Feasibility of Extracorporeal Shock Wave Therapy for Complex Upper Limb Morbidity in Breast Cancer Patient

Upper limb morbidity including shoulder pain, lymphedema, adhesive capsulitis, myofascial pain syndrome, and limited range of motions (LROMs) occurs frequently in breast cancer patients. Especially restricted upper limb motion aggravated by chronic lymphedema results in functional limitation and impaired activities of daily living (ADL). However, conventional rehabilitation therapy including complex decongestive therapy and stretching exercise is insufficient for managing advanced breast cancer patients with complex upper limb morbidity. Here, we report a case of breast cancer-related chronic lymphedema in a 62-years old female with severe LROM in all joints of the affected upper extremity that caused severe disability in ADL. Significant improvements in range of motion and upper extremity function were observed after serial extracorporeal shock wave therapy (ESWT), combined with conventional rehabilitation therapy. Therefore, ESWT might be recommended for managing the extensive limited joint motion which causes functional decline in a patient of chronic lymphedema with trophic skin change.

Feasibility of Extracorporeal Shock Wave Therapy for Complex Upper Limb Morbidity in Breast Cancer Patient

Upper limb morbidity including shoulder pain, lymphedema, adhesive capsulitis, myofascial pain syndrome, and limited range of motions (LROMs) occurs frequently in breast cancer patients. Especially restricted upper limb motion aggravated by chronic lymphedema results in functional limitation and impaired activities of daily living (ADL). However, conventional rehabilitation therapy including complex decongestive therapy and stretching exercise is insufficient for managing advanced breast cancer patients with complex upper limb morbidity. Here, we report a case of breast cancer-related chronic lymphedema in a 62-years old female with severe LROM in all joints of the affected upper extremity that caused severe disability in ADL. Significant improvements in range of motion and upper extremity function were observed after serial extracorporeal shock wave therapy (ESWT), combined with conventional rehabilitation therapy. Therefore, ESWT might be recommended for managing the extensive limited joint motion which causes functional decline in a patient of chronic lymphedema with trophic skin change.

The Korean Dysphagia Society (KDS) Position Statement for Oropharyngeal Dysphagia / 대한연하장애학회지

Oropharyngeal dysphagia is a clinical condition caused by various underlying diseases and is characterized by difficulty in swallowing. Diagnosis and treatment of oropharyngeal dysphagia require multidisciplinary consultations. This position statement for oropharyngeal dysphagia was developed by The Korean Dysphagia Society (KDS) to outline its position on oropharyngeal dysphagia. The clinical practice guideline, position statements, a recent meta-analysis, a systematic review, and randomized controlled trials for oropharyngeal dysphagia were all performed. An expert Delphi survey was also done to achieve a consensus of opinion on this position statement. This position statement for oropharyngeal dysphagia aims to help make evidence-based decisions in clinical practice, improve clinical evaluation and manage oropharyngeal dysphagia in Korea.

Isolated musculocutaneous nerve injury following a pedestrian-automobile collision: A case report

@#Isolated musculocutaneous nerve (MCN) lesion is rare and usually associated with direct trauma. Along with the rarity of this condition, other muscles involved in elbow flexion, such as brachioradialis and pronator teres, can mask the weakness induced by the MCN injury and make it difficult to identify it. Here, we report a 17-year-old patient with isolated MCN palsy following a single episode of anterior shoulder contusion. A lack of suspicion for this rare condition delayed diagnosis until 7 months post injury, when atrophy of muscles in the left upper arm became prominent and weakness of the elbow flexors persisted. After 6 months of rehabilitation therapy rather than undergoing surgical exploration, elbow flexor strength was nearly fully recovered but sensory symptoms remained. The mechanism of injury is speculated to be a sudden overloading of the anterior shoulder with extension and external rotation, which overstretched and compressed the MCN within the coracobrachialis muscle where the nerve is relatively fixed. Although isolated peripheral nerve injury is rare, it can be caused by a single episode of vigorous impact. Therefore, even in patients without any external wounds, careful physical examination with suspicion of peripheral nerve injury as one of the differential diagnoses is needed.

