Defining Physiatry and Future Scope of Rehabilitation Medicine

To identify the 'physiatry' in a single word is difficult. This may be due that physiatry originated from two different fields, physical medicine and rehabilitation and focuses on assisting the general improvement of functional recovery in disabled patients. In addition, physiatry has new markets to develop; health and welfare. Therefore, the identity of physiatry will change depending on how physiatrists act in these fields. We attempt to define the physiatry from several aspects.

Effect of Botulinum Toxin A for Upper Limb Function in Post Stroke Spastic Hemiplegia

OBJECTIVE: Botulinum Toxin A (BoNT-A) is one of the therapeutic methods for the spastic decrement of the upper limb which appears from the patient after stroke. Decrement of stiffness is announced from many studies, but the effect of functional improvement was few examined closely so far clearly. The purpose of this study is to evaluate the effects of BoNT-A for the improvement of upper limb function in post stroke spastic hemiplegia. METHOD: Eleven chronic stroke patients (mean age 44.4 years) were included and injected BoNT-A (Dysport®, Ipsen, UK) according to degree of stiffness of each individual. Motor assessment scale, Box and Block test, Peg board test, Ashworth Scale, manual muscle test, Visual analogue scale, and subject satisfaction were applied at the baseline, and 1 week, 1, 2 and 3 months after interventions. All subjects were also submitted to ongoing rehabilitation therapy. RESULTS: Motor assessment scale results were statistically significant improvements at 1, 2 and 3 months after intervention (p<0.05). Also, statistically significant decreases in muscle tone as determined by the Ashworth scale were found at 1 week, 1, 2 and 3 months after injections (p<0.05). CONCLUSION: Botulinum Toxin A could derive the functional improvements as well as the tone reduction of upper limb in post stroke spastic hemiplegia.

Development of Algorithm for Patient Specific Rehabilitation of Acute Stroke Patient

OBJECTIVE: Team approach for patient-specific rehabilitation for acute stroke patient is important to minimize loss of function and facilitate recovery as well as cost effectiveness. We tried to establish acute stroke rehabilitation algorithm to maximize efficiency of delivering patient-specific and comprehensive rehabilitation in acute stroke patients. METHOD: We developed the clinical algorithms through the informal consensus development process by thorough discussions within the rehabilitation team members. Before and after adoption of the rehabilitation algorithms in clinical activity, we investigated satisfaction of patients and staffs by questionnaire. In addition, length of hospitalization was assessed. RESULTS: Ten algorithms were developed on the general rehabilitation, physical, occupational, and speech therapy, dysphagia, cognitive rehabilitation, nursing care and complication, and psychosocial rehabilitation. Every algorithm was comprised to take care of patients from the acute stage of rehabilitation to long term management. After algorithms to the clinical practice, total mean score of satisfaction was significantly improved in patients and staffs (p<0.05). Mean length of stay for rehabilitation tended to decline without statistical significance. CONCLUSION: Algorithm for patient specific acute stroke rehabilitation could contribute to increase the level of satisfaction among patients and staffs.

Brain Lesions in Conduction Aphasia

OBJECTIVE: To investigate the neuroanatomical correlation of conduction aphasia by analyzing neuroimage data of patients who were diagnosed as conduction aphasia after stroke. METHOD: Nine patients with conduction aphasia after stroke were retrospectively reviewed with their medical records. Language functions of patients were assessed by Korean-version Western Aphasia Battery (K-WAB). Stroke lesions were assessed by brain computed tomography or magnetic resonance images taken within 1 month after onset of stroke. RESULTS: The stroke subtypes were cerebral infarction in 5 patients and intracranial hemorrhage in 4 patients. The lesions were located in left hemisphere in 8 subjects and right hemisphere in 1 subject. The left hemispheric lesion were located in the insula and superior temporal lobe in 3, the inferior parietal lobe in 2, the corona radiate in 1, the basal ganglia in 1 patient and both corona radiata and basal ganglia in 1. The right hemispheric lesion was located in the inferior parietal and superior temporal lobe. CONCLUSION: 6 of 9 patients with conduction aphasia had brain lesions in the path of arcuate fasciculus in the left hemisphere, however, 3 of 9 patients showed other brain lesions. These findings suggested that conduction aphasia could be caused by heterogeneous brain lesions. The characteristic features of conduction aphasia according to diverse brain lesions may need further investigation.

Effects of Robot-assisted Gait Therapy on Locomotor Recovery in Stroke Patients

OBJECTIVE: To investigate the effects of robot-assisted gait therapy on locomotor recovery in hemiparetic patients after stroke. METHOD: Twenty five stroke patients were randomly divided into 2 groups. Robotic training group received 30 minutes of robot-assisted gait therapy, 3 times a week for 4 weeks, while control group received conventional gait training with same duration and frequency as robotic group. Outcome was measured using Motricity index, Fugl-Meyer assessment (FMA), function ambulation category, modified motor assessment scale, 10-meter gait speed, isometric torque, Ashworth scale, gait analysis, body tissue composition, and Beck's depression inventory (BDI). RESULTS: Robotic training group showed significant improvement in motor functions measured by Motricity Index, FMA, 10-meter gait speed, isometric torque of hip compared with the baseline and with those of control group. Ashworth scale of hip, BDI, and muscle mass showed significantly greater improvement in robotic training group than control group. In gait analysis, stride length of unaffected leg demonstrated significant improvement in robotic training group (p<0.05). CONCLUSION: The robot-assisted gait therapy with body weight-support is considered to facilitate locomotor recovery of the hemiparetic stroke patient.

