Central motor conduction time reveals upper motor neuron involvement masked by lower motor neuron impairment in a significant portion of patients with amyotrophic lateral sclerosis

ObjectiveWe retrospectively investigated the utility of the central motor conduction time (CMCT) in detecting upper motor neuron (UMN) involvements in patients with amyotrophic lateral sclerosis (ALS).MethodsFifty-two ALS patients and 12 disease control patients participated in this study. Surface electromyograms were recorded from the first dorsal interosseous (FDI) and tibialis anterior (TA) muscles. We stimulated the motor cortex, brainstem, and spinal nerve using transcranial magnetic stimulation (TMS) in order to measure the cortical, brainstem, and spinal latencies. We divided the ALS patients into 2 subgroups (with UMN impairment vs. without UMN impairment) and calculated the rates of abnormal CMCT prolongation judged by their comparison with the normal ranges obtained by the measurement in the control patients.ResultsThe CMCTs in the FDI and TA were abnormally prolonged in over 40% of the ALS patients with UMN impairment and in nearly 30% of those without UMN impairment.ConclusionsCMCT shows UMN dysfunction in ALS patients without clinical UMN impairment.SignificanceTMS still has diagnostic utility in a significant portion of ALS patients.     

Posteroanterior cervical transcutaneous spinal stimulation targets ventral and dorsal nerve roots

ObjectiveWe aim to non-invasively facilitate activation of spared neural circuits after cervical spinal cord injury (SCI) and amyotrophic lateral sclerosis (ALS). We developed and tested a novel configuration for cervical transcutaneous spinal stimulation (cTSS).MethodscTSS was delivered via electrodes placed over the midline at ~T2-T4 levels posteriorly and ~C4-C5 levels anteriorly. Electromyographic responses were measured in arm and hand muscles across a range of stimulus intensities. Double-pulse experiments were performed to assess homosynaptic post-activation depression (PAD). Safety was closely monitored.ResultsMore than 170 cTSS sessions were conducted without major safety or tolerability issues. A cathode-posterior, 2 ms biphasic waveform provided optimal stimulation characteristics. Bilateral upper extremity muscle responses were easily obtained in subjects with SCI and ALS. Resting motor threshold at the abductor pollicis brevis muscle ranged from 5.5 to 51.0 mA. As stimulus intensity increased, response latencies to all muscles decreased. PAD was incomplete at lower stimulus intensities, and decreased at higher stimulus intensities.ConclusionsPosteroanterior cTSS has the capability to target motor neurons both trans-synaptically via large-diameter afferents and non-synaptically via efferent motor axons.SignificancePosteroanterior cTSS is well tolerated and easily activates upper extremity muscles in individuals with SCI and ALS.     

The relationship between ankle dorsiflexion range of motion,frontal plane projection angle,and patellofemoral pain syndrome

BackgroundAnkle range of motion abnormalities have been often linked with alteration in knee kinematics leading to the development of patellofemoral pain syndrome (PFPS). Literature exploring the relationship between ankle dorsiflexion range of motion (DF ROM) and knee kinematics during functional tasks is scanty. This study aims to assess the relation between ankle DF ROM and frontal plane projection angle (FPPA), one of the knee kinematic variables, in individuals with and without PFPS during a step-down test.MethodsThis is a case-control study in which seventy PFPS patients and other 70 asymptomatic control subjects had their ankle DF ROM measured using an inclinometer with the knee flexed and extended. Their FPPA angles were measured using Kinovea software while doing the step-down test.ResultsWhen the two groups were compared, ankle DF ROM measured with the knee flexed was higher in the control group (33.15 ± 4.96) than in the PFPS group (30.20 ± 6.93) (p = 0.03). In both the PFPS group and the control group, the correlation between FPPA and ankle DF ROM with the knee flexed was statistically insignificant (p = 0.075 and 0.323 respectively).ConclusionDecreased ankle DF ROM can be one of the contributing factors to the development of PFPS in the context of greater dynamic knee valgus.     

Osteotomies of the second phalanx of the great toe: A clinical experience

BackgroundAt the time of the first report on the feasibility of corrective osteotomies of the distal phalanx (DP) of the great toe there were no published studies addressing this type of surgery. Along this line, and throughout our clinical experience, this paper tries to show the clinical benefits of hallux DP osteotomies when correcting interphalangeal valgus deformities (IHV) of the great toe, either with open or percutaneous procedure.Material and MethodsThis is a review of 18 cases in which a DP osteotomy was performed in 2 different institutions, 8 cases were performed using open technique and 10 cases percutaneously. The correction obtained was analyzed by measuring the distal articular set angle (DASA), obliquity angle (AP1), asymmetry angle (AP2), and global distal phalanx deviation (GDPD) angle before and after the surgery on dorso-plantar weight-bearing radiographs in all cases. Clinical results were also recorded.ResultsExcellent clinical and radiological results were achieved with both techniques in all patients with no complications. The average DP angular deformity correction in terms of AP1, AP2 and GDPD angles were 4.58º ± 5.55º, 8.95º ± 4.77º and 16.53º ± 7.26 respectively. In 10 cases an Akin osteotomy was associated.ConclusionIn cases with valgus deviation in the hallux DP, a corrective osteotomy of the DP alone or associated to osteotomy of the PP should be considered as a useful tool. The technique is feasible and has no technical difficulties for an orthopedic surgeon with experience on feet surgery.     

Denervation findings on EMG in amyotrophic lateral sclerosis and correlation with prognostic milestones: Data from a retrospective study

ObjectiveTo verify whether the finding of denervation activity on EMG at the time of diagnosis has a prognostic value in amyotrophic lateral sclerosis (ALS).MethodsWe retrospectively studied all the patients discharged with a diagnosis of ALS between January 2009 and January 2017. 92 patients met the inclusion criteria. We mainly verified three prognostic targets:

• (1)Time to non-invasive ventilation (NIV) or tracheostomy.
• (2)Time to percutaneous endoscopic gastrostomy or parental nutrition.
• (3)Survival.

All EMG examinations were reviewed and a denervation score (DS) was calculated.The association of DS with clinical milestones was analysed, adjusting for disease duration, age , sex, and clinical phenotype.ResultsWe found a significant association between bulbar DS and time to NIV/tracheostomy (HR: 3.34, 95% CI: 1.49 to 7.48, p = 0.002) and with survival (HR 3.633, 95% CI 1.681–7.848, p = 0.001), regardless of the clinical phenotype. Furthermore, we found a significant influence of a general DS on survival (HR: 2.62, 95% CI 1.335–5.160, p = 0.005).ConclusionEMG assessment could be of value not just for ALS diagnosis but also for its intrinsic prognostic value.SignificanceEMG could provide additional information about the rate of progression of ALS as early as the diagnosis is made.