Clinical Practice Guidelines for Oropharyngeal Dysphagia / 대한연하장애학회지

Objective@#Dysphagia is a common clinical condition characterized by difficulty in swallowing. It is sub-classified into oropharyngeal dysphagia, which refers to problems in the mouth and pharynx, and esophageal dysphagia, which refers to problems in the esophageal body and esophagogastric junction. Dysphagia can have a significant negative impact one’s physical health and quality of life as its severity increases. Therefore, proper assessment and management of dysphagia are critical for improving swallowing function and preventing complications. Thus a guideline was developed to provide evidence-based recommendations for assessment and management in patients with dysphagia. @*Methods@#Nineteen key questions on dysphagia were developed. These questions dealt with various aspects of problems related to dysphagia, including assessment, management, and complications. A literature search for relevant articles was conducted using Pubmed, Embase, the Cochrane Library, and one domestic database of KoreaMed, until April 2021. The level of evidence and recommendation grade were established according to the Grading of Recommendation Assessment, Development and Evaluation methodology. @*Results@#Early screening and assessment of videofluoroscopic swallowing were recommended for assessing the presence of dysphagia. Therapeutic methods, such as tongue and pharyngeal muscle strengthening exercises and neuromuscular electrical stimulation with swallowing therapy, were effective in improving swallowing function and quality of life in patients with dysphagia. Nutritional intervention and an oral care program were also recommended. @*Conclusion@#This guideline presents recommendations for the assessment and management of patients with oropharyngeal dysphagia, including rehabilitative strategies.

Laryngotracheal Separation for Intractable Aspiration in Severe Brain Damage / 대한연하장애학회지

Laryngotracheal separation (LTS) is one of the treatment options for intractable aspiration. Here, we present two cases of LTS with successful prevention of intractable aspiration.The first case was a 60-year-old man with severe hypoxic brain damage caused by hydrogen sulfide (H2S) intoxication; he was admitted to our department for comprehensive rehabilitation. Frequent tracheal suction was required due to the excess secretion from saliva aspiration. Matters were complicated when he suffered frequent regurgitation and vomiting, which was followed by tracheal aspiration. In the second case, a 78-year-old man presented with a severe traumatic brain injury. He had experienced recurrent aspiration pneumonia, which was unresponsive to conventional therapy. In both cases, LTS was performed to prevent intractable aspiration pneumonia. Subsequent to the LTS procedure, videofluoroscopic swallowing study showed complete prevention of the aspiration in both patients. Moreover, tracheal secretion was reduced, and tracheal suction was no longer required. Post-surgery, there was no development of aspiration pneumonia during their hospital stays.

Romosozumab in Postmenopausal Korean Women with Osteoporosis: A Randomized, Double-Blind, Placebo-Controlled Efficacy and Safety Study

Background@#This phase 3 study evaluated the efficacy and safety of 6-month treatment with romosozumab in Korean postmenopausal women with osteoporosis. @*Methods@#Sixty-seven postmenopausal women with osteoporosis (bone mineral density [BMD] T-scores ≤–2.5 at the lumbar spine, total hip, or femoral neck) were randomized (1:1) to receive monthly subcutaneous injections of romosozumab (210 mg; n=34) or placebo (n=33) for 6 months. @*Results@#At month 6, the difference in the least square (LS) mean percent change from baseline in lumbar spine BMD (primary efficacy endpoint) between the romosozumab (9.5%) and placebo (–0.1%) groups was significant (9.6%; 95% confidence interval, 7.6 to 11.5; P<0.001). The difference in the LS mean percent change from baseline was also significant for total hip and femoral neck BMD (secondary efficacy endpoints). After treatment with romosozumab, the percent change from baseline in procollagen type 1 N-terminal propeptide transiently increased at months 1 and 3, while that in C-terminal telopeptide of type 1 collagen showed a sustained decrease. No events of cancer, hypocalcemia, injection site reaction, positively adjudicated atypical femoral fracture or osteonecrosis of the jaw, or positively adjudicated serious cardiovascular adverse events were observed. At month 9, 17.6% and 2.9% of patients in the romosozumab group developed binding and neutralizing antibodies, respectively. @*Conclusion@#Treatment with romosozumab for 6 months was well tolerated and significantly increased lumbar spine, total hip, and femoral neck BMD compared with placebo in Korean postmenopausal women with osteoporosis (ClinicalTrials.gov identifier NCT02791516).

