Complex regional pain syndrome type II caused by iatrogenic lateral dorsal cutaneous nerve injury: A case report.

RATIONALE: Complex regional pain syndrome (CRPS) is a painful condition classified as type I or II depending on the absence or presence of nerve injury, respectively. Injury to the lateral dorsal cutaneous nerve (LDCN), a branch of the sural nerve, is a rare occurrence observed after a sprain or procedures conducted on the lateral side of the ankle. PATIENT CONCERNS: A 38-year-old female, who had undergone prolotherapy for a sprain in the lateral side of the left ankle 3 months ago, presented with persistent causalgia and dysesthesia around the injection site. DIAGNOSIS: An electrodiagnostic study was conducted, which confirmed that the patient had peripheral neuropathy of the left LDCN. Considering the digital infrared thermal imaging and three-phase bone scan findings and the clinical presentation, the condition was diagnosed as CRPS type II due to iatrogenic LDCN injury according to the Budapest diagnostic criteria for CRPS. INTERVENTIONS: The patient was treated with steroid pulse therapy, physical therapy, and transcutaneous electrical nerve stimulation, as well as nonsteroidal anti-inflammatory drugs, pregabalin, and tricyclic antidepressants. OUTCOMES: After 1 month of treatment, allodynia of the left foot persisted, but the pain reduced from 6 points to 3 points on the numeric rating scale. Partial recovery of amplitude and conduction velocity was confirmed in the follow-up electrodiagnostic study. LESSONS: LDCN injury should be considered in patients who complain of persistent lateral ankle and foot paresthesia or pain after sprain or procedures performed on the lateral side of the ankle. Early diagnosis and treatment can lead to a good prognosis when the LDCN injury has progressed to CRPS.

Feasibility of segmental bioelectrical impedance analysis for mild- to moderate-degree breast cancer-related lymphedema: Correlation with circumferential volume measurement and phase angle.

ABSTRACT: Segmental multi-frequency bioelectrical impedance analysis (s-MFBIA) has been adopted recently to evaluate the volume of breast cancer-related lymphedema (BCRL). This procedure uses the segmental phase angle (s-PhA) as an indicator of cellular integrity. In the smaller-built Asian population, the BCRL often has a small volume difference and can be overlooked by tape circumference volume measurement (TVM). This study aimed to investigate the clinical feasibility of s-MFBIA for the assessment of lymphedema severity compared with TVM and evaluate the association between lymphedema severity and cellular integrity of the affected arm based on s-PhA values for a patient with mild- to moderate-degree BCRL.Segmental PhA and extracellular water (ECW)/total body water (TBW) ratio of bilateral arms were measured using InBody S10, an s-MFBIA device, in 128 BCRL patients. Inter-limb volume ratio was measured using TVM. The inter-limb ECW/TBW ratio was correlated with inter-limb volume ratio. Inter-limb ECW/TBW ratio and inter-limb volume ratio were then correlated with inter-limb PhA ratio to demonstrate the association between lymphedema severity and arm cellular integrity.The inter-limb ECW/TBW ratio and inter-limb volume ratio were positively correlated (r = 0.654, P < .001). The same result was obtained after adjusting for age, body mass index, postoperative survival, and duration of lymphedema (r = 0.636, 0.653, 0.652, and 0.648, P < .001). The inter-limb PhA ratio demonstrated significant negative correlation with inter-limb ECW/TBW ratio and inter-limb volume ratio (r = -0.896, -0.562, P < .001).s-MFBIA has high consistency with the conventional TVM method, and its relation to cellular integrity by segmental PhA enables better understanding of the cellular state of the affected limb in mild- to moderate-degree BCRL. Therefore, it is clinically feasible for severity assessment and monitoring of mild- to moderate-degree BCRL in smaller-built Asian patients.

Comprehensive Respiratory Muscle Training Improves Pulmonary Function and Respiratory Muscle Strength in Acute Stroke Patients.

PURPOSE: To evaluate the effects of respiratory muscle training (RMT) on pulmonary function, respiratory complications, and stroke-related disabilities in patients with acute stroke. METHODS: One hundred twenty-two subjects with stroke admitted to the stroke rehabilitation center of Inje Hospital between August 2016 and May 2018 were recruited. After the initial exclusion, the remaining patients were assigned to the RMT group (36 patients) or the standard rehabilitation (SR) group (28 patients who did not undergo RMT). A total of 44 patients completed the study, with 22 patients in each group. The RMT program consisted of air-stacking exercise, manually assisted coughing, inspiratory and expiratory muscle strengthening, cough exercises, and respiratory reeducation. Pulmonary function and respiratory muscle strength were evaluated before commencement and after 1 mo of RMT. The Functional Ambulation Category score, Korean version of the Modified Barthel Index, Shoulder Abduction and Finger Extension score, and handgrip power were assessed. The incidence of pneumonia was also evaluated. RESULTS: Both pulmonary function and respiratory muscle strength significantly improved in both groups. However, differences (%) in the RMT group was greater for all parameters of pulmonary function and respiratory muscle strength. Respiratory complications at 1 yr were significantly lower in the RMT group (P = .016). CONCLUSION: Four weeks of comprehensive RMT in patients with acute stroke resulted in significantly greater improvements in both pulmonary function and respiratory muscle strength than SR. Therefore, RMT has the potential to reduce post-stroke respiratory complications.

