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Two randomized, placebo-controlled studies evaluated the pulmonary function safety of onabotulinumtoxinA (onabotA) for treatment of upper and/or lower limb spasticity. Patients with stable baseline respiratory status received one or two treatments with placebo, 240 U, or 360 U of onabotA. Pulmonary function tests, adverse events, and efficacy were measured at least every 6 weeks for 18 weeks (Study 1) or 30 weeks (Study 2). Study 1 enrolled 109 patients ( n = 36-37/group) and Study 2 enrolled 155 patients ( n = 48-54/group). Mean baseline forced vital capacity (FVC) was 76-78% of predicted per group in Study 1 and 71% of predicted per group in Study 2. In Study 1, change from baseline FVC values were significantly ( p < 0.05) decreased vs. placebo at weeks 3 (240 U -57 mL vs. placebo +110 mL) and 12 (360 U -6 mL vs. +167 mL placebo). In Study 2, change from baseline FVC values were significantly decreased in the 360 U group vs. placebo at weeks 6 (-78 mL vs. +49 mL placebo), 13 (-60 mL vs. +119 mL placebo), 18 (-128 mL vs. +80 mL placebo), and 24 (-82 mL vs. +149 mL placebo). Individual pulmonary function-related adverse events were not correlated with PFT decreases. The most frequent pulmonary-related adverse events were nasopharyngitis (Study 1) and upper respiratory tract infection (Study 2). Ashworth scores were significantly improved at multiple time points in both studies. Injection of onabotA for spasticity in patients with decreased pulmonary function, at single and repeated doses of up to 360 U, was associated with small but statistically significant decreases in FVC or forced expiratory volume 1 s (FEV1) (>12% and 200 mL) that were subclinical and not correlated with any adverse clinical pulmonary events.

Background: The purpose of our study was to determine the incidence and average cost of nerve injuries in patients presenting with upper extremity trauma., Methods: The Nationwide Emergency Department Sample database was queried using International Classification of Diseases, Ninth Revision codes specific to peripheral nerve injuries of the upper extremity. Data on the incidence, patient demographics, average number of associated diagnoses, Injury Severity Scale (ISS) score, mechanism of injury, and average cost of care were collected and analyzed., Results: Of 1.58 million upper extremity traumatic injuries, there were 5244 nerve injuries, resulting in an annual incidence of 16.9 per 100,000 persons with an average age of 38.42 years. Ulnar nerve injuries were the most common (3.86 per 100,000) followed by digital nerve (2.96 per 100,000), radial nerve (2.90 per 100,000), and median nerve (2.01 per 100,000). Injuries to the brachial plexus had the highest average ISS score (9.79 ± 0.71) and number of presenting diagnoses (8.85 ± 0.61) while having a lower than average emergency department (ED) cost. Patients with digital nerve injuries had the highest average ED cost ($8931.01 ± $847.03), whereas their ISS score (2.82 ± 0.19) and number of presenting diagnoses (4.92 ± 0.22) were the lowest. The most commonly reported mechanism of injury in this study population was from a laceration (29.2%) followed by blunt injury, fall (14.8%), and being struck (7.20%). Males were 2.14 (2.01-2.28) times more likely to have an injury to an upper extremity nerve and 3.25 (2.79-3.79) times more likely to injure a digital nerve., Conclusions: While there was a low incidence of upper extremity nerve injuries associated with upper extremity trauma, the ulnar nerve was most frequently injured. Males were twice as likely to sustain a traumatic upper extremity nerve injury, with laceration being the most common mechanism of injury. The average ED cost associated with upper extremity nerve injuries in the United States was determined to be approximately $5779.

Injuries to the limb are the most frequent cause of permanent disability following combat wounds. We reviewed the medical records of 450 soldiers to determine the type of upper limb nerve injuries sustained, the rate of remaining motor and sensory deficits at final follow-up, and the type of Army disability ratings granted. Of 189 soldiers with an injury of the upper limb, 70 had nerve-related trauma. There were 62 men and eight women with a mean age of 25 years (18 to 49). Disabilities due to nerve injuries were associated with loss of function, neuropathic pain or both. The mean nerve-related disability was 26% (0% to 70%), accounting for over one-half of this cohort's cumulative disability. Patients injured in an explosion had higher disability ratings than those injured by gunshot. The ulnar nerve was most commonly injured, but most disability was associated with radial nerve trauma. In terms of the final outcome, at military discharge 59 subjects (84%) experienced persistent weakness, 48 (69%) had a persistent sensory deficit and 17 (24%) experienced chronic pain from scar-related or neuropathic pain. Nerve injury was the cause of frequent and substantial disability in our cohort of wounded soldiers.

Objective: To examine the prevalence and severity of upper limb entrapment syndromes in a sample of veterans with lower limb amputations., Design: A descriptive survey, pilot study., Setting: 2008 National Disabled Veterans Winter Sports Clinic., Participants: Twenty participants with various lower limb amputations., Methods: All study participants completed a questionnaire that included symptoms of both upper limbs, medical history, time since amputation, medication history, use of assistive technology, and wheelchair characteristics. A physical examination and electrodiagnostic testing were then performed on each participant. The physical examination included an assessment of bilateral upper limb weakness or sensory abnormalities, thenar/hypothenar atrophy, deep tendon reflexes, Tinel test of the wrist and elbow, and the Phalen maneuver. All nerve conduction studies were performed by an American Board of Electrodiagnostic Medicine-certified physiatrist., Outcome Measures: Correlation between symptoms, examination findings, and electrodiagnostic findings with the participant's demographic data in the questionnaire., Results: Twenty participants (19 men and 1 woman) were enrolled in the study, with a total of 38 upper limbs evaluated. The mean age of the study population was 59 +/- 13 years, with an average of 23 years since the amputation. Sixteen (80%) of 20 participants had electrodiagnostic findings consistent with median neuropathy across the wrist (26/38 affected limbs, 6 participants with unilateral and 10 with bilateral findings), and 14 (70%) of 20 participants had ulnar entrapment neuropathy across the elbow (22/38 affected limbs, 6 participants with unilateral and 8 with bilateral findings). Several participants (6 of 20, 30%) were found to have electrodiagnostic evidence of ulnar entrapment neuropathy across the wrist (10 of 38 affected limbs, 2 participants unilateral and 4 bilateral findings)., Conclusion: A high number of veterans with lower limb amputations presented with upper limb nerve entrapment syndromes. Careful attention to these nerve entrapment syndromes in lower limb amputees is necessary because the symptoms may be confounded by other chronic pain-related disorders.

Since the beginning of Operation Enduring Freedom and Operation Iraqi Freedom, over 541 clients with major limb amputations have been seen in the Military Healthcare System. As a result of the nature and severity of injuries and the prevalence of concomitant injuries seen in this population, amputee care has become a specialized type of rehabilitative care at Walter Reed and Brooke Army Medical Centers. To streamline and accommodate the needs of clients with upper extremity limb loss, a five-phased upper extremity amputee protocol of care was developed. The five phases of the protocol include acute management; preprosthetic training; basic prosthetic training; advanced prosthetic training; and discharge planning. For the readers ease, these phases will be presented in the following categories: acute care, subacute care, and long-term rehabilitation needs. Furthermore, this article seeks to offer insight into the ideal treatment of an individual with upper extremity limb loss based on experience and collective expertise of the authoring therapists.