Comparison of Two Static Stretching Techniques for the Triceps Surae in Healthy Individuals: Wall and Inclined Board Stretchings

Objective@#To compare the effectiveness of static stretching techniques for correcting the tightness of the triceps surae. @*Methods@#In this observational, cross-sectional study, participants (30 healthy volunteers) completed 10 repetitions of each stretching exercise, holding each stretch for 10 seconds, with a 1-minute rest period between repetitionsand a 1-hour rest period between the two stretching techniques, namely, wall and inclined board stretchings. The length of the triceps surae and range of ankle dorsiflexion were measured on lateral view radiographs. The muscle activity during the stretch was measured using quantified surface electromyography of the lateral gastrocnemius. The subjective stretching sensation was evaluated using the visual analog scale. @*Results@#Both stretching techniques showed statistical differences in all the parameters. Stretching on an inclined board yielded a greater increase in the triceps surae length than did wall stretching (mean difference, 0.72; p=0.02). The range of ankle dorsiflexion was higher with inclined board stretching than with wall stretching (mean difference, 2.57; p=0.03). The mean muscle activity was significantly lower withinclined board stretching than with wall stretching (mean difference, 53.72; p<0.01). The visual analog scale score was higher with inclined board stretching than with wall stretching (mean difference, 2.07; p<0.01). @*Conclusion@#In this study, inclined board stretching was more effective than wall stretching for correcting tightness of the triceps surae. Therefore, inclined board stretching should be encouraged for the triceps surae.

Efficacy of Portable Low Power Laser Therapy on Pain and Functions in Chronic Low Back Pain

Objective@#A prospective, assessor-blinded, randomized controlled trial was conducted in patients with chronic low back pain to evaluate the efficacy of portable low power laser therapy (LPLT) and the effect when combined with exercise therapy on pain and functions. Method: 60 patients were recruited and 56 patients, excluding 4 dropouts, were randomly allocated to the LPLT group (Group 1: 19 patients), placebo laser therapy with exercise group (Group 2: 18 patients), and LPLT with exercise group (Group 3: 19 patients). Laser therapy and exercise was performed five times a week for 4 weeks. Visual analogue scale (VAS), Schober test, lumbar range of motion (ROM) measures (flexion, extension and lateral flexion), Oswestry Disability index (ODI) were measured at baseline, at 4 weeks after intervention, and at 6 weeks after 2 weeks of no intervention. @*Results@#Statistically significant improvements were noted in all group by time interaction with respect to all outcome parameters (p＜0.05). All parameters in each group improved not only in the period of treatment (4 weeks), but also in the final evaluation (6 weeks) 2 weeks after the end of treatment. Post-hoc analysis showed statistically significant difference between the LPLT with exercise group and the other groups in all outcome parameters except for the ODI at 4 weeks and at 6 weeks. @*Conclusion@#Portable LPLT is effective treatment in reducing pain and improving lumbar ROM and with exercise is more effective than laser or exercise monotherapy for the chronic low back pain patients.

Efficacy of Portable Low Power Laser Therapy on Pain and Functions in Chronic Low Back Pain

Objective@#A prospective, assessor-blinded, randomized controlled trial was conducted in patients with chronic low back pain to evaluate the efficacy of portable low power laser therapy (LPLT) and the effect when combined with exercise therapy on pain and functions. Method: 60 patients were recruited and 56 patients, excluding 4 dropouts, were randomly allocated to the LPLT group (Group 1: 19 patients), placebo laser therapy with exercise group (Group 2: 18 patients), and LPLT with exercise group (Group 3: 19 patients). Laser therapy and exercise was performed five times a week for 4 weeks. Visual analogue scale (VAS), Schober test, lumbar range of motion (ROM) measures (flexion, extension and lateral flexion), Oswestry Disability index (ODI) were measured at baseline, at 4 weeks after intervention, and at 6 weeks after 2 weeks of no intervention. @*Results@#Statistically significant improvements were noted in all group by time interaction with respect to all outcome parameters (p＜0.05). All parameters in each group improved not only in the period of treatment (4 weeks), but also in the final evaluation (6 weeks) 2 weeks after the end of treatment. Post-hoc analysis showed statistically significant difference between the LPLT with exercise group and the other groups in all outcome parameters except for the ODI at 4 weeks and at 6 weeks. @*Conclusion@#Portable LPLT is effective treatment in reducing pain and improving lumbar ROM and with exercise is more effective than laser or exercise monotherapy for the chronic low back pain patients.

