Efficacy of home-based virtual cycling training on bone mineral density in ambulatory children with cerebral palsy.

UNLABELLED: The 12-week home-based virtual cycling training (hVCT) improved lower limb muscle strength and areal bone mineral density (aBMD) than the control program in children with cerebral palsy (CP). A muscle strengthening program, rather than general physical activity, is more specific in enhancing aBMD for these children. A novel hVCT is an effective and efficient strategy that enhances lower limb bone density in these children. INTRODUCTION: This is the first study to assess the efficacy of a novel hVCT program on bone density for children with spastic CP using a well-designed randomized controlled trial. METHODS: Twenty-seven ambulatory children with spastic CP, aged 6-12 years, were randomly assigned to the hVCT group (n=13) or control group (n=14). Outcome measures-motor function [Gross Motor Function Measure-66 (GMFM-66)], muscle strength (curl up scores and isokinetic torque of knee extensor and flexor muscle) and aBMD of the lumbar and distal femur-were administered before and immediately after the 12-week intervention. RESULTS: Analysis of covariance results show that the hVCT group had greater distal femur aBMD and isokinetic torques of knee extensor and flexor muscles than the control group at posttreatment (p<0.05). However, curl up scores, GMFM-66, and lumbar aBMD at posttreatment did not differ between the two groups. CONCLUSIONS: Analytical findings suggest that the muscle strengthening program is more specific in enhancing bone density for children with CP than general physical activity. Thus, the proposed 12-week hVCT protocol is an effective and efficient strategy for improving lower limb aBMD in these children.

Symmetrical body-weight distribution training in stroke patients and its effect on fall prevention.

OBJECTIVE: To determine the role of symmetrical body-weight distribution training in preventing falls among patients with hemiplegic stroke. DESIGN: A prospective study using a standing biofeedback trainer. SETTING: Hospital-based rehabilitation units. PATIENTS: Fifty-four patients with hemiplegic stroke (30 in the training group, 24 in the control group). INTERVENTIONS: Conventional stroke rehabilitation program, plus symmetrical standing training and repetitive sit-to-stand training, with a standing biofeedback trainer. Training effect was evaluated by assessing the sit-to-stand performance and comparing the occurrence of falls in the 2 groups at a 6-month follow-up. MAIN OUTCOME MEASURES: Occurrence of falls, sit-to-stand performance, including body-weight distribution, rate of rise in force, and sway in center of pressure (COP). RESULTS: Significant improvement in sit-to-stand performance was found in patients in the training group. Body weight was distributed more symmetrically in both legs, with less mediolateral sway in the COP when rising and sitting down. The mean difference in body-weight distribution between the left and right legs while subjects were rising from a chair significantly decreased, from 49.5% +/- 18.9% to 38.6% +/- 15.8% of body weight (BW) (p < .005). The rate of rise in force while rising from a chair significantly increased, from 28.3% +/- 13.5%BW/s to 53.6% +/- 20.5%BW/s (p < .001). At the 6-month follow-up, 10 of 24 patients (41.7%) in the control group had fallen, compared with only 5 of 30 patients (16.7%) in the training group (p < .05). CONCLUSIONS: Symmetrical body-weight distribution training may improve sit-to-stand performance and, consequently, decrease the number of falls by stroke patients.

Pulmonary function and spinal characteristics: their relationships in persons with idiopathic and postpoliomyelitic scoliosis.

