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Affiliation(s)
- A Mallik
- Department of Clinical Neurophysiology, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, UK.
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52
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Pugdahl K, Tankisi H, Fuglsang-Frederiksen A, Johnsen B, de Carvalho M, Fawcett PRW, Labarre-Vila A, Liguori R, Nix W, Olsen ML, Schofield IS. Influence of medical audit on electrodiagnostic evaluation of polyneuropathy. A multicentre study. Clin Neurophysiol 2005; 116:49-55. [PMID: 15589183 DOI: 10.1016/j.clinph.2004.07.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2004] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Since 1992, 7 European neurophysiologists have participated in the ESTEEM project concerned with improvements in electrodiagnostic medicine. This study assesses whether the collaboration that includes peer review medical audit has influenced the involved physicians' electrodiagnostic criteria for polyneuropathy (PNP) diagnosing and classification. METHODS Two sets of each physician's PNP examinations performed early and late in the study were examined for changes in (1) number of studies with abnormal electrophysiological findings required for diagnosing PNP, and (2) agreement between the classifications given by the individual physicians and the peer review group. RESULTS The average number of abnormal motor nerve segments per patient increased from 4.6 to 6.4 during the study. Although most individual changes were minor, the second set of examinations showed an increased homogeneity among the physicians in the number of abnormal motor nerve segments and abnormal F wave studies, and a tendency towards increased homogeneity in the number of abnormal sensory nerve segments. There was also an increased agreement on pathophysiological PNP classification in the second set of examinations compared to the first set. CONCLUSIONS The participation in the ESTEEM project seems to have impacted the physicians' clinical routine, possibly as they have accustomed themselves to apply criteria more strictly. SIGNIFICANCE This study support that international collaboration is a useful step towards improvements in electrodiagnostic medicine.
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Affiliation(s)
- Kirsten Pugdahl
- Department of Clinical Neurophysiology, Aarhus University Hospital, Nørrebrogade 44, Building 10, 8000 Aarhus C, Denmark
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53
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Weiss LD, Weiss JM, Johns JS, Strommen JA, Kim CT, Williams FH, Rashbaum IG. Neuromuscular rehabilitation and electrodiagnosis. 2. Peripheral neuropathy. Arch Phys Med Rehabil 2005; 86:S11-7. [PMID: 15761795 DOI: 10.1016/j.apmr.2004.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
UNLABELLED This self-directed learning module highlights peripheral neuropathies. It is part of the chapter on neuromuscular rehabilitation and electrodiagnosis in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on diagnostic criteria and classifications of peripheral neuropathy, including diabetic, alcoholic, carcinomatous, human immunodeficiency virus-associated, and critical illness polyneuropathies. Treatment options are reviewed. The causes for difficult to obtain nerve conduction studies are highlighted. OVERALL ARTICLE OBJECTIVE To summarize the diagnosis, classification, and treatment of peripheral neuropathies.
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Affiliation(s)
- Lyn D Weiss
- Department of Physical Medicine and Rehabilitation, Nassau University Medical Center, 2201 Hempstead Tpke, East Meadow, NY 11554, USA.
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54
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Abstract
Falls among elderly persons remain a difficult problem with few easy solutions. Falls are symptomatic of underlying clinical deficits, and a multidisciplinary approach is essential in identifying the risk factors and appropriate treatments for these patients. Patients with chronic medical conditions, such as spinal cord injury, traumatic brain injury, and amputations, possess additional unique risk factors that must be addressed. Interventions include treatment of potentially reversible medical conditions such as B12 and vitamin D deficiencies and home modifications,balance and exercise training programs, medication modification, hip protectors, and monitoring devices. Physicians, patients, family members, and caretakers should be reminded that minimizing falls risk requires persistence, patience, and dedication. Progress may not be noted overnight, but adherence to recommendations correcting intrinsic and extrinsic factors can help to minimize falls and their potentially devastating complications.
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Affiliation(s)
- Julie T Lin
- Department of Physiatry, Hospital for Special Surgery, The New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, NY 10021, USA.
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55
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Brunelli B, Gorson KC. The use of complementary and alternative medicines by patients with peripheral neuropathy. J Neurol Sci 2004; 218:59-66. [PMID: 14759634 DOI: 10.1016/j.jns.2003.10.013] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2003] [Revised: 10/24/2003] [Accepted: 10/25/2003] [Indexed: 11/21/2022]
Abstract
Complementary and alternative medicine (CAM) therapies have become increasingly popular and are used regularly by patients with chronic neurological disorders. The prevalence and characteristics of CAM use by patients with peripheral neuropathy is unknown. We performed a prospective, questionnaire-based study to determine the prevalence and patterns of use of CAM therapies in 180 consecutive outpatients with peripheral neuropathy. The use of CAM was reported by 77 patients (43%) with neuropathy. The most frequent were megavitamins (35%), magnets (30%), acupuncture (30%), herbal remedies (22%), and chiropractic manipulation (21%); 37 (48%) tried more than one form of alternative treatment. Seventeen respondents (27%) thought their neuropathy symptoms improved with these approaches. Those who used CAM were slightly younger (mean age 62 vs. 65 years, p = 0.05) and more often college educated (39% vs. 24%, p = 0.03) compared to CAM nonusers. They also more often reported burning neuropathic pain (62% vs. 44%, p = 0.01). Patients with diabetic neuropathy used CAM more frequently than others (p = 0.03). The most common reason for using CAM was inadequate pain control (32%). Almost half of patients did not consult a physician before starting CAM. We conclude that there is a high prevalence of CAM use in our patients with neuropathy, and one-quarter reported that their symptoms improved. CAM users were better educated than nonusers, but most did not discuss CAM treatments with their physician. Neuropathic pain was substantially more common in CAM users, and lack of pain control was the most common reason for CAM use.
