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Tracheomalacia is characterized by weakness of the tracheal walls and supporting cartilage. It results in dynamic compression of the airway, where the cross-sectional area of the trachea is reduced by expiratory compression. Acquired tracheomalacia results from complications associated with the use of endotracheal or tracheostomy tubes. In this report, we present three cases of patients with amyotrophic lateral sclerosis (ALS) successfully treated for tracheomalacia, including one case where the patient underwent surgery for combined tracheoesophageal fistula. We discuss the appropriate management strategies for tracheomalacia in patients with ALS. Through these case reports, we note the results of ALS patients who will have tracheostomy, and who are therefore at risk of sustaining a long term high cuff pressure, this study provides an evaluation for tracheomalacia and therapeutic management which should be considered for improving patient care outcomes.
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To analyze the amount of weight-bearing during tilt table increments, with a review of neutral and unilateral knee flexion postures.
There were 17 healthy participants enrolled in this study. The subjects were tilted from 10° to 90°, and their body weight was measured at each 10° increment. In the first test, both plantar pressures, with the subjects in neutral posture, were recorded. During the second and third tests, the angle of inclination was thus recorded and increased, with the subjects in unilateral knee flexion posture; flexion was maintained at 25° by attaching a cylindrical support to the tilt table at the level of the popliteal fossa.
The study was divided into two types of postures: neutral and unilateral knee flexion. The percentage of body weight (%BW) between each leg during neutral posture was noted as not being statistically significant. The %BW of one side during tilt table inclination was significantly different between the two postures at 10° to 80° (p<0.05). The weight during unilateral knee flexion posture was lower as analyzed, regardless of tilt table inclination compared with that in neutral posture. We note that fifty percent of the ratio of %BW was noted at 33.12° and 38.76° in neutral and flexion postures, respectively.
The unilateral knee flexion could induce the effect of decreased body weight compared with non-flexion side. The results of this study will help in setting a safe and quantitative percentage of weight-bearing on the lower extremity during tilt training.
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To investigate the current status of pharmacotherapy prescribed by physiatrists in Korea for cognitive-behavioral disorder.
A cross-sectional study was performed by mailing questionnaires to 289 physiatrists working at teaching hospitals. Items on the questionnaire evaluated prescribing patterns of 16 drugs related to cognitive-behavioral therapy, the status of combination pharmacotherapy, and tools for assessing target symptoms.
Fifty physiatrists (17.3%) including 24 (48%) specializing in neurorehabilitation completed the questionnaires. The most common target symptom was attention deficit (29.5%). Donepezil and methylphenidate (96.0%) were the most frequently prescribed drugs for cognitive-behavioral improvement. Mostly, a combination of two drugs was prescribed (38.0%), and the most common combination therapy included donepezil plus methylphenidate (19.1%). Pharmacotherapy for cognitive-behavioral disorder after brain injury was typically initiated within 2 months (69.5%). A follow-up assessment was usually performed at 1 month after treatment initiation (31.0%). The most common reason for treatment discontinuation was improvement of target symptoms (37.8%). The duration of pharmacotherapy was 3–12 months (57.7%), 1–2 years (17.9%), or 1–2 months (13.6%).
According to the survey, combination pharmacotherapy is preferred to monotherapy for the treatment of cognitive-behavioral disorder in patients with brain injury. Physiatrists expressed diverse views on the definition of target symptoms, prescribing patterns, and the status of drug combination therapy. Guidelines are needed for cognitive-behavioral pharmacotherapy. Further research should investigate drug costs and aim to reduce polypharmacy and adverse drug reactions.
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To evaluate the association between balance function and asymmetry of knee extension strength in an elderly Korean population.
The strength of the knee extensors in each leg was measured in 306 community-dwelling elderly subjects (age, 76.70±4.85 years) and 25 young healthy subjects (age, 34.23±8.93 years). Based on the difference in strength of both legs, the elderly subjects were divided into symmetric (n=128) and asymmetric (n=178) strength groups using an asymmetry cutoff 20%. We determined the postural control ability of the subjects using InBody posturography, Berg Balance Scale (BBS), Timed Up and Go test (TUG) and Short Physical Performance Battery (SPPB). The sway index (SI) of the subjects in four positions was assessed using posturography.
The group with asymmetric strength presented a significantly higher SI than the group with symmetric strength, in the normal position with eyes open and eyes open on pillows. In the normal position with the eyes closed and in postures with the eyes closed on pillows, the statistical analysis revealed no significant differences between the two groups. The three tests for physical performance (BBS, TUG, and SPPB) show no statistically significant difference between the two groups.
The asymmetric strength group showed a significantly lower balance than the group with symmetric strength based on several posturographic parameters. Ambulatory elderly individuals with asymmetry in knee extension strength, showed deficits in balance control even in normal clinical tests.
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To determine if there is muscle mass reduction in patients with ankylosing spondylitis (AS) compared to the general population and to examine the relationship between skeletal muscle mass, quality of life (QOL), strength, and mobility in patients with AS.
A total of 30 AS patients were enrolled in this study. Skeletal muscle mass was measured by bioelectrical impedance analysis, and it was expressed as the skeletal muscle mass index (SMI). QOL was assessed using the EuroQOL (EQ-5D). To measure mobility, the modified Schöber test and chest expansion test were used. To measure grip strength as a measure of muscle strength, we used the hydraulic hand dynamometer. Additionally, we divided the patients into two groups according to the degree of X-ray finding and compared the differences between the two groups.
