Sick Sinus Syndrome Combined with Wallenberg Syndrome: a Case Report

Cardiac arrhythmia is a rare manifestation of the Wallenberg syndrome; lesions are located in the brainstem, especially the lower medulla, which regulates sympathetic and parasympathetic activity. A 55-year-old man was admitted to the university hospital with symptoms including ataxia, left ptosis, decreased sensation of pain and temperature on the right side, left facial numbness, and dizziness. Brain magnetic resonance imaging revealed an infarction in the left dorsolateral medulla. Therefore, he was diagnosed with Wallenberg syndrome. While he underwent conservative treatment for Wallenberg syndrome, he experienced several events of self-limiting heart pounding, which required an evaluation of cardiac function. The 24-hour Holter monitor showed an increased RR interval with bradycardia and prolonged sinus pause. As a result, the diagnosis of sick sinus syndrome combined with Wallenberg syndrome was made. Sick sinus syndrome is a rare cardiac complication of the Wallenberg syndrome, and clinicians could overlook it when the initial electrocardiography shows a normal sinus rhythm. Sick sinus syndrome can cause sudden death without appropriate medical intervention. Therefore, clinicians should consider further evaluation, including a 24-hour Holter monitor, to check for the potential presence of sick sinus syndrome in the acute phase of Wallenberg syndrome.

Epidemiology of Spinal Cord Injury: Changes to Its Cause Amid Aging Population, a Single Center Study

Objective@#To investigate the epidemiologic and demographic characteristics of patients with spinal cord injury (SCI) who were admitted to a department of rehabilitation of a university hospital. @*Methods@#This was a descriptive cross-sectional study. Medical records including sex, age at injury, type of disability, traumatic or non-traumatic etiology and presence of ossification of posterior longitudinal ligament (OPLL) of patients with SCI who were admitted to the department of rehabilitation between 2012 and 2018 were reviewed. @*Results@#Of the 221 cases of SCI, 161 were traumatic and 60 were non-traumatic. The mean age at injury was 52.8 years. People aged 40–49 years showed highest proportion among overall SCI patients (19.0%). The proportion of male patients was higher in traumatic SCI at 4.96:1 than in non-traumatic SCI at 1.30:1. The most common cause of traumatic SCI was falling off (37.3%), followed by motor vehicle crash (35.4%) and tripping over (19.3%). Meanwhile, the most common cause of non-traumatic SCI was neoplasm (35.0%). Tripping over was the leading cause of traumatic SCI in patients aged ≥60 years (42.6%). A high proportion of traumatic SCI patients were found to have underlying OPLL (26.1%), particularly those who were injured by tripping over (64.5%). @*Conclusion@#The mean age of SCI patients was higher than that of previous studies. Falls was the single most common cause of traumatic SCI, and tripping over was the most common cause of injury in the elderly patients. OPLL was prevalent in patients who were injured from tripping over.

Evaluation and prognosis of spinal cord injury

It is important to perform an accurate neurological assessment using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) to judge the prognosis of spinal cord injury patients. We can gauge the prognosis for upper extremity function or gait ability according to the ISNCSCI results. ISNCSCI involves both sensory and motor examination, and it is performed with the patient in the supine position to enable a comparison between the initial and follow-up exams. The sensory exam is performed on the 28 key sensory points of dermatomes for light touch and pinprick. The motor exam is performed on 10 key muscles on each side. The sensory and motor levels for the right and left sides are determined according to the sensory and motor exam results. The neurological level of injury is the most caudal level of the cord at which both the motor and sensory functions are intact. Finally, the American Spinal Injury Association Impairment Scale (AIS) is determined. AIS A indicates complete injury, and AIS B, C, and D indicate incomplete injuries. Once the sensory and motor levels, neurological level of injury, and AIS scale of a spinal cord injury patient are determined through ISNCSCI, the patient's prognosis can be predicted based on those results. Furthermore, ISNCSCI performed at 72 hours after an injury yields the most significant prognostic factors.

