Reference Standards for Nerve Conduction Studies of Individual Nerves of Lower Extremity With Expanded Uncertainty in Healthy Korean Adults

Objective@#To develop a set of reference standards for tibial motor, common peroneal motor, sural sensory, and superficial peroneal sensory nerve conduction studies (NCSs) with expanded uncertainty in a healthy Korean population. @*Methods@#Standardized procedures were conducted for individual lower extremity NCSs of 199 healthy participants in their 20s (n=100) and 50s (n=99). Mean values and expanded uncertainties for parameters were analyzed with thorough consideration of multiple uncertainty factors under the International Guide to the Expression of Uncertainty in Measurement. In addition, side-to-side differences in onset latency, amplitude, and nerve conduction velocity (NCV) were analyzed. @*Results@#Mean (reference range) for distal onset latency, baseline to negative peak amplitude, NCV of tibial motor nerve in males in their 20s were 4.3 ms (3.1–5.4 ms), 7.1 mV (3.4–10.9 mV), and 50.7 m/s (42.2–59.3 m/s), respectively; sural sensory nerve baseline to negative peak amplitude in males in their 20s was 21.7 μV (8.3–35.2 μV). Including the aforementioned data, we present a vast dataset of normative mean values and expanded uncertainties for NCSs of the leg in a healthy Korean population. Furthermore, upper limits for normal side-to-side differences for onset latency, amplitude, and NCV of each nerve are suggested. @*Conclusion@#To our knowledge, this is the first study to present the reference standards of leg NCSs with consideration for multifactorial uncertainties in an Asian population. We expect these results to help practitioners make reliable and reproducible clinical decisions.

Mesenchymal Stem Cells Use in the Treatment of Tendon Disorders: A Systematic Review and Meta-Analysis of Prospective Clinical Studies

Objective@#To evaluate the efficacy and safety of mesenchymal stem cells (MSCs) therapy in patients with tendon disorders enrolled in prospective clinical studies. @*Methods@#We systematically searched prospective clinical studies that investigated the effects of MSC administration on human tendon disorders with at least a 6-month follow-up period in the PubMed-MEDLINE, EMBASE, and Cochrane Library databases. The primary outcome of interest was the change in pain on motion related to tendon disorders. Meta-regression analyses were performed to assess the relationship between MSC dose and pooled effect sizes in each cell dose. @*Results@#Four prospective clinical trials that investigated the effect of MSCs on tendon disorders were retrieved. MSCs showed a significant pooled effect size (overall Hedges’ g pooled standardized mean difference=1.868; 95% confidence interval, 1.274–2.462; p<0.001). The treatment with MSCs improved all the aspects analyzed, namely pain, functional scores, radiological parameters (magnetic resonance image or ultrasonography), and arthroscopic findings. In the meta-regression analysis, a significant cell dose-dependent response in pain relief (Q=9.06, p=0.029) was observed. @*Conclusion@#Our meta-analysis revealed that MSC therapy may improve pain, function, radiological, and arthroscopic parameters in patients with tendon disorders. A strong need for large-scale randomized controlled trials has emerged to confirm the long-term functional improvement and adverse effects of MSC therapies in tendon disorders.

Mesenchymal Stem Cells Use in the Treatment of Tendon Disorders: A Systematic Review and Meta-Analysis of Prospective Clinical Studies

Objective@#To evaluate the efficacy and safety of mesenchymal stem cells (MSCs) therapy in patients with tendon disorders enrolled in prospective clinical studies. @*Methods@#We systematically searched prospective clinical studies that investigated the effects of MSC administration on human tendon disorders with at least a 6-month follow-up period in the PubMed-MEDLINE, EMBASE, and Cochrane Library databases. The primary outcome of interest was the change in pain on motion related to tendon disorders. Meta-regression analyses were performed to assess the relationship between MSC dose and pooled effect sizes in each cell dose. @*Results@#Four prospective clinical trials that investigated the effect of MSCs on tendon disorders were retrieved. MSCs showed a significant pooled effect size (overall Hedges’ g pooled standardized mean difference=1.868; 95% confidence interval, 1.274–2.462; p<0.001). The treatment with MSCs improved all the aspects analyzed, namely pain, functional scores, radiological parameters (magnetic resonance image or ultrasonography), and arthroscopic findings. In the meta-regression analysis, a significant cell dose-dependent response in pain relief (Q=9.06, p=0.029) was observed. @*Conclusion@#Our meta-analysis revealed that MSC therapy may improve pain, function, radiological, and arthroscopic parameters in patients with tendon disorders. A strong need for large-scale randomized controlled trials has emerged to confirm the long-term functional improvement and adverse effects of MSC therapies in tendon disorders.

