Balance Ability in Low Back Pain Patients With Lumbosacral Radiculopathy Evaluated With Tetrax: A Matched Case-Control Study

Objective@#To compare postural balance ability in patients with low back pain between groups with and without lumbosacral radiculopathy. @*Methods@#Patients who were referred for electromyography because of low back pain during the period from April 2017 through June 2018 were chosen as subjects. They were divided into groups with and without lumbosacral radiculopathy based on the results of electromyography. We used Tetrax (Sunlight Medical Ltd., Ramat Gan, Israel) to objectively evaluate postural balance ability, and to measure the fall risk, stability index, weight distribution index, and Fourier index. @*Results@#Patients in the lumbosacral radiculopathy group showed significantly higher fall risk (73.25 vs. 38.00; p<0.05), weight distribution index (8.57 vs. 5.00; p<0.05), and stability index (21.19 vs. 13.16; p<0.05) than those in the group without lumbosacral radiculopathy. The Fourier index at high-medium frequency was significantly increased in the lumbosacral radiculopathy group (8.27 vs. 5.56; p<0.05), whereas weight-bearing on the side of radiculopathy was significantly decreased. @*Conclusion@#Patients with lumbosacral radiculopathy have decreased postural balance compared with patients without this condition. Somatosensory disturbances in lumbosacral radiculopathy might cause postural balance impairment. Assessment and treatment plan not only for pain reduction but also for postural balance improvement should be considered in the management of patients with lumbosacral radiculopathy.

Treatment-Induced Neuropathy of Diabetes

Treatment-induced neuropathy in diabetes (TIND) is a reversible neuropathy that occurs in patients with diabetes, usually after a fast improvement in glycemic control. TIND is defined as the sudden onset of neuropathic pain or autonomic dysfunction with a large improvement in glycemic control (glycated hemoglobin [HbA1c] level of ≥ 2% over 3 months). We report the first case of a 24-year-old woman with type 1 diabetes mellitus who developed TIND in Korea. Her HbA1c level had decreased from 16.7% to 7.3% within a 3-month period. She developed acute-onset, severe, and continuous burning pain affecting her back and lower extremities. She was administered tapentadol (50 mg), pregabalin (75 mg), and vitamin B with minerals twice daily for neuropathic pain. She complained of orthostatic hypotension; thus, midodrine (2.5 mg) and anti-embolic stockings were prescribed. She almost completely recovered 6 months after the onset. A physician should be aware of TIND and gradually reduce HbA1c levels to prevent the occurrence of TIDN. They must also try to provide relief from severe pain or autonomic dysfunction and emphasize on an almost complete recovery.

Treatment-Induced Neuropathy of Diabetes

Treatment-induced neuropathy in diabetes (TIND) is a reversible neuropathy that occurs in patients with diabetes, usually after a fast improvement in glycemic control. TIND is defined as the sudden onset of neuropathic pain or autonomic dysfunction with a large improvement in glycemic control (glycated hemoglobin [HbA1c] level of ≥ 2% over 3 months). We report the first case of a 24-year-old woman with type 1 diabetes mellitus who developed TIND in Korea. Her HbA1c level had decreased from 16.7% to 7.3% within a 3-month period. She developed acute-onset, severe, and continuous burning pain affecting her back and lower extremities. She was administered tapentadol (50 mg), pregabalin (75 mg), and vitamin B with minerals twice daily for neuropathic pain. She complained of orthostatic hypotension; thus, midodrine (2.5 mg) and anti-embolic stockings were prescribed. She almost completely recovered 6 months after the onset. A physician should be aware of TIND and gradually reduce HbA1c levels to prevent the occurrence of TIDN. They must also try to provide relief from severe pain or autonomic dysfunction and emphasize on an almost complete recovery.

Investigating the Dose-Related Effects of Video Game Trunk Control Training in Chronic Stroke Patients With Poor Sitting Balance

