Ernest W. Johnson

Development of Gait in Childhood: Part II

Twenty‐eight children were filmed sequentially throughout the initial period of independent gait. Pelvic tilt and pelvic rotation were observed prior to independent gait or shortly thereafter. With few exceptions, heel strike, flexion at mid‐stance and a mature foot and knee mechanism appeared within 40 weeks following the initiation of independent gait. In every case, these characteristics were present by 55 weeks. The width of base narrowed within the lateral dimensions of the trunk and synchronous upper extremity movement was observed by this time also. It would appear that the adult pattern of gait appears significantly earlier than is generally accepted.

Rehabilitation of the Shoulder after Radical Neck Dissection

After classical radical neck dissection with removal of the sternocleidomastoid muscle and division of the spinal accessory nerve, there are certain disabling or disagreeable musculoskeletal defects. This paper describes the muscular deficiencies and gives a set of exercises which can be counted on to minimize the problems.

Development of Gait in Childhood. Part I: Method

An assessment of methods by which to study the development of independent locomotion in the child was made. Changes in the position of the hip and knee were measured directly from film frames and these measurements were compared with those obtained electro‐goniometrically. Electrogoniometry appeared to be the more accurate method.

Determining Neurapraxia in Carpal Tunnel Syndrome

In the evaluation of carpal tunnel syndrome by nerve conduction testing it is desirable to produce prognostic as well as diagnostic information. The finding of conduction block, or neurapraxia, is regarded as evidence that treatment can result in prompt recovery of nerve function. A technique is presented for stimulating the motor branch of the median nerve in the palm in order to detect the degree of neurapraxia due to entrapment in the carpus. In 23 normal subjects the response after palmar stimulation compared to a wrist stimulation site had a mean increase in amplitude of 0.56 mV. Persons affected with carpal tunnel syndrome had a mean amplitude increase of 2.2 mV demonstrating partial conduction block. The difference between these two values is statistically significant (P=0.001). The routine use of this method is recommended both for more accurate diagnosis and for evaluation of the degree of neurapraxia.

A preventable cause of foot drop during childbirth

Compression of the peroneal nerve is an uncommon complication of labor and delivery. We describe a case of common peroneal nerve injury associated with positioning the knees in hyperflexion during delivery. The pathophysiologic mechanisms, clinical course, and possible prevention of this uncommon complication are discussed.

Phrenic nerve stimulation in the evaluation of ventilator-dependent individuals with C4-and C5-level spinal cord injury

Strakowski JA, Pease WS, Johnson EW: Phrenic nerve stimulation in the evaluation of ventilator-dependent individuals with C4- and C5-level spinal cord injury. Am J Phys Med Rehabil 2007;86:153–157. Three individuals with C4 or C5 spinal cord injuries (SCI) were seen in follow-up for management of their late complications, which included impaired ventilation. Electrodiagnostic studies were performed on all three as part of the assessment of the function of their phrenic nerves and diaphragm muscles in relation to their need for mechanical ventilator support. Each patient had evidence of lower–motor neuron injury to the phrenic nerves. Two of the patients who initially displayed small-amplitude (<0.1 mV) compound muscle action potentials (CMAP) bilaterally were later reevaluated during the course of their observation in the outpatient rehabilitation clinic. The CMAP amplitude of the diaphragm increased in these two cases during the 3–11 mos after SCI. Evidence of nerve recovery occurred in parallel with improvements in pulmonary function testing and was followed by successful weaning from the ventilator. These individuals both gained ventilator independence after the CMAP amplitude of least one hemidiaphragm was >0.4 mV. In the third case, early failure of ventilator weaning was reported to the patient as a poor prognostic sign. At the time of our first evaluation 11 mos after injury, a CMAP of 1.0 mV was seen on the right, with an absent response on the left. In case 3, the needle electromyogram demonstrated voluntary active motor unit action potentials that provided additional electrophysiologic support for phrenic nerve function. Phrenic nerve–conduction studies can provide useful measures in assessing the recovery of lower–motor neuron diaphragm function in relation to impaired ventilation in individuals with C4- or C5-level SCI.