Recovery of Proprioception in the Upper Extremity by Robotic Mirror Therapy: a Clinical Pilot Study for Proof of Concept

A novel robotic mirror therapy system was recently developed to provide proprioceptive stimulus to the hemiplegic arm during a mirror therapy. Validation of the robotic mirror therapy system was performed to confirm its synchronicity prior to the clinical study. The mean error angle range between the intact arm and the robot was 1.97 to 4.59 degrees. A 56-year-old male who had right middle cerebral artery infarction 11 months ago received the robotic mirror therapy for ten 30-minute sessions during 2 weeks. Clinical evaluation and functional magnetic resonance imaging (fMRI) studies were performed before and after the intervention. At the follow-up evaluation, the thumb finding test score improved from 2 to 1 for eye level and from 3 to 1 for overhead level. The Albert's test score on the left side improved from 6 to 11. Improvements were sustained at 2-month follow-up. The fMRI during the passive motion revealed a considerable increase in brain activity at the lower part of the right superior parietal lobule, suggesting the possibility of proprioception enhancement. The robotic mirror therapy system may serve as a useful treatment method for patients with supratentorial stroke to facilitate recovery of proprioceptive deficit and hemineglect.

Clinical Outcomes of Conservative Treatment and Arthroscopic Repair of Rotator Cuff Tears: A Retrospective Observational Study

OBJECTIVE: To compare the clinical outcomes following conservative treatment and arthroscopic repair in patients with a rotator cuff tear. METHODS: In this retrospective study, patients aged >50 years with a symptomatic rotator cuff tear were reviewed. The rotator cuff tendons were evaluated using ultrasonography, shoulder magnetic resonance imaging or MR arthrography, and the patients with either a high-grade partial-thickness or small-to-medium-sized (≤3 cm) full-thickness tear were included in this study. The primary outcome measures were a pain assessment score and range of motion (ROM) at 1-year follow-up. The secondary outcomes were the rate of tear progression or retear along with the rate of symptom aggravation after the treatments. RESULTS: A total of 357 patients were enrolled, including 183 patients that received conservative treatment and 174 patients who received an arthroscopic repair. The pain assessment score (p50 years old with a less than medium-sized rotator cuff tear in a 1-year follow-up period. Further study is warranted to find the optimal combination of conservative treatment for a symptomatic rotator cuff tear.

Clinical Outcomes of Cervical Stellate Ganglion Block in Patients with Secondary Lymphedema: A Pilot Study

OBJECTIVE: To investigate the clinical effect of stellate ganglion block in patients with secondary lymphedema after breast cancer treatment. METHOD: In a prospective clinical trial, the consecutive stellate ganglion block (SGB) was performed every two weeks to 10 patients (Mean age 46.0+/-9.4 (yr)) who was diagnosed as of secondary lymphedema after breast cancer treatment. The parameters were the circumstance of arm and the thickness of skin and subcutaneous tissue of the affected arm measured by ultrasonography. We measured these parameters with baseline value before SGB treatment and repeated the evaluation after each SGB treatment. And the subjective data of satisfaction, softness and improvement were obtained by questionnaires. RESULTS: 10 patients were treated with stellate ganglion block. The mean circumferences of upper arm and forearm after three consecutive SGB treatments reduced significantly: upper arm from 31.39 cm to 29.72, forearm from 25.14 cm to 23.64 cm (p <0.05). And the thickness of subcutaneous tissue of upper arm significantly decreased under no- compression measuring technique after three SGB treatments (p <0.05). The compliance of superficial tissue showed significant change with serial procedure. Almost all of the patients had a satisfaction and feeling of softness in their affected arm after treatments. CONCLUSION: The cervical stellate-ganglion block reduced the circumstance and the thickness of arm with lymphedema and satisfied almost lymphedema patients. So this treatment presents a favorable outcome to the breast cancer-related lymphedema patient clinically.

