Trends and Cost Analysis of Upper Extremity Nerve Injury Using the National (Nationwide) Inpatient Sample.

OBJECTIVE: Epidemiology in upper extremity peripheral nerve injury (PNI) has not been comprehensively evaluated. The aim of this study was to calculate updated incidence of upper extremity PNIs in the United States and examine clinical trends and costs using a national database. METHODS: The National (Nationwide) Inpatient Sample was used to evaluate patients with upper extremity PNI (International Classification of Diseases, Ninth Revision, Clinical Modification 9534, 9550-9559) in 2001-2013. RESULTS: A weighted total of 170,579 patients experienced upper extremity PNI, representing a mean incidence of 43.8/1 million people annually. Mean (± SEM) age of patients was 38.1 ± 0.05 years, 74.3% of patients were male, and 49.0% were Caucasian. PNIs occurred to the ulnar (17.8%), radial (15.1%), digital (18.0%), median (13.0%), multiple (11.5%), and other (10.1%) nerves and brachial plexus (14.5%). The number of upper extremity PNIs decreased overall. Average care charge was $47,004 ± $185, with an average increase of $4623/year and compound annual growth rate of 9.59%. Although surgical nerve repair and home disposition were common with isolated PNIs, patients with brachial plexus PNIs did not have nerve surgery and were more likely to be discharged to skilled nursing facilities. Multivariate analysis showed that length of stay (ß = 0.677, P = 0.0001) and number of procedures (ß = 0.188, P = 0.0001) most affected total patient charges. CONCLUSIONS: These results suggest an overall decrease in number of PNIs, suggesting lower incidence or frequency of detection; however, the cost of care has increased. Despite advances in nerve repair techniques, nerve surgery rates have not increased, especially for brachial plexus injuries, which may be undertreated.

Intermuscular coherence in amyotrophic lateral sclerosis: A preliminary assessment.

INTRODUCTION: Simple laboratory tests of upper motor neuron involvement in amyotrophic lateral sclerosis (ALS) are not available. Intermuscular coherence has been shown to distinguish patients with primary lateral sclerosis, a pure upper motor neuron disorder, from normal subjects, suggesting it could be useful for assessing ALS. We aimed to determine whether intermuscular coherence can distinguish ALS patients from normal subjects. METHODS: We measured biceps brachii and brachioradialis activity using surface electromyography while subjects held the elbow at flexion and the forearm in semipronation. Intermuscular coherence was calculated at between 20 and 40 Hz in 15 ALS patients and 15 normal subjects. RESULTS: On average, intermuscular coherence was 3.8-fold greater in normal subjects than in ALS patients (P < 0.01), and it distinguished ALS patients from normal subjects with a sensitivity of 87% and specificity of 87%. CONCLUSION: Intermuscular coherence measurement is a rapid, painless method that may detect upper motor neuron dysfunction in ALS. Muscle Nerve 55: 862-868, 2017.

Motor costs and the coordination of the two arms.

We have two arms, many muscles in each arm, and numerous neurons that contribute to their control. How does the brain assign responsibility to each of these potential actors? We considered a bimanual task in which people chose how much force to produce with each arm so that the sum would equal a target. We found that the dominant arm made a greater contribution, but only for specific directions. This was not because the dominant arm was stronger. Rather, it was less noisy. A cost that included unimanual noise and strength accounted for both direction- and handedness-dependent choices that young people made. To test whether there was a causal relationship between unimanual noise and bimanual control, we considered elderly people, whose unimanual noise is comparable in the two arms. We found that, in bimanual control, the elderly showed no preference for their dominant arm. We noninvasively stimulated the motor cortex to produce a change in unimanual strength and noise, and found a corresponding change in bimanual control. Using the noise measurements, we built a neuronal model. The model explained the anisotropic distribution of preferred directions of neurons in the monkey motor cortex and predicted that, in humans, there are changes in the number of these cortical neurons with handedness and aging. Therefore, we found that coordination can be explained by the noise and strength of each effector, where noise may be a reflection of the number of task-related neurons available for control of that effector in the motor cortex.

The role of anticipatory postural adjustments in interlimb coordination of coupled arm movements in the parasagittal plane: III. difference in the energy cost of postural actions during cyclic flexion-extension arm movements, ISO- and ANTI-directionally coupled.

