Ultrasound-guided-electromyography in plegic muscle: Usefulness of nerve stimulation

INTRODUCTION/AIMS

In traumatic nerve lesions (TNLs), motor unit potentials (MUPs) may be difficult to detect in early injury. Ultrasound-guided electromyography (US-EMG) can aid in identifying areas of muscle activation, but its sensitivity can be improved. In this study we compare the sensitivity of US-EMG alone with US-EMG after peripheral nerve stimulation (NC-US-EMG) to better identify active muscle regions.

METHODS

In this prospective study, 32 patients with severe TNLs were evaluated with standard EMG (ST-EMG), US-EMG, and NC-US-EMG at baseline (T0), after 2 to 3 months (T1), and after 5 to 6 months (T2).

RESULTS

NC-US-EMG was more sensitive in detecting MUPs compared with US-EMG and ST-EMG at T0 (19 patients vs 14 and 5 patients, respectively). In addition, both US-guided techniques were more sensitive than ST-EMG in detecting MUPs (ST-EMG vs US-EMG: P = .014; ST-EMG vs NC-US-EMG: P = .003). At T1, ST-EMG remained less sensitive NC-US-EMG (P = .019). No significant differences were observed among the three techniques at T2.

DISCUSSION

In the evaluation of severe TNLs, the combination of peripheral nerve stimulation and US increases the sensitivity of EMG for MUP detection at baseline and 2 to 3 months postinjury.

Intensive Care Unit-Acquired Weakness and Positioning-Related Peripheral Nerve Injuries in COVID-19: A Case Series of Three Patients and the Latest Literature Review

A subgroup of COVID-19 patients requires intensive respiratory care. The prolonged immobilization and aggressive treatments predispose these patients to develop intensive care unit-acquired weakness (ICUAW). Furthermore, this condition could increase the chance of positioning-related peripheral nerve injuries. On the basis of the latest literature review, we describe a case series of three patients with COVID-19 who developed ICUAW complicated by positioning-related peripheral nerve injuries Every patient presented sensorimotor axonal polyneuropathy and concomitant myopathy in electrophysiological studies. Furthermore, muscle MRI helped the diagnosis of ICUAW, showing massive damage predominantly in the proximal muscles. Notably, nerve ultrasound detected positioning-related peripheral nerve injuries, even though the concomitant ICUAW substantially masked their clinical features. During the acute phase of severe COVID-19 infection, most medical attention tends to be assigned to critical care management, and neuromuscular complications such as ICUAW and positioning-related peripheral nerve injuries could be underestimated. Hence, when starting post-ICU care for COVID-19 cases, the combination of electrophysiological and imaging studies will aid appropriate evaluation on the patients with COVID-19-related ICUAW.

Personalized Clinical Phenotyping through Systems Medicine and Artificial Intelligence

Personalized Medicine (PM) has shifted the traditional top-down approach to medicine based on the identification of single etiological factors to explain diseases, which was not suitable for explaining complex conditions. The concept of PM assumes several interpretations in the literature, with particular regards to Genetic and Genomic Medicine. Despite the fact that some disease-modifying genes affect disease expression and progression, many complex conditions cannot be understood through only this lens, especially when other lifestyle factors can play a crucial role (such as the environment, emotions, nutrition, etc.). Personalizing clinical phenotyping becomes a challenge when different pathophysiological mechanisms underlie the same manifestation. Brain disorders, cardiovascular and gastroenterological diseases can be paradigmatic examples. Experiences on the field of Fondazione Policlinico Gemelli in Rome (a research hospital recognized by the Italian Ministry of Health as national leader in "Personalized Medicine" and "Innovative Biomedical Technologies") could help understanding which techniques and tools are the most performing to develop potential clinical phenotypes personalization. The connection between practical experiences and scientific literature highlights how this potential can be reached towards Systems Medicine using Artificial Intelligence tools.

