Many patients with the carpal tunnel syndrome present with nocturnal paresthesia in the digits innervated by the median nerve, but atypical presentations are not uncommon. The combination of neck and wrist pain is a common complaint and the pain may be due to compression of the same nerve at two different levels -a "double crush" syndrome. Distinguishing a single lesion from a double lesion is important for effective treatment of the patients. This study was done to identify the cases of carpal tunnel syndrome and median double crush syndrome with electroneurophysiological testing the patients with upper extremity complaints and also to assess the bilateral involvement of these syndrome. We assessed the clinical findings, electroneurophysiological findings and teratment status of the 137 patients with pain and paresthesia is the digits, arm or neck from January 1989 to August 1992. The patients with direct nerve trauma and systemic diseases such as diabetes, hypothyroidism were excluded this time. The diagnosis was established on the basis of abnormalities of distal median antidromic sensory latency at 14cm longer than 3.8msec, distal median motor latency longer than 4.2msec and needle electromyography of muscles of upper extremity and paracervical muscles. The results were as follows; 1) Thirty four cases (24.82%) showed no abnormalities in electrophysiolgical testing, 55 cases (40.15%) were diagnosed as carpal tunnel syndrome, 42 cases (30.66%) were cervical radiculopathy, and 6 cases (4.38%) were double crush syndrome. 2) Bilateral involvement was 63.64% in the carpal tunnel group, and 100.0% in the double crush group. 3) The mean distal sensory were 2.90±0.29 msec in the control group, 2.95±0.37msec in no abnormalities group, 6.08±2.16 msec in the carpal tunnel group, 2.99±0.31 msec in the cervical radculopathy group, and 5.60±2.16 msec in the double crush group. 4) the mean age of patients was 46 (17∼77)years. The proportion of female patients was higher in the carpal tunnel group as 87.27% and 66.67% in the double crush group than that of the cervical radiculopathy group as 11.9%. 5) Distal finger pain was dominant in the carpal tunnel and double crush groups but proximal neck and arm pain was common is the cervical radiculopathy group. 6) Medical and surgical treatment was done in 38.2% in no abnormalities group, 80.0% in the carpal tunnel group, 51.1% in the cervical radiculopathy group, and 100.0% in the double crush group but most of patients received anti-inflammatories.
Measurements of spasticity are divided into two groups, subjective and objective methods. The examples of the subjective methods are Ashworth scale and Brunnstrom stage and there are various measures in the objective quantification of spasticity: biomechanical analyis(pendulum test, ramp and hold test), electrophysiologic testing(dynamic multichannel EMG, gait analysis, H reflexes, F waves). The aims of this study are to identify variability and reliability of Cybex pendulum test, to compare the results of pendulum test and electrophysiologic tests of involved leg with those of univolved side, and to identify correlation of subjective measure of spasticity with objective measures in 25 hemiplegic patients with varing degrees of spasticity. We conclude that: 1) Cybex pendulum test is a reliable method for evaluation of muscle spasticity. 2) Relaxation index, swing time and angular velocity of pendulum test, H/m ratio, F amplitude and F/M ratio are useful parameters for documenting spasticity in hemiplegic patients(especially RI is the most reliable parameters of all). 3) Subjective measure of spasticity(Modified Ashworth scale) correlates well with cybex pendulum test(especially with RI). 4) H amplitude correlates well with Brunnstrom stage 2&3, and also 3&4.
Nine normal subjects and fourteen hemiparetic patients were studied using transcranial magnetic stimulation and somatosensory evoked potential. The stroke location, degree of recovery in terms of muscle power and Modified Barthel Index score, which represent the functional status of a stroke patient, assessed at the tine of evoked potential testing within 2 months after stroke onset and again of follow-up 2 months later were compared with the evoked potentials elicited. Motor response was better(p<0.05) than somatosensory response, at predicting an outcome in terms of functional recovery. The central motor conduction times in the examined muscles facilitated by contraction of the contralateral corresponding muscles were significantly increased on the involved side. While absence of response and normal response were seen after both cortical and subcortical lesions, delayed central motor conduction time only were seen in cases of subcortical lesions, which may be indicative of subcortical lesions following stroke(p<0.05). There were no signigicant relationship between evoked potential response and degree of recovery in muscle power. There were no untoward side effects.
