Impact of Critical Illness Polyneuromyopathy in Rehabilitation: A Prospective Observational Study.

BACKGROUND: Critical illness polyneuromyopathy (CIPNM) increasingly is recognized as a source of disability in patients requiring intensive care unit (ICU) admission. The prevalence and impact of CIPNM on patients in the rehabilitation setting has not been established. OBJECTIVES: To determine the proportion of at-risk rehabilitation inpatients with evidence of CIPNM and the functional sequelae of this disorder. DESIGN: Prospective observational study. SETTING: Tertiary academic rehabilitation hospital. PATIENTS: Rehabilitation inpatients with a history of ICU admission for at least 72 hours. METHODS: Electrodiagnostic studies were performed to evaluate for axonal neuropathy and/or myopathy in at least one upper and one lower limb. MAIN OUTCOME MEASUREMENTS: The primary outcome was prevalence of CIPNM. Secondary outcomes included Functional Independence Measure (FIM) scores, rehabilitation length of stay (RLOS), and discharge disposition. RESULTS: A total of 33 participants were enrolled; 70% had evidence of CIPNM. Admission FIM score, discharge FIM, FIM gain, and FIM efficiency were 64.1, 89.9, 25.5, and 0.31 in those with CIPNM versus 78.4, 94.6, 16.1, and 0.33 in those without CIPNM, respectively. Average RLOS was 123 days versus 76 days and discharge to home was 57% versus 90% in the CIPNM and non-CIPNM groups, respectively. CONCLUSIONS: CIPNM is very common in rehabilitation inpatients with a history of ICU admission. It was associated with a lower functional status at rehabilitation admission, but functional improvement was at a similar rate to those without CIPNM. Longer RLOS stay may be required to achieve the same functional level. LEVEL OF EVIDENCE: III.

A review of thoracic outlet syndrome and the possible role of botulinum toxin in the treatment of this syndrome.

The objective of this paper is to discuss the classification, diagnosis, pathophysiology and management of Thoracic outlet syndrome (TOS). Thoracic outlet syndrome (TOS) is a complex entity that is characterized by different neurovascular signs and symptoms involving the upper limb. TOS is defined as upper extremity symptoms due to compression of the neurovascular bundle in the area of the neck just above the first rib. Compression is thought to occur at one or more of the three anatomical compartments: the interscalene triangle, the costoclavicular space and the retropectoralis minor spaces. The clinical presentation can include both neurogenic and vascular symptoms. TOS can be difficult to diagnose because there is no standardized objective test that can be used and the clinician must rely on history and several positive findings on physical exam. The medial antebrachial cutaneous nerve conduction may be a sensitive way to detect pathology in the lower trunks of the brachial plexus which is promising for future research. Treatment options continue to be conservative and surgical. However, for those who have failed physical therapy there is research to suggest that botulinum toxin may help with symptom relief. However, given that there has been conflicting evidence, further research is required using randomized controlled trials.

Contribution of flexor pollicis longus to pinch strength: an in vivo study.

PURPOSE: To estimate the contribution of the flexor pollicis longus (FPL) to key pinch strength. Secondary outcomes include tip pinch, 3-point chuck pinch, and grip strength. METHODS: Eleven healthy volunteers consented to participate in the study. We recorded baseline measures for key, 3-point chuck, and tip pinch and for grip strength. In order to control for instability of the interphalangeal (IP) joint after FPL paralysis, pinch measurements were repeated after immobilizing the thumb IP joint. Measures were repeated after subjects underwent electromyography-guided lidocaine blockade of the FPL muscle. Nerve conduction studies and clinical examinations were used to confirm FPL blockade and to rule out median nerve blockade. Paired t-tests were used to compare pre- and postblock means for both unsplinted and splinted measures. The difference in means was used to estimate the contribution of FPL to pinch strength. RESULTS: All 3 types of pinch strength showed a significant decrease between pre- and postblock measurements. The relative contribution of FPL for each pinch type was 56%, 44%, and 43% for key, chuck, and tip pinch, respectively. Mean grip strength did not decrease significantly. Splinting of the IP joint had no significant effect on pinch measurements. CONCLUSIONS: FPL paralysis resulted in a statistically significant decrease in pinch strength. IP joint immobilization to simulate IP joint fusion did not affect results. CLINICAL RELEVANCE: Reconstruction after acute or chronic loss of FPL function should be considered when restoration of pinch strength is important.

