Made available in DSpace on 2016-01-26T12:51:22Z (GMT). No. of bitstreams: 1 thiagoguimaraesnaves -dissert.pdf: 396666 bytes, checksum: 322f0d9f8506ec60598fc70d1e33cc6a (MD5) Previous issue date: 2009-10-20 / Objective: To establish electrophysiologic values for CTS diagnosis in the elderly. Casuistic and methods: thirty healthy volunteers with at least 65 years old were selected. Exclusion criteria were: any sensory symptom, peripheral neuropathy, sistemic diseases, alcohol abuse and wrist fracture. The following parameters were calculated: 1. Median sensory distal latency on the segment wrist - digit II, 14 cm (SDL); 2. Median/radial latency difference on the segment wrist - digit I, 10 cm (MRD); 3. Median/ulnar latency difference on the segment wrist - digit IV, 14 cm (MUD4); 4. Median/ulnar mixed latency difference on the segment palm - wrist, 8 cm (MUPD); 5. Combined sensory index (CSI), calculated as the adding of MRD, MUD4 and MUPD; 6. Mixed median palmar latency (PL), 8 cm; 7. Median/ulnar motor latency difference, lumbrical/interossei, 8 cm (LUMB); 8. Median motor distal latency, pulse-APB, 8 cm (DML). Results: Twenty-one volunteers were female and 9 were male. Mean age was 69.9 (range 65-86). The 97.5th upper normal limits suggested were: SDL 3.80 ms, MRD 0.95 ms, MUD4 0.95 ms, MUPD 0.50 ms, PL 2.45 ms, CSI 2.20 ms and DML 4.30 ms. Conclusions: The reference values for MRD, MUD4, MUDP and CSI in elderly are different from youngers. There are quite less differences for DSL and PL and none at all for DML. The use of these new values in elderly will reduce the number of false positives. / Objetivo: determinar parâmetros eletrofisiológicos para diagnóstico da STC em idosos. Casuística e Métodos: Trinta voluntários saudáveis com no mínimo 65 anos de idade foram selecionados. Os critérios de exclusão foram: quaisquer sintomas sensitivos, neuropatia periférica, doenças sistêmicas, abuso alcoólico e antecedente de fratura no pulso. Os seguintes parâmetros foram estudados: 1. Latência distal sensitiva do nervo mediano, segmento pulso-dedo II, 14 cm (LDS); 2. Diferença de latência sensitiva mediano/radial, pulso-dedo I, 10 cm (DMR); 3. Diferença de latência sensitiva mediano/ulnar, pulso-IV dedo, 14 cm (DMU4) ; 4. Diferença de latência mista mediano/ulnar, palma-pulso, 8 cm (DMUP); 5. Índice sensitivo combinado (ISC), calculado pela soma de DMR, DMU4 e DMUP; 6. Latência palmar mista do nervo mediano, 8cm (LP); 7. Diferença de latência motora mediano/ulnar lumbrical-interósseo, 8 cm (LUMB); 8. Latência distal motora do nervo mediano, pulso-APB, 8 cm (LDM). Resultados: Vinte e um voluntários eram mulheres e 9 homens com média de idade de 69,9 anos (variação 65-86). Os limites superiores de normalidade 97,5% sugeridos foram: LDS 3,80 ms, DMR 0,95 ms, DMU4 0,95 ms, DMUP 0,50 ms, LP 2,45 ms, ISC 2,20 ms e LDM 4,30 ms. Conclusões: Os valores de referência para DMR, DMU4, DMUP e ISC em idosos são diferentes em relação aos jovens. As diferenças foram menores para LDS e LP; não houve diferença para LDM. O uso destes novos valores reduzirá o número de exames falso-positivos em idosos.

