A Comprehensive Rehabilitation Approach in a Patient With Serious Neuropsychiatric Systemic Lupus Erythematosus

Neuropsychiatric systemic lupus erythematosus (NPSLE) involves the central and peripheral nervous system in patients with systemic lupus erythematosus (SLE). It is essential to specify the problems faced by patients with NPSLE because it causes diverse disabilities and impairs quality of life. After performing a comprehensive evaluation, tailored management should be provided for the patient's specific problems. We report here the case of a 30-year-old female with SLE who experienced serious neuropsychiatric symptoms cerebral infarction followed by posterior reversible encephalopathy syndrome and peripheral polyneuropathy. We systemically assessed the patient using the International Classification of Functioning, Disability and Health model as a clinical problem-solving tool and provided comprehensive rehabilitation by focusing on her problems.

Adding Endoscopist-Directed Flexible Endoscopic Evaluation of Swallowing to the Videofluoroscopic Swallowing Study Increased the Detection Rates of Penetration, Aspiration, and Pharyngeal Residue

BACKGROUND/AIMS: Currently, the videofluoroscopic swallowing study (VFSS) is the standard tool for evaluating dysphagia. We evaluated whether the addition of endoscopist-directed flexible endoscopic evaluation of swallowing (FEES) to VFSS could improve the detection rates of penetration, aspiration, and pharyngeal residue, compared the diagnostic efficacy between VFSS and endoscopist-directed FEES and assessed the adverse events of the FEES. METHODS: In single tertiary referral center, a retrospective analysis of prospectively collected data was conducted. Fifty consecutive patients suspected of oropharyngeal dysphagia were enrolled in this study between January 2012 and July 2012. RESULTS: The agreement in the detection of penetration and aspiration between VFSS and FEES of viscous food (kappa=0.34; 95% confidence interval [CI], 0.15 to 0.53) and liquid food (kappa=0.22; 95% CI, 0.02 to 0.42) was "fair." The agreement in the detection of pharyngeal residue between the two tests was "substantial" with viscous food (kappa=0.63; 95% CI, 0.41 to 0.94) and "fair" with liquid food (kappa=0.37; 95% CI, 0.10 to 0.63). Adding FEES to VFSS significantly increased the detection rates of penetration, aspiration, and pharyngeal residue. No severe adverse events were noted during FEES, except for two cases of epistaxis, which stopped spontaneously without requiring any packing. CONCLUSIONS: This study demonstrated that the addition of endoscopist-directed FEES to VFSS increased the detection rates of penetration, aspiration, and pharyngeal residue.

Traumatic Atypical Tetraplegia Without Radiologic Abnormalities Including Magnetic Resonance Imaging in an Adult: A Case Report

Although spinal cord injury without radiographic abnormality (SCIWORA) literally refers to the specific type of spinal cord injury, however, some extents of spinal cord injuries can be detected by magnetic resonance imaging (MRI) in most of cases. We introduce an atypical case of spinal cord injury without radiologic abnormality. A 42-year-old male tetraplegic patient underwent MRI and computed tomography, and no specific lesions were found in any segments of the spinal cord. Moreover, the tetraplegic patient showed normal urodynamic function despite severe paralysis and absent somatosensory evoked potentials from the lower limbs.

Anterior Cervical Osteophytes Causing Dysphagia and Paradoxical Vocal Cord Motion Leading to Dyspnea and Dysphonia

Anterior cervical osteophytes are common and usually asymptomatic in elderly people. Due to mechanical compressions, inflammations, and tissues swelling of osteophytes, patients may be presented with multiple complications, such as dysphagia, dysphonia, dyspnea, and pulmonary aspiration. Paradoxical vocal cord motion is an uncommon disease characterized by vocal cord adductions during inspiration and/or expiration. This condition can create shortness of breath, wheezing, respiratory stridor or breathy dysphonia. We report a rare case demonstrating combined symptoms of dyspnea, dysphonia as well as dysphagia at the same time in a patient with asymptomatic anterior cervical osteophytes. Moreover, this is the first report demonstrating that anterior osteophytes can be a possible etiological factor for paradoxical vocal cord motion that induces serious respiratory symptoms.