OBJECTIVE: To investigate the dose-related effect of trunk control training (TCT) using Trunk Stability Rehabilitation Robot Balance Trainer (TSRRBT) in chronic stroke patients with poor sitting balance. METHODS: This was a retrospective study of 38 chronic stroke patients with poor sitting balance that underwent TCT with TSRRBT. The participants were assigned either to the low-dose training (LDT) group (n=18) or to the highdose training (HDT) group (n=20). In addition to the conventional rehabilitation therapy, the LDT group received 5 sessions of TSRRBT intervention per week, whereas the HDT group received 10 sessions of TSRRBT intervention per week. The outcome measures were the scores on the Trunk Impairment Scale (TIS) and its subscales, Berg Balance Scale (BBS), Functional Ambulation Classification (FAC), and the Korean version of Modified Barthel Index (K-MBI). All outcome measures were assessed before the training and at the end of the 4-week training. RESULTS: After the 4-week intervention, TIS, BBS, FAC, and K-MBI scores showed improvement in both LDT and HDT groups. Furthermore, the improvements in TIS scores and its subscales were significantly greater in the HDT group than in the LDT group (p < 0.05). CONCLUSION: TCT using TSRRBT could be an additional treatment for the conventional rehabilitation therapy of chronic stroke patients with poor sitting balance. HDT may provide more beneficial effects on improving patients’ sitting balance than LDT.

Clinical and Biomechanical Effects of Low-Dye Taping and Figure-8 Modification of Low-Dye Taping in Patients With Heel Pad Atrophy

OBJECTIVE: To investigate and compare the effect of low-dye taping (LDT) and figure-8 modification of LDT (MLDT) on peak plantar pressure and heel pain in patients with heel pad atrophy. METHODS: There were reviewed 32 feet of 19 patients who have been diagnosed with heel pad atrophy who were enrolled in this study. The patients were diagnosed with heel pad atrophy with clinical findings, and loaded heel pad thickness measured by ultrasonography. At the first visit, patients were taught how to do LDT and MLDT. They were instructed to do daily living with barefoot, LDT and MLDT at least one time per day. Patients performed pedobarography with barefoot, LDT and MLDT within 2 weeks. The severity of heel pain was also checked with the visual analogue scale (VAS) during daily living with barefoot, LDT and MLDT. RESULTS: VAS of hindfoot were significantly decreased after LDT and MLDT (p < 0.01). Peak plantar pressure under hindfoot were also decreased after LDT and MLDT (p < 0.01). The effect of MLDT in decreasing peak plantar pressure of hindfoot (p < 0.01) and pain relief (p=0.001) was better than the effect of LDT. CONCLUSION: The LDT technique is clinically useful for pain management and reducing peak plantar pressure of hindfoot in patients with heel pad atrophy. MLDT is more effective than LDT in reducing peak plantar pressure and heel pain in patients with heel pad atrophy.

Relationship Between Functional Level and Muscle Thickness in Young Children With Cerebral Palsy

OBJECTIVE: To investigate the relationship between functional level and muscle thickness (MT) of the rectus femoris (RF) and the gastrocnemius (GCM) in young children with cerebral palsy (CP). METHODS: The study participants were comprised of 26 children (50 legs) with spastic CP, aged 3–6 years, and 25 age-matched children with typical development (TD, 50 legs). The MT of the RF, medial GCM, and lateral GCM was measured with ultrasound imaging. The functional level was evaluated using the Gross Motor Function Measurement-88 (GMFM-88), Gross Motor Function Classification System (GMFCS), and based on the mobility area of the Korean version of the Modified Barthel Index (K-MBI). The measurement of spasticity was evaluated with the Modified Ashworth Scale (MAS). RESULTS: We note that the height, weight, body mass index, and MT of the RF, and the medial and lateral GCM were significantly higher in the TD group (p < 0.05). There was a direct relationship between MT of the RF and medial GCM and the GMFM-88, GMFCS, and mobility scores of the K-MBI in individuals with early CP. In addition, we have noted that there was a direct relationship between MT of the lateral GCM and the GMFM-88 and GMFCS. Although there was a tendency toward lower MT with increasing MAS ratings in the knee and ankle, the correlation was not statistically significant. CONCLUSION: In young children with CP, MT of the RF and GCM was lower than in age-matched children with TD. Furthermore, it is noted with confidence that a significant positive correlation existed between MT and functional level as evaluated using the GMFM-88, GMFCS, and mobility area of K-MBI.

Upper Limb Pain and Paresthesia in a Post-Stroke Patient Treated with Ultrasound-Guided Electrical Twitch-Obtaining Intramuscular Stimulation (ETOIMS) of Scalene Muscles

In post-stroke patients, the pain or paresthesia of the affected limb is common. These symptoms may be caused by a variety of pathologic conditions. Considering the debilitating effects of the pain, it is important to determine the exact cause and manage appropriately. A 41-year-old woman who had experienced a hemorrhagic lesion in the right basal ganglia and corona radiata 4 months previously presented with an irritating tingling sensation in her left upper extremity. She failed to respond to a number of treatment options including medications and physical agent modalities. Following a diagnosis of disputed thoracic outlet syndrome (TOS) caused by scalene muscle dysfunctions, she received ultrasound-guided electrical twitch-obtaining intramuscular stimulation (ETOIMS) which significantly alleviated the pain. This case suggests that the disputed TOS should be considered as one of the possible causes of post-stroke pain, and that detailed history-taking and physical examination, as well as imaging or electrophysiological studies, might be required for accurate diagnosis. Furthermore, ultrasound-guided ETOIMS can be used as a safe and minimally invasive technique for the treatment of the disputed TOS with fewer systemic and local side effects.