Rapid Functional Enhancement of Ankylosing Spondylitis with Severe Hip Joint Arthritis and Muscle Strain

Arthritis of hip joints deteriorates the quality of life in ankylosing spondylitis (AS) patients. Secondary to the articular inflammatory process, the shortened hip-girdle muscles contribute to the decreased joint mobility which may lead to the functional impairment. As the limitation of range of motion (ROM) usually progress slowly, clinicians regard it as a chronic condition and prescribe long-term therapy. However, by short-term intensive multimodal treatment, a 20-year-old man diagnosed as AS with severely limited hip joint ROM who relied on crutches doubled the joint angle and could walk independently only within 2 weeks. The combination included intra-articular steroid injection, electrical twitch obtaining intramuscular stimulation, extracorporeal shock wave therapy, heat, manual therapy, and stretching exercises. The management focused on the relaxation of hip-girdle muscles as well as the direct control of intra-articular inflammation. Hereby, we emphasize the effectiveness of intensive multimodal treatment in improving the function even within a short period.

Ultrasound-guided auriculotemporal nerve block for post-herpetic auriculotemporal neuropathy: A case report

Auriculotemporal neuropathy is a rare aetiology of orofacial pain. A 66-year old female patientpresented with severe, throbbing pain around the right ear after herpes zoster. The pain was consistentwith post-herpetic neuropathy and was not relieved by oral medications. To alleviate neuropathicpain, ultrasound-guided auriculotemporal nerve block was done. The pain was relieved completelyand the patient remained symptom-free until the last follow up at eight months after treatment. Withunderstanding of the anatomy and related symptoms of auriculotemporal nerve, auriculotemporalneuropathy can be controlled by ultrasound-guided auriculotemporal nerve block.

Decrement of Serum Vitamin D Level After Stroke

OBJECTIVE: To investigate the serum vitamin D level and its determinant factors in stroke patients. METHODS: Fifty-one stroke patients who had documented serum level of 25-hydroxyvitamin D(25(OH)D) were included. Patients were divided into subacute (n=23) and chronic groups (n=28). The mean levels of 25(OH)D of the two groups were compared. Correlations between each 25(OH)D level and post-stroke duration were also analyzed. To assess other possible influencing factors, patients were subdivided by ambulation ability and feeding methods for comparison of 25(OH)D level. RESULTS: The mean level of 25(OH)D was significantly lower in the chronic group than in the subacute group (12.3 vs. 16.3 ng/mL; p < 0.05). The serum 25(OH)D level decreased according to the duration after stroke (r=−0.52, p=0.01). Patients with a history of total parenteral nutrition had lower 25(OH)D levels than subjects who had enteral nutrition in the subacute group (7.3 vs. 18.8 ng/mL; p < 0.01). However, the levels of 25(OH)D were not different between the oral feeding and tube feeding groups. Among the chronic group subjects, patients who could walk without assistance had higher 25(OH)D levels than non-ambulatory patients (ambulatory vs. non-ambulatory group; 18.3 vs. 11.3 ng/mL; p < 0.05). CONCLUSION: After stroke onset, serum vitamin D level decreases with time regardless of feeding methods, and total parenteral nutrition may aggravate its deficiency. In terms of long-term care, non-ambulatory patients might be at a higher risk of vitamin D deficiency. Supplementation of vitamin D should be considered especially for stroke patients who are non-ambulatory and on total parenteral nutrition.