There was no significant reduction in skeletal muscle mass in patients with AS compared to the general population. Also, there was no significant correlation between SMI and QOL. On the other hand, there was a significant positive correlation between SMI and mobility, and grip strength. A significant positive correlation was found between mobility and QOL. Additionally, there was a statistically significant difference in mobility between the two groups according to the degree of X-ray finding.
Maintaining muscle mass in AS patients may not be helpful for improving QOL, but it may contribute to achieving adequate mobility and strength.
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To investigate the differences in biomechanical parameters measured by gait analysis systems between healthy subjects and subjects with plantar fasciitis (PF), and to compare biomechanical parameters between ‘normal, barefooted’ gait and arch building gait in the participants.
The researchers evaluated 15 subjects (30 feet) with bilateral foot pain and 15 subjects (15 feet) with unilateral foot pain who had a clinical diagnosis of PF. Additionally, 17 subjects (34 feet) who had no heel pain were recruited. Subjects were excluded if they had a traumatic event, prior surgery or fractures of the lower limbs, a leg length discrepancy of 1 cm or greater, a body mass index greater than 35 kg/m2, or had musculoskeletal disorders. The participants were asked to walk with an arch building gait on a treadmill at 2.3 km/hr for 5 minutes. Various gait parameters were measured.
With the arch building gait, the PF group proved that gait line length and single support line were significantly decreased, and lateral symmetry of the PF group was increased compared to that of the control group. The subjects with bilateral PF displayed significantly increased maximum pressure over the heel and the forefoot during arch building gait. In addition, the subjects with unilateral PF showed significantly increased maximum pressure over the forefoot with arch building gait.
The researchers show that various biomechanical differences exist between healthy subjects and those with PF. Employing an arch building gait in patients with PF could be helpful in changing gait patterns to normal biomechanics.
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To assess the cross-sectional area (CSA) of the muscles for investigating the occurrence of asymmetry of the paraspinal (multifidus and erector spinae) and psoas muscles and its relation to the chronicity of unilateral lumbar radiculopathy using magnetic resonance imaging (MRI).
This retrospective study was conducted between January 2012 to December 2014. Sixty one patients with unilateral L5 radiculopathy were enrolled: 30 patients had a symptom duration less than 3 months (group A) and 31 patients had a symptom duration of 3 months or more (group B). Axial MRI measured the CSA of the paraspinal and psoas muscles at the middle between the lower margin of the upper vertebra and upper margin of the lower vertebra, and obtained the relative CSA (rCSA) which is the ratio of the CSA of muscles to that of the lower margin of L4 vertebra.
There were no differences in the demographics between the two groups. In group B, rCSA of the erector spinae at the L4–5 level, and that of multifidus at the L4–5 and L5–S1 levels, were significantly smaller on the involved side as compared with the uninvolved side. In contrast, no significant muscle asymmetry was observed in group A. The rCSA of the psoas was not affected in either group.
The atrophy of the multifidus and erector spinae ipsilateral to the lumbar radiculopathy was observed only in patients suffering from unilateral radiculopathy for 3 months or more.
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To determine the effects of combining robot-assisted game training with conventional upper extremity rehabilitation training (RCT) on motor and daily functions in comparison with conventional upper extremity rehabilitation training (OCT) in stroke patients.
Subjects were eligible if they were able to perform the robot-assisted game training and were divided randomly into a RCT and an OCT group. The RCT group performed one daily session of 30 minutes of robot-assisted game training with a rehabilitation robot, plus one daily session of 30 minutes of conventional rehabilitation training, 5 days a week for 2 weeks. The OCT group performed two daily sessions of 30 minutes of conventional rehabilitation training. The effects of training were measured by a Manual Function Test (MFT), Manual Muscle Test (MMT), Korean version of the Modified Barthel Index (K-MBI) and a questionnaire about satisfaction with training. These measurements were taken before and after the 2-week training.
Both groups contained 25 subjects. After training, both groups showed significant improvements in motor and daily functions measured by MFT, MMT, and K-MBI compared to the baseline. Both groups demonstrated similar training effects, except motor power of wrist flexion. Patients in the RCT group were more satisfied than those in the OCT group.
There were no significant differences in changes in most of the motor and daily functions between the two types of training. However, patients in the RCT group were more satisfied than those in the OCT group. Therefore, RCT could be a useful upper extremity rehabilitation training method.
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To evaluate the association between baseline characteristics, three physical performance tests and fall history in a sample of the elderly from Korean population.
A total of 307 participants (mean age, 76.70±4.85 years) were categorized into one of two groups, i.e., fallers and non-fallers. Fifty-two participants who had reported falling unexpectedly at least once in the previous 12 months were assigned to the fallers group. Physical performance tests included Short Physical Performance Battery (SPPB), Berg Balance Scale (BBS), Timed Up and Go test. The differences between the two study groups were compared and we analyzed the correlations between fall histories and physical performance tests.
SPPB demonstrated a significant association with fall history. Although the BBS total scores did not show statistical significance, two dynamic balance test items of BBS (B12 and B13) showed a significant association among fallers.
This study suggests that SPPB and two dynamic balance test items of the BBS can be used in screening for risk of falls in an ambulatory elderly population.
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To investigate whether the polymorphisms of
Genomic DNA from 121 ischemic stroke patients and 201 healthy control subjects were extracted, and polymerase chain reaction products were sequenced. To investigate the association of polymorphisms and the development, and National Institutes of Health Stroke Scale (K-NIHSS), logistic regression models were analyzed.
Polymorphism of the untranslational region of
These results indicate the possibility that
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To evaluate the clinical efficacy and safety following percutaneous disc decompression, using navigable disc decompression device for cervical herniated nucleus pulposus (HNP).
