Objective
To evaluate the correlation of the cross-sectional areas (CSA) of paraspinal (multifidus and erector spinae) and psoas muscles and chronic low back pain by MRI (magnetic resonance image) in young and middle-aged patients. Method: Medical records of eighty subjects (50 young-aged and 30 middle-aged men) with low back pain were retrospectively reviewed. Their MR images were scanned and analysed by means of pixel to find the lumbar paraspinal and psoas muscle CSA and evaluated the correlation of the types of disc and age. Results: There were significant increases of body mass index (BMI) in middle-aged patients compared with young- aged, and no difference in the disc types. Paraspinal muscle atrophy was increased in young patients with HIVD (herniated intervertebral disc), but not in middle-aged patients although they had HIVD. Conclusion: The paraspinal and psoas muscle atrophy could be assessed by MRI of lumbar spine in young patient with chronic low back pain. It may helpful for further evaluation and planning the treatment of low back pain. (J Korean Acad Rehab Med 2007; 31: 1-6)

Objective
To compare treatment effects of translaminar epidural steroid injections (TLESIs) only and selective nerve root injections (SNRIs) with TLESIs in lumbosacral spinal stenosis. Method: Thirty-four patients diagnosed with magnetic resonance imaging (MRI), somatosensory evoked potential (SEP) and electromyography (EMG) were included. 16 patients who had somatosensory pathway dysfunction or abnormal spontaneous activity received combined SNRIs with TLESIs and 20 patients received only TLESIs. The visual analogue scale (VAS) and functional rating index (FRI) were measured before injection, 1 week and 3 months after 3 times injection. Results: The mean values of VAS before injection, 1 week and 3 months after 3 times injection were 7.55, 3.22, 3.61 in only TLESIs and 7.37, 2.06, 2.31 in SNRIs with TLESIs. The mean values of FRI before injection, 1 week and 3 months after 3 times injection were 25.16, 16.00, 15.83 in only TLESIs and 22.50, 8.37, 8.31 in SNRIs with TLESIs. In the mean values of VAS and FRI were significantly lower SNRIs with TLESIs than only TLESIs (p＜0.05). Conclusion: Combined SNRIs with TLESIs were more effective treatment for reduction of pain and improvement of function than only TLESIs in lumbosacral spinal stenosis. (J Korean Acad Rehab Med 2007; 31: 7-13)

Objective
To compare the long-term clinical outcome of conservative treatment between herniated soft cervical disc with radiculopathy (HCD-R) and cervical spondylotic radiculopathy (CSR) Method: Clinical outcomes of each twenty patients with foraminal stenosis and with herniated cervical disc in magentic resonance image were evaluated prospectively for one year. All patients received cervical transforaminal epidural steroid injection. Clinical outcomes were measured by visual analogue scale (VAS), Neck Disability Index (NDI) at initial, one, three, six, and twelve months after injection. Twelve months after injection, we categorized patients' satisfaction. Results: All assessements were significantly reduced (p＜0.05). The averages of VAS for upper extremity and neck pain decreased from 6.7, 5.1 to 1.5, 1.2 in the CSR group, and also decreased from 5.6, 6.3 to 1.3, 2.3 in the HCD-R group, respectively. The averages of NDI in the CSR group decreased from 42% to 8%, and in the HCD-R group from 53% to 14%, respectively. 88.8% in the CSR group and 88.1% in the HCD-R group were satisfied at posttreatment 12 months. There was no difference between groups in all comparison. Conclusion: CSR responded very well to conservative treatment as well as HCD-R, and the effects sustained for long- term. (J Korean Acad Rehab Med 2007; 31: 14-19)

