Tamsulosin-induced life-threatening hypotension in a patient with spinal cord injury: A case report.

BACKGROUND: Tamsulosin, a selective α1-adrenergic receptor antagonist, is commonly used for treating neurogenic bladder in patients with spinal cord injury (SCI). No severe adverse events have been described with such tamsulosin use. To our knowledge, we report the first case of severe life-threatening hypotension as an adverse effect of tamsulosin in a person with SCI. Therefore, we report this case to inform that this severe adverse effect of tamsulosin can occur when treating patients with SCI. CASE SUMMARY: A 59-year-old woman was diagnosed with cervical spinal cord myelopathy and was classified as American Spinal Injury Association Impairment Scale D, neurological level of injury C3. Because she suffered from voiding difficulty due to neurogenic bladder, we prescribed tamsulosin. Her vital signs remained stable, but occasional hypotensive symptoms followed defecation. We reduced the dose of tamsulosin, but after administering tamsulosin for 9 d, she experienced life-threatening hypotension with no evidence of hypovolemic shock, neurogenic shock, cardiogenic shock, or septic shock. A hypotensive condition induced by tamsulosin was the suspected cause, and her symptoms could be associated with adverse effects of tamsulosin. As symptoms resolved after stopping tamsulosin, and no other reason was found, we concluded that tamsulosin was the cause of her symptoms. CONCLUSION: Caution for severe hypotension is needed when administering tamsulosin for neurogenic bladder in a patient with SCI.

Is mannitol combined with furosemide a new treatment for refractory lymphedema? A case report.

BACKGROUND: Mannitol is a hyperosmolar agent and the combination of mannitol and furosemide is a widely used treatment for intracranial pressure control. Considering the hypertonic properties of mannitol to move water out of intracellular spaces, we hypothesized that mannitol combined with furosemide could relieve focal tissue swelling in refractory lymphedema. CASE SUMMARY: A 90-year-old female had been diagnosed with intracranial hemorrhage and received a combination of mannitol and furosemide for intracranial pressure control. Independent of the intracranial hemorrhage, she had refractory lymphedema of the left lower extremity since 1998. Remarkably, after receiving the mannitol and furosemide, the patient's lower extremity lymphedema improved dramatically. After the mannitol and furosemide were discontinued, the lymphedema worsened in spite of complete decongestive therapy (CDT) and intermittent pneumatic compression treatment (IPC). To identify the presumed effect of mannitol and furosemide on the lymphedema, these agents were resumed, and the lymphedema improved again. CONCLUSION: The present case raises the possibility that a combination of mannitol and furosemide might be considered another effective therapeutic option for refractory lymphedema when CDT and IPC are ineffective.

Complete recovery of herpes zoster radiculopathy based on electrodiagnostic study: A case report.

BACKGROUND: Herpes zoster is a painful infectious disease caused by the varicella zoster virus. Herpes zoster radiculopathy, which is a type of segmental zoster paresis, can complicate the disease and cause motor weakness. This complication should be considered when a patient with a rash complains of acute-onset motor weakness, and the diagnosis can be verified via electrodiagnostic study. CASE SUMMARY: A 64-year-old female with a history of asthma presented to the emergency department with stabbing pain, an itching sensation, and a rash on the right anterior shoulder that had begun 5 d prior. Physical examination revealed multiple erythematous grouped vesicles in the right C4-5 and T1 dermatome regions. Because herpes zoster was suspected, the patient immediately received intravenous acyclovir. On the third hospital day, she complained of motor weakness in the right upper extremity. Magnetic resonance imaging of the cervical spine revealed mild intervertebral disc herniation at C4-C5 without evidence of nerve root compression. On the 12th hospital day, electrodiagnostic study revealed right cervical radiculopathy, mainly in the C5/6 roots. Six months later, monoparesis resolved, and follow-up electrodiagnostic study was normal. CONCLUSION: This case emphasizes that clinicians should consider the possibility of post-herpetic paresis, such as herpes zoster radiculopathy, and that electrodiagnostic study is useful for diagnosis and follow-up.

