To investigate the effects of transcranial direct current stimulation (tDCS) applied over the prefrontal cortex on the improvement of verbal, visuospatial working memory and naming in healthy adults.
Thirty two healthy adults (15 males and 17 females, mean age 37.3±13.0 years) were enrolled in this study. The subjects were divided into four groups randomly. They underwent sham or anodal tDCS over the left or right prefrontal cortex, for 20 minutes at a direct current of 1 mA. Before and immediately after tDCS, the subjects performed the Korean version of the mini-mental state exam (K-MMSE) and stroop test (color/word/interference) for the screening of cognitive function. For working memory and language evaluation, the digit span test (forward/backward), the visuospatial attention test in computer assisted cognitive program (CogPack®) and the Korean-Boston Naming Test (K-BNT) were assessed before tDCS, immediately after tDCS, and 2 weeks after tDCS.
The stroop test (word/interference), backward digit span test and K-BNT were improved in the left prefrontal tDCS group compared with that of the sham group (p<0.05). The stroop test (interference) and visuospatial attention test were in the right prefrontal tDCS group compared with that of the sham group (p<0.05). Their improvement lasted for 2 weeks after stimulation.
tDCS can induce verbal working memory improvement and naming facilitation by stimulating the left prefrontal cortex. It can also improve the visuospatial working memory by stimulating the right prefrontal cortex. Further studies which are lesion and symptom specific tDCS treatment for rehabilitation of stroke can be carried out.
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To evaluate the effects of electric cortical stimulation in the experimentally induced focal traumatic brain injury (TBI) rat model on motor recovery and plasticity of the injured brain.
Twenty male Sprague-Dawley rats were pre-trained on a single pellet reaching task (SPRT) and on a Rotarod task (RRT) for 14 days. Then, the TBI model was induced by a weight drop device (40 g in weight, 25 cm in height) on the dominant motor cortex, and the electrode was implanted over the perilesional cortical surface. All rats were divided into two groups as follows: Electrical stimulation (ES) group with anodal continuous stimulation (50 Hz and 194 µs duration) or Sham-operated control (SOC) group with no electrical stimulation. The rats were trained SPRT and RRT for 14 days for rehabilitation and measured Garcia's neurologic examination. Histopathological and immunostaining evaluations were performed after the experiment.
There were no differences in the slice number in the histological analysis. Garcia's neurologic scores & SPRT were significantly increased in the ES group (p<0.05), yet, there was no difference in RRT in both groups. The ES group showed more expression of c-Fos around the brain injured area than the SOC group.
Electric cortical stimulation with rehabilitation is considered to be one of the trial methods for motor recovery in TBI. However, more studies should be conducted for the TBI model in order to establish better stimulation methods.
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To describe inpatient course and length of hospital stay (LOS) for people who sustain brain disorders nationwide.
We interviewed 1,903 randomly selected community-dwelling patients registered as 'disabled by brain disorders' in 28 regions of South Korea.
Seventy-seven percent were initially admitted to a Western medicine hospital, and 18% were admitted to a traditional Oriental medicine hospital. Forty-three percent were admitted to two or more hospitals. Mean LOS was 192 days. Most patients stayed in one hospital for more than 4 weeks. The transfer rate to other hospitals was 30-40%. Repeated admissions and increased LOS were related to younger onset age, higher education, non-family caregiver employment, smaller families, and more severe disability.
Korean patients with brain disorders showed significantly prolonged LOS and repeated admissions. Factors increasing burden of care influenced LOS significantly.
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To identify the subtle change of postural control in elderly patients with unilateral knee osteoarthritis (OA) with computerized dynamic posturography.
Twenty-two healthy women and twenty-six women with unilateral knee OA, aged 60 and over, were enrolled. The computerized posturographic measures included a weight bearing pattern during squatting and sit-to-stand, sway velocity of center of gravity (COG) during one leg standing, on-axis velocity and directional control of COG during rhythmic weight shift, rising index during sit-to-stand, end sway during tandem walk, and movement time during step up/over.
