To determine whether patients with lumbosacral (LS) radiculopathy and peripheral polyneuropathy (PPNP) exhibit sudomotor abnormalities and whether SUDOSCAN (Impeto Medical, Paris, France) can complement nerve conduction study (NCS) and electromyography (EMG).
Outpatients with lower extremity dysesthesia underwent electrophysiologic studies and SUDOSCAN. They were classified as normal (group A), LS radiculopathy (group B), or PPNP (group C). Pain severity was measured by the Michigan Neuropathy Screening Instrument (MNSI) and visual analogue scale (VAS). Demographic features, electrochemical skin conductance (ESC) values on hands and feet, and SUDOSCAN-risk scores were analyzed.
There were no statistical differences in MNSI and VAS among the three groups. Feet-ESC and hands-ESC values in group C were lower than group A and B. SUDOSCAN-risk score in group B and C was higher than group A. With a cut-off at 48 microSiemens of feet-ESC, PPNP was detected with 57.1% sensitivity and 94.2% specificity (area under the curve [AUC]=0.780; 95% confidence interval [CI], 0646–0.915). With a SUDOSCAN-risk score cut-off at 29%, NCS and EMG abnormalities related to LS radiculopathy and PPNP were detected with 64.1% sensitivity and 84.2% specificity (AUC=0.750; 95% CI, 0.674–0.886).
SUDOSCAN can discriminate outpatients with abnormal electrophysiological findings and sudomotor dysfunction. This technology may be a complementary tool to NCS and EMG in outpatients with lower extremity dysesthesia.
Citations
A pontine intracranial hemorrhage (ICH) evokes several neurological symptoms, due to the various nuclei and nerve fibers; however, hearing loss from a pontine ICH is rare. We have experienced a non-traumatic pontine ICH patient, with hearing loss. A 43-year-old male patient had a massive pontine hemorrhage; his brain magnetic resonance imaging revealed the hemorrhage on the bilateral dorsal pons, with the involvement of the trapezoid body. Also, profound hearing loss on the pure-tone audiogram and abnormal brainstem auditory evoked potential were noticed. Fifty-two months of long-term follow-up did not reveal any definite improvement on the patient's hearing ability.
Citations
To investigate the predictive value of the sympathetic skin response (SSR) in diagnosing complex regional pain syndrome (CRPS) by comparing three diagnostic modalities-SSR, three-phasic bone scans (TPBS), and thermography.
Thirteen patients with severe limb pain were recruited. Among them, 6 were diagnosed with CRPS according to the proposed revised CRPS clinical diagnostic criteria described by the International Association for the Study of Pain. SSR was measured in either the hands or feet bilaterally and was considered abnormal when the latency was prolonged. A positive TPBS finding was defined as diffuse increased tracer uptake on the delayed image. Thermographic findings were considered positive if a temperature asymmetry greater than 1.00℃ was detected between the extremities.
Five of 6 CRPS patients showed prolonged latency on SSR (83% sensitivity). TPBS was positive in the 5 CRPS patients who underwent TPBS (100% sensitivity). Thermography was positive in 4 of 5 CRPS patients who underwent the procedure (80% sensitivity). The remaining 7 non-CRPS patients differed on examination. SSR latencies within normal limit were noted in 4 of 7 non-CRPS patients (57% specificity). Results were negative in 4 of 5 non-CRPS patients who underwent TPBS (80% specificity), and negative in 3 of 5 non-CRPS patients who underwent thermography (60% specificity).
SSR may be helpful in detecting CRPS.
Citations
Evaluation of the Sympathetic Skin Response in Men with Chronic Prostatitis: A Case-Control Study
It can be difficult for clinicians to distinguish a paradoxical response to antituberculous therapy, worsening of an existing lesion despite adequate treatment, treatment failure, and drug resistance. We report a case of a 69-year-old woman who experienced bilateral lower extremity paralysis secondary to a paradoxical response. She had been suffering for 1 month from low back pain, due to tuberculous spondylitis. Her low back pain improved after antituberculous therapy. The low back pain, however, reappeared 2 months after treatment, accompanied by newly developed lower extremity weakness. Imaging studies showed an increased extent of her previous lesions. Consequently, the patient underwent a vertebral corpectomy with interbody fusion of the thoracolumbar spine. Histopathological examination showed chronic inflamed granulation tissue with no microorganisms. Although the antituberculous medication was not changed, the patient's symptoms and signs, including the paralysis, resolved after surgery.
