Tyng-Guey Wang

Evaluating swallowing dysfunction using a 100-ml water swallowing test.

This study used comparison with videofluoroscopic examination of swallowing (VFES) to examine the validity of a 100-ml water swallowing test (WST) in assessing swallowing dysfunction. Fifty-nine consecutive outpatients (15 females, 44 males) with clinically suspected dysphagia were enrolled in this study. Each subject underwent a 100-ml WST followed by VFES. Data was obtained on swallowing speed and signs of choking (coughing and a wet-hoarse voice). The analytical results revealed that 49 subjects had abnormal swallowing speeds (< 10 ml/s) in the 100-ml WST, and 47 of them were identified as having dysphagia by VFES. Among the ten participants with normal swallowing speed (> 10 ml/s), eight were diagnosed with dysphagia by VFES. Notably, 14 participants choked in the 100-ml WST, 11 of whom exhibited aspiration or penetration in VFES. Among the 45 participants without choking in WST, 12 displayed aspiration or penetration in VFES. The sensitivity of swallowing speed in detecting the swallowing dysfunction was 85.5%, and the specificity was 50%. Moreover, the sensitivity of using choking or wet-horse voice in the 100-ml WST as the sole factor for predicting the presence of aspiration was 47.8%, while the specificity was 91.7%. Therefore, this study concluded that swallowing speed is a sensitive indicator for identifying patients at risk for swallowing dysfunction. Moreover, choking in the 100-ml WST may be a potential specific indicator for followup aspiration.

Dysphagia in Patients with Nasopharyngeal Cancer After Radiation Therapy: A Videofluoroscopic Swallowing Study

This study evaluated swallowing status and the factors influencing swallowing in patients with nasopharyngeal carcinoma (NPC) after radiation therapy. During the period from July 1995 to June 1999, this cross-sectional study used videofluoroscopic swallowing study (VFSS) to evaluate 184 NPC patients who had completed radiation therapy [113 cases had completed radiation therapy ≤12 months prior to evaluation (acute group) and 71 cases had completed radiation therapy >12 months prior to evaluation (chronic group)]. The numbers of patients with tumors in each of the four stages were as follows: 24 in stage I, 45 in stage II, 41 in stage III, and 74 in stage IV. Swallowing abnormalities of the acute and chronic groups were correlated with multiple variables, including gender, age, the stage of the tumor, use of either neoadjuvant chemotherapy or radiosensitizer, and radiation modality. The analytical results indicated that the chronic group had a significantly higher proportion of swallowing abnormalities. Radiation modality, chemotherapy, and tumor staging were not significantly associated with swallowing dysfunction. Trend analysis revealed a progressive deterioration of most parameters of swallowing function in this group of patients. These findings indicate that swallowing function continues to deteriorate over time, even many years after radiation therapy in patients with NPC. Our results indicate that the time elapsed since radiation therapy correlates with the severity of dysphagia in NPC patients.

Sonoelastography of the Plantar Fascia

PURPOSE To compare the stiffness of the plantar fascia by using sonoelastography in healthy subjects of different ages, as well as patients with plantar fasciitis. MATERIALS AND METHODS The study protocol was approved by the Research Ethics Committee of the hospital, and all of the subjects gave their informed consent. Bilateral feet of 40 healthy subjects and 13 subjects with plantar fasciitis (fasciitis group) were examined by using color-coded sonoelastography. Healthy subjects were divided into younger (18-50 years) and older (> 50 years) groups. The color scheme was red (hard), green (medium stiffness), and blue (soft). The color histogram was subsequently analyzed. Each pixel of the image was separated into red, green, and blue components (color intensity range, 0-255). The color histogram then computed the mean intensity of each color component of the pixels within a standardized area. Mixed model for repeated measurements was used for comparison of the plantar fascia thickness and the intensity of the color components on sonoelastogram. RESULTS Quantitative analysis of the color histogram revealed a significantly greater intensity of blue in older healthy subjects than in younger (94.5 ± 5.6 [± standard deviation] vs 90.0 ± 4.6, P = .002) subjects. The intensity of red and green was the same between younger and older healthy subjects (P = .68 and 0.12). The intensity of red was significantly greater in older healthy subjects than in the fasciitis group (147.8 ± 10.3 vs 133.7 ± 13.4, P < .001). The intensity of green and blue was the same between older healthy subjects and those in the fasciitis group (P = .33 and .71). CONCLUSION Sonoelastography revealed that the plantar fascia softens with age and in subjects with plantar fasciitis.

