Transverse myelitis is a rare inflammatory myelopathy characterized by loss of motor and sensory function below the affected level of the spinal cord, and causes neurogenic bowel and bladder. Occasionally, it also causes neuropathic pain with spasticity. Traditional therapies for neuropathic pain are multiple, including multimodal analgesic regimens, antiepileptic or antidepressant medications, opioids, sympathetic blocks, and spinal cord stimulation. Persistent neuropathic pain can cause emotional distress by affecting sleep, work, recreation, and emotional well-being. Here we report the case of a patient suffering from intractable neuropathic pain following acute transverse myelitis that was not relieved by combinations of nonsteroidal anti-inflammatory, anti-epileptic, antidepressant, and opioid medications, or by acupuncture. Implantation of an intrathecal morphine pump controlled the pain successfully without side effects, and enabled the patient to embark on intensive rehabilitation. The patient’s muscle strength has improved significantly and the patient may soon be able to use a walker with minimal assistance.
intrathecal morphine pump; neuropathic pain; rehabilitation; transverse myelitis
Central hyperthermia is characterized by a rapid onset, high temperature, marked temperature fluctuation, and poor response to antipyretics and antibiotics. Although poststroke central hyperthermia is common, prolonged instances are rare. We report a case of prolonged central fever after an intracranial hemorrhage. Before the accurate diagnosis and management of central fever, the patient underwent long-term antibiotic use that led to pseudomembranous colitis. Bromocriptine was used to treat the prolonged central hyperthermia, after which the fever did not exceed 39°C. A week later, the body temperature baseline was reduced to 37°C and a low-grade fever with minor temperature fluctuation occurred only a few times. No fever occurred in the month following the treatment. After the fever subsided, the patient could undergo an aggressive rehabilitation program.
bromocriptine; central hyperthermia; fever; stroke
The current study aims to investigate the effects of primary caregiver participation in vestibular rehabilitation (VR) on improving the measures of neglect, activities of daily living (ADL), balance, and falls of unilateral neglect (UN) patients.
This study is a single-blind randomized controlled trial. Both experimental (n = 24) and control groups (n = 24) received conventional rehabilitation. The experimental group undertook VR for a month. During the first and second weeks, a registered nurse trained the experimental group in VR. The primary caregivers in the experimental group supervised and guided their patients in VR during the third and fourth weeks. The outcome measures were neglect, ADL, balance, and falls.
The two groups of UN patients showed a significant improvement in neglect, ADL, and balance over time. Based on the generalized estimating equations model, an interaction was observed between groups and times. Significant interactions were observed between the VR group at days 14 and 28 in the areas of neglect, ADL, and balance. No significant difference was observed between the two groups in the number of falls.
Neglect, ADL, and balance among UN patients with right hemispheric stroke can be improved through the participation of primary caregivers in VR. Trained informal caregivers were recommended to provide VR guidance and supervision to patients who suffer from UN.
neglect; vestibular rehabilitation; falls; balance; caregiver
Myofascial pain syndrome (MPS) has been defined as a regional pain syndrome characterized by muscle pain caused by myofascial trigger points (MTrPs) clinically. MTrP is defined as the hyperirritable spot in a palpable taut band of skeletal muscle fibers. Appropriate treatment to MTrPs can effectively relieve the clinical pain of MPS. Needling therapies, such as MTrP injection, dry needling, or acupuncture (AcP) can effectively eliminate pain immediately. AcP is probably the first reported technique in treating MPS patients with dry needling based on the Traditional Chinese Medicine (TCM) theory. The possible mechanism of AcP analgesia were studied and published in recent decades. The analgesic effect of AcP is hypothesized to be related to immune, hormonal, and nervous systems. Compared to slow-acting hormonal system, nervous system acts in a faster manner. Given these complexities, AcP analgesia cannot be explained by any single mechanism. There are several principles for selection of acupoints based on the TCM principles: “Ah-Shi” point, proximal or remote acupoints on the meridian, and extra-meridian acupoints. Correlations between acupoints and MTrPs are discussed. Some clinical and animal studies of remote AcP for MTrPs and the possible mechanisms of remote effectiveness are reviewed and discussed.
