Approach to gait disorders and orthotic management in adult onset neuromuscular diseases.

In order to understand abnormal gait, this article will first review normal gait, discuss how neuromuscular diseases disturb gait patterns and review orthotic interventions. In normal gait, concentric contractions accelerate and eccentric contractions decelerate the limb. Neuromuscular gait disorders can be grouped into (1) proximal weakness, (2) distal weakness, (3) nonlength-dependent or generalized weakness, (4) asymmetric weakness, and (5) sensory disorders. Identification of gait disturbance type in neuromuscular diseases leads to the appropriate orthotic prescription since orthotic strategies are grouped into (1) proximal weakness, (2) distal weakness, and (3) sensory disturbances. Orthotics is not indicated in all types of gait disturbance. Weakness in proximal hip musculature can be managed with gait aids such as walkers. In contrast, distal muscle weakness can be managed with orthotics. Preservation of gait assists in maintenance of daily function and integration in society.

Musculoskeletal mimics of cervical radiculopathy.

Musculoskeletal mimics of cervical radiculopathy will be explored in this AANEM monograph. A review of the literature and textbooks was conducted. Musculoskeletal cervical radiculopathy mimics include: (1) head/neck pain, such as neck tension, cervicogenic headache, and temporomandibular disorder; (2) referred pain from shoulder pathology, such as rotator cuff tears/impingement; (3) elbow region abnormalities, including medial/lateral epicondylitis; (4) wrist/hand conditions, such as DeQuervain's tenosynovitis and intersection syndrome; (5) muscle connective tissue disorders, including myofascial trigger points; (6) conditions that have decreased range of motion, including frozen shoulder and rounded shoulders with tight pectoral/scalene muscles; (7) conditions with joint hyperlaxity and instability, as seen in post-stroke shoulder subluxation; (8) vascular conditions, such as thoracic outlet syndrome; and (9) autonomic controlled soft tissue changes associated with complex regional pain syndrome. Formulating a differential diagnosis and recognizing mimics of cervical radiculopathy can decrease the time between symptom onset and diagnosis/treatment plan.

Musculoskeletal ultrasound for traumatic and torsional alterations.

The sonographic appearance of soft tissue can be altered by trauma and positional change with torsional stress. This creates challenges for ultrasonographic interpretation, because most descriptive literature and standard instructional references are displayed in anatomically neutral or other conventional positions. Knowledge of anatomic alteration and changes in sonographic appearance with torsional stress is essential for accurately assessing soft tissue abnormalities in conditions of spasticity, traumatic and post-surgical changes, and other conditions that distort musculoskeletal relationships. A systematic scanning approach to these alterations is needed for accurate diagnostic interpretation, optimizing electrode placement for electrodiagnostic techniques, effective needle placement for therapeutic ultrasound-guided procedures, and even planning for restorative surgery. This review describes expected positional changes of normal structures with torsional alteration, as well as sonographic recognition of scars, burns, hematomas, fat layer fracture, Morel-Lavallee lesions, abscesses, foreign bodies, myotendinous lesions, muscle injury and denervation, and traumatic peripheral nerve injury.

Ultrasound Visualization of Torsional Anatomic Changes From External Rotation of the Anterior Shoulder.

The sonographic appearance of soft tissue can be altered with movement. This can be related to both position change as well as torsional stress. The objective of this article is to demonstrate sonographic anatomy of the anterior shoulder as it moves into full external rotation. METHODS: Ultrasound images were obtained in a healthy human subject. Conventional imaging locations were selected that are typically utilized to assess musculoskeletal and peripheral nerve anatomy as well as perform therapeutic injections. The transducer was centered over each region to obtain both short- and long-axis views. A pair of sonographic images was recorded for both imaging planes at each site: the first in anatomic neutral and second in full external rotation. In addition, a video recording was made at each site to track the movement of the muscles and nerves during external rotation. RESULTS: The rotator interval including the intertubercular groove and biceps brachii long head moves far laterally when viewed in short axis, and it becomes out of plane when viewed in long axis. The subscapularis is relatively poorly visualized with the shoulder in neutral position, but the tendon and more distal aspect of the muscle are well visualized in full external rotation. The pectoralis major tendon insertion is well visualized in long axis with the shoulder in both neutral position and full external rotation. Movement of the humerus and the pectoralis major insertion are seen with shoulder rotation. The muscle appears to tighten and lengthen. The pectoralis major muscle is also seen in greater detail in external rotation. The cord level of the brachial plexus is also visualized at the infraclavicular portion of the anterior shoulder. The medial, posterior, and lateral cords are visualized in relation to the axillary artery. The relative position of the cords is only minimally altered with external rotation; however, the overlying pectoralis minor is tightened, and its influence can be visualized. DISCUSSION: External rotation has a considerable effect on the sonographic appearance of the anterior shoulder. Targets used for therapeutic injections, such as the bicipital groove, rotate out of clear view. Some chemodenervation targets, such as the muscle of the subscapularis, can only be accessed with the shoulder in full external rotation. Full external rotation of the shoulder also places torsional stress on some of the anterior shoulder structures, such as the pectorals, which can provide diagnostic clues in certain pathologic conditions. CONCLUSION: Movement into external rotation changes the sonographic appearance of the anatomic relationships of the anterior shoulder. Knowledge of these torsional changes can have both diagnostic and therapeutic implications.

