Impact of Cognitive Function on Functional Recovery during Rehabilitation in Patients with Stroke

OBJECTIVE: Cognitive dysfunction is an important factor on functional recovery after stroke. This study investigated the relationship between functional outcome and cognitive status during rehabilitation after stroke. METHOD: This retrospective study included 80 patients with rehabilitation program after first-ever stroke. The independent variables were mini-mental status examination (MMSE) and computerized neurocognitive function test (CNT). The dependent variables were modified Barthel index (MBI), Berg balance scale (BBS), National Institute of Health Stroke Scale (NIHSS) and discharge destination. The correlation analysis was applied. RESULTS: Mean interval from onset to rehabilitation program was 29.5 days and duration of inpatient rehabilitation program was 31.1 days. Mean score of initial MMSE was 20.5 and CNT showed abnormal performance in at least one of the domain specific tests in all patients. The scores of MMSE, MBI, NIHSS and BBS were improved after rehabilitation program (p<0.05). Cognitive improvement contributing to the functional recovery were significant in the early participants in rehabilitation and in older patients (p<0.05). The home-discharge group demonstrated higher scores in executive function tests (p<0.001). Visual attention, visual working memory and reasoning revealed significant correlation with the MBI score at discharge. CONCLUSION: The results of present study suggest that cognitive function, especially attention and working memory, is a predictor of functional outcome after stroke rehabilitation.

Development of Korean Academy of Medical Sciences Guideline for Rating Physical Disability of Upper Extremity

While the lower extremities support the weight and move the body, the upper extremities are essential for the activities of daily living, which require many detailed movements. Therefore, a disability of the upper extremity function should include a limitation of all motions of the joints and sensory loss, which affects the activities. In this study, disabilities of the upper extremities were evaluated according to the following conditions: 1) amputation, 2) joint contracture, 3) diseases of upper extremity, 4) weakness, 5) sensory loss of the finger tips, and 6) vascular and lymphatic diseases. The order of 1) to 6) is the order of major disability and there is no need to evaluate a lower order disability when a higher order one exists in the same joint or a part of the upper extremity. However, some disabilities can be either added or substituted when there are special contributions from multiple disabilities. An upper extremity disability should be evaluated after the completion of treatment and full adaptation when further functional changes are not expected. The dominance of the right or left hand before the disability should not be considered when there is a higher rate of disability.

Correlation of Pain Drawing Patterns with Electrophysiological Findings in Carpal Tunnel Syndrome

OBJECTIVE: To evaluate the association between neuralgic pain distribution and the severity of carpal tunnel syndrome (CTS). METHOD: Pain drawings using computerized pain chart system were collected from 131 patients (213 hands) with CTS. The presence and severity of CTS were determined by means of median motor and sensory nerve conduction studies. The severity was divided into 3 classes on the basis of electrophysiological findings: mild (93 hands), moderate (70 hands) and severe (50 hands). The similarities between pain drawing patterns and median nerve dermatome in the hands were evaluated. The pain distributions of the palmar and dorsal sides of each five fingers, palm and dorsum of hand were also evaluated. RESULTS: There were no significant differences in similarity values of pain distribution among the groups of CTS hands divided by severity: similarity values were 0.22+/-0.14 in mild CTS patients, 0.24+/-0.16 in moderate CTS patients and 0.27+/-0.14 in severe CTS patients. In the CTS patients, the pain drawings showed relatively frequent distributions in the palmar side of 2nd to 4th fingers. CONCLUSION: There was no significant correlation between pain drawing patterns and severity of CTS. The pain drawings of patients with CTS indicate distribution to be most frequent in the palmar side of 2nd to 4th fingers.

