Wartenberg Test Research Articles

Oropharyngeal Dysphagia as The Presenting Symptom of Myasthenia Gravis with Diabetes Mellitus

Background: Oropharyngeal dysphagia may caused by a variety of causes. Myasthenia gravis is a common autoimmune disease affecting the neuromuscular junction. While ocular symptoms are common in myasthenia gravis, bulbar symptoms such as dysarthria and dysphagia are less common. Aim: To present the importance of recognizing atypical presentations of myasthenia gravis and utilizing electromyography in diagnosis when AChR antibody testing is unavailable. Case Presentation: A 57-year-old woman was referred because of progressive dysphagia for both solid and liquid food. She also experienced weight loss, heaviness of the right eyelid, drooling, and chewing difficulty. Medical history revealed diabetes. Vital signs were stable. Physical examination revealed right ptosis without any other neurological deficits. Wartenberg test and dysarthria counting test were positive. Laboratory examination revealed a blood glucose level of 270 mg/dL and an HbA1c level of 9.4%. The barium swallow study revealedno abnormalities. Esophagogastroduodenoscopy revealed esophageal candidiasis. Electromyography showed more than 20% decremental response of the orbicularis oculi muscle. This result is suggestive of neuromuscular junction disorder. Improvement of the condition was achieved after the administration of intravenous steroids and oral pyridostigmine combined with therapeutic plasma exchange. Discussion: Oropharyngeal dysphagia accompanied by ptosis and positive Wartenberg & dysarthria counting test is suggestive of myasthenia gravis. Although an AChR antibody test cannot be performed, significant electromyography alongside relevant clinical presentation is sufficient to diagnose myasthenia gravis. Conclusion: It is crucial to recognize the accompanying signs and symptoms of oropharyngeal dysphagia. EMG may be used to diagnose MG in the appropriate clinical context.

Myasthenia gravis and arrhythmias in COVID-19: a case report

Background: Myasthenia Gravis (MG) is an autoimmune disorder, which autoantibodies against postsynaptic (muscle) nicotinic acetylcholine receptors (nAChR). MG patients have a higher prevalence of cardiac manifestations in the presence of thymoma. It is not known whether Coronavirus disease 2019 (COVID-19) can cause more severe illness in patients with chronic neuromuscular disorders such as MG, which can cause respiratory muscle weakness, or in those who are immunosuppressed. This case report will discuss patient with MG, thymoma, atrial fibrillation, and COVID-19.Case presentation:Â A 60-year old man came to the hospital with difficulty of swallowing. He had nasal voice and dropping of eyelids. These complaints were happened repeatedly, worsened at night and got better in the next morning. From the neurological examination, it was also obtained Wartenberg test (+), counting test (+), and prostigmine test (+). Atrial fibrillation was found with normal ventricular response and decreased systolic left ventricular function on the electrocardiogram and echocardiography. On the chest MSCT, a lobulated homogeneous solid mass was found in anterior mediastinum which supported the image of thymoma, and there was the imaging of typical viral pneumonia. The patient also had the positive result of COVID-19 PCR test.Conclusion: MG patients have been shown with abnormal manifestations of heart rhythm. This may reflect as a complication of myocarditis or autonomic nervous system dysfunction. COVID-19 infection in MG can be challenging for many reasons. Current guidelines recommend continuing the current standard care treatment of MG during hospitalization.

Could lower leg Wartenberg test be used as a predictor of restrictions in temporomandibular joint movements in CP patients?

Patients with spasticity suffer not only from neurological problems but also from various dentistry problems due to spasticity of the jaw muscles. Measurements of motion in temporomandibular joints should reflect the amount of abnormal muscle tone of these muscles. The aim of this study was to find out if the measurements of temporomandibular joint movements performed with the ultrasound Zebris device are different in cerebral palsy patients than in healthy subjects; and to find out if the information on the degree of spasticity in the lower legs provided by the Wartenberg test could be used to predict the degree of spasticty in the jaw muscles. Twenty five healthy subjects and 25 cerebral palsy patients participated in the study. Two types of measurements were performed: temporomandibular movements measured with Zebris device, and instrumented Wartenberg test. The laterotrusion and opening movements are different in CP patients than in healthy subjects. Laterotrusion movement correlates with velocity measured during the Wartenberg test. This finding suggests that high spasticity in the lower legs could indicate jaw movement restrictions in CP patients.

