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We studied 46 consecutive patients with multifocal motor neuropathy with conduction block (MMN-CB). Typically, asymmetric weakness and atrophy of the hands or arms developed insidiously, but spontaneous improvement (without treatment) or death from this disease did not occur and 94% remained employed. For 18 patients examined on multiple occasions using the weakness subscore of the neuropathy impairment score [NIS(W)] for a median time of 2.3 years, worsening of 1.3 points per year was observed; many patients, however, had received intensive immunomodulating therapy. Median worsening to our first evaluation (generally without treatment) was estimated at 4.2 points per year, perhaps suggesting that treatment had influenced course. Three criteria for conduction block (CB) were compared, but the least stringent was sensitive for the diagnosis. Conduction block accompanied by weakness and atrophy typically affected only motor fibers, especially of midforearm nerves, and these sites of dysfunction persisted for months or years. Neurological signs and electrodiagnostic features were consistent with CB, axonal degeneration, a variable degree of reinnervation, and segmental demyelination. Although this study did not focus on therapy, intravenous gammaglobulin and cyclophosphamide appeared to be associated with neurological improvement, which was seldom complete or sustained. Axonal degeneration and faulty regeneration may in part explain this muted response. Possibly, treatment must be earlier, more intense, or different., (Copyright 2000 John Wiley & Sons, Inc.)

Many studies have shown that ACL-surgery leads to a decrease of proprioception abilities. In spite of the resulting high importance of coordinative exercise, there is nothing like a phase specific concept for coordinative training after ACL-operations going along with rehabilitation. Following a model, including all coordinative abilities, and a current after-care concept of ACL-surgery, the presented method is based on different categories of coordinative demands.

Over the past three decades there has been increasing interest in acute weakness syndromes in critically ill mechanically ventilated patients. Many of these patients require rehabilitation, and some understanding of potential etiologies and functional outcomes for these syndromes is useful to rehabilitation practitioners. A clearer understanding of these syndromes has evolved over time, as has the terminology to describe these conditions. This article will review commonly encountered causes of acute weakness in critically ill patients, including disorders of the peripheral nerves, the neuromuscular junction, and muscle.

Recent research into muscle dysfunction in patients with low back pain has led to discoveries of impairments in deep muscles of the trunk and back. These muscles have a functional role in enhancing spinal segmental support and control. The muscle impairments are not those of strength but rather problems in motor control. These findings call for a different approach in therapeutic exercise, namely a motor learning exercise protocol. The specific exercise approach has an initial focus on retraining the cocontraction of the deep muscles (ie, the transversus abdominis and lumbar multi-fidus Initial clinical trials point to the effectiveness of the approach in patients with both acute and chronic low back pain in terms of reducing the neuromuscular impairment and in control of pain.

Chronic skeletal myopathy may affect one third of chronic alcohol misusers. It is generally accepted that abstinence allows partial recovery, and that continued high-dose ethanol consumption progressively deteriorates muscle function. However, the effect of low-dose ethanol consumption in alcoholic myopathy has not been studied. We studied 58 chronic alcoholic male patients with biopsy-proven chronic alcoholic myopathy over 5 years. We evaluated ethanol intake, biochemical and nutritional parameters, and assessed muscle strength. Eighteen patients who remained abstinent showed marked improvement in muscle strength. As expected, the 19 patients who persisted in high-dose ethanol consumption further diminished in their muscle strength. In the 11 patients who maintained low-dose (

We report the use of a mechatronic device for assessing arm movement impairment after chronic brain injury. The device, called the "Assisted Rehabilitation and Measurement Guide," is designed to guide reaching movements across the workspace, to measure movement and force generation, and to apply controlled forces to the arm along linear reaching paths. We performed a series of experiments using the device in order to identify the contribution of active muscle and passive tissue restraint to decreased active range of motion of guided reaching (i.e., "workspace deficits") in a group of five chronic, spastic hemiparetic, brain-injured subjects. Our findings were that passive tissue restraint was increased in the spastic arms, as compared to the contralateral, nonparetic arms. Active muscle restraint, on the other hand, was typically comparable in the two arms, as quantified by measurements of active arm stiffness at the workspace boundary during reaching. In all subjects, there was evidence of movement-generated weakness, consistent with a small contribution of spasticity to workspace deficits. These results demonstrate the feasibility of mechatronic assessment of the causes of decreased functional movement, and could provide a basis for enhanced treatment planning and monitoring following brain injury.