Objective. To obtain electrophysiological effects of Fu's subcutaneous needling (FSN) on needling distance by assessment of endplate noise (EPN) recorded from the myofascial trigger spots (MTrSs) in rabbit skeletal muscle. Method. Eighteen New Zealand rabbits weighing 2.5–3.0 kg were randomly divided into two groups as follows: proximal needling (PN) group and distal needling (DN) group. The needling procedure followed the instructions described by the inventor of FSN, including needling insertion and swaying movement. The amplitudes of EPN on the MTrS region of BF muscle were recorded as an index of MTrS irritability. Random sampling of EPN tracings were taken for further analyses before, during, and after FSN treatment. Results. In PN and DN groups, the trends of EPN amplitude alterations were similar at conditions before, during, and after FSN treatment. The degree of reduction in the EPN amplitude in PN group was significantly higher than that in DN group. There were no significant changes in EPN amplitudes in the MTrS of contralateral BF without FSN intervention either in DN or PN group. Conclusion. The irritability of proximal MTrSs could be modulated after ipsilateral FSNs. The placement of FSN may affect the effectiveness of suppression of irritability of MTrSs.
Background and Purpose. Dry needling is an effective therapy for the treatment of pain associated with myofascial trigger point (MTrP). However, the biochemical effects of dry needling that are associated with pain, inflammation, and hypoxia are unclear. This study investigated the activities of β-endorphin, substance P, TNF-α, COX-2, HIF-1α, iNOS, and VEGF after different dosages of dry needling at the myofascial trigger spots (MTrSs) of a skeletal muscle in rabbit. Materials and Methods. Dry needling was performed either with one dosage (1D) or five dosages (5D) into the biceps femoris with MTrSs in New Zealand rabbits. Biceps femoris, serum, and dorsal root ganglion (DRG) were sampled immediately and 5 d after dry needling for β-endorphin, substance P, TNF-α, COX-2, HIF-1α, iNOS, and VEGF immunoassays. Results. The 1D treatment enhanced the β-endorphin levels in the biceps femoris and serum and reduced substance P in the biceps femoris and DRG. The 5D treatment reversed these effects and was accompanied by increase of TNF-α, COX-2, HIF-1α, iNOS, and VEGF production in the biceps femoris. Moreover, the higher levels of these biochemicals were still maintained 5 d after treatment. Conclusion. Dry needling at the MTrSs modulates various biochemicals associated with pain, inflammation, and hypoxia in a dose-dependent manner.
Objective. The purpose of this pilot study is to investigate the effectiveness of the percutaneous soft tissue release for the treatment of recurrent myofascial pain in the forearm due to recurrent lateral epicondylitis. Methods. Six patients with chronic recurrent pain in the forearm with myofascial trigger points (MTrPs) due to chronic lateral epicondylitis were treated with percutaneous soft tissue release of Lin's technique. Pain intensity (measured with a numerical pain rating scale), pressure pain threshold (measured with a pressure algometer), and grasping strength (measured with a hand dynamometer) were assessed before, immediately after, and 3 months and 12 months after the treatment. Results. For every individual case, the pain intensity was significantly reduced (P < 0.01) and the pressure pain threshold and the grasping strength were significantly increased (P < 0.01) immediately after the treatment. This significant effectiveness lasts for at least one year. Conclusions. It is suggested that percutaneous soft tissue release can be used for treating chronic recurrent lateral epicondylitis to avoid recurrence, if other treatment, such as oral anti-inflammatory medicine, physical therapy, or local steroid injection, cannot control the recurrent pain.
