Rai-Chi Chan

Task-oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke:

Objective: To examine the effectiveness of task-oriented progressive resistance strength training on lower extremity strength and functional performance in chronic stroke subjects. Design: Single-blind, randomized controlled trial. Setting: Medical centre and district hospital. Subjects: Forty-eight subjects at least one year post stroke. Interventions: Participants randomly allocated to two groups, control (n-/24) and experimental (n-/24). Subjects in the control group did not receive any rehabilitation training. Subjects in the experimental group were put on a four-week task-oriented progressive resistance strength training. Main measures: Lower extremity muscle strength, gait velocity, cadence, stride length, six-minute walk test, step test, and timed up and go test. Results: Muscle strength significantly improved in the experimental group for strong side muscle groups (ranged from 23.9% to 36.5%) and paretic side muscle groups (ranged from 10.1% to 77.9%). In the control group muscle strength changes ranged from 6.7% gain to 11.2% decline. The experimental group showed significant improvement in all selected measures of functional performance except for the step test. In the control group, the number of repetitions of the step test significantly decreased (-20.3%) with no change in other functional tests. There was a significant difference between groups for muscle strength and all functional measures. The strength gain was significantly associated with gain in the functional tests. Conclusions: The task-oriented progressive resistance strength training programme could improve lower extremity muscle strength in individuals with chronic stroke and could carry over into improvement in functional abilities.

Cubital tunnel syndrome : Diagnosis by high-resolution ultrasonography

The purpose of this study was to evaluate the morphologic changes in the ulnar nerve in cubital tunnel syndrome with high‐resolution ultrasonography. The mean values of the short axis (cm) x long axis (cm) at the arm, epicondyle, and forearm levels were 0.057 +/‐ 0.01, 0.068 +/‐ 0.019, and 0.062 +/‐ 0.01 in control group; 0.069 +/‐ 0.04, 0.139 +/‐ 0.06, and 0.066 +/‐ 0.023 in the symptomatic side in patients with cubital tunnel syndrome; and 0.063 +/‐ 0.029, 0.068 +/‐ 0.029, and 0.057 +/‐ 0.012 in the normal side in patients with cubital tunnel syndrome. No significant difference was found in the area (short axis x long axis) of the ulnar nerve at the arm, epicondyle and forearm levels between the left and right ulnar nerve in the control group and between the control group and the normal side in symptomatic patients. However, the mean value of the area of the ulnar nerve at the epicondyle level in symptomatic patients was significantly larger than that of the control group and that of the contralateral side in patients, and the P value was less than 0.001. High resolution ultrasonography can detect morphologic changes in the ulnar nerve accurately, and it could therefore be useful as a screening and even follow‐up modality in patients with cubital tunnel syndrome.

Central Modulation of Pain Evoked From Myofascial Trigger Point

ObjectivesLow-intensity low-frequency electrostimulation delivered within a myofascial trigger point (MTP) has been used as intervention to deactivate MTPs. The therapeutic effect has been suggested to be due to peripheral mechanisms. However, nonpainful stimuli are also known to reduce simultaneous pain through central effects. The primary objective of the present study was to assess if central pain modulation occurs after intervention with low-intensity electrostimulation within an MTP. We hypothesized that intervention induces pain inhibition via the periaqueductal gray (PAG). MethodsTwenty-four patients with myofascial pain syndrome participated in the study. During functional magnetic resonance scanning, painful (high-intensity) intramuscular electrostimulation was delivered at random intervals (mean interstimulus interval=10.2 s) within an MTP of the upper left trapezius muscle. In-between scanning sessions, intervention (intramuscular electrostimulation, low-intensity, interstimulus interval=0.5 s) was applied to the same area. Patients were divided into responders and nonresponders according to their change in pressure pain thresholds relative to intervention. In addition to a whole brain search, a region of interest approach was also implemented to test the effect of intervention on PAG signal change. ResultsThe main findings were: (1) intervention modulated PAG activity to painful stimuli more in responders than in nonresponders, (2) change in PAG activity from the whole patient population correlated with change in pressure pain threshold, and (3) a network known to regulate affective qualities of the pain experience was (subsignificantly) engaged more in responders than in nonresponders. DiscussionThe applied intervention most likely involves supraspinal pain control mechanisms related to both antinociception and regulation of pain affect.

Central representation of hyperalgesia from myofascial trigger point

The aim of the study was to investigate if an abnormal brain response to pain exists in patients with myofascial pain syndrome (MPS) when stimulated in a hypersensitive myofascial trigger point (MTP). Event-related functional magnetic resonance imaging was used to characterize the brain response to pain evoked from an MTP. Activation patterns from patients were compared with those evoked from an equivalent site in healthy controls with stimulus intensity matched and pain intensity matched stimuli. Compared to healthy controls at matched stimulus intensity, patients experienced significantly higher pain intensity (hyperalgesia). The corresponding brain response revealed significantly enhanced somatosensory (SI, SII, inferior parietal, mid-insula) and limbic (anterior insula) activity and suppressed right dorsal hippocampal activity in patients compared with controls. At matched pain intensity, enhanced activity was found in the same somatosensory areas but not in limbic areas. Our results show that the hyperalgesic state observed in MPS patients was associated with abnormal hyperactivity in regions processing stimulus intensity and negative affect. We speculate that suppressed hippocampal activity might reflect stress-related changes in relation to chronic pain as an effective physical and emotional stressor.