The shoulder joint is a complex structure that requires intricate precision to function purposefully, with full motion, synchronous patterns, and high endurance. Injury and trauma hamper this process, and surgery represents significant traumatic stress for any joint. Any surgical procedure may be accompanied by consequences that, left untreated, can develop into problems that result in dysfunctional performance of daily living and sports activities. This article addresses common challenges resulting from shoulder surgery and some of the treatments that can be administered to minimize problems.

Objective: To evaluate the impact of a program of muscle strengthening and physical conditioning on impairment and disability in chronic stroke subjects., Design: A randomized pretest and posttest control group, followed by a single-group pretest and posttest design., Subjects: Thirteen community-dwelling stroke survivors of at least 9 months., Intervention: A 10-week (3 days/week) program consisting of a warm-up, aerobic exercises, lower extremity muscle strengthening, and a cool-down., Main Outcome Measures: Peak isokinetic torque of the major muscle groups of the affected lower limb, quadriceps and ankle plantarflexor spasticity, gait speed, rate of stair climbing, the Human Activity Profile (HAP), and the Nottingham Health Profile (NHP) were recorded twice for the treatment group and three times for the control group., Results: Significant improvements were found for all the selected outcome measures (HAP, NHP, and gait speed) for the treatment group (p < .001). In terms of overall training effects, the 13 subjects demonstrated increases in strength of the affected major muscle groups, in HAP and NHP profiles, and in gait speed and rate of stair climbing without concomitant increases in either quadriceps or ankle plantarflexor spasticity., Conclusions: The 10-week combined program of muscle strengthening and physical conditioning resulted in gains in all measures of impairment and disability. These gains were not associated with measurable changes of spasticity in either quadriceps or ankle plantarflexors.

Objective: To objectively quantify muscle strength changes over the course of functional rehabilitation and up to 15 months postdischarge in individuals with spinal cord injury (SCI)., Method: Hand-held dynamometry was used to evaluate the strength of six muscle groups in 31 individuals after acute SCI (tetraplegia, n = 13, paraplegia, n = 18). Assessment was performed by a single research therapist at admittance and discharge from functional rehabilitation and 3 months and 15 months after discharge., Results: There were significant increases of mean strength values for all muscle groups between admittance and discharge in individuals with parapalegia (median value between 13% and 22%) and tetraplegia (median value between 33% and 83%). Three months after discharge, only individuals with tetraplegia continued to significantly improve their mean strength for four muscle groups (elbow flexors-extensors and shoulder flexors-extensors). One year later, elbow flexors were significantly improved in both paraplegic and tetraplegic persons, while shoulder extensors showed significant gains only in individuals with paraplegia. Study results showed a large variability in the individual profiles of upper limb strength recovery, particularly in tetraplegic individuals. Although some individuals showed strength gains exceeding 200%, some strength decreases were noted., Conclusion: Recovery of muscle strength in individuals with tetraplegia over individuals with parapalegia continues for a longer period since it depends initially on recovery of muscle innervation. This study quantified strength improvements during rehabilitation and clearly showed that these gains can be maintained or even increased when the person returns to community living.

Spastic paretic stiff-legged gait is a frequently encountered gait problem in patients with traumatic brain injury, as well as in many other patients with upper motor neuron disease. Formerly, spasticity of the quadriceps was considered to be the sole cause of stiff-legged gait. Quantitative gait analysis, however, may implicate hip flexor weakness or poor ankle mechanics as the cause of stiff-legged gait. We discuss the use of an algorithm to evaluate stiff-legged gait in traumatic brain injury using a quantitative gait analysis system such that the specific etiology of stiff-legged gait can be identified and can serve as the basis of a treatment plan.