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Affiliation(s)
- Brian Brunelli
- Division of Neurology, St. Elizabeth's Medical Center, 736 Cambridge Street, Boston, MA 02135, USA
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56
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Abstract
Diabetic sensorimotor polyneuropathy (DSP) is the most common complication of diabetes. In order to manage DSP effectively, it is necessary to formulate an accurate diagnosis and monitor subjects regularly. This review of important aspects of the diagnosis of DSP starts with a conceptual framework that includes elements of DSP epidemiology, pathophysiology, and therapy. The emphasis of the review is to present our current understanding of diagnostic methods for DSP including their utility and limitations. Screening for DSP in the diabetes clinic can be achieved successfully using simple clinical tests. Clinical neurophysiological methods are necessary to exclude other diagnoses, stage severity, and monitor the course of DSP. Novel investigative techniques are highly promising, but their usefulness in the clinic setting remains limited at this time. This article presents an overview of diagnostic methods for DSP.
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Affiliation(s)
- Bruce A Perkins
- EN 11-209, TGH, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, Ontario, Canada M5G 2C4
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57
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Carter GT, England JD, Hecht TW, Han JJ, Weydt P, Chance PF. Electrodiagnostic evaluation of hereditary motor and sensory neuropathies. Phys Med Rehabil Clin N Am 2003; 14:347-63, ix-x. [PMID: 12795520 DOI: 10.1016/s1047-9651(02)00127-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Electrodiagnosis can classify hereditary motor and sensory neuropathies (HMSN) into two basic types: primarily demyelinating with secondary axonal loss and primarily axonal. For the most part, the various forms of HMSN show uniform symmetric nerve conduction slowing, in contrast to acquired neuropathies, which may be multifocal with nonuniform conduction velocity slowing and temporal dispersion. Nevertheless, there are exceptions. This article reviews the available literature and describes the electrodiagnostic approach to HMSN, detailing potential sources of error that can lead to misinterpretation of data.
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Affiliation(s)
- Gregory T Carter
- Department of Rehabilitation Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Avenue, Seattle, WA 98195, USA.
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58
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Abstract
Electrodiagnosis has a key role in the evaluation of patients presenting with weakness. The electrodiagnostician should maintain a broad inclusive differential diagnosis and tailor the examination using a sound conceptual framework. A clear understanding of what is normal provides the proper foundation upon which to judge electrodiagnostic findings. Many peripheral neuromuscular conditions manifest themselves in characteristic ways on NEE and nerve conduction testing, making them identifiable to the skilled electrodiagnostic medicine consultant.
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Affiliation(s)
- Timothy R Dillingham
- Department of Physical Medicine and Rehabilitation, Froedtert Memorial Lutheran Hospital, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226, USA.
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59
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Tankisi H, Johnsen B, Fuglsang-Frederiksen A, de Carvalho M, Fawcett PRW, Labarre-Vila A, Liguori R, Nix W, Olsen M, Schofield I. Variation in the classification of polyneuropathies among European physicians. Clin Neurophysiol 2003; 114:496-503. [PMID: 12705430 DOI: 10.1016/s1388-2457(02)00419-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Considerable debate still exists regarding the classification of polyneuropathies (PNPs) into predominantly demyelinating, predominantly axonal loss, mixed or unclassified. This study was designed to determine the variation among physicians in the classification of PNPs by using the European Standardized Telematic tool to Evaluate Electromyography knowledge-based systems and Methods (ESTEEM) multicenter database. METHODS Seven physicians from 6 laboratories in Europe sent a total of 156 prospectively collected cases of PNP with electromyography (EMG) data including diagnosis (examination diagnosis) to the database. Each physician interpreted the electrophysiological data from all cases (interpretation diagnosis) and a final diagnosis was given at the consensus meetings of the group (consensus diagnosis). RESULTS Comparison of each physician's examination diagnosis with his/her interpretation diagnosis, i.e. intra-physician variation, showed a change towards less classified PNPs (P < 0.05). Interpretation diagnoses showed large inter-physician variation in the classification of PNPs. The consensus group was more cautious than individual physicians in classifying PNPs as mixed and axonal. The probability of the consensus diagnosis increased with increasing number of abnormal motor and sensory segments tested. CONCLUSIONS Recognition of variation in classification of PNP as shown in this study and suggesting standards of good clinical practice developed by a consensus group may increase the quality of EMG practice.
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Affiliation(s)
- H Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, AKH. Nørrebrogade 44, 8000, Aarhus, Denmark
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60
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Bromberg MB, Smith AG. Toward an efficient method to evaluate peripheral neuropathies. J Clin Neuromuscul Dis 2002; 3:172-182. [PMID: 19078676 DOI: 10.1097/00131402-200206000-00007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The diagnosis of peripheral polyneuropathies can be challenging. A structured diagnostic approach can help make the endeavor efficient and increases the diagnostic yield. This review is in two parts. In the first part, we present the elements of a structured approach that consists of a set of steps that leads to a full characterization of the clinical features of the neuropathy. Electrodiagnosis will be emphasized because it has a key role in accurately defining the pattern of nerve involvement and determining the underlying pathology. After characterization, a rational list of laboratory tests can be ordered. The second part of this review describes the clinical and pathologic features of common peripheral neuropathies. This review of neuropathies emphasizes how the structured approach can facilitate the diagnosis. The second part concludes with the practical experience from evaluating peripheral neuropathies, emphasizing the point that a diagnosis may not be forthcoming in a third or more of patients.
