Deep Venous Thrombosis and Heterotopic Ossification in the Patients with Traumatic Spinal Cord Injury

OBJECTIVE: To investigate the incidence, time of onset, and risk factors of deep vein thrombosis asssociated with heterotopic ossification in patients with spinal cord injury. METHOD: The medical records of 201 patients with spinal cord injury were reviewed. Duplex ultrasound and/or venography were used for the diagnosis of deep vein thrombosis and 3 phase bone scan and/or plain radiologic studies were used for the diagnosis of heterotopic ossification. RESULTS: Whereas the incidence of heterotopic ossification and deep vein thrombosis in this population were 10.0% and 4.5%, respectively, 55.5% of the individuals with deep vein thrombosis developed heterotopic ossification. The overall incidence of coexistence of deep vein thrombosis and heterotopic ossification was 2.5%. The significant difference between the occurrence of heterotopic ossification and deep vein thrombosis in this SCI population reached statistical significance (Fisher's exact test p<0.005). CONCLUSION: The results of this study suggest that there exists an association between the occurrence of deep vein thrombosis and heterotopic ossification following SCI.

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.

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 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.

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.

Prevalence and Associated Factors of Falls in the Elderly Community / 예방의학회지

OBJECTIVES: To analyze factors associated with elderly falls in a community dwelling, a comparatively important, but somewhat neglected, health matter. METHODS: Data came from personal interview surveys using a questionnaire of 552 people aged 65 or older living in a community. Socioeconomic, and health related characteristics were investigated as independent variables and experiences of falling in the previous year as the dependent variable. RESULTS: 118(21.4%) of the elderly subjects experienced a fall in the previous year. 24 subjects experienced more than two falls, accounting for 20.3% of the elderly fall victims studied. Factors affecting the falls were families living together, level of daily activity, heart disease, and aconuresis;, therefore an elderly person who lives alone, lives independently, has heart disease, or suffers urinary incontinence had a demonstrated increased chance of falling. CONCLUSION: Groups at risk for falling included elderly persons living alone, living independently, suffering heart disease, or experiencing urinary incontinence. When an elderly fall prevention program is developed and implemented, these results should be considered.

Usefulness of the Portable Cystometer

OBJECTIVE: To evaluate the usefulness of a newly devised portable cystometer to measure the pressure of bladder in a low cost and easier accessability. METHOD: This study was performed in 47 patients with a conventional instrumental cystometer (Jupiter 8000, Wiest) and the newly devised portable cystometer. In the supine position, we measured the maximal intravesical pressure, abdominal pressure and bladder volume with the portable cystometer just after the measurement of the maximal detrusor pressure and bladder volume with the conventional instrumental cystometer. Paired t-test was utilized to analyze and compare the result. RESULTS: 1) There was no significant difference in the average maximal detrusor pressures measured by maximal intravesical pressures minus abdominal pressures, which were 38.32 20.97 cmH2O by the conventional instrumental cystometer and 40.02 20.70 cmH2O by the portable cystometer (p>0.05). 2) There was no significant difference in the average bladder volumes at maximal detrusor pressure, which were 302.13 83.92 cc by the conventional instrumental cystometer and 314.04 94.17 cc by the portable cystometer (p>0.05). CONCLUSION: We conclude that there is no significant difference between the conventional instrumental cystometer and the portable cystometer in the measurement of detrusor pressure and bladder volume. We believe this portable cystometer would be a useful tool to evaluate the function of bladder in a low cost and easier accessability.

