Determinants of Perceived Physical Environment Barriers among Community-Dwelling Elderly in Taiwan.

OBJECTIVES: To test the hypothesis that mobility, activities of daily living, and the interaction between them can play a key role in determining perceived physical environment barriers among community-dwelling elderly. DESIGN: Cross-sectional. SETTING: Community. PARTICIPANTS: One hundred and ninety-seven community-dwelling elderly with more than 7 points on the Short Portable Mental State Questionnaire and less than 7 points on the Geriatric Depression Scale (15 items). INTERVENTION: None. MEASUREMENTS: Time Get-up and Go test (TUG), the subscales of basic activity of daily living (BADL)/instrumental activities of daily living (IADL) of the Hierarchy of Care Required (HCR), and the physical/structural subscale of the Craig Hospital Inventory of Environmental Factors in Community-dwelling Elderly in Taiwan were used to measure mobility, activities of daily living and perceived physical environment barriers, respectively. Hierarchical linear regression analyses were used to test the study hypothesis. RESULTS: Significant and positive relations were found to exist between perceived physical environment barriers and (1) the TUG time (ß=.300, p<.05), and (2) the IADL score for the HCR (ß=.322, p<.05), respectively. A significant and negative relation existed between perceived physical environment barriers and the interaction term (the TUG time and the IADL score for the HCR) (ß=-.211, p<.05). CONCLUSION: Mobility, IADL and the interaction between them are found to be significant determinants of perceived physical environment barriers in the community-dwelling elderly under consideration. Strategies targeting the enhancement of mobility among community-dwelling elderly are suggested to lead to improvements in the degree to which physical environment barriers are perceived. This beneficial effect could be greater in the case of elderly individuals with better IADL function.

Inhibitory effect of dry needling on the spontaneous electrical activity recorded from myofascial trigger spots of rabbit skeletal muscle.

OBJECTIVE: Dry needling of myofascial trigger points can relieve myofascial pain if local twitch responses are elicited during needling. Spontaneous electrical activity (SEA) recorded from an active locus in a myofascial trigger point region has been used to assess the myofascial trigger point sensitivity. This study was to investigate the effect of dry needling on SEA. DESIGN: Nine adult New Zealand rabbits were studied. Dry needling with rapid insertion into multiple sites within the myofascial trigger spot region was performed to the biceps femoris muscle to elicit sufficient local twitch responses. Very slow needle insertion with minimal local twitch response elicitation was conducted to the other biceps femoris muscle for the control study. SEA was recorded from 15 different active loci of the myofascial trigger spot before and immediately after treatment for both sides. The raw data of 1-sec SEA were rectified and integrated to calculate the average integrated value of SEA. RESULTS: Seven of nine rabbits demonstrated significantly lower normalized average integrated value of SEA in the treatment side compared with the control side (P < 0.05). The results of two-way analysis of variance show that the mean of the normalized average integrated value of SEA in the treatment group (0.565 +/- 0.113) is significantly (P < 0.05) lower than that of the control (0.983 +/- 0.121). CONCLUSIONS: Dry needling of the myofascial trigger spot is effective in diminishing SEA if local twitch responses are elicited. The local twitch response elicitation, other than trauma effects of needling, seems to be the primary inhibitory factor on SEA during dry needling.

Correlating factors and clinical significance of flexible flatfoot in preschool children.

To elucidate the correlating factors and clinical significance of flexible flatfoot (FF) in preschool children of Taiwan, a cross-sectional study was conducted in a research laboratory equipped with a gait analysis facility. Altogether, 377 preschool children (201 boys, 176 girls), ranging in age from 2 to 6 years, were enrolled in this investigation. The results show that age, height, weight, foot progression angle, occurrence of physical knock-knee, and joint laxity score correlate with FF. Children with FF, compared with children without, performed physical tasks poorly and walked slowly, as determined by gait parameters. The FF should not simply be regarded as a problem of static alignment of the ankle and foot complex, but may be the consequence of a dynamic functional change of the lower extremity. Better understanding of the correlating factors and the clinical relevance of FF may prove helpful in deciding on the most appropriate treatment for a particular patient.