Objective
To evaluate the therapeutic effect of local steroid injection and prolotherapy on the iliac crest pain syndrome (ICPS) in patients with nonspecific low back pain. Method: 44 patients with ICPS were chosen randomly. The treatment groups were divided into two. The first group received a mixture of triamcinolone and lidocaine. The second received with a mixture of dextrose and lidocaine. The patients in each group were injected once a week over 4 weeks. The effectiveness of treatment was evaluated by a visual analogue scale (VAS), a pressure threshold and patient's life activities with modified Oswestry questionnaire before injection, 30 minutes, 1 week, 4 weeks and 3 months later after injection respectively. Results: VAS, pressure threshold and patient's life activities of two groups were all improved at 30 minutes, 1 week, 1 month and 3 months after injection compared with those of pre-injection, and there was no significant difference between groups. Conclusion: The low back pain on ICPS can be significantly improved by local steroid injection and prolotherapy equally. Therefore, patients with risk of steroid injection could be treated by prolotherapy. (J Korean Acad Rehab Med 2007; 31: 20-24)

Objective
To evaluate the effective stimulating mode of transcutaneous electrical nerve stimulation (TENS) and acupuncture for pain relief. Method: The subjects were 40 patients with MPS. In 20 patients, TENS were applied to the trigger point. In other 20 patients, acupuncture mode electrical stimulation were applied to the acupuncture site by measuring skin impedance of affected muscle. Results: The visual Analogue Scale (VAS) decreased 20.48 (19.15%) in the group applied TENS mode and 30.08 (16.97%) in the group applied acupuncture mode after 1 week. The VAS decreased 33.19 (25.76%) in the group applied TENS mode and 46.48(17.76%) in the group applied acupuncture mode after 2 week (p＜0.05). The pressure threshold was increased 16.07 (17.45%) in the group applied TENS mode and 26.09 (22.20%) in the group applied acupuncture mode after 1 week. The pressure threshold increased 24.88 (23.25%) in the group applied TENS mode and 41.11 (27.35%) in the group applied acupuncture mode after 2 week. Conclusion: Acupuncture mode was more effective treatment modality in MPS for pain relief than TENS mode. (J Korean Acad Rehab Med 2007; 31: 25-29)

Objective
To evaluate that lower back pain would influence postural control ability. Method: Thirty-eight adults (18 men, 20 women) participated and were divided into two groups; the study (patients with lower back pain) group and the control (healthy adults) group. Postural control ability of participants was evaluated through the Balance Master^Ⱂ system. A total of seven measurements were analyzed to determine the difference between the study and control group. Results: Patients with lower back pain demonstrated weight bearing patterns on the non-tender side, wider area of sway (^o) under conditions (unilateral stance on firm surface with eye closed) in modified clinical test sensory interaction on balance (p＜0.05). Wider area of turn sway (^o) and long turn time (sec) during step/quick turn were demonstrated in patients with lower back pain (p＜0.05). Conclusion: The results showed that patients with lower back pain was reduced in the postural control ability. Further studies about the effect of back exercise on postural control ability of patients with lower back pain should be carried out. (J Korean Acad Rehab Med 2007; 31: 30-36)

Objective
In treating patients with frozen shoulder, posterior and anterior approach glenohumeral injections are well known methods. But the accuracy of the above injection methods is low. In this study, we introduce the superior approach glenohumeral injection method and evaluate its success rate. Method: Twenty six patients who were clinically diagnosed with frozen shoulder were enrolled. Patients received a superior approach glenohumeral injection of 1 cc radiographic contrast (UrografinⰒ, Schering, Germany). The success of superior approach was determined by radiography study of the shoulder joint taken after the injection. Results: 24 of the 26 procedures (92.3%) were judged to be accurately placed by the radiography study and there was no significant complication after the superior approach intrarticular injection. Conclusion: Superior approach glenohumeral injection in frozen shoulder showed the high success rate. We consider this superior approach as a very effective method. If the study for the interrater reliability is added, the superior approach will be considered to be a useful approach. (J Korean Acad Rehab Med 2007; 31: 37-40)

