Jae Hyeok Chang

Screening for the coexistence of congenital muscular torticollis and developmental dysplasia of hip.

Objective To investigate the coexistence rate and related factors of developmental dysplasia of the hip (DDH) and congenital muscular torticollis (CMT), and to determine whether ultrasonography (US) gives good value for screening of DDH in CMT. Method We prospectively examined 121 infants (73 males and 48 females) diagnosed with CMT to determine the incidence of DDH by US. We also assessed the relationship between neck US findings and DDH occurrence, and investigated the clinical features of CMT related to DDH. Results 18 patients (14.9%) were diagnosed as having DDH by US. However, most DDH was subclinical and spontaneously resolved. Only 2 patients (1.7%) needed to be treated with a harness. The positive predictive value of clinical examinations for DDH was 52.6% and patients treated by harness were all clinically positive. DDH was more common in the left side (13 left, 4 right, 1 both), but 6 out of 18 DDH (33.3%) cases presented on the contralateral side of CMT. Sex difference was not observed. Breech presentation and oligohydramnios were not related to DDH occurrence. Neck US findings did not correlate with DDH occurrence. Conclusion The coexistence rate of CMT and DDH was concluded to be 14.9%. If only DDH cases that required treatment were included, the coexistence rate of these two disorders would be lowered to 1.7%. All of these patients showed positive findings in clinical examination. Therefore, hip US should not be recommended routinely for patients with CMT.

The Correlation between Modified Ashworth Scale and Biceps T-reflex and Inter-rater and Intra-rater Reliability of Biceps T-reflex.

Objective To establish a correlation between the modified Ashworth scale (MAS) and amplitude and latency of T-reflex and to demonstrate inter-rater and intra-rater reliability of the T-reflex of the biceps muscle for assessing spasticity after stroke. Method A total of 21 patients with hemiplegia and spasticity after ischemic stroke were enrolled for this study. The spasticity of biceps muscle was evaluated by an occupational therapist using the MAS. The mean value of manual muscle test of biceps muscles was 2.3±0.79. Latency and amplitude of T-reflex were recorded from biceps muscles by two physicians. The onset latency and peak to peak amplitude of the mean of 5 big T-reflex were measured. The examinations were carried out by two physicians at the same time to evaluate the inter-rater reliability. Further, one of the physicians performed the examination again after one week to evaluate the intra-rater reliability. The correlations between MAS and T-reflex, and the intra- and inter-rater reliability of biceps T-reflex were established by calculating the Spearman correlation coefficients and the intra-class correlation coefficients (ICCs). Results Amplitude of the biceps T-reflex increased with increasing level of MAS (rs=0.464 and 0.573, respectively, p<0.01). ICCs of latency and amplitude of biceps T-reflex were 0.914 and 0.822. The Spearman correlation coefficients of latency and amplitude of biceps T-reflex were 0.937 and 0.635, respectively (p<0.01). Conclusion Biceps T-reflex demonstrates a good quantitative measurement and correlation tool with MAS for spasticity, and also shows acceptable inter- and intra-rater reliability, which can be used for patients with spasticity after stroke.

Botulinum Toxin in the Treatment of Drooling in Tetraplegic Patients With Brain Injury

Objective To investigate the effect of botulinum toxin type A (BTA) injection into the salivary gland and to evaluate the changes of drooling in varied postures in tetraplegic patients with brain injury. Methods Eight tetraplegic patients with brain injury were enrolled. BTA was injected into each parotid and submandibular gland of both sides under ultrasonographic guidance. Drooling was measured by a questionnaire-based scoring system for drooling severity and frequency, and the sialorrhea was measured by a modified Schirmer test for the patients before the injection, 3 weeks and 3 months after the injection. Drooling was evaluated in each posture, such as supine, sitting, and tilt table standing, and during involuntary mastication, before and after the injection. Results The severity and frequency of drooling and the modified Schirmer test improved significantly at 3 weeks and 3 months after the injection (p<0.05). Drooling was more severe and frequent in tilt table standing than in the sitting position and in sitting versus supine position (p<0.05). The severity of drooling was significantly increased in the patients with involuntary mastication (p<0.05). Conclusion Salivary gland injection of BTA in patients with tetraplegia resulting from brain injury who had drooling and sialorrhea could improve the symptoms for 3 months without complications. The severity and frequency of drooling were dependent on posture and involuntary mastication. Proper posture and involuntary mastication of the patients should be taken into account in planning drooling treatment.

A case of generalized auditory agnosia with unilateral subcortical brain lesion.

The mechanisms and functional anatomy underlying the early stages of speech perception are still not well understood. Auditory agnosia is a deficit of auditory object processing defined as a disability to recognize spoken languages and/or nonverbal environmental sounds and music despite adequate hearing while spontaneous speech, reading and writing are preserved. Usually, either the bilateral or unilateral temporal lobe, especially the transverse gyral lesions, are responsible for auditory agnosia. Subcortical lesions without cortical damage rarely causes auditory agnosia. We present a 73-year-old right-handed male with generalized auditory agnosia caused by a unilateral subcortical lesion. He was not able to repeat or dictate but to perform fluent and comprehensible speech. He could understand and read written words and phrases. His auditory brainstem evoked potential and audiometry were intact. This case suggested that the subcortical lesion involving unilateral acoustic radiation could cause generalized auditory agnosia.

