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Lin RJ, Munin MC, Belsky M, Smith B, Grose E, Nisenbaum R, Rosen CA, Smith LJ. Technical Challenges for Laryngeal Electromyography. Laryngoscope 2024; 134:831-834. [PMID: 37676073 DOI: 10.1002/lary.31035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND/OBJECTIVE Laryngeal electromyography (LEMG) is a useful diagnostic test in the evaluation of vocal fold paralysis (VFP). This study investigates factors that can make LEMG challenging to perform. METHODS Patients with subacute unilateral VFP presented for LEMG were prospectively enrolled. Demographic data including BMI, previous neck surgery, and anatomic factors were collected. Patient-reported pain related to the procedure was recorded on a visual analogue scale (VAS). Electromyographer and otolaryngologist recorded a consensus rating of the perceived difficulty in performing the test and confidence in using the results for clinical decision-making. RESULTS A total of 111 patients (56.8% female) were enrolled between August 2015 and August 2018. The mean age was 55 ± 14 years, and the average body mass index (BMI) was 28.5 ± 6.4. The mean patient-reported VAS score for pain was 35 ± 24. Notably, 31.2% of the tests were considered "very easy," 32.1% were considered "mildly challenging" and 23.9% and 12.8% were considered "moderately challenging" and "extremely challenging," respectively, by the clinicians. Common factors affecting LEMG difficulty included poorly palpable surface anatomy (50.5%) and patient intolerance (15.6%). Clinicians felt confident in 76.1% of the test findings. Bivariate analyses showed that prior neck surgery is associated with elevated VAS (p = 0.02), but clinician-perceived difficulty of performing the test is not associated with elevated VAS scores (p = 0.55). CONCLUSIONS Majority of LEMG tests are well tolerated by patients. Physicians reported more confidence using LEMG for clinical decision-making when the test was easier to perform. Difficult surface anatomy and patient intolerance affects clinician confidence in integrating the test results with clinical care. LEVEL OF EVIDENCE 3 Laryngoscope, 134:831-834, 2024.
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Affiliation(s)
- R Jun Lin
- Department of Otolaryngology - Head & Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Michael Belsky
- Department of Otolaryngology - Head & Neck Surgery, Stanford University, Stanford, California, U.S.A
| | - Brandon Smith
- Department of Otolaryngology - Head & Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Elysia Grose
- Department of Otolaryngology - Head & Neck Surgery, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Clark A Rosen
- Department of Otolaryngology - Head & Neck Surgery, UCSF Voice & Swallowing Center, University of California San Francisco, San Francisco, California, U.S.A
| | - Libby J Smith
- Department of Otolaryngology - Head & Neck Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
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Molteni F, Wissel J, Fheodoroff K, Munin MC, Patel AT, Althaus M, Comes G, Dekundy A, Pulte I, Scheschonka A, Vacchelli M, Santamato A. Improvement in Quality-of-Life-Related Outcomes Following Treatment with IncobotulinumtoxinA in Adults with Limb Spasticity: A Pooled Analysis. Toxins (Basel) 2023; 16:19. [PMID: 38251237 PMCID: PMC10821091 DOI: 10.3390/toxins16010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/05/2023] [Accepted: 12/16/2023] [Indexed: 01/23/2024] Open
Abstract
A strong correlation has been reported between patient-reported quality of life (QoL) and the investigator-rated Disability Assessment Scale (DAS) in patients with spasticity. The current analysis evaluates the effect of incobotulinumtoxinA on QoL-related outcomes (limb position abnormality, as well as dressing- and hygiene-related disability, measured with the DAS) in adults with upper limb spasticity, using pooled data from six studies. Separate analyses for each DAS domain were performed using data from patients with disabilities for that domain (DAS score ≥1). Results showed that a significantly greater proportion of incobotulinumtoxinA-treated compared with placebo-treated patients achieved a ≥1-point reduction from baseline in each of the DAS domains (improvement) 4 weeks after the first injection. The benefits of incobotulinumtoxinA were observed regardless of the baseline severity of DAS impairment and of the time elapsed since stroke. The effects of incobotulinumtoxinA 4 weeks after injection were maintained or enhanced over multiple injection cycles for all three DAS domains, supporting the use of repeated injection cycles to provide sustained QoL benefit. IncobotulinumtoxinA represents an important treatment option to achieve better QoL-related outcomes for patients with upper limb spasticity, irrespective of the duration of their condition.
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Affiliation(s)
- Franco Molteni
- Department of Rehabilitation, Valduce Villa Beretta Hospital, 23845 Costa Masnaga, Italy
| | - Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Hospital Spandau, 13585 Berlin, Germany
| | | | - Michael C. Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Atul T. Patel
- Kansas City Bone and Joint Clinic, Overland Park, KS 66211, USA
| | - Michael Althaus
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Georg Comes
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Andrzej Dekundy
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Irena Pulte
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Astrid Scheschonka
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Matteo Vacchelli
- Merz Therapeutics GmbH, 60318 Frankfurt am Main, Germany; (M.A.); (G.C.)
| | - Andrea Santamato
- Unit of Spasticity and Movement Disorders, Division of Physical Medicine and Rehabilitation, University Hospital of Foggia, 71100 Foggia, Italy
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Francisco G, Feng W, Munin MC, Ngo K, Schwartz M, Sadeghi M, Zuzek A, Esquenazi A. OnabotulinumtoxinA Treatment of Upper Limb Spasticity: Analysis of US Practice Patterns From the ASPIRE Study. Arch Phys Med Rehabil 2022. [DOI: 10.1016/j.apmr.2022.08.602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Belsky MA, Lin RJ, Rosen CA, Munin MC, Smith LJ. Vocal fold injection material does not preclude interpretation of laryngeal electromyography. Muscle Nerve 2021; 64:104-108. [PMID: 33961288 DOI: 10.1002/mus.27262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 04/26/2021] [Accepted: 05/04/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION/AIMS Temporary vocal fold injection (VFI) is a common treatment for acute and subacute vocal fold paralysis (VFP). Laryngeal electromyography (LEMG) is useful for diagnosing neurogenic causes of VFP. This study evaluated whether the presence of VFI material prevents interpretation of LEMG in patients with acute and subacute VFP. METHODS Patients with acute and subacute unilateral VFP (onset ≤6 mo) who underwent temporary VFI within 3 mo preceding LEMG were evaluated. A matched control group that did not undergo VFI was also studied. The LEMG team (laryngologist and electromyographer) performed and interpreted LEMG using a pre-specified protocol, including qualitative and quantitative motor unit analysis. RESULTS Eighteen patients with VFI underwent LEMG successfully with interpretation of spontaneous activity and motor unit recruitment. Fourteen patients were seen in follow-up to determine accuracy of established LEMG prognosis. Seven of seven subjects with poor LEMG prognosis did not recover vocal fold motion. Five of seven subjects with fair LEMG prognosis recovered vocal fold motion. Findings were similar for the control group. DISCUSSION VFI augmentation material did not prevent interpretation of meaningful LEMG data in patients with acute and subacute VFP, and accurate prognoses of vocal fold motion recovery were established.
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Affiliation(s)
- Michael A Belsky
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - R Jun Lin
- Department of Otolaryngology - Head & Neck Surgery, University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Clark A Rosen
- UCSF Voice and Swallowing Center, Division of Laryngology, Department of Otolaryngology - Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Libby J Smith
- Department of Otolaryngology, University of Pittsburgh Voice Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Kaňovský P, Elovic EP, Munin MC, Hanschmann A, Pulte I, Althaus M, Hiersemenzel R, Marciniak C. Sustained efficacy of incobotulinumtoxina repeated injections for upper-limb post-stroke spasticity: A post hoc analysis. J Rehabil Med 2021; 53:jrm00138. [PMID: 33112408 PMCID: PMC8772361 DOI: 10.2340/16501977-2760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This post hoc analysis assessed the impact of repeated incobotulinumtoxinA injections on muscle tone, disability, and caregiver burden in adults with upper-limb post-stroke spasticity. DESIGN Data from the double-blind, placebo-controlled main period and three open-label extension cycles of two Phase 3, randomized, multicentre trials were pooled. METHODS Subjects received incobotulinumtoxinA 400 Units at 12-week intervals (±3 days) (study 3001, NCT01392300) or ≤ 400 Units at ≥12-week intervals based on clinical need (study 0410, NCT00432666). Ashworth Scale (AS) arm sumscore (sum of elbow, wrist, finger and thumb flexor, and forearm pronator AS scores), Disability Assessment Scale (DAS), and Carer Burden Scale (CBS) scores were assessed. RESULTS Among 465 subjects, from study baseline to 4 weeks post-injection, mean (standard deviation) AS arm sumscore improved continuously: main period, -3.23 (2.55) (placebo, -1.49 (2.09)); extension cycles 1, 2, and 3, -4.38 (2.85), -4.87 (3.05), and -5.03 (3.02), respectively. DAS principal target domain responder rate increased from 47.4% in the main period (placebo 27.2%) to 66.6% in extension cycle 3. Significant improvements in CBS scores 4 weeks post-injection accompanied improved functional disability in all cycles. CONCLUSION IncobotulinumtoxinA conferred sustained improvements in muscle tone, disability, and caregiver burden in subjects with upper-limb post-stroke spasticity.
