Kyung Hee Do

Injury of the corticoreticular pathway in patients with proximal weakness following cerebral infarct: diffusion tensor tractography study.

The corticoreticular pathway (CRP) innervates mainly the proximal muscles of extremities. Identification of the CRP by diffusion tensor tractography (DTT) in the human brain has recently become possible. However, little is known about the relation between proximal weakness and injury of the CRP in stroke patients. In this study, we attempted to investigate the usefulness of DTT for elucidation of the relation between proximal motor weakness and injury of the CRP in patients with cerebral infarct. Among 247 consecutive patients with cerebral infarct, four hemiparetic patients who showed more severe weakness in proximal joints (shoulder and hip) than distal joints (finger and ankle) of the affected extremities were recruited for this study. Evaluation of motor function, DTT, and transcranial magnetic stimulation (TMS) for evaluation of the corticospinal tract state by analysis of the characteristics of the motor-evoked potential were performed at the early stage of cerebral infarct (mean: 17.0 days; range: 11-29). The integrity of the CST on DTT findings in the affected hemisphere was preserved in all four patients and TMS findings in terms of latency and amplitude showed within normal range (one patient) and partial injuries (three patients) of the corticospinal tract. By contrast, on DTT of the CRP in the affected hemispheres, we observed Wallerian degeneration in two patients and discontinuations at infarct level in two patients. The injury of the CRP appeared to attribute the proximal weakness of the shoulder and hip observed in these four patients. Therefore, DTT of the CRP would be useful for elucidating the relation between proximal weakness and injury of the CRP in patients with cerebral infarct.

Effect of a hybrid ankle foot orthosis made of polypropylene and fabric in chronic hemiparetic stroke patients.

Objective The ankle foot orthosis (AFO) has been used for control of ankle motion in stroke patients for a long time. However, studies on the materials used in construction of AFOs have been limited. In this study, the authors attempted to investigate the effect of a hybrid AFO made with polypropylene and fabric in comparison with a conventional plastic AFO in terms of convenience and effect in patients with chronic hemiparetic stroke. Design Seventeen patients with chronic hemiparetic stroke who have used plastic AFOs were recruited for this study. Two types of AFOs were used: plastic AFO made with polypropylene and hybrid AFO made with polypropylene covered with canvas fabric, which were individually molded and fitted. Convenience was evaluated using a self-developed questionnaire on patients’ satisfaction and weights of AFO, and effect was evaluated using gait analysis. Results On the satisfaction questionnaire, satisfaction was greater for the hybrid AFO, and it was lighter in weight than the plastic AFO (P < 0.05). In gait analysis, faster walking speed, larger mean and peak ankle dorsiflexion angles, and ankle dorsiflexion angles at heel strike and toe off were observed for the hybrid and plastic AFOs compared with barefoot (P < 0.05). No significant difference was observed between the two orthoses, except for ankle dorsiflexion angle at heel strike, in which the plastic AFO showed higher ankle dorsiflexion angle than did the hybrid AFO. Conclusions According to the results of this study, the hybrid AFO showed a similar effect in function, except for ankle dorsiflexion angle at heel strike, and was superior with regard to convenience compared with the conventional plastic AFO in chronic hemiparetic stroke patients. Therefore, it seems that, in general, the hybrid AFO can be recommended for hemiparetic stroke patients who require an AFO.

Comparison of intra-articular lumbar facet joint pulsed radiofrequency and intra-articular lumbar facet joint corticosteroid injection for management of lumbar facet joint pain: A randomized controlled trial