Twenty subjects diagnosed with cervical HNP and refractory to conservative management were enrolled for the study. The herniated discs were decompressed under fluoroscopic guidance, using radiofrequency ablation device with navigable wand. The sagittal and axial plain magnetic resonance images of the clinically significant herniated disc, decided the space between the herniated base and outline as the target area for ablation. Clinical outcome was determined by Numeric Rating Scale (NRS), Neck Disability Index (NDI), and Bodily Pain scale of Short Form-36 (SF-36 BP), assessed after 48 weeks. After the procedure, we structurally matched the magnetic resonance imaging (MRI) and C-arm images through bony markers. The wand position was defined as being ‘correct’ if the tip was placed within the target area of both AP and lateral views; if not, the position was stated as ‘incorrect’.
The average NRS fell from 7 to 1 at 48 weeks post procedure (p<0.05). In addition, statistically significant improvement was noted in the NDI and SF-36BP (p<0.05). The location of the wand tip resulted in 16 correct and 4 incorrect placements. Post-48 weeks, 3 of the incorrect tip cases and 1 correct tip case showed unsuccessful outcomes.
The study demonstrated the promising results and safety of the procedure. Thus, focal plasma ablation of cervical HNP with navigable wand can be another effective treatment option.
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To evaluate effects of caregiver's education program on their satisfaction, as well as patient functional recovery, performed in addition to daily conventional rehabilitation treatment.
Three hundred eleven subjects diagnosed with first-onset stroke and transferred to the Department of Physical Medicine and Rehabilitation of Inha University Hospital were surveyed. In 2015, caregivers attended an education program for acute and subacute stroke patients. Patients who received an additional rehabilitation therapy were assigned to the experimental group (n=81), whereas the control group (n=100) consisted of transfer cases in 2014 with only conventional treatment. The experimental group was classified by severity using the Korean version of the National Institutes of Health Stroke Scale (K-NIHSS), which was administered to all 181 subjects, in addition to, the Korean version of the Mini Mental Status Examination (K-MMSE), a Modified Barthel Index (K-MBI), and the Berg Balance Scale (K-BBS). Caregiver satisfaction and burden before and after education programs were assessed using the Canadian Occupational Performance Measure (COPM), as well as family burden and caregiver burnout scales.
No significant intergroup difference was observed between initial K-NIHSS, K-MMSE, K-BBS, K-MBI scores, and times from admission to transfer. Those with moderate or severe strokes under the experimental condition showed a more significant improvement than the control group as determined by the K-NIHSS and K-BBS, as well as tendential K-MMSE and K-MBI score increases. Satisfaction was significantly greater for family members and formal caregivers of patients with strokes of moderate severity in the experimental group.
The caregiver's education program for stroke subjects had a positive outcome on patients' functional improvement and caregiver satisfaction. The authors believe that the additional rehabilitation therapy with the education program aids patients to achieve functional improvements for an optimal return to social life.
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To evaluate the relationships between tongue pressure and different aspects of the oral-phase swallowing function.
We included 96 stroke patients with dysphagia, ranging in age from 40 to 88 years (mean, 63.7 years). Measurements of tongue pressure were obtained with the Iowa Oral Performance Instrument, a device with established normative data. Three trials of maximum performance were performed for lip closure pressure (LP), anterior hard palate-to-tongue pressure (AP), and posterior hard palate-to-tongue pressure (PP); buccal-to-tongue pressures on both sides were also recorded (buccal-to-tongue pressure, on the weak side [BW]; buccal-to-tongue pressure, on the healthy side [BH]). The average pressure in each result was compared between the groups. Clinical evaluation of the swallowing function was performed with a videofluoroscopic swallowing study.
The average maximum AP and PP values in the intact LC group were significantly higher than those in the inadequate lip closure group (AP, p=0.003; PP, p<0.001). AP and PP showed significant relationships with bolus formation (BF), mastication, premature bolus loss (PBL), tongue to palate contact (TP), and oral transit time (OTT). Furthermore, LP, BW, and BH values were significantly higher in the groups with intact mastication, without PBL and intact TP.
These findings indicate that the tongue pressure appears to be closely related to the oral-phase swallowing function in post-stroke patients, especially BF, mastication, PBL, TP and OTT.
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To assess the correlation between the anorectal function and bladder detrusor function in patients with complete spinal cord injury (SCI) according to the type of lesion.
Medical records of twenty-eight patients with SCI were included in this study. We compared the anorectal manometric and urodynamic (UD) parameters in total subjects. We analyzed the anorectal manometric and UD parameters between the two groups: upper motor neuron (UMN) lesion and lower motor neuron (LMN) lesion. In addition, we reclassified the total subjects into two groups according to the bladder detrusor function: overactive and non-overactive.
In the group with LMN lesion, the mean value of maximal anal squeeze pressure (MSP) was slightly higher than that in the group with UMN lesion, and the ratio of MSP to maximal anal resting pressure (MRP) was statistically significant different between the two groups. In addition, although the mean value of MSP was slightly higher in the group with non-overactive detrusor function, there was no statistical correlation of anorectal manometric parameters between the groups with overactive and non-overactive detrusor function.
The MSP and the ratio of MSP to MRP were higher in the group with LMN lesion. In this study, we could not identify the correlation between bladder and bowel function in total subjects. We conclude that the results of UD study alone cannot predict the outcome of anorectal manometry in patients with SCI. Therefore, it is recommended to perform assessment of anorectal function with anorectal manometry in patients with SCI.
