Chul Ho Yoon

The Effect of Extracorporeal Shock Wave Therapy on Lower Limb Spasticity in Subacute Stroke Patients

Objective To evaluate the effect of extracorporeal shock wave therapy (ESWT) on lower limb spasticity in subacute stroke patients. Methods We studied thirty hemiplegic subacute stroke patients with ankle plantar flexor spasticity. ESWT was applied for 1 session/week, with a total of 3 sessions at the musculotendinous junction of medial and lateral gastrocnemius muscles. Patients were evaluated both clinically and biomechanically at baseline, after sham stimulation, and at immediately 1 week and 4 weeks after ESWT. For clinical assessment, Modified Ashworth Scale (MAS), clonus score, passive range of motion of ankle, and Fugl-Myer Assessment for the lower extremity were used. A biomechanical assessment of spasticity was conducted by an isokinetic dynamometer. Two parameters, peak eccentric torque (PET) and torque threshold angle (TTA), were analyzed at the velocities of 60°/sec, 180°/sec, and 240°/sec. Results After sham stimulation, there were no significant changes between each assessment. MAS and PET (180°/sec and 240°/sec) were significantly improved immediately and 1 week after ESWT. However, these changes were not significant at 4 weeks after ESWT. PET (60°/sec) and TTA (60°/sec, 180°/sec, and 240°/sec) were significantly improved immediately after ESWT. Yet, these changes were not significant at 1 week and 4 weeks after ESWT as well. Conclusion Lower limb spasticity in subacute stroke patients was significantly improved immediately after ESWT. Although the therapeutic effect of ESWT reduced with time and therefore was not significant at 4 weeks after ESWT, the degree of spasticity was lower than that of the baseline. Future studies with a larger sample of patients are warranted in order to verify the protocols which can optimize the effect of ESWT on spasticity.

Cigarette Smoke Extract-induced Reduction in Migration and Contraction in Normal Human Bronchial Smooth Muscle Cells

The proliferation, migration, cytokine release, and contraction of airway smooth muscle cells are key events in the airway remodeling process that occur in lung disease such as asthma, chronic obstruction pulmonary disease, and cancer. These events can be modulated by a number of factors, including cigarette smoke extract (CSE). CSE-induced alterations in the viability, migration, and contractile abilities of normal human airway cells remain unclear. This study investigated the effect of CSE on cell viability, migration, tumor necrosis factor (TNF)-α secretion, and contraction in normal human bronchial smooth muscle cells (HBSMCs). Treatment of HBSMCs with 10% CSE induced cell death, and the death was accompanied by the generation of reactive oxygen species (ROS). CSE-induced cell death was reduced by N-acetyl-l-cysteine (NAC), an ROS scavenger. In addition, CSE reduced the migration ability of HBSMCs by 75%. The combination of NAC with CSE blocked the CSE-induced reduction of cell migration. However, CSE had no effect on TNF-α secretion and NF-κB activation. CSE induced an increase in intracellular Ca2+ concentration in 64% of HBSMCs. CSE reduced the contractile ability of HBSMCs, and the ability was enhanced by NAC treatment. These results demonstrate that CSE treatment induces cell death and reduces migration and contraction by increasing ROS generation in normal HBSMCs. These results suggest that CSE may induce airway change through cell death and reduction in migration and contraction of normal HBSMCs.

Clinical and genetic analysis of Korean patients with Miyoshi myopathy: identification of three novel mutations in the DYSF gene.

Miyoshi myopathy (MM) is an autosomal recessive distal muscular dystrophy caused by mutations in the dysferlin gene (DYSF) on chromosome 2p13. Although MM patients and their mutations in the DYSF gene have been found from all over the world, there is only one report of genetically confirmed case of MM in Korea. Recently, we encountered three unrelated Korean patients with MM and two of them have previously been considered as having a type of inflammatory myopathy. The clinical and laboratory evaluation showed typical features of muscle involvement in MM in all patients but one patient initially had moderate proximal muscle involvement and another showed incomplete quadriparesis with rapid progression. Direct sequencing analysis of the DYSF gene revealed that each patient had compound heterozygous mutations (Gln832X and Trp992Arg, Gln832X and Trp999Cys, and Lys1103X and Ile1401HisfsX8, respectively) among which three were novel. Although MM has been thought to be quite rare in Korea, it should be considered in a differential diagnosis of patients exhibiting distal myopathy.

