Predicting the Effect of Complex Physical Therapy: Utility of Manual Lymph Drainage Performed on Lymphoscintigraphy

OBJECTIVE: To evaluate the utility of manual lymph drainage (MLD) during lymphoscintigraphy (LS) in predicting the effect of complex physical therapy (CPT). METHOD: Forty seven patients were included in this study. MLD was done for 30 minutes after one hour LS image was obtained. 24 patients were followed up for 3~6 months. According to one hour LS image, patients were assigned to visible lymph node or lymphatic vessel group (Either group) and invisible lymph node and lymphatic vessel group (Neither group), and also according to LS changes after MLD, good and poor response group. The limb volume was checked before, and immediately after CPT, and at 1 month and 3~6 months after CPT. The treatment response was evaluated by percent volume reduction (PVR). RESULTS: There were no significant differences in volume reduction between Either group and Neither group. Otherwise, good response group showed significantly greater volume reduction after CPT than poor response group. Mean PVR in the good response group was 37.02% immediately after CPT, 41.2% at 1 month after CPT, and 47.4% at 3~6 months after CPT. Mean PVR in the poor response group was 19.22% immediately after CPT, 13.0% at 1 month after CPT, and 5.21% at 3~6 months after CPT. CONCLUSION: LS changes after MLD reflected the effects of CPT more accurately than one hour LS image.

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.

Gabapentin-induced Neutropenia: A case report

Gabapentin, a novel anti-convulsant, is recently used to manage symptomatic treatment of neuropathic pain. Gabapentin is known to have few side effect profiles such as drowsiness, dizziness, somnolence, and nausea. We experienced a case of neutropenia associated with gabapentin. A 74-year-old man was hospitalized because of left side weakness caused by acute thalamocortical infarction. He complained of tingling sen- sation, aching pain, and dysesthesia on his left side. We prescribed gabapentin to manage his symptoms. Fever developed at 22 days of gabapentin therapy and peripheral blood examination revealed neutropenia. At 2 days after stopping gabapentin, neutrophil counts started to revert.

The Effect of Gabapentin on Muscle Stretch Reflex in Spinal Cord Injured Rabbit

OBJECTIVE: To document the anti-spastic effect and dose-response relationship of gabapentin (GBP) quantitatively using muscle stretch reflex in spinal cord injured rabbits. METHOD: Spinal cords of 25 rabbits were contused by 20 gx20 cm weight drop in the 11th thoracic spine. After 2 weeks, muscle stretch reflex was measured. Triceps surae was dissected and stretched for 5 mm at the rate of 2 mm/sec and the length-tension curve were obtained. The slope in the length-tension curve was defined as stiffness index (SI). After baseline measurement, group I (n=6) received 50 mg/kg GBP IM injection and group II (n=8) received 100 mg/kg GBP IM injection, but control group (n=5) did not. Muscle stretch reflex was measured again after 30 minutes and 60 minutes, and then after sciatic nerve section. Active tension was calculated by subtracting passive tension from total tension. Proportion of SI was calculated by dividing follow-up SI with baseline SI. RESULTS: The proportion of SI of active tension reduced significantly at 30 minutes and 60 minutes compared to baseline (p<0.001, p<0.001). The proportion of SI of active tension in both group I and group II reduced significantly than control group (p=0.041, p<0.001). The proportion of SI of active tension in group II reduced than group I, but it was not statistically significant (p=0.166). CONCLUSION: The GBP reduced significantly muscle stretch reflex in spinal cord injured rabbits and showed dose-response tendency.

Musculoskeletal Causes of Anterior Chest Wall Pain

OBJECTIVE: To investigate the musculoskeletal causes of anterior chest pain and know the prevalencies of the diseases. METHOD: During 4-year periods (1997-2001), 37 patients with anterior chest wall pain was analyzed with regard to the causes of pain and the frequencies of the diseases. RESULTS: 17 patients (45.9%) had systemic diseases and 20 patients (54.1%) had focal joint problems. Systemic disease included the undifferentiated spondyloarthropathy (18.9%), ankylosing spondylitis (13.5%), psoriatic arthritis (2.7%), SAPHO (Synovitis, Acne, Psoriasis, Hyperostosis, Osteitis) syndrome (8.1%), and rheumatoid arthritis (2.7%). Focal joint diseases included costochondritis (10.8%), sterno clavicular inflammatory arthropahty (5.4%), sternoclavicular hyperostosis (2.7%) and infective arthritis (2.7%). Other focal joint problems were pain in sternoclavicular joint with the tenderness and swelling (2.7%), pain in costochondral joint (13.6%), sternoclavicular joint (5.4%), xyphoid process (2.7%) with only focal tenderness. 3 (8.1%) patients had pain in chest wall which had no focal tenderness and swellings on the joint. CONCLUSION: Diverse systemic diseases were identified as causes of the anterior chest wall pain. So physiatrist keep in mind this result and make use of them in diagnostic approaching of the anterior chest pain due to chest wall skeletal involvemen.

