Diet quality in adults with cerebral palsy: a modifiable risk factor for cardiovascular disease prevention.

AIM: To assess diet quality and its relationship with cardiovascular health measures for adults with cerebral palsy (CP). METHOD: A convenience sample of 45 adults with CP (26 females, 19 males; mean age 35y 10mo [SD 14y 9mo]). were recruited for this cross-sectional study. Demographic, medical, and Gross Motor Function Classification System (GMFCS) information were obtained through in-person visits. Participants completed two 24-hour dietary recalls using the Automated Self-Administered 24-hour Dietary Assessment Tool. Specific macronutrient intake was compared to 2015 to 2020 US Department of Agriculture (USDA) guidelines. Other data included body mass index (BMI), waist-to-hip ratio (WHR), blood pressure, and hemoglobin A1c (HgA1c;n=43). RESULTS: Adults across GMFCS levels I to V were enrolled, 20 participants were in GMFCS levels IV or V. Mean calorie intake was 1777.91/day (SD 610.54), while sodium intake was 3261.75mg/day (SD 1484.92). Five participants met USDA vegetable and seven fruit guidelines. None met whole grain targets. Sixteen were overweight/obese by BMI. Sixteen participants without hypertension diagnoses had elevated blood pressure and nine had abnormal HgA1c without prediabetes/diabetes history. Percent calories from saturated fat was inversely associated with WHR in unadjusted and adjusted models (p=0.002 and p=0.003 respectively); all other dietary recommendations assessed (total calories, sodium, and sugar) were non-significant. Post hoc analyses were unchanged using 2020 to 2025 USDA guidelines. INTERPRETATION: Assessment of nutrient intake and diet quality is feasible and warrants further study in adults with CP, as USDA guidelines are largely unmet. What this paper adds Adults with cerebral palsy (CP) do not meet US Department of Agriculture dietary quality recommendations. Prediabetes and hypertension may be common, but unrecognized, in adults with CP. Screening for nutrient intake and diet quality should be performed to facilitate nutritional counseling.

Cross-Sectional Study of Bowel Symptoms in Adults With Cerebral Palsy: Prevalence and Impact on Quality of Life.

OBJECTIVES: To determine the prevalence and type of bowel symptoms, and their impact on health-related quality of life (HRQOL) in adults with cerebral palsy (CP). DESIGN: Prospective cross-sectional study. SETTING: Urban, outpatient rehabilitation facility. PARTICIPANTS: Adults with CP (N=91; 46 men, 45 women; mean age, 36y; age range, 18-79y). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Participants were interviewed using standardized instruments to assess the frequency and types of bowel dysfunction. The International Consultation of Incontinence Questionnaire-Bowel was used to assess bowel incontinence and impact on quality of life, and constipation presence was determined using the Rome III criteria for constipation. Constipation symptoms were rated by the Patient Assessment of Constipation-Symptom Scale. Participants' mobility status was classified using the Gross Motor Function Classification System (GMFCS). Interactions between mobility measures, anthropometric measures, and bowel symptoms were assessed. RESULTS: Of the 91 participants enrolled, 62.6% were GMFCS IV or V. Twenty-eight participants (30.8%) reported severe difficulty with control of liquid stool (rating never or rarely); these participants were more likely to have a greater GMFCS level (P=.0004). Twenty-six participants (28.6%) reported that bowel function caused embarrassment some/most/all of the time. Fifty-nine participants (64.8%) met criteria for chronic constipation, which did not differ by GMFCS levels. Overall, 57.1% of participants reported that bowel symptoms interfered with life; 40.7% reported moderate to severe interference. CONCLUSIONS: Bowel symptoms were frequent, a source of embarrassment, and impacted HRQOL in these adults with CP. Addressing bowel-related symptoms has the potential to improve HRQOL in these adults.

Blood pressure in adults with cerebral palsy: a systematic review and meta-analysis of individual participant data.