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Affiliation(s)
- Petr Kaňovský
- Faculty of Medicine and Dentistry and University Hospital, Palacký University Olomouc, Olomouc, Czech Republic. E-mail:
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Moreta MC, Fleet A, Reebye R, McKernan GP, Berger M, Farag J, Munin MC. Reliability and validity of the modified Heckmatt scale in evaluating muscle changes with ultrasound in spasticity. Toxicon 2021. [DOI: 10.1016/j.toxicon.2020.11.447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Esquenazi A, Bavikatte G, Bandari DS, Jost WH, Munin MC, Tang SFT, Largent J, Adams AM, Zuzek A, Francisco GE. Long-Term Observational Results from the ASPIRE Study: OnabotulinumtoxinA Treatment for Adult Lower Limb Spasticity. PM R 2020; 13:1079-1093. [PMID: 33151636 PMCID: PMC8519010 DOI: 10.1002/pmrj.12517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 09/24/2020] [Accepted: 10/23/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION OnabotulinumtoxinA treatment for spasticity varies according to numerous factors and is individualized to meet treatment goals. OBJECTIVE To explore real-world onabotulinumtoxinA utilization and effectiveness in patients with lower limb spasticity from the Adult Spasticity International Registry (ASPIRE) study. DESIGN Two-year, multicenter, prospective, observational registry (NCT01930786). SETTING Fifty-four international clinical sites. PATIENTS Adults (naïve or non-naïve to botulinum toxin[s] treatment for spasticity, across multiple etiologies) with lower limb spasticity related to upper motor neuron syndrome. INTERVENTIONS OnabotulinumtoxinA administered at the clinician's discretion. MAIN OUTCOME MEASURES OnabotulinumtoxinA treatment utilization, clinician- and patient-reported satisfaction. RESULTS In ASPIRE, 530 patients received ≥1 onabotulinumtoxinA treatment for lower limb spasticity (mean age, 52 years; stroke, 49.4%; multiple sclerosis, 20.4%). Equinovarus foot was treated most often (80.9% of patients), followed by flexed knee (26.0%), stiff extended knee (22.5%), and flexed toes (22.3%). OnabotulinumtoxinA doses ranged between 10 and 1100 U across all presentations. Electromyography (EMG) was most commonly used for injection localization (≥41.1% of treatment sessions). Despite low patient response on the satisfaction questionnaire, clinicians (94.6% of treatment sessions) and patients (84.5%) reported satisfaction/extreme satisfaction that treatment helped manage spasticity, and clinicians (98.3%) and patients (91.6%) would probably/definitely continue onabotulinumtoxinA treatment. These data should be interpreted with care. Twenty-one adverse events (AEs) in 18 patients (3.4%) were considered treatment-related. Sixty-seven patients (12.6%) reported 138 serious AEs; 3 serious AEs in two patients (0.4%) were considered treatment-related. No new safety signals were identified. CONCLUSIONS ASPIRE provides long-term observational data on the treatment of lower limb spasticity with onabotulinumtoxinA. Real-world data from this primary analysis can help to guide the clinical use of onabotulinumtoxinA to improve spasticity management.
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Affiliation(s)
| | | | | | - Wolfgang H Jost
- Department of Neurology, University of Freiburg, Freiburg im Breisgau, Germany.,Parkinson-Klinik Ortenau, Wolfach, Germany
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Simon Fuk Tan Tang
- Department of Physical Medicine and Rehabilitation, Lotung Poh-Ai Hospital, Yilan, Taiwan
| | - Joan Largent
- IQVIA Real-World Evidence Solutions, Cambridge, MA, USA
| | | | | | - Gerard E Francisco
- University of Texas Health Science Center McGovern Medical School and TIRR Memorial Hermann, Houston, TX, USA
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Leclerc AA, Munin MC, Smith LJ, Rosen CA. Abnormal Laryngeal Electromyography Findings in Asymptomatic Adults Across the Age Spectrum. Laryngoscope 2020; 131:2065-2069. [PMID: 33125187 DOI: 10.1002/lary.29213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS Laryngeal electromyography (LEMG) is a diagnostic tool for patients with suspected neurogenic abnormalities of the larynx. LEMG is often used with the assumption that any abnormality is symptom-/disease-related. We sought to determine the prevalence of abnormal LEMG findings in a group of healthy asymptomatic adults across a large age spectrum. STUDY DESIGN Open, prospective study, gender-match and age balanced by decade. METHODS Forty-six healthy participants (age 20-78) underwent LEMG, including 178 muscles. Participants had no history of voice problems, normal VHI-10, and normal flexible laryngoscopy. Qualitative and quantitative LEMG (bilateral) were performed involving the thyroarytenoid-lateral cricoarytenoid muscle complex (TA-LCA) and cricothyroid (CT) muscles. LEMG parameters included evaluation for fibrillation potentials, sharp waves, reduced recruitment, polyphasic potentials, electrical synkinesis, and measurement of turns per second. RESULTS Of participants, 4% had at least one abnormal qualitative finding (slightly reduced recruitment or two to three discrete polyphasic potentials). There were no findings of fibrillation potentials or sharp waves. There were no abnormal qualitative findings in the CT muscles tested. Of participants, 16% had at least one abnormal synkinesis finding. LEMG qualitative abnormalities and quantitative abnormalities do not appear to correlate with gender or age. CONCLUSION Abnormal qualitative and quantitative LEMG findings were uncommon and minor in severity in our group of asymptomatic healthy adults. The likelihood of abnormal LEMG results in asymptomatic adults was 2.2% for qualitative findings, 9.3% for synkinesis, and 5.4% for turns/s. LEVEL OF EVIDENCE 3 Laryngoscope, 131:2065-2069, 2021.
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Affiliation(s)
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Libby J Smith
- UPMC Voice Center, Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, U.S.A
| | - Clark A Rosen
- UCSF Voice and Swallowing Center, Division of Laryngology, Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco School of Medicine, San Francisco, California, U.S.A
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Moreta MC, Fleet A, Reebye R, McKernan G, Berger M, Farag J, Munin MC. Reliability and Validity of the Modified Heckmatt Scale in Evaluating Muscle Changes With Ultrasound in Spasticity. Arch Rehabil Res Clin Transl 2020; 2:100071. [PMID: 33543098 PMCID: PMC7853393 DOI: 10.1016/j.arrct.2020.100071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objectives To determine the reliability and validity of the Modified Heckmatt scale in assessing muscle echotexture in spasticity. Design Prospective, observational, 2-center study. Two residents and 2 ultrasound experienced staff physicians each rated 100 ultrasound images that were also analyzed using quantitative gray-scale. Setting Academic ambulatory spasticity clinic. Participants Participants (N=50) included 45 patients with upper or lower extremity spasticity and 5 healthy references. Interventions Not applicable. Main Outcome Measures Modified Heckmatt scale ratings and quantitative gray-scale scores Results Inter- and intra-rater intraclass correlation coefficients were 0.76 and 0.81, respectively (P<.001), indicating good to excellent reliability. A significant relationship was found between Modified Heckmatt scores and quantitative gray-scale scores (r=0.829; P<.001). Conclusions The Modified Heckmatt scale demonstrated good reliability and validity to assess the pathologic muscle changes that occur in patients with spasticity. Spasticity can alter muscle architecture as viewed with ultrasound. Spastic muscles can show increased echointensity (EI). Spastic muscles with increased EI may respond less favorably to botulinum toxin. Muscle EI can be quantified using the Modified Heckmatt scale. The Modified Heckmatt scale demonstrated good reliability and validity.