Wernicke's Encephalopathy after Sleeve Gastrectomy for Morbid Obesity: A Case Report

Morbid obesity is a curable systemic disease that can cause several complications, including hypertension, diabetes mellitus, and osteoarthritis. However, it is not easy to control solely by conservative management. Bariatric surgeries, such as sleeve gastrectomy and gastric banding, are recently developed treatments that are applied to patients with morbid obesity in Korea. However, gastric surgery can cause surgical or metabolic complications, such as thiamine deficiency, which can lead to Wernicke's encephalopathy. This metabolic complication presents with typical symptoms of confusion, ophthalmoplegia, nystagmus, and ataxia. In this case report, we present a case of Wernicke's encephalopathy, which developed slowly following sleeve gastrectomy in a patient with morbid obesity.

Predictive Value of Test of Infant Motor Performance for Infants based on Correlation between TIMP and Bayley Scales of Infant Development

OBJECTIVE: To assess the relationship of scores on the test of infant motor performance (TIMP), with those on the Bayley scales of infant development (BSID), and to investigate the sensitivity and specificity of TIMP and the optimal cut-off value of TIMP scores using ROC analysis. METHOD: Seventy-six preterm and term infants were recruited from neonatal intensive care units. Subjects were tested with the TIMP at their initial visit and after 6 months, they were tested by using BSID. RESULTS: In the reliability study, TIMP scores showed highly significant correlation with the Bayley physical developmental index (BPDI) (p=0.001) and Bayley mental developmental index (BMDI) (p=0.017). Receiver operator characteristics (ROC) curve analysis was performed to evaluate the TIMP test for screening infant motor development. ROC analysis showed an area under the curve (AUC) of 0.825 (p=0.005) in BPDI and 0.992 (p=0.014) in BMDI, indicating an excellent classification performance of the model. The optimal cut-off value where a sensitivity of 86%, and specificity of 68% were achieved with the TIMP was 1.50 (between average and below average) in BPDI and where a sensitivity of 100%, and specificity of 66% were achieved with the TIMP was 1.50 in BMDI. CONCLUSION: Our results indicate that the TIMP provides a reliable and valid measurement that can be used for the evaluation of motor function in preterm and term infants. TIMP was highly sensitive and specific with the follow-up examination of BSID. Therefore it can be used as a reliable screening tool for neonates and infants aged <4 months.

Two cases of Fabry disease identified in brothers / 소아과

Fabry disease is a rare, X-linked inborn error of glycosphingolipid catabolism caused by a mutation in the gene encoding the alpha-galactosidase A (GLA) enzyme. We report two cases of Fabry disease in a 12-year-old boy who had acroparesthesia and in his elder brother with milder symptoms who were diagnosed by GLA activity assays and the presence of the GLA gene mutation.

Syringomyelia Presenting as Lower Cervical Radiculopathy: A case report

Syringomyelia may present with confusing, unilateral patterns of segmental muscle involvement and dissociated sensory loss. The objective of this study was to report a patient with syringomyelia and Chiari malformation type 1 (CM 1) who had an unusual presentation suggesting lower cervical radiculopathy. A 50-year-old woman presented with clinical evidence of left lower cervical radiculopathy. Nerve conduction studies revealed normal in both motor and sensory nerves of the left upper extremity. Electromyography showed abnormal spontaneous activities in the paracervical muscles at C7-T1 levels and in some examined muscles of the left upper extremity such as abductor pollicis brevis and abductor digiti minimi muscles. Magnetic resonance imaging of cervical spine demonstrated syringomyelia at C4- T4 levels. Syringomyelia may clinically mimic lower cervical radiculopathy.

The Relationship between Lumbar Shape and Lumbar Disc Herniation

OBJECTIVE: We designed this study to investigate the relationship among lumbar disc herniation, vertebral endplate area and shape, and lumbar and sacral parameters. METHOD: 78 experimental patients with low back pain and 27 controls were enrolled. Experimental patients were divided into group A with low back pain without trauma and lumbar disc herniation and group B with low back pain due to lumbar disc herniation without trauma. Controls had low back pain due to recent trauma but no previous history of back pain and lumbar disc herniation. We reviewed MRI (magnetic resonance image) films of these patients with anteroposterior and transverse diameter of endplates, lumbar lordosis angle, and sacral angle. The relationship of these data and sex, age, body weight, height, intervertebral disc herniation, low back pain were statistically studied. RESULTS: Patients' sex, age, body weight, height, vertebral endplate area and shape, lumbar and sacral parameters were not related to disc herniation. But the more circular vertebral shape was, the larger lumbar lordosis angle was. And the larger lumbar lordosis angle was, the less sacral angle was. CONCLUSION: There were no relationships between the development of disc herniation at L4-5, L5-S1 and the shape of the vertebral body at the endplate level.

