Neuromuscular Conditions Research Articles

Dynamic contraction and fatigue analysis in biceps brachii muscles using synchrosqueezed wavelet transform and singular value features.

In this study, the dynamic contractions and the associated fatigue condition in biceps brachii muscle are analysed using Synchrosqueezed Wavelet Transform (SST) and singular value features of surface Electromyography (sEMG) signals. For this, the recorded signals are decomposed into time-frequency matrix using SST. Two analytic functions namely Morlet and Bump wavelets are utilised for the analysis. Singular Value Decomposition method is applied to this time-frequency matrix to derive the features such as Maximum Singular Value (MSV), Singular Value Entropy (SVEn) and Singular Value Energy (SVEr). The results show that both these wavelets are able to characterise nonstationary variations in sEMG signals during dynamic fatiguing contractions. Increase in values of MSV and SVEr with the progression of fatigue denotes the presence of nonstationarity in the sEMG signals. The lower values of SVEn with the progression of fatigue indicate the randomness in the signal. Thus, it appears that the proposed approach could be used to characterise dynamic muscle contractions under varied neuromuscular conditions.

Cardiopulmonary exercise performance and factors associated with aerobic capacity in neuromuscular diseases

Aerobic deconditioning, due to lower levels of physical activity, could impact independence for people with neuromuscular conditions. We report the maximal cardiopulmonary response in a cohort of people with Charcot Marie Tooth disease type 1A (CMT 1A) and inclusion body myositis (IBM). We also explored potential predictors of aerobic capacity with measures of physical impairment and functional performance. Participants underwent maximal cardiopulmonary exercise testing (CPET) using a semi-recumbent cycle ergometer. Data were analyzed to determine the peak O2 consumption (VO2 peak), anaerobic threshold (AT), maximum heart rate (MHR), ventilatory equivalent for CO2 slope (VE /VCO2 ), and respiratory exchange ratio (RER). Impairment, functional and patient reported measures were also recorded. Predicted CPET variables were calculated based on published normative data for age, gender, and weight. Twenty-two people with CMT and 17 people with IBM were recruited. Both groups showed significantly lower VO2 peak, MHR, AT, and VE /VCO2 . The CMT group overall performed better than the IBM group, with significantly higher VO2 peak, MHR, and AT, but lower VE /VCO2. Linear regression analysis demonstrated that VO2 peak was related to body fat percentage and 6-min walk distance for both groups, and steps per day for the IBM group. Lower than predicted CPET variables were observed that were not explained by cardiopulmonary limitations or reduced effort, implicating peripheral factors in limiting the cycling task. Regression analysis implied prediction of VO2 peak by body fat percentage and 6-min walk distance. Six-minute walk distance could be a potential proxy measure of cardiopulmonary fitness.

Application of neuromuscular electrical stimulation on the support limb during reactive balance control in persons with stroke: a pilot study.

The aim of the present study was to investigate the effect of the application of neuromuscular electrical stimulation to the quadriceps muscle of the paretic limb during externally induced stance perturbations on reactive balance control and on fall outcomes in people with chronic stroke. Ten participants experienced 12 stance treadmill perturbation trails, 6 forward balance perturbation trials and 6 backward balance perturbation trials. For each perturbation condition, three perturbation trials were delivered synchronized with neuromuscular electrical stimulation applied to the quadriceps of the paretic limb and three perturbation trials were delivered without stimulation. Behavioral outcome measures, such as incidence of laboratory falls and number of compensatory steps, kinematic outcome measures, such as margin of stability and minimum hip high values after the perturbation, step initiation time, step execution time and step length of the stepping leg were analyzed. The application of neuromuscular electrical stimulation on the paretic quadriceps between the range of 50 and 500ms after stance forward and backward perturbations reduced the laboratory falls incidence (p < 0.05), improved stability values (p < 0.05) and reduced the hip height descent (p < 0.05) compared to the experimental condition in which participants were exposed to stance perturbations without neuromuscular electrical stimulation. Additionally, step initiation time of the recovery step was lower in neuromuscular electrical stimulation condition during the forward balance perturbation protocol. Our results showed that the application of neuromuscular electrical stimulation on the knee extensor muscles of the paretic limb reduces the incidence of laboratory falls, enhances reactive stability control and reduces vertical limb collapse after stance forward and backward perturbations in people with chronic stroke.