OBJECTIVE: To identify what influence the various features of spinal deformity have on pulmonary function in persons with idiopathic and the postpoliomyelitic scoliosis. DESIGN: Prospective, cohort, observational study with clinical and radiologic evaluations. SETTING: Hospital-based rehabilitation units. PATIENTS: Forty-four patients with idiopathic scoliotis and 16 with postpoliomyelitic scoliotis. Each group was divided into subgroups: normal and abnormal pulmonary function. INTERVENTION: Clinical and radiologic evaluation of spinal deformity, full pulmonary functional test and respiratory muscle strength were performed. Presence of dyspnea on exertion and low back pain (LBP) was recorded. MAIN OUTCOME MEASURES: Pulmonary function: spirometry, lung volume test, and diffusing capacity. Respiratory muscle strength: maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). Presence of dyspnea on exertion (DOE), and LBP were also recorded. Characteristics of spinal deformity: direction of convexity, uppermost vertebra, number of involved vertebrae, Cobb angle, the apical vertebra, degree of rotation at the apical vertebra, type of scoliotic curve, and presence of balanced spine and pelvic obliquity. Chi-square analyses and Mann-Whitney U test for between-groups comparisons. Spearman's rho correlation coefficient to determine the existence and magnitude of a relationship. RESULTS: We found significant differences between the idiopathic and postpoliomyelitis groups in the degree of rotation at the apical vertebra, MIP, average percentage of predicted vital capacity, residual volume/total lung capacity, presence of double or triple curves, pelvic obliquity, and DOE. Between the idiopathic scoliotis subgroups we found significant differences in the uppermost vertebra and number of vertebrae in the scoliotic curve. Between the subgroups of the postpoliomyelitis group were significant differences in the location of the apical vertebra and the uppermost vertebral body of scoliotic curve. In the idiopathic group, pulmonary function was mostly related to scoliotic angle, number of vertebrae in the scoliotic curve, location of the uppermost vertebra, and the patients' age; MIP and MEP were negatively related to the scoliotic angle and degree of rotation of apical vertebra. In the postpoliomyelitis group, pulmonary function was mostly related to scoliotic angle, kyphotic angle, location of the uppermost vertebra of the scoliotic curve, and age. CONCLUSION: No single factor can predict the severity of impairment in scoliotic patients' pulmonary function. In both groups, severity of pulmonary impairment was related to the combined features of the spinal deformity. However, uppermost vertebra, scoliotic angle, and patient's age may play important roles influencing pulmonary function in both groups.

Balance evaluation in hemiplegic stroke patients.

BACKGROUND: Decreased equilibrium in standing and walking is a common problem associated with hemiplegic stroke patients. Stroke patients with balance problems are prone to falls. In addition to spatial recognition, the appropriate pattern of muscle activity to preserve balance depends on sensory and motor processes. Previous reports have mentioned that the right posterior parietal cortex seems to be predominantly involved in spatial integration. We therefore wanted to conduct a study to quantify and compare the balance control between right hemispheric stroke and left hemispheric stroke patients. METHODS: Thirty hemiplegic stroke patients (14 right, 16 left) and 15 age-matched healthy subjects were included in this study. The objective measurement of the basic components of balance control was performed using the SMART Balance Master. The motor status of the hemiplegic limbs was evaluated by Brunnstrom staging. The functional outcome of the stroke patients was evaluated by the functional independence measure (FIM). RESULTS: The balance function of stroke patients was significantly worse as compared to that of the healthy subjects especially in dynamic stability. However, different from the other reports, our right hemispheric stroke patients had better balance function than our left hemispheric patients. The locomotion and mobility scores of the FIM were also better in the right hemispheric stroke patients. CONCLUSION: This result suggested that the motor function of the healthy limbs of stroke patients may play an important role in their balance function. The results of this study may provide a guide for prescribing a more efficient rehabilitation program for stroke patients.

Resistive inspiratory muscle training: its effectiveness in patients with acute complete cervical cord injury.

OBJECTIVE: To evaluate if resistive inspiratory muscle training (RIMT) can improve lung function in patients with complete tetraplegia within half a year after trauma. DESIGN: A prospective study. The experimental patients received training with a Diemolding Healthcare Division inspiratory muscle trainer for 15 to 20 minutes per session, twice per day, 7 days a week for 6 weeks. SETTING: Hospital-based rehabilitation units. PATIENTS: Twenty patients who were in their first 6 months of complete cervical cord injury were randomly enrolled into RIMT (10 patients) and control (10 patients) groups. MAIN OUTCOME MEASURE: Spirometry, lung volume test, maximal inspiratory pressure, maximal expiratory pressure, and modified Borg scale measurements at rest were performed before training and at the end of 6 weeks of training. RESULTS: Most of the pulmonary parameters showed statistically significant improvements within the RIMT and control groups, but the improvements were greater in the RIMT group. In addition, the improvements in total lung capacity, total lung capacity predicted percentage, vital capacity, minute ventilation, forced expiratory volume in 1 second predicted percentage, and the resting Borg scale in the RIMT group showed significantly greater improvement. CONCLUSION: RIMT can improve ventilatory function, respiratory endurance, and the perceived difficulty of breathing in patients with complete cervical spinal cord injury within half a year after trauma.

Clinical trial of electrical acupuncture on hemiplegic stroke patients.