The Effect of Intrathecal Baclofen Injection on Muscle Stretch Reflex in Spinal Cord Injured Rabbit

OBJECTIVE: To develop an experimental model that is useful to evaluate the effect of antispastic medication administered intrathecally and to titrate the intrathecal baclofen effect quantitatively by using muscle stretch reflex. METHOD: Ten rabbits were laminectomized posteriorly and intrathecal catheter was inserted. Then the spinal cords were contused by 12.5 gx20 cm weight drop around 12th thoracic vertebra. After 8~12 days, muscle stretch reflex was measured before intrathecal baclofen injection (ITBI) and after ITBI 30 minutes, 60 minutes, and 120 minutes. Rabbits' triceps surae were dissected and stretched 5 mm at the rate of 2 mm/sec using a step motor. The change of muscle tension was graphed into the time (length)-tension curve. The slope in the time (length)-tension curve was defined as stiffness index (SI). RESULTS: The measurement of muscle stretch reflex was available in 5 of 10 spinal cord injured rabbits. The proportion of SI reduced significantly at 60 minutes and 120 minutes compared to baseline (p=0.005, p<0.001). CONCLUSION: Our data proved the antispastic effect of ITBI quantitatively by using muscle stretch reflex. We concluded that the quantitative measurement method of the antispastic effect of ITBI will be useful in evaluating antispastic effect by intrathecal administration of the other antispastic medications.

The Changes of Markers of Bone Metabolism and Bone Mineral Densities in Patients with Spinal Cord Injury

OBJECTIVE: In patients with spinal cord injury, it is more susceptible to osteoporosis because bone resorption is more prominent than bone formation. Thus we evaluated the change of biochemical markers and bone mineral densities (BMDs) according to the duration of injury, the spinal cord injury level, and the injury severity. METHOD: The subjects were included 26 patients with spinal cord injury and 22 healthy men. We measured serum osteocalcin and urine deoxypyridinoline (DPYD) in 2 hours after awakening and measured BMDs in lumbar vertebrae, femur, and distal forearm in patients and control group. The patients were 21 men, 5 women, mean age 43.2+/-14.3 years, and mean duration 28.3+/-45.0 months, who were divided by injury level and injury severity respectively. RESULTS: The biochemical markers of bone metabolism in patients group had significant differences comparing to control group (p<0.05). The urine DPYD and BMDs in femur showed significantly negative correlation with the duration of spinal cord injury (p<0.05). CONCLUSION: In patients with spinal cord injury, urine DPYD and BMDs in femur had significant correlation with the duration of injury. But, the injury level and injury severity had no significant correlation with the markers of bone metabolism and BMDs.

The Abnormal Ultrasonographic Findings of Carpal Tunnel in Carpal Tunnel Syndrome

OBJECTIVE: The purpose of this study was to find out what was the diagnostic usefulness of ultrasonography in carpal tunnel syndrome METHOD: Subjects included 30 hands of 25 carpal tunnel syndrome patients and 20 hands of 17 healthy adults with no electrophysiologic evidence of carpal tunnel syndrome. All subjects were examined with real-time ultrasonography. The ultrasonography was evaluated quantitatively with regard to the cross-sectional area and the flattening ratio of the median nerve and the palmar displacement of the flexor retinaculum. The analysis of difference between normal control group and carpal tunnel syndrome group was done by independent t-test. RESULTS: The carpal tunnel syndrome patients group had significantly increased cross-sectional area of the median nerve at distal radio-ulnar joint, pisiform and hamate. The carpal tunnel syndrome patients group had significantly increased flattening ratio of median nerve at hamate. The carpal tunnel syndrome patients group had significantly increased palmar displacement of the flexor retinaculum. CONCLUSION: Based on the result of this study, the ultrasonography is useful in the diagnosis of the carpal tunnel syndrome.