Obturator Externus Bursitis: Cases report

The obturator externus bursa has been described as a potential bursa between the tendon of the obturator externus muscle and the posterior hip capsule. Although pathologic involvement of the iliopsoas bursa by intraarticualr hip disease has been extensively described, obturator externus bursa has not been fully investigated. We describe a patient who presented with hip pain and limited range of motion. Her magnetic resonance imaging of pelvis revealed an enhancing cystic lesion that extends inferomedially displacing obturator externus muscle and mild synovitis of the right hip. She was diagnosed as having obturator externus bursitis, and after symptomatic treatment pain and limited range of motion disappeared. The obturator externus bursa is a potential communication of the hip joint, can be a site of disease spread from the hip joint, and can be identified with magnetic resonance imaging.

Relationship between Cognitive-perceptual Function and Functional Independence in Patients with Ischemic Stroke

OBJECTIVE: To determine the relationship between cognitive-perceptual function and functional independence in stroke patients. METHOD: Thirty-three patients (16 male, 17 female) with first ever ischemic stroke were enrolled. Their mean age was 60.4 years and the mean post-onset duration was 8.1 months. Subjects underwent detailed cognitive assessment including digit span test, line bisection test, Albert test, Wechsler nonverbal memory scale, Korean Hopkins verbal learning Test, Rey complex figure test, and trail making test A. Their functional outcomes were assessed using Functional Independence Measure (FIM) and Modified Barthel Index (MBI). RESULTS: Among the cognitive subtests, Wechsler nonverbal memory scale, Albert test, and Rey complex figure test scores had significant correlation with both FIM and MBI scores. Patients with right hemispheric stroke showed significantly lower scores in line bisection test and Rey complex figure test than those with left hemispheric stroke patients. CONCLUSION: Visuospatial perception and nonverbal memory functions seemed to be two most important cognitive- perceptual domains for functional recovery of stroke patients.

Clinical Usefulness of Computer Assisted Line Bisection Task for the Assessment of Sensory-Attenional Aspect of Visuospatial Neglect

OBJECTIVE: To assess the clinical usefulness of computer- assisted line bisection task for the patients with sensory- attentional visuospatial neglect. METHOD: Forty patients with unilateral hemispheric stroke (25 right, 15 left) and 15 normal age-matched subjects participated in this study. Computer-assisted line bisection task (CALBT) was designed using modified Milner landmark test to assess the sensory-attentional aspect of visuospatial neglect. Accuracy of response and reaction time for the transected lines, and response rate for the bisected lines were measured. Correlation between the results of CALBT and conventional line bisection test and Albert test was evaluated. RESULTS: In patients with right hemispheric lesion, results of CALBT demonstrated shifting of attention to the right hemifield and neglect of the stimulus in the left hemifield. In contrast, patients with left hemispheric lesion showed significantly decreased attention to the right hemifield and shifting of attention to the left hemifield. Performances of CALBT correlated with the line bisection test, but not with the Albert test. CONCLUSION: Computed assisted line bisection task can be used for the quantitative assessment of the sensory attentional aspect of visuospatial attention in patients with unilateral neglect.

Effect of Repetitive Transcranial Magnetic Stimulation in Patients with Intractable Neuropathic Pain: Cases report

Drug resistant neuropathic pain can be relieved by non-invasive new therapy of repetitive transcranial magnetic stimulation (rTMS). Three patients who have been suffered from intractable neuropathic pain with diverse underlying causes were enrolled. The causes of their pain were the thalamic hemorrhage, the complex regional pain syndrome (CRPS) after resection of neurilemmoma, and the trigeminal schwanoma respectively. A thousand pulses of 10 Hz rTMS were delivered over the contralateral primary motor cortex at 80% of resting motor threshold for a period of 20 minutes per each treatment session. The intensity of pain was assessed using a visual analogue scale before and after rTMS session for 5 consecutive days. Immediate and dramatic analgesic effects were noticed as a result of rTMS in patients with thalamic hemorrhage and trigerminal schwanoma. Moderate analgesic effect was noticed in patient with CRPS. The duration of analgesic effect was variable.

