Biomechanical Assessment with Electromyography of Post-Stroke Ankle Plantar Flexor Spasticity

Spasticity has been defined as a motor disorder characterized by a velocity-dependent increase in tonic stretch reflex (muscle tone). Muscle tone consists of mechanical-elastic characteristics, reflex muscle contraction and other elements. The aims of this study were to determine whether to assess spasticity quantitatively, and to characterize biomechanical and electromyographic spasticity assessment parameters. These assessment parameters were described by investigating the correlation between clinical measures and the response to passive sinusoidal movement with consecutive velocity increments. Twenty post-stroke hemiplegic patients and twenty normal healthy volunteers were included in the study. Five consecutive sinusoidal passive movements of the ankle were performed at specific velocities (60, 120, 180, and 240 degrees/ sec). We recorded the peak torque, work, and threshold angle using a computerized isokinetic dynamometer, and simultaneously measured the rectified integrated electromyographic activity. We compared these parameters both between groups and between different velocities. The peak torque, threshold angle, work, and rectified integrated electromyographic activity were significantly higher in the post-stroke spastic group at all angular velocities than in the normal control group. The threshold angle and integrated electromyographic activity increased significantly and linearly as angular velocity increased, but the peak torque and work were not increased in the post-stroke spastic group. Peak torque, work, and threshold angle were significantly correlated to the Modified Ashworth scale, but the integrated electromyographic activity was not. The biomechanical and electromyographic approach may be useful to quantitatively assess spasticity. However, it may also be very important to consider the different characteristics of each biomechanical parameter.

The Efficacy of Spinal Epiduroscopy in Patients with Low Back Pain

OBJECTIVE: Spinal epiduroscopy has been introduced. Thus, we herein present low back pain patients with variable duration of herniated intervertebral disc (HIVD), spinal stenosis and failed back surgery syndrome to determine and analyze the result of spinal epiduroscopy. METHOD: Fifty low back pain patients who enrolled in Bundang CHA rehabilitation center from April 2000 to November 2001 with variable duration of HIVD, spinal stenosis and failed back surgery syndrome were treated with spinal epiduroscopy. The patients were grouped according to the duration and the disease. The efficacy of treatment was assessed with visual analog scale (VAS), Oswestry low back pain (LBP) questionnaire and Pain Disability Index (PDI)before the treatment, at 1 day, 1 week, 3 months and 6 months after the treatment. RESULTS: VAS of all patients after spinal endoscopic epiduroplasty were significantly decreased (p<0.05). PDI of all patients after spinal endoscopic epiduroplasty were significantly decreased (p<0.05). Oswestry LBP questionnaire of all patients after spinal endoscopic epiduroplasty were significantly decreased (p<0.05). CONCLUSION: Spinal endoscopic epiduroplasty is one of the best treatment that can be applied to low back pain patients with variable duration of HIVD, spinal stenosis and failed back surgery syndrome.

The Efficacy of Repetitive Bilateral Arm Training with Rhythmic Auditory Cueing for Patients with Stroke

OBJECTIVE: To evaluate the effect of repetitive bilateral arm training with rhythmic auditory cueing (BATRAC) on functional motor performances of the hemiplegic upper limb. METHOD: Twenty four subjects with stroke (12 males, 12 females) were enrolled and classified into two groups, experimental and control group. The control group received conventional rehabilitation therapy while the experimental group received additional BATRAC. The motor function of patient's upper extremity was assessed by Fugl-Meyer Motor Function Assessment (FMA), Manual Function Test (MFT), and Functional Independence Measure (FIM) before the treatment, at 4 weeks and at 6 weeks after begining of the treatment. RESULTS: There were no differences in FMA between two groups before the treatment and the continual improvements in the function at 4 weeks and at 6 weeks after begining of the treatment (p0.05). CONCLUSION: BATRAC improves motor performance of the paretic upper extremity and will be useful as an additional tool of improving motor function in patients with stroke.