Objective
To evaluate usefulness of uptake ratio of three phase bone scintigraphy in assessing the complex regional pain syndrome (CRPS) type I in stroke patients Method: Forty three stroke patients were diagnosed as CRPS type I based on their symptoms and confirmed by three phase bone scintigraphy. Uptake ratio was calculated by dividing the radioactivity count on the affected side by that on the unaffected side in each phase. Mean uptake ratio was compared among the groups classified by the clinical diagnosis and by the response to treatment. In addition, uptake ratio was compared before and after treatment. Results: Mean uptake ratio of the wrist in blood pool phase was significantly higher than other parts of the body (p＜0.05). However, there was no significant difference among the groups classified by the clinical diagnosis nor by the response to treatment. The changes of uptake ratio were variable after treatment, but only the uptake ratio of the wrist in blood flow phase showed correlation with the degree of swelling. Conclusion: Uptake ratio of three phase bone scintigraphy was not correlated with clinical findings. (J Korean Acad Rehab Med 2007; 31: 41-47)

Objective
To evaluate the effects of functional magnetic stimulation (FMS) on shoulder subluxation following hemiplegia due to stroke or traumatic brain injury. Method: Twenty-four hemiplegic patients were participated in this study as FMS group (12 subjects) and FES (functional electric stimulation) group (12 subjects). FMS or FES were applied on the supraspinatus and posterior deltoid muscle area for 20 minutes, 5 days a week for 3 weeks. The effect of treatment was evaluated by assessment of the degree of shoulder subluxation using radiologic measurements, pain threshold and pain tolerance pressure, range of motion of the shoulder, muscle power and spasticity. Results: The degree of shoulder subluxation was signifi cantly decreased after 3 weeks in both groups, and the FMS group improved more than the FES group. However there were no differences between two groups significantly. There was no significant effect of disease duration on change of shoulder subluxation. The ranges of motion of shoulder were increased in FMS group significantly. Pain threshold and pain tolerance pressure were increased in pectoralis major and infraspinatus muscles shortly after FMS application. Conclusion: This study suggests that the FMS could be applied effectively in preventing and reducing the shoulder subluxation in patient with hemplegia irrespective of disease duration. (J Korean Acad Rehab Med 2007; 31: 48-55)

Objective
To evaluate the effectiveness of the modified constraint-induced movement therapy (CIMT) for inpatient rehabilitation of the stroke patients. Method: Twenty-four patients admitted by subacute or chronic stroke were enrolled and divided into two groups, experimental and control groups. The experimental group (n=13) received the CIMT five days a week for 2 weeks. Less affected arm was restrained for 14 hours a day, practicing purposeful activities with more affected arm for 6 hours a day in group setting. The control group (n=11) received conventional occupational therapy for the same period. The outcome was measured by Fugl-Meyer Motor Assessment (FMA), Brunnstrom stage, Jebsen hand function test, grip strength, Box and Block test, nine hole peg test, Functional Independence Measure (FIM), and Motor Activity Log (MAL). Results: The experimental group showed significantly higher improvements (p＜0.05) in FMA, Brunnstorm stage, Jebsen hand function test, grip strength, Box and Block test, FIM, and MAL. Conclusion: Modified CIMT delivered in group setting is considered to be an effective treatment to improve functional use of the hemiparetic arm of stroke patients in inpatient setting. (J Korean Acad Rehab Med 2007; 31: 56-62)

Objective
To determine if the physical design and organizational structure of rehabilitation stroke unit (RSU) is related to the amount of patients' activity pattern. Method: An observational study was conducted using behavioral mapping method. Time samples of the motor activity of patients following stroke were taken at 10-minute interval, between 7 AM and 7 PM both on weekdays and weekends. At each observation, physical activity patterns, location in which the patients spent their time, and other person present were recorded. Results: RSU patient spent less time in non-therapeutic activity and more time in therapeutic activity (p＜0.05). There were significant differences in the locations of patient's position between the two types of ward (p＜0.05). RSU patients had significantly more interaction with formal carer and less time disengaged (p＜0.05). The proportion of time in therapeutic activity was low in all location, with patients spending many hours in bed and doing nothing. There was no significant differences in total Functional Independence Measure (FIM) scores at admission and on discharge, FIM gain, and FIM efficiency between RSU and mixed rehabilitation ward (p＜0.05). Conclusion: In spite of quantitative difference, the two wards had similar patterns of treatment activity and deployment of staff. These maybe resulted in similar treatment experiences for patient and no functional differences between two wards. It appears that strategies are required so that patients can be practicing at an more appropriate level. (J Korean Acad Rehab Med 2007; 31: 63-69)

