Modifying the Medical Research Council grading system through Rasch analyses

Natural History of Facioscapulohumeral Dystrophy in Children: A 2-Year Follow-up

Background and Objectives

Data on the natural history of facioscapulohumeral dystrophy (FSHD) in childhood are limited and critical for improved patient care and clinical trial readiness. Our objective was to describe the disease course of FSHD in children.

Methods

We performed a nationwide, single-center, prospective cohort study of FSHD in childhood assessing muscle functioning, imaging, and quality of life over 2 years of follow-up.

Results

We included 20 children with genetically confirmed FSHD who were 2 to 17 years of age. Overall, symptoms were slowly progressive, and the mean FSHD clinical score increased from 2.1 to 2.8 (p = 0.003). The rate of progression was highly variable. At baseline, 16 of 20 symptomatic children had facial weakness; after 2 years, facial weakness was observed in 19 of 20 children. Muscle strength did not change between baseline and follow-up. The most frequently and most severely affected muscles were the trapezius and deltoid. The functional exercise capacity, measured with the 6-minute walk test, improved. Systemic features were infrequent and nonprogressive. Weakness-associated complications such as lumbar hyperlordosis and dysarthria were common, and their prevalence increased during follow-up. Pain and fatigue were frequent complaints in children, and their prevalence also increased during follow-up. Muscle ultrasonography revealed a progressive increase in echogenicity.

Discussion

FSHD in childhood has a slowly progressive but variable course over 2 years of follow-up. The most promising outcome measures to detect progression were the FSHD clinical score and muscle ultrasonography. Despite this disease progression, an improvement on functional capacity may still occur as the child grows up. Pain, fatigue, and a decreased quality of life were common symptoms and need to be addressed in the management of childhood FSHD. Our data can be used to counsel patients and as baseline measures for treatment trials in childhood FSHD.

Disease Progression and Mutation Pattern in a Large Cohort of LGMD R1/LGMD 2A Patients from India

Calpainopathy is caused by mutations in the CAPN3. There is only one clinical and genetic study of CAPN3 from India and none from South India. A total of 72 (male[M]:female [F] = 34:38) genetically confirmed probands from 72 independent families are included in this study. Consanguinity was present in 54.2%. The mean age of onset and duration of symptoms are 13.5 ± 6.4 and 6.3 ± 4.7 years, respectively. Positive family history occurred in 23.3%. The predominant initial symptoms were proximal lower limb weakness (52.1%) and toe walking (20.5%). At presentation, 97.2% had hip girdle weakness, 69.4% had scapular winging, and 58.3% had contractures. Follow-up was available in 76.4%, and 92.7% were ambulant at a mean age of 23.7 ± 7.6 years and duration of 4.5 years, remaining 7.3% became wheelchair-bound at 25.5 ± 5.7 years of age (mean duration = 13.5 ± 4.6), 4.1% were aged more than 40 years (duration range = 5–20). The majority remained ambulant 10 years after disease onset. Next-generation sequencing (NGS) detected 47 unique CAPN3 variants in 72 patients, out of which 19 are novel. Missense variants were most common occurring in 59.7% (homozygous = 29; Compound heterozygous = 14). In the remaining 29 patients (40.3%), at least one suspected loss of function variant was present. Common recurrent variants were c.2051–1G > T and c.2338G > C in 9.7%, c.1343G > A, c.802–9G > A, and c.1319G > A in 6.9% and c.1963delC in 5.5% of population. Large deletions were observed in 4.2%. Exon 10 mutations accounted for 12 patients (16.7%). Our study highlights the efficiency of NGS technology in screening and molecular diagnosis of limb-girdle muscular dystrophy with recessive form (LGMDR1) patients in India.

Atypical presentation of Charcot-Marie-Tooth disease type 1C with a new mutation: a case report

Background

Charcot-Marie-Tooth 1C (CMT1C) is a rare form of dominantly inherited CMT1 neuropathy caused by a mutated gene encoding lipopolysaccharide-induced tumour necrosis alpha factor (LITAF).

Case presentation

We report a 56-year-old patient with an atypical clinical phenotype of CMT1C, which started as progressive weakness of a single upper limb resembling acquired inflammatory neuropathy. Nerve conduction studies (NCS) and temporarily limited and partial effects of immunotherapy supported the diagnosis of inflammatory neuropathy. Significant progression of polyneuropathy, despite intensive long-lasting immunotherapy, together with repeatedly negative auxiliary investigations (CSF, MRI and antibodies) and genetic testing results finally led to the diagnosis of CMT1C neuropathy.

Conclusions

CMT1C should be added to the list of inherited neuropathies that need to be considered in suspected cases of inflammatory demyelinating neuropathy.

Disproportionate Vertebral Bodies and Their Impact on Lumbar Disc Herniation

BACKGROUND

The aim of this study was to determine whether the presence of disproportionate vertebral bodies is a risk factor for disc herniation (DH).

METHODS

Sixty-seven consecutive patients (m: 31 f: 36) who underwent lumbar discectomy for symptomatic DH at one level between L3 and S1 were retrospectively included. The last three motion segments (3 × 67 = 201) were assessed on sagittal MRI scans. A disproportionate motion segment was defined as the difference of more than 10% of the antero-posterior diameter of two adjacent endplates.

RESULTS

DH was present in 6/67 (9%), 26/67 (38.8%), and 35/67 (52.2%) patients at L3/4, L4/5, and L5/S1, respectively. A total of 14 of 67 patients demonstrated a disproportionate motion segment at the discectomy level (20.9%). A total of 23 of the 201 (11.4%) investigated motion segments met our criteria for a disproportionate motion segment. In our study population, when one of the 201 segments was disproportionate, the positive predictive value (PPV) for DH increased toward the lower segments: the PPV at the L5/S1 level was 83.0%. The odds ratio of disproportion for DH was the highest at the L5/S1 level, with 6.0 ± 0.82 (p = 0.017).

CONCLUSIONS

The presence of a disproportionate motion segment in the lower spine may lead to a significant higher risk for DH in patients undergoing discectomy.

Assessment of variability in motor grading and patient-reported outcome reporting: a multi-specialty, multi-national survey

BACKGROUND

The goal of this survey-based study was to evaluate the current practice patterns of clinicians who assess patients with peripheral nerve pathologies and to assess variance in motor grading on the Medical Research Council (MRC) scale using example case vignettes.

METHODS

An electronic survey was distributed to clinicians who regularly assess patients with peripheral nerve pathology. Survey sections included (1) demographic data, (2) vignettes where respondents were asked to assess on the MRC scale, and (3) assessment of practice patterns regarding the use of patient-reported outcome measures. Inter-rater reliability statistics were calculated for the application of the MRC scale on example vignettes.