Singing and Dancing With Neuromuscular Conditions: A Mixed-Methods Study.

The purpose of this study was to assess the safety and meaningfulness of a 15-week recreational dance and singing program for people with neuromuscular conditions. Within a transformative mixed-methods design, pulmonary function tests, plethysmography through wearable technology (Hexoskin vests), individualized neuromuscular quality-of-life assessments (version 2.0), and semistructured interviews were used. The interviews were analyzed through inductive, semantic thematic analysis. Although the sample sizes were small (six people with neuromuscular conditions), the authors found no evidence of safety concerns. There was evidence of respiratory improvements and reported improvements in swallowing and speech. The most notable quality-of-life changes included improvements related to weakness, swallowing, relationships, and leisure. The participants shared that the program offered meaningful social connection and embodied skills and safe and pleasurable physical exertion. The authors learned that recreational singing and dancing programs could be a safe and deeply meaningful activity for those with neuromuscular conditions that impact respiration.

Inpatient Diagnosis and Management of Neuromuscular Disorders.

Although many neuromuscular conditions are evaluated on an outpatient basis owing to their chronic or progressive nature, more urgent evaluation and management is often required for the inpatient presenting with acute to subacute focal or generalized numbness or weakness. This review focuses on clinical pattern recognition and basic anatomic localization principles to aid in the identification of common, as well as some less frequently encountered, neuromuscular disorders in hospitalized patients. The characteristic clinical and diagnostic features, associated complications, and recommended treatments of key neuromuscular conditions with acute and subacute manifestations are discussed. These conditions can be life-threatening in some cases, such as in Guillain-Barré syndrome, owing to associated oropharyngeal weakness, respiratory failure, or marked dysautonomia. Prompt recognition of the clinical and pathologic features is therefore necessary to reduce associated morbidity and mortality.

Differential DNA methylation and transcriptional signatures characterize impairment of muscle stem cells in pediatric human muscle contractures after brain injury.

Limb contractures are a debilitating and progressive consequence of a wide range of upper motor neuron injuries that affect skeletal muscle function. One type of perinatal brain injury causes cerebral palsy (CP), which affects a child's ability to move and is often painful. While several rehabilitation therapies are used to treat contractures, their long-term effectiveness is marginal since such therapies do not change muscle biological properties. Therefore, new therapies based on a biological understanding of contracture development are needed. Here, we show that myoblast progenitors from contractured muscle in children with CP are hyperproliferative. This phenotype is associated with DNA hypermethylation and specific gene expression patterns that favor cell proliferation over quiescence. Treatment of CP myoblasts with 5-azacytidine, a DNA hypomethylating agent, reduced this epigenetic imprint to TD levels, promoting exit from mitosis and molecular mechanisms of cellular quiescence. Together with previous studies demonstrating reduction in myoblast differentiation, this suggests a mechanism of contracture formation that is due to epigenetic modifications that alter the myogenic program of muscle-generating stem cells. We suggest that normalization of DNA methylation levels could rescue myogenesis and promote regulated muscle growth in muscle contracture and thus may represent a new nonsurgical approach to treating this devastating neuromuscular condition.

COVID-19 AND NEUROMUSCULAR DISEASES: EP.22 COVID-19 in children with neuromuscular disorders

Children with neuromuscular disorders have been assumed to be a particularly vulnerable population since the beginning of COVID-19. Although this is a plausible hypothesis, there is no evidence that complications or mortality rates in neuromuscular patients are higher than in the general population. The aim of this study is to describe the clinical characteristics and outcome of COVID-19 in children with neuromuscular disorders. A registry of children with neuromuscular conditions and laboratory-confirmed-SARS-CoV-2 infection was set up by the Neuromuscular Working Group of the Spanish Pediatric Neurology Society (SENEP).