Functional electrical stimulation on chronic and acute hemiplegic shoulder subluxation.

OBJECTIVE The present study investigated and assessed the effectiveness of a functional electrical stimulation (FES) program in the management of acute and chronic shoulder subluxation. DESIGN By their postonset duration, hemiplegic subjects with subluxation participating in the study were placed into a short-duration group and a long-duration group. Subjects in each group were further assigned randomly to either a control subgroup or an experimental subgroup. The experimental subgroups of both short and long duration received FES therapy in which supraspinatus and posterior deltoid were induced to contract repetitively up to 6 hr/day for 6 wk. The duration of the FES session and muscle contraction/relaxation ratio were progressively increased as performance improved. RESULTS The experimental subgroup of short duration showed significant improvements in reducing subluxation as indicated by x-ray compared with the control subgroup of short duration after the first FES treatment. The same effect was not shown for the experimental subgroup of long duration. The second FES treatment program only resulted in an insignificant change of shoulder subluxation for both the short- and long-duration subgroups. CONCLUSIONS The present study suggests that hemiplegic subjects with short postonset duration are effectively trained for shoulder subluxation by the first FES treatment program. The same FES showed not to be effective when applied to the subjects with subluxation of > 1 yr.

Extracorporeal shock wave therapy for chronic calcific tendinitis of the shoulders: a functional and sonographic study

OBJECTIVES To evaluate the therapeutic effect of extracorporeal shock wave therapy (ESWT) in shoulders with chronic calcific tendinitis, to compare the functional outcomes of ESWT and transcutaneous electric nerve stimulation (TENS) therapy, and to investigate which types of calcium deposit effectively respond to ESWT. DESIGN Randomized controlled trial. SETTING Outpatient clinics of the departments of physical medicine and rehabilitation and of orthopedics and traumatology of a veterans hospital in Taiwan. PARTICIPANTS Sixty patients with continuous shoulder pain for 6 months or more and with radiographically and sonographically verified calcific tendinitis. Patients were randomly allocated to receive ESWT (33 shoulders) or TENS treatment (30 shoulders). INTERVENTIONS ESWT was performed with 2000 shock waves at 2Hz and energy level between.26 and.32mJ/mm(2) per session. Treatment was given in 2 sessions, 14 days apart. TENS therapy was given 3 times a week for 4 weeks. MAIN OUTCOME MEASURES Mean Constant score, visual analog scale (VAS), manual muscle test, and changes of sonographic size and shape of calcium deposits were calculated for 4 time points: at baseline, 2 weeks, 4 weeks, 12 weeks posttherapy. RESULTS In both groups, Constant score and VAS improved significantly at 2-, 4-, and 12-week follow-ups (P<.05), and the size of calcium deposits decreased significantly at the 4- and 12-week follow-ups. Moreover, the arc-shaped calcific plaques of the rotator cuff were markedly meliorated with ESWT. CONCLUSIONS ESWT is more effective in the treatment of chronic calcific tendinitis of the shoulder than is TENS therapy, especially for arc-type calcific plaque.

Differences in seated postural control in children with spastic cerebral palsy and children who are typically developing.

Liao S-F, Yang T-F, Hsu T-C, Chan R-C, Wei T-S: Differences in seated postural control in children with spastic cerebral palsy and children who are typically developing. Am J Phys Med Rehabil 2003;82:622–626. ObjectiveTo quantitatively evaluate the difference of posture control in sitting position between children with spastic cerebral palsy and normal subjects. DesignTwenty children with spastic cerebral palsy who could sit independently and 20 age- and sex-matched normal children were enrolled. The Chatteex Balance System was used to evaluate static and dynamic posture control as the subjects were sitting on a bench. The sway distance in sagittal and lateral directions, sway ratio, and sway index in both the static and dynamic sitting positions were recorded by the Chatteex Balance System. ResultsThere was a significantly lower static and dynamic sway ratio and a greater static sway index and dynamic lateral sway distance in the study group. The dynamic sway index in the study group was greater than the index in the control group, although it did not reach statistical significance. ConclusionsChildren with diplegic cerebral palsy did perform significantly worse in sitting posture control compared with normal subjects of similar chronological age. The sway index and sway ratio proved to be the objective and sensitive indicators that can be used to distinguish children with cerebral palsy from normal peer groups.