Development of the Korean Version of Modified Barthel Index (K-MBI): Multi-center Study for Subjects with Stroke

OBJECTIVE: To develop a Korean version of Modified Barthel Index (K-MBI) for subjects with stroke and to test the reliability and validity of K-MBI. METHOD: Six senior physiatrists translated the 5th version of MBI into K-MBI and we administered K-MBI to 30 subjects with stroke. Fifteen different examiners working at the 5 different university hospitals evaluated video-recorded examination cases independently to test the reliability and validity of K-MBI. We analyzed intra- and inter-rater reliabilities of the K-MBI by the Kendall's coefficient of concordance and Spearman's correlation coefficients, respectively. Cronbach's alpha coefficient was used for assessing internal consistency of the K-MBI and Spearman's correlation between the K-MBI and Brunnstr?m stage was employed to evaluate the validity of the K-MBI. RESULTS: The intra-rater reliabilities of physiatrists, resident physicians of rehabilitation medicine and occupational therapists were 0.93~1.00, 0.87~0.99, and 0.97~1.00 (p< 0.01), respectively. The inter-rater reliabilities were 0.93~0.98 (p<0.01) and Cronbach's alpha was 0.84 (p<0.01) as the internal consistency reliability of K-MBI. For construct validation study, each item of K-MBI had significant correlation with total score of K-MBI (r=0.54~0.78, p< 0.01). CONCLUSION: The K-MBI is a reliable and valid instrument for measuring functional status of subjects with stroke.

Anatomical Considerations of Lateral and Medial Antebrachial Cutaneous Nerves

OBJECTIVE: To evaluate the anatomic course of the lateral antebrachial cutaneous nerve (LABCN) and medial antebrachial cutaneous nerve (MABCN) in the forearm. METHOD: We dissected 29 upper extremities of 16 cadavers for LABCN and 20 upper extremities of 15 cadavers for the MABCN. We measured the distance (BT_L) between the biceps tendon (BT) and LABCN on the intercondylar line. The BT is the point at which biceps tendon crosses intercondylar line. The distance (L12) between LABCN and the point of 12 cm distal to BT on the line between BT and radial artery at wrist was measured. The distance (ME_M) between MABCN and medial epicondyle on the intercondylar line was measured. M8 and M10 are the distances between MABCN and the points 8 cm and 10 cm distal to BT on the line from BT to mid-point of flexor carpi radialis and palmaris longus at the wrist respectively. RESULTS: BT_L and L12 were 1.4+/-3.7 mm and 4.4+/-3.7 mm respectively. ME_M, M8 and M10 were 28.6+/-6.9 mm, 18.9+/-8.9 mm and 18.3+/-8.2 mm respectively. The thickness of LABCN and MABCN was 19.1+/-4.9 mm and 13.2+/-4.2 mm respectively. CONCLUSION: The LABCN was emerge just lateral to biceps tendon at the elbow and ran down to radial artery. The anatomic course of MABCN was variable at the elbow and forearm.

Intramuscular Hemangioma Mimicking Myofascial Pain Syndrome: A Case Report

Intramuscular hemangioma, an infrequent but important cause of musculoskeletal pain, is often difficult to establish the diagnosis clinically. This report describes a case of a 32-yr-old woman who presented with severe left calf pain for 10 yr. Initial conservative treatments consisting of intramuscular electrical stimulation, herb medication, acupuncture, and intramuscular lidocaine injection under the diagnosis of myofascial pain syndrome in other facilities, failed to alleviate the symptoms. On physical examination, there was no motor weakness or sensory change. Conventional radiography of the leg revealed a soft tissue phlebolith. Conventional angiography study showed hemangioma. Intramuscular hemangioma within the soleus muscle was confirmed by magnetic resonance imaging. Following surgical excision of the hemangioma, the patient's symptom resolved completely. Intramuscular hemangioma is a rare cause of calf pain and should be considered in the differential diagnosis if a patient with muscle pain, particularly if associated with a soft tissue mass, fails to respond to conservative treatment.

