William P. Waring

Compressive mononeuropathies of the upper extremity in chronic paraplegia

Controversy exists with regard to the actual prevalence of compressive mononeuropathies at the wrist which may occur following chronic paraplegia. Thirty one chronic paraplegics, with a mean age of 37.9 years (range 20–68 years), and mean time since injury of 9.7 years (range 1–28 years), were studied with a comprehensive neurologic and electrodiagnostic (EDX) assessment. No patient had any clinical or EDX evidence of a peripheral polyneuropathy. The diagnosis of a median mononeuropathy at the wrist was determined by the following criteria: (a) prolonged median sensory distal latency > ipsilateral ulnar sensory distal latency ≥ 0.5 msec; (b) a median mid-palmar sensory latency > ipsilateral ulnar mid-palmar sensory latency of ≥ 0.3 msec; or (c) a median motor distal latency ≥ 1.7 milliseconds as compared to the ipsilateral ulnar motor distal latency. Ulnar mononeuropathy at the wrist or across the elbow was also characterised. The EDX criteria for a median mononeuropathy at the wrist was met in 55% of subjects (24% of these with bilateral presentations). The location of ulnar mononeuropathies included: two at the superficial sensory branch at the wrist, one at the deep motor branch at the wrist, and three patients with a conduction block across the elbow. Overall, 67% of all patients tested had evidence of at least one mononeuropathy of the upper extremity.There was no association between prevalence of compressive mononeuropathies and age of the patient or time since onset of injury.

Shoulder pain in acute traumatic quadriplegia

Fifty two patients with traumatic quadriplegia admitted to a spinal cord injury program within 6 months of injury were studied retrospectively. Seventy five per cent had shoulder pain documented in their medical records during initial rehabilitation, and 60% had shoulder pain for 2 weeks or more. When shoulder pain was documented it was bilateral in 61% of the cases. Age greater than 50 years, decreased shoulder range of motion, and not receiving shoulder exercise during the first 2 weeks after injury were positive risk factors associated with the onset of shoulder pain. At discharge 42% of the patients with shoulder pain were pain-free, 35% were noted to have improvement of their pain, and 23% had the same or worse shoulder pain. Study results demonstrate the high incidence of shoulder pain during initial rehabilitation of patients with traumatic quadriplegia and the importance of starting shoulder exercises during early acute care.

THE INTEROBSERVER RELIABILITY OF THE REVISED AMERICAN SPINAL INJURY ASSOCIATION STANDARDS FOR NEUROLOGICAL CLASSIFICATION OF SPINAL INJURY PATIENTS

To test the interobserver reliability of clinicians using the American Spinal Injury Associations 1989 revised “Standards for Neurological Classification of Spinal Injury Patients,” two quizzes were given to 15 house officers and physician faculty members of a department of Physical Medicine and Rehabilitation. The first quiz consisted of five spinal cord injury cases of varying degrees of complexity. The participants were asked to classify each case with respect to sensory level, motor level, zone of injury and Frankel classification by using the original standards. Two months later, after a brief explanation of the significant changes in the revised standards, the same group was given five slightly different cases to classify. With the use of the 1989 revision of the standards, the percent correct improved for Frankel grade (65–81%), motor level (59-85%), sensory level (71–93%) and zone of injury (31–89%). Many of the same type of errors were repeated in both quizzes, i.e., T-12 and L-1 sensory level distinction and the classification of thoracic motor levels. We conclude that the interobserver reliability for the revised ASIA standards, although improved, continues to be less than optimal. We recommend that changes clarifying sensory levels near the inguinal ligament and motor level classification with very incomplete injuries be made in the standards. In addition, training methods should be developed to improve the interobserver reliability of the standards when they are used by clinicians and researchers

Risk Factors for Median Mononeuropathy of the Wrist in Postpoliomyelitis Patients

There is evidence that chronic cane, crutch, and wheelchair users are at increased risk for developing pain and functional compromise of the wrist and hand. This investigation examined the prevalence and risk factors for median mononeuropathy at the wrist in the postpoliomyelitis population. The medical records of 148 consecutive patients with histories of poliomyelitis were reviewed. Forty-nine percent of this cohort had complaints of wrist pain. The prevalence rate of carpal tunnel syndrome was 22% (n = 33). Age, sex, duration of disability, and work history did not significantly influence the relative risk of developing this disorder. However, the relative risk of developing this compression neuropathy at the wrist by using the combination of a cane and/or a crutch and a wheelchair was 4.86 (95% confidence interval 2.35-10.06). The high risk associated with chronic cane, crutch, and wheelchair use shows the need for developing preventive strategies.

Clinical management of carpal tunnel syndrome in patients with long-term sequelae of poliomyelitis***

Thirty-three patients with long-term sequelae of poliomyelitis with a diagnosis of carpal tunnel syndrome established by either abnormal nerve conduction studies or previous carpal tunnel surgery were surveyed. There was no significant long-term resolution of symptoms in the patients who had surgery (n = 9) or were currently using wrist orthoses (n = 11) compared with patients without such treatment (n = 13). In patients who used a single cane or those who used crutches (N = 10), there was a direct correlation between the hand holding the cane or crutch and the hand in which carpal tunnel syndrome developed. The chronic use of cane and crutch predisposes these patients to development of carpal tunnel syndrome, and caution should be used when considering wrist surgery.

Serum creatine kinase in the post-polio population

Elevated creatine kinase (CK) levels may be noted in neuromuscular patients as a result of muscle damage and necrosis. We measured the serum CK levels of 62 post-polio patients with chronic neurologic disease (Neuro) and 13 post-polio patients with no evidence of neurologic compromise (Control). Patient groups were comparable for age, gender and years since onset of poliomyelitis. The Neuro group had substantially increased CK levels compared with the Control group, 211 ± 19.0 IU v 114 ± 26.2 IU (mean ± 1 SE; P<0.05). Of the Neuro group, 40% had abnormally elevated CK values, compared with 8% of the Control group. Within the Neuro group, there was a robust correlation between elevated CK values and self-reports of strenuous work and level of community ambulation (P<0.05). These findings support the hypothesis that chronic muscle overuse may be a contributing factor to the advanced senescence reported by post-polio patients with neuromuscular compromise.

Evaluation, Treatment, and Follow-Up Results of Post Polio Patients with Dysphagia

Twenty consecutive patients were evaluated for reports of dysphagia from post-polio clinics. Only half the patients reported a history of swallowing problems at the time of their acute poliomyelitis. Each patient received a videofluorographic evaluation of the oral and pharyngeal phases of swallowing, and then was provided with recommendations to improve swallowing skills. A follow-up questionnaire was sent to all patients. The respondents had an average interval of 12 months since the initial evaluation. Of the 18 patients responding to the questionnaire, 14 (77%) reported regular use of the swallowing suggestions. Comparison of pre-evaluation results to followup of the18 respondents yielded a statistically significant decline in the frequency of choking (p = 0.0156) and food sticking in the throat (p = 0.0195). We conclude that a dysphagia program can result in significant improvement of the swallowing symptoms reported with the post-polio population.