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Objective: The aim of this study was to quantify and characterize pain in patients undergoing lower limb postsurgical orthopedic rehabilitation and to investigate the impact of pain in slowing or interrupting their rehabilitation., Design: The study was designed as a multicenter cross-sectional study., Setting: The study was set in rehabilitation departments of the Don Gnocchi Foundation., Subjects: The study subjects were the inpatients attending rehabilitation., Interventions: There were no interventions used in the study., Outcome Measures: Pain intensity was measured with a numeric rating scale (NRS); pain characteristics were assessed with the McGill Pain Questionnaire and the ID Pain (able to discriminate nociceptive from neuropathic pain). Quality of life (QoL) was measured with the Short Form 36 Health Status Survey. A semi-structured questionnaire on pain occurrence, impact, and management was administered by the physiotherapist in charge of the patients and by the physician., Results: We studied 139 patients, 82% of whom complained of at least moderate pain (NRS ≥ 3). According to ID pain, 45.6% patients complained of probable (33.8%) or highly probable (11.8%) neuropathic pain. A higher pain intensity was significantly related to the probability of having neuropathic pain (P < 0.001). Patients with more severe pain reported lower physical and mental QoL scores. In 38.6% of cases, pain interfered with the rehabilitation process, and in 18.5% it was the cause of physical therapy discontinuation., Conclusions: In light of the high occurrence and intensity of pain in the sample, and of the significant impact on the rehabilitation program, clinicians should pay more attention to pain, especially neuropathic pain, in postsurgical patients. Tailored pain pharmacological therapy could possibly improve patient compliance during the rehabilitation process and enhance long-term outcomes., (Wiley Periodicals, Inc.)

Introduction: Nerve involvement in immune-related neuropathies is non-homogeneous, and therefore characterization of ultrasound (US) abnormalities is difficult. We developed two measures to quantify US abnormalities in immune-related neuropathies., Methods: Intranerve cross-sectional area (CSA) variability for each nerve was calculated as: maximal CSA/minimal CSA. Internerve CSA variability for each patient was calculated as: maximal intranerve CSA variability/minimal intranerve CSA variability. Six patients underwent US evaluation of the median, ulnar, and fibular nerves, and the abnormalities were scored with our newly developed measures., Results: The new measures were applicable to all nerves and patients. The highest degree of intra- and internerve CSA variability was observed in multifocal motor neuropathy, consistent with the asymmetric characteristics of this neuropathy., Conclusions: The application of intra- and internerve CSA variability measures allows us to quantify the heterogeneity of nerves and nerve segments and identify different US patterns in diverse immune-related neuropathies., (Copyright © 2012 Wiley Periodicals, Inc.)

Objective: Our aim was to investigate CO(2) laser-evoked potential (LEP) habituation to experimental pain in a group of patients affected by medication-overuse headache, with a history of episodic migraine becoming chronic, before and after treatment, consisting in acute medication withdrawal and a preventive treatment cycle., Background: One of the main features of LEPs in migraineurs is a lower habituation to repetitive noxious stimuli during the interictal phase., Methods: LEPs were recorded to stimulation of both the right hand and the right perioral region in 14 patients and in 14 healthy subjects. The habituation of both the N1 and the vertex N2/P2 components was assessed by measuring the LEP amplitude changes across 3 consecutive repetitions of 30 trials each., Results: In the 8 patients who had clinically improved after treatment, the N2/P2 amplitude habituation was significantly higher after treatment than before treatment following both hand (F = 43.2, P < .0001) and face stimulation (F = 6.9, P = .01). In these patients, the N2/P2 amplitude habituation after treatment was not different from that obtained in healthy controls (P = .18 and P = .73 for hand and face stimulation, respectively). On the contrary, in the patients who did not improve, the N2/P2 amplitude still showed reduced habituation after both hand (F = 3.1, P = .08) and face (F = 0.7, P = .4) stimulation., Conclusion: The deficient habituation of the vertex N2/P2 complex was partly restored after successful treatment of medication-overuse headache, reflecting a modification in pain-processing pathways., (© 2012 American Headache Society.)

Introduction: Polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes (POEMS) syndrome is a rare multisystem disorder associated with plasma cell dyscrasia whose main neurological feature is a demyelinating polyneuropathy. The aim of our study was to assess the pattern of ultrasound (US) nerve abnormalities in POEMS syndrome patients., Methods: Eight POEMS syndrome patients underwent neurological examination and US evaluation of the median, ulnar, fibular, tibial, and sural nerves. Nerve cross-sectional area and echogenicity abnormalities were analyzed., Results: US abnormalities were mostly localized at entrapment sites. Enlargements outside the entrapment sites were uncommon. No correlation was found between muscle weakness and focal US findings., Conclusions: No specific pattern of US abnormalities was identified in this cohort of patients with POEMS syndrome. The lack of correlation between US and clinical findings may be secondary to the chronic nerve damage that is common in POEMS syndrome, where the diagnosis is often delayed., (Copyright © 2011 Wiley Periodicals, Inc.)