Efficacy of Systemic Postoperative Pulmonary Rehabilitation After Lung Resection Surgery

Objective To investigate the efficacy of systemic pulmonary rehabilitation (PR) after lung resection in patients with lung cancer. Methods Forty-one patients undergoing lung resection were enrolled and classified into the experimental (n=31) and control groups (n=10). The experimental group underwent post-operative systemic PR which was conducted 30 min/day on every hospitalization day by an expert physical therapist. The control group received the same education about the PR exercises and were encouraged to self-exercise without supervision of the physical therapist. The PR group was taught a self-PR program and feedback was provided regularly until 6 months after surgery. We conducted pulmonary function testing (PFT) and used a visual analog scale (VAS) to evaluate pain, and the modified Borg Dyspnea Scale (mBS) to measure perceived respiratory exertion shortly before and 2 weeks, 1, 3, and 6 months after surgery. Results A significant improvement on the VAS was observed in patients who received systemic PR >3 months. Significant improvements in forced vital capacity (FVC) and mBS score were observed in patients who received systemic PR >6 months (p<0.05). Other PFT results were not different compared with those in the control group. Conclusion Patients who received lung resection suffered a significant decline in functional reserve and increases in pain and subjective dyspnea deteriorating quality of life (QoL). Systemic PR supervised by a therapist helped improve reduced pulmonary FVC and QoL and minimized discomfort during the postoperative periods in patients who underwent lung resection.

Differences in Urodynamic Variables for Vesicoureteral Reflux Depending on the Neurogenic Bladder Type

Objective To compare the urodynamic study variables at the onset of vesicoureteral reflux (VUR) between the overactive and underactive bladders in patients with spinal cord injury who presented with VUR. Methods A total of 28 (13 cases of detrusor overactivity and 15 detrusor underactivity) men were enrolled. We compared the urodynamic variables between the two groups; detrusor pressure and bladder compliance, the infused volume at the onset of VUR measured on a voiding cystourethrography and cystometric capacity, maximum detrusor pressure, and bladder compliance during filling cystometry were recorded. Results At the onset of VUR, the bladder volume and compliance, except for the detrusor pressure, showed a significant difference between the two groups. The detrusor pressure, bladder volume, and bladder compliance relative to the cystometric capacity showed a significant difference between the two groups. The detrusor pressure, bladder volume, and bladder compliance at the onset of VUR relative to the cystometric bladder capacity did not show any significant difference between the two groups. Conclusion There were differences in some variables at the onset of VUR depending on the type of neurogenic bladder. The VUR occurred at a lower capacity in neurogenic bladder with detrusor overactivity than in neurogenic bladder with detrusor underactivity at the same pressure. VUR occurred at a lower intravesical pressure compared to that known as the critical detrusor pressure (≥40 cm H2O) required for the development of VUR. The results of our study demonstrate that the detrusor pressure should be maintained lower than the well known effective critical detrusor pressure for the prevention and treatment of VUR.

Autonomic dysreflexia-induced reversible posterior leukoencephalopathy syndrome in patients with spinal cord injury: two case reports.

Abstract Background/objectives To report two cases of reversible posterior leukoencephalopathy syndrome (RPLS) in patients with traumatic cervical spinal cord injury. Design Case report. Setting Rehabilitation Inpatient Unit, Pusan National University Hospital, Yangsan-si, Korea. Results Two men with spastic tetraplegia developed autonomic dysreflexia. Use of antihypertensive medication and Foley catheter insertion prevented further episodes of acute arterial hypertension and development of new symptoms. Conclusion RPLS can occur in the setting of autonomic dysreflexia in patients with traumatic cervical cord injury. The prompt recognition of this syndrome is of importance to prevent further morbidity and mortality in patients with spinal cord injury.

Hyperthyroidism as a cause of autonomic dysreflexia.

Chang JH, Han JE, Sohn HJ, Shin YB, Ko H-Y: Hyperthyroidism as a cause of autonomic dysreflexia. Am J Phys Med Rehabil 2008;87:768–772. A 25-yr-old female tetraplegic patient experienced autonomic dysreflexia episodes involving hypertension, headache, facial flushing, and tachycardia. The symptoms were not related to the bladder or bowel. The episodes did not seem to be linked to any mechanical cause. The patient was incidentally diagnosed with hyperthyroidism. Treatment with antithyroid medication resulted in resolution of the autonomic dysreflexia. This case suggests that hyperthyroidism may trigger autonomic dysreflexia in tetraplegic patients.

Effects of Botulinum Toxin on Reducing the Co-contraction of Antagonists in Birth Brachial Plexus Palsy

Birth brachial plexus palsy (BBPP) is usually caused by plexus traction during difficult delivery. Although the possibility of complete recovery is relatively high, 5% to 25% of BBPP cases result in prolonged and persistent disability. In particular, muscle imbalance and co-contraction around the shoulder and elbow cause abnormal motor performance, osseous deformities, and joint contracture. Physical and occupational therapies have most commonly been used, but these conventional therapeutic strategies have often been inadequate, in managing the residual muscle imbalance and muscle co-contraction. Therefore, we attempted to improve the functional movements, by using botulinum toxin type A, to reduce the abnormal co-contraction of the antagonist muscles.

Isolated bilateral abducens nerves palsy due to traumatic delicate arteriovenous fistula

Background: Ocular motor dysfunction is common in patients with head trauma. Also, traumatic lateral gaze palsy is usually associated with brain stem lesion, peripheral nerve injury with or without basilar skull fracture and lateral rectus muscle injury or entrapment. However, isolated bilateral abducens nerve palsy is extremely rare. Case study: This study describes a case of isolated bilateral abducens nerve palsy in a 35-year-old male with head trauma without cervical and skull fractures. He was diagnosed with mild diffuse axonal injury. During his assessment, he developed mild limb weakness, an ataxic gait and impaired abductive movement in both eyes. Angiography of the left common carotid artery revealed multiple small arteriovenous fistulae in both inferior nasal conchae. After embolization, lateral gaze palsy of his eyes was significantly improved. Conclusions: Based on this case, arteriovenous fistula should be considered as a cause of bilateral isolated abducens nerve palsy.