Rest-Activity Rhythm Differences in Acute Rehabilitation Between Poststroke Patients and Non-Brain Disease Controls: Comparative Study.

BACKGROUND: Circadian rhythm disruptions are a common concern for poststroke patients undergoing rehabilitation and might negatively impact their functional outcomes. OBJECTIVE: Our research aimed to uncover unique patterns and disruptions specific to poststroke rehabilitation patients and identify potential differences in specific rest-activity rhythm indicators when compared to inpatient controls with non-brain-related lesions, such as patients with spinal cord injuries. METHODS: We obtained a 7-day recording with a wearable actigraphy device from 25 poststroke patients (n=9, 36% women; median age 56, IQR 46-71) and 25 age- and gender-matched inpatient control participants (n=15, 60% women; median age 57, IQR 46.5-68.5). To assess circadian rhythm, we used a nonparametric method to calculate key rest-activity rhythm indicators-relative amplitude, interdaily stability, and intradaily variability. Relative amplitude, quantifying rest-activity rhythm amplitude while considering daily variations and unbalanced amplitudes, was calculated as the ratio of the difference between the most active 10 continuous hours and the least active 5 continuous hours to the sum of these 10 and 5 continuous hours. We also examined the clinical correlations between rest-activity rhythm indicators and delirium screening tools, such as the 4 A's Test and the Barthel Index, which assess delirium and activities of daily living. RESULTS: Patients who had a stroke had higher least active 5-hour values compared to the control group (median 4.29, IQR 2.88-6.49 vs median 1.84, IQR 0.67-4.34; P=.008). The most active 10-hour values showed no significant differences between the groups (stroke group: median 38.92, IQR 14.60-40.87; control group: median 31.18, IQR 18.02-46.84; P=.93). The stroke group presented a lower relative amplitude compared to the control group (median 0.74, IQR 0.57-0.85 vs median 0.88, IQR 0.71-0.96; P=.009). Further analysis revealed no significant differences in other rest-activity rhythm metrics between the two groups. Among the patients who had a stroke, a negative correlation was observed between the 4 A's Test scores and relative amplitude (ρ=-0.41; P=.045). Across all participants, positive correlations emerged between the Barthel Index scores and both interdaily stability (ρ=0.34; P=.02) and the most active 10-hour value (ρ=0.42; P=.002). CONCLUSIONS: This study highlights the relevance of circadian rhythm disruptions in poststroke rehabilitation and provides insights into potential diagnostic and prognostic implications for rest-activity rhythm indicators as digital biomarkers.

Fall risk classification with posturographic parameters in community-dwelling older adults: a machine learning and explainable artificial intelligence approach.

BACKGROUND: Computerized posturography obtained in standing conditions has been applied to classify fall risk for older adults or disease groups. Combining machine learning (ML) approaches is superior to traditional regression analysis for its ability to handle complex data regarding its characteristics of being high-dimensional, non-linear, and highly correlated. The study goal was to use ML algorithms to classify fall risks in community-dwelling older adults with the aid of an explainable artificial intelligence (XAI) approach to increase interpretability. METHODS: A total of 215 participants were included for analysis. The input information included personal metrics and posturographic parameters obtained from a tracker-based posturography of four standing postures. Two classification criteria were used: with a previous history of falls and the timed-up-and-go (TUG) test. We used three meta-heuristic methods for feature selection to handle the large numbers of parameters and improve efficacy, and the SHapley Additive exPlanations (SHAP) method was used to display the weights of the selected features on the model. RESULTS: The results showed that posturographic parameters could classify the participants with TUG scores higher or lower than 10 s but were less effective in classifying fall risk according to previous fall history. Feature selections improved the accuracy with the TUG as the classification label, and the Slime Mould Algorithm had the best performance (accuracy: 0.72 to 0.77, area under the curve: 0.80 to 0.90). In contrast, feature selection did not improve the model performance significantly with the previous fall history as a classification label. The SHAP values also helped to display the importance of different features in the model. CONCLUSION: Posturographic parameters in standing can be used to classify fall risks with high accuracy based on the TUG scores in community-dwelling older adults. Using feature selection improves the model's performance. The results highlight the potential utility of ML algorithms and XAI to provide guidance for developing more robust and accurate fall classification models. Trial registration Not applicable.