In 1978, Brettle3) have been credited with the first report of an apparently beneficial effect of plasma exchange in acute Guillail-Barre syndrome. Followed reports5,14,25,27) have demonstrated a shortened length of illness, decreased death rate and serious complications, improved muscular weakness. So this study is purposed th evaluate the effectiveness of plasma exchange in Guillain-Barre syndrome and to compare with other conservative treatment. To study of the effect of plasma exchange in Guillain-Barre syndrome , 10 subjects with plasmapheresis and 19 patients with conservative and corticosteriod therapy were included. Plasmapheresis was done one to four time for each patient as possible. Plasma exchange volumes are 40∼50 ml/kg of body weight at each trial and not to exceed over 200ml/kg in total exchange volume. There were significantly improved grade in the plasmapheresis group comparing with control group after 4 weeks' of treatment. And the median time to improve and grade and to reach grade 2(the point at which patiests were able tot walk unassisted) was reduced significantly by treatment to plasmapheresis. And there were no significant adverse side effects or complications in plasmapheresis procedures. These results suggest that plasmapheresis may be the one of the first choice in treatment of acute stage of Guillain-Barre syndrome.
Thermograpy, which maps body surface temperature, has been proposed as a safe, economic and effective diagnostic test for lumbar radiculopathy. This study involves the relative value of digital infrared thermographic imaging as compared to CT-myelograpy and electromyography in examination of 44 patients with low back pain who have received conservative treatment for more than 3 months after industrial accident. The results were as follows: 1) In comparing CT-myelograpy with the electromyography and digital infrared thermographic imaging in lumbar herniated nucleus pulposus, there was a slightly better percentage of agreement between the CT-myelograpy and the electromyography(89%) than exists with digital infrared thermographic imaging. 2) Of 10 patients with specific nerve root compression due to lumbar herniated nucleus pulposus on CT-myelograpy, electromyography was abnormal in 9 patients but digital infrared thermographic imaging was abnormal in only 7 patients. Thermography, though a simple and less invasive procedure with a potential of usefulness for detecting lumbar herniated nucleus pulposus, appears to have limitation in differentiating the exact nerve root and need to be supplemented by other electrophysiologic tests.
We studied electronic averaging technique of F wave in the median nerves of normal volunteers to get most appropriate numbers of averaging and to determine the amount of cancellation effects of amplitudes and areas of averaged F waves and to get normal data about averaged median nerve F wave latency and amplitude. To determine the most reasonable numbers of averaging, we studied 10, 20 and 50 numbers of averaging in bilateral median nerves of 20 volunteers. There was on statistically significant differences of latency, amplitude, and negative area among 10, 20 and 50 numbers of averaging. But there was decreasing tendency, amplitude and negative area and increasing tendency in reproducibillity and cancellation effect as increasing numbers of averaging. Considering about more information with less discomfort and study time, we determined 10 and 20 numbers of averaging to be adequate. And the latency and amplitude of averaged F waves could be considered as useful clinical parameters. We concluded that 10 and 20 averaged F waves in human were convenient, reproducible, and deviated little due to cancellation effect.