When oscillating the upper limbs together in the parasagittal plane, movements coordination is lower (i.e., variability of the interlimb relative phase is higher) in antidirectional (ANTI) than in isodirectional (ISO) coupling. In contrast, we previously observed that for arm movements in the horizontal plane, the coordination was worse in ISO than ANTI and the energetic cost of postural activities was higher in ISO. Having hypothesised that the higher postural cost was one factor responsible for the coordination deficit in horizontal ISO, we measured the oxygen uptake ([Formula: see text]) in parasagittal movements, expecting that in this case too, the postural cost is higher in the less-coordinated mode (ANTI). Breath-by-breath metabolic ([Formula: see text], [Formula: see text]) and cardiorespiratory (HR, [Formula: see text]) parameters were measured in seven participants, who performed cyclic flexions-extensions in the parasagittal plane with either one arm or both arms, in ISO or ANTI coupling and at 1.4, 2.2 and 2.6 Hz. In each condition, the intermittent exercise (12 s movement, 12 s rest) lasted 264 s. A force platform recorded the mechanical actions to the ground. The exercise metabolic cost ([Formula: see text]) was found to be significantly higher in parasagittal ANTI than ISO. The movement amplitude being equal in the two modes, the ANTI-ISO difference should be ascribed to postural activities. This would confirm that the less-coordinated coupling mode requires the higher postural effort in parasagittal movements too. When rising the movement frequency, [Formula: see text] increased and linearly correlated with the coordination loss. Comparison of parasagittal with horizontal movements showed that [Formula: see text] was lower in parasagittal ANTI than in horizontal ISO (the less-coordinated modes), while it was not different between parasagittal ISO and horizontal ANTI (the more-coordinated modes).

A solution to the online guidance problem for targeted reaches: proportional rate control using relative disparity tau.

We provide a solution to a major problem in visually guided reaching. Research has shown that binocular vision plays an important role in the online visual guidance of reaching, but the visual information and strategy used to guide a reach remains unknown. We propose a new theory of visual guidance of reaching including a new information variable, tau(alpha) (relative disparity tau), and a novel control strategy that allows actors to guide their reach trajectories visually by maintaining a constant proportion between tau(alpha) and its rate of change. The dynamical model couples the information to the reaching movement to generate trajectories characteristic of human reaching. We tested the theory in two experiments in which participants reached under conditions of darkness to guide a visible point either on a sliding apparatus or on their finger to a point-light target in depth. Slider apparatus controlled for a simple mapping from visual to proprioceptive space. When reaching with their finger, participants were forced, by perturbation of visual information used for feedforward control, to use online control with only binocular disparity-based information for guidance. Statistical analyses of trajectories strongly supported the theory. Simulations of the model were compared statistically to actual reaching trajectories. The results supported the theory, showing that tau(alpha) provides a source of information for the control of visually guided reaching and that participants use this information in a proportional rate control strategy.

Botulinum toxin assessment, intervention and follow-up for paediatric upper limb hypertonicity: international consensus statement.

The primary objective of this paper was to evaluate the published evidence of efficacy and safety of botulinum neurotoxin (BoNT) injections in paediatric upper limb hypertonia (PULH). Secondary objectives included the provision of clinical context, based on evidence and expert opinion, in the areas of assessment, child and muscle selection, dosing, and adjunctive treatment. A multidisciplinary panel of authors systematically reviewed, abstracted, and classified relevant literature. Recommendations were based on the American Academy of Neurology (AAN) evidence classification. Following a literature search, 186 potential articles were screened for inclusion, and 15 of these met the criteria and were reviewed. Grade A evidence was found to support the use of BoNT to reach individualized therapeutic goals for PULH. There is grade B evidence (probably effective) for tone reduction following BoNT injections and grade U evidence (inconclusive) for improvement in upper limb (UL) activity and function. BoNT injections were generally found to be safe and well tolerated with the most common side effect identified as a transient decrease in grip strength.

Botulinum toxin assessment, intervention and after-care for upper limb hypertonicity in adults: international consensus statement.

Upper limb spasticity affecting elbow, wrist, and finger flexors can be safely and effectively reduced with injections of botulinum toxin type-A (BoNT-A). It has been best studied in adults in the context of post-stroke spasticity. The clinical benefits include reduction in pain and deformity, improvement in washing and dressing the upper limb, and a reduction in caregiver burden (Class I evidence, recommendation level A). Some patients show improvement in function performed by active movement of the affected upper limb (Class III evidence, recommendation C), but predicting and measuring this is difficult, and further research is needed. An individually based approach to treatment and outcome measurement is preferred (Class IV, recommendation U). More research is needed to resolve many unknown issues of assessment and treatment, using research methods appropriate to the question.

Assessment of upper-limb sensorimotor function of subacute stroke patients using visually guided reaching.