Calcaneal Osteomyelitis due to Non-tuberculous Mycobacteria: A Case Report

Osteomyelitis is a bone infection caused by bacteria or other germs. Gram-positive cocci are the most common etiological organisms of calcaneal osteomyelitis; whereas, non-tuberculous mycobacteria (NTM) are rarely documented. We reported a case of NTM calcaneal osteomyelitis in a 51-year-old female patient. She had been previously treated in many local clinics with multiple local steroid injection over 50 times and extracorporeal shock-wave therapy over 20 times with the impression of plantar fasciitis for 3 years prior. Diagnostic workup revealed a calcaneal osteomyelitis and polymerase chain reaction assay on bone aspirate specimens confirmed the diagnosis of non-tuberculous mycobacterial osteomyelitis. The patient had a partial calcanectomy with antitubercular therapy. Six months after surgery, a follow-up magnetic resonance imaging showed localized chronic osteomyelitis with abscess formation. We continued anti-tubercular therapy without operation. At 18-month follow-up after surgery and comprehensive rehabilitation therapy, she was ambulating normally and able to carry out her daily activities without any discomfort.

Usefulness of Submental Ultrasonographic Evaluation for Dysphagia Patients

OBJECTIVE: To investigate the usefulness of ultrasonographic measurement of hyoid bone movement during swallowing. METHODS: Fifty-two patients who had swallowing dysfunction were enrolled in this study. When a patient swallowed 5 mL of water while maintaining an upright sitting position, hyoid bone movement during swallowing was measured with ultrasonography. Recorded images were analyzed to measure the maximum change in hyoid bone displacement. Mandible was used as reference point to calculate hyoid bone displacement. The farthest distance from resting position and the nearest distance during swallowing were measured and their differences were recorded. Participants also underwent videofluoroscopic swallowing study (VFSS). Based on penetration-aspiration scale (PAS), they were grouped to non-aspirators (PAS 1), penetrators (PAS 2-5), or aspirators (PAS 6-8). Measured hyoid bone displacements by submental ultrasonography were compared among groups. RESULTS: The mean hyoid bone displacement in non-aspirators group (n=21, 15.9±2.7 mm) was significantly (p<0.05) greater than that in penetrators group (n=20, 11.5±2.8 mm) or aspirators group (n=11, 8.0±1.0 mm). Hyoid bone displacement below 13.5 mm as a cutoff point for detecting penetration or aspiration had a sensitivity and specificity of 83.9% and 81.0%, respectively. CONCLUSION: Submental ultrasonographic evaluation was well correlated with PAS measured by VFSS. Therefore, submental ultrasonographic evaluation could be a useful screening tool for dysphagic patients.

Participation in Leisure Activity and Exercise of Chronic Stroke Survivors Using Community-Based Rehabilitation Services in Seongnam City

OBJECTIVE: To clarify how participation in leisure activities and exercise by chronic stroke survivors differs before and after a stroke. METHODS: Sixty chronic stroke survivors receiving community-based rehabilitation services from a health center in Seongnam City were recruited. They completed a questionnaire survey regarding their demographic characteristics and accompanying diseases, and on the status of their leisure activities and exercise. In addition, their level of function (Korean version of Modified Barthel Index score), risk of depression (Beck Depression Inventory), and quality of life (SF-8) were measured. RESULTS: After their stroke, most of the respondents had not returned to their pre-stroke levels of leisure activity participation. The reported number of leisure activities declined from a mean of 3.9 activities before stroke to 1.9 activities post-stroke. In addition, many participants became home-bound, sedentary, and non-social after their stroke. The most common barriers to participation in leisure activities were weakness and poor balance, lack of transportation, and cost. The respondents reported a mean daily time spent on exercise of 2.6+/-1.3 hours. Pain was the most common barrier to exercise participation. CONCLUSION: Chronic stroke survivors need information on leisure activities and appropriate pain management.