Correlation between Bone Mineral Density and Interverterbral Disc Degeneration

OBJECTIVE: To examine the correlation between bone mineral density and intervertebral disc degeneration through retrospective study. METHOD: Bone mineral density (BMD) and Magnetic resonance (MR) image of lumbar spine from 61 postmenopausal women were assessed to examine the correlation between bone mineral density and intervertebral disc degeneration. We determined BMD of lumbar spine using the dual energy X-ray absorptiometry (DEXA). And we evaluated signal intensity of intervertebral disc, disc height and disc herniation at each lumbar disc level using the MR image. The correlation between BMD (mean value of 2nd, 3rd and 4th lumbar spine BMD) and the sum of grading scores of intervertebral disc degeneration was assessed in all the patients. RESULTS: There was a positive correlation between BMD of lumbar spine and the sum of grading scores of intervertebral disc degeneration (r=0.415, p value=0.00087). CONCLUSION: Bone mineral density has an inverse correlation to intervertebral disc degeneration and which is important when considering degenerative spinal disease and osteoporosis.

Assessment of Autonomic Nervous Function with Power Spectral Analysis of Heart Rate Variability in Spinal Cord Injured Patients

OBJECTIVE: To investigate the autonomic activities in spinal cord injured patients, and to compare their activities according to the level and completeness of spinal cord lesions. METHOD: Thirty-five spinal cord injured patients and thirty healthy adults participated in this study. The ECG signals were recorded at the tilt angle of 0o and 70o for 5 minutes, and power spectral analysis of Heart Rate Variability (HRV) was done at each angle. RESULTS: The data reveals two major components such as a low-frequency (LF) component (0.05~0.15 Hz) reflecting primarily sympathetic activities with orthostatic stress, and a high- frequency (HF) component (0.2~0.3 Hz) reflecting parasympathetic activity. In supine position, all frequency components were not significantly different regardless the level and completeness of spinal cord lesion. At 70o head-up tilt position, the LF power and heart rate didn't increase in complete tetraplegia but significantly increased in paraplegia and healthy adults (p<0.05). However, the HF power didn't reveal any differences in four groups by decreasing significantly in all groups. CONCLUSION: We concluded that there is an abnormal control of autonomic activities especially the sympathetic function in complete tetraiplegia, compared with paraplegia and healthy adults.

The Analysis of Sit-to-Stand Motion in Stroke Patients

OBJECTIVE: The ability to get up from a chair is an important component in maintaining independence and a prerequisite for upright mobility for stroke patients. The purpose of this study was to compare the sit-to-stand movement in stroke patients with that in healthy adult. METHOD: Twenty-three stroke patients and thirty-seven young healthy subjects were included in this study. Subjects sat on an adjustable chair with their feet on force plates and performed the standing up movement at a self-paced, comfortable speed. The study patients were tested barefoot. The changes in joint angle, maximal moment, power, and ground reaction force in lower limb were calculated using 3 dimensional motion analyzer throughout the sit-to-stand transfer. RESULTS: The mean time needed was significantly longer in stroke patients than in young healthy subjects. Pelvic tilting and hip flexion angle at initial and final angle were significantly greater in stroke patients than in young healthy subjects. Maximal momentum, power and change of ground reaction force in ankle joint were significantly lower in stroke patients than in young healthy subjects. Hip external rotation angle at standing point showed significant correlation with maximal hip external rotation and slow walking speed during the comfortable walking. CONCLUSION: We concluded that the analysis of sit-to-stand movement in stroke patients may provide a useful guide for gait recovery and training.

Sleep Apnea Syndrome and Prognosis in Stroke Patients

OBJECTIVE: The purpose of this study was to evaluate the prognostic value of sleep apnea syndrome in stroke patients by polysomnography. METHOD: Fifteen patients with ischemic stroke were studied with polysomnography. Medical history, sleep history, location of stroke, and severity of neurological deficit were recorded. Patients were observed by physician for evidence of snoring and excessive daytime sleepiness. Functional abilities were measured with the use of the Modified Barthel Index (MBI). To evaluate the autonomic nervous system, heart rate variability (HRV) study was done. RESULTS: Mean SaO2 during polysomnography was 88.2%, and mean recording time was 321 minutes. Apnea types were obstructive, mixed, and central. Respiratory Distress Index (RDI) correlated with functional outcome and mean SaO2. HRV study showed no significant changes under the orthostatic stress in apnea patients. CONCLUSION: We concluded that the sleep apnea syndrome could be a prognostic factor in rehabilitation outcome of stroke.