Long COVID and rehabilitation.

Coronavirus disease 2019 (COVID-19) has caused tremendous morbidity and mortality worldwide. The large number of post-COVID survivors has drawn attention to the management of post-COVID condition, known as long COVID. This review examines current knowledge of long COVID, regarding its epidemiology, mechanism, and clinical presentations in both adults and children. We also review the rehabilitation principles, modules, and effects, and share Taiwan's efforts to provide a top-down, nationwide care framework for long COVID patients. Dyspnea, chronic cough, and fatigue are the most commonly reported symptoms in the first 6 months after infection, but cognitive impairment and psychological symptoms may persist beyond this time. Several possible mechanisms behind these symptoms were proposed, but remained unconfirmed. These symptoms negatively impact individuals' function, activities, participation and quality of life. Rehabilitation is a key element of management to achieve functional improvement. Early management should start with comprehensive evaluation and identification of red flags. Exercise-based therapy, an essential part of management of long COVID, can be conducted with different modules, including telerehabilitation. Post-exertional symptom exacerbation and orthostatic hypotension should be carefully monitored during exercise. Randomized control trials with a large sample size are needed to determine the optimal timing, dosage, and modules.

Cross-cultural adaptation and psychometric property testing of the Taiwan Chinese version of the iconographical falls efficacy scale.

BACKGROUND: The Iconographical Falls Efficacy Scale (Icon-FES) uses short phrases and images to depict activities. This study culturally adapted and validated the Taiwan Chinese version of the 30- and 10-item Icon-FESs (Icon-FESs [TW]) in community-dwelling older individuals. METHODS: The Icon-FES (TW) was developed using forward-backward translation. A total of 120 community-dwelling older individuals were recruited. They completed the Taiwan Chinese version of the Falls Efficacy Scale-International (FES-I [TC]), the Icon-FES (TW), the Mini-Mental State Examination, and the World Health Organization Quality of Life Questionnaire Brief Version (WHOQOL-BREF) and were assessed using the Berg Balance Scale and the Short Physical Performance Battery (SPPB). The Icon-FES (TW) was recompleted 1 week later. Confirmatory factor analysis was used to evaluate the overall structure and measurement properties. RESULTS: Cronbach's alpha values of 0.97 and 0.91 indicated that the 30- and 10-item Icon-FESs (TW) had high internal consistency. The 30- and 10-item Icon-FESs (TW) exhibited significantly high correlation with the FES-I (r = 0.88 and 0.84, respectively). Both versions of the Icon-FES (TW) exhibited mild correlation with the physical domain of the WHOQOL-BREF. The 30- and 10-item Icon-FESs (TW) discriminated by intensity of concern and SPPB score. Their test-retest reliability was high (intraclass correlation coefficient = 0.79 and 0.80 for the 30- and 10-item Icon-FESs (TW), respectively). Neither floor nor ceiling effects were observed. CONCLUSION: The Icon-FES (TW) is a reliable and valid questionnaire useful for assessing the levels of concern regarding falling among older adults in clinical practice and research.

Impact of age on the postural stability measured by a virtual reality tracker-based posturography and a pressure platform system.