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To investigate the effect of radial extracorporeal shock wave therapy (rESWT) on hemiplegic shoulder pain (HSP) syndrome.
In this monocentric, randomized, patient-assessor blinded, placebo-controlled trial, patients with HSP were randomly divided into the rESWT (n=17) and control (n=17) groups. Treatment was administered four times a week for 2 weeks. The visual analogue scale (VAS) score and Constant-Murley score (CS) were assessed before and after treatment, and at 2 and 4 weeks. The Modified Ashworth Scale and Fugl-Meyer Assessment scores and range of motion of the shoulder were also assessed.
VAS scores improved post-intervention and at the 2-week and 4-week follow-up in the intervention group (p<0.05). Respective differences in VAS scores between baseline and post-intervention in the intervention and control groups were –1.69±1.90 and –0.45±0.79, respectively (p<0.05), between baseline and 2-week follow-up in the intervention and control groups were –1.60±1.74 and –0.34±0.70, respectively (p<0.05), and between baseline and 4-week follow-up in the intervention and control groups were –1.61±1.73 and –0.33±0.71, respectively (p<0.05). Baseline CS improved from 19.12±11.02 to 20.88±10.37 post-intervention and to 20.41±10.82 at the 2-week follow-up only in the intervention group (p<0.05).
rESWT consisting of eight sessions could be one of the effective and safe modalities for pain management in people with HSP. Further studies are needed to generalize and support these results in patients with HSP and a variety conditions, and to understand the mechanism of rESWT for treating HSP.
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Interventions for Post-Stroke Shoulder Pain: An Overview of Systematic Reviews
To evaluate the inter-rater and intra-rater reliability of ultrasonographic measurements of axillary recess (AR) thickness in healthy individuals, and to analyze the factors affecting the thickness of the AR capsule.
We recruited 20 healthy individuals (10 male, 10 female) with a mean age of 37 years (standard deviation ±10). Two physiatrists (an experienced and a novice rater) independently investigated the AR thickness in three rounds. The AR thickness was measured for each individual at three shoulder abduction angles (50°, 70°, and 90°). Intra-class correlation (ICC) coefficients were used to assess the reproducibility of each measurement.
Excellent intra-rater reliability coefficients were observed at the three shoulder abduction angles, in the analysis of both raters. The inter-rater reliability coefficient was also was excellent in both studies. There were significant differences in the AR thickness, according to the angle of shoulder abduction. The AR was thicker at 50° than at 70° and 90° (all p<0.001), and the AR was thicker at 70° than at 90° (p<0.001). Height (r=0.62, p=0.003) and body mass index (r=0.52, p=0.019) were positively correlated with AR thickness. Males had a thicker AR capsule than females at all three angles (all p<0.001).
Ultrasonographic measurements of AR thickness in healthy individuals demonstrate excellent intra-rater and inter-rater reliability. AR thickness may depend on anthropometric variables and position of the shoulder.
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To investigate whether baculoviral inhibitor of apoptosis (IAP) repeat containing 5 gene (
We enrolled 121 ischemic stroke patients and 291 control subjects. Ischemic stroke patients were divided into subgroups according to the scores of National Institutes of Health Stroke Survey (<6 or ≥6) and Modified Barthel Index (<60 or ≥60). Single nucleotide polymorphisms (SNPs) of BIRC5 (rs3764383 and rs2071214) were selected and genotyped by direct sequencing for all subjects. Multiple logistic regression models (codominant 1 and 2, dominant, recessive, overdominant and log-additive) were used to estimate odds ratios (ORs), 95% confidence intervals (CIs), and p-values.
In analysis of stroke susceptibility, the genotype and allele frequencies of rs3764383 exhibited no difference between the control group and the ischemic stroke group. SNP rs2071214 was associated with ischemic stroke in the codominant (p=0.003), dominant (p=0.002), overdominant (p=0.005), and log-additive (p=0.008) models, respectively. The G allele frequency of rs2071214 was significantly (p=0.009) associated with susceptibility for ischemic stroke (OR, 1.57; 95% CI, 1.12–2.21). However, in the analysis for clinical phenotype, no SNP of the
These results suggest that a missense SNP (rs2071214) of BIRC5 may be associated with the development of ischemic stroke in the Korean population.
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Patients with C5 or C6 radiculopathy complain of shoulder area pain or shoulder girdle weakness. Typical idiopathic neuralgic amyotrophy (INA) is also characterized by severe shoulder pain, followed by paresis of shoulder girdle muscles. Recent studies have demonstrated that magnetic resonance neurography (MRN) of the brachial plexus and magnetic resonance imaging (MRI) of the shoulder in patients with INA show high signal intensity (HSI) or thickening of the brachial plexus and changes in intramuscular denervation of the shoulder girdle. We evaluated the value of brachial plexus MRN and shoulder MRI in four patients with typical C5 or C6 radiculopathy. HSI of the brachial plexus was noted in all patients and intramuscular changes were observed in two patients who had symptoms over 4 weeks. Our results suggest that HSI or thickening of the brachial plexus and changes in intramuscular denervation of the shoulder girdle on MRN and MRI may not be specific for INA.
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A 54-year-old man with poliomyelitis had been using a conventional, passive knee-ankle-foot orthosis (KAFO) with a drop ring lock knee joint for about 40 years. A stance control KAFO (SCKAFO) with an electromagnetically controlled (E-MAG) knee joint system was prescribed. To correct his gait pattern, he also underwent rehabilitation therapy, which included muscle re-education, neuromuscular electrical stimulation, strengthening exercises for the lower extremities, and balance training twice a week for about 4 months. Both before and after rehabilitation, we conducted a gait analysis and assessed the physiological cost index in energy expended during walking in a locked-knee state and while he wore a SCKAFO with E-MAG. When compared with the pre-rehabilitation data, the velocity, step length, stride length, and knee kinematic data were improved after rehabilitation. Although the SCKAFO with E-MAG system facilitated the control of knee motion during ambulation, appropriate rehabilitative therapy was also needed to achieve a normal gait pattern.