Swallowed Oro-esophageal Tube: A Case Report / 대한연하장애학회지

Tube feeding is used to provide nutritional support to patients who have difficulty taking food orally. A nasogastric tube is commonly used for these patients but there are some complications. Therefore, the oro-esophageal tube feeding method was developed to avoid these disadvantages. A 33-year-old male with a history of right basal ganglia intracranial hemorrhage was admitted to the rehabilitation department for the treatment of dysphagia caused by a new onset left basal ganglia intracranial hemorrhage. After the videofluoroscopic swallowing study, the nasogastric tube feeding was changed to intermittent feeding via an oro-esophageal tube. Unfortunately, the patient swallowed the tube during insertion. Hence, an emergent endoscopy was performed for tube removal. This article reports a rare case of a patient who underwent oro-esophageal tube removal with an esophagogastroduodenoscopy after tube swallowing during insertion. The insertion of an oro-esophageal tube requires a careful approach after considering the cognitive function, muscle strength, and family education.

Subacute Combined Degeneration Caused by Nitrous Oxide Intoxication: A Report of Two Cases

We report two cases of subacute combined degeneration (SCD) caused by nitrous oxide (N₂O) gas intoxication, which is rarely reported in Korea. Two patients recreationally inhaled N₂O gas daily for several months. They presented with paresthesia of limbs, voiding difficulty, and gait disturbance. The initial vitamin B₁₂ levels were normal or decreased, but homocysteine levels of the two patients were increased. Magnetic resonance imaging of the cervical spine showed T2-weighted hyperintensity in the bilateral dorsal columns of the cervical spinal cord. Electromyography and somatosensory evoked potential tests for both patients suggested posterior column lesion of the spinal cord combined with sensorimotor polyneuropathy. According to these findings, we concluded that the two patients had SCD. The patient’s symptoms partially improved after cessation of N₂O gas inhalation and the receiving of vitamin B₁₂ supplementation therapy. As the incidence of recreational N₂O gas inhalation is increasing in Korea, physicians must be alert to the N₂O induced SCD in patients presenting with progressive myelopathy.

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.

Quantitative Lymphoscintigraphy to Predict the Possibility of Lymphedema Development After Breast Cancer Surgery: Retrospective Clinical Study

OBJECTIVE: To predict the probability of lymphedema development in breast cancer patients in the early post-operation stage, we investigated the ability of quantitative lymphoscintigraphic assessment. METHODS: This retrospective study included 201 patients without lymphedema after unilateral breast cancer surgery. Lymphoscintigraphy was performed between 4 and 8 weeks after surgery to evaluate the lymphatic system in the early postoperative stage. Quantitative lymphoscintigraphy was performed using four methods: ratio of radiopharmaceutical clearance rate of the affected to normal hand; ratio of radioactivity of the affected to normal hand; ratio of radiopharmaceutical uptake rate of the affected to normal axilla (RUA); and ratio of radioactivity of the affected to normal axilla (RRA). During a 1-year follow-up, patients with a circumferential interlimb difference of 2 cm at any measurement location and a 200-mL interlimb volume difference were diagnosed with lymphedema. We investigated the difference in quantitative lymphoscintigraphic assessment between the non-lymphedema and lymphedema groups. RESULTS: Quantitative lymphoscintigraphic assessment revealed that the RUA and RRA were significantly lower in the lymphedema group than in the non-lymphedema group. After adjusting the model for all significant variables (body mass index, N-stage, T-stage, type of surgery, and type of lymph node surgery), RRA was associated with lymphedema (odds ratio=0.14; 95% confidence interval, 0.04–0.46; p=0.001). CONCLUSION: In patients in the early postoperative stage after unilateral breast cancer surgery, quantitative lymphoscintigraphic assessment can be used to predict the probability of developing lymphedema.

Falsely Elevated Postvoid Residual Urine Volume in Uterine Myoma

Precise measurement of postvoid residual (PVR) urine volume is a key factor in assessing patients with voiding dysfunction, including those with lower urinary tract problems. The safe and noninvasive ultrasound bladder scan is the preferred mode to measure PVR volume. However, this procedure has a false-positive rate up to 9%, in the presence of ovarian cysts, renal cysts, ascites, or uterine myoma with cystic degeneration. Until now, cystic lesions are known to cause false positivity in ultrasound bladder scanner. However, we encountered falsely-elevated PVR in two cases of non-cystic uterine myomas. We present these cases with detailed radiologic images and volume measurement data.