Effects of Wearable Powered Exoskeletal Training on Functional Mobility, Physiological Health and Quality of Life in Non-ambulatory Spinal Cord Injury Patients.

BACKGROUND: Spinal cord injury (SCI) is a serious clinical condition that impacts a patient's physical, psychological, and socio-economic status. The aim of this pilot study was to evaluate the effects of training with a newly developed powered wearable exoskeleton (Hyundai Medical Exoskeleton [H-MEX]) on functional mobility, physiological health, and quality of life in non-ambulatory SCI patients. METHODS: Participants received 60 minutes of walking training with a powered exoskeleton 3 times per week for 10 weeks (total 30 sessions). The 6-minute walking test (6MWT) and timed-up-and-go test (TUGT) were performed to assess ambulatory function. The physiological outcomes of interest after exoskeleton-assisted walking training were spasticity, pulmonary function, bone mineral density, colon transit time, and serum inflammatory markers. Effects of walking training on subjective outcomes were estimated by the Korean version of the Falls Efficacy Scale-International and the 36-Item Short-Form Health Survey version 2. RESULTS: Ten participants finished 30 sessions of training and could ambulate independently. No severe adverse events were reported during the study. After training, the mean distance walked in the 6MWT (49.13 m) was significantly enhanced compared with baseline (20.65 m). The results of the TUGT also indicated a statistically significant improvement in the times required to stand up, walk 3 m and sit down. Although not statistically significant, clinically meaningful changes in some secondary physiological outcomes and/or quality of life were reported in some participants. CONCLUSION: In conclusion, this study demonstrated that the newly developed wearable exoskeleton, H-MEX is safe and feasible for non-ambulatory SCI patients, and may have potential to improve quality of life of patients by assisting bipedal ambulation. These results suggest that the H-MEX can be considered a beneficial device for chronic non-ambulatory SCI patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04055610.

Effect of Peat Intervention on Pain and Gait in Patients with Knee Osteoarthritis: A Prospective, Double-Blind, Randomized, Controlled Study.

METHODS: Knee osteoarthritis patients with Visual Analog Scale (VAS) of 3 or more and Kellgren-Lawrence osteoarthritis grades 1 to 3 were included. Patients with history of intraarticular injection treatment were excluded. Forty-one participants were randomly allocated to the peat intervention group (n = 22) or the hot-pack-only control group (n = 19). Peat and hot pack were applied to both knees of each group of patients. Each intervention session lasted 20 minutes, and eight sessions were completed over five days. VAS, serum cartilage oligomeric matrix protein (COMP), and gait parameters were evaluated before and after the whole interventions. RESULTS: VAS in the peat group decreased from 6.000 to 3.409 after intervention (p < 0.001) and also decreased in the control group from 5.737 to 4.421 (p < 0.001). VAS score reduction between two periods was greater in the peat group than that in the control group (p < 0.001). There was no significant difference in the serum COMP level in either intergroup or intragroup analysis. In gait analysis, the gait velocity of the peat group increased from 0.781 m/s to 0.873 m/s after intervention (p=0.002), while it decreased in the control group. The knee varus/valgus range of motion during gaits was reduced from 11.455° to 8.439° after intervention in the peat group (p=0.006). CONCLUSIONS: This study showed that peat can be considered as a therapeutic option for pain relief of knee osteoarthritis patients. The reduction in knee joint varus/valgus range of motion and the increase in gait velocity after peat intervention were also identified through this research, which is the first to analyze the effects of peat on gait.

Comparisons between end-effector and exoskeleton rehabilitation robots regarding upper extremity function among chronic stroke patients with moderate-to-severe upper limb impairment.

