Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial

Brininger TL, Rogers JC, Holm MB, Baker NA, Li Z-M, Goitz RJ. Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial.

Objective

To compare the effects of a neutral wrist and metacarpophalangeal (MCP) splint with a wrist cock-up splint, with and without exercises, for the treatment of carpal tunnel syndrome (CTS).

Design

A 2×2×3 randomized factorial design with 3 main factors: splint (neutral wrist and MCP and wrist cock-up), exercise (exercises, no exercise), and time (baseline, 4wk, 8wk).

Setting

Subjects were evaluated in an outpatient hand therapy clinic.

Participants

Sixty-one subjects with mild to moderate CTS; 51 subjects completed the study.

Interventions

There were 4 groups: the neutral wrist and MCP group and the neutral wrist and MCP-exercise group received fabricated customized splints that supported the wrist and MCP joints; the wrist cock-up group and the wrist cock-up-exercise group received wrist cock-up splints. The neutral wrist and MCP-exercise and wrist cock-up-exercise groups also received tendon and nerve gliding exercises and were instructed to perform exercises 3 times a day. All subjects were instructed to wear the assigned splint every night for 4 weeks.

Main Outcome Measures

We used the CTS Symptom Severity Scale (SSS) and the Functional Status Scale (FSS) to assess CTS symptoms and functional status.

Results

Analysis of variance showed a significant main effect for splint and time on the SSS (P<.001, P=.014) and FSS (P<.001, P=.029), respectively. There were no interaction effects.

Conclusions

Our results validate the use of wrist splints for the treatment of CTS, and suggest that a splint that supports the wrist and MCP joints in neutral may be more effective than a wrist cock-up splint.     

Ultrasonographic Median Nerve Changes After a Wheelchair Sporting Event

Impink BG, Boninger ML, Walker H, Collinger JL, Niyonkuru C. Ultrasonographic median nerve changes after a wheelchair sporting event.

Objectives

To investigate the acute median nerve response to intense wheelchair propulsion by using ultrasonography and to examine the relationship between carpal tunnel syndrome (CTS) signs and symptoms and the acute median nerve response.

Design

Case series.

Setting

Research room at the National Veterans Wheelchair Games.

Participants

Manual wheelchair users (N=28) competing in wheelchair basketball.

Intervention

Ultrasound images collected before and after a wheelchair basketball game.

Main Outcome Measures

Median nerve cross-sectional area, flattening ratio, and swelling ratio and changes in these after activity. Comparison of median nerve characteristics and patient characteristics between participants with and without positive physical examination findings and with and without symptoms of CTS.

Results

Significant changes in median nerve ultrasound characteristics were noted after activity. The group as a whole showed a significant decrease in cross-sectional area at the radius of 4.05% (P=.023). Participants with positive physical examinations showed significantly different (P=.029) and opposite changes in swelling ratio compared with the normal group. Subjects with CTS symptoms had a significantly (P=.022) greater duration of wheelchair use (17.1y) compared with the asymptomatic participants (9y).

Conclusions

Manual wheelchair propulsion induces acute changes in median nerve characteristics that can be visualized by using ultrasound. Studying the acute median nerve response may be useful for optimizing various interventions, such as wheelchair set up or propulsion training, to decrease both acute and chronic median nerve damage and the likelihood of developing CTS.     

Static Magnetic Field Therapy for Carpal Tunnel Syndrome: A Feasibility Study

Colbert AP, Markov MS, Carlson N, Gregory WL, Carlson H, Elmer PJ. Static magnetic field therapy for carpal tunnel syndrome: a feasibility study.

Objectives

To assess the feasibility of conducting trials of static magnetic field (SMF) therapy for carpal tunnel syndrome (CTS), to collect preliminary data on the effectiveness of 2 SMF dosages, and to explore the influence of an SMF on median nerve conduction.

Design

Randomized, double-blind, sham-controlled trial with a 6-week intervention and a 12-week follow-up.

Setting

University hospital outpatient clinics.

Participants

Women and men (N=60), ages 21 to 65 years, with an electrophysiologically confirmed CTS diagnosis recruited from the general population.

Interventions

Participants wore nightly either neodymium magnets that delivered either 15 or 45mTesla (mT) to the contents of the carpal canal or a nonmagnetic disk.