Compressive peroneal neuropathy by an intraneural ganglion cyst combined with L5 radiculopathy: A case report.

RATIONALE: Most cases of foot drop are known to result from lower motor neuron pathologies, particularly lumbar radiculopathy and peripheral neuropathy, including common peroneal neuropathy. To improve the prognosis of foot drop, it is important to quickly and accurately diagnose the etiology and provide appropriate treatment. PATIENT CONCERNS: A 65-year-old female patient with a history of L4-5 intervertebral disc herniation presented with right foot drop that had developed 1 month previously. DIAGNOSIS: Electrodiagnostic examination revealed common peroneal neuropathy combined with L5 radiculopathy, with the former being the main cause of the foot drop. MRI of the right knee was performed to identify the cause of the peroneal nerve lesion, which revealed an intraneural ganglion cyst in the common peroneal nerve. INTERVENTIONS: The patient was treated by ultrasound-guided percutaneous cyst aspiration and corticosteroid injection into the decompressed ganglion, followed by strengthening exercise, electrical stimulation therapy, and prescription of an ankle foot orthosis. OUTCOMES: We confirmed regeneration of the injured peroneal nerve at the follow-up electrodiagnostic examination 12 weeks after the intervention. In addition, the manual motor power test demonstrated an increase in the ankle dorsiflexor function score by one grade. LESSONS: Diagnosing the cause of foot drop can be difficult with multiple co-existing pathologies, and consideration of various possible etiologies is the key for appropriate diagnosis and treatment. In addition to imaging modalities such as MRI, electrodiagnostic examination can help to improve diagnostic accuracy. Intraneural ganglion cyst of the common peroneal nerve is rare, but should be considered as a possible cause of foot drop.

Characteristics and Clinical Course of Dysphagia Caused by Anterior Cervical Osteophyte.

OBJECTIVE: To investigate swallowing characteristics of patients with dysphagia caused by anterior cervical osteophytes (ACOs) and compare clinical courses according to treatment options. METHODS: A retrospective analysis of 1,866 videofluoroscopic swallowing studies (VFSS) of patients with ACOs from electronic medical records was performed. Patients with other diseases that could explain the dysphagia were excluded. Dysphagia characteristics and severity and clinical and radiological characteristics of subjects with ACOs were evaluated. Dysphagia characteristics and clinical course were compared among three treatment groups: surgical treatment, swallowing rehabilitation, and conservative treatment. RESULTS: Subjects were 22 men and 1 woman with a mean age of 78.69±8.01 years. The mean osteophyte thickness was 9.07±3.84 mm. It was significantly thicker in the surgical group than that in other groups (p=0.01). ACOs were most frequently found at C5 level. This level also had the thickest osteophytes. However, videofluoroscopic dysphagia scales (VDS) were not significantly different among the three treatment groups. The pharyngeal phase score of the VDS was significantly higher in the surgical group (p=0.041). Dysphagia severity was decreased significantly in the surgical group at 3 months after the initial VFSS (p=0.004). CONCLUSION: The main swallowing characteristics in patients with ACOs were dysphagia features of the pharyngeal phase, including inappropriate airway protection, decreased laryngeal elevation, and reduced epiglottis inversion. When determining treatment options, it may be helpful to consider dysphagia severity at pharyngeal phase and osteophyte thickness.

Botulinum Toxin-A Injection in the Treatment of Spasticity in a Infantile-Onset Neurodegeneration With Brain Iron Accumulation: A Case Report.

Pantothenate kinase-associated neurodegeneration (PKAN) is a neurodegenerative disorder characterized by iron accumulation in the globus pallidus (GP) of the brain (neurodegeneration with brain iron accumulation [NBIA]), which is characterized by dystonia and spasticity resulting in postural difficulties. A 33-month-old boy was admitted with a pronounced gait disturbance. Marked hypertonicity in the patient's both calf muscles was noted, resulting in waddling with repeated slip-falls. NBIA was suspected by high T2 intensity in the GP on brain MRI, then it was confirmed by detecting PANK2 mutation. Botulinum toxin-A injection was administered to both calf muscles. After 2 weeks, a decrease in spasticity and an increase in range of motion were observed, and consequently, an increase in the patient's gait stability with both heels touching the ground, enabling him to walk straight independently. A definitive treatment for NBIA has not been established, and a symptomatic therapy is currently the mainstay of treatment in this case. This is the first case report of botulinum toxin injection for treatment of gait disturbance caused by spasticity in an infantile-onset PKAN.

Efficacy of Aquatic Treadmill Training on Gait Symmetry and Balance in Subacute Stroke Patients.