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To investigate the clinical significance of upper and lower extremity transcranial magnetic stimulation (TMS)-induced motor evoked potentials (MEPs) in patients with parkinsonism.
Twenty patients (14 men, 6 women; mean age 70.5±9.1 years) suffering from parkinsonism were included in this study. All participants underwent single-pulse TMS session to assess the corticospinal excitability of the upper and lower extremity motor cortex. The resting motor threshold (RMT) was defined as the lowest stimulus intensity able to evoke MEPs of an at least 50 µV peak-to-peak amplitude in 5 of 10 consecutive trials. Five sweeps of MEPs at 120% of the RMT were performed, and the mean amplitude and latency of the MEPs were calculated. Patients were also assessed using the Unified Parkinson's Disease Rating Scale part III (UPDRS-III) and the 5-meter Timed Up and Go (5m-TUG) test.
There was a significant positive correlation between the RMTs of MEPs in the upper and lower extremities (r=0.612, p=0.004) and between the amplitude of MEPs in the upper and lower extremities (r=0.579, p=0.007). The RMT of upper extremity MEPs showed a significant negative relationship with the UPDRS-III score (r=–0.516, p=0.020). In addition, RMTs of lower extremity MEPs exhibited a negative relationship with the UPDRS-III score, but the association was not statistically significant (r=–406, p=0.075).
These results indicated that the RMT of MEPs reflect the severity of motor dysfunction in patients with parkinsonism. MEP is a potential quantitative, electrodiagnostic method to assess motor function in patients with parkinsonism.
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We report a 57-year-old man with bilateral cranial nerve IX and X palsies who presented with severe dysphagia. After a mild head injury, the patient complained of difficult swallowing. Physical examination revealed normal tongue motion and no uvular deviation. Cervical X-ray findings were negative, but a brain computed tomography revealed a skull fracture involving bilateral jugular foramen. Laryngoscopy indicated bilateral vocal cord palsy. In a videofluoroscopic swallowing study, food residue remained in the vallecula and pyriform sinus, and there was reduced motion of the pharynx and larynx. Electromyography confirmed bilateral superior and recurrent laryngeal neuropathy.
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To follow up the long-term functioning in a community through assessing personal background and status based on the International Classification of Functioning, Disability and Health (ICF) after a stroke, by using a Korean version of World Health Organization Disability Assessment Scale II (K-WHODAS II).
We surveyed 146 patients diagnosed at the first-onset of acute stroke and discharged after Inha University Hospital, and 101 patients answered the K-WHODAS II survey. We analyzed the relationship of six functioning domains of K-WHODAS II with K-MMSE (Korean version of Mini-Mental State Examination) and K-MBI (Korean version of Modified Barthel Index) at admission and discharge, and personal background. All subjects were divided into five groups, according to the disease durations, to assess the functional changes and the differences of K-MMSE and K-MBI at the admission and discharge.
K-MBI and K-MMSE at admission and discharge showed no significant differences in all five groups, respectively (p>0.05), reflecting no baseline disparity for long-term follow-up. All subjects showed positive gains of K-MBI and K-MMSE at discharge (p<0.05). The six functioning domains and total scores of K-WHODAS II had decreasing trends until 3 years after the stroke onset, but rose thereafter. Higher scores of K-MBI and K-MMSE, younger age, women, working status, higher educational level, and living with a partner were correlated with lower scores of K-WHODAS II (p<0.05).
The long-term functioning after stroke was affected not only by cognitive and motor status in hospital, but also by certain kinds of personal background. K-WHODAS II may be used to monitor functioning status in a community and to assess personal backgrounds in subjects with chronic stroke.
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To investigate whether four single nucleotide polymorphisms (SNPs) rs2293054 [Ile734Ile], rs1047735 [His902His], rs2293044 [Val1353Val], rs2682826 (3'UTR) of nitric oxide synthase 1 (NOS1) are associated with the development and clinical phenotypes of ischemic stroke.
We enrolled 120 ischemic stroke patients and 314 control subjects. Ischemic stroke patients were divided into subgroups according to the scores of the National Institutes of Health Stroke Survey (NIHSS, <6 and ≥6) and Modified Barthel Index (MBI, <60 and ≥60). SNPStats, SNPAnalyzer, and HelixTree programs were used to calculate odds ratios (ORs), 95% confidence intervals (CIs), and p-values. Multiple logistic regression models were performed to analyze genetic data.
No SNPs of the
These results suggest that NOS1 may be related to the clinical phenotypes of ischemic stroke in Korean population.
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The thalamus, located between the cerebrum and midbrain, is a nuclear complex connected to the cerebral cortex that influences motor skills, cognition, and mood. The thalamus is composed of 50-60 nuclei and can be divided into four areas according to vascular supply. In addition, it can be divided into five areas according to function. Many studies have reported on a thalamic infarction causing motor or sensory changes, but few have reported on behavioral and executive aspects of the ophthalmoplegia of the thalamus. This study reports a rare case of a paramedian thalamus infarction affecting the dorsomedial area of the thalamus, manifesting as oculomotor nerve palsy, an abnormal behavioral change, and executive dysfunction. This special case is presented with a review of the anatomical basis and function of the thalamus.