Stimulation of the sciatic nerve generally requires needle electrodes because of the relatively inaccessible deep location of the nerve. Human magnetic stimulation of deep seated nerves such as sciatic nerve is feasible and effective with advantage of being noninvasive and painless. We compared magnetic stimulation with electrical stimulation of the sciatic nerve and investigated the clinical usefulness of magnetic stimulation of the sciatic nerve. Thirty healthy adults were studied and the results were as follows: 1) The latencies of compound muscle action potential obtained with electrical stimulation and magnetic stimulation showed no significant difference in both peroneal and tibial component of sciatic nerve. 2) The amplitudes obtained with magnetic stimulation were significantly smaller than those obtained with electrical stimulation in both peroneal and tibial component of sciatic nerve. 3) the conduction velocities in gluteal to popliteal area segment showed no significant difference in both peroneal and tibial component of sciatic nerve. The use of magnetic stimulation may be a reasonable alternative to electrical stimulation in sciatic nerve conduction study, especially in unilateral lesion. But to make it more suitable for clinical use, further technical development increasing the focality of magnetic stimulation is desirable.
Traumatic spinal cord injuries produce paralysis of muscles innervated by the damaged spinal segment and segments caudal to it. Abnormal respiratory function has been observed in patients with cervical cord injuries, especially by postural changes in quadriplegics.
The purpose of this study was to evaluate the pulmonary function of the cervical cord injured (CCI) according to the postural changes. The study was performed on 26 cervical cord injury patients and 20 normal controls. Among the 26 CCI patients, there were 18 complete quadriplegics and 8 incomplete quadriplegics. The forced vital capacity (FVC), tidal volume (TV) and forced expiratory volume during first second (FEV1) were collected in each subject during supine, sitting and standing postures. The results were as follows; 1) In control group, FVC showed increasing pattern according to the postural changes (from supine to sitting, sitting to standing). In the CCI, the pattern was reversed. 2) For the CCI, the FVC was decreased, but FEV1/FVC ratio of the CCI was normal. This means that the respiratory pattern of the CCI was not obstructive, but restrictive. 3) There was no significant difference in pulmonary function between the complete and incomplete CCI in all postures. 4) There was no significant difference in pulmonary function between the upper (C4, 5, 6) and lower (C7, 8) CCI in all postures.
Congenital hypotonia is a symptom that may have a number of causes.
Determining these causes can tax the most astute physician. By using a few clinical criteria, congenital hypotonia can be divided into broad categories. There is controversy over the usefulness of electromyography (EMG) in the examination of hypotonic infants. However in this study, the EMG diagnosis was identical to that obtained by muscle biopsy in 72.7% of cases in which biopsy was done. Therefore electromyography is a sensitive and noninvasive diagnostic tool of congenital hypotonia.
Ultrasound therapy is an established clinical tool in the treatment of soft tissue lesion. However, in seeking scientific evidence to verify the benefits of ultrasound in a given area, or to decide on the optimum treatment parameters, we are confronting with inadequate and ofter confusing evidence. There appears to be little direct information on precise temperature changes in tissues by different ultrasound application techniques of the ultrasound treatment parameters. The clinical application in the treatment of soft tissues by the thermal effect remained an empirical science. The objective of this study was to determine how the tissue temperature is changed by different stroking techniques, parallel, cross, and circular to the muscle fibers. The area of tibialis anticus muscle in 16 limbs of 16 subjects were exposed to ultrasound diathermy of 2.0 watts/cm2 for 10 minutes. The temperature changes in the skin and tibialis anticus muscle at depth of 1 cm were recorded. The delineated area was confined to the most muscular portion of the tibialis anticus muscle. The transducer was gently moved, with slight pressure, over the delineated area in repeated regular manner so as to favor an even distribution of the ultrasound energy. There was no statistical significance in skin temperature change. Intramuscular temperatures at depth of 1 cm by all stroking techniques were observed to be significantly higher than the preapplication temperature. The mean postapplication intramuscular temperature by parallel stroking technique to the muscle fibers was significantly higher than that of cross and circular stroking technique (p<0.05)
The purpose of this study was to identify the correlation of shoulder pain to cervical pathology and effectiveness of cervical treatment on the neck and shoulder.