RESULTS

There were 109 respondents. There was significant dispersion in motor grading seen on the example vignettes. For the raw responses grading the example vignettes on the MRC scale, Krippendorff's alpha was 0.788 (95% CI 0.604, 0.991); Gwet's AC2 was 0.808 (95% CI 0.683, 0.932); Fleiss' kappa was 0.416 (95% CI 0.413, 0.419). Most respondents reported not utilizing any patient-reported outcome measures across peripheral nerve pathologies.

DISCUSSION

Our data show that there is significant disagreement among providers when applying the MRC scale. It is important for us to reassess our current tools for patient evaluation in order to improve upon both clinical evaluation and outcomes reporting. Consensus guidelines for outcomes reporting are needed, and domains outside of manual muscle testing should be included.

Intraoperative Classification System Yields Favorable Outcomes for Patients Treated Surgically for Greater Trochanteric Pain Syndrome

PURPOSE

To use a prospectively collected database to internally validate a previously published intraoperative classification system by determining its utility in improving patient-reported outcome scores (PROS).

METHODS

Open or endoscopic procedures performed at a single center between February 2008 and March 2018 with minimum 2-year follow-up were reviewed. Patients were prospectively classified intraoperatively as one of five greater trochanteric pain syndrome (GTPS) types according to the Lall GTPS classification system and underwent one of the six following surgical procedures: trochanteric bursectomy (TB, type I); TB with trochanteric micropuncture (type II); endoscopic suture staple repair (type IIIA); endoscopic single row transtendinous repair (type IIIB); open or endoscopic double row repair (type IV); and gluteus maximus/tensor fasciae latae transfers (type V). The following PROS were analyzed to assess the efficacy of treatment and validity of the classification scheme: modified Harris Hip Score (mHHS), Nonarthritic Hip Score, The International Hip Outcome Tool, Hip Outcome Score-Sport-Specific Subscale, and visual analog scale for pain.

RESULTS

In total, 324 patients (287 female, 37 male) underwent surgical management per GTPS classification type: 109 type I; 26 type II; 20 type IIIA; 118 type IIIB; 44 type IV; and 7 type V. The mean age and follow-up time were 51.9 ± 12.5 years and 44.5 ± 20.5 months, respectively. All patients PROS improved from baseline to minimum 2-year follow-up (P < .05). High rates of the minimal clinically important difference for mHHS (70.0-100.0) and Nonarthritic Hip Score (73.1-92.7) and patient acceptable symptomatic state for mHHS (70.0-94.5) and International Hip Outcome Tool (58.1-86.7) were achieved per GTPS type. Patient satisfaction was 7.9/10.

CONCLUSIONS

This validation study supports that the classification system and treatment algorithm for surgical treatment of various GTPS types leads to favorable patient-reported outcomes. These findings provide surgeons with a validated classification system and treatment algorithm to manage peritrochantric pathology diagnosed intraoperatively.

LEVEL OF EVIDENCE

III, prognostic study.

Intravenous immunoglobulins as first-line treatment in idiopathic inflammatory myopathies: a pilot study

OBJECTIVES

We explored efficacy and safety of IVIg as first-line treatment in patients with an idiopathic inflammatory myopathy.

METHODS

In this investigator-initiated phase 2 open-label study, we included 20 adults with a newly diagnosed, biopsy-proven idiopathic inflammatory myopathy, and a disease duration of less than 9 months. Patients with IBM and prior use of immunosuppressants were excluded. The standard treatment regimen consisted of IVIg (Privigen) monotherapy for 9 weeks: a loading dose (2 g/kg body weight) and two subsequent maintenance doses (1 g/kg body weight) with a 3-week interval. The primary outcome was the number of patients with at least moderate improvement on the 2016 ACR/EULAR Total Improvement Score. Secondary outcomes included time to improvement, the number of patients requiring rescue medication and serious adverse events.

RESULTS

We included patients with DM (n = 9), immune-mediated necrotizing myopathy (n = 6), non-specific myositis/overlap myositis (n = 4) and anti-synthetase syndrome (n = 1). One patient was excluded from analyses because of minimal weakness resulting in a ceiling effect. Eight patients (8/19 = 42.0%; Clopper-Pearson 95% CI: 19.6, 64.6) had at least moderate improvement by 9 weeks. Of these, six reached improvement by 3 weeks. Seven patients required rescue medication due to insufficient efficacy and prematurely ended the study. Three serious adverse events occurred, of which one was pulmonary embolism.

CONCLUSION

First-line IVIg monotherapy led to at least moderate improvement in nearly half of patients with a fast clinical response in the majority of responders.

TRIAL REGISTRATION

Netherlands Trial Register identifier, NTR6160.

MRI and muscle imaging for idiopathic inflammatory myopathies

Although idiopathic inflammatory myopathies (IIM) are a heterogeneous group of diseases nearly all patients display muscle inflammation. Originally, muscle biopsy was considered as the gold standard for IIM diagnosis. The development of muscle imaging led to revisiting not only the IIM diagnosis strategy but also the patients' follow-up. Different techniques have been tested or are in development for IIM including positron emission tomography, ultrasound imaging, ultrasound shear wave elastography, though magnetic resonance imaging (MRI) remains the most widely used technique in routine. Whereas guidelines on muscle imaging in myositis are lacking here we reviewed the relevance of muscle imaging for both diagnosis and myositis patients' follow-up. We propose recommendations about when and how to perform MRI on myositis patients, and we describe new techniques that are under development.

Functional Outcomes and Health-Related Quality of Life Following Glioma Surgery

Functional outcome following glioma surgery is defined as how the patient functions or feels. Functional outcome is a coprimary end point of surgery in patients with diffuse glioma, together with oncological outcome. In this review, we structure the functional outcome measurements following glioma surgery as reported in the last 5 yr. We review various perspectives on functional outcome of glioma surgery with available measures, and offer suggestions for their use. From the recent neurosurgical literature, 160 publications were retrieved fulfilling the selection criteria. In these publications, neurological outcomes were reported most often, followed by activities of daily living, seizure outcomes, neurocognitive outcomes, and health-related quality of life or well-being. In more than a quarter of these publications functional outcome was not reported. A minimum essential consensus set of functional outcome measurements would benefit comparison across neurosurgical reports. The consensus set should be based on a combination of clinician- and patient-reported outcomes, assessed at a predefined time before and after surgery. The selected measurements should have psychometric properties supporting the intended use including validity-related evidence, reliability, and sensitivity to detect meaningful change with minimal burden to ensure compliance. We circulate a short survey as a start towards reporting guidelines. Many questions remain to better understand, report, and improve functional outcome following glioma surgery.