BACKGROUND: Center of pressure (CoP) parameters are commonly used to evaluate age-related changes in postural control during standing. However, they mainly reflect ankle strategies and provide limited information about hip strategies, which are essential for postural control among the aged population. Body displacement at the lumbar level (LD) can be used as a proxy for hip strategies. OBJECTIVES: We set up a virtual reality tracker-based posturography to measure LD and compared the CoP and LD parameters in two age groups to explore the roles of ankle and hip strategies during bipedal stance. METHODS: Twenty-seven older healthy participants (63.8 ± 7.1 years old) and 27 younger controls (31.7 ± 9.9 years old) performed four standing tasks with their postural steadiness measured simultaneously with both systems under four stance conditions (combination of eyes-open/eyes-closed and wide-based/narrow-based). Five parameters were calculated from the trajectories of the CoP and LD. The difference in the parameters between two groups was analyzed with the Mann-Whitney U test. The discriminative ability of the parameters from the two systems was computed by the receiver operating characteristic curve analysis and area under the curve (AUC). We also used the intraclass correlation coefficient (ICC) to assess the correlation between two measures. RESULTS: Most of the parameters obtained from both systems were significantly different between the younger and older groups. Mean velocity in the medial-lateral and anterior-posterior directions could effectively discriminate age-related changes, especially with the LD parameters. The receiver's operation curve analysis gained the largest AUC (0.85 with both systems) with mean velocity in the medial-lateral direction during narrow-based standing with eyes closed. Meanwhile, we observed a low correlation between parameters obtained from the two methods in velocity measures, with the lowest ICC in the mean velocity in the medial-lateral direction in the older group (ICC = 0.34 ~ 0.41). CONCLUSION: Both systems could differentiate age-related changes in postural steadiness, but with dissociated information about mean velocity, especially the mean velocity in the medial-lateral direction in the older group. The results support the complimentary role of using tracker-based posturography to understand the effect of age on the mechanisms of postural control.

Cross-cultural adaptation of the Taiwan Chinese version of the Falls Efficacy Scale-International for community-dwelling elderly individuals.

BACKGROUND: The Falls Efficacy Scale-International (FES-I) is a commonly used questionnaire to evaluate concerns about falling. We adapted a Taiwan Chinese version (FES-ITC) and evaluated its reliability and validity in community-dwelling elderly individuals. The discriminative validity was tested in relation to several known risk factors for fear of falling (FOF). METHODS: The questionnaire was adapted through translation, back-translation, and expert review processes. A convenience sample of 135 community-dwelling elderly individuals (at least 60 years old) completed the adapted questionnaire, and 31 of them had a retest within 7-10 days. Cronbach's α and an intraclass correlation coefficient (ICC) were used to evaluate the internal consistency and test-retest reliability. Principal component factor analysis was performed to assess the factor-construct validity. The discriminative validity was tested in relation to demographic features, fall-related history and performances on three functional tests: timed up and go, four-stage balance and 30-s chair stand tests. Effect sizes were computed. Correlation coefficients between physical functional performance and FES-ITC scores were computed. Receiver operating characteristic curves were used to determine the cutoff point for the score to differentiate high and low concern of falling. RESULTS: The FES-ITC questionnaire had high internal consistency (Cronbach's α = 0.94) and excellent test-retest reliability (ICC = 0.94). Principal component factor analysis yielded a two-factor model, with several items requiring high demand on postural control loading on factor 2. FES-ITC scores discriminated individuals with different ages, reporting FOF, reporting falls in the past year and using walking aids. However, FES-ITC scores did not differ between the participants who were at risk of falling and those who were not at risk based on functional test performance and there was no correlation found between them. CONCLUSION: The FES-ITC was highly reliable and had adequate construct and discriminative validity. The lack of correlation between FES-ITC scores and functional test performance implied the presence of FOF even in individuals with good functional performance. Further follow up studies are warranted to verify the predictive validity of the FES-ITC.

Validity of the Osteoarthritis Research Society International (OARSI) recommended performance-based tests of physical function in individuals with symptomatic Kellgren and Lawrence grade 0-2 knee osteoarthritis.

