Effects of Bilateral Transcutaneous Tibial Nerve Stimulation on Neurogenic Detrusor Overactivity in Spinal Cord Injury: A Urodynamic Study.

OBJECTIVE: To study the short-term effect of bilateral transcutaneous tibial nerve stimulation (TTNS) on urodynamic study (UDM) parameters in spinal cord injury (SCI) patients with neurogenic detrusor overactivity (NDO). DESIGN: Single-blinded sham-controlled study. SETTING: Rehabilitation center. PARTICIPANTS: SCI patients with NDO (N=17) were recruited. Fifteen patients (mean age, 40±18y) completed the study. Most of the patients had chronic incomplete SCI. INTERVENTIONS: UDM was performed 3 times. The first UDM was performed after taking anticholinergics for 1 hour to assess the effects of medication. After stopping anticholinergics for a 5 half-lives, the second UDM was performed immediately after a 20-minute sham TTNS (switch on for 30s at the beginning, switch off for 20min, and switch on for 30s before stopping). The third UDM was performed immediately after a 20-minute bilateral TTNS. MAIN OUTCOME MEASURES: Reflex volume (mL), cystometric capacity (mL), maximum pressure detrusor (mmH2O), and bladder compliance (mL/mmH2O). RESULTS: UDM tracings were interpreted by 2 blinded assessors. This study used per-protocol analysis and repeated measures Analysis of variance with Bonferroni post hoc analysis. When compared with sham stimulation, bilateral TTNS and anticholinergics produced greater increases in reflex volume (136.1±99.88, 212.2±112.82, and 226.3±111.52 mL; P<.001), cystometric capacity (218.3±137.66, 319.1±143.74, and 350.7±163.43 mL; P<.001), and compliance (5.8±6.81, 7.9±6.74, 9.7±8.12 mL/cmH2O; P=.02). No significant differences were found in reflex volume, cystometric capacity, or compliance between bilateral TTNS and anticholinergics (P>.05). The maximum pressure detrusor was not significantly different between groups (P>.05). CONCLUSION: Bilateral TTNS may be an effective short-term intervention to improve UDM parameters in SCI with NDO. Further study is necessary to determine the long-term effects and benefits of combined bilateral TTNS with anticholinergics.

Ultrasound-Guided Physiological Saline Injection for Patients with Myofascial Pain.

BACKGROUND: Based on the histological confirmation of the presence of nerve structure in the fascia, hence, myofascial pain was treated by the mechanism referred to as interfascial block. To date, the studies of physiological saline for treating patients with myofascial pain has been limited. Ultrasound (US) guided with physiological saline injection (PSI) technique has been routinely practiced among patients with myofascial pain in outpatient service at the Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital. The main objective of this present study is to find the overview data including the percentage of patients responding, acceptable pain period, and adverse events. MATERIALS AND METHODS: Electronic medical reports among 142 patients receiving US-guided PSI from August 1, 2016, to November 20, 2017, at the Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital, were retrospectively reviewed by the first author. Procedures were performed by the last author. The analysis was independently performed by the first author. RESULTS: One hundred and forty-two patients with complete medical records were compatible with analysis. The average age of patients was 55 years. Most of the patients were female (68.3%). Most of the patients (76.8%) had chronic suffering from myofascial pain. Approximately half of the patients (56.4%) are currently received pain-relieving medications. Upper trapezius muscle (19.5%) was the most common muscle receiving the procedure, followed by multifidus (10.0%) and quadratus lumborum (9.5%). Most of the patients (86.8%) received the procedure one muscle. Approximately 30% of the patients were able to stop pain-relieving medications after the procedure. The median of acceptable pain period was 63 days. The percentage of patients having an acceptable pain period >3 months was 43.9%. No major adverse events were demonstrated. CONCLUSION: US-guided PSI technique demonstrated pain reduction in 72.8% of the analyzed patients, with an acceptable pain period of 63 days. No major adverse events were demonstrated among all the patients. This technique should be considered as another invasive procedure for eradication myofascial trigger point.

Comparison of the effectiveness between generic and original form of gabapentin for pain relief in suspected neuropathic component of low back pain.