Main Outcome Measures

Symptom Severity Scale (SSS) and Function Severity Scale (FSS) of the Boston Carpal Tunnel Questionnaire (BCTQ) and 4 median nerve parameters: sensory distal latency, sensory nerve action potential amplitude, motor distal latency and compound motor action potential amplitude.

Results

Fifty-eight of 60 randomized participants completed the study. There were no significant between-group differences for change in the primary endpoint SSS or for FSS or median nerve conduction parameters. For the SSS and the FSS, each group showed a reduction at 6 weeks indicating improvement in symptoms.

Conclusions

This study showed the feasibility and safety of testing SMF therapy for CTS. There were no between-group differences observed for the BCTQ or median nerve parameters after 6 weeks of SMF therapy. Significant within-group, symptomatic improvements of the same magnitude were experienced by participants in both active and sham magnet groups. Future studies are needed to optimize SMF dosimetry and resolve issues related to the use of sham controls in SMF trials.     

The Effects of Hypertonic Dextrose Injection on Connective Tissue and Nerve Conduction Through the Rabbit Carpal Tunnel

Yoshii Y, Zhao C, Schmelzer JD, Low PA, An K-N, Amadio PC. The effects of hypertonic dextrose injection on connective tissue and nerve conduction through the rabbit carpal tunnel.

Objective

To investigate the effects of hypertonic dextrose injection on the subsynovial connective tissue (SSCT) in a rabbit model. We hypothesized that dextrose injection would induce proliferation of the SSCT, hinder median nerve conduction, and alter SSCT mechanical properties, similar to what is observed in patients with carpal tunnel syndrome (CTS).

Design

Randomized, controlled prospective study.

Setting

Not applicable.

Participants

New Zealand white rabbits (N=28) weighing 4.0 to 4.5kg.

Intervention

One forepaw was randomly injected with 0.1mL 10% dextrose solution. The contralateral paw was injected with a similar amount of 0.9% saline solution as a control. Animals were killed at 12 weeks after injection.

Main Outcome Measures

Animals were evaluated by electrophysiology (EP), mechanical testing, and histology. EP was evaluated by distal motor latency and amplitude. Shear force was evaluated when the middle digit flexor digitorum superficialis tendon was pulled out from the carpal tunnel. The ultimate tensile load and the energy absorption were also measured. Tissue for histology was evaluated qualitatively.

Results

EP demonstrated significant prolongation of distal motor latency. The energy absorption and stiffness were also significantly increased in the dextrose group. Histologically, the dextrose group showed thickening of the collagen bundles and vascular proliferation within the SSCT compared with the saline group.

Conclusions

These results are consistent with the findings in patients with CTS and suggest that hypertonic dextrose injection has the potential to create a novel animal model in which to study the evolution of CTS.     

Comparison of Proximal and Distal Cross-Sectional Areas of the Median Nerve,Carpal Tunnel,and Nerve/Tunnel Index in Subjects With Carpal Tunnel Syndrome

Objectives

To provide a quantitative analysis of ultrasonographic measurements and possible pathophysiology of carpal tunnel syndrome by comparing cross-sectional areas of the median nerve, carpal tunnel, and nerve/tunnel index and the difference in ultrasonographic findings between affected and nonaffected hands and between sexes.

Design

Blinded comparison study.

Setting

Secondary referral and training hospital of institutional practice.

Participants

Patients (N=51; 42 women, 9 men) with suspected carpal tunnel syndrome who underwent sonography within 1 week after the electrodiagnostic study.

Interventions

Not applicable.

Main Outcome Measures

Electrodiagnostic and ultrasonographic studies were conducted on both upper extremities. Cross-sectional areas of the median nerve and carpal tunnel were measured at 2 separate levels; proximal and distal cross-sectional areas of the carpal tunnel were each measured at the scaphoid-pisiform and trapezium-hamate levels, respectively.

Results

Comparison between normative (n=24) and abnormal hands (n=78) revealed the following: the mean proximal cross-sectional areas of the median nerve, carpal tunnel, and nerve/tunnel index of electrodiagnostically normative hands were 10.941mm², 192.43mm², and 5.635%, respectively, whereas those of abnormal hands were 13.74mm², 208.87mm², and 6.693%, respectively, showing statistically significant differences for all (P<.05). Distal measurements of the cross-sectional area of the median nerve, carpal tunnel, and nerve/tunnel index were 10.088mm², 150.4mm², and 6.762%, respectively, in normative hands, and 11.178mm², 149.6mm², and 7.493%, respectively, in abnormal hands, showing no statistically significant differences (P>.05). In women, proximal cross-sectional areas of the median nerve and nerve/tunnel index of abnormal hands showed statistically significant differences, but no ultrasonographic measurement with a statistically significant difference was observed in men.