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Affiliation(s)
- Mark B Bromberg
- From the Department of Neurology, University of Utah, Salt Lake City, Utah, U.S.A
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61
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Wein TH, Albers JW. Electrodiagnostic approach to the patient with suspected peripheral polyneuropathy. Neurol Clin 2002; 20:503-26, vii. [PMID: 12152445 DOI: 10.1016/s0733-8619(01)00010-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Peripheral neuropathy has a multitude of potential causes, which at times may make a clinician feel overwhelmed. This often leads to the performance of a number of costly investigations in the hope of finding an explanation or treatable cause for the neuropathy. The authors propose that by performing a thorough history and physical examination in conjunction with findings on electrodiagnostic studies, a rational and limited differential diagnosis may be generated so that a targeted and cost effective investigation may be performed.
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Affiliation(s)
- Theodore H Wein
- Department of Neurology and Neurosurgery, McGill University, St. Mary's Hospital, 3830 Avenue Lacombe, Montréal, Québec H3T 1M5, Canada.
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62
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Bowler RM, Lezak M, Booty A, Hartney C, Mergler D, Levin J, Zisman F. Neuropsychological dysfunction, mood disturbance, and emotional status of munitions workers. APPLIED NEUROPSYCHOLOGY 2002; 8:74-90. [PMID: 11515244 DOI: 10.1207/s15324826an0802_2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The objective of this study was to compare the neuropsychological function, emotional status, visual function, and illness prevalence of 265 former munitions plant workers (M age = 56.7 years, M years of education = 12.07; 201 African American, 64 White) exposed to organic solvents for an average of 17.03 years with that of a group of 77 unexposed controls (M age = 51.3 years, M years of education = 13.07; 30 African American, 47 White). Neuropsychological tests were selected from the World Health Organization Neurobehavioral Core Test Battery, Wechsler Adult Intelligence Scale-III (WAIS-III), and Wechsler Memory Scale-III (WMS-III) and also included the Brief Symptom Inventory, Profile of Mood States, Beck Anxiety Inventory, and Beck Depression Inventory. Vision tests included the Lanthony d-15 color vision, the Vistech Contrast Sensitivity, and the Snellen. The exposed group showed greater deficits than the controls in verbal learning (WMS-III Logical Memory I Learning Slope and Word Lists I Recall), visuomotor tracking speed (Cancellation H, WAIS-III Digit Symbol-Coding) and psychomotor function (Dynamometer and Grooved Pegboard), and dysfunction in emotional status, illness prevalence, and visual function. African American workers reported higher levels of exposure than Whites. Exposure relations demonstrated increased neuropsychological dysfunction with increased exposure.
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Affiliation(s)
- R M Bowler
- Department of Psychology, San Francisco State University, San Francisco, California, USA.
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63
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Rosenberg NR, Portegies P, de Visser M, Vermeulen M. Diagnostic investigation of patients with chronic polyneuropathy: evaluation of a clinical guideline. J Neurol Neurosurg Psychiatry 2001; 71:205-9. [PMID: 11459893 PMCID: PMC1737522 DOI: 10.1136/jnnp.71.2.205] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE (1) To evaluate a clinical guideline for the diagnostic investigation of patients presenting with signs and symptoms (present for longer than 6 weeks) suggesting a chronic polyneuropathy. (2) To investigate the contribution of electrophysiological studies to a focused search for aetiology in these patients. METHODS A chart review was carried out of a consecutive group of outpatients in 1993-7 at a university department of neurology, with signs and symptoms suggesting a polyneuropathy in whom the diagnostic investigation had been carried out according to a recently introduced guideline. Diagnostic tests were performed and final diagnoses were made. RESULTS Unnecessary investigations were carried out in 108 (51%) of 213 patients and too few tests in 23 (11%) of these patients. In 82 (48%) of the 172 patients who fulfilled the inclusion criteria neurophysiological tests did not contribute to the final diagnosis. Neurophysiological criteria for demyelination were fulfilled in only 13 (8%) of the 172 patients. CONCLUSION In patients presenting with signs and symptoms of chronic polyneuropathy the number of tests in the diagnostic investigation can be considerably reduced. In patients with signs and symptoms of polyneuropathy, providing the clinical phenotype is typical, in the presence of diabetes mellitus, renal failure, HIV infection, alcoholism, or use of potentially neurotoxic drugs further investigations are non-contributory. The significance of electrophysiological studies in the investigation of patients with polyneuropathy is rather to separate sensorimotor neuropathies from pure sensory neuropathies than to distinguish between demyelinating and axonal neuropathies.
