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issn:2234-0.53
1.  The Insertion/Deletion Polymorphism of Angiotensin I Converting Enzyme Gene is Associated With Ossification of the Posterior Longitudinal Ligament in the Korean Population 
Objective
To determine whether ACE insertion/deletion (I/D) polymorphism is associated with the ossification of the posterior longitudinal ligament (OPLL) of the spine in the Korean population.
Methods
A case-control study was conducted to investigate the association between I/D polymorphism of the angiotensin I converting enzyme (peptidyl-dipeptidase A) 1 (ACE) gene and OPLL. The 95 OPLL patients and 274 control subjects were recruited. Polymerase chain reaction for the genotyping of ACE I/D polymorphism was performed. The difference between the OPLL patients and the control subjects was compared using the contingency χ2 test and the logistic regression analysis. For statistical analysis, SPSS, SNPStats, SNPAnalyzer, and Helixtree programs were used.
Results
The genotype and allele frequencies of ACE I/D polymorphism showed significant differences between the OPLL patients and the control subjects (genotype, p<0.001; allele, p=0.009). The frequencies of D/D genotype and D allele in the OPLL group were higher than those in the control group. In logistic regression analysis, ACE I/D polymorphism was associated with OPLL (dominant model; p=0.002; odd ratio, 2.20; 95% confidence interval, 1.33-3.65).
Conclusion
These results suggest that the deletion polymorphism of the ACE gene may be a risk factor for the development of OPLL in the Korean population.
doi:10.5535/arm.2014.38.1.1
PMCID: PMC3953350  PMID: 24639919
Ossification of the posterior longitudinal ligament; Angiotension converting enzyme; Genetic polymorphism; Genetic association analysis
2.  Comparing Self-Selected Speed Walking of the Elderly With Self-Selected Slow, Moderate, and Fast Speed Walking of Young Adults 
Annals of Rehabilitation Medicine  2014;38(1):101-108.
Objective
To find the characteristics of elderly gait, we compared the elderly walking at a moderate speed with the young adult walking at a slow, moderate, and fast speed.
Methods
3D gait analysis was performed on 15 elderly and 15 young adults. Temporo-spatial, kinematic, and kinetic parameters were obtained. Self-selected moderate speed of the elderly walking was compared with self-selected varying speed of the young adults walking.
Results
The elderly walked at slower speeds and had shorter step length, but showed similar cadences compared to the young adults. These results remained identical even after the normalization with height. The kinematic and the kinetic graph patterns did not show specific differences between the elderly and the young subjects. Ankle plantarflexion (APF) motion was prominently decreased in the elderly subjects. Hip flexion (HF) motion remained within similar range for the young adults'. HF moment and power were similar with the young adults', but APF power and hip extension power were decreased in the elderly subjects'.
Conclusion
A decreased APF motion and power were thought to be specific findings in the elderly walking. The preservation of HF motion and power could be considered a compensation mechanism or a modified neuromuscular pattern in the elderly. The characteristics of the elderly walking should be taken into account when planning rehabilitation strategies of elderly gait training and for future studies on the elderly population.
doi:10.5535/arm.2014.38.1.101
PMCID: PMC3953351  PMID: 24639933
Aging; Gait
3.  Sonographic Evaluation of the Peripheral Nerves in Hereditary Neuropathy With Liability to Pressure Palsies: A Case Report 
Annals of Rehabilitation Medicine  2014;38(1):109-115.
Hereditary neuropathy with liability to pressure palsies (HNPP) is an autosomal dominantly inherited disorder that affects peripheral nerves by repeated focal pressure. HNPP can be diagnosed by clinical findings, electrodiagnostic studies, histopathological features, and genetic analysis. Ultrasonography is increasingly used for the diagnosis of neuromuscular diseases; however, sonographic features of HNPP have not been clearly defined. We report the sonographic findings and comparative electrodiagnostic data in a 73-year-old woman with HNPP, confirmed by genetic analysis. The cross-sectional areas of peripheral nerves were enlarged at typical nerve entrapment sites, but enlargement at non-entrapment sites was uncommon. These sonographic features may be helpful for diagnosis of HNPP when electrodiagnostic studies are suspicious of HNPP and/or gene study is not compatible.
doi:10.5535/arm.2014.38.1.109
PMCID: PMC3953352  PMID: 24639934
Hereditary neuropathy with liability to pressure palsies; Ultrasonography; Electrophysiology
4.  Stepwise Rehabilitation of the Triple Amputee Combined With Dysfunction of the Sound Limb 
Annals of Rehabilitation Medicine  2014;38(1):116-121.
