The Functional Outcome of Stroke Patients with Anterior Cerebral Artery Territorial Infarct

OBJECTIVE: To investigate the functional outcomes of anterior cerebral artery (ACA) territorial infarcts in comparison to those of middle cerebral artery (MCA) territorial infarcts. METHOD: Medical records of 1998 stroke patients admitted to Asan Medical Center in Seoul, Korea, from January 1, 1992 to June 31, 1999 were reviewed. Fifty-three patients had ACA occlusions. Sixteen of 53 patients who were given comprehensive rehabilitation were involved in this study. Thirty-nine patients with MCA territorial infarcts served as a control group. The data collected from chart reviews included the age, sex, the hemiparetic side, days from onset to arrival at rehabilitation service, lengths of stay in rehabilitation service, and Functional Independence Measure (FIM) score of each patient. RESULTS: The ACA group showed better motor and total FIM score at discharge. They acquired better FIM efficiency, motor FIM gain, and motor FIM efficiency. Both groups showed no significant differences in cognitive FIM gain and efficiency. CONCLUSION: The ACA group had better performance in ADL than that of the MCA group as evidenced by the fact that it showed a higher FIM efficiency resulting from higher motor FIM efficiency after comprehensive rehabilitation management.

The Comparison of Videofluoroscopic Findings between the Patients with Lateral Medullary Infarct and Middle Cerebral Artery Territorial Infarct

OBJECTIVE: To compare the videofluoroscopic findings between the patients with lateral medullary infarct and middle cerebral artery infarct and to investigate specific findings relevant to lateral medullary infarct. METHOD: Among patients with stroke taking videofluoroscopic study for swallowing problems, thirteen patients had a lesion in lateral medulla in imaging study and twenty-six patients in middle cerebral arterial territory. The findings of videofluoroscopic study on two groups were analyzed and compared. RESULTS: In oral phase, the ability of mastication and bolus formation were better in lateral medullary group. In pharyngeal phase, lateral medullary group revealed significantly impaired triggering of pharyngeal reflex, impaired laryngeal elevation, larger amount of residual materials, repeated swallow, delayed pharyngeal transit time, weaker pharyngeal muscle contraction, and poorer upper esophageal sphincter relaxation. Inadequate relaxation of upper esophageal sphincter was most significant factor in indicating the possibility of lateral medullary infarct (positive predictability 90.0%). Inadequate triggering of pharyngeal swallow indicated least possibility of lateral medullary infarct (negative predictability 92.3%). CONCLUSION: Lateral medullary group has the characteristics of more impaired pharyngeal function and better oral function during swallowing than middle cerebral artery group in videofluoroscopic study. Inadequate upper esophageal relaxation and triggering of pharyngeal swallow are the most predictive for lateral medullary infarct.

Traumatic Cauda Equina Syndrome Due to Spinal Stenosis in an Achondroplastic Patient: A Case Report

Achondroplasia is a congenital developmental condition characterized pathologically by defective enchondral ossification, affecting chiefly the long bones, and clinically by peculiar dwarfism with short extremities and normal trunk. One of the most common neurologic manifestation in achondroplastic patients in adulthood is spinal stenosis where the prominent characteristics of lumbar vertebrae structure are shortening of interpedicular distance and hypertrophy of vertebral pedicle. There has been no case report of traumatic cauda equina syndrome resulted in paraparesis among achondroplasic patients in Korea. We experienced a 30 year-old achondroplastic man sustained paraparesis as the result of an accidental slipping down. After the surgical decompression, the patient made slow recovery in all aspects of function via rehabilitation therapy.