Cortical connectivity from EEG data in acute stroke: A study via graph theory as a potential biomarker for functional recovery

Cerebral post-stroke plasticity has been repeatedly investigated via functional neuroimaging techniques mainly based on blood flow/metabolism. However, little is known on predictive value of topological properties of widely distributed neural networks immediately following stroke on rehabilitation outcome and post-stroke recovery measured by early functional outcome. The utility of EEG network parameters (i.e. small world organization) analysis as a potential rough and simple biomarker for stroke outcome has been little explored and needs more validation. A total of 139 consecutive patients within a post-stroke acute stage underwent EEG recording. A group of 110 age paired healthy subjects constituted the control group. All patients were clinically evaluated with 3 scales for stroke: NIHSS, Barthel and ARAT. As a first result, NIHSS, Barthel and ARAT correlated with Small World index as provided by the proportional increment/decrement of low (delta) and viceversa of high (beta2 and gamma) EEG frequency bands. Furthermore, in line with the aim of the present study, we found a strong correlation between NIHSS at follow up and gamma Small World index in the acute post-stroke period, giving SW index a significant weight of recovery prediction. This study aimed to investigate possible correlations between functional abnormalities of brain networks, measured by small world characteristics detected in resting state EEG source investigation, and early post-stroke clinical outcome in order to find a possible predictive index of functional recovery to address and/or correct the rehabilitation program.

Immediate effects of rhythmic auditory stimulation on gait kinematics in Parkinson's disease ON/OFF medication

OBJECTIVE

Gait impairment is a highly disabling symptom for Parkinson's disease (PD) patients. Rhythmic auditory stimulation (RAS), has shown to improve spatio-temporal gait parameters in PD, but only a few studies have focused on their effects on gait kinematics, and the ideal stimulation frequency has still not been identified.

METHODS

We enrolled 30 PD patients and 18 controls. Patients were evaluated under two conditions (with (ON), and without (OFF) medications) with three different RAS frequencies (90%, 100%, and 110% of the patient's preferred walking cadence). Spatial-temporal parameters, joint angles and gait phases distribution were evaluated. A novel global index (GPQI) was used to quantify the difference in gait phase distribution.

RESULTS

Along with benefits in spatial-temporal parameters, GPQI improved significantly with RAS at a frequency of 110% for both ON and OFF medication conditions. In the most severe patients, the same result was observed also with RAS at 100%.

CONCLUSIONS

RAS administration, at a frequency of 110% of the preferred walking frequency, can be beneficial in improving the gait pattern in PD patients.

SIGNIFICANCE

When rhythmic auditory stimulation is provided to patients with PD, the selection of an adequate frequency of stimulation can optimize their effects on gait pattern.

Ultrasound Diagnosis of Postoperative Complications of Nerve Repair

BACKGROUND

Peripheral nerve injuries often undergo surgical repair, but poor postoperative functional recovery is frequently observed.

CASE DESCRIPTION

We describe 4 cases of traumatic nerve lesions in whom postoperative recovery was prevented by complications such as detachment of nerve sutures or neuroma growth. To the best of our knowledge, no similar cases have been reported in literature so far. It is important to obtain an early diagnosis of such condition because it prevents recovery and delays reintervention, which should be performed before complete muscle denervation and atrophy.

CONCLUSION

Nerve ultrasound is a valuable tool in traumatic nerve injury and has proven to be useful in postoperative follow-up, especially in diagnosing surgical complications such as detachment of nerve direct sutures.

Carpal tunnel syndrome: clinical features, diagnosis, and management

Carpal tunnel syndrome is the most common peripheral nerve entrapment syndrome worldwide. The clinical symptoms and physical examination findings in patients with this syndrome are recognised widely and various treatments exist, including non-surgical and surgical options. Despite these advantages, there is a paucity of evidence about the best approaches for assessment of carpal tunnel syndrome and to guide treatment decisions. More objective methods for assessment, including electrodiagnostic testing and nerve imaging, provide additional information about the extent of axonal involvement and structural change, but their exact benefit to patients is unknown. Although the best means of integrating clinical, functional, and anatomical information for selecting treatment choices has not yet been identified, patients can be diagnosed quickly and respond well to treatment. The high prevalence of carpal tunnel syndrome, its effects on quality of life, and the cost that disease burden generates to health systems make it important to identify the research priorities that will be resolved in clinical trials.

