To evaluate characteristics of the postural instability in patients with stroke and to present a prediction model of post-stroke falls.
Patients with a first-ever stroke who had been evaluated by the Balance Master (BM) at post-stroke 3 months (±1 month) between August 2011 and December 2015 were enrolled. Parameters for the postural instability, such as the weight bearing asymmetry (WBA) and postural sway velocity (PSV), were obtained. The fall events in daily lives were assessed via structured telephone interview with a fall related questionnaire.
A total of 71 patients (45 men; 45 with ischemic stroke) were enrolled in this study. All subjects underwent BM evaluation at 3.03±0.40 months after stroke. The mean WBA was 17.18%±13.10% and mean PSV (measured as °/s) were noted as 0.66±0.37 (eyes-open on firm surface), 0.89±0.75 (eyes-closed on firm surface), 1.45±1.09 (eyes-open on soft surface), and 3.10±1.76 (eyes-closed on soft surface). A prediction model of post-stroke falls was drawn by multiple logistic regression analysis as follows: Risk of post-stroke falls = -2.848 + 1.878 x (PSVECSS) + 0.154 x (age=1 if age≥65; age=0 if age<65).
The weight bearing asymmetry and postural sway were significantly increased in patients with stroke. Older age and impaired postural control increased the risk of post-stroke falls.
Citations
To investigate the effects of mirror therapy using a tablet PC for post-stroke central facial paresis.
A prospective, randomized controlled study was performed. Twenty-one post-stroke patients were enrolled. All patients performed 15 minutes of orofacial exercise twice daily for 14 days. The mirror group (n=10) underwent mirror therapy using a tablet PC while exercising, whereas the control group (n=11) did not. All patients were evaluated using the Regional House–Brackmann Grading Scale (R-HBGS), and the length between the corner of the mouth and the ipsilateral earlobe during rest and smiling before and after therapy were measured bilaterally. We calculated facial movement by subtracting the smile length from resting length. Differences and ratios between bilateral sides of facial movement were evaluated as the final outcome measure.
Baseline characteristics were similar for the two groups. There were no differences in the scores for the basal Modified Barthel Index, the Korean version of Mini-Mental State Examination, National Institutes of Health Stroke Scale, R-HBGS, and bilateral differences and ratios of facial movements. The R-HBGS as well as the bilateral differences and ratios of facial movement showed significant improvement after therapy in both groups. The degree of improvement of facial movement was significantly larger in the mirror group than in the control group.
Mirror therapy using a tablet PC might be an effective tool for treating central facial paresis after stroke.
Citations
To delineate the effect of early cranioplasty on the recovery of cognitive and functional impairments in patients who received decompressive craniectomy after traumatic brain injury or spontaneous cerebral hemorrhage.
Twenty-four patients who had received cranioplasty were selected and divided according to the period from decompressive craniectomy to cranioplasty into early (≤90 days) and late (>90 days) groups. The Korean version of the Mini-Mental State Examination (K-MMSE), Korean version of the Modified Barthel Index (K-MBI), and Functional Independence Measure (FIM) were evaluated at admission just after decompressive craniectomy and during the follow-up period after cranioplasty.
Twelve patients were included in the early group, and another 13 patients were included in the late group. The age, gender, type of lesion, and initial K-MMSE, K-MBI, and FIM did not significantly differ between two groups. However, the total gain scores of the K-MMSE and FIM in the early group (4.50±7.49 and 9.42±15.96, respectively) increased more than those in the late group (−1.08±3.65 and −0.17±17.86, respectively), and some of K-MMSE subscores (orientation and language) and FIM subcategories (self-care and transfer-locomotion) in the early group increased significantly when compared to those in the late group without any serious complications. We also found that the time to perform a cranioplasty was weakly, negatively correlated with the K-MMSE gain score (r=−0.560).
Early cranioplasty might be helpful in restoring cognitive and functional impairments, especially orientation, language ability, self-care ability, and mobility in patients with traumatic brain injury or spontaneous cerebral hemorrhage.
Citations
To develop the Korean version of the Cognitive Assessment Scale for Stroke Patients (K-CASP) and to evaluate the test reliability and validity of the K-CASP in stroke patients.