Relationships between three potentiation effects of plyometric training and performance

This study measured the potentiation effects of plyometric training [normalized electromyography (EMG) in triceps surae, stiffness and elastic energy utilization of the Achilles tendon] and investigated the correlations between these effects and performances [voluntary electromechanical delay (EMD) and jump height]. Twenty‐one subjects were randomly assigned either to the control group (10 subjects: age 22.3±1.6 years) or to a training group (11 subjects: age 22.1±1.6 years) that performed 8 weeks of plyometric training. Results: As compared with the performances before training, normalized EMG in the soleus were significantly (P≤0.001) increased after 4 and 8 weeks of training. Tendon stiffness, elastic energy storage, release and jump height determined after training were significantly increased (P<0.05), with a concomitantly reduced voluntary EMD (P=0.01). These variables also showed significant differences vs the control group (all P<0.05). The other variables remained unchanged. Correlations were observed between tendon stiffness and either voluntary EMD (r=−0. 77, P=0.014) or jump height (r=0.54, P=0.031). Conclusions: Plyometric training specifically potentiated the normalized EMG, tendon stiffness and elastic energy utilization in the myotendinous complex of the triceps surae. Although these changes are possibly essential determinants, only increases of tendon stiffness were observed to correlate with performance improvements.

Sonographic detection of occult fractures in the foot and ankle

The purpose of this retrospective study was to determine whether high‐resolution sonography can aid in the diagnosis of radiographically occult fractures in the foot and ankle.

Introduction to musculoskeletal diagnostic ultrasound: examination of the upper limb.

Lew HL, Chen CPC, Wang T-G, Chew KTL: Introduction to musculoskeletal diagnostic ultrasound: examination of the upper limb. Am J Phys Med Rehabil 2007;86:310–321. With recent advances in computer technology and equipment miniaturization, the clinical application of diagnostic ultrasonography (U/S) has spread across various medical specialties. Diagnostic U/S is attractive in terms of its noninvasiveness, lack of radiation, readiness of use, cost-effectiveness, and its ability to make dynamic examinations possible. Dynamic imaging deserves special emphasis because it is useful in differentiating full-thickness from partial-thickness tendon tears, muscle tears, and tendon and nerve subluxations or dislocations. It is also a quick and easy avenue for side-to-side comparisons. When appropriately used, diagnostic U/S can be considered as an extension of ones physical examination. However, there are limitations of U/S, which will be discussed in this review article. This is part 1 of two articles; this first part will focus on the ultrasound examination of the upper extremity, using selected examples relevant to musculoskeletal medicine. Part 2 will cover common pathologies of the lower extremity.

Effects of functional electrical stimulation on dysphagia caused by radiation therapy in patients with nasopharyngeal carcinoma.

PurposeThis study aimed to assess the effectiveness of functional electrical stimulation on the swallowing function of irradiated nasopharyngeal carcinoma patients with dysphagia.Materials and methodsTwenty nasopharyngeal carcinoma subjects with dysphagia were divided into a functional electrical stimulation (FES) and a home rehabilitation program (HRP) group. Each subject completed a quality of life questionnaire on swallowing and a videofluoroscopic study at the commencement and the end of the procedures. The FES group received functional electrical stimulation of the supra-hyoid muscles over 15 sessions. The HRP group performed self-swallowing exercises at home. The evaluation parameters included the quality of life questionnaire scores, the penetration–aspiration scale (PAS), the movement of the hyoid bone, and the amount of pyriform sinuses stasis.ResultsMost swallowing outcomes of the FES group improved after FES. The quality of life score (p = 0.003), the duration of the movement of thin barium through the hyoid (p = 0.001), the moving speed of paste barium through the hyoid (p = 0.028), and the pyriform sinus stasis area of the paste barium (p = 0.026) reached significant difference in the FES group. Most swallowing outcomes did not improve in the HRP group. The degree of improvement in the movement speed of the hyoid bone in the thin barium (p = 0.018) and the PAS of the paste barium (p = 0.016) were statistically significantly greater in the FES group than in the HRP group.ConclusionFES will improve the swallowing function of NPC patients with dysphagia and bring about better quality of life.