Static Posturographic Characteristics during Balance Control under Virtual Moving Surround in Patients with Chronic Ankle Sprain

OBJECTIVE: To investigate static posturographic characteristics during balance control under virtual moving surround (VMS) using force platform and head mount display (HMD) device in patients with chronic ankle sprain as compared with that of normal adults. METHOD: Ten patients with chronic ankle sprain and 24 healthy adults participated. Center of pressure (COP) parameters were obtained for 20 seconds using force platform as total path distance and total sway area in following conditions (1) comfortable standing with opened and closed eyes, (2) VMS delivered using HMD with four different moving patterns. The virtual moving patterns composed of close-far, superior-inferior tilting (pitch), right-left tilting (roll) and horizontal rotation (yaw) movement. RESULTS: No significant difference was found between patients with chronic ankle sprain and healthy adults on comfortable standing with both open and closed eyes. But, patients revealed significantly increased total path distance and sway area of COP on all VMS conditions. CONCLUSION: These results showed that under VMS conditions patients with the weaker balance control problem were more sensitive to balance control than simple comfortable standing conditions with opened and closed eyes.

Plastic Changes of Motor Network after Constraint-Induced Movement Therapy

The effects of short-term constraint-induced movement (CIM) therapy on the activation of the motor network were investigated with functional magnetic resonance imaging (fMRI). Movement of the less-affected arms of five patients was restricted and intensive training of the affected upper limb was performed. Functional MRI was acquired before and after two-weeks of CIM therapy. All patients showed significant improvement of motor function in their paretic limbs after CIM therapy. For three patients, new activation in the contralateral motor/premotor cortices was observed after CIM therapy. Increased activation of the ipsilateral motor cortex and SMA was observed in the other patient. Our results demonstrated that plastic changes of the motor network occurred as a neural basis of the improvement subsequent to CIM therapy following brain injury.

Neural Network for Visuospatial Attention in Patients with Traumatic Brain Injury

PURPOSE: To investigate the brain areas related with the deficit in visuospatial attention in patients with traumatic brain injury (TBI) using functional MRI (fMRI). METHOD: Twenty TBI and fifteen normal subjects were enrolled. The endogenous visuospatial attention task was used as an activation paradigm during fMRI. FMRI was performed on a 3T ISOL Forte scanner. Thirty slices were acquired using a single-shot EPI sequences (TR/TE=3000/ 30 ms, Flip angle 70 degrees, FOV=220 mm, 64x64 matrix, slice thickness 4 mm). The accuracy and reaction time to the attention task were measured during fMRI. Imaging data were analyzed using SPM-99 software. RESULTS: The ratio of accurate responses was lower (p<0.01) and the average reaction time was slower (p<0.01) in the TBI group than the normal group. The fMRI analysis showed more activation in the bilateral prefrontal cortices (the middle and inferior frontal gyri) and less activation in the cingulate gyrus, medial frontal lobe, bilateral temporo- occipital areas, and cerebellum in the TBI group compared with the normal group. CONCLUSION: In TBI patients, impaired visuospatial attention might be resulted from the decreased activity of the cingulate, medial frontal, and temporo-occipital regions accompanied with compensatory hyperactivation of the prefrontal cortex.

Localization of the Motor Nerve Branches and Motor Points of the Hamstring Muscles and Triceps Surae Muscle

OBJECTIVE: To identify the precise locations of the motor branches and motor points of hamstring and triceps surae muscles to the bony landmarks. METHOD: Twenty-eight limbs of 14 adult cadavers were anatomically dissected. The adult cadavers were selected randomly without regard to gender and age. The cadravers which were unable to obtain a neutral position or which received a trauma to the posterior thighs or the lower legs were excluded from the study. The number and location of the motor branches and motor points from sciatic nerve to each hamstirng muscles and from tibial nerve to each triceps surae muscles were identified related to the bony landmarks. Bony landmarks were ischial tuberosity, medial and lateral epicondyles of femur, and medial and lateral malleolli of tibia. The length of femur was defined as the distance from the ischial tuberosity to the intercondylar line of femur and the length of lower leg was defined as the distance from the intercondylar line of femur to the intermalleolar line of tibia. The locations of the muscular branches and the motor points were expressed as the percentage of the length of femur and lower leg. RESULTS: One muscular branch from the sciatic nerve to the semimembranosus muscle and from the posterior tibial nerve to the soleus muscle, and one or two muscular branches to the biceps femoris, semitendinosus, and semimembranosus, medial gastrocnemius, lateral gastrocnemius and soleus muscle were located at 23.0+/-5.7%, 21.0+/-10.5%, 25.0+/-10.3% of the femur from the ischial tuberosity and 2.0+/-6.2%, 4.0+/-3.3% and 10.0+/-3.3% of the lower leg from the intercondylar line of femur. There were one to four motor points in the hamstring and triceps surae muscles. The motor points of biceps femoris, semitendinosus and semimembranosus were located at 33.0+/-7.8%, 28.0+/-14.5% and 48.0+/-19.0% of the femur. The motor points of the medial gastrocnemius, lateral gastrocnemius and soleus were located in 5.0+/-0.6%, 10.0+/-3.0% and 18.0+/-4.3% of the lower leg below the intercondylar line of femur. CONCLUSION: The identification of the locations of muscular branches and motor points related to the bony landmarks from this study would increase the accuracy of the motor branch blocks or motor point blocks to the hamstrings and triceps surae muscles.