Response to a multidisciplinary rehabilitation program focused on the cervical radiculopathy and shoulder pain was excellent. Thirty patient complaining of shoulder pain only without neck pain were evaluated by physical examination, cervical X-rays and electrodiagnostic study. The results were as follows: 1) Twenty four cases were abnormal in plain cervical spine x-ray with straightening of cervical lordotic curve in 15 cases, cervical spondylosis in 13 cases, and disc space narrowing in 5 cases. 2) Cervical radiculopathies were diagnosed 24 cases which showed abnormal spontaneous activities in needle EMG：13 cases in paraspinal muscles and 11 cases in both paraspinal and upper extremity muscles. 3) The results of treatment were excellent in 6 cases and good in 18 cases. Therefore patients complaining of shoulder pain should be examined their neck with various laboratory study.
The purpose of this study was to review the problems of bladder overdistention and to analyze the effects on bladder training in the patients with spinal cord injury. The subjects of study were 34 spinal cord injured patients with neurogenic bladder dysfunction.
Of the total of 34 patients, 28 patients (82.4%) experienced bladder overdistention in early phase of spinal cord injury. Assuming that the detrusor, internal urethral sphincter, and external urethral sphincter muscles of 24 patients become hyperreflexic (Group I), detrusor areflexia was seen in four of the 20 patients with overdistended bladder. In four patients with detrusor areflexia, the amount of bladder volume was over 1,000 cc. The recovery of detrusor reflex was delayed in 16 patients with experience of overdistened bladder and significant correlation between time of recovery of detrusor reflex and frequency of bladder overdistention. Assuming that the detrusor and external urethral sphincter muscles of ten patients become areflexic (Group II), bladder overdistention did not affect the achievement of a balanced bladder or the time required for this. Therefore, we conclude that bladder overdistention do not cause irreversible damage to the detrusor muscle but delayed recovery of detrusor reflex. The prevention of bladder overdistention is very important in the early management of neurogenic bladder in the patients with spinal cord injury.
Currently, a major factor limiting the widespread clincal application of functional electrical stimulation is rapid muscle fatigue which accompanies its use. This study compared the both stimulating frequencies, 25 Hz and 50 Hz, on the rate of muscle fatigue of dorsiflexor muscles of the human ankle. We found that higher-frequency stimuli (50 Hz) will fatigue more rapidly than the lower-frequency (25 Hz), when using surface electrodes for functional electrical stimulation (FES). Rapid muscle fatigue during higher-frequency electrical stimulation may be due to a impaired excitability of the muscle-fiber membrane.
Thus, the lower-frequency functional electrical stimuli may provide significant advantages than high-frequency functional electrical stimuli for decreasing rapid muscle fatigue.
Posterior antebrachial cutaneous (PABC) nerve, a sensory branch of radial nerve supplies the posterior aspect of the forearm and its peripheral nenropathy is rare.
We are reporting the case of PABC neuropathy which was confirmed by the sensory nerve conduction study. The neuropathy developed associated with the injury of left elbow, biting by a dog. Sensory nerve condution study of the PABC nerve showed delayed latency and slow conduction velocity but normal amplitude. For the standardization of the PABC nerve conduction study, we examined 80 nerves from the 40 healthy Korean adults.
Selective posterior rhizotomy (SPR) is a neurosurgical procedure designed to alleviate spasticity and has been successfully used for children with spastic cerebral palsy. In our hospital, 30 patients had undergone SPR between June, 1988 and June, 1992, and the only 20 patients were followed over 6 months after operation. The authors have analyzed the status of 20 children with spastic cerebral palsy before and after operation to determine the effects of this therapy on muscle tone, range of movement and motor function. Postoperative tests showed a reduction in muscle tone in all cases compared with preoperative assessments. Range of motion in lower extrimities was increased in 65 to 85% of cases while motor function continued to improve in 10 cases. Functional gains were greatest in children operated on under the age of 5. The complications of SPR were not serious only one case had transitory bladder problem, 2 cases had mild spinal instability, 2 cases had mild scoliosis.