Citations
Central hyperthermia is a very rare disease; however, once it happens, it is associated with a poor prognosis and high mortality for patients with severe brainstem strokes. Following a pontine hemorrhage, a 46-years-old female developed prolonged hyperthermia. Work-ups to the fever gave no significant clues for the origin of fever, and hyperthermia did not respond to any empirical antibiotics or antipyretic agents. The patient's body temperature still fluctuated in a range of 37.5℃ to 39.2℃. Considering the lesion of hemorrhage, we suspected central hyperthermia rather than infectious diseases. We started with baclofen administration at a dose of 30 mg/day. The body temperature changed to a range of 36.6℃ to 38.2℃. We raised the dose of baclofen to 60 mg/day. The patient's body temperature finally dropped to a normal range. Central hyperthermia, caused by failures of thermoregulatory pathways in brainstem, following the pontine hemorrhage rarely occurs. Baclofen can be used to treat suspected central hyperthermia in a patient with pontine hemorrhage.
Citations
To examine the cardiorespiratory responses of patients with spinal cord injury (SCI) paraplegia using a motor driven rowing machine.
Ten SCI patients with paraplegia [A (n=6), B (n=1), and C (n=3) by the American Spinal Injury Association impairment scale] were selected. Two rowing techniques were used. The first used a fixed seat with rowing achieved using only upper extremity movement (fixed rowing). The second used an automatically moving seat, facilitating active upper extremity movement and passive lower extremity movement via the motorized seat (motor rowing). Each patient performed two randomly assigned rowing exercise stress tests 1-3 days apart. The work rate (WR), time, respiratory exchange ratio (R), oxygen consumption (VO2), heart rate (HR), metabolic equivalents (METs), and rating of perceived exertion (RPE) were recorded.
WR, time, VO2, and METs were significantly higher after the motor rowing test than after fixed motor rowing test (p<0.05). HR after motor rowing was significantly lower than fixed rowing (p<0.05).
Cardiorespiratory responses as VO2, HR and METs can be elicited by the motor rowing for people with paraplegic SCI.
Citations
To understand the neural generator of double-peak potentials and the change of latency and amplitude of double peaks with aging.
In 50 healthy subjects made up of groups of 10 people per decade from the age of 20 to 60, orthodromic sensory nerve conduction studies were performed on the median nerves using submaximal stimulation. Various stimulus durations and interstimulation distances were used to obtain each double peak in the different age groups. The latency and amplitude of the second peak were measured. Statistical analyses included one-way ANOVA and correlation tests. p-values<0.05 were considered significant.
When the cathode moved in a proximal direction, the interpeak intervals increased. Second peak amplitudes decreased, and second peak latencies were delayed with aging (p<0.05). In some older people, second peaks were not obtained.
Our experiments indicate that the double-peak response represented the two stimulation sites under the cathode and anode. The delayed latency and decreased amplitude of the second peak that occurs with aging represented peripheral nerve degeneration in aging, which starts at the distal nerve.
Citations
Method: The subjects were 50 healthy adults (mean age, 45.6 years) without the clinical signs and symptoms of peripheral neuropathy. All subjects underwent electrodiagnostic evaluation of the following sensory nerves in lower limbs: superficial peroneal, sural, proximal sural, lateral dorsal cutaneous branch of sural nerve (LDSN), and medial plantar. Examined late responses included: tibial F-wave, peroneal F-wave, and H-reflex recorded from the soleus muscle.
Results: No response rates of sensory nerve conduction studies such as superficial peroneal, sural, proximal sural, LDSN, and medial plantar nerves were 2%, 0%, 0%, 24%, and 18%, respectively. No response rates of late responses such as tibial F-wave, peroneal F-wave, and H-reflex were 0%, 2%, and 8%, respectively. And no response rates were significantly correlated with age (p＜0.05).
Conclusion: No response rate of sensory and late responses of lower limbs are relevant to age increments, the results should be considered for an early diagnosis of peripheral neuropathy in the lower limbs of old population. (J Korean Acad Rehab Med 2003; 27: 220-223)
Objective: The purposes of these study were to evaluate the changes of temperature and sympathetic skin response (SSR) before and after sympathectomy in patients with palmar hyperhidrosis and to quantify long standing effect of sympathectomy.
