-
Current Pain and Headache Reports Jan 2019Chronic pain of the lower extremity remains challenging to manage. Radiofrequency treatment applies heat to nerve fibers with the goal of mitigating chronic pain...
BACKGROUND
Chronic pain of the lower extremity remains challenging to manage. Radiofrequency treatment applies heat to nerve fibers with the goal of mitigating chronic pain conditions. The clinical efficacy has not yet been adequately established for pathologies of the ankle and foot. In this review paper, we report the use and efficacy of radiofrequency treatment applied to foot and ankle pain.
RECENT FINDINGS
PubMed and the Cochrane Controlled Trials Register were searched (final search 30 March 2018) using the MeSH terms "radiofrequency ablation," "neurolysis," "radiofrequency therapy," "pain syndrome," "analgesia," "plantar heel pain," "plantar fascitis," and "chronic pain" in the English literature. Of the 23 papers screened, 18 were further investigated for relevance. Our final search methodology yielded 15 studies that investigated the use of radiofrequency treatment at the ankle. Of these 15 studies, there were three randomized control trials, four prospective studies, three retrospective studies, and five case reports. The quality of selected publications was assessed using the Cochrane risk of bias instrument. The evidence from our studies suggests that radiofrequency treatment can be used safely for the management foot and ankle pain. The technique (continuous vs pulsatile), temperature, location of treatment, and duration of administration need more thorough evaluation. Randomized control trials are needed to establish the efficacy and safety profile of radiofrequency ablation and its long-term benefits in patients with chronic pain of the foot and ankle.
CONCLUSION
The evidence from our studies suggests that radiofrequency treatment can be used safely for the management foot and ankle pain. The technique (continuous vs pulsatile), temperature, location of treatment, and duration of administration need more thorough evaluation. Randomized control trials are needed to establish the efficacy and safety profile of radiofrequency ablation and its long-term benefits in patients with chronic pain of the foot and ankle.
Topics: Ankle; Chronic Pain; Foot Diseases; Humans; Pain Management; Pulsed Radiofrequency Treatment; Treatment Outcome
PubMed: 30661127
DOI: 10.1007/s11916-019-0745-5 -
Foot (Edinburgh, Scotland) Jun 2018An intermetatarsal neuroma is a plantar digital neuritis causing metatarsalgia of the affected inter-metatarsal space. At present the evidence to support the management...
An intermetatarsal neuroma is a plantar digital neuritis causing metatarsalgia of the affected inter-metatarsal space. At present the evidence to support the management of the condition is poor with only some quality evidence supporting the short-term management of intermetatarsal neuromas using steroid injections. Some authors have supported the use of alcohol sclerosing intra-lesional injections to treat intermetatarsal neuromas. Following a search of the evidence 11 articles were identified. The systematic review found that alcohol injections appear to be safe although some papers report a short-term side effect of a flogistic reaction and there are variances in the alcohol concentration used and guiding verses not guiding the injection using ultrasound imaging. Some of the evidence may suggest a sclerosing histological effect of the nerve. However, all the studies reviewed present a research design offering a low level of evidence that is open to methodological biases and interpretation. Thus, this review found insufficient high-quality research evidence to afford conclusions on the management of intermetatarsal neuromas with alcohol sclerosing agent injections.
Topics: Adult; Aged; Animals; Disease Models, Animal; Ethanol; Female; Follow-Up Studies; Humans; Injections, Intralesional; Male; Metatarsalgia; Middle Aged; Morton Neuroma; Pain Measurement; Rats; Risk Assessment; Sclerosing Solutions; Sclerotherapy; Severity of Illness Index; Treatment Outcome; Ultrasonography, Doppler
PubMed: 29778841
DOI: 10.1016/j.foot.2017.12.003 -
Clinical Rehabilitation Sep 2018To evaluate (1) the effectiveness of transcutaneous electrical nerve stimulation (TENS) at improving lower extremity motor recovery in stroke survivors and (2) the... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To evaluate (1) the effectiveness of transcutaneous electrical nerve stimulation (TENS) at improving lower extremity motor recovery in stroke survivors and (2) the optimal stimulation parameters for TENS.