Increases in the aging population and in the number of accidents have resulted in more people suffering from physical impairments or disabilities. Rehabilitation therapy thus attracts greater attention as a means of helping patients recover and return to a normal life. With the extremely long and tedious nature of traditional rehabilitation, patients are reluctant to continue the entire process, thus the expected effects of the therapy cannot be obtained. Games are well known to help patients improve their concentration and shift their attention away from the discomfort of their injuries during rehabilitation. Thus, incorporating game technology into a rehabilitation program may be a promising approach.
In this study, a gaming system used for shoulder rehabilitation was developed. The mechanical parts and electric circuits were integrated to mimic the functionalities of a shoulder wheel. Several games were also designed to suit the rehabilitation needs of the patients based on the age and gender differences among the individual users, enabling individuals to undergo the rehabilitation process by playing games. Two surveys were conducted to evaluate the satisfaction of the participants regarding the gaming system.
The results of the online survey among a larger population coincide with the responses of the hands-on participants through a paper-and-pencil survey. Statistical results suggest that the participants are willing to accept this novel approach.
This gaming system can distract a patient from the sensation of pain or anxiety, and increase their motivation to participate in the therapeutic program. Advantages in terms of low-cost and easy setup increase the attractiveness of this new equipment for various potential users.
virtual reality; virtual rehabilitation; shoulder wheel; game design
Incomplete bladder emptying (IBE) is defined as having a postvoid residual (PVR) urine volume greater than 100 mL for 2 consecutive days. IBE is common in stroke patients and could necessitate indwelling or intermittent catheterization. The condition is correlated with urinary tract infections, which could impede rehabilitation progress and increase medical costs. Treatment for patients with IBE includes bladder retraining, biofeedback, medication, and botulinum toxin injection, but none of these interventions are completely effective.
All patients with acute stroke who were admitted to the rehabilitation ward between August 2010 and April 2011 were included in the study and their PVR urine volume was checked. Electroacupuncture (EA; 1 Hz, 15 minutes) was performed on the acupoints Sanyinjiao (SP6), Ciliao (BL32), and Pangguangshu (BL28) of stroke patients with IBE for a total of ten treatments (five times a week for 2 weeks). Bladder diaries, which included the spontaneous voiding and PVR urine volumes, were recorded during the course of treatment.
The presence of IBE was not related to sex, history of diabetes mellitus, stroke type (hemorrhagic or ischemic), or stroke location (P > 0.05). Among the 49 patients in the study, nine (18%) had IBE, and seven of the stroke patients with IBE were treated with EA. Increased spontaneous voiding volume and decreased PVR urine volume were noted after ten sessions of EA.
EA may have beneficial effects on stroke survivors with IBE, thereby making it a potential safe modality with which to improve urinary function.
acupuncture; electroacupuncture; incomplete bladder emptying; rehabilitation; stroke; urinary retention
The purpose of this study was to investigate the effectiveness of sensory processing strategies in improving the activity level of children with sensory integration dysfunction.
The study used a matching-only pretest–posttest control group design, which requires random matching of sensory integration dysfunction to the corresponding intervention group (n = 18) and control group (n = 18). The intervention group comprised 3–6-year-old children who received an 8-week school-day intervention during implementation of the theme curriculum.
The 8-week treatment significantly reduced the activity level and foot-swinging episodes in children with sensory integration dysfunction, and obtained a medium-effect size. However, the level of improvement in the control group did not show any statistically significant change.