End-effector (EE) and exoskeleton (Exo) robots have not been directly compared previously. The present study aimed to directly compare EE and Exo robots in chronic stroke patients with moderate-to-severe upper limb impairment. This single-blinded, randomised controlled trial included 38 patients with stroke who were admitted to the rehabilitation hospital. The patients were equally divided into EE and Exo groups. Baseline characteristics, including sex, age, stroke type, brain lesion side (left/right), stroke duration, Fugl-Meyer Assessment (FMA)-Upper Extremity score, and Wolf Motor Function Test (WMFT) score, were assessed. Additionally, impairment level (FMA, motor status score), activity (WMFT), and participation (stroke impact scale [SIS]) were evaluated. There were no significant differences in baseline characteristics between the groups. After the intervention, improvements were significantly better in the EE group with regard to activity and participation (WMFT-Functional ability rating scale, WMFT-Time, and SIS-Participation). There was no intervention-related adverse event. The EE robot intervention is better than the Exo robot intervention with regard to activity and participation among chronic stroke patients with moderate-to-severe upper limb impairment. Further research is needed to confirm this novel finding.

Extracorporeal shock wave therapy treatment of painful hematoma in the calf: A case report.

BACKGROUND: Extracorporeal shock wave therapy (ESWT) can be applied to various musculoskeletal conditions including calcific tendinitis. Muscle injuries can lead to hematomas, and unabsorbed hematomas sometimes cause pain. We report a case of painful hematoma successfully treated with ESWT. To our knowledge, this is the first reported case of painful intramuscular hematoma treated with ESWT. CASE SUMMARY: A 65-year-old man visited the outpatient department for left calf pain with swelling that had persisted since he slipped two weeks prior. The calf pain had persisted and was rated visual analog scale 7. On physical examination, there was a localized, stiff, ovoid mass on his left upper posterior calf. The pain was aggravated by dorsiflexion of the left ankle or weight-bearing on the left foot. Initial diagnostic ultrasonography showed a hematoma in the left gastrocnemius muscle; its texture was firm with low heterogeneity. We applied ESWT to the hematoma. His pain decreased immediately to a visual analog scale 3, and the mass was softened. The texture of the hematoma became more heterogeneous on ultrasonography. Due to planned overseas travel, he returned three months after the initial visit to report that the pain and swelling were dramatically relieved after ESWT. CONCLUSION: We propose that painful hematomas could be a new indication for ESWT. Further investigation on the effects of ESWT for hematomas is needed.

Botulinum Toxin Injections and Electrical Stimulation for Spastic Paresis Improve Active Hand Function Following Stroke.

Botulinum toxin type A (BTX-A) injections improve muscle tone and range of motion (ROM) among stroke patients with upper limb spasticity. However, the efficacy of BTX-A injections for improving active function is unclear. We aimed to determine whether BTX-A injections with electrical stimulation (ES) of hand muscles could improve active hand function (AHF) among chronic stroke patients. Our open-label, pilot study included 15 chronic stroke patients. Two weeks after BTX-A injections into the finger and/or wrist flexors, ES of finger extensors was performed while wearing a wrist brace for 4 weeks (5 days per week; 30-min sessions). Various outcomes were assessed at baseline, immediately before BTX-A injections, and 2 and 6 weeks after BTX-A injections. After the intervention, we noted significant improvements in Box and Block test results, Action Research Arm Test results, the number of repeated finger flexions/extensions, which reflect AHF, and flexor spasticity. Moreover, significant improvements in active ROM of wrist extension values were accompanied by marginally significant changes in Medical Research Council wrist extensor and active ROM of wrist flexion values. In conclusion, BTX-A injections into the finger and/or wrist flexors followed by ES of finger extensors improve AHF among chronic stroke patients.

Sciatic neuropathy and rhabdomyolysis after carbon monoxide intoxication: A case report.

