Dynamic postural stability in patients with diabetic peripheral neuropathy and relationship to presence of autonomic neuropathy

@#Diabetic neuropathy is a common complication that can negatively influence balance and is a major cause of falls. We evaluated the association between postural sway and diabetic autonomic neuropathy (DAN) among patients with diabetic peripheral neuropathy (DPN). Patients with DPN documented by typical symptoms with abnormal results of nerve conduction study were included and postural stability was assessed using dynamic posturography. Composite autonomic scoring scale (CASS) score was calculated by evaluating sudomotor, cardiovagal, and adrenergic functions. CASS score ≥2 indicated DAN and the severity of DAN was indicated by the CASS scores divided into three subscales of 10-point total CASS: none or mild autonomic failure (0-3), moderate failure (4-6), and severe failure (7-10). A total of 34 patients comprised the DAN group (n=19) and non-DAN group (n=15). Patients with DAN had higher prevalence of diabetic retinopathy(p=0.011), higher urine albumin-creatinine ratio (p = 0.009), and lower HbA1c levels (p<0.001) than those with non-DAN. With regard to dynamic postural instability, the presence (p=0.025) as well as the severity of DAN (p<0.05) was associated with postural instability in the eyes-opencondition. Interestingly, the poorer dynamic postural instability in moderate/severe DAN compared to mild DAN was observed only in medio-lateral direction and this association remained significant after adjusting for age, sex, and glycemic control state (HbA1c). In patients with DAN accompanied by DPN, the dynamic postural instability was affected by visual feedback and medio-lateral directional instability was closely associated with the severity of DAN.

Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016

“Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” is the 3rd edition of clinical practice guideline (CPG) for stroke rehabilitation in Korea, which updates the 2nd edition published in 2014. Forty-two specialists in stroke rehabilitation from 21 universities and 4 rehabilitation hospitals and 4 consultants participated in this update. The purpose of this CPG is to provide optimum practical guidelines for stroke rehabilitation teams to make a decision when they manage stroke patients and ultimately, to help stroke patients obtain maximal functional recovery and return to the society. The recent two CPGs from Canada (2015) and USA (2016) and articles that were published following the 2nd edition were used to develop this 3rd edition of CPG for stroke rehabilitation in Korea. The chosen articles' level of evidence and grade of recommendation were decided by the criteria of Scotland (2010) and the formal consensus was derived by the nominal group technique. The levels of evidence range from 1++ to 4 and the grades of recommendation range from A to D. Good Practice Point was recommended as best practice based on the clinical experience of the guideline developmental group. The draft of the developed CPG was reviewed by the experts group in the public hearings and then revised. “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” consists of ‘Chapter 1; Introduction of Stroke Rehabilitation’, ‘Chapter 2; Rehabilitation for Stroke Syndrome, ‘Chapter 3; Rehabilitation for Returning to the Society’, and ‘Chapter 4; Advanced Technique for Stroke Rehabilitation’. “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” will provide direction and standardization for acute, subacute and chronic stroke rehabilitation in Korea.

The Effect of Human Placental Extract on Rheumatoid Arthritis in an Animal Model

OBJECTIVE: To assess the efficacy of human placental extract (HPE) in an animal model of rheumatoid arthritis (RA). METHOD: We used (i) KRN C57BL/6 TCR transgenic x NOD mice (KBx/N) serum transfer arthritis and (ii) collagen-induced arthritis (CIA) mice to evaluate the effi cacy of HPE (1 ul or 100 ul, intra-peritoneal, three times per week) on RA. Incidence, severity of arthritis, and hind-paw thickness were quantifi ed. Joint destruction was analyzed using modifi ed mammographic imaging. Histopathological analysis for inflammation, cartilage, and osteoclasts was performed using Hematoxylin-eosin (H-E), safranin-O, and tartrate-resistant acidic phosphatase (TRAP). ELISAs were used for detection of various cytokines in serum and joint tissue. RESULTS: There were no significant differences in incidence of arthritis, clinical scores of arthritis, and hind-paw thickness between HPE-treated and vehicle-treated groups for up to 2 weeks in the KBx/N serum transfer arthritis model. Histopathological analysis also showed no differences 2 weeks after treatment. Levels of TNF-alpha, IL-1beta, IL-6, IL-10, and RANKL in serum and joint tissues were similar in all groups. Furthermore, there were no differences in clinical, radiological, and histological parameters between HPE-treated and vehicle-treated group for 3 weeks in the CIA model. CONCLUSION: Systemic treatment with HPE has no beneficial effects on arthritis in animal models of RA. Therefore, indiscreet use of HPE in RA should be forbidden.