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Affiliation(s)
- N R Rosenberg
- Department of Neurology, Academic Medical Centre, University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, The Netherlands
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64
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Electrodiagnostic Approach to Patients with Suspected Generalized Neuromuscular Disorders. Phys Med Rehabil Clin N Am 2001. [DOI: 10.1016/s1047-9651(18)30068-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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65
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Abstract
Electrodiagnostic studies comprising electromyography (EMG) and nerve conduction studies (NCS) are well-established objective methods for the diagnosis, quantification and classification of polyneuropathies (PNP). This paper reviews examination techniques, their pathophysiological interpretation, examination strategies and diagnostic criteria for the diagnosis and classification of a PNP. The routine electrodiagnostic evaluation includes sensory NCSs performed with surface or needle electrodes, motor NCSs, F-wave studies and EMG by qualitative or quantitative techniques. Sensory NCSs and F-wave studies have a high sensitivity in PNPs and the different techniques complement each other. The distinction between a PNP with predominantly axonal loss and a PNP with predominantly demyelination is one of the major aims of the electrophysiological examination. There are, however, large variation in suggested criteria for predominantly demyelination. The degree of slowing in conduction taken to indicate demyelination varies between a decrease of 50 to 30% from mean of controls, distal latency prolongation criteria vary from 35% to 70% of mean of controls, F-wave latency prolongation criteria vary from 120% to 150% of upper limit of controls, and criteria for partial motor conduction block vary from 11 to 50% reduction of CMAP amplitude and/or area between proximal and distal stimulation. Needle EMG studies may be valuable in order to detect and quantify denervation activity, to assess chronicity by an evaluation of the extent of reinnervation, and to evaluate the topographical distribution of changes. It is concluded that electrodiagnostic studies are valuable in patients with suspected PNP and the results may have consequences for prognosis and therapy of individual patients. Large variation in examination techniques, strategies, interpretations and diagnostic criteria have been found among electromyographers and it is suggested that the value of electrodiagnostic studies may be further improved by international standardisation.
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Affiliation(s)
- B Johnsen
- Department of Clinical Neurophysiology, University Hospital, Nørrebrogade HH, DK 8000, Aarhus, Denmark
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66
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Abstract
The effects of several substances known to produce peripheral neuropathy are reviewed, as are the criteria espoused to be useful in establishing their neurotoxicity. Included is a description of systemic and neurologic symptoms and signs important in identification of the neurotoxic disorder, and a description of the resultant electrodiagnostic abnormalities.
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Affiliation(s)
- M B Bromberg
- Department of Neurology, Neuromuscular Program, University of Utah, Salt Lake City 84132, USA
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67
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van Dijk JG. 'Rules of conduct': some practical guidelines for testing motor-nerve conduction. Arch Physiol Biochem 2000; 108:229-47. [PMID: 11094376 DOI: 10.1076/1381345520000710831zft229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The testing of nerve conduction using electromyography (EMG) is a frequently used diagnostic method for the identification of various neuropathies. The present article illustrates a variety of conditions on the basis of clinical data, and suggests how one can obtain the best results by observing a few simple rules.
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Affiliation(s)
- J G van Dijk
- Dept. of Neurology and Clinical Neurophysiology, Leiden University Medical Centre, The Netherlands.
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68
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Duyff RF, Van den Bosch J, Laman DM, van Loon BJ, Linssen WH. Neuromuscular findings in thyroid dysfunction: a prospective clinical and electrodiagnostic study. J Neurol Neurosurg Psychiatry 2000; 68:750-5. [PMID: 10811699 PMCID: PMC1736982 DOI: 10.1136/jnnp.68.6.750] [Citation(s) in RCA: 207] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To evaluate neuromuscular signs and symptoms in patients with newly diagnosed hypothyroidism and hyperthyroidism. METHODS A prospective cohort study was performed in adult patients with newly diagnosed thyroid dysfunction. Patients were evaluated clinically with hand held dynamometry and with electrodiagnosis. The clinical features of weakness and sensory signs and the biochemical data were evaluated during treatment. RESULTS In hypothyroid patients 79% had neuromuscular complaints, 38% had clinical weakness (manual muscle strength testing) in one or more muscle groups, 42% had signs of sensorimotor axonal neuropathy, and 29% had carpal tunnel syndrome. Serum creatine kinase did not correlate with weakness. After 1 year of treatment 13% of the patients still had weakness. In hyperthyroid patients 67% had neuromuscular symptoms, 62% had clinical weakness in at least one muscle group that correlated with FT4 concentrations, but not with serum CK. Nineteen per cent of the patients had sensory-motor axonal neuropathy and 0% had carpal tunnel syndrome. The neuromuscular signs developed rapidly, early in the course of the disorder and were severe, but resolved rapidly and completely during treatment (average time 3.6 months). CONCLUSIONS Neuromuscular symptoms and signs were present in most patients. About 40% of the hypothyroid patients and 20% of the hyperthyroid patients had predominantly sensory signs of a sensorimotor axonal neuropathy early in the course of thyroid disease. Weakness in hyperthyroidism evolved rapidly at an early stage of the disorder and resolved completely during treatment, suggesting a functional muscle disorder. Hand held dynamometry is sensitive for the detection of weakness and for the clinical evaluation of treatment effects. Weakness in hypothyroidism is more difficult to treat, suggesting myopathy.
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Affiliation(s)
- R F Duyff
- Department of Neurology, St Lucas Andreas Hospital, Jan Tooropstraat 164, 1061 AE Amsterdam, The Netherlands
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69
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Pastore C, Izura V, Geijo-Barrientos E, Dominguez JR. A comparison of electrophysiological tests for the early diagnosis of diabetic neuropathy. Muscle Nerve 1999; 22:1667-73. [PMID: 10567079 DOI: 10.1002/(sici)1097-4598(199912)22:12<1667::aid-mus8>3.0.co;2-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Clinical criteria and several electrophysiological parameters for detecting nerve damage were compared in 99 patients with diabetes mellitus type 1 and type 2. Abnormal results were found in sural/radial amplitude ratio (51%), minimal F-wave latency of the tibial nerve (36.4%), sensory conduction velocity of the sural nerve (29.8%), and sural sensory nerve action potential amplitude (29.3%) when pooling data from all patients and comparing them to age- and height-matched normal control subjects. Analysis of all the parameters revealed large differences between the diabetes mellitus type 1 and type 2 groups, suggesting that the type of diabetes must be taken into account when comparing the sensitivity of nerve conduction tests. In diabetes mellitus type 1, the sural/radial ratio had the clearest correlation with course of illness and was the first parameter to show a significant reduction. We conclude that the simple ratio between sural and radial amplitudes is a very sensitive parameter and abnormalities in this ratio provide the means for earliest detection of neuropathy in diabetes mellitus type 1.
