Falls in patients with neuromuscular disorders

We monitored the incidence and consequences of falls during a 3-month follow-up in 66 patients with a variety of neuromuscular disorders and in 44 age-matched controls. Patients fell more often than controls (27% versus 5%). Falls frequently caused injuries (minor in 79% of subjects and major in 5%) and were often accompanied by fear of falling (58%) and reduced activities (48%). We conclude that falling is a clinically important problem in patients with neuromuscular disorders.

Early development of critical illness myopathy and neuropathy in patients with severe sepsis

OBJECTIVES

To characterize the prevalence, time of onset, and cause of neuromuscular dysfunction in patients with severe sepsis.

METHODS

We conducted a prospective cohort study in which participants with severe sepsis underwent weekly neurologic examinations and nerve conduction studies (NCSs) within 72 hours of developing severe sepsis until intensive care unit (ICU) discharge. Electromyography was preformed if clinical weakness developed or if there was a significant reduction in nerve conduction response amplitudes.

RESULTS

Abnormal NCS were present upon enrollment in 63% of patients (31/48). The presence of abnormal baseline NCS was predictive of hospital mortality (55% vs 0% for patients with normal baseline NCS; p < 0.001). Development of acquired neuromuscular dysfunction could be predicted by NCS done on day 7. Twenty patients remained in the ICU long enough to have serial NCSs; 50% of these patients developed acquired neuromuscular dysfunction. Most patients with acquired neuromuscular dysfunction had electrophysiologic evidence of both critical illness myopathy and critical illness neuropathy.

CONCLUSION

Changes in nerve conduction studies occur in the majority of patients early in the course of severe sepsis and predict the development of acquired neuromuscular dysfunction and mortality in intensive care unit patients. Most patients with acquired neuromuscular dysfunction after sepsis have both critical illness myopathy and critical illness neuropathy.

Pain and neuromuscular disease: the results of a survey

OBJECTIVE

The objective of this study was to evaluate pain frequency, severity, location, treatment, and relief in a population of adult patients with neuromuscular disorders (NMD).

DESIGN

The authors used a self-completion mail questionnaire from the Physical Medicine Clinic at the Lille University Medical Center (northern France). Two hundred eighty-one adults with a confirmed diagnosis of hereditary neuromuscular disease were mailed a questionnaire, which was returned by 125 subjects (response rate = 45%). The main outcome measures were mean motor deficiency scores (on the Brooke and Vignos scales), anxiety and depression scores, pain intensity (on a 0-10 numeric scale) and location, frequency of pain-aggravating situations, and pain treatment and relief.

RESULTS

Seventy-three percent of respondents reported pain and 62% reported chronic pain (defined as pain for at least 3 mos). The mean pain intensity was 6.1/10 with 40% reporting severe pain (a score of > or = 7). Forty-six percent and 16% of subjects had a high risk for anxiety and depression, respectively. The most common pain-aggravating situations were "walking," "standing," and "muscle stretching." Walking was more frequently cited as a pain-aggravating situation by the chronic pain population than by the acute pain population. Seventy percent of patients with pain had received at least one analgesic drug. Massage was the most frequently prescribed physical treatment.

CONCLUSIONS

Pain is a frequent symptom in adult patients with NMD and needs to be better characterized in this population. The use of painkillers and physical pain treatments did not seem to provide adequate relief for the patients studied here.

Plasma exchange in neuroimmunological disorders: part 2. Treatment of neuromuscular disorders

Plasma exchange is a well-established therapeutic procedure commonly used in many neurological disorders of autoimmune etiology. In this second part of our review, we assess the role of plasma exchange in the treatment of neuromuscular disorders. In Guillain-Barré syndrome and other immune-mediated neuropathic disorders, randomized controlled trials have demonstrated the therapeutic efficacy of plasma exchange. Myasthenia gravis and Lambert-Eaton syndrome represent neuromuscular disorders where plasmapheresis might be of potential efficacy.

Demographics and patterns of acupuncture use in the Chinese population: the Taiwan experience

BACKGROUND

The use of complementary and alternative medicine (CAM), including Traditional Chinese Medicine (TCM) and acupuncture, has substantially increased in western countries in the past decade. However, informative data concerning large-scale investigations of acupuncture used in the Chinese society remain rare so far. DESIGN AND OUTCOME MEASURE: The complete datasets of acupuncture outpatient reimbursement claims from 1996 to 2002 were supplied by the National Health Insurance Research Database, Taiwan, and the usage frequencies and characteristics of the acupuncture users, as well as the disease categories that were treated by acupuncture in Taiwan were analyzed.