BACKGROUND: Performance-based physical tests have been widely used as objective assessments for individuals with knee osteoarthritis (KOA), and the core set of tests recommended by the Osteoarthritis Research Society International (OARSI) aims to provide reliable, valid, feasible and standardized measures for clinical application. However, few studies have documented their validity in roentgenographically mild KOA. Our goal was to test the validity of five performance-based tests in symptomatic KOA patients with X-ray findings of Kellgren and Lawrence (K-L) grade 0-2. METHODS: We recruited a convenience sample of thirty KOA patients from outpatient clinics and 30 age- and sex-matched asymptomatic controls from the community. They performed five OARSI-recommended physical tests and the KOA group answered the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index. The tests included the 9-step stair-climbing test (9 s-SCT), timed up and go (TUG) test, 30-second chair-stand test (30sCST), 40-m fast walking-test (40MFPW) and 6-minute walking test (6MWT). The discriminant validity of these physical tests were assessed by comparisons between the KOA and control groups, receiver operating curve and multivariate logistic regression analysis. The convergent/divergent validity was assessed by correlation between the physical tests results and the three subscale scores of the WOMAC in the KOA group. RESULTS: The KOA group had significantly worse performance than the control group. The percentage of difference was the largest in the 9 s-SCT (57.2%) and TUG tests (38.4%). Meanwhile, Cohen's d was above 1.2 for the TUG test and 6MWT (1.2 ~ 2.0), and between 0.8 and 1.2 for the other tests. The areas under the curve to discriminate the two groups were mostly excellent to outstanding, except for the 30sCST. Convergent validity was documented with a moderate correlation between the 9 s-SCT and the physical function (WOMAC-PF) subscale scores (Spearman's ρ = 0.60). CONCLUSIONS: The OARSI recommended core set was generally highly discriminative between people with K-L grade 0-2 KOA and their controls, but convergent/divergent validity was observed only in the 9 s-SCT. Further studies are required to evaluate the responsiveness of these tests and understand the discordance of physical performance and self-reported measures.

Application of a virtual reality tracker-based system to measure seated postural stability in stroke patients.

BACKGROUND: Postural stability while sitting is an important indicator of balance and an early predictor for future functional improvement in neurorehabilitation, but the evaluation is usually dependent on clinical balance function measures. Meanwhile, instrumental posturography has been used widely to obtain quantitative data and characterize balance abilities and underlying control mechanisms, but not as often for sitting balance. Moreover, traditional kinetic methods using a force platform to test sitting stability often require modification and are costly. We proposed a tracker-based posturography with a commercial virtual reality system, the VIVE Pro system (HTC, Inc. Taiwan), to record the trunk displacement (TD) path with a lumbar tracker for evaluation of sitting stability. The goals were to test the reliability and validity of the TD parameters among stroke patients. METHODS: Twenty-one stroke individuals and 21 healthy adults had their postural sway measured with this system under four sitting conditions, i.e., sitting on a solid surface or a soft surface, with eyes open or closed. The test-retest reliability of the TD parameters was evaluated with intraclass correlation coefficients in 22 participants. We also tested the discriminative validity of these parameters to discriminate between stroke and healthy controls, and among four sitting conditions. Furthermore, the TD parameters were correlated with the three balance function tests: the Berg Balance Scale (BBS), the Postural Assessment Scale for Stroke Patients (PASS) and the Function in Sitting Test (FIST). RESULTS: The results indicated that the TD parameters obtained by tracker-based posturography had mostly moderate to good reliability across the four conditions, with a few exceptions in the solid surface and eyes open tasks. The TD parameters could discriminate the postural stability between sitting on solid and soft surfaces. The stroke group had more seated postural sway than the control group, especially while sitting on a soft surface. In addition, velocity measures in the sagittal and frontal planes had moderate to high correlations with the PASS and BBS scores. CONCLUSIONS: This tracker-based system is a cost-effective option for the clinical assessment of body stability for stroke patients in a seated position and shows acceptable reliability and validity.

A multi-disciplinary rehabilitation approach for people surviving severe COVID-19-a case series and literature review.