Conclusions

Compared with nonaffected hands, the proximal cross-sectional areas of the median nerve and carpal tunnel were greater, but the distal ultrasonographic measurements were not in affected hands. Ultrasonographic findings of carpal tunnel syndrome were different according to sex.     

Asymptomatic median mononeuropathy among men with chronic paraplegia

Liang H-W, Wang Y-H, Pan S-L, Wang TG, Huang T-S. Asymptomatic median mononeuropathy among men with chronic paraplegia.

Objectives

To compare electrophysiologic abnormalities of the median nerve in asymptomatic paraplegic subjects and able-bodied controls and to examine the influence of personal factors on these parameters.

Design

Cross-sectional survey.

Setting

University hospital.

Participants

Forty-seven men with paraplegia and 36 able-bodied controls underwent nerve conduction studies on both upper limbs. All were free of hand numbness in the past month, diabetic mellitus, or neuromusculoskeletal injuries to the upper limbs.

Interventions

Not applicable.

Main Outcome Measure

Nerve conduction studies of the bilateral median and ulnar nerves.

Results

Although the 2 groups were of comparable age and had a similar body mass index (BMI), the subjects with paraplegia had a significantly higher proportion of asymptomatic median mononeuropathy than the controls (25.5% vs 5.6%, P=.02). The spinal cord injury (SCI) group had a prolonged median distal latency and a slowed digit-wrist sensory nerve conduction velocity. Multivariate general linear model analysis showed that prolonged motor and sensory latencies of the median nerve were associated with the SCI group and with greater BMI.

Conclusions

The asymptomatic subjects with paraplegia had a significantly higher frequency of median mononeuropathy than the able-bodied controls. There was also an association between BMI and distal latency of the median nerve.     

Median nerve conduction study through the carpal tunnel using segmental nerve length measured by ultrasonographic and conventional tape methods

Rha D-W, Im SH, Kim S-K, Chang WH, Kim KJ, Lee SC. Median nerve conduction study through the carpal tunnel using segmental nerve length measured by ultrasonographic and conventional tape methods.

Objective

(1) To determine whether a 5-cm segment includes the entire anatomic carpal tunnel in live subjects, and to compare surface, ultrasonographic, and direct measures of the median nerve length in human cadavers. (2) To investigate the actual difference of sensory conduction velocities between the conventional tape method and the ultrasonographic method.

Design

Cross-sectional study.

Setting

University rehabilitation hospital.

Participants

Healthy volunteers (N=40; 20 men, 20 women).

Interventions

Not applicable.

Main Outcome Measures

Onset latencies at the palm and wrist, nerve conduction velocity (NCV) in nerve conduction study (NCS), median nerve length measured by ultrasound and tape method.

Results

A real-time ultrasonographic study revealed that a 5-cm segment included the entire carpal tunnel. In the cadaveric study, the median nerve length measured by ultrasound was closer to the actual nerve length than the conventional surface length. The median nerve length in the wrist-to-palm segment measured by ultrasound was shorter than the surface distance. The sensory NCV using the nerve length measured by ultrasound was slower than that using the surface distance (P<.05).

Conclusions

The 5-cm segment test included the entire carpal tunnel and might be advantageous in the diagnosis of carpal tunnel syndrome (CTS), especially for early lesions. We expect that ultrasonographic measurement of nerve length might raise the sensitivity of NCSs for the diagnosis of CTS.     

Quantification of the Effects of Transcutaneous Electrical Nerve Stimulation With Functional Magnetic Resonance Imaging: A Double-Blind Randomized Placebo-Controlled Study

Kara M, Özçakar L, Gökçay D, Özçelik E, Yörübulut M, Güneri S, Kaymak B, Ak?nc? A, Çetin A. Quantification of the effects of transcutaneous electrical nerve stimulation with functional magnetic resonance imaging: a double-blind randomized placebo-controlled study.

Objective

To evaluate the effects of transcutaneous electric nerve stimulation (TENS) by using functional magnetic resonance imaging (fMRI) in patients with carpal tunnel syndrome (CTS).

Design

Randomized controlled trial.

Settings

University medical center and an outpatient imaging center.