Initial Assessment and Management of Patients with Spinal Cord Injury

STUDY DESIGN: Literature review. OBJECTIVES: To summarize the most up-to-date information on the initial management and neurological examination of patients with spinal cord injury (SCI). SUMMARY OF LITERATURE REVIEW: Secondary injuries result from acute pathophysiological processes such as bleeding, hypoperfusion, inflammation, necrosis, and apoptosis around neural elements that initially survive a mechanical injury. MATERIALS AND METHODS: Orthopedic surgeons must be familiar with the anatomy of the spinal cord and the initial management of a patient with SCI. A detailed neurological examination in accordance with the International Standards for the Neurological Classification of Spinal Cord Injury is a prerequisite. It is important to distinguish between spinal shock and neurogenic shock, which are characteristic phenomena in patients with SCI. RESULTS: Rapid realignment of the spine and proper medical management to avoid hypoperfusion are important in the overall care of a patient with SCI. CONCLUSIONS: Patients with SCI should be managed and treated properly to enable them to return home and to their work as soon as possible.

Long Term Effect of Custom-Molded Foot Orthoses on Foot Pain and Balance in Children with Symptomatic Flexible Flat Feet

OBJECTIVE: To evaluate the long termeffect of custom-molded foot orthoses on foot pain and balance ability in children with symptomatic flexible flat feet after 1 year.METHOD: A total of 35 children over 6 year-old with flexible flat feet and foot pain for at least 6 months were recruited. Individual custom-molded rigid foot orthoses fabricated with the inverted orthotic technique was prescribed. Pain related parameters (pain sites, degree, and frequency) were obtained through questionnaires. Pain assessment was performed prior to application of the foot orthoses, and 1, 3, 6, 12 months after applying the orthoses. Balance ability was tested by computerized posturography. Such measures were evaluated prior to, 3 months, and 12 months after applying the foot orthoses. Additionally, the difference inbalance ability between barefoot and withfoot orthosesat 12 months was assessed to estimate carryover effect.RESULTS: 17 out of 35 children completed the study. Significant improvements were noted upto 12 months in pain parameters and balance ability. The carry over effect of the orthoses was confirmed.CONCLUSION: There were significant improvements offoot pain and balance ability in children with symptomatic flexible flat foot after wearing foot orthoses fabricated with the inverted orthotic technique over 1year period.

Initial Assessment and Management of Patients with Spinal Cord Injury

OBJECTIVES@#To summarize the most up-to-date information on the initial management and neurological examination of patients with spinal cord injury (SCI).SUMMARY OF LITERATURE REVIEW: Secondary injuries result from acute pathophysiological processes such as bleeding, hypoperfusion, inflammation, necrosis, and apoptosis around neural elements that initially survive a mechanical injury.@*MATERIALS AND METHODS@#Orthopedic surgeons must be familiar with the anatomy of the spinal cord and the initial management of a patient with SCI. A detailed neurological examination in accordance with the International Standards for the Neurological Classification of Spinal Cord Injury is a prerequisite. It is important to distinguish between spinal shock and neurogenic shock, which are characteristic phenomena in patients with SCI.@*RESULTS@#Rapid realignment of the spine and proper medical management to avoid hypoperfusion are important in the overall care of a patient with SCI.@*CONCLUSIONS@#Patients with SCI should be managed and treated properly to enable them to return home and to their work as soon as possible.

Femoral Neuropathy Secondary to Autosomal Dominant Polycystic Kidney Disease: A Case Report

Compressive femoral neuropathy is a disabling condition accompanied by difficulty in hip flexion and knee extension. It may result from retroperitoneal hematoma or bleeding, or from complications associated with pelvic, hip surgery, and renal transplants. A 55-year-old female with autosomal dominant polycystic kidney disease presented with proximal muscle weakness in lower extremities. The patient experienced recurrent renal cyst infection, with aggravated weakness during each event. Electromyography and nerve conduction study revealed bilateral femoral neuropathy. Computed tomography and magnetic resonance images were added to further identify the cause. As a result, a diagnosis of femoral neuropathy caused by enlarged polycystic kidney was made. Cyst infection was managed with antibiotics. Renal function was maintained by frequent regular hemodialysis. While avoiding activities that may increase abdominal pressure, rehabilitation exercises were provided. Motor strength in hip flexion and knee extension improved, and was confirmed via electrodiagnostic studies.