Background: This study aimed to demonstrate the effect of intra-articular (IA) lumbar facet joint (LFJ) pulsed radiofrequency (PRF) for the management of LFJ pain, and to compare the effect of IA LFJ PRF to IA corticosteroid injection (ICI). Pathology in the LFJ is a common source of lower back pain (LBP). It is responsible for chronic LBP in approximately 15% to 45% of patients. It has been reported that PRF stimulation can effectively reduce refractory joint pain. Methods: Sixty patients with LFJ pain were recruited and randomly assigned to 1 of 2 groups: the IA PRF group and the ICI group. There were 30 patients in each group. At pretreatment, 2 weeks, 1, 3, and 6 months after treatment, we assessed the severity of LBP using a numeric rating scale (NRS). Results: Compared with the pretreatment NRS scores, patients in both groups showed a significant decrease in NRS scores at 2 weeks, and 1, 3, and 6 months after each treatment. Between groups, changes in the NRS scores were significantly different over time. At 2 weeks and 1 month after each procedure, the NRS score after ICI was significantly lower than that after the PRF stimulation. However, at 3 and 6 months after the procedures, the decrements of NRS scores were not significantly different between the 2 groups. Six months after treatment, about half of patients in both groups reported successful pain relief (pain relief of ≥50%). Conclusion: In the current study, both IA PRF stimulation and ICI into the LFJ significantly relieved LFJ pain. Their effects persisted for at least 6 months after the procedure. Thus, IA PRF is a useful therapeutic option for the management of LFJ pain.

The difference of gait pattern according to the state of the corticospinal tract in chronic hemiparetic stroke patients

OBJECTIVES The lateral corticospinal tract (CST) is one of the most important neuronal pathways that mediate voluntary movements in the human brain. However, little is known about the role of the lateral CST on the gait. We attempted to investigate differences in gait pattern using a motion analysis system according to the integrity of the contralateral CST, which was classified using diffusion tensor tractography (DTT) in chronic hemiparetic stroke patients. METHODS We recruited 16 chronic hemiparetic stroke patients and 12 normal subjects for this study. DTT findings of the CST for patients were classified into two groups: group A (eight patients); the integrity of the CST was preserved, group B (eight patients) - the CST was discontinued at or below the stroke lesion. We compared variables of gait between group A, group B, and normal controls using the motion analysis system. RESULTS Group A and the control group showed a significantly higher peak angle for ankle dorsiflexion, knee internal rotation, and hip flexion, compared with group B (p < 0.05). On the other hand, the peak angle for ankle plantarflexion/external rotation, knee flexion/abduction, and hip extension of group A and group B were significantly lower than those of the control group (p < 0.05). CONCLUSION We found that severe injury of the contralateral CST caused decreased movement of ankle dorsiflexion, knee internal rotation, and hip flexion in chronic hemiparetic stroke patients. As a result, the circumduction and abduction gait pattern in stroke patients is closely associated with severe injury of the contralateral CST.

Comparison of Intra-articular Thoracic Facet Joint Steroid Injection and Thoracic Medial Branch Block for the Management of Thoracic Facet Joint Pain

Study Design. A prospective observational study. Objective. The aim of this study was to show the effect of intra-articular (IA) thoracic facet joint (TFJ) steroid injection for the management of TFJ pain, and to compare it with the effect of therapeutic thoracic medial branch block (MBB) with a local anesthetic and steroid. Summary of Background Data. Several studies have shown the effects of thoracic MBB with local anesthetics with or without steroids and radiofrequency neurotomy in managing TFJ pain, but thus far, the effectiveness of IA TFJ steroid injection has not been studied. Methods. Forty patients with TFJ pain were recruited and randomly assigned to one of two groups, the IA steroid injection and the MBB group, each with 20 patients. For IA TFJ steroid injection and therapeutic MBB, we injected 0.5 mL of 0.5% bupivacaine, mixed with 10 mg (0.25 mL) of dexamethasone. We assessed the severity of TFJ pain using a numeric rating scale (NRS) before treatment and at 1, 3, and 6 months after treatment. Results. Compared to the pretreatment NRS scores, the NRS scores at 1, 3, and 6 months after each treatment showed a significant decrease in patients in both the groups. Intergroup changes in the NRS scores were not significantly different over time. Six months after the treatment, 65% of the patients in the IA steroid injection group reported successful pain relief (pain relief ≥50%), and 40% of the patients in the MBB group showed successful pain relief. Conclusion. In the present study, both IA TFJ steroid injection and therapeutic MBB significantly relieved TFJ pain. Their effects persisted for at least 6 months after the procedure. Thus, we think that both IA TFJ steroid injection and therapeutic thoracic MBB are useful treatment options for managing TFJ pain. Level of Evidence: 2