The Effect of Cognitive Deficit on Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: To investigate the functional outcome with regard to cognitive deficits in patients with aneurysmal subarachnoid hemorrhage (SAH). METHOD: Two hundred thirty-four patients who underwent surgical procedure for aneurysmal SAH were enrolled. Medical records of the patients were reviewed. RESULTS: Mental confusion (52.1%) was more common symptom than the motor (20.3%) and language (30.9%) impairment in patients with aneurysmal SAH. Neurological grade at admission (Hunt and Hess grade), cerebral vasospasm, and mental confusion were major prognostic factors. In terms of functional outcome, patients with mental confusion showed lower Functional Independence Measure (FIM) scores at admission and on discharge, lower FIM gain and FIM efficiency, and longer hospital stay with statistical significance than those without confusion. CONCLUSION: The patients with cognitive deficits achieved poor functional outcome in the patients with aneurysmal SAH. More attention to cognitive impairment is necessary to achieve better rehabilitation goal.

Nerve Conduction Study on Patients with Severe Liver Disease and Its Change after Transplantation

OBJECTIVE: To investigate the character of peripheral neuropathy associated with end-stage liver disease and the effect of liver transplantation on peripheral neuropathy. METHOD: Twenty five patients admitted for a liver transplantation were involved in this study. All patients underwent nerve conduction study before liver transplantation and 6 months after liver transplantation. Based on results of this study, motor amplitude (MAS), motor velocity (MVS), sensory amplitude (SAS), and sensory velocity score (SVS) were calculated. Neuropathy symptom score (NSS), and neuropathy disability score (NDS) were estimated. The scores from the nerve conduction study were compared with NSS and NDS to find out the correlation between them. The changes in nerve conduction study, NSS and NDS after liver transplantation were evaluated. RESULTS: All patients had abnormalities on their nerve conduction study preoperatively, but 10 patients (40%) showed normal findings 6 months after transplantation. Only SAS disclosed significant correlation with NDS preoperatively. SAS, SVS, and MVS showed significant correlation with NDS after transplantation. SAS and MVS substantially increased after transplantation. CONCLUSION: Nerve conduction study showed the improvement both in sensory and motor nerve after liver transplantation. The correlation between the nerve conduction study and clinical estimates after liver transplantation was closer than before the transplantation.

The Effect of Complications of Stroke Patients on Prognosis during Rehabilitation Management

OBJECTIVE: To investigate complications of stroke patients with regard to incidence, predisposing risk factors and their effect on the patients's prognosis during rehabilitation management. METHOD: Two hundred fifty nine patients with stroke admitted to Department of Rehabilitation Medicine were included in this study. We analyzed types of stroke, incidence of complications, outcome of rehabilitation treatment and the length of the hospital stay. RESULTS: Of the 259 patients who had received rehabilitation, shoulder pain occurred in 59 patients (22.8%), depressions in 24 (9.3%), falls in 24 (9.3%) and pneumonia in 21 (8.1%); 112 patients (42.9%) had a total of 174 complications. The incidence of complication was higher in patients who had lower initial FIM score or previous cardiac disease. The patients with complication had longer rehabilitation hospital stay and lower FIM gain and efficacy. CONCLUSION: Early detection and treatment of the complications of acute stroke patients during rehabilitation will shorten the length of the hospital stay and improve the overall prognosis of the patients.

Congenital Achilles Tendon Contracture

Congenital Achilles tendon contracture is an autosomal dominant disease which is relatively rare. The disease manifests itself as 'toe walking'. Since the clinical condition is relatively benign, it is easy to be overlooked by the clinicians. To the patients, it presents problems of ambulation and activities of daily living. We present a case of 23 year old man who has been walking on his toes. The patient had a difficulty in squatting and tieing shoes and performed poorly gym activities. The patient's father and brother also walked on toes, which made the patient become indifferent to his condition. Upon physical examination, plantarflexion contractures of both ankle joints were 10 degree and the knee were 5 degree. We could not find any abnormal findings in motor or sensory function tests of both lower limbs. Deep tendon reflexes on patella and ankle were within normal range. There were no abnormalities in ankle X-ray, electromyography, blood sample test including muscle enzymes. Gait analysis showed increased ankle plantarflexion moment during entire gait cycle, increased knee flexion during terminal stance, and decreased both knee flexion during initial swing.