Timing of Muscle Response to a Sudden Leg Perturbation: Comparison between Adolescents and Adults with Down Syndrome

Movement disturbances associated with Down syndrome reduce mechanical stability, worsening the execution of important tasks such as walking and upright standing. To compensate these deficits, persons with Down syndrome increase joint stability modulating the level of activation of single muscles or producing an agonist-antagonist co-activation. Such activations are also observed when a relaxed, extended leg is suddenly released and left to oscillate passively under the influence of gravity (Wartenberg test). In this case, the Rectus femoris of adults with Down syndrome displayed peaks of activation after the onset of the first leg flexion. With the aim to verify if these muscular reactions were acquired during the development time and to find evidences useful to give them a functional explanation, we used the Wartenberg test to compare the knee joint kinematics and the surface electromyography of the Rectus femoris and Biceps femoris caput longus between adolescents and adults with Down syndrome. During the first leg flexion, adolescents and adults showed single Rectus femoris activations while, a restricted number of participants exhibited agonist-antagonist co-activations. However, regardless the pattern of activation, adults initiated the muscle activity significantly later than adolescents. Although most of the mechanical parameters and the total movement variability were similar in the two groups, the onset of the Rectus femoris activation was well correlated with the time of the minimum acceleration variability. Thus, in adolescents the maximum mechanical stability occurred short after the onset of the leg fall, while adults reached their best joint stability late during the first flexion. These results suggest that between the adolescence and adulthood, persons with Down syndrome explore a temporal window to select an appropriate timing of muscle activation to overcome their inherent mechanical instability.

Efficacy and tolerability of eperisone and baclofen in spastic palsy: a double-blind randomized trial

Few trials have compared different central muscle relaxants in the treatment of spastic palsy. This head-to-head phase 3 trial compares oral eperisone, a central muscle relaxant with a promising activity in spasticity therapy, and oral baclofen. Patients (>18 years) with moderate to severe spastic palsy were eligible in this double-blind, randomized study; they received eperisone 300 mg/ day or baclofen 60 mg/day for 6 weeks. The efficacy evaluations included: functional analysis (Pedersen's scale, muscular tone, joint range of motion, 10-meter walking time); physiological and pathological reflexes; and electromyography (Hmax/Mmax amplitude ratio and the Wartenberg test). Physicians and patients globally assessed treatment efficacy. Both eperisone (n=40) and baclofen (n=40) significantly improved functionality of lower limbs versus baseline (eperisone: -9.1%, P<0.01; baclofen: -8.3%, P<0.05), but only eperisone improved this parameter in the upper limbs (-7.8%, P<0.01 vs. -6.3%, P=NS). Both drugs reduced muscular tone from week 2. Only eperisone improved the joint range of motion (-32.5%, P<0.01 vs. -14.6%, P=NS). Both treatments reduced the 10-meter walking time (eperisone: -20.2%, P<0.01; baclofen: -24.0%, P<0.01); this effect was evident at week 2 with eperisone only. Both drugs improved reflexes. Eperisone and baclofen decreased the Hmax/Mmax amplitude ratio (eperisone: -30.0%, baclofen: -18.6%; P<0.01 for both). Eperisone increased the number of leg oscillations at the Wartenberg test (P<0.05) while baclofen increased the velocity of leg falling (P<0.01). For tolerability, no differences were observed between eperisone and baclofen in any parameters. Eperisone was judged as "good" by a higher number of physicians and patients than baclofen. Eighteen adverse events, most of mild intensity, were reported with eperisone and 27 with baclofen. Eperisone 300 mg/day and baclofen 60 mg/day, administered orally, are effective and well-tolerated drugs in the treatment of spastic palsy. However, eperisone might be associated with some additional clinical benefits when compared with baclofen.