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To determine clinical and radiological factors that predict the successful outcome of percutaneous disc decompression (PDD) in patients with lumbar herniated nucleus pulposus (HNP).
We retrospectively reviewed the clinical and radiological features of patients who underwent lumbar PDD from April 2009 to March 2013. Sixty-nine patients with lumbar HNP were studied. Clinical outcome was assessed by the visual analogue scale (VAS) and the Oswestry Disability Index (ODI). Multivariate logistic regression analysis was performed to assess relationship among clinical and radiological factors and the successful outcome of the PDD.
The VAS and the ODI decreased significantly at 1 year follow-up (p<0.01). One year after PDD, the reduction of the VAS (ΔVAS) was significantly greater in the patients with pain for <6 months (p=0.03) and subarticular HNP (p=0.015). The reduction of the ODI (ΔODI) was significantly greater in the patients with high intensity zone (p=0.04). Multivariate logistic regression analysis revealed the following 5 factors that were associated with the successful outcome after PDD: pain duration for <6 months (odds ratio [OR]=14.036; p=0.006), positive straight leg raising test (OR=8.425, p=0.014), the extruded HNP (OR=0.106, p=0.04), the sequestrated HNP (OR=0.037, p=0.026), and the subarticular HNP (OR=10.876, p=0.012).
PDD provided significant improvement of pain and disability of patients. The results of the analysis indicated that the duration of pain <6 months, positive straight leg raising test, the subarticular HNP, and the protruded HNP were predicting factors associated with the successful response of PDD in patients with lumbar HNP.
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To investigate the effects of glenohumeral internal rotation deficit (GIRD) on the isokinetic strength, body pain, and the quality of life in male high school baseball players of Korea.
Fifty-six male high school baseball players were divided into either group A (GIRD≥20°, n=12) or group B (GIRD<20°, n=44). The range of motion in the shoulder and the isokinetic strength were measured. Questionnaires were administered regarding the body pain location by using the visual analogue scale, and the quality of life was measured by using the SF-36 Form.
All subjects had increased external rotation range of motion and decreased internal rotation in the throwing shoulder. The incidence of GIRD (≥20°) was 21.43% in the present study. In the isokinetic strength test, a significantly weaker muscular state at an angular velocity of 180°/s was observed in group A, compared to group B. For the comparison of the pain, the frequency of shoulder pain was higher (33.93%) than other body pain, among the study subjects.
GIRD is one of the main risk factors of glenohumeral joint damage, and it is correlated with reduced isokinetic strength and quality of life. High school baseball players will need appropriate shoulder rehabilitation programs for the improvement in their quality of life and performance.
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Acute transverse myelitis (ATM) is an upper motor neuron disease of the spinal cord, and concomitant association of peripheral polyneuropathy, particularly the axonal type, is rarely reported in children. Our cases presented with ATM complicated with axonal type polyneuropathy. Axonal type polyneuropathy may be caused by acute motor-sensory axonal neuropathy (AMSAN) or critical illness polyneuropathy and myopathy (CIPNM). These cases emphasize the need for nerve and muscle biopsies to make the differential diagnosis between AMSAN and CIPNM in patients with ATM complicated with axonal polyneuropathy.
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Monomelic amyotrophy (MMA), also known as Hirayama disease, is a sporadic juvenile muscular atrophy in the distal upper extremities. This disorder rarely involves proximal upper extremities and presents minimal sensory symptoms with no upper motor neuron (UMN) signs. It is caused by anterior displacement of the posterior dural sac and compression of the cervical cord during neck flexion. An 18-year-old boy visited our clinic with a 5-year history of left upper extremity pain and slowly progressive weakness affecting the left shoulder. Atrophy was present in the left supraspinatus and infraspinatus. On neurological examination, positive UMN signs were evident in both upper and lower extremities. Electrodiagnostic study showed root lesion involving the fifth to seventh cervical segment of the cord with chronic and ongoing denervation in the fifth and sixth cervical segment innervated muscles. Cervical magnetic resonance imaging (MRI) showed asymmetric cord atrophy apparent in the left side and intramedullary high signal intensity along the fourth to sixth cervical vertebral levels. With neck flexion, cervical MRI revealed anterior displacement of posterior dural sac, which results in the cord compression of those segments. The mechanisms of myelopathy in our patient seem to be same as that of MMA. We report a MMA patient involving proximal limb with UMN signs in biomechanical concerns and discuss clinical importance of cervical MRI with neck flexion. The case highlights that clinical variation might cause misdiagnosis.
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We report the findings of 18F-fluorodeoxyglocese positron emission tomography (FDG-PET) and diffusion tensor tractography (DTT) in a right-handed patient presenting with callosal disconnection syndrome, including alien hand syndrome, after an anterior communicating artery aneurysmal rupture. The 49-year-old patient had right hemiparesis and unintended movement of the right hand during action of the left hand. A brain magnetic resonance imaging revealed lesions in the upper part of the genu and body in the corpus callosum as well as hemorrhage in the inter-hemispheric fissure. We observed extensive disruption of corpus callosum fibers in the upper genu and trunk by DTT for the evaluation of inter-hemispheric connection. FDG-PET revealed severe hypometabolism in the left cerebral hemisphere, including basal ganglia and thalamus, and hypermetabolism in the right cerebral hemisphere. Based on findings of FDG-PET and DTT, the callosal disconnection syndrome presented in the patient could be the result of loss of transcallosal inhibition in the contralateral hemisphere.
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To obtain information on the socioeconomic, medical, and functional status of polio survivors, and to use these results as the preliminary data for establishing the middle-aged cohort of polio survivors.