Decrement of Serum Vitamin D Level After Stroke

OBJECTIVE: To investigate the serum vitamin D level and its determinant factors in stroke patients. METHODS: Fifty-one stroke patients who had documented serum level of 25-hydroxyvitamin D(25(OH)D) were included. Patients were divided into subacute (n=23) and chronic groups (n=28). The mean levels of 25(OH)D of the two groups were compared. Correlations between each 25(OH)D level and post-stroke duration were also analyzed. To assess other possible influencing factors, patients were subdivided by ambulation ability and feeding methods for comparison of 25(OH)D level. RESULTS: The mean level of 25(OH)D was significantly lower in the chronic group than in the subacute group (12.3 vs. 16.3 ng/mL; p < 0.05). The serum 25(OH)D level decreased according to the duration after stroke (r=−0.52, p=0.01). Patients with a history of total parenteral nutrition had lower 25(OH)D levels than subjects who had enteral nutrition in the subacute group (7.3 vs. 18.8 ng/mL; p < 0.01). However, the levels of 25(OH)D were not different between the oral feeding and tube feeding groups. Among the chronic group subjects, patients who could walk without assistance had higher 25(OH)D levels than non-ambulatory patients (ambulatory vs. non-ambulatory group; 18.3 vs. 11.3 ng/mL; p < 0.05). CONCLUSION: After stroke onset, serum vitamin D level decreases with time regardless of feeding methods, and total parenteral nutrition may aggravate its deficiency. In terms of long-term care, non-ambulatory patients might be at a higher risk of vitamin D deficiency. Supplementation of vitamin D should be considered especially for stroke patients who are non-ambulatory and on total parenteral nutrition.

Changes in Activation of Serratus Anterior, Trapezius and Latissimus Dorsi With Slouched Posture

OBJECTIVE: To compare quantitative muscle activation between erect and slouched sitting postures in the muscles around the scapula, and to investigate the correlation between the angle of thoracic kyphosis and the alteration of muscle activity depending on two different sitting postures. METHODS: Ten healthy males participated in the study. Unilateral surface electromyography (SEMG) was performed for serratus anterior, middle trapezius (MT), and lower trapezius (LT), which are scapular stabilizer muscles, as well as latissimus dorsi. Participants elevated their shoulders for 3 seconds up to 90° abduction in the scapular plane, tilting 30° anterior in the coronal plane. They were told to hold the position for 10 seconds and voluntary isometric contractions were recorded by SEMG. These movement procedures were conducted for three times each for erect and slouched sitting postures and data were averaged. RESULTS: Activities of MT and LT increased significantly more in the slouched sitting posture than in the erect one. There was no significant correlation between kyphotic angle and the area under curve of each muscle. CONCLUSION: Because MT and LT are known as prime movers of scapular rotation, the findings of this study support the notion that slouched sitting posture affects scapular movement. Such scapular dyskinesis during arm elevation leads to scapular stabilizers becoming overactive, and is relevant to muscle fatigue. Thus, slouched sitting posture could be one of the risk factors involved in musculoskeletal pain around scapulae.

Visual Evoked Potential Using Head-Mounted Display Versus Cathode Ray Tube: A Pilot Study

OBJECTIVE: To present a new stimulation method based on the use of a head-mounted display (HMD) during pattern reversal visual evoked potential (PR-VEP) testing and to compare variables of HMD to those of conventional cathode ray tube (CRT). METHODS: Twenty-three normal subjects without visual problems were recruited. PR-VEPs were generated using CRT or HMD stimuli. VEP outcome measures included latencies (N75, P100, and N145) and peak-to-peak amplitudes (N75-P100 and P100-N145). Subjective discomfort associated with HMD was determined using a self-administered questionnaire. RESULTS: PR-VEPs generated by HMD stimuli showed typical triphasic waveforms, the components of which were found to be correlated with those obtained using conventional CRT stimuli. Self-administered discomfort questionnaires revealed that HMD was more comfortable in some aspects. It allowed subjects to concentrate better than CRT. CONCLUSION: The described HMD stimulation can be used as an alternative to the standard CRT stimulation for PR-VEPs. PR-VEP testing using HMD has potential applications in clinical practice and visual system research because HMD can be used on a wider range of subjects compared to CRT.