To find a multiple amputee more severe than a triple amputee is not easy. This is a report of a 36-year-old patient with right knee disarticulation, left trans-femoral amputation and right elbow disarticulation due to peripheral ischemic necrosis, when he was applied vasopressor in septic shock condition. His left hand was also 2nd, 3rd, 4th, and 5th distal interphalangeal joint disarticulation status, and it was more difficult for him to do rehabilitation program, such as donning and doffing the prostheses. For more efficient rehabilitation training program, we first focused on upper extremities function, since we believed that he might need a walking aid for gait training later. After 13 weeks of rehabilitation program, he has become sit to stand and walk short distance independently with an anterior walker. Although he still needs some assistance with activities of daily living, his Functional Independence Measure score improved from 48 to 90 during the course of 13 weeks.
doi:10.5535/arm.2014.38.1.116
PMCID: PMC3953353  PMID: 24639935
Multiple limb amputation; Amputation rehabilitation; Hand contracture
5.  Videofluoroscopy-Guided Balloon Dilatation for the Opening Dysfunction of Upper Esophageal Sphincter by Postoperative Vagus Nerve Injury: A Report on Two Cases 
Annals of Rehabilitation Medicine  2014;38(1):122-126.
Dysphagia secondary to peripheral cranial nerve injury originates from weak and uncoordinated contraction-relaxation of cricopharyngeal muscle. We report on two patients who suffered vagus nerve injury during surgery and showed sudden dysphagia by opening dysfunction of upper esophageal sphincter (UES). Videofluoroscopy-guided balloon dilatation of UES was performed. We confirmed an early improvement of the opening dysfunctions of UES, although other neurologic symptoms persisted. While we did not have a proper comparison of cases, the videofluoroscopy-guided balloon dilatation of UES is thought to be helpful for the early recovery of dysphagia caused by postoperative vagus nerve injury.
doi:10.5535/arm.2014.38.1.122
PMCID: PMC3953354  PMID: 24639936
Dysphagia; Balloon dilatation; Vagus nerve injuries
6.  Effects of Botulinum Toxin on Reducing the Co-contraction of Antagonists in Birth Brachial Plexus Palsy 
Annals of Rehabilitation Medicine  2014;38(1):127-131.
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.
doi:10.5535/arm.2014.38.1.127
PMCID: PMC3953355  PMID: 24639937
Birth brachial plexus palsy; Obstetric brachial plexus injury; Botulinum toxin type A; Brachial plexus neuropathies
7.  Usefulness of the Combined Motor Evoked and Somatosensory Evoked Potentials for the Predictive Index of Functional Recovery After Primary Pontine Hemorrhage 
Objective
To investigate the predictive index of functional recovery after primary pontine hemorrhage (PPH) using the combined motor evoked potential (MEP) and somatosensory evoked potential (SEP) in comparison to the hematoma volume and transverse diameter measured with computerized tomography.
Methods
Patients (n=14) with PPH were divided into good- and poor-outcome groups according to the modified Rankin Score (mRS). We evaluated clinical manifestations, radiological characteristics, and the combined MEP and SEP responses. The summed MEP and SEP (EP sum) was compared to the hematoma volume and transverse diameter predictive index of global disability, gait ability, and trunk stability in sitting posture.
Results
All measures of functional status and radiological parameters of the good-outcome group were significantly better than those of the poor-outcome group. The EP sum showed the highest value for the mRS and functional ambulatory category, and transverse diameter showed the highest value for "sitting-unsupported" of Berg Balance Scale.
Conclusion
The combined MEP and SEP is a reliable and useful tool for functional recovery after PPH.
doi:10.5535/arm.2014.38.1.13
PMCID: PMC3953356  PMID: 24639921
Pontine hemorrhage; Motor evoked potential; Somatosensory evoked potential; Predictive Index
8.  Right Calf Claudication Revealing Leriche Syndrome Presenting as Right Sciatic Neuropathy 
Annals of Rehabilitation Medicine  2014;38(1):132-137.
The syndrome of aortoiliac occlusive disease, also known as Leriche syndrome, is characterized by claudication, pain, and diminished femoral pulse. We highlight an unusual case of right sciatic neuropathy caused by Leriche syndrome, which was initially misdiagnosed. A 52-year-old male, with a past medical history of hypertension and bony fusion of the thoracolumbar spine, visited our hospital complaining of right leg pain and claudication, and was initially diagnosed with spinal stenosis. The following electrophysiologic findings showed right sciatic neuropathy; but his symptom was not relieved, despite medications for neuropathy. A computed tomography angiography of the lower extremities revealed the occlusion of the infrarenal abdominal aorta, and bilateral common iliac and right external iliac arteries. All these findings suggested omitted sciatic neuropathy associated with Leriche syndrome, and the patient underwent a bilateral axillo-femoral and femoro-femoral bypass graft.
doi:10.5535/arm.2014.38.1.132
PMCID: PMC3953357  PMID: 24639938
Leriche syndrome; Sciatic neuropathy; Spinal stenosis
9.  Clinical Features and Associated Abnormalities in Children and Adolescents With Corpus Callosal Anomalies 
Annals of Rehabilitation Medicine  2014;38(1):138-143.