OBJECTIVE: Using robotic technology, we examined the ability of a visually guided reaching task to assess the sensorimotor function of patients with stroke. METHODS: Ninety-one healthy participants and 52 with subacute stroke of mild to moderate severity (26 with left- and 26 with right-affected body sides) performed an unassisted reaching task using the KINARM robot. Each participant was assessed using 12 movement parameters that were grouped into 5 attributes of sensorimotor control. RESULTS: A number of movement parameters individually identified a large number of stroke participants as being different from 95% of the controls-most notably initial direction error, which identified 81% of left-affected patients. We also found interlimb differences in performance between the arms of those with stroke compared with controls. For example, whereas only 31% of left-affected participants showed differences in reaction time with their affected arm, 54% showed abnormal interlimb differences in reaction time. Good interrater reliability (r > 0.7) was observed for 9 of the 12 movement parameters. Finally, many stroke patients deemed impaired on the reaching task had been scored 6 or less on the arm portion of the Chedoke-McMaster Stroke Assessment Scale, but some who scored a normal 7 were also deemed impaired in reaching. CONCLUSIONS: Robotic technology using a visually guided reaching task can provide reliable information with greater sensitivity about a patient's sensorimotor impairments following stroke than a standard clinical assessment scale.

Comprehensive assessment of gesture production: a new test of upper limb apraxia (TULIA).

BACKGROUND: Only few standardized apraxia scales are available and they do not cover all domains and semantic features of gesture production. Therefore, the objective of the present study was to evaluate the reliability and validity of a newly developed test of upper limb apraxia (TULIA), which is comprehensive and still short to administer. METHODS: The TULIA consists of 48 items including imitation and pantomime domain of non-symbolic (meaningless), intransitive (communicative) and transitive (tool related) gestures corresponding to 6 subtests. A 6-point scoring method (0-5) was used (score range 0-240). Performance was assessed by blinded raters based on videos in 133 stroke patients, 84 with left hemisphere damage (LHD) and 49 with right hemisphere damage (RHD), as well as 50 healthy subjects (HS). RESULTS: The clinimetric findings demonstrated mostly good to excellent internal consistency, inter- and intra-rater (test-retest) reliability, both at the level of the six subtests and at individual item level. Criterion validity was evaluated by confirming hypotheses based on the literature. Construct validity was demonstrated by a high correlation (r = 0.82) with the De Renzi-test. CONCLUSION: These results show that the TULIA is both a reliable and valid test to systematically assess gesture production. The test can be easily applied and is therefore useful for both research purposes and clinical practice.

Topographical assessment of symptom resolution following open carpal tunnel release.

PURPOSE: Patients with carpal tunnel syndrome commonly present with paresthesias and pain extending into the small finger and proximal to the hand. This study was conducted to assess the ability of carpal tunnel release to relieve symptoms outside of the median nerve distribution. METHODS: We enrolled 34 consecutive surgical patients (40 wrists) diagnosed exclusively with carpal tunnel syndrome based on the history, physical examination, and electrodiagnostic studies. Preoperative symptoms were categorized as pain, numbness, tingling, or "burning and electrical shocks." The presence or absence of each symptom type was recorded in 5 topographical areas (zone I, palmar thumb/index/long; zone II, small finger; zone III, volar forearm; zone IV, volar arm; and zone V, dorsal hand/forearm/arm). Patients were contacted at 4 to 6 weeks postoperatively to assess resolution of each symptom type by topographic zone. RESULTS: Preoperatively, the cohort reported symptoms in all zones: zone I, 120 reports; zone II, 47 reports; zone III, 33 reports; zone IV, 7 reports; and zone V, 23 reports. Numbness (n = 40) and tingling (n = 38) were the most common symptoms, followed by pain (n = 29) and "burning/shocks" (n = 16). Postoperatively, the total number of reports within the 5 zones decreased from 230 to 20. The probability that surgery would eliminate patient symptoms was 88% (104 of 120) in zone I, 96% (45 of 47) in zone II, 97% (32 of 33) in zone III, 86% (6 of 7) in zone 4, and 100% (23 of 23) in zone V. Across zones, the overall probability of symptom resolution was as follows: pain > 80%, numbness/tingling > 85%, and "burning/shocks" > 90%. CONCLUSIONS: Symptoms experienced outside of the median nerve distribution had a high likelihood of resolution after carpal tunnel release. Over 85% of symptoms in each of the anatomic zones studied resolved. Feelings of burning or shock-like sensations were most reliably relieved at early follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Predicting hand motor recovery in severe stroke: the role of motor evoked potentials in relation to early clinical assessment.

