The relation between lower extremity strength and shoulder overuse symptoms: a model based on polio survivors

Association Between Manual Loading and Newly Developed Carpal Tunnel Syndrome in Subjects With Physical Disabilities: A Follow-Up Study

OBJECTIVE

To identify the association between body composition and newly developed carpal tunnel syndrome (CTS) and to search for the best probabilistic cutoff value of associated factors to predict subjects with physical disabilities developing new CTS.

DESIGN

Longitudinal.

SETTING

University-affiliated medical center.

PARTICIPANTS

Subjects with physical disabilities (N=47; mean age ± SD, 42.1±7.7y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Median and ulnar sensory nerve conduction velocity (SNCV) were measured at the initial and follow-up tests (interval >2y). Total and regional body composition were measured with dual-energy x-ray absorptiometry at the initial test. Leg lean tissue percentage was calculated to delineate each participant's manual loading degree during locomotion. Leg lean tissue percentage is the lean tissue mass of both legs divided by body weight.

RESULTS

Based on median SNCV changes, we divided all participants into 3 groups: subjects with bilateral CTS (median SNCV value <45m/s plus a normative ulnar SNCV value >37.8m/s) in the initial test (n=10), subjects with newly developed CTS in the follow-up test (n=8), and subjects without additional CTS in the follow-up test (n=27). Eight of 35 subjects not having bilateral CTS initially developed new CTS (8.8% per year; mean follow-up period, 2.6y). Leg lean tissue percentage was associated with the probability of newly developed CTS (adjusted odds ratio, .64; P<.05). Subjects with a leg lean tissue percentage >12% were less likely to have developed new CTS at the follow-up test (sensitivity, .75; specificity, .85; area under the curve, .88; P<.005).

CONCLUSIONS

Leg lean tissue percentage may be useful for early identification of developing new CTS in subjects with physical disabilities. Therefore, a preventive program for those subjects at risk can start early.

Does a subgroup of postpolio patients need different management?

Throughout the 30 years of postpolio syndrome (PPS) research, there have been many puzzling anomalies in the data and not enough information to make sense of them. It is therefore welcome that Winberg et al have examined physical activity in relation to life satisfaction, sex and age. They hypothesized that activity would decrease with age and found the opposite. This result is not so surprising as Ostlund et al found that vitality was associated with older age and that younger age was associated with more pain, increasing physical fatigue, decreasing sleep quality and reducing activity. This commentary will examine past postpolio research with unexpected results in order to describe a subgroup of patients who may be more susceptible to overusing muscles and have particular exercise and activity needs.

Prevalence and determinants of pain in the ipsilateral upper limb of stroke patients

This study investigated the prevalence of pain in the ipsilateral upper-limb in stroke patients. 229 stroke patients (133 men, 96 women; M age = 59.0 yr., SD = 12.4) were assessed with the Pain Behaviors Scales and their motor weakness was measured with the Motricity Index. Results indicated that over 27% of patients experienced pain in at least one joint of the ipsilateral upper limb. Shoulder pain was the most common. Further analysis indicated that the occurrence of pain in the ipsilateral upper limb was higher among women, among patients who used a cane, and among patients with a greater weakness of the affected lower limb.

A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications

The term 'regional interdependence' or RI has recently been introduced into the vernacular of physical therapy and rehabilitation literature as a clinical model of musculoskeletal assessment and intervention. The underlying premise of this model is that seemingly unrelated impairments in remote anatomical regions of the body may contribute to and be associated with a patient's primary report of symptoms. The clinical implication of this premise is that interventions directed at one region of the body will often have effects at remote and seeming unrelated areas. The formalized concept of RI is relatively new and was originally derived in an inductive manner from a variety of earlier publications and clinical observations. However, recent literature has provided additional support to the concept. The primary purpose of this article will be to further refine the operational definition for the concept of RI, examine supporting literature, discuss possible clinically relevant mechanisms, and conclude with a discussion of the implications of these findings on clinical practice and research.

Physical therapist management following rotator cuff repair for a patient with postpolio syndrome

BACKGROUND AND PURPOSE

Postpoliomyelitis sequelae, such as gait instability and progressive weakness, predispose people with postpolio syndrome to secondary disabilities. With aging, people who depend on their upper extremities to accommodate lower-extremity deficits may anticipate overuse injuries. The purpose of this case report is to describe the use of mobilization and exercise in postoperative rehabilitation of rotator cuff surgery on a patient with postpolio syndrome.

CASE DESCRIPTION

A 48-year-old woman with postpolio syndrome had rotator cuff surgical repair followed by physical therapy intervention. Maitland mobilization and mild functional exercises were chosen to avoid triggering fatigue.

OUTCOMES

Measurements taken preoperatively, before and after physical therapy intervention, and 2 years after intervention showed return to independent status with excellent retention.