Dynamic Imbalance of Lumbo-Pelvic Motion in Pregnant Women with Back and Pelvic Pain

OBJECTIVE: To investigate a biomechanism of pelvic pain in pregnancy by use of motion analyzer. METHOD: Ten pregnant women in the early third trimester and 10 healthy women as control were enrolled. A gait analysis by a Vicon 370 motion analyzer system was performed to investigate the dynamic lumbo-pelvic motion of pregnancy in biomechanical aspects. RESULTS: The mean maximal surface lordotic angle of pregnant women was 24.42+/-3.98 degrees, the mean minimal surface lordotic angle 20.64+/-4.27 degrees, and the mean maximal surface lordotic angle of controls was 21.61+/-2.43 degrees, the mean minimal surface lordotic angle 18.38+/-2.29 degrees (p>0.05). The mean maximal anterior pelvic tilt of pregnant women was 21.11+/-5.91 degrees, and the mean maximal anterior pelvic tilt of controls was 15.28+/-4.94 degrees (p<0.05). CONCLUSION: The angle of lumbar lordosis was within normal ranges but the anterior pelvic tilt was increased significantly in pregnancy. This can place mechanical stress on lumbo-pelvic region. This dynamic sagittal imbalance of the spine may be a considerable cause for low back and pelvic pain in pregnancy as indicated by the results of this study.

Thoracic Arachnoiditis Following Surgical Lumbar Fixation: A case report

This 32 year-old man sustained crush injury and resultant in paraplegia. Lumbar MRI was taken and revealed fracture and dislocation between L2 and L3 vertebrae bodies. On the day of the injury, he underwent a surgical intervention of posterolateral fixation and bone graft from L1 to L4 vertebrae. He was transferred to Rehabilitation Medicine Department of Asan Medical Center where patient was subsequently found to have an unexpected neurologic finding of decreased sensation below T5 dermatome on right and below T6 on left. Accordingly we took a thoracic MRI which showed features consistent with arachnoiditis at thoracic and lumbar cord segment. A dermatomal somatosensory evoked potential study was performed with finding of abnormal somatosensory pathway below mid thoracic dermatome. We reported an unusual case of thoracic arachnoiditis occurred after the surgical fixation of the lumbar vertebral fracture and dislocation.

Causes and Types of Childhood Strokes

OBJECTIVE: We documented childhood strokes in this hospital to ascertain the causes of childhood strokes and the proportion of stroke types. METHOD: We reviewed the medical records and brain imaging studies of all children with possible strokes who were admitted to Asan Medical Center from 1990 to 1999. Our review of charts identified 131 acute childhood stroke patients aged from one to eighteen years old. RESULTS: Seventy boys (53.4%) and 61 girls (46.6%) were involved in this study. The predominant diagnoses responsible for the stroke were arteriovenous malformation (42.0%) and moyamoya disease (24.4%). The diagnoses of 30 stroke patients (22.9%) were undetermined, 16 of them were ischemic and 14 hemorrhagic. The total number of hemorrhagic stroke was almost twice as that of ischemic stroke. As patients aged, the incidence of ischemic stroke decreased while the opposite trend was observed in hemorrhagic stroke. There were 14 death (10.7%) consisting of 13 hemorrhagic stroke patients and 1 ischemic during the admission period. Relapse of stroke were noted in 19 of 131 patients (14.5%) with the main cause being arteriovenous malformation. CONCLUSION: Although the main diagnoses of childhood strokes were arteriovenous malformation and moyamoya disease, the cause of strokes in 23% could not be confirmed. The incidence of ischemia decreased while that of hemorrhage increased with the increase in age. Death, relapse, and complication occurred more frequently in hemorrhagic than ischemic stroke.