The Effect of an Epidural Corticosteroid Injection on the Early Stage of Bone Metabolism

OBJECTIVE: The purpose of this study is to find out what is the effect of epidural corticosteroid injection on bone metabolism. METHOD: We have assessed the systemic effects of a single epidural triamcinolone acetonide injection on biochemical indices of bone formation and resorption in patients with lumbosacral radiculopathy. Twenty patients who had lumbosacral radiculopathy and free from exposure to corticosteroid for at least 6 weeks were selected for this study. Patients were classifed as two groups; 1) epidural block with 2% lidocaine 3 ml and 0.9% normal saline 15 ml (4 men, 5 women; mean age 47.2+/-7.6 years) and 2) combination of triamcinolone acetonide 40 mg (5 men, 6 women; mean age 49.6+/-8.2 years). Fasting serum and the second voided urine were collected at 0, 1, 3, 7 and 14 days after the single epidural injection for bone-related biochemicalmarkers measurements. RESULTS: 1) Level of serum osteocalcin showed a significant time trend in the epidural corticosteroid injection group. Osteocalcin decreased dramatically from 11.2+/-3.4 ng/ml on day 0 to 5.9+/-2.8 ng/ml on day 1, 6.1+/-1.5 ng/ml on day 3 (p<0.05). After the initial drop, the level recovered to 9.8+/-3.7 ng/ml by day 7, and returned to preinjection level on day 14, at 10.9+/-4.1. 2) Urinary deoxypyridinoline levels did not show any significant changes. CONCLUSION: According to the above results, the epidural injection of corticosteroid may be a better therapeutic mode, with less potential for harmful effects to bone metabolism, in providing effective relief of symptoms to patients with lumbosacral radiculopaties.

Clinical Analysis on the Efficacy of Stellate Ganglion Block in the Patients with Cervical Herniated Intervertebral Disc

OBJECTIVE: The purpose of this study is to evaluate the efficacy of stellate ganglion block for the patients with cervical Herniated Intervertebral Disc (HIVD). METHOD: Forty patients with cervical HIVD were selected for the study. Patients were randomly assigned to one of two groups: Group 1, stellate ganglion block of 1% lidocaine and physical modalities (n=20); Group 2, only physical modalities as a control group (n=20). Group 1 patients were treated with the stellate ganglion block of 1% lidocaine three times over two-week period. The efficacy of stellate ganglion block was assessed with Visual Analog Scale (VAS) on pre- and post-stellate ganglion blocks and with Rubin scale (success rate). RESULTS: The VAS scores of post-block were significantly lower than pre-score (p<0.05) in both groups, but there was no statistically significance between the two groups. After treatment, Rubin scale was with excellent or good in 75% in group 1 and in 50% in group 2, but there was no statistically significance. CONCLUSION: The stellate ganglion block may be effective therapeutic method for patient with cervical HIVD. But the efficacy of additional stellate ganglion block for cervical HIVD remains controversial.

Spontaneous Intraperitoneal Hemorrhage in a Cervical Spinal Cord Injured Patient with Warfarin Therapy: A Case Report

Spontaneous intraperitoneal hemorrhage in the patient who has cervical spinal cord injury and been treated by warfarin, is rarely reported. In general, adverse drug reactions of warfarin were reported as bleeding, cutaneous microvascular thrombosis. A 46-year-old C4 tetraplegia (ASIA A) patient had been treated by warfarin for a treatment and prevention of pulmonary embolism after cardiopulmonary resuscitation. Suddenly, the patient complained dyspnea and abdominal distension and we noticed that his hemoglobin count was very much lower than usual. So, we had the patient to take the abdominal CT and find out there was a bleeding in intraperitoneal area. We did angiography trying to find out the bleeding focus but in vain. We concluded that it was the spontaneous intraperitoneal hemorrhage due to warfarin therapy and we finally made an improvement with the conservative treatment.

Significance of Amplitude and Area Ratio of Compound Muscle Action Potential in Diagnosis of Diabetic Neuropathy

OBJECTIVE: The purpose of this study is to find out whether amplitude ratio and area ratio have correlation with nerve conduction velocity in the diabetes mellitus patients. METHOD: Median and deep peroneal motor nerve conduction study was performed in thirty-five normal control group and sixty diabetes mellitus patients group. The motor conduction velocity, amplitude ratio, and area ratio of the compound muscle action potential (CMAP) were measured. The experimental subjects were divided into 6 subgroups (in median nerve: M1, M2, M3, in peroneal nerve: P1, P2, P3) according to the median value of conduction velocity of each nerve; group M1 (n=35) and P1 (n=30): normal control group, group M2 (n=25) and P2 (n=30): below the median value of motor nerve conduction velocity in diabetes mellitus patients, group M3 (n=23) and P3 (n=29): above the median value of motor nerve conduction velocity in diabetes mellitus patients. RESULTS: There was no significant difference of area ratio between the each subgroups in both median and peroneal nerves. There was a significant difference of amplitude ratio between the M1 and M2 subgroups. There was a significant difference of amplitude ratio between the P1 and P2, P3 subgroups. CONCLUSION: According to above results, the decrease of amplitude of compound muscle action potential along with the decrease of conduction velocity seems to be helpful in the electrophysiologic diagnosis of diabetic neuropathy.

