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e: Diabetic Lumbosacraladiculoplexus Neuropathy

o the Editor,With keen interest we reviewed the article on diabetic

umbosacral radiculoplexus neuropathy by Greenberg et al inhe August 2009 issue of PM&R [1]. These cases are challeng-ng to manage and infrequently present to outpatient spinelinics with the assumption of spinal causality. Acute func-ional management involves fall prevention with the associ-ted L2�4 more than L5 and S1 radicular nerve distributioneakness. The usual presentation includes profound quad-

iceps weakness, knee buckling, and falling. The authorsecommend using an “orthoses (most often an AFO [ankle-oot orthoses] for residual foot drop)” because foot drop is the

ost common long-term sequella of diabetic lumbosacraladiculoplexus neuropathy [2].

In our experience, acute management in patients withnee extensor weakness requires a knee-AFO with a lock-

ng mechanism to keep the knee in extension or offsetnee joint to control the knee flexion moment at heeltrike, yet allow swing phase. A knee immobilizer and aalker may be used until brace fabrication is completed.onversely, a solid ankle AFO will increase the kneeexion moment at heel strike, increasing fall risk in pa-ients without sufficient knee extensor strength [3]. Theuthor’s choice to change the patients AFO to a knee AFOecause of insufficient knee stabilization after 3 months ofome therapy supports our recommendation. Thus treat-

ng practitioners should be keenly aware of proximal, ie,trength prior to orthotic prescription.

Michael Jaffe, MDPhysical Medicine & Rehabilitation

Intermountain HealthcareSalt Lake City, UT

Richard Kendell, DOPhysical Medicine & Rehabilitation

University of UtahSalt Lake City, UT

M.J. Disclosure: nothing to discloseR.K. Disclosure: nothing to disclose

DOI: 10.1016/j.pmrj.2009.12.009

PM&R © 2011934-1482/10/$36.00

Printed in U.S.A.22

EFERENCES. Greenberg JS, Singh J, Falcon N. Evaluation and rehabilitation of a

patient with diabetic lumbosacral radiculoplexus neuropathy. PM&R2009;1(8):774-777.

. Dyck PJB, WIndebank AJ. Diabetic and nondiabetic lumbosacral radicu-loplexus neuropathies: New insights into pathophysiology and treat-ment. Muscle Nerve 2002;25:477-491.

. Lehmann JF. The biomechanics of ankle foot orthoses: Prescription anddesign. Arch Phys Med Rehabil 1979;60:200-207.

e: Post-Polio Syndrome

o the Editor,I am writing in regards to the Point/Counterpoint on

Post-Polio Syndrome: A Perspective from Three Countries,”hich appeared in the November 2009 issue of PM&R [1].or the past 20 years, I have evaluated at least one post-polioatient weekly. In reviewing the case scenario, I believe thatpulmonary-thoracic compliance” should have been in-luded in the discussion of fatigue. I note that the patient hadolio at age 2, thus one could suspect some involvement ofotor neurons to diaphragm or accessory ventilatory mus-

les so that 40 to 50 years later she could have had ventilatorynsufficiency to explain her fatigue. Pulmonary-thoracicompliance is the work necessary to expand the lungs; mosts related to pulmonary and less to thoracic, but both couldlay a role. This used to be measured by noting the volume ofir inhaled with a given pressure on the tank ventilator andlotting at various inhalation pressures. It is amazing to noteow the reduced pulmonary-thoracic compliance would note identified by vital capacity or tidal volume alone and couldxplain the fatigue. There are, of course, other viable expla-ations for fatigue, but this is one that deserves mention.

Ernest W. Johnson, MDOhio State University

Dodd Hall, Room 1036,Columbus, OH

E.W.J. Disclosure: nothing to disclose

DOI: 10.1016/j.pmrj.2010.01.008

EFERENCE. Grimby G, Li J, Vandenakker C, Sandel ME. Post-polio syndrome: A

perspective from three countries. PM&R 2009;1:1035-1040.

0 by the American Academy of Physical Medicine and RehabilitationVol. 2, 222, March 2010