RESULTS

At the end of 2002, among the 21,869,478 total valid beneficiaries of National Health Insurance (NHI), 1,362,351 subjects (6.2%) used acupuncture during this year, but 4,948,464 subjects (22.6%) had used it for the whole 7-year period since 1996. A mean increment of 1,191,164 (53.6%) new users had been involved yearly. Among all those acupuncture users, a female predominance was observed (female:male = 1.12:1), and the age distribution displayed a peak at around the 40s, followed by the 30s and 50s. Private TCM clinics provided more acupuncture usage (82.0%) than did private TCM hospitals (13.7%). The disease categories treated mostly by acupuncture were diseases of the musculoskeletal system (46.2%); injury (41.8%); diseases of the nervous system (3.5%); and symptoms, signs, and ill-defined conditions (2.7%).

CONCLUSIONS

Twenty-three percent (23%) of people in Taiwan had used acupuncture during this 7-year period. Musculoskeletoal and neurologic disorders were two major categories commonly treated with acupuncture.

Laryngospasm in neurological diseases

Laryngospasm is a clinical symptom characterized by involuntary spasms of the laryngeal muscles, which leads to paroxysms of coughing, inspiratory stridor, and sometimes to episodes of complete upper-airway occlusion. Although laryngospasm is a symptom mainly seen in otolaryngeal diseases and in the context of anesthesiological complications, it also occurs in neurological disorders. In this review of the occurrence of laryngospasms in neurological diseases, the clinical symptomatology, additional circumstances, possible underlying causes, and therapeutic options are presented.

Familial idiopathic hyper-CK-emia: an underrecognized condition

Persistent elevation of serum creatine kinase (CK) in individuals with normal neurological and laboratory examinations has been called idiopathic hyperCKemia (IH). IH has been reported in rare families and was recently ascribed to caveolin-3 gene mutations. We retrospectively found that IH was familial in 13 of 28 subjects in whom serum CK was measured in relatives. These 13 families had a total of 41 subjects with IH, including six over 60 years of age. In eight families there was male-to-male transmission and a higher prevalence of males with hyperCKemia. Muscle biopsy in one member of all families was normal or showed minimal, nonspecific changes. Morphometric examination disclosed different patterns of changes in fiber size and distribution. Caveolin-3 expression was normal and in five families molecular genetics excluded caveolin-3 gene mutations. Our findings suggest that IH is familial in 46% of cases. Familial IH is a benign genetically heterogeneous condition that is autosomal-dominant in at least 60% of cases, with a higher penetrance in men.

Follow-up of a large population of asymptomatic/oligosymptomatic hyperckemic subjects

Six years before the present study we performed a retrospective study of 114 subjects presenting with asymptomatic / oligosymptomatic hyperckemia (raised creatine kinase blood levels), a diagnosis being made in 21 of them. We now present the results of a long-term follow-up in 55 of the still undiagnosed 93 individuals. Most of them have remained asymptomatic and did not develop specific neuromuscular disorders. One subject became frankly symptomatic manifesting limb-girdle weakness. A diagnosis of dystrophinopathy carrier and one of possible type I SMA carrier were indirectly made in another two subjects. Almost all subjects still have hyperckemia, though the mean creatine kinase (CK) value is lower than before. CK levels have become normal in 12 subjects. Two died of neoplasia, and six developed non-neuromuscular disorders. We noted no follow-up differences in terms of CK modifications between subjects with pathological EMG and/or muscle biopsy findings and those with normal findings at first examination.

Survey of behaviour problems in children with neuromuscular diseases

Previous research on clinic samples has suggested that children with neuromuscular diseases may be affected by mental health problems. The aim of this study was to establish the carer-reported prevalence of social, communication, and behavioural problems in middle childhood in a total population with neuromuscular diseases. From a target population of 111, 82 carers of children aged 5-13 years with a diagnosed neuromuscular disease living in the Northern Region of UK were interviewed about service utilisation and needs, and 66 completed the Strengths and Difficulties Questionnaire, Social Communication Questionnaire and Children's Communication Checklist. Two-fifths of children scored above the clinical cut-off on at least one questionnaire. These results were significantly higher than are reported for national and normally developing samples. Nine out of 82 had a diagnosis of autism spectrum disorder. Carers of children with problems reported significantly higher levels of unmet need. Behaviour, social and communication problems are common in children with neuromuscular diseases and Regional Neuromuscular Clinics should consider mental health screening and assessment.

