To date, most studies investigating the neural signature of pain in humans have focused on the brain, and those studies concerned with more caudal areas (such as the spinal cord (SC) or brainstem) have used only experimental models of pain. The objectives of this study were 1) to determine the neural activity in the human brainstem and SC that is caused by a noxious mechanical stimulus and 2) to compare the neural response to noxious stimuli in healthy controls and a patient population diagnosed with peripheral neuropathic pain. The SC and brainstem contain important synaptic points in several major pain pathways, and comparing the neural response between a control and patient population in these areas provides a more complete picture of healthy and pathological pain processing. Functional MRI studies of the SC and brainstem were carried out in healthy control subjects and patients diagnosed with carpal tunnel syndrome (CTS) in a 3T Siemens Magnetom Trio. Subjects reported the point at which the pressure (in mmHg, applied to the wrist at the location of the median nerve) corresponded to a pain level of 2, 4, and 6 on a numerical 11 point pain scale. Spatially normalized group results superimposed on anatomical templates in the axial orientation were visually identified using several stereotaxic atlases. We observed consistent signal intensity change in areas implicated in the transmission and modulation of pain in both control and CTS groups. Both groups showed a similar decrease in signal change with increasing pain, as results at pain level 2 are predominantly positive signal change and at pain level 6 are typically negative. This may indicate a reduction in the tonic inhibition of painful sensations. Differences between groups were readily visible in regions anatomically consistent with the dorsal horn (DH) of the cervical SC, rostral ventromedial medulla (RVM), dorsolateral pontine tegmentum (DLPT), and midbrain periaqudectal gray (PAG). The anatomical variation in signal change between groups may represent, for the first time, a visualization of the functional difference between healthy and pathological pain processing in the SC and brainstem using spinal fMRI. / Thesis (Master, Neuroscience Studies) -- Queen's University, 2010-08-03 14:46:01.7

Made available in DSpace on 2014-06-11T19:22:50Z (GMT). No. of bitstreams: 0 Previous issue date: 2009-02-16Bitstream added on 2014-06-13T19:47:17Z : No. of bitstreams: 1 oliveira_ajjv_me_botfm.pdf: 288626 bytes, checksum: 08a257cbb3a60279d6803950ece099be (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / Este trabalho estudou pacientes com síndrome do túnel do carpo, submetidos a estudos de condução nervosa em diferentes equipamentos: Nihon-Kohden e Nicolet Viking Select (Grupo I), Neuromax 1000 e Nicolet compass meridien (Grupo II). Para os estudos de condução nervosa sensitiva, não foram observadas diferenças estatisticamente significativas entre os equipamentos. Para os estudos de condução nervosa motora, foram observadas latências motoras mais prolongadas nos aparelhos Nicolet que nos equipamentos Nihon-Kohden e Neuromax. As diferenças entre os equipamentos foram mais pronunciadas para os casos menos graves. / This work analysed motor and sensory conduction studies in patients with carpal tunnel syndrome. Different equipments were employed: Nihon- Kohden and Nicolet Viking Select (Group I), Neuromax 1000 and Nicolet compass meridien (Group II). For sensory conduction studies no significant statistic differences were found; for motor conduction studies enlargements of the distal motor latencies were observed for Nicolet equipments in relation to the Nihon-Kohden and Neuromax. The differences were more marked for the slight cases.