Phenolic Constituents from the Flowers of Hamamelis japonica Sieb. et Zucc

Hamamelis japonica (Hamamelidaceae), widely known as Japanese witch hazel, is a deciduous flowering shrub that produces compact clumps of yellow or orange-red flowers with long and thin petals. As a part of our ongoing search for phenolic constituents from this plant, eleven phenolic constituents including six flavonol glycosides, a chalcone glycoside, two coumaroyl flavonol glycosides and two galloylated compounds were isolated from the flowers. Their structures were elucidated as methyl gallate (1), myricitrin (2), hyperoside (3), isoquercitrin (4), quercitrin (5), spiraeoside (6), kaempferol 4'-O-beta-glucopyranoside (7), chalcononaringenin 2'-O-beta-glucopyranoside (8), trans-tiliroside (9), cis-tiliroside (10), and pentagalloyl-O-beta-D-glucose (11), respectively. These structures of the compounds were identified on the basis of spectroscopic studies including the on-line LCNMR- MS and conventional NMR techniques. Particularly, directly coupled LC-NMR-MS afforded sufficient structural information rapidly to identify three flavonol glycosides (2 - 4) with the same molecular weight in an extract of Hamamelis japonica flowers without laborious fractionation and purification step. Cytotoxic effects of all the isolated phenolic compounds were evaluated on HCT116 human colon cancer cells, and pentagalloyl-O-beta-D-glucose (11) was found to be significantly potent in inhibiting cancer cell growth.

The Association Between Serum Leptin Levels and Post-Stroke Depression: A Retrospective Clinical Study

OBJECTIVE: To investigate the question of whether serum leptin levels might be associated with post-stroke depression. METHODS: We studied 130 patients who experienced a first episode of stroke of more than three months' duration, without any previous history of depression or speech disorders. Data were collected regarding the patient demographics, depressive mood (Diagnostic and Statistical Manual of Mental Disorders 4th edition [DSM-IV] criteria and Beck Depression Inventory) and serum leptin levels measured by an enzyme-linked immunosorbent assay (ELISA). In addition, the Korean version of Modified Barthel Index (K-MBI) and Korean version of Mini-Mental State Examination (K-MMSE) were used to assess the subjects' independence, in regard to the activities of daily living and cognition. A statistical analysis was performed to determine differences the serum leptin levels between patients with depression and those without depression, and to determine the difference in the MBI and K-MMSE scores between the groups separated according to the serum leptin levels. RESULTS: Higher serum leptin levels were observed in patients with depression, compared with those without depression (38.5 ng/mL [range, 25.1-59.2 ng/mL] vs. 8.2 ng/mL [range, 4.9-17.8 ng/mL]; p30 mg/dL), compared to the other two groups. CONCLUSION: High serum leptin levels are associated with depression after stroke, and patients with elevated serum leptin levels were disadvantaged in regard to functional and cognitive outcomes.

Occipital Condyle Fracture With Isolated Unilateral Hypoglossal Nerve Palsy

Occipital condyle fractures (OCFs) with selective involvement of the hypoglossal canal are rare. OCFs usually occur after major trauma and combine multiple fractures. We describe a 38-year-old man who presented with neck pain and a tongue deviation to the right side after a traffic accident. Severe limitations were detected during active and passive range of neck motion in all directions. A physical examination revealed a normal gag reflex and normal mobility of the palate, larynx, and shoulder girdle. He had normal taste and general sensation in his tongue. However, he presented with a tongue deviation to the right side on protrusion. A videofluoroscopic swallowing study revealed piecemeal deglutition due to decreased tongue mobility but no aspiration of food. Plain X-ray film findings were negative, but a computed tomography study with coronal reconstruction demonstrated a right OCF involving the hypoglossal canal. An electrodiagnostic study revealed evidence of right hypoglossal nerve palsy. We report a rare case of isolated hypoglossal nerve palsy caused by an OCF.

Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012

"Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012" is a 2nd edition of clinical practice guideline (CPG) for stroke rehabilitation in Korea, which updates the 1st edition published in 2009. After 1st stroke rehabilitation CPG, many studies concerning stroke rehabilitation have been published and the necessity for update has been raised. The Korea Centers for Disease Control and Prevention supported the project "Development of Clinical Practice Guideline for Stroke Rehabilitation" in 2012. Thirty-two specialists in stroke rehabilitation from 18 universities and 3 rehabilitation hospitals and 10 consultants participated in this project. The scope of this CPG included both ischemic and hemorrhagic stroke from the acute to chronic stages. The purpose of this CPG is to provide guidelines for doctors and therapists to make a decision when they manage stroke patients and ultimately, to help stroke patients obtain maximal functional recovery and return to the society. "Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012" consists of 'Chapter 1; Introduction of Stroke Rehabilitation', 'Chapter 2; Rehabilitation for Stroke Syndrome, 'Chapter 3; Rehabilitation for Return to the Society', and 'Chapter 4; Advanced Technique for Stroke Rehabilitation'. Both the adaptation and de novo development methods were used to develop this 2nd edition of CPG. The appraisal of foreign CPGs was performed using 'Korean appraisal of guidelines for research and evaluation II' (K-AGREE II); moreover, four CPGs from Scotland (2010), Austrailia (2010), USA (2010), Canada (2010) were chosen for adaptation. For de novo development, articles that were published following the latest foreign CPGs were searched from the database system, PubMed, Embase, and Cochrane library. Literatures were assessed in the aspect of subjects, study design, study results' consistency, language and application possibility in the Korean society. 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. GPP (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.

Treatment Effects of Ultrasound Guide Selective Nerve Root Block for Lower Cervical Radicular Pain: A Retrospective Study of 1-Year Follow-up

OBJECTIVE: To compare the long-term effects and advantages of ultrasound (US)-guided selective cervical nerve root block with fluoroscopy (FL)-guided transforaminal block. METHODS: From March 2009 to November 2012, 162 patients received steroid injections for lower cervical radicular pain. A total of 114 patients fulfilled the inclusion criteria. All procedures were performed by using US or FL. We compared the intravascular injections during the procedure with the effects and functional scales at 3, 6, and 12 months after the procedure between the two groups. Successful treatments occurred when patients obtained significant pain reliefs (as measured by >50% improvements in the verbal numerical scale [VNS] score and >40% improvements in the neck disability index [NDI] score) and reported a patient satisfaction score of 3 or 4 points at 12 months after the injection. Image analysis of intravascular injection and chart review were performed. Logistic regression was performed to reveal the correlations between successful treatments and variables (patient's age, gender, duration of the disease, cause, injection method, and radiologic finding). RESULTS: The VNS and NDI improved 3 months after the injection and continued to improve until 12 months for both groups. But there were no statistical differences in changes of VNS, NDI, and effectiveness between these two groups. The proportion of patients with successful treatment is illustrated as 62.5% in US-guided group and 58% in FL-guided group at 12 months. There were no significant differences between the groups or during follow-up periods. Three cases of the intravascular injections were done in FL-guided group. CONCLUSION: The US-guided selective cervical nerve root blocks are facilitated by identifying critical vessels at unexpected locations relative to the foramen and to protect injury to such vessels, which is the leading cause of reported complications from FL-guided transforaminal blocks. On treatment effect, significant long-term improvements in functions and pain reliefs were observed in both groups after the intervention. However, significant differences were not observed between the groups. Therefore, the US-guided selective cervical nerve root block was shown to be as effective as the FL-guided transforaminal block in pain reliefs and functional improvements, in addition to the absence of radiation and protection vessel injury at real-time imaging.

Effect of Medial Branch Block in Chronic Facet Joint Pain for Osteoporotic Compression Fracture: One Year Retrospective Study

OBJECTIVE: To evaluate the outcomes of medial branch block in facet joint pain for osteoporotic compression fracture and utilize multiple regression, the relationship between their impact on treatment outcome and other factor, such as the radiologic finding, clinical parameters was analyze. METHODS: Fifty-three patients with axial back pain from osteoporotic compression fracture were enrolled. The clinical outcomes were measured by Verbal Numeric Rating Scale (VNS) and Oswestry Disability Index (ODI) before treatment, 2 weeks, 3 months, and 12 months after the medial branch block. Radiographic analysis included measurement of overall sagittal alignment, collapsed vertebral height, and vertebral kyphotic angle. After 12 months, patients' satisfaction was classified to five categories: excellent, good, fair, poor or fail. Statistical analysis of both radiographic and clinical parameters along with treatment outcome was performed to determine any significant correlations between the two. RESULTS: VNS and ODI was improved 2 weeks after the injection and continued to improve until 12 months. Significant improvement with significant pain relief (>40%), functional improvement (>20%), and the patients rated their satisfaction level as "excellent" or "good" at 12 months after the first injection were observed in 78.9%. The radiographic and clinical parameters were not significantly correlated with treatment outcome. CONCLUSION: Our retrospective study demonstrated that the medial branch block provided significant pain relief and functional recovery to the patients with osteoporotic spinal compression fractures complaining of continuous facet joint pain after vertebroplasty or conservative treatment. A placebo-controlled prospective randomized double-blind study should be conducted in the future to evaluate the treatment effects.