Bedside voluntary and evoked forces evaluation in intensive care unit patients: a narrative review

Around one third of intensive care unit (ICU) patients will develop severe neuromuscular alterations, known as intensive care unit-acquired weakness (ICUAW), during their stay. The diagnosis of ICUAW is difficult and often delayed as a result of sedation or delirium. Indeed, the clinical evaluation of both Medical Research Council score and maximal voluntary force (e.g., using handgrip and/or handheld dynamometers), two independent predictors of mortality, can be performed only in awake and cooperative patients. Transcutaneous electrical/magnetic stimulation applied over motor nerves combined with the development of dedicated ergometer have recently been introduced in ICU patients in order to propose an early and non-invasive measurement of evoked force. The aim of this narrative review is to summarize the different tools allowing bedside force evaluation in ICU patients and the related experimental protocols. We suggest that non-invasive electrical and/or magnetic evoked force measurements could be a relevant strategy to characterize muscle weakness in the early phase of ICU and diagnose ICUAW.

Monitoring Clinical Course and Treatment Response in Chronic Inflammatory Demyelinating Polyneuropathy During Routine Care: A Review of Clinical and Laboratory Assessment Measures

Importance

Identifying clinical change in many neurologic diseases, including chronic inflammatory demyelinating polyneuropathy (CIDP), can be challenging. At the same time, how change is defined heavily influences a patient's diagnostic and treatment pathway. It can be especially problematic when equivocal subjective observations are interpreted as clinically meaningful and then used to make diagnostic and treatment decisions. Change in clinical trials is strictly defined by a preselected metric, but there is a perception that formal outcomes collection during routine clinical care is neither feasible nor necessary. Given the importance placed on how change is interpreted, there is a need to select assessments that can be applied to routine care that are representative of the neurologic disease state.

Observations

For an outcome measure to be useful during clinical trials, it must have good reliability, validity, be responsive to change, and have clinical meaning. To be useful during routine clinical care, the assessment must additionally be easy to collect without the need for extensive training or equipment and should provide an immediately available result that can be rapidly quantified and interpreted. Chronic inflammatory demyelinating polyneuropathy is clinically heterogeneous and so is best evaluated with a diverse group of assessment tools. Assessing strength impairment, disability, and quality of life is ideally suited for everyday practice when caring for patients with CIDP. While electrophysiologic studies, imaging, cerebrospinal fluid, and nodal/paranodal antibodies can provide diagnostic data, they are less practical and helpful longitudinal assessment tools.

Conclusions and Relevance

Sound clinimetric outcome measures in CIDP are widely available and have the potential to help clinicians objectify treatment response and disease progression. Such data are critically important when justifying the need for ongoing or periodic immunotherapy, documenting relapse or deterioration, or providing reassurance of disease improvement, stability, or remission.

Pain in adult myotonic dystrophy type 1: relation to function and gender

Background

Pain is prevalent in myotonic dystrophy 1 (DM1). This study investigated whether CTG repeat size, disease duration, BMI and motor and psychological function were related to pain in adult patients with DM1, and if there were gender differences regarding intensity and location of pain.

Method

Cross-sectional design. Pain was investigated in 50 genetically confirmed DM1 patients by combining clinical assessment and self-reports of pain intensity and locations. Pain scoring results were related to CTG size, disease duration, muscle strength, walking capacity measured by 6-min walk test, activity of daily life by Katz ADL Index, respiratory function by Forced Vital Capacity and BMI. In addition, the degree of reported pain was related to Quality of life measured by WHOQOL-BREF; fatigue was measured by Fatigue severity scale; psychological functions were measured by Beck Depression Inventory, Beck Anxiety Inventory, IQ and Autism spectrum Quotient.

Results

Pain was reported in 84% of the patients and was significantly correlated with CTG size (r = 0.28 p = 0.050), disease duration (r = 0.38 p = 0.007), quality of life (r = − 0.37 p = 0.009), fatigue (r = 0.33 p = 0.02) and forced vital capacity (r = − 0.51, p = 0.005). Significant gender differences, with higher scores for females, were documented. In male subjects the number of pain locations was significantly correlated with quality of life and the autism quotient. In females, pain intensity was significantly correlated with activity, respiratory function and BMI.

Conclusions

Pain in DM1 was prevalent, with a strong association to lung function and other aspects of the disease. Significant gender differences were present for pain intensity and number of pain locations. How pain was related to other symptoms differed between male and female subjects. Our findings highlight the importance of assessments of pain in DM1 patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02124-9.

Parkinson's disease and virtual reality rehabilitation: cognitive reserve influences the walking and balance outcome

INTRODUCTION

Parkinson's disease (PD) is a neurodegenerative pathology characterized by motor and non-motor symptoms that often lead to several impairments. Many studies show the efficacy of different rehabilitation protocols aimed to improve balance and gait functions in PD patients. However, multiple factors may influence rehabilitation outcome. Recently, it has been observed as the cognitive reserve (CR) may influence the rehabilitation outcome, helping to address the patient toward technological or conventional rehabilitation. Our study investigated how CR may affect motor rehabilitation outcomes in PD patients who undergo virtual reality (VR) rehabilitation, aimed at improving walking and balance.

MATERIALS AND METHODS

Thirty patients affected by idiopathic PD were enrolled. Patients underwent 12 sessions VR training, over 6 weeks (45 min). Six-Minute Walk Test (6MWT) and Berg Balance Scale (BBS) were used to assess walking and balance, respectively. CR was assessed by Cognitive Reserve Index questionnaire (CRIq).

RESULTS

Significant correlations between CR and change from baseline in walking and balance measures were found, with a significant positive correlation between CRIq and 6MWT (r=0.50, p=0.01) and between CRIq and BBS (r=0.41, p=0.04).

DISCUSSION

Our results showed that PD patients with higher CR treated with VR improved significantly more in their balance and walking distance than those with lower CR. The current study suggests that VR when aimed to improve balance and walking in PD patients is more effective in patients with higher CR.

Rasch analysis to evaluate the motor function measure for patients with facioscapulohumeral muscular dystrophy

Patient-relevant outcome measures for facioscapulohumeral muscular dystrophy (FSHD) are needed. The motor function measure (MFM) is an ordinal-based outcome measure for neuromuscular disorders, but its suitability to measure FSHD patients is questionable. Here, we performed Rasch analyses on MFM data from 194 FSHD patients to assess clinimetric properties in this patient group. Both the total scale and its three domains were analyzed (D1: standing position and transfers; D2: axial and proximal motor function; D3: distal motor function). Fit to the Rasch model, sample-item targeting, individual item fit, threshold ordering, sex- and age-based differential item functioning, response dependency and unidimensionality were assessed. Rasch analysis revealed multiple limitations of the MFM for FSHD, the most important being a large ceiling effect and suboptimal sample-item targeting, which were most pronounced for domains D2 and D3. There were disordered thresholds for most items, often resulting in items functioning in a dichotomous fashion. It was not possible to remodel the MFM into a Rasch-built interval scale. Remodeling of domain D1 into an interval scale with adequate fit statistics was achieved, but sample-item targeting remained suboptimal. Therefore, the MFM should be used with caution in FSHD patients, as it is not optimally suited to measure functional abilities in this patient group.