Introduction: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment seen within the outpatient orthopaedic clinic; therefore assessment and management of this common condition is of significant importance. Traditionally diagnosis has been made through detailed questioning; clinical examination and nerve conduction studies (NCS). There is however no true consensus as to the gold standard assessment of CTS and the use of NCS can confer additional costs and delay treatment. Previous studies have explored methods of predicting the presence of CTS including the clinician-administered Carpal Tunnel Questionnaire (CTQ) (Kamath and Stothard, 2003). The aim of the present studies is therefore to explore the versatility of the CTQ to see how a novel Patient-completed Version of the CTQ compares to the original Clinican-completed version. Psychometric properties of the questionnaire will be explored together the economic impact of integrating both versions within an orthopaedic care pathway. A further aim is to answer whether the CTQ more effective and cost-effective than NCS for patients referred to an orthopaedic clinic with suspected CTS. Method: 100 patients referred for further investigation of suspected CTS were assessed using parallel patient and clinician-completed versions of the CTQ and results were subsequently compared with those obtained from NCS. Item analysis explored each of the nine constructs of the questionnaire and the original scoring algorithm was validated using binary logistic regression and compared with alternative algorithms. Sensitivity and specificity of the questionnaire when compared to results of NCS was explored using Receiver Operating Characteristic (ROC) analyses. Inter-rater reliability was explored through Pearson’s correlation coefficient. Economic analysis and modelling was carried out to explore potential cost savings of use of the questionnaire rather than NCS for those with suspected CTS. Results demonstrated sensitivity of 92% and specificity of 54.67% (positive predictive value 95.35%) for the patient-completed questionnaire and 96% sensitivity with 70.67% specificity (98.15 positive predictive value) for the clinician-completed questionnaire when used to predict the outcome of NCS. Binary logistic regression confirmed the original scoring algorithm and a revised algorithm did not significantly improve sensitivity. Adoption of the clinician-completed CTQ would have screen out 54% of referrals for NCS, which in the case of the study site would have conferred cost savings of £73,305 per annum (base upon a referral rate of 750 per annum). The patient-completed CTQ in the current sample resulted in 43% of referrals with suspected CTS not requiring NCS to assist in diagnosis with a potential saving of £58,372.5 per annum. There are further considerations of the reduction in waiting times, which are explored further within the analysis. Conclusion: Economic evaluation is complex due to the variety of pathways adopted by different orthopaedic departments. While the results of the Patient-complete version of the CTQ may not be as convincing as the clinician completed the study does provide validation for its use and expands the versatility of this useful adjunct to the assessment of CTS. Both versions could potentially confer significant cost savings and reduce demands on investigative services, reducing waiting times and improving the patient journey in suspected CTS.

Bakgrund: Karpaltunnelsyndrom är den vanligaste typen av perifera nervinklämningar och orsakas av att medianusnerven blir klämd i karpaltunneln. De symtom som kännetecknar karpaltunnelsyndrom är nattliga domningar och smärta i hand och fingrar.  Syfte: Att undersöka effekt och evidens för nervmobilisering som behandling vid karpaltunnelsyndrom.  Metod: Sökningar genomfördes i databaserna PudMed, PEDro, CINAHL, AMED och Scopus med målet att identifiera randomiserade kontrollerade studier där nervmobilisering som behandling vid karpaltunnelsyndrom undersökts. Inkluderade artiklar kvalitetsgranskades enligt PEDro och de med hög kvalitet evidensgraderades enligt GRADEstud.  Resultat: Nio studier inkluderades i översikten. I alla studier observerades en positiv effekt av nervmobilisering avseende symtom och/eller funktion och en signifikant skillnad sågs mellan grupperna i 7 av 9 studier. Sex av nio studier hade hög kvalitet och tre hade låg kvalitet enligt PEDro-skalan. Evidensgraderingen visade att nervmobilisering som behandling vid karpaltunnelsyndrom har måttligt hög tillförlitlighet (+++). Små studier med få deltagare resulterade i ett poängs avdrag för bristande precision. Slutsats: Nervmobilisering tycks ge positiva effekter på funktion och symtom vid karpaltunnelsyndrom och har enligt GRADEstud måttligt hög tillförlitlighet. Nervmobilisering kan ge effekt även på lång sikt och kan minska behovet av operation men fler större studier med god kvalitet behövs för att kunna bekräfta detta. Nyckelord: Carpal tunnel syndrome, CTS, neural mobilization, nerve gliding / Background: Carpal tunnel syndrome is the most common type of peripheral neuropathy caused by compression of the median nerve in the carpal tunnel. The condition is characterized by night time tingling and pain in the hand and fingers.  Objective: The purpose of this study was to investigate the effects and evidence of neural mobilization as a treatment for carpal tunnel syndrome.  Methods: Searches were made in the databases PubMed, PEDro, CINAHL, AMED and Scopus to try and find randomized controlled trials that investigated neural mobilization as treatment for carpal tunnel syndrome. All of the included articles were appraised by the PEDro-scale and the level of evidence was graded using GRADEstud.  Results: Nine studies were included in this review. In all of the included studies a positive effect could be seen by neural mobilization on symptoms and/or function with a significant difference between groups in seven out of the nine studies. Six out of the nine studies had high quality and three had low quality according to the PEDro-scale. The grading of evidence showed that neural mobilization as treatment for carpal tunnel syndrome has a moderately high level of evidence (+++). Few studies with few participants resulted in one point deduction for lack of precision. Conclusion: Neural mobilization could have positive effects on symptoms and function in patients with carpal tunnel syndrome and has a moderately high level of evidence according to GRADEstud. Neural mobilization may have positive effects long term and could reduce need for surgery but more high quality research is needed to confirm this. Key words: Carpal tunnel syndrome, CTS, neural mobilization, nerve gliding.

