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.

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.

Current Situation of Assistive Devices and Appliances Provision for Persons with Cerebral Palsy in Korea / 보건행정학회지

BACKGROUND: The aim of this study was to investigate the current state of the assistive devices and appliances provision system for cerebral palsy patients registered with brain disability. METHODS: From 2003 to 2013, we analyzed the records of cerebral palsy patients who had assistive devices and appliances provisioned at least once in their lives based on National Health Information Database. Patients with cerebral palsy were divided into three groups: infants and toddlers, school age and adolescence, and adults. RESULTS: Data on short leg plastic orthoses, ankle joint orthoses, and wheelchair were mainly analyzed. The types of ankle joint orthoses divided into three categories: limited, 90° limited, and Klenzac. Limited ankle joint orthoses was most frequently supported of the three in all age groups. Powered wheelchair and scooter were most supported to adult patients. When the re-supply duration was evaluated, the duration was suitable to the duration on guideline of regulation of re-supplement according to the related laws in adult patients but not in infants/toddlers and school age/adolescence as the actual re-supplement duration was much shorter than the reference value. CONCLUSION: This study confirmed the pattern of assistive devices and appliances supply differed depending on the age of cerebral palsy patients.

The Nutritional Status and the Clinical Outcomes of Patients With a Spinal Cord Injury Using Nutritional Screening Tools

OBJECTIVE: To assess the nutritional status of Korean patients with spinal cord injury (SCI), identify the predictors of undernutrition, and investigate the relationship between undernutrition and clinical outcomes. METHODS: A retrospective study design was used to determine the nutritional status of 130 patients over 19 years old admitted to the rehabilitation hospital of Yonsei University Health System between June 2015 and February 2017. The nutritional status was assessed using the malnutrition universal screening tool (MUST) and the spinal nutrition screening tool (SNST). The relationship between undernutrition and clinical outcomes was examined by comparing a low-risk group with an at-risk group using a t-test. RESULTS: Among the SCI patients, 70 (50.8%) were confirmed with undernutrition based on the MUST scores, while 60 (46.2%) had undernutrition based on the SNST scores. It was found that undernutrition has an effect on functional outcomes. CONCLUSION: We assessed the undernutrition risk in Korean SCI patients, and found that approximately 50% of the patients were at risk of undernutrition. We also found that undernutrition can affect functional recovery.

Incidence of Cerebral Palsy in Korea and the Effect of Socioeconomic Status: A Population-Based Nationwide Study

PURPOSE: Cerebral palsy (CP) is a neurodevelopmental disorder that causes serious disability. Prematurity and low birth weight (LBW) are known to be the strongest risk factors of CP. While socioeconomic status (SES) has been found to influence the occurrence of CP, prematurity, and LBW, no studies have investigated this effect in Korea. The aim of this study was to evaluate the incidence of CP, prematurity, and LBW in Korea, as well as the effect of SES thereon. MATERIALS AND METHODS: Data were obtained from the National Health Information Database from 2007 to 2013; persons with a history of CP, prematurity, and LBW were investigated by year. SES was defined in accordance with income quintiles, birth regions, and coverage classification. RESULTS: The incidence of CP decreased over the last five years, despite increased rates of prematurity and LBW. CP incidence was significantly lower in affluent groups than in the most deprived group, although this difference disappeared after controlling for confounders. The incidence of CP was significantly higher in medical aid beneficiaries, even after controlling for confounders. CONCLUSION: CP incidence in Korea has decreased over the last five years, despite an increase in high-risk deliveries. Income level had no effect in CP incidence. These results may aid CP management and prevention policies.

Rehabilitation treatment system for the convalescent and maintenance periods

Since rehabilitation treatment does not simply treat a disease, but treats the patient who has a disease, it is not desirable to determine the treatment strategies based soly on the time of onset of a disease. Rehabilitation treatment should involve carefully evaluating the features of the disease and the patient, which requires considerable time. The convalescent (subacute) period requires a system in which rehabilitation treatment for central nervous system diseases can be administered for at least 2 years. In addition, the definitions and details of rehabilitation treatment that can be conducted by a rehabilitation specialist in the convalescent period and those of rehabilitation treatment conducted in the maintenance (chronic) period should be determined in advance, and these steps should be combined with the development of appropriate provisions in the medical insurance system for each period.