Bethlem myopathy is an early-onset benign autosomal dominant myopathy with contractures caused by mutations in collagen type VI genes. It has been reported that onset occurs in early childhood. We investigated the natural course of Bethlem myopathy in five previously published kindreds and two novel pedigrees, with particular attention to the mode of onset in 23 children and the progression of weakness in 36 adult patients. Our analysis shows that nearly all children exhibit weakness or contractures during the first 2 years of life. Early features include diminished foetal movements, neonatal hypotonia and congenital contractures which are of a dynamic nature during childhood. The course of Bethlem myopathy in adult patients is less benign than previously thought. Due to slow but ongoing progression, more than two-thirds of patients over 50 years of age use a wheelchair.

Background: Leg strength correlates with functional ability in the frail elderly, many of whom can be reached through a private practice setting. The purpose of this study was to demonstrate the feasibility of physician-prescribed, home-based, clinic-monitored, high-intensity leg-strengthening treatment among elderly patients with a variety of medical problems., Methods: Twenty-two elderly patients with a variety of chronic medical conditions were invited to participate during regularly scheduled office visits if they had difficulty rising from a chair and an unsteady, cautious gait (age 85.1 +/- 5.7, 14 female). Physical therapists (PT) instructed patients to lift ankle weights at home, three times per week. Patients visited PT five times over a 12-week period. Weights were increased at each visit., Results: Patients' one-repetition maximum increased (right leg 13 to 21 lb, P = 0.00; left leg 15 to 22 lb, P = 0.00). Patients also improved in habitual (18 to 12 s, P = 0.01) and tandem (38 to 26 s, P = 0.00) 20-foot walking times and sit-to-stand time (5 to 3 s, P = 0.01)., Conclusion: The primary care physician can initiate a home-based leg-strengthening program that is practical for and well tolerated by the frail elderly.

Objective: To determine whether the Neurologic Disability Score (NDS), the Neuropathic Symptom Score (NSS), and the Medical Research Council (MRC) "sumscore" are reliable, and to determine whether they provide information regarding the functional status of patients with peripheral neuropathies., Methods: The authors analyzed homogeneity of the frequently used outcome measures in 97 patients using Cronbach's alpha coefficient and corrected item-total correlations. Their association with functional status (sickness impact profile and modified Rankin score) was analyzed univariately with Pearson's and Spearman's correlation coefficients, and multivariately with linear regression analysis., Results: The NDS and MRC scales were homogeneous (range of Cronbach's alpha, 0.81 to 0.97) compared with the NSS scales (range, 0.20 to 0.63). The correlation patterns between neurologic signs and symptoms and functional status ranged from 0.13 to 0.65. Multivariate linear regression analyses showed that 40% or less of patients' functional status could be explained by the three tested outcome measures., Conclusion: The NDS and MRC are reliable measures, but these measures do not correlate with measures of functional status.

A principle component of age-related weakness and frailty in women is sarcopenia. This decrease in skeletal muscle mass is a progressive syndrome that will affect the quality of life for elderly women by decreasing the ability to perform many activities of daily living. Strength training is known to be an effective means of increasing muscular strength and size in many populations, and can be utilized successfully to significantly improve muscle strength, muscle mass and functional mobility in elderly women up to the age of 96 years. Such exercise can minimize the syndrome of physical frailty due to decreased muscle mass and strength. Any rehabilitation or exercise program for the elderly woman would benefit from the inclusion of such a training regime.

Transverse myelitis is a rare neurologic disorder. It is an interruption of spinal cord function not caused by macrotrauma. Symptoms develop rapidly and consist of ascending paralysis, diminished or absent sensation below the cervical or thoracic region, and often urinary retention. Etiologies include parainfectious events, multiple sclerosis, autoimmune disorders, vascular insufficiency, paraneoplastic myelopathy, postvaccinial events, idiopathic occurrence, and minimal trauma. Treatment generally consists of supportive measures. The use of steroids to hasten recovery remains controversial but is routine in most cases. The time period and degree of recovery is variable. We present a case of rapid onset of neurologic symptoms in a college football player right before a game. No other sports related cases have been reported in the sports medicine literature. Diagnostic, therapeutic, and historical aspects of this rare but important disorder are discussed.

