Publications by authors named "Chang-Zern Hong"

49 Publications

Therapeutic effects of acupuncture on sensory ataxia after a cerebral hemorrhage: A case report.

Medicine (Baltimore) 2020 Jul;99(29):e21124

Department of Physical Medicine and Rehabilitation, China Medical University Hospital.

Introduction: Sensory ataxia is a dysfunction of dynamic balance due to impairment of sensory input into the control of movement. The sequelae of stroke, such as hemiplegia, somatosensory impairment, and impaired balance may cause significant disability and may affect patients' quality of life. In addition to rehabilitation programs, acupuncture therapy has been applied to stroke patients and is recommended as a complementary therapy in stroke rehabilitation.

Patient Concerns: A 70-year-old male had a sudden onset of conscious loss. The brain computed tomography showed intracerebral hemorrhage with subdural hemorrhage and subarachnoid hemorrhage.

Diagnosis: Intracerebral hemorrhagic stroke was diagnosed.

Interventions: He received craniotomy with hematoma evacuation immediately and waked up 3 weeks with bilateral hemiparesis (right side weaker than left), impaired position sensation and tactile perception in the right lower limb. He then began to receive rehabilitation therapy and had significant improvement in muscle strength and static balance, but no improvement in tactile perception of position sense in the right lower limbs and reached plateau. Then he received acupuncture therapies to Yongquan (KI1), Tongtien (BL7) and Houxi (SI3).

Outcomes: The patient's walking ability recovered after receiving rehabilitation programs for 3 years, but the impairment in proprioception and dynamic balance persisted. The perception and dynamic balance had significantly improved after patient received acupuncture therapy, especially the acupuncture point of Yongquan (KI1).

Conclusion: The clinical effect of acupuncture in combination with conventional rehabilitation therapy for neurological impairment recovery, improving activity of daily living performance and improving post-stroke imbalance was explored. We hope that this report can facilitate further well controlled quantitative objective studies on a big size of samples.
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http://dx.doi.org/10.1097/MD.0000000000021124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7373561PMC
July 2020

Percutaneous soft tissue release performed using a blunt cannula in rabbits with chronic collagenase-induced Achilles tendinopathy.

Foot Ankle Surg 2019 Apr 29;25(2):186-192. Epub 2017 Oct 29.

Department of Physical Medicine and Rehabilitation, China Medical University, Bei-Gang Hospital, Yun-Lin 65152, Taiwan; Department of Rehabilitation Medicine, School of Medicine, College of Medicine, China Medical University, Taichung 40402, Taiwan. Electronic address:

Background: This study investigated the effects of percutaneous soft tissue release (PSTR) performed using a blunt cannula on (1) the inflammatory cells-count, (2) expressions of calcitonin gene-related peptide (CGRP) and (3) substance P (SP) in rabbits with chronic phase of collagenase-induced Achilles tendinopathy.

Methods: Thirty-two adult male New Zealand rabbits were randomly divided into four groups: (1) collagenase and PSTR treatment; (2) collagenase and sham-operated PSTR treatment; (3) vehicle-only injection and PSTR treatment; and (4) vehicle-only injection and sham-operated PSTR treatment. Achilles tendon of adult male rabbits was injected with 10μl of collagenase under ultrasonography localization. After 30 days, PSTR was performed using an 18G beauty cosmetic blunt tip micro cannula needle to release the soft tissue and paratenon above the inflamed Achilles tendon. The treated tendons and spinal cords of L5-S2 were harvested 5days after treatment for histological assessment and immunohistochemical analysis.

Results: Histopathological examination revealed that PSTR achieved significant reduction in hypercellularity with pronounced infiltration of immune cells at the site of paratenon in tendons injected with collagenase compared with sham operation (p<0.05). Immunohistochemical analysis also showed marked decrease in expression of CGRP in tendon and SP in dorsal horns after PSTR (p<0.05).

Conclusions: This study showed positive effects in an animal model of chronic tendinopathy, and can be considered a treatment option, but that further research is necessary to determine its role in clinical practice.
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http://dx.doi.org/10.1016/j.fas.2017.10.007DOI Listing
April 2019

Acupuncture at distant myofascial trigger spots enhances endogenous opioids in rabbits: a possible mechanism for managing myofascial pain.

Acupunct Med 2016 Aug 3;34(4):302-9. Epub 2016 May 3.

Department of Physical Medicine and Rehabilitation, Cheng Ching General Hospital, Taichung, Taiwan.

Background And Aim: Acupuncture applied at myofascial trigger points (MTrPs) of distant anatomical regions, to reduce pain in a patient's area of primary complaint, is one strategy that is available to manage myofascial pain. However, the endogenous opioid-mediated analgesic mechanism of distant acupuncture associated with pain control is still unclear. This aims of this study were to evaluate the changes in enkephalin and β-endorphin in serum, spinal cord, dorsal root ganglion (DRG) and muscle induced by acupuncture at distant myofascial trigger spots (MTrSs, similar to human MTrPs) in rabbits, to explore its underlying remote analgesic mechanism.

Methods: Acupuncture at MTrSs of a distant muscle (gastrocnemius) was performed either for one session or five daily sessions in rabbits. The levels of enkephalin and β-endorphin in proximal muscle (biceps femoris), serum, DRGs and spinal cords (L5-S2) were then determined by immunoassay immediately and 5 days after treatment.

Results: Immediately after treatment, acupuncture comprising both one dose and five doses significantly enhanced spinal enkephalin expression and serum β-endorphin levels (p<0.05). However, only five-dose acupuncture significantly enhanced the β-endorphin levels in the biceps femoris and DRGs (p<0.05), while 1-dose acupuncture did not (p>0.05). Furthermore, 5 days after treatment, significantly increased levels of spinal enkephalin and serum β-endorphin persisted in animals that received 5-dose acupuncture (p<0.05).