RATIONALE: Peripheral neuropathy is a rare complication of carbon monoxide intoxication. Peripheral neuropathy following carbon monoxide intoxication is known to completely recover within a few months. PATIENT CONCERNS: A 40-year-old man complained of motor weakness and hypoesthesia of the right lower extremity with swelling of his right thigh after carbon monoxide intoxication resulting from a suicide attempt. DIAGNOSES: Following nerve conduction and electromyographic studies, the patient was diagnosed with sciatic neuropathy with severe axonopathy. Clinical and laboratory findings led to a diagnosis of rhabdomyolysis. INTERVENTIONS: The patient was treated conservatively for rhabdomyolysis and underwent comprehensive rehabilitation for sciatic neuropathy during hospitalization. OUTCOMES: After discharge, he underwent serial follow-up tests with nerve conduction and electromyographic studies, which showed prolonged persistence of sciatic neuropathy; however, he showed significant improvement at his 26-month post-discharge follow-up. LESSON: Patients presenting with peripheral neuropathy secondary to carbon monoxide intoxication may show variable recovery periods; however, a favorable prognosis can be expected regardless of the concomitant occurrence of rhabdomyolysis and/or compartment syndrome.

Risk Factor, Job Stress and Quality of Life in Workers With Lower Extremity Pain Who Use Video Display Terminals.

OBJECTIVE: To investigate the general characteristics of video display terminal (VDT) workers with lower extremity pain, to identify the risk factors of work-related lower extremity pain, and to examine the relationship between work stress and health-related quality of life. METHODS: A questionnaire about the general characteristics of the survey group and the musculoskeletal symptom was used. A questionnaire about job stress used the Korean Occupational Stress Scale and medical outcome study 36-item Short Form Health Survey (SF-36) to assess health-related quality of life. RESULTS: There were 1,711 subjects in the lower extremity group and 2,208 subjects in the control group. Age, sex, hobbies, and feeling of loading affected lower extremity pain as determined in a crossover analysis of all variables with and without lower extremity pain. There were no statistically significant difference between the two groups in terms of job stress and SF-36 values of the pain and control groups. CONCLUSION: Job stress in VDT workers was higher than average, and the quality of life decreased as the stress increased. Factors such as younger age, women, hobbies other than exercise, and feeling of loading influenced lower extremity pain of workers. Further long-term follow-up and supplementary studies are needed to identify risk factors for future lower extremity pain, taking into account ergonomic factors such as worker's posture.

Complications and Socioeconomic Costs Associated With Falls in the Elderly Population.

OBJECTIVE: To explore the incidence, characteristics, complications and socioeconomic impacts associated with falls in community-dwelling elderly. METHODS: From September 1, 2015 to October 12, 2015, a questionnaire-based survey was conducted involving a total of 2,012 elderly who lived in Guro-gu (Seoul), Yeongdeungpo-gu (Seoul), Yangpyeong-gu (Gyeonggi-do), Dalseong-gu (Daegu), and Jung-gu (Daegu). The subjects were interviewed using a structured questionnaire to obtain demographic characteristics and comprehensive falling histories. The socioeconomic cost related to falls was estimated using the statistical data provided by the Health Insurance Review and Assessment Service. RESULTS: Falls were recorded in 666 out of the 2,012 subjects (33.1%) during the past year. Frequent falls occurred during December, in the afternoons, when the floor was slippery. The most common injuries included the low back and the most common injury type was sprain. The total direct costs related to falls involving the 2,012 subjects were 303,061,019 KRW (Korean won). The average medical cost related to falls in the 2,012 subjects was 150,627 KRW and the average medical cost of 666 subjects who experienced falls was 455,047 KRW. Estimates of the total population over the age of 60 years showed that the annual direct costs associated with falls in Korea over the age of 60 years were about 1.378 trillion KRW. CONCLUSION: This study was conducted to explore the incidence, characteristics, complications, and socioeconomic impacts of falls in community-dwelling elderly. This study is expected to be used as a source of basic data for the establishment of medical policy for the elderly and the development of a fall prevention program for the elderly in Korea.

