Differential Diagnosis and Management of Abnormal Posture of the Head and Neck

Abnormal posture of the head and neck can happen to anybody from neonates to adults, which requires appropriate interventions according to etiologies. Congenital muscular torticollis is the most common cause of abnormal posture of the head and neck in infancy, where early intervention as soon as possible is critical for better therapeutic outcome. Childhood laterocollis is heterogeneous condition, which needs etiological diagnosis for the proper management. Cervical dystonia is the most common form of focal dystonia and an overview on clinical presentations and therapeutic options including chemodenervation with botulinum toxin injection was provided. Abnormal posture of the head and neck of acute onset could be a sign of serious conditions and needs differential diagnosis.

A Floppy Baby with Congenital Myotonic Dystrophy Complicated with Huge Subgaleal Hematoma Occurring in Non-instrumental Vaginal Delivery

Not only is the concurrence of congenital myotonic dystrophy (CDM) and subgaleal hematoma (SGH) hardly ever seen but also the development of SGH during unassisted vaginal delivery is rare. We report a boy who developed huge SGH in vaginal delivery without any use of vacuum or forceps and later was diagnosed as maternally transmitted CDM. The boy had prenatal history of polyhydramnios and decreased fetal movement. Six hours after birth, severe molding of the skull associated with huge SGH on left parieto-occipital area was recognized by CT scan. At corrected age of two months, he was diagnosed as maternally transmitted CDM. This is the first report of CDM complicated by SGH occurring in non-instrumental vaginal delivery.

A Case of Disappeared Complex Regional Pain Syndrome after Spinal Cord Injury: A case report

The pathophysiology of complex regional pain syndrome is still unkown. Implantation of spinal cord stimulator is generally considered to be a safe and effective procedure. The reported complications are generally minor without serious neurologic deficit. A 21-year-old male patient with CRPS in the right foot had undergone spinal cord stimulator implantation. After the surgery, spinal epidural hemorrhage occurred and he became paraplegic. After spinal cord injury, symptoms of CRPS disappeared. This supports the hypothesis of spinal neuronal sensitization. This case would help to understand pathophysiology of CRPS development.

Congenital Muscular Torticollis in Siblings: A case report and literature review

Congenital muscular torticollis (CMT) is the most common cause of abnormal posture of the head and neck in infancy. Familial transmission of CMT has not been reported in Korean literature, to our knowledge. Four cases with CMT found in siblings are presented in this paper along with the review of literature on hereditary factor as one of the possible mechanisms on pathogenesis of CMT. Further case reports are required in order to verify heredity as a possible pathogenetic factor of CMT.

Usefulness of Uptake Ratio of Three Phase Bone Scintigraphy in Complex Regional Pain Syndrome after a Stroke

OBJECTIVE: To evaluate usefulness of uptake ratio of three phase bone scintigraphy in assessing the complex regional pain syndrome (CRPS) type I in stroke patients METHOD: Forty three stroke patients were diagnosed as CRPS type I based on their symptoms and confirmed by three phase bone scintigraphy. Uptake ratio was calculated by dividing the radioactivity count on the affected side by that on the unaffected side in each phase. Mean uptake ratio was compared among the groups classified by the clinical diagnosis and by the response to treatment. In addition, uptake ratio was compared before and after treatment. RESULTS: Mean uptake ratio of the wrist in blood pool phase was significantly higher than other parts of the body (p<0.05). However, there was no significant difference among the groups classified by the clinical diagnosis nor by the response to treatment. The changes of uptake ratio were variable after treatment, but only the uptake ratio of the wrist in blood flow phase showed correlation with the degree of swelling. CONCLUSION: Uptake ratio of three phase bone scintigraphy was not correlated with clinical findings.