A Weight Loading Device as a Method for Assessment of Unilateral Knee Pain

OBJECTIVE: To identify the effectiveness of a weight loading device as a method for assessment of unilateral knee pain. METHOD: Twenty-five patients with unilateral knee pain and 25 pain-free controls participated in this study. Patients with a score of 2 or more on modified Kellgren-Lawrence scale based on the radiologic findings were diagnosed as degenerative arthritis. We constructed a device of segmental foot plates with strain gauge weight sensors to measure the weight load of each leg during self-selected walking speed. Using this device, we obtained the ratio of symptomatic side to asymptomatic side of weight load (RATIO) for each patient. The degree of pain according to visual analogue scale (VAS), abnormalities in radiologic findings, and weight load ratio were compared with each other. RESULTS: The RATIO was 1.00+/-0.03 in the control group, and 0.92+/-0.08 in the patient group (p<0.05). In the patient group, there was a significant correlation between RATIO and the VAS score (r=-0.44, p=0.03). In the patient group with degenerative arthritis, the RATIO (p=0.75) and VAS (p=0.94) were not different from those in patient group without degenerative arthritis. CONCLUSION: The foot plate weight loading device may be an effective tool for convenient measurements of knee pain.

The Influence of the Median Nerve Length on the Diagnosis of Carpal Tunnel Syndrome

OBJECTIVE: To evaluate the influence of the length of the median nerve in the diagnosis of carpal tunnel syndrome (CTS). METHOD: Inching test of median sensory nerve using Ten Electrodes was performed in 114 hands of 68 CTS patients and 68 hands of 34 controls. The abnormal cut-off values of 1-cm, 2-cm, 3-cm, 4-cm, 5-cm, 6-cm, and 7-cm segment studies were calculated as the maximal conduction delay per centimeter (maximal CD/cm)+SD x 2 for each segment in controls. Based on such values, the sensitivity of each segment study in the CTS group and the specificity in controls were obtained. RESULTS: In controls, mean CD/cm was 0.20+/-0.08 ms, and maximal CD/cm was 0.26+/-0.08 ms in the segment between 2 and 3 cm distal to distal wrist crease. With the abnormal cut-off value set at 0.26 ms, the sensitivity of the 1-cm segment study was 98.5% in CTS. The sensitivities of the 2-cm through 7-cm segment studies were 93.9%, 93.9%, 92.4%, 92.4%, 92.4%, and 90.9%, respectively. CONCLUSION: These suggest that studies of longer nerve segments tend to lower the sensitivity of the test because the inclusion of the unaffected segments in calculation attenuates the effect of conduction delay at the site of the lesion.

The Correlation between Plasma Leptin Concentration and Adiposity in Obesity

BACKGROUND: Obesity can be considered as hyperaccumulation of body fat. Therefore, the aim to treat obesity is to decrease body fat. Abdominal total fat calculated in computed tomography is thought to be the most accurate index measuring body fat. The body mass index (BMI) and body fat mass are the representative indices also. Leptin is a protein hormone expressed by obesity gene in adipose tissue. It inhibits food intake and increases energy consumption, thereby controls obesity. With a study of relationship between plasma leptin level and body mass index and abdominal total fat area, we tried to find the usefulness of leptin as an index of adiposity. METHODS: The adiposity level was approximated by BMI, computed tomography and bioelectical impedence. To further explore the relationship with body composition, body fat distribution was determined by computed tomograph. To quantify the relationship between serum leptin level and adiposity, correlation analyses have been conducted. RESULTS: The subjects were 32 females with a BMI of over 25 kg/m2. The mean plasma leptin level was 14.2 5.9 ug/L. We investigated the correlation of plasma leptin level with subcutaneous and visceral fat. The plasma leptin level showed a significant correlation with BMI and body fat mass, and was significantly correlated with subctaneous fat (P<0.01), but not with abdominal visceral fat. CONCLUSION: A significant correlation between plasma leptin level and body fat mass was observed. The distribution of subcutaneous fat showed differences in plasma leptin level. Therefore, the plasma leptin level may be used as an index of change of body fat mass, especially subcutaneous fat.