The original CASP was translated into Korean, back-translated into English, then reviewed and compared with the original version. Thirty-three stroke patients were assessed independently by two examiners using the K-CASP twice, with a one-day interval, for a total of four test results. To evaluate the reliability of the K-CASP, intra-class correlation coefficients were used. Pearson correlations were calculated and simple regression analyses performed with the Korean version of Mini-Mental State Examination (K-MMSE) and the aphasia quotient (AQ) to assess the validity.
The mean score was 24.42±9.47 (total score 36) for the K-CASP and 21.50±7.01 (total score 30) for the K-MMSE. The inter-rater correlation coefficients of the K-CASP were 0.992 on the first day and 0.995 on the second day. The intra-rater correlation coefficients of the K-CASP were 0.997 for examiner 1 and 0.996 for examiner 2. In the Pearson correlation analysis, the K-CASP score significantly correlated with the K-MMSE score (r=0.825, p<0.001). The coefficients of determination (r2) of the AQ were 0.586 for the K-MMSE and 0.513 for the K-CASP in the simple regression analysis.
The K-CASP is a reliable and valid instrument for cognitive dysfunction screening in post-stroke patients. It is more applicable than other cognitive assessment tools in stroke patients with aphasia.
Citations
To determine the efficacy of aquatic treadmill training (ATT) as a new modality for stroke rehabilitation, by assessing changes in gait symmetry, balance function, and subjective balance confidence for the paretic and non-paretic leg in stroke patients.
Twenty-one subacute stroke patients participated in 15 intervention sessions of aquatic treadmill training. The Comfortable 10-Meter Walk Test (CWT), spatiotemporal gait parameters, Berg Balance Scale (BBS), and Activities-specific Balance Confidence scale (ABC) were assessed pre- and post-interventions.
From pre- to post-intervention, statistically significant improvements were observed in the CWT (0.471±0.21 to 0.558±0.23, p<0.001), BBS (39.66±8.63 to 43.80±5.21, p<0.001), and ABC (38.39±13.46 to 46.93±12.32, p<0.001). The step-length symmetry (1.017±0.25 to 0.990±0.19, p=0.720) and overall temporal symmetry (1.404±0.36 to 1.314±0.34, p=0.218) showed improvement without statistical significance.
ATT improves the functional aspects of gait, including CWT, BBS and ABC, and spatiotemporal gait symmetry, though without statistical significance. Further studies are required to examine and compare the potential benefits of ATT as a new modality for stroke therapy, with other modalities.
Citations
To establish the reliability and validity the Korean version of the Stroke Impact Scale (K-SIS) 3.0.
A total of 70 post-stroke patients were enrolled. All subjects were evaluated for general characteristics, Mini-Mental State Examination (MMSE), the National Institutes of Health Stroke Scale (NIHSS), Modified Barthel Index, Hospital Anxiety and Depression Scale (HADS). The SF-36 and K-SIS 3.0 assessed their health-related quality of life. Statistical analysis after evaluation, determined the reliability and validity of the K-SIS 3.0.
A total of 70 patients (mean age, 54.97 years) participated in this study. Internal consistency of the SIS 3.0 (Cronbach's alpha) was obtained, and all domains had good co-efficiency, with threshold above 0.70. Test-retest reliability of SIS 3.0 required correlation (Spearman's rho) of the same domain scores obtained on the first and second assessments. Results were above 0.5, with the exception of social participation and mobility. Concurrent validity of K-SIS 3.0 was assessed using the SF-36, and other scales with the same or similar domains. Each domain of K-SIS 3.0 had a positive correlation with corresponding similar domain of SF-36 and other scales (HADS, MMSE, and NIHSS).
The newly developed K-SIS 3.0 showed high inter-intra reliability and test-retest reliabilities, together with high concurrent validity with the original and various other scales, for patients with stroke. K-SIS 3.0 can therefore be used for stroke patients, to assess their health-related quality of life and treatment efficacy.
Citations
To investigate the causes and characteristics of golf-related shoulder injuries in Korean amateur golfers.
Golf-related surveys were administered to, and ultrasonography were conducted on, 77 Korean amateur golfers with golf-related shoulder pain. The correlation between the golf-related surveys and ultrasonographic findings were investigated.