OBJECTIVE: To compare effectiveness of the generic form of gabapentin with its original form. MATERIAL AND METHOD: A single-blind evaluation randomized controlled trial (RCT) of patients that were diagnosed with low back pain with suspected neuropathic component at the Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital were included in the present study. Patients were randomized into two treatment groups. The first group received gabapentin generic form (GGF) or Gabapentin Sandoz, whereas the other received gabapentin original form (GOF) or Neurontin. The primary endpoint was the VisualAnalogue Scale (VAS) pain score. The secondary endpoints were the Thai version of the Oswestry low back pain disability index (ODI) score, lumbar spine's range ofmotion, safety profiles, and average medical cost. Non-inferiority was pre-specified at 20%. The amount of medication was increased to maintain VAS less than 40 mm and tapered off in case of adverse event. RESULTS: Forty-one patients, GGF 21 and GOF 20, had completed the study. At 8th week, the visual analogue scale (VAS) and ODI scores significantly decreased in both groups. Mean and standard deviation (SD) of VAS improvement were 31.4+/- 22.1 mm for the GGF group versus 34.3 +/- 22.6 mm for the GOF group (p = 0.69), within pre-specified 20% non-inferiority margin (difference 2.9 mm 95% CI-17.7 mm, 11.8 mm). Mean ODI improvement was 1.1% for the GGF group versus 7.6%for the GOF group (p = 0.42), within pre-specified 20% non-inferiority margin, (difference 3.5, 95% CI = -12.3%, 5.3%). Both groups have significantly gainedflexion of the lumbar spine. Both groups revealed similar safety profiles. The GGF group showed significantly lower average cost for medications (2,844 baht). CONCLUSION: In comparison with the GOF (Neurontin) group, the non-inferior effectiveness for pain reduction and improvement of back function has been revealed in the GGF (Gabapentin Sandoz) group. Similar safety profiles were demonstrated in both groups. The average medication cost of GGF is much lower than GOF (4.67 times).

Knowledge and acceptance of Thai women toward the pelvic floor muscle training.

BACKGROUND: Pelvic floor muscle training (PFMT) is considered as an effective management for relieving pelvic organ prolapse (POP) and urinary incontinence (UI). Although the benefits of PFMT are known among the health care professionals, the benefits from PFMT among the Thai women are not known. OBJECTIVE: To evaluate the basic knowledge and acceptance of PFMT in women who visited the gynecologic out-patient clinic. MATERIAL AND METHOD: A cross-sectional survey was conducted by administering a brief anonymous 2-part questionnaire to 415 women who visited the gynecologic out-patient clinic at King Chulalongkorn Memorial Hospital between November 2010 and January 2011. A questionnaire, consisting of 24 questions, was divided into two parts where part one, made up of 10 questions, collected demographic data and the remaining 14 questions in part 2 gathered more information about the knowledge and acceptance towards PFMT. These questionnaires required approximately five minutes for completion. RESULTS: Mean age of all women was 42.9 years. The percentage of patients having stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed urinary incontinence (MUI) were 21.9%, 5.3%, and 15.2%, respectively. Overactive bladder (OAB) and pelvic organ prolapse (POP) were found in 19.5% and 9.9%, respectively. Half of the respondents were unaware of PFMT efficacy. Most of them (80.2%) never received instruction from their health care providers. However 52.8% of women expressed interest for requesting PFMT instruction while 84.6% were willing to practice if they were made aware of benefits. CONCLUSION: A limited understanding and acceptance of PFMT exists among Thai women. However if informed, most women express interest in practicing PFMT after clinic visit.

Rectal balloon training as an adjunctive method for pelvic floor muscle training in conservative management of stress urinary incontinence: a pilot study.

BACKGROUND: Pelvic floor muscle training (PFMT) is currently considered as the first line conservative management for women with stress urinary incontinence (SUI). However, it is difficult for some women to self-identify the contraction of the pelvic floor muscle after they were trained by verbal instruction. Various techniques including rectal balloon probe have been developed to improve PFMT. OBJECTIVE: To compare vaginal squeezing pressure, one-hour pad test, leakage episodes, rating scores about severity of SUI, and patient satisfaction between traditional PFMT and rectal balloon training (RBT). MATERIAL AND METHOD: Twenty-eight patients with SUI were randomized into two groups, PFMT, and RBT groups. The PFMT group was verbally instructed to perform exercise as the traditional technique. In the RBT group, a Foley catheter filled with tap water to create balloon was inserted into the rectum in combination with the same exercise as in the PFMT group. The vaginal squeezing pressure before and after 6-week exercise program was measured by biofeedback machine model MYO420. RESULTS: One patient in each group was lost to follow-up. This left 13 patients in each group. Both groups had statistically significant gained in vaginal squeezing pressure after exercise. The different pressure between pre and post exercise were 9.9 mmHg and 9.2 mmHg in PFMT and RBT group respectively (p = 0.84). Significant improvement of leakage episodes and self-rating scores assessed the severity of SUI after exercise was reported in both groups, although there was no significant difference between both groups. The number of patients wearing protection after exercise was lowered in both groups, which were 75% in PFMT group and 80% in RBT group. However satisfaction was greater after completing exercise in both groups. CONCLUSION: PFMT is an effective conservative treatment of SUI. PFMT combined with rectal balloon training did not provide greater strength of the pelvic floor muscle than isometric contraction.