To assess the efficacy of electrical acupuncture in the rehabilitation of patients with hemiplegia in stroke, we randomized 128 patients within 2 wk of stroke onset to receive either comprehensive rehabilitation plus electrical acupuncture (n = 59) or comprehensive rehabilitation only (n = 59). Electrical acupuncture was administered by electrical stimulation of acupuncture points through adhesive surface electrodes five times per week. Neurological status (Brunnstrom's stage) and the Chinese version of the Functional Independence Measure were assessed before treatment and at discharge. Patients treated with electrical acupuncture had a shorter duration of hospital stay for rehabilitation and better neurological and functional outcomes than the control group had, with a significant difference in scores for self-care and locomotion (P = 0.02). This result did not postulate the previous study that acupuncture therapy for stroke patients should depend on needle manual and "de qi" response. We suggest that electrical acupuncture through adhesive surface electrodes in conjunction with current optimal rehabilitation programs is a convenient and effective therapy for stroke patients.

Central representation of phantom limb phenomenon in amputees studied with single photon emission computerized tomography.

To explore the possible mechanisms of phantom limb discomfort after amputation, three amputees with phantom limb pain were studied. This study examined the change of regional cerebral blood flow using technetium-99m hexamethylpropyleneamine oxime-single photon emission computerized tomography, which was arranged at the time of severe phantom limb discomfort and after the discomfort subsided or was completely relieved. Nine representative transverse slices parallel to the orbitomeatal line were selected for quantification. The cortical ribbon (2-cm thickness) was equally subdivided into 12 symmetrical pairs of sector regions of interest in each slice. The irregularly shaped regions of interest were drawn manually around the right thalamus and basal ganglion and then mirrored to the left thalamus and basal ganglion. The contralateral to ipsilateral ratio of regional cerebral blood flow for each area was calculated. The intensity of phantom limb pain was evaluated on a 0 to 10 visual analog scale. In Cases 1 and 2, the contralateral to ipsilateral regional cerebral blood flow ratios of multiple areas of the frontal, temporal, or parietal lobes were increased at the time of more severe phantom limb pain, and the ratios were normalized or even decreased when the phantom limb pain subsided. In Case 3, increased contralateral to ipsilateral regional cerebral blood flow ratios were also found over the frontal, temporal, and parietal lobe. However, most of the increased regional cerebral blood flow ratios of regions of interest in the first study persisted in the follow-up study. Also, the regional cerebral blood flow ratios of greater number of regions of interest of the same gyrus and new gyrus were increased. There was no significant right-left difference of regional cerebral blood flow over bilateral thalami and basal ganglia in all three cases. The results suggested that phantom limb pain might be associated with cortical activation involving the frontal, temporal, or parietal cortex, and it may imply the possibility of the existence of an ascending polysynaptic pathway that conveys the uncomfortable phantom limb sensation to the cerebral cortex. These findings may also indicate that reorganization of the cortical blood flow occurs in amputees. However, it is still difficult to conclude that the changes in regional cerebral blood flow were attributable directly to pain. With no comparison group of amputees and because of the small number of cases, it is hard to generalize about cerebrocortical involvement in phantom pain, and it is possible that the findings represent a normal phenomenon seen after 'amputation. Another possibility is that the findings represent increased arousal caused by pain rather than an intrinsic pain pathway. Further study is worthwhile.

The sit-to-stand movement in stroke patients and its correlation with falling.

OBJECTIVE: To use kinetic assessment of the sit-to-stand movement as a means of sorting out those stroke patients at risk for falling. DESIGN: A retrospective study, using a force platform to assess sit-to-stand performance and to determine its correlation with falls in stroke patients. SETTING: Hospital-based rehabilitation units. METHODS: Thirty-three stroke patients (18 fallers, 15 nonfallers) and 25 age-matched healthy subjects were included in this study. Subjects sat in an adjustable chair with their feet on two force plates and performed the standing up/sitting down movement at a self-paced, comfortable speed. RESULTS: The rate of rise in force (dF/dT) was significantly lower in stroke fallers than in stroke nonfallers and healthy subjects (23.78+/-17.38, 55.23+/-31.24, and 85.96+/-42.4 percent body weight per second, respectively [p < .005]). The center of pressure sway in mediolateral direction during rising/ sitting down was much greater in stroke fallers than in stroke nonfallers or healthy subjects (p < .05). Body weight distribution was asymmetric on the feet of stroke patients, with much more body weight on their sound side. CONCLUSIONS: The significantly lower rate of rise in force and greater postural sway while rising/sitting down may be useful in identifying stroke patients who are at risk for falling.

A multidisciplinary pulmonary rehabilitation program for patients with moderately severe chronic obstructive pulmonary disease.