It was shown that patients bore significantly less weight on the affected side during the 30° and 60° squat and sit-to-stand. Sway velocity of COG during one leg standing was greater whereas the on-axis velocity and directional control during the front/back rhythmic weight shift were significantly lower in the patient group. The rising index during sit-to-stand was significantly lower and movement time during step up/over with the affected side was significantly longer in patients.
This study demonstrated in detail a decline of postural balance by utilizing computerized posturography in elderly women with unilateral knee OA. They had less weight-bearing, more sway, and less ability of intentional postural control on the affected side.
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To evaluate the feasibility of ultrasound guided atlanto-occipital joint injection.
Six atlanto-occipital joints of three cadavers were examined. Cadavers were placed in prone position with their head slightly rotated towards the contra-lateral side. The atlanto-occipital joint was initially identified with a longitudinal ultrasound scan at the midline between occipital protuberance and mastoid process. Contrast media 0.5cc was injected into the atlanto-occipital joint using an in-plane needle approach under ultrasound guide. The location of the needle tip and spreading pattern of the contrast was confirmed by fluoroscopic evaluation.
After ultrasound guided atlanto-occipital joint injection, spreading of the contrast media into the joint was seen in all the injected joints in the anterior-posterior fluoroscopic view.
The ultrasound guided atlanto-occipital injection is feasible. The ultrasound guided injection by Doppler examination can provide a safer approach to the atlanto-occipital joint.
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To compare the efficacy of ultrasonography guided stellate ganglion block (US-SGB) with that of blind SGB in management of the stroke patients with complex regional pain syndrome (CRPS) type 1.
Forty-two patients with post-stroke CRPS were randomly assigned to either US-guided SGB (22 patients) or blind SGB group (20 patients). The mean age of US-guided SGB and blind SGB groups was 61.3±5.6 years and 59.1±4.5 years. We performed two blockades at 7-day intervals on the affected side of patients with CRPS. Pain intensity, using a visual analog score (VAS), score of CRPS clinical severity, and the amounts of affected hand swelling with a hand volumeter were assessed before, 2 weeks and 4 weeks after treatment.
In both groups, VAS and the amount of hand swelling were significantly decreased after 2 weeks and after 4 weeks. Between two groups, VAS difference of US-guided SGB group and that of blind SGB group were 2.61±1.09, 1.88±0.62 at 2 weeks and 3.67±1.03, 3.13±0.62 at 4 weeks, respectively. US-guided SGB group showed more significant improvement in mean change of VAS compared to the blind SGB group (p-value<0.05).
Both US-guided SGB and blind SGB techniques were effective in relieving pain in subacute stroke patients with CRPS. US-guided SGB was better in pain relief but has no advantages in reduction of hand swelling in this study.
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To compare a newly developed minimally-invasive method for percutaneous transforaminal epidural injection (INJ group) with the existing method for lumbar epidural catheterization (CATH group).
Through anatomical review of experimental rats, the cephalic one fourth of the neural foramen was selected as the target point for drug delivery. After the rats had undergone lumbar epidural catheterization, lidocaine, and 1% methylene blue were injected through the unilateral or bilateral L5/6 neural foramen in the INJ group, and through an epidural catheter in the CATH group. Measurement of body weight and the mechanical allodynia test before and after injection of lidocaine, and fine dissection after injection were performed.
Results of the mechanical allodynia test of 1.0% lidocaine 50 µl injection in the CATH group were statistically similar to those of 0.5% lidocaine 100 µl injection in the INJ group. The results of 2.0% lidocaine 50 µl injection in the CATH group were statistically similar to those of 1.0% lidocaine 100 µl injection in the INJ group. After dissection, only one distal partial spinal nerve was stained by methylene blue 50 µl through the transforaminal pathway. However, the dorsal root ganglion, nerve root, and adjacent hemi-partial spinal cord were stained by methylene blue 100 µl through the transforaminal pathway.
The percutaneous transforaminal epidural injection is practical, easy, and safe, and, in particular, does not cause significant pain compared to the existing lumbar epidural catheterization. We expect this method to be effective in an animal study showing that drug delivery to the spinal epidural space is necessary.
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To investigate the efficacy and safety of percutaneous intradiscal monopolar pulsed radiofrequency (PRF) in patients with chronic disabling discogenic back pain.