BACKGROUND/PURPOSE: COronaVIrus Disease 2019 (COVID-19) has caused tremendous casualties and morbidities worldwide. Multisystem manifestations, including muscle weakness, dyspnea, cognitive decline, dysphagia, and dysarthria are frequently reported among critically ill patients. The resultant activity limitations and participation restrictions call for an organized and multidisciplinary approach to rehabilitation. Taiwan had a rapid surge in community infection cases from May to July 2021, and our team established a team-based approach in response to the rehabilitation needs for the in-patients, especially the critically-ill group. METHODS: We built a core treatment team and established a referral pathway for critically ill patients with COVID-19 based on a multidisciplinary approach. The care process and outcomes of a case series of patients who received in-patient rehabilitation after medical stabilization were presented. RESULTS: Our clinical care module was established according to interim World Health Organization guidance and current research and demonstrated a high degree of feasibility. Five patients with multiple impairments received in-patient rehabilitation and experienced significant functional improvement. We documented improvements in motor function, swallowing function, and activities of daily living after the rehabilitation. CONCLUSION: Our clinical experience suggests considerable benefits can be obtained from a well-organized and multidisciplinary rehabilitation approach for severe COVID-19 patients.

Ultrasound guidance may have advantages over landmark-based guidance for some nerve conduction studies.

BACKGROUND: Precise placement of stimulating and recording electrodes is vital when performing nerve conduction studies (NCSs). In this study, we aimed to determine whether ultrasonography (US) was more precise in localizing the superficial radial nerve (SRN), dorsal ulnar cutaneous nerve (DUCN), ulnar nerve (UN) crossing the cubital tunnel, and radial nerve (RN) crossing the spiral groove (SG) compared to conventional techniques. METHODS: Thirty healthy young subjects (15 male) were recruited. Each subject underwent both landmark-based and US-guided NCS. Onset latencies and amplitudes of compound motor action potentials (CMAPs) and sensory nerve action potentials (SNAPs), and stimulation levels (ie, intensity × duration) required to obtain maximal CMAP amplitudes were compared between the two techniques. RESULTS: The mean CMAP amplitudes of the UN above the cubital tunnel (9.55 ± 1.96 vs 8.96 ± 1.94 mV, P = .030), UN below the cubital tunnel (10.11 ± 2.07 vs 9.37 ± 1.95 mV, P < .001), and RN below the SG (5.21 ± 1.56 vs 4.34 ± 1.03 mV, P < .001) were significantly greater using US-guided NCSs compared to landmark-based NCSs. The mean onset latency of the DUCN was significantly shorter using US-guided NCSs (1.49 ± 0.15 vs 1.57 ± 0.14 ms, P = .020). The required stimulation level in the UN and RN was significantly lower using US-guided NCSs. CONCLUSIONS: When performing NCSs, US guidance provides a more precise localization of the stimulator and electrodes for the DUCN, UN, and RN, while providing comparable localization for the SRN, compared to landmark-based techniques.

The need scoping and prioritization of the medical team to integrate new technologies for inpatient rehabilitation services.

BACKGROUND/PURPOSE: To explore unmet needs for inpatient rehabilitation services and assess the relative preference of new technology versus current practice by a structured decision-making model. METHODS: The clinical needs for in-patient rehabilitation care were explored by an in-depth interview with the aid of a service blueprint in 2 affiliated hospitals of a university. A questionnaire was constructed according to the analytic hierarchical process (AHP) model to make pairwise comparison between the clinical needs for prioritization. The preference between traditional practice and new technology to fulfill the criteria was compared. RESULTS: Seven categories of unmet needs were summarized through focus group interviews to construct a questionnaire for the analytic hierarchical process. The results showed that assessment and recording ranked first as important applications, followed by clinical alerts, implementation of rehabilitation, patient/family education, team communication, schedule management and finally, the localization of patients/workers. The subjects from different professional disciplines had different rankings of preference weight, reflecting the individualized needs related to their practice. In addition, the subjects placed a higher preference on new technology than on current practice in all the categories. CONCLUSION: The preference global weights on the needs to integrate new technologies into rehabilitation services aims to improve efficiency, safety and outcome. Further studies are needed to explore the needs from the perspective of the patients.

Comparison of complaints to the intensive care units and those to the general wards: an analysis using the Healthcare Complaint Analysis Tool in an academic medical center in Taiwan.