Made available in DSpace on 2015-09-25T12:23:16Z (GMT). No. of bitstreams: 1 ValeriaRibeiroNogueiraBarbosa.pdf: 2894050 bytes, checksum: 2496af522e31ec83452db4d278903717 (MD5) Previous issue date: 2003-09-29 / Carpal Tunnel Syndrome (CTS) represents the most common entrapment neuropathy, better defined and more studied in the human being. The diagnosis is commonly presumed in patients with painful syndrome in the upper limbs, whose symptoms aggravate at night. The gold-standard for the diagnosis is the occurring of alterations in the sensitive and muscled conduction of the median nerve. Despite the CTS being well clinically characterized, when it is typical, a lot of painful factors in the upper limbs are not caused by CTS, and these patients neuralgic exam may vary from normal to serious alterations. This paper has as objectives: 1. To evaluate the profile of the painful symptoms that may presumably occur in patients with idiopatic CTS or without CTS; 2. to evaluate the profile of the neuralgic exam in patients with idiopatic CTS. Between April and December of 2002, 35 patients with idiopatic CTS (34 women and one man) with diagnosis confirmed by the clinical and electrophysiological exam were examined. They were paired according to their age and sex with 35 citzens of the general population (34 women and one man, aged between 34 and 72, average 51, +/- 9,7 years old). The frequency of paintful syndromes distribution in the two groups studied was analysed by the square test. The age average in both groups of patients was compared by the t-Student test. There was not statistical difference concerning the ages. In the group with CTS the complaints of pain were prevalent in the neck (45,7%), Phalen`s test (68,5%), and fist compression (74,3%) are common, being the last two ones prevalent ( α = 0,05). The severity of the CTS was evaluated by the eletrophysiological exam. Most of the CTS cases are of light degree and occur bilaterally. Just seven patients have unilateral CTS. Concluding: 1- One must cogitate the CTS diagnosis in every case of pain of obscure origin in the lower limbs, being the location either proximal or distal; 2- Just one of patients with CTS had, clearly, signs of cervical radicular injury. One cannot establish etiological relation between these two conditions. What is told about the existence of double-crush syndrome as a nosological entity; 3- In the neurogical exam, the alteration in the sensibility to pain was the most observed sign. The discriminatitive sensibility test seems not to have value to support the CTS diagnosis; 4- the Phalen and the carpal compression tests are more useful to the CTS diagnosis than the Tinel sign, for they are more prevalent. / A Síndrome do Túnel do Carpo (STC) representa a neuropatia compressiva mais comum, melhor definida e mais estudada no ser humano. O diagnóstico é comumente presumido em pacientes com síndrome dolorosa nos membros superiores, cujos sintomas se agravam à noite. O padrão-ouro para o diagnóstico é a ocorrência de alterações na condução sensitiva e motora do nervo mediano. Apesar da STC ser bem caracterizada clinicamente, quando é típica, muitos quadros dolorosos nos membros superiores não são causados por STC, e o exame neurológico desses pacientes pode variar de normal a alterações graves. Este trabalho tem como objetivos: 1- avaliar o perfil dos sintomas dolorosos que presumivelmente possam ocorrer em pacientes com STC idiopático e sem STC; 2- avaliar o perfil do exame neurológico em pacientes com STC idiopático. Entre abril e dezembro de 2002, 35 pacientes com STC idiopático (34 mulheres e um homem, idades entre 34 e 72 anos, média 51, + 9,8 anos) com diagnóstico confirmado pelo exame clínico e eletrofisiológico foram examinados. Eles foram pareados por idade e sexo com 35 sujeitos da população geral (34 mulheres e um homem, idades entre 34 e 72 anos, média 51, + 9,7 anos). A freqüência de distribuição de síndromes dolorosas nos dois grupos estudados foi analisada pelo teste do qui-quadrado. A média de idade dos dois grupos de pacientes foi comparada pelo teste t de Student. Não houve diferença estatística quanto às idades. No grupo com STC as queixas de dor são prevalentes no pescoço (42,8%), membros superiores (36,8%) e mãos (82,8%). Nos sujeitos sem STC a localização do quadro doloroso predomina na cabeça (11,4%), região axial do corpo (37,1%) e membros inferiores (22,8%), (α = 0,05). Entre os sujeitos com STC, 85,7% apresentam queixas de parestesias nos membros superiores e 74,2% destes apenas nas mãos. Os chamados testes provocativos: sinal de Tinel (45,7%), teste de Phalen (68,5%) e compressão do punho (74,3%) são comuns, sendo os dois últimos prevalentes (α = 0,05). A gravidade da STC foi avaliada pelo exame eletrofisiológico. A maioria dos casos de STC são de grau leve e ocorrem bilateralmente. Apenas sete pacientes têm STC unilateral. Em conclusão: 1 - Deve-se cogitar o diagnóstico de STC em todos os casos de dor de origem obscura nos membros superiores, seja de localização proximal ou distal; 2 - apenas uma das pacientes com STC teve, claramente, sinais de lesão radicular cervical. Não se pôde estabelecer relação etiológica entre as duas condições. O que fala contra a existência de síndrome da dupla compressão como uma entidade nosológica; 3 no exame neurológico, a alteração da sensibilidade à dor foi o sinal mais observado. O teste da sensibilidade discriminativa parece não ter valor para suportar o diagnóstico de STC; 4 os testes de Phalen e da compressão carpal são mais úteis para o diagnóstico de STC do que o sinal de Tinel, pois são mais prevalentes.

Thesis (Ph. D.)--Uniformed Services University of the Health Sciences, 2005. / Typescript (photocopy).