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Affiliation(s)
- Marisa C Moreta
- Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Alana Fleet
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rajiv Reebye
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gina McKernan
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael Berger
- International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jordan Farag
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael C Munin
- Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Beringer CR, Mansouri M, Fisher LE, Collinger JL, Munin MC, Boninger ML, Gaunt RA. The effect of wrist posture on extrinsic finger muscle activity during single joint movements. Sci Rep 2020; 10:8377. [PMID: 32433481 PMCID: PMC7239904 DOI: 10.1038/s41598-020-65167-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 04/26/2020] [Indexed: 11/09/2022] Open
Abstract
Wrist posture impacts the muscle lengths and moment arms of the extrinsic finger muscles that cross the wrist. As a result, the electromyographic (EMG) activity associated with digit movement at different wrist postures must also change. We sought to quantify the posture-dependence of extrinsic finger muscle activity using bipolar fine-wire electrodes inserted into the extrinsic finger muscles of able-bodied subjects during unrestricted wrist and finger movements across the entire range of motion. EMG activity of all the recorded finger muscles were significantly different (p < 0.05, ANOVA) when performing the same digit movement in five different wrist postures. Depending on the wrist posture, EMG activity changed by up to 70% in individual finger muscles for the same movement, with the highest levels of activity observed in finger extensors when the wrist was extended. Similarly, finger flexors were most active when the wrist was flexed. For the finger flexors, EMG variations with wrist posture were most prominent for index finger muscles, while the EMG activity of all finger extensor muscles were modulated in a similar way across all digits. In addition to comprehensively quantifying the effect of wrist posture on extrinsic finger EMG activity in able-bodied subjects, these results may contribute to designing control algorithms for myoelectric prosthetic hands in the future.
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Affiliation(s)
- Carl R Beringer
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Center for the Neural Basis of Cognition, Pittsburgh, PA, 15213, USA
| | - Misagh Mansouri
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Lee E Fisher
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Center for the Neural Basis of Cognition, Pittsburgh, PA, 15213, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Jennifer L Collinger
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Center for the Neural Basis of Cognition, Pittsburgh, PA, 15213, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Veterans Affairs, Pittsburgh, PA, 15206, USA
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Michael L Boninger
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, USA
- Department of Veterans Affairs, Pittsburgh, PA, 15206, USA
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, 15219, USA
| | - Robert A Gaunt
- Rehab Neural Engineering Labs, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
- Center for the Neural Basis of Cognition, Pittsburgh, PA, 15213, USA.
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, 15213, USA.
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Francisco GE, Jost WH, Bavikatte G, Bandari DS, Tang SFT, Munin MC, Largent J, Adams AM, Zuzek A, Esquenazi A. Individualized OnabotulinumtoxinA Treatment for Upper Limb Spasticity Resulted in High Clinician- and Patient-Reported Satisfaction: Long-Term Observational Results from the ASPIRE Study. PM R 2020; 12:1120-1133. [PMID: 31953896 PMCID: PMC7687094 DOI: 10.1002/pmrj.12328] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/23/2019] [Indexed: 11/17/2022]
Abstract
Introduction OnabotulinumtoxinA treatment for spasticity is dependent on numerous factors and varies according to selected treatment goals. Objective To examine real‐world onabotulinumtoxinA treatment utilization and effectiveness in patients with upper limb spasticity over 2 years from the Adult Spasticity International Registry (ASPIRE) study. Design Multicenter, prospective, observational registry (NCT01930786). Setting Fifty‐four international clinical sites in North America, Europe, and Asia. Patients Adults (naïve or non‐naïve to botulinum toxins for spasticity) with upper limb focal spasticity related to upper motor neuron syndrome across multiple etiologies. Interventions OnabotulinumtoxinA administered at clinician's discretion. Main Outcome Measures OnabotulinumtoxinA utilization, clinician and patient satisfaction. Results Four hundred eighty‐four patients received ≥1 treatment of onabotulinumtoxinA for upper limb spasticity. Patients were on average 55.1 years old, 50.8% male, predominantly Caucasian (72.3%), and 38.6% were naïve to botulinum toxins. Stroke was the most frequently reported underlying etiology (74.0%). Most patients (81.2%) had moderate to severe spasticity at baseline. The most commonly treated upper limb clinical presentation was clenched fist (79.1% of patients). Across all presentations, onabotulinumtoxinA doses ranged between 5‐600U. Electromyography (EMG) was most often utilized to localize muscles (≥57.0% of treatment sessions). Clinicians (92.9% of treatment sessions) and patients (85.7%) reported being extremely satisfied/satisfied that treatment helped manage spasticity, and clinicians (98.6%) and patients (92.2%) would definitely/probably continue onabotulinumtoxinA treatment. One hundred seventy‐nine patients (37.0%) reported 563 adverse events (AEs); 15 AEs in 14 patients (2.9%) were considered treatment related. Sixty‐nine patients (14.3%) reported 137 serious AEs; 3 serious AEs in 2 patients (0.4%) were considered treatment related. No new safety signals were identified. Conclusions ASPIRE captured the real‐world individualized nature of onabotulinumtoxinA utilization for upper limb spasticity over 2 years, with consistently high clinician‐ and patient‐reported satisfaction. Data in this primary analysis will guide clinical use of onabotulinumtoxinA, as well as provide insights to improve educational programs on spasticity management.
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Affiliation(s)
- Gerard E Francisco
- The University of Texas Health Science Center McGovern Medical School and TIRR Memorial Hermann, Houston, TX
| | - Wolfgang H Jost
- Department of Neurology, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Daniel S Bandari
- Multiple Sclerosis Center of California & Research Group, Newport Beach, CA
| | - Simon F T Tang
- Department of Physical Medicine and Rehabilitation, Lotung Poh-Ai Hospital, Yilan, Taiwan
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joan Largent
- IQVIA Real-World Evidence Solutions, Cambridge, MA
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Marciniak C, Munin MC, Brashear A, Rubin BS, Patel AT, Slawek J, Hanschmann A, Hiersemenzel R, Elovic EP. IncobotulinumtoxinA Treatment in Upper-Limb Poststroke Spasticity in the Open-Label Extension Period of PURE: Efficacy in Passive Function, Caregiver Burden, and Quality of Life. PM R 2020; 12:491-499. [PMID: 31647185 DOI: 10.1002/pmrj.12265] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 10/04/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Poststroke spasticity affects motor function and the ability to perform activities of daily living, with the potential to affect quality of life (QoL) and increase caregiver burden. OBJECTIVE To investigate the effect of repeated incobotulinumtoxinA treatment on spasticity-associated functional disability, caregiver burden, and QoL in the 36-week open-label extension of the phase 3 PURE study (NCT01392300). DESIGN Open-label extension period of a prospective, double-blind, placebo-controlled, randomized, multicenter study. SETTING Forty-six investigation sites in seven countries (Czech Republic, Germany, Hungary, India, Poland, Russia, United States). PARTICIPANTS Adults, aged 18-80 years, ≥12 months since last botulinum neurotoxin injection or entirely toxin naïve, with median poststroke upper-limb spasticity of >2 years' duration. METHODS Participants who completed the 12-week, double-blind main period could enter the open-label extension and receive up to three additional incobotulinumtoxinA treatments (fixed total dose 400 U at 12-week intervals) into the affected muscles of one upper limb. MAIN OUTCOME MEASURES Functional disability (Disability Assessment Scale; DAS), caregiver burden (Carer Burden Scale), and quality of life (QoL; EuroQol [EQ] 5-dimensions three-level [EQ-5D-3L]). RESULTS The open-label extension included 296 treated patients. Mean DAS score for the principal target domain improved significantly from the main period baseline to the end-of-study visit (P < .0001). Carer Burden Scale scores also significantly improved from the main period baseline to the end-of-study visit (P < .05 for all caregiving activities except "applying a splint"). At the end-of-study visit, versus the main period baseline, 19.7%-33.3% of patients experienced improvements for each parameter on the EQ-5D-3L, except "mobility," with significant improvement in EQ-5D visual analog scale scores (P < .001). CONCLUSIONS Repeated incobotulinumtoxinA treatments at 12-week intervals in participants with chronic poststroke upper-limb spasticity resulted in significant improvements in QoL, as well as significant reductions in upper-limb functional disability and caregiver burden.