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Affiliation(s)
- C Pastore
- S. de Neurofisiología Clínica (EMG), Hospital Universitario de San Juan, Ctra. Alicante-Valencia s/n, 03550 San Juan, Alicante, Spain.
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70
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Glocker FX, Rösler KM, Linden D, Heinen F, Hess CW, Lücking CH. Facial nerve dysfunction in hereditary motor and sensory neuropathy type I and III. Muscle Nerve 1999; 22:1201-8. [PMID: 10454715 DOI: 10.1002/(sici)1097-4598(199909)22:9<1201::aid-mus6>3.0.co;2-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Facial nerve function was studied in 19 patients with hereditary motor and sensory neuropathy type I (HMSN I) and 2 patients with hereditary motor and sensory neuropathy type III (HMSN III, Déjérine-Sottas), and compared to that in 24 patients with Guillain-Barré syndrome (GBS). The facial nerve was stimulated electrically at the stylomastoid fossa, and magnetically in its proximal intracanalicular segment. Additionally, the face-associated motor cortex was stimulated magnetically. The facial nerve motor neurography was abnormal in 17 of 19 HMSN I patients and in both HMSN III patients, revealing moderate to marked conduction slowing in both the extracranial and intracranial nerve segments, along with variable reductions of compound muscle action potential (CMAP) amplitudes. The facial nerve conduction slowing paralleled that of limb nerves, but was not associated with clinical dysfunction of facial muscles, because none of the HMSN I patients had facial palsy. Conduction slowing was most severe in the HMSN III patients, but only slight facial weakness was present. In GBS, conduction slowing was less marked, but facial weakness exceeded that in HMSN patients in all cases. We conclude that involvement of the facial nerve is common in HMSN I and HMSN III. It affects the intra- and extracranial part of the facial nerve and is mostly subclinical.
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Affiliation(s)
- F X Glocker
- Department of Neurology, University of Freiburg, Breisacher Strasse 64, D-79106 Freiburg, Germany
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71
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Abstract
A 19-year-old male developed complaints including weakness of the lower extremities and right hand, numbness, dysphagia and urinary difficulties following a 2 month exposure to an industrial solvent constituted mainly of 1-bromopropane, but also containing butylene oxide, 1,3 dioxolane, nitromethane, and other components. Nerve conduction studies revealed evidence of a primary, symmetric demyelinating polyneuropathy. Evidence of CNS involvement came from gadolinium enhanced MRI scans of the brain, showing patchy areas of increased T2 signal in the periventricular white matter, similar scans of the spinal cord revealing root enhancement at several lumbar levels, and SSEP studies. The patient's symptoms had started to resolve following the discontinuation of the exposure, before he was lost to follow-up. Similar findings have been reported following 1-bromopropane exposure in rats. I hypothesize that this patient's symptoms may have been due to 1-bromopropane-induced neurotoxicity.
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Affiliation(s)
- G Sclar
- Department of Neurosciences, University of Medicine and Dentistry of New Jersey, Newark 07103, USA.
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72
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73
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Sakakibara R, Hattori T, Kuwabara S, Yamanishi T, Yasuda K. Micturitional disturbance in patients with Guillain-Barré syndrome. J Neurol Neurosurg Psychiatry 1997; 63:649-53. [PMID: 9408108 PMCID: PMC2169821 DOI: 10.1136/jnnp.63.5.649] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To examine the frequency and pathophysiology of micturitional disturbance in patients with Guillain-Barré syndrome. METHODS Micturitional symptoms were noted and neurological examinations made repeatedly during admission to hospital of patients with clinical and neurophysiologically definite Guillain-Barré syndrome. Urodynamic studies consisted of uroflowmetry, measurement of residual urine, urethral pressure profilometry, medium fill water cystometry, and external sphincter EMG. RESULTS Seven of 28 (25%) patients with Guillain-Barré syndrome showed micturitional disturbance. The symptoms included voiding difficulty in six, urinary retention in three, nocturnal urinary frequency in three, and urge incontinence in two. These micturitional symptoms appeared after weakness occurred, and improved gradually along with the neurological signs. All three patients who showed retention became able to urinate. Urodynamic studies were made on four symptomatic patients two of whom underwent repeated study. Disturbed bladder sensation was noted in one patient, bladder areflexia in one, and absence of the bulbocavernosus reflex in one. Cystometry showed decreased bladder volume in two and bladder overactivity in two, one of whom had urge urinary incontinence and the other urinary retention. CONCLUSIONS A quarter of the patients with Guillain-Barré syndrome tend to have micturitional disturbance. The patients studied had evacuation and storage disorders, as well as bladder areflexia and disturbed bladder sensation indicative of peripheral types of parasympathetic and somatic nerve dysfunction. Decreased bladder volume with bladder overactivity but no evidence of CNS involvement was also found, evidence that bladder overactivity also occurs in peripheral nerve lesions with probable pelvic nerve irritation.