Evaluation of Neurogenic Bladder with Newly Developed Natural-fill Cystometric Device : Cases report

We developed a new, affordable, and easy-to-use natural-fill cystometric device to overcome the limitation of conventional cystometry, long been criticized for being unphysiological. The device was composed of one transurethral catheter, one rectal catheter, two digital manometers, and a portable computer. The transurethral and rectal catheters were connected to manometers, which were then connected to the computer. Three persons with neurogenic bladder were recruited for testing the device. To shorten the test duration, we gave patients 500 ml water before the test. As urine filled inside the bladder, the transurethral and rectal catheters transmitted respectively the intravesical and abdominal pressures to the digital manometers. The pressures were stored within the portable computer and turned into graphs indicating pressure changes. The natural-fill cystometry is thought to be a physiological test that is affordable and convenient because of its simple structure and small size.

Comparison between Natural Filling Cystometry and Conventional Retrograde Filling Cystometry in Patients with Stroke

OBJECTIVE: To compare the personally developed natural filling cystometry (NFC) and conventional retrograde filling cystometry (RFC) METHOD: NFC and RFC were performed on 15 patients with stroke. RESULTS: Patients were classified into three groups according to their usual lower urinary tract symptom. Four patients without urinary symptom did not show any detrusor overactivity or detrusor underactivity during NFC or RFC. Of the nine patients with urinary frequency or urgency, five (55.6%) showed detrusor overactivity during NFC and two (22.2%) during RFC. Two patients with straining showed detrusor underactivity during both tests. CONCLUSION: There was no significant difference of cystometric findings between NFC and RFC in case of patients without urinary symptom or with detrusor underactivity, but those patients with urinary symptom that is suspected of detrusor overactivity showed a more frequent detrusor overactivity during NFC than RFC. Therefore, NFC is thought to be a useful tool in evaluating the neurogenic bladder of stroke patients suspected of detrusor overactivity since it can detect detrusor overactivity which were less detectable in RFC.

A New Method for Vestibulo-Collic Reflex

OBJECTIVE: Vestibulo-collic reflex (VCR) has been thought to be a simple and reliable test in evaluating the vestibular function. But it can only be examined by actively contracting the sternocleidomastoid muscle (SCM) and it would be impossible to conduct the examination without the cooperation of the subject. The aim of this study was to demonstrate a new method for VCR in the absence of the subject's cooperation. METHOD: Records were collected from 20 volunteers. Each subject was properly positioned on the bed with the head flexed, ipsilaterally bent and contralaterally rotated. An active electrode was placed over the belly of the SCM. 100 dB clicks were delivered through headphones. We compared the active contraction and passive positioning of the SCM in terms of the P1 latency and amplitude. RESULTS: Vestibular-evoked myogenic potentials (VEMPs) were recorded without actively contracting the SCMs for all the subjects by using our new method. There was no difference in P1 latency and amplitude between the active contraction and passive positioning of the SCM. CONCLUSION: With our new method, VEMPs can be recorded without actively contracting the SCM. It may be useful for evaluating the vestibular function of children and patients who cannot cooperate.

Quality of Life in Primary Caregivers for the Home-Bound Severe Stroke Patients

OBJECTIVE: To evaluate the level of depression, anxiety and quality of life in primary caregivers for the severe stroke patients. METHOD: We studied a sample of 44 severe stroke patients and their primary caregivers. Functional status of the severe stroke patients was evaluated by Modified Barthel Index (MBI). We collected the data through interviewing the caregivers and using the Beck Depression Inventory (BDI), State- Trait Anxiety Inventory (STAI), Ego-strength scale, Short Form Health Survey-36 (SF-36) and Family APGAR (Adaptation, Partnership, Growth, Affection and Resolve) score. RESULTS: The average level of depression in caregivers was low. The mean socres of STAI were 41.5 for state anxiety and 44.3 for trait anxiety, respectively. Ego-strength scale was significantly inversely related to BDI score and trait anxiety inventory score, but positively related to SF-36 score. The most influencing factor for the SF-36 score was the BDI score. CONCLUSION: Primary caregivers for the home-bound severe stroke patients demonstrated a lower level of quality of life, especially mental health, general health and vitality component. Community based rehabilitation should more focus on the evaluation and support for caregiver's psychologic status and their quality of life.