Torsional Anatomy of the Lower Limb: The Appearance of Anatomy in Hemispastic Position.

OBJECTIVE: The aim of the study was to determine whether there are relevant anatomical variations to the typical injection sites for antispasticity procedures in the lower limb. METHODS: Sonographic images were obtained at traditional injection locations for spasticity in the lower limb. Images were recorded in neutral and contracted postures. Doppler imaging was obtained for sites that contained vasculature. The images were analyzed, and schematics were created that highlighted relevant findings. RESULTS: The adductor longus in commonly used injection sites was close to vasculature making accidental injection of the latter a higher risk. The sciatic nerve was vulnerable to injections at the proximal biceps femoris injection side if injected too deeply. Hamstring injection sites can be adjusted to the midline to improve accuracy. The proximity of the tibial nerve to the flexor hallucis longus and the deep fibular nerve to the extensor hallucis longus puts these nerves at risk for accidental injection. DISCUSSION: Contracted posture results in altered positions of lower extremity muscles that could lead to inadvertent neurovascular injection or decreased efficacy with injections. Findings in this study may be helpful for planning and executing injections to reduce spasticity in the lower extremity. CONCLUSIONS: Sonographic imaging allows a better localization of muscles associated with spasticity and can instruct the clinician to alter usual injection pathways. This article documents visual evidence that previous assumptions for injection strategies require updating.

Repetitive nerve stimulation and single-fiber electromyography in the evaluation of patients with suspected myasthenia gravis or Lambert-Eaton myasthenic syndrome: Review of recent literature.

INTRODUCTION: Our aim in this study was to provide an updated literature review of electrodiagnostic testing in myasthenia gravis and Lambert-Eaton myasthenic syndrome. METHODS: A systematic review of the recent literature was performed using the following key words: myasthenia gravis (MG); Lambert-Eaton myasthenic syndrome (LEMS); electromyography (EMG); repetitive nerve stimulation (RNS); single-fiber electromyography (SFEMG); nerve conduction study; and normative values. RESULTS: Several articles supported testing of facial, bulbar, and respiratory muscles in the diagnosis of neuromuscular junction (NMJ) disorders, including muscle-specific kinase antibody (MuSK)-seropositive MG. Several articles supported use of concentric needle EMG as an alternative to SFEMG jitter in disorders of neuromuscular transmission. A limited number of articles addressed measurement of area (vs. amplitude) decrement in RNS and decreasing the threshold of post-exercise facilitation. CONCLUSIONS: Electrodiagnostic testing continues to be useful for diagnosis of MG and LEMS, although the quality of the evidence is not great. This literature review summarizes RNS and jitter measurement of facial and respiratory muscles and use of concentric needle EMG for SFEMG.

Procedure-oriented sectional anatomy of the hip.

This is the fourth in a series of articles related to procedure-oriented joint anatomy. This article reviews the anatomy of the hip and its relationship to procedures in the clinical setting with or without imaging guidance. Anatomically correct axial and coronal schematics allow injections to be envisioned relative to clinically important anatomy for common hip procedures. Cross-sectional schematics for the hip were drawn as they appear in imaging projections. The levels and planes of cross section were selected to highlight important anatomic landmarks for injection. It is hoped that these schematics allow for safer and more accurate needle procedures in the knee area.