Method: The SSR and skin temperature were measured before, one day and 30 days after thoracoscopic sympathectomy. SSR was recorded from palm and sole bilaterally. Temperature was recorded on 9 sites of each hand and 11 site of each sole. Patient's satisfaction with operation was assessed by 10-point scale.
Results: One day after sympathectomy, the amplitude of SSR was significantly decreased and latency of SSR was delayed in all cases on bilateral palm and sole. However, after sympathectomy 30 days, the amplitude of SSR was normalized in all cases on bilateral sole. All patients who had undergone sympathectomy showed significant clinical improvement. The temperature increased dramatically over 3oC on postoperation 1 day and maintained 1.72oC higher in post-operation 30 days than pre-operation on both hands. There was no significant difference of temperature among pre-operation and post-operation 1 day and post-operation 30 days on sole.
Conclusion: Our study proved effect of thoracoscopic sympathectomy to the patients with palmar hyperhidrosis objectively and quantified the decrement of sympathetic tone. Further study is needed for long term follow up over 2 months or more. (J Korean Acad Rehab Med 2002; 26: 543-549)
Objective: To investigate sympathetic vasomotor response of the hands to cold and warm stress on the foot with Digital Infrared Thermal Imaging (DITI) in normal healthy subjects.
Method: Fifteen healthy subjects were participated in this study. The DITI was taken during immersing right foot in cold and warm water bath. The thermal images of the dorsal hands were captured at the starting point and then every 5-minute up to 30 minutes. The ratio of temperature between the ending point (30T) and the starting point (0T) was calculated.
Results: In cold stress test, the mean 30T/0T ratio were 92.8⁑2.4% and 92.2⁑2.7% in the right and left hands, respectively. There were no statistically significant side to
side differences. The temperature of the each hand was significantly lowered at every 5 minutes interval (p＜0.05). In warm stress test, the mean 30T/0T ratio were 104.5⁑1.8% and 104.4⁑2.0% in the right and left hands, respectively. The temperature of each hand was significantly increased at the first 5 minutes (p＜0.05), and tended to increase until 10 minutes. After then, the temperature was not significantly changed until 30 miniutes.
Conclusion: We could identify the normal sympathetic vasomotor response to the cold and warm stress with DITI. It might be served as an useful baseline data for the identification of sympathetic dysfunction. (J Korean Acad Rehab Med 2002; 26: 223-227)
Objective: The purpose of this study is to evaluate the effect of visible light therapy for the management of somatic pain.
Method: Subjects consisted of 42 patients with pain and were divided into two groups; control (n=22) and experimental (n=20) groups. Control group received conventional physical therapy only, while experimental group received additional light therapy with blue light (light intensity 4080 lux, wave length 581 nm, distance from lamp 5 cm). Intensity of pain was assessed by visual analogue scale (VAS) and McGill pain questionnaire. Sympathetic skin response was measured to assess the status of autonomic nervous system. VAS and McGill pain questionnaire were administered before treatment and at 1 day, 2 days, 3 days, 1 week, and 2 weeks after treatment. Sympathetic skin response were performed before and 2 weeks after treatment.
Results: 1) In both experimental and control groups, VAS became significantly lower at two weeks after treatment compared to pretreatment scale (p＜0.05). 2) McGill pain questionnaire showed significantly lower scores two weeks after treatment compared to pretreatment score, only in experimental group (p＜0.05). 3) Experimental group showed significantly lower McGill pain questionnaire score than control group at two weeks after treatment (p＜0.05). 4) Latency and amplitude of sympathetic skin response showed no significant difference between experimental and control groups.
Conclusion: Visible light therapy can be used as an effective therapeutic modality for the management of symptomatic pain in combination with conventional physical therapy. (J Korean Acad Rehab Med 2002; 26: 81-85)
Objective: To evaluate the autonomic nervous system function in chronic renal failure patients compared to normal control and to assess the effect of dialysis method and underlying diseases such as diabetes mellitus and hypertension, on autonomic nervous system function in chronic renal failure patients.
Method: We checked palm and sole skin temperature with digital thermometer, sympathetic skin responses and heart rate variability in chronic renal failure patients (77 persons) and normal control group (77 persons).