Effect of Patient Education on Reducing Medication in Spinal Cord Injury Patients With Neuropathic Pain

OBJECTIVE: To determine whether providing education about the disease pathophysiology and drug mechanisms and side effects, would be effective for reducing the use of pain medication while appropriately managing neurogenic pain in spinal cord injury (SCI) patients. METHODS: In this prospective study, 109 patients with an SCI and neuropathic pain, participated in an educational pain management program. This comprehensive program was specifically created, for patients with an SCI and neuropathic pain. It consisted of 6 sessions, including educational training, over a 6-week period. RESULTS: Of 109 patients, 79 (72.5%) initially took more than two types of pain medication, and this decreased to 36 (33.0%) after the educational pain management program was completed. The mean pain scale score and the number of pain medications decreased, compared to the baseline values. Compared to the non-response group, the response group had a shorter duration of pain onset (p=0.004), and a higher initial number of different medications (p<0.001) and certain types of medications. CONCLUSION: This study results imply that an educational pain management program, can be a valuable complement to the treatment of spinal cord injured patients with neuropathic pain. Early intervention is important, to prevent patients from developing chronic SCI-related pain.

Stepwise Rehabilitation of the Triple Amputee Combined With Dysfunction of the Sound Limb

To find a multiple amputee more severe than a triple amputee is not easy. This is a report of a 36-year-old patient with right knee disarticulation, left trans-femoral amputation and right elbow disarticulation due to peripheral ischemic necrosis, when he was applied vasopressor in septic shock condition. His left hand was also 2nd, 3rd, 4th, and 5th distal interphalangeal joint disarticulation status, and it was more difficult for him to do rehabilitation program, such as donning and doffing the prostheses. For more efficient rehabilitation training program, we first focused on upper extremities function, since we believed that he might need a walking aid for gait training later. After 13 weeks of rehabilitation program, he has become sit to stand and walk short distance independently with an anterior walker. Although he still needs some assistance with activities of daily living, his Functional Independence Measure score improved from 48 to 90 during the course of 13 weeks.

Clinical Significance of Urodynamic Study Parameters in Maintenance of Renal Function in Spinal Cord Injury Patients

OBJECTIVE: To analyze association between urodynamic study (UDS) parameters and renal function in spinal cord injured (SCI) patients with neurogenic detrusor overactivity. METHODS: Patients with a suprasacral SCI, who underwent UDS and radioisotope renogram at least twice between January 1, 2006 and January 31, 2013, were included. UDS (cystometric capacity, reflex volume, compliance, and maximal detrusor pressure) and radioisotope renogram (total effective renal plasma flow [ERPF] of both kidneys) data were collected. The following were conducted to reanalyze any association between reflex volume and ERPF: initial and follow-up results of consecutive evaluations were compared; a mixed-model regression analysis to account for clustered data was conducted to evaluate the association between UDS parameters and ERPF; and finally, a mixed-model analysis type 3 test with data pairs, of which the first evaluation showed involuntary detrusor contraction. RESULTS: A total of 150 patients underwent 390 evaluations which were arranged into 240 pairs of consecutive evaluations, of which 171 had first evaluations with observed involuntary detrusor contraction. The following results were obtained: cystometric capacity was significantly larger and maximal detrusor pressure was significantly lower on follow-up; on univariate analysis, reflex volume and maximal detrusor pressure were significant, and multivariate analysis using these two parameters showed that maximal detrusor pressure is significantly associated with total ERPF; and no significant differences were observed. CONCLUSION: Maximal detrusor pressure should be closely monitored in the urologic management of neurogenic detrusor overactivity in SCI patients. The results also may serve as a reference for regular UDS follow-up.

Effect of Robotic-Assisted Gait Training in Patients With Incomplete Spinal Cord Injury

OBJECTIVE: To determine the effect of robotic-assisted gait training (RAGT) compared to conventional overground training. METHODS: Sixty patients with motor incomplete spinal cord injury (SCI) were included in a prospective, randomized clinical trial by comparing RAGT to conventional overground training. The RAGT group received RAGT three sessions per week at duration of 40 minutes with regular physiotherapy in 4 weeks. The conventional group underwent regular physiotherapy twice a day, 5 times a week. Main outcomes were lower extremity motor score of American Spinal Injury Association impairment scale (LEMS), ambulatory motor index (AMI), Spinal Cord Independence Measure III mobility section (SCIM3-M), and walking index for spinal cord injury version II (WISCI-II) scale. RESULTS: At the end of rehabilitation, both groups showed significant improvement in LEMS, AMI, SCIM3-M, and WISCI-II. Based on WISCI-II, statistically significant improvement was observed in the RAGT group. For the remaining variables, no difference was found. CONCLUSION: RAGT combined with conventional physiotherapy could yield more improvement in ambulatory function than conventional therapy alone. RAGT should be considered as one additional tool to provide neuromuscular reeducation in patient with incomplete SCI.