Participants

Female patients with CTS (n=20) were randomized into 2 groups receiving either TENS (n=10) or sham TENS (n=10). In both groups, an initial baseline fMRI session was performed via stimulating digits 2, 5, and 3 in turn, 1 scan run for each. TENS versus sham TENS treatment was given, and a repeat imaging was performed starting 20 minutes after the treatment as follows: second finger on the 20th minute, fifth finger on the 25th minute (ulnar nerve innervated control finger), and third finger on the 30th min.

Interventions

Not applicable.

Main Outcome Measure

Differences in fMRI activation between the 2 groups were evaluated.

Results

Our results demonstrated that 20 to 25 minutes after TENS treatment—but not in the sham TENS group—a significant fMRI signal decrease for digit 2 (post-TENS vs baseline) was observed in the secondary somatosensory regions, ipsilateral primary motor cortex (M1), contralateral supplementary motor cortex (SMA), contralateral parahippocampal gyrus, contralateral lingual gyrus, and bilateral superior temporal gyrus. Measurements on the 25th to 30th minutes for digit 5 were similar between the groups, with presence of activities in areas other than generally activated regions because of painful stimuli. Thirty to 35 minutes after TENS treatment, a significant fMRI signal decrease for digit 3 was detected in the contralateral M1 and contralateral SMA only in the TENS group.

Conclusions

Our findings showed that TENS treatment significantly decreased the pain-related cortical activations caused by stimulation of the median nerve-innervated fingers up to 35 minutes after treatment.     

Carpal Tunnel Syndrome. Part II: Effectiveness of Surgical Treatments—A Systematic Review

Huisstede BM, Randsdorp MS, Coert JH, Glerum S, van Middelkoop M, Koes BW. Carpal tunnel syndrome. Part II: effectiveness of surgical treatments—a systematic review.

Objective

To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions to treat carpal tunnel syndrome (CTS).

Data Sources

The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs).

Study Selection

Two reviewers independently applied the inclusion criteria to select potential studies.

Data Extraction

Two reviewers independently extracted the data and assessed the methodologic quality.

Data Synthesis

A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 25 RCTs were included. Moderate evidence was found in favor of surgical treatment compared with splinting or anti-inflammatory drugs plus hand therapy in the midterm and long term, and for the effectiveness of corticosteroid irrigation of the median nerve before skin closure as additive to carpal tunnel release in the short term. Limited evidence was found in favor of a double-incision technique compared with the standard incision technique. Also, limited evidence was found in favor of a mini-open technique assisted by a Knifelight instrument compared with a standard open release at 19 months of follow-up. However, in the short term and at 30 months of follow-up, no significant differences were found between the mini-open technique assisted by a Knifelight instrument compared with a standard open release. Many studies compared different surgical interventions, but no evidence was found in favor of any one of them. No RCTs explored the optimal timing strategy for surgery. No evidence was found for the efficacy of various presurgical or postsurgical treatment programs, including splinting.

Conclusions

Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the midterm and long term to treat CTS. However, there is no unequivocal evidence that suggests one surgical treatment is more effective than the other. More research is needed to study conservative to surgical treatment in which also should be taken into account the optimal timing of surgery. Future research should also concentrate on optimal presurgical and postsurgical treatment programs.     

Carpal tunnel pressure measurement during two-portal endoscopic carpal tunnel release

Background

Although there remain concerns of median nerve damage during endoscopic carpal tunnel release for carpal tunnel syndrome, carpal tunnel pressure variations during Chow's two-portal techinique have not been well investigated.

Methods

We performed a modified two-portal endoscopic carpal tunnel release on 30 patients by inserting a catheter pressure transducer into the carpal tunnel for continuous pressure measurement during the procedure. Grip and pinch strengths, Semmes–Weinstein monofilament test, and nerve conduction studies were examined preoperatively and at postoperative 1, 3, and 6 months. Numbness and the Disabilities of the Arm, Shoulder and Hand score were also evaluated pre and postoperatively.

Findings

Subjective symptoms and nerve conduction study findings improved uneventfully. The pressure was always observed to be maximum pressure immediately before the cannula was withdrawn from the exit portal, and carpal tunnel pressure > 300 mm Hg was recorded in most of the patients.

Interpretation

A transient increase in the carpal tunnel pressure occurred in all the patients; however, it did not correlate with their clinical outcome or with increased risk of peri-operative complications. Since time–pressure threshold of the median nerve during endoscopic carpal tunnel release is still unknown, our results did not guarantee its safety.     