Callosal anomalies are frequently associated with other central nervous system (CNS) and/or somatic anomalies. We retrospectively analyzed the clinical features of corpus callosal agenesis/hypoplasia accompanying other CNS and/or somatic anomalies. We reviewed the imaging and clinical information of patients who underwent brain magnetic resonance imaging in our hospital, between 2005 and 2012. Callosal anomalies were isolated in 13 patients, accompanied by other CNS anomalies in 10 patients, associated with only non-CNS somatic anomalies in four patients, and with both CNS and non-CNS abnormalities in four patients. Out of 31 patients, four developed normally, without impairments in motor or cognitive functions. Five of nine patients with cerebral palsy were accompanied by other CNS and/or somatic anomalies, and showed worse Gross Motor Function Classification System scores, compared with the other four patients with isolated callosal anomaly. In addition, patients with other CNS anomalies also had a higher seizure risk.
doi:10.5535/arm.2014.38.1.138
PMCID: PMC3953358  PMID: 24639939
Callosal agenesis; Gross motor function
10.  Factors Affecting the Motor Evoked Potential Responsiveness and Parameters in Patients With Supratentorial Stroke 
Objective
To investigate the factors which affect the motor evoked potential (MEP) responsiveness and parameters and to find the correlation between the function of the upper extremities and the combined study of MEP with a diffusion tensor tractography (DTT) in patients with stroke.
Methods
A retrospective study design was used by analyzing medical records and neuroimaging data of 70 stroke patients who underwent a MEP test between June 2011 and March 2013. MEP parameters which were recorded from the abductor pollicis brevis muscle were the resting motor threshold, latency, amplitude, and their ratios. Functional variables, Brunnstrom stage of hand, upper extremity subscore of Fugl-Meyer assessment, Manual Function Test, and the Korean version of Modified Barthel Index (K-MBI) were collected together with the biographical and neurological data. The DTT parameters were fiber number, fractional anisotropy value and their ratios of affected corticospinal tract. The data were compared between two groups, built up according to the presence (MEP-P) or absence (MEP-N) of MEP on the affected hand.
Results
Functional and DTT variables were significantly different between MEP-P and MEP-N groups (p<0.001). Among the MEP-P group, the amplitude ratio (unaffected/affected) was significantly correlated with the Brunnstrom stage of hand (r=-0.427, p=0.013), K-MBI (r=-0.380, p=0.029) and the time post-onset (r=-0.401, p=0.021). The functional scores were significantly better when both MEP response and DTT were present and decreased if one or both of the two studies were absent.
Conclusion
This study indicates MEP responsiveness and amplitude ratio are significantly associated with the upper extremity function and the activities of daily living performance, and the combined study of MEP and DTT provides useful information.
doi:10.5535/arm.2014.38.1.19
PMCID: PMC3953359  PMID: 24639922
Motor evoked potential; Diffusion tensor imaging; Stroke; Motor function; Activities of daily living
11.  Ultrasonographic Diaphragmatic Motion Analysis and Its Correlation With Pulmonary Function in Hemiplegic Stroke Patients 
Objective
To evaluate diaphragmatic motion via M-mode ultrasonography and to correlate it with pulmonary function in stroke patients.
Methods
This was a preliminary study comprised of ten stroke patients and sixteen healthy volunteers. The M-mode ultrasonographic probe was positioned in the subcostal anterior region of the abdomen for transverse scanning of the diaphragm during quiet breathing, voluntary sniffing, and deep breathing. We analyzed diaphragmatic motion and the relationship between diaphragmatic motion and pulmonary function.
Results
All stroke patients had restrictive pulmonary dysfunction. Compared to that exhibited by control subjects, stroke patients exhibited a significant unilateral reduction in motion on the hemiplegic side, primarily during volitional breathing. Diaphragmatic excursion in right-hemiplegic patients was reduced on both sides compared to that in control subjects. However, diaphragmatic excursion was reduced only on the left side and increased on the right side in left-hemiplegic patients compared to that in control subjects. Left diaphragmatic motion during deep breathing correlated positively with forced vital capacity (rho=0.86, p=0.007) and forced expiratory volume in 1 second (rho=0.79, p=0.021).