The Effect of Human Placental Extract on Rheumatoid Arthritis in an Animal Model

OBJECTIVE: To assess the efficacy of human placental extract (HPE) in an animal model of rheumatoid arthritis (RA). METHOD: We used (i) KRN C57BL/6 TCR transgenic x NOD mice (KBx/N) serum transfer arthritis and (ii) collagen-induced arthritis (CIA) mice to evaluate the effi cacy of HPE (1 ul or 100 ul, intra-peritoneal, three times per week) on RA. Incidence, severity of arthritis, and hind-paw thickness were quantifi ed. Joint destruction was analyzed using modifi ed mammographic imaging. Histopathological analysis for inflammation, cartilage, and osteoclasts was performed using Hematoxylin-eosin (H-E), safranin-O, and tartrate-resistant acidic phosphatase (TRAP). ELISAs were used for detection of various cytokines in serum and joint tissue. RESULTS: There were no significant differences in incidence of arthritis, clinical scores of arthritis, and hind-paw thickness between HPE-treated and vehicle-treated groups for up to 2 weeks in the KBx/N serum transfer arthritis model. Histopathological analysis also showed no differences 2 weeks after treatment. Levels of TNF-alpha, IL-1beta, IL-6, IL-10, and RANKL in serum and joint tissues were similar in all groups. Furthermore, there were no differences in clinical, radiological, and histological parameters between HPE-treated and vehicle-treated group for 3 weeks in the CIA model. CONCLUSION: Systemic treatment with HPE has no beneficial effects on arthritis in animal models of RA. Therefore, indiscreet use of HPE in RA should be forbidden.

Lance-Adams Syndrome

It is not common for a patient who survives cardiac arrest to experience significant neurologic impairment such as acute and chronic post-hypoxic myoclonus, known as Lance-Adams syndrome. This syndrome is predominantly characterized by myoclonus that starts days to weeks after cardiopulmonary resuscitation in patients who regained consciousness. Although several cases of LAS were reported, the decisive treatment method has not been established. We report a 43 year old man with Lance-Adams syndrome who showed long-term improvement through treatment with anti-myoclonic agents and participation in a rehabilitation program.

Clinical Characteristics Associated with Quality of Sleep in Old Stroke Patients : Preliminary Study

OBJECTIVES: Although sleep problem is a common complaint in stroke survivors, there is paucity of studies on quality of sleep in old patients with stroke. The purpose of this study was to investigate the clinical characteristics associated with quality of sleep in old patients with stroke. METHODS: A comprehensive clinical and psychiatric assessments was performed in 30 patients who were admitted in rehabilitation department. Quality of sleep was evaluated with the Pittsburgh sleep quality index (PSQI). Other rating scales such as Modified Barthel Index, Korean mini mental state examination, Hamilton rating scale for anxiety, and Hamilton rating scale for depression were also performed to evaluate the clinical characteristics. RESULTS: Thirteen patients (43%) were 'poor sleeper' defined as a global PSQI score >5. In the partial correlation test, poor sleeper group were significantly associated with anxiety (r=0.69, p<0.01) and depression (r=0.76, p<0.01). In the multivariate logistic regression analysis, depression symptoms (OR=1.51, p=0.01) were only significant predictor of 'poor sleep' compared with other factors including age, sex, stroke type, stoke location, stroke site, past medical history, anxiety, and cognitive function. CONCLUSION: The results may suggest that it is important to assess depression when old patients with stroke show decreased quality of sleep. Further following studies will be needed for finding relation with other clinical factors.