Energy Expenditures for Activities of Daily Living in Korean Young Adults: A Preliminary Study

OBJECTIVE: To investigate the energy expenditure (EE) of Korean young adults based on activities refined to a deskbound lifestyle. METHODS: Sixty-four healthy office workers aged between 25 and 46 years participated in this study. EE was expressed as metabolic equivalent of task (MET). Participants were evaluated in terms of their EE during physical activities of sleeping (n=22), typing (n=37), folding laundry (n=34), dishwashing (n=32), studying (n=18), mopping (n=35), walking (n=33), stair climbing (n=23), and running (n=29). Volume of oxygen consumption was measured by indirect calorimetry K4b² (COSMED). The results were compared to the established Compendium MET. RESULTS: The MET of activities were: sleeping, 1.24±0.43; typing, 1.35±0.25; folding laundry, 1.58±0.51; dishwashing, 2.20±0.51; studying, 2.11±0.90; mopping, 2.72±0.69; walking at 4 km/hr, 3.48±0.65; stair climbing of five stories, 6.18±1.08; and running at 8 km/hr, 7.57±0.57. The values of typing and mopping were similar to those in the Compendium, whereas those of sleeping, folding laundry, dishwashing, studying, walking, stair climbing and running were different. CONCLUSION: To our knowledge, this estimation of EE in MET during activities of daily living is the first data of young adults in Korea. These data could be used as a reference to modify the guidelines of physical activities for the age group examined in this study.

Hemiparetic Knee Extensor Strength and Balance Function Are Predictors of Ambulatory Function in Subacute Stroke Patients

OBJECTIVE: To identify the potential predictors of ambulatory function in subacute stroke patients, and to determine the contributing factors according to gait severity. METHODS: Fifty-three subacute stroke patents were enrolled. Ambulatory function was assessed by gait speed and endurance. Balance function was evaluated by the Berg Balance Scale score (BBS) and the Timed Up and Go test (TUG). The isometric muscular strengths of bilateral knee extensors and flexors were measured using an isokinetic dynamometer. Cardiovascular fitness was evaluated using an expired gas analyzer. Participants were assigned into the household ambulator group ( or =0.4 m/s) based on gait severity. RESULTS: In the linear regression analyses of all patients, paretic knee isometric extensor strength (p=0.007) and BBS (p<0.001) were independent predictors of gait endurance (R2=0.668). TUG (p<0.001) and BBS (p=0.037) were independent predictors of gait speed (R2=0.671). Paretic isometric extensor strength was a predictor of gait endurance (R2=0.340, p=0.008). TUG was a predictor of gait speed (R2=0.404, p<0.001) in the household ambulator group, whereas BBS was a predictive factor of gait endurance (R2=0.598, p=0.008) and speed (R2=0.713, p=0.006). TUG was a predictor of gait speed (R2=0.713, p=0.004) in the community ambulator group. CONCLUSION: Our results reveal that balance function and knee extensor isometric strength were strong predictors of ambulatory function in subacute stroke patients. However, they work differently according to gait severity. Therefore, a comprehensive functional assessment and a different therapeutic approach should be provided depending on gait severity in subacute stroke patients.

Effectiveness of Commercial Gaming-Based Virtual Reality Movement Therapy on Functional Recovery of Upper Extremity in Subacute Stroke Patients

OBJECTIVE: To investigate the effectiveness of commercial gaming-based virtual reality (VR) therapy on the recovery of paretic upper extremity in subacute stroke patients. METHODS: Twenty patients with the first-onset subacute stroke were enrolled and randomly assigned to the case group (n=10) and the control group (n=10). Primary outcome was measured by the upper limb score through the Fugl-Meyer Assessment (FMA-UL) for the motor function of both upper extremities. Secondary outcomes were assessed for motor function of both upper extremities including manual function test (MFT), box and block test (BBT), grip strength, evaluated for activities of daily living (Korean version of Modified Barthel Index [K-MBI]), and cognitive functions (Korean version of the Mini-Mental State Examination [K-MMSE] and continuous performance test [CPT]). The case group received commercial gaming-based VR therapy using Wii (Nintendo, Tokyo, Japan), and the control group received conventional occupational therapy (OT) for 30 minutes a day during the period of 4 weeks. All patients were evaluated before and after the 4-week intervention. RESULTS: There were no significant differences in the baseline between the two groups. After 4 weeks, both groups showed significant improvement in the FMA-UL, MFT, BBT, K-MBI, K-MMSE, and correct detection of auditory CPT. However, grip strength was improved significantly only in the case group. There were no significant intergroup differences before and after the treatment. CONCLUSION: These findings suggested that the commercial gaming-based VR therapy was as effective as conventional OT on the recovery of upper extremity motor and daily living function in subacute stroke patients.