Biomechanical Evaluation of the Capsular Stiffness and Clinical Features in Adhesive Capsulitis of Shoulders

OBJECTIVE: To evaluate the capsular stiffness of the glenohumeral joint by measuring the slope of pressure-volume curves generated during intra-articular hydraulic distension (IHD) and analyze its correlation with clinical variables and outcomes in terms of limitation of range of motion (LOM) and severity of pain. METHOD: IHD with real-time intra-articular pressure monitoring was performed for 53 patients with adhesive capsulitis and the capsular stiffness was measured from pressure-volume curves by calculating the slope of elastic deformation region. LOM, measured by LOM score and sum of ROMs (range of motion), and degree of pain, measured by visual analog scale (VAS), were evaluated before and after IHD: three days (3D) and one month (1M) after IHD. RESULTS: In patients with stiffer capsules, LOM and pain were severe before IHD (Pearson's correlation coefficient (r)= 0.291, -0.348, 0.381 and p=0.065, 0.026, 0.014 for LOM score, sum of ROMs and VAS, respectively. By this order, henceforth). On 3D follow up, the correlation between the stiffness and LOM or pain was maintained (r=0.291, -0.348, 0.381 and p=0.065, 0.026, 0.014). The improvement of LOM score on 3D follow up was less as the capsules were stiffer (r=-0.368, p=0.023). On 1M follow up, LOM remained severer in stiffer capsules whereas pain did not (r=0.372, -0.402, 0.183 and p=0.039, 0.025, 0.342). CONCLUSION: The stiffness of the glenohumeral joint capsule, measured from the slope of pressure-volume curves during IHD, showed significant correlation with the severity of LOM and pain in patients with adhesive capsulitis of shoulder.

Rehabilitation of Sports Related Shoulder Injuries / 한양의대학술지

variety of sports activities can result in shoulder injuries either by an accidental strong trauma or by repetitive but cumulative stress for a long period. Based on the huge amount of basic or clinical researches, several mechanisms of repetitive injuries have been suggested: subacromial (external) impingement, internal impingment, and scapular dyskinesia, which are believed to cause or, at least, contribute to the development of rotator cuff injuries, superior labrum anterior posterior lesions, and shoulder intabilities. It has been reported that the pain and disabilities of the shoulder injuries could be prevented or minimized by an appropriate rehabilitation program especially undertaken in the early phase of dysfunctions or injuries. The core components of the rehabilitation program include stretching of the posterior glenohumeral joint capsule, scapular stabilizing exercise, and strengthening the rotator cuff muscles. It is crucial to proceed onto the proper steps of the rehabilitation program as the functional recovery progresses. To gain a strong and sound biomechanics not only on the shoulder but also for the whole body kinetic chain would be the most important factor for the injured athlete to regain his or her previous athletic activities.

Rehabilitation of Sports Related Shoulder Injuries / 한양의대학술지

variety of sports activities can result in shoulder injuries either by an accidental strong trauma or by repetitive but cumulative stress for a long period. Based on the huge amount of basic or clinical researches, several mechanisms of repetitive injuries have been suggested: subacromial (external) impingement, internal impingment, and scapular dyskinesia, which are believed to cause or, at least, contribute to the development of rotator cuff injuries, superior labrum anterior posterior lesions, and shoulder intabilities. It has been reported that the pain and disabilities of the shoulder injuries could be prevented or minimized by an appropriate rehabilitation program especially undertaken in the early phase of dysfunctions or injuries. The core components of the rehabilitation program include stretching of the posterior glenohumeral joint capsule, scapular stabilizing exercise, and strengthening the rotator cuff muscles. It is crucial to proceed onto the proper steps of the rehabilitation program as the functional recovery progresses. To gain a strong and sound biomechanics not only on the shoulder but also for the whole body kinetic chain would be the most important factor for the injured athlete to regain his or her previous athletic activities.