Twenty-six subjects (7 males; mean age 43.2 years) with chronic back pain refractory to active rehabilitative management were recruited. All subjects underwent MRI for evaluation of Modic changes, and monopolar PRF (20 min at 60 V) at the center of target lumbar intervertebral disc confirmed by pressure-controlled provocative discography. Clinical outcomes were measured by the visual analogue scale (VAS), Oswestry disability index (ODI), and sitting tolerance time (ST) for 12 months after treatment. Successful clinical outcome was described as a minimum of 2 point reduction in VAS compared with the baseline at each follow-up period.
The mean VAS for low back pain reduced significantly from 6.4±1.1 at pre-treatment to 4.4±1.9 at 12 months (p<0.05). The mean ODI score was 47.3±15.4 points at pre-treatment and 36.7±19.5 at 12 months (p<0.001). The ST was 27.8±20.4 minutes at pre-treatment and 71.5±42.2 at 12 months (p<0.001). However, successful clinical outcome was achieved at 58%, 50%, and 42%, measured at 3, 6, and 12 months post-treatment. There were no significant relationship between the clinical outcome and Modic changes; no adverse events were recorded.
The results demonstrated that the application of intradiscal monopolar PRF might be relatively effective but limited; successful intervention for chronic refractory discogenic back pain is needed. To achieve the optimal outcome through intradiscal PRF, we suggested further studies about stimulation duration, mode, and intensity of PRF.
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To evaluate the efficacy of intradiscal methylene blue (MB) injection in patients with chronic discogenic low back pain.
Twenty patients with discogenic low back pain (4 males, 16 females; mean age 45.6 years) refractory to conservative management were recruited. All subjects underwent MB injection in target lumbar intervertebral discs confirmed by provocative discography. The clinical outcome was assessed by visual analog scale (VAS) and Oswestry disability index (ODI) at baseline and 1, 3, 6 and 12 months after treatment. Successful outcome was described as minimum of 2 points reduction in pain intensity compared with the baseline.
VAS and ODI significantly decreased after one injection. The average VAS and ODI were reduced significantly from 5.1 and 38.0 at baseline to 3.2 and 27.4 at 3 months after injection (p<0.05). However, the mean score of VAS at 12 month follow-up was 4.5 and we could not observe any difference between 12 months after injection and pretreatment. Eleven of twenty patients (55%) reported successful outcomes after intradiscal MB injection at 3 month follow up and the average VAS was reduced by 3.3±1.1 (p<0.05). At the time of 12 month follow up, pain had relapsed in 6 patients who have had satisfactory effect at 3 month follow up. Successful outcome was maintained in only 5 patients (20%) for 1 year.
The intradiscal MB injection is a short-term effective minimally invasive treatment indicated for discogenic back pain but it may lose its effectiveness long-term.
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To investigate the effect of extracorporeal shock wave therapy (ESWT) on myofascial pain syndrome (MPS).
Thirty patients with MPS in trapezius muscle were randomly divided into two groups, ESWT group (n=15), and trigger point injections (TPI)+transcutaneous electrical nerve stimulation (TENS) group (n=15). For a total of 3 weeks, ESWT was undertaken with 1,500 pulse each time at one week interval totaling 4,500 pulse, TPI for once a week totaling three times and TENS for five times a week totaling three weeks.
The changes in pain threshold (lb/cm2) showed the values of 6.86±1.35 before first therapy, 11.43±0.27 after first therapy, and 12.57±0.72 after third therapy, while TPI+TENS group showed the values of 6.20±1.92 before first therapy, 8.80±0.48 after first therapy, and 9.60±2.19 after third therapy, and the changes between the groups were significantly different (p=0.045). The changes in visual analog scale were estimated to be 6.86±0.90 before first therapy, 2.86±0.90 after first therapy, and 1.86±0.69 after third therapy in case of ESWT group, whereas the figures were estimated to be 7.20±1.30 before first therapy, 4.60±0.55 after first therapy, and 2.80±0.84 after third therapy in case of TPI+TENS group, and the changes between the groups were significantly different (p=0.010). The changes in McGill pain questionnaire (p=0.816) and pain rating scale (p=0.644) between the groups were not significantly different. The changes in neck ROM were also not significantly different between the groups (p>0.05).