METABOLIC MYOPATHIES: EP.207 Clinical findings of late-onset long-chain fatty acid oxidation disorders overlap with neuromuscular conditions in a sponsored genetic testing program

METABOLIC MYOPATHIES: EP.207 Clinical findings of late-onset long-chain fatty acid oxidation disorders overlap with neuromuscular conditions in a sponsored genetic testing program

LGMD: EP.177 Clinical and genetic spectrum of a large cohort of delta-sarcoglycan muscular dystrophy.

Sarcoglycanopathies comprise four subtypes of autosomal recessive limb-girdle muscular dystrophies (LGMDR3-6) that are caused by mutations in the SGCA, SGCB, SGCG and SGCD genes. Delta-sarcoglycanopathy (LGMDR6) is the least frequent of all sarcoglycanopaphies and it is considered an ultra-rare disease. Our aim was to characterize the clinical and genetic data of a large cohort of LGMDR6 patients and to investigate whether genetic or protein expression data could predict the severity of the disease. We contacted a total of 90 different neuromuscular units/neurology departments over the world and collected demographic, genetic, clinical and remaining protein expression in muscle biopsy data of patients with a genetic confirmed diagnosis of LGMDR6. We contacted more than 90 pediatric and adult neuromuscular units/neurology departments around the world and identified 23 patients from 9 different countries after reviewing genetic data of more than 10.000 patients with a neuromuscular disorder. There was a history of consanguinity in 87% of the patients and 52.2% of patients had another affected relative. Ninety-one percent of the patients were symptomatic at the time of the analysis. Upper and lower limb proximal muscle weakness was the most common presenting symptom. Distal muscle weakness was observed early on the progression of the disease. Cardiac involvement was observed in 5 patients (21.7%) and 4 patients (17.4%) required non-invasive ventilation. Sixty percent of patients were wheelchair-bound since a mean age of 14.6 years old. Patients with an undetectable expression of the sarcoglycan complex measure by muscle immunohistochemistry have a significant early onset of the disease and early age of lost ambulation compared to patients with residual protein expression. This study confirms that delta-sarcoglycanopathy is an ultra-rare neuromuscular condition and describes the clinical and molecular data of the largest cohort of patients reported so far. International collaboration has been crucial to collect these data. Our results show that this is a very severe and quickly progressive disease characterized by global muscle weakness affecting proximal and distal muscles of the limbs. As happen with other types of sarcoglycanopathy, there is a correlation between remaining protein expression, age at onset and disease's severity.

What Are the Rate and Risk Factors for Developing a Complication With the Pavlik Method for the Treatment of Hip Dysplasia?

The Pavlik method for the treatment of developmental dysplasia of the hip (DDH) has been proven successful for over 85 years. The high success rate and reproducibility have made it the mainstay of treatment. We performed a retrospective cohort study of patients with DDH treated with the Pavlik method between September 2016 and August 2018 with at least 24 months of follow up in a single academic center. We excluded patients with neuromuscular conditions, teratologic dislocations, and arthrogryposis. We identified and included a total of 307 patients in the analysis. There were 66 patients with dysplasia, 97 with instability, and 144 with a dislocation. Data collected included age at initiation of the Pavlik method, diagnosis (isolated dysplasia, subluxation, or dislocation), duration of treatment, follow up duration and any complication. At final follow up, anteroposterior radiographs of the pelvis were used to determine the Severin classification. Major complications were proximal femoral growth disturbance (5.8%) and femoral nerve palsy (0.98%). Multivariate analysis showed that an initial diagnosis of a dislocated hip (odds ratio, 2.20; P<0.01), was significantly associated with developing a complication. At final follow up, we found Severin type I or II radiographic findings in 100% of patients with dysplasia, 95% of patients with instability and 54% of patients with dislocation (P=0.001). Complications are not entirely uncommon when the Pavlik method is used for the treatment of DDH. The overall rate of major complications was 7%. The Pavlik method is safe, and independent risk factors for complications were being over 5 months of age and having a dislocated hip at initial presentation. Level IV-cohort study.

Age-Related Functional Reserve Decline Is Not Seen in Pharyngeal Swallowing Pressures.