Effect of Hand Warming on Electrodiagnostic Testing Results and Diagnosis in Patients With Suspected Carpal Tunnel Syndrome

Burnham RS, Burnham TR. Effect of hand warming on electrodiagnostic testing results and diagnosis in patients with suspected carpal tunnel syndrome.

Objectives

To evaluate the effects of hand warming on electrodiagnostic (EDX) parameters of carpal tunnel syndrome (CTS). Specifically, to evaluate the type and magnitude of change in EDX values; to determine whether warming can change the EDX diagnosis of CTS and, if so, to determine whether specific EDX tests are more vulnerable to the effects of warming.

Design

Interventional before-after trial.

Setting

Community EDX laboratory.

Participants

Consecutive patients (N=33) referred for EDX evaluation of suspected CTS.

Intervention

Each upper limb was tested at room temperature (average hand temperature, 31.9°C) and retested after 20 minutes of heating pad warming (average hand temperature, 33.5°C).

Main Outcome Measures

Median and ulnar nerve motor and sensory latency, conduction velocity, and amplitude.

Results

Warming resulted in significantly faster transcarpal tunnel sensory and motor conduction (6%–10%), reduced median: ulnar sensory latency to digit 4 difference (23%), and reduced sensory nerve and compound motor action potential amplitude (10% and 13%, respectively). The changes resulted in 15% fewer limbs meeting the EDX conduction velocity criteria of CTS and 9% fewer by median: ulnar sensory latency to digit 4 difference. Waveform amplitudes became abnormally low after warming in 12% of limbs.

Conclusions

Hand warming using a heating pad for 20 minutes increases median nerve transcarpal tunnel conduction velocity and reduces amplitude. These phenomena introduce potential sources of diagnostic error, particularly in borderline cases. Generally, within hand, between nerve, and within nerve comparison techniques are less susceptible to the conduction velocity effects of warming.     

Orthoses Alter In Vivo Segmental Foot Kinematics During Walking in Patients With Midfoot Arthritis

Rao S, Baumhauer JF, Tome J, Nawoczenski DA. Orthoses alter in vivo segmental foot kinematics during walking in patients with midfoot arthritis.

Objective

To assess the effect of a 4-week intervention with a full-length carbon graphite (FL) orthosis on pain and function in patients with midfoot arthritis, and to identify alterations in in vivo foot kinematics accompanying FL use in patients with midfoot arthritis. These results have immediate application for enhancing patient care through effective orthotic recommendations.

Design

Experimental laboratory study supplemented by a case series.

Setting

University based clinical research laboratory.

Participants

Patients (n=30) with midfoot arthritis and age-, sex-, and body mass index-matched control subjects (n=20).

Intervention

Four-week intervention with FL orthoses.

Main Outcome Measures

Pain and function were assessed using the Foot Function Index-Revised (FFI-R). In vivo foot kinematics were quantified as peak and total range of calcaneal eversion, forefoot abduction, first metatarsal plantarflexion, and first metatarsophalangeal joint dorsiflexion during walking in 2 conditions: with FL orthoses and with shoes only. A paired t test and repeated-measures analysis of variance were used to assess statistical significance (α=.05) of change in FFI-R score and in vivo foot kinematics, respectively.

Results

Significant improvements in pain and function, discerned as lower FFI-R scores (P<.001), were noted after the 4-week intervention with FL orthoses. During walking, FL orthosis use resulted in decreased first metatarsophalangeal joint dorsiflexion (P=.024) and first metatarsal plantarflexion range of motion (P=.038), compared with the shoe-only condition.

Conclusions

Orthotic intervention emphasizing a “stiffening” strategy of the first metatarsal and first metatarsophalangeal joint may be valuable in patients with midfoot arthritis and early degenerative changes.     

Mechanosensitivity of the median nerve and mechanically produced motor responses during Upper Limb Neurodynamic Test 1

Objectives

In spite of the widespread use and recognised importance of the Upper Limb Neurodynamic Test 1 (ULNT1) in clinical practice, controversy remains about the neurophysiological basis for sensory and motor responses to the test. The aims of this study were to determine the effects of two limb positions (neutral and ULNT1) on mechanosensitivity of the median nerve, and to investigate the mechanisms underlying muscle stiffness and loss of range during the elbow extension component of the ULNT1.

Design

In both limb positions, a KIN-COM^® dynamometer controlled passive elbow extension at 3°/second, and recorded both elbow extension range of movement and elbow flexor resistive torque.