Conclusions: This study demonstrates that interactions within the endogenous opioid system may be involved in the remote effects of acupuncture treatment and could be a potential analgesic mechanism underlying MTrP pain management.
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http://dx.doi.org/10.1136/acupmed-2015-011026DOI Listing
August 2016

Folate Deficiency Triggered Apoptosis of Synoviocytes: Role of Overproduction of Reactive Oxygen Species Generated via NADPH Oxidase/Mitochondrial Complex II and Calcium Perturbation.

PLoS One 2016 15;11(1):e0146440. Epub 2016 Jan 15.

Department of Microbiology, Immunology and Biopharmaceuticals, Collage of Life Sciences, National Chiayi University, Chiayi City 60004, Taiwan.

Despite a plethora of literature has documented that osteoarthritis (OA) is veritably associated with oxidative stress-mediated chondrocyte death and matrix degradation, yet the possible involvement of synoviocyte abnormality as causative factor of OA has not been thoroughly investigated. For this reason, we conduct the current studies to insight into how synoviocytes could respond to an episode of folate-deprived (FD) condition. First, when HIG-82 synoviocytes were cultivated under FD condition, a time-dependent growth impediment was observed and the demise of these cells was demonstrated to be apoptotic in nature mediated through FD-evoked overproduction of reactive oxygen species (ROS) and drastically released of cytosolic calcium (Ca2+) concentrations. Next, we uncovered that FD-evoked ROS overproduction could only be strongly suppressed by either mitochondrial complex II inhibitors (TTFA and carboxin) or NADPH oxidase (NOX) inhibitors (AEBSF and apocynin), but not by mitochondrial complex I inhibitor (rotenone) and mitochondrial complex III inhibitor (antimycin A). Interestingly, this selective inhibition of FD-evoked ROS by mitochondrial complex II and NOX inhibitors was found to correlate excellently with the suppression of cytosolic Ca2+ release and reduced the magnitude of the apoptotic TUNEL-positive cells. Taken together, we present the first evidence here that FD-triggered ROS overproduction in synoviocytes is originated from mitochondrial complex II and NOX. Both elevated ROS in tandem with cytosolic Ca2+ overload serve as final arbitrators for apoptotic lethality of synoviocytes cultivated under FD condition. Thus, folate supplementation may be beneficial to patients with OA.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0146440PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4714898PMC
July 2016

The Kinesio Taping Method for Myofascial Pain Control.

Evid Based Complement Alternat Med 2015 21;2015:950519. Epub 2015 Jun 21.

Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung 40447, Taiwan ; School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung 40402, Taiwan ; Research Center for Chinese Medicine & Acupuncture, China Medical University, Taichung 40402, Taiwan.

Many people continue suffering from myofascial pain syndrome (MPS) defined as a regional pain syndrome characterized by muscle pain caused by myofascial trigger points (MTrPs) clinically. Muscle spasm and block of blood circulation can be noticed in the taut bands. In the MTrP region, nociceptors can be sensitized by the peripheral inflammatory factors and contracture of fascia can also be induced. Traditional treatments of MPS include stretching therapy, thermal treatment, electrical stimulation, massage, manipulation, trigger points injection, acupuncture, and medicine. However, the pain syndrome may not be relieved even under multiple therapies. Recently, the Kinesio Taping (KT) method is popularly used in sports injuries, postoperative complications, and various pain problems, but little research is focused on MPS with KT method. In this paper, we review the research studies on the application to KT in treating MPS and other related issues. It appears that the KT application can elevate the subcutaneous space and then increase the blood circulation and lymph fluid drainage to reduce the chemical factors around the MTrP region. Therefore, it is suggested that KT method can be used as a regular treatment or added to the previous treatment for myofascial pain.
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http://dx.doi.org/10.1155/2015/950519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4491400PMC
July 2015

Needling therapy for myofascial pain: recommended technique with multiple rapid needle insertion.

Biomedicine (Taipei) 2014 2;4:13. Epub 2014 Aug 2.

Department of Physical Therapy, Hung Kuang University, 34, Chung-Chie Road, Sha Lu, Taichung, Taiwan.

Myofascial trigger point (MTrP) is a major cause of muscle pain, characterized with a hyperirritable spot due to accumulation of sensitized nociceptors in skeletal muscle fibers. Many needling therapy techniques for MTrP inactivation exist. Based on prior human and animal studies, multiple insertions can almost completely eliminate the MTrP pain forthwith. It is an attempt to stimulate many sensitive loci (nociceptors) in the MTrP region to induce sharp pain, referred pain or local twitch response. Suggested mechanisms of needling analgesia include effects related to immune, hormonal or nervous system. Compared to slow-acting biochemical effects involving immune or hormonal system, neurological effects can act faster to provide immediate and complete pain relief. Most likely mechanism of multiple needle insertion therapy for MTrP inactivation is to encounter sensitive nociceptors with the high-pressure stimulation of a sharp needle tip to activate a descending pain inhibitory system. This technique is strongly recommended for myofasical pain therapy in order to resume patient's normal life rapidly, thus saving medical and social resources.
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http://dx.doi.org/10.7603/s40681-014-0013-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4264979PMC
August 2014

Remote dose-dependent effects of dry needling at distant myofascial trigger spots of rabbit skeletal muscles on reduction of substance P levels of proximal muscle and spinal cords.

Biomed Res Int 2014 3;2014:982121. Epub 2014 Sep 3.

Department of Physical Therapy, Hungkuang University, Taichung 43302, Taiwan.

Background: Dry needling at distant myofascial trigger points is an effective pain management in patients with myofascial pain. However, the biochemical effects of remote dry needling are not well understood. This study evaluates the remote effects of dry needling with different dosages on the expressions of substance P (SP) in the proximal muscle, spinal dorsal horns of rabbits.