Diabetic Muscle Infarction in Diabetes; Three cases report

Spontaneous muscle infarction in diabetic patients is a rare condition that usually occurs in those with advanced diabetic complications. Increased clinical awareness is important for early recognition, particularly in a diabetic patient presenting with a painful thigh or leg swelling. However, the disorder has received little attention in the rehabilitation medicine literature. Magnetic resonance imaging is the diagnostic choice of study, and in the appropriate clinical setting, may obviate the need for a muscle biopsy. We reported three patients with diabetic muscle infarction, review additional reported cases, and discussed the principles of diagnosis and management.

The Long Term Prognosis of Postoperative Femoral Neuropathy

OBJECTIVE: To evaluate long-term prognosis of postoperative femoral neuropathy. METHOD: 15 patients who confirmed as femoral neuropathy by electrodiagnostic study after renal transplantation or abdominal hysterectomy were included in this study. Retrospective chart review and telephone interview of 12 available patients were performed at 36 months on average after operation. Second telephone interview were available in 4 out of 12 patients one year after first telephone interview. After the second telephone interview, we evaluated muscle strength and gait function of them in our labaratory. RESULTS: At immediate postoperative stage (average 16.8 days), knee extensor strength was less than grade III in 8 out of 12 patients. In gait function evaluation, six patients were unable to walk on flat surface. At first interveiw, recovery of muscle strength was excellent in five patients, good in five and fair in two. In gait function, all could walk without walking aids for more than 30 minutes and 9 could run and mount up the stairs. The second follow-up showed functional improvement even after 24 months of onset. The findings of physical examination correlated well with telephone interview. CONCLUSION: Almost all patients who diagnosed as postoperative femoral neuropathy regained near normal motor strength and functional ambulation in the long-term follow-up.

A Quantitative Assessment of Knee Extensor Spasticity Using Isokinetic Dynamometer

OBJECTIVE: To find useful parameters in biomechanical assessment of spasticity. METHOD: Knee extensor muscles of 60 limbs of 47 patients which showed clinical spasticity were stretched by isokinetic dynamometer. Stretch was done with the velocities of 60o/sec, 120o/sec, 180o/sec, 240o/sec. Four parameters [torque onset angle (TOA), peak torque angle (PTA), peak eccentric torque (PET), peak eccentric torque area (PETA)] were measured at each stretch velocity. Then, regression analysis was performed in relationship between each parameter and strech velocity. We analysed the correlation between the slope of each parameter in regression equation and clinical Modified Ashworth Scale (MAS) RESULTS: The slope of TOA and PTA had negative value so that they showed the decreasing trend of their value according to increasing velocity. On the other hand the slope of PET and PETA had positive value which meant that those parameters increased according to increasing velocity. The slope of PET and PETA were correlated statistically. The higher the MAS score was, the larger value of slope of PET, PTEA were noted. CONCLUSION: Peak eccentric torque and Peak eccentric torque area are thought to be useful parameters in biomecha nical assessment of spasticity.

The Effects of Dilution Volume and Muscle Activity on the Paralysis of Gastrocnemius Muscle of Rabbit after Botulinum Toxin A Injection

OBJECTIVE: To evaluate the effects of botulinum toxin A (BT) dilution volume and post- injection exercise with electrical stimulation on muscle paralysis. METHOD: Eighteen New Zealand white rabbits are randomly assigned to 0.1 ml dilution group, 0.5 ml dilution group or control group. Control group did not receive any injection and 10 units of BT was diluted with 0.1 ml (B1) or 0.5 ml (B5) normal saline and injected to the both gastrocnemius muscles. The right lower limbs of experimental groups did not have any treatment after botulinum toxin A injection (B1C, B5C) and left lower limbs had stretching exercise after injection (B1S, B5S) for 2 hours using the pneumatic kicking machine. Electrical stimulation was also applied to the gastrocnemius muscle with the intensity of 20 mA to 30 mA to evoke plantar flexion of ankle joint. Muscle paralysis effect of BT was evaluated with compound muscle action potential (CMAP) amplitude of gastrocnemius muscle with the sciatic nerve stimulation before and 1 week after injection. RESULTS: There were significant CMAP amplitude decreases in all animals after BT injection. There were significant decreases of CMAP amplitudes in B5 group compared with that of B1 group (p<0.001). Left limbs with stretching exercise and electrical stimulation showed lower CMAP amplitude (p=0.01) compared with right limbs which did not have any treatment after BT injection. CONCLUSION: To maximize muscle paralysis effect of the botulinum toxin A, increasing dilution volume and performing post-injection stretching exercise with electrical stimulation are considered a good strategy.