The Availability of Radiological Measurement of Tibial Torsion: Three-Dimensional Computed Tomography Reconstruction

OBJECTIVE: To assess the intra-rater and inter-rater reliability for measuring tibial torsion measurements by a radiographic method using three-dimensional computed tomography reconstruction (3D-CT) and to compare the physical measures to those of 3D-CT. METHOD: The study included 33 children who presented with intoeing gait. Tibial torsion was measured by 3D-CT. Distal reference point was the bimalleolar axis. Proximal reference points were the transtibial axis and posterior condylar axis. Physical measurements included thigh-foot angle (TFA) and bimalleolar angle (BMA). 3D-CT measurement and physical measurement were performed twice at both lower extremities by each rater. The intra-rater and inter-rater reliability were calculated by intraclass correlation coefficiency (ICC). The relationship between radiological and physical examination was calculated by Spearman correlation coefficient. RESULTS: The 3D-CT measures for tibial torsion were reliable within individual raters and between different raters. However, physical measures for tibial torsion were reliable within an individual rater but not reliable between raters. The 3D-CT measures by any proximal reference axis were more reliable within a rater and between raters than physical measurements. There was no significant impact introduced by the selection of the proximal reference axis. The correlation coefficiency between 3D-CT and physical measurement methods was low. CONCLUSION: Because the 3D-CT measurements for tibial torsion are more reliable than physical measurements, we recommend that accurate diagnosis of internal tibial torsion should be detected by using 3D-CT measurements. Also, considering the disadvantages of radiological measurements, physical measurement may be used for short term follow-up by same raters, as intra-rater reliability is relatively good.

Pseudoaneurysm Detected in Stroke Patient with Acquired Hemophilia: case report

Pseudoaneurysm arises from disruption in arterial wall continuity resulting from inflammation, trauma or iatrogenic cause. Stroke patient with pseudoaneurysm during rehabilitation has not been reported yet. A 62-year-old man who participated in comprehensive rehabilitation program after stroke presented with right thigh swelling and pain. On physical examination, non-pulsatile tender and broad mass was palpated in the lateral region of right lower thigh. A 2.7 cm-sized pseudoaneurysm in right vastus muscle was identified by a duplex ultrasonography and enhanced CT-angiogram. The patient was successfully treated with ultrasonography-guided thrombin injection and embolization. At this time, laboratory test revealed prolongation of aPTT, undetectable factor VIII levels and the presence of the factor VIII antibody, which made the diagnosis of acquired hemophilia A. The patient was discharged 7 weeks later. We report a case of pseudoaneurysm during rehabilitation program in hemiplegic patient with acquired hemophilia A.

Idiopathic Lumbosacral Plexopathy with Abnormal Finding in MRI: A case report

Idiopathic lumbosacral plexopathy is an uncommon idiopathic disorder characterized by acute onset of severe lower extremity pain, followed by weakness, atrophy of affected muscle, and variable sensory disturbance. A 61-year-old man experienced sudden onset of dysesthesia with weakness in right lower extremity. Electrodiagnostic study revealed patch pattern denervation at L3 and L4 root without paraspinal muscle involvement. Lumbar MRI showed abnormal signals in the right lumbar plexus. Pulse intravenous administration of high-dose immunoglobulin alleviated the sensorimotor symptoms. Abnormal signals in lumbar MRI reduced 6 months later.

Korean Guideline Development for the Evaluation of Permanent Impairment of the Spine: Proposal by the Korean Academy of Medical Sciences Committee

The criteria for the evaluation of spinal impairment are diverse, complex, and have no standardized form. This makes it difficult and somewhat troublesome to accurately evaluate spinal impairment patients. A standardized guideline was studied for the evaluation of spinal impairment, based on the American Medical Association (AMA) Guides and the McBride method. This guideline proposal was developed by specialty medical societies under the Korean Academy of Medical Sciences. In this study, the grades of impairment were assessed by dividing patients into three different categories: spinal cord impairment, spinal injury impairment and spinal disorder impairment. The affected regions of the spine are divided into three: the cervical region, the thoracic region, and the lumbosacral region. The grade of impairment was differentially evaluated according to the affected region. The restricted range of motion was excluded in the evaluation spinal impairment because of low objectivity. Even though the new Korean guideline for the evaluation of spinal impairment has been proposed, it should be continuously supplemented and revised.

Pyogenic Sacroiliitis with Psoas Abscess: A case report

Pyogenic sacroiliitis is a rare infection that may accompany psoas muscle abscess with vague clinical presentation, which present a diagnostic challenge requiring a high index of suspicion. We report a 48-year-old male, diagnosed pyogenic sacroiliitis with psoas abscess caused by Streptococcus intermedius and Sphingomonas paucimobilis. Magnetic resonance imaging showed multiloculated rim-enhancing lesion in right psoas muscle and joint effusion with osteomyelitis around sacroiliac joint. Intravenous antibiotics were administered after ultrasonographically guided abscess aspiration. Surgical drainage was done and his fever and symptom gradually subsided.