We performed a prospective study to evaluate the prevalence of bifid median nerve (BMN) and if it has a higher prevalence in carpal tunnel syndrome (CTS) patients than symptom-free subjects. We evaluated by ultrasound (US) 162 median nerves at wrist of 89 consecutive patients with symptoms suggestive of CTS and 104 of 52 consecutive symptom-free subjects. Neurophysiological evaluation confirmed CTS diagnosis. All patients underwent ultrasonographic evaluation of median nerve in the elbow-palm segment through high-frequency probe; BMN was arbitrarily classified as "complete" and "incomplete" on the basis of US results. BMN was observed in 16/104 wrists (15.4%) in control group and in 30/162 (18.5%) wrists in CTS group. Our study showed that BMN is frequent, not always bilateral, more often is "incomplete" and it has similar prevalence in CTS and control group. These findings suggest that BMN is not a risk factor of developing CTS.

Neuropathic pain is a disabling symptom frequently reported by patients with neuropathies. Pain-questionnaires are the best way to investigate it. Neuropathic Pain Symptom Inventory (NPSI) questionnaire specifically assesses the different symptoms of neuropathic pain. The objective of this study was to evaluate, through the NPSI, the different neuropathic painful symptoms in a population of neuropathic patients. 277 patients with different neuropathies were evaluated with the NPSI to investigate the prevalence of the different neuropathic symptoms. Neuropathic pain was reported by 94.4% of the patients, resulting to be common not only in diabetic and iatrogenic neuropathies, but also in hereditary, paraproteinemic, and idiopathic neuropathies. The majority of our patients (88.6%) presented paresthesia/dysesthesia. The results of our study point out the difference in the occurrence of the painful symptoms. A scale able to discriminate distinct types of neuropathic pain may provide clinicians with adequate therapeutic choices in the daily practice.

Introduction: The purpose of this study was to determine whether single-fiber conduction velocity (SF-CV) of a small number of axons increases sensitivity for identification of motor nerve conduction alterations in patients with diabetes., Methods: Twenty-one consecutive diabetic patients in good metabolic control were studied. For each patient, conventional (C-CV) and SF-CV results were correlated with the presence of neuropathic symptoms., Results: Nine of 21 patients reported symptoms suggestive of mild nerve impairment. Three patients had abnormal sural nerve CV, 1 of whom also had abnormal motor nerve conduction. Eighteen patients had normal findings on conventional tests, 3 of whom had slowing of SF-CV., Conclusions: SF-CV is able to detect mild myelin damage with higher sensitivity than conventional tests. The use of SF-CV may be a helpful tool in the early identification of diabetic polyneuropathy, and it may be useful for tailoring an approach to diabetic polyneuropathy., (Copyright © 2010 Wiley Periodicals, Inc.)

The reported incidence of pregnancy-related carpal tunnel syndrome (PRCTS) ranges from 0.8% to 70%, and little is known of its natural history. We systematically reviewed the reported incidence of PRCTS and evaluated its natural history. We identified 214 studies that fulfilled our selection criteria. Six publications fulfilled the inclusion criteria. Five fulfilled the incidence criteria, 3 fulfilled the natural history criteria, and 2 of the 6 publications satisfied both. The reported incidence of neurophysiologically confirmed PRCTS ranged from 7% to 43%, whereas the incidence of clinically diagnosed PRCTS ranged from 31% to 62%. Symptoms persisted in more than 50% of the patients after 1 year and in about 30% after 3 years. Our review suggests that variations in the reported incidence of PRCTS largely depend on the methods used to detect this syndrome. Our data also suggest that symptoms persist in a substantial number of patients 1 or more years after delivery.