Setting

Electrophysiology laboratory, School of Physiotherapy, University of South Australia.

Participants

Twenty-six asymptomatic subjects.

Main outcome measures

Range of elbow extension and elbow flexor resistive torque. Surface electrodes placed over 10 upper limb muscles recorded electromyographic (EMG) activity. Using a hand-held micro-switch, participants indicated occurrence of pain onset and pain that limited further movement.

Results

The median nerve was more sensitive to mechanical longitudinal stresses during passive elbow extension in the ULNT1 position than in the neutral position, as demonstrated by increased EMG activity and increased mean elbow flexor resistive torque (neutral position, 0.8 Nm, 95% confidence interval 0.7-0.9 Nm; ULNT1 position, 3.9 Nm, 95% confidence interval 3.8-4.0 Nm). Pain onset and pain limit occurred earlier in range in the ULNT1 position (pain onset, 45°, 95% confidence interval 40-50°) than in the neutral position (3°, 95% confidence interval 0-6°). In the ULNT1 position, EMG activity was greater in muscles responsible for an antalgic posture in the upper limb, although some EMG activity was evident prior to pain onset.

Conclusions

The mechanosensitivity of the median nerve was greater during elbow extension in the ULNT1 position than in the neutral position. The increased EMG activity that occurred primarily in muscles contributing to an antalgic posture with concurrent changes in resistive torque and range of movement may be explained by a flexor withdrawal response to pain that acts to reduce the stretch on the median nerve. Muscle activity prior to pain onset is probably due to mechanoreceptor activation following preferential stretch of the median nerve.     

Carpal Tunnel Syndrome. Part I: Effectiveness of Nonsurgical Treatments-A Systematic Review

Huisstede BM, Hoogvliet P, Randsdorp MS, Glerum S, van Middelkoop M, Koes BW. Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments-a systematic review.

Objective

To review literature systematically concerning effectiveness of nonsurgical interventions for treating carpal tunnel syndrome (CTS).

Data Sources

The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs).

Study Selection

Two reviewers independently applied the inclusion criteria to select potential studies.

Data Extraction

Two reviewers independently extracted the data and assessed the methodologic quality.

Data Synthesis

A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 20 RCTs were included. Strong and moderate evidence was found for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, and the use of ergonomic keyboards compared with a standard keyboard, and traditional cupping versus heat pads in the short term. Also, moderate evidence was found for ultrasound in the midterm. With the exception of oral and steroid injections, no long-term results were reported for any of these treatments. No evidence was found for the effectiveness of oral steroids in long term. Moreover, although higher doses of steroid injections seem to be more effective in the midterm, the benefits of steroids injections were not maintained in the long term. For all other nonsurgical interventions studied, only limited or no evidence was found.

Conclusions

The reviewed evidence supports that a number of nonsurgical interventions benefit CTS in the short term, but there is sparse evidence on the midterm and long-term effectiveness of these interventions. Therefore, future studies should concentrate not only on short-term but also on midterm and long-term results.     

The experience of spinal cord injury: using Frank's narrative types to enhance physiotherapy undergraduates’ understanding

Objectives

To consider physiotherapy students’ responses to three illness narratives common in rugby players who have suffered a spinal cord injury (SCI).

Design

A narrative vignette was provided to first and third year students reading for a Batchelor of Science degree in physiotherapy.

Setting

A university in the West Midlands during a year cohort meeting.

Participants

Seventy-seven first year students and 45 third year students took part in the study. All students were attending the university at the time of the study. None of the first year students had completed any clinical placement hours, and all of the third year students had completed the required number of clinical hours for a physiotherapy degree.

Main outcome measures

The narrative vignette consisted of nine questions relating to the vignette. Thematic content analysis was applied to the results.

Results

The role of experience appeared to influence students’ responses. The third year students’ reactions to each narrative appeared more consistent and unified as a medical voice. This appeared to support their preference for an ideal type of story and patient. Problems with each narrative were identified, although often not critiqued.

Conclusions

Students need more time to consider different illness narratives in order to accept and understand them.     

Diagnosis From Functional Perspectives: Usefulness of a Manual Tactile Test for Predicting Precision Pinch Performance and Disease Severity in Subjects With Carpal Tunnel Syndrome

Objectives

To investigate how the severity levels revealed in a nerve conduction study (NCS) affect the results of the Manual Tactile Test (MTT) for patients with carpal tunnel syndrome (CTS), and to examine the relationships between the results of the MTT and precision pinch performance.