REVIEW METHODS
A systematic search was conducted for studies published up to October 2017 using eight electronic databases (CINAHL, ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, PEDro, PubMed and Web of Science). Randomized controlled trials that evaluated the effectiveness of the application of TENS at improving lower extremity motor recovery in stroke survivors were assessed for inclusion. Outcomes of interest included plantar flexor spasticity, muscle strength, walking capacity and balance.
RESULTS
In all, 11 studies met the inclusion criteria which involved 439 stroke survivors. The meta-analysis showed that TENS improved walking capacity, as measured by either gait speed or the Timed Up and Go Test (Hedges' g = 0.392; 95% confidence interval (CI) = 0.178 to 0.606) compared to the placebo or no-treatment control groups. TENS also reduced paretic plantar flexor spasticity, as measured using the Modified Ashworth Scale and Composite Spasticity Scale (Hedges' g = -0.884; 95% CI = -1.140 to -0.625). The effect of TENS on walking capacity in studies involving 60 minutes per sessions was significant (Hedges' g = 0.468; 95% CI = 0.201-0.734) but not in study with shorter sessions (20 or 30 minutes) (Hedges' g = 0.254; 95% CI = -0.106-0.614).
CONCLUSION
The results support the use of repeated applications of TENS as an adjunct therapy for improving walking capacity and reducing spasticity in stroke survivors.
Topics: Gait Disorders, Neurologic; Humans; Muscle Spasticity; Postural Balance; Stroke; Stroke Rehabilitation; Transcutaneous Electric Nerve Stimulation
PubMed: 29232981
DOI: 10.1177/0269215517745349 -
The Cochrane Database of Systematic... Jun 2017Plantar heel pain, commonly resulting from plantar fasciitis, often results in significant morbidity. Treatment options include nonsteroidal anti-inflammatory drugs... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Plantar heel pain, commonly resulting from plantar fasciitis, often results in significant morbidity. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), orthoses, physical therapy, physical agents (e.g. extracorporeal shock wave therapy (ESWT), laser) and invasive procedures including steroid injections.
OBJECTIVES
To assess the effects (benefits and harms) of injected corticosteroids for treating plantar heel pain in adults.
SEARCH METHODS
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, CINAHL, clinical trials registries and conference proceedings. Latest search: 27 March 2017.
SELECTION CRITERIA
Randomised and quasi-randomised trials of corticosteroid injections in the treatment of plantar heel pain in adults were eligible for inclusion.
DATA COLLECTION AND ANALYSIS
At least two review authors independently selected studies, assessed risk of bias and extracted data. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcome measures. We used a fixed-effect model unless heterogeneity was significant, when a random-effects model was considered. We assessed the overall quality of evidence for individual outcomes using the GRADE approach.
MAIN RESULTS
We included a total of 39 studies (36 randomised controlled trials (RCTs) and 3 quasi-RCTs) that involved a total of 2492 adults. Most studies were small (median = 59 participants). Participants' mean ages ranged from 34 years to 59 years. When reported, most participants had heel pain for several months. The trials were usually conducted in outpatient specialty clinics of tertiary care hospitals in 17 countries. Steroid injection was given with a local anaesthetic agent in 34 trials. Follow-up was from one month to over two years. With one exception, trials were assessed at high risk of bias in one or more domains, mostly relating to lack of blinding, including lack of confirmation of allocation concealment. With two exceptions, we rated the available evidence as very low quality, implying in each case that we are 'very uncertain about the estimate'.The 39 trials covered 18 comparisons, with six of the seven trials with three or four groups providing evidence towards two comparisons.Eight trials (724 participants) compared steroid injection versus placebo or no treatment. Steroid injection may lead to lower heel pain visual analogue scores (VAS) (0 to 100; higher scores = worse pain) in the short-term (< 1 month) (MD -6.38, 95% CI -11.13 to -1.64; 350 participants; 5 studies; I² = 65%; low quality evidence). Based on a minimal clinically significant difference (MCID) of 8 for average heel pain, the 95% CI includes a marginal clinical benefit. This potential benefit was