The non-dominant shoulder is more likely to have golf-related pain and abnormal findings on ultrasonography than is the dominant shoulder. Supraspinatus muscle tear was the most frequent type of injury on ultrasonography, followed by subscapularis muscle tear. Investigation of the participants' golf-related habits revealed that only the amount of time spent practicing golf was correlated with supraspinatus muscle tear. No correlation was observed between the most painful swing phases and abnormal ultrasonographic findings. Participants who had not previously visited clinics were more likely to present with abnormal ultrasonographic findings, and many of the participants complained of additional upper limb pain.
Golf-related shoulder injuries and pain are most likely to be observed in the non-dominant shoulder. The supraspinatus muscle was the most susceptible muscle to damage. A correlation was observed between time spent practicing golf and supraspinatus muscle tear.
Citations
To evaluate the effects of early regular exercise and to assess the electrophysiological and histopathological findings of the rat tail nerve in relation to the timing of exercise training for swimming exercise in rats with diabetic neuropathy.
We used 70 Sprague-Dawley male rats, and the experimental group comprised 60 rats, and the control group comprised 10 rats. Diabetes was induced by intraperitoneal injection of streptozotocin. Blood glucose concentrations were measured in tail vein blood samples. The experimental group was divided into 6 subgroups according to insulin treatment and swimming exercise: group 1, diabetic control; group 2, insulin treated; group 3, insulin untreated with early swimming exercise; group 4, insulin treated and early swimming exercise; group 5, insulin treated and late swimming exercise; and group 6, insulin untreated with late swimming exercise. Sensory and motor nerve conduction studies were performed weekly up to the 13th week using rat tail nerves. The effect on structural diabetic neuropathy was assessed by morphometry and ultrastructural examination of the rat tail nerve fiber at the 14th week.
An exercise effect was observed in the insulin treated groups, but it was not observed in the insulin untreated groups. The sensory nerve conduction study in the rat tail revealed significantly prolonged latency and decreased amplitude in groups 1 and 6, and a further delay was observed in group 5 when compared to group 4. Decreased thickness of myelin was found in groups 1 and 6 through morphometry.
Early regular exercise programs in addition to conventional insulin treatment may retard the progression of diabetic peripheral neuropathy.
Citations
To observe the contrast spread in superoposterior transforaminal epidural steroid injection (SP TFESI) and investigate the correlation between spread patterns and efficacy.
Thirty-one patients with lumbosacral radiculopathy underwent single-level TFESI under fluoroscopy. The final needle tip position was targeted toward the SP quadrant of the intervertebral foramen. To observe the spread, 1 mL of contrast material was injected, followed by a steroid injection. The contrast spread was graded anteroposteriorly and vertically in the epidural space. The effect of SP TFESI was evaluated by proportional pain score reduction.
Levels injected were L4-5 (n=20) and L5-S1 (n=11). Seventeen cases were lateral, and 14 were central herniated disc (HD). Baseline mean visual analog scale score was 6.23. Contrast dispersed dorsally in all the cases, and 45.2% cases showed a concurrent ventral spread. The proportion of the pain reduction after 2 weeks showed no difference between the two groups. In vertical spreading analysis, mean cephalic/caudal grades were 1.40/1.55 at L4-5 level and 1.73/1.64 at L5-S1 level. The HD location had no effect on contrast dispersion.
In SP TFESI, ventral contrast spread did not guarantee a better effect; however, the extent of cephalic flow in ventral expansion group correlated with the proportion of pain reduction.
Citations
To define the anatomy of the lateral antebrachial cutaneous nerve (LABCN) and the cephalic vein (CV) in the anterior forearm region of living humans using ultrasonography for preventing LABCN injury during cephalic venipuncture.
Thirty forearms of 15 healthy volunteers were evaluated using ultrasonography to identify the point where the LABCN begins to contact with the CV, and the point where the LABCN separates from the CV. The LABCN pathway in the forearm in relation to a nerve conduction study was also evaluated.
The LABCNs came in contact with the CV at a mean of 0.6±1.6 cm distal to the elbow crease, and separated from the CV at a mean of 7.0±3.4 cm distal to the elbow crease. The mean distance between the conventionally used recording points (point R) for the LABCN conduction study and the actual sonographic measured LABCN was 2.4±2.4 mm. LABCN usually presented laterally at the point R (83.3%).
The LABCN had close proximity to the CV in the proximal first quarter of the forearm. Cephalic venipuncture in this area should be avoided, and performed with caution if needed.
Citations
To investigate the impact of tracheostomy tube capping on swallowing physiology in stroke patients with dysphagia via videofluoroscopic swallowing study (VFSS).