Ultrasonographic and Physical Examination to Investigate the Cause of Painful Hemiplegic Shoulder

OBJECTIVE: To investigate the musculoskeletal cause of hemiplegic shoulder pain using ultrasonographic evaluation of hemiplegic shoulder. METHOD: Thirty-six hemiplegic patients admitted to rehabilitation department were enrolled. Ultrasonographic investigation of shoulder and physical examinations including range of motion (ROM), muscle power, spasticity and subluxation of shoulders were performed. RESULTS: Eighteen (55.6%) patients reported pain in hemiplegic shoulder. The abnormal sonographic findings, ROM, muscle power, spasticity, and subluxation of hemiplegic shoulder were not significantly different between subjects with painful hemiplegic shoulder and those without. The presence of ultrasonographic abnormality combined with focal tenderness, however, was significantly related with the painfulness of hemiplegic shoulder (p-value = 0.03). CONCLUSION: These results suggest that ultrasonographic evaluation is useful to investigate the musculoskeletal component of painful hemiplegic shoulder, when collaborated with physical examination of focal tenderness.

The Usefulness and Indications of Arthrosonography to Differentiate Full-thickness Tears from Partial-thickness Tears of the Rotator Cuff

OBJECTIVE: To investigate the usefulness and indications of arthrosonography by testing if the new technique could provide additional information on the degrees of rotator cuff tears when compaired to the findings of conventional ultrasonographic examinations. METHOD: Thirty six patients, who were identified to have partial or full-thickness rotator cuff tears by conventional ultrasonography, were included. Intraarticular injection of 15 ml of fluid was performed via posterior approach under ultrasound-guidance, which was followed by arthrosonography. RESULTS: Among 26 patients with partial-thickness tear which was detected by the conventional ultrasonography, eight were identified to have full-thickness tears by the arthrosonography. Although the difference was not significant, the grade 3 partial-thickness tear in the conventional sonography had a higher rate of being identified as full- thickness tear in the arthrosonography than the grade 2 partial-thickness tears. The size of partial-thickness tear was increased after instillation of fluid in the arthrosonography. CONCLUSION: Arthrosonography would be useful in differentiating partial- and full-thickness tears. When a tear of the rotator cuff tendon, especially a grade 3 partial-thickness tear, is detected in the conventional sonographic examination, an obscured full-thickness tear should be suspected and subsequent arthrosonographic procedure could be administered to clarify the extent of the lesion. Moreover, arthrosonography might be helpful in detecting partial-thickness tears by making them appear larger after instillation of fluid.

The Impact of Upper Limb Dysfunctions on Quality of Life in Patients with Breast Cancer

OBJECTIVE: To investigate the type of upper limb dysfunctions and to determine major dysfunctions influencing on the quality of life (QoL) in the early phase after mastectomy. METHOD: Among the female patients with mastectomy after diagnosed as breast cancer followed by chemotherapy and/or radiation therapy, 38 patients who had shoulder pain or arm edema were selected. Visual analog scale (VAS) for pain at rest and during activity, range of motion of shoulder and arm circumference were measured. Disabilities of Arm, Shoulder and Hand (DASH) and Short form-36 v2 questionnaire were used to assess the functional disability and health-related QoL. RESULTS: Lymphedema (31.6%), limitation of motion (31.6%) and shoulder pain (26.3%) were major dysfunctions. Patients who had limited motion showed more severe dysfunctions. The cases with shoulder pain showed low level of QoL in mental component. VAS during activity and activity of daily living (ADL) domain of DASH were major impact factors on QoL related to physical functioning. In mental component, social domain of DASH was the most influencing factor on QoL. CONCLUSION: Pain during activity, limited ADL and social activity were major problems lowering QoL in patients with breast cancer. The proper managements for these problems is needed.

Rehabilitative Treatments of Chronic Low Back Pain

Chronic low back pain (CLBP) is a complicated clinical condition related with pathologic pain generators in the spinal column, weakened and deconditioned muscles in the trunk and extremities that control the motion and stability of the spine and pelvis, faulty biomechanics caused by connective tissue contractures, and behavioral problems such as fear-avoidance beliefs and emotional distress. Since it is initiated and maintained by these complicated causal factors, CLBP could not be successfully treated by one or two specific rehabilitative treatment options. A multidisciplinary approach with an appropriate individualization to each patient is known to be more successful than simple and passive physical therapeutic agents. Among the rehabilitative therapeutics, sustained exercise for 2 to 3 months appears to be the most effective, providing CLBP patients with significant pain relieves and functional improvements that last for a long-term period. There have been several different types of low back exercises including strengthening, flexibility training, aerobic exercise, lumbar flexion exercise, and McKenzie's extension exercise, with which favorable outcomes were reported. Recent advances in the field of spine biomechanics introduced a principle, the core stabilizing exercise, to stabilize the spine and pelvis by strengthening and improving the control of the several specific truncal muscles. Although supported by some reports showing excellent results, the core stabilizing exercise in itself may not be the most effective therapeutic exercise for CLBP. Instead, it could be a useful adjunctive measure to the exercises that have been used to date. A novel rehabilitative therapeutic modality is anticipated to be developed in the near future to theat the spine more specifically, addressing its particular pathologic conditions.