Effects of Functional Electric Stimulation on Upper Limb Motor Function and Shoulder Range of Motion in Hemiplegic Patients

Wang RY, Yang YR, Tsai MW, Wang WTJ, Chan RC: Effects of functional electric stimulation on upper limb motor function and shoulder range of motion in hemiplegic patients. Am J Phys Med Rehabil 2002;81:283–290. Objectives The present study examines functional electric stimulation (FES) applied on patients with hemiplegia of short and long duration for the purpose of upper limb motor recovery and increasing shoulder range of motion. Design Patients with hemiplegia with subluxation participating in the study were placed into a short-duration group or a long-duration group. Subjects in each group were then randomly assigned to either the control or the experimental subgroup. The experimental groups of both short- and long-duration groups received FES therapy in which the supraspinatus and posterior deltoid muscles were induced to contract repetitively up to 6 hr a day for 6 wk. Duration of FES session and muscle contraction/relaxation ratio were progressively increased as performance improved. The experimental groups also received a second 6-wk FES therapy 6 wk after completing the first FES therapy. Results After the first 6-wk FES therapy, the experimental group of short-duration hemiplegia showed significant improvements in motor recovery as indicated by Fugl-Meyer scores compared with the control group. Such significant improvement did not occur for the experimental group of long-duration hemiplegia. The changes in the second FES treatment program were insignificant. Conclusions This study suggests that patients with hemiplegia of short duration are effectively trained by FES for motor recovery.

Use of serum procalcitonin to detect bacterial infection in patients with autoimmune diseases: A systematic review and meta‐analysis

OBJECTIVE To systematically review evidence of the accuracy of the procalcitonin test for diagnosis of bacterial infection in patients with autoimmune disease. METHODS The major databases Medline, EMBase, and the Cochrane Library were searched for studies published between January 1966 and October 2011 that evaluated procalcitonin, alone or in comparison with other laboratory markers such as C-reactive protein (CRP), as a diagnostic marker for bacterial infection in patients with autoimmune disease and provided sufficient data to permit construction of 2 × 2 tables. RESULTS Nine studies were included in the final meta-analysis. The area under the summary receiver operating characteristic curve values were 0.91 (95% confidence interval [95% CI] 0.88-0.93) for procalcitonin and 0.81 (95% CI 0.78-0.84) for CRP. In general, testing for procalcitonin was highly specific for identifying infectious complications, although it was not as sensitive as testing for CRP. Pooled sensitivity was 0.75 (95% CI 0.63-0.84) for procalcitonin tests and 0.77 (95% CI 0.67-0.85) for CRP tests. Pooled specificity was 0.90 (95% CI 0.85-0.93) for procalcitonin tests and 0.56 (95% CI 0.25-0.83) for CRP tests. The positive likelihood ratio for procalcitonin (7.28 [95% CI 5.10-10.38]) was sufficiently high to qualify procalcitonin testing as a rule-in diagnostic tool, while the negative likelihood ratio (0.28 [95% CI 0.18-0.40]) was not sufficiently low to qualify procalcitonin testing as a reliable rule-out diagnostic tool. CONCLUSION Procalcitonin has higher diagnostic value than CRP for the detection of bacterial sepsis in patients with autoimmune disease, and the test for procalcitonin is more specific than sensitive. A procalcitonin test is not recommended to be used in isolation as a rule-out tool.

Comparison of clinical characteristics and performance of pneumonia severity score and CURB-65 among younger adults, elderly and very old subjects

Background Age-related alterations in the clinical characteristics and performance of severity scoring systems for community-acquired pneumonia (CAP) are unknown. Methods Consecutive patients with CAP presenting to the emergency department were prospectively studied. Patients were classified as younger adults (age 18–64 years), elderly (age 65–84 years) and very old subjects (age ≥85 years). Clinical characteristics, complications, outcomes and validity of the pneumonia severity index (PSI) and CURB-65 categories were compared across these three age categories. Results Analysis involved 348 (35.3%) younger adult patients, 438 (44.3%) elderly patients and 201 (20.0%) very old patients. Compared with younger adults, elderly and very old patients had a higher burden of comorbidities and a higher incidence of CAP-related complications. The 30-day mortality rate was 5.2% in younger adults, 7.1% in elderly patients and 9.5% in very old patients. The area under the ROC curve (AUCs) for PSI were 0.87 (95% CI 0.77 to 0.97), 0.85 (95% CI 0.803 to 0.897) and 0.69 (95% CI 0.597 to 0.787) and the AUCs for CURB-65 were 0.80 (95% CI 0.67 to 0.93), 0.73 (95% CI 0.65 to 0.82) and 0.60 (95% CI 0.47 to 0.73) in the younger adult, elderly and very old patients, respectively. A modified PSI or CURB-65 excluding the age variable increased the AUC in most age categories. There was no significant effect of age on 30-day mortality after adjusting for other PSI or CURB-65 variables. Conclusion Elderly patients with CAP have more atypical clinical manifestations and worse outcomes. The underperformance of the PSI in elderly patients may be due to the inappropriate weight given to the age variable. A modification of the cut-off point for PSI or CURB-65 to define severe pneumonia may improve the score performance in elderly patients.