Knee Pain: Pain Patterns of Myofascial Pain Syndrome and Degenerative Arthritis

OBJECTIVE: To evaluate the pain patterns of patients with osteoarthritis (OA) of the knee. METHOD: Forty-four patients (mean age 56.1 years) with pain around the knee who met the Simons' criteria for myofascial pain syndrome (MPS). Patients drew in their pain areas on a pain drawing diagram. The pain areas were input into the Pain Chart System (PCS) software program for analysis. Physical examination, trigger point injection, and exercises for knee muscles were performed. Oral analgesics were not prescribed. RESULTS: MPS was clinically diagnosed in all 44 patients. Radiologic examination revealed degenerative changes in 49 knees. Pain patterns detected by the PCS revealed pain patterns compatible with myofascial trigger point in the vastus medialis in 37 cases, rectus femoris in 32 cases, adductor longus in 5 cases, sartorius in 2 cases, vastus lateralis in 1 case, and the popliteus in 1 case. Following treatment, 36 of the 44 patients experienced pain relief. CONCLUSION: Degenerative changes of the joint seem not to be cause of the knee joint pain. Instead, pain relief following MPS treatment indicates the cause of knee pain as MPS. We recommend that the first step in the treatment for knee pain include recognition and treatment of MPS before applying invasive treatment.

The Reliability of Patient Pain Drawings Using 3D Virtual Human Body System

OBJECTIVE: The purpose of this study was to evaluate the reliability of patient pain drawings using a 3-dimensional (3D) virtual human body system. METHOD: Pain drawings were collected from thirty-four patients with various types of musculoskeletal pain. On the first clinic visit, patients were instructed to draw in their pain areas on a diagram depicting the body (P1). The examining physiatrist, blinded to the patients drawing, also drew in the pain areas on a separate diagram based on thorough history taking (D). After 2 to 9 days without treatment, patients repeated their pain drawings (P2). A second physiatrist input each of the pain drawings into thePain Chart System (PCS), for comparison of pain distribution sites and areas among the three drawings. The weighted-sum of comparison algorithms was calculated for similarity determinations between drawings. RESULTS: The similarity values between P1 and P2, and P1 and D were 0.63+/-0.18 (mean+/-S.D.) and 0.62+/-0.18 (mean+/-S.D.), respectively, reflecting a high reliability of pain drawings. CONCLUSION: High test-retest and inter-individual reliability of successive pain drawings suggest that pain drawings may be a useful tool to describe the painful sites.

Tenelectrodes: a New Stimulator for Inching Technique in the Diagnosis of Carpal Tunnel Syndrome

This study was designed to evaluate the usefulness of a new multielectrode stimulator, TenElectrodes, in the diagnosis and localization of the compression site in the wrists of carpal tunnel syndrome (CTS) patients. Antidromic inching technique (IT) of the median nerve at the wrist was performed with the TenElectrodes, on 46 controls and 21 CTS patients. In controls, mean conduction delay per centimeter (CD/cm) was 0.21 milliseconds (ms), and maximal CD/cm was 0.27 ms in the segment 3 to 4 centimeters distal to the distal wrist crease. The abnormal cut-off value, calculated as the maximal CD/cm + 2SD, was 0.45 ms. In the CTS group, the maximal CD/cm was 0.56 ms in the segment 2 to 3 centimeters distal to the distal wrist crease, and the CD/cm values in all segments between the distal wrist crease and 4 cm distal to the distal wrist crease were greater than 0.45 ms. Antidromic IT using TenElectrodes may be an easy, fast and accurate method as the electrodes of the stimulator are aligned at 1-cm intervals and are adjustable to the wrist contour by springs.

The Effects of Vibration Baths on Abdominal Fat and Blood Lipid Profile in Obese Women