The Optimal Electrical Stimulation Frequency to Improve the Muscle Endurance in Spinal Cord Injured Rabbit

OBJECTIVE: Clinical application of Functional Electrical Stimulation (FES) was limited due to the muscle fatigue phenomenon. This study was undertaken to find an electrical stimulation frequency, which optimally improves muscle endurance in spinal cord injured rabbit. METHOD: Fifteen rabbits were experimentally spinal cord injured at the T10 or T11 spinal cord level. Three kinds of stimulation frequency (10, 20, 40 Hz) and sham control stimulation were applied to the tibialis anterior muscle of each four group for 1 hour per day, for 2 weeks. Muscle fatigue index and peak torque were measured during electrical stimulation, and proportion of the type I musclefiber was measured at ATPase (pH 9.4) staining. RESULTS: Complete paraplegia was obtained in all 12 rabbits. Muscle fatigue index and peak torque were not changed after 2 weeks of electrical stimulation in all four groups. The proportion of the type I muscle fiber was reduced in all four groups after 2 weeks. However, 40 Hz stimulation group showed less decline in proportion of type I muscle fiber than control or 10 Hz group. CONCLUSION: High frequency electrical stimulation applied at an early stage of spinal cord injury is more effective in preserving muscle endurance than low frequency stimulation.

The Desk Height and Keyboard Design as Determinants of Posture and Trapezius Tension

OBJECTIVE: To test the hypothesis that changing the desk height or keyboard design with fixed neck posture will change posture of the upper extremity and the trapezius tension, and to suggest the appropriate the desk height and the keyboard design to relieve the tension of the trapezius. METHOD: Five men volunteered. Four desk heights (5 cm below, same as, 5 cm above, 10 cm above the olecranon) and three keyboard designs (flat, wrist support, natural) were set up. The posture of the upper extremity was analysed by 3 dimensional Ariel performance analysis system. The tension of trapezius was measured by surface EMG. RESULTS: The trapezius tension was low when the desk height was below the olecranon in 'flat' keyboard, and was low when the desk height was no higher than 5 cm above the olecranon in 'wrist support' and 'natural' keyboard. The trapezius tension went with the change of the shoulder flexion, abduction, elevation and the elbow flexion in 'flat' keyboard, and went with the change of the shoulder flexion and elevation in 'wrist support' and 'natural' keyboard. CONCLUSION: To lessen the tension of the trapezius, the desk height should be below the olecranon in 'flat' keyboard and no higher than 5 cm above the olecranon in 'wrist support' and 'natural' keyboard. The keyboard design should include the wrist support which relieved the tension of trapezius by giving the resting point.

Comparison between the Barefeet Gait and the Shoe Gaitin the Transtibial Amputees

OBJECTIVE: The aims of this study were to evaluate gait patterns in transtibial amputees with the barefeet relative to the shoe and also to identify the differences between their gait patterns of two different types of prosthetic feet. METHOD: An optoelectronic motion analysis of gait was done in six transtibial amputees using both the SACH foot and the single axis foot. In both cases we compared the state of the barefeet with the shod. RESULTS: The gait abnormalities which were observed during the barefeet gait with the SACH foot showed knee joint hyperextension of 9.9+/-2.0 degrees and the loss of ankle plantar flexion at the early stance phase. When the single axis foot was used, there was a reduction in knee flexion thrust from 9.9+/-3.7 degrees to 7.2+/-3.8 degrees and also in plantar flexion from 9.9+/-2.8 degrees to 7.0+/-2.1 degrees during the early stance phase. CONCLUSION: There were significant gait abnormalities during the barefoot walking state in transtibial amputees with the SACH foot. We observed that gait patterns have been improved when the single axis prosthetic foot was used.