The ESWT in patients with MPS in trapezius muscle are as effective as TPI and TENS for the purpose of pain relief and improving cervical range of motion.
Citations
To evaluate the effect of extracorporeal shock wave therapy (ESWT) in myofascial pain syndrome of upper trapezius with visual analogue scale (VAS) and pressure threshold by digital algometer.
Twenty-two patients diagnosed with myofascial pain syndrome in upper trapezius were selected. They were assigned to treatment and standard care (control) groups balanced by age and sex, with eleven subjects in each group. The treated group had done four sessions of ESWT (0.056 mJ/mm2, 1,000 impulses, semiweekly) while the control group was treated by the same protocol but with different energy levels applied, 0.001 mJ/mm2. The VAS and pressure threshold were measured twice: before and after last therapy. We evaluated VAS of patients and measured the pressure threshold by using algometer.
There were two withdrawals and the remaining 20 patients were three men and 17 women. Age was distributed with 11 patients in their twenties and 9 over 30 years old. There was no significant difference of age, sex, pre-VAS and pre-pressure threshold between 2 groups (p>0.05) found. The VAS significantly decreased from 4.91±1.76 to 2.27±1.27 in the treated group (p<0.01). The control group did not show any significant changes of VAS score. The pressure threshold significantly increased from 40.4±9.94 N to 61.2±12.16 N in the treated group (p<0.05), but there was no significant change in the control group.
ESWT in myofascial pain syndrome of upper trapezius is effective to relieve pain after four times therapies in two weeks. But further study will be required with more patients, a broader age range and more males.
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To evaluate the effectiveness of initial extracorporeal shock wave therapy (ESWT) for patients newly diagnosed with lateral or medial epicondylitis, compared to local steroid injection.
An analysis was conducted of twenty-two patients who were newly confirmed as lateral or medial epicondylitis through medical history and physical examination. The ESWT group (n=12) was treated once a week for 3 weeks using low energy (0.06-0.12 mJ/mm2, 2,000 shocks), while the local steroid injection group (n=10) was treated once with triamcinolone 10 mg mixed with 1% lidocaine solution. Nirschl score and 100 point score were assessed before and after the treatments of 1st, 2nd, 4th and 8th week. And Roles and Maudsley score was assessed one and eight weeks after the treatments.
Both groups showed significant improvement in Nirschl score and 100 point score during the entire period. The local steroid injection group improved more in Nirschl score at the first week and in 100 point score at the first 2 weeks, compared to those of the ESWT group. But the proportion of excellent and good grades of Roles and Maudsley score in the ESWT group increased more than that of local steroid injection group by the final 8th week.
The ESWT group improved as much as the local steroid injection group as treatment for medial and lateral epicondylitis. Therefore, ESWT can be a useful treatment option in patients for whom local steroid injection is difficult.
Citations
To understand the injury pattern of contact burns from therapeutic physical modalities.
A retrospective study was done in 864 patients with contact burns who discharged from our hospital from January 2005 to December 2008. The following parameters were compared between patients with contact burns from therapeutic modalities and from other causes: general characteristics, burn extent, cause of burn injury, place of occurrence, burn injury site, treatment methods, prevalence of underlying disease, and length of hospital stay were compared between patients with contact burns.
Of the 864 subjects, 94 patients were injured from therapeutic modalities. A hot pack (n=51) was the most common type of therapeutic modality causing contact burn followed by moxibustion (n=21), electric heating pad (n=16), and radiant heat (n=4). The lower leg (n=31) was the most common injury site followed by the foot & ankle (n=24), buttock & coccyx (n=9), knee (n=8), trunk (n=8), back (n=6), shoulder (n=4), and arm (n=4). Diabetes mellitus was associated with contact burns from therapeutic modalities; the odds ratio was 3.99. Injuries took place most commonly at home (n=56), followed by the hospital (n=33), and in other places (n=5).
A hot pack was the most common cause of contact burns from therapeutic modalities, and the lower leg was the most common injury site. Injuries took place most commonly at home. The patients with contact burns from therapeutic modalities showed high correlation to presence of diabetes mellitus. These results would be helpful for the prevention of contact burns due to therapeutic modalities.