OBJECTIVES: This systematic review and meta-analysis was designed to determine the overall mean blood pressure and prevalence of hypertension among a representative sample of adults living with cerebral palsy by combining individual participant data. Additional objectives included estimating variations between subgroups and investigating potential risk factors for hypertension. METHODS: Potential datasets were identified by literature searches for studies published between January 2000 and November 2017 and by experts in the field. Samples of adults with cerebral palsy (n ≥ 10, age ≥ 18 years) were included if blood pressure data, cerebral palsy-related factors (e.g. cerebral palsy subtype), and sociodemographic variables (e.g. age, sex) were available. Hypertension was defined as at least 140/90 mmHg and/or use of antihypertensive medication. RESULTS: We included data from 11 international cohorts representing 444 adults with cerebral palsy [median (IQR) age of the sample was 29.0 (23.0-38.0); 51% men; 89% spastic type; Gross Motor Function Classification System levels I-V]. Overall mean SBP was 124.9 mmHg [95% confidence interval (CI) 121.7-128.1] and overall mean DBP was 79.9 mmHg (95% CI 77.2-82.5). Overall prevalence of hypertension was 28.7% (95% CI 18.8-39.8%). Subgroup analysis indicated higher blood pressure levels or higher prevalence of hypertension in adults with cerebral palsy above 40 years of age, men, those with spastic cerebral palsy or those who lived in Africa. BMI, resting heart rate and alcohol consumption were risk factors that were associated with blood pressure or hypertension. CONCLUSION: Our findings underscore the importance of clinical screening for blood pressure in individuals with cerebral palsy beginning in young adulthood.

Daily vs twice daily enoxaparin in the prevention of venous thromboembolic disorders during rehabilitation following acute spinal cord injury.

BACKGROUND: Subcutaneous administration of low molecular weight heparin (eg, enoxaparin) has been shown to be safe and effective in the prevention of acute venous thromboembolic (TE) disease following acute spinal cord injury (SCI) in the rehabilitation setting. However, emerging evidence suggests that different dosing strategies may be equivalent. OBJECTIVE: To determine whether subcutaneous enoxaparin, 40 mg once daily, when compared with subcutaneous enoxaparin, 30 mg twice daily, is equally safe and effective in the prevention of venous TE disease in patients with SCI. DESIGN: Retrospective chart review. SETTING: A freestanding, inpatient, acute, rehabilitation hospital. PATIENTS: One hundred and twenty-nine patients admitted from June 2000 through June 2002 for inpatient rehabilitation following an acute SCI who received either enoxaparin, 40 mg once daily, or enoxaparin, 30 mg twice daily, for prophylaxis for TE disease. RESULTS: Equivalent prophylaxis efficacy was seen in both enoxaparin groups. Symptomatic venous thromboembolism did not differ, with deep vein thromboses occurring in 1 of 49 (2.0%) patients receiving twice-daily enoxaparin, and 1 of 80 (1.25%) patients receiving once-daily enoxaparin (chi2 = 0.125, NS). Pulmonary embolism was seen in 1 of 49 (2.0%) patients treated with twice-daily enoxaparin and in none of the patients in the once-daily group (chi2 = 1.64, NS). Bleeding complications also did not differ between the 2 treatment groups; these were observed in 2 of 49 (4.1%) patients receiving twice-daily enoxaparin and in 5 of 80 (6.3%) patients receiving once-daily enoxaparin (chi2 = 0.228, NS). CONCLUSION: Subcutaneous enoxaparin administered once or twice daily is equally effective for the prevention of venous TE disease. Both dosing strategies are associated with a low incidence of bleeding in patients with SCI who are undergoing rehabilitation.

Long-term intrathecal baclofen: outcomes after more than 10 years of treatment.

OBJECTIVE: To report outcomes of intrathecal baclofen (ITB) therapy for spasticity management in a cohort of patients who had received this treatment for at least 10 years. DESIGN: A cross-sectional survey and retrospective chart review. SETTING: An academic rehabilitation outpatient clinic. PARTICIPANTS: Adult patients with spasticity treated with ITB for at least 10 years. MAIN OUTCOME MEASUREMENTS: Surveys included the Brief Pain Inventory, Penn Spasm Frequency Scale, Epworth Sleepiness Scale, Fatigue Severity Scale, Diener Satisfaction with Life, Life Satisfaction Questionnaire, and Intrathecal Baclofen Survey. RESULTS: Twenty-four subjects completed the surveys. The subjects had been treated with ITB from 10.0-28.4 years, with a mean (standard deviation) of 14.7 ± 4.2 years. The mean (standard deviation) dose of ITB was 627.9 ± 306.7 µg/d, with only 6 subjects averaging daily dose changes of more than 10% compared with 3 years earlier. The mean (standard deviation) scores on outcomes surveys were the following: 2.6 ± 2.3 for pain severity on the Brief Pain Inventory, 1.4 ± 0.7 for spasm severity on the Penn Spasm Frequency Scale, 7.9 ± 5.4 on the Epworth Sleepiness Scale, 4.1 ± 1.6 on the Fatigue Severity Scale, 19.4 ± 8.1 on the Diener Satisfaction with Life, 3.9 ± 0.9 on the Life Satisfaction Questionnaire, and 8.8 ± 1.9 for overall satisfaction with ITB on the Intrathecal Baclofen Survey. On the Brief Pain Inventory, the mean scores for pain severity and interference of pain with life showed moderate inverse correlations with ITB dose (r = -0.386, P = .115; and r = -0.447, P = .062, respectively). On the Life Satisfaction Questionnaire, the mean scores for life satisfaction showed statistically significant positive correlation with ITB dose (r = 0.549, P = .021). CONCLUSIONS: The subjects reported low levels of pain, moderate levels of life satisfaction, normal levels of sleepiness, low-to-moderate levels of fatigue, infrequent spasms at mild-to-moderate severity, and high levels of satisfaction. The efficacy and favorable adverse effect profile of ITB therapy was sustained in this cohort of subjects with more than a decade of treatment.