The Relationships Between Determination of Treatment Success and Emotional Factors in Patients With Chronic Musculoskeletal Pain

OBJECTIVE: To investigate the relationship of the patient's criteria of successful treatment to emotional factors in patients with chronic musculoskeletal pain. METHODS: Patients who visited our outpatient hospital due to chronic musculoskeletal pain were evaluated using a questionnaire survey. Patients were evaluated with the Patient-Centered Outcomes Questionnaire (PCOQ) to investigate their expectation and criteria for success regarding treatment of chronic musculoskeletal pain. Beck Depression Inventory and State-Trait Anxiety Inventory were used to check for psychological variables. Correlations among each of the variables were evaluated statistically. RESULTS: Patients with higher levels of depression and anxiety needed larger improvements to consider the treatment as a success in the pain domain (depression, r=0.398, p=0.04; anxiety, r=0.447, p=0.02) and emotional distress domain (depression, r=0.617, p=0.001; anxiety, r=0.415, p=0.03), but had lower level of expectation of the treatment in the pain domain (depression, r=-0.427, p=0.01; anxiety, r=-0.441, p=0.004), emotional distress domain (depression, r=-0.454, p=0.01; anxiety, r=-0.395, p=0.04), and interference of daily activities domain (depression, r=-0.474, p=0.01; anxiety, r=-0.396, p=0.04). Patients were classified into 3 clusters based on the importance rating of each domain via a hierarchical analysis. The cluster of the patients with the higher rating of importance across all domains (importance of pain domain, 9.54; fatigue domain, 9.08; emotional distress domain, 9.23; interference of daily activities domain, 9.23) had the highest level of depression and anxiety. CONCLUSION: Consideration of psychological factors, especially in patients who require larger improvements in all treatment domains, may be helpful for the successful treatment of chronic musculoskeletal pain.

Reliability of Single Leg Balance Test Using Posturography / 대한스포츠의학회지

Posturographic examination is commonly used by clinicians to evaluate standing balance. Because it is perfomed with double leg standing, it cannot sensitively detect the minor balance problem like functional ankle instability. This study aims to evaluate the test retest reliability of the single leg balance test using Tetrax posturography and its correlation with modified star excursion balance test (mSEBT). 30 healthy participants (16 male, 14 female, mean age 26.3+/-3.3) were volunteered for this study. We manufactured a specially designed wood plate to assess their single leg standing balance. It was set on each of the 4 force plates of Tetrax posturography (Sunlight Medical Ltd., Ramat Gan, Israel). Stability index were measured based on each single leg stance. Participants performed the single leg balance test on Tetrax posturography in three different times, and they also performed the mSEBT. The test retest reliability of stability index measured by Tetrax posturography was assessed by the intraclass correlation coefficient, and its correlation with the normalized composite distance of mSEBT was assessed by Pearson correlation coefficient. The single leg balance test using Tetrax posturography showed good test retest reliability. There was a negative correlation between the stability index of Tetrax posturography and the normalized composite distance of mSEBT, based on right and left leg stance, respectively. These findings suggest that Tetrax posturography is a useful and reliable tool for single leg balance assessment.

Neuropsychological and Psychiatric Impairment after West Nile Virus Encephalitis in Korean: A Case Report

West Nile virus (WNV) is the most widespread arbovirus in the world. It can cause serious or fatal central nervous system (CNS) infection. We present a case of 58-year-old man who developed neuropsychologic and psychiatric impairment such as cognitive impairment, depressive symptoms, health concerns and thought disorder after West Nile virus encephalitis. This is the first imported case of West Nile virus infection in Korean.

Motor Axonal Neuropathy Associated With Idiopathic CD4+ T-Lymphocytopenia

Idiopathic CD4+ T-lymphocytopenia is a rare immune disorder characterized by an unexplained deficit of CD4+ T cells and results in various opportunistic infections. Herein, we report a case of new onset weakness in a 10-year-old boy secondary to motor axonal neuropathy associated with idiopathic CD4+ T-lymphocytopenia. The patient was referred to rehabilitation for an evaluation of progressive weakness involving all four limbs. A subsequent nerve conduction study and needle electromyography identified motor axonal neuropathy. At that time, laboratory studies specific to the differential diagnosis of motor axonal neuropathy were performed; however, the abnormality noted was a decreased CD4+ T-lymphocyte count. Motor axonal neuropathy represents an uncommon manifestation of idiopathic CD4+ T-lymphocytopenia and is probably associated with an underlying immune process.