Our aim was to study the association of lower limb strength with maximum walking speed in disabled older women and to try to detect the reserve capacity threshold for maximum walking speed and the minimum strength required for walking at a speed of 1.22 m x s(-1), which is required in crossing signaled intersections. The data are from the baseline of Women's Health and Aging Study, a population-based study on causes and course of disability. Altogether, 1,002 disabled women participated in the tests, which took place at their homes. Maximum isometric hip flexion and knee extension forces were measured on both sides using a handheld dynamometer. For analytic purposes, knee extension torque/body mass ratio (KET/BM) was calculated. Maximum walking speed was measured with a stopwatch during a 4-m walk. KET/BM had a significant effect on walking speed after controlling for number of chronic conditions, balance, use of walking aid, joint pain, age, and body height and mass. A total of 42.3% of the variation in maximum walking speed was explained by these variables. The cumulative percentage distribution of KET/BM of those able to attain a maximum walking speed of 1.22 m x s(-1) (n = 148) was flat to the level of 1.1 N x m x kg(-1), after which it turned upward, indicating that the probability of attaining 1.22 m x s(-1) started to increase after that level. By using segmented linear regression analysis, 2.3 N x m x kg(-1) was found to be the cutoff point beyond which an increase in KET/BM did not correspond to an increase in maximum walking speed. Muscle strength was positively but not linearly associated with maximum walking speed. Strength testing may help to identify people close to functional thresholds and, thus, at risk of impaired walking, who would benefit most from strengthening exercises.

Involvement of the quadriceps muscle group in knee osteoarthritis is receiving increasing research interest. The motor and sensory functions of muscle are intimately linked, and deficits in the sensorimotor functions of the quadriceps have been identified and proposed as possible factors in the pathogenesis of knee osteoarthritis or as consequences of the disease. Weakness of the quadriceps as a clinical feature of knee osteoarthritis has been well recognized for some time, but causes for this weakness and its significance as a determinant of the patient's disability is only now being investigated. Rehabilitation regimens that increase quadriceps weakness also effect improvements in the patient's disability, but the length and cost most of these research regimens would be impractical in the clinical setting. More clinically practicable rehabilitation regimens need to be devised that could be implemented in the community, if the management of this chronic, prevalent condition is to be managed effectively and cost-effectively.

Background: Strength loss is strongly associated with functional decline and is reversible with exercise. The effect of increased strength on function has not been clearly established. The purpose of this study was to determine whether strength gain is associated with improvement in physical performance and disability., Methods: One hundred functionally impaired community-dwelling men and women (77.6 +/- 7.6 yrs) were tested at baseline and outcome for lower extremity strength, physical performance, and disability. After random group assignment, exercise participants received strengthening exercises in their homes three times a week for 10 weeks while control subjects continued their normal activities. Using multiple regression techniques, the relationship between strength gain and improvement in physical performance and disability was assessed, controlling for age, depression, and baseline strength., Results: A significant impact of strength gain on mobility skills (p = .0009) was found. The impact of strength gain on chair rise performance was significant in participants who were more impaired (p = .04). Strength gain was associated with gain in gait speed (p = .02) and in falls efficacy (p = .05), but not with other balance, endurance, or disability measures., Conclusions: Lower extremity strength gain is associated with gains in chair rise performance, gait speed, and in mobility tasks such as gait, transfers, stooping, and stair climbing, but not with improved endurance, balance, or disability. Strength gain is also associated with improvement in confidence in mobility. Factors that may influence the ability of strength gain to affect function are initial level of frailty and specificity of exercise. These results support the idea that strength training is an intervention that can potentially improve physical health status in many frail elders.