Special anatomy series. Imaging inner ear structures with high-frequency ultrasound: Application to physical rehabilitation space medicine.

Objective: The objective of this paper is to document the feasibility of image acquisition, image optimization, and sonographic appearance of the exposed anatomic windows of cadaveric inner ear dissection for purposes of potential future clinical evaluation as part of the developing area of physical and rehabilitation space medicine. Methods: Cadaveric dissection of the inner ear was conducted with the goal of exposing areas relevant to vestibular balance. Middle and inner ear structures of 3 human cadavers were imaged with multiple broadband transducers, including emphasis with higher frequency transducers. Results: The images were best optimized with 17 MHz and 22 MHz small footprint transducers. High-frequency ultrasound (US) images of the semicircular canals, vestibular and facial nerves, and utricles with reflected otoliths (otoconia) were obtained and reported in this article. Detailed visualization of both the vestibular nerve and facial nerve was accomplished, including identification of fascicular architecture. In addition, US reflection from the otoliths contained within the utricle was identified with sufficient clarity to provide surface measurements. Bony acoustic landmarks of the middle ear bones were identified by scanning externally from the tympanic membrane, including the dynamic movement of the bones with manual manipulation. Conclusion: US visualization has the potential to be an effective imaging modality to monitor potential changes to the otolith's size throughout extended space flight. To our knowledge, no prior study has reported US images of human inner ear structures.

Procedure-oriented sectional anatomy of the elbow.

This is the second in a series of papers related to procedure-oriented joint anatomy. This article will review the anatomy of the elbow and its relationship to procedures in the clinical setting. Needle procedures of the elbow joint include medial and lateral epicondyle injections, olecranon bursa injection, elbow joint aspiration, phlebotomies in the antecubital fossa, and intramuscular injections such as trigger point and botulinum toxin injections. Complications related to these procedures include infection, skin atrophy, injuries to peripheral nerves, tendon rupture associated with the use of corticosteroids, iatrogenic vascular injuries, and chronic local pain. This article provides anatomically accurate schematics of the elbow anatomy relevant to needle procedures. Cross-sectional anatomical schematics of the elbow were drawn as they appear on axial and coronal projections. Superficial and deep landmarks are highlighted as well as sources of potential complications. These schematics allow for safer and more accurate needle procedures in the elbow area, for both nonguided and musculoskeletal ultrasound-guided techniques.

Procedure-oriented sectional anatomy of the wrist and hand.

This is the third in a series of papers related to procedure-oriented joint anatomy. This article reviews the anatomy of the wrist and hand and its relationship to procedures in the clinical setting with or without ultrasound/electromyography (EMG) guidance. Anatomically correct axial and coronal schematics allow injections to be envisioned relative to clinically important anatomy for common wrist and finger procedures. Cross-sectional schematics for the wrist and hand were drawn as they appear in imaging projections. The levels and planes of cross section were selected to highlight important anatomic landmarks for injection. It is hoped that these schematics allow for safer and more accurate needle procedures in the wrist and hand area.

Sectional neuroanatomy of the pelvic floor.

This is the sixth in a series of articles on the spine. The first 5 reviewed the sectional anatomy of the cervical, thoracic, and lumbosacral spines. This paper will review both the male and female pelves. Procedures performed in the pelvis include electromyography of the anal sphincter, pudendal and sacral nerve stimulator implants, and botulinum toxin type A injections into the prostate, the bladder, the urethra, and the anus. Complications from these procedures are rare. Electromyography in this region is particularly uncomfortable. Botulinum toxin type A denervation may result in local effects such as incontinence or urinary retention or rarely remote effects such as limb weakness. Neurostimulators may get infected or may fail. This article provides anatomically accurate schematics of innervations of the pelvis that can be used to interpret magnetic resonance images of muscles and nerves in the pelvic floor region. Cross-sectional schematics of the male and female pelves were drawn as they appear on imaging projections. The relevant nerves were color coded. The muscles and the skin surfaces were labeled and assigned the color of the appropriate nerves. An organized comprehensive map of the motor innervation of both the male and female pelves allows the physician to increase the accuracy and efficacy of interventional procedures. This anatomic map could also assist the electromyographer in correlating the clinical and electrophysiologic findings on magnetic resonance images.

Procedure-oriented sectional anatomy of the shoulder.