Efficacy of Mirror Therapy Containing Functional Tasks in Poststroke Patients

OBJECTIVE: To investigate the effect of mirror therapy containing functional tasks on upper extremity function and activities of daily living in patients with subacute stroke. METHODS: The subjects were randomly divided into two groups: the mirror therapy group (30 patients) and the sham therapy group (30 patients). The mirror therapy group underwent a mirror therapy program together with conventional therapy for 20 minutes per day on 5 days per week for 4 weeks. The control group received a sham conventional therapy program under the same schedule as the mirror therapy group. The Fugl-Meyer Motor Function Assessment (FMA), Brunnstrom motor recovery stage, and Modified Barthel Index (MBI) were evaluated 4 weeks after the treatment. RESULTS: The upper extremity function on the affected side and ability to perform daily life activities after the intervention were significantly improved in both groups. After 4 weeks of intervention, improvements in the FMA (p=0.027) and MBI (p=0.041) were significantly greater in the mirror therapy group than the sham therapy group. CONCLUSION: In this study, we found that the mirror therapy containing functional task was effective in terms of improving the upper extremity functions and activities of daily living in patients with subacute stroke.

Effect of Custom-Molded Foot Orthoses on Foot Pain and Balance in Children With Symptomatic Flexible Flat Feet

OBJECTIVE: To evaluate the effect of custom-molded foot orthoses on foot pain and balance in children with symptomatic flexible flat foot 1 month and 3 months after fitting foot orthosis. METHOD: A total of 24 children over 6 years old with flexible flat feet and foot pain for at least 6 months were recruited for this study. Their resting calcaneal stance position and calcaneal pitch angle were measured. Individual custom-molded rigid foot orthoses were prescribed using inverted orthotic technique to control foot overpronation. Pain questionnaire was used to obtain pain sites, degree, and frequency. Balancing ability was determined using computerized posturography. These evaluations were performed prior to custom-molded foot orthoses, 1 month, and 3 months after fitting foot orthoses. RESULT: Of 24 children with symptomatic flexible flat feet recruited for this study, 20 completed the study. Significant (p<0.001) improvements in pain degree and frequency were noted after 1 and 3 months of custom-molded foot orthoses. In addition, significant (p<0.05) improvement in balancing ability was found after 3 months of custom-molded foot orthoses. CONCLUSION: Short-term use of custom-molded foot orthoses significantly improved foot pain and balancing ability in children with symptomatic flexible flat foot.

Effect of Foot Orthoses on Children With Lower Extremity Growing Pains

OBJECTIVE: To evaluate the effect of custom molded foot orthoses on children with growing pains of the lower extremities. METHODS: Children with growing pains were recruited during a clinic visit. None had any bony deformities, inflammatory joint disease or depression. Resting calcaneal stance position (RCSP) and calcaneal pitch angle were measured, and individual custom molded rigid foot orthoses were prescribed using the inverted orthotic technique to control for foot overpronation using the RCSP angle. Pain sites, degree and frequency of pain, and balance ability were evaluated using Balance Master computerized posturography prior to foot orthosis fitting, and 1 and 3 months later. RESULTS: Twenty children completed the study. Seventeen (75%) had overpronated feet. Significant improvements were noted after 1 and 3 months in pain degree and frequency, and after 3 months in balancing ability. CONCLUSION: The use of custom molded foot orthoses is a good method for treating children with multiple musculoskeletal pains in the leg.

Evaluation of Pain and Ultrasonography on Shoulder in Poliomyelitis Wheelchair Basketball Players / 대한스포츠의학회지