Charcot-Marie-Tooth (CMT) disease is the most common inherited neuropathy. The CMT1A type can be considered the typical phenotype of this disease. Although pain is not considered a relevant symptom in CMT patients by physicians and no study assessed it comprehensively, this symptom is frequently complained by patients. The objective of the present study was to investigate the nociceptive system in a sample of CMT1A patients suffering from pain by laser-evoked potentials (LEPs). Moreover, we also used a pain specific questionnaire in order to obtain patient-oriented data about their painful symptoms, the Neuropathic Pain Diagnostic Questionnaire (DN4). We evaluated 16 patients affected by CMT1A and 14 controls. All subjects underwent a standard LEP recording session (foot, hand, and face stimulation) and filled in the DN4. While the N2/P2 amplitude to foot stimulation was lower in CMT patients than in controls (p=0.003), no difference in LEP amplitude to both hand and face stimulation was found between patients and healthy subjects (p>0.05). This result is probably due to a length-dependent Adelta-fiber loss which involves mostly the longer fibers coming from the lower limb. In our patients, there was a significant association between a reduced N2/P2 amplitude to foot stimulation and a high DN4 score (p=0.03), meaning that patients with highly probable neuropathic pain had also low N2/P2 amplitude values to painful foot stimulation. This suggests that in our CMT1A patients neuropathic pain is probably related to a reduction of the Adelta afferents., (Copyright 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Neuropathic pain is a complex subject, not completely understood yet, and it is quite common in clinical practice, even outside of a neurological context. Neuropathic pain, often being a chronic process, alters and profoundly affects the quality of life. Therefore, the management of neuropathic pain involves a multidimensional approach, as physicians have to take care not only of the objective aspects of the problem, but also of the subjective experiences of pain. This explains why the attainment of a diagnosis becomes so important, as it allows clinicians to treat the patients with the best therapeutic approach. Several studies report the use of brain-evoked potentials for studying patients suffering from neuropathic pain. In particular, laser- and contact heat-evoked potentials have proved useful for the diagnosis of clinical conditions characterized by neuropathic pain. However, although these tools are reliable and safe instruments to assess function of the nociceptive system, their use is still largely confined to research purposes.

The aim of this study was to validate the Italian version of the Neuropathic Pain Symptom Inventory (NPSI) in patients with neuropathic pain due to peripheral nerve diseases, and also to evaluate the validity of a new NPSI score: a frequency weighted NPSI score (NPSI-FW). First, the original version of the NPSI was translated into Italian. Then the validity and reliability of the Italian NPSI (I-NPSI) were tested in 392 Italian patients consecutively referred to 16 Italian outpatient services for peripheral nerve diseases, by correlating the I-NPSI scores with other pain scales. The repeatability and responsiveness were assessed. A significant correlation between the I-NPSI scores and all the other pain measures was seen. Reproducibility and responsiveness were good. Our study shows the validity of the I-NPSI and demonstrates its reliability for assessing neuropathic pain in patients with peripheral nerve diseases. The I-NPSI scores represent reliable measurements to assess neuropathic symptoms and effectiveness of treatment on them.

The aims of this study were to evaluate differences between women with carpal tunnel syndrome (CTS) and symptom onset in pregnancy (pregnancy cohort) and women with idiopathic CTS (control cohort) and to report changes in symptoms assessed by the Levine Boston Questionnaire (BQ) administered by phone 3 years after diagnosis. Forty-five pregnant women with CTS (mean age 32 +/- 3.9 years) and 90 age-matched women with idiopathic CTS were consecutively enrolled. Diagnosis was based on clinical findings and abnormal transcarpal median nerve conduction. Univariate analysis showed that the pregnancy cohort had a shorter duration of symptoms, higher frequency of bilateral symptoms and non-blue-collar workers, and lower clinical and electrophysiological severity evaluated by ordinal scales and BQ scores. Multivariate analysis showed that the pregnancy cohort had a probability of improvement of symptoms 3-4 times greater than the control cohort. The need for further treatment depended on BQ functional score; 50% of pregnant women had tolerable CTS symptoms and 85% did not require further treatment 3 years after diagnosis, whereas 72% of women in the control cohort did not require long-term therapy. The probability of need for CTS treatment did not depend on the cohort, but only on the severity of hand disability.

Objective: To verify whether the distribution of paresthesias in patients with Carpal Tunnel Syndrome (CTS) is related to the degree of the neurophysiological involvement., Methods: We performed a cross-sectional study and retrospectively evaluated 163 patients who referred to our electromyography lab and to which a clinical and electrophysiological diagnosis of CTS was made. We divided the patients into two groups: (1) patients complaining of paresthesias at the hand as a whole and (2) patients with paresthesias in the territory of the median nerve. We referred to the distribution of paresthesias at the hand as GLOVE and to the distribution in the territory of the median nerve as MEDIAN. We compared the neurophysiological impairment in GLOVE and MEDIAN distributions. Moreover, we performed multiple regression analysis to evaluate which clinical-neurophysiological variables determined GLOVE and MEDIAN distribution., Results: In our sample, 70.4% of patients had GLOVE distribution and 29.6% of patients MEDIAN distribution. The risk of presenting MEDIAN distribution increases about twice (OR = 2.07; 95% IC: 1.51-2.83) for each unitary increment of neurophysiological class., Conclusions: The distribution of paresthesias reflects the degree of nerve damage at wrist; patients suffering of SEV/EXT CTS present MEDIAN distribution., Significance: Our data have important clinical implications because they strongly suggest that we have to consider the possibility of a severe neurophysiological involvement of the median nerve at wrist in patients complaining of MEDIAN distribution.