diminished when data were restricted to three placebo-controlled trials. Steroid injection made no difference to average heel pain in the medium-term (1 to 6 months follow-up) (MD -3.47, 95% CI -8.43 to 1.48; 382 participants; 6 studies; I² = 40%; low quality evidence). There was very low quality evidence for no effect on function in the medium-term and for an absence of serious adverse events (219 participants, 4 studies). No studies reported on other adverse events, such as post-injection pain, and on return to previous activity. There was very low quality evidence for fewer treatment failures (defined variously as persistent heel pain at 8 weeks, steroid injection at 12 weeks, and unrelieved pain at 6 months) after steroid injection.The available evidence for other comparisons was rated as very low quality. We are therefore very uncertain of the estimates for the relative effects on people with heel pain of steroids compared with other interventions in:1. Tibial nerve block with anaesthetic (2 trials); orthoses (4 trials); oral NSAIDs (2 trials); and intensive physiotherapy (1 trial).2. Physical modalities: ESWT (5 trials); laser (2 trials); and radiation therapy (1 trial).3. Other invasive procedures: locally injectable NSAID (1 trial); platelet-rich plasma injections (5 trials); autologous blood injections (2 trials); botulinum toxin injections (2 trials); cryopreserved human amniotic membrane injection (1 trial); localised peppering with a needle (1 trial); dry needling (1 trial); and mini scalpel needle release (1 trial).We are also uncertain about the estimates from trials testing different techniques of local steroid injection: ultrasonography-guided versus palpation-guided (5 trials); and scintigraphy-guided versus palpation-guided (1 trial).An exploratory analysis involving pooling data from 21 trials reporting on adverse events revealed two ruptures of plantar fascia (reported in 1 trial) and three injection site infections (reported in 2 trials) in 699 participants allocated to steroid injection study arms. Five trials reported a total of 27 participants with less serious short-term adverse events in the 699 participants allocated steroid injection study arms. Reported treatments were analgesia, ice or both. Given the high risk of selective reporting for these outcomes and imprecision, this evidence was rated at very low quality.
AUTHORS' CONCLUSIONS
We found low quality evidence that local steroid injections compared with placebo or no treatment may slightly reduce heel pain up to one month but not subsequently. The available evidence for other outcomes of this comparison was very low quality. Where available, the evidence from comparisons of steroid injections with other interventions used to treat heel pain and of different methods of guiding the injection was also very low quality. Although serious adverse events relating to steroid injection were rare, these were under-reported and a higher risk cannot be ruled out.Further research should focus on establishing the effects (benefits and harms) of injected steroids compared with placebo in typical clinical settings, subsequent to a course of unsuccessful conservative therapy. Ideally, this should be preceded by research, including patient involvement, aimed to obtain consensus on the priority questions for treating plantar heel pain.
Topics: Adrenal Cortex Hormones; Adult; Anesthetics, Local; Foot Diseases; Heel; Humans; Middle Aged; Non-Randomized Controlled Trials as Topic; Pain; Pain Measurement; Publication Bias; Randomized Controlled Trials as Topic; Treatment Failure
PubMed: 28602048
DOI: 10.1002/14651858.CD009348.pub2 -
Plastic and Reconstructive Surgery Dec 2015Absence of plantar sensation is a critical factor considered in favor of amputation for patients with lower limb-threatening injuries. This study aims to assess outcomes... (Review)
Review
BACKGROUND
Absence of plantar sensation is a critical factor considered in favor of amputation for patients with lower limb-threatening injuries. This study aims to assess outcomes of limb salvage in a group of patients with severe lower extremity injuries associated with posterior tibial nerve transection.
METHODS
The authors studied eight cases of limb salvage after traumatic injuries with documented tibial nerve laceration managed at Ganga Hospital, India. Functional and health-related quality-of-life outcomes were assessed. Outcomes from this case series were compared to outcomes of studies from a systematic literature review on salvage of the severely injured lower extremity.