Foot disorders and falls in older persons.

BACKGROUND: Fall rates are high among older people even in the healthy population. An aging foot may affect ambulatory function and increase the risk of fall(s). OBJECTIVE: To study foot musculoskeletal disorders, falls and associated factors in healthy elderly subjects. METHODS: Healthy volunteers aged 60-80 years who were independent in self-care and walking were recruited from urban Bangkok. Trained physicians evaluated health status, foot problems, and fall(s) history of all subjects. Walking performance was assessed using the 'Timed Get Up & Go' test and 6-m walking speed. Footprints were taken from the standing position. Foot dimensions and footwear were also measured by certified orthotists. Associated factors of foot disorders and falls were analyzed. RESULTS: There were 213 subjects: 108 men, 105 women with a mean age of 68.6 +/- 5.4 years. Foot deformities presented in 87% and were not significantly associated with walking performance or falls. Foot pain was found in 14% with a male:female sex ratio of 1:4. The causes of pain were plantar fasciitis, hallux valgus, callus, metatarsalgia, and inappropriate footwear. Subjects with foot pain had slower walking speed (1.14 +/- 0.12 vs. 1.19 +/- 0.12 m/s, p = 0.056). Falls were reported in 29.5% of women and 12.9% of men (p = 0.004). Multivariate analyses demonstrated that fall risk factors were female gender (OR = 2.4, 95% CI = 1.13-5.12), plantar fasciitis (OR = 6.8, 95% CI = 1.52-31.02), and knee osteoarthritis (OR = 3.6, 95% CI = 1.71-7.59). Subgroup analyses revealed that visual deficit was associated with falls in women (OR = 4.7, 95% CI = 1.75-12.73), and impaired foot protective sensation was associated with falls in men (OR = 5.1, 95% CI = 1.46-18.38). CONCLUSIONS: Aging foot deformities presented different characteristics among genders and were mostly asymptomatic. Foot pain, especially from plantar fasciitis, increased risk of falls in healthy older persons. Foot assessment, foot pain management, and proper footwear play important roles in fall prevention.

Common foot problems in diabetic foot clinic.

OBJECTIVE: To study common foot problems presented in diabetic foot clinic. MATERIAL AND METHOD: A retrospectively review of out patient department records and diabetic foot evaluation forms of patients who visited the diabetic foot clinic at King Chulalongkorn Memorial Hospital between 2004 and 2006. RESULTS: Of all diabetic patients, 70 men and 80 women with the average age of 63.8 years were included in this study. About 32% of all reported cases had lower extremity amputation in which the toe was the most common level. Foot problems were evaluated and categorized in four aspects, dermatological, neurological, musculoskeletal, and vascular, which were 67.30%, 79.3%, 74.0%, and 39.3% respectively. More than half of the patients had skin dryness, nail problem and callus formation. Fifty six percent had the abnormal plantar pressure area, which was presented as callus. The great toe was the most common site of callus formation, which was correlated with gait cycle. The current ulcer was 18.8%, which was presented mostly at heel and great toe. Three-fourth of the patients (75.3%) had lost protective sensation, measured by the 5.07 monofilament testing. The most common problem found in musculoskeletal system was limited motion of the joint (44.0%). Claw toe or hammer toe were reported as 32.0% whereas the other deformities were bunnion (12.0%), charcot joint (6.0%) and flat feet (5.3%). The authors classified patients based on category risk to further lower extremity amputation into four groups. Forty-seven percent had highest risk for having further amputation because they had lost protective sensation from monofilament testing, previous current ulcer, or history of amputation. Only half of the patients had previous foot care education. CONCLUSION: Multidisciplinary diabetic foot care including patient education (proper foot care and footwear), early detection, effective management of foot problems, and scheduled follow-up must be emphasized to prevent diabetes-related lower extremities amputation.

Proper shoe sizes for Thai elderly.