BACKGROUND: The management of complaints in the setting of intensive care may provide opportunities to understand patient and family experiences and needs. However, there are limited reports on the structured application of complaint analysis tools and comparisons between healthcare complaints in the critical care setting and other settings. METHODS: From the complaint management database of a university-affiliated medical center in Taiwan, we retrospectively identified the records of healthcare complaints to the intensive care units (ICUs) from 2008 to 2016. Complaints to the general wards in the same period were randomly selected from the database with twice the number of that of the ICU complaints. We coded, typed, and compared the complaints from the two settings according to the Healthcare Complaint Analysis Tool. RESULTS: We identified 343 complaints to the ICUs and randomly selected 686 complaints to the general wards during the 9-year study period. Most (94.7%) of the complaints to the ICUs came from the family members, whereas more complaints to the general wards came from the patients (44.2%). A total of 1529 problems (441 from ICU and 818 from general wards) were identified. Compared with the general ward complaints, in the ICU there were more complaints with multiple problems (25.1% vs. 16.9%, p = 0.002), complaints were referred more frequently to the nurses (28.1% vs. 17.5%, p < 0.001), and they focused more commonly on the care on the ICU/ward (60.5% vs. 54.2%, p = 0.029). The proportions of the three domains (clinical, management, and relationship) of complaints were similar between the ICU and general ward complaints (p = 0.121). However, in the management domain, the problems from ICU complaints focused more on the environment than on the institutional processes (90.9% vs. 74.5%, p < 0.001), whereas in the relationship domain, the problems focused more on communication (17.9% vs. 8.0%) and less on listening (34.6% vs. 46.5%) (p = 0.002) than the general ward complaints. CONCLUSIONS: A structured typing and systematic analysis of the healthcare complaints to the ICUs may provide valuable insights into the improvement of care quality, especially to the perceptions of the ICU environment and communications of the patients and their families.

Influence of smartphone use styles on typing performance and biomechanical exposure.

Twenty-seven subjects completed 2-min typing tasks using four typing styles: right-hand holding/typing (S-thumb) and two-hand typing at three heights (B-low, B-mid and B-high). The styles had significant effects on typing performance, neck and elbow flexion and muscle activities of the right trapezius and several muscles of the right upper limb (p < 0.0001 by repeated-measure analysis of variance). The subjects typed the fewest words (error-adjusted characters per minute: 78) with the S-thumb style. S-thumb style resulted in similar flexion angles of the neck, elbow and wrist, but significantly increased muscle activities in all tested muscles compared with the B-mid style. Holding the phone high or low reduced the flexion angles of the neck and right elbow compared with the B-mid style, but the former styles increased the muscle activity of the right trapezius. Right-hand holding/typing was not a preferable posture due to high muscle activities and slow typing speed. Practitioner Summary: Right-hand holding/typing was not favoured, due to increased muscle activities and slower typing speed. Holding the phone high or low reduced the flexion angles of the neck and right elbow, but the former styles increased the muscle activity of the right trapezius compared with holding the phone at chest level.

Parkinson disease and risk of acute myocardial infarction: A population-based, propensity score-matched, longitudinal follow-up study.

OBJECTIVES: Previous studies on the risk of acute myocardial infarction (AMI) in patients with Parkinson disease (PD) have generated inconsistent results. The purpose of this population-based longitudinal follow-up study was to investigate whether incident PD is associated with an increased risk of AMI. METHODS: A total of 3,211 subjects with at least 2 ambulatory visits with the principal diagnosis of PD in 2001 were enrolled in the PD group. The non-PD group consisted of 3,211 propensity score-matched subjects without PD. The propensity scores were computed using a logistic regression model that included age, sex, preexisting comorbidities, and socioeconomic status. The 3-year AMI-free survival rates of the 2 groups were estimated using the Kaplan-Meier method. Stratified Cox proportional hazard regression with patients matched by propensity score was used to estimate the effect of PD on subsequent occurrence of AMI. RESULTS: During the 3-year follow-up period, 83 subjects in the PD group and 53 in the non-PD group developed AMI (either fatal or nonfatal) events. The hazard ratio of AMI for the PD group compared with the non-PD group was 1.67 (95% CI 1.15-2.41, P = .0067). The AMI-free survival rate of the PD group was significantly lower than that of the non-PD group (P = .0032). The hazard ratios associated with PD for the combined end point 1 (AMI or cardiovascular death) and combined end point 2 (AMI or all-cause death) were 1.46 (95% CI 1.14-1.88, P = .0029) and 1.42 (95% CI 1.24-1.64, P < .0001), respectively. CONCLUSIONS: This study shows that PD is related to an increased risk of AMI. Further studies are required to investigate the mechanism underlying this association.