Effect on Diarrhea of Dietary Soluble Fiber Added to Nasogastric Tube-Fed Formulas in Stroke or Traumatic Brain Injury Patients

OBJECTIVE: The purpose of this study was to investigate the effect of dietary soluble fibers added to nasogastric tube-fed formulas and to compare the difference of the degree of diarrhea according to the amount of dietary soluble fibers in stroke or traumatic brain injury patients for comprehensive rehabilitative management. METHOD: Fifty-two stroke or traumatic brain injury patients fed by nasogastric tube due to dysphagia were included. They received fiber-free formulas for the first 30 days and then they were randomly assigned to three groups, including the control (fiber-free) group, moderate fiber (3.5 gm fiber/L) group and high fiber (7 gm fiber/L) group. Each group received their respective formulas for the next 30 days. We compared diarrhea score and frequency. RESULTS: In the control group, the degree of diarrhea was not changed with time. In the moderate and high fiber groups, daily diarrhea score and monthly diarrhea frequency were low compared to the control group (p<0.05). Also, the incidence of pseudomembraneous colitis was low in fiber groups. CONCLUSION: We concluded that adding dietary soluble fibers to nasogastric tube-fed formulas may be helpful to reduce the diarrhea and the development of pseudomembraneous colitis. The proper fiber amount will be determined through the following more case studies.

Comparison of Gait Analysis and Energy Consumption between Various Types of Plastic Ankle Foot Orthoses in Hemiplegic Patients

OBJECTIVE: The purpose of this study were to investigate the temporospatial, kinematic data and energy consumption in hemiplegic patients according to the types of ankle-foot orthosis (AFO), and to determine the most effective type of AFO for gait training. METHOD: A prospective study was performed for 10 patients with hemiplegia who was able to walk independently at indoor level. The temporospatial, kinematic data and energy consumption were compared in each five different conditions: 1) barefoot, 2) donning AFO with posterior leaf spring (PLS), 3) donning PLS with the distal part of metatarsal head trimmed off (PLS-C), 4) donning hinged PLS (HPLS), 5) donning hinged PLS with the distal part of metatarsal head trimmed off (HPLS-C). RESULTS: With four types of PLS, maximal ankle plantar flexion was significantly decreased, however we didn't find any difference in kinematic data of the pelvis and hip as compared with barefoot and with PLS, HPLS, HPLS-C and maximal knee extension angle was significantly decreased compared with barefoot. With HPLS-C, cadence and walking speed significantly increased and double support time and oxygen cost significantly decreased as compared with barefoot. CONCLUSION: This study showed increased walking speed, decreased energy cost and improvedgait pattern after donning HPLS-C especially in hemiplegic patients. So HPLS-C may be effective in hemiplegic patients for gait training.

The Effects of Epidural Steroid Injection in the Management of Low Back Pain

OBJECTIVE: Several kinds of steroids had been used epidurally for the treatment of low back pain, but there were few available medical reports as to the effects of each steroid. The purposes of this study were to evaluate the effects of epidural steroid injections and to investigate the factors affecting the results. METHOD: Forty four backache patients were randomly assigned to one of three groups: Group 1, epidural saline as a control group(n=12); Group 2, epidural triamcinolone and 1% lidocaine(n=13); Group 3, epidural dexamethasone and 1% lidocaine(n=19). The effects of epidural injections were measured by pain self-assessment scale(pain score) and Rubin scale(success rate). RESULTS: The pain scores of steroid groups after one to seven days after the injections were significantly lower than those of the control group(p0.05) between two steroid groups. The overall success rate of the steroid groups was 68.8%. Although there were no statistically significant differences between the steroid groups with respect to sex, age and duration, the younger age group seemed to respond better to the treatment. CONCLUSION: We founded that epidural steroid injection could be a valuable adjunct to the management of low back pain but its effective duration was relatively short. Physicians should keep in mind that comprehensive treatment including rest, medication, physical therapy, exercise and education ought to be provided for the better clinical results.