Effects of Adjuvant Hydrotherapy on Functional Status and Mental Relaxation in Patients with Knee Osteoarthritis: Preliminary Study

BACKGROUND: The aim of this study is to test if adjuvant hydrotherapy with viscosupplement is beneficial on management of pain, stiffness, function, and mental relaxation in knee osteoarthritis (OA). METHODS: Nineteen patients with OA were randomly assigned to hydrotherapy or control groups. All patients received viscosupplement injections once a week for 3 weeks. Hydrotherapy group (n=9) had a spa containing green tea, 3 days a week for 2 weeks. The control group (n=10) received only injections. All patients were assessed at baseline and after the third injection. All were assessed for pain (visual analog scale, VAS), pain severity, and functional status (Western Ontario and McMaster Universities osteoarthritis index, WOMAC), emotional status, quality of life (Euro quality of life health-related quality of life inventory five dimension, EQ-5D), and relative spectral power of alpha waves in electroencephalography (EEG). RESULTS: Both groups reported a statistically significant reduction of pain at the end of treatment and detailed assessment of pain, and function in WOMAC and the relative power of alpha in electroencephalogram showed statistical significant difference only in the hydrotherapy group. However, there were no significant intergroup differences, except for VAS score. CONCLUSION: Adjuvant 2-week hydrotherapy to viscosupplement might have a modest role in the management of pain and functional disability and the mental relaxation in patients with knee OA. Larger, randomized controlled trials with intervention of long term period to determine efficacy in treating knee OA are warranted.

Improvement in Anxiety and Pain After Whole Body Whirlpool Hydrotherapy Among Patients With Myofascial Pain Syndrome

OBJECTIVE: To evaluate the effect of the Whirlpool hydrotherapy on pain and anxiety in chronic myofascial pain syndrome (MPS) patients, compared to the conventional hydrocollator pack therapy. METHODS: Forty-one subjects who have MPS in the upper trapezius muscles without depression were recruited. The patients were randomly assigned into two groups: the whirlpool therapy group whose bodies were immersed in a whirlpool bath at 34degrees C-36degrees C for 30 minutes; the hydrocollator group who took a 30-minute application of a standard hot hydrocollator pack. Patients in both groups received therapy three days a week for 2 weeks and underwent several evaluations at baseline and after treatment. The variables we analyzed during evaluations were as follows: the primary outcome we considered was pain severity using a visual analogue scale. And the secondary outcomes examined included anxiety using the Korean version of the Beck Anxiety Inventory and quality of life (QoL) using the Korean version of the World Health Organization QoL Assessment, Brief Form. All follow-up values were compared with the baseline values. RESULTS: The baseline parameters did not show significant differences between two groups. And after 2-week treatment, both groups revealed significant improvement in anxiety levels and QoL, as well as in pain. However, the improvement on pain (p=0.002) and anxiety (p=0.010) was significantly greater in the whirlpool group, compared to the hydrocollator group. CONCLUSION: The whirlpool hydrotherapy can be used as a more effective therapeutic method to reduce pain and anxiety in chronic MPS patients without depression.

The Effects of Assisted Ergometer Training With a Functional Electrical Stimulation on Exercise Capacity and Functional Ability in Subacute Stroke Patients

OBJECTIVE: To determine if assistive ergometer training can improve the functional ability and aerobic capacity of subacute stroke patients and if functional electrical stimulation (FES) of the paretic leg during ergometer cycling has additional effects. METHODS: Sixteen subacute stroke patents were randomly assigned to the FES group (n=8) or the control group (n=8). All patients underwent assistive ergometer training for 30 minutes (five times per week for 4 weeks). The electrical stimulation group received FES of the paretic lower limb muscles during assistive ergometer training. The six-minute walk test (6MWT), Berg Balance Scale (BBS), and the Korean version of Modified Barthel Index (K-MBI) were evaluated at the beginning and end of treatment. Peak oxygen consumption (Vo2peak), metabolic equivalent (MET), resting and maximal heart rate, resting and maximal blood pressure, maximal rate pressure product, submaximal rate pressure product, submaximal rate of perceived exertion, exercise duration, respiratory exchange ratio, and estimated anaerobic threshold (AT) were determined with the exercise tolerance test before and after treatment. RESULTS: At 4 weeks after treatment, the FES assistive ergometer training group showed significant improvements in 6MWT (p=0.01), BBS (p=0.01), K-MBI (p=0.01), Vo(2peak) (p=0.02), MET (p=0.02), and estimated AT (p=0.02). The control group showed improvements in only BBS (p=0.01) and K-MBI (p=0.02). However, there was no significant difference in exercise capacity and functional ability between the two groups. CONCLUSION: This study demonstrated that ergometer training for 4 weeks improved the functional ability of subacute stroke patients. In addition, aerobic capacity was improved after assisted ergometer training with a FES only.