In vivo measurements of muscle fiber conduction velocity (MFCV) have not gained wide application as compared to other electrodiagnostic study. This is partly due to a lack of clear clinical applications and partly due to the cumbersome techniques. The MFCV was determined from recordings of muscle fiber potentials with monopolar needle electrode in the fiber direction. Twenty two healthy volunteers ranging in age from 24 to 42 years served as subjects. The short head of biceps brachii of the right arm was selected for this study. Five muscle fiber potentials were recorded after distal electrical stimulation through a monopolar needle electrode at a distance of 5 cm and mean latency of each sample by averaging was calculated. Then the recording electrodes were moved proximally along the same bundles of fivers guided by the place of the twitching fibers easily found with palpation and averaged muscle fiber potentials were obtained from the motor point and 10 cm apart from the stimulation electrode by same manner. Their recording positions were adjusted until steep polypohasic potentials of and all-or-none type were recorded. The MFCV was then calculated according to the latency of the initial deflection. The mean and standard deviation of the conduction velocity were 4.25⁑0.35 m/sec (at 5 cm proximal to the stimulation electrode), 4.38⁑0.61 m/sec (at motor point) and 4.04⁑0.41 m/sec (at 10 cm proximal to the stimulation electrode), respectively. Among MFCVs, the comparison observed to be significant was that between the MFCV (over motor point) and MFCV (at 5 cm)(p<0.05), and between MFCV (at 5 cm) and MFCV (at 10 cm) (p<0.05). The MFCV recorded over motor point was significantly higher than MFCV recorded at 5 cm and 10 cm proximal to the stimulation electrode.
Many patients with herniated nucleus pulposus of the lumbar spine can be expected to resolve their conditions with conservative management. Two exercise protocols for the conservative managements are the Williams' flexion exercise and the lumbar hyperextension exercise. The extension exercise may be attempted with paraspinous extensors in a flexed or neutral position in order to improve motor strength and endurance, or attempt in the hyperextended position with the goal of improving mobility, strengthening the back extensors, or promoting a shift of nuclear material to a normal position. Some controversy exsists in beneficial effects advocated by McKenizie protocols. This paper demonstrates the clinical recovery patterns of the lumbar hyperextension exercise of 2 weeks duration wihich may contribute to evaluate the effectiveness of the treatment.
Of 30 patients who met the criteria for inclusion in the study, 21 patients (70%) were improved in the clinical symptoms and physical findings within the 14 days. Thirteen (92%) of the patients that have the duration of less than 6 months were improved, and 8 (50%) of the patients that have the duration of less than 6 months were improved. It appeares that the application of the lumbar hyperextension in the patients with short duration of the symptoms was more effective than the long duration. Some of these patients demonstrated so dramatic effect that the hyperextension exercise could be recommended as essential therapeutic modality.
Pentazocine is a good drug as non-narcotics for pain control, but repeated intramuscular injection can cause the disorders of skin and muscles as side effect.
13 cases who has been treated by injection chronically for pain control, were evaluated clinically, laboratory and electrodiagnostically. The obtained results are as follows: 1) The most injured muscles were deltoids, gluteus, biceps brachii, and quadriceps. 2) There were swelling, induration, inflammatory nodule and abscess formation in skin, and fibrous contracture in muscle (especially, hip and shoulder is abducted), which showed fixed posture. 3) There increment of the serum CPK (creatine phosphokinase), serum LDH (lactate dehydrogenase) in 2 cases, and urine myoglogbin in 5 cases were observed, but there were no significance statiscally. 4) Electrodiagnostic study revealed myopathic pattern, i.e. short amplitude polypohasic motor unit and normal conduction velocity with low amplitude of motor action potential. As indicated above, since the repetitive injection of pentazocine on the same site causes a serious skin and muscle disorders, it is considered that pain control by means of other non-narcotic analgesics is proper in the future.
Electrophysiologic techniques to study the upper cervical nerves are scarce. Some of these nerves are superficial and easily accessible for nerve conduction studies. The great auricular nerve, a purely sensory branch of the cervical plexus has been documented to be abnormally thickened and to be easily palpable in patients with leprosy, inherited or non-inherited hypertrophied neuropathy and even in some normal subjects. The nerve is also easily susceptible to neck injury because of its anatomical pathway. It supplies the skin over the mastoid and the back of the lower part of the auricle.