Changes of Plasma Lipids in Stroke Patients

OBJECTIVE: To investigate plasma lipid changes in pre- and poststroke patients and to evaluate the difference of these changes between hemorrhagic and ischemic strokes. METHOD: Two hundred thirty five stroke patients who underwent blood tests for health check-up before stroke were included in this study. Lipids profile among blood tests included total cholesterol, triglyceride, low density lipoprotein cholesterol, and high density lipoprotein cholesterol. These tests were taken again within 48 hours, at 1 week, and 3 months after stroke. Prestroke lipid profile was compared with the control group, which was composed of two hundred forty seven healthy men. RESULTS: The difference between lipid profile of prestroke and within 48 hours after stroke was not statistically significant. Total cholesterol at 1 week after stroke was significantly lower, but its concentration increased at 3 months after. There's no significant changes in triglyceride, low density lipoprotein cholesterol, or high density lipoprotein cholesterol according to time. There was no significant difference in lipid profile between the ischemic and hemorrhagic strokes and no significant changes between the subtypes of ischemic stroke were noted. CONCLUSION: Our results suggest that the lipid profile after stroke is changed, so the lipid profile taken after stroke are not reflect clearly the state of prestroke lipid concentration.

Prevalence of Cerebral Palsy in Very Low Birth Weight Infants

OBJECTIVE: To investigate the survival rate and the prevalence of cerebral palsy in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants as well as the risk factors for the development of cerebral palsy. METHOD: We reviewed medical records of 471 VLBW infants admitted to Asan medical center from 1989 to 1997 retrospectively. RESULTS: Ninety seven infants died before discharge from hospital, 7 died during follow-up, 55 status unknown due to discharge against medical advice, 26 discontinued follow-up. At corrected chronologic age of 2 years old, the prevalence of cerebral palsy was 10.5%, delayed development 4.5% and normal development 85.0%. Survival rate and prevalence of cerebral palsy among survivors remained statistically insignificant with time. Cerebral palsy was found in 8.5% of VLBW and 19.2% of ELBW. Decreasing gestation, abnormal neurosonographic findings, assisted ventilation, bronchopulmonary dysplasia, sepsis were risk factors associated with increased odds for cerebral palsy. CONCLUSION: The prevalence of cerebral palsy in VLBW infants admitted to this hospital were comparable with recent studies from developed countries, and some of the predictors of cerebral palsy, ie, gestation period, neurosonographic findings, history of respirator use and sepsis, were also similar to those of western countries.

Changes of Nerve Conduction at High Temperature in Patients with Carpal Tunnel Syndrome

OBJECTIVE: High body temperature may alter nerve conduction in demyelinated neurons. This study was designed to investigate the changes in nerve conduction parameters in response to the heat applied over the wrist in the patients with carpal tunnel syndrome (CTS). METHOD: 16 hands of CTS patients and 16 hands of normal subjects were involved in this study. Motor and sensory nerve responses were measured at 32degrees C and 42degrees C in all the subjects. Infrared was applied on the wrist to warm the skin to 42degrees C. Changes of relative amplitude, duration, and latency of evoked potentials in median sensory and motor nerves of CTS patients were compared with those of the normal subjects. Correlation between the latency measured at 32degrees C and changes of amplitude of motor and sensory nerve responses after warming to 42degrees C was evaluated in CTS group. RESULTS: Relative reduction in duration of motor responses in CTS group was significantly greater than in normal group. Relative reduction of motor and sensory amplitude, and sensory latency were greater in CTS. There was no significant relation between motor and sensory latency at 32degrees C and relative amplitude reduction in motor and sensory responses at 42degrees C. CONCLUSION: Increase in temperature may increase the number of blocked nerve fibers in patients with CTS than in normal subjects.