Citations
To investigate swallowing laterality in hemiplegic patients with stroke and recovery of dysphagia according to the laterality.
The sample was comprised of 46 dysphagic patients with hemiplegia after their first stroke. The sample's videofluoroscopic swallowing study (VFSS) was reviewed. Swallowing laterality was determined by the anterior-posterior view of VFSS. We measured width difference of barium sulfate liquid flow in the pharyngoesophageal segment. If there was double or more the width of that from the opposite width in the pharyngoesophageal segment more than twice on three trials of swallowing, then it was judged as having laterality. Subjects were assigned to no laterality (NL), laterality that is ipsilateral to hemiplegic side (LI), and laterality that is contralateral to hemiplegic side (LC) groups. We measured the following: prevalence of aspiration, the 8-point penetration-aspiration scale, and the functional dysphagia scale of the subjects at baseline and follow up.
Laterality was observed in 45.7% of all patients. Among them, 52.4% were in the hemiplegic direction. There was no significant difference between groups at baseline in all measurements. When we compared the changes in all measurements on follow-up study, there were no significant differences between groups.
Through this study, we found that there was no significant relation between swallowing laterality and the severity or prognosis of swallowing difficulty. More studies for swallowing laterality on stroke patients will be needed.
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To investigate the relationship between severity of peripheral polyneuropathy (PPN) and degree of depression and quality of life in chronic renal failure (CRF) patients on hemodialysis (HD).
Forty seven chronic renal failure patients on hemodialysis were recruited (22 male, 25 female, mean age of 63.17±12.52) and etiology, disease duration, hemodialysis duration, creatinine and hemoglobin were recorded. Motor and sensory nerve conduction studies were carried out on bilateral median, ulnar, tibial and peroneal nerves for diagnosis of polyneuropathy according to our laboratory criteria. The Korean version of Beck depression inventory (BDI) questionnaire translated into Korean for diagnosis of depression, and Korean version of Short Form 36 health survey (SF-36) questionnaire for measurement of general health level were measured in those diagnosed with uremic PPN.
Out of 52 patients, 47 were diagnosed with polyneuropathy and mean score for BDI was 18.49±9.18. Mean scores for each of Mental Component Summary (MCS) and Physical Component Summary (PCS) of SF-36 were 50.84±15.42 and 47.41±18.68. The correlation between the scores and polyneuropathy were analyzed by Pearson coefficient. The MCS score was the significant (p<0.05) correlation parameter with depression (R=-0.635) and the PCS score was the only parameter with a significant (p<0.05) correlation with polyneuropathy (R=-0.340).
Uremic polyneuropathy is commonly observed in chronic renal failure patients on hemodialysis. Depression in CRF with uremic PPN is affected by psychological factors other than the PPN itself.
Citations
Massage is generally accepted as a safe and a widely used modality for various conditions, such as pain, lymphedema, and facial palsy. However, several complications, some with devastating results, have been reported. We introduce a case of a 43-year-old man who suffered from tetraplegia after a neck massage. Imaging studies revealed compressive myelopathy at the C6 level, ossification of the posterior longitudinal ligament (OPLL), and a herniated nucleus pulposus (HNP) at the C5-6 level. After 3 years of rehabilitation, his motor power improved, and he is able to walk and drive with adaptation. OPLL is a well-known predisposing factor for myelopathy in minor trauma, and it increases the risk of HNP, when it is associated with the degenerative disc. Our case emphasizes the need for additional caution in applying manipulation, including massage, in patients with OPLL; patients who are relatively young (i.e., in the fifth decade of life) are not immune to minor trauma.