Hemiplegic gait of stroke patients: the effect of using a cane.

OBJECTIVE: To assess the effects of cane use on the hemiplegic gait of stroke patients, focusing on the temporal, spatial, and kinematic variables. DESIGN: Case-control study comparing the effect of walking with and without a cane using a six-camera computerized motion analysis system. SETTING: Stroke clinic of a tertiary care hospital. PARTICIPANTS: Fifteen ambulatory stroke patients were analyzed, including 10 men and 5 women (mean age, 56.9 years; mean time since stroke, 9.8 weeks). Nine age-matched healthy elderly subjects were recruited as a control group. RESULTS: Stroke patients walking with a cane showed significantly increased stride period, stride length, and affected side step length, as well as decreased cadence and step width (p < .05) in comparison with those who walked without a cane. There were no significant differences in the gait phases and the five gait events of hemiplegic gait walking with or without a cane. Cane use thus may have more effect on spatial variables than on temporal variables. The affected-side kinematics of hemiplegic gait with a cane showed increased pelvic obliquity, hip abduction, and ankle eversion during terminal stance phase; increased hip extension, knee extension, and ankle plantar-flexion during preswing phase; and increased hip adduction, knee flexion, and ankle dorsiflexion during swing phase as compared with hemiplegic gait without a cane. A cane thus improved the hemiplegic gait by assisting the affected limb to smoothly shift the center of body mass toward the sound limb and to enhance push off during preswing phase. It also improved circumduction gait during swing phase. CONCLUSION: Stroke patients walking with a cane demonstrated more normal spatial variables and joint motion than did those without a cane.

Performance of static standing balance in children with spastic diplegic cerebral palsy under altered sensory environments.

Seven children with spastic diplegic cerebral palsy and 14 age- and gender-matched nondisabled children participated in the present study for an investigation and comparison of their static standing balance under altered sensory environments. The type of visual input (full, occluded, or sway referenced vision) and the type of somatosensory input (fixed or compliant foot support) were varied factorially to give six sensory environments. Each participant was tested barefooted for 30 s under all six conditions. A force platform collected the ground reaction force, from which standing balance was calculated as the sway area of the center of pressure. The results showed that when somatosensory information was reliable (fixed foot support), there was no significant difference in stance stability between the children with spastic diplegic cerebral palsy and their matched controls, and both types of children were equally affected by the type of visual input. However, when somatosensory information was unreliable (compliant foot support), the difference in stance stability between the children with spastic diplegic cerebral palsy and their matched controls was significantly greater when the visual input was deprived (occluded) or unreliable (sway referenced) than when it was reliable. These results suggest that the children with spastic diplegic cerebral palsy may have difficulties in resolving intersensory conflicts for maintenance of standing balance, or the demands of motor control in sensory conflict conditions outweigh the motor ability of children with spastic diplegic cerebral palsy.

Phentolamine effect on the spontaneous electrical activity of active loci in a myofascial trigger spot of rabbit skeletal muscle.

OBJECTIVE: To investigate the effect of phentolamine, a sympathetic blocking agent, on the spontaneous electrical activity (SEA) recorded from a locus of a myofascial trigger spot (MTrS), equivalent to a human trigger point, in rabbit skeletal muscle. DESIGN: Randomized control trial. SETTING: A university medical laboratory. PATIENTS OR OTHER PARTICIPANTS: Nine adult New Zealand rabbits. INTERVENTION: In the experimental group phentolamine mesylate (1mg/kg) was injected into the external iliac artery, followed by flushing with normal saline. The control group was treated with normal saline instead of phentolamine using the same procedure. MAIN OUTCOME MEASURES: SEA was recorded from multiple active loci of MTrSs in the biceps femoris muscle: initially SEA in the same locus was recorded before and immediately after phentolamine (or normal saline) injection; then SEA was recorded from 25 different active loci. The mean of the average integrated signal (AIS) of SEA was analyzed, comparing the effects of phentolamine and normal saline on SEA. RESULTS: In the same active locus, the AIS of SEA showed statistically a linear decay with time after phentolamine injection, with a correlation coefficient of .56 at p < .05. However, no statistical relationship could be derived for the control group data with time by using regression analysis, probably because of large variations among the rabbits and movement artifacts during the experiment. In 25 different loci in the phentolamine group, the mean of the AIS of SEA (7.92 microV) was significantly lower than that of the control group (9.89 microV) at p < .05. CONCLUSIONS: The results support the hypothesis that the autonomic nervous system is involved in the pathogenesis of myofascial trigger points. The application of the AIS as an evaluation index seems to be feasible in the quantitative measurement of SEA.

