Myung Jun Shin

Effect of constraint-induced movement therapy and mirror therapy for patients with subacute stroke.

Objective To evaluate the effectiveness of constraint-induced movement therapy (CIMT) and combined mirror therapy for inpatient rehabilitation of the patients with subacute stroke. Methods Twenty-six patients with subacute stroke were enrolled and randomly divided into three groups: CIMT combined with mirror therapy group, CIMT only group, and control group. Two weeks of CIMT for 6 hours a day with or without mirror therapy for 30 minutes a day were performed under supervision. All groups received conventional occupational therapy for 40 minutes a day for the same period. The CIMT only group and control group also received additional self-exercise to substitute for mirror therapy. The box and block test, 9-hole Pegboard test, grip strength, Brunnstrom stage, Wolf motor function test, Fugl-Meyer assessment, and the Korean version of Modified Barthel Index were performed prior to and two weeks after the treatment. Results After two weeks of treatment, the CIMT groups with and without mirror therapy showed higher improvement (p<0.05) than the control group, in most of functional assessments for hemiplegic upper extremity. The CIMT combined with mirror therapy group showed higher improvement than CIMT only group in box and block test, 9-hole Pegboard test, and grip strength, which represent fine motor functions of the upper extremity. Conclusion The short-term CIMT combined with mirror therapy group showed more improvement compared to CIMT only group and control group, in the fine motor functions of hemiplegic upper extremity for the patients with subacute stroke.

Effect of increased axial rotation angle on bone mineral density measurements of the lumbar spine.

BACKGROUND CONTEXT Osteoporosis frequently occurs in elderly people and is commonly associated with neuromuscular diseases or severe cerebral palsy. Osteoporosis can cause pain via compression fractures or secondary neurologic deficits; thus, accurate evaluation of bone mineral density (BMD) is essential for the prevention and treatment of osteoporosis. However, spinal axial rotation caused by scoliosis may affect the outcome of BMD tests, such that BMD measurements may be significantly greater than actual BMD in patients with severe scoliosis of the spine. PURPOSE We investigated the effect of axial rotation angle on BMD measurements of the phantom spine. STUDY DESIGN/SETTING Investigation for the effect of axial rotation with aluminum phantom spine. METHODS A GE-Lunar Aluminum Spine Phantom was used to assess BMD. Bone mineral content (BMC), BMD, and cross-sectional area were measured 100 times at L1-L4 using a GE Lunar Prodigy Vision system. Dual-energy X-ray absorptiometry was performed at axial rotation angles of 0° to 25° (5° intervals). RESULTS Cross-sectional area decreased and BMD values increased as the axial rotation angle increased, whereas BMC did not change significantly. A fitting function was obtained to evaluate the relationships among axial rotation angle, cross-sectional area, and BMD. We obtained an equation to estimate BMD at L1-L4: 1.000-0.001674x+0.0001043x(2)-0.000005333x(3), where x denotes the axial rotation angle. We found that the observed BMD needed adjustment when the angle was more than 5°. CONCLUSIONS Bone mineral density values may be overestimated in patients with even slight (>5°) axial rotation. When osteoporosis is suspected in a clinical setting, the degree of axial rotation should be measured on a lumbar spine X-ray.

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.

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.

Cauda Equina Syndrome Caused by Spinal Dural Arteriovenous Fistula

Spinal dural arteriovenous fistula (SDAVF) is rare but still the most commonly encountered vascular malformation of the spinal cord. A 31-year-old male developed gait disturbance due to weakness of his lower extremities, voiding difficulty and sexual dysfunction with a progressive course since 3 months. He showed areflexia in both knees and ankles. Electromyographic findings were suggestive of multiple root lesions involving bilateral L2 to S4 roots of moderate degree. Magnetic resonance images showed high signal intensity with an ill-defined margin in T2-weighted images and intensely enhanced by a contrast agent through the lumbosacral spinal cord. Selective spinal angiography confirmed a dural arteriovenous fistula with a nidus at the L2 vertebral level. After selective endovascular embolization, his symptoms drastically improved except sexual dysfunction. We report a rare case of cauda equina syndrome due to spinal arteriovenous fistula with drastic improvement after endovascular embolization.