Application of Ultrasound-Guided Trigger Point Injection for Myofascial Trigger Points in the Subscapularis and Pectoralis Muscles to Post-Mastectomy Patients: A Pilot Study

PURPOSE: To investigate the therapeutic effectiveness of ultrasound (US)-guided trigger point injection for myofascial trigger points (MTrPs) in the internal rotator muscles of the shoulder in post-mastectomy patients. MATERIALS AND METHODS: This pilot study was a non-controlled, prospective, clinical trial. Nineteen post-mastectomy patients with a diagnosis of at least one active MTrP in the subscapularis and/or pectoralis muscles were included. We performed trigger point injections into the subscapularis muscle deep behind the scapula as well as the pectoralis muscle for diagnostic and therapeutic purpose by the newly developed US-guided method. RESULTS: Visual analogue scale and range of motion of the shoulder for external rotation and of abduction showed significant improvement immediately after the first injection and 3 months after the last injection compared with baseline (p<0.05 for both). Duration from onset to surgery and duration of myofascial pain syndrome in the good responder group were significantly shorter than in the bad responder group (p<0.05). Patients did not report any complications related to the procedure or serious adverse events attributable to the treatment. CONCLUSION: In post-mastectomy patients with shoulder pain, US-guided trigger point injections of the subscapularis and/or pectoralis muscles are effective for both diagnosis and treatment when the cause of shoulder pain is suspected to originate from active MTrPs in these muscles, particularly, the subscapularis.

Epidemiologic Change of Patients With Spinal Cord Injury

OBJECTIVE: To evaluate the epidemiologic change of patients with spinal cord injury who were admitted to a Rehabilitation Hospital, Yonsei University College of Medicine, during 1987-1996 and 2004-2008. METHODS: Medical records of 629 patients with spinal cord injury admitted to the Rehabilitation Hospital, Yonsei University College of Medicine, from 2004 to 2008 were collected and reviewed retrospectively. RESULTS: The male-to-female ratio decreased to 2.86:1, the mean age at injury increased, nontraumatic etiology increased, traffic accident remained to be the most common in traumatic spinal cord injury, and falling increased significantly. Tumor was the most common etiology in nontraumatic spinal cord injury, tetraplegia and incomplete injuries occurred more than paraplegia and complete injuries, indwelling catheter was the most common voiding method, and the duration of hospitalization decreased. CONCLUSION: Many trends changed in epidemiology of spinal cord injury.

Usefulness of radial extracorporeal shock wave therapy for the spasticity of the subscapularis in patients with stroke: a pilot study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>There are not many studies about treatment of shoulder spasticity. Although botulinum toxin injection has been reported to be effective for shoulder spasticity, the effectiveness was judged by pain and limited motion change, but not the spasticity itself. Shoulder spasticity is considered to play an important role in hemiplegic frozen shoulder. However, the subscapularis muscle, unlike the pectoralis major muscle, is located deep beneath scapula, where conventional injection is difficult to perform. As extracorporeal shock wave therapy (ESWT) has been reported to be effective for spasticity relief, and we thought spasticity of subscapularis muscle located deep beneath the scapula would be a good candidate for ESWT treatment. This study was to evaluate the beneficial effects of radial ESWT (rESWT) on spastic subscapularis muscle in stroke patients.</p><p><b>METHODS</b>This is an uncontrolled, prospective, unicenter, clinical pilot study. Stroke patients (n = 57; mean age 55.4 years) with spastic shoulders were recruited between June 2011 and February 2012 at the University Rehabilitation Hospital. rESWT was administered to each patient every two or three days for two weeks (five total treatments). Evaluation consisted of 11 measurements for each patient; at the start of each of the five treatments and once per week during the following six weeks. Spasticity was measured at external rotator muscles of the shoulder using the modified Ashworth scale (MAS), and passive range of motion (ROM) of the shoulder in external rotation was recorded. Pain was measured using a visual analogue scale (VAS) during passive ROM of the shoulder in external rotation, and was additionally recorded for patients who preserved cognitive and communicative ability (Pain group).</p><p><b>RESULTS</b>Reduction in MAS and VAS and improvement of ROM during and after rESWT treatments were prominent compared to baseline. The reduction in MAS and VAS and improvement of ROM continued four weeks after the last treatment and the effects of the treatment decreased afterward.</p><p><b>CONCLUSION</b>rESWT will be able to provide stroke patients with an effective and safe procedure for the reduction of spasticity and pain as well as for the improvement of ROM of spastic shoulders.</p>