A Survey on Spinal Cord Injury Persons in Suwon City

OBJECTIVE: To collect the informations of the traumatic spinal cord injury persons in Suwon city. METHOD: Seventy-five traumatic spinal cord injury persons were evaluated by the neurological level, American Spinal Injury Association scale, Functional Independence Measure (FIM), Craig Handicap Assessment and Reporting Technique (CHART), Beck Depression Inventory (BDI), and questionnaire on their voiding methods, complications, etc. RESULTS: The leading cause of 75 persons with traumatic spinal cord injury was a traffic accident. Among them, paraplegics were 46 persons. The most common complication was a pressure sore which was also the leading cause of their rehospitalization. Twenty-six persons voided by reflex. Among five dimensions of CHART, the physical independence score was the highest and the economic self sufficiency score was the lowest. The total CHART scores were significantly correlated with BDI scores, FIM scores, and level of injury. CONCLUSION: This study revealed that physical impairment, disability and depression affect the handicaps of spinal cord injury persons. These data could be used to develop a social rehabilitation program for the spinal cord injury persons in the community.

Urethral Stent as a Part of Management of the Neurogenic Bladder in Spinal Cord Injury: Two cases report

In spinal cord injury, various options exist for the management of the neurogenic bladder. For the management of neurogenic bladder, urethral stent was placed under a cystoscopic guidance as one day procedure. Urethral stents were inserted in a T12 spinal cord injured patient who had recurrent urinary tract infections and a vesicoureteral reflux (VUR) and a T3 spinal cord injured patient who had a detrusor-sphincter dyssynergia. In the first case, recurrent urinary tract infection and VUR were resolved after the stenting. In the second case, urethral stent was removed because of the failure of continuous drainage. Because of its easily reversible nature, the urethral stent can be adopted for use in pateints as an option of neurogenic bladder management.

The Environmental Control System for a Patient with Quadriplegia

Environmental control system (ECS) is an assistive device to help the severely disabled persons to live their daily lives more independently. An 'ECS By Voice' suitable to a 54-year old C4 quadriplegic man was developed and installed in his own room for one week. The physical and psychologic impacts of the subject and caregiver were also evaluated using questionnaires including the Activity Pattern Indicator (API) and Beck Depression Inventory (BDI) before and after the application of the device. The results were as follows: (1) The voice recognition rate of the device was 97.5% in the laboratory and there was no difference in recognition rate according to the specific commanding words. (2) While using the device, both the dependency on the attendant care and the depression tendency of the subject were decreased. (3) While using the device, both caring time and depression tendency of the caregiver were decreased. We found the usefulness of ECS for the quadriplegics and the possibility of developing a Korean model of ECS which can be commercialized at a considerably less cost.

Assessment of Ischemic Heart Disease in Patients with Stroke Using Myocardial Perfusion SPECT: Preliminary report

OBJECTIVE: The purpose of this study was to investigate cardiac events and ischemic heart disease in patients with stroke. The patients were studied by myocardial perfusion SPECT (single photon emission computed tomography) and evaluated the functional outcome after rehabilitation. METHOD: Subjects were 31 patients with stroke who had myocardial perfusion SPECT for abnormal findings on the electrocardiography. There were eighteen patients with ischemic stroke: 12 patients with hemorrhagic stroke; and one patient with both ischemic and hemorrhagic stroke. We screened the patients for the hypertension, diabetes mellitus, previous history of stroke, smoking, alcohol use, and hyperlipidemia as risk factors of ischemic stroke and ischemic heart disease. For the dichotomous classification of positive or negative myocardial perfusion SPECT, reversible and persistent defects were considered as positive. We investigated the functional outcomes on the admission and discharge using the Modified Rankin scale (MRS) and functional independence measure (FIM) scores. Cardiac events in patients with stroke were investigated. RESULTS: The myocardial perfusion SPECT was positive in 10 of 18 patients (55.6%) with ischemic stroke. Four out of ten patients with ischemic stroke had cardiac events. Positive myocardial perfusion SPECT was significantly associated with cardiac events (p0.05). CONCLUSION: The results of our study suggested that myocardial perfusion SPECT is useful in the screening of silent ischemic heart disease in patients with ischemic stroke and to assess future cardiac events of them.