RESULTS
Patients in this case series reported mild pain (median score, 20 on a visual analogue scale ranging from 0 to 100), with some return of plantar sensation in patients with tibial nerve repairs (median score, 2 of 5). Patients demonstrated a decrease in ankle motion (27.5 degrees' plantar flexion and 10 degrees' extension) and muscle strength (median heel flexor score, 3 of 5). All patients could ambulate independently. Quality of life and function measured by validated instruments revealed minimal disability. The authors identified 1767 articles on lower extremity trauma, and 14 articles were reviewed systematically. Relative to the case series, published articles reported similarly diminished ankle motion and muscle strength, with reports of mild pain in select studies. Patient-reported outcomes instruments found variations in the degree of physical disability based on the time from injury.
CONCLUSION
Although limited in number, this case series demonstrates the value of limb salvage even for patients with posterior tibial nerve injury.
Topics: Adult; Hospitals; Humans; Injury Severity Score; Leg Injuries; Limb Salvage; Male; Middle Aged; Multiple Trauma; Tibial Nerve; Young Adult
PubMed: 26270902
DOI: 10.1097/PRS.0000000000001814 -
Journal of Vascular Surgery Sep 2009The purpose of this systematic review is to evaluate current evidence in the literature on the efficacy of Semmes Weinstein monofilament examination (SWME) in diagnosing... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The purpose of this systematic review is to evaluate current evidence in the literature on the efficacy of Semmes Weinstein monofilament examination (SWME) in diagnosing diabetic peripheral neuropathy (DPN).
METHODS
The PubMed database was searched through August 2008 for articles pertaining to DPN and SWME with no language or publication date restrictions. Studies with original data comparing the diagnostic value of SWME with that of one or more other modalities for DPN in patients with diabetes mellitus were analyzed. Data were extracted by two independent investigators. Diagnostic values were calculated after classifying data by reference test, SWME methodology, and diagnostic threshold.
RESULTS
Of the 764 studies identified, 30 articles were selected, involving 8365 patients. There was great variation in both the reference test and the methodology of SWME. However, current literature suggests that nerve conduction study (NCS) is the gold standard for diagnosing DPN. Four studies were identified which directly compared SWME with NCS and encompassed 1065 patients with, and 52 patients without diabetes mellitus. SWME had a sensitivity ranging from 57% (95% confidence interval [CI], 44% to 68%) to 93% (95% CI, 77% to 99%), specificity ranging from 75% (95% CI, 64% to 84%) to 100% (95% CI, 63% to 100%), positive predictive value (PPV) ranging from 84% (95% CI, 74% to 90%) to 100% (95% CI, 87% to 100%), and negative predictive value (NPV) ranging from 36% (95% CI, 29% to 43%) to 94% (95% CI, 91% to 96%).
CONCLUSIONS
There is great variation in the current literature regarding the diagnostic value of SWME as a result of different methodologies. To maximize the diagnostic value of SWME, a three site test involving the plantar aspects of the great toe, the third metatarsal, and the fifth metatarsals should be used. Screening is vital in identifying DPN early, enabling earlier intervention and management to reduce the risk of ulceration and lower extremity amputation.
Topics: Diabetic Neuropathies; Early Diagnosis; Evidence-Based Medicine; Foot; Humans; Mass Screening; Neural Conduction; Neurologic Examination; Predictive Value of Tests; Sensitivity and Specificity; Touch
PubMed: 19595541
DOI: 10.1016/j.jvs.2009.05.017 -
The Cochrane Database of Systematic... Jul 2008Symmetrical peripheral neuropathy is a common complication of diabetic neuropathy. No treatments are known to be effective for progressive pain and sensory loss... (Review)
Review
BACKGROUND
Symmetrical peripheral neuropathy is a common complication of diabetic neuropathy. No treatments are known to be effective for progressive pain and sensory loss associated with diabetic neuropathy. Alternative effective treatment strategies have been sought.
OBJECTIVES
To systematically review the evidence from randomized controlled trials concerning the role of decompressive surgery of lower limbs for symmetrical diabetic peripheral neuropathy.
SEARCH STRATEGY
We searched the Cochrane Neuromuscular Disease Trials Register (May 2006), CENTRAL (The Cochrane Library, Issue 2 2006), MEDLINE from (January 1966 to August 2006), EMBASE (from January 1980 to August 2006), LILACS (from January 1982 to August 2006), and CINAHL (from January 1982 to August 2006).