Depression and Quality of Life in Patients within the First 6 Months after the Spinal Cord Injury

OBJECTIVE: To evaluate the severity of depression, degree of life satisfaction, level of stress, and resilience among patients in the first 6 months after a spinal cord injury (SCI). METHOD: 36 patients with SCI were asked to fill out questionnaires concerning Beck Depression Inventory (BDI), World Health Organization Quality of Life Questionnaire-BREF, Stress Response Inventory, and Connor-Davidson resilience scale. All patients had experienced an SCI within the last 6 months before the commencement of this study. RESULTS: In our study, the patients who experienced the SCI within the last six months had a higher rate of depression (63.9%) and a higher overall level of depression (13.8 points). The unmarried group had a significantly higher quality of life (QOL; p<0.05) when compared with the married group. In the motor complete group, severity of depression and level of stress were higher, whereas QOL was lower than the motor incomplete group (p<0.05). The mean American Spinal Injury Association (ASIA) Motor Score (AMS) was much higher in the non-depressive group (p<0.05) when compared with the depressive group. CONCLUSION: We found the patients within six months after SCI injury had higher rate of depression and higher overall level of depression. Also, patients with motor complete injury had affected significantly on depression, QOL and stress. We found the married patients had poorer QOL and depressive group had lower AMS score of lower extremity. Therefore, there should be emphasis of psychological care who have motor complete injury and are married during the early stage.

Comprehension and Compliance of Medication of Spinal Cord Injured Patients Who Visited to Outpatient Clinic

OBJECTIVE: To investigate the drug compliance and factors that have an influence on drug compliance of spinal cord injured patients. METHOD: From January to June in 2009, spinal cord injured patients who visited our hospital for regular prescription were asked to fill out questionnaires about demographic data, comprehension and compliance of medication. RESULTS: Forty-eight patients completed questionnaires. Thirty-three were male and the rest were female. Twenty were tetraplegic and 26 paraplegic. Twenty-two were completely injured and 26 had incomplete injuries. The level of awareness of names, shapes and effects of medication were 70.8%, 87.5% and 77.1%, respectively. The compliant group that had more than 80% of drug compliance was 38 patients. The non-compliant group that had less than 80% compliance had 10 patients. In respect of compliance of medication, the patients tended to miss the time of administration more than the number of administration. Twenty patients didn't tell their doctors that they hadn't been taking their medication properly. There were no statistically significant differences between drug compliance and the following: patient's age, sex, spinal cord injury type, education level, time elapsed since the injury, number of medication per day, and comprehension of name, shapes and effects of medication. CONCLUSION: Drug compliance of spinal cord injured patients was high. Education on necessity, side effects and usage of medication may be needed to maintain high drug compliance. To investigate the drug compliance and factors that have an influence on drug compliance of spinal cord injured patients.

Noninvasive Respiratory Management for Patients with Cervical Spinal Cord Injury

OBJECTIVE: To verify the safety and clinical utility of noninvasive respiratory management as an alternative method of invasive respiratory management for the patients with cervical spinal cord injury (CSCI) who often present with ventilatory insufficiency (due to inspiratory muscle paralysis) or difficulty in removing airway secretions (because of expiratory muscle weakness). METHOD: Nineteen patients with CSCI (male: 15, female: 4, mean age: 45.6) were recruited. All of the patients were in need of mechanical ventilation due to ventilatory failure or indwelling tracheostomy tube for secretion management. In order to switch from invasive to noninvasive means of respiratory management, expiratory muscle aids such as manual assist or CoughAassist(R) and inspiratory muscle aids such as noninvasive ventilatory support were applied to all candidates. RESULTS: Fifteen out of the 19 patients had indwelling tracheostomy tubes, and the remaining 4 patients were intubated via endotracheal tubes at admission. Through the noninvasive respiratory management, we were able to remove intubation or traheostomy tubes for all of the patients. Eleven patients were able to maintain normal ventilation status without ventilatory support, as time went on. The rest 8 patients were continuously in need of ventilatory support, but they could maintain normal ventilation status by noninvasive method. CONCLUSION: Noninvasive respiratory management is safe and equally effective in treating ventilatory insufficiency or removing airway secretions for patients with CSCI. In cases of long-term ventilator dependency or chronic tracheostomy state, it can be replaced as a creditable alternative to invasive respiratory management.