Purpose Functional reserve represents the difference between an individual's ability to produce a maximum output function and the ability to perform a functional task. Several studies have documented an age-related decrease in functional reserve with oral tongue pressure generation. Whether this pattern is seen in pharyngeal swallowing pressures is unknown. The aim of this study was to investigate pharyngeal functional reserve using high-resolution manometry during normal-effort and effortful swallows. Method Pharyngeal high-resolution manometry was performed on 38 younger healthy individuals (≤ 40 years) and 18 older healthy individuals (≥ 60 years) during normal-effort and effortful water swallows. Pressure metrics included maximum pressure in the velopharynx, tongue base, and hypopharynx, as well as pharyngeal contractile integral and minimum pressure in the upper esophageal sphincter (UES). Repeated-measures analysis of variance was used to determine the effects of swallow task, age, and pharyngeal region on pressure generation. Results Maximum pharyngeal pressures and pharyngeal contractile integral were significantly increased during the effortful swallows compared to normal-effort swallows (p < .001), but there were no interactions between task and age in pharyngeal pressures. In the UES, minimum pressures were significantly elevated in older individuals during effortful swallows compared to normal-effort swallows (p = .007) but did not follow a pattern consistent with reduced functional reserve. Conclusions Healthy individuals increase pharyngeal driving pressures during effortful swallows, without an age-related reduction in the magnitude of pressure increase. Thus, this study did not find evidence for an age-related reduction in pharyngeal functional reserve. The preserved ability to increase pharyngeal pressures during effortful swallowing in aging may support the use of behavioral swallowing interventions in older individuals without neuromuscular conditions. Supplemental Material https://doi.org/10.23641/asha.16606709.

Factors Associated With COVID‐19 Disease Severity in US Children and Adolescents

Little is known about the clinical factors associated with COVID-19 disease severity in children and adolescents. We conducted a retrospective cohort study across 45 US children's hospitals between April 2020 to September 2020 of pediatric patients discharged with a primary diagnosis of COVID-19. We assessed factors associated with hospitalization and factors associated with clinical severity (eg, admission to inpatient floor, admission to intensive care unit [ICU], admission to ICU with mechanical ventilation, shock, death) among those hospitalized. Among 19,976 COVID-19 encounters, 15,913 (79.7%) patients were discharged from the emergency department (ED) and 4063 (20.3%) were hospitalized. The clinical severity distribution among those hospitalized was moderate (3222, 79.3%), severe (431, 11.3%), and very severe (380, 9.4%). Factors associated with hospitalization vs discharge from the ED included private payor insurance (adjusted odds ratio [aOR],1.16; 95% CI, 1.1-1.3), obesity/type 2 diabetes mellitus (type 2 DM) (aOR, 10.4; 95% CI, 8.9-13.3), asthma (aOR, 1.4; 95% CI, 1.3-1.6), cardiovascular disease, (aOR, 5.0; 95% CI, 4.3- 5.8), immunocompromised condition (aOR, 5.9; 95% CI, 5.0-6.7), pulmonary disease (aOR, 5.3; 95% CI, 3.4-8.2), and neurologic disease (aOR, 3.2; 95% CI, 2.7-5.8). Among children and adolescents hospitalized with COVID-19, greater disease severity was associated with Black or other non-White race; age greater than 4 years; and obesity/type 2 DM, cardiovascular, neuromuscular, and pulmonary conditions. Among children and adolescents presenting to US children's hospital EDs with COVID-19, 20% were hospitalized; of these, 21% received care in the ICU. Older children and adolescents had a lower risk for hospitalization but more severe illness when hospitalized. There were differences in disease severity by race and ethnicity and the presence of selected comorbidities. These factors should be taken into consideration when prioritizing mitigation and vaccination strategies.

Effects of Cognitive Sensory Motor Training on Lower Extremity Muscle Strength and Balance in Post Stroke Patients: A Randomized Controlled Study.