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Affiliation(s)
- Christina Marciniak
- Department of Physical Medicine and Rehabilitation and Department of Neurology, Northwestern University Feinberg School of Medicine and Shirley Ryan Ability Lab, Chicago, IL
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Allison Brashear
- Department of Neurology, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC
| | | | - Atul T Patel
- Kansas City Bone & Joint Clinic, Overland Park, KS
| | - Jaroslaw Slawek
- Department of Neurological-Psychiatric Nursing, Medical University of Gdansk, Gdansk, Poland
| | | | | | - Elie P Elovic
- Department of Medicine, University of Nevada at Reno, Reno, NV
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Marciniak C, Munin MC, Brashear A, Rubin BS, Patel AT, Slawek J, Hanschmann A, Hiersemenzel R, Elovic EP. IncobotulinumtoxinA Efficacy and Safety in Adults with Upper-Limb Spasticity Following Stroke: Results from the Open-Label Extension Period of a Phase 3 Study. Adv Ther 2019; 36:187-199. [PMID: 30484117 PMCID: PMC6318229 DOI: 10.1007/s12325-018-0833-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Indexed: 01/12/2023]
Abstract
Introduction The objective of the study was to investigate the efficacy and safety of repeated incobotulinumtoxinA injections for the treatment of upper-limb post-stroke spasticity in adults. Methods Adults 18–80 years of age with post-stroke upper-limb spasticity who completed the 12-week randomized, double-blind, placebo-controlled main period (MP) of a phase 3 trial (NCT01392300) were eligible to enrol in the 36-week open-label extension period (OLEX). The OLEX included three treatment cycles at fixed 12-week injection intervals; subjects were injected with 400 U incobotulinumtoxinA into the affected upper limb. Efficacy assessments included evaluation of muscle tone using the Ashworth Scale (AS) and the Global Impression of Change Scale (GICS) assessed by the investigator, subject, and caregiver. The incidence of adverse events (AEs) was monitored throughout the OLEX. Results A total of 296 of 299 subjects (99.0%) who completed the MP received incobotulinumtoxinA in the OLEX, and 248 subjects completed the 36-week OLEX. The proportion of subjects with at least a 1-point improvement in AS score from each incobotulinumtoxinA treatment to the respective 4-week post-injection visit ranged by cycle from 52.3% to 59.2% for wrist flexors, 49.1% to 52.3% for elbow flexors, 59.8% to 64.5% for finger flexors, 35.5% to 41.2% for thumb flexors, and 37.4% to 39.9% for forearm pronators (P < 0.0001 for all). Over 90% of subjects were assessed by the investigator to be at least minimally improved (4 weeks post-injection) on the GICS during each injection cycle; 61.0% in the 1st cycle, 58.2% in the 2nd cycle, and 57.4% in the 3rd cycle were considered much improved or very much improved on the GICS. Three percent of subjects (9/296) reported treatment-related AEs; the most frequently reported were pain in the extremity (n = 2, 0.7%) and constipation (n = 2, 0.7%). Serious AEs were reported by 22 subjects (7.4%); however, none were considered treatment-related. Conclusions Repeated injections of incobotulinumtoxinA for the treatment of post-stroke upper-limb spasticity led to significant improvements in muscle tone and investigator’s global impression of change. Treatment was well tolerated, with no serious treatment-related AEs. Funding Merz Pharmaceuticals GmbH.
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Affiliation(s)
- Christina Marciniak
- Department of Physical Medicine and Rehabilitation and Department of Neurology, Northwestern University Feinberg School of Medicine, Shirley Ryan AbilityLab, Chicago, IL, USA.
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Allison Brashear
- Department of Neurology, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston Salem, NC, USA
| | | | - Atul T Patel
- Kansas City Bone & Joint Clinic, Overland Park, KS, USA
| | - Jaroslaw Slawek
- Department of Neurological-Psychiatric Nursing, Medical University of Gdansk, Gdansk, Poland
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Kaňovský P, Elovic EP, Munin MC, Hanschmann A, Pulte I, Althaus M, Hiersemenzel R, Marciniak C. Sustained efficacy of incobotulinumtoxinA in upper-limb poststroke spasticity: Pooled analysis of 2 phase 3 trials. Toxicon 2018. [DOI: 10.1016/j.toxicon.2018.11.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Marciniak C, Munin MC, Brashear A, Rubin BS, Patel AT, Slawek J, Hanschmann A, Hiersemenzel R, Elovic EP. Efficacy of incobotulinumtoxinA in upper-limb spasticity following stroke: results from the open-label extension period of pure. Toxicon 2018. [DOI: 10.1016/j.toxicon.2018.11.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Esquenazi A, Bavikatte G, Jost WH, Bandari DS, Munin MC, Tan Tang SF, Largent J, Zuzek A, Patel A, Francisco GE. Individualized onabotulinumtoxinA treatment for lower limb spasticity resulted in high patient and clinician satisfaction in the aspire study. Toxicon 2018. [DOI: 10.1016/j.toxicon.2018.11.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Esquenazi A, Jost WH, Bavikatte G, Bandari DS, Munin MC, Zuzek A, Patel A, Largent J, Francisco GE. Poster 75: Exploring Real-World OnabotulinumtoxinA Utilization Patterns for the Treatment of Lower Limb Spasticity: The Adult Spasticity International Registry (ASPIRE) Study. PM R 2018. [DOI: 10.1016/j.pmrj.2018.08.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Henderson G, Harrington AL, Kaufmann RA, Munin MC. Poster 260: Persistent Upper Extremity Pain and Weakness in a Woman with Central Cord Syndrome: A Case Report. PM R 2018. [DOI: 10.1016/j.pmrj.2018.08.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Lin RJ, Smith LJ, Munin MC, Sridharan S, Rosen CA. Innervation status in chronic vocal fold paralysis and implications for laryngeal reinnervation. Laryngoscope 2018; 128:1628-1633. [DOI: 10.1002/lary.27078] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 10/25/2017] [Accepted: 12/04/2017] [Indexed: 11/11/2022]
Affiliation(s)
- R. Jun Lin
- Department of Otolaryngology-Head and Neck Surgery; University of Toronto, St. Michael's Hospital; Toronto Ontario Canada
| | - Libby J. Smith
- the University of Pittsburgh Voice Center, Division of Laryngology, Department of Otolaryngology, University of Pittsburgh School of Medicine; University of Pittsburgh
| | - Michael C. Munin
- the University of Pittsburgh Voice Center, Division of Laryngology, Department of Otolaryngology, University of Pittsburgh School of Medicine; University of Pittsburgh
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania U.S.A
| | - Shaum Sridharan
- the University of Pittsburgh Voice Center, Division of Laryngology, Department of Otolaryngology, University of Pittsburgh School of Medicine; University of Pittsburgh
| | - Clark A. Rosen
- the University of Pittsburgh Voice Center, Division of Laryngology, Department of Otolaryngology, University of Pittsburgh School of Medicine; University of Pittsburgh
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Matsumoto ME, Berry J, Yung H, Matsumoto M, Munin MC. Comparing Electrical Stimulation With and Without Ultrasound Guidance for Phenol Neurolysis to the Musculocutaneous Nerve. PM R 2017; 10:357-364. [PMID: 28919499 DOI: 10.1016/j.pmrj.2017.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 09/01/2017] [Accepted: 09/08/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ultrasound guidance is increasingly being used for neurolytic procedures that have traditionally been done with electrical stimulation (e-stim) guidance alone. Ultrasound visualization with e-stim-guided neurolysis can potentially allow adjustments in injection protocols that will reduce the volume of neurolytic agent needed to achieve clinical improvement. OBJECTIVE This study compared e-stim only to e-stim with ultrasound guidance in phenol neurolysis of the musculocutaneous nerve (MCN) for elbow flexor spasticity. We also evaluated the ultrasound appearance of the MCN in this population. DESIGN Retrospective review. SETTING University hospital outpatient clinic. PARTICIPANTS Adults (N = 167) receiving phenol neurolysis to the MCN for treatment of elbow flexor spasticity between 1997 and 2014 and adult control subjects. METHODS For each phenol injection of the MCN, the method of guidance, volume of phenol injected, technical success, improved range of motion at the elbow postinjection, adverse effects, reason for termination of injections, and details of concomitant botulinum toxin injection were recorded. The ultrasound appearance of the MCN, including nerve cross-sectional area and shape, were recorded and compared between groups. MAIN OUTCOME MEASURES The volume of phenol injected and MCN cross-sectional area and shape as demonstrated by ultrasound. RESULTS The addition of ultrasound to e-stim-guided phenol neurolysis was associated with lower doses of phenol when compared to e-stim guidance alone (2.31 mL versus 3.69 mL, P < .001). With subsequent injections, the dose of phenol increased with e-stim guidance (P < .001), but not with e-stim and ultrasound guidance (P = .95). Both methods of guidance had high technical success, improved ROM at elbow postinjection, and low rates of adverse events. In comparing the ultrasound appearance of the MCN in patients with spasticity to that of normal controls, there was no difference in the cross-sectional area of the nerve, but there was more variability in shape. CONCLUSIONS Combined e-stim and ultrasound guidance during phenol neurolysis to the MCN allows a smaller volume of phenol to be used for equal effect, both at initial and repeat injection. The MCN shape was more variable in individuals with spasticity; this should be recognized so as to successfully locate the nerve to perform neurolysis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Mary E Matsumoto