A Case of Hemiballism in Elderly Stroke Improved by Conventional Rehabilitation Therapy and Low Dose Quetiapine

Hemiballism describes involuntary severe, violent, arrhythmic, rotatory and large amplitude movements of limb from proximal joint. We experienced an elderly stroke patient with hemiballism accompanied dysphagia that persisted for several months severity was evaluated by the Universidade Federal de Minas Gerais Sydenham's chorea rating scale (USCRS) and video fluoroscopic swallowing study (VFSS). In this case, we observed the improvement of hemiballism by conventional rehabilitation therapy and low dose quetiapine. Therefore, we recommend geriatrists considers vthese therapies in elderly patients with hemiballism.

The Effects of Neuromuscular Electrical Stimulation on Cardiopulmonary Function in Healthy Adults

OBJECTIVE: To evaluate the effect of neuromuscular electrical stimulation (NMES) on cardiopulmonary function in healthy adults. METHOD: Thirty-six healthy adults without a cardiac problem were enrolled. All patients were randomly assigned to either a control (17 subjects, mean age 29.41) or an electrical stimulation group (19 subjects, mean age 29.26). The electrical stimulation group received NMES on both sides of quadriceps muscle using a Walking Man II(R) in a sitting position for 30 minutes over 2 weeks. Maximum oxygen consumption (VO2max), metabolic equivalent (MET), resting, maximal heart rate (RHR, MHR), resting, maximal blood pressure (RBP, MBP), and maximal rate pressure product (MRPP), exercise tolerance test (ETT) duration were determined using an exercise tolerance test and a 6 minute walk test (6MWT) before and after treatment. RESULTS: The electrical stimulation group showed a significant increase in VO2max (p=0.03), 6MWT (p<0.01), MHR (p<0.04), MsBP (p<0.03), ETT duration (p<0.01) and a significant decrease in RsBP (p<0.02) as compared with the control group after two weeks. NMES induced changes improved only in RsBP (p<0.049) and ETT duration (p<0.01). The effects of NMES training were stronger in females. CONCLUSION: We suggest that NMES is an additional therapeutic option for cardiopulmonary exercise in disabled patients with severe refractory heart failure or acute AMI.

Therapeutic Exercise Strategies in Patients with Dementia

Numerous studies have reported that physical activity and exercise training has beneficial effects in not only healthy elderly individuals, but also patients with mild cognitive impairment and dementia. Although various types of exercise appear to present positive effect for cognitive function, there is no definite exercise guideline as treatment or disease modifying strategies in dementia. The purpose of current article is to review the literatures related to the effect of exercise on cognitive function and to suggest the therapeutic exercise strategies in patients with dementia. Further prospective, longitudinal investigations using this exercise guideline should be warranted to prove the beneficial effects of exercise on cognitive function in patients with dementia.

Clinical Application of Neurodevelopmental Assessment for Infants and Toddlers

Early detection and intervention is critical in improving prognosis of developmental disorders. Developmental delay can have many different causes and the clinical features of developmental delay are diverse according to its etiologic causes and severity. The vast and rapid growth of the child's neurobehavioral repertoire from birth through adolescence requires the physician's abundant experience, knowledge, and understanding of development. Here, we summarize instruments for use in neurodevelopmental assessment of infants and toddlers, focusing on motor development, which is the most frequent complaint listed in the developmental clinic.