Reliability and validity of the Taiwan Chinese version of the Lower Extremity Functional Scale.

BACKGROUND/PURPOSE: The Lower Extremity Functional Scale (LEFS) is a region-specific functional outcome measure designed for patients with lower extremity musculoskeletal dysfunction. In this study, a Taiwan Chinese version was adapted and its validity and reliability were tested. METHODS: The LEFS questionnaire was adapted and tested in 159 patients with lower extremity disorders from two university hospitals. The Cronbach α-coefficient value was calculated for internal consistency. Intraclass correlation coefficient (ICC), Bland-Altman plot, and minimal detectable change (MDC) were used for evaluating the test-retest reliability and agreement in 40 patients followed up within 7 days. Construct and convergent/divergent validity were examined by principal component analysis and correlation was examined with the Medical Outcomes Study Short Form-36 (SF-36) questionnaire. RESULTS: The internal consistency and test-retest reliability of the adapted LEFS questionnaire were satisfactory [Cronbach α: 0.98; ICC(2,1), 0.97]. The Bland-Altman plot of the two tests showed a relatively consistent distribution, with limits of agreement in the range of -9.32 to 13.02. The MDC at 90% confidence interval was 9.6. One-factor model was confirmed by principal component analysis. Also, there was a moderate association between the LEFS and the physical component scores and several subscales of SF-36, but not with the mental component scores. CONCLUSION: The Taiwan Chinese version of the LEFS questionnaire is a valid and reliable measure of health status for patients with lower extremity disorders.

Ultrasonographic median nerve changes under tendon gliding exercise in patients with carpal tunnel syndrome and healthy controls.

STUDY DESIGN: Case control study. PURPOSE OF THE STUDY: To evaluate the ultrasonographic median nerve changes under tendon gliding exercise in patients with carpal tunnel syndrome (CTS) and healthy controls. METHODS: Seventy-three patients with CTS and 53 healthy volunteers were consecutively recruited. Each subject underwent a physical examination, nerve conduction studies and ultrasonographic examinations of the median nerve during tendon gliding exercises. RESULTS: Significant changes in the cross-sectional area of the median nerve were found while moving from the straight position to the hook position and from the hook position to the fist position. There were also significant changes in the flattening ratio when moving from the hook position to the fist position. CONCLUSIONS: Ultrasonography revealed that the median nerve was compressed in the fist position in both CTS patients and healthy volunteers. Thus, forceful grasping should be avoided during tendon gliding exercises performed in the fist position. LEVEL OF EVIDENCE: 3b.

Integrating health-related quality of life with sickness leave days for return-to-work assessment in traumatic limb injuries.

PURPOSE: A novel indicator called health-adjusted leave days (HALDs) is proposed. It integrates the opposite level of health-related quality of life (HRQoL) with the sick leave days (LDs) before return-to-work (RTW) to better measure the impact of injuries on occupational health. METHODS: A total of 1,167 limb injuries were consecutively recruited in a teaching hospital from January to December 2009. The number of LDs was calculated between the date of injury and the first episode of RTW. Each subject was repeatedly assessed with EuroQol instrument (EQ-5D) before RTW. The HRQoL index is defined as 1 minus the EQ-5D utility and re-scaled to 0-1 range to reflect the impact of injuries. The expected HALD of each group is calculated by integrating the product of the proportion of non-RTW function and the mean HRQoL index function over the days followed up to 2 years for the group. We compared the expected HALDs between subgroups according to various demographic characteristics and consequences of injury. RESULTS: Older and female workers tended to have longer LDs than men and younger workers, with an increase in percentage change of 16.0 or 139.5 %, respectively. After adjusting for HRQoL index, the percentages for HALDs were changed to 28.7 or 186.6 %, respectively. The percentages for the less-educated workers and blue collar workers were 185.7 and 155.8 %. The expected HALDs showed statistical significant differences in all subgroup analyses. CONCLUSION: We believed that the proposed HALD could better measure the impact of injuries and is potentially useful for the clinical decision and industrial policy-making with respect to the assessment of the importance of limb injury due to a worker's sick leaves.