Background: Sensory motor impairment, the most common neuromuscular condition in stroke patients, often contributes to muscle weakness and imbalance. Objective: The purpose of this research was to investigate the effects of cognitive sensory-motor training (CSMT) on the muscle strength and balance ability in post-stroke patients. Methods: Thirty-five participants after stroke were randomly assigned to the CSMT (n = 17) or control group (n = 18). All participants received 30 min of training each time, five times per week, for six weeks. Lower extremity muscle strength of tibialis anterior (LEMTA) was evaluated using a digital muscular dynamometer. The Medical Research Council (MRC) scale was used to evaluate muscle strengths of the hip joint, knee joint, and ankle joint. For balance ability test, the center of pressure (COP) movement distance and limited of stability (LOS) were measured using BioRescue. Results: LEMTA, MRC scale, balance ability were significantly more improved in the CSMT group than in the control group (p < 0.05). Conclusions: Our findings indicate that CSMT is beneficial and effective for improving muscle strength of the lower extremity and balance ability of post-stroke patients.

Palliative Care in Pediatric Pulmonology

Children with End Stage Lung Disease (ESLD) are part of the growing population of individuals with life-limiting conditions of childhood. These patients present with a diverse set of pulmonary, cardiovascular, neuromuscular, and developmental conditions. This paper first examines five cases of children with cystic fibrosis, bronchopulmonary dysplasia, neuromuscular disease, pulmonary hypertension, and lung transplantation from Texas Children’s Hospital. We discuss the expected clinical course of each condition, then review the integration of primary and specialized palliative care into the management of each diagnosis. This paper then reviews the management of two children with end staged lung disease at Hospital Civil de Guadalajara, providing an additional perspective for approaching palliative care in low-income countries.

Clinical and genetic spectrum of a large cohort of patients with δ-sarcoglycan muscular dystrophy.

Sarcoglycanopathies include four subtypes of autosomal recessive limb-girdle muscular dystrophies (LGMDR3, LGMDR4, LGMDR5 and LGMDR6) that are caused, respectively, by mutations in the SGCA, SGCB, SGCG and SGCD genes. Delta-sarcoglycanopathy (LGMDR6) is the least frequent and is considered an ultra-rare disease. Our aim was to characterize the clinical and genetic spectrum of a large international cohort of LGMDR6 patients and to investigate whether or not genetic or protein expression data could predict a disease’s severity.This is a retrospective study collecting demographic, genetic, clinical and histological data of patients with genetically confirmed LGMDR6 including protein expression data from muscle biopsies.We contacted 128 paediatric and adult neuromuscular units around the world that reviewed genetic data of patients with a clinical diagnosis of a neuromuscular disorder. We identified 30 patients with a confirmed diagnosis of LGMDR6 of which 23 patients were included in this study. Eighty-seven per cent of the patients had consanguineous parents. Ninety-one per cent of the patients were symptomatic at the time of the analysis. Proximal muscle weakness of the upper and lower limbs was the most common presenting symptom. Distal muscle weakness was observed early over the course of the disease in 56.5% of the patients. Cardiac involvement was reported in five patients (21.7%) and four patients (17.4%) required non-invasive ventilation. Sixty per cent of patients were wheelchair-bound since early teens (median age of 12.0 years). Patients with absent expression of the sarcoglycan complex on muscle biopsy had a significant earlier onset of symptoms and an earlier age of loss of ambulation compared to patients with residual protein expression.This study confirmed that delta-sarcoglycanopathy is an ultra-rare neuromuscular condition and described the clinical and molecular characteristics of the largest yet-reported collected cohort of patients. Our results showed that this is a very severe and quickly progressive disease characterized by generalized muscle weakness affecting predominantly proximal and distal muscles of the limbs. Similar to other forms of sarcoglycanopathies, the severity and rate of progressive weakness correlates inversely with the abundance of protein on muscle biopsy.