OBJECTIVE: To determine the efficacy of aquatic treadmill training (ATT) as a new modality for stroke rehabilitation, by assessing changes in gait symmetry, balance function, and subjective balance confidence for the paretic and non-paretic leg in stroke patients. METHODS: Twenty-one subacute stroke patients participated in 15 intervention sessions of aquatic treadmill training. The Comfortable 10-Meter Walk Test (CWT), spatiotemporal gait parameters, Berg Balance Scale (BBS), and Activities-specific Balance Confidence scale (ABC) were assessed pre- and post-interventions. RESULTS: From pre- to post-intervention, statistically significant improvements were observed in the CWT (0.471±0.21 to 0.558±0.23, p<0.001), BBS (39.66±8.63 to 43.80±5.21, p<0.001), and ABC (38.39±13.46 to 46.93±12.32, p<0.001). The step-length symmetry (1.017±0.25 to 0.990±0.19, p=0.720) and overall temporal symmetry (1.404±0.36 to 1.314±0.34, p=0.218) showed improvement without statistical significance. CONCLUSION: ATT improves the functional aspects of gait, including CWT, BBS and ABC, and spatiotemporal gait symmetry, though without statistical significance. Further studies are required to examine and compare the potential benefits of ATT as a new modality for stroke therapy, with other modalities.

Thoracic Radiculopathy due to Rare Causes.

Thoracic radiculopathy represents an uncommon spinal disorder that is frequently overlooked in the evaluation of thoracic, or abdominal pain syndrome. The clinical representation of this uncommon disorder is often atypical. With many differential diagnoses to consider, it is not surprising that the cause of thoracic radiculopathy is often not discovered for months, or years, after the symptoms arise. We report two rare cases of thoracic radiculopathy; one case was caused by extraskeletal Ewing sarcoma (EES) along the thoracic paraspinal area, and the other by foraminal stenosis, due to a bony spur of the thoracic vertebra. As such, thoracic radiculopathy should be considered in the diagnosis of patients with thoracic and abdominal pain, especially if initial diagnostic studies are inconclusive.

Analysis of Vertical Ground Reaction Force Variables Using Foot Scans in Hemiplegic Patients.

OBJECTIVE: To analyze the differences in the vertical ground reaction force (GRF) variables of hemiplegic patients compared with a control group, and between the affected and unaffected limbs of hemiplegic patients using foot scans. METHODS: Patients (n=20) with hemiplegia and healthy volunteers (n=20) underwent vertical force analysis. We measured the following: the first and second peak forces (F1, F2) and the percent stances at which they occurred (T1, T2); the vertical force impulse (VFI) and stance times. The GRF results were compared between the hemiplegic patients and control individuals, and between the affected and unaffected limbs of hemiplegic patients. Additionally, we analyzed the impulse of the unaffected limb according to the motor assessment scale (MAS), Brunnstrom stage, and a Timed Up and Go Test. RESULTS: The F1s and F2s of the affected and unaffected limbs were significantly less than those of the normal control individuals (p<0.05). The T1s of both the affected and unaffected limbs of the patients were greater than control individuals, whilst the T2s were lower (p<0.05). Greater impulses and stance times were recorded on both sides of the patients than in the limbs of the control individuals (p<0.05). The MAS, Brunnstrom stage and Timed Up and Go Test results were significantly correlated with the VFI of the unaffected limbs (p<0.05). CONCLUSION: The high impulse values of the unaffected limb were associated with complications during gait rehabilitation. Therefore, these results suggest that unaffected limbs should also be taken into consideration in these patients.

Relationship between Physical Examinations and Two-Dimensional Computed Tomographic Findings in Children with Intoeing Gait.

OBJECTIVE: To evaluate the validity of physical examinations by assessment of correlation between physical examinations and CT measurements in children with intoeing gait and the causes of intoeing gait by age using CT measurements. METHOD: Twenty-six children with intoeing gait participated in this study. The internal and external hip rotation, thigh-foot angle and transmalleolar angle were measured. In addition, femoral anteversion and tibial torsion of the subjects were assessed using a CT scan. The measurements of torsional angles were performed twice by two raters. The correlation coefficients between physical examinations and CT measurements were calculated using Pearson correlation. The data was analyzed statistically using SPSS v12.0. RESULTS: The correlation coefficients between physical examinations and CT measurements were not high. Before 5 years of age, intoeing gait was caused by femoral anteversion in 17.86%, tibial torsion in 32.29% and the combination of causes in 35.71% of cases. After 6 years of age, the contributions changed to 29.17%, 8.33% and 45.83%, respectively. CONCLUSION: Before 5 years of age, the common cause of an intoeing gait was tibial torsion, whereas after 6 years of age it was femoral anteversion. Regardless of age, the most common cause of intoeing gait was a combination of causes. This study shows poor correlation between physical examinations and CT. Therefore, it is limiting to use physical examination only for evaluating the cause of intoeing gait in clinical practice.