Objective
To investigate whether suppression of right inferior frontal gyrus (Broca's homologue) by 1 Hz repetitive transcranial magnetic stimulation (rTMS) can improve speech recovery. Method: We applied low frequency rTMS on right Broca's homologue twice a week for 6 weeks in eight subcortical aphasia patients who were 3 months to 3 years poststroke onset. They were tested with Korean Version-Western Aphasia Battery before and after procedure. Also, they were tested with Parallel Short Forms for the Korean-Boston Naming Test and Animal Naming Test serially for outcome measure. rTMS was performed with intensity of 80% of motor threshold for 10 min (600 pulses) at 1 Hz frequency. Results: Significant improvement was observed in picture naming at post-rTMS only in nonfluent aphasia patients but not in fluent aphasia patients. Conclusion: rTMS may provide a novel treatment for aphasia by possibly modulating the distributed, bi-hemispheric language network. (J Korean Acad Rehab Med 2007; 31: 70-77)

Objective
To examine the effects of auditory and visual cues on gait in patients with idiopathic Parkinson's disease (IPD). Method: Patients were 16 persons with IPD, and controls were 14 age-matched healthy persons. Controls were allowed to walk at self-selected gait speed and patients walked at no, auditory and visual cues. Gait parameters were gained, and stride variability were measured at each gait trial. Results: In patients, cadence at visual cues was decreased compared with that of controls, no and auditory cues in the statistics. Walking velocity was decreased in all patients than controls, but there was no difference in each cues. Stride length at visual cues was increased compared with that of no and auditory cues, and increased to that of controls. Stride variability was decreased at visual cues compared with that of no and auditory cues, and decreased to that of controls. Conclusion: With the use of visual cues in patients with IPD, the cadence was decreased but stride length was increased and stride variability was decreased to the level of controls. Thus, visual cues could be one of the useful method for gait training in patients with IPD. (J Korean Acad Rehab Med 2007; 31: 78-84)

Objective
To determine the effect of functional electrical stimulation (FES) in the paralyzed muscles of rabbits with spinal cord injury (SCI). Method: Fifteen male New Zealand white rabbits were injured by spinal cord transection at the T6 level. We classified animals into a normal control group (n=3), and SCI without FES (n=3), SCI with 10 Hz FES (n=6) and SCI with 40 Hz FES (n=6) groups. FES was applied on both tibialis anterior (TA) muscles at two frequencies (10 Hz, 40 Hz) for 1 hour daily for 2 weeks. After treatment TA muscles were separated and apoptotic features were measured by in situ DNA nick-end labeling (TUNEL), DNA fragmentation assays and western blotting for Bcl-2 and Bax protein. Results: In TUNEL and DNA fragmentation assay results, the FES groups showed more fragmented myonuclei and DNA, and western blotting showed more Bax protein expression in FES groups than no FES group and control (higher in 40Hz group), whereas Bcl-2 protein expressions were similar in all groups. Conclusion: Apoptosis of paralyzed muscle was increased in FES group with higher Bax/Bcl-2 in 40 Hz than in 10 Hz. To evaluate the clinical significance of muscle apoptosis with FES in SCI, further study would be needed. (J Korean Acad Rehab Med 2007; 31: 85-91)

