Andrew Travlos

Quantification of Pronator Quadratus Contribution to Isometric Pronation Torque of the Forearm

PURPOSE The contribution of the pronator quadratus (PQ) muscle in generation of pronation torque has not been determined. The purpose of this study was to investigate pronation torque in healthy volunteers before and after temporary paralysis of the PQ with lidocaine, under electromyographic guidance. METHODS A custom apparatus was designed to allow isometric testing of pronation torque at 5 positions of rotation: 90 degrees of supination, 45 degrees of supination, neutral, 45 degrees of pronation, and 80 degrees of pronation. After validation of the apparatus, 17 (9 male, 8 female) right-hand-dominant volunteers were recruited. They were tested at all 5 positions in random order and then had their PQ muscles paralyzed with lidocaine. Repeat testing was performed in the same random order 30 minutes after injection. Three unblinded subjects underwent testing after injection of saline instead of lidocaine to determine effect of fluid volume alone on PQ function. RESULTS The validation trial demonstrated reproducibility of the testing apparatus. After paralysis of PQ with lidocaine, pronation torque decreased by an average 21% (range, 16.7% to 23.2%) at all positions compared with preinjection testing. All were statistically significant except at 80 degrees of pronation. The subjects who underwent injection of saline showed no evidence of decrease in pronation torque. CONCLUSIONS This study demonstrated a significant decrease in pronation torque with controlled elimination of PQ function. Open reduction and internal fixation of distal radius fractures damages the PQ and may result in a pronation torque deficit. Pronation torque measurement may help in postoperative outcome analysis of surgical procedures using the volar approach to the distal radius.

Botulinum toxin injection for management of thoracic outlet syndrome: A double-blind, randomized, controlled trial

Summary Botulinum toxin injections to the scalene muscles did not reduce pain in subjects with thoracic outlet syndrome in this double‐blind, randomized, controlled trial. ABSTRACT We studied the effect of botulinum toxin type A (BTX‐A) injections to the scalene muscles on pain in subjects with thoracic outlet syndrome (TOS) in this double‐blind, randomized, parallel group trial with follow‐up at 6 weeks, 3 months, and 6 months. Thirty‐eight patients referred to physiatrists for management of TOS with BTX‐A injection were included. One subject was lost to follow‐up and all other subjects completed the trial. A 75‐unit dose of BTX‐A reconstituted with 0.75 cc of normal saline was injected to the anterior scalene (37.5 units) and middle scalene (37.5 units) muscles using electromyographic guidance. The primary outcome measure was pain as measured on a horizontal visual analog scale (VAS) 6 weeks‐post‐injection. Secondary outcomes were paresthesias measured on a VAS and function measured with the Disabilities of the Arm, Shoulder and Hand (DASH) and Short‐form 36 (SF‐36) questionnaires. For the primary outcome measure of VAS scores for pain at 6 weeks, the difference in the means adjusted for baseline VAS scores between placebo and BTX‐A was 5.03 mm in favor of BTX‐A (95% confidence interval −15.7 to 5.7, P = .36). Changes in secondary outcome measures were also not statistically significant. We conclude that BTX‐A injections to the scalene muscles did not result in clinically or statistically significant improvements in pain, paresthesias, or function in this population of subjects with TOS.

A Review of Thoracic Outlet Syndrome and the Possible Role of Botulinum Toxin in the Treatment of This Syndrome

The objective of this paper is to discuss the classification, diagnosis, pathophysiology and management of Thoracic outlet syndrome (TOS). Thoracic outlet syndrome (TOS) is a complex entity that is characterized by different neurovascular signs and symptoms involving the upper limb. TOS is defined as upper extremity symptoms due to compression of the neurovascular bundle in the area of the neck just above the first rib. Compression is thought to occur at one or more of the three anatomical compartments: the interscalene triangle, the costoclavicular space and the retropectoralis minor spaces. The clinical presentation can include both neurogenic and vascular symptoms. TOS can be difficult to diagnose because there is no standardized objective test that can be used and the clinician must rely on history and several positive findings on physical exam. The medial antebrachial cutaneous nerve conduction may be a sensitive way to detect pathology in the lower trunks of the brachial plexus which is promising for future research. Treatment options continue to be conservative and surgical. However, for those who have failed physical therapy there is research to suggest that botulinum toxin may help with symptom relief. However, given that there has been conflicting evidence, further research is required using randomized controlled trials.