Contributing Factors Analysis for the Changes of the Gross Motor Function in Children With Spastic Cerebral Palsy After Physical Therapy

OBJECTIVE: To investigate the factors which contribute to the improvements of the gross motor function in children with spastic cerebral palsy after physical therapy. METHODS: The subjects were 45 children with spastic cerebral palsy with no previous botulinum toxin injection or operation history within 6 months. They consisted of 24 males (53.3%) and 21 females (46.7%), and the age of the subjects ranged from 2 to 6 years, with the mean age being 41+/-18 months. The gross motor function was evaluated by Gross Motor Function Measure (GMFM)-88 at the time of admission and discharge, and then, the subtractions were correlated with associated factors. RESULTS: The GMFM-88 was increased by 7.17+/-3.10 through 52+/-16 days of physical therapy. The more days of admission, the more improvements of GMFM-88 were attained. The children with initial GMFM-88 values in the middle range showed more improvements in GMFM-88 (p<0.05). The children without dysphagia and children with less spasticity of lower extremities also showed more improvements in GMFM-88 (p<0.05). CONCLUSION: We can predict the improvements of the gross motor function after physical therapy according to the days of admission, initial GMFM-88, dysphagia, and spasticity of lower extremities. Further controlled studies including larger group are necessary.

Femoral Neuropathy and Meralgia Paresthetica Secondary to an Iliacus Hematoma

Compressive femoral and lateral femoral cutaneous neuropathies from an iliacus hematoma are unusual presentation. We report a case of a 16-year-old boy who developed right femoral and lateral femoral cutaneous neuropathies as a complication of traumatic ipsilateral iliacus hematoma formation. The patient complained of numbness in the right thigh and calf as well as right leg weakness, and pain in the right inguinal area. Nerve conduction study and needle electromyography identified the neuropathies. After the electrodiagnostic studies, the pelvic bone MRI revealed a large, 9x5x4.5 cm right iliacus hematoma. As a result, diagnosis of a right iliacus hematoma compressing the femoral and lateral femoral cutaneous nerves was made, and the patient underwent an operation to remove the hematoma. Symptoms and neurological signs showed notable improvement after surgical decompression. Subsequent follow-up electrodiagnostic studies after 11 weeks demonstrated regeneration evidence.

Reliability of the Supraspinatus Muscle Thickness Measurement by Ultrasonography

OBJECTIVE: To assess the intrarater and interrater reliability of the supraspinatus thickness measured by ultrasonography (US) in normal subjects and to identify the relationship between the supraspinatus thickness measured by US and cross sectional area (CSA) of the supraspinatus muscle by magnetic resonance imaging (MRI) in hemiplegic patients. METHOD: We examined 20 shoulders of normal subjects and 10 shoulders of hemiplegic patients. In normal subjects, one examiner measured the supraspinatus thickness twice by US at the scapular notch and another examiner measured the supraspinatus thickness several days later. The intrarater and interrater reliability of supraspinatus thickness measurements were then evaluated. In hemiplegic patients, the supraspinatus thickness at the scapular notch was measured by US in affected side and compared with CSA of the supraspinatus muscle at the scapular notch and the Y-view of MRI. RESULTS: One examiner's supraspinatus thickness measurement average was 1.72+/-0.21 cm and 1.74+/-0.24 cm, and the other examiner's supraspinatus thickness measurement average was 1.74+/-0.22 cm in normal subjects. Intraclass correlation coefficients of intrarater and interrater examination were 0.91 and 0.88, respectively. For hemiplegic patients, the supraspinatus thickness measured by US was 1.66+/-0.13 cm and CSA by MRI was 4.83+/-0.88 cm2 at the Y-view and 5.61+/-1.19 cm2 at the scapular notch. The Pearson Correlation Coefficient between the supraspinatus thickness at the scapular notch and the CSA at the Y-view was 0.72 and that between the supraspinatus thickness and CSA at the scapular notch was 0.76. CONCLUSION: The supraspinatus thickness measurement by US is a reliable method and is positively correlated with the CSA of the supraspinatus muscle in MRI in hemiplegic patients. Therefore, supraspinatus thickness measurement by US can be used in the evaluation of muscle atrophy and to determine therapeutic effects in hemiplegic patients.