Conclusion
Reductions in diaphragmatic motion and pulmonary function can occur in stroke patients. Thus, this should be assessed prior to the initiation of rehabilitation therapy, and M-mode ultrasonography can be used for this purpose. It is a non-invasive method providing quantitative information that is correlated with pulmonary function.
doi:10.5535/arm.2014.38.1.29
PMCID: PMC3953360  PMID: 24639923
Stroke; Hemiplegia; Diaphragm; Ultrasonography; Pulmonary function tests
12.  Factors That Influence Employment After Spinal Cord Injury in South Korea 
Objective
To investigate employment status after spinal cord injury (SCI) and identify personal, family, and injury characteristics those affect their employment in South Korea.
Methods
Participants were 334 community-dwelling persons 20-64 years of age who had sustained SCI for more than one year. Investigators visited each participant's home to carry out the survey. Bivariate and binary logistic regression analyses were performed to identify personal, family, and injury characteristics that influenced employment after SCI.
Results
Employment rate decreased significantly from 82.5% to 27.5% after SCI. Logistic regression showed that the probability of employment was higher in men than women, and in individuals older than 45 years at the time of injury than those aged 31-45 years of age. Moreover, employment was higher in individuals injured for longer than 20 years than those injured for 1-5 years and in individuals with incomplete tetraplegia than those with complete paraplegia. Employment was lower in individuals with SCI caused by industrial accidents than those injured in non-industrial accidents.
Conclusion
Injury characteristics are the most important predictors of employment in persons with SCI. For persons with lower employment rate, individualized vocational rehabilitation and employment-support systems are required.
doi:10.5535/arm.2014.38.1.38
PMCID: PMC3953361  PMID: 24639924
Spinal cord injuries; Employment; Persons; Family; Industrial accident
13.  Ultrasonographic Evaluation of Sural Nerve for Nerve Conduction Study 
Objective
To understand various morphologic types and locations of the sural nerve (SN) that are important for nerve conduction studies or nerve grafting procedures. The aim of this study was to describe the course and variations of the SN based on ultrasonographic findings for an adequate nerve conduction study.
Methods
A total of 112 SNs in 56 volunteers with no history of trauma or surgery were examined by ultrasonography. The location and formation of the SNs in relation to the medial and lateral sural cutaneous nerve were investigated. We measured the horizontal distance between the SNs and the midline of the calf at the level of 14 cm from the lateral malleolus, and the distance between the SNs and the most prominent part of the lateral malleolus.
Results
SN variants was classified into four types according to the medial and lateral sural cutaneous nerve; type 1 (73.2%), type 2 (17.9%), type 3 (8.0%), and type 4 (0.9%). The mean distance between the SN and the midline of the calf was 1.02±0.63 cm, the SN and the most prominent part of the lateral malleolus was 2.14±0.15 cm.
Conclusion
Variations in the location and formation of the SN was examined by ultrasonography, and the results of this study would increase the accuracy of the SN conduction study.
doi:10.5535/arm.2014.38.1.46
PMCID: PMC3953362  PMID: 24639925
Sural nerve; Ultrasonography; Nerve conduction study
14.  Ultrasonographic Findings of Superficial Radial Nerve and Cephalic Vein 
Objective
To investigate the anatomic relationship between the superficial radial nerve (SRN) and the cephalic vein (CV) through ultrasonography due to the possibility of SRN injury during cephalic venipuncture.
Methods
Both forearms of 51 healthy volunteers with no history of trauma or surgery were examined in proximal to distal direction using ultrasonography. We measured the distance between the radial styloid process (RSP) and the point where the SRN begins contact with the CV, and measured the distance between the RSP and the point where the SRN is separated from the CV. The point where the SRN penetrates the brachioradialis fascia was also evaluated.
Results
The SRN came in contact with the CV at a mean of 9.35±1.05 cm from the RSP and separated from the CV at a mean of 6.29±1.17 cm from the RSP. The SRN pierced the brachioradialis fascia at a mean of 10.31±0.89 cm from the RSP and horizontally 1.35±0.36 cm medial to the radius margin. All parameters had no significant differences in gender or direction.
Conclusion
The SRN had close approximation to the CV in the distal second quarter of the forearm. We recommend for cephalic venipuncture to be avoided in this area, and, if needed, it should be carried out with care not to cause injury to the SRN.
doi:10.5535/arm.2014.38.1.52
PMCID: PMC3953363  PMID: 24639926
Radial nerve; Forearm; Ultrasonography
15.  The Quantitative Relationship Between Physical Examinations and the Nerve Conduction of the Carpal Tunnel Syndrome in Patients With and Without a Diabetic Polyneuropathy 
Objective
To understand the quantitative correlation between the clinical severity and physical examinations along with the electrodiagnostic findings by subjects with carpal tunnel syndrome (CTS) and also the influence of diabetic polyneuropathy (DPN) on physical examinations by subjects with CTS.