Cerebrospinal fluid cell count following spinal cord injury

Cerebrospinal fluid (CSF) changes after spinal cord injury (SCI) were evaulated by retrospective analysis of all patients admitted to the Acute Spinal Cord Injury Unit (ASCIU) at University Hospital, Shaughnessy Site in Vancouver, British Columbia. A total of 1,917 admissions occurred during the 10-year study period with 1,151 due to acute trauma. The charts of all patients with SCI due to trauma were reviewed to identify patients in whom a CSF puncture was performed for any reason. Traumatic SCI is associated with elevations in the corrected white blood cell count (cWBC) that we believe reflect an inflammatory response to injury. The elevation in cWBC is greatest in the first week after injury. Elevations in cWBC more than 1 week after injury do occur but are uncommon. The white cell differential count consists primarily of lymphocytes and polymorphonucleocytes. Three weeks after injury cell counts should be normal. Protein levels are elevated after trauma and should not be used to assess the presence of infection. LP should be part of the septic workup of SCI patients just as it would be for any other population if meningitis is a consideration.

Assessing and predicting successful tube placement outcomes in ALS patients.

This study reviews feeding tube placement outcomes in 69 ALS outpatients seen at an outpatient interdisciplinary ALS clinic in British Columbia, Canada. The objective was to determine at which point the risks outweigh the benefits of tube placement by reviewing outcomes against parameters of respiratory function, nutritional status and speech and swallowing deterioration. The study was a retrospective review of tube placements between January 2000 and 2005, analysing data on respiratory function (forced vital capacity and respiratory status), weight change from usual body weight (UBW) and speech/swallowing deterioration using ALS Severity Score ratings (Hillel et al., 1989) at time of tube placement. Results show a statistically significant association between nutritional status and successful tube placement outcomes (p=0.003), and none between respiratory status, speech/swallowing variables, or number of deteriorated variables in each patient. Study findings were impacted by lack of available respiratory data. The only study variable that predicted successful tube placement outcome was a body weight greater than or equal to 74% UBW at time of tube placement. In the absence of access to respiratory testing, the relatively simple assessment of weight may assist patients and caregivers in appropriate decisions around tube placement.

Nonneurologic hand pain versus carpal tunnel syndrome: do psychological measures differentiate?

Crossman MW, Gilbert CA, Travlos A, Craig KD, Eisen A: Nonneurologic hand pain versus carpal tunnel syndrome: do psychological measures differentiate? Am J Phys Med Rehabil 2001;80:100–107. ObjectiveTo determine whether psychological measures would differentiate a group of patients with physician-diagnosed nonneurologic hand pain from patients with carpal tunnel syndrome (CTS). Many patients, who also displayed symptoms of psychological distress, were referred to an electrodiagnostic clinic with a diagnosis of possible CTS; they subsequently had normal nerve conduction studies. DesignSixty patients with hand pain were referred to either of two university clinics for electrophysiologic testing, were assigned to either the CTS or nonneurologic group, and were compared on a series of psychometric tests. ResultsThe Beck Depression Inventory and McGill Pain Questionnaire showed that the physician-assigned nonneurologic patients have a greater degree of depression, use more affective adjectives, and choose more words on the McGill Pain Questionnaire than the physician-assigned CTS group. The nonneurologic group also scored higher on indices of self-reported disability on the Pain Disability Inventory in five of seven categories. Although the CTS group perceived more control over their pain, no differences were observed in the types of coping strategies used on the Coping Strategy Questionnaire. Finally, the nonneurologic group had more Workers’ Compensation Board claims. ConclusionEvidence of important psychological issues in some patients with hand pain suggests a need for greater awareness among treating physicians.