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Early diagnosis and treatment of heterotopic ossification (HO) is essential to the prevention of complications. It is difficult to diagnose HO in its initial phase because non-specific clinical manifestations, laboratory findings and imaging findings of immature HO may mimic other diseases such as cellulitis, osteomyelitis, thrombophlebitis, deep vein thrombosis and local infection with abscess. We experienced two cases of HO, which were misdiagnosed as pyomyositis at first by clinical signs and MRI findings indicating the deep infection; the extensive intramuscular ossification appeared later on. We observed an increase of C-reactive protein and creatine kinase followed by the elevation of alkaline phosphatase with abnormal triphasic bone scan. The trajectory of these biomarkers was analyzed to get more insight into the early stages of HO along with the imaging findings. Although our cases cannot be generalized as typical of immature HO, they clearly demonstrate that the change of specific biomarkers with a careful history taking and physical examination should be noted to detect HO as early as possible while avoiding confusion with other mimicking conditions.
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This study reports a rare case of ulnar neuropathy around the arm with Martin-Gruber anastomosis of a moderate conduction block in the forearm segment and a severe conduction block in the arm segment. Inching tests and ultrasonography showed a lesion between 12 and 14 cm from the medial epicondyle. It is concluded that axilla stimulation may provide diagnostic clues, and inching tests and ultrasonography may be helpful for localizing a lesion.
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In herpes zoster infection, neurological complications may be overlooked because pain is a more prominent symptom and because peripheral polyneuropathy associated with weakness is rare. A 57-year-old male visited our hospital, complaining of pain and skin eruptions on the right flank. He was diagnosed as having herpes zoster and the symptoms were alleviated by administration of acyclovir for a week. After three weeks, the herpes zoster relapsed. He was re-admitted and diagnosed with chronic myeloid leukemia (CML), and imatinib mesylate was prescribed for five weeks. Ten weeks after the onset of herpes zoster, bilateral foot drops and numbness of the right foot dorsum developed. Through an electrodiagnostic study, he was diagnosed as having peripheral polyneuropathy that was suspected to be caused by neural invasion by varicella zoster virus. After administration of famciclovir, not only the pain but also the neurologic symptoms improved. We herein report a case of peripheral polyneuropathy that was supposed to be related to herpes zoster.
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Anterior cervical hyperostosis may be a cause of dysphagia. For anterior cervical hyperostosis, medical or surgical treatments can be adhibited in view of the causative mechanisms and intensities of dysphagia. We report 3 cases of cervical hyperostosis-derived progressive dysphagia that underwent operation. Radiologic diagnosis and Video Fluoroscopic Swallowing Study were performed on the three patients for evaluation. One had history of recurrent aspiration pneumonia accompanied by weight loss, another complained of dysphagia only when swallowing pills, and the third experienced recurrence symptom with reossification. All patients reported gradual improvement of dysphagia immediately after their cervical osteophytes were resected through the anterior approach. In relation to postoperative improvement, however, they expressed different degrees of satisfaction according to severity of symptoms. Surgical treatment, performed for the anterior cervical hyperostosis-derived dysphagia, can immediately relieve symptoms of difficulty in swallowing. This might especially be considered as an appropriate treatment option for severe dysphagia.
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Thyroid carcinoma is the commonest endocrinological malignancy. After papillary thyroid carcinoma (PTC), follicular thyroid carcinoma (FTC) is the second most common histological subtype. Common presentations of FTC include a solitary thyroid nodule and cervical lymphadenopathy. The incidence of individuals diagnosed with thyroid cancer showing initially distant metastatic disease ranges from 1 to 9%. Also, the incidence of solitary bone metastasis from thyroid is only 2 to 3%. We report a case of a patient with FTC whose initial presentation was low back pain and right buttock pain due to vertebral metastasis rather than the usual neck lumps or symptoms of thyroid disease.
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Plasmacytoma is a rare disease, which afflicts 2 to 3 people per every 100,000 of the general population. Solitary plasmacytoma accounts for 5% of the plasma cell neoplasm. Solitary plasmacytoma of the bone appears more vividly in the axial skeleton (25-60%), which has the red marrow and usually affects the thoracic vertebrae. We report a case of 54-year-old man who has a chest pain on the right side. After being treated for the muscle pain, his symptoms of pain were changed into weakness and allesthesia. We checked the MRI and found a mass lesion in the T5 vertebra, but there were no significant laboratory findings, in blood and urine samples. Finally, he got an operation due to the aggravation of the weakness. The result of biopsy indicated that it was a solitary plasmacytoma of the spine. After 5 months later, the weakness and allesthesia had disappeared.
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