The purpose of this study was to determine shoulder pain and shoulder ultrasonographic findings in poliomyelitis Wheelchair Basketball (WB) players. Three physicians performed physical examinations and interviewed WB players about their shoulder pain by using Wheelchair User's Shoulder Pain Index (WUSPI), Performance-Corrected WUSPI (PC-WUSPI), and Shoulder Pain and Disability Index (SPADI). One physician performed shoulder ultrasonography on WB players. All confirmed their International Wheelchair Basketball Federation (IWBF) classifications through Korean Wheelchair Basketball Federation (KWBF). Seventeen men and 6 women players were enrolled in the study, with 46 shoulders evaluated. Nine players had unilateral lower extremity weakness and 14 players were bilateral weakness. Six players used wheelchair for daily living, and 17 players used wheelchair only when playing WB. They were 44.35+/-5.42 years old on average. They had played WB for 11.09+/-9.49 years and trained 8.69+/-3.83 hours a week. PC-WUSPI was significantly correlated with age (p=0.014). There were no significant differences between time spent playing WB, training time for WB, types of poliomyelitis involvement, their use of wheelchair, and WUSPI, PC-WUSPI and SPADI. Tendon tear prevalence was significantly different with training time for WB (p=0.021). Most common abnormal shoulder ultrasonographic findings were subscapularis and supraspinatus tendinopathy. Tendinopathy and tendon tear prevalence did not differ significantly with age, time spent playing WB, types of poliomyelitis, and the use of wheelchair. High prevalence of shoulder pain and rotator cuff pathology were found by physical and ultrasonographic examination in the poliomyelitis wheelchair basketball players. Rotator cuff injury prevention program are needed for prevent shoulder pain and rotator cuff pathology.

Effect of Low-Frequency rTMS and NMES on Subacute Unilateral Hemispheric Stroke With Dysphagia

OBJECTIVE: To investigate the effect of low-frequency repetitive transcranial magnetic stimulation (rTMS) and neuromuscular electrical stimulation (NMES) on post-stroke dysphagia. METHODS: Subacute (<3 months), unilateral hemispheric stroke patients with dysphagia were randomly assigned to the conventional dysphagia therapy (CDT), rTMS, or NMES groups. In rTMS group, rTMS was performed at 100% resting motor threshold with 1 Hz frequency for 20 minutes per session (5 days per week for 2 weeks). In NMES group, electrical stimulation was applied to the anterior neck for 30 minutes per session (5 days per week for 2 weeks). All three groups were given conventional dysphagia therapy for 4 weeks. We evaluated the functional dysphagia scale (FDS), pharyngeal transit time (PTT), the penetration-aspiration scale (PAS), and the American Speech-Language Hearing Association National Outcomes Measurement System (ASHA NOMS) swallowing scale at baseline, after 2 weeks, and after 4 weeks. RESULTS: Forty-seven patients completed the study; 15 in the CDT group, 14 in the rTMS group, and 18 in the NMES group. Mean changes in FDS and PAS for liquid during first 2 weeks in the rTMS and NMES groups were significantly higher than those in the CDT group, but no significant differences were found between the rTMS and NMES group. No significant difference in mean changes of FDS and PAS for semi-solid, PTT, and ASHA NOMS was observed among the three groups. CONCLUSION: These results indicated that both low-frequency rTMS and NMES could induce early recovery from dysphagia; therefore, they both could be useful therapeutic options for dysphagic stroke patients.

Cardiovascular Response During Submaximal Underwater Treadmill Exercise in Stroke Patients

OBJECTIVE: To evaluate the cardiovascular response during head-out water immersion, underwater treadmill gait, and land treadmill gait in stroke patients. METHODS: Ten stroke patients were recruited for underwater and land treadmill gait sessions. Each session was 40 minutes long; 5 minutes for standing rest on land, 5 minutes for standing rest in water or on treadmill, 20 minutes for treadmill walking in water or on land, 5 minutes for standing rest in water or on treadmill, and 5 minutes for standing rest on land. Blood pressure (BP) and heart rate (HR) were measured during each session. In order to estimate the cardiovascular workload and myocardial oxygen demand, the rate pressure product (RPP) value was calculated by multiplying systolic BP (SBP) by HR. RESULTS: SBP, DBP, mean BP (mBP), and RPP decreased significantly after water immersion, but HR was unchanged. During underwater and land treadmill gait, SBP, mBP, DBP, RPP, and HR increased. However, the mean maximum increases in BP, HR and RPP of underwater treadmill walking were significantly lower than that of land treadmill walking. CONCLUSION: Stroke patients showed different cardiovascular responses during water immersion and underwater gait as opposed to standing and treadmill-walking on land. Water immersion and aquatic treadmill gait may reduce the workload of the cardiovascular system. This study suggested that underwater treadmill may be a safe and useful option for cardiovascular fitness and early ambulation in stroke rehabilitation.