Ultrasound-Guided Measurement of Piriformis Muscle Thickness to Diagnose Piriformis Syndrome

Background: Piriformis syndrome (PS) is a neuromuscular condition caused by the entrapment of the sciatic nerve at the level of the piriformis muscle (PM). Diagnosing PS remains challenging despite recent invasive and non-invasive diagnostic methods. Response to invasive nerve block is still one of the most reliable diagnostic modalities because there is no gold standard test for PS. As early diagnosis may prevent delayed diagnosis that results in chronic somatic dysfunction and muscle weakness, a screening test with high sensitivity could guide clinicians in performing the next appropriate step in diagnosing PS.Aim: The purpose of this study is to determine the sensitivity, specificity, and best cut-off point of ultrasound-guided PM thickness in PS.Method: This case-control study was conducted in a general hospital in Tangerang during a 3-month period. We recruited 58 patients clinically diagnosed with PS and 58 healthy patients (without a history of hip and buttock pain) during their visits to the outpatient clinic. All patients underwent ultrasound assessment to measure bilateral PM thickness. Sex, age, body mass index, history of micro-/macro-trauma, and prolonged sitting duration were recorded. Statistical analyses were performed using the Statistical Package for the Social Sciences version 25.Result: The PS and control groups predominantly comprised female subjects, with mean ages of 51.79 ± 14.10 and 50.09 ± 13.26 years on PS and healthy subjects, respectively. The mean ultrasound-guided PM thickness was higher in PS subjects compared to healthy subjects with mean thicknesses of 1.16 ± 0.13 and 0.85 ± 0.11 cm, respectively (p < 0.05). The area under the receiver operating characteristic curve of the PM was 0.970 (95% confidence interval 0.943–0.998, p < 0.05). The best cut-off point defined by Youden's J index was 0.9950 cm for all PS subjects.Conclusion: We propose 0.9950 cm as the cut-off point for diagnosing PS by ultrasound, which has the sensitivity and specificity of 94.8 and 87.9%, respectively.

Comparison of the United Kingdom and United States approaches to approval of new neuromuscular therapies.

Many novel therapies are now available for rare neuromuscular conditions that were previously untreatable. Hereditary transthyretin amyloidosis and spinal muscular atrophy are two examples of diseases with new medications that have transformed our field. The United States and the United Kingdom have taken disparate approaches to the approval and coverage of medications, despite both providing incentives to develop therapies targeting rare diseases. The US requires less evidence for approval when compared with medications for common diseases and does not have a mechanism to ensure or even encourage cost-effectiveness. The Institute of Clinical and Economic Review provides in-depth cost-effectiveness analyses in the US, but does not have the authority to negotiate drug costs. In contrast, the UK has maintained a similar scientific threshold for approval of all therapies, while requiring negotiation with National Institute for Health and Care Excellence to ensure that medications are cost-effective for rare diseases. These differences have led to approval of medications for rare diseases in the US that have less evidence than required for common diseases. Importantly, these medications have not been approved in the UK. Even when medications meet traditional scientific thresholds, they uniformly arrive with high list prices in the US, whereas they are available at cost-effective prices in the UK. The main downsides to the UK approach are that cost-effective medications are often available months later than in the US, and some medications remain unavailable.