Assessment of Autonomic Function in Stroke Patients by Power Spectral Analysis of Heart Rate Variability

OBJECTIVE: To evaluate the effects of orthostatic stress with a head-up tilt on the autonomic nervous system and to determine how a cerebral stroke influences the cardiac autonomic function, using the power spectral analysis(PSA) of heart rate variability(HRV). METHOD: We studied 11 stroke patients with a left hemiplegia and 14 patients with a right hemiplegia. Their hemispheric brain lesions were confirmed by the MRI. The ECG and respiration signals were recorded at the tilt angle of 0o and 70o for 5 minutes under the condition of frequency controlled respirtaion(0.25 Hz). Data were compared with the age- and sex-matched 12 healthy controls. RESULT: In a control group, the normalized high frequency power showed a significant decrease during the head-up tilt(p0.05). Compared with the right hemiplegia and control groups, the left hemiplegia group was associated more with a reduced low and high frequency power and showed no significant changes under the orthostatic stress. CONCLUSION: PSA of HRV can identify the reduced cardiac autonomic activity in stroke patients, with a greater reduction in the left hemiplegia group than in the right hemiplegia group, which may cause a high risk of cardiac arrhythmias and sudden death.

Diaschisis and Motor Recovery in Stroke Patients

OBJECTIVE: To find out the motor recovery in stroke patients according to the presence of diaschisis. METHOD: Computed tomography (CT) and/or magnetic resonance imaging (MRI) scan and single photon emission computed tomography (SPECT) study were performed on a consecutive series of 98 inpatients from July 1995 to August 1996. Among them 42 stroke patients were included in this study with cerebellar, pontine, and bilateral hemispheric lesions excluded. RESULTS: The types of diaschisis were crossed cerebellar diaschisis (CCD) (36 cases), thalamocortical diaschisis (6 cases), striatocortical diaschisis (5 cases), and capsulocortical diaschisis (1 case). And the functional recovery scale improved from 37.5 points to 53.0 points by the motricity index and from 41.2 points to 68.8 points by the MBI score. Only the motricity index showed a significant inverse correlation with the asymmetry index in CCD. CONCLUSION: Although other types of diaschisis were found, the most frequent type was CCD. The lower the asymmetry score was the lower motricity index. Therefore, CCD could be a prognostic factor for the motor recovery.

Recent Epidemiologic Trends of Stroke

OBJECTIVE: The purpose of this study is to present the epidemiological data on patients with a stroke admitted to the severance hospital, Yonsei University College of Medicine (YUMC) and to investigate the significant risk factors of stroke. METHODS: We reviewed medical records of 532 patients with a stroke admitted to the hospital of from 1992 to 1996 retrospectively. RESULTS: The incidence was highest in the sixth decade. Ischemic stroke (64.3%) was more common than a hemorrhagic stroke (35.7%) and the thrombotic infarction was the leading type (28.3%) of all kinds of stroke. Middle cerebral arterial territory was the most commonly involved site for the thrombotic and embolic stroke. Of the intracerebral hemorrhages, basal ganglia (48.4%) was the most commonly involved site with was followed by the thalamus (24.2%), lobar (19.3%), and cerebellum (6.5%). In subarachnoid hemorrhages, the aneurysm was most frequently located in the middle cerebral artery (34.4%). The possible contributing factors of stroke were hypertension, hypercholesterolemia, cigarette smoking and diabetes mellitus. The common complications during hospitalization were the frozen shoulders, depression, pneumonia, reflex sympathetic dystrophy (RSD), and hydrocephalus. CONCLUSION: This study showed the changing trends of stroke in its distribution of subtypes. Multicenter prospective study using stroke registry would be required for the determination of national epidemiologic trends.

Shoulder Subluxation in Hemiplegia: Comparison of Therapeutic Effects of Four Different Types of Slings

The purpose of this study is to compare the effectiveness of the Rolyan, hemisling, remodified Bobath, and the newly designed triangular Bobath slings. Sixteen patients with a shoulder subluxation were evaluated by the simple shoulder AP X-rays with and without slings. The hemisling was applied with the elbow flexed at 90 and 120 degrees. The radiologic evaluation for the detection of shoulder subluxation was done by measuring the vertical and horizontal displacement on a plain AP view. The mean value of vertical displacement without a sling application was 5.21 cm which was reduced to 4.30 cm by a triangular Bobath sling application and 4.32 cm by a hemisling application at 120degrees elbow flexion. These two slings significantly corrected the vertical displacement, but other were not. In nine of sixteen patients, the triangular Bobath sling was the best sling for the vertical correction. All slings except a hemisling increased the horizontal displacement even though it was not statistically significant. The triangular Bobath sling improved the discomfort of the axilla better than the remodified Bobath sling. The results support that the triangular Bobath sling was the best among 4 slings for the correction of shoulder subluxation, although a reduction in lateral displacement and an improvement in applicability need to be explored further.