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.

Comparative analysis of the beneficial effects of treadmill training and electroacupuncture in a rat model of neonatal hypoxia-ischemia

In the present study, we investigated whether treadmill training and electroacupuncture (EA) have autonomous or synergistic beneficial effects on deficits caused by neonatal hypoxia-ischemia in Sprague-Dawley rats. For this purpose, rats subjected to hypoxia-ischemia underwent treadmill training and EA stimulation from 4 to 8 weeks of age. Conventional EA (CEA) and scalp EA (SEA) were delivered by electrical stimulation (2 Hz, 1 mA) at traditional acupoints and at the scalp to the primary motor area, respectively. In the behavioral examination, markedly improved performances in the rotarod test were observed in the rats that underwent treadmill exercise, and in the rats that underwent treadmill exercise and CEA compared to the untreated rats subjected to hypoxia-ischemia. An improvement was also observed in the passive avoidance test in the rats that underwent treadmill training and EA. As shown by western blot analysis, the expression levels of neuronal nuclei (NeuN), 2′,3′-cyclic-nucleotide 3′-phosphodiesterase and myelin basic protein (MBP) exhibited a significant decrease in the contralateral subventricular zone (SVZ) of the rats subjected to hypoxia-ischemia compared to the controls; however, these expression levels increased following treadmill exercise and EA stimulation. As shown by immunohistochemical analyses, the thickness of the corpus callosum and the integrated optical density (IOD) of MBP were significantly increased in the rats subjected to treadmill exercise and EA compared to the untreated rats subjected to hypoxiaa-ischemia. The synergistic effects of treadmill training and EA were also observed in the protein levels and IOD of MBP. A marked increase in the number of bromodeoxyuridine (BrdU)- and BrdU/NeuN-positive cells in the contralateral SVZ was also observed in the rats that underwent treadmill training and EA; the number of BrdU-positive cells was synergistically affected by treadmill training and EA. These results suggest that treadmill training and EA stimulation contribute to the enhancement of behavioral recovery following hypoxia-ischemia via the upregulation of myelin components and neurogenesis. Thus, treatment with EA stimulation, as well as treadmill training offers another treatment option to promote functional recovery in cerebral palsy.

Short-Term Caloric Restriction Does Not Reduce Bone Mineral Density in Rats with Early Type 2 Diabetes

Background The effect of caloric restriction (CR) in the setting of diabetes on bone metabolism has not yet been fully studied. The aim of this study is to determine if short-term CR alters bone mass and metabolism in Otsuka Long-Evans Tokushima fatty (OLETF) rats, an animal model of type 2 diabetes. Methods Four groups (n=5) were created: OLETF rats with food ad libitum (AL), OLETF rats with CR, Long-Evans Tokusima Otsuka (LETO) rats with food AL, and LETO rats with CR. The CR condition was imposed on 24-week-old male rats using a 40% calorie reduction for 4 weeks. The effect of CR on femoral bone mineral density (BMD) was assessed by dual-energy X-ray absorptiometry. Serum markers were measured by immunoassay. Results After 4 weeks of CR, body weight decreased in both strains. The BMD decreased in LETO rats and was maintained in OLETF rats. After adjustment for body weight, BMD remained lower in LETO rats (P=0.017) but not OLETF rats (P=0.410). Bone-specific alkaline phosphatase levels decreased in LETO rats (P=0.025) but not in OLEFT rats (P=0.347). Serum leptin levels were reduced after CR in both strains, but hyperleptinemia remained in OLETF rats (P=0.009). CR increased 25-hydroxyvitamin D levels in OLETF rats (P=0.009) but not in LETO rats (P=0.117). Additionally, interleukin-6 and tumor necrosis factor-α levels decreased only in OLETF rats (P=0.009). Conclusion Short-term CR and related weight loss were associated with decreases of femoral BMD in LETO rats while BMD was maintained in OLETF rats. Short-term CR may not alter bone mass and metabolism in type 2 diabetic rats.

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.