Sensory processing strategies could improve activity levels in children with sensory integration dysfunction. However, this study was unable to exclude a developmental effect. The social validity results show that sensory processing strategies can be integrated into the theme curriculum and improve activity levels in children.
activity level; preschool inclusive classroom; sensory integration dysfunction; sensory processing strategy
We report a case of thymic carcinoma presenting as unilateral shoulder pain for 13 months. Before an accurate diagnosis was made, the patient received conservative treatment, cervical discectomies, and myofascial trigger point injection, none of which relieved his pain. When thymic carcinoma was eventually diagnosed, he received total resection of the tumor and the shoulder pain subsided completely. Thymic carcinoma is a rare carcinoma, and our review of the literature did not show shoulder pain as its initial presentation except for one case report. The purpose of this report is to document our clinical experience so that other physiatrists can include thymic carcinoma in their differential diagnosis of shoulder pain.
referred pain; shoulder pain; thymic carcinoma
Escherichia coli is the most common cause of urinary tract infections (UTIs). E. coli genes epidemiologically associated with UTIs are potentially valuable in developing strategies for treating and/or preventing such infections as well as differentiating uropathogenic E. coli from nonuropathogenic E. coli. To identify E. coli genes associated with UTIs in humans, we combined microarray-based and PCR-based analyses to investigate different E. coli source groups derived from feces of healthy humans and from patients with cystitis, pyelonephritis, or urosepsis. The cjrABC-senB gene cluster, sivH, sisA, sisB, eco274, and fbpB, were identified to be associated with UTIs. Of these, cjrABC-senB, sisA, sisB, and fbpB are known to be involved in urovirulence in the mouse model of ascending UTI. Our results provide evidence to support their roles as urovirulence factors in human UTIs. In addition, the newly identified UTI-associated genes were mainly found in members of phylogenetic groups B2 and/or D.
There are few reports in the literature of tuberculous brain abscess. Tuberculous brain abscess usually occurs in an immunocompromised host. Almost all previously documented cases have involved acquired immune deficiency syndrome. We encountered a 53-year-old right-handed immunocompetent male who was initially suspected of having a cerebrovascular accident due to acute-onset right hemiparesis and paresthesia. A tentative diagnosis of brain tumor versus brain abscess was made on imaging studies. The patient was finally diagnosed with a tuberculous brain abscess based upon deterioration on imaging and a positive tuberculosis culture. The tuberculous brain abscess was located in the left parietal lobe, which resulted in Gerstmann’s syndrome and right-sided apraxia. Stereotactic surgery was performed. He was also given antituberculosis chemotherapy and comprehensive rehabilitation. Considerable improvement was noted after rehabilitation. The patient even returned to a normal life and work. Our case demonstrates that an aggressive intensive inpatient rehabilitation program combined with stereotactic surgery and effective antituberculosis therapy play an important role in improving the outcome for patients with tuberculous brain abscess, Gerstmann’s syndrome, and right-sided apraxia.
tuberculous brain abscess; Gerstmann’s syndrome; rehabilitation
It is still unclear when latent myofascial trigger points (MTrPs) develop during early life. This study is designed to investigate the mechanical pain sensitivity of deep tissues in children in order to see the possible timing of the development of latent MTrPs and attachment trigger points (A-TrPs) in school children.
Five hundreds and five healthy school children (age 4- 11 years) were investigated. A pressure algometer was used to measure the pressure pain threshold (PPT) at three different sites in the brachioradialis muscle: the lateral epicondyle at elbow (site A, assumed to be the A-TrP site), the mid-point of the muscle belly (site B, assumed to be the MTrP site), and the muscle-tendon junction as a control site (site C).
The results showed that, for all children in this study, the mean PPT values was significantly lower (p < 0.05) at the assumed A-TrP site (site A) than at the other two sites, and was significantly lower (p < 0.05) at the assumed MTrP site (site B) than at the control site (site C). These findings are consistent if the data is analyzed for different genders, different dominant sides, and different activity levels.