Lubiprostone vs Senna in postoperative orthopedic surgery patients with opioid-induced constipation: a double-blind, active-comparator trial.

AIM: To investigate the efficacy of lubiprostone compared to Senna on bowel symptoms and constipation in post-operative orthopedic patients treated with opioids. METHODS: In this double blind, randomized, active comparator trial, adults who required opioids for analgesia following orthopedic procedures and who were admitted in inpatient rehabilitation were randomized following baseline assessments to lubiprostone (Amitza(®)), orally twice a day or Senna (generic) two capsules administered daily for six days. Subjects were assessed using the patient assessment of constipation (PAC)-symptoms (PAC-SYM) and the PAC-quality of life (PAC-QOL) scales measured at baseline and Day 7; Subjects were assessed daily for secondary measures included the Bristol stool scale bowel consistency, specific bowel symptom score (Nausea, cramping, straining, completeness, abdominal pain, time per lavatory attempt, assistance needed), adverse events and rescue medications required. Function was measured using the functional independence measure (FIM) at admission and discharge; length of stay (LOS) and missed treatments due to gastrointestinal symptoms were also assessed. RESULTS: 64 adults were enrolled; 56 participants (28 in each group) had baseline and follow up measures and were included in the intention to treat (ITT) analyses. 43 participants completed the study, 21 in the active lubiprostone and 22 in the active Senna group. The mean age of the participants was 71.5 years (SD = 11.4 years, range: 28-96 years). In the ITT analyses, participants showed significant improvement in bowel symptoms as measured by the PAC-SYM (mean ± SD, -0.28 ± 0.60, range: -1-2.33) and PAC-QOL (mean ± SD, 0.33 ± 0.81, range: -1.5-2.0) over time, but there were no significant differences between the lubiprostone and Senna groups in mean change in the PAC-SYM (-0.20 ± 0.60 vs -0.36 ± 0.61, P = 0.61 respectively) or the PAC-QOL (0.29 ± 0.76 vs 0.37 ± 0.87, P = 0.61 respectively). The mean change in each bowel symptom also did not significantly differ between treatment groups on ITT analyses, except for completeness of bowel movement, with the Senna group showing greater negative mean change in bowel movement completeness (-0.56 ± 1.01 vs -2.00 ± 1.41, P = 0.03) and for reduction of abdominal pain, favoring Senna (-0.14 ± 0.73 vs -0.73 ± 1.08, P = 0.04). Fifteen (75%) participants in the lubiprostone and in the Senna group requested rescue treatments. Participants made significant functional improvement from admission to discharge over a median LOS of 12 d, with a mean FIM change of 29.13 ± 13.58 and no significant between group differences (27.0 ± 9.2 vs 31.5 ± 16.6, P = 0.27). CONCLUSION: Both lubiprostone and Senna improved constipation-related symptoms and QOL in opioid-induced constipation, with no significant between-group differences.

Wii Fit balance board playing improves balance and gait in Parkinson disease.