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Affiliation(s)
- R Sakakibara
- Department of Neurology, Chiba University School of Medicine, Japan
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74
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Rutkove SB, Kothari MJ, Raynor EM, Levy ML, Fadic R, Nardin RA. Sural/radial amplitude ratio in the diagnosis of mild axonal polyneuropathy. Muscle Nerve 1997; 20:1236-41. [PMID: 9324079 DOI: 10.1002/(sici)1097-4598(199710)20:10<1236::aid-mus5>3.0.co;2-d] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
As proximal nerves are relatively spared in length-dependent, axonal polyneuropathy, we theorized that a sural/radial amplitude ratio (SRAR) might be a sensitive indicator of mild polyneuropathy. In this study, sural amplitudes and SRARs in patients with signs of mild axonal polyneuropathy were compared to those of normal, age-matched control subjects. Sural and radial sensory responses were measured in a standard fashion in all subjects. Thirty polyneuropathy patients had an average SRAR of 0.29 as compared to 0.71 for the 30 normal subjects. An SRAR of less than 0.40 was a strong predictor of axonal polyneuropathy, with 90% sensitivity and 90% specificity, as compared to an absolute sural amplitude of less than 6.0 microV, which had sensitivity of only 66%. Additionally, unlike the sural amplitude, the ratio did not vary significantly with age. We conclude that the SRAR is a sensitive, specific, age-independent electrodiagnostic test for mild axonal polyneuropathy.
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Affiliation(s)
- S B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA
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75
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Abstract
General techniques of electrodiagnostic examination, how such examination can predict the pathophysiology of nerve injury, and specific techniques and findings of the major entrapments such as carpal tunnel syndrome and ulnar nerve neuropathy are described in detail. Additional disease states that relate to hand surgery, such as anterior interosseous syndrome, brachial plexopathy, radiculopathy, polyneuropathy, and the nebulous entity of thoracic outlet syndrome are discussed.
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Affiliation(s)
- D Campion
- Department of Medicine, University of California, Los Angeles, USA
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76
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Uncini A, Di Guglielmo G, Di Muzio A, Gambi D, Sabatelli M, Mignogna T, Tonali P, Marzella R, Finelli P, Archidiacono N. Differential electrophysiological features of neuropathies associated with 17p11.2 deletion and duplication. Muscle Nerve 1995; 18:628-35. [PMID: 7753126 DOI: 10.1002/mus.880180610] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
UNLABELLED Hereditary neuropathy with liability to pressure palsies (HNPP) and hereditary motor-sensory neuropathy type IA (HMSN IA) are quite distinct clinical entities recently associated to deletion and duplication, respectively, of the 17p11.2 segment including the gene for peripheral myelin protein 22 (PMP-22). We studied the electrophysiological features of 48 HNPP and 62 HMSN IA motor nerves. Conduction velocities (CV) and compound muscle action potential amplitudes were significantly reduced and distal latencies prolonged in HMSN IA compared to HNPP. CV was uniformly slowed in HMSN IA nerves whereas in HNPP it was focally slowed in 80% of ulnar and 12% of peroneal nerves at usual compression sites. Conduction block was present in 6% of HNPP nerves but in none of HMSN IA. IN CONCLUSION (1) HMSN IA with 17p11.2 duplication presents marked, diffuse, and uniform slowing; (2) HNPP with 17p11.2 deletion presents focal electrophysiological abnormalities possibly correlated with the presence of tomaculae; and (3) under- and overexpression of PMP-22 in concurrence with environmental factors might be responsible for the distinctive features of HNPP and HMSN IA.
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Affiliation(s)
- A Uncini
- Center for Neuromuscular Diseases, University of Chieti, Italy
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77
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Gelot A, Vallat JM, Tabaraud F, Rocchiccioli F. Axonal neuropathy and late detection of Refsum's disease. Muscle Nerve 1995; 18:667-70. [PMID: 7538630 DOI: 10.1002/mus.880180617] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- A Gelot
- Centre Paul Broca, Neurology Department, CHU Bretonneau, Tours, France
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78
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McDeavitt JT, Graziani V, Kowalske KJ, Hays RM. Neuromuscular disease: rehabilitation and electrodiagnosis. 2. Nerve disease. Arch Phys Med Rehabil 1995; 76:S10-20. [PMID: 7741625 DOI: 10.1016/s0003-9993(95)80593-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The purpose of this section of the Self-Directed Physiatric Education Program Study Guide on rehabilitation in diseases affecting nerve and muscle is to assist practitioners and trainees in physical medicine and rehabilitation by providing an overview of the evaluation, treatment, and rehabilitative care of patients with inherited and acquired neuropathies. Both diffuse and focal processes are discussed. Current research is briefly reviewed, and the utility and limitations of electrodiagnostic studies are discussed.