Manual Medicine

Manual medicine is as old as the science and art of medicine itself. Spinal manipulation in manual medicine is widely used as a treatment modality for spinal disorders. But one of the problems as perceived by the medical profession is that the therapy is often treated as a business rather than a science. In addition, its reputation has been blurred by some of its advocates claiming far too much for its effectiveness and using it as a panacea. Another observation is that many patients have been subjected to a prolonged and failed trial of spinal manipulation. It was written with one purpose in mind. The purpose is to give a basic overview of the present day practice and scope of the field of manual medicine. If, in addition, the information thus provided helps reduce certain existing prejudices toward this field.

Characteristics of the Patients with Pain in Rehabilitation Medicine Outpatient Practice

OBJECTIVE: The purposes of this study are to find out the characteristics of patients with pain in outpatient practice of rehabilitation medicine and to provide basic data for outpatient management. METHOD: We surveyed a hundred one outpatient practices with questionnaire including the distribution of diagnosis, pain site, disease related with pain, pain treatment method, etc. RESULTS: 1) Distribution of diagnosis was traumatic brain injury (TBI) 10.5%, stroke 14.8%, spinal cord injury (SCI) 10.8%, musculoskeletal disorder (MSD) 55.8% and others 8.1% in training hospital, and TBI 6.7%, stroke 10.6%, SCI 14.0%, MSD 58.7% and others 10.0% in non-training general hospital, and TBI 2.6%, stroke 4.9%, SCI 2.9%, MSD 78.3% and others 11.3% in private clinic. 2) The most common site of pain was low back area. 3) The most common disease related with pain was myofascial pain syndrome. 4) Trigger point injection and physical therapy were performed for pain treatment in most of outpatient practice, whereas local injection and nerve block were less used. CONCLUSION: We believe that this study's results will provide helpful basic-data for management of outpatient with pain.

Use of Alternative Therapies by Rehabilitation Outpatients with the Musculoskeletal Pain

OBJECTIVE: The purpose of this study is to document the prevalence and patterns of use of alternative therapies and effectiveness in a rehabilitation medicine outpatient practice. METHOD: This study was performed that a random sample of 200 patients of rehabilitation outpatient were given a questionnaire addressing their use of alternative therapies. RESULTS: One or more alternative therapies had been used by 51.3% of subjects for their presenting problem. The most common therapies were acupuncture, oriental medicine, chiropractic and massage. Musculoskeletal pain syndrome involving the low back and shoulder were the most common problems of use of alternative therapies. Of the patients who used alternative treatments, 40.2% reported some degree of efficacy. CONCLUSION: A significant proportion of rehabilitation outpatients use alternative therapies and frequently perceived a benefit from them. Incorporating alternative therapies into physiatric practice is a desirable future direction for the speciality.

The Effect of Spinal Manipulation for Patients with Acute Low Back Pain

OBJECTIVE: To assess the efficacy of spinal manipulation for the patients with acute low back pain. METHOD: Twenty patients with acute low back pain have been received spinal manipulation 3 times per week. The 10-point scale and the distance of the fingertips from the floor on maximum forward flexion (fingertip-flexion test) were checked pretreatment, immediately posttreatment, 2 days posttreatment, 1 week posttreatment, and 2 weeks posttreatment. RESULTS: The results were as follows: 1) The 10-point scale at pretreatment, immediately posttreatment, 2 days posttreatment, 1 week posttreatment, and 2 weeks post-treatment were 10.0+/-0.0, 5.8+/-1.4, 2.2+/-1.0, 1.1+/-0.2, and 1.0+/-0.0, respectively (P<0.01). 2) The fingertip-flexion test at pretreatment, immediately posttreatment, 2 days posttreatment, 1 week posttreatment, 2 weeks posttreatment were 35.4+/-8.4 cm, 22.4+/-7.0 cm, 14.1+/-4.9 cm, 7.4+/-3.6 cm, and 5.4+/-4.6 cm, respectively (P<0.01). CONCLUSION: In our study, the spinal manipulation for the patients with acute low back pain offered significant efficacy and appeared to be a reasonable therapeutic option. But the effectiveness of this method leaves a critical aspect that should be dealt with in future studies.