Objective
To examine how consistently patients with spinal cord injured (SCI) after discharge use the clean intermittent catheterization (CIC). Method: The participants were 146 SCI patients hospitalized for regular urinary tract surveillance program, who resided in a community for over one year after discharge. The mean age was 40.3 years old and the mean time after injury was 6.2 years, consisted of 118 males and 28 females, and of 68 tetraplegics and 78 paraplegics. Results: At discharge, the CIC as a voiding methods was used by 97 patients, Valsalva or reflexic voiding by 43, indwelling catheterization by 3, and diaper voiding by 3. At follow-up, CIC was used by 96, Valsalva or reflexic voiding by 37, indwelling catheterization by 7, and diaper voiding by 6. Among 97 patients who used CIC at discharge, 83 consistently used the CIC (compliance=85.5%). The patients with tetraplegia showed 82.9% of compliance while the patients with paraplega showed 88.0% of compliance, but there was no statistical difference. Conclusion: The compliance with the CIC method was comparatively high (85.5%). The CIC method can be effectively applied to the management of neurogenic bladder for the SCI patients residing in a community after discharge. (J Korean Acad Rehab Med 2007; 31: 92-96)

Objective
To survey the current status of rehabilitation programs for disabled children in Korea. Method: Questionnaires were distributed to hospitals and rehabilitation centers around the country which provides pediatric rehabilitation services to disabled children. Questions included the number of physiatrists, therapists specialized in managing children, frequency and duration of therapeutic session, waiting period required to receive the therapy, and burden of costs, etc. Results: Survey found 2.2 mean number of physiatrists in 45 hospitals and only one rehabilitation center had full time physiatrist among 21 rehabilitation centers. These institutions had mean number of 2.3 physical therapists, 1.4 occupational therapists, and 1.1 speech therapists. According to parents, these children received average of 16 times of therapeutic sessions in a month. For most of patients, they had to wait 6.8 months to start the physical therapy, 9.4 months for occupational therapy, and 13.8 months for speech therapy. The whole cost of receiving the treatment was found to be 586,000 won in a month. Conclusion: Survey found the medical health system and human resources related to pediatric rehabilitation were not enough and they have to be supported to satisfy the needs of appropriate pediatric rehabilitation program around the country. (J Korean Acad Rehab Med 2007; 31: 97-102)

Objective
To investigate the acoustic characteristics of the vowel phonation in children with spastic cerebral palsy (CP) and normal children Method: Twenty-six children with spastic diplegic CP and seventeen normally developed children were recruited as subjects. Voice samples were collected by pronouncing at full length /a/, /i/, and /u/ three times each into a microphone. With these samples, maximum phonation time using Multi-speech model 3,700, fundamental frequency, jitter percent, shimmer percent, noise to harmony ratio using Multi-Dimensional Voice Program model 5105, and 1st formant, 2nd formant using PraatTM were measured. Results: Maximum phonation time was significantly shorter in the CP group than normal group (p＜0.05). Jitter percent and Shimmer percent were significantly increased in the CP group than in the normal group (p＜0.05). Fundamental frequency, 1st formant and 2nd formant were not significantly different between the two groups. Conclusion: Relatively short duration of maximum phonation time in the CP group suggests poor respiratory control and capacity in children with CP. Higher level of shimmer percent in CP group indicates instability of voice quality that result from poor laryngeal function. No significant difference in 1st formant and 2nd formant between the CP and control group suggests similar vowel articulatory ability. (J Korean Acad Rehab Med 2007; 31: 103-108)

Objective
To observe the termination point of graded exercise test (GXT) in cardiac patients and the reasons for the premature termination. Method: Cardiac patients taking GXT within 4 weeks after medical intervention or surgery were reviewed. If the GXT was stopped below the respiratory exchange ratio of 1.0, the subjects were chosen as the final study subjects and reviewed for the reason of premature termination. Results: 115 out of a total of 715 subjects terminated GXT prematurely. There were 36 cardiovascular, and 79 non- cardiovascular reasons. The cardiovascular reasons were abnormal blood pressure response (19.1%), dysrhythmia (6.1%), ST abnormality (3.5%), vascular claudication (2.6%). The non-cardio-vascular reasons were subjective dyspnea (45.2%), lower limb fatigue (7.8%), hemiplegic gait (5.2%), arthralgia (3.5%), anxiety (3.5%), neurogenic claudication (2.6%), and abdominal pain (0.9%). The causes of dyspnea were low physical fitness (71.1%), concurrent chronic obstructive pulmonary disease (15.4%), poor motivation (5.8%), and secondary gain (7.7%). Conclusion: 16.1% of GXT were terminated prematurely and 68.7% of those for non-cardiovascular reasons. The main causes of the non-cardiovascular premature GXT were subjective dyspnea due to low physical fitness. (J Korean Acad Rehab Med 2007; 31: 109-112)