Hennekam Syndrome: A Case Report.

Hennekam syndrome is a rare autosomal recessive disorder resulting from malformation of the lymphatic system. The characteristic signs of Hennekam syndrome are lymphangiectasia, lymph edema, facial anomalies, and mental retardation. This is a case in which a patient presented with left-arm lymphedema, facial-feature anomalies, and multiple organ lymphangiectasia consistent with symptoms of Hennekam syndrome. There is no curative therapy at this time, but rehabilitative treatments including complete decongestive therapy for edema control appeared to be beneficial.

Impact of midfoot and Hindfoot involvement on functional disability in Korean patients with rheumatoid arthritis.

BACKGROUND: Foot involvement in rheumatoid arthritis (RA) patients has been reported to severely affect functional capacity and quality of life. We aimed to determine the impact of midfoot and hindfoot involvement on functional disability in Korean patients with RA. METHODS: We evaluated the RA involvement and deformity of three regions of the foot (forefoot, midfoot and hindfoot) and ankle using conventional radiography in Korean patients with RA. We compared the clinical features between RA patients with and without foot or ankle involvement. Using multivariable logistic regression analyses, the impact of midfoot or hindfoot involvement on functional disability in RA patients was evaluated. RESULTS: Overall, 120 patients with a median age of 48.0 [interquartile range (IQR), 37-56] years and median disease duration of 58.0 (IQR, 10-89) months were included. The prevalence of foot or ankle RA involvement was 74 (61.7%). The number of patients with forefoot, midfoot, hindfoot and ankle involvement was 32 (43.2%), 24 (32.4%), 46 (62.2%) and 4 (5.4%), respectively. Compared to patients without foot or ankle involvement those with such involvement had greater disease activity and functional disability, more of them were treated with biologic agents, and they had a lower health-related quality of life. After adjusting for potential confounders, hindfoot involvement was associated with a higher degree of functional disability. However, walking difficulty was more associated with midfoot involvement rather than with involvement in other regions. CONCLUSIONS: In Korean patients with RA, hindfoot involvement is associated with functional disability and midfoot involvement affects walking.

Effect of Intravenous Infusion of G-CSF-Mobilized Peripheral Blood Mononuclear Cells on Upper Extremity Function in Cerebral Palsy Children.

OBJECTIVE: To investigate the effect of intravenous infusion of peripheral blood mononuclear cells (mPBMC) mobilized by granulocyte-colony stimulating factor (G-CSF) on upper extremity function in children with cerebral palsy (CP). METHODS: Fifty-seven children with CP were enrolled. Ten patients were excluded due to follow-up loss. In total, 47 patients (30 males and 17 females) were analyzed. All patients' parents provided signed consent before the start of the study. After administration of G-CSF for 5 days, mPBMC was collected and cryopreserved. Patients were randomized into two groups 1 month later. Twenty-two patients were administered mPBMC and 25 patients received normal saline as placebo. Six months later, the two groups were switched, and administered mPBMC and placebo, respectively. Quality of Upper Extremity Skills Test (QUEST) and the Manual Ability Classification System (MACS) were used to evaluate upper motor function. RESULTS: All subdomain and total scores of QUEST were significantly improved after mPBMC and placebo infusion, without significant differences between mPBMC and placebo groups. A month after G-CSF, all subdomain and total scores of QUEST were improved. The level of MACS remained unchanged in both mPBMC and placebo groups. CONCLUSION: In this study, intravenously infused mPBMC showed no significant effect on upper extremity function in children with CP, as compared to placebo. The effect of mPBMC was likely masked by the effect of G-CSF, which was used in both groups and/or G-CSF itself might have other neurotrophic potentials in children with CP.

An intradural extramedullary bronchogenic cyst in the thoracolumbar spine: A case report.