Methods
Among 200 patients suffering from hand tingling sensations, 68 patients were diagnosed with CTS on at least one hand by nerve conduction tests. Therefore, the Phalen test (PT), hand elevation test (HET), Tinel sign (TS) results were recorded on both hands. The physical examination grades were compared with the electrophysiological CTS grades in 126 hands of 68 patients. Also the comorbidity effect of DPN to CTS was evaluated. For the evaluation of the severity correlations between CTS, PT, HET, and TS, the Spearman analysis was used. An attempt was started to create a formula which could depict the electrophysiological severity of CTS.
Results
Out of the 68 tested subjects, 31 were diagnosed with both DPN and CTS, and 37 with CTS only. Both PT and HET correlated well with the severity of CTS where the correlation of PT was higher than that of HET. The formula were the motor distal latency (MDL)=(72.4-PT)/5.3 and MDL=(76-HET)/7.2. Both PT and HET showed in the presence of DPN a relatively higher relation with CTS without significance.
Conclusion
PT and HET would be useful screening tools for the diagnosis and treatment of CTS as the grade of PT and HET present the severity of CTS well. During this study, a formula was created expecting the severity of nerve conduction study with PT and HET through the time domain value of physical examinations.
doi:10.5535/arm.2014.38.1.57
PMCID: PMC3953364  PMID: 24639927
Carpal tunnel syndrome; Diabetic polyneuropathy; Physical examination; Electrodiagnosis
16.  Associating Factors Regarding Nasogastric Tube Removal in Patients With Dysphagia After Stroke 
Objective
To demonstrate associating factors regarding nasogastric tube (NGT) removal in patients with dysphagia after stroke.
Methods
This study is a retrospective medical chart review. Patients were divided into non-brain stem (NBS) and brain stem (BS) groups. A videofluoroscopic swallowing study was conducted until swallowing functions were recovered. Initial disease status was measured using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS). Risk factors related to stroke were evaluated. The penetration-aspiration scale (PAS) was used as the swallowing test. Functional status was measured by Mini-Mental Status Examination (MMSE) and Modified Barthel Index (MBI). Within each group, initial evaluations and their subsequent changes were compared according to the NGT removal status. Correlation between the NGT removal time and other initial factors were evaluated.
Results
Ninety-nine patients were allocated to the NBS group and 39 to the BS group. In NBS, age, PAS, MMSE, and MBI were significantly different according to the NGT removal status. In BS, smoking and PAS were significantly different. In NBS, changes in PAS, MMSE, and MBI were significantly different according to the NGT removal status. In BS, only PAS change was significantly different. In NBS, initial NIHSS, mRS, MMSE, and MBI were correlated with removal time.
Conclusion
In stroke patients with NTG, younger age, better initial disease and functional status seems to remove NGT in NBS stroke. Therefore, when deciding to remove NGT, those three factors should be considered discreetly.
doi:10.5535/arm.2014.38.1.6
PMCID: PMC3953365  PMID: 24639920
Stroke; Dysphagia; Nasogastric tube; Fluoroscopy
17.  Subclinical Ulnar Neuropathy at the Elbow in Diabetic Patients 
Objective
To demonstrate the prevalence and characteristics of subclinical ulnar neuropathy at the elbow in diabetic patients.
Methods
One hundred and five patients with diabetes mellitus were recruited for the study of ulnar nerve conduction analysis. Clinical and demographic characteristics were assessed. Electrodiagnosis of ulnar neuropathy at the elbow was based on the criteria of the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM1 and AANEM2). The inching test of the ulnar motor nerve was additionally performed to localize the lesion.
Results
The duration of diabetes, the existence of diabetic polyneuropathy (DPN) symptoms, the duration of symptoms, and HbA1C showed significantly larger values in the DPN group (p<0.05). Ulnar neuropathy at the elbow was more common in the DPN group. There was a statistically significant difference in the number of cases that met the three diagnostic criteria between the no DPN group and the DPN group. The most common location for ulnar mononeuropathy at the elbow was the retrocondylar groove.
Conclusion
Ulnar neuropathy at the elbow is more common in patients with DPN. If the conduction velocities of both the elbow and forearm segments are decreased to less than 50 m/s, it may be useful to apply the AANEM2 criteria and inching test to diagnose ulnar neuropathy.
doi:10.5535/arm.2014.38.1.64
PMCID: PMC3953366  PMID: 24639928
Diabetes mellitus; Diabetic polyneuropathy; Ulnar neuropathy; Elbow; Entrapment
18.  Appropriate Depth of Needle Insertion During Rhomboid Major Trigger Point Block 
Objective
To investigate an appropriate depth of needle insertion during trigger point injection into the rhomboid major muscle.