Tibialis anterior muscle herniation with superficial peroneal nerve involvement: Ultrasound role for diagnosis and treatment

Ultrasound is helpful to identify nerve suffering cause. We report a case of pain at leg associated with burning paresthesia. Ultrasound found tibialis muscle herniation, close to superficial fibular nerve. The morphological alteration was supposed to be the cause of symptoms. Neurolysis, based on ultrasonographic findings, allowed symptoms relief.

Prolonged phone-call posture causes changes of ulnar motor nerve conduction across elbow

OBJECTIVE

Postures and work-hobby activities may play a role in the origin and progression of ulnar neuropathy at the elbow (UNE), whose occurrence appears to be increasing. The time spent on mobile-phone has increased in the last decades leading to an increased time spent with flexed elbow (prolonged-phone-posture, PPP). We aimed to assess the effect of PPP both in patients with symptoms of UNE and in symptom-free subjects.

METHODS

Patients with pure sensory symptoms of UNE and negative neurophysiological tests (MIN-UNE) and symptom-free subjects were enrolled. We evaluated ulnar motor nerve conduction velocity across elbow at baseline and after 6, 9, 12, 15, and 18min of PPP in both groups. Fifty-six symptom-free subjects and fifty-eight patients were enrolled. Globally 186 ulnar nerves from 114 subjects were studied.

RESULTS

Conduction velocity of ulnar nerve across the elbow significantly changed over PPP time in patients with MIN-UNE, showing a different evolution between the two groups.

CONCLUSIONS

PPP causes a modification of ulnar nerve functionality in patients with MIN-UNE.

SIGNIFICANCE

PPP may cause transient stress of ulnar nerve at elbow.

Neuromyelitis optica spectrum disorder as a paraneoplastic manifestation of lung adenocarcinoma expressing aquaporin-4

Background:

The observations of neuromyelitis optica spectrum disorders (NMOSD) occurring in the setting of cancer suggest that aquaporin-4 (AQP4) autoimmunity may in some cases be paraneoplastic.

Results:

We describe a 72-year-old patient who developed a longitudinally extensive transverse myelitis associated with AQP4 autoantibodies in the setting of a lung adenocarcinoma recurrence. AQP4 expression was demonstrated in tumor cells. IgG in patient’s cerebrospinal fluid bound to tumor cells co-localizing with AQP4 immunoreactivity.

Conclusions and relevance:

This case expands the spectrum of paraneoplastic AQP4 autoimmunity highlighting the importance of considering an oncological screening in patients with late-onset NMOSD.

Sonographic diagnosis of anatomical variations associated with carpal tunnel syndrome

Bifid median nerve is an anatomic variation that occurs in about 18% of patients with symptoms suggestive of carpal tunnel syndrome and in about 15% of symptom-free subjects. Reversed palmaris longus is a rare anatomic muscular variation. The simultaneous presence of a bifid median nerve and a reversed palmaris longus has been very rarely described, usually during surgical exploration or in cadavers. We present two cases where ultrasound showed the presence of both abnormalities, allowing a correct diagnosis and influencing the treatment plan.

Validation of Italian version of Brace Questionnaire (BrQ)

Background

Brace questionnaire (BrQ) is a tool used to evaluate Health Quality of Life (HRQoL) in patients with Adolescent Idiopathic Scoliosis (AIS) that undergo bracing treatment. The BrQ has not been translated and validated for Italian-speaking patients with AIS. The aim of the study was to perform a trans-cultural validation of BrQ to be used in an Italian speaking population.

Methods

Translation into Italian (I-BrQ) and back translation to the original Greek (G-BrQ) was performed. The final I-BrQ was then analyzed for Italian cultural characteristics and no inconsistencies were found. After that, construct validity was measured analyzing the I-BrQ relationship with 1) Scoliosis Research Society-22 patient Questionnaire (SRS-22), in order to evaluate the relationship with another patient-oriented questionnaire not focused on brace therapy; 2) Cobb degree scale, in order to evaluate the relationship with the magnitude of the curve. Reproducibility was also tested.

Results

Translation of the G-BrQ into Italian was successful and back-translation to Greek corresponded well with the original Greek version.