OBJECTIVE: To assess the effect of exercise training by using the Nintendo Wii Fit video game and balance board system on balance and gait in adults with Parkinson disease (PD). DESIGN: A prospective interventional cohort study. SETTING: An outpatient group exercise class. PARTICIPANTS: Ten subjects with PD, Hoehn and Yahr stages 2.5 or 3, with a mean age of 67.1 years; 4 men, 6 women. INTERVENTIONS: The subjects participated in supervised group exercise sessions 3 times per week for 8 weeks by practicing 3 different Wii balance board games (marble tracking, skiing, and bubble rafting) adjusted for their individualized function level. The subjects trained for 10 minutes per game, a total of 30 minutes training per session. MAIN OUTCOME MEASUREMENTS: Pre-and postexercise training, a physical therapist evaluated subjects' function by using the Berg Balance Scale, Dynamic Gait Index, and Sharpened Romberg with eyes open and closed. Postural sway was assessed at rest and with tracking tasks by using the Wii balance board. The subjects rated their confidence in balance by using the Activities-specific Balance Confidence scale and depression on the Geriatric Depression Scale. RESULTS: Balance as measured by the Berg Balance Scale improved significantly, with an increase of 3.3 points (P = .016). The Dynamic Gait Index improved as well (mean increase, 2.8; P = .004), as did postural sway measured with the balance board (decreased variance in stance with eyes open by 31%; P = .049). Although the Sharpened Romberg with eyes closed increased by 6.85 points and with eyes opened by 3.3 points, improvements neared significance only for eyes closed (P = .07 versus P = .188). There were no significant changes on patient ratings for the Activities-specific Balance Confidence (mean decrease, -1%; P = .922) or the Geriatric Depression Scale (mean increase, 2.2; P = .188). CONCLUSIONS: An 8-week exercise training class by using the Wii Fit balance board improved selective measures of balance and gait in adults with PD. However, no significant changes were seen in mood or confidence regarding balance.

Functional outcomes of childhood dorsal rhizotomy in adults and adolescents with cerebral palsy.

OBJECT: In this descriptive study the authors evaluated medical outcomes, interventions, satisfaction with life, and subjective impressions about selective dorsal rhizotomy (SDR) in older adolescents and adults who had undergone the procedure as children. METHODS: A survey was administered to older adolescents (16-20 years old) and adults with CP who had undergone SDR between 1986 and 2000 at two academic centers. The patients or their caregivers participated in telephone or clinic interviews. Subjective impressions about the SDR and a history of post-SDR medical interventions were obtained. Current functional status, history and ratings of pain, educational achievement, living situation, and subjective health status were also recorded. The Diener Satisfaction with Life Scale (SWLS) was administered. RESULTS: Eighty-eight participants, mean age 25.6 ± 4.8 years (mean ± standard deviation), were interviewed at a mean of 19.6 ± 3.0 years after surgery. The distribution of current reported Gross Motor Function Classification System levels was as follows: I, 7%; II, 18%; III, 23%; IV, 36%; and V, 16%. Moreover, 56% of respondents were living with parents and 25% were living alone. Thirty-five percent were employed, and 39% were still in school. The mean overall SWLS score was 26.0 ± 7.3, indicating a high level of satisfaction with life. According to 65% of the patients, the SDR was helpful; 31% were uncertain about the procedure's efficacy. Sixty-five percent would recommend the procedure to others. Fifty-eight percent reported excellent to very good health. Forty-four percent reported pain in the past week. Fifty-one percent reported chronic back pain in general. Logistic regression analysis suggested that an increased satisfaction with life was a predictor (p = 0.01) of an affirmative response to the question about recommending the procedure to others and that better overall health showed a trend toward being such a predictor (p = 0.08). Additional interventions were frequently performed after the SDR. Seventy-four percent of participants underwent orthopedic surgery. Thirty-eight percent were currently taking oral medications for tone, and 53% had received botulinum toxin injections for spasticity treatment. Thirteen patients (15%) had an intrathecal baclofen pump placed. CONCLUSIONS: The majority of adults who had undergone SDR as children would recommend the procedure to others. Very few reported negative impressions of the procedure. Levels of satisfaction with life were generally high. Pain prevalence was similar to what has been reported in the literature for adults with cerebral palsy. Despite the SDR, further interventions, both surgical and nonsurgical, were used in the majority of patients.

Enoxaparin versus tinzaparin for venous thromboembolic prophylaxis during rehabilitation after acute spinal cord injury: a retrospective cohort study comparing safety and efficacy.