No description available.

No description available.

Carpal tunnel syndrome (CTS) is a peripheral median neuropathy that is commonly characterized by thickening and fibrosis of the subsynovial connective tissue (SSCT) surrounding finger flexor tendons. The degenerative process affecting SSCT can be initiated with excessive relative motion between the tendon and SSCT that ruptures interconnecting collagen. We used colour Doppler ultrasound to evaluate flexor digitorum superficialis tendon motion at two movement speeds with palmar compression, forearm compression, and partial ischemia (via brachial blood pressure cuff). Partial ischemia decreased SSCT displacement (22.9 ± 3.3 mm vs. 22.0 ± 3.3 mm; p = 0.015) while tendon displacement did not change. There was also a trend for increased relative tendon-SSCT displacement and shear strain index (SSI – relative displacement normalized to tendon displacement), which suggested partial ischemia might increase the strain in collagen that connects tendon and SSCT. Forearm compression decreased tendon displacement (28.5 ± 4.1 mm vs. 27.0 ± 4.6 mm; p = 0.043) while SSCT displacement also trended to decrease (24.0 ± mm vs. 22.5 mm; p = 0.059). With a lack of change in relative tendon-SSCT displacement and SSI, maintaining flexion-extension range of motion may have meant that forearm compression strained the musculotendinous unit at a location where SSCT was uncompromised. Palmar compression did not significantly affect any dependent motion variables, which suggested palmar compressive forces likely do not affect tendon-SSCT shear injury risk. The fast movement speed increased relative tendon-SSCT displacement and SSI while decreasing mean velocity ratio (MVR), which suggested greater tendon-SSCT shear strain in all baseline and compression conditions. Previously, increased relative tendon-SSCT displacement with fast movement speed was only shown in cadaveric investigations, but we confirmed this effect is transferable in an in vivo model. We induced ischemia proximally and found a reduction in SSCT displacement at the distal carpal tunnel. This finding suggests that the vascular network integrated within SSCT may play a role in altering tendon-SSCT excursion, independent of other external mechanical factors previously shown to increase relative motion and potential shear injury risk. Overall, this thesis showed that external mechanical compression at the palm or forearm likely do not negatively affect relative tendon-SSCT motion and that local ischemia and carpal tunnel blood flow should be considered when evaluating tendon and SSCT motion in relation to CTS development and progression. / Thesis / Master of Science (MSc)