The Discharge Destination of Rehabilitation Inpatients in a Tertiary Hospital

OBJECTIVE: To identify the factors which can delay home discharges or transfers to other hospitals of rehabilitation inpatients in a tertiary hospital and the change of discharge destination during past 6 years. METHOD: This was a retrospective study of patients with a diagnosis of stroke, traumatic brain injury or spinal cord injury who were admitted to our hospital in 1996, 1999, 2001 and 2003. Demographic data, length of stay, discharge destination and functional status by the FIM(TM) instrument were studied by a medical record review. RESULT: Patients who were transferred to other hospitals or discharged with delay showed significantly lower admission and discharge FIM scores, lower FIM efficiencies, longer length of stays and longer intervals between the onset and admission to a rehabilitation ward. CONCLUSION: Lower functional outcome was associated with a longer length of stay and discharge to another hospital. It would be necessary to establish the long term rehabilitation care facilities with extended rehabilitation program for the patients with lower functional gains in a rehabilitation unit of the tertiary hospitals.

The Measurement of Force and Endurance during Wheelchair Propulsion in Paraplegics Using BTE Work Simulator

OBJECTIVE: To evaluate the force, endurance and influencing factors for wheelchair propulsion in paraplegics using BTE work simulator, and to find out a better method improving fitness levels for the paraplegics. METHOD: Seventeen paraplegic men were enrolled for the study. Isometirc and isotonic strength and dynamic endurance levels for wheelchair propulsion were measured using BTE work simulator. Neurological and demographical characteristics of patients were collected by personal interviews and direct examinations. RESULT: The spinal cord injured level showed a significant correlation with dynamic endurance (r=0.503, p<0.05) but not with the isometric and isotonic strength. The total duration of wheelchair use showed a significant correlation with the isotonic strength (r=0.497, p<0.05), but not with the isometric strength and dynamic endurance. The age and outdoor activities or exercise time during one week showed no significant correlation. CONCLUSION: Spinal cord injured level positively correlated with dynamic endurance. Both cardiorespiratory effect and trunk balance may influence this correlation. The total duration of wheelchair use wasn't correlate with dynamic endurnace. It seems to be more advisable trunk balance training goes with dynamic endurance training in rehabilitation program.

Normative Data and Developmental Characteristics of Hand Function for Elementary School Children in Suwon Area of Korea: Grip, Pinch and Dexterity Study

This study was designed to establish norms of hand function, and to identify developmental characteristics of hand function among the Korean children. 712 elementary school children participated in measurement of grip strength, three kinds of pinch strength, and dexterity. The hand strength of the Korean children appeared to be weaker than that of western children. The grip strength of boys was significantly stronger than that of girls in all ages for both hands. The order of magnitude of three kinds of pinch strength was, in descending order, lateral pinch, palmar pinch and tip pinch for both boys and girls. There was no significant difference of hand function according to the type of hand dominance in boys. However, girls with left hand dominance showed weakness of bilateral grip, right tip pinch, and bilateral lateral pinch strength compared with girls with right hand dominance. In conclusion, this study provided normative data of hand functions including dexterity, and enabled us to identify some developmental characteristics of hand functions for the Korean elementary school children.

Quality of Life and Life Satisfaction of the Registered Disabled Persons in Uiwang City

OBJECTIVE: The purposes of this study were to investigate the factors influencing life satisfaction and quality of life (QOL) of the disabled persons and to help the planning and evaluation of Community Based Rehabilitation (CBR). METHOD: Data were collected through personal interviews of 503 registrated disabled persons in Uiwang City. Demographic variables and scores of modified Barthel index (MBI), modified Lambeth disability screening questionnaire (MLDSQ), Craig handicap assessment and reporting technique (CHART) and life domain satisfaction measure (LDSM) were obtained. RESULTS: The score of LDSM was 4.0+/-1.0. Life satisfaction was related to the age, sex, employment status, severity of disability, educational level, housing and residence, level of instrumental activities of daily living and social integration. MLDSQ score was the most strong predictor of life satisfaction (p=0.00) followed by social integration (p=0.001) and total CHART scores (p=0.017). And the factors influencing the handicap were monthly income, severity of disability, employment, level of education and age. CONCLUSION: Based on our study, we suggest that the CBR program of Uiwang City need to focus on improving functional ability and social skill of disabled individual and housing, and also promoting their vocational and educational status.