It is concluded that a child had increased sensitivity at the tendon attachment site and the muscle belly (endplate zone) after age of 4 years. Therefore, it is likely that a child may develop an A-Trp and a latent MTrP at the brachioradialis muscle after the age of 4 years. The changes in sensitivity, or the development for these trigger points, may not be related to the activity level of children aged 7-11 years. Further investigation is still required to indentify the exact timing of the initial occurrence of a-Trps and latent MTrPs.
myofascial trigger points; children; pressure pain threshold; algometry
Hypoxia is a feature of the inflamed synovium in rheumatoid arthritis (RA). Intra-articular injection of hyaluronan (HA) may be considered a potential way to treat RA. However, the exact molecular mechanism of HA on decreased cellular responses to hypoxic environment is unclear. The present study has been designed to use the adjuvant-induced arthritis model to examine the effects of HA on the changes of immunohistochemical expressions of hypoxia-inducible factor-1alpha (HIF-1alpha), inducible nitric oxide synthase (iNOS), and matrix metalloproteinase-3 (MMP3) in the synovial tissues at the early phase of arthritic inflammation.
Monoarthritis was induced in adult male Sprague-Dawley (250-300 g) via intraarticular injection of complete Freund's adjuvant (CFA) into the tibiotarsal joint. The CFA-induction arthritis animals were divided into three groups: treatment (intraarticular injection of HA), placebo (intraarticular injection of saline) and controls (no treatments). Functional evaluations of edema and pain behavior, histology, and HIF-1alpha, iNOS, and MMP3 immunohistochemistry were performed before, after the first injection, three injections, and on the follow-up injection of the treatments.
Intra-articular injection of HA also significantly suppressed the mechanical allodynia (p < 0.001) and overexpressions of HIF-1alpha (p < 0.001), iNOS (p = 0.004) and MMP3 (p < 0.001) immunoreactivity in synovium.
This study demonstrated that early intervention of HA is an effective protection against accumulation of inflammation-induced HIF-1alpha, iNOS, and MMP3 to limit erosive damage in CFA-induced model of arthritis.
During functional electrical stimulation (FES), both the frequency and intensity can be increased to increase muscle force output and counteract the effects of muscle fatigue. Most current FES systems, however, deliver a constant frequency and only vary the stimulation intensity to control muscle force. This study compared muscle performance and fatigue produced during repetitive electrical stimulation using three different strategies: (1) constant pulse-duration and stepwise increases in frequency (frequency-modulation); (2) constant frequency and stepwise increases in pulse-duration (pulse-duration-modulation); and (3) constant frequency and pulse-duration (no-modulation). Surface electrical stimulation was delivered to the quadriceps femoris muscles of 12 healthy individuals and isometric forces were recorded. Muscle performance was assessed by measuring the percent changes in the peak forces and force–time integrals between the first and the last fatiguing trains. Muscle fatigue was assessed by measuring percent declines in peak force between the 60 Hz pre- and post-fatigue testing trains. The results showed that frequency-modulation showed better performance for both peak forces and force–time integrals in response to the fatiguing trains than pulse-duration-modulation, while producing similar levels of muscle fatigue. Although frequency-modulation is not commonly used during FES, clinicians should consider this strategy to improve muscle performance.
Functional electrical stimulation (FES); Pulse-duration; Low-frequency fatigue; Muscle performance
To compare the effectiveness of progressively increasing stimulation intensity, progressively increasing frequency, or progressively increasing both frequency and intensity on paralyzed quadriceps femoris muscle force maintenance during repetitive activation.
Factorial design with different stimulation protocols as independent variables.
A muscle performance laboratory.
People (N=8) with spinal cord injury (SCI) (age, 14.63±1.77y).
Main Outcome Measure
Number of contractions when the peak force was 90% or more of a subject’s maximal twitch force.
The protocol involving progressively increasing stimulation intensity and then frequency generated more successful contractions (189.88±53.33) than progressively increasing the frequency followed by intensity (122.75±26.56 contractions). Regardless of the order, progressively increasing both intensity and frequency generated more successful contractions than progressively increasing intensity (97 contractions) or frequency (62 contractions) alone.
Our findings suggest that during repetitive electric activation, progressively increasing both stimulation frequency and intensity can produce more successful contractions than progressively increasing only frequency or intensity. These findings can help researchers and clinicians design more effective stimulation protocols for persons with SCI during functional electric stimulation applications.