Gait Analysis of Patients with Unilateral Total Hip Arthroplasty

OBJECTIVE: The purpose of this study is to evaluate objectively and quantitatively gait improvement after total hip arthroplasty (THA) using a 3-dimensional computerized Vicon motion analyzer. METHOD: A preoperative gait evaluation was performed within one month before surgery and two postoperative gait evaluations at 6 months intervals after surgery. Pre- and postoperative gait parameters of 176 patients with unilateral total hip arthroplasty were evaluated and data were compared with those of 56 healthy persons. RESULTS: 1) Single limb support of affected limb increased significantly at postoperative 6 and 12 months compared with preoperative data. 2) The improvements of hip flexion and abduction of affected limb were in almost normal range at postoperative 12 months. 3) Maximal hip flexor moment in terminal stance of affected limb reached to nearly normal level at postoperative 12 months. CONCLUSION: A quantitative gait analyzer is a very useful tool to assess objectively the success of THA as substantiated by the results of this study with a significant improvement in all the parameters of gait.

The Effect of Chronic Low Back Pain on Bone Mineral Density and Trunk Muscle Strength in Women

OBJECTIVE: To evaluate (1) the effect of chronic low back pain on bone mineral density, and (2) the effect of chronic low back pain on trunk muscle strength in women. METHOD: Subjects were 118 women patients (ages of 28~65 years) suffering from chronic low back pain more than three months and control groups were 218 healthy women (age of 26~72 years). We measured bone mineral density (BMD) at the lumbar spine and proximal femur using Dual X-ray absorptiometry and trunk muscle strength using Cybex 660 dynamometer. RESULTS: There was no significant difference between groups in lumbar spine BMD, in proximal femur BMD, or in trunk flexor muscle strength. However, trunk extensor muscle strength was reduced significantly in patient group. Trunk extensor muscle peak torque was 64.69+/-18.48 Nm in the patient group and 73.84+/-22.50 Nm in the control group in 30 degrees/sec, and 58.65+/-18.59 Nm in the patient group and 65.68+/-20.28 Nm in the control group in 60 degrees/sec. CONCLUSION: The results suggest that chronic low back pain does not affect the BMD. However, it causes trunk extensor muscle weakness; therefore, trunk extension exercise will be help to the patients with chronic low back pain.

Application of Gait Analysis to the Patients with Cervical Myelopathy

No abstract available.

Cerebrovascular and Cardiovascular Changes According to Postural Change in Spinal Cord Injured Patients: Preliminary report

OBJECTIVE: To investigate the changes of cerebral and cardiovascular hemodynamics in response to postural change in tetraplegics after cervical spinal cord injury. METHOD: We studied 5 healthy volunteers and 14 cervical cord injured patients with orthostatic hypotension. We continuously monitored heart rate (HR), blood pressure (BP) by volume clamp photoplethysmography, and cerebral blood flow velocity (BFV), pulsatility index (PI) of middle cerebral artery (MCA) by transcranial Doppler sonography at rest and during head-up-tilt (HUT). Tilt table set at 30o initially and then increased gradually 10o every 5 minutes up to 80o. RESULTS: In the control group, BP and BFV of MCA remained unchanged during HUT. Although a decrease of BFV observed in all patients during both systolic and diastolic phases, the degree of BFV drop during diastolic phase, especially early diastolic phase was much greater than that during systolic phase. The change of BFV of MCA was significantly correlated with that of systemic hemodynamic parameters, especially systolic BP. After rehabilitative therapy for one month, there was no definite evidence of the change in cerebral autoregulation. CONCLUSION: This study suggests that we can use systemic hemodynamic parameters for predicting changes of cerebral blood flow in response to orthostatic hypotension, but we fail to observe any compensatory mechanism of cerebrovascular system to maintain cerebral blood flow against systemic hemodynamic collapse.