Return to work and quality of life in workers with traumatic limb injuries: a 2-year repeated-measurements study.

OBJECTIVES: To assess the impact of return-to-work (RTW) status on health-related quality of life (HRQOL) over a 2-year period in workers with traumatic limb injuries and to elucidate factors that may contribute to the association of RTW with HRQOL. DESIGN: A 2-year repeated-measurements follow-up study using the generalized estimating equations approach for model fitting to account for within-subject correlations of HRQOL. SETTING: One teaching hospital. PARTICIPANTS: Injured patients (N=966, 61% men) with a mean age of 44.7 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The RTW status, HRQOL (assessed by the EuroQol five-dimensional questionnaire), and activity/participation were repeatedly surveyed at 2 weeks and 1, 3, 6, 12, 18, and 24 months after injury. A series of regression models was used to examine the associations between HRQOL and RTW, with sequential adjustment for explanatory variables such as personal and environmental factors, body structure and function, activity/participation, and postinjury period. RESULTS: Over a 2-year study period, 81.2% of the study participants had 1 or more RTW episodes; 38.2% of them successfully maintained their RTW status until the end. A significant positive association was found between RTW status and HRQOL. The association could largely be explained by the domains of activity/participation. A higher HRQOL was associated with a shorter length of hospital stay, better coping ability, frequent participation in activities of daily living, and a longer postinjury period. A reduced HRQOL, however, was observed for participants with more depressive symptoms. CONCLUSIONS: RTW showed a positive and independent influence on HRQOL in workers with limb injury. In addition, the activity/participation domains and the elapsed time since injury largely explained the association between RTW and HRQOL.

Ultrasound-guided injection of steroid in multiple postamputation neuromas.

After limb amputation, neuromas may be asymptomatic when not compressed, but can cause unexplained discomfort when a prosthesis is worn. The sonographic presentation of multiple postamputation neuromas has rarely been reported. A 40-year-old female with a left, below-elbow amputation suffered from late-onset stump pain and prosthesis intolerance. Physical examination revealed a painful nodule, whereas sonographic findings disclosed three hypoechoic masses derived from the median, ulnar, and radial nerves. Marked pain reduction was reported 2 weeks after sonography-guided steroid injection. Investigation of all damaged nerves in the residual limbs is important.

Discriminative Changes in Sitting and Standing Postural Steadiness in Patients With Chronic Low Back Pain.

Postural control is reduced in patients with low back pain (LBP), which is considered an important factor attributing to the chronicity of LBP and a target for treatment. It is proposed that the changes in postural steadiness in sitting reflect the trunk control better than those in standing, but the previous study results are inconsistent. Thus, this study aimed to compare trunk sway parameters during standing and sitting between patients with chronic LPB (CLBP) and controls using a tracker-based posturography to record the trunk displacement trajectories at the lumbar level (TD [Formula: see text]. A total of 64 participants (32 patients with CLBP and 32 pain-free controls) were included in this study. The postural sway was measured under four conditions, sitting or standing on unstable surface, with eyes open or closed. The TDL parameters were compared between the two groups to explore their discriminative ability. The CLBP group had more body sway than the control group, characterized by several TDL parameters in sitting with eyes closed and standing with eyes open. The TDL parameters with the highest area under the curve according to the receiver operating characteristic curve analysis were the root mean square distance and mean frequency in the medial-lateral direction obtained in the sitting with eyes closed. In conclusion, we confirmed the advantage of using sitting posturographic parameters as a sensitive measure to detect impaired trunk control in patients with CLBP. The results would help choose sensitive outcome measures to reflect the postural control of patients with LBP.