Suprascapular Nerve Injury Restricted to the Infraspinatus Muscle by a Ganglion Cyst: A case report

Suprascapular nerve injury restricted to the infraspinatus muscle is an uncommon condition. We present a 29 year-old man who complained of right shoulder pain and weakness for 8 months. Physical examination revealed atrophy of right infraspinatus muscle and T2 weighted MRI of the right shoulder revealed a mass with homogeneous high intensity at the spinoglenoid notch and atrophy of right infraspinatus muscle. EMG study revealed abnormal spontaneous activities and reduced recruitment pattern of motor units in right infraspinatus muscle. Symptoms improved after the excision of a mass which was a ganglion cyst by pathologic examination. We were reporting a case of suprascapular nerve injury restricted to the infraspinatus muscle.

Effects of Psyllium Husk for the Management of Neurogenic Bowel in Chronic Spinal Cord Injured Persons

OBJECTIVE: The purposes were to determine the baseline colon transit time (CTT) and to assess the effect of dietary fiber (psyllium husk) on neurogenic bowel function in chronic spinal cord injured (SCI) persons. METHOD: Eleven chronic spinal cord injured persons with upper motor neuron type neurogenic bowel were participated. Personal interview were carried out for all studied subjects at pre and post treatment period. The baseline colon transit time (CTT) were measured for the right (rCTT), left (lCTT), rectosigmoid (rsCTT) colons as well as for the entire colon using radio-opaque markers. After 4 weeks treatment of psyllium husk, the subjects were reevaluated for their CTTs and the results were compared to the pretreatment values. RESULTS: The mean age of the subjects was 33.9+/-11.0 years and the level of injury ranged from C3 to T10. The mean duration after SCI was 22.6 months (6~47 months). The rCTT, lCTT, rsCTT and tCTT were not affected after the treatment of psyllium husk. Also their bowel care patterns and satisfaction were unaffected by the treatment. CONCLUSION: The results of this study suggest that the use of psyllium husk in chronic spinal cord injured persons do not show the same effect on bowel function as has been previously reported in general population with idiopathic constipation.

The Effect of Body Mass Index on Nerve Conduction Studies

OBJECTIVE: To determine whether there is a difference in nerve conduction studies depend on the body mass index (BMI) of subjects METHOD: Twenty normal healthy volunteers were enrolled for the study. A routine usual sensory and motor nerve conduction study and a sensory nerve conduction study using the near nerve needle technique were performed. BMI was calculated as weight (kg) divided by height (m) squared. In order to evaluate the effect of BMI on the various measure ments of the nerve conduction study, one-way analysis of variance (ANOVA) was used. RESULTS: The sensory nerve amplitudes of median, ulnar and sural nerves correlated significantly (p<0.05) with BMI. However, no correlation was noted between BMI and sensory nerve amplitude by near nerve needle technique. There was no statistical differences noted in the measurements of latency of examined motor and sensory nerves neither the velocity of examined motor nerves. CONCLUSION: In clinical practice, the effect of BMI should be taken into account when the interpretation of abnormal sensory nerve study has to be soli.

The Prevalence of Mental Retardation Among Third Grade Elementary School Children in the Suwon Area, Korea

The purpose of this study was to estimate the prevalence of mental retardation (MR) in Korea. The study population comprised 1,757 third-grade elementary school children residing in a single school district in Suwon, Korea. We conducted the total population survey for 1,537 children who attended one of 5 schools in the district. For the remaining 220 children who did not attend a school in the school district, we found children with MR via inspection of the register list of the disabled. A total of 16 children (7 of the 1,537 children and 9 of the 220 children) were found to have MR, yielding a prevalence of MR of 9.1/1,000. Considering that about 60% of the people with disabilities are registered in Korea, there would be at least 6 unregistered children with MR among the 220 children, so that the prevalence of MR can be estimated at 12.5/1,000 for the Suwon area.