Reliability of the Pinch Strength with Digitalized Pinch Dynamometer

Objective To examine the intra-rater, inter-rater, and inter-instrumental reliability of the digitalized pinch muscle strength dynamometer. Method Thirty normal subjects were examined for pinch strength, using both the Preston pinch gauge and the digitalized pinch dynamometer. The participants performed all pinch strength tests in the seated position as recommended by the American Society of Hand Therapists (ASHT). Three successive measurements were taken for each hand. The mean of the three trials was used for data analysis. The pinch strength tests performed used a repeated measure design and measurements were taken by each rater. Results The relationship between the Preston pinch gauge and the digitalized pinch dynamometer in pinch strength was reliable (the ICC were 0.821 and 0.785 in rater 1 and rater 2 respectively). The relationship between the first session and second session in pinch strength using the digitalized pinch dynamometer was reliable (the ICC were 0.872 and 0.886 in rater A and rater B respectively). The relationship between rater A and rater B in pinch strength using the digitalized pinch dynamometer was reliable (the ICC was 0.754). Conclusion The pinch strength measurement using the digitalized pinch dynamometer is reliable within the rater and between raters. Thus, the Preston pinch gauge and the digitalized dynamometer measure grip strength equivalently, and can be used interchangeably.

The Availability of Radiological Measurement of Tibial Torsion: Three-Dimensional Computed Tomography Reconstruction

Objective To assess the intra-rater and inter-rater reliability for measuring tibial torsion measurements by a radiographic method using three-dimensional computed tomography reconstruction (3D-CT) and to compare the physical measures to those of 3D-CT. Method The study included 33 children who presented with intoeing gait. Tibial torsion was measured by 3D-CT. Distal reference point was the bimalleolar axis. Proximal reference points were the transtibial axis and posterior condylar axis. Physical measurements included thigh-foot angle (TFA) and bimalleolar angle (BMA). 3D-CT measurement and physical measurement were performed twice at both lower extremities by each rater. The intra-rater and inter-rater reliability were calculated by intraclass correlation coefficiency (ICC). The relationship between radiological and physical examination was calculated by Spearman correlation coefficient. Results The 3D-CT measures for tibial torsion were reliable within individual raters and between different raters. However, physical measures for tibial torsion were reliable within an individual rater but not reliable between raters. The 3D-CT measures by any proximal reference axis were more reliable within a rater and between raters than physical measurements. There was no significant impact introduced by the selection of the proximal reference axis. The correlation coefficiency between 3D-CT and physical measurement methods was low. Conclusion Because the 3D-CT measurements for tibial torsion are more reliable than physical measurements, we recommend that accurate diagnosis of internal tibial torsion should be detected by using 3D-CT measurements. Also, considering the disadvantages of radiological measurements, physical measurement may be used for short term follow-up by same raters, as intra-rater reliability is relatively good.

Effect of Anteromedial Portal Entrance Drilling Angle during Anterior Cruciate Ligament Reconstruction: A Three-Dimensional Computer Simulation

Purpose The object of this study was to evaluate entrance angle effects on femoral tunnel length and cartilage damage during anteromedial portal drilling using three-dimensional computer simulation. Materials and Methods Data was obtained from an anatomic study performed using 16 cadaveric knees. The anterior cruciate ligament femoral insertion was dissected and the knees were scanned by computer tomography. Tunnels with different of three-dimensional entrance angles were identified using a computer simulation. The effects of different entrance angles on the femoral tunnel length and medial femoral cartilage damage were evaluated. Specifically, tunnel length and distance from the medial femoral condyle to a virtual cylinder of the femoral tunnel were measured. Results In tunnels drilled at a coronal angle of 45°, an axial angle of 45°, and a sagittal angle of 45°, the mean femoral tunnel length was 39.5±3.7 mm and the distance between the virtual cylinder of the femoral tunnel and the medial femoral condyle was 9.4±2.6 mm. The tunnel length at a coronal angle of 30°, an axial angle of 60°, and a sagittal angle of 45°, was 34.0±2.9 mm and the distance between the virtual cylinder of the tunnel and the medial femoral condyle was 0.7±1.3 mm, which was significantly shorter than the standard angle (p<0.001). Conclusion Extremely low and high entrance angles in both of axial plane and coronal plane produced inappropriate tunnel angles, lengths and higher incidence of cartilage damage. We recommend that angles in proximity to standard angles be chosen during femoral tunnel drilling through the anteromedial portal.