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Kaufmann Medical Building, Ste 201, 3471 Fifth Ave, Pittsburgh, PA 15213
| | - Jessica Berry
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Kaufmann Medical Building, Ste 201, 3471 Fifth Ave, Pittsburgh, PA 15213
| | - Herbie Yung
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Kaufmann Medical Building, Ste 201, 3471 Fifth Ave, Pittsburgh, PA 15213
| | - Martha Matsumoto
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Kaufmann Medical Building, Ste 201, 3471 Fifth Ave, Pittsburgh, PA 15213
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Kaufmann Medical Building, Ste 201, 3471 Fifth Ave, Pittsburgh, PA 15213
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Marciniak C, Kaňovský P, Munin MC, Althaus M, Hanschmann A, Pulte I, Hiersemenzel R. Poster 70: IncobotulinumtoxinA Sustainably Improves Upper Limb Spasticity – Pooled Analysis of Two Phase 3 Trials. PM R 2017. [DOI: 10.1016/j.pmrj.2017.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Petr Kaňovský
- Rehabilitation Institute of Chicago, Chicago, IL, USA
| | | | | | | | - Irena Pulte
- Rehabilitation Institute of Chicago, Chicago, IL, USA
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Lin RJ, Munin MC, Rosen CA, Smith LJ. Effect of intralaryngeal muscle synkinesis on perception of voice handicap in patients with unilateral vocal fold paralysis. Laryngoscope 2017; 127:1628-1632. [DOI: 10.1002/lary.26390] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 09/12/2016] [Accepted: 09/27/2016] [Indexed: 11/08/2022]
Affiliation(s)
- R. Jun Lin
- University of Pittsburgh Voice Center; Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh; Pittsburgh Pennsylvania U.S.A
| | - Michael C. Munin
- University of Pittsburgh Voice Center; Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh; Pittsburgh Pennsylvania U.S.A
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania U.S.A
| | - Clark A. Rosen
- University of Pittsburgh Voice Center; Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh; Pittsburgh Pennsylvania U.S.A
| | - Libby J. Smith
- University of Pittsburgh Voice Center; Division of Laryngology, Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh; Pittsburgh Pennsylvania U.S.A
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Kaňovský P, Elovic EP, Munin MC, Hanschmann A, Pulte I, Althaus M, Hiersemenzel R, Marciniak C. Incobotulinumtoxina (Xeomin) sustainably improves upper limb spasticity: Pooled analysis of two phase III trials. Toxicon 2016. [DOI: 10.1016/j.toxicon.2016.11.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Marciniak C, Patel AT, Munin MC, Hanschmann A, Hiersemenzel R, Elovic EP. Efficacy and Safety of Repeated Incobotulinumtoxina Injections for Upper-Limb Post-Stroke Spasticity. Arch Phys Med Rehabil 2016. [DOI: 10.1016/j.apmr.2016.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Roscher M, Munin MC. Poster 291 Improved Upper Extremity Spasticity During Continuous Intrathecal Baclofen Trial with High Cervical Catheter Placement: A Case Report. PM R 2016; 8:S255. [DOI: 10.1016/j.pmrj.2016.07.464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Smith LJ, Rosen CA, Munin MC. Vocal fold motion outcome based on excellent prognosis with laryngeal electromyography. Laryngoscope 2016; 126:2310-4. [DOI: 10.1002/lary.25910] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 12/31/2015] [Accepted: 01/14/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Libby J. Smith
- Department of Otolaryngology-Head and Neck Surgery; University of Pittsburgh Voice Center, University of Pittsburgh; Pittsburgh Pennsylvania U.S.A
| | - Clark A. Rosen
- Department of Otolaryngology-Head and Neck Surgery; University of Pittsburgh Voice Center, University of Pittsburgh; Pittsburgh Pennsylvania U.S.A
| | - Michael C. Munin
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh Voice Center, University of Pittsburgh; Pittsburgh Pennsylvania U.S.A
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Munin MC, Heman-Ackah YD, Rosen CA, Sulica L, Maronian N, Mandel S, Carey BT, Craig E, Gronseth G. Consensus statement: Using laryngeal electromyography for the diagnosis and treatment of vocal cord paralysis. Muscle Nerve 2016; 53:850-5. [PMID: 26930512 DOI: 10.1002/mus.25090] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2016] [Indexed: 11/07/2022]
Abstract
INTRODUCTION The purpose of this study was to develop an evidence-based consensus statement regarding use of laryngeal electromyography (LEMG) for diagnosis and treatment of vocal fold paralysis after recurrent laryngeal neuropathy (RLN). METHODS Two questions regarding LEMG were analyzed: (1) Does LEMG predict recovery in patients with acute unilateral or bilateral vocal fold paralysis? (2) Do LEMG findings change clinical management in these individuals? A systematic review was performed using American Academy of Neurology criteria for rating of diagnostic accuracy. RESULTS Active voluntary motor unit potential recruitment and presence of polyphasic motor unit potentials within the first 6 months after lesion onset predicted recovery. Positive sharp waves and/or fibrillation potentials did not predict outcome. The presence of electrical synkinesis may decrease the likelihood of recovery, based on 1 published study. LEMG altered clinical management by changing the initial diagnosis from RLN in 48% of cases. Cricoarytenoid fixation and superior laryngeal neuropathy were the most common other diagnoses observed. CONCLUSIONS If prognostic information is required in a patient with vocal fold paralysis that is more than 4 weeks and less than 6 months in duration, then LEMG should be performed. LEMG may be performed to clarify treatment decisions for vocal fold immobility that is presumed to be caused by RLN. Muscle Nerve 53: 850-855, 2016.
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Affiliation(s)
- Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yolanda D Heman-Ackah
- Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.,Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Clark A Rosen
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lucian Sulica
- Department of Otolaryngology-Head & Neck Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Nicole Maronian
- Ear, Nose and Throat Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Steven Mandel
- Department of Neurology, Hofstra North Shore LIJ School of Medicine, Hempstead, New York, USA
| | - Bridget T Carey
- Department of Neurology, Weill Cornell Medical College, New York, New York, USA
| | - Earl Craig
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gary Gronseth
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
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Elovic EP, Munin MC, Kaňovský P, Hanschmann A, Hiersemenzel R, Marciniak C. Randomized, placebo-controlled trial of incobotulinumtoxina for upper-limb post-stroke spasticity. Muscle Nerve 2015. [PMID: 26201835 PMCID: PMC5064747 DOI: 10.1002/mus.24776] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Efficacy and safety of incobotulinumtoxinA in post-stroke upper-limb spasticity were studied. METHODS Subjects randomized 2:1 to incobotulinumtoxinA (fixed dose 400 U) or placebo, with fixed doses for the primary target clinical pattern (PTCP; flexed elbow, 200 U; flexed wrist, 150 U; clenched fist, 100 U). Doses for non-primary patterns were flexible within predefined ranges. RESULTS At week 4, incobotulinumtoxinA led to larger improvements in PTCP Ashworth scale (AS) scores than placebo [least-squares mean change ± standard error: -0.9 ± 0.06 (n = 171) vs. -0.5 ± 0.08 (n = 88); P < 0.001], and more subjects were PTCP AS responders (≥1-point improvement) with incobotulinumtoxinA (69.6%) than with placebo (37.5%; P < 0.001). Investigator's Global Impression of Change confirmed superiority of incobotulinumtoxinA vs. placebo (P = 0.003). IncobotulinumtoxinA was associated with functional improvements, as demonstrated in responder rates for Disability Assessment Scale principal target at week 4 (P = 0.007). Adverse events were mainly mild/moderate, and were reported by 22.4% (incobotulinumtoxinA) and 16.8% (placebo) of subjects. CONCLUSIONS IncobotulinumtoxinA significantly improved upper-limb spasticity and associated disability, and was well-tolerated.