Methods: Male New Zealand rabbits (2.5-3.0 kg) received dry needling at myofascial trigger spots of a gastrocnemius (distant muscle) in one (1D) or five sessions (5D). Bilateral biceps femoris (proximal muscles) and superficial laminaes of L5-S2, T2-T5, and C2-C5 were sampled immediately and 5 days after dry needling to determine the levels of SP using immunohistochemistry and western blot.

Results: Immediately after dry needling for 1D and 5D, the expressions of SP were significantly decreased in ipsilateral biceps femoris and bilateral spinal superficial laminaes (P < .05). Five days after dry needling, these reduced immunoactivities of SP were found only in animals receiving 5D dry needling (P < .05).

Conclusions: This remote effect of dry needling involves the reduction of SP levels in proximal muscle and spinal superficial laminaes, which may be closely associated with the control of myofascial pain.
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http://dx.doi.org/10.1155/2014/982121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4168154PMC
June 2015

Fluence-dependent effects of low-level laser therapy in myofascial trigger spots on modulation of biochemicals associated with pain in a rabbit model.

Lasers Med Sci 2015 Jan 5;30(1):209-16. Epub 2014 Sep 5.

Department of Physical Therapy, Graduate Institute of Rehabilitation Science, China Medical University, Taichung, Taiwan, 40402,

Evidence strongly supports that low-level laser therapy (LLLT) is an effective physical modality for the treatment of pain associated with myofascial trigger points (MTrP). However, the effect of laser fluence (energy intensity in J/cm(2)) on biochemical regulation related to pain is unclear. To better understand the biochemical mechanisms modulated by high- and low-fluence LLLT at myofascial trigger spots (MTrSs; similar to human MTrPs) in skeletal muscles of rabbits, the levels of β-endorphin (β-ep), substance P (SP), tumor necrosis factor-α (TNF-α), and cyclooxygenase-2 (COX-2) were investigated in this study. New Zealand rabbits (2.5-3.0 kg in weight) were used in this study. High-fluence LLLT (27 J/cm(2)), low-fluence LLLT (4.5 J/cm(2)), or sham operations were applied on MTrSs of biceps femoris of rabbits for five sessions (one session per day). Effects of LLLT at two different fluences on biceps femoris, dorsal root ganglion (DRG), and serum were determined by β-ep, SP, TNF-α, and COX-2 immunoassays. LLLT irradiation with fluences of 4.5 and 27 J/cm(2) at MTrSs can significantly reduce SP level in DRG. LLLT with lower fluence of 4.5 J/cm(2) exerted lower levels of TNF-α and COX-2 expression in laser-treated muscle, but LLLT with higher fluence of 27 J/cm(2) elevated the levels of β-ep in serum, DRG, and muscle. This study demonstrated fluence-dependent biochemical effects of LLLT in an animal model on management of myofascial pain. The findings can contribute to the development of dosage guideline for LLLT for treating MTrP-induced pain.
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http://dx.doi.org/10.1007/s10103-014-1654-9DOI Listing
January 2015

Lumbar facet injection for the treatment of chronic piriformis myofascial pain syndrome: 52 case studies.

Patient Prefer Adherence 2014 20;8:1105-11. Epub 2014 Aug 20.

Department of Sports Medicine, China Medical University, Taichung, Taiwan.

Background And Aims: The aim of this study was to demonstrate the effectiveness of lumbar facet joint injection for piriformis myofascial pain syndrome.

Methods: Fifty-two patients with chronic myofascial pain in the piriformis muscle each received a lumbar facet injection into the ipsilateral L5-S1 facet joint region, using the multiple insertion technique. Subjective pain intensity, trunk extension range, and lumbar facet signs were measured before, immediately after, and 2 weeks after injection. Thirty-six patients received follow-up for 6 months.

Results: Immediately after the injection, 27 patients (51.9%) had complete pain subsidence, 19 patients (36.5%) had pain reduction to a tolerable level, and only 6 patients (11.5%) had no pain relief to a tolerable level. Mean pain intensity was reduced from 7.4±0.9 to 1.6±2.1 after injection (P<0.01). This effectiveness lasted for 2 weeks in 49 patients (94.2%), and lasted for approximately 6 months in 35 (97.2%) of 36 patients. The mean range of motion increased from 13.4±6.8 degrees to 22.1±6.0 degrees immediately after injection, and further increased 2 weeks and 6 months later. Immediately after injection, 45 patients (86.5%) had no facet sign. In addition, 90.4% and 94.4% of patients had no facet sign after 2 weeks and after 6 months, respectively.

Conclusions: It is important to identify the possible cause of piriformis myofascial pain syndrome. If this pain is related to lumbar facet lesions, lumbar facet joint injection can immediately suppress piriformis myofascial pain symptoms. This effectiveness may last for at least 6 months in most patients. This study further supports the importance of eliminating the underlying etiological lesion for complete and effective relief of myofascial pain syndrome.
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http://dx.doi.org/10.2147/PPA.S64736DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4144931PMC
August 2014

Brain meningioma with initial manifestation similar to cervical radiculopathy: a case report.

Neuropsychiatr Dis Treat 2014 25;10:1175-81. Epub 2014 Jun 25.

Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung, Taiwan ;

Meningiomas are the most common benign brain tumors, and are characterized by slow growth and a long asymptomatic period. Once the tumor becomes symptomatic, the various presentations may be related to the location and compression of adjacent structures. Meningioma is primarily treated through surgical intervention, and thus earlier diagnosis is likely to result in better prognosis. The symptoms of the meningioma may mimic other diseases, making precise diagnosis difficult, which will then delay treatment. We report a case of brain meningioma that showed initial signs and symptoms similar to cervical radiculopathy. The symptoms extended gradually, and the ultimate diagnosis of meningioma was confirmed based on brain-image studies. After brain-tumor excision, postoperation radiotherapy, and aggressive rehabilitation, the patient was able to perform better in daily activities.
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http://dx.doi.org/10.2147/NDT.S64192DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4077786PMC
July 2014

Lysophosphatidic acid enhanced the angiogenic capability of human chondrocytes by regulating Gi/NF-kB-dependent angiogenic factor expression.