Quality of Life in Spinal Cord Injured Persons

OBJECTIVE: The purpose of this study was to analyze relationships between injury-related variables, demographic variables, disability, handicap and life satisfaction of persons with spinal cord injury. METHOD: Data was collected through personal interviews of 96 persons with spinal cord injury. Neurologic variables, demographic variables, FIM (functional independence measure) scores and CHART (Craig Handicap Assessment and Reporting Technique) scores were obtained. Life domain satisfaction measure, a self-administered questionnare containing 12 items, was used to assess the life satisfaction. RESULTS: Life satisfaction was related with the total CHART score (p=0.00), severity of disability (p=0.02), annual family income (p=0.019) and employment status (p=0.008). Life satisfaction was not related with the level of injury, age, duration of injury, sex or marital status (p>0.05). Social integration was the most strong predictor of life satisfaction (p=0.00). Economic-self sufficiency (p=0.004) and FIM scores (p=0.018) were also predictors of the life satisfaction. CONCLUSION: The result of this study provides an evidence that social integration and employment warrant a priority in rehabilitation efforts to promote the quality of life following spinal cord injury.

Insertion of Urethral Wallstent (MemothermR) at External Urethral Sphincter for the Treatment of Patients with Complicated Detrusor Sphincter Dyssynergia / 대한비뇨기과학회지

In patients with spinal cord injury, detrusor sphincter dyssynergia is a common and troublesome problem that may evoke progressive deterioration of upper urinary tract and urinary tract infection including sepsis. Instead of external sphincterotomy, urethral wallstent may be the useful treatment for the patients with detrusor sphincter dyssynergia refractory to conventional treatment. In addition, this method has some advantages of less invassive, less morbid and simpler technique than other treatment methods. We report our preliminary results of the urethral wallstent(MemothermR) for the treatment of 2 patients with complicated detrusor sphincter dyssynergia.

Bladder Volume Measurement using Bladder Manager PCI 5000 in Spinal Cord Injury Patients

A portable ultrasound scanner has been developed to provide a noninvasive technique of measuring the bladder urine volume. This study was undertaken to determine if bladder volumes could be accurately measured in a group of spinal cord injury patients on a clean intermittent catheterization program, using a portable ultrasound scanner(BladderManager PCI 5000). We assessed the effects of different patient positions, presence of central obesity and bladder types by the urodynamic study on the accuracy of measurements as well as the inter-tester difference. Ultrasound measurements of urine volume performed by two physicians were compared to the volumes obtained by catheterization in 17 spinal cord injury patients. Subjects were tested in the seated and supine positions. The results showed a good correlation between the catheterized volumes and ultrasound measurements (Pearson correlation coefficient=0.97, r2=0.88). The mean % error was 18% for the catheterized volumes within the ranges of 45ml-640ml. But the ultrasound measurements revealed a significantly higher % error for the bladder volumes less than 200ml. Ultrasound measurements were more accurate in a supine position and among the non-obese subjects(p<0.05). There was no significant difference in the ultrasound measurements between areflexic type bladder and hyperreflexic type bladder neither in the inter-tester measurements. We conclude that the Bladder Manager PCI 5000 is not an accurate tool for the assesssment of post-void residual urine volumes, however it can be a useful tool for the patients with neurogenic bladder who are performing volume-directed clean intermittent catheterization, in reducing the unnecessary catheterization or preventing the bladder overdistensions.

Hemodynamic Study of Foot in Diabetic Patient Using Portable Doppler Machine

The importance of neuropathy in the pathogenesis of foot lesions has been well recognized in diabetes. Blood flow in ischemic limbs has been extensively investigated but the circulation of limbs affected by peripheral neu ropathy has received little attention. Some studies on blood flow in peripheral neuropathy have shown a remarkable increase in resting flow, transcutaneous venous oxygen tension, and vascularity, along with loss of the spontaneous variations which occur normally with sympathetic activity of the foot in patients with diabetes. The aim of present study is to find out the effects of somatic and autonomic nervous function in early change of blood flow of foot in diabetic patients, We have studied fifty-one patients of non-insulin-dependent(type II) diabetes with no history of hypertension of diabetic foot ulcers. The evidence of neuropathy was screened by nerve conduction studies and sympathetic skin response of both lower extremities. Blood flow of dorsalis pedls and posterior tibial arteries was measured by portable doppler machine and presented as pressure index(ankle-to-arm systolic pressure ratio). The patients with sympathetic dysfunction showed significant decrease in pressure index compared to normal control and diabetic patients with normal sympathetic function, suggesting that changes of the blood flow occur in diabetic patients with sympathetic dysfunction.