The Effects of Surface Electrical Stimulation on Spasticity in Spinal Cord Injured Patients

The current available treatment methods of spasticity are consisted of physical therapies, medications, surgeries, injections of phenol or botulinum, and electrical stimulations. The purposes of this study were to evaluate the effectiveness of surface electrical stimulation in reducing spasticity in the spinal cord injured patients, to find out carry-over effects of electrical stimulation and to find out the factors influencing the effects of the treatment. The subjects were 10 quadriplegics with the cervical cord injuries. The electrical stimulation was applied to the antagonists of major spastic muscles of the knee joints for 2 weeks. The evaluation of spasticity were done by using the modified Ashworth scale, beats of ankle clonus, patellar tendon reflex(latency and amplitude), and relaxation index of patellar knee by pendulum test before and after treatment sessions. The results of the study revealed no statistically significant changes in relaxation index, modified Ashworth scale, ankle clonus and the latency and amplitude of patellar tendon reflex(P<0.05), however there were tendencies of improvement in relaxation index and modified Ashworth scale after the stimulations. We could not find out statistically significant factors influencing the effects of the surface electrical stimulation. Further investigations to assess the mechanism of electrical stimulation and the adquate parameters of electrical stimulation in a larger population of subjects will be needed.

Assessment of Autonomic Nervous Function in Young Adults by Power Spectral Analysis of Heart Rate Variability

The powers of the low-frequency(LF) and high-frequency(HF) components characterizing heart rate variability (HRV) appear to reflect, in their reciprocal relationship, changes in the state of the sympatho-vagal balance occurring during orthostatic stress with head-up tilt. We studied 24 healthy volunteers (median age, 23.1 years) who were subjected after a rest period to a series of passive head-up tilt steps chosen from the following angles: 0 degree. 15 degrees, 30degrees, 45degrees, 70degrees, and 90degrees under the condition of frequency controlled respiration(0.25Hz) in order to get data of the Korean young adults. During head-up tilt, heart rate and normalized low frequency power(LF(N : 0.05-0.15 Hz) of HRV showed significant increase(p=0.000), but normalized high frequency power(HFN : 0.2-0.3 Hz) and total power showed progressive decrease(p=0.000, p<0.01 respectively). Male showed significantly higher LF(N and lower HFN than female at tilt table angle 0degree(p<0.01). Power spectral analysis of HRV appears to be capable of providing a noninvasive quantitatibve evaluation of graded changes in the state of the sympatho-vagal balance.

Correlation of Visual Perceptual Dysfunction with Brain Lesion in Stroke Patients

Visual perceptual dysfunction in stroke patients causes a failure in activties of daily living and learning. Therefore, the correct diagnosis and remediation of visual perceptual dysfunction are important. Since the mechanism of visual perception is not well studied, it is difficult to treat visual perceptual dysfunction effectively. In this study, we tried to correlate visual perceptual dysfunction with anatomical lesion of brain for the use of visual perceptual training. We assesed the visual perception and the brain lesions of fiftroke patients, with Motor-Free Visual Perception Test(MVPT), and brain computerized tommography respectively. The visual responses of contralateral side of the lesions were diminished. The raw score of MVPT was low in patients with lesions in both parietal and, right temporal lobes. The right parietal lobe lesions correlated with tests for figure-ground and visual closure, and the left parietal lobe lesions with visual processing time. The result suggests that the right parietal lobe has an important role in visual perceptions. The right temporal, and the left parietal lobes as well as the subcortex of both hemisphere also has significant roles in visual perceptions.

The difference of the relaxation index, angular velocity, and angular acceleration of pendulum test in elbow joint according to muscle tone

No abstract available.

Non-traumatic paralysis of posterior interosseous nerve which developed spontaneously: 2cases

No abstract available.

The effectiveness of pendulum test for quantifying spasticity in the upper extremity: reliminary report

No abstract available.