Association of active myofascial trigger points and cervical disc lesions.

We investigated the occurrence of active myofascial trigger points in specific muscle groups in relation to the existence of cervical disc bulging at various levels. One hundred and five patients (48 men, 57 women; mean age, 45.8 +/- 12.1 yr) who had active trigger points in the neck or upper back after trauma were divided into two groups on the basis of magnetic resonance imaging (MRI) evidence of bulging disc(s). The discN group consisted of 46 patients who had normal MRI findings in the cervical spine. The other 59 patients, with mild cervical disc bulging, were assigned to the disc' group. The correlations between specific muscles with active trigger points (clinical finding) and cervical disc lesions at specific levels (MRI finding) were analyzed. There were significant associations between the level of disc lesion and the muscles with trigger points, namely C3-4 lesions with levator scapulae and latissimus dorsi trigger points; C4-5 lesions with splenius capitis, levator scapulae, and rhomboid minor trigger points; C5-6 lesions with splenius capitis, deltoid, levator scapulae, rhomboid minor, and latissimus dorsi trigger points; and C6-7 lesions with latissimus dorsi and rhomboid minor trigger points. For each disc level, the average pain intensity (assessed using a numerical analog scale) of trigger points in certain correlated muscles (as indicated above) in the disc group was significantly higher than that in the discN group (p < 0.05 for all disc levels). We conclude that active trigger points are more likely to occur in certain muscles in the presence of cervical disc lesions at specific levels.

Myofascial trigger points in intercostal muscles secondary to herpes zoster infection of the intercostal nerve.

Chronic pain in the chest wall is a major complication after herpes zoster infection of intercostal nerves. It is usually difficult to control pain of such origin. Two cases are reported of postherpetic neuralgia after herpes zoster infection involving the intercostal nerves. Both patients had shooting, burning, aching, and localized pain in the muscle supplied by the involved intercostal nerves 1 to 3 months after onset. Compression palpation of a tender spot in one of these muscles induced a referred pain that followed the corresponding interspace, usually in the distal anterior direction. Local twitch responses could be elicited during injection of 0.5% or 1% lidocaine into one of these tender spots; the pain in the interspace was consistently eliminated immediately after injection. One patient had complete pain relief after three series of injections. The effect of pain relief for the other patient lasted for 1 to 2 weeks after the initial injection and lasted progressively longer (up to 2 months) after repeated injections. It appears that many of the tender spots formed in intercostal muscles after herpes zoster are myofascial trigger points that respond to injection with referred pain, local twitch responses, and immediate pain relief.

Referred pain elicited by palpation and by needling of myofascial trigger points: a comparison.

OBJECTIVE: To investigate the occurrence of referred pain (ReP) elicited by palpation (Pal-ReP) or by needle injection (Inj-ReP) of myofascial trigger point (MTrP), and to assess the correlated factors, including the pain intensity of an active MTrP and the occurrence of local twitch response (LTR). DESIGN: Correlational study. PATIENTS: Ninety-five patients who were treated with MTrP injections. INTERVENTION: MTrP injections. MAIN OUTCOME MEASURE: Pain intensity of MTrP and occurrence of Pal-ReP, Inj-ReP, and LTR. RESULTS: Both Pal-ReP and Inj-ReP were elicited in 53.9% of MTrPs, Inj-ReP, but not Pal-ReP, was elicited in 33.7% of MTrPs. Both Pal-ReP and Inj-ReP were unobtainable in 12.3% of MTrPs. The occurrence of ReP was significantly correlated to the pain intensity of active MTrP and the occurrence of LTR. CONCLUSION: ReP could be elicited more frequently by needling than by palpation. The frequency of occurrence in ReP mainly depends on pain intensity of an active MTrP.