This study was conducted as a prospective study that involved 30 stroke patients. Then, 4 mL semisolid swallowing was conducted with capping of the tracheostomy tube or without capping of the tracheostomy tube. The following five parameters were measured: laryngeal elevation, pharyngeal transit time, post-swallow pharyngeal remnant, upper esophageal sphincter width (UES), and penetration-aspiration scale (PAS) score.
On assessment of the differences in swallowing parameters during swallowing between ‘with capping’ and ‘without capping’ statuses, statistically significant differences were found in the post-swallow pharyngeal remnant (without capping, 48.19%±28.70%; with capping, 25.09%±19.23%; p<0.001), normalized residue ratio scale for the valleculae (without capping, 0.17±0.12; with capping, 0.09±0.12; p=0.013), normalized residue ratio scale for the piriform sinus (without capping, 0.16±0.12; with capping, 0.10±0.07; p=0.015), and UES width (without capping, 3.32±1.61 mm; with capping, 4.61±1.95 mm; p=0.003). However, there were no statistically significant differences in laryngeal elevation (x-axis without capping, 2.48±1.45 mm; with capping, 3.26±2.37 mm; y-axis without capping, 11.11±5.24 mm; with capping, 12.64±6.16 mm), pharyngeal transit time (without capping, 9.19± 10.14 s; with capping, 9.09±10.21 s), and PAS score (without capping, 4.94±2.83; with capping, 4.18±2.24).
Tracheostomy tube capping is a useful way to reduce post-swallow remnants and it can be considered an alternative method for alleviating dysphagia in stroke patients who can tolerate tracheostomy tube capping when post-swallow remnants are observed.
Citations
To explore both the early prediction and diagnosis of dysphagia in preterm infants as an important developmental aspect as well as the prevention of respiratory complications, we developed the simple and-easy-to-apply Dysphagia Screening Test for Preterm Infants (DST-PI) to predict supraglottic penetration and subglottic aspiration.
Fifty-two infants were enrolled in a videofluoroscopic swallowing study (VFSS) due to clinical suspicions of dysphagia. Thirteen items related to supraglottic penetration or subglottic aspiration were initially selected from previous studies for the DST-PI. Finally, 7 items were determined by linear logistic regression analysis. Cutoff values, sensitivity, specificity, and the area under the ROC curve (AUC) of the DST-PI for predicting supraglottic penetration or subglottic aspiration were calculated using a ROC curve. For inter-rater reliability, the kappa coefficient was calculated.
Seven items were selected: ‘gestational age,’ ‘history of apnea,’ ‘history of cyanosis during feeding,’ ‘swallowing pattern,’ ‘coughs during or after feeding,’ ‘decreased oxygen saturation within 3 minutes of feeding,’ and ‘voice change after feeding.’ The Spearman correlation coefficient between the DST-PI and the penetration-aspiration scale (PAS) was 0.807 (p<0.001). The sensitivity and specificity at different cutoff values for detecting supraglottic penetration and subglottic aspiration were 96.6% and 76.9% at 3.25, and 88.9% and 75.8% at 6.25, respectively.
The DST-PI is a valid and reliable dysphagia screening test for supraglottic penetration or subglottic aspiration in preterm infants that is easy to apply in a clinical context.
Citations
To develop and test the validity and reliability of a new instrument for measuring the thigh-foot angle (TFA) for the patients with in-toeing and out-toeing gait.
The new instrument (Thigh-Foot Supporter [TFS]) was developed by measuring the TFA during regular examination of the tibial torsional status. The study included 40 children who presented with in-toeing and out-toeing gaits. We took a picture of each case to measure photographic-TFA (P-TFA) in the proper position and to establish a criterion. Study participants were examined by three independent physicians (A, B, and C) who had one, three and ten years of experience in the field, respectively. Each examiner conducted a separate classical physical examination (CPE) of every participant using a gait goniometer followed by a TFA assessment of each pediatric patient with or without the TFS. Thirty minutes later, repeated in the same way was measured.
Less experienced examiner A showed significant differences between the TFA values depending on whether TFS used (left p=0.003 and right p=0.008). However, experienced examiners B and C did not show significant differences. Using TFS, less experienced examiner A showed a high validity and all examiner's inter-test and the inter-personal reliabilities increased.