OBJECTIVE: To compare the safety and efficacy of 3 low-molecular-weight heparin (LMWH) treatments (enoxaparin, 40 mg once daily, with an alternative LMWH, tinzaparin, 3500 or 4500 units once daily) for the prevention of venous thromboembolic events (VTEs) after acute spinal cord injury (SCI). DESIGN: Retrospective, chart review study. SETTING: Acute inpatient rehabilitation facility. PARTICIPANTS: Patients admitted to acute rehabilitation within 3 months of either a traumatic or nontraumatic SCI during a 15-month time frame and who received either enoxaparin or tinzaparin for VTE prophylaxis. MAIN OUTCOME MEASURES: Symptomatic VTE incidence and bleeding events during acute rehabilitation. RESULTS: A total of 140 participants who met inclusion criteria were admitted at a median of 15 days after an acute SCI. Before admission to rehabilitation, 23.6% were not on any VTE prophylaxis, 55.7% were on enoxaparin, 17.1% were on unfractionated heparin, 1.4% were on treatment doses of a LMWH, and 2.1% did not have documentation available regarding type of prophylaxis before admission. No patients were receiving tinzaparin before admission. During rehabilitation, 68 participants received prophylaxis with enoxaparin, whereas 14 and 58 participants received tinzaparin 3500 or 4500 units, respectively. Symptomatic VTE developed in 14 patients during rehabilitation, including 4 developing pulmonary emboli. Compared with patients receiving tinzaparin 3500 units, both those receiving enoxaparin had significantly reduced odds of VTE (odds ratio [OR] 0.12; 95% confidence interval [95% CI] 0.02-0.65)] and those receiving tinzaparin 4500 units had significantly reduced odds of VTE (OR 0.18; 95% CI 0.03-0.93). After we adjusted for age, previous pharmacologic prophylaxis, and etiology for the SCI (traumatic vs nontraumatic) via propensity scores, pharmacologic prophylaxis with enoxaparin remained protective for VTE compared with tinzaparin 3500 units (adjusted OR 0.15; 95% CI 0.02-0.93). The use of prophylaxis before admission with enoxaparin compared with no prophylaxis was associated with decreased risk of VTE during rehabilitation (adjusted OR 0.20; 95% CI 0.04-0.88); however, this association was no longer significant when we adjusted for prophylaxis during rehabilitation. The etiology for the SCI and the presence of an inferior vena cava filter were not associated with VTE. One patient receiving enoxaparin required transfer for a bleeding event, and no patients had greater than a 1-g decrease in hemoglobin during the rehabilitation stay. CONCLUSIONS: VTE was more prevalent in participants receiving tinzaparin 3500 units than in participants who received tinzaparin 4500 units or enoxaparin. Bleeding events were low with the use of LMWH for prophylaxis during acute rehabilitation. Although the use of prophylaxis before rehabilitation may be protective of VTE events, after we adjusted for VTE prophylaxis during rehabilitation, type of previous prophylaxis was not found to be significantly protective of VTE events during rehabilitation.

Does botulinum toxin type A decrease pain and lessen disability in hemiplegic survivors of stroke with shoulder pain and spasticity?: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: The aim of this study was to assess the efficacy of botulinum toxin type A injections in reducing pain, impairment, and disability in patients who have had a stroke with shoulder pain and spasticity. DESIGN: In this prospective randomized, double-blind, placebo-controlled trial, adults (n = 37) with post-stroke shoulder spasticity were screened for preinjection spasticity, rated 3 or 4 on the Modified Ashworth Scale for the shoulder adductors/internal rotators and shoulder pain. After the baseline screening, 21 subjects were randomized to receive either onabotulinumtoxinA (Botox; 140-200 units), into the pectoralis major with or without injections to the teres major, or placebo (saline) injections. Daily pain ratings using visual analog scales of best and worst pain and Disability Assessment Scale for dressing, hygiene, pain, and cosmesis; McGill Pain Questionnaire-Short Form; Fugl-Meyer Scale; upper limb range of motion; and Modified Ashworth Scale scores were assessed at baseline and 2, 4, and 12 wks after injection. Primary outcomes were assessed at week 4. RESULTS: The subject groups were well matched at baseline. Both the botulinum toxin type A and placebo groups showed decreased pain scores at 4 wks (P's < 0.05), with no significant differences between the groups found for any of the daily pain ratings (P's > 0.05). Significant improvement (P < 0.05) in change scores for hygiene on the Disability Assessment Scale was found in the botulinum toxin type A group compared with the placebo group at week 4, and there was a similar trend toward significance for improvement on the Disability Assessment Scale dressing scale (P = 0.061). CONCLUSIONS: Although botulinum toxin type A shoulder muscle injections in patients who have had a stroke with spasticity and shoulder pain resulted in improvement in selected disability measures, the observed pain reduction was not greater than that found for placebo.