Retrospective Assessment of the Implementation of Critical Pathway in Stroke Patients in a Single University Hospital

Objective To evaluate the effects of the implementation of critical pathway (CP) in stroke patients treated at a single university hospital. Methods A retrospective medical review collected data from 497 patients who had suffered acute stroke in the rehabilitation center. Stroke outcomes were compared between before and after the implementation of CP based on factors including demographic factors, stroke characteristics, pre-existing medical conditions, medical complications, functional states, and length of stay (LOS). Results After the implementation of CP, the patients showed significantly higher stage for upper proximal (p=0.008) and lower extremity (p=0.001) on Brunnstrom stage and significantly lower scores for modified Rankin Scale (p=0.003) at transfer. For those with pre-existing medical conditions, there were significantly increased osteoarthritis (p=0.002) and valvular heart disease (p=0.011). Regarding medical complications during acute inpatient rehabilitation, there were significantly decreased shoulder pain (p=0.001) and dysphagia (p=0.017), and significantly increased gastrointestinal symptoms (p=0.001). Functional gain and efficiency of stroke patients during rehabilitation center hospitalization did not significantly change after implementation of CP. But, shorter LOS of total hospitalization, pre-rehabilitation center hospitalization, and rehabilitation center hospitalization were evident. Conclusion After the implementation of CP, patients less often developed complications and displayed no changes in functional gain and efficiency. They had shorter LOS of total hospitalization, pre-rehabilitation center hospitalization and rehabilitation center hospitalization.

Collet-Sicard Syndrome With Hypoglossal Nerve Schwannoma: A Case Report

Collet-Sicard syndrome is a rare syndrome that involves paralysis of 9th to 12th cranial nerves. We report an uncommon case of schwannoma of the hypoglossal nerve in a 39-year-old woman presented with slurred speech, hoarse voice, and swallowing difficulty. Physical examination revealed decreased gag reflex on the right side, decreased laryngeal elevation, tongue deviation to the right side, and weakness of right trapezius muscle. MRI revealed a mass lesion in the right parapharyngeal space below the jugular foramen. The tumor was surgically removed. It was confirmed as hypoglossal nerve schwannoma via pathologic examination. Videofluoroscopic swallowing study revealed aspiration of liquid food and severe bolus retention in the vallecula and piriform sinus. Laryngoscopy revealed right vocal cord palsy. Electrodiagnostic study revealed paralysis of the right 11th cranial nerve. In summary, we report an uncommon case of schwannoma of the hypoglossal nerve with 9th to 12th cranial nerve palsy presenting as Collet-Sicard syndrome.

Prevalence and Related Characteristics of Carpal Tunnel Syndrome Among Orchardists in the Gyeongsangnam-do Region

Objective To determine the prevalence and related characteristics of carpal tunnel syndrome (CTS) in orchardists and to investigate the association between electrodiagnostic severity and physical examinations. Methods Between July 2013 and September 2014, 377 subjects (174 men and 203 women) visited the Gyeongsang National University Hospitals Center for Farmers Safety and Health. All the subjects underwent electrodiagnostic tests and physical examination, including Phalens test, Tinels sign, and Durkans carpal compression test (CCT). The subjects were classified into 2 groups, the normal group and the CTS group, according to electrodiagnostic test results. To determine the related characteristics of CTS, potential variables, including age, sex, drinking, smoking, body mass index, waist circumference, and total work time, were compared between the 2 groups. The association between electrodiagnostic severity and physical examinations was analyzed. Results CTS was diagnosed in 194 subjects based only on electrodiagnostic test results, corresponding to a prevalence of 51.5%. Among the variables, mean age (p=0.001) and total work time (p=0.007) were significantly correlated with CTS. With respect to the physical examinations, low specificities were observed for Tinels sign, Phalens test, and Durkans CCT (38.4%, 36.1%, and 40.9%, respectively) in the subjects aged ≥65 years. In addition, Phalens test (p=0.003) and Tinels sign (p=0.032) in men and Durkans CCT (p=0.047) in women showed statistically significant differences with increasing CTS severity. The odds ratio was 2.066 for Durkans CCT in women according to the multivariate logistic regression analysis. Conclusion CTS prevalence among orchardists was high, and Durkans CCT result was significantly quantitatively correlated with the electrodiagnostic test results. Therefore, Durkans CCT is another reliable examination method for CTS.