Social Issues of Young Adult Stroke Patients

OBJECTIVE: The purpose of this study is to evaluate the psychosocial factors and outcomes in young adult stroke patients. METHOD: The study group consisted of 59 stroke patients under the age of 45. Retrospective chart reviews of demographic findings, functional status, primary caregiver, marital and child status, discharge destination, employment and psychological difficulties were recorded by rehabilitation team during hospitalization. Telephone and mail surveys were carried out for the functional status, marital status, employment and social factors of the study group after discharge. RESULTS: The proportion of young adult stroke was 13.7% of all stroke patients. Young adult stroke were 20 cases (34%) of cerebral infarction and 39 cases (66%) of cerebral hemorrhage. Of the 39 married patients, 2 couples were separated. The marital adjustment skill was significantly lower in these couples than ordinary couples under age of 45. Forty-two of 51 patients were able to return to their premorbid residence. Of the 39 patients employed at the time of stroke, only 4 (10.3%) were able to return to work after discharge. Two of the 4 patients returned to school after discharge. CONCLUSION: Rehabilitation of young adult stroke patients is associated with variety of social factors including marital adjustment and returning to work.

Intravesical Capsaicin Instillation Therapy for the Management of Hyperreflexic Neurogenic Bladder

OBJECTIVE: The aim of this study was to investigate the efficacy of capsaicin, a neurotoxin for C-fiber afferents, applied intravesically in the treatment of neurogenic bladder with detrusor hyperreflexia (DH). METHOD: Six subjects, three women and three men with traumatic spinal cord injury who had neurogenic bladder manifested with DH and urinary incontinence resistant to oral and intravesical anticholinergic instillation treatment were tried with intravesical administration of capsaicin (1 mmol/l 100 ml) for 30 minutes. Single instillation was given in five subjects and two instillations in one. Maximal detrusor pressure and maximal bladder volume were monitored by the portable cystometer. Follow-up monitor of pressure and volume was recorded after 1 week and every 3 weeks afterwards for 21 weeks, with one exception (31 weeks). RESULTS: Average maximal detrusor pressure decreased by 50.8% and average bladder capacity at maximal detrusor pressure increased by 68% in five subjects after single instillation of capsaicin. Clinical benefit from single instillation lasted over 21 weeks and same as the subject with two instillations. Maximal effect on detrusor pressure appears during 6~9 weeks period and bladder capacity during 9~15 weeks period. Although autonomic dysreflexia in 5 of 6 subjects during instillation and macroscopic hematuria in 2 subjects during the 1st two days were noted, they were resolved spontaneously. CONCLUSION: Single and repeated intravesical instillation of capsaicin were safe and effective in the management of neurogenic bladder with DH in traumatic spinal cord injured patients.

Effects of Plastic Ankle-Foot Orhtosis on Hemiplegic Ambulation

OBJECTIVE: This study was performed to investigate the energy expenditure at self-selected comfortable and fast walking speeds with or without plastic ankle-foot orthosis in hemiplegic patients. METHOD: Objects of this study were 10 ambulatory hemiplegic patients. To estimate oxygen consumption, we used K2 machine and measured gait speed, stride length, stride frequency, and heart rate energy expenditure index (EEI) with or without plastic ankle-foot orthosis. RESULTS: Stride length and gait speed of the hemiplegic patients with plastic ankle-foot orthosis significantly increased at their comfortable walking speed pattern. Oxygen consumption, oxygen cost and EEI significantly decreased in hemiplegic patients with plastic ankle-foot orthosis whether their gait speed pattern. CONCLUSION: The plastic ankle-foot orthosis is useful for the hemiplegic patients to increase walking speed and to reduce energy expenditure.