SELECTION CRITERIA
We included all randomized or quasi-randomized controlled human trials in which any form of decompressive surgery of the lower limbs nerves had been used to treat diabetic symmetrical distal polyneuropathy (DSDP) compared with no treatment or medical therapy. Patients with DSDP were included if they had decompression (with or without neurolysis) of at least two of the following nerves in both lower limbs, for the treatment of DSDP: the posterior tibial nerve (including calcaneal, medial and lateral plantar nerves), deep peroneal nerve at the ankle, common peroneal nerve at the knee, lateral femoral cutaneous nerve and sural nerves in the posterior calf region. The primary outcome measure was the change in pain measured by the visual analogue scale (VAS) between the baseline and a follow-up period of greater than three months.
DATA COLLECTION AND ANALYSIS
We identified 142 publications from the above search strategies. The three authors of this manuscript reviewed abstracts of all papers independently. Only eight of these were considered relevant to the question at hand. The data from these 8 studies were entered onto standardized data extraction forms. We planned to use Review Manager to pool the results from appropriate studies comparing the same treatments; dichotomous outcomes to obtain pooled relative risks (RR); measured outcomes to obtain pooled weighted mean differences; and a fixed-effect analysis unless there was evidence of serious heterogeneity between studies sufficient to justify the use of random-effects analysis.
MAIN RESULTS
This review failed to identify a single randomized controlled trial or any other well designed prospective study controlling for the non-operated limb that showed improvements in pre defined end points after decompressive surgery.
AUTHORS' CONCLUSIONS
The results of this review suggest that the role of decompressive surgery for diabetic symmetric distal neuropathy is unproven.
Topics: Decompression, Surgical; Diabetic Neuropathies; Humans; Lower Extremity
PubMed: 18646138
DOI: 10.1002/14651858.CD006152.pub2 -
The Cochrane Database of Systematic... 2004Morton's neuroma is a common, paroxysmal neuralgia affecting the web spaces of the toes, typically the third. The pain is often so debilitating that patients become... (Review)
Review
BACKGROUND
Morton's neuroma is a common, paroxysmal neuralgia affecting the web spaces of the toes, typically the third. The pain is often so debilitating that patients become anxious about walking or even putting their foot to the ground. Insoles, corticosteroid injections, excision of the nerve, transposition of the nerve and neurolysis of the nerve are commonly used treatments. Their effectiveness is poorly understood.
OBJECTIVES
To examine the evidence from randomised controlled trials concerning the effectiveness of interventions in adults with Morton's neuroma.
SEARCH STRATEGY
We searched the Cochrane Neuromuscular Disease Group trials register (searched January 2003), MEDLINE (January 1966 to January Week 2 2003), EMBASE (January 1980 to February Week 2 2003), and CINAHL (January 1982 to February Week 1 2003).
SELECTION CRITERIA
Randomised or quasi-randomised (methods of allocating participants to an intervention which were not strictly random e.g. date of birth, hospital record, number alternation) controlled trials of interventions for Morton's neuroma were selected. Studies where participants were not randomised into intervention groups were excluded.
DATA COLLECTION AND ANALYSIS
Two reviewers selected trials for inclusion in the review, assessed their methodological quality and extracted data independently.
MAIN RESULTS
Three trials involving 121 people were included. There is, at most, a very limited indication that transposition of the transected plantar digital nerve may yield better results than standard resection of the nerve in the long term. There is no evidence to support the use of supinatory insoles. There are, at best, very limited indications to suggest that dorsal incisions for resection of the plantar digital nerve may result in less symptomatic post-operative scars when compared to plantar excision of the nerve.
REVIEWERS' CONCLUSIONS
There is insufficient evidence with which to assess the effectiveness of surgical and non-surgical interventions for Morton's neuroma. Well designed trials are needed to begin to establish an evidence base for the treatment of Morton's neuroma pain.
Topics: Foot Diseases; Humans; Metatarsalgia; Neuroma; Randomized Controlled Trials as Topic; Toes
PubMed: 15266472
DOI: 10.1002/14651858.CD003118.pub2