Cyclic vomiting syndrome plus

Cyclic vomiting syndrome, which is characterized by severe discrete episodes of nausea, vomiting, and lethargy, is a fairly common, disabling, predominately childhood condition. Approximately 25% of cases have coexisting neuromuscular disease manifestations (cyclic vomiting syndrome plus). To determine whether patients with cyclic vomiting syndrome and neuromuscular disease represent a distinct subentity within cyclic vomiting syndrome, a clinical interview was conducted regarding 80 randomly ascertained sufferers of cyclic vomiting syndrome from a disease association database. Cyclic vomiting syndrome plus and "cyclic vomiting syndrome minus," herein defined as the presence of at least two and zero neuromuscular disease manifestations, were present in 23 and 44 subjects, respectively. Neuromuscular disease manifestations, including cognitive disorders, skeletal myopathy, cranial nerve dysfunction, and seizure disorders, were found to statistically cluster together among the same subjects. In addition, subjects with cyclic vomiting syndrome with neuromuscular disease had an earlier age at onset for vomiting episodes and a three- to eightfold statistically increased prevalence for certain dysautonomia-related (migraine, chronic fatigue, neurovascular dystrophy) and constitutional (growth retardation and birth defects) disorders. However, subjects with cyclic vomiting syndrome with and without neuromuscular disease were equally likely to have a sibling affected with neuromuscular disease manifestations. We conclude that cyclic vomiting syndrome plus, although likely not genetically distinct from cyclic vomiting syndrome minus, represents a distinct phenotypic entity that predicts an earlier onset of disease and increased comorbidity with a distinct list of medical conditions, possibly owing to a higher degree of mitochondrial dysfunction.

Service provision for adults with long-term disability: A review of services for adults with chronic neuromuscular conditions in the United Kingdom

The purpose of the study is to determine the level of service provision for adults with neuromuscular disease in the United Kingdom. The method is questionnaire survey of clinicians running specialist clinics for adults with NMD. Specialist services are mostly concentrated in areas of high population density with rural areas being less well served. Access to specialist clinical services is generally good, although funding for respiratory support is erratic. Joint paediatric/adult or adolescent clinics are relatively uncommon. Availability of therapists with an interest in muscular disease is variable. There are long waiting times for powered wheelchairs in many areas. Provision of disabled parking spaces was thought to be inadequate in most hospitals. Current service provision is inadequate to meet the complex needs of this patient population in the UK. Particular areas of concern are the transfer of care from paediatric to adult services and the availability of experienced therapists.

Urinary storage symptoms and comorbidities: a prospective population cohort study in middle-aged and older women

OBJECTIVE

to identify predictive morbidities for urinary storage syndromes including indicators for neurological, musculoskeletal, cardiovascular, immune, lower bowel and psychological systems. This is the first study to test prior hypotheses, based on a literature review.

DESIGN

this was a prospective cohort study involving 12,570 female respondents aged 40 or more registered with general practitioners and living at home in Leicestershire. Postal questionnaires were used at baseline and 1-year follow-up (response rates 65 and 79%, respectively).

MEASURES

pure stress urinary incontinence (SUI) and overactive bladder syndrome (OAB) were defined using standardised symptom indicators. Specific morbidities included reported medical diagnoses, standardised symptoms and general health indicators. Associations were identified using logistic regression, adjusting for age and physical impairment, with separate models for general and specific morbidities.

RESULTS

multivariate morbidities consistently associated (i.e. both longitudinally and cross-sectionally) were SUI-cystitis and obesity; and OAB-bowel urgency, osteoporosis, imbalance, ankle swelling, cystitis, poor health and old age. Other independent predictors were SUI-multiple sclerosis and joint pain; and OAB-deep vein thrombosis and diabetes. Consistent univariate indicators supported neurological, musculoskeletal, cardiovascular, immunological and psychological connections with both types of storage disorder plus an association with lower bowel problems for OAB.