Evaluating the Impact: A Review of NABH Standards in Ayurvedic Hospitals

In recent years, there has been a noticeable surge in the demand for Ayurvedic treatments within the context of medical tourism. This growing trend can be attributed to several factors, including the reputation of Ayurveda for providing quality healthcare and its cost-effectiveness compared to conventional medical treatments. Notably, individuals with uncontrolled neuro-muscular conditions, such as Muscular dystrophy, myopathies, Multiple sclerosis, Myasthenia gravis, Parkinson’s disease, and Autism, are increasingly turning to Ayurveda in search of potential remedies and therapies. The allure of Ayurveda lies in its array of specialized treatments and techniques, including Panchakarma, Yoga, Marma Chikitsa, Ksharsutra, and Rasaushadhi, which are not commonly available in other medical systems. These unique offerings have positioned Ayurvedic hospitals as attractive destinations for medical tourists, with Kerala emerging as a prominent hub for Ayurvedic medical tourism within India. Against this backdrop, the evaluation of healthcare organizations based on their performance and adherence to quality standards has become paramount in the Indian healthcare sector. The National Accreditation Board for Hospitals &amp; Healthcare Providers (NABH) has played a pivotal role in this regard by establishing stringent standards aimed at enhancing the overall health system, fostering continuous quality improvement, and ensuring patient safety. The primary objective of this review is to critically assess the implementation of NABH standards within Ayurvedic hospitals. By delving into the second edition of NABH accreditation standards for Ayurveda hospitals, we aim to provide insights into the extent to which these standards are being embraced and integrated into Ayurvedic healthcare practices. The NABH accreditation standards for Ayurvedic hospitals are comprehensive, comprising 10 chapters, each delineating specific standards and incorporating a total of 590 objective elements. These standards serve as a framework designed to facilitate the delivery of safe, high-quality care within Ayurvedic healthcare settings. It is evident that patients seeking Ayurvedic treatments, particularly within the realm of medical tourism, place a premium on standardized and safe healthcare services. The implementation of NABH accreditation standards in Ayurvedic hospitals not only provides patients with a sense of assurance regarding the quality and safety of their treatments but also elevates the status and significance of AYUSH hospitals within the broader healthcare landscape of India. In conclusion, the convergence of Ayurveda and medical tourism presents a unique opportunity for India to showcase its rich heritage of traditional healthcare systems while simultaneously adhering to modern standards of quality and safety. The NABH accreditation standards serve as a cornerstone in this endeavor, setting benchmarks and driving continuous improvement in Ayurvedic healthcare delivery. As the demand for Ayurvedic treatments continues to grow both domestically and internationally, adherence to these standards becomes increasingly imperative in ensuring the credibility and sustainability of Ayurvedic healthcare practices. In summary, the adoption of NABH standards represents a significant step forward in positioning Ayurveda as a credible and globally recognized form of healthcare, thereby enhancing its appeal and accessibility to patients seeking alternative treatment options.

Botulinum Toxin Services for Neurorehabiliation: Recommendations for Challenges and Opportunities during the COVID-19 Pandemic.

The COVID-19 pandemic severely impacted the function of medical facilities and rehabilitation services worldwide, including toxin services delivering Botulinum toxin treatments for neuromuscular conditions such as spasticity, dystonia, and sialorrhea. The aim of this paper is to understand how toxin services have dealt with the situation and what strategies have been adopted to continue services. The recommendations are based on a virtual round table held with toxin services experts from different European countries who shared their experiences and discussed the best practices. The challenges for toxin services were reviewed based on the experts’ experiences and on relevant literature from 2020 and 2021. A set of recommendations and best practices were compiled, focusing firstly on guidance for clinical practice, including assessing patients’ health and risk status and the urgency of their treatment. Secondly, it was discussed how patients on botulinum toxin therapy can be cared for and supported during the pandemic, and how modern technology and tele-medicine platforms can be generally used to optimize effectiveness and safety of toxin treatments. The technological advances prompted by the COVID-19 crisis can result in better and more modern patient care in the future.

Not so Shocking: Electromyography in Pediatrics Remains Feasible and Diagnostically Useful.

Electrodiagnostic testing, including nerve conduction studies (NCS) and electromyography (EMG), assists with localizing lesions within the peripheral nervous system. NCS/EMG in children can be technically challenging and its relevance has been questioned in the era of affordable genetic testing. NCS/EMG provides information that may not be available in the examination of a young or developmentally delayed child. Our goal was to review the volume and referral sources of NCS/EMG studies and evaluate its feasibility and diagnostic yield at a pediatric tertiary care hospital. Retrospective chart review of NCS/EMG studies done in pediatric patients at one center from 2014 to 2019. A total of 725 studies were performed, with a median age of 13.2 years (range 0-18 years). The annual number of studies remained constant throughout the study period. Neurologists and surgeons were the most common referral sources, but an increased number of referrals from geneticists was observed. Most (94.5%) NCS/EMG were done on awake patients, with only 5.5% of studies being terminated early due to tolerability of the patient. Of all studies, 326/725 (44%) demonstrated a neuromuscular abnormality, of which 63.5% (207/326) were acquired conditions. Mononeuropathies and polyneuropathies were the most common electrophysiologic diagnoses. Our study indicates that NCS/EMG remains a useful diagnostic tool, both for the diagnosis of acquired neuromuscular conditions but also as an adjunct for interpreting genetic results, as indicated by the recent increase in referrals from geneticists. Overall NCS/EMG is well tolerated and able to be performed without sedation in children of all ages.