Rehabilitation of Football Players With Lumbar Spine Injury (Part 1 of 2).

In brief: Rehabilitation of football players with low back pain caused by injury is a comprehensive process. Accurate diagnosis followed by early intervention is necessary. The rehabilitation plan can be divided into two phases: the pain-control phase, discussed in this article, and the training phase, to be discussed in part 2 in a coming issue. The pain-control phase may include a variety of passive modalities, flexion or extension exercises, lumbar mobilization, traction, and selective (precise localization with precise center) injections. The author stresses the importance of understanding the anatomy and biomechanics of the lumbar spine, referred pain and potential pain generators, the stages of the degenerative process, and lumbar spine injuries when planning a rehabilitation program.

Acute common peroneal neuropathy due to hand positioning in normal labor and delivery.

BACKGROUND: Foot drop has been described as an infrequent complication from common peroneal nerve injury related to external compression and forceful knee flexion while pushing during vaginal delivery. Past recommendations include placing the hands at the posterior thighs rather than the legs to avoid this complication. CASE: A 32-year-old woman developed unilateral foot drop after vaginal delivery. Electromyography was diagnostic for an acute compression neuropathy of the common peroneal nerve above the knee. CONCLUSION: The patients likely mechanism of injury occurred during delivery from external compression by the patients dominant hand to the distal posterior thigh while under epidural anesthesia. Labor and delivery teams should be aware that nerve injury is also possible at the distal thigh with excessive external pressure.

Spinal nerve stimulation in S1 radiculopathy

The H reflex plays an important role in electrodiagnosis, but it does not give specific information about any particular segment of its long conduction pathway. Direct stimulation at the SI spinal nerve might provide more complete information by dividing the H reflex pathway into its peripheral and spinal conduction portions. Patients with electromyographic evidence of SI radiculopathy (n=77) and normal control subjects (n=56) were evaluated. Standard H reflex conduction studies were followed by monopolar needle stimulation of the first sacral spinal nerve. The ratio of the spinal nerve latency to the H reflex latency (SI ratio) was calculated. The abnormal SI ratio seen in 77% of the subjects suggested relative slowing within the spinal segment of the nerve. The remainder of the subjects with SI radiculopathy had slowed conduction also affecting the peripheral segment that could have been caused by Wallerian degeneration. The SI ratio can provide evidence that H reflex conduction slowing is the result of injury involving the intraspinal nerves. This technique should be especially useful in cases of acute lumbosacral injury when needle electromyographic study is often nondiagnostic.

H reflex and F wave latencies to soleus normal values and side-to-side differences.

Strakowski JA, Redd DD, Johnson EW, Pease WS: H reflex and F wave latencies to soleus normal values and side-to-side differences. Am J Phys Med Rehabil 2001;80:491–493. ObjectiveElectromyographers must reliably differentiate between H reflexes and F waves when recording from the soleus muscle in the evaluation of S1 radiculopathy. The use of F waves in root-level injuries is questioned, whereas H reflexes have shown value in the evaluation of S1 radiculopathy. We studied the relationship between the tibial H reflex and F wave latencies in the limbs of 40 subjects. DesignAfter recording the H wave latency, we changed the gain to 200 &mgr;V/cm and increased the stimulation to supramaximal for ten additional responses without moving the recording or stimulating electrodes. We also calculated the predicted H wave latency with the standard formula. Forty subjects, mean age 32 yr, consented and participated. ResultsThe mean of the average F wave was 1.76 ms longer than the ipsilateral H reflex latency. The mean side-to-side difference of the average F wave was 0.56 ms. The H reflex latency side-to-side difference was 0.36 ms. ConclusionThe findings suggest that the average F wave latencies have a predictive value in the clinical context similar to the H reflex.