PLoS One 2014 30;9(5):e95180. Epub 2014 May 30.

Department of Physical Medicine and Rehabilitation, Chia-Yi Chang Gung Memorial Hospital, Chia-Yi, Taiwan; Department of Nursing, Chang-Gung University of Science and Technology, Chia-Yi, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.

Lysophosphatidic acid (LPA) has been found to mediate myeloid differentiation, stimulate osteogenesis, alter cell proliferation and migration, and inhibit apoptosis in chondrocytes. The effect of LPA on the angiogenic capability of chondrocytes is not clear. This study aimed to investigate its effect on the angiogenic capability of human chondrocytes and the underlying mechanism of these effects. Human chondrocyte cell line, CHON-001, commercialized human chondrocytes (HC) derived from normal human articular cartilage, and human vascular endothelial cells (HUVECs) were used as cell models in this study. The angiogenic capability of chondrocytes was determined by capillary tube formation, monolayer permeability, cell migration, and cell proliferation. An angiogenesis protein array kit was used to evaluate the secretion of angiogenic factors in conditioned medium. Angiogenin, insulin-like growth factor-binding protein 1 (IGFBP-1), interleukin (IL)-8, monocyte chemoattractant protein-1 (MCP-1), matrix metalloproteinase (MMP)-9, and vascular endothelial growth factor (VEGF) mRNA and protein expressions were evaluated by Q-RT-PCR and EIA, respectively. LPA receptor (LPAR) expression was determined by RT-PCR. Signaling pathways were clarified using inhibitors, Western blot analysis, and reporter assays. The LPA treatment promoted the angiogenic capability of CHON-001 cells and HC, resulting in enhanced HUVEC capillary tube formation, monolayer permeability, migration, and cell growth. Angiogenin, IGFBP-1, IL-8, MCP-1, MMP-9, and VEGF mRNA and protein expressions were significantly enhanced in LPA-treated chondrocytes. LPA2, 3, 4 and 6 were expressed in CHON-001 and HC cells. Pretreatment with the Gi/o type G protein inhibitor, pertussis toxin (PTX), and the NF-kB inhibitor, PDTC, significantly inhibited LPA-induced angiogenin, IGFBP-1, IL-8, MCP-1, MMP-9, and VEGF expressions in chondrocytes. The PTX pretreatment also inhibited LPA-mediated NF-kB activation, suggesting the presence of active Gi/NF-kB signaling in CHON-001 and HC cells. The effect of LPA on the angiogenesis-inducing capacity of chondrocytes may be due to the increased angiogenesis factor expression via the Gi/NF-kB signaling pathway.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0095180PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4039431PMC
January 2015

Muscle pain intensity and pressure pain threshold changes in different periods of stroke patients.

Am J Phys Med Rehabil 2014 Apr;93(4):299-309

From the Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Yunlin, Taiwan (C-HL); Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chiayi, Taiwan (K-HC, C-MC, H-CH); School of Medicine, Chang Gung University, Taoyuan, Taiwan (K-HC, C-MC); Department of Nursing, Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan (C-HC, H-CH); Department of Neurology, Chang Gung Memorial Hospital, Chiayi, Taiwan (YCH); Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan (H-CH); and Department of Physical Therapy, Hung Kuang University, Taichung County, Taiwan (C-ZH).

Objective: This study aimed to investigate the role of muscle pain in post-stroke pain syndromes.

Design: This cross-sectional-designed study enrolled 145 stroke patients at three different stroke duration periods (≤3 mos, 3 mos to 1 yr, and >1 yr) receiving inpatient or outpatient rehabilitation programs in a regional teaching hospital. Three common muscle tender points (two at the upper trapezius and one at the brachioradialis) and two relative periosteum points of the healthy and hemiparetic sides were identified for evaluation. Spontaneous pain intensity measured with the verbally reported numerical rating scale and pressure pain threshold were assessed. Associations between variables were analyzed.

Results: Among 145 subjects, 56 were women, and the mean ± SD age was 62.1 ± 13.2 yrs. The patients with stroke duration within 3 mos had the highest spontaneous muscle pain intensity and were most sensitive to pressure pain, with a prevalence of 48.3% of moderate to severe pain intensity (verbally reported numerical rating scale, 4-10) in the hemiparetic side. Spontaneous pain was more severe in the hemiparetic side than in the healthy side, but there were no obvious differences between the sides in the pressure pain threshold of the muscle or the periosteum.

Conclusions: In stroke patients, spontaneous muscle pain in the hemiparetic side is a common finding. Bilaterally symmetric changes of pressure pain threshold are probably caused by central sensitization mechanisms.
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http://dx.doi.org/10.1097/PHM.0000000000000003DOI Listing
April 2014

Kinematics and muscle activity of the head, lumbar and knee joints during 180° turning and sitting down task in older adults.

Clin Biomech (Bristol, Avon) 2014 Jan 31;29(1):14-20. Epub 2013 Oct 31.

Department of Biomedical Engineering, Hungkuang University, Taichung, Taiwan.

Background: The "180° turning and sitting down task" is a very conscious movement that requires focusing on turning at the exact moment, and very few studies address on this topic in older adults. The purpose of the study was to compare kinematics and electromyography of the head, lumbar and knee joints during 180°turning in older and young adults.

Methods: Twenty older adults and 20 younger adults were assessed. A 16-channel telemetry electromyography system with electrogoniometers and an inclinometer were used to record the head, lumbar and knee joint kinematic and electromyography data during the 180° turning. This movement had been further divided into 4 phases (braking, mid-stance, swing, and terminal loading) for analysis.