We have described and compared with two different techniques for evaluating nerve conduction test of the great auricular nerve, using only the surface stimulating and recording electrodes. The first one by Kimura is recorded at earlobe and the second one by Palliyath is recorded at mastoid process region. The results such as peak latencies, amplitudes, durations and velocities of sensory nerve action potentials by these techniques are summarized as follows; 2.01⁑0.68 msec, 17.05⁑4.82μV, 1.02⁑0.17 msec and 46.02⁑6.43 m/sec on earlobe, and 1.7⁑0.10 msec, 14.19⁑5.12μV, 0.66⁑0.13 msec and 46.67⁑5.66 m/sec on mastoid process, respectively.
There was no statistical significance between the results of two different methods. We have concluded that we may use these two different techniques interchangeably for the study of great auricular nerve conduction.
Myotonia dystrophica, described first in 1909 by Steinert, is a multisystemic disorder inherited as a dominant trait.
In addition to generalized weakness, gait disturbance and myotonia, the clinical features include prominent facial weakness, mild limb weakness, swan-line neck posture, frontal baldness, cataract, infertility, abnormal ECG finding, dysphagia, recurrent pulmonary infection, megacolon, hypersomnia, hypothyroidism, abnormal glucose and insulin metabolism, and mental defect.
We present here the clinical features, EMG, muscle biopsy, and other laboratory findings of two patients of one family who have adult onset myotonia dystrophica.
Anomalous muscles of the upper extremity are common, but symptomatic anomalies are rare, usually masquerading as soft tissue tumors, ganglia, or peripheral neuropathy of undertermined etiology. Tingling, numbness, and weakness may arise from nerve compression, or may be produced by the muscle itself. EDBM (Extensor digitorum brevis manus) is a small accessory extensor of the fingers and is found on the dorsum of the hand in 1∼3% of the population, and occasionally it is present bilaterally. It arises form the dorsal carpus and may have tendons to the index, middle, ring, and rarely to the fifth fingers-but nerve to the thumb.
The evolutionary origin of the EDBM is uncertain. Some authors consider it to be derived from the dorsal interosseous musculature. Others believe that it is an atavistic muscle, which may be homologous with the extensor brevis in the foot, produced by delamination of forearm extensors. Electrophysiologic documentation of the innervation of the EDBM by the posterior interosseous nerve favors the latter suggestion.
Anomalous hand muscles consistent with EDBM muscles were noted in a 31 year-old man. Well-defined CMAP (compound muscle action potentials) were ellicited in these muscles with stimulation of the posterior interosseous nerve. Needle electromyography showed poor recruitment and large motor unit potentials only in the anomalous muscles.
We report a case of EDBM with electrophysiologic documentation that this accessory muscle is innervated by the posterior interosseous nerve.
Patients with ankylosing spondylitis are susceptible to spine fracture, usually in the cervical spine. Less frequently, the thoracic and lumbar spines are affected. The fracture line may involve anterior and posterior elements. Frequently, it extends through the entire width of the spine and as a result the fracture tends to be unstable and may cause neurologic damage. In this case, prompt immobilization and reduction of the dislocated spine followed by stabilization is required.
We report a 71 year-old man who slipped down and sustained a fracture-dislocation of T11 vertebra, which was able to be diagnosed due to development of complete paralysis of bilateral lower extremities. The patient was operated for stabilizing fracture with Kaneda device. Postoperatively, the patient regained poor to good range of muscle power.
Many fractures in patients with ankylosing spondylitis may occur even with following minor trauma. We feel that one of the important aspects in ankylosing spondylitis management is the prevention of spinal fractures.
Alerting patients of spinal fragility and teaching them how to evade situations leading to spinal trauma may help avoid this kind of tragedy.
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