A Study on Handicap of Persons with Spinal Cord Injury in Korea by CHART

According to the World Health Organization(WHO), handicaps exist when individual is unable to fulfill expected social roles. The purposes of this study were to assess the handicap in spinal cord injury(SCI) outpatients, and to investigate the correlation of handicaps, impairments, disabilities and depression. Eighty-five SCI outpatients were evaluated by the Craig Handicap Assessment and Reporting Technique(CHART), Katz scale, neurologic level and Frankel classification and Beck Depression Inventory (BDI). Seventy(82.4%) were male and 15(17.6%) were female. Average age of the subjects was 34.5 years with the age range of 18 to 63. The subjects were devided into four groups: complete quadriplegics (9), incomplete quadriplegics(12), complete paraplegics (41) and incomplete paraplegics(23). There was no significant statistical difference in total CHART scores between male and female subjects. However, male subjects had higher mobility and social integration scores than female subjects. The occupation score was low and the social integration score was high in all groups. No correlation was found between sex, severity and the level of injury, time since injury and the CHART scores. However, significant correlation was noted between the CHART scores and BDI scores. We can carefully conclude that the CHART can be a valuable tool in the assessment of handicaps of disabled people. Futher extensive studies are recommended to identify the factors which might influence the handicaps of spinal cord injury persons.

Grip, Key Pinch, and Three Point Pinch Strength Measurement Using BTE Work Simulator

Recently, increased emphasis has been placed on the need for rehabilitation professionals to objectively evaluate a patient's potential for and progress toward a return to normal function. But as medical recovery nears completion, additional questions are commonly asked by physicians regarding work function and ability to return to full active employment. In the past, therapists have attempted to reestablish the work situation using real tools, but these machines were expensive, have space limitations and in some cases, potentially dangerous as well. A Baltimore Therapeutic Equipment(BTE) Work Simulator overcomes these shortcomings. It can be used for isometric and isotonic evaluation and treatment and assisted in providing the information needed to make determinations regarding progress in therapy, return-to-work status and job modifications. We are going to obtain normative isometric, dynamic and endurance of grip strength, key pinch strength and three point pinch strength data using BTE Work Simulator model WS20. We also compare these data between ages and sexs. This study will be helpful in clinical applications of the BTE Work Simulator and providing the more specific job related occupational therapy and developing special vocational rehabilitation program.

Spontaneous Bacterial Peritonitis Associated with Cervicomedullary Tumor: A case report

Spontaneous bacterial peritonitis(SBP) is a diffuse bacterial infection of peritoneum without an apparent intra-abdominal source of infection. Initially, it was believed to be associated with an alcholic liver cirrhosis, however, its clinical spectrum has been broadened and now it is thought to be a variant syndrome rather than an unique complication of liver cirrhosis. A 25 year old quadriparetic man with a low-grade astrocytoma of cervicomedullary junction underwent a partial resection of tumor and a course of radiation therapy. While recieving rehabilitation therapy, the patient developed sudden abdominal pain, constipation and fever. The laboratory findings including CBC, plain abdominal X-rays, gastroduodenal endoscopy, abdominal ultrasonography were not specific. Physical examination revealed rebound tenderness over the epigastric region and signs suggesting paralytic ileus. A diagnostic peritoneal lavage was performed and its result was compatible with SBP even though no specific orgnisms were identified. The patient was taken parenteral antibiotics. On the 13th day of treatment, his symptoms and physical signs were subsided and antibiotics were discontinued. The patient remained symptom free until rehabilitation therapies were completed.