BACKGROUND: Abdominal obesity is recognized as an important risk factor of metabolic diseases and atherosclerosis. The purpose of this study was to investigate the effects of vibration baths on abdominal fat and blood lipid profiles in obese women. METHODS: From Apr. to Jun 2000, the 32 obese women received vibration baths for 4 weeks (30 minutes/day, repeated 5 times per week). The people were divided randomly into two groups, the case (n=17) and the control (n=15) group. The case group received vibration baths (55 Hz) and the control group took baths only. Body weight, height, body mass index (BMI), body fat distribution, lipid profiles, and blood pressures were measured in all subjects immediately before and after 4 weeks of the study. The body fat distribution was assessed by CT scan by which both total abdominal and visceral fat areas were measured at the level of the umbilicus. RESULTS: After 4 weeks, 13 subjects remained in both groups, respectively, and the total abdominal and visceral fat area decreased significantly in the case group compared from those of the control group. There were no significant differences in body weight, body fat mass, serum lipid profiles, and blood pressures before and after the baths in the two groups. CONCLUSIONS: These results suggest that vibration baths is effective in decreasing abdominal fat. But there were no significant weight change, the effect is insufficient in obesity treatment goal.

Evaluation and Management of Chronic Pain

Chronic pain is a self-sustaining, self-reinforcing, and self- regenerating process. It persists beyond 3~6 months regardless of initial diagnostic category. It is not a symptom of an underlying acute somatic injury but rather, a destructive illness in its own right. It is an illness of the whole person and not a disease caused by the pathological state of an organ system. Chronic pain is persistent, long-lived, and progressive. Pain perception is markedly enhanced. Pain related behaviour becomes maladaptive and grossly disproportional to any underlying noxious stimulus, which usually has healed and no longer serves as an underlying pain generator. The purpose of this paper to present an approach to the prevention of chronic pain and disability, and to provide the clinician with potentially useful tools for the recognition of individuals at risk for chronic illness for whom multidisciplinary treatment is indicated.

Local Botulinum Toxin Type A Injection for the Management of Congenital Muscular Torticollis

OBJECTIVE: To evaluate the effectiveness of local intramuscular botulinum toxin type A injection in patients with congenital muscular torticollis. METHOD: Six patients (mean age, 13.3 months) with congenital muscular torticollis who did not respond to physical therapy were participated with the informed consent of their parents. Twenty-five to fifty Speywood units of Dysport (Beaufour Ipsen, France) were injected into the palpated mass of the sternocleidomastoid muscle. The angle of tilt and range of motion of the neck in sitting position were obtained before and after injection. The size of the mass within the sternocleidomastoid muscle was measured with ultrasonogram. RESULTS: Satisfactory improvement of 3 parameters at post- injection 6-month follow-up was achieved in all patients. The tilting angle and range of motion of the neck to rotation were normalized in 5 patients. The size of the mass within the sternocleidomastoid muscle was decreased significantly with ultrasonographic evaluation. CONCLUSION: Local intramuscular BTA injection might be effective for patients with congenital muscular torticollis who do not respond to conservative management.

Ultrasound and Pathologic Findings of Nodules in the Medial Hamstring Muscle of the Rabbit: Experimental Study for Myofascial Pain Syndrome

OBJECTIVE: To establish the objective method of diagnosing the myofascial pain syndrome through diagnostic ultrasound and pathology. METHOD: Hamstring muscles of 7 female house rabbits, weighing 2.5~3.0 Kg, were studied. The existence of nodule was confirmed by palpation and through diagnostic ultrasound. A horizontal length, vertical length, thickness, and an area of hyperechoic region were measured. Hyperechoic regions were biopsied and stained with hematoxylin-eosin. RESULTS: All examined rabbits had muscular nodules in the medial hamstring. Characteristic increase of echogenecity was observed in the medial hamstring muscles. Some uneven hyperechoic areas were seen in the lateral hamstring muscles. Fatty degeneration and giant round cells were observed in the medial hamstring where the echogenecity was increased. The giant round cells were observed only in the lateral hamstring. CONCLUSION: Increased echogenecity of the medial hamstring muscle is probably contributed by muscles cells with fatty degeneration and giant round cells, and some portions of hyperechogenecity of lateral hamstring requires further study.