Sirolimus for treatment of patients with inclusion body myositis: a randomised, double-blind, placebo-controlled, proof-of-concept, phase 2b trial

BACKGROUND

Inclusion body myositis is the most frequent myositis in patients older than 50 years. Classical immunosuppressants are ineffective in treating inclusion body myositis, and to date there are no recommendations for pharmacological approaches to treatment. When used after organ transplantation, sirolimus can block the proliferation of effector T cells, while preserving T regulatory cells, and induce autophagy, all of which are processes that are impaired in inclusion body myositis. In this pilot study, we aimed to test the efficacy of sirolimus in patients with inclusion body myositis.

METHODS

This randomised, double-blind, placebo-controlled, proof-of-concept, phase 2b trial was done at a single hospital in Paris, France. The study included men and women (aged 45-80 years) who had a defined diagnosis of inclusion body myositis according to established criteria. Eligible participants were randomly assigned (1:1) to receive once-daily oral sirolimus 2 mg or placebo. Centralised balanced block randomisation (blocks of four) was computer generated without stratification. The study comprised a 15-day screening period (days -15 to 0) and a 52-week treatment period (day 0 to month 12). The primary endpoint was the relative percentage change from baseline to month 12 in maximal voluntary isometric knee extension strength. Secondary endpoints included the following assessments at months 6 and 12: 6-min walking distance, isometric muscle strength for hand grip (finger flexors), knee flexion and elbow flexion and extension, forced vital capacity, muscle replacement with fat measured by quantitative nuclear MRI, Inclusion Body Myositis Weakness Composite Index (IBMWCI), Inclusion Body Myositis Functional Rating Scale (IBMFRS), Health Assessment Questionnaire without Disability Index (HAQ-DI), and analyses of T-cell subpopulations by mass cytometry. The primary analysis was done on the intention-to-treat population. The trial is registered at ClinicalTrials.gov, NCT02481453.

FINDINGS

Between July 15, 2015, and May 13, 2016, we screened 285 patients, 44 of whom were randomly allocated to sirolimus (22 patients) or placebo (22 patients). We observed no difference in the primary outcome of relative percentage change from baseline to month 12 of the maximal voluntary isometric knee extension strength (median difference 3·78, 95% CI -10·61 to 17·31; p=0·85). For secondary outcomes, differences between the groups were not significant for changes in strength of other muscle groups (grip, elbow flexion and extension, or knee flexion), IBMWCI, IBMFRS, and lower limb muscle fat fraction. However, we observed significant differences in favour of sirolimus between the study groups for HAQ-DI, forced vital capacity, thigh fat fraction, and 6-min walking distance. Ten (45%) of 22 patients in the sirolimus group had a serious adverse event compared with six (27%) of 22 patients in the placebo group. Four (18%) patients in the sirolimus group stopped their treatment because of adverse events (severe mouth ulcers, aseptic pneumonia, renal insufficiency, and peripheral lower limb oedema), which resolved after treatment discontinuation. Canker sores were the most frequent side-effect and were mainly mild or moderate in ten patients.

INTERPRETATION

We found no evidence for efficacy of sirolimus for treating inclusion body myositis based on maximal voluntary isometric knee extension strength and other muscle strength measures, and the side-effects of treatment were substantial for some patients. However, we believe there was enough evidence of benefit in certain secondary outcomes to pursue a multicentre phase 3 trial to further assess the safety and efficacy of sirolimus.

FUNDING

Institut national de la santé et de la recherche médicale, Direction générale de l'offre de soins, and Association Française contre les Myopathies.

Outcome Measures for Functional Neurological Disorder: A Review of the Theoretical Complexities

The development and selection of optimal outcome measures is increasingly recognized as a key component of evidence-based medicine, particularly the need for the development of a standardized set of measures for use in clinical trials. This process is particularly complex for functional neurological disorder (FND) for several reasons. FND can present with a wide range of symptoms that resemble the full spectrum of other neurological disorders. Additional physical (e.g., pain, fatigue) and psychological (e.g., depression, anxiety) symptoms are commonly associated with FND, which also can be highly disabling with implications for prognosis, and warrant concurrent assessment, despite an unclear etiological relationship with FND. Furthermore, several unique clinical aspects of FND make it likely that the usual prioritization of "objective" (or clinician-rated) over "subjective" (or patient-rated) measures might not be appropriate. Self-report measures may be more clinically meaningful in this patient population. Despite being a common and disabling disorder, there has been little research into outcome measures in FND, and to date trials have largely used measures designed for the assessment of other disorders. An international FND Core Outcome Measure group (FND-COM) has been established to develop a consensus battery of outcomes for FND: a "core outcome set." In this perspective article, the authors reviewed the process of outcome measure development and selection before considering the specific features of FND affecting the development of a core outcome set, as well as a research agenda to optimize outcome measurement in this complex neuropsychiatric disorder.

Combined Transfer of the Gluteus Maximus and Tensor Fasciae Latae for Irreparable Gluteus Medius Tear Using Contemporary Techniques: Short-Term Outcomes

Combined transfer of the gluteus maximus and tensor fasciae latae (TFL) has been acknowledged as a treatment for irreparable full-thickness gluteus medius tears; yet, there is a paucity of reports on outcomes for this topic in the current literature. The purpose of the present study was to report short-term patient-reported outcome scores in patients who underwent combined transfer of the gluteus maximus and TFL in the setting of an irreparable gluteus medius tear.

METHODS

Data for patients who underwent hip preservation and hip arthroplasty between July 2011 and November 2017 were prospectively collected and retrospectively reviewed. Patients were considered for this study if they had undergone combined transfer of the gluteus maximus and TFL for irreparable gluteus medius tears. Inclusion criteria consisted of patients who had a minimum 1-year follow-up for the modified Harris hip score, Non-Arthritic Hip Score, Hip Outcome Score Sports Specific Subscale, visual analog scale score for pain, and patient satisfaction. The exclusion criterion was Workers' Compensation status.

RESULTS

The study included 18 hips in 18 patients who underwent combined transfer of the gluteus maximus and TFL, with a mean follow-up of 39.75 months (range, 12.04 to 93.88 months). The average age was 68.48 ± 11.05 years, the average body mass index was 29.54 ± 6.23 kg/m2, and 13 patients were female. Abductor strength improved in 7 of 17 patients, with abduction data unavailable for 1 patient. Significant improvements were observed in modified Harris hip score from 49.73 ± 16.85 to 74.94 ± 17.91 (p < 0.001), Non-Arthritic Hip Score from 55.02 ± 22.53 to 72.78 ± 19.17 (p = 0.032), and visual analog scale for pain from 5.42 ± 3.42 to 1.57 ± 1.68 (p = 0.0004). No secondary surgeries were reported.

CONCLUSIONS

Significant improvements in patient-reported outcomes were observed in patients who underwent combined transfer of the gluteus maximus and TFL for the treatment of irreparable full-thickness gluteus medius tears at short-term follow-up.