This is the first in a series of papers on procedure-oriented joint anatomy. This paper will review anatomy of the shoulder joint and focus on non-imaging-guided procedures. Needle procedures of the shoulder include glenohumeral, subacromial, and acromioclavicular joint injections; electromyography; trigger point and other intramuscular injections; bicipital tendon sheath injection; suprascapular nerve blocks; and botulinum toxin injections. The accuracy of these non-imaging-guided procedures is reviewed. Complications of these procedures include infection, damage to tendon, and local or systemic response to medication. This paper provides anatomically accurate schematics of the shoulder anatomy relevant to needle procedures. Cross-sectional schematics of the shoulder were drawn as they appear on axial and sagittal projections. Superficial and deep landmarks are highlighted and sources of potential complications. The schematics allow for safer and more accurate non-image-guided needle procedures in the shoulder region.

Electromyographic approach to neuromuscular junction disorders repetitive nerve stimulation and single-fiber electromyography.

Understanding the physiology of the NMJ aids the electromyographer in understanding how NMJ testing was developed. Practicing the RNS protocol on healthy subjects helps the electromyographer gain greater comfort with the implementation of a test that is not performed daily. The practice parameter proposed by the AAEM has established guidelines for testing and for diagnosing NMJ disorders using RNS and single-fiber EMG.

Caregiver characteristics and their relationship to health service utilization in minority patients with first episode stroke.

The purpose of the current study was to investigate the contribution of caregivers' characteristics to health service utilization by minority persons with first episode stroke. Participants were 61 primary caregivers of minority persons (41% African American; 59% Hispanic) with first episode symptomatic stroke consecutively admitted to an inpatient rehabilitation unit at a county hospital. Caregiver characteristics included resources for daily living, general health, social support, and health beliefs. Health service utilization was defined as the percentage of medical and therapy appointments attended for the first 6 months following discharge from inpatient rehabilitation. There was no difference in percentage of appointments attended between African American and Hispanic caregivers. There was a significant difference between caregivers on the External Control by Powerful Others subscale of the Multidimensional Health Locus of Control Scale (MHLC), with Hispanic caregivers reporting a greater belief that powerful others exerted control over their health. There was a trend for Hispanics to score higher on the External Control by Chance subscale of the MHLC. Results of logistic regression analyses indicated that persons with stroke were less likely to attend appointments if their caregiver believed that health was related to chance factors. These results suggest that caregiver health beliefs play an important role in patient adherence to medical recommendations. Education of caregivers may result in improved follow-through with medical recommendations.

Neuroimaging in posttraumatic hypopituitarism.

Posttraumatic hypopituitarism is the failure of the hypothalamic-pituitary axis secondary to traumatic brain injury. It can clinically present as decreased muscle mass, concentration, libido, and fertility. It can also present as increased fatigue, depression, and cognitive deficits. In addition, electrolyte abnormalities such as hyponatremia can occur in hypopituitarism. As a result of heightened awareness of posttraumatic hypopituitarism, it is a phenomenon that is becoming more commonly diagnosed. Posttraumatic hypopituitarism is a diagnosis based on clinical evaluation, laboratory testing, and neuroimaging. Of the radiological techniques, magnetic resonance imaging is the preferred technique to image the pituitary gland. This article contains coronal and sagittal magnetic resonance imaging of the posterior fossa, illustrating the normal hypothalamus and pituitary gland as well as adjacent structures. The sequential enhancement pattern of the normal pituitary gland is consistent with its vascular supply. A colored illustration was created to display the vascular supply to the hypothalamus, pituitary stalk, and pituitary gland.

Sectional neuroanatomy of the lumbosacral spine (L1-S5).

This paper will review the lumbosacral spine (L1-S5). Procedures performed in the lumbosacral spine include electromyography, spinal stimulator implants, spinal infusion implants for spasticity or pain medications, sacroiliac spine injections, facet blocks, and steroid injections. Complications from these procedures include iatrogenic paraplegia or paraplegia due to transverse myelitis, intravascular penetration, dural puncture, increased pain at the injection site, increased radicular pain, increased spine pain, lightheadedness, nausea, nonspecific headache, and vomiting. Long-term complications include implant infection, implant or catheter dislodgment/kinking, and device failure. This paper provides anatomically accurate schematics of innervations of the lumbosacral spine (L1-S5) that can be used to interpret magnetic resonance images of the muscles and nerves. Cross-sectional schematics of the lumbosacral spine were drawn as they appear on imaging projections. The relevant nerves were color coded. The muscles and skin surfaces were labeled and assigned the color of the appropriate nerves. An organized comprehensive map of the motor innervation of the lumbosacral spine allows the physician to increase the accuracy and efficacy of interventional procedures. This anatomical map could also assist the electromyographer in correlating the clinical and electrophysiological findings on magnetic resonance images.