Objective: To determine test-retest reliability of hand-held dynamometry (HHD) in measuring strength of persons with neuropathic weakness., Design: Intratester and intertester reliability of HHD-measured strength over a 7- to 10-day period. In addition, HHD knee strength was compared with criterion standard of fixed dynamometry (FD)., Setting: Human performance laboratory of a university., Participants: Convenience sample of ambulatory outpatients with Hereditary Motor and Sensory Neuropathy, Type I (HMSN) (n = 10) and able-bodied controls (CTL) (n = 11)., Main Outcome Measure: Maximal isometric torque., Results: Intratester intraclass correlation coefficients (ICCs) were high, generally ranging from .82 to .96 for HHD- and FD-measured strength for both HMSN and CTL groups. There were no significant differences between sessions for HHD-measured strength, while FD-measured strength was only significantly different for knee extension (p < .01). Intertester reliability was generally good for both HHD- and FD-measured strength, with ICCs ranging from .72 to .97 for HMSN and CTL groups. Exceptions were knee extensors and ankle dorsiflexors for the CTL group. Knee extensor strength was significantly lower measured by HHD compared with FD (p < .01), but knee flexor strength was similar for the two methods., Conclusion: HHD appears to be a reliable method to measure maximal isometric strength in persons with neurogenic weakness, and may be useful to quickly and objectively evaluate strength in the clinical setting.

Purpose: To determine whether isokinetic training can improve the strength of the hemiparetic knee musculature, functional mobility, and physical activity and to evaluate its effect on spasticity in long-term stroke survivors., Design: Nonrandomized self-controlled trial., Subjects: A volunteer sample of 15 community-dwelling stroke survivors of at least 6 months., Intervention: A 6-week (3 days/week, 40 minutes/day) program consisting of warm-up, stretches, reciprocal knee extension and flexion isokinetic strengthening, and cool-down for the paretic limb., Main Outcome Measures: Peak isokinetic hamstring and quadriceps torque, quadriceps spasticity, gait velocity, timed Up and Go, timed stair climb, and the Human Activity Profile (HAP) scores were recorded at baseline, after training, and 4 weeks after training cessation (follow-up)., Results: Paretic muscle strength improved after training (p < .05) while tone remained consistent (p > .87). Gait velocity increased after training (p < .05) and at follow-up (p < .05). Changes in stair climbing and timed Up and Go were not significant (p > .37; p > .91), although subjects perceived gains in their physical abilities at follow-up (p < .01)., Conclusions: Gains in strength and gait velocity without concomitant increases in muscle tone are possible after a short-term strengthening program for stroke survivors. The psychological benefit associated with physical activity is significant.

Purpose of the Study: Severe motor weakness is a rather infrequent symptom in the course of lumbar stenosis. The objectives of this study are three fold: describe the motor deficit, evaluate the prognosis factors and determine the type of stenosis the most likely to be complicated by motor loss., Material and Methods: 61 consecutive patients with a mean age of 63 years, operated on for a lumbar stenosis and with a severe motor deficit have been retrospectively studied. The mean follow-up was 38 months. The overall functional result was evaluated according to a rating scale, specially developed in our unit for the follow-up of lumbar stenosis. The motor capacity was rated from 0 (complete paralysis) to 5 (normal strength). According to that scale the motor weakness was rated as 0, 11 times as 1, 11 times, as 2, 11 times and as 3, 28 times. The deficit was unilateral in 79 per cent of cases and multiradicular in 58 per cent of patients. Sphincter abnormalities were also present in 9 cases. In 9 out of 10 patients the motor deficit was in the L5 territory. Stenosis was extended to 3 levels in 30 cases and was focal in the remaining cases. Degenerative spondylolishthesis was disclosed in 20 patients. In 3 out of 4 cases decompression was performed after 3 weeks of motor weakness and within 3 weeks in the remaining cases., Results: According to our rating scale the overall results were considered excellent in 29 cases, good in 21 cases and fair in the 11 remaining cases. There was no complication, and no postoperative worsening of the deficit was observed. Regression of motor weakness was complete 22 times, partial 29 times and null 10 times. In the eleven complete deficits with a 0 cotation one receded completely, 7 receded partially and no improvement was noted in the 3 remaining cases. 6 out of the 9 patients with sphincter abnormalities recovered completely. In this study favourable prognosis parameters were as follows: age under 62 years, monoradicular deficit, stenosis at one level and association with a discal herniation. In contrast, severity of the initial motor weakness, association with sphincter abnormalities, presence or not of degenerative spondylolisthesis, or of a complete block on the myelogram were not influential variables. Chances of recovery were statistically diminished when decompression was performed after 6 weeks., Discussion and Conclusion: No study dealing specifically with the postoperative outcome of motor deficit caused by lumbar stenosis has been published. However the rate of motor recovery (complete or partial) disclosed in our series is comparable with that found in other series dealing more generally with the overall post-surgery outcome. At our last follow-up, 82 per cent of our patients were considered as having an excellent or good result. It can be concluded that the existence of a motor deficit is not a major pejorative factor of the overall final functional result. Motor weakness is more frequently observed in elderly patients, in cases with degenerative spondylolisthesis, or when a discal herniation is associated with a bony compression. Chances of recovery are better, when the deficit is monoradicular, when the stenosis is focal, or associated with a discal herniation and when the patient is relatively young.