Methods
Sixty-two patients who visited our department with shoulder or upper back pain participated in this study. The distance between the skin and the rhomboid major muscle (SM) and the distance between the skin and rib (SB) were measured using ultrasonography. The subjects were divided into 3 groups according to BMI: BMI less than 23 kg/m2 (underweight or normal group); 23 kg/m2 or more to less than 25 kg/m2 (overweight group); and 25 kg/m2 or more (obese group). The mean±standard deviation (SD) of SM and SB of each group were calculated. A range between mean+1 SD of SM and the mean-1 SD of SB was defined as a safe margin.
Results
The underweight or normal group's SM, SB, and the safe margin were 1.2±0.2, 2.1±0.4, and 1.4 to 1.7 cm, respectively. The overweight group's SM and SB were 1.4±0.2 and 2.4±0.9 cm, respectively. The safe margin could not be calculated for this group. The obese group's SM, SB, and the safe margin were 1.8±0.3, 2.7±0.5, and 2.1 to 2.2 cm, respectively.
Conclusion
This study will help us to set the standard depth of safe needle insertion into the rhomboid major muscle in an effective manner without causing any complications.
doi:10.5535/arm.2014.38.1.72
PMCID: PMC3953367  PMID: 24639929
Pneumothorax; Trigger point injection; Rhomboid major muscle
19.  The Relationships Between Determination of Treatment Success and Emotional Factors in Patients With Chronic Musculoskeletal Pain 
Objective
To investigate the relationship of the patient's criteria of successful treatment to emotional factors in patients with chronic musculoskeletal pain.
Methods
Patients who visited our outpatient hospital due to chronic musculoskeletal pain were evaluated using a questionnaire survey. Patients were evaluated with the Patient-Centered Outcomes Questionnaire (PCOQ) to investigate their expectation and criteria for success regarding treatment of chronic musculoskeletal pain. Beck Depression Inventory and State-Trait Anxiety Inventory were used to check for psychological variables. Correlations among each of the variables were evaluated statistically.
Results
Patients with higher levels of depression and anxiety needed larger improvements to consider the treatment as a success in the pain domain (depression, r=0.398, p=0.04; anxiety, r=0.447, p=0.02) and emotional distress domain (depression, r=0.617, p=0.001; anxiety, r=0.415, p=0.03), but had lower level of expectation of the treatment in the pain domain (depression, r=-0.427, p=0.01; anxiety, r=-0.441, p=0.004), emotional distress domain (depression, r=-0.454, p=0.01; anxiety, r=-0.395, p=0.04), and interference of daily activities domain (depression, r=-0.474, p=0.01; anxiety, r=-0.396, p=0.04). Patients were classified into 3 clusters based on the importance rating of each domain via a hierarchical analysis. The cluster of the patients with the higher rating of importance across all domains (importance of pain domain, 9.54; fatigue domain, 9.08; emotional distress domain, 9.23; interference of daily activities domain, 9.23) had the highest level of depression and anxiety.
Conclusion
Consideration of psychological factors, especially in patients who require larger improvements in all treatment domains, may be helpful for the successful treatment of chronic musculoskeletal pain.
doi:10.5535/arm.2014.38.1.77
PMCID: PMC3953368  PMID: 24639930
Chronic pain; Questionnaire; Depression; Anxiety
20.  Reliability and Validity of Isometric Knee Extensor Strength Test With Hand-Held Dynamometer Depending on Its Fixation: A Pilot Study 
Objective
To determine the reliability and validity of hand-held dynamometer (HHD) depending on its fixation in measuring isometric knee extensor strength by comparing the results with an isokinetic dynamometer.
Methods
Twenty-seven healthy female volunteers participated in this study. The subjects were tested in seated and supine position using three measurement methods: isometric knee extension by isokinetic dynamometer, non-fixed HHD, and fixed HHD. During the measurement, the knee joints of subjects were fixed at a 35° angle from the extended position. The fixed HHD measurement was conducted with the HHD fixed to distal tibia with a Velcro strap; non-fixed HHD was performed with a hand-held method without Velcro fixation. All the measurements were repeated three times and among them, the maximum values of peak torque were used for the analysis.
Results
The data from the fixed HHD method showed higher validity than the non-fixed method compared with the results of the isokinetic dynamometer. Pearson correlation coefficients (r) between fixed HHD and isokinetic dynamometer method were statistically significant (supine-right: r=0.806, p<0.05; seating-right: r=0.473, p<0.05; supine-left: r=0.524, p<0.05), whereas Pearson correlation coefficients between non-fixed dynamometer and isokinetic dynamometer methods were not statistically significant, except for the result of the supine position of the left leg (r=0.384, p<0.05). Both fixed and non-fixed HHD methods showed excellent inter-rater reliability. However, the fixed HHD method showed a higher reliability than the non-fixed HHD method by considering the intraclass correlation coefficient (fixed HHD, 0.952-0.984; non-fixed HHD, 0.940-0.963).