The subjects were recruited based on the medical records of multiple hospitals and centers. They were assessed through a structured questionnaire over the phone. Post-poliomyelitis syndrome (PPS) was identified according to the specified diagnostic criteria. Differences between polio survivors with or without PPS were evaluated, and the risk factors for PPS were analyzed by the odds ratio (OR).
Majority of polio survivors were middle-aged and mean age was 51.2±8.3 years. A total of 188 out of 313 polio survivors met the adopted criteria for PPS based on the symptoms, yielding a prevalence of 61.6%. Mean interval between acute poliomyelitis and the development of PPS was 38.5±11.6 years. Female gender (OR 1.82; confidence interval [CI] 1.09-3.06), the age at onset of poliomyelitis (OR 1.75; CI 1.05-2.94), the use of orthoses or walking aids (OR 2.46; CI 1.44-4.20), and the history of medical treatment for paralysis, pain or gait disturbance (OR 2.62; CI 1.52-4.51) represented independent risk factors for PPS.
We found that the majority of Korean polio survivors entered middle age with many medical, functional, and social problems. Female gender, early age of onset of poliomyelitis, the use of orthoses or walking aids, and the history of medical treatment for paralysis, pain or gait disturbance were identified as the significant risk factors for PPS. A comprehensive and multidisciplinary plan should be prepared to manage polio survivors considering their need for health care services and the risk factors for late effects, such as PPS.
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Arnold-Chiari malformation type III (CM III) is an extremely rare anomaly with poor prognosis. An encephalocele with brain anomalies as seen in CM II, and herniation of posterior fossa contents like the cerebellum are found in CM III. The female infant was a twin, born at 33 weeks, weighing 1.7 kg with a huge hydrocele on the craniocervical junction. After operations were performed, she was referred to the department of rehabilitation medicine for poor motor development, swallowing dysfunction, and poor eye fixation at 22 months. The child was managed with neurodevelopmental treatment, oromotor facilitation, and light perception training. After 14 months, improvement of gross motor function was observed, including more stable head control, rolling, and improvement of visual perception. CM III has been known as a condition with poor prognosis. However, with the improvement in operative techniques and intensive rehabilitations, the prognosis is more promising than ever before. Therefore, more attention must be paid to the rehabilitation issues concerning patients with CM III.
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Ullrich congenital muscular dystrophy (UCMD) is characterized by congenital weakness, proximal joint contractures, and hyperlaxity of distal joints. UCMD is basically due to a defect in extra cellular matrix protein, collagen type VI. A 37-year-old woman who cannot walk independently visited our outpatient clinic. She had orthopedic deformities (scoliosis, joint contractures, and distal joint hyperlaxity), difficulty of respiration, and many skin keloids. Her hip computed tomography showed diffuse fatty infiltration and the 'central shadow' sign in thigh muscles. From the clinical information suggesting collagen type VI related muscle disorder, UCMD was highly considered.
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Neuralgic amyotrophy (NA) is characterized by acute onset of severe pain, followed by muscular weakness and wasting of the shoulder girdle. While the diagnosis of NA mainly relies on the clinical history and examination, some investigations including electrophysiologic study and radiologic study may help to confirm the diagnosis. Magnetic resonance neurography (MRN), a new technique for the evaluation of peripheral nerve disorders, can be helpful in the diagnosis of NA. MRN presents additional benefits in comparison to conventional magnetic resonance imaging in the diagnosis of idiopathic NA (INA). In this report, we present the first four cases of classic INA diagnosed with MRN in subacute stage. MRN imaging modality should be considered in patients clinically suspected of INA.
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To understand the quantitative correlation between the clinical severity and physical examinations along with the electrodiagnostic findings by subjects with carpal tunnel syndrome (CTS) and also the influence of diabetic polyneuropathy (DPN) on physical examinations by subjects with CTS.
Among 200 patients suffering from hand tingling sensations, 68 patients were diagnosed with CTS on at least one hand by nerve conduction tests. Therefore, the Phalen test (PT), hand elevation test (HET), Tinel sign (TS) results were recorded on both hands. The physical examination grades were compared with the electrophysiological CTS grades in 126 hands of 68 patients. Also the comorbidity effect of DPN to CTS was evaluated. For the evaluation of the severity correlations between CTS, PT, HET, and TS, the Spearman analysis was used. An attempt was started to create a formula which could depict the electrophysiological severity of CTS.
Out of the 68 tested subjects, 31 were diagnosed with both DPN and CTS, and 37 with CTS only. Both PT and HET correlated well with the severity of CTS where the correlation of PT was higher than that of HET. The formula were the motor distal latency (MDL)=(72.4-PT)/5.3 and MDL=(76-HET)/7.2. Both PT and HET showed in the presence of DPN a relatively higher relation with CTS without significance.
PT and HET would be useful screening tools for the diagnosis and treatment of CTS as the grade of PT and HET present the severity of CTS well. During this study, a formula was created expecting the severity of nerve conduction study with PT and HET through the time domain value of physical examinations.
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To determine whether ACE insertion/deletion (I/D) polymorphism is associated with the ossification of the posterior longitudinal ligament (OPLL) of the spine in the Korean population.
A case-control study was conducted to investigate the association between I/D polymorphism of the angiotensin I converting enzyme (peptidyl-dipeptidase A) 1 (
The genotype and allele frequencies of ACE I/D polymorphism showed significant differences between the OPLL patients and the control subjects (genotype, p<0.001; allele, p=0.009). The frequencies of D/D genotype and D allele in the OPLL group were higher than those in the control group. In logistic regression analysis, ACE I/D polymorphism was associated with OPLL (dominant model; p=0.002; odd ratio, 2.20; 95% confidence interval, 1.33-3.65).