Objective: To compare the effects of expiratory muscle training and sham training on respiratory muscle strength in patients with multiple sclerosis (MS)., Design: A randomized control trial; subjects were randomly assigned to either expiratory muscle training or sham training., Setting: Training and measurement of respiratory muscle pressures were conducted in patients' homes. Weekly home visits were conducted to assure compliance with the training protocols and to obtain measurements., Patients: Twenty subjects with clinically definite MS and decreased expiratory muscle strength entered the study; 10 subjects completed 3 months of expiratory training using a threshold training device and 5 subjects completed 3 months of sham training using the same device but without an expiratory training threshold load., Measurement: Respiratory muscle strength was assessed at baseline and after 1, 2, and 3 months of training; maximal inspiratory and expiratory pressures were used as measures of respiratory muscle strength., Results: There was a significant increase in expiratory muscle strength after 3 months of training when the expiratory training group was compared to the sham group (p = .003); no significant change in inspiratory muscle strength was observed., Conclusions: The results of this pilot study suggest that the strength of the expiratory muscles of persons with MS can be increased through respiratory muscle training targeted to the expiratory muscles. Further research is indicated to determine if increasing the strength of the expiratory muscles in MS has an effect on clinical outcomes in this patient population.

The association between subjective experience in pain reduction and objective measurements in improvement of physical functioning was analyzed with chronic low back pain (CLBP) patients (n = 143) who attended a 12-week multidimensional back treatment program emphasizing active functional restoration. Low back flexion-extension, lateral flexion and rotation, isometric strength, and mobility and their changes were measured. The results showed that 79% of the subjects reported subjective decrease in LBP during the 12-week restoration program, and simultaneous increases in isometric strength and mobility also were measured in approximately 80% of the subjects. Concordance of these findings was high, i.e., the reduction of pain and improvement of function occurred mostly in the same subjects. However, the correlations between physical functioning parameters and pain reduction were low (rs below 0.22). Baseline strength and mobility values did not differ between those who benefited from the treatment regarding pain and those who did not. Thus, absolute levels at the baseline or magnitude of changes in the measurements of maximum isometric strength or mobility were not associated with pain reduction. The results indicate that subjective pain reduction is significantly associated with improvement per se in trunk muscle function and spinal mobility during active functional restoration, but not with the magnitude of the improvements. This should be considered when designing rehabilitation programs and outcome criteria for rehabilitation.

Postpoliomyelitis syndrome describes a ¿new¿ weakness, unrelated to any other neurological or medical disorder. It appears 10 to 15 years or more after recovery from the initial paralysis. This new weakness interferes with activities of daily living. The management of postpoliomyelitis syndrome may include orthotics, special exercises, a change in their lifestyle, or a combination of these regimens. This article is especially concerned with knee joint stabilization in various deformities that are weakened by the postpoliomyelitis syndrome.