CONCLUSIONS

abnormal urinary storage symptoms were predicted by obesity and poor general health, involving a range of systems of the body. OAB showed more extensive links than SUI with specific morbidities, including more medically diagnosed as opposed to symptom-based conditions. These findings were independent of problems with physical impairment.

Sensorimotor performance in school-age children with autism, developmental language disorder, or low IQ

The purpose of the study was to determine the prevalence of 'soft' motor deficits in school-aged children with either developmental language disorder (DLD), autism (with high IQ [HiAD] or low IQ [LoAD]), or low IQ without autism (LoIQ), and to evaluate the utility of a refined neurological examination to discriminate between these groups. A total of 242 children (74% male), aged 7 or 9 years, were evaluated as part of a longitudinal, multi-institutional study, with a standardized neurological examination that included Denckla's Physical and Neurological Examination for Soft Signs. Most of the scores separated children into two groups defined by nonverbal IQ, with the DLD and HiAD groups performing better than the LoAD and LoIQ groups. Exceptions included motor impersistence and stereotypies, which were more likely in the autistic groups. The neurologists' summary clinical impressions indicated better sensory/motor skills, oromotor skills, and praxis in the HiAD than in the DLD children. Inability/unwillingness to perform tasks was much more frequent in LoAD than LoIQ children.

Respiratory insufficiency and limb muscle weakness in adults with Pompe's disease

The objective of the present study was to prospectively evaluate relationships linking age, respiratory function and locomotor function in 29 outpatients with late-onset Pompe's disease and to retrospectively determine clinical outcomes. Using univariate regression analysis, vital capacity (VC) was weakly, but significantly, correlated to shoulder motility, Walton score and lower-limb Modified Medical Research Council score. Six patients were able to walk without a walking aid and with only the help of a handrail on the stairs (Walton score=3), although VC was <50%. No parameters were significantly correlated with age. As assessed retrospectively, VC and locomotion deteriorated over time in most patients. In contrast, among the 16 patients started on invasive or noninvasive ventilation with VC monitoring, eight had a VC increase at the first measurement time-point. The absence of correlation with age and the presence, in some patients, of severe respiratory insufficiency without severe limb girdle muscle weakness indicate that respiratory function should be monitored independently from the degree of peripheral muscle weakness. Mechanical ventilation and tracheostomy may improve vital capacity and should, therefore, be taken into account when evaluating treatments for the adult form of Pompe's disease.

Sleep and Neuromuscular Disorders

Nocturnal sleep-related ventilatory alterations may occur in dis-proportion to the severity of the neuromuscular disorder. Diaphragm paralysis occurring with a neuromuscular disorder is an overlooked complication. Failure to thrive, daytime tiredness, and incapacitating fatigue may be the result of a correctable sleep-related abnormality, not the result of relentless progression of a neuromuscular condition. Polysomnographic evaluation is recommended for patients who have neuromuscular disorder who develop symptoms and signs of sleep-wake abnormality or nocturnal respiratory failure. Application of noninvasive positive airway ventilation and, in some cases, administration of supple-mental oxygen may improve quality of life and prolong survival of patients who have neuromuscular disorder.

Neuromuscular sequelae of critical illness

PURPOSE OF REVIEW

To investigate the impact of critical illness polyneuropathy and critical illness myopathy on short-term and long-term patient outcome.

RECENT FINDINGS

In the acute-care setting, critical illness polyneuropathy and critical illness myopathy are important causes of acute paralysis in critically ill comatose patients, and may cause inappropriately pessimistic prognoses. Duration of weaning from artificial ventilation is 2 to 7 times greater in patients with critical illness polyneuropathy than in patients without critical illness polyneuropathy. After intensive care unit and hospital discharge, many patients diagnosed with critical illness polyneuropathy or critical illness myopathy are reported to complain of profound muscle weakness. Chronic disability was a common finding among them. Complete functional recovery with patients regaining the ability to breathe spontaneously and to walk independently was reported in 180 of 263 patients (68.4%); severe disability with tetraparesis, tetraplegia, or paraplegia was reported in 74 patients (28.1%). Persisting milder disabilities were common even in patients with complete functional recovery, and included reduced or absent deep tendon reflexes, stocking and glove sensory loss, muscle atrophy, painful hyperesthesia, and foot drop. An association of critical illness polyneuropathy and critical illness myopathy with increased intensive care unit and hospital mortality has been demonstrated only in selected intensive care unit populations; data are insufficient to demonstrate any association with long-term mortality.