Findings: There were significant differences in the joint displacement and muscular activity among the different phases. Comparison between groups showed that the older adults group had less lateral lumbar flexion, less knee flexion and lower velocity of the head and knee flexion compared to young adults during turning. The electromyography data of the left biceps femoris, left gastrocnemius and left erector spinae muscles in the older adults group showed significantly higher levels than in the young adults.

Interpretation: Older adults need to adjust velocities of moving joints and increase the extensor synergy muscles of the back and the stance leg to provide posture stability. Kinematics and neuromuscular modulations of the head, lumbar and knee are required according to the various phases of the turn movements and change with aging.
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http://dx.doi.org/10.1016/j.clinbiomech.2013.10.020DOI Listing
January 2014

Needling therapy for myofascial pain control.

Authors:
Chang-Zern Hong

Evid Based Complement Alternat Med 2013 26;2013:946597. Epub 2013 Aug 26.

Department of Physical Therapy, Hungkuang University, Sha-Lu, Tai-Chung 433, Taiwan ; Department of Physical Medicine and Rehabilitation, University of California Irvine, Irvine, CA 92818, USA.

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http://dx.doi.org/10.1155/2013/946597DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3770065PMC
September 2013

Kinematic variability of the head, lumbar spine and knee during the "walk and turn to sit down" task in older and young adults.

Gait Posture 2014 Jan 6;39(1):272-7. Epub 2013 Aug 6.

Department of Internal Medicine, Cheng Ching Hospital, Taichung, Taiwan.

Unlabelled: This study investigates the kinematic variability of the head, lumbar spine and knee during the various walk and turn to sit phases in older and young adults. Sixteen older adults and eighteen young adults were recruited for this study. Each subject performed the "Walk and turn to sit down" test. A 16-channel telemetry system with electrogoniometers and an inclinometer was used to record the kinematic data. The turning step was divided into braking, mid-stance, swing and terminal load phases for kinematic analysis. The results showed that the older adults had a lower displacement angle and velocity of the lumbar spine, head and knee during different turning phases than the young adults. However, older adults performed turning with a higher variability in angular velocity of head flexion than the young adults during the turning step. The onset of lumbar movement and lateral flexion of the head occurred significantly earlier in older adults than in the young adults during turning.

Conclusion: Older adults more cautiously control their motion by changing their trunk movement amplitude, velocity and timing in relation to their lower extremity movements during turning. The larger variability in angular velocity of head flexion may imply that older adults cannot precisely estimate the required movement for smooth turning.
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http://dx.doi.org/10.1016/j.gaitpost.2013.07.129DOI Listing
January 2014

Effectively managing intractable central hyperthermia in a stroke patient by bromocriptine: a case report.

Neuropsychiatr Dis Treat 2013 3;9:605-8. Epub 2013 May 3.

Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung, Taiwan;

Central hyperthermia is characterized by a rapid onset, high temperature, marked temperature fluctuation, and poor response to antipyretics and antibiotics. Although poststroke central hyperthermia is common, prolonged instances are rare. We report a case of prolonged central fever after an intracranial hemorrhage. Before the accurate diagnosis and management of central fever, the patient underwent long-term antibiotic use that led to pseudomembranous colitis. Bromocriptine was used to treat the prolonged central hyperthermia, after which the fever did not exceed 39°C. A week later, the body temperature baseline was reduced to 37°C and a low-grade fever with minor temperature fluctuation occurred only a few times. No fever occurred in the month following the treatment. After the fever subsided, the patient could undergo an aggressive rehabilitation program.
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http://dx.doi.org/10.2147/NDT.S44547DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647378PMC
May 2013

Propyl gallate inhibits TPA-induced inflammation via the nuclear factor-κB pathway in human THP-1 monocytes.

Exp Ther Med 2013 Mar 16;5(3):964-968. Epub 2013 Jan 16.

Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chiayi;

Propyl gallate (PG) is an antioxidant that has been used as an additive in several foods to protect against oxidation. The present study examined the anti-inflammatory effect of PG on 12-O-tetradecanoylphorbol-13-acetate (TPA)-induced inflammation in human THP-1 monocytes. Pretreatment with PG markedly inhibited the TPA-induced expression levels of cyclooxygenase-2 and prostaglandin E2. The application of PG significantly inhibited the nuclear translocation of p65, a subunit of nuclear factor-κB (NF-κB) and phosphorylation of p65 (Ser536) in TPA-treated THP-1 cells. PG also inhibited the phosphorylation of IκB and IκB kinase. These results indicate that PG inhibits the inflammatory response by blocking the NF-κB signaling pathway in TPA-induced THP-1 monocytes. Therefore, PG may be useful as a therapeutic agent in inflammatory diseases.
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http://dx.doi.org/10.3892/etm.2013.896DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3570264PMC
March 2013

Remote subcutaneous needling to suppress the irritability of myofascial trigger spots: an experimental study in rabbits.

Evid Based Complement Alternat Med 2012 25;2012:353916. Epub 2012 Dec 25.

FSN Institute, Nanjing University of Chinese Medicine, Nanjing 210029, China.