A multidisciplinary pulmonary rehabilitation program was conducted for 13 outpatients (mean age 66 +/- 6.7 yr) with moderately severe chronic obstructive pulmonary disease. Changes in pulmonary function and blood gas data were not significant. Exercise capability, including 6-minute walking distance (WkD6), maximal work load (WkLmax), endurance time, and maximum heart rate, improved significantly (p < 0.05), as did subjective symptoms and quality of life. Of the observed changes, only baseline PaO2 and oxygen saturation were positively correlated with changes in maximum heart rate. The initial maximum heart rate was inversely related to both the absolute and percentage improvement. There were no significant relationships between improvement in WkD6 and age, initial arterial blood gas, or pulmonary function, but a significant relationship was found between baseline forced expired volume in the first second (FEV1) and percentage change in WkLmax. Our results indicate that patients with moderately severe chronic obstructive pulmonary disease can improve their exercise capacity, subjective symptoms, and quality of life through a pulmonary rehabilitation program. All patients can increase their endurance, regardless of their initial exercise performance. Maximum heart rate and FEV1 are predictors of exercise capability improvement.

Spontaneous electromyographic potentials in cervical cord-injured patients are related to dysesthetic pain.

A total of 61 traumatic cervical cord-injured patients were included in this study. Needle electromyography and nerve conduction study were performed at 6 to 24 weeks postinjury. Correlation between the presence of spontaneous electromyographic potentials and the presence of dysesthetic pain, as well as other clinical characteristics including age, gender, level of injury, severity of injury, spasticity, duration of injury, and performance of spinal surgery was statistically analyzed. Of the 31 patients who had spontaneous electromyographic potentials in their hands, 27 (87%) had dysesthetic pain in their limbs. Only 9 (30%) of the other 30 patients without spontaneous potentials developed dysesthetic pain. A significant correlation (P < 0.001) between the presence of spontaneous electromyographic potential and dysesthetic pain was found. The presence of spontaneous electromyographic potentials was also significantly (P < 0.05) correlated with severity of injury but not with age, gender, injury level, duration of injury, operation, and spasticity. In conclusion, the presence of spontaneous electromyographic potentials in cervical cord-injured patients was significantly related to the presence of dysesthetic pain. They occurred more often in patients with more severe injury.

Bilateral diaphragmatic paralysis--a rare cause of acute respiratory failure managed with nasal mask bilevel positive airway pressure (BiPAP) ventilation.

A 68 yr old woman presented with acute respiratory failure. She was suspected of having a phrenic-diaphragmatic impairment, without evidence of an intrinsic lung disease or generalized neuromuscular disorder, after 3 weeks of prolonged mechanical ventilation. A series of studies, including fluoroscopy, phrenic nerve stimulation test and diaphragmatic electromyography, was performed before the diagnosis of bilateral diaphragmatic paralysis (BDP) was confirmed. The patient was successfully weaned from the conventional mechanical ventilator, and was placed on nasal mask bi-level positive airway pressure (BiPAP) ventilation. A high degree of clinical suspicion of bilateral diaphragmatic paralysis should always be raised in patients suffering respiratory failure without definite predisposing factors. Weaning with noninvasive nasal mask ventilation should be tried first instead of direct tracheostomy.

[The effects of leg elevation to reduce leg edema resulting from prolonged standing].

In order to find the most comfortable and effective posture to reduce lower leg edema, 31 young women working in Chang Gung Memorial Hospital, ages ranging from 20 to 40, were studied by the volumetric displacement method with leg placed in a specially designed container. The effects of five different angles of leg elevation on reduction of leg edema were separately evaluated in 5 days. For each evaluation, two measurements of volumetric displacement of lower leg edema were performed after prolong sitting or standing of more than 4 hours, and at the end of 15 minutes of supine lying (angle of leg elevation = 0 degrees), or after the leg was elevated in an angle of 30 degrees, 45 degrees, 60 degrees, or 90 degrees respectively. A good correlation was found between the displaced volume and increasing angle of leg elevation (regression line Y = 99.109-0.016X, r = -0.96). There was a significant difference between leg elevation of 90 degrees and supine lying (t = 3.01, p less than 0.01). The degree of comfort in leg elevation was in the order of 30 degrees, 45 degrees, 60 degrees, 0 degrees, 90 degrees. Many subjects complained of numbness and throbbing pain over the lower legs or pain at the buttocks in the upright leg elevation to 90 degrees posture, but felt rather comfortable in the 30 degrees posture. Seventeen of these subjects were further studied for the degree of comfort in leg elevation at 30 degrees for 30 minutes as compared with those of 30 degrees, 15 minutes and 90 degrees, 15 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)