Background: Carpal Tunnel Syndrome (CTS) is a condition affecting wrists and hands, causing pain, tingling, and numbness. Despite the high prevalence of CTS and the existence of several diagnostic tools, there is no consensus over a diagnostic gold standard test. Thesis Objectives: To conduct a systematic review of diagnostic test accuracy of clinical scales, questionnaires and hand symptom diagrams/maps for the diagnosis of CTS in people suspected with this condition; and to do a cognitive interviewing qualitative study of the Kamath and Stothard questionnaire, a diagnostic tool for CTS, to identify and resolve potential sources of error. Methods: In the first study, we searched MEDLINE, CINAHL, and Embase databases keywords related to diagnostic accuracy and clinical tests of CTS. In the second study, we interviewed clinicians and people diagnosed with CTS and other upper extremity conditions. We recorded, and content analyzed their opinion on comprehensiveness and comprehensibility of Kamath and Stothard questionnaire. Results: Twenty-one articles met the eligibility criteria of the systematic review, of which nine were on the diagnostic accuracy of hand symptom diagrams and twelve assessed the diagnostic accuracy of clinical scales and questionnaires for the diagnosis of CTS. Positive likelihood ratios (LRs) to diagnose or rule in CTS ranged from 0.94 for Boston carpal tunnel questionnaire to 10.5 for CTS-6 scale, and negative LRs to rule out CTS ranged from 1.05 to 0.05 for the same diagnostic tools. In the cognitive interviewing study, we categorized the areas of uncertainty in the participants’ responses into five themes: clarity and comprehension (51%), relativeness (38%), inadequate response definition (3.75%), perspective modifiers (3.75%), and a reference point (2.5%). Conclusions: Very few high-quality studies exist on the diagnostic accuracy of CTS-6, Kamath and Stothard questionnaire, Bland questionnaire, and Katz and Stirrat’s hand symptom diagram. By doing cognitive interviews, we identified options for potential improvement in the wording of the Kamath and Stothard questionnaire. Future studies should assess the diagnostic properties of the proposed modified questionnaire, and high-quality studies are warranted to assist in deciding on ruling in or out CTS. / Thesis / Master of Science (MSc) / Carpal tunnel syndrome is a condition affecting the hands, causing feelings of burning pain, pins and needles, heaviness and/or lack of sensation. This condition is very common among people who do manual work and can make them unable to do their jobs and daily living tasks. Early diagnosis of carpal tunnel syndrome is very important in starting an appropriate plan of treatment. The best diagnostic test for carpal tunnel syndrome is still uncertain. In the first study, we collected studies of the questionnaires and hand maps that exist for the diagnosis of carpal tunnel syndrome. We then tried to summarize the information that assists clinicians in making a diagnostic decision. In the second study, we interviewed people about their opinion of a questionnaire that is used in hand clinics to diagnose carpal tunnel syndrome. We concluded that more studies with high quality are needed to confidently decide which diagnostic test is best. Also, we revised a questionnaire that is currently used, and we hope that these revisions make the questionnaire more relecant and understandable for people.

A síndrome do túnel do carpo é a neuropatia compressiva mais comum do membro superior. Cerca de 5% dos pacientes com insuficiência renal crônica submetidos à hemodiálise apresentam esta condição. A história clínica e o exame físico continuam sendo as ferramentas mais adequadas para seu diagnóstico. Testes complementares têm sido usados para auxiliar o diagnóstico, dentre eles os de avaliação da sensibilidade cutânea. O objetivo deste estudo é descrever a utilização do PSSD (Pressure- specified sensory device ) como auxiliar ao diagnóstico de síndrome do túnel do carpo. O PSSD consiste de aparelho que incorpora transdutor de pressão com duas extremidades rombas e com regulagem de distância entre elas, acoplado a um computador capaz de determinar os limiares cutâneos de pressão. Para tanto, os pacientes foram divididos em três grupos: Grupo 1- grupo controle, pacientes sem neuropatia no membro superior ou insuficiência renal. Grupo 2- pacientes com síndrome do túnel do carpo e insuficiência renal crônica submetidos à hemodiálise. Grupo 3- pacientes com síndrome do túnel do carpo sem insuficiência renal. Os resultados demonstraram haver um maior benefício do uso do PSSD para o diagnóstico da síndrome para os pacientes do grupo 2 em dois dos quatro parâmetros avaliados quando comparados com os pacientes do grupo 3. / Carpal Tunnel Syndrome is the most common compressive neuropathy of the superior limb. Close to 5% of the patients with chronic renal insufficiency who need hemodialysis have carpal tunnel syndrome. There are controversies about the most reliable test to complement the clinical history and physical exam that remain as the most adequate tools for the diagnosis. Evaluation of sensory thresholds is being used as one of these tests. The aim of this study is to use the PSSD (Pressure-specified sensory device) for the diagnosis of carpal tunnel syndrome. The PSSD is a tool that incorporates a pressure transducer with two prongs, linked to a computer capable of measuring the cutaneous pressure thresholds referred by the patient. The patients were divided in three groups: Group 1- patients with neither superior limb neuropathy nor renal insufficiency. Group 2- patients with carpal tunnel syndrome related to chronic renal insufficiency under hemodialysis. Group 3- patients with carpal tunnel syndrome but no renal insufficiency. The results showed, for two of the four parameters measured, that group 2 had more benefits for the diagnosis of carpal tunnel syndrome than group 3.