RATIONALE: We report the symptoms beginning with weakness and the clinical courses of a patient who was diagnosed with an intradural extramedullary bronchogenic cyst. PATIENT CONCERNS: The patient was a 44-year-old man visited the Department of Physical Medicine and Rehabilitation for walking difficulties characterized by limping due to muscle weakness of left lower extremity for 5 months and atrophy in left calf muscle. DIAGNOSES: Lumbar spine MRI was repeated, since radiating pain in the left hip and posterior thigh with low back pain developed 16 months later. Intraspinal mass of T12 and L1 levels that was not found in the first MRI was newly found in the follow-up MRI. INTERVENTIONS: Total tumor removal was conducted with laminectomy. It was finally diagnosed as an intradural extramedullary bronchogenic cyst on the basis of the pathological analysis results. OUTCOMES: His left calf circumference was increased compared to before surgery the radiating pain also disappeared. LESSONS: If the patient's MRI findings are not correlated with the electrophysiologic and physical examination findings, additional MRI should be accompanied with other tests for an early detection.

Muscle Mass, Strength, Mobility, Quality of Life, and Disease Severity in Ankylosing Spondylitis Patients: A Preliminary Study.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: Maintaining muscle mass in AS patients may not be helpful for improving QOL, but it may contribute to achieving adequate mobility and strength.

Comparison of Balance, Proprioception and Skeletal Muscle Mass in Total Hip Replacement Patients With and Without Fracture: A Pilot Study.

OBJECTIVE: To determine whether there was a difference in balance, proprioception, and skeletal muscle mass among patients who undergo hip fracture surgery relative to and elective total hip replacement (THR). METHODS: Thirty-one THR patients were enrolled. The patients were categorized into two groups: fracture group (n=15) and non-fracture group (n=16). Berg Balance Scale (BBS) was used to balance the proprioception of the hip joint while a joint position sense (JPS) test was used to evaluate it. Skeletal muscle mass was measured by bioelectrical impedance analysis and expressed as a skeletal muscle mass index (SMI). Quality of life (QOL) was also assessed using a 36-item short form health survey (SF-36). All tests were assessed at 3 months after the surgery. An independent t-test was used to compare the fracture group and non-fracture group. Spearman correlation was used to identify the correlation of each variable. RESULTS: In an independent t-test, the BBS score of patients undergoing elective surgery was higher than the BBS score of patients undergoing hip fracture surgery. There was a significant correlation between the BBS and JPS score after a THR. SMI also correlated with the score of BBS. CONCLUSION: It seems that THR patients undergoing surgery for a hip fracture might have more trouble balancing than elective THR patients. Therefore THR patients undergoing hip fracture surgery might need more care during rehabilitation.

Change in Musculoskeletal Pain in Patients With Work-Related Musculoskeletal Disorder After Tailored Rehabilitation Education: A One-Year Follow-Up Survey.

OBJECTIVE: To apply tailored rehabilitation education to video display terminal (VDT) workers with musculoskeletal pain and to assess changes in musculoskeletal pain after rehabilitation education. METHODS: A total of 8,828 VDT workers were screened for musculoskeletal disorders using a self-report questionnaire. Six hundred twenty-six VDT workers selected based on their questionnaires were enrolled in musculoskeletal rehabilitation education, which consisted of education on VDT syndrome and confirmed diseases, exercise therapy including self-stretching and strengthening, and posture correction. One year later, a follow-up screening survey was performed on 316 VDT workers, and the results were compared with the previous data. RESULTS: Compared with the initial survey, pain intensity was significantly decreased in the neck area; pain duration and frequency were significantly decreased in the low back area; and pain duration, intensity, and frequency were significantly decreased in the shoulder and wrist after tailored rehabilitation education. In addition, pain duration, intensity, and frequency showed a greater significant decrease after tailored rehabilitation education in the mild pain group than in the severe pain group. CONCLUSIONS: This study found that work-related musculoskeletal pain was reduced after tailored rehabilitation education, especially in the shoulder, wrist, and low back.