Do co-morbidities and cognition impact functional change and discharge needs in Parkinson disease?

OBJECTIVE: The aim of this study was to assess the impact of cognition, baseline motor function, and co-morbid medical conditions on functional change, discharge destination, and discharge needs in patients admitted to acute rehabilitation for Parkinson-related impairments. DESIGN: This retrospective chart review study evaluated the records of patients admitted to acute rehabilitation over a 5-yr period with a primary impairment category of parkinsonism. Functional status was measured at admission and discharge; 3-mo follow-up function was also collected in a sample of discharged patients. RESULTS: Eighty-nine patients (mean age, 74.26 yrs) were admitted over the 5-yr time frame. A more complicated Medicare tier diagnosis (tier 2) was associated with lower total and motor score Functional Independence Measure gains compared with tier 3 (P = 0.009 and P = 0.016, respectively). Cognitive scores at admission were not related to need for caregivers upon discharge. Overall Functional Independence Measure gain (adjusted R(2) = 0.073, P = 0.006) and Functional Independence Measure gain efficiency (adjusted R(2) = 0.142, P < 0.001) inversely correlated with age. At the 3-mo follow-up, a random sample (38%) of patients contacted postdischarge demonstrated continued improvements. CONCLUSIONS: Significant improvement may be seen after acute rehabilitation in patients with Parkinson disease, irrespective of cognitive impairment. More complicated medical tier diagnoses result in less Functional Independence Measure gain, and older individuals with Parkinson disease are more likely to show less functional change. However, functional improvements are still statistically significant.

Effect of interelectrode distance on sural nerve action potential parameters.

OBJECTIVE: To assess differences in amplitude, latency, and duration, using a 3-cm vs. 4-cm distance between the active and reference electrodes when performing sural nerve conduction studies (NCS). Current normative data in lower-limb studies are generally based on 3-cm interelectrode differences, although 4-cm differences have been reported to be optimal in the upper limb. DESIGN: Prospective study comparing the onset latency, peak latency, duration, and amplitude for the sural sensory nerve action potential (SNAP) recording at two interelectrode distances in adult volunteers. RESULTS: Forty-three sural nerves were studied in 22 normal subjects. Peak latencies recorded with a 4-cm interelectrode distance were significantly longer than those recorded with a 3-cm distance (mean difference = 0.06 msecs [SD = 0.09, P = 0.0073]). Duration was significantly longer (mean difference = 0.03 msecs [SD = 0.07, P = 0.0270]), conduction velocities were significantly slower (mean difference = -0.7 msecs [SD 1.0, P = 0.0012]), and onset latency and amplitude were not found to differ significantly. Average differences in peak latencies, duration, velocity, onset latency, and amplitude were not correlated with gender, age, or BMI. CONCLUSIONS: In contrast to studies of upper-limb sensory NCS, sural SNAP parameters obtained with 3- and 4-cm interelectrode distances did not differ for onset latencies and amplitude. Peak latencies, duration, and conduction velocity differences, though statistically significant, were of insufficient magnitude to be clinically meaningful. By using a 4-cm instead of a 3-cm interelectrode difference for sural nerve studies, the small prolongation of 0.06 msecs in peak latency and tiny increment of 0.27 muV observed in our investigation is unlikely to influence the electrodiagnostician's interpretation of the study.

Myotonic dystrophy presenting as new-onset hand weakness and recurrent pneumonia in a patient with paraplegia: a case report.

We describe a previously independent T11 paraplegic patient who had delayed-onset hand weakness and recurrent pneumonia caused by myotonic dystrophy. A man in his late thirties suffered a thoracic spinal cord injury (SCI) from a gunshot wound at the age of 17 years, with resultant T11 American Spinal Injury Association class A paraplegia. He lived independently until the age of 36 years when he was hospitalized multiple times for pneumonia. During a rehabilitation stay after one of the acute hospitalizations, the patient's hand weakness and diffuse muscular atrophy were noted. Electrodiagnostic testing was performed, which showed myotonic discharges. Genetic testing was consistent with myotonic dystrophy. This case shows the importance of considering causes of weakness that affect the population as a whole when evaluating a patient with SCI who presents with delayed-onset weakness.