LEVEL OF EVIDENCE

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Dramatic clinical response to ultra-high dose IVIg in otherwise treatment resistant inflammatory neuropathies

BACKGROUND

Intravenous immunoglobulin (IVIg) has short and long-term efficacy in both chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy with conduction block (MMNCB). There is potential for under and over-treatment if trial regimens are strictly adhered to in clinical practice where titrating dose to clinical response is recommended.

METHODS

We report the response to high-dose IVIg (>2 g/kg/6 weeks) in a subgroup of patients with definite CIDP or MMNCB who were unresponsive to 'usual' dosing. IVIg frequency and dosing was determined for each individual by subjective and objective outcome measures for impairment, grip strength, and activity and participation.

RESULTS

Six patients (three with chronic inflammatory demyelinating polyneuropathy (CIDP), three with MMN) were included. Two patients (one CIDP and one MMNCB) returned to full-time work on fractionated IVIg doses of 5 g/kg/month and 9 g/kg/month. Patient three (CIDP) failed numerous other immunosuppressants but responded to short-term fractionated 4 g/kg/month of IVIg. Patient four has severe, refractory, childhood-onset CIDP, remains stable but dependent currently on 6.9 g/kg/month of IVIg. Patients five and six, both with MMNCB, required short term 4.5-5 g/kg/month to recover significant bilateral hand strength. No IVIg-related adverse events occurred in any individual.

CONCLUSIONS

These six cases demonstrate the safety and effectiveness of a treatment approach that includes individualised but evidence-based clinical assessment and, when necessary, high-doses of IVIg to restore patients' strength and ability to participate in activities of daily activities. Careful patient selection is important.

Outcome measures for chronic inflammatory demyelinating polyneuropathy in research: relevance and applicability to clinical practice

Outcome measures are recommended in the management of chronic inflammatory demyelinating polyneuropathy (CIDP). Various scales have been proposed in recent years, some now commonly utilized in daily clinical practice. The available evidence base relies itself on randomized controlled trial data obtained over the past 30 years, with several studies using different primary and secondary outcomes. We here review the different outcome measures used in CIDP research in relation to those currently recommended for clinical management. We consider the evidence base for CIDP treatment from the primary and secondary outcomes used in these studies and attempt to assess how this may relate to current clinical practice of routine evaluation of treatment effects and long-term monitoring.

Full-Thickness Gluteus Medius Tears With or Without Concomitant Hip Arthroscopy: Minimum 2-Year Outcomes Using an Open Approach and Contemporary Tendon Repair Techniques

Background:

Gluteus medius (GM) tears are a well-established source of pain and disability. An open approach has been recognized with complete full-thickness and large GM tears, yet the current literature provides few reports on outcomes for this specific situation.

Purpose:

To report and analyze minimum 2-year patient-reported outcomes (PROs) from patients who underwent open GM repair in the setting of a full-thickness tear with or without concomitant hip arthroscopy through use of contemporary tendon repair techniques.

Study Design:

Case series; Level of evidence, 4.

Methods:

Prospectively collected data were retrospectively reviewed for patients who underwent hip preservation surgery and total hip arthroplasty (THA) between April 2008 and May 2017. Patients were included in this study if they underwent open repair of GM full-thickness tears. The exclusion criteria were incomplete follow-up, workers’ compensation status, repair regarding size and pattern of the GM, open repair of partial GM tear, open repair with allograft or autograft augmentation, and/or additional gluteus maximus transfer. Pre- and postoperative PROs for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score Sport-Specific Subscale (HOS-SSS), and visual analog scale (VAS) score for pain and satisfaction were recorded. Statistical significance was set at P < .05.

Results:

A total of 36 patients were included, of whom 12 received concomitant hip arthroscopy for intra-articular procedures. The mean ± SD age, body mass index, and follow-up time were 65.18 ± 12.69 years, 28.97 ± 4.95 kg/m², and 40.8 ± 26.19 months, respectively. At minimum 2-year follow-up, the following outcome measures improved significantly: mHHS (from 54.72 ± 15.89 to 73.12 ± 19.47; P < .0001), NAHS (from 56.05 ± 12.47 to 75.22 ± 19.15; P < .0001); HOS-SSS (from 20.30 ± 20.21 to 44.23 ± 35.85; P < .0001), and VAS (from 4.95 ± 2.70 to 2.67 ± 2.81; P < .0001). There was 1 (2.8%) conversion to THA at 48 months after the index procedure.

Conclusion:

Patients who underwent open repairs in the setting of full-thickness GM tears via contemporary tendon repair techniques, with or without concomitant hip arthroscopy, achieved favorable results in several PRO scores at minimum 2-year follow-up.

Home monitoring of maintenance intravenous immunoglobulin therapy in patients with chronic inflammatory neuropathy

To evaluate the utility of different outcome measures to monitor dose adjustment of intravenous immunoglobulin (IVIg) therapy in patients with chronic inflammatory neuropathy (CIN). We assessed the adjustment of IVIg maintenance therapy in 20 patients (10 CIDP and 10 MMN) by regularly monitoring grip strength (GS) using a Martin Vigorimeter, RODS, and quality of life using the SF-36 questionnaire. These measures were regularly performed by the patient at home. We also assessed the extended MRC sumscore (eMRC sumscore) at each outpatient visit for IVIg infusion. We also enrolled 30 healthy controls to measure any possible training effect of GS with time and to analyze random fluctuation of GS. Clinically relevant change was detected by eMRC sumscore in 14 (93%) patients, by RODS in 11 (73%) patients, and by GS in 8 (53%) patients. Early sensitivity was greatest for RODS (73%), followed by GS (53%), and eMRC sumscore (27%). This differed from CIDP, with an early change in RODS in 100% of patients, and MMN with an early change in GS in 75%. None of the outcome measures alone was sufficient to detect clinically significant changes in all patients. Home monitoring of outcome measures objectively assisted clinical decision during individualization of IVIg treatment. We recommend a multimodal approach using different outcome measures to monitor the individual patient with CIN.

Pronator Quadratus to Extensor Carpi Radialis Brevis Nerve Transfer in C5-C7 or C5-C8 Brachial Plexus Injuries for Independent Wrist Extension

Background Patients with lesions affecting C7 and C8 roots (in addition to C56) demonstrate loss of independent wrist dorsiflexion in addition to loss of shoulder abduction and elbow flexion. Traditionally, this deficit has been addressed using tendon transfers after useful function at the shoulder and elbow has been restored by primary nerve surgery. Confidence with nerve transfer techniques has prompted attempts to replace this method by incorporating procedures for wrist dorsiflexion in the primary operation itself.

Aim The objective of this study was to report the results of pronator quadratus motor branch transfers to the extensor carpi radialis brevis motor branch to reconstruct wrist extension in C5–C8 root lesions of the brachial plexus.