Conclusion
Fixation of HHD during measurement in the supine position increases the reliability and validity in measuring the quadriceps strength.
doi:10.5535/arm.2014.38.1.84
PMCID: PMC3953369  PMID: 24639931
Muscle strength dynamometer; Isometric contraction; Physical restraint; Dimensional measurement accuracy; Knee joint
21.  Comparison of Different Gum-Based Thickeners Using a Viscometer and Line Spread Test: A Preliminary Study 
Objective
To compare fluid thickeners composed of starch polysaccharide (STA), guar gum-based polysaccharide (GUA), and xanthan gum-based polysaccharide (XAN) with the use of a viscometer and a line spread test (LST) under various measurement conditions.
Methods
The viscosity of thickened fluid with various concentrations (range, GUA 1%-4%, XAN 1%-6%, STA 1%-7%, at intervals of 1%) was measured with a rotational viscometer with various shear rates (1.29 s-1, 5.16 s-1, 51.6 s-1, and 103 s-1) at a temperature of 35℃, representing body temperature. The viscosity of STA showed time dependent alteration. So STA was excluded. Viscosities of GUA and XAN (range of concentration, GUA 1%-3%, XAN 1%-6%, at intervals of 1%) were measured at a room temperature of 20℃. LST was conducted to compare GUA and XAN (concentration, 1.5%, 2.0%, and 3.0%) at temperatures of 20℃ and 35℃.
Results
The viscosities of 1% GUA and XAN were similar. However, viscosity differences between GUA and XAN were gradually larger as concentration increased. The shear thinning effect, the inverse relationship between the viscosity and the shear rate, was more predominant in XAN than in GUA. The results of LST were not substantially different from GUA and XAN, in spite of the difference in viscosity. However manufacturers' instructions do not demonstrate the rheological properties of thickeners.
Conclusion
The viscosities of thickened fluid were different when the measurement conditions changed. Any single measurement might not be sufficient to determine comparable viscosity with different thickeners. Clinical decision for the use of a specific thickener seems to necessitate cautious consideration of results from a viscometer, LST, and an expert's opinion.
doi:10.5535/arm.2014.38.1.94
PMCID: PMC3953370  PMID: 24639932
Deglutition disorders; Diet; Viscosity
22.  Effect of Transcranial Direct Current Stimulation on Postural Stability and Lower Extremity Strength in Hemiplegic Stroke Patients 
Annals of Rehabilitation Medicine  2013;37(6):759-765.
Objective
To evaluate the effect of anodal transcranial direct current stimulation (tDCS) over the lesioned leg motor cortex, which can enhance the strength and coordination of the contralateral lower extremity and furthermore, enhance the postural stability of the hemiplegic subject.
Methods
Anodal or sham stimulation on the lesioned cortex of a lower extremity was delivered to 11 ambulatory hemiplegic patients. The stimulation intensity was 2 mA. All subjects took part in two 10-minute tDCS sessions consisting of anodal stimulation and sham stimulation. The interval period between real and sham stimulation was 48 hours. The order was counter-balanced among the subjects. Before and after each stimulation session, static postural stability was evaluated with eyes opened and closed. Also, the isometric strength of the hemiplegic side of the treated knee was measured before and after each stimulation session. Repeated measure ANOVA was used to determine the statistical significance of improvements in postural stability and strength.
Results
There was significant improvement for overall stability index with eyes opened and closed after anodal tDCS (p<0.05). Isometric strength of the lesioned quadriceps tended to increase after anodal tDCS (p<0.05). Postural stability and quadriceps strength were not changed after sham stimulation.
Conclusion
Anodal tDCS has potential value in hemiplegic stroke patients to improve balance and strengthen the affected lower extremity.
doi:10.5535/arm.2013.37.6.759
PMCID: PMC3895515  PMID: 24466510
tDCS; Postural balance; Stroke; Strength
23.  Randomized, Sham Controlled Trial of Transcranial Direct Current Stimulation for Painful Diabetic Polyneuropathy 
Annals of Rehabilitation Medicine  2013;37(6):766-776.
Objective
To investigate the analgesic effect of transcranial direct current stimulation (tDCS) over the primary motor (M1), dorsolateral prefrontal cortex (DLPFC), and sham tDCS in patients with painful diabetic polyneuropathy (PDPN).