Factors that Influence Quiet Standing Balance of Patients with Incomplete Cervical Spinal Cord Injuries

OBJECTIVE: To investigate the factors influencing the quiet standing balance of patients with incomplete cervical spinal cord injuries. Also to find the correlations between posturographic parameters and clinical balance tests as well as to find the correlation between posturographic parameters and functional independence. METHOD: We conducted a tetra-ataxiometric posturography, lower extremity motor score (LEMS), Korean version of the Berg Balance Scale (K-BBS), Timed Up and Go test (TUG), and Korean Version of the Modified Barthel Index (K-MBI) of 10 patients. 10 healthy adults carried out the posturography. We checked stability, weight distribution, Fourier and synchronization indices of eight positions, and the fall index of the posturography. RESULTS: The patient group showed significantly higher stability and weight distribution indices in all eight positions. Stability indices significantly increased with eyes closed or standing on pillows. Weight distribution indices were significantly higher with eyes closed or the head bent backwards. The patient group showed significantly higher Fourier indices of low, low-medium, and high frequency in eight positions. The Fourier indices at high-medium frequency were significantly higher with eyes closed on pillows or in variable head positions. There were no significant differences of synchronization indices between the patient and the control group. The falling index of the patient group significantly correlated with K-BBS, TUG, and K-MBI. LEMS had significant correlation with some synchronization indices, but not with the falling index. CONCLUSION: The quiet standing balance of the patients was influenced by somatosensory limitations or insufficient visual compensation. We should try to improve the postural balance and functional independence of patients through proper proprioceptive and lower extremity strength training for better postural and pedal control, and to make efforts to minimize environmental hazards.

Nutritional Status of Children with Cerebral Palsy

OBJECTIVE: To determine the nutritional status of children with cerebral palsy (CP) and to compare their anthropometric and functional indices. METHOD: Seventy children with cerebral palsy, were at class I (12), II (17), III (18), IV (9) and V (14) on Gross Motor Function Classification System (GMFCS). They varied by age from 25 to 130 months with a mean of 48 months, and consisted of spastic diplegic cerebral palsy (30), quadriplegia (28), triplegia (3), hemiplegia (4), athetoid (4) and hypotonia (1). Evaluation of weight, height, subcutaneous fat thickness, brachial circumference, Body Mass Index (BMI), level of albumin, lymphocyte and blood ferritn were conducted. To identify the factors affecting nutritional status, dietary status and symptoms of dysphagia were investigated. RESULTS: Low BMI percentile was in 23 children (32.9%) and obese condition in 3 children (4.3%). Low BMI percentile tends to frequently observed in groups III, IV, V of GMFCS. BMI percentile with subcutaneous fat thickness, Gross Motor Function Measure (GMFM) score were significantly related (p<0.05). Seen from the symptom of dysphagia, low BMI percentile was correlated with decreased tongue motion (p<0.05). CONCLUSION: Cerebral palsy children with lower GMFM score, decreased tongue motion were significantly related with low BMI percentile. Subcutaneous fat thickness can be useful tool for evaluation of malnutrition of cerebral palsy children.

The Effects of Modified Low-Dye Taping in the Patient with Heel Pad Atrophy

OBJECTIVE: To evaluate whether the change of heel pad thickness improves the pain after Modified Low-Dye Taping (MLDT) in the patient with heel pad atrophy. METHOD: Thirty-five feet of 20 volunteers with heel pad atrophy were selected for the measurement of heel-pad thickness and compressibility index (CI) of the center of calcaneus bone using ultrasound. The subjects were laid in prone with the knees flexed to 90degrees, and an electronic body weight scale was inserted beneath the anterior surface of their knees to take measurements of both UHPT (unloaded heel pad thickness) and LHPT (6 kg-loaded heel pad thickness), which were repeated 3 times respectively. CI was calculated base on LHPT divided by UHPT. After MLDT, the same method was repeated. visual analogue scale (VAS) score was checked at first visit and followed up at second visit. RESULTS: Prior to MLDT, the average value of UHPT (cm), LHPT (cm) and CI value was 0.92+/-0.11, 0.25+/-0.06 and 0.27+/-0.04 respectively. After MLDT, the average was 1.24+/-0.17 for UHPT (cm) and 0.42+/-0.11, for LHPT (cm) while CI stood at 0.33+/-0.06. VAS before MLDT was 7.35+/-1.27 and after MLDT was 3.50+/-1.36, which presented 54% of decrease than initial. CONCLUSION: It was confirmed that the average values of the heel-pad thickness, CI and VAS of patients with heel pad atrophy were improved for MLDT. Accordingly it is considered that application of MLDT is an efficacious treatment and thus further study is needed to develop foot orthoses for heel pad atrophy using the principle of MLDT.