Electric stimulation; Rehabilitation; Spinal cord injuries
Background and Purpose
During functional electrical stimulation (FES), clinicians typically increase stimulation intensity to offset fatigue and maintain functional levels of force production. However, recent studies have suggested that increasing the stimulation frequency is an effective strategy for overcoming fatigue during FES. The purpose of this study was to compare the effectiveness of 5 stimulation strategies on maintaining forces during repetitive isometric muscle activation.
Subjects and Methods
The right quadriceps femoris muscles of 12 subjects with no history of lower-extremity orthopedic, neurological, or vascular problems were tested. The 5 stimulation strategies were: progressively increasing the frequency, progressively increasing the intensity, and 3 combination protocols that first increased the intensity and then increased the frequency. The only difference among the 3 combination protocols was the starting frequency used in each protocol (20, 30, or 40 Hz). For all protocols, the stimulation frequency or intensity was increased progressively every time the peak force declined more than 10% from a targeted force level. The specific step increases in frequency or intensity were customized for each subject. A contraction was defined as successful when its peak force exceeded 90% of the targeted force level.
The results showed that progressively increasing only the frequency produced 59% more successful contractions than progressively increasing only the intensity. In addition, the combination stimulation protocol that began with 30-Hz trains produced the most successful contractions (mean=1,205 contractions; 35%–74% more than the other 4 protocols tested).
Discussion and Conclusions
The results suggest that increasing the stimulation intensity and then the frequency is the best strategy to maintain muscle performance and could help clinicians design optimal stimulation protocols to use for each patient during FES.
We have previously developed and tested a muscle model that predicts the effect of stimulation frequency on muscle force responses. The aim of this study was to enhance our isometric mathematical model to predict muscle forces in response to stimulation trains with a wide range of frequencies and intensities for the quadriceps femoris muscles of individuals with spinal cord injuries. Isometric forces were obtained experimentally from 10 individuals with spinal cord injuries (time after injury, 1.5-8 years) and then compared to forces predicted by the model. Our model predicted accurately the force-time integrals (FTI) and peak forces (PF) for stimulation trains of a wide range of frequencies (12.5-80 HZ) and intensities (150-600-μs pulse duration), and two different stimulation patterns (constant-frequency trains and doublet-frequency trains). The accurate predictions of our model indicate that our model, which now incorporates the effects of stimulation frequency, intensity, and pattern on muscle forces, can be used to design optimal customized stimulation strategies for spinal cord-injured patients.
constant-frequency trains; doublet-frequency trains; force-time integral; isometric forces; mathematical muscle models; paralyzed muscle; peak force
Functional electrical stimulation (FES) has not gained widespread application for a number of factors; two of which are rapid muscle fatigue and imprecise control in force. Stimulation intensity is adjusted during FES to overcome the decline in muscle force due to fatigue and precisely control muscle force output. The purpose of this study was to understand the relationship between muscle force output and stimulation intensity and to see how this relationship changes with fatigue.
Quadriceps femoris muscles of 10 able-bodied adults were tested isometrically. Pre- and post-fatigue muscle force responses to stimulation trains with different intensities and frequencies were recorded and analyzed. In addition, a case study using a subject with spinal cord injury was presented to illustrate the use of the force-intensity relationship to reduce muscle fatigue and improve the control of muscle force during repetitive electrical stimulation.
An exponential relationship between muscle force and stimulation intensity was observed; interestingly, the normalized force-intensity relationship did not change with stimulation frequency or fatigue.
The observed consistencies in the force-intensity relationship should assist scientists and clinicians to more accurately predict the forces produced by a muscle with changes in pulse duration during repetitive electrical stimulation.
The findings of this study provide guidelines for clinicians and researchers to adjust the stimulation intensity to achieve precise control of force repetitively during the application of FES.
Functional electrical stimulation (FES); Quadriceps femoris muscles; force-intensity relationship