Methods
Patients with PDPN (n=60) were divided randomly into the three groups (n=20 per group). Each group received anodal tDCS with the anode centered over the left M1, DLPFC, or sham stimulation for 20 minutes at intensity of 2 mA for 5 consecutive days. A blinded physician rated the patients' pain using a visual analog scale (VAS), Clinical Global Impression (CGI) score, anxiety score, sleep quality, Beck Depression Inventory (BDI), and the pain threshold (PT) to pressure.
Results
After the tDCS sessions, the M1 group showed a significantly greater reduction in VAS for pain and PT versus the sham and DLPFC groups (p<0.001). The reduction in VAS for pain was sustained after 2 and 4 weeks of follow-up in the M1 group compared with the sham group (p<0.001, p=0.007). Significant differences were observed among the three groups over time in VAS for pain (p<0.001), CGI score (p=0.01), and PT (p<0.001). No significant difference was observed among the groups in sleep quality, anxiety score, or BDI score immediately after tDCS.
Conclusion
Five daily sessions of tDCS over the M1 can produce immediate pain relief, and relief 2- and 4-week in duration in patients with PDPN. Our findings provide the first evidence of a beneficial effect of tDCS on PDPN.
doi:10.5535/arm.2013.37.6.766
PMCID: PMC3895516  PMID: 24466511
Transcranial direct current stimulation; Chronic pain; Diabetic neuropathy
24.  Threshold of Clinical Severity of Cervical Dystonia for Positive 18F-FDG PET/CT 
Annals of Rehabilitation Medicine  2013;37(6):777-784.
Objective
To examine whether the clinical severity of cervical dystonia (CD) significantly correlates with 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) findings as well as to determine the threshold of the clinical severity of CD for positive 18F-FDG PET/CT study findings.
Methods
Forty-seven subjects with torticollis as one of the symptoms of CD were included. The clinical severity of CD was evaluated with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) at the time of 18F-FDG PET/CT. The correlation between the clinical severity of CD and the highest SUVmax was examined. The threshold of the clinical severity of CD necessary for positive 18F-FDG PET/CT findings was determined using receiver operating characteristics curve analysis.
Results
Thirty-three of the 47 subjects (70.21%) showed positive 18F-FDG PET/CT findings. The ipsilateral splenius capitis/cervicis, oblique capitis inferior, and longus colli/capitis were the rotators most frequently involved. The highest SUVmax of 18F-FDG PET/CT was significant correlated with the TWSTRS. Subjects with a total TWSTRS exceeding 39 showed positive 18F-FDG PET/CT findings, with those having a total TWSTRS ≤22 showing negative 18F-FDG PET/CT results. The cutoff value of the total TWSTRS for positive 18F-FDG PET/CT findings was set at 27.5 with 90.9% sensitivity and 64.3% specificity.
Conclusion
A significant correlation was evident between the clinical severity of CD and 18F-FDG PET/CT findings, providing a threshold of the clinical severity of CD for acquisition of positive 18F-FDG PET/CT findings.
doi:10.5535/arm.2013.37.6.777
PMCID: PMC3895517  PMID: 24466512
Cervical dystonia; Fluorodeoxyglucose F18; Positron-emission tomography
25.  Comparison of Helmet Therapy and Counter Positioning for Deformational Plagiocephaly 
Annals of Rehabilitation Medicine  2013;37(6):785-795.
Objective
To compare effectiveness on correcting cranial and ear asymmetry between helmet therapy and counter positioning for deformational plagiocephaly (DP).
Methods
Retrospective data of children diagnosed with DP who visited our clinic from November 2010 to October 2012 were reviewed. Subjects ≤10 months of age who showed ≥10 mm of diagonal difference were included for analysis. For DP treatment, information on both helmet therapy and counter positioning was given and either of the two was chosen by each family. Head circumference, cranial asymmetry measurements including diagonal difference, cranial vault asymmetry index, radial symmetry index, and ear shift were obtained by 3-dimensional head-surface laser scan at the time of initiation and termination of therapy.
Results
Twenty-seven subjects were included: 21 had helmet therapy and 6 underwent counter positioning. There was no significant difference of baseline characteristics, head circumferences and cranial asymmetry measurements at the initiation of therapy. The mean duration of therapy was 4.30±1.27 months in the helmet therapy group and 4.08±0.95 months in the counter positioning group (p=0.770). While cranial asymmetry measurements improved in both groups, significantly more improvement was observed with helmet therapy. There was no significant difference of the head circumference growth between the two groups at the end of therapy.
Conclusion
Helmet therapy resulted in more favorable outcomes in correcting cranial and ear asymmetry than counter positioning on moderate to severe DP without compromising head growth.
doi:10.5535/arm.2013.37.6.785
PMCID: PMC3895518  PMID: 24466513
Deformational plagiocephaly; Nonsynostotic plagiocephaly; Patient positioning; Cephalometry; Facial asymmetry

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