TFS may increase validity and reliability in measuring tibial torsion in patients who has a rotational problem in lower extremities. It would be more useful in less experienced examiners.
Citations
To report successful cases of extubation from invasive mechanical ventilation at our institution using pulmonary rehabilitation consisting of noninvasive ventilation (NIV) in neuromuscular patients with experience of reintubation.
Patients who experienced extubation failure via the conventional weaning strategy but afterwards had extubation success via NIV were studied retrospectively. Continuous end-tidal CO2 (ETCO2) and pulse oxyhemoglobin saturation (SpO2) monitoring were performed. Extubation success was defined as a state not requiring invasive mechanical ventilation via endotracheal tube or tracheotomy during a period of at least 5 days.
A total of 18 patients with ventilatory failure who initially experienced extubation failure were finally placed under part-time NIV after extubation. No patient had any serious or long-term adverse effect from NIV, and all patients left the hospital alive.
NIV may promote successful weaning in neuromuscular patients with experience of reintubation.
Citations
To explore the feasibility of cardiopulmonary exercise test (CPET) in leukemia patients after chemotherapy.
Leukemia patients with histologically confirmed hematologic malignancies were reviewed. We evaluated for CPET, between receiving chemotherapy and undergoing stem cell transplantation after 2 weeks. We recorded exercise testing and physiologic parameters during CPET between January 2013 to May 2015. All patients were subjected to symptoms limited to exercise testing, according to the Modified Bruce Protocol. We considered that if respiratory exchange ratio achieved was over 1.10, participants had successfully completed CPET. We dichotomized all participants into two groups (normal group, normal range of resting heart rate; higher group, over 100 per minute of heart rate).
30 patients were finally enrolled. All participants had no adverse effects during the exercise test. Mean peak double product was 26,998.60 mmHg·beats/min (range, 15,481–41,004), and mean peak oxygen consumption (VO2 peak) was 22.52±4.56 mL/kg/min. Significant differences were observed in the normal group with VO2 peak (mean, 24.21 mL/kg/min; p=0.027) and number of prior intensive chemotherapy, compared to the higher group (mean, 1.95; p=0.006).
Our results indicate that CPET in leukemia patients before stem cell transplantation was very safe, and is an efficient method to screen for patients with poor cardiac functions. As CPET presents the parameters which reveal the cardiopulmonary functions, including VO2 peak, double product and exercise capacity, this exercise test would help to predict the physical performance or general condition of the leukemia patients.
Citations
To assess the effect of neuromuscular electrical stimulation (NMES) on the recovery of abdominal muscle strength in postnatal women with diastasis of recti abdominis muscles (DRAM).
Sixty women, 2 months postnatal, participated in this study. They were divided randomly into two equal groups. Group A received NMES in addition to abdominal exercises; group B received only abdominal exercises. The intervention in both groups was for three times per week for 8 weeks. The outcome measures were body mass index (BMI), waist/hip ratio, inter recti distance (IRD), and abdominal muscle strength in terms of peak torque, maximum repetition total work, and average power.
Both groups showed highly significant (p<0.05) improvement in all outcomes. Further, intergroup comparisons showed significant improvement (p<0.05) in all parameters in favor of group A, except for the BMI.
NMES helps reduce DRAM in postnatal women; if combined with abdominal exercises, it can augment the effects.
Citations
To investigate trends of the research designs and statistical methods in the
The authors reviewed all articles published in ARM and APMR for the years 2005 and 2015 in order to determine their research designs as well as their statistical methods used in each article.
In ARM, randomized controlled trials increased from 4.5% in 2005 to 6.5% in 2015. In APMR, randomized controlled trials increased from 8.1% in 2005 to 14.0% in 2015, meta-analyses increased to 5.3%, and systematic reviews increased to 6%. The number of studies using statistical methods increased in ARM from 1.9 to 2.6 per article and in APMR, from 2.7 to 3.1. Use of advanced methods in ARM also showed an increase from 2005 to 2015.
This study concludes that there is a trend of increased awareness and attempts to use varied research approaches in ARM articles. There should also be more in-depth discussions and opportunities for researchers to share their experiences regarding statistical methods in the clinical field.