These results suggest that the deletion polymorphism of the
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Acute multiple cranial neuropathies are considered as variant of Guillain-Barre syndrome, which are immune-mediated diseases triggered by various cases. It is a rare disease which is related to infectious, inflammatory or systemic diseases. According to previous case reports, those affected can exhibit almost bilateral facial nerve palsy, then followed by bulbar dysfunctions (cranial nerves IX and X) accompanied by limb weakness and walking difficulties due to motor and/or sensory dysfunctions. Furthermore, reported cases of the acute multiple cranial neuropathies show electrophysiological abnormalities compatible with the typical Guillain-Barre syndromes (GBS). We recently experienced a patient with a benign infectious disease who subsequently developed symptoms of variant GBS. Here, we describe the case of a 48-year-old male patient who developed multiple symptoms of cranial neuropathy without limb weakness. His laboratory findings showed a positive result for anti-GQ1b IgG antibody. As compared with previously described variants of GBS, the patient exhibited widespread cranial neuropathy, which included neuropathies of cranial nerves III-XII, without limb involvement or ataxia.
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To investigate the relationships between spinal mobility, pulmonary function, structural change of the spine, pain, fatigue, and quality of life (QOL) in patients with ankylosing spondylitis (AS).
Thirty-six patients with AS were recruited. Their spinal mobility was examined through seven physical tests: modified Schober test, lateral bending, chest expansion, occiput to wall, finger to ground, bimalleolar distance, and range of motion (ROM) of the spine. Pulmonary Function Test (PFT) was performed using a spirometer, and vertebral squaring was evaluated through the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). QOL, disease activity, functional capacity, and fatigue were evaluated by SF-36 Health Survey (SF-36), the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), the Bath Ankylosing Spondylitis Functional Index (BASFI), and the Multidimensional Assessment of Fatigue (MAF) scale, respectively. Perceived physical condition and degree of pain were assessed using 10 cm visual analogue scale.
Participants showed reduced spinal mobility, which was negatively correlated with mSASSS. PFT results showed reduced forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) and increased FEV1/FVC. Reduced FEV1 and FVC showed positive correlations with reduced spinal mobility and a negative relationship with mSASSS. Perceived physical condition and degree of pain were both significantly related to the SF-36, BASDAI, BASFI, and MAF scores.
This study shows that both reduced spinal mobility and radiographic changes in the vertebral body may have a predictive value for pulmonary impairment in patients with AS. Likewise, pain and perceived physical condition may play an important role in the QOL, functional capacity, and fatigue level of these patients.
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Myeloid sarcoma is a solid, extramedullary tumor comprising of immature myeloid cells. It may occur in any organ; however, the invasion of peripheral nervous system is rare. Herein, we report the case of myeloid sarcoma on the brachial plexus. A 37-year-old woman with acute myelogenous leukemia achieved complete remission after chemotherapy. One year later, she presented right shoulder pain, progressive weakness in the right upper extremity and hypesthesia. Based on magnetic resonance images (MRI) and electrophysiologic study, a provisional diagnosis of brachial plexus neuritis was done and hence steroid pulse therapy was carried out. Three months later the patient presented epigastric pain. After upper gastrointestinal endoscopy, myeloid sarcoma of gastrointestinal tract was confirmed pathologically. Moreover, 18-fluoride fluorodeoxyglucose positron emission tomography showed a fusiform shaped mass lesion at the brachial plexus overlapping with previous high signal lesion on the MRI. Therefore, we concluded the final diagnosis as brachial plexopathy due to myeloid sarcoma.
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Ischiofemoral impingement syndrome is known as one of the causes of hip pain due to impingement of ischium and femur, and usually correlated with trauma or operation. We report a rare case of ischiofemoral impingement syndrome that has no history of trauma or surgery. A 48-year-old female patient was referred for 2 months history of the left hip pain, radiating to lower extremity with a hip snapping sensation. She had no history of trauma or surgery at or around the hip joint and femur. The magnetic resonance imaging (MRI) of the lumbar spine showed no abnormality, except diffuse bulging disc without cord compression at the lumbosacral area. Electrophysiologic study was normal, and there were no neurologic abnormalities compatible with the lumbosacral radiculopathy or spinal stenosis. Hip MRI revealed quadratus femoris muscle edema with concurrent narrowing of the ischiofemoral space. The distance of ischiofemoral space and quadratus femoris space were narrow. It was compatible with ischiofemoral impingement syndrome. After treatment with nonsteroidal anti-inflammatory drugs, physical therapy, and exercise program, the patient's pain was relieved and the snapping was improved. To our knowledge, this is the first reported case of a nontraumatic, noniatrogenic ischiofemoral impingement syndrome, and also the first case to be treated by a nonsurgical method in the Republic of Korea.
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Spinal accessory neuropathy is commonly caused by iatrogenic injury or secondary to trauma or infection. Nevertheless, the tumor related palsy is rare. We present a case of an 18-year-old male patient suffering from paralysis of his right trapezius and sternocleidomastoid muscle. An electrophysiologic diagnostic study confirmed the spinal accessory neuropathy of the proximal segment. In addition, magnetic resonance imaging showed the location of tumor on the jugular foramen. However, the type of the tumor was not confirmed through biopsy because the patient refused surgical procedure. Based on the study, it is hypothesized that the tumor located on the jugular foramen should be considered as a cause of the spinal accessory nerve of the proximal segment.
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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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