Objective. To obtain electrophysiological effects of Fu's subcutaneous needling (FSN) on needling distance by assessment of endplate noise (EPN) recorded from the myofascial trigger spots (MTrSs) in rabbit skeletal muscle. Method. Eighteen New Zealand rabbits weighing 2.5-3.0 kg were randomly divided into two groups as follows: proximal needling (PN) group and distal needling (DN) group. The needling procedure followed the instructions described by the inventor of FSN, including needling insertion and swaying movement. The amplitudes of EPN on the MTrS region of BF muscle were recorded as an index of MTrS irritability. Random sampling of EPN tracings were taken for further analyses before, during, and after FSN treatment. Results. In PN and DN groups, the trends of EPN amplitude alterations were similar at conditions before, during, and after FSN treatment. The degree of reduction in the EPN amplitude in PN group was significantly higher than that in DN group. There were no significant changes in EPN amplitudes in the MTrS of contralateral BF without FSN intervention either in DN or PN group. Conclusion. The irritability of proximal MTrSs could be modulated after ipsilateral FSNs. The placement of FSN may affect the effectiveness of suppression of irritability of MTrSs.
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http://dx.doi.org/10.1155/2012/353916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544156PMC
January 2013

The comparison of multiple F-wave variable studies and magnetic resonance imaging examinations in the assessment of cervical radiculopathy.

Am J Phys Med Rehabil 2013 Sep;92(9):737-45

Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Yunlin, Taiwan.

Objective: The aims of this study were to investigate the correlation of the findings of multiple median and ulnar F-wave variables and magnetic resonance imaging examinations in the prediction of cervical radiculopathy.

Design: The data of 68 patients who underwent both nerve conduction studies of the upper extremities and cervical spine magnetic resonance imaging within 3 mos of the nerve conduction studies were retrospectively reviewed and reinterpreted. The associations between multiple median and ulnar F-wave variables (including persistence, chronodispersion, and minimal, maximal, and mean latencies) and magnetic resonance imaging evidence of lower cervical spondylotic radiculopathy (i.e., C7, C8, and T1 radiculopathy) were investigated.

Results: Patients with lower cervical radiculopathy exhibited reduced right median F-wave persistence (P = 0.011), increased right ulnar F-wave chronodispersion (P = 0.041), and a trend toward increased left ulnar F-wave chronodispersion (P = 0.059); however, there were no other consistent significant differences in the F-wave variables between patients with and patients without magnetic resonance imaging evidence of lower cervical radiculopathy. In comparison with normal reference values established previously, the sensitivity and positive predictive value of F-wave variable abnormalities for predicting lower cervical radiculopathy were low.

Conclusions: There was a low correlation between F-wave studies and magnetic resonance imaging examinations. The diagnostic utility of multiple F-wave variables in the prediction of cervical radiculopathy was not supported by this study.
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http://dx.doi.org/10.1097/PHM.0b013e31827d6546DOI Listing
September 2013

Chronic shoulder pain referred from thymic carcinoma: a case report and review of literature.

Neuropsychiatr Dis Treat 2012 4;8:399-403. Epub 2012 Sep 4.

Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung.

We report a case of thymic carcinoma presenting as unilateral shoulder pain for 13 months. Before an accurate diagnosis was made, the patient received conservative treatment, cervical discectomies, and myofascial trigger point injection, none of which relieved his pain. When thymic carcinoma was eventually diagnosed, he received total resection of the tumor and the shoulder pain subsided completely. Thymic carcinoma is a rare carcinoma, and our review of the literature did not show shoulder pain as its initial presentation except for one case report. The purpose of this report is to document our clinical experience so that other physiatrists can include thymic carcinoma in their differential diagnosis of shoulder pain.
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http://dx.doi.org/10.2147/NDT.S36476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435118PMC
September 2012

Low-level laser therapy alleviates neuropathic pain and promotes function recovery in rats with chronic constriction injury: possible involvements in hypoxia-inducible factor 1α (HIF-1α).

J Comp Neurol 2012 Sep;520(13):2903-16

Department of Physical Therapy, Graduate Institute of Rehabilitation Science, China Medical University, Taichung, Taiwan 40402.

Nerve inflammation plays an important role in the development and progression of neuropathic pain after chronic constrictive injury (CCI). Recent studies have indicated that hypoxia-inducible factor 1α (HIF-1α) is crucial in inflammation. Low-level laser therapy has been used in treating musculoskeletal pain, but rare data directly support its use for neuropathic pain. We investigated the effects of low-level laser on the accumulation of HIF-1α, tumor necrosis factor-α (TNF-α), and interleukin-1β (IL-1β) in controlling neuropathic pain, as well as on the activation of vascular endothelial growth factor (VEGF) and nerve growth factor (NGF) in promoting functional recovery in a rat CCI model. CCI was induced by placing four loose ligatures around the sciatic nerve of rats. Treatments of low-level laser (660 nm, 9 J/cm(2)) or sham irradiation (0 J/cm(2)) were performed at the CCI sites for 7 consecutive days. The effects of laser in animals with CCI were determined by measuring the mechanical paw withdrawal threshold, as well as the sciatic, tibial, and peroneal function indices. Histopathological and immunoassay analyses were also performed. Low-level laser therapy significantly improved paw withdrawal threshold and the sciatic, tibial, and peroneal functional indices after CCI. The therapy also significantly reduced the overexpressions of HIF-1α, TNF-α, and IL-1β, and increased the amounts of VEGF, NGF, and S100 proteins. In conclusion, a low-level laser could modulate HIF-1α activity. Moreover, it may also be used as a novel and clinically applicable therapeutic approach for the improvement of tissue hypoxia/ischemia and inflammation in nerve entrapment neuropathy, as well as for the promotion of nerve regeneration. These findings might lead to a sufficient morphological and functional recovery of the peripheral nerve.
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http://dx.doi.org/10.1002/cne.23072DOI Listing
September 2012

Infections in acute older stroke inpatients undergoing rehabilitation.

Am J Phys Med Rehabil 2012 Mar;91(3):211-9

Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chiayi, Taiwan.

Objective: The present study compares the incidence of various infections among patients in acute and rehabilitation wards and examines the risk factors and pathogens involved in rehabilitation ward infections.

Design: The study included 341 acute stroke patients (age, ≥65 yrs). The assessment of risk factors was done by comparison of patients with or without infection, urinary tract infection, and pneumonia. Possible precipitating factors in each comparison were included in the statistical analysis.