The Therapeutic Effect of Neurologic Music Therapy and Speech Language Therapy in Post-Stroke Aphasic Patients

OBJECTIVE: To investigate the therapeutic effect of neurologic music therapy (NMT) and speech language therapy (SLT) through improvement of the aphasia quotient (AQ) in post-stroke aphasic patients. METHODS: Twenty-one post-stroke, nonfluent aphasia patients who had ischemic/hemorrhagic stroke on radiologic evaluation were divided into the NMT and SLT groups. They received NMT and SLT for 1 month. Language function was assessed by Korean version-Western Aphasia Battery before and after therapy. NMT consisted of therapeutic singing and melodic intonation therapy, and SLT consisted of language-oriented therapy. RESULTS: Significant improvements were revealed in AQ, repetition, and naming after therapy in the NMT group and improvements in repetition in the SLT group of chronic stroke patients (p<0.05). There were significant improvements in language ability in the NMT group of subacute stroke patients. However, there was no significant improvement in the SLT group of subacute stroke patients. CONCLUSION: We concluded that the two therapies are effective treatments in the chronic stage of stroke and NMT is effective in subacute post-stroke aphasic patients.

Comprehension and Compliance of Medication of Spinal Cord Injured Patients Who Visited to Outpatient Clinic

OBJECTIVE: To investigate the drug compliance and factors that have an influence on drug compliance of spinal cord injured patients. METHOD: From January to June in 2009, spinal cord injured patients who visited our hospital for regular prescription were asked to fill out questionnaires about demographic data, comprehension and compliance of medication. RESULTS: Forty-eight patients completed questionnaires. Thirty-three were male and the rest were female. Twenty were tetraplegic and 26 paraplegic. Twenty-two were completely injured and 26 had incomplete injuries. The level of awareness of names, shapes and effects of medication were 70.8%, 87.5% and 77.1%, respectively. The compliant group that had more than 80% of drug compliance was 38 patients. The non-compliant group that had less than 80% compliance had 10 patients. In respect of compliance of medication, the patients tended to miss the time of administration more than the number of administration. Twenty patients didn't tell their doctors that they hadn't been taking their medication properly. There were no statistically significant differences between drug compliance and the following: patient's age, sex, spinal cord injury type, education level, time elapsed since the injury, number of medication per day, and comprehension of name, shapes and effects of medication. CONCLUSION: Drug compliance of spinal cord injured patients was high. Education on necessity, side effects and usage of medication may be needed to maintain high drug compliance. To investigate the drug compliance and factors that have an influence on drug compliance of spinal cord injured patients.

Relationship between Gross Motor Function, Oromotor Function and Nutritional Status in Children with Cerebral Palsy

OBJECTIVE: To investigate the non-speech mechanism function in relation with functional status and find out the relationship between nutritional status and non-speech mechanism function in children with cerebral palsy (CP). METHOD: Eighty four children with CP were participated in this study. Non-speech mechanism function was investigated with a simple scale of oral motor status (OMS) and a feeding-swallowing evaluaton protocol for children (FEP-C). Higher score represents more severe in dysfunction in both tests. As well, Gross motor function classification system (GMFCS), the nutritional status based on body mass index were assessed in these subjects. GMFCS level I to III were grouped into high functioning group while GMFCS level IV and V were grouped into low functioning group. RESULTS: Fifty seven (67.9%) individuals with CP showed dysphagia symptoms (OMS sore > or =1). The mean scores of non-speech mechanism function in low functioning group were higher than in high functioning group (p<0.05). The mean scores of both OMS and FEP-C were higher in individuals with underweight (p<0.05). Compared to high functioning individuals with CP, underweight was more prevalent along with higher scores in oral motor function in low functioning group. OMS scores were significantly correlated with the mean scores of non-speech mechanism in all subareas (p<0.05). CONCLUSION: Non-speech mechanism function was closely related with GMFCS level. As well, this study revealed that the oromotor function and nutritional status in these individuals with CP related with non-speech mechanism function.