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Affiliation(s)
- Elie Paul Elovic
- HealthSouth Rehabilitation Hospital of Utah, 8074 South 1300 East, Sandy, Utah, 84094, USA
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Petr Kaňovský
- Faculty of Medicine and Dentistry and University Hospital, Palacky University Olomouc, Olomouc, Czech Republic
| | | | | | - Christina Marciniak
- Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine and Rehabilitation Institute of Chicago, Chicago, Illinois, USA
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Wininger YD, Buckalew NA, Kaufmann RA, Munin MC. Ultrasound combined with electrodiagnosis improves lesion localization and outcome in posterior interosseous neuropathy. Muscle Nerve 2015. [PMID: 26206065 DOI: 10.1002/mus.24782] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Posterior interosseous nerve (PIN) syndrome is a rare compression neuropathy. Electrodiagnostic studies (EDx) combined with neuromuscular ultrasound (US) enable precise lesion localization and may improve patient outcome. METHODS In 4 patients with finger extension weakness, US was used to accurately localize concentric electromyographic (EMG) needle placement in PIN muscles and to visualize the lesion site. RESULTS EMG with US guidance showed decreased recruitment with abnormal configuration in PIN muscles. Active denervation was not always observed. US scanning demonstrated larger PIN diameter in the affected arm. All patients had surgical intervention to confirm EDx and US findings and had improved outcome on follow-up. CONCLUSION These cases demonstrate the benefits of augmenting EDx with US by guiding accurate electrode localization and providing diagnostic information about lesion location.
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Affiliation(s)
- Yevgeniya Dvorkin Wininger
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, 3457 Fifth Avenue, Kaufmann Building, Suite 201, Pittsburgh, Pennsylvania, 15213, USA
| | - Neilly A Buckalew
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, 3457 Fifth Avenue, Kaufmann Building, Suite 201, Pittsburgh, Pennsylvania, 15213, USA
| | - Robert A Kaufmann
- Department of Orthopedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, 3457 Fifth Avenue, Kaufmann Building, Suite 201, Pittsburgh, Pennsylvania, 15213, USA
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Elovic E, Munin MC, Kanovsky P, Hanschmann A, Hiersemenzel R, Marciniak CM. Poster 54 Efficacy and Safety of Repeated IncobotulinumtoxinA Injections for Upper-Limb Post-Stroke Spasticity. PM R 2015. [DOI: 10.1016/j.pmrj.2015.06.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Yung H, Munin MC. Poster 360 Ultrasound Guided EMG of an Isolated Supinator Muscle Injury: A Case Report. PM R 2015. [DOI: 10.1016/j.pmrj.2015.06.396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Siebens HC, Sharkey P, Aronow HU, Deutscher D, Roberts P, Munin MC, Radnay CS, Horn SD. Variation in Rehabilitation Treatment Patterns for Hip Fracture Treated With Arthroplasty. PM R 2015; 8:191-207. [PMID: 26226210 DOI: 10.1016/j.pmrj.2015.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/08/2015] [Accepted: 07/13/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Recommendations for health care redesign often advocate for comparative effectiveness research that is patient-centered. For patients who require rehabilitation services, a first step in this research process is to understand current practices for specific patient groups. OBJECTIVE To document in detail the physical and occupational therapy treatment activities for inpatient hip fracture rehabilitation among 3 patient subgroups distinguished by their early rate of functional recovery between time of surgery to rehabilitation admission. DESIGN Multicenter prospective observational cohort, practice-based evidence, study. SETTING Seven skilled nursing facilities and 11 inpatient rehabilitation facilities across the United States. PARTICIPANTS A total of 226 patients with hip fractures treated with hip arthroplasty. METHODS Comparisons of physical and occupational therapy treatment activities among 3 groups with different initial recovery trajectory (IRT) rates (slower, moderate, faster). MAIN OUTCOME MEASURE(S) Percent of patients in each IRT group exposed to each physical and occupational therapy activity (exposure), and mean minutes per week for each activity (intensity). RESULTS The number of patients exposed to different physical or occupational therapy activities varied within the entire sample. More specifically, among the 3 IRT groups, significant differences in exposure occurred for 44% of physical therapy activities and 39% of occupational therapy activities. More patients in the slower recovery group, IRT 1, received basic activities of daily living treatments and more patients in the faster recovery group, IRT 3, received advanced activities. The moderate recovery group, IRT 2, had some treatments similar to IRT 1 group and others similar to IRT 3 group. CONCLUSIONS Analyses of practice-based evidence on inpatient rehabilitation of hip fracture patients treated with arthroplasty identified differences in therapy activities among three patient groups classified by IRT rates. These results may enhance physiatrists', other physicians', and rehabilitation teams' understanding of inpatient rehabilitation for these patients and help design future comparative effectiveness research.
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Affiliation(s)
- Hilary C Siebens
- Siebens Patient Care Communications, 13601 Del Monte Dr, Suite 47A, Seal Beach, CA 90740(∗).
| | - Phoebe Sharkey
- Department of Information Systems and Operations Management, Loyola University Maryland, Baltimore, MD(†)
| | | | | | | | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA(#)
| | - Craig S Radnay
- Insall Scott Kelly Institute for Orthopaedics and Sports Medicine, New York, NY(∗∗)
| | - Susan D Horn
- Institute for Clinical Outcomes Research, Salt Lake City, UT(§)
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Phillips MM, Miljkovic N, Ramos-Lamboy M, Moossy JJ, Horton J, Buhari AM, Munin MC. Clinical Experience With Continuous Intrathecal Baclofen Trials Prior to Pump Implantation. PM R 2015; 7:1052-1058. [PMID: 25828204 DOI: 10.1016/j.pmrj.2015.03.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 03/20/2015] [Accepted: 03/24/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To report our clinical experience using continuous intrathecal baclofen (ITB) trials prior to permanent pump implantation. DESIGN Retrospective chart review. SETTING An inpatient neurosurgery unit and outpatient physical medicine and rehabilitation clinics. PARTICIPANTS Fifty-seven patients with refractory spasticity who underwent a continuous ITB trial during the years 2006-2012. METHODS Patients underwent placement of a temporary intrathecal catheter that was connected to an external pump. A successful trial was defined as a one-level reduction in lower limb modified Ashworth scores in key spastic lower limb muscles identified for each individual patient. Subjective improvement in function or ease of performing functional tasks also were monitored. MAIN OUTCOME MEASURES Modified Ashworth scores, functional mobility in ambulatory patients only, and the incidence and severity of adverse events during the trial and up to 1 year after implantation. RESULTS Spasticity significantly decreased during the trial. Average ambulation distance was unchanged, although 34% of ambulatory patients progressed to a less restrictive assistive device by trial completion. Adverse events (AEs) occurred in 26 patients. Minor AEs were seen in 18 patients, with the most common being nausea, transient urinary retention, and headache. Pumps were implanted in 86% of patients; 14% did not receive a pump because of AEs or because goals were not met. Six patients had their pump removed at 12 months for the following reasons: pump malfunctions (3), skin breakdown around the pump (1), infection (1), and expectations not met (1). CONCLUSIONS Continuous trials via an external catheter could be an option if patients and clinicians desire a comprehensive assessment of systemic and functional effects of ITB before pump implantation. The majority of AEs were minor and resolved spontaneously, and the most effective starting intrathecal dose was determined by pump insertion.