Comparison between Gugging Swallowing Screen and Other Dysphagia Screening Tests

OBJECTIVE: Screening tests for dysphagia have been introduced to prevent complications arising from dysphagia in stroke patients. Among them, Gugging swallowing screen (GUSS) was proven as an effective screening tests for dysphagia of stroke patients in 24 hours after onset. We compared several screening tests and clinical scales including GUSS. METHOD: Subjects were 37 stroke patients 3 months after onset. GUSS, 3 oz water test, Burke dysphagia screening test (BDST) and Standardized swallowing assessment (SSA) were carried out at bedside. VFS was performed in 24 hours after other studies were done. Functional dysphagia scale (FDS) and Penetration-aspiration scale (P/A scale) were derived from VFS. Clinical scales such as American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) swallowing scale and Clinical dysphagia scale (CDS) were measured to see the correlation between GUSS and another dysphagia scales. RESULTS: GUSS had a sensitivity of 90.9% and a specificity of 69.2%. 3 oz water test had a sensitivity of 81.8% and a specificity of 76.9%. Sensitivity and specificity of BDST were respectively 90.9%, 61.5%. Sensitivity of SSA was 90.9%, specificity 61.5%. Correlation between GUSS and FDS was significant (r =-0.527, p<0.01). Correlation between GUSS and P/A scale also showed significance (r=-0.747, p<0.01). ASHA NOMS swallowing scale and GUSS showed significant correlation (r=0.432, p<0.01). CDS and GUSS showed significant correlation as well (r=-0.815, p<0.01). CONCLUSION: The screening ability of GUSS was equal to other screening tests for dysphagia of stroke patients. Correlations among GUSS and other VFS and clinical scales showed availability of GUSS as a clinical scale for dysphagia.

Open-Set Monosyllabic Speech Perception Test for Preschool Children / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: An open-set monosyllabic speech perception test is necessary, not only to devise habilitation programs but to select candidates and estimate performance in pediatric cochlear implant program. The purpose of this study is to develop a validated open-set monosyllabic speech perception test for preschool children. SUBJECTS AND METHOD: Qualitative test development was based on vocabulary familiarity, syllabic and phonemic frequency, and phonetic balancing between the lists. The devised test lists were applied to 138 normal hearing children and 46 children with cochlear implant to examine the validity and reliability. RESULTS: The final two test lists were made up of 100 items with 260 phonemics. The consequential validity of this devised test was proven by the applied results that the speech perception score of children with implanted devices was significantly lower than that of normal children, when controlling for the length of auditory experience. CONCLUSION: The developed monosyllabic speech perception test is the validated instrument for preschool children. It is sensitive to perceptual characteristics of articulatory function in cochlear implanted children. The validity of this test needs to be enhanced by clinical application and further item analysis.

Increase of Independence in a Hemipelvectomy Patient with a Custom-Molded Supportive Seating and a Cosmetic Prosthesis : A case report

We report a case of hemipelvectomy, which was successfully treated with custom-molded supportive seating and a cosmetic prosthesis. A 32-year-old woman with a history of right traumatic hemipelvectomy, 24 years ago, visited our outpatient clinic for proper prosthetic rehabilitation. After injury, she was not able to use functional prostheses because of persistent skin problems of the hemipelvectomy site. She was able to perform all activities of daily living independently, but had to rely on crutch walking and was not able to sit on an even surface for longer periods of time. With the molded supportive seating the patient was able to perform outdoor activities for up to 10 hours. This case shows an approach in amputee rehabilitation, in which the ultimate goal of prosthetic fitting is not independent walking, but the improvement of independence and hence the improvement of quality of life.