Physical medicine and rehabilitation conditions in the Astrodome clinic after hurricane Katrina.

OBJECTIVE: To report the physical medicine and rehabilitation (PMR) conditions seen in the Astrodome Clinic after Hurricane Katrina. DESIGN: Retrospective chart analysis from the county hospital-sponsored disaster-relief clinic in large urban city, including a study of 239 patients with 292 PMR conditions. The total number of patients seen in the Astrodome Medical Clinic was 11,245. The Astrodome database was reviewed for PMR condition diagnostic codes. A retrospective chart analysis was conducted, including date of visit, age, gender, ethnicity, and PMR diagnosis category. Descriptive statistics were obtained for the entire sample. chi2 or t tests were used to determine gender, age, or date-of-service predominance for the most common diagnostic categories. RESULTS: Mean +/- SD age was 45.7 +/- 14.3 yrs; 56% were women, 43% were men (1% unspecified), and 76% were African American. The majority (75%) of PMR conditions presented in the first week. Most frequent were swollen feet and legs (22%), leg pain and cramps (17%), headache (12%), and neck and back pain (10%). Persons with headaches were younger than those without (41.3 vs. 46.3 yrs, P = 0.048). Persons with neck and/or back pain were older than those without those conditions (51.3 vs. 44.8 yrs, P = 0.004). Women had more headaches (20.9%) than did men (6.7%, P = 0.002). There were no Caucasians with leg pain/cramps, whereas 20.2% of African Americans had this condition (P = 0.028). CONCLUSIONS: This study documents the time of clinic presentation and most frequent types of PMR conditions of patients treated in the Astrodome Clinic after a historic hurricane. Most PMR conditions were treated by PMR personnel during the first week. Thus, future disaster planning should include PMR professionals as early responders.

Racial/ethnic differences in FIM scores and length of stay for underinsured patients undergoing stroke inpatient rehabilitation.

OBJECTIVE: To explore racial/ethnic differences in FIM data from admission to discharge in underinsured patients undergoing inpatient stroke rehabilitation. DESIGN: This is a retrospective analysis of the Uniform Data System for Medical Rehabilitation (UDSMR) database of an inpatient rehabilitation unit of a county hospital in a large urban city. Data included 171 adult patients admitted to the stroke rehabilitation unit between January 2000 and October 2003. Main outcome measures included admission and discharge total FIM score, FIM gain, FIM efficiency, and length of stay (LOS). Data were analyzed using chi analyses, t tests, univariate analysis of variance, binary logistic regression, and hierarchical multiple regression. RESULTS: Data from 68 Hispanic, 83 black, and 20 white patients were included in the study. Univariate tests revealed that race/ethnicity groups differed significantly on admission FIM score (F=5.38, P<0.005), FIM gain (F=4.35, P<0.014), and FIM efficiency (F=3.42, P<0.035). Post hoc pairwise comparisons revealed that Hispanics had lower admission FIM scores than blacks (58.9 vs. 68.9). However, Hispanics had higher FIM gain scores than blacks (26.8 vs. 21.5). Race/ethnicity was not significantly related to age, gender, side of stroke, type of stroke, time from onset of stroke to rehabilitation admission, discharge FIM score, or LOS. Multiple regression analyses revealed that after controlling for all other available factors, race/ethnicity accounted for a significant amount of additional variance in admission FIM score (5.8%) and FIM efficiency (4.6%), but not in discharge FIM score, FIM gain, or LOS. Race/ethnicity was not predictive of discharge disposition. CONCLUSIONS: Differences in functional independence at admission to poststroke rehabilitation and the average daily improvement in function are related, in part, to patients' race/ethnicity. Differences in change in functional independence from admission to discharge (FIM gain) are not related to race/ethnicity once other factors, particularly admission FIM score, are taken into account. Future studies should identify reasons why Hispanics have lower admission FIM scores because demographic and stroke-related variables were not related to ethnicity yet have outcomes similar to blacks and whites at discharge.