Results: The amplitude of sympathetic skin response (SSR) and heart rate variability (RRIV) of patients group showed statistically significant difference compared to control group (p＜0.05). The diabetic patient group with chronic renal failure showed prolonged latency of SSR in sole but significant differences were shown in amplitude and RRIV (p＜0.05). The hypertensive group with chronic renal failure showed prolonged latency of SSR in both palm and sole (p＜0.05) but the amplitude and RRIV of those didn,t show statistical difference (p＞0.05). CRF without diabetes mellitus and hypertension showed significant difference on amplitude of SSR and RRIV (p＜0.05) but autonomic nervous system function tests showed no difference (p＞0.05) between hemodialysis and peritoneal dialysis groups.
Conclusion: SSR test and RRIV could be valuable measure to evaluate autonomic nervous system functions in the patients with chronic renal failure.
Objective: The purpose of this study is to evaluate the effectiveness and safety of aerobic exercise program in cardiac patients.
Method: Twenty patients participated in 6 weeks of aerobic exercise with telemetry monitoring as an outpatient rehabilitation program. For the comparison of physiologic changes, we used graded exercise test (GXT) by means of modified Bruce protocol before and in 6 weeks after aerobic exercise training. Exercise prescription for cardiac rehabilitation was composed of intensity, mode, frequency and duration. By use of EKG telemetry and monitoring of blood pressure and Borg RPE (ratings of perceived exertion) scale, we were monitored patients status during exercise.
Results: In six weeks after aerobic exercise training, the hemodynamic and metabolic responses were improved and statistically significant parameters were as follows: exercise time, maximal METs, resting heart rate, maximal heart rate, submaximal rate pressure product, maximal expired volume, maximal oxygen consumption rate and anaerobic threshold.
Conclusion: We concluded that six week cardiac rehabilitation program is useful and safe to improve the aerobic capacity for cardiac patients.
Objective: The sympathetic skin response (SSR) was measured in patients with chronic renal failure (CRF) for diagnosis of uremic polyneuropathy and its correlations with nerve conduction study (NCS) and clinical autonomic symptoms were investigated.
Method: The SSR was measured in 15 patients with CRF on regular hemodialysis, aged 26 to 67 years. With median nerve stimulation at the wrist using the extremity without arteriovenous fistula, the SSR was recorded from both palm and sole simultaneously. The responses were interpreted as normal (presence) or abnormal (absence). Routine nerve conduction study was also performed in the same extremities and clinical autonomic symptoms were investigated.
Results: Nine of fifteen patients (60.0%) had symptoms suggestive of autonomic dysfunction: the most frequent findings were orthostatic dizziness and sweating problem. The SSR was absent in four of fifteen patients (26.7%). There is no significant relationship between SSR and autonomic symptoms (P＞0.05). The nerve conduction study was abnormal in eight of fifteen patients (53.3%), and the SSR was absent in two of seven patients with normal NCS. There is no significant relationship between NCS and SSR (P＞0.05).
Conclusion: Although the proportion of abnormal SSR was small, it may be a valuable method in the assessment of uremic polyneuropathy in conjunction with routine nerve conduction study in CRF patients.
Objective: To compare the R3 response of the blink reflex in medullar and spinal cord lesion and to investigate whether the reflex arc of the R3 response descend to the cervical spinal cord or not.
Method: We have studied 3 patients with medullar lesion and 5 patients with cervical spinal cord or vertebral lesion. Normal ranges of the R3 response refer to the results suggested by Moon et al.
Results: In 3 patients with medullar lesion, two patients with lateral medullar lesion showed delayed R3 latency or no evoked potential. Four patients with cervial spinal cord lesion showed no R3 response. In one patient with disc protrusion R3 was normal.
Conclusion: Our results support the hypothesis that the reflex arc of the R3 response descend to the cervical spinal cord.
Objective: To observe the change of sympathetic skin response (SSR) before and after sympathectomy in patients with idiopathic palmar hyperhidrosis and to find the usefulness of SSR for assessment of the effects of sympathectomy
Method: The SSR was measured in 20 patients with palmar hyperhidrosis and 20 normal control group. Ten days after thoracoscopic sympathectomy, SSR was also measured. A 50∼150 V stimulus was applied over the median nerve and SSR was recorded on bilateral palms and soles with Viking IV (Nicolet Biomedical Ins., U.S.A.). Patient's satisfaction with operation was assessed by questionnaire.