OBJECTIVE: The primary aim of this study was to compare the predictive value of motor evoked potentials (MEPs) and early clinical assessment with regard to long-term hand motor recovery in patients with profound hemiplegia after stroke. METHODS: The sample was an inception cohort of 39 stroke patients with an acute, ischemic, supratentorial stroke and an initial upper-extremity paralysis admitted to an academic hospital. Hand motor function recovery was defined at 26 weeks poststroke as a Fugl-Meyer Motor Assessment (FMA) hand score>3 points. The following prognostic factors were compared at week 1 and week 3 poststroke: motor functions as assessed by the FMA upper-extremity and lower-extremity subscores, and the presence of an MEP in the abductor digiti minimi and biceps brachii muscle. RESULTS: Both the presence of an abductor digiti minimi-MEP and any motor recovery in the FMA upper-extremity subscore showed a positive predictive value of 1.00 at weeks 1 and 3. The FMA lower-extremity subscore showed the best negative predictive value (0.90; 95% CI 0.78-1.00 at week 1 and 0.95; 95% CI 0.87-1.00 at week 3). CONCLUSIONS: In stroke patients with an initial paralysis of the upper extremity the presence or absence of an MEP has similar predictive value compared with early clinical assessment with regard to long-term hand motor recovery.

Objective assessment of cervical spinal cord injury levels by transcranial magnetic motor-evoked potentials.

BACKGROUND: The neurologic examination serves as the optimal method to record the level of spinal cord injury (SCI). However, this test is subject to interexaminer variability. To address this shortcoming, we describe a technique that uses transcranial magnetic motor-evoked potentials (tcMMEPs) and dermatomal somatosensory-evoked potentials (d-SSEPs) to more accurately measure the precise level of SCI. METHODS: Two groups of subjects were studied: (1) complete cervical SCI (n = 10) and (2) neurologically intact volunteers (n = 10). Two additional patients were evaluated: one with a cervical central spinal cord syndrome and another with a head injury with a suspected cervical SCI. Each subject underwent upper extremity tcMMEPs and d-SSEPs. RESULTS: Transcranial magnetic motor-evoked potentials were elicited from all upper limb myotomes (C4-T1, bilaterally) in neurologically intact volunteers (20 sides). The level of injury was determined using tcMMEPs by observing the lowest level of measurable response. The level of injury obtained using tcMMEPs was the same as that determined by neurologic examination in 13 (65%) of the 20 sides. In 7 sides, tcMMEP responses were obtained 1 level lower than that assessed by physical examination. Dermatomal somatosensory-evoked potentials were obtained from all dermatomes of volunteers tested in the laboratory compared with only 5 of the 9 patients with SCI who underwent d-SSEP testing. CONCLUSION: Testing using tcMMEPs provides an objective supplement to the neurologic examination after acute cervical SCI. Dermatomal somatosensory-evoked potentials were of limited value in determining the level of cervical SCI.

Tetraplegia Hand Activity Questionnaire (THAQ): the development, assessment of arm-hand function-related activities in tetraplegic patients with a spinal cord injury.

STUDY DESIGN: Development of Tetraplegia Hand Activity Questionnaire (THAQ). SETTING: Patients and spinal cord injury (SCI) professionals from five rehabilitation centres in the Netherlands and Belgium. OBJECTIVE: To construct a disease-specific questionnaire to evaluate interventions to the arm-hand of tetraplegics in terms of gained and lost activities relevant to the patient. METHODS: All arm-hand function-related activities were inventoried by examining existing scales and interviewing spinal cord injury patients and professionals in the field. Subsequently, item reduction was achieved; first, in the technical construction by incorporating all activities in an item list, then reducing the list by selecting the items most likely to be sensitive to change after surgical or functional electro stimulation interventions on the arm-hand as judged by an expert panel, using a Delphi method. RESULTS: The arm-hand-related activity inventory comprised 652 activities. The technical construction of the items and the Delphi procedure resulted in a questionnaire with 153 items. The experts considered many of the 'new' activities more relevant for the evaluation of hand function interventions than those found in scales studied in the literature. This is reflected in a relatively large proportion of new activities (69%) for the item list of the THAQ, and even more in the domains work/admin/telecom (88%) and leisure (100%). CONCLUSION: The questionnaire constructed to assess hand function-related activities contains relevant activities to evaluate arm-hand function-related interventions for tetraplegic SCI patients.

Assessment of reorganization in the sensorimotor cortex after upper limb amputation.