Thinner plantar fascia predicts decreased pain after extracorporeal shock wave therapy

Increased plantar fascia thickness is common with chronic plantar fasciitis, and reduction of the thickness after extracorporeal shock wave therapy or steroid injection has been reported. We hypothesized a decrease of plantar fascia thickness was associated with pain reduction after extracorporeal shock wave therapy. Fifty-three eligible patients with 78 symptomatic feet were randomly treated with piezoelectric-type extracorporeal shock wave therapy of two intensity levels (0.12 and 0.56 mJ/mm2). Two thousand shock waves for three consecutive sessions were applied at weekly intervals. A visual analog scale for pain, the Foot Function Index, the Short Form-36 Health Survey, and ultrasonographic measurement of plantar fascia thickness were evaluated at baseline and 3 and 6 months after treatment. We analyzed the association between pain level and plantar fascia thickness with generalized estimating equation analysis and adjusted for demographic and treatment-related variables. Patients with thinner plantar fascia experienced less pain after treatment; high-intensity treatment and regular exercise were associated with lower pain level. The overall success rates were 63% and 60% at the 3- and 6-month followups. High- and low-intensity treatments were associated with similar improvements in pain and function. Receiving high-intensity treatment, although associated with less pain at followup, did not provide a higher success rate.Level of Evidence: Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Early Versus Delayed Passive Range of Motion Exercise for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials.

Background: Postoperative shoulder stiffness complicates functional recovery after arthroscopic rotator cuff repair. Purpose: To compare early passive range of motion (ROM) exercise with a delayed rehabilitation protocol with regard to the effectiveness of stiffness reduction and functional improvements and rates of improper healing in patients undergoing arthroscopic repair for torn rotator cuffs. Study Design: Systematic review and meta-analysis. Methods: Randomized controlled trials (RCTs) comparing both rehabilitation approaches were identified in PubMed and Scopus. Between-group differences in shoulder function were transformed to effect sizes for comparisons, whereas the effectiveness against stiffness and the risk of tendon failure were reported using standardized mean differences of ROM degrees and odds ratios (ORs) of recurrent tears, respectively. Results: Six RCTs were included, consisting of 482 patients. No significant difference in shoulder function existed across both protocols. The early ROM group demonstrated more improvement in shoulder forward flexion than the delayed rehabilitation group, with a standardized mean difference of 7.45° (95% CI, 3.20°-11.70°) at 6 months and 3.51° (95% CI, 0.31°-6.71°) at 12 months. Early ROM exercise tended to cause a higher rate of recurrent tendon tears (OR, 1.43; 95% CI, 0.90-2.28), and the effect became statistically significant (OR, 1.93; 95% CI, 1.04-3.60) after excluding 2 RCTs that recruited only those patients with small to medium-sized tears. Conclusion: Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair but was likely to result in improper tendon healing in shoulders with large-sized tears. The choice of either protocol should be based on an accommodation of the risks of recurrent tears and postoperative shoulder stiffness.

Dysphagia screening decreases pneumonia in acute stroke patients admitted to the stroke intensive care unit

Dysphagia increases the risk of pneumonia in stroke patients. This study aimed to evaluate bedside swallowing screening for prevention of stroke-associated pneumonia (SAP) in acute stroke patients admitted to the intensive care unit (ICU). Consecutive acute stroke patients admitted to the stroke ICU from May 2006 to March 2007 were included. Patients were excluded if they were intubated on the first day of admission or had a transient ischemic attack. A 3-Step Swallowing Screen was introduced since October 2006 and therefore patients were divided into pre-screen and post-screen groups. A binary logistic regression model was used to determine independent risk factors for SAP and in-hospital death. There were 74 and 102 patients included in the pre- and post-screen groups, respectively. Pneumonia was associated with higher National Institutes of Health Stroke Scale (NIHSS) score, older age, nasogastric and endotracheal tube placement. After adjusting for age, gender, NIHSS score and nasogastric and endotracheal tube insertion, dysphagia screening was associated with a borderline decrease in SAP in all stroke patients (odds ratio, 0.42; 95% CI, 0.18-1.00; p=0.05). However, dysphagia screening was not associated with reduction of in-hospital deaths. Systematic bedside swallowing screening is helpful for prevention of SAP in acute stroke patients admitted to the ICU.