Role of (18)F-fluoride PET/CT over dual-phase bone scintigraphy in evaluation and management of lesions causing foot and ankle pain.

OBJECTIVE: The purpose of this study was to assess the potential role of (18)F-fluoride PET/CT over dual-phase bone scintigraphy (DBS) in evaluation and management of lesions causing foot and ankle pain. METHODS: (99m)Tc-HDP DBS and (18)F-fluoride PET/CT were performed in consecutive patients who visited rehabilitation department due to foot or ankle pain. Focal painful lesions in fore, mid, and hindfoot or ankle, and diffuse pain in foot were evaluated on DBS and (18)F-fluoride PET/CT (conclusive, inconclusive, nonvisible) and lesions on each modality were correlated. The clinical course was followed to see if the results of (18)F-fluoride PET/CT affected the decision of patient management. RESULTS: Sixty-one painful lesions in 31 patients included 16 forefoot (26.2 %), 11 midfoot (18.0 %), 19 hindfoot (31.2 %), 6 ankle (9.8 %), and 9 diffuse footpain (14.8 %). Forty lesions (40/61, 65.6 %) were detected on DBS, including 21 conclusive diagnostic (21/40, 52.5 %), mainly including hindfoot lesions (n = 11). The inconclusive 19 lesions (19/40, 47.5 %) on DBS showed conclusive diagnostic findings on (18)F-fluoride PET/CT, mainly in fore and midfoot lesions (n = 15). Twenty-one painful lesions (21/61, 34.4 %) which were nonvisible on DBS revealed conclusive diagnostic findings on (18)F-fluoride PET/CT in 7 lesions (7/21, 33.3 %), including 5 hindfoot lesions. Fourteen nonvisible lesions (14/21, 66.7 %) on both modalities included all 9 diffuse painful foot lesions. Patient management was affected by findings of (18)F-fluoride PET/CT in 31 lesions (31/61, 50.8 %). CONCLUSIONS: (18)F-fluoride PET/CT provided more confirmative diagnostic information in painful foot and ankle over DBS, and influenced patient management in many inconclusive or nonvisible cases on DBS. Increasing role of (18)F-fluoride PET/CT in benign diseases including foot and ankle pain is expected in the near future.

Relief of Chronic Posterior Neck Pain Depending on the Type of Forest Therapy: Comparison of the Therapeutic Effect of Forest Bathing Alone Versus Forest Bathing With Exercise.

OBJECTIVE: To compare the pain-reducing effect of forest bathing alone versus forest bathing in combination with stretching and strengthening exercises in patients with chronic posterior neck pain. METHODS: Sixty-four subjects with posterior neck pain that had lasted more than 3 months were enrolled. They were randomly divided into a forest bathing alone (FBA) group and a forest bathing with exercise (FBE) group; each group included 32 subjects. All subjects from both groups walked every morning in the forest for about 2 hours for 5 days. In the afternoon, the FBE group did a stretching and strengthening exercise for about 4 hours; the FBA group had free time in the woods. Visual analog scale (VAS) on one day, VAS over the previous week, neck disability index (NDI), EuroQol 5D-3L VAS (EQ VAS) and index (EQ index), McGill pain questionnaire (MPQ), the number of trigger points in the posterior neck region (TRPs), and the range of motion of the cervical spine were evaluated on the first and last day of the program and compared between the two groups. RESULTS: The number of TRPs were significantly reduced in the FBE group compared with the FBA group (p=0.013). However, the other scales showed no significant difference between the two groups. CONCLUSION: When patients with chronic posterior neck pain underwent a short-term forest bathing (less than 7 days) program, FBE was more effective in the reduction of the number of TRPs than FBA. However, all other pain measurement scales we evaluated showed no statistically significant difference between the two protocols.