SUMMARY

Intensive care unit-acquired critical illness polyneuropathy and critical illness myopathy influence the evaluation of acutely ill comatose patients and may instigate unreasonably pessimistic prognosis. Critical illness polyneuropathy and critical illness myopathy are an important cause of difficult weaning of patients from the ventilator and of persisting muscle weakness and disability after intensive care unit discharge.

Therapy with both magnesium sulfate and nifedipine does not increase the risk of serious magnesium-related maternal side effects in women with preeclampsia

OBJECTIVE

Does the use of nifedipine and magnesium sulfate together increase serious magnesium-related effects?

STUDY DESIGN

This was a retrospective chart review of women who were admitted to BC Women's Hospital and Health Centre (1997-2001) and were given intravenous magnesium sulfate for preeclampsia. Serious magnesium-related effects were compared among 162 cases who received magnesium sulfate and contemporaneous nifedipine and 215 control subjects who received magnesium sulfate and either another antihypertensive (n=32 women) or no antihypertensive (n=183 women) medication. Chi-squared test, Fisher's exact test, or the Student t test was used for data comparison between cases and each control group. A probability value of <.05 was considered statistically significant.

RESULTS

The cases had more severe preeclampsia and a longer magnesium sulfate infusion. However, cases had no excess of neuromuscular weakness (53.1%) versus control subjects who received antihypertensive medication (53.1%; P=.99) or control subjects who received no antihypertensive medication (44.8%; P=.13) or other serious magnesium-related effects. Cases versus control subjects who received antihypertensive medication had less neuromuscular blockade (odds ratio, 0.04; 95% CI, 0.002-0.80). Cases versus control subjects who received no antihypertensive medication had less maternal hypotension (41.4% vs 53.0%; P=.04).

CONCLUSION

The use of nifedipine and magnesium sulfate together does not increase the risk of serious magnesium-related effects.

Comparison of Neuromuscular Injuries to the Surgeon during Hand-Assisted and Standard Laparoscopic Urologic Surgery

BACKGROUND AND PURPOSE

Hand-assisted procedures have assumed a greater role in the practice of many laparoscopists. We surveyed major laparoscopy program directors to compare the incidence and location of neuromuscular injury to the surgeon during hand-assisted laparoscopic (HAL) and standard laparoscopic (SL) surgery.

MATERIALS AND METHODS

A questionnaire on neuromuscular injuries was e-mailed to 42 laparoscopic program directors. Respondents were instructed to report only injuries or pain associated with laparoscopic surgery when they were the primary responsible surgeon and not during open or endoscopic procedures.

RESULTS

Surveys were returned from 23 attending laparoscopic surgeons and 2 laparoscopic fellows. Surgeons reported an average of 3.9 HAL and 6.3 SL cases per month as the primary surgeon. The HAL was completed with the GelPort, LapDisk, Omniport, or a combination of devices 55%, 22%, 5%, and 14%, respectively, of the time. Comparing HAL with SL, there was significantly more hand/wrist, forearm, and shoulder pain/injuries associated with HAL (P < 0.004). There was significantly more neck pain associated with SL than HAL (P < 0.003), but no significant difference in lower-back pain (P = 0.40). Comparing the two most commonly used hand-assist devices (GelPort and LapDisk), the LapDisk demonstrated significantly more hand/wrist pain or injury (P = 0.001).

CONCLUSION

Hand-assisted laparoscopy is associated with more frequent neuromuscular strain to the upper extremity than SL, but SL surgeons experience more neck pain or injury. Surgeon discomfort is also dependent on the type of hand-assist device. The long-term consequences of physical strain on the laparoscopic surgeon are unknown currently, but measures to minimize neuromuscular strain should be considered.

[The prevalence and character of neurologic deficit relating to clinical forms of cervical spondylosis]

The research was performed on 86 male patients between 41 and 83 years who were either hospitalised or treated in the out-patients clinic due to cervical spondylosis. The aim of the research was to evaluate the frequency and advance of neurologic, complications relating to the type and severity of lesions in cervical spine. The study showed significant relation between the degree of advance of cervical spondylosis and age, pain as well as prevalence and severity of neurologic deficit in the tested group. The authors have emphasized the need of precise evaluation and differentiation of presented forms of degenerative spine disease.