Sciatic Nerve Injury Caused by a Stretching Exercise in a Trained Dancer

Sciatic nerve injury after stretching exercise is uncommon. We report a case of an 18-year-old female trained dancer who developed sciatic neuropathy primarily involving the tibial division after routine stretching exercise. The patient presented with dysesthesia and weakness of the right foot during dorsiflexion and plantarflexion. The mechanism of sciatic nerve injury could be thought as hyperstretching alone, not caused by both hyperstretching and compression. Electrodiagnostic tests and magnetic resonance imaging revealed evidence of the right sciatic neuropathy from the gluteal fold to the distal tibial area, and partial tear of the left hamstring origin and fluid collection between the left hamstring and ischium without left sciatic nerve injury. Recovery of motor weakness was obtained by continuous rehabilitation therapy and some evidence of axonal regeneration was obtained by follow-up electrodiagnostic testing performed at 3, 5, and 12 months after injury.

Comparison of Sono-guided Capsular Distension with Fluoroscopically Capsular Distension in Adhesive Capsulitis of Shoulder

OBJECTIVE: To investigate the short-term effects and advantages of sono-guided capsular distension, compared with fluoroscopically guided capsular distension in adhesive capsulitis of shoulder. METHOD: In this prospective, randomized, and controlled trial, 23 patients (group A) were given an intra-articular injection of a mixture of 0.5% lidocaine (9 ml), contrast dye (10 ml), and triamcinolone (20 mg); they received the injection once every 2 weeks, for a total of 6 weeks, under sono-guidance. Twenty-five patients (group B) were treated similarly, under fluoroscopic guidance. Instructions for the self-exercise program were given to all subjects, without physiotherapy and medication. Effects were then assessed using a visual numeric scale (VNS), and the shoulder pain and disability index (SPADI), as well as a range of shoulder motion examinations which took place at the beginning of the study and 2 and 6 weeks after the last injection. Incremental cost-effective ratio (ICER), effectiveness, preference, and procedure duration were evaluated 6 weeks post-injection. RESULTS: The VNS, SPADI, and shoulder motion range improved 2 weeks after the last injection and continued to improve until 6 weeks, in both groups. However, no statistical differences in changes of VNS, SPADI, ROM, and effectiveness were found between these groups. Patients preferred sono-guided capsular distension to fluoroscopically guided capsular distension due to differences in radiation hazards and positional convenience. Procedure time was shorter for sono-guided capsular distension than for fluoroscopically guided capsular distension. CONCLUSION: Sono-guided capsular distension has comparable effects with fluoroscopically guided capsular distension for treatment of adhesive capsulitis of the shoulder. Sono-guided capsular distension can be substituted for fluoroscopic capsular distension and can be advantageous from the viewpoint of radiation hazard mitigation, time, cost-effectiveness and convenience.

Treatment of Dysphagia with Pyridostigmine Bromide in a Patient with the Pharyngeal-Cervical-Brachial Variant of Guillain-Barre Syndrome

A 24-year-old male developed bulbar palsy, ophthalmoplegia, ptosis, and shoulder weakness bilaterally 2 weeks after he had experienced an upper respiratory infection. The electrodiagnostic study demonstrated axonal polyradiculoneuropathy. The repetitive nerve stimulation study (RNS) showed no significant decrement of the compound muscle action potentials (CMAPs). The videofluoroscopic swallowing study (VFSS) showed severe impairment of the pharyngeal phase of swallowing. He was diagnosed as having the pharyngeal-cervical-brachial variant of Guillain-Barre syndrome. The patient's dysphagia was not improved for 3 months. A follow up RNS showed a significant decrement of the CMAPs. Pyridostigmine bromide was tried to improve the dysphagia. The patient showed immediate improvement of his dysphagia on the VFSS after the trial with pyridostigmine bromide. Pyridostigmine bromide was given before each meal for 8 days and he showed continuous improvement of his dysphagia. The follow up VFSS after 3 months showed complete recovery of dysphagia.