Global I-BrQ correlated strongly with SRS-22 (r = 0.826; p < 0.001). Almost all sub scores from each I-BrQ domain strongly correlated with the single domain scores of SRS-22. Only two I-BrQ sub scores weakly inversely correlated with Cobb degree value.

Reproducibility was good (Spearman-Brown coefficient value was 0.943; p < 0.05).

Conclusions

Trans-cultural validation in Italian language showed the validity and reliability of the I-BrQ.

Ultrasound diagnosis of bony nerve entrapment: case series and literature review

INTRODUCTION

Nerve entrapment due to osseous callus formation is a rare complication after bone fracture. Electrodiagnostic studies and routine radiographic imaging often fail to demonstrate the pathology. The diagnosis is difficult and is often made incidentally upon surgical exploration. Nerve ultrasonography has not been used routinely to assess such lesions.

METHODS

We report 5 cases of nerve entrapment in osseous callus after fractures that occurred in 2011 and 2012. The diagnosis was made by ultrasound (US). We then performed a review of the relevant literature.

CONCLUSIONS

US is becoming an invaluable tool for diagnosing peripheral nerve entrapments. The current cases suggest that nerve US should be strongly considered as an adjunctive diagnostic tool for nerve palsies developing after trauma.

Balance and walking involvement in facioscapulohumeral dystrophy: a pilot study on the effects of custom lower limb orthoses

BACKGROUND

Autosomal dominant facioscapulohumeral dystrophy (FSHD), the third most common muscular dystrophy, is characterised by asymmetric and highly variable muscle weakness. In FSHD patients, the coupling of the ankle muscles impairment with the knee, hip and abdominal muscles impairment, causes complex alterations of balance and walking with deterioration of quality of life (QoL).

AIM

The aim of this pilot study is to evaluate the effects of custom orthoses (foot orthosis-FO and ankle foot orthosis-AFO) on balance, walking and QoL of FSHD patients through a multidimensional approach.

DESIGN

Pilot study.

SETTING

Outpatient Rehabilitation Department of Don Gnocchi Foundation.

POPULATION

Fifteen patients with facioscapulohumeral muscular dystrophy were studied.

METHODS

On 15 FSHD patients clinical evaluation (Manual Muscle Test-MMT, Clinical Severity Score), performance tests (10 meter Walking test-10mWT and 2 minute Walking Test-2minWT), instrumental assessment (stabilometric evaluation), disability (Rivermead Mobility Index- RMI, Berg Balance Scale-BBS) and patient-oriented (Medical Outcome Study 36-item Short Form-SF-36, North American Spine Society-NASS and Visual Analogue Scale-VAS) measures were performed. Patients were evaluated first, wearing their shoes and then wearing their shoes plus orthoses. This evaluation was performed 1 month after wearing the orthoses.

RESULTS

The shoes plus orthoses evaluation, performed after one month in which the patients daily wore the custom lower limb orthoses, showed a significant improvement of walking performance (10-mWT p<0.01), balance (Romberg Index p<0.05; Medio-Lateral Velocity p<0.05) and QoL (PCS p<0.01).

CONCLUSION

This pilot study shows that in FSHD patients' custom lower limb orthoses (foot-orthoses and ankle-foot-orthoses); evaluated by using a multidimensional approach, improve walking, balance and QoL.

CLINICAL REHABILITATION IMPACT

These preliminary results suggest that custom lower limb orthoses could reduce the risk of falling with a positive effect on our patients' safety. Our results should encourage the scientific community to do efficacy study on this hot topic.

Ultrasound study is useful to discriminate between axonotmesis and neurotmesis also in very small nerves: a case of sensory digital ulnar branch study

Discrimination between axonotmesis and neurotmesis is crucial in traumatic nerve injury. We present the case of a 43-year-old woman which presented hypoesthesia in the fourth and fifth right fingers, started after surgery for Dupuytren syndrome. At ultrasound study, the ulnar digital sensory branch was identified. Before the division into the two terminal branches, a neuroma was observed, while neurotmesis was excluded. This case shows the utility of ultrasonography in peripheral nervous system examination and the possibility of visualization of very small nerves and their terminal branches.