Patients and Methods Twenty-three patients, average age 30 years, with C5–8 root injuries underwent operations an average of 4.7 months after their accident. Extrinsic extension of the fingers and thumb was weak or absent in two cases while the remaining 18 patients could open their hand actively. The patients lacked independent wrist extension when they were examined with the fingers flexed as the compensatory action of the extrinsic finger extensors was removed. The average follow-up was 21 months postoperative with the minimal follow-up period was at least 12 months.

Results Successful reinnervations of the extensor carpi radialis brevis (ECRB) were demonstrated in all patients. In 17 patients, wrist extension scored M4, and in 3 patients it scored M3.

Conclusions The pronator quadratus (PQ) to ECRB nerve transfer in C5–C7 or C5–C8 brachial plexus injuries for independent wrist extension reconstruction gives consistently good results with minimal donor morbidity.

Management challenges for chronic dysimmune neuropathies during the COVID-19 pandemic

Since March 2020, the COVID-19 pandemic has led to the need to re-think the delivery of services to patients with chronic dysimmune neuropathies. Telephone/video consultations have become widespread but have compounded concerns about objective evaluation. Therapeutic decisions need, more than ever before, to be considered in the best interests of both patients, and society, while not denying function-preserving/restoring treatment. Immunoglobulin therapy and plasma exchange, for those treated outside of the home, expose patients to the hazards of hospital or outpatient infusion centers. Steroid therapy initiation and continuation pose increased infectious risk. Immunosuppressant therapy similarly becomes highly problematic, with the risks of treatment continuation enhanced by uncertainties regarding duration of the pandemic. The required processes necessitate considerable time and effort especially as resources and staff are re-deployed to face the pandemic, but are essential for protecting this group of patients and as an integral part of wider public health actions.

Rare Disease: Cardiac Risk Assessment With MRI in Patients With Myotonic Dystrophy Type 1

Introduction: To evaluate myocardial strain and extracellular volume in myotonic dystrophy type 1 (DM1) patients as potential imaging biomarkers of subclinical cardiac pathology. Materials and methods: We retrospectively analyzed 9 DM1 patients without apparent cardiac disease who had undergone cardiac magnetic resonance at our center. Patients were age- and sex-matched with healthy controls. The Mann-Whitney U test was used to compare cardiac strain between the two groups. The t-test was used to compare the extracellular volume obtained in DM1 patients with that in healthy subject. Spearman's ρ was used for studying the associations among imaging parameters. Results: Global cardiac strain (median -19.1%; IQR -20.5%, -16.5%) in DM1 patients was lower (p = 0.011) than that in controls (median-21.7%; IQR-22.7%,-21.3%). Global extracellular volume in DM1 patients (median 32.3%; IQR 29.3%,36.8%) was significantly (p = 0.008) higher than that reported in literature in healthy subjects (median 25.6%; IQR 19.9%,31.9%). Global cardiac strain showed a strong, positive correlation with septal strain (ρ = 0.767, p = 0.016) and with both global (ρ = 0.733 p = 0.025) and septal extracellular volume (ρ = 0.767, p = 0.016). Discussion: The increase in cardiac extracellular volume and decrease in strain are signs of early cardiac pathology in DM1. Physicians dealing with DM1 may take into consideration cardiac magnetic resonance as a screening tool to identify early cardiac involvement in this condition.

Feasibility of Ultrasound-Guided Trigger Point Injection in Patients with Myofascial Pain Syndrome

We compared the feasibility of ultrasound (US)-guided myofascial trigger point (MTrP) injection with that of a blind injection technique following the use of shear wave elastography (SWE) for the measurement of stiffness at the MTrPs in patients with trapezius myofascial pain syndrome (MPS). A total of 41 patients (n = 41) were randomized to either the trial group (n = 21, SWE combined with US-guided injection) or the control group (n = 20, SWE combined with blind injection). At baseline and four weeks, they were evaluated for the manual muscle test (MMT), the range of motion (ROM), pain visual analogue scale (VAS) scores, Shoulder Pain and Disability Index (SPADI) scores and Neck Disability Index (NDI) scores during the abduction, adduction, flexion, extension, external rotation and internal rotation of the shoulder joint. Differences in changes in pain VAS scores, NDI scores and SPADI scores at four weeks from baseline between the two groups reached statistical significance (p = 0.003, 0.012, and 0.018, respectively). US-guided MTrP injection is a more useful modality as compared with a blind injection in patients with MPS.

Ophthalmological findings in facioscapulohumeral dystrophy

Ophthalmological abnormalities in facioscapulohumeral dystrophy may lead to treatable vision loss, facilitate diagnostics, could help unravelling the pathophysiology and serve as biomarkers. In this study, we provide a detailed description of the ophthalmological findings in a well-defined cohort of patients with facioscapulohumeral dystrophy using state of the art retina imaging techniques. Thirty-three genetically confirmed patients (aged 7-80 years) and 24 unrelated healthy controls (aged 6-68 years) underwent clinical ophthalmological examination, fundus photography, optical coherence tomography/angiography, genotyping and neurological examination. All patients had normal corrected visual acuity and normal intraocular pressure. In 27 of the 33 patients, weakness of the orbicularis oculi was observed. Central retinal pathology, only seen in patients and not in healthy controls, included twisting (tortuosity) of the retinal arteries in 25 of the 33 patients and retinal pigment epithelium defects in 4 of the 33 patients. Asymmetrical foveal hypoplasia was present in three patients, and exudative abnormalities were observed in one patient. There was a correlation between the severity of retinal tortuosity and the D4Z4 repeat array size (R 2 = 0.44, P < 0.005). Follow-up examination in a subgroup of six patients did not show any changes after 2 years. To conclude, retinal abnormalities were frequent but almost always subclinical in patients with facioscapulohumeral dystrophy and consisted primarily of arterial tortuosity and foveal abnormalities. Retinal tortuosity was seen in the retinal arterioles and correlated with the D4Z4 repeat array size, thereby providing clinical evidence for an underlying genetic linkage between the retina and facioscapulohumeral dystrophy.

Trans-labyrinthine Infra-trigeminal Approach for Recurrent Pontomedullary Cavernoma: A Step-wise Technical Note

Recurrent brainstem cavernoma is a challenging lesion due to the neurological risks associated with different surgical approaches. In this technical report, we present a 35-year-old female with a history of multiple brain cavernomas. She underwent midline suboccipital craniotomy and trans-fourth ventricle approach for resection of the brain stem cavernoma following two major bleeding episodes, one year prior to the presentation. Following the trans-labyrinthine infra-trigeminal approach, the patient recovered well postoperatively with a baseline neuro exam and was discharged to acute rehab on postoperative day 5 (POD5). The translabyrinthine approach is a safe and effective corridor for pontine or pontomedullary lesions in carefully selected patients. Appropriate selection of surgical approach (based on location), meticulous surgical technique, and intraoperative neuromonitoring help in maximizing surgical resection while minimizing neurological deficits.