Introducción. Existe controversia en el impacto de la cirugía descompresiva sobre los parámetros electrofisiológicos posteriores al procedimiento en pacientes con síndrome de túnel del carpo. (STC) Objetivos. Evaluar los cambios de los patrones electrofisiológicos y evaluar los factores asociados a dichos cambios después de la descompresión quirúrgica del nervio mediano en pacientes con STC Metodología. Estudio observacional analítico transversal de pacientes con STC severo sometidos a cirugía descompresiva que cuenten con estudios electrofisiológicos pre y post quirúrgicos realizado en el Hospital Kaelin de la Fuente EsSalud en Lima, Perú entre el 2015 al 2019. La comparación de los cambios electrofisiológicos pre y post quirúrgicos se evaluó utilizando la prueba de T de student para muestras pareadas. Los factores asociados al cambio se evaluaron la prueba de U-mann Whitney o correlación de Spearman, para variables categóricas y numéricas respectivamente. Para el análisis multivariado se utilizó un modelo de regresión lineal múltiple. Resultados. Se evaluaron 55 pacientes. La latencia distal motora del nervio mediano no presentó un cambio significativo luego de la cirugía (-0.47ms; p=0.211). Se encontraron mejorías significativas en la latencia distal sensitiva (-0.5ms; p=0.010), velocidad distal motora (2.53m/s; p=0.005), amplitud distal motora (en 0.9 mV/s; p=0.0048) y la amplitud distal sensitiva (4.9 mV/s; p=0.034). Se encontró asociación entre el género masculino y una evolución desfavorable de la latencia distal motora del nervio mediano. (Coeficiente β =2.85; IC 0.453 - 5.248; p=0.040). Conclusiones. Se evidenció cambios electrofisiológicos favorables luego de la cirugía de descompresión del nervio mediano. El género masculino y el IMC se asociaron a una evolución electrofisiológica desfavorable. / Introduction. There is controversy of the impact of the decompressive surgery in the electrophysiological parameters following the procedure in patients with carpal tunnel syndrome (CTS). Objectives. Evaluate the changes in the electrophysiological parameters and evaluate the factors associated to these changes after the surgical decompression of the median nerve in patients with CTS. Methodology. Cross-sectional analytical study of patients with severe CTS submitted to decompressive surgery that have pre and post-surgical electrophysiological studies in Kaelin de la Fuente hospital EsSalud in Lima, Peru between 2015 and 2019. The comparison between the pre and post-surgical changes was evaluated using T-student test for paired samples. The associated factors were analyzed using U-Mann Whitney test or spearman correlation, for categorical variables and numerical, respectively. For the multivariate analysis a multiple simple regression model was used. Results. 55 patients were analyzed. Median nerve´s distal motor latency did not show significant changes after the surgery (-0.47ms; p=0.211). Improvement was found in the distal sensitive latency (-0.5ms; p=0.010), distal motor velocity (2.53m/s; p=0.005), distal motor amplitude (0.9 mV/s; p=0.0048) and distal sensitive amplitude (4.9 mV/s; p=0.034). An association between male and an unfavorable evolution of the distal motor latency of the median nerve was found. (Coefficient β = 2.85, CI 0.453 - 5.248, p = 0.040). Conclusions. Favorable electrophysiological changes after the surgery where evidenced. Male gender and BMI where associated to an unfavorable electrophysiological evolution. / Tesis

Les exercices neurodynamiques sont fréquemment recommandés par les physiothérapeutes pour améliorer la douleur et la fonction chez des individus atteints du syndrome du tunnel carpien (STC). Toutefois, l’efficacité de ces exercices demeure incertaine considérant que leurs mécanismes thérapeutiques reposent largement sur des bases théoriques. En fait, peu d’études ont rapporté quantitativement les effets des exercices neurodynamiques sur l’intégrité biologique et les propriétés biomécaniques du nerf médian au poignet (effets périphériques) et sur la structure et la fonction des aires corticales motrices (effets centraux). Les objectifs principaux de cette thèse étaient 1) d’évaluer les qualités psychométriques des mesures d’excursion longitudinale du nerf médian à l’aide de l’imagerie quantitative par ultrasonographie, 2) de caractériser les adaptations périphériques et centrales potentiellement liées à la performance des exercices neurodynamiques et 3) d’évaluer la faisabilité et l’efficacité d’un programme fondé sur les exercices neurodynamiques offerts à des individus atteints du STC. Pour répondre à ces objectifs, quatre projets distincts ont été menés : Projet no1 : La fidélité test-retest et le changement minimal détectable des mesures d’excursion longitudinale du nerf médian ont été quantifiés chez un groupe de 11 individus asymptomatiques et sept individus atteints du STC. Projet no2: La validité concourante entre les mesures de l'excursion longitudinale d’un modèle artificiel de nerf médian obtenues à l’aide de l’imagerie quantitative par ultrasonographie et d’un système tridimensionnel d'analyse de mouvement a été évaluée. Projet no3 : Une étude clinique exploratoire a été réalisée pour évaluer les effets périphériques et centraux d’un programme d’exercices neurodynamiques auprès d’une cohorte de 