Spinal muscular atrophy (SMA) is a neuromuscular disorder characterized by progressive anterior horn cell degeneration leading to motor weakness, muscular atrophy and denervation. Recently, the genes responsible for proximal muscular atrophy have been identified and named as survivor motor neuron (SMN) and neuronal apoptosis inhibitory protein genes. The clinical symptoms, courses and evaluation findings of proximal SMA type III are similar to those of distal SMA and proximal muscle myopathies such as limb girdle muscular dystrophy and fascioscapulohumeral muscular dystrophy. It cannot be diagnosed with muscle biopsy and electromyographic findings exclusively. In our case, the patient showed similar clinical manifestations of distal SMA. So we couldn't diagnose this case as SMA type III until we detected SMN 1 gene deletion. This case could be a good model for diagnostic approach to SMA type III and differential diagnosis to similar diseases. (J Korean Acad Rehab Med 2007; 31: 113-118)

Parkinsonism is characterized by clinical symptoms of rigidity, bradykinesia, tremor, and gait disturbance. There are many causes of secondary parkinsonism. The present report discusses a secondary parkinsonism of extrapontine myelinolysis (EPM) without central pontine myelinolysis (CPM) after rapid correction of hyponatremia. EPM is a demyelinating process of the brain. EPM with CPM is relatively common, but EMP without CPM is rare. A 57- year-old woman with Tsutsugamushi disease had a subacute onset of parkinsonism on the fourteenth day after a rapid correction of severe hyponatremia. Magnetic resonance imaging of the bilateral basal ganglia showed a high signal intensity on T2-weighted images, and a low signal on T1- weighted images. She was started on levodopa, and parkinsonian features slowly improved. We report an unusual case of EPM without CPM, that presented with parkinsonism. (J Korean Acad Rehab Med 2007; 31: 119-122)

Triple amputee is an uncommon impairment and has been rarely reported. We reported a case of success in independent bipedal ambulation of a triple amputee with bilateral lower limb prostheses. We selected a thirty five-year-old male who underwent a left shoulder disarticulation and a left very short transfemoral amputation and a right transfemoral amputation due to trauma. After program of gait training for eight weeks, he could walk independently, donning right hip disarticulation prosthesis and left transfemoral prosthesis and left shoulder disarticulation prosthesis with right Lofstrand forearm orthosis. We measured the amount of oxygen consumption of the patient before and after rehabilitation program done, of which all parameters including oxygen consumption were more improved than before that program. The patient preferred to walk by himself and got a feeling of full achievement. Nevertheless higher energy consumption, young active triple amputees need fitting prostheses with intensive rehabilitation training program for bipedal ambulation to prevent deterioration of physical function and mental health due to immobilization. (J Korean Acad Rehab Med 2007; 31: 123-126)

Segmental spinal dysgenesis (SSD) is a rare congenital abnormality in which a segment of the spine and spinal cord fails to develop properly. Segmental vertebral anomalies involve the thoracolumbar, lumbar, or lumbosacral spine. We report two cases of SSD associated with other spinal dysraphism. Radiologic investigations revealed segmental dysgenesis of thoracic spinal cord without an associated vertebral bony anomaly in one case and segmental dysgenesis of the cervico-thoracic cord with diastematomyelia in the other case. The neurologic picture depends on the severity of the malformation and on its segmental level along the longitudinal embryonic axis. The pathogenesis of SSD syndrome is not clear but its cause is probably related to a segmental maldevelopment of the neural tube. (J Korean Acad Rehab Med 2007; 31: 127-130)