Results: Ninety-five (27.9%) patients experienced infections, and the most common type in the rehabilitation ward was urinary tract infection. The frequency of incidence of pneumonia in the rehabilitation ward (6.7%) was significantly lower than in the acute ward (23.8%) (P < 0.001). Patients with infection had a longer rehabilitation ward stay compared with those without infection (30.9 vs. 18.8 days, P = 0.002). A postvoid residual urine volume greater than 50 ml (odds ratio, 2.314; 95% CI, 1.204-4.448, P = 0.012) was found to be the most important risk factor for infection.

Conclusions: Infection may prolong the length of stay in acute stroke patients in a rehabilitation ward. The present study provides important information for clinicians to help identify risk factors for infection.
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http://dx.doi.org/10.1097/PHM.0b013e31824661a9DOI Listing
March 2012

Mechanical pain sensitivity of deep tissues in children--possible development of myofascial trigger points in children.

BMC Musculoskelet Disord 2012 Feb 8;13:13. Epub 2012 Feb 8.

Department of Physical Medicine and Rehabilitation, Taipei City Hospital, Taipei, Taiwan.

Background: It is still unclear when latent myofascial trigger points (MTrPs) develop during early life. This study is designed to investigate the mechanical pain sensitivity of deep tissues in children in order to see the possible timing of the development of latent MTrPs and attachment trigger points (A-TrPs) in school children.

Methods: Five hundreds and five healthy school children (age 4- 11 years) were investigated. A pressure algometer was used to measure the pressure pain threshold (PPT) at three different sites in the brachioradialis muscle: the lateral epicondyle at elbow (site A, assumed to be the A-TrP site), the mid-point of the muscle belly (site B, assumed to be the MTrP site), and the muscle-tendon junction as a control site (site C).

Results: The results showed that, for all children in this study, the mean PPT values was significantly lower (p < 0.05) at the assumed A-TrP site (site A) than at the other two sites, and was significantly lower (p < 0.05) at the assumed MTrP site (site B) than at the control site (site C). These findings are consistent if the data is analyzed for different genders, different dominant sides, and different activity levels.

Conclusions: It is concluded that a child had increased sensitivity at the tendon attachment site and the muscle belly (endplate zone) after age of 4 years. Therefore, it is likely that a child may develop an A-Trp and a latent MTrP at the brachioradialis muscle after the age of 4 years. The changes in sensitivity, or the development for these trigger points, may not be related to the activity level of children aged 7-11 years. Further investigation is still required to identify the exact timing of the initial occurrence of a-Trps and latent MTrPs.
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http://dx.doi.org/10.1186/1471-2474-13-13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298468PMC
February 2012

Motorcycle for persons with disabilities.

Authors:
Chang-Zern Hong

Am J Phys Med Rehabil 2012 May;91(5):461

Department of Physical Therapy, Hung-Kuang University, Sha Lu, Taichung, Taiwan.

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http://dx.doi.org/10.1097/PHM.0b013e31824662e2DOI Listing
May 2012

Remote therapeutic effectiveness of acupuncture in treating myofascial trigger point of the upper trapezius muscle.

Am J Phys Med Rehabil 2011 Dec;90(12):1036-49

Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung, Taiwan.

Objective: This study aimed to investigate the remote effect of acupuncture (AcP) on the pain intensity and the irritability of the myofascial trigger point in the upper trapezius muscle.

Design: Forty-five patients were equally divided into three groups: patients in the placebo control group received sham AcP, those in the simple needling group were treated using simple needling, and those in the modified AcP received AcP with the rapid "screwed in and out" into multiple sites to elicit local twitch responses. The acupoints of Wai-guan and Qu-chi were treated. The outcome assessments included changes in subjective pain intensity, pressure pain threshold, range of motion, and mean amplitude of endplate noise in the myofascial trigger point region.

Results: Immediately after acupuncture, all measured parameters improved significantly in the simple needling and modified AcP groups, but not in the placebo control group. There were significantly larger changes in all parameters in the modified AcP group than that in the simple needling group.

Conclusions: The myofascial trigger point irritability could be suppressed after a remote acupuncture treatment. It appears that needling to the remote AcP points with multiple needle insertions of modified AcP technique is a better technique than simple needling insertion of simple needling technique in terms of the decrease in pain intensity and prevalence of endplate noise and the increase in pressure pain threshold in the needling sites (represented either AcP points and or myofascial trigger points). We have further confirmed that the reduction in endplate noise showed good correlation with a decreased in pain.
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http://dx.doi.org/10.1097/PHM.0b013e3182328875DOI Listing
December 2011

Spinal cord mechanism involving the remote effects of dry needling on the irritability of myofascial trigger spots in rabbit skeletal muscle.

Arch Phys Med Rehabil 2011 Jul 6;92(7):1098-105. Epub 2011 May 6.

Department of Physical Therapy and Graduate Institute of Rehabilitation Science, Taichung, Taiwan.

Objective: To elucidate the neural mechanisms underlying the remote effects produced by dry needling rabbit skeletal muscle myofascial trigger spots (MTrSs) via analyses of their endplate noise (EPN) recordings.

Design: Experimental animal controlled trial.

Setting: An animal laboratory of a university.

Animals: Male New Zealand rabbits (N=96) (body weight, 2.5-3.0kg; age, 16-20wk).

Intervention: Animals received no intervention for neural interruption in group I, transection of the tibial nerve in group II, transection of L5 and L6 spinal cord in group III, and transection of the T1 and T2 spinal cord in group IV. Each group was further divided into 4 subgroups: animals received ipsilateral dry needling, contralateral dry needling, ipsilateral sham needling, or contralateral sham needling of gastrocnemius MTrSs.