Clinician-rated measures for distal symmetrical axonal polyneuropathy: ACTTION systematic review

Distal symmetrical axonal polyneuropathy (DSP) is due to injury to peripheral sensory, motor, and autonomic nerve fibers, resulting in distal predominant sensory loss, pain, and gait instability. DSP occurs as a complication of multiple medical conditions including diabetes or HIV, or following exposure to various toxins such as chemotherapy. It affects at least 10% of the United States population. Few treatments for DSP are approved by regulatory agencies. Reliable and responsive outcome measures are integral to developing new DSP treatments. Multiple clinician-rated measures that incorporate neuropathy signs exist, however, it is not clear which of these measures performs best for various DSP phenotypes. This systematic review summarizes the content of 18 published measures of DSP identified using PubMed and from personal archives of the authors. The relative percentage of scoring dedicated to motor, reflex, large and small fiber sensory, and autonomic domains varied considerably among measures. The most common neurologic examination items included in the scales were (1) vibration perception (n = 18, 100%), (2) reflexes (n = 16, 89%), (3) pinprick perception (n = 14, 78%), (4) muscle strength (n = 11, 61%), (5) touch-pressure perception (n = 9, 50%), and (6) joint position perception (n = 8, 44%). This review can be used to inform decisions regarding which of the available clinician-rated sign outcome measures would be most appropriate for use in a particular DSP population, based on the domains most affected by that neuropathy or on the domains most likely to be affected by a particular experimental therapy.

Development of grading scales of pedal sensory loss using Mokken scale analysis on the Rotterdam Diabetic Foot Study Test Battery data

INTRODUCTION

Loss of sensation due to diabetes-related neuropathy often leads to diabetic foot ulceration. Several test instruments are used to assess sensation, such as static and moving 2-point discrimination (S2PD, M2PD), monofilaments, and tuning forks.

METHODS

Mokken scale analysis was applied to the Rotterdam Diabetic Foot Study data to select hierarchies of tests to construct measurement scales.

RESULTS

We developed 39-item and 31-item scales to measure loss of sensation for research purposes and a 13-item scale for clinical practice. All instruments were strongly scalable and reliable. The 39 items can be classified into 5 hierarchically ordered core clusters: S2PD, M2PD, vibration sense, monofilaments, and prior ulcer or amputation.

DISCUSSION

Guided by the presented scales, clinicians may better classify the grade of sensory loss in diabetic patients' feet. Thus, a more personalized approach concerning individual recommendations, intervention strategies, and patient information may be applied.

MRI of trunk muscles and motor and respiratory function in patients with myotonic dystrophy type 1

Background

Myotonic Dystrophy 1 (DM1) causes progressive myopathy of extremity muscles. DM1 may also affect muscles of the trunk. The aim of this study was to investigate fat infiltration and muscle size in trunk muscles in DM1 patients, and in an age and gender matched control group. Further, explore how fat infiltration and degree of atrophy in these muscles are associated with motor and respiratory function in DM1 patients.

Method

We measured fat infiltration and trunk muscle size by MRI in 20 patients with genetically confirmed classic form of DM1, and compared these cases with 20 healthy, age and gender matched controls. In the DM1 group, we investigated correlations between MRI findings and clinical measures of muscle strength, mobility and respiration. We used sum scores for fat infiltration and muscle size in trunk flexors and trunk extensors in the analysis of group differences and correlations.

Results

Significant differences between cases and controls were present for fat infiltration in trunk flexors (p = 0.001) and trunk extensors (p = < 0.001), and for muscle size in trunk flexors (p = 0.002) and trunk extensors (p = 0.030). Fat infiltration in trunk flexors were significant correlated to back extension strength (rho = − 0.523 p = 0.018), while muscle size in trunk flexors was significantly correlated to trunk flexion strength (rho = 0.506 p = 0.023). Fat infiltration in trunk flexors was significantly correlated with lower general mobility (rho = − 0.628, p = 0.003), reduced balance (rho = 0.630, p < 0.003) and forced vital capacity (rho − 0.487 p = 0.040).

Conclusions

Trunk muscles in DM1 patients had significant higher levels of fat infiltration and reduced muscle size compared to age and gender matched controls. In DM1 patients, fat infiltration was associated with reduced muscle strength, mobility, balance and lung function, while muscle size was associated with reduced muscle strength and lung function. These findings are of importance for clinical management of the disease and could be useful additional outcome measures in future intervention studies.

Electronic supplementary material

The online version of this article (10.1186/s12883-019-1357-8) contains supplementary material, which is available to authorized users.

Children’s Psychological Representation of Earthquakes: Analysis of Written Definitions and Rasch Scaling

Natural disasters have a potential highly traumatic impact on psychological functioning. This is notably true for children, whose vulnerability depends on their level of cognitive and emotional development. Before formal schooling, children possess all the basic abilities to represent the phenomena of the world, including natural disasters. However, scarce attention has been paid to children’s representation of earthquakes, notwithstanding its relevance for risk awareness and for the efficacy of prevention programs. We examined children’s representation of earthquakes using different methodologies. One hundred and twenty-eight second- and fourth-graders completed a written definition task and an online recognition task, analyzed through the Rasch model. Findings from both tasks indicated that, in children’s representation, natural elements such as geological ones were the most salient, followed by man-made elements, and then by person-related elements. Older children revealed a more complex representation of earthquakes, and this was detected through the online recognition task. The results are discussed taking into account their theoretical and applied relevance. Beyond advancing knowledge of the development of the representation of earthquakes, they also inform on strengths and limitations of different methodologies. Both aspects are key resources to develop prevention programs for fostering preparedness to natural disasters and emotional prevention.

Sacro-iliac joint fusion system for high-grade Spondylolisthesis using "Reverse Bohlman technique": a technical report and overview of the literature

BACKGROUND

High-grade Spondylolisthesis (HGS) is a complex clinical problem that poses significant challenges to the treating physician. There is a contentious debate regarding the most optimal surgical approach in these patients. A variety of trans-sacral and transvertebral techniques have been described in the literature.

CASE ILLUSTRATION

In this report, we present two cases of 35-year-old and 26-year-old Caucasian females who presented with low back pain and radicular symptoms. CT and MRI scan revealed progressive HGS (Grade III), which was not relieved with conservative measures. They underwent transsacral fixation using Reverse Bohlman technique (RBT) at L5-S1, L4-5 Anterior lumbar interbody fusion (ALIF) combined with postero-lateral fusion (PLF). At 9 and 10 months follow up, patients reported minimal back pain with no radicular symptoms and imaging showed satisfactory fusion in both patients.

CONCLUSION

This is the first report to demonstrate the utility of SI joint fusion cage (using RBT) in patients with HGS with successful clinical outcome. This technique is safe, feasible, and effective in carefully selected patients.