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Affiliation(s)
- Mary Miller Phillips
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Kaufmann Medical Building, Suite 201, 3471 Fifth Ave, Pittsburgh, PA 15213
| | - Natasa Miljkovic
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Kaufmann Medical Building, Suite 201, 3471 Fifth Ave, Pittsburgh, PA 15213
| | - Marlyn Ramos-Lamboy
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Kaufmann Medical Building, Suite 201, 3471 Fifth Ave, Pittsburgh, PA 15213
| | - John J Moossy
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA
| | - John Horton
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Kaufmann Medical Building, Suite 201, 3471 Fifth Ave, Pittsburgh, PA 15213
| | - Alhaji M Buhari
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Kaufmann Medical Building, Suite 201, 3471 Fifth Ave, Pittsburgh, PA 15213
| | - Michael C Munin
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Kaufmann Medical Building, Suite 201, 3471 Fifth Ave, Pittsburgh, PA 15213
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Rosen CA, Smith LJ, Young V, Krishna P, Muldoon MF, Munin MC. Reply: Timing of nimodipine therapy for treatment of vocal fold paralysis. Muscle Nerve 2014; 50:1027. [DOI: 10.1002/mus.24468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Clark A. Rosen
- Department of Otolaryngology; University of Pittsburgh Voice Center, University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania USA
| | - Libby J. Smith
- Department of Otolaryngology; University of Pittsburgh Voice Center, University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania USA
| | - VyVy Young
- Department of Otolaryngology; University of Pittsburgh Voice Center, University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania USA
| | - Priya Krishna
- Department of Otolaryngology; Loma Linda University; Loma Linda CA USA
| | - Matthew F. Muldoon
- Heart and Vascular Institute; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania USA
| | - Michael C. Munin
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania USA
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Sridharan SS, Rosen CA, Smith LJ, Young VN, Munin MC. Timing of nimodipine therapy for the treatment of vocal fold paralysis. Laryngoscope 2014; 125:186-90. [DOI: 10.1002/lary.24903] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/16/2014] [Accepted: 08/04/2014] [Indexed: 11/09/2022]
Affiliation(s)
| | - Clark A. Rosen
- Department of Otolaryngology; University of Pittsburgh Voice Center
| | - Libby J. Smith
- Department of Otolaryngology; University of Pittsburgh Voice Center
| | - VyVy N. Young
- Department of Otolaryngology; University of Pittsburgh Voice Center
| | - Michael C. Munin
- Department of Physical Medicine and Rehabilitation; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania U.S.A
- Department of Otolaryngology; University of Pittsburgh School of Medicine; Pittsburgh Pennsylvania U.S.A
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Elovic E, Munin MC, Hanschmann A, Hiersemenzel R, Marciniak CM. Poster 397 Topline Results from a Randomized, Placebo‐Controlled, Phase III Study Investigating the Safety and Efficacy of IncobotulinumtoxinA in Treating Post‐Stroke Spasticity of the Upper Limb. PM R 2014. [DOI: 10.1016/j.pmrj.2014.08.772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Elie Elovic
- HealthSouth Rehabilitation Hospital of Utah, Sandy, UT, United States
| | - Michael C. Munin
- HealthSouth Rehabilitation Hospital of Utah, Sandy, UT, United States
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Rosen CA, Smith L, Young V, Krishna P, Muldoon MF, Munin MC. Prospective investigation of nimodipine for acute vocal fold paralysis. Muscle Nerve 2014; 50:114-8. [PMID: 24639294 DOI: 10.1002/mus.24111] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 10/21/2013] [Accepted: 10/28/2013] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Nimodipine has been shown to be beneficial for recovery from acute vocal fold paralysis (AVFP) in an animal model. METHODS prospective, open-label trial of patients with AVFP was performed using nimodipine. Consecutive patients were evaluated and offered nimodipine therapy. RESULTS Fifty-three patients were considered for treatment with nimodipine. Thirteen did not qualify for inclusion, 5 were lost to follow-up, and 7 had side effects requiring cessation of treatment. Thus 28 patients (30 paralyzed vocal folds) were analyzed. Eighteen of the paralyzed vocal folds experienced recovery of purposeful motion (60%). Historical controls and laryngeal electromyography meta-analysis suggest no more than a 20% recovery rate from AVFP. CONCLUSIONS This open label study using nimodipine for treatment of AVFP demonstrates tripling of the recovery rate of vocal fold motion compared with historical controls. Further study in a randomized, controlled manner is warranted.
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Affiliation(s)
- Clark A Rosen
- University of Pittsburgh Voice Center, Department of Otolaryngology, University of Pittsburgh School of Medicine, UPMC Mercy Building B, Suite 11500, 1400 Locust Street, Pittsburgh, Pennsylvania, 15219, USA
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Jayabalan P, Munin MC, Woods SG, Helm ER. The Development of Fibular Nerve Mononeuropathy in a Collegiate Football Player Following Acute Knee Dislocation. Med Sci Sports Exerc 2014. [DOI: 10.1249/01.mss.0000494812.55555.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Siebens H, Sharkey P, Aronow HU, Horn S, Deutscher D, Roberts P, Munin MC, Radnay C. Variation in Rehabilitation Treatment Patterns for Patients with Hip Fracture Treated with Arthroplasty. PM R 2013. [DOI: 10.1016/j.pmrj.2013.08.321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Everaert DG, Stein RB, Abrams GM, Dromerick AW, Francisco GE, Hafner BJ, Huskey TN, Munin MC, Nolan KJ, Kufta CV. Effect of a foot-drop stimulator and ankle-foot orthosis on walking performance after stroke: a multicenter randomized controlled trial. Neurorehabil Neural Repair 2013; 27:579-91. [PMID: 23558080 DOI: 10.1177/1545968313481278] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Studies have demonstrated the efficacy of functional electrical stimulation in the management of foot drop after stroke. OBJECTIVE To compare changes in walking performance with the WalkAide (WA) foot-drop stimulator and a conventional ankle-foot orthosis (AFO). METHODS Individuals with stroke within the previous 12 months and residual foot drop were enrolled in a multicenter, randomized controlled, crossover trial. Subjects were assigned to 1 of 3 parallel arms for 12 weeks (6 weeks/device): arm 1 (WA-AFO), n = 38; arm 2 (AFO-WA), n = 31; arm 3 (AFO-AFO), n = 24. Primary outcomes were walking speed and Physiological Cost Index for the Figure-of-8 walking test. Secondary measures included 10-m walking speed and perceived safety during this test, general mobility, and device preference for arms 1 and 2 for continued use. Walking tests were performed with (On) and without a device (Off) at 0, 3, 6, 9, and 12 weeks. RESULTS Both WA and AFO had significant orthotic (On-Off difference), therapeutic (change over time when Off), and combined (change over time On vs baseline Off) effects on walking speed. An AFO also had a significant orthotic effect on Physiological Cost Index. The WA had a higher, but not significantly different therapeutic effect on speed than an AFO, whereas an AFO had a greater orthotic effect than the WA (significant at 12 weeks). Combined effects on speed after 6 weeks did not differ between devices. Users felt as safe with the WA as with an AFO, but significantly more users preferred the WA. CONCLUSIONS Both devices produce equivalent functional gains.
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Hong JS, Sathe GG, Niyonkuru C, Munin MC. Elimination of dysphagia using ultrasound guidance for botulinum toxin injections in cervical dystonia. Muscle Nerve 2012; 46:535-9. [PMID: 22987694 DOI: 10.1002/mus.23409] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Dysphagia is a common side effect after botulinum toxin injections for cervical dystonia, with an incidence of 10-40%, depending upon the study and dose used. METHODS Our study consisted of 5 preselected women who met criteria for cervical dystonia and subsequent dysphagia after electromyography (EMG)-guided injections. Injections were performed with ultrasound (US) imaging, and the effects on swallowing were examined. Separately, sternocleidomastoid (SCM) thickness in healthy controls and treated patients was measured. RESULTS There were 34 episodes of dysphagia over 98 injection sessions using EMG guidance for a cumulative rate of 34.7%. Using US plus EMG guidance, there was 0% dysphagia across 27 injection sessions. SCM thickness was <1.1 cm. CONCLUSION US combined with EMG guidance eliminated recurrent dysphagia after botulinum toxin treatment, possibly by keeping the injectate within the SCM.