Nerve ultrasound follow-up in a child with Guillain-Barré syndrome

INTRODUCTION

Nerve ultrasound has been used increasingly in neurophysiology laboratories, but data on Guillain-Barré syndrome (GBS) are still limited, and no follow-up studies are available.

CASE REPORT

An 8-year-old boy was admitted with severe demyelinating GBS. Serial neurophysiological evaluations were performed initially and in follow-up. Ultrasound studies showed diffuse and heterogeneous nerve swelling and focal enlargement of single fascicles inside the nerve. Together with clinical and electrophysiological improvement, progressive normalization of ultrasound changes was seen.

CONCLUSIONS

Ultrasound demonstrated structural nerve abnormalities in GBS. These changes normalized as the patient improved clinically and electrophysiologically. Further studies are needed to elucidate the diagnostic and prognostic value of ultrasound in GBS.

Balance and walking in facioscapulohumeral muscular dystrophy: multiperspective assessment

BACKGROUND

In the Facioscapulohumeral muscular dystrophy (FSHD), the association of ankle muscle impairment with knee, hip and abdominal weakness causes complex alterations of static (postural) and dynamic (walking) balance, increasing the risk of recurrent falls. Stereophotogrammetric system and body-worn gyroscopes were used to focus on locomotor capacity and upper body movements in FSHD patients respectively. No data have been reported about static balance (plantar pressure and stabilometric parameters) and dynamic balance (spatio-temporal parameters during walking) in patients with FSHD. Moreover it is not known if the balance involvement influences disability and quality of life (QoL) of these patients.

AIM

The aim of this study is to quantitatively assess static and dynamic balance in FSHD patients and their influence on disability and QoL.

DESIGN

Case control-study.

SETTING

Outpatient Rehabilitation Department.

POPULATION

Sixteen FSHD patients were compared with 16 matched healthy subjects.

METHODS

A baropodometric platform was used to measure plantar pressure and centre of pressure in stance (static evaluation), and spatio-temporal parameters during walking (dynamic evaluation). These quantitative results in FSHD patients were also correlated with validated clinical (Clinical Severity Scale), performance (10m and 2 min Walking Test), disability (Berg Balance Scale, Rivermead Mobility Index) and quality of life (QoL) measures (SF-36, NASS).

RESULTS

The patients moved the plantar pressure forward from hindfoot to forefoot. Static balance was significantly reduced in patients compared with healthy subjects. Dynamic evaluation of walking showed a significant reduction of velocity and step length in the patients, and a significant increase in step width. Dynamic and static parameters were significantly related to a reduction of 10 mWT performance while only dynamic parameters were strongly related to disability and QoL.

CONCLUSION

FSHD patients present an abnormal static and dynamic balance and they show compensation strategies to avoid falling . The involvement of the dynamic balance worsens the physical aspects of QoL and induces disability. The involvement of static balance induces a reduction of the performance in brief distances.

CLINICAL REHABILITATION IMPACT

The balance training should be considered in the rehabilitation program of FSHD patients; the compensation strategies adopted by these patients should be considered in the ankle foot orthosis treatment. The static and dynamic balance assessment in FSHD patients can be used in natural history studies.

Intra- and internerve cross-sectional area variability: new ultrasound measures

INTRODUCTION

Nerve involvement in immune-related neuropathies is non-homogeneous, and therefore characterization of ultrasound (US) abnormalities is difficult. We developed two measures to quantify US abnormalities in immune-related neuropathies.

METHODS

Intranerve cross-sectional area (CSA) variability for each nerve was calculated as: maximal CSA/minimal CSA. Internerve CSA variability for each patient was calculated as: maximal intranerve CSA variability/minimal intranerve CSA variability. Six patients underwent US evaluation of the median, ulnar, and fibular nerves, and the abnormalities were scored with our newly developed measures.

RESULTS

The new measures were applicable to all nerves and patients. The highest degree of intra- and internerve CSA variability was observed in multifocal motor neuropathy, consistent with the asymmetric characteristics of this neuropathy.

CONCLUSIONS

The application of intra- and internerve CSA variability measures allows us to quantify the heterogeneity of nerves and nerve segments and identify different US patterns in diverse immune-related neuropathies.