Usefulness of Electronic Pressure Algometer in Evaluation of Pressure Pain Threshold in Normal Korean Adults

OBJECTIVE: To examine pressure pain threshold (PPT) on several skeletal muscles in upper extremity, trunk, and lower extremity by using electronic pressure algometer and to evaluate it's interrater reliability, reproducibility, difference between gender and dominance, correlation with body mass index, and comparison among each muscles. METHOD: Forty healthy adults (male 27, female 13) were examined by two raters and reexamined in the same order after a rest of 10 minute. PPT at the splenius capitis, upper trapezius, infraspinatus, lumbar paraspinal muscle, extensor carpi radialis, vastus medialis, and gluteus medius muscles of both side was measured by medical electronic algometer. Rate of force application was approximately 2 lb/sec. Body mass index (BMI) was estimated from the individual's body weight by the square of their height. RESULTS: There were no statistical differences of PPTs at all muscles between two raters, between two test with time interval, and between dominant and nondominant side, respectively. PPT in man was higher than female at all muscles. There was significant correlation between BMI and PPT at lumbar paraspinal muscle, vastus medialis, and gluteus medius only in male. PPT was highest at lumbar paraspinal muscle and lowest at splenius capitis. CONCLUSION: Electronic pressure algometer is a reliable tool for evaluation of PPT which has high interrater reliability and high reproducibility and is not affected by dominance and location of muscles. Therefore, it is a useful clinical tool to compare PPT before and after treatment and to study the mechanism of musculoskeletal pain research program.

A clinical study on superiorly based platysma myocutaneous cervical flap for reconstruction following intraoral soft tissue cancer surgery

Development of the Korean Version of Modified Barthel Index (K-MBI): Multi-center Study for Subjects with Stroke

OBJECTIVE: To develop a Korean version of Modified Barthel Index (K-MBI) for subjects with stroke and to test the reliability and validity of K-MBI. METHOD: Six senior physiatrists translated the 5th version of MBI into K-MBI and we administered K-MBI to 30 subjects with stroke. Fifteen different examiners working at the 5 different university hospitals evaluated video-recorded examination cases independently to test the reliability and validity of K-MBI. We analyzed intra- and inter-rater reliabilities of the K-MBI by the Kendall's coefficient of concordance and Spearman's correlation coefficients, respectively. Cronbach's alpha coefficient was used for assessing internal consistency of the K-MBI and Spearman's correlation between the K-MBI and Brunnstr?m stage was employed to evaluate the validity of the K-MBI. RESULTS: The intra-rater reliabilities of physiatrists, resident physicians of rehabilitation medicine and occupational therapists were 0.93~1.00, 0.87~0.99, and 0.97~1.00 (p< 0.01), respectively. The inter-rater reliabilities were 0.93~0.98 (p<0.01) and Cronbach's alpha was 0.84 (p<0.01) as the internal consistency reliability of K-MBI. For construct validation study, each item of K-MBI had significant correlation with total score of K-MBI (r=0.54~0.78, p< 0.01). CONCLUSION: The K-MBI is a reliable and valid instrument for measuring functional status of subjects with stroke.

Diffusion-Weighted MR Imaging of Unusual White Matter Lesion in a Patient with Menkes Disease

We report here on the diffusion-weighted imaging of unusual white matter lesions in a case of Menkes disease. On the initial MR imaging, the white matter lesions were localized in the deep periventricular white matter in the absence of diffuse cortical atrophy. The lesion showed diffuse high signal on the diffusion-weighted images and diffuse progression and persistent hyperintensity on the follow up imaging. Our case suggests that the white matter lesion may precede diffuse cortical atrophy in a patient with Menkes disease.

A Case of Paraplegia Associated with Intrathecal Methotrexate : A case report

The treatment and prophylactic therapy of meningeal leukemia with intrathecal methotrexate in acute lymphoblastic leukemia is the standard method. Intrathecal overdose of methotrexate may produce severe toxicities such as paraplegia. We experienced a case of paraplegia diagnosed by magnetic imaging examination of the spine in a 24-year-old woman received repeated intrathecal methotrexate for meningeal leukemia.