Change of Dynamic Gastrocnemius Length after the Block of Spastic Gastrocnemius Muscle in Cerebral Palsy

OBJECTIVE: To evaluate the clinical utility of the dynamic gastrocnemius length, calculated with gait analysis after phenol or botulinum toxin block in spastic cerebral palsy. METHOD: Gastrocnemius muscles were injected with phenol or botulinum toxin. Kinematic gait parameters including dynamic gastrocnemius length were surveyed with 3-dimensional gait analysis system before and after the procedure. RESULTS: The dynamic gastrocnemius lengths improved significantly after block of calf muscles, except 3 cases which showed severe genu recurvatum. The vertical displacement of the center of gravities and the maximal ankle dorsiflexion angles after the block were not significantly different from those before the block. CONCLUSION: Dynamic gastrocnemius length calculated with gait analysis can be used as a tool to determine the efficacy of spastic calf muscle block, in the absence of severe genu recurvatum. In case of associated severe genu recurvatum, other parameters may be substituted.

Clinical Features of Lower Extremity Amputees in Hwa Sung Goon: One Korean County

OBJECTIVE: To evaluate the prevalence and prosthetic uses of lower extremity amputee in one Korean county. METHOD: We asked community health worker in Hwa Sung Goon to recruit lower extremity amputees. We contacted them by telephone and tried to know their prosthetic uses, adaptations and their behavior about prosthetic usage. Also, we recruited all lower extremity amputees in Hwa Sung Goon. RESULTS: In Hwa Sung Goon, the prevalence of lower extremity amputees was 35 persons per 100,000. 93.8% of them had prostheses, more than half of them were not satisfied with their prosthetic use. For last 10 years, they changed into new prosthesis per 2.3 years. CONCLUSION: In one Korean county, the prevalence of lower extremity amputees was 0.03%. Most of them used their prosthesis, and walked independently. Their compliances with rehabilitative intervention were very low.

Clinical and Electrophysiologic Features in Four Cases of Castleman's Disease with Peripheral Polyneuropathy

Castleman's disease is a rare clinicopathological entity characterized by multicentric angiofollicular lymph node hyperplasia and sometimes associated with polyneuropathy. We report 4 cases identified with diagnosis of Castleman's disease by lymph node biopsy and peripheral polyneuropathy. They had a hypesthesia of all limbs, gait disturbance, weakness of distal lower limbs and enlargement of lymph nodes. Among them 2 patients were combined with POEMS (polyneuropathy, organomegaly, endocrinopathy, increase of M protein, skin change) syndrome. Motor and sensory nerve conduction velocities were below 70% of lower normal limit, the amplitudes of compound muscle action potential (CMAP) and sensory nerve action potential (SNAP) were reduced. Deterioration of nerve conduction study was more severe in lower limb than the upper. More denervation potentials were found in lower limbs than the upper and in distal limbs than the proximal. As disease getting worse, the slower conduction velocity and lower amplitude of CMAP and SNAP were observed.

The Pattern of Malnutrition in Cerebral Palsy and Relating Factors

OBJECTIVE: This study was undertaken to characterize the nutritional status, the status of growth and the relation to various factors in cerebral palsy. METHOD: Forty patients with cerebral palsy (20 quadriplegia, 20 diplegia) were investigated. Information was obtained from medical record, clinical measure and anthropometric measure (weight for height, triceps skinfolds thickness per age, height for age). Values of weight for height or triceps skinfold below the 2.5 percentile were defined as "undernutrition", values of height for age below the 2.5 percentile were defined as "growth retardation". Denver Developmental Screening Test (DDST) at the 12 months old and at the examined time, oromotor score, pattern of defecation, duration of gait per day of patients were interviewed from caregivers. Spasticity was measured by using Modified Ashworth's scale. RESULTS: Eleven children (27.5%) were in undernutrition state and 9 (22.5%) growth retardation. Oromotor dysfunction was positive in 62.5% and constipation in 30%. Less gait time, more severe oromotor dysfunction and fine motor delay in DDST and more quadriplegic type (p<0.05) were found in undernutrition group and no significant difference of spasticity and constipation. With logistic regression, quadriplegic type is the only significant factor to undernutrition. CONCLUSION: Undernutrition is common in cerebral palsy and quadriplegic type is significantly related to undernutrition.