Contribution of Flexor Pollicis Longus to Pinch Strength: An In Vivo Study

PURPOSE To estimate the contribution of the flexor pollicis longus (FPL) to key pinch strength. Secondary outcomes include tip pinch, 3-point chuck pinch, and grip strength. METHODS Eleven healthy volunteers consented to participate in the study. We recorded baseline measures for key, 3-point chuck, and tip pinch and for grip strength. In order to control for instability of the interphalangeal (IP) joint after FPL paralysis, pinch measurements were repeated after immobilizing the thumb IP joint. Measures were repeated after subjects underwent electromyography-guided lidocaine blockade of the FPL muscle. Nerve conduction studies and clinical examinations were used to confirm FPL blockade and to rule out median nerve blockade. Paired t-tests were used to compare pre- and postblock means for both unsplinted and splinted measures. The difference in means was used to estimate the contribution of FPL to pinch strength. RESULTS All 3 types of pinch strength showed a significant decrease between pre- and postblock measurements. The relative contribution of FPL for each pinch type was 56%, 44%, and 43% for key, chuck, and tip pinch, respectively. Mean grip strength did not decrease significantly. Splinting of the IP joint had no significant effect on pinch measurements. CONCLUSIONS FPL paralysis resulted in a statistically significant decrease in pinch strength. IP joint immobilization to simulate IP joint fusion did not affect results. CLINICAL RELEVANCE Reconstruction after acute or chronic loss of FPL function should be considered when restoration of pinch strength is important.

Poster 117: Severe complex regional pain syndrome type I managed with amputation: a case report.1

Abstract Setting: University hospital. Patient: A 22-year-old woman with complex regional pain syndrome type I (CRPS I). Case Description: The patient developed CRPS I in her dominant upper extremity after a motor vehicle collision. This caused severe pain and dysfunction, recurrent subluxation of the shoulder, and flexion deformities in the hand. Symptoms were aggressively treated on an inpatient and outpatient basis with conventional therapies as well as botulinum toxin type A (Botox) injections into the pectoral muscles and the finger flexors. Ultimately, 4 years after the onset of symptoms when the disease had plateaued, she was managed with amputation of 2 fingers. Assessment/Results: Botox was ineffective in the hand, but was helpful in reducing shoulder subluxations. Amputation resulted in significant improvements in hand function, but did not eliminate other signs and symptoms of the disorder, nor did it flare the disease process. Discussion: CRPS I may follow a severe and protracted course requiring a creative and multidisciplinary approach to management. Our use of Botox was likely unsuccessful in the hand because of contracture formation. Amputation for CRPS I is highly controversial, due in part to the potential for exacerbation or recurrence of symptoms and phantom limb pain. In this case, the explicit goal of amputation was to improve hand function with little expectation of cure of CRPS I. Conclusions: Consideration may be given to amputation in patients with CRPS I if the disease has plateaued and there is a clear indication for improvement of residual function rather than pain relief.

Impact of Critical Illness Polyneuromyopathy in Rehabilitation: A Prospective Observational Study.

Critical illness polyneuromyopathy (CIPNM) increasingly is recognized as a source of disability in patients requiring intensive care unit (ICU) admission. The prevalence and impact of CIPNM on patients in the rehabilitation setting has not been established.

Poster 276 Impact of Critical Illness Polyneuromyopathy in Rehabilitation: A Prospective Observational Pilot Study

Disclosures: C. Cunningham: I Have No Relevant Financial Relationships To Disclose. Objective: To determine the prevalence and functional impact of Critical Illness Polyneuromyopathy (CIPNM) on inpatient rehabilitation. Design: Prospective observational study. Setting: Inpatient rehabilitation. Participants: Participants had ICU admission 72 hours, were admitted to inpatient rehabilitation from 2013-2014, were 19 years old, had no contraindications to electromyography or nerve conduction studies (EMG/NCS), and had no known history of neuropathy, myopathy, neuromuscular junction disorder or diabetes. Interventions: EMG/NCS to evaluate for axonal neuropathy and/or myopathy in at least one upper and one lower limb. Main Outcome Measures: Primary outcome measure was prevalence of CIPNM. Secondary outcome measures were Functional Independence Measure (FIM) scores at admission and discharge, FIM gain, FIM efficiency, rehabilitation length of stay and discharge disposition. Results or Clinical Course: 33 participants were enrolled. 23 (69.7%) had evidence of CIPNM. Average admission FIM score, discharge FIM and FIM gain were 60.0, 97.5 and 30.2 in those with CIPNM versus 74.8, 102.8 and 15.5 in those without. FIM efficiency was 0.37 in both groups. Average rehabilitation length of stay was 117 days versus 63 days and discharge to home was 43% versus 80% in the CIPNM and nonCIPNM groups, respectively. Conclusion: Our results suggest that CIPNM is very common in rehabilitation inpatients with a history of ICU admission. CIPNM is associated with lower admission FIM scores. Discharge FIM scores were similar between groups, but those with CIPNM had longer lengths of stay and were less likely to be discharged home. Our results will enable design of appropriately powered future studies to further determine the impact of CIPNM on rehabilitation outcomes.