DISCUSSION

No fatigue or overuse weakness was encountered. This is the first case report to document physical therapy following rotator cuff repair in a patient with postpolio syndrome.

Musculoskeletal pain in polio survivors and strength-matched controls

OBJECTIVES

To determine whether a significant difference exists between musculoskeletal symptoms of polio survivors and those of older adults with no history of polio, and to determine if activity level and strength predict pain in either group.

DESIGN

Matched research design.

SETTING

A research laboratory in a rehabilitation setting.

PARTICIPANTS

Fifty-four polio survivors and 54 adults with no history of polio were matched for gender, race, and bilateral knee extensor strength and selected from a cohort of 316 subjects who participated in a study on the relation between activity level and health status.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Location and severity of musculoskeletal pain, activity frequency and intensity level, maximum voluntary isometric strength, and physical performance measures.

RESULTS

Polio survivors reported significantly more symptoms than the matched controls ( P <.05). Symptom status among the polio survivors was strongly associated with performance strain, perceived exertion, and activity intensity. Although the polio survivors had activity frequencies and habitual walking speeds that were similar to those from the matched controls, there was evidence that they performed activities at higher intensity levels.

CONCLUSIONS

Activity level is a factor in the development of musculoskeletal symptoms in polio survivors. Polio survivors who perform at higher intensity levels are more likely to have moderate to severe pain and more mobility difficulties.

Post-Polio Syndrome

Post-polio syndrome (PPS) is the term used for the new late manifestations that occur in patients 30 to 40 years after the occurrence of acute poliomyelitis. PPS has been recognized for over 100 years, but is more common at the present time because of the large epidemics of poliomyelitis in the 1940s and 1950s. PPS is manifested by neurologic, musculoskeletal, and general manifestations. Neurologic manifestations include new weakness, muscle atrophy, dysphagia, dysphonia, and respiratory failure. Musculoskeletal manifestations include muscle pain, joint pain, spinal spondylosis and scoliosis, and secondary root and peripheral nerve compression. General manifestations include generalized fatigue and cold intolerance. New muscle weakness of a mild-to-moderate degree responds well to a nonfatiguing exercise program and pacing of activity with rest periods to avoid muscle overuse. Generalized fatigue may be treated with energy conservation and weight loss programs and lower extremity orthoses. Pharmacologic agents also may be helpful, but have not been beneficial in controlled trials. Bulbar muscle weakness includes dysphagia, dysphonia, sleep disorders, and chronic respiratory failure. Dysphagia may be improved with instruction on compensatory swallowing techniques. Dysphonia is treated with voice exercise therapy and voice amplification devices. Sleep disorders are treated similarly to sleep disorders in non-PPS patients. Respiratory failure may be treated with continuous positive airway pressure, bilevel positive airway pressure, and nasal ventilation, or tracheotomy and permanent ventilation if necessary. Musculoskeletal (muscle and joint) pain is treated with weight loss, pacing of activities, use of assistive devices, and prescribing anti-inflammatory medications and physical therapy techniques. Cardiopulmonary conditioning can be improved without muscle overuse with cycle or arm ergometer exercise or dynamic aquatic exercise.

A comparison of the effects of exercise and lifestyle modification on the resolution of overuse symptoms of the shoulder in polio survivors: a preliminary study

OBJECTIVE

To compare the effectiveness of exercise and lifestyle modification therapy in treating shoulder symptoms in polio survivors with lower-extremity weakness.

DESIGN

A randomized parallel group study.

SETTING

Research laboratory.

PARTICIPANTS

Twenty-three subjects recruited from a cohort of 194 polio survivors who had participated in a previous study had bilateral hip-extensor and knee-extensor weakness and reported experiencing shoulder pain on a regular basis with daily activity.

INTERVENTIONS

Subjects were randomly assigned to 1 of 3 treatment groups. Members of group 1 were placed on a home exercise program that focused on strengthening their hip and knee extensors. Members of group 2 were instructed in lifestyle modification techniques designed to avoid shoulder overuse. Members of group 3 received both interventions.

MAIN OUTCOME MEASURES

Shoulder symptoms were quantified in terms of number and severity. Isometric strength of bilateral hip and knee extensors was measured with a hand-held dynamometer.

RESULTS

Symptoms improved in all 3 groups. However, members of the exercise-only group (group 1) were the only ones to show a significant difference in both number and severity of symptoms when pre- and posttreatment values were compared.

CONCLUSIONS

Both exercise and lifestyle modification therapies that focus on reducing the stress related to lower-extremity weakness are effective in treating shoulder overuse symptoms in polio survivors. A trend toward greater improvement in shoulder symptoms in subjects who participated in the exercise program and who also showed a trend toward increased knee-extensor strength supports muscle strength and/or endurance as a key factor.