Citations
This case report describes a severe nerve injury to the right ulnar nerve, caused by bee venom acupuncture. A 52-year-old right-handed man received bee venom acupuncture on the medial side of his right elbow and forearm, at a Traditional Korean Medicine (TKM) clinic. Immediately after acupuncture, the patient experienced pain and swelling on the right elbow. There was further development of weakness of the right little finger, and sensory changes on the ulnar dermatome of the right hand. The patient visited our clinic 7 days after acupuncture. Electrodiagnostic studies 2 weeks after the acupuncture showed ulnar nerve damage. The patient underwent steroid pulse and rehabilitation treatments. However, his condition did not improve completely, even 4 months after acupuncture.
Citations
Lipomas are mostly located in the subcutaneous tissues and rarely cause symptoms. Occasionally, peripheral nerve compression by lipomas is reported. We describe a case of a 59-year-old man with a left-middle cerebral artery infarction who was newly diagnosed as right basal ganglia and thalamic intracranial hemorrhage. He had neuropathic pain in the left arm and leg that was suspected to be central post-stroke pain. The administration of pain medication brought only temporary symptom relief. Nerve conduction and electromyography studies revealed left L5 radiculopathy and he showed a positive ‘sign of the buttock’ in the left hip. Left-hip magnetic resonance imaging revealed an intermuscular lipoma compressing the sciatic nerve. After surgery, the range of motion in the left hip joint was significantly increased, and the patient's pain was relieved.
Citations
Churg-Strauss syndrome (CSS) is a rare systemic vasculitis that affect small and medium-sized blood vessels and is accompanied by asthma, eosinophilia, and peripheral neuropathy. This report describes a case of a 52-year-old man who had a history of sinusitis, asthma, and thymus cancer and who had complained of bilateral lower extremity paresthesia and weakness for a month. Peripheral neuropathy was detected by electrodiagnostic studies. Resection of a mediastinal mass, which was diagnosed as thymic neuroendocrine carcinoma, was performed five months before his visit. After thymectomy, peripheral blood tests revealed a gradual increase in eosinophils. Two months after surgery, he was admitted to the hospital for dyspnea, and nodules of focal consolidation were found in his chest X-ray. One month later, pyoderma occurred in the right shin, and the skin biopsy showed extravascular eosinophilic infiltration. He was diagnosed with CSS after thymectomy, and we report a very rare case of CSS presented with thymic neuroendocrine carcinoma.
Citations
Extracorporeal shockwave therapy (ESWT) has been reported to be a safe and effective method for decreasing pain and relieving range of motion (ROM) limitations caused by neurogenic heterotopic ossification (NHO), though there has been no report that it might cause hematoma if applied to NHO. We hereby report a case of massive hematoma after ESWT, specifically the radial shockwave therapy (RSWT) device at both hips in a 49-year-old female patient with NHO. She had developed NHO after extensive subarachnoid hemorrhage. We had applied RSWT according to the previous report. The pain and the ROM limitations were gradually improved. Six weeks later, she reported pain and ROM limitations on the right hip. From a medial aspect, swelling and bruising of the right thigh could be seen. Magnetic resonance imaging and ultrasonography suggested a large hematoma between right hip adductor muscles. The symptoms disappeared after conservative treatment for one month, and subsequent follow-up imaging studies demonstrated resolution of the hematoma.
Citations
Diagnostic exome sequencing (DES) is a powerful tool to analyze the pathogenic variants leading to development delay (DD) and intellectual disability (ID). Recently, heterozygous
Citations
Grisel syndrome is a rare, non-traumatic atlanto-axial subluxation associated with an inflammatory or infectious process in the upper neck. According to the two-hit hypothesis, which is widely accepted for the pathogenesis of Grisel syndrome, preexisting ligamentous laxity of the atlanto-axial joint is regarded as the first hit. An inflammatory or infectious process of the atlanto-axial joint acts as the second hit, resulting in non-traumatic atlanto-axial subluxation. We report on a 6-year-old girl with atlanto-axial subluxation following retropharyngeal and cervical lymphadenitis. She was diagnosed with Grisel syndrome, for which an initial computed tomography did not show any preexisting ligamentous laxity of the atlanto-axial joint. A literature review found only 4 case reports on Grisel syndrome with an initially normal atlanto-axial joint. The present case offers some evidence that a single hit, such as inflammatory changes in the atlanto-axial joint, might cause Grisel syndrome, even without underlying ligamentous laxity.
Citations
First
Prev
