA. Aim of the work The aim of the present study was to assess peripheral and central sensory abnormalities in pediatric SMA patients. Materials and methods The present study included 29 type I and 11 type II SMA patients diagnosed on the basis of clinical history and typical electromyographic patterns, and 25 age-matched and sex-matched healthy pediatric participants, who comprised the control group. Sensory and motor conduction studies were carried out for both groups. Sensory conduction studies of sural and median nerves assessed peak latency, sensory nerve action potential (SNAP) amplitude, and sensory nerve conduction velocity. Mixed posterior tibial somatosensory evoked potential latency and amplitude were also assessed for both groups. Results SMA I patients had lower sural and median SNAP amplitudes, as well as lower peroneal and femoral compound muscle action potential amplitudes, slower tibial motor conduction velocity (MCV), and prolonged femoral and peroneal distal latency compared with the control group. SMA II patients had lower sural SNAP amplitude, slower sural sensory nerve conduction velocity, lower tibial somatosensory evoked potential amplitude, and lower tibial peroneal and femoral compound muscle action potential amplitudes, as well as slower tibial motor conduction velocity and prolonged peroneal distal latency, compared with the control group. Conclusion Sensory neuron and/or axonal affection have been demonstrated in the studied series of pediatric SMA patients suggesting that the pathological changes in SMA may also involve the sensory system.
  1,074 140 -
Impact of obesity on functional and laboratory parameters in patients with rheumatoid arthritis
Abdou Ellabban, Mohammed Abdelhakeem, Mona Hamdy, Israa Fathy
January-March 2016, 43(1):21-26
DOI:10.4103/1110-161X.177423  
Background Overweight patients with rheumatoid arthritis (RA) have more disease activity, lower rates of remission, and twice as likely to require a tumor necrosis factor inhibitor. Provided that the prevalence of obesity is increasing, this may significantly affect RA incidence. An association between obesity and RA is logic, as biologic mechanisms of inflammation are present in fatty tissue, and it may be a trigger to chronic systemic inflammation. Human obesity is characterized by increased plasma leptin levels, which if elevated in morbidly obese patients may enhance constitutive immunological stimuli and increased levels of inflammatory marker. Objectives The aim of this study was to assess the impact of obesity and serum leptin level on disease activity and functional outcome in RA patients. Patients and methods This study was carried out at Minia University Hospital, Egypt. Patients were recruited from Rheumatology Outpatient Clinic from October 2012 to June 2013. It included 36 RA patients, fulfilling the 2010 ACR/EULAR classification criteria. They were divided into two groups: obese patients with a BMI of 25 or greater and nonobese patients (BMI ≤ 25). A total of 12 healthy individuals were included as controls. All patients were subjected to history taking and clinical examination; patient's functional status and disease activity were assessed using the Health Assessment Questionnaire (HAQ) disability index and DAS-28, respectively. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and rheumatoid factor (RF) were determined. Serum level of leptin was measured using enzyme-linked immunosorbent assay. Data were analyzed using SPSS for Windows, version 16.0. Results RA obese patients showed a higher duration of morning stiffness (P = 0.02), HAQ index (P = 0.001), DAS-28 (P = 0.0001), visual analogue scale (VAS) of pain (P = 0.0001), and articular index (P = 0.001) compared with nonobese ones. They showed higher ESR (P = 0.003), serum leptin (P = 0.008), CRP (P = 0.0001), and RF (P = 0.002). There was a positive correlation between BMI and each of ESR (P = 0.003), CRP (P = 0.0001), and RF (P = 0.01). There was a positive correlation between waist circumference and each of ESR (P = 0.03), serum leptin (P = 0.03), CRP (P = 0.0001), and RF (P = 0.04). There was a positive correlation between BMI and HAQ index (P = 0.0001), DAS-28 (P = 0.001), articular index (P = 0.003), and VAS of pain (P = 0.0001). There was a positive correlation between waist circumference and HAQ index (P = 0.001), DAS-28 (P = 0.03), and VAS of pain (P = 0.0001). Moreover, there was a positive correlation between VAS of pain and serum leptin (P = 0.04). Serum leptin was correlated with CRP (P = 0.01). Linear regression analysis showed that the VAS was the first and most significant risk factor (β = 0.73; P = 0.01) and that HAQ was the second (β = −0.53; P = 0.04) to affect serum leptin levels. Conclusion Obese RA patients had higher disease activity parameters, clinical scores and laboratory indices, and worse functional outcomes compared with nonobese patients. Higher serum leptin levels were associated with higher disease activity scores.
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