Botulinum toxin injection for management of thoracic outlet syndrome: a double-blind, randomized, controlled trial.

We studied the effect of botulinum toxin type A (BTX-A) injections to the scalene muscles on pain in subjects with thoracic outlet syndrome (TOS) in this double-blind, randomized, parallel group trial with follow-up at 6 weeks, 3 months, and 6 months. Thirty-eight patients referred to physiatrists for management of TOS with BTX-A injection were included. One subject was lost to follow-up and all other subjects completed the trial. A 75-unit dose of BTX-A reconstituted with 0.75 cc of normal saline was injected to the anterior scalene (37.5 units) and middle scalene (37.5 units) muscles using electromyographic guidance. The primary outcome measure was pain as measured on a horizontal visual analog scale (VAS) 6 weeks-post-injection. Secondary outcomes were paresthesias measured on a VAS and function measured with the Disabilities of the Arm, Shoulder and Hand (DASH) and Short-form 36 (SF-36) questionnaires. For the primary outcome measure of VAS scores for pain at 6 weeks, the difference in the means adjusted for baseline VAS scores between placebo and BTX-A was 5.03 mm in favor of BTX-A (95% confidence interval -15.7 to 5.7, P=.36). Changes in secondary outcome measures were also not statistically significant. We conclude that BTX-A injections to the scalene muscles did not result in clinically or statistically significant improvements in pain, paresthesias, or function in this population of subjects with TOS.

Assessing and predicting successful tube placement outcomes in ALS patients.

This study reviews feeding tube placement outcomes in 69 ALS outpatients seen at an outpatient interdisciplinary ALS clinic in British Columbia, Canada. The objective was to determine at which point the risks outweigh the benefits of tube placement by reviewing outcomes against parameters of respiratory function, nutritional status and speech and swallowing deterioration. The study was a retrospective review of tube placements between January 2000 and 2005, analysing data on respiratory function (forced vital capacity and respiratory status), weight change from usual body weight (UBW) and speech/swallowing deterioration using ALS Severity Score ratings (Hillel et al., 1989) at time of tube placement. Results show a statistically significant association between nutritional status and successful tube placement outcomes (p=0.003), and none between respiratory status, speech/swallowing variables, or number of deteriorated variables in each patient. Study findings were impacted by lack of available respiratory data. The only study variable that predicted successful tube placement outcome was a body weight greater than or equal to 74% UBW at time of tube placement. In the absence of access to respiratory testing, the relatively simple assessment of weight may assist patients and caregivers in appropriate decisions around tube placement.

Quantification of pronator quadratus contribution to isometric pronation torque of the forearm.

PURPOSE: The contribution of the pronator quadratus (PQ) muscle in generation of pronation torque has not been determined. The purpose of this study was to investigate pronation torque in healthy volunteers before and after temporary paralysis of the PQ with lidocaine, under electromyographic guidance. METHODS: A custom apparatus was designed to allow isometric testing of pronation torque at 5 positions of rotation: 90 degrees of supination, 45 degrees of supination, neutral, 45 degrees of pronation, and 80 degrees of pronation. After validation of the apparatus, 17 (9 male, 8 female) right-hand-dominant volunteers were recruited. They were tested at all 5 positions in random order and then had their PQ muscles paralyzed with lidocaine. Repeat testing was performed in the same random order 30 minutes after injection. Three unblinded subjects underwent testing after injection of saline instead of lidocaine to determine effect of fluid volume alone on PQ function. RESULTS: The validation trial demonstrated reproducibility of the testing apparatus. After paralysis of PQ with lidocaine, pronation torque decreased by an average 21% (range, 16.7% to 23.2%) at all positions compared with preinjection testing. All were statistically significant except at 80 degrees of pronation. The subjects who underwent injection of saline showed no evidence of decrease in pronation torque. CONCLUSIONS: This study demonstrated a significant decrease in pronation torque with controlled elimination of PQ function. Open reduction and internal fixation of distal radius fractures damages the PQ and may result in a pronation torque deficit. Pronation torque measurement may help in postoperative outcome analysis of surgical procedures using the volar approach to the distal radius.