BACKGROUND: Problems from improper shoe fitting are common, but there are limited foot data for the older Thai population. OBJECTIVES: To study foot dimensions and determine proper shoe sizes for Thai elderly. METHODS: Healthy older people: 108 men, 105 women, aged 60-80 years, who were independent in walking, were recruited. Thirteen foot dimensions and current shoes used were measured. Side-to-side, gender difference, and correlations of main foot measurements were analyzed. RESULTS: About 50% women and 34% men wore too narrow shoes, and this was found to be associated with foot pain. At the same foot length (FL), men had larger foot width (FW) and toe depth. Foot width=2.39+(0.29 x FL), r=0.50, p=0.001 for women and=2.48+(0.31 x FL), r=0.56, p=0.002 for men. Arch length=1.0+(0.7 x FL), r=0.93, p=0.001 for both genders. Toe depth had constant values in all shoe sizes of each gender. Correlations of other foot parameters were reported. CONCLUSIONS: These anthropometric data is essential for proper shoe fitting in order to provide foot ergonomics and prevent foot problems for older Thai people.

Uropathogens and empiric antibiotics for the treatment of urinary tract infections in spinal cord injured patients at rehabilitation center, Thai Red Cross Society during 2001 to 2005.

BACKGROUND: Urinary tract infection (UTI) is common in spinal cord injured patients. The authors investigated the epidemiology of bacteria associated with UTI to select an appropriate antibiotic for empirical treatment of UTI before obtaining a bacterial culture. OBJECTIVE: To determine the prevalence, as well as the causative bacteria and their susceptibility pattern of urinary tract infection in spinal cord injured patients hospitalized to the Rehabilitation Center, Thai Red Cross Society, Samutprakarn, Thailand from January 2001 to December 2005. MATERIAL AND METHOD: A retrospective chart review of 76 spinal cord injured patients. RESULTS: Of all spinal cord injured patients, there were 50 males and 26 females, with the average age of 44.70 years. The average length of hospitalization was 104.5 days. 71.2% of the patients needed intermittent catheterization for bladder drainage, and only 2.7% had suprapubic cystostomy. None of patient had indwelling catheterization. Forty-six patients had 68 episodes of UTI (60.52%). Eighteen patients had recurrent UTI (14 patients had two episodes and four patients had three episodes). E. coli was the most common isolated pathogen (74.36%) followed by K. pneumoniae (12.82%), E. faecalis (5%) and P. mirabilis (5%). Most gram-negative pathogens were susceptible to amikacin and third generation cephalosporins. The susceptibility of these organisms to cotrimoxazole, amoxicillin/clavulanate, and ciprofloxacin were in the range of 34.6-60.0%, 44.0-50.0% and 25.9-50.0%, respectively. CONCLUSION: Urinary tract infections were commonly observed among spinal cord injured patients in the presented institution. E. coli was the most common isolated pathogen. Surprisingly, most gram-negative pathogens were resistant to cotrimoxazole, amoxicillin/clavulanate, and ciprofloxacin. An antibiotic of choice for UTI in our patients should be aminoglycoside or third generation cephalosporins.

Reliability of foot caliper.

OBJECTIVES: To determine the reliability of foot caliper DESIGN: Descriptive study. SETTING: Rehabilitation Medicine Outpatient Department, King Chulalongkorn Memorial Hospital. SUBJECT: Fifteen volunteers were recruited from Rehabilitation residents and health care professionals of Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital. MATERIAL AND METHOD: The authors created 3 sets of simple Foot Caliper and measured foot dimension including foot width, foot length and toe depth while subjects stood with equal weight bearing to both feet. The authors set 3 examiners to measure foot dimension by the same method. To determine reliability of 3 sets of foot caliper, one examiner was assigned to measure foot dimension of 30 feet with all calipers. To determine the reliability of examiners, all examiners measured foot dimension of the same 30 feet. All parameters were recorded in millimeters. The data was analyzed and presented as intraclass correlation coefficients (ICC) with 95% CI. RESULTS: There were fifteen volunteers (8 men and 7 women). The average age was 28.6 +/- 4.11 years (range 22-39). Average foot width,length and great toe depth (millimeters) were 9.64 +/- 0.63, 24.17 +/- 1.10 and 1.91 +/- 0.24 respectively. For reliability analysis of 3 sets off foot caliper, the intraclass correlation coefficients (ICC) with 95% CI were 0.985 (0.972-0.992), 0.996 (0.992-0.998) and 0.982 (0.968-991) for foot width, length and great toe depth, respectively. For Inter-examiner reliability, intraclass correlation coefficients (ICC) were 0.941 (0.864-0.969), 0.850 (0.46-0.920) and 0.834 (0.721-0.910) for foot width, length and great toe depth, respectively. These results showed high agreement of data. CONCLUSION: These simple foot calipers have high reliability forf oot measurement. These devices are appropriate for clinical use.