OBJECTIVE: We wanted to investigate plastic changes occurring in the motor and somatosensory cortex after upper limb amputation, and their possible relationship to phantom pain. METHOD: To assess these plastic changes, we used transcranial magnetic stimulation (TMS) and source localization of somatosensory evoked potentials (SEP). Eleven patients with upper limb amputation were investigated. The phantom pain intensity was assessed by visual analogue scaling (VAS). RESULTS: Using TMS mapping, we found a significant lateralization of the amplitude-weighted centre of gravity (P<0.01) and an enlargement of the excitable area (P<0.05) on the hemisphere contralateral to the amputation. SEP mapping showed a significant medialization of the N20 dipole (P<0.05) on this side. None of these changes correlated with the phantom pain intensity. CONCLUSIONS: We conclude that after limb amputation, the relationship between plastic changes occurring in the sensorimotor cortex and phantom pain seems to be more complex than previously believed.

[Incidence and etiology of brachial plexus upper arm paralysis in newborn infants. A review and basic principles for legal assessment]. / Häufigkeit und Ursachen der Oberarm-Plexus-Lähmungen beim Neugeborenen. Eine Ubersicht und Grundlage für juristische Uberlegungen.

OBJECTIVE: Brachial plexus injury (BPI) is a rare complication of pregnancy which is out of proportion involved in medical litigation. The aim of this study was to establish the relationship between shoulder dystocia (SD) and BPI and the frequency of BPI without explanation. METHOD: The pertinent literature was reviewed. In total 86 papers of the international literature were evaluated in regard to the frequency of SD and BPI and their relationship. Also BPI without obstetrical explanation were of interest (birth weight < 4000 g, cesarian section, palsies without SD). CONCLUSIONS: This literature review allows for the following conclusions: 1. The large number of papers describing SD in contrast to the much smaller numbers of BPI justifies the proposal to use the term SD only when it is associated with BPI. Otherwise the term "difficult shoulder delivery" seems more adequate and might reduce the number of papers. 2. The large number of BPI without SD, unexplained palsies without explanation and PPI at newborns with a birthweight < 4000 g do not allow a prima facie conclusion that BPI is the result of poor obstetrics (especially pulling on the head). 3. The lack of an operating note might establish such an association as well as the misinterpretation or failure of appropriate manoeuvers published in the literature. 4. The lack of a service regulation regarding the treatment of SD might be considered as failure of organisational standards.

Mononeuropathy multiplex in hemophilia: an electrophysiologic assessment.

Single nerve lesion or mononeuropathy caused by extrinsic compression of hematoma or hemarthrosis is consistently reported for hemophilic patients. To study the manifestation of peripheral nerve lesions, an extensive nerve conduction study of peripheral nerves and specific nerves in correlation with clinical involvement was carried out on 126 hemophilic patients. We found 24 patients with 34 peripheral nerve lesions. The frequency of nerve lesion positively correlated with the severity of hemophilia (p < 0.01) and increasing age (p < 0.05). Nerve lesions occurred more commonly in lower extremities than in upper extremities. The femoral nerve was most commonly involved. Seven patients were identified to have mononeuropathy multiplex with 2 or more nerve lesions involving more than one extremity. All of these patients had chronic condition. Our findings suggest that mononeuropathy multiplex may occur in hemophilic patients.

[Electromyographic diagnosis of 772 patients in the Móstoles Hospital]. / Diagnósticos electromiográficos de 772 pacientes en el Hospital de Móstoles.

INTRODUCTION AND OBJECTIVE: There are few references in the literature to demographic data of the disorders most frequently studied by electromyography. Our objective was to obtain a demographic description of the patients usually sent to us for electromyographic studies. MATERIAL AND METHODS: Descriptive and analytical assessment was done of 914 electromyographic diagnoses seen in a sample of 722 patients sent to Mostoles Hospital, referral centre of Health District VIII of the Community of Madrid with an estimated population of 407,836 inhabitants, for conventional electroneurographic and electromyographic studies between May 1995 and February 1996. We recorded data regarding electromyographic diagnosis, localization, intensity, whether the study was for diagnostic purposes or follow-up, medical centre referring the patient, medical speciality sending the patient, clinical impression, age and sex. RESULTS: The commonest pathology seen was carpal trapping of the median nerve, both in men and in women (three times more frequent in women). There was an estimated incidence of 136 cases per year per 100,000 women and 36 cases per year per 100,000 men (most frequent in patients aged 20-70, with a maximum frequency in those in their fifties). There was marked right sided predominance. The commonest pathology in men was polyneuropathy, with an estimated incidence of 80 cases per 100,000 men and 72 cases per 100,000 women. This was the commonest diagnosis in the patients aged over 70. Mononeuropathy of the legs was most commonly seen in men and in the first twenty years of life.