POLYNEUROPATHIES IN THE ELDERLY: A CLINICO PATHOLOGICAL STUDY OF 74 CASES

Stride-to-stride fluctuations in transtibial amputees are not affected by changes in push-off mechanics from using different prostheses

Stride-to-stride fluctuations of joint kinematics during walking reflect a highly structured organization that is characteristic of healthy gait. The organization of stride-to-stride fluctuations is disturbed in lower-limb prosthesis users, yet the factors contributing to this difference are unclear. One potential contributor to the changes in stride-to-stride fluctuations is the altered push-off mechanics experienced by passive prosthesis users. The purpose of our study was to determine if changes in push-off mechanics affect stride-to-stride fluctuations in transtibial amputees. Twenty-two unilateral transtibial amputees were enrolled in the 6-week cross-over study, where High and Low Activity (based on the Medicare Functional Classification System) prostheses were worn for three weeks each. Data collection took place at the end of the third week. Participants walked on a treadmill in a motion capture laboratory to quantify stride-to-stride fluctuations of the lower extremity joint angle trajectories using the largest Lyapunov Exponent, and over floor-embedded force platforms to enable calculating push-off work from the prosthesis and the sound limb. Push-off work was 140% greater in the High Activity prosthesis compared to the Low Activity prosthesis (p < 0.001), however no significant change was observed in stride-to-stride fluctuations of the ankle between the two prosthesis types (p = 0.576). There was no significant correlation between changes in prosthesis push-off work and the largest Lyapunov exponent. Though differences in push-off work were observed between the two prosthesis types, stride-to-stride fluctuations remained similar, indicating that prosthesis propulsion mechanics may not be a strong determinant of stride-to-stride fluctuations in unpowered transtibial prosthesis users.

Vasculitic neuropathy in elderly: A study from a tertiary care university hospital in South India

Objective:

To describe clinical, electrophysiological, and histopathological profile of vasculitic neuropathy in elderly subjects aged 65 years or more.

Design:

Retrospective chart review.

Setting:

Departments of Neurology and Neuropathology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Patients and Methods:

Elderly subjects, diagnosed vasculitic neuropathy by nerve biopsy over one decade, were studied.

Results:

The cohort consisted of 46 subjects. Symptom duration was 21.54 ± 33.53 months. Onset was chronic in majority (82.6%). Key features included paresthesias (89%), weakness (80%), sensory loss (70%), wasting (63%), and relapsing-remitting course (6.5%). Most Common clinico-electrophysiological patterns were distal symmetrical sensorimotor polyneuropathy - 19, mononeuritis multiplex - 9, and asymmetric sensorimotor neuropathy - 10. Diagnosis of vasculitis was not suspected before biopsy in 31 (67.3%). Nerve biopsy revealed definite vasculitis - 12, probable - 10, and possible - 24. Treatment included immunomodulatory agents (41), symptomatic medications only (9), and antiretroviral therapy (1). Twenty-four patients were followed up for mean period of 6.5 months. Outcome at last follow-up was improved (13), unchanged (8), and worsened (3).

Conclusion:

Vasculitis is an important, treatable cause of neuropathy in elderly. Nerve biopsy should be used judiciously for early diagnosis and appropriate treatment.

Neuropathy in elderly: lessons learnt from nerve biopsy

OBJECTIVE

To study the utility of nerve biopsy in providing diagnostic, therapeutic or prognostic information that aid in clinical management in elderly subjects with peripheral neuropathy.

METHODS

Clinico-pathological data of 100 elderly subjects aged 65 and above with peripheral neuropathy who underwent nerve biopsy in the last decade (2002-2011) was reviewed.

RESULTS

The study included 100 subjects (M:F 78:22). Mean age at biopsy and symptom duration was 69.62±4.8 years and 24.17±40.4 months, respectively. The most common pattern of was distal symmetric sensorimotor polyneuropathy (35%), followed by multiple mononeuropathy (29%) and asymmetric sensorimotor neuropathy (15%). The nerve biopsy was 'diagnostic' in 24%, (definite vasculitis in 12, leprosy in 10 and acute inflammatory demyelinating polyradiculoneuropathy in 2) and proved 'essential' or 'helpful' in therapeutic management in 81% subjects. In 60 (60%) patients, where a pre-biopsy aetiological diagnosis could be arrived at based on the available data, nerve biopsy confirmed the diagnosis in 29 of 60 (48.3%), and offered a new diagnosis in 25 (41.7%). A higher yield of biopsy was noted in subjects with asymmetric/multiple mononeuropathy compared with symmetric neuropathies (32.7% versus 17.7%). In 40 (40%) patients without a pre-biopsy aetiological diagnosis, nerve biopsy was 'essential' in 7 of 40 (17.5%) as it provided a definitive diagnosis (definite vasculitis: 5, leprosy: 2), and 'helpful' in 21 of 40 (52.5%) (ischaemic neuropathy: 10, possible vasculitis: 9, probable vasculitis: 2).

CONCLUSION

Nerve biopsy aided in the detection of potentially treatable disorders and influenced patient management in a significant proportion of elderly subjects with peripheral neuropathy (81%), particularly in subset with undiagnosed neuropathies confirming that it's a useful tool in diagnosis of neuropathy in the elderly. With minor differences, the aetiological profile in our biopsied neuropathic elderly subjects may reflect the findings in other similar cohorts.

Vasculitic neuropathy

Vasculitis is a primary phenomenon in autoimmune diseases such as polyarteritis nodosa, Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, and essential mixed cryoglobulinemia. As a secondary feature vasculitis may complicate, for example, connective tissue diseases, infections, malignancies, and diabetes. Vasculitic neuropathy is a consequence of destruction of the vessel wall and occlusion of the vessel lumen of small epineurial arteries. Sometimes patients present with nonsystemic vasculitic neuropathy, i.e., vasculitis limited to peripheral nerves and muscles with no evidence of further systemic involvement. Treatment with corticosteroids, sometimes in combination with other immunosuppressants, is required to control the inflammatory process and prevent further ischemic nerve damage.

My legs are getting old: sinvastatin-induced polyneuropathy

Axonal degeneration is the most common type of neuropathy induced by medication. The literature describes isolated cases in which polyneuropathy of the lower limb was observed during treatment with statins. The authors present a case of polyneuropathy associated with the use of a statin. An 82-year-old female patient presented with a complaint of weakness and discomfort in her lower limbs after 7 years of therapy with simvastatin. The results of an electromyographic study were compatible with polyneuropathy (sensorimotor axonal neuropathy--moderate to severe). One month after the therapy with simvastatin was discontinued, the symptoms were reduced.