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Affiliation(s)
- J T McDeavitt
- Charlotte Institute of Rehabilitation, NC 28203, USA
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79
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Raynor EM, Ross MH, Shefner JM, Preston DC. Differentiation between axonal and demyelinating neuropathies: identical segments recorded from proximal and distal muscles. Muscle Nerve 1995; 18:402-8. [PMID: 7715625 DOI: 10.1002/mus.880180406] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The presence of significant slowing of motor nerve conduction velocity is considered one of the electrodiagnostic hallmarks of demyelinating neuropathies; however, slowing of conduction velocity may also accompany severe axonal loss. When compound muscle action potential (CMAP) amplitudes are markedly reduced, it is frequently difficult to determine if conduction velocity slowing is due to axonal loss with dropout of the fastest conducting fibers or demyelination. To evaluate the relationship between conduction velocity and axonal dropout, we compared conduction velocities through the same segment of nerve recording from distal and proximal peroneal muscles in patients with chronic neuropathies, in patients with motor neuron disease, and in control subjects. In controls and patients with motor neuron disease, conduction velocities were normal with no significant difference between proximal and distal sites. In patients with axonal neuropathies, conduction velocities were preferentially slowed when recording from distal muscles and relatively normal when recording from proximal sites. Patients with demyelinating neuropathies showed marked slowing of conduction at both sites. We conclude that comparing conduction velocity obtained from proximal versus distal muscle recordings provides a simple, reliable aid for differentiating between chronic axonal and demyelinating polyneuropathies, especially in cases with conduction velocity slowing and low CMAP amplitudes.
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Affiliation(s)
- E M Raynor
- Division of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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80
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Bergin PS, Bronstein AM, Murray NM, Sancovic S, Zeppenfeld DK. Body sway and vibration perception thresholds in normal aging and in patients with polyneuropathy. J Neurol Neurosurg Psychiatry 1995; 58:335-40. [PMID: 7897416 PMCID: PMC1073371 DOI: 10.1136/jnnp.58.3.335] [Citation(s) in RCA: 85] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Body sway and vibration perception in the lower limbs were measured in 32 normal subjects and 25 patients with peripheral neuropathies; nerve conduction studies were also performed in the patients with neuropathies. Body sway was measured by means of force-plate posturography, and three methods were used to assess vibration perception: a neurothesiometer, a semiquantitative tuning fork, and the bone vibrator of a conventional audiometer. Body sway and vibration perception were increased in the patients with peripheral neuropathies and there was significant correlation between these measures.d These findings, together with the lack of correlation between sway and muscle strength, indicate that the main source of unsteadiness in these patients is the loss of proprioceptive information. Vibration perception and body sway did not correlate with the electrophysiological variables, indicating that these measures assess different aspects of peripheral nerve function. In all subjects there was close correlation between vibration perception as assessed by the neurothesiometer and the audiometer could be used to screen proprioceptive function in patients with balance disorders. In normal subjects age correlated with vibration perception (measured with the neurothesiometer and audiometer) and also with body sway standing on foam. This suggests that the increased body sway in elderly people may partly be due to redue proprioception in the lower limbs.
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Affiliation(s)
- P S Bergin
- MRC Human Movement and Balance Unit, National Hospital for Neurology and Neurosurgery, London UK
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81
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Knowledge-based expert systems. Clin Neurophysiol 1995. [DOI: 10.1016/b978-0-7506-1183-1.50021-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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82
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Denislic M, Meh D. Neurophysiological assessment of peripheral neuropathy in primary Sjögren's syndrome. THE CLINICAL INVESTIGATOR 1994; 72:822-9. [PMID: 7894206 DOI: 10.1007/bf00190735] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Peripheral nervous system complications are rare in patients with primary Sjögren's syndrome. We investigated a group of six women aged 43-64 years who complained of pain and sensory symptoms. Conventional neurophysiological tests reflecting large nerve fiber function revealed normal motor conduction in all patients, whereas sensory nerve action potentials were absent in two. On the other hand, quantitative thermometry and autonomic nerve function tests indicating small nerve fiber function were more sensitive in the assessment of nerve dysfunction; these showed abnormalities in all cases. Vibrametry showed dysfunctions in four patients. The latter methods possess great sensitivity in discovering sensory disturbances. Neurophysiological assessment of the sensory and autonomic nervous system demonstrating sensory neuropathy contributes to early diagnosis of primary Sjögren's syndrome.
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Affiliation(s)
- M Denislic
- University Institute of Clinical Neurophysiology, University Medical Center, Ljubljana, Slovenia
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83
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Ruijten MW, De Haan GJ, Michels RP, Pruijs-Brands A, Ongerboer de Visser BW, Verberk MM. Motor nerve refractory period distribution assessed by two techniques in diabetic polyneuropathy. ELECTROENCEPHALOGRAPHY AND CLINICAL NEUROPHYSIOLOGY 1994; 93:306-11. [PMID: 7521291 DOI: 10.1016/0168-5597(94)90033-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The techniques introduced by Kimura and Ingram et al. were applied to assess the distribution of motor refractory periods (DMRPs) in peroneal nerve fibres of 28 diabetics with symptoms indicating polyneuropathy and in 28 controls. Results were compared with conventional motor nerve conduction velocity (MNCV) and compound muscle action potential (CMAP) measurements. MRP95 and MRP90 (the 5% and 10% slowest recovering fibres) obtained with Ingram's technique were prolonged in the diabetic patients. In the 26 patients with a value of MRP95 and MNCV, a prolonged MRP95 and a decreased MNCV were found in 12 patients. Thus conventional MNCV had a sensitivity of 46% to detect neuropathy; addition of MRP95 obtained with Ingram's technique raised the sensitivity to 73%. Specificity was 100% in both cases. With Kimura's technique or with the fast recovering fibres in Ingram's technique, it was not possible to discriminate the patients from the controls. This study indicates that measurement of the DMRP with the technique introduced by Ingram et al. improves the electrophysiological diagnosis of diabetic polyneuropathy.