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Affiliation(s)
- Justin S Hong
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, 201 Kaufmann Building, 3471 Fifth Avenue, Pittsburgh, Pennsylvania 15213, USA
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Smith LJ, Rosen CA, Niyonkuru C, Munin MC. Quantitative electromyography improves prediction in vocal fold paralysis. Laryngoscope 2012; 122:854-9. [PMID: 22344543 DOI: 10.1002/lary.21884] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 04/27/2011] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Quantitative laryngeal electromyography (LEMG) using turns analysis can differentiate acute vocal fold paralysis from normal controls. The objective of this study is to determine if using both traditional qualitative LEMG measurements in addition to turns analysis improves prognostic accuracy in patients with acute vocal fold paralysis who demonstrate voluntary motor activity. STUDY DESIGN Retrospective review of LEMG data (qualitative and quantitative) and charts of patients with vocal fold paralysis on flexible laryngoscopy, recurrent laryngeal neuropathy, and varying degrees of motor unit recruitment. METHODS Laryngeal EMG using a standardized protocol involving qualitative (evaluation of recruitment, motor unit configuration, detection of fibrillations, synkinesis) and quantitative (turns analysis) measurements was performed. Prognosis was correlated with vocal fold motion recovery status (minimum of 6 months following onset) using positive and negative predictive values (PPV, NPV). RESULTS Twenty-three patients underwent LEMG for acute recurrent laryngeal neuropathy. All four patients with excellent LEMG prognosis recovered motion, whereas 17/19 patients with fair/poor LEMG prognosis were without motion at least 6 months following onset, resulting in a 100% PPV and 89.5% NPV. CONCLUSIONS Integrating both qualitative and quantitative LEMG data improves prognostic accuracy in vocal fold paralysis patients who demonstrate voluntary motor unit activity.
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Affiliation(s)
- Libby J Smith
- University of Pittsburgh Voice Center, Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh, Pittsburgh, Pennslyvania, USA.
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Aronow HU, Sharkey P, Siebens HC, Horn SD, Smout RJ, DeJong G, Munin MC, Radnay CS. Initial Recovery Trajectories Among Patients With Hip Fracture: A Conceptual Approach to Exploring Comparative Effectiveness in Postacute Care. PM R 2012; 4:264-72. [DOI: 10.1016/j.pmrj.2011.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 09/20/2011] [Accepted: 10/05/2011] [Indexed: 11/16/2022]
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Munin MC, Weber DJ, Skidmore ER. Letter by Munin et al regarding article, "Botulinum Toxin for the Upper Limb after Stroke (BoTULS) trial: effect on impairment, activity limitation, and pain". Stroke 2011; 42:e412; author reply e413. [PMID: 21636823 DOI: 10.1161/strokeaha.111.621219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Tian W, DeJong G, Munin MC, Smout R. Patterns of rehabilitation after hip arthroplasty and the association with outcomes: an episode of care view. Am J Phys Med Rehabil 2010; 89:905-18. [PMID: 20962601 DOI: 10.1097/phm.0b013e3181f1c6d8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To examine the patterns of rehabilitation after elective and nonelective hip arthroplasty and its association with outcomes over an episode of postacute care. DESIGN Data were obtained from a multisite prospective observational cohort study and its companion follow-up study. Patterns of care were measured by the combination of settings of care where hip arthroplasty patients received rehabilitation therapy. Main outcome measure was motor portion of the functional independence measure. RESULTS Approximately 90% of hip arthroplasty patients received rehabilitation care from more than one setting. Eight patterns of care were identified in the follow-up period. Patterns of subsequent care were driven more by initial setting than by etiology. Nonelective hip arthroplasty patients had lower motor functional independence measure scores and used more rehabilitation services than did elective hip arthroplasty patients. Patterns of care were modest factors (accounted for only 7% of variance) in predicting patient motor functional independence measure over an episode of postacute care. CONCLUSIONS Etiology of hip arthroplasty is associated with amounts of rehabilitation care used and outcomes. After the initial postacute rehabilitation setting, patients continued to receive considerable amounts of therapy in various settings. It is important to look beyond a single setting of care to an entire episode of care when examining clinical outcomes.
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Affiliation(s)
- Wenqiang Tian
- Center for Post-acute Studies, National Rehabilitation Hospital, Washington, DC 20010, USA
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Henzel MK, Munin MC, Niyonkuru C, Skidmore ER, Weber DJ, Zafonte RD. Comparison of surface and ultrasound localization to identify forearm flexor muscles for botulinum toxin injections. PM R 2010; 2:642-6. [PMID: 20659720 DOI: 10.1016/j.pmrj.2010.05.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Revised: 04/07/2010] [Accepted: 05/04/2010] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine if ultrasound (US) localization is equivalent to surface landmark localization to identify botulinum toxin injection targets for forearm muscle spasticity. DESIGN Observational. SETTING Outpatient spasticity clinic in a tertiary care center. SUBJECTS Eighteen patients with upper-extremity flexor spasticity that interferes with function were included. Individuals with severe fixed contractures or traumatic injury of the involved forearm were excluded. METHODS Flexor pollicis longus, flexor carpi radialis, pronator teres, and flexor digitorum superficialis (FDS) were identified by 2 separate localization techniques: the method of Delagi et al for flexor carpi radialis, pronator teres, and flexor pollicis longus; and a surface landmark technique by Bickerton et al to identify the 4 muscle bellies of FDS. Proximodistal and lateral (radial) coordinates were recorded relative to a landmark line from the medial epicondyle to pisiform bone, and percentage of landmark line distance was calculated. After surface measurements were collected, the best point for injection was determined by using real-time US with a 12-MHz linear transducer. US measurements were recorded by using the same landmark line system. RESULTS Localization techniques were compared by using the Wilcoxon signed rank test. One-sample t-tests compared surface-mapped lateral coordinates to US-derived lateral coordinates with controls for multiple testing. Significant differences were observed between surface and US proximodistal and lateral coordinates for several flexor muscles. CONCLUSIONS US should be considered as an adjunct for localization in patients with upper-limb spasticity. US can improve accuracy of toxin placement and help to avoid injection into vascular and nerve structures.
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Affiliation(s)
- M Kristi Henzel
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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Statham MM, Rosen CA, Nandedkar SD, Munin MC. Quantitative laryngeal electromyography: Turns and amplitude analysis. Laryngoscope 2010; 120:2036-41. [DOI: 10.1002/lary.21046] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Khan MI, Ingham SJ, Munin MC, Niyonkuru C. Poster 120: Impact of Heterotopic Ossification in Lower Limb Amputation Due to Traumatic and Nontraumatic Etiologies. PM R 2010. [DOI: 10.1016/j.pmrj.2010.07.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Weber DJ, Skidmore ER, Niyonkuru C, Chang CL, Huber LM, Munin MC. Cyclic functional electrical stimulation does not enhance gains in hand grasp function when used as an adjunct to onabotulinumtoxinA and task practice therapy: a single-blind, randomized controlled pilot study. Arch Phys Med Rehabil 2010; 91:679-86. [PMID: 20434603 DOI: 10.1016/j.apmr.2010.01.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 01/10/2010] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine whether onabotulinumtoxinA injections and task practice training with or without functional electrical stimulation (FES) improve upper limb motor function in chronic spastic hemiparesis. DESIGN Randomized controlled trial. SETTING Outpatient spasticity clinic. PARTICIPANTS Participants (N=23) had chronic spastic hemiparesis with moderate-severe hand impairment based on Chedoke-McMaster Assessment greater than or equal to 2. INTERVENTIONS OnabotulinumtoxinA injections followed by 12 weeks of postinjection task practice. Participants randomly assigned to FES group were also fitted with an orthosis that provided FES. MAIN OUTCOME MEASURES Motor Activity Log (MAL)-Observation was the primary outcome. Secondary outcomes were Action Research Arm Test (ARAT) and MAL-Self-Report. RESULTS For the entire cohort, MAL-Observation mean item scores improved significantly from baseline to week 6 (P=.005) but did not remain significant at week 12. MAL-Self-Report mean item scores improved significantly (P=.009) from baseline to week 6 and remained significantly higher (P=.014) at week 12. ARAT total scores also improved significantly from baseline to week 6 (P=.018) and were sustained at week 12 (P=.032). However, there were no significant differences between the FES and no-FES groups for any outcome variable over time. CONCLUSIONS Rehabilitation strategies that combine onabotulinumtoxinA injections and task practice therapy are feasible and effective in improving upper-limb motor function and reducing spasticity in patients with chronic spastic hemiparesis. However, the cyclic FES protocol used in this study did not increase gains achieved with the combination of onabotulinumtoxinA and task practice alone.
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Affiliation(s)
- Douglas J Weber
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, PA, USA
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