Clinical Predictors of Oro-esophageal Tube Feeding Success in Brain Injury Patients With Dysphagia

Objective To identify possible clinical predictors of intermittent oro-esophageal (OE) tube feeding success, and evaluate the clinical factors associated with OE tube treatment. Methods A total of 135 dysphagic patients were reviewed, who received OE tube treatment and were hospitalized in the department of rehabilitation medicine between January 2005 and December 2014. The 76 eligible cases enrolled were divided into two groups, based on the OE tube training success. Clinical factors assessed included age, cause of brain lesion, gag reflex, cognitive function and reasons for OE tube training failure. Results Of the 76 cases enrolled, 56 study patients were assigned to the success group, with the remaining 20 in the failure group. There were significant differences between these two groups in terms of age, gag reflex, ability to follow commands, and the score of Korean version of Mini-Mental Status Examination (K-MMSE). Location of the brain lesion showed a borderline significance. Multivariable analysis using logistic regression revealed that age, cause of brain lesion, gag reflex, and K-MMSE were the main predictors of OE tube training success. Conclusion A younger age, impaired gag reflex and higher cognitive function (specifically a K-MMSE score ≥19.5) are associated with an increased probability of OE tube training success in dysphagic patients.

Hypercapnia Caused by a Therapeutic Dosage of Pregabalin in a Tetraplegic Patient With Cervical Spinal Cord Injury

Pregabalin is often used for the treatment of neuropathic pain in patients with spinal cord injury (SCI). We reported a patient with C5 [S(C5/C6)] ASIA Impairment Scale C SCI due to cervical myelopathy who presented CO2 retention when taking a therapeutic dosage of pregabalin. An 88-year-old patient with cervical SCI was transferred to the department of physical medicine and rehabilitation. When he had transferred, his neuropathic pain had been treated with 150-mg pregabalin per day (75 mg twice a day); however, he still exhibited severe neuropathic pain with a Numeric Pain Rating Scale score of 7 to 8. Dosage for the pregabalin increased from 150 mg/d (75 mg twice a day) to 225 mg/d (150 mg at morning and 75 mg at dinner). That afternoon, he presented drowsiness and confusion, and arterial blood gas analysis (ABGA) demonstrated respiratory acidosis with CO2 retention; pH, 7.312; PaCO2, 62.8 mm Hg; PaO2,58.9 mm Hg; HCO3 concentration, 30.8 mmol/L; base excess, 3.2 mmol/L; and oxygen saturation, 90.4%. Finally, he required tracheal intubation and ventilation. After 6 weeks, the patient was transferred to a general ward, and the follow-up ABGA and end-tidal CO2 showed normal range with the discontinuation of pregabalin. We demonstrated CO2 retention via ABGA in a patient with SCI due to cervical myelopathy who developed hypercapnia after taking a therapeutic dose of pregabalin. Physicians should pay particular attention to CO2 retention when prescribing a therapeutic dosage of pregabalin in a patient with cervical SCI.

The Therapeutic Effect of Tibia Counter Rotator With Toe-Out Gait Plate in the Treatment of Tibial Internal Torsion in Children

Objective To evaluate the therapeutic effect of a Tibia Counter Rotator (TCR) with toe-out gait plate (GP) upon tibial internal torsion by a comparative analysis of transmalleolar angle (TMA) and gait analysis with GP alone. Methods Twenty participants with tibial internal torsion were recruited for this study. Each 10 participants were included in group A with TCR and GP application and in group B with GP application only. The TMA and the kinematic results were used for the evaluation of the therapeutic effects of orthoses. Results Within each group, TMA showed a significant increase after treatment. Group A showed a continuous improvement up to six months, however, group B showed an improvement up to five months only. Group A showed a significantly higher correction effect than group B after treatment. Regarding kinematic data, both groups showed a significantly decreased mean ankle adduction angle after treatment. However, group A showed a significantly lower mean ankle adduction angle than group B after six months. Conclusion The group with TCR and GP showed a significantly better outcome and continued correction force compared to the group with GP only. Our results suggest that TCR with GP may be useful therapeutic orthoses for children with tibial internal torsion.