Results: Absent or unstable SSR recordings rate was increased and amplitudes of SSR were significantly decreased in patients with palmar hyperhidrosis compared with control group. After sympathectomy, SSR was absent in all cases on bilateral palms and these results were correlated with clinical improvment. All patients who had undergone surgery showed significant clinical improvement for palmar hyperhidrosis and about 75% of the cases were found to have compensatory sweating from other site of the body.
Conclusion: Abnormal sympathetic nerve system responses were observed in patients with palmar hyperhidrosis. SSR recordings and clinical manifestations were influenced by sysmpathectomy.
Objective: The diagnosis of myofascial pain syndrome (MPS) is commonly made by Simons' clinical diagnostic criteria which is mainly based on patients' complaints, so it is difficult to distinguish from malingering. The purpose of this study is to evaluate local twitch response by needling (LTR) as an objective diagnostic criterion of MPS.
Method: Forty four industrial designers complaining of regional pain in neck, shoulder, or upper arm were examined by a physiatrist. If trigger point was detected, local twitch response by needling was confirmed and than severity was measured by 4 grades. Sensitivity, specificity, and positive predictive value of local twitch response was calculated with diagnosis made by Simons' clinical diagnostic criteria. Correlation between grade of local twitch response and sum of clinical features in Simons' criteria was also evaluated.
Results: Local twitch response by needling was corresponding with the diagnosis of MPS by Simons' criteria (sensitivity 100%, specificity 96.7%, positive predictive value 93.3%), and the severity of local twitch response was significantly associated with sum of clinical features in Simons' criteria (Spearman correlation 0.950; p=0.048)
Conclusion: Local twitch response by needling is an important and objective diagnostic criterion of MPS.
Objective: This study was designed to assess the influences of skin temperature and age on latency and amplitude of the sympathetic skin response (SSR).
Method: We examined the sympathetic skin responses in 77 normal subjects aged 25 to 73 years. With stimulation of both median nerve and both tibial nerve at the wrist and ankle, the SSRs were recorded from both palms and soles simulaneously. To determine the effects of skin temperature change on SSR, we examined the SSRs in 12 healthy subjects before and after heating. The heat was applied on right forearm by infra-red lamp.
Results: The mean latency and the mean amplitude of SSR with stimulation of the right median nerve at the wrist were 1.47 sec and 6.08 mV at the right palm, 1.50 sec and 6.07 mV at the left palm, 1.95 sec and 3.38 mV at right sole, and 1.95 sec and 3.09 mV at left sole. There was no side-to-side difference in the latency and the amplitude. Regardless of the site of stimulation, latency was longer at the sole than at the palm, and amplitude was greater at the palm than at the sole (p＜0.05). The latency of the SSR was positively correlated with the age of subjects (p＜0.05), and the amplitude was negatively correlated with the age of subjects (p＜0.05). At higher skin temperature, the latency of SSR was shortened and the amplitude was reduced significantly (p＜0.05).
Conclusion: The amplitude of the SSR decreases with aging and the latency increases with aging. As the skin temperature rises, the latency and amplitude show tendency to decrease. We suggest that the skin temperature and age are important factors to be considered carefully in assessing the SSR parameters.
Objective: Most spinal cord injured patients suffered form various autonomic dysfunction. The purpose of this study is evaluation of sympathetic skin response (SSR) and R-R interval variability (RRIV) as a method of autonomic function test in spinal cord injured patients.
Method: Thirty-six spinal cord injured patients were enrolled in this study. SSR was recorded in the palm and sole by electrical stimulation of right median nerve and RRIV during rest, deep breathing and Valsalva maneuver for 1 minute.
Results: The higher level of spinal cord injury, the higher rate of the abnormal sympathetic skin response in the palm and sole and more reduced values of Valsalva ratio (p＜0.05). The parameters of sympathetic skin response and R-R interval variability were not correlated with injury severity of spinal cord and their autonomic symptoms.
Conclusion: Evaluation of SSR and RRIV could be helpful methods to evaluate autonomic function in the spinal cord injured patients.
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