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Affiliation(s)
- M W Ruijten
- Coronel Laboratory, University of Amsterdam, The Netherlands
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84
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Kuntzer T, Ochsner F, Schmid F, Regli F. Quantitative EMG analysis and longitudinal nerve conduction studies in a Refsum's disease patient. Muscle Nerve 1993; 16:857-63. [PMID: 7687325 DOI: 10.1002/mus.880160809] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A patient with aosmia and night blindness had repeated clinical and electrophysiological examinations during a 21-year period. Within the first 11 years, he experienced two subacute episodes of numbness with weakness and ataxia. Over the 10 ensuing years, no additional functional disability appeared. We looked retrospectively for a correlation between repeated manual muscle scoring and different nerve conduction parameters. Further studies were done in order to estimate reinnervation in proximal and distal muscles and to assess autonomic functions. A direct relationship was found between the magnitude of muscle weakness and the amplitude of compound muscle action potentials, whereas nerve conduction velocities were inhomogeneously reduced but almost unchanged over time. Parasympathetic tests were normal but sympathetic skin responses were absent. As estimated by macro-EMG and turns-amplitude analysis the compensatory reinnervation was very high. We conclude that, in Refsum's disease, recurrent segmental demyelination of a significant portion of the motor units can occur in parallel with exacerbations of weakness, and that a considerable degree of progressive motor and sudoromotor axonal loss can be found although there is an apparent long-term clinical stabilization of the neuropathy.
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Affiliation(s)
- T Kuntzer
- Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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85
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Uncini A, Di Muzio A, Sabatelli M, Magi S, Tonali P, Gambi D. Sensitivity and specificity of diagnostic criteria for conduction block in chronic inflammatory demyelinating polyneuropathy. ELECTROENCEPHALOGRAPHY AND CLINICAL NEUROPHYSIOLOGY 1993; 89:161-9. [PMID: 7686848 DOI: 10.1016/0168-5597(93)90129-d] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Detection of conduction block (CB) has important clinical implications because it suggests segmental demyelination potentially reversible following treatment. There are no universally accepted criteria to define CB. We tested the sensitivity of two diagnostic criteria of partial motor CB in patients with chronic inflammatory demyelinating polyneuropathy (CIDP) and hereditary motor-sensory neuropathy type I (HMSN I) which are thought to be the prototypes of segmental and uniform demyelination respectively. Criterion I requires > 20% drop in negative peak amplitude and area and < 15% change in duration between proximal and distal compound muscle action potentials (CMAPs). Criterion II requires > 50% drop in negative peak amplitude and area of proximal CMAP independently from temporal dispersion. Twenty-eight percent of CIDP nerves and 65% of CIDP patients had CB according to criterion I. However, 29% of nerves and 61% of patients with HMSN I also fulfilled the same criterion. Thirty-four percent of CIDP nerves and 78% of CIDP patients and none of HMSN I patients fulfilled criterion II. Criterion II has the same sensitivity as criterion I, but seems to be highly specific in diagnosis of the segmental demyelination characteristic of CIDP. Therefore this criterion should be employed, as the diagnostic tool of CB, in chronic neuropathies presenting high stimulation threshold and coexisting axonal loss.
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Affiliation(s)
- A Uncini
- Center for Neuromuscular Diseases, University of Chieti, Italy
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86
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Bromberg MB, Albers JW. Patterns of sensory nerve conduction abnormalities in demyelinating and axonal peripheral nerve disorders. Muscle Nerve 1993; 16:262-6. [PMID: 8383290 DOI: 10.1002/mus.880160304] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The pattern of an abnormal median-normal sural (AMNS) sensory response is associated with acute and chronic inflammatory demyelinating polyradiculoneuropathy (AIDP and CIDP) and considered unusual in other types of neuropathy, although specificity and sensitivity of this pattern have not been evaluated. We compared sensory responses (patterns and absolute values) in patients with AIDP, CIDP, diabetic polyneuropathy (DP), and motor neuron disease (MND). Using strict criteria, the AMNS pattern occurred more frequently in recent onset AIDP (39%) compared with CIDP (28%), DP (14%-23%), or MND (22%) patients. This pattern was found in 3% of control subjects. The extreme pattern of an absent median-present sural response occurred only in AIDP and CIDP patients and in no other groups. Abnormalities of both nerves were more common in long-standing polyneuropathies such as CIDP and DP compared with AIDP or MND. Median nerve amplitudes were reduced significantly in AIDP, CIDP, and DP patients compared with MND patients, whereas sural nerve amplitudes were significantly reduced only in DP and CIDP patients. These findings may reflect early distal nerve involvement particularly in AIDP patients which is highlighted by differences in median and sural nerve recording electrode placement. We conclude that, in the appropriate clinical setting, the AMNS pattern, an absent median-present sural response pattern, or a reduced median amplitude compared with the sural amplitude supports a diagnosis of a primary demyelinating polyneuropathy.
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Affiliation(s)
- M B Bromberg
- Department of Neurology, University of Michigan Medical Center, Ann Arbor 48109-0316
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87
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Aoun M, Jacquy C, Debusscher L, Bron D, Lehert M, Noel P, van der Auwera P. Peripheral neuropathy associated with fluoroquinolones. Lancet 1992; 340:127. [PMID: 1352007 DOI: 10.1016/0140-6736(92)90460-k] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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88
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Exploration neurophysiologique des neuropathies périphériques. Rev Med Interne 1992. [DOI: 10.1016/s0248-8663(05)81496-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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89
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90
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Leonard JA. Electrodiagnostic Studies and the Evaluation of Peripheral Neuropathies. Phys Med Rehabil Clin N Am 1990. [DOI: 10.1016/s1047-9651(18)30748-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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