Design

Case-control studies.

Setting

Hospital and local community.

Participants

Patients with CTS (N=70) with 119 affected hands were studied. A control group matched by age, sex, and hand dominance was also recruited.

Intervention

Not applicable.

Main Outcome Measures

CTS severity was determined based on NCS findings. The MTT, traditional sensory tests, and precision pinch performance were used to examine the functional sensory status of the hand from different perspectives.

Results

The patients with CTS exhibited deterioration in all of the sensibility tests (P<.001). The results showed that the MTT could classify subgroups of severity in CTS (P<.001). A moderate correlation was found between the results of the MTT and precision pinch performance (r=.526–.585, P<.001). Multiple linear regression analysis showed that the MTT results were useful indicators for predicting precision pinch performance and differentiating severity in subjects with CTS (r²=.376 and .323, respectively).

Conclusions

The findings indicate that the MTT could be a valid and useful assessment for hand sensibility and prehensile pinch performance in patients with CTS.     

Ulnar nerve and cubital tunnel ultrasound in ulnar neuropathy at the elbow

Yoon JS, Hong S-J, Kim B-J, Kim SJ, Kim JM, Walker FO, Cartwright MS. Ulnar nerve and cubital tunnel ultrasound in ulnar neuropathy at the elbow.

Objective

To determine the accuracy of the ultrasonographic measurement of ulnar nerve to cubital tunnel area for diagnosis of ulnar neuropathy at the elbow.

Design

Patients with confirmed ulnar neuropathy at the elbow and normative, healthy volunteers were evaluated with high-resolution ultrasound. The cross-sectional areas (CSAs) of the ulnar nerve and cubital tunnel were measured with the elbow extended and flexed, and results from the 2 groups were compared.

Setting

Electromyography laboratory and radiology department of a tertiary care center.

Participants

Twenty-seven patients with ulnar neuropathy at the elbow and 20 controls.

Interventions

Not applicable.

Main Outcome Measure

The ratio of ulnar nerve to cubital tunnel CSA with the elbow flexed.

Results

The ulnar nerve, with the elbow flexed, was larger in those with ulnar neuropathy at the elbow, and this group also had larger cubital tunnels than did controls. In those with ulnar neuropathy at the elbow, the ratio of the ulnar nerve to cubital tunnel was .31, and in the controls it was .32, which was not significantly different (P=.89).

Conclusions

The ratio of ulnar nerve to cubital tunnel did not differentiate those with ulnar neuropathy at the elbow from controls.     

Differential features of burden between spouse and adult-child caregivers of patients with Alzheimer's disease: An exploratory comparative design

Background

Research into burden among spouse and adult-child caregivers of patients with Alzheimer's disease has generated contradictory results as regards the group which suffers the greatest burden and the factors underlying any differences.

Objectives

The aim of the present study was to identify and compare the factors associated with caregiver burden among spouse and adult-child caregivers.

Design

Cross-sectional analytic study.

Settings

All clinical subjects had been referred on an out-patient basis to the Memory and Dementia Assessment Unit of the Santa Caterina Hospital in Girona (Spain).

Participants

Data were collected from 251 patients and their caregivers, 112 with spouse and 139 with adult-child caregivers.

Methods

The association between caregiver burden and the socio-demographic and clinical variables of both patients and caregivers was analysed, the results being compared for spouse vs. adult-child caregivers. Burden was analysed using a multivariate linear regression including all the variables for the two groups of caregivers.

Results

The results show greater burden among adult-child caregivers (p < .05), who experience more feelings of guilt (p < .001). In both groups the behavioural and psychological symptoms of patients were correlated with burden (p < .001). Living with the patient has a notable influence on burden among adult children (p < .001). Husbands, wives, daughters and sons, in this order, showed increasing levels of burden (p < .05) and progressively worse mental health (p < .01). However, the correlations between burden and mental health were strongest in daughters (p < .001).

Conclusion

The differences in burden between spouse and adult-child caregivers were not associated with age, physical health or clinical factors of the patients. Overall burden was greater among adult-child caregivers, especially those who lived with the patient and who had other family duties. Feelings of guilt were associated with not living with the patient, and there was a strong correlation between burden and mental health. These results support the hypothesis that spouses regard caregiving as part of their marital duties, whereas for adult children such tasks imply an important change in their lifestyle.