International chronic inflammatory demyelinating polyneuropathy outcome study (ICOS): Protocol of a prospective observational cohort study on clinical and biological predictors of disease course and outcome

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a heterogeneous immune-mediated disorder with extensive variation in clinical presentation, electrophysiological phenotype, treatment response and long-term outcome. This heterogeneity may reflect the existence of distinct subtypes of CIDP with a different pathogenesis that require personalized treatment. The International CIDP Outcome Study (ICOS) is a prospective, observational, multicenter cohort study that aims to describe this variation and to define clinical and biological determinants and predictors of these subtypes, disease activity, treatment response and outcome. All patients fulfilling the European Federation of Neurological Societies/Peripheral Nerve Society 2010 diagnostic criteria for CIDP can participate, independent of age, duration and severity of the disease or treatment. We collect data on the clinical presentation, diagnostics, validated clinical outcome measures, (response to) treatment, and we collect biomaterials (DNA, cerebrospinal fluid and serial serum samples). We aim to include at least 1000 CIDP patients with a follow-up of at least 2 years. ICOS started in November 2015 in three academic medical centers in The Netherlands and by October 2018 169 patients are included: 69 new and 100 prevalent cases. ICOS is based on the format of the International Guillain-Barré syndrome (GBS) Outcome Study (IGOS). Dutch centers are invited to participate in ICOS that will continue as an independent national registry. International centers will be able to collect data and biomaterials according to the ICOS protocol by using the optional ICOS module within the INCbase infrastructure. ICOS will help to standardize the collection of data and biosamples for future research in CIDP.

Facioscapulohumeral Dystrophy in Childhood: A Nationwide Natural History Study

OBJECTIVE

Facioscapulohumeral dystrophy (FSHD) is one of the most frequent heritable muscular dystrophies, with a large variety in age at onset and disease severity. The natural history and molecular characteristics of FSHD in childhood are incompletely understood. Our objective is to clinically and genetically characterize FSHD in childhood.

METHODS

We performed a nationwide, single-investigator, natural history study on FSHD in childhood.

RESULTS

Multiple-source recruitment resulted in 32 patients with FSHD (0-17 years), leading to an estimated prevalence of 1 in 100,000 children in The Netherlands. This series of 32 children with FSHD revealed a heterogeneous phenotype and genotype in childhood. The phenotypic hallmarks of FSHD in childhood are: facial weakness with normal or only mildly affected motor performance, decreased functional exercise capacity (6-minute walk test), lumbar hyperlordosis, and increased echo intensity on muscle ultrasonography. In addition, pain and fatigue were frequent and patients experienced a lower quality of life compared to healthy peers. In contrast to the literature on early-onset FSHD, systemic features such as hearing loss and retinal and cardiac abnormalities were infrequent and subclinical, and epilepsy and intellectual disability were absent. Genotypically, patients had a mean D4Z4 repeat array of 5 units (range, 2-9), and 14% of the mutations were de novo.

INTERPRETATION

FSHD in childhood is more prevalent than previously known and the genotype resembles classic FSHD. Importantly, FSHD mainly affects functional exercise capacity and quality of life in children. As such, these results are paramount for counseling, clinical management, and stratification in clinical research. Ann Neurol 2018;84:635-645.

Impact of multilevel joint contractures of the hips, knees and ankles on the Gait Profile score in children with cerebral palsy

BACKGROUND

Children with cerebral palsy are at risk of developing muscle contractures, often contributing to pain, structural deformities and mobility limitations. With the increasing use of gait indices to summarise the findings of three dimensional gait analysis (3DGA), the purpose of this study is to determine whether there is a relationship between multilevel joint contractures and the Gait Profile Score in children with cerebral palsy.

METHODS

The Gait Profile Score, calculated from 3D gait analysis, and passive range of motion, strength and spasticity of the hips, knees and ankles in the sagittal plane were measured in 145 children with cerebral palsy (mean age:11 years,4 months; SD:2 years,10 months) (83 males) enrolled in the NSW Paediatric Gait Analysis Service Research Registry from 2011 to 2016. The relationships between these physical measures and the Gait Profile Score were explored using bivariate and multivariate correlations.

FINDINGS

Reduced hip extension, knee extension and ankle dorsiflexion (knee extended) range of motion were correlated with a higher (worse) Gait Profile Score (r = -0.348 to -0.466, p < .001). Children with all joints contracted had a significantly higher Gait Profile Score (mean 17.5°, SD 6.2°) than those with no contractures (mean 11.0°, SD 2.3°) or ankle contractures only (mean 12.8°, SD 5.1°) (p < .05). Knee flexion weakness, reduced hip extension and ankle dorsiflexion (knee extended) range of motion predicted 47% of the Gait Profile Score.

INTERPRETATION

The Gait Profile Score is a sensitive measure for demonstrating the relationship between multilevel sagittal plane joint contractures and kinematic gait. Clinically, this supports the use of the Gait Profile Score as a simplified measure to understand the contribution of contractures to functional gait limitations. Monitoring knee flexion strength, and hip extension and ankle dorsiflexion (knee extended) range of motion may assist clinicians in prioritising interventions to improve gait in this population.

Normal limits of home measured spatial gait parameters of the elderly population and their association with health variables

Gait studies in the elderly population have been always conducted in gait labs or spacious clinical facilities, which influence gait parameters, and also implies that the participants have to be able to move to these facilities. Indoors gait characteristics of the elderly population have been very little studied. In this study, we aim to define the normal limits of the spatial gait parameters of the elderly, when walking at home, and to analyze relationship existing between the spatial gait parameters to other health variables. For such purpose, we conducted a transversal study on a probabilistic sample of 431 Spanish community-dwelling older, in which the spatial gait parameters were recorded by using an ink footprints method. We found that the mean stride length indoors was 88.47 cm (SD:26.05 cm; mean CI95%:85.52–91.41 cm), and the mean step width was 10.34 cm (SD:4.37 cm; mean CI95%:9.84–10.83 cm). Stride length was shorter in women and the oldest group, and was significantly influenced by the strength, balance, and physical activity. Stride width was larger in the oldest group and mainly affected by balance. A composite parameter including width and normalized stride length was independent from sex, and strongly differentiated between age groups. This parameter was affected by strength.

Grading the loss of sensation in diabetic patients: A psychometric evaluation of the rotterdam diabetic foot study test battery

Introduction: Static‐ and moving 2‐point discrimination (S2PD, M2PD), 10‐g monofilaments‐ and tuning fork are validated outcome measures of clinical manifestations of diabetes‐related neuropathy. No modern statistical techniques have been used to investigate how well these instruments combine to measure sensory loss. Methods: To grade sensory loss at the feet, we fitted parametric forms of Item Response Theory models to the data of these instruments. Results: The fit statistics indicate that the loss of sensation is gradable, with readily available instruments. S2PD and M2PD are lost first, followed by vibration sense, the 10‐g monofilament and the ability to feel a cold stimulus. Conclusions: This test battery appears to provide sound measurement properties in a group of diabetic patients with diverse amounts of sensory loss. This approach may be used in clinical practice to grade sensory loss reliably and quickly, with instruments that are easy to use. Muscle Nerve58: 559–565, 2018