The immediate effectiveness of electrical nerve stimulation and electrical muscle stimulation on myofascial trigger points.

This study is designed to investigate the immediate effectiveness of electrotherapy on myofascial trigger points of upper trapezius muscle. Sixty patients (25 males and 35 females) who had myofascial trigger points in one side of the upper trapezius muscles were studied. The involved upper trapezius muscles were treated with three different methods according to a random assignment: group A muscles (n = 18) were given placebo treatment (control group); group B muscles (n = 20) were treated with electrical nerve stimulation (ENS) therapy; and group C muscles (n = 22) were given electrical muscle stimulation (EMS) therapy. The effectiveness of treatment was assessed by conducting three measurements on each muscle before and immediately after treatment: subjective pain intensity [(PI) with a visual analog scale], pressure pain threshold [(PT) with algometry], and range of motion [(ROM) with a goniometer] of upper trapezius muscle (lateral bending of cervical spine to the opposite side). When the effectiveness of treatment was compared with that of the placebo group (group A), there was significant improvement in PI and PT in group B (P < 0.01) but not in group C (P > 0.05). The improvement of ROM was significantly more in group C (P < 0.01) as compared with that in group A or group B. When each group was divided into two additional subgroups based on the initial PI, it was found that ENS could reduce PI and increase PT significantly (P < 0.05), but did not significantly (P > 0.05) improve ROM, as compared with the placebo group for both subgroups. EMS could significantly (P < 0.05) improve ROM, but not PT, better than the placebo groups, for either subgroup. It could reduce PI significantly more (P < 0.05) than placebo controls only for the subgroup with mild to moderate pain, but not with severe pain. For pain relief, ENS was significantly better (P < 0.05) than EMS; but for the improvement of ROM, EMS was significantly better (P < 0.05) than ENS. It is concluded that ENS is more effective for immediate relief of myofascial trigger point pain than EMS, and EMS has a better effect on immediate release of muscle tightness than ENS.

Influence of renal function on the pharmacokinetics of ramipril (HOE 498).

The pharmacokinetics of ramipril (HOE 498) were studied after oral administration of a single 10 mg dose to 24 hypertensive patients with different degrees of renal function. The creatinine clearance ranged between 4.1 and 126 ml/min/1.73 m2 and was below 35 ml/min/1.73 m2 in 16 patients. Angiotensin converting enzyme activity and the concentrations of ramipril and its active diacid metabolite ramiprilat were measured in plasma up to 10 days after drug intake. Urine levels of ramipril, ramiprilat, their glucuronides and 2 major metabolites (a diketopiperazine and a diketopiperazine acid) were measured up to 4 days after medication. The plasma concentration-time curve of ramiprilat was polyphasic with an initial steep decline after the peak level and a subsequent very long terminal phase at low concentrations. Impaired renal function resulted in higher peak levels of ramiprilat, longer times to peak and a markedly slower decline of plasma ramiprilat levels. Hence, the duration of angiotensin converting enzyme inhibition was considerably prolonged in renal failure and depended on the severity of renal impairment. The urinary excretion of ramipril and its metabolites decreased with decreasing renal function and was linearly related to the creatinine clearance, suggesting an alternative pathway of elimination. The pattern of excretion rates of ramipril and its various metabolites was not affected by renal failure. In contrast to the marked changes in the renal elimination, no relevant differences were observed in the absorption of ramipril from the gastrointestinal tract. Systolic and diastolic blood pressure decreased in all groups. The single 10 mg dose of ramipril was well tolerated.