14 individus atteints du STC. Projet no4 : Une étude clinique pilote randomisée a été réalisée pour évaluer la faisabilité d’un programme d’exercices neurodynamiques préopératoire exécuté par 15 individus atteints du STC en attente d’une première chirurgie de décompression et évaluer l’efficacité de ce programme chez ces mêmes individus pour améliorer l’intégrité biologique, les propriétés biomécaniques du nerf médian; réduire la douleur, les déficiences sensorimotrices et optimiser la capacité fonctionnelle du membre supérieur en comparaison à un groupe contrôle de 15 individus atteints du STC ne complétant aucun programme d’exercice avant et après la chirurgie (approche actuelle). En résumé, les résultats des projets no1 et 2 soutiennent que i l’imagerie quantitative par ultrasonographie est un outil fidèle et valide pour mesurer l’intégrité biologique et l’excursion longitudinale du nerf médian. Les résultats du projet no3 suggèrent que les changements cliniques observés suite aux exercices neurodynamiques potentialisent les adaptations centrales alors qu’ils n’ont aucun ou peu d’effets sur les adaptations périphériques, notamment l’excursion du nerf médian. Les résultats du projet no4 démontrent que, bien que le programme d’exercices neurodynamiques proposé soit faisable et relativement sécuritaire lorsqu’offert à des individus en attente d’une chirurgie de décompression, ils ne démontrent pas la supériorité du programme proposé sur l'amélioration des déficiences sensorimotrices, de la douleur et des capacités fonctionnelles des membres supérieurs chez les patients atteints de STC immédiatement avant ou un mois après une opération de décompression du canal carpien par rapport à l’approche actuelle. Certains résultats, démontrant des tailles d’effet modérées à importantes ou qui tendaient vers le seuil statistiquement significatif, appuient toutefois la pertinence de poursuivre les efforts de recherche. / Neuromobilizations exercises are frequently advocated by physiotherapists to improve pain and function in individuals with Carpal Tunnel Syndrome (CTS). However, the effectiveness of these exercises remains uncertain since they remain in most part based on theoretical and empirical foundations. In fact, few studies have reported the effects of neurodynamic exercises on the biological integrity and biomechanical properties of the median nerve at the wrist (peripheral adaptations) and on the structure and function of cortical motor areas (central adaptations). The main objectives of this thesis were 1) to evaluate the psychometric properties of median nerve longitudinal excursion measurements using quantitative ultrasound imaging, 2) to characterize the peripheral and central adaptations potentially linked to the performance of neuromobilization exercises and 3) to evaluate the feasibility and effectiveness of a neuromobilization exercise program completed by individuals with CTS. To meet these objectives, four separate projects were conducted. Project # 1: Test- retest reliability and minimal detectable change in median longitudinal nerve excursion measurements were evaluated in a group of 11 asymptomatic individuals and seven individuals with CTS. Project # 2: The concurrent validity between longitudinal excursion measurements of an artificial median nerve model obtained with quantitative ultrasound imaging and a three- dimensional motion analysis system was evaluated. Project # 3: An exploratory clinical study was conducted to evaluate the potential peripheral and central adaptations following completion of a neuromobilization exercise program in a cohort of 14 individuals with CTS. Project # 4: A pilot randomized clinical trial was conducted to evaluate the feasibility of a preoperative neuromobilization exercise program performed by 15 individuals with CTS awaiting decompression surgery and to evaluate the efficacy of this program for these same individuals to improve the biological integrity, biomechanical properties of the median nerve; reduce pain, sensorimotor deficiencies and optimize upper limb functional capacity compared to a control group of 15 individuals with CTS that does not perform any exercise program before and after carpal surgery (standard care). In summary, the results of projects # 1 and 2 demonstrate that ultrasound imaging is a reliable and valid tool for measuring the biological integrity and longitudinal excursion of the iii median nerve. The results of project # 3 suggest that the clinical changes observed following neuromobilization exercises potentiate central adaptations while they have no or little effect on peripheral adaptations, including nerve excursion. The results of project # 4 demonstrate that, although the proposed neuromobilization exercise program is feasible and relatively safe when completed by individuals awaiting decompression surgery, they do not demonstrate the superiority of the proposed program in improving sensorimotor impairments, pain and upper extremity functional abilities in individuals with CTS immediately before or one month after carpal tunnel decompression surgery compared with standard care. However, pain subscales and biological integrity outcomes demonstrated moderate to large effect sizes or trends towards the statistically significance, thus supporting the need for further research.