Quantifying repeatability of the Wartenberg pendulum test parameters in children with spasticity

The Wartenberg (pendulum) test is commonly used in a variety of studies involving healthy subjects, patients with CP, stroke patients, and other neurological conditions. There is some evidence that the Wartenberg test may be able to differentiate healthy people from patients with spasticity. The aim of the study was to explore the within-session repeatability of primary outcome measures, i.e. relaxation indices derived from the Wartenberg test when test was performed by single investigator.Patients were lying supine, thigh along the horizontal line. The lower legs were allowed to hang freely over the table edge, and the knee motion in response to leg drop from the horizontal position was measured using motion system VICON with external markers attached to each leg at greater trochanter, lateral knee epicondyle, and lateral malleolus. Data from four consecutive trials were collected at 1min intervals. The set of relaxation indices and maximum velocity was calculated for each trial. Data of 21 children (42 limbs) who underwent the evaluation due to spasticity problem were analysed.The repeated measure ANOVA test, one way analysis of variance, coefficients of correlation and determination were used to determine the repeatability of the relaxation indices, the association between the indices in time, and influence of the spasticity origin on the variability.The results show that relaxation indices, did not differ between the trails in statistically significant way in our group of patients with spasticity, however they exhibited high within-session variability in the individual patients (16–90%). Therefore the variability of the relaxation indices may restrict the clinical usefulness of the indices to monitor the changes of spasticity over time. Further, our findings do not seem to conform to the earlier reports demonstrating a systematic, time-dependent, change in the relaxation indices when repeated measures were taken within a session. In conclusion, this study demonstrates that although the Wartenberg test is repeatable in groups of patients, it does not provide us with repeatable measures in individual patients, thus if it is to be used as a replacement for other clinical tests of spasticity further investigations are needed to explain the substantial variability of the indices.

The pendulum test as a tool to evaluate passive knee stiffness and viscosity of patients with rheumatoid arthritis

BackgroundThe pendulum test of Wartenberg is a technique commonly used to measure passive knee motion with the aim to assess spasticity. We used this test to evaluate changes of the knee angular displacement, passive stiffness and viscosity in rheumatoid arthritis patients. Stiffness and viscosity represent passive resistances to joint motion associated with the structural properties of the joint tissue and of the muscular-tendon complex. Stiffness can be considered an intrinsic property of the tissues to resist deformation, while viscosity is related to cohesive forces between adjacent layers of tissues. Both parameters may influence the joint range of motion affecting angular displacement.MethodsNine women with rheumatoid arthritis were compared with a group of healthy women. With the subject half-lying, the relaxed knee was dropped from near-full extension and the characteristics of the ensuring damped unsustained knee oscillation evaluated. The kinematics of leg oscillations was recorded using ultrasonic markers (Zebris CMS HS 10) and the kinetic data were calculated from kinematic and anthropometric measures.ResultsKnee stiffness significantly increased (p < 0.001) in patients with respect to the control group, while differences in viscosity were not significant. Moreover, the amplitudes of first knee flexion (the maximal flexion excursion after knee release) and first knee extension (the maximal extension excursion after the first knee flexion) were significantly decreased (p < 0.001). A regression analysis showed that disease severity correlated moderately with stiffness (R2 = 0.68) and first flexion (R2 = 0.78). Using a multivariate regression, we found that increasing stiffness was the main factor for the reduction of flexion and extension motions.ConclusionWe showed that the Wartenberg test can be considered a practical tool to measure mechanical changes of knee caused by rheumatoid arthritis. This novel application of Wartenberg test could be useful to follow up the effects of pharmacological and rehabilitative interventions in this disease.

A comparison of the assessment of spasticity by the Wartenberg pendulum test and the Ashworth grading scale in patients with multiple sclerosis

The Wartenberg pendulum test is an objective quantitative method for the assessment of muscle tone. We have compared the results of measurements of muscle tone using this method with traditional clinical assessments graded on the Ashworth scale. Two indices ( R1 and R2) were measured from the Wartenberg test. Both were related to readings from the Ashworth scale. The ratio R2 (the ratio of the amplitude of the first swing to the difference in angle between the start and finish positions), however, showed a linear relationship throughout the range of spasticity tested in contrast to the curvilinear relationship shown by R1 (the ratio of the amplitude of the first swing to the difference between the rebound angle and the start angle). Significant changes in the ratio R2 without any corresponding change in the Ashworth grading were observed. It is concluded that the Wartenberg ratio R2 and the Ashworth scale assess similar features of the muscle and/or its motor control, but that the pendulum test provides a more finely graded observer- independent measurement.