Orientador: Luiz Antônio de Lima Resende / Banca: Claudi Ferreira da Rosa Sobreira / Banca: José Luiz Pedroso / Resumo: A síndrome do túnel do carpo (CTS) é a neuropatia compressiva mais comum. Após cirurgias descompressivas diferentes tipos de complicações podem ocorrer, donde a necessidade de procurarmos novas opções de tratamento. O objetivo deste estudo foi avaliar eventual eficácia da terapia com Laser de baixa intensidade na CTS. Foram realizadas avaliações clínicas e ENMG antes e após tratamento com Laser de baixa intensidade. Terapia com Laser utilizou emissor de Laser gálioíndio- fósforo-alumínio, com comprimento de onda de 660 nm, potência média de 30 nW, regime contínuo de área de 0,06 cm2. A fluência de irradiação foi de 10 J/cm2, com energia de 0,6 J, com exposição de 10 segundos por ponto, e 2 J/cm² no modo varredura, totalizando 6 pontos de irradiação sobre o canal do carpo, no sentido proximal-distal, sobre o trajeto anatômico do nervo mediano, no retináculo flexor. O Laser foi posicionado a 90o em relação à pele. Foram realizadas 2 sessões por semana, durante 12 semanas (total de 24 sessões). Os dados antes e após tratamento foram analisados pelo teste "t" de Student para amostras correlatas. Até o momento foram estudadas 20 mãos de 13 pacientes. Escala visual analógica de dor, força muscular do músculo abdutor pollicis brevis e velocidades de condução sensitiva do nervo mediano apresentaram melhora após tratamento (p < 0.0001, 0.0003 and 0.045, respectivamente). Entre estes 3 parâmetros não foram observadas correlações pelo teste de correlação de Spearman. Em nossa opinião terapia com Laser de baixa intensidade para pacientes com síndrome do túnel do carpo é inovadora, barata e não invasiva, com resultados iniciais encorajadores / Abstract: The carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. After surgery different types of complication may occur, than search for new clinical forms of treatment is necessary. The aim of this study was to test the effectiveness of low intensity laser therapy in patients with CTS. Patients with clinical and ENMG diagnosis of CTS never previously treated were included and submitted to clinical evaluation and conduction studies before and after treatment. Sensory and motor conduction studies were performed by conventional described techniques. Low intensity laser treatment was by 660 nm wave length, average power of 30 nw, continuous operation area of 0.06 cm2, fluence of irradiation of 10 J/cm2, exposure of 10 seconds per point, totaling 6 points of irradiation on the carpal tunnel, from the proximal to the distal sense. Laser was positioned at 90o to the skin, 2 sessions per week during 3 months were performed (24 sessions). To this moment 20 hands of 13 patients were studied. Visual analogic scale of pain (VAS), strength of the abductor pollicis brevis and sensory velocity of the median nerve showed improvement after the treatment (p < 0.0001, 0.0003 and 0.045, respectively). No correlation between these 3 parameters were observed from the Spearman correlation test. In our opinion low intensity laser therapy is a new, no expensive and easy to apply encouraging treatment for CTS / Mestre