Usefulness of Current Withdrawal Threshold on Evaluation of the Neuropathic Pain in Animal Model

OBJECTIVE: To evaluate usefulness of the current withdrawal threshold (CWT) on evaluation of the neuropathic pain in animal model. METHOD: Surgical neuropathy was induced in 40 Sprague-Dawley rats. Fourteen days after the surgery, neuropathic rats were evaluated by von Frey hair. The CWT was determined by various stimulus intensities which induce the tail-withdrawal response or vocalization of rats. The experimental group was compared with the control group by CWT. Then the experimental group was subdevided to two groups. The experimental group 1 was injected with beta-methasone 0.1 mg/kg, intra-peritoneally and experimental group 2 was injected with normal saline with the same amount as steroid. The CWT of two experimental subgroups were measured before and 30 minutes after injections. RESULTS: The experimental group showed significant decrease of the CWT compared with the control group after the neuropathic pain was induced. The CWT of experimental group 1 was increased after steroid administration (p<0.01). CONCLUSION: This preliminary study suggests that the measurement of CWT would be an useful tool to study the neuropathic pain in experimental animal model.

Diagnosis of Carpal Tunnel Syndrome by Diagnostic Ultrasound

OBJECTIVE: To evaluate the usefulness of the diagnostic ultrasound (US) to diagnose carpal tunnel syndrome (CTS) and the correlation between electrodiagnosis and US findings. METHOD: Forty hands of 30 patients diagnosed with CTS by electrodiagnosis and 28 hands of 19 controls were examined with US. The 7.5 MHz probe of the US was used to view the median nerve in the carpal tunnel. The short and the long axis and the area at the two points, 2 cm proximal and 1 cm distal to the distal wrist crease were measured. The flattening and compression ratio and the ratio of the area in both groups were analysed. The correlation between the eletrodiagnostic severity and compression ratio were analyzed. RESULTS: The compression ratio of CTS was significantly increased comparing with that of control group. The compression ratio of severe CTS was significantly increased comparing with that of mild and moderate CTS. CONCLUSION: These results suggest that US is useful in diagnosis of CTS.

New Instrument to Measure the Stiffness of the Finger Joints; StifMeter

OBJECTIVE: To examine the stiffness of finger joints with StifMeter among the patients with rheumatoid arthritis and to calculate the absolute value of the stiffness with a unit of power and to compare the values of the StifMeter with visual analog scale about stiffness (VASstiff). METHOD: Subjects were 53 rheumatoid arthritis patients (male 8, female 45) with disease duration at least 6 months. StifMeter was made up of 10 graded springs of a same spring-constant. Stiffness and pain by VAS and StifMeter, finger circumference and pinch strength were measured at outpatient clinic as well as questionaire, prospectively. Laboratory data were reviewed from medical records to verify the state of disease. We compared StifMeter with VASstiff and VASpain. RESULTS: Mean score of StifMeter was 5.59 on the right side and 5.53 on the left. The corrected values of the StifMeter with a unit of power were 0.01684 on the right side and 0.01672 on the left side. VASstiff score was positively correlated with that of StifMeter. The older the age, the higher the score of VASstiff that was positively correlated with that of StifMeter. The longer the duration of disease, the higher the score of VASstiff that was positively correlated with that of StifMeter. CONCLUSION: StifMeter is a semi-objective method which may be of value in the measurement of finger joint stiffness.

Quantitative Measurement of Current Perception Threshold in Carpal Tunnel Syndrome

OBJECTIVE: To compare current perception threshold with nerve conduction study, we measured current perception threshold (CPT) in healthy control and patients with carpal tunnel syndrome (CTS). METHOD: Twenty control subjects and twenty patients with CTS were included. Latency and amplitude of median and ulnar motor and sensory nerves were measured. The sensory current perception threshold was measured at the distal interphalangeal joint of third and fifth fingers and the palm with electrical current of 5 Hz, 250 Hz, and 2,000 Hz in frequency. We compared the results of the nerve conduction study with the data of the CPT. RESULTS: We found that measuring of the sensory threshold might detect carpal tunnel syndrome, especially with 2,000 Hz and 250 Hz stimulation and that CPT data correlated to sensory latency and amplitude of the median nerve. CONCLUSION: The sensory threshold test might be useful for diagnosis and follow up test in carpal tunnel syndrome.