The Phrenic Nerve Conduction Study in Diabetic Patients

OBJECTIVE: To assess the possibility of phrenic neuropathy in diabetic patients, and to define the factors that influence phrenic neuropathy in those patients. METHOD: Seventeen diabetic patients and sixteen controls participated in this study. The fasting and postprandial 2 hours blood sugar levels, HbA1c study, motor and sensory nerve conduction study, pulmonary function test, and phrenic nerve conduction study were examined in all subjects. The neuropathic disability score (NDS) was measured for clinical assessment in diabetic patients. RESULTS: 1) The mean duration of diabetes was 12.3+/-7.7 years, and the mean NDS score was 3.2+/-3.8. 2) In pulmonary function test, FEV1 and FVC of diabetic patients were lower than controls (p<0.05). 3) The prolonged latency and decreased amplitude of phrenic nerve were shown in diabetic patients compared with controls (p<0.05). The FEV1 and FVC in the diabetics with phrenic neuropathy were lower than ones without phrenic neuropathy (p<0.05). 4) The duration of diabetes, NDS are related to prolonged phrenic latency. CONCLUSION: The diabetic patients with decreased pulmonary function with might be related phrenic neuropathy. The prolonged latencies of phrenic nerve were related with longer duration of diabetes and higher NDS score.

The Incidence of Secondary Poststroke Complications in Stroke Patients in Korea as Compared with Those in Western Countries

OBJECTIVE: It has been well known that many of patients with stroke have developed secondary poststroke complications which encompassed pneumonia, urinary tract infection, depression, fall and/or fracture, deep vein thrombosis, decubitus ulcer, and others. Our experience with Korean stroke patients indicated that the incidences of such complications were not as high as reported on the western literatures. This study was aimed to obtain the precise data in terms of occurrence of poststroke complications in Korea as compared with those in western countries. METHOD: Nine-hundred-eighty-four (984) charts of Stroke patients who were hospitalized at Asan Medical Center during the periods of 3 years from 1994 through 1997 were reviewed. The data from the review were compared with the data excerpted from the literatures. RESULTS: The review of charts disclosed that there was a great disparity of the incidences of complications in stroke patients between Korea and Western (U.S.A.) countries. The incidences of all stroke complications were uniformly much lower in Korea than Western countries. CONCLUSION: Compared with western countries, stroke patients in Korea presented significantly lower incidences of poststroke complications: 5.8% pneumonia; 3.7% urinary tract infection; 3.0% fall; 2.7% decubitus ulcer; and 2.4% deep vein thrombosis. Although there were a many factors accounting for lower incidences of complication, an extensive nursing service around the clock seemed to be a major attributing factor. However, the nursing services such as position change, massage, joint motion exercise etc. have been rendered not by registered nurse but by a caregiver hired by patient's family or a member of patient's family. Since patient's family or caregiver had not formally received an education of health care, their service may be liable for incidences against patient's quality care. Therefore, the strengthening of the manpower of registered nurse is essential to meet a standard of nursing service.

Gait Analysis of Patients with Unilateral Hip Lesion Treated with Total Hip Arthroplasty / 대한정형외과학회잡지

Total hip replacement arthroplasty ( THA ) is a useful treatment method in the patients with avascular necrosis ( AVN ) or degenerative arthritis ( DA ) to relieve pain and recovery of function. Beside pain relief , patients want improvement in gait pattern , which is related with Jeg length discrepancy, range of motion, and muscle power. It could be difficult to analyse the cause of limp accuratelv by the clini-cal observation. Therefore gait analysis will he a good tool for the identification of the factors related to the recovery of patients after the operation. This study was undertaken in an attempt to evaluate the gait characteristics of 16 patients with unilateral hip disease treated with THA. We compared the outcome of qualitative and quantitative analysis of gait and also compared with those of 14 healthy person. The results were as followed : 1. The patients showed short single support time on their painful limb prior to THA , but postoperatively , it was increased to near normal (p<0.05). 2. Preoperatively, the range of hip flexion of the sound side was increased more than those of the normal control and the painful limh. After the THA, it returned to the near normal (p<0.05~). The hip extension of the painful limh uas increased postoperatively (P<0.05) but still it was lower than normai subject. The hip ahduction and internal roiation of sound side was also increased to near normal after THA. In conclusion, great improvement ot the gait characteristics in patients with hip disease after THA was found and this gait improvement can he analyzed quantitatively hy gait analysis.