A Case of Acrocallosal Syndrome with Developmental Delay: A case report

Agenesis of the corpus callosum is a frequent anomaly that presents with a spectrum of clinical features and exhibits variable findings in neurological studies. Callosal agenesis may be an isolated anomaly or may be syndromic as part of more extensive malformations, metabolic and genetic disorders. We experienced a case of agenesis of corpus callosum with developmental delay, diagnosed to acrocallosalsyndrome. Acrocallosal syndrome is an autosomal recessive condition, characterized by agenesis of the corpus callosum, pre- and postaxial polydactyly, minor craniofacial anomalies, and, in most patients, severe psychomotor retardation. We here reported a case of acrocallosal syndrome with the review of literatures.

Body Composition before and after the Marathon Run

OBJECTIVE: We studied the effect of marathon running on body composition without fluid and food restriction. METHOD: The subjects were 17 nonprofessional male athletes, aged from 27 years to 47 years, who participated in a marathon run. Body composition was measured before and after marathon run with bioelectrical impedance analysis. RESULTS: After the marathon, body mass was decreased by 1.99 +/- 0.51 kg (p<0.0001), fat mass was decreased by 4.81 +/- 2.64 kg (p<0.0001), percent body fat mass was decreased by 6.11 +/- 3.67% (p<0.0001), and body mass index was decreased by 0.69 +/- 0.19 kg/m2 (p<0.0001). Circumferences of upper arm, abdomen, hip, and thigh were significantly reduced by 0.5 +/- 0.2 cm, 3.0 +/- 2.88 cm, 2.33 +/- 2.3 cm, and 0.71 1.18 cm, respectively. Lean body mass was increased by 2.82 +/- 2.63 kg (p=0.001). Total body water was increased by 1.97 1.84 liter (p=0.001). CONCLUSION: These results demonstrated that marathon run reduced body fat mass and preserved lean body mass.

Post-traumatic Hypertrophic Olivary Degeneration: A case report

Hypertrophic olivary degeneration is usually caused by a lesion in the triangle of Guillain and Mollaret. The inciting pathology includes ischemic, inflammatory, degenerative or, less frequently, traumatic lesions. Clinically, it is usually accompanied by palatal myoclonus or other forms of segmental myoclonus. We present four patients with hypertrophic olivary degeneration studied with MRI after severe head trauma. MRI was performed between 5 and 18 months respectively after trauma. Although post-traumatic tremor was observed in three patients, none of patients showed palatal myoclonus. MRI showed multiple post-traumatic lesions within the dentato-rubro-olivary pathway associated with enlargement and increased signal intensity of the inferior olives.

The Value of the Dermatomal Somatosensory Evoked Potentials in Patients with Lumbosacral Radiculopathy

OBJECTIVE: The purposes of this study were to evaluate the diagnostic value of dermatomal somatosensory evoked potentials (DSEPs) in the unilevel/unilateral lumbosacral radiculopathies. METHOD: The study was performed on 41 patients with herniated lumbosacral disc which was confirmed by magnetic resonance imaging, and the patients with clinical lumbosacral radiculopathies (L5 radiculopathy in 33 cases and S1 radiculopathy in 8 cases). Stimulation sites were over the dorsum of the foot on the distal fifth metatarsal bone for the S1 dermatome and at the interdigital web space between first and second toe for the L5 dermatome. Recordings were made at Cz' and reference to Fz. Conventional nerve conduction study, needle EMG and H-reflex were also examined. RESULTS: While the needle EMG showed abnormalities in 32 patients (78.0%), the abnormalities of DSEPs were in 13 patients (31.7%): 33.3% for the L5 radiculopathy and 25.0% for the S1 radiculopathy, respectively. Moreover, there was no significant relationship between the abnormal findings of needle EMG and DSEPs (p>0.05). The H-reflexes were abnormal in 6 of 7 patients (85.7%). And then two of them were found abnormal in S1 DSEPs. CONCLUSION: The conventional needle EMG appears to be the more useful electrophysiological technique in the diagnosis of lumbosacral radiculopathies. The ultimate diagnostic value of DSEPs in lumbosacral radiculopathies is doubtful and controversial.