Main Outcome Measures: EPN amplitudes of biceps femoris (BF) MTrSs.

Results: BF MTrS mean EPN amplitudes significantly increased (P<.05) initially after gastrocnemius verum needling but reduced to a level significantly lower (P<.05) than the preneedling level in groups I and IV with ipsilateral dry needling or contralateral dry needling, and in group II with contralateral dry needling (but not ipsilateral dry needling). No significant EPN amplitude changes were observed in BF MTrS in group III or in the control animals receiving superficial needling (sham).

Conclusion: This remote effect of dry needling depends on an intact afferent pathway from the stimulating site to the spinal cord and a normal spinal cord function at the levels corresponding to the innervation of the proximally affected muscle.
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http://dx.doi.org/10.1016/j.apmr.2010.11.018DOI Listing
July 2011

Postural control strategies related to anticipatory perturbation and quick perturbation in adolescent idiopathic scoliosis.

Spine (Phila Pa 1976) 2011 May;36(10):810-6

Department of Physical Therapy, Medicine, and Nursing College, Hungkuang University, Taichung, Taiwan.

Study Design: Cross-sectional study.

Objective: To investigate the automatic balance correction related to anticipatory perturbation (AP) and quick backward perturbation in adolescent idiopathic scoliosis (AIS).

Summary Of Background Data: Most previous studies on AIS patients focused on posture sway and lacked analysis of muscle activated patterns in dynamic standing control.

Methods: Thirty-two AIS patients and 23 age-matched normal subjects received perturbation balance tests on an unstable platform. The tilting angle of the platform and the muscle activity of the bilateral lumbar multifidi, gluteus medii, and gastrocnemii muscles were recorded. Electromyographic (EMG) amplitude, onset latencies, and duration were calculated with software accompanied with machine.

Results: The AIS group had less posture tilting but higher muscle activities than normal subjects under both perturbation conditions (P < 0.05). Under the AP test, AIS showed earlier onset and prolonged activation of left multifidus and right gastrocnemius compared with normal subjects (P < 0.05). The latency of the multifidus on the lumbar convex side occurred earlier than on the concave side. However, the asymmetric onset timing of the gastrocnemius was the opposite of the multifidi in the AIS group (P < 0.05). In contrast to the AP condition, bilateral leg and trunk muscles activated at similar latencies and durations in the AIS group (P < 0.05). Under the quick backward perturbation test, the control group had longer active duration of right multifidus and bilateral gastrocnemii than AIS to cope with larger platform tilting. In addition, asymmetric onset of gluteus medii and duration of multifidi was observed in the control group (P < 0.05).

Conclusion: There were significant differences in posture control patterns between AIS and normal subjects. AIS subjects have asymmetric habitual muscle activities for AP, whereas when coping with sudden balance threats, they react with synchronized recruitment of bilateral postural muscles.
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http://dx.doi.org/10.1097/BRS.0b013e3181d0f80cDOI Listing
May 2011

Serial ultrasonographic findings of plantar fasciitis after treatment with botulinum toxin a: a case study.

Arch Phys Med Rehabil 2011 Feb;92(2):316-9

Department of Physical Medicine and Rehabilitation, China Medical University Hospital, Taichung, Taiwan.

Plantar fasciitis is a common cause of heel pain and is the result of a degenerative process of the plantar fascia at its calcaneal attachment. A case study of a preliminary experience with local injections of botulinum toxin A (BTX-A) for the treatment of chronic plantar fasciitis in a 43-year-old woman is presented. We injected the patient with 70 units of BTX-A (0.7mL) in 2 divided doses: 40 units (0.4mL) in the tender region of the heel, and 30 units (0.3mL) in the most tender point of the foot arch. Visual analog scale (VAS) and pressure pain threshold (PPT) were measured to evaluate the efficacy of BTX-A injections. Real-time, high-resolution ultrasonographic findings of the plantar fascia after BTX-A injections were also used for serial follow-ups. After BTX-A injection, decreased VAS values were reported and increased PPT was observed. In ultrasonographic studies, the thickness of the plantar fascia and the hypoechogenicity of the fascia were reduced. Decreased plantar fascia thickness was observed on the first and third week after BTX-A injections. The findings were compatible with the changes in pain assessed by VAS and PPT. Ultrasonographic findings also indicated a progressive decrease in the thickness of the underlying muscle belly. Ultrasonography seems to be a valuable, noninvasive diagnostic tool for the evaluation of plantar fasciitis treated with BTX-A injections. It can offer objective measurements of therapeutic effects and is feasible for serial follow-ups.
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http://dx.doi.org/10.1016/j.apmr.2010.10.013DOI Listing
February 2011

Squat-to-reach task in older and young adults: kinematic and electromyographic analyses.

Gait Posture 2011 Jan 20;33(1):124-9. Epub 2010 Nov 20.

Department of Physical Therapy, Medicine & Nursing College, Hungkuang University, 34 Chung-Chie Road Shalu, Tai-Chung County, Taiwan.

The purpose of this study was to compare the two-dimensional kinematic and electromyographic (EMG) changes during the squat-to-reach task in older and young adults. Twenty-six older adults and thirty-three young adults were studied. A 16-channel telemetry system was used for recording muscular activity and kinematic data during two trials of a squat-to-reach task. Surface EMG data were recorded on select muscles of the trunk and the lower extremity on the dominant side. An electrogoniometer was fixed over the knee joint, and an inclinometer was fastened on the head and thigh to record kinematic data. The task was split into six movement phases based on the angular displacement and velocities of the knee joint. The mean values of the maximal displacements in the sagittal plane of the head, knee, and thigh were significantly (p<0.05) lower, but those in the frontal plane of the head and thigh were significantly (p<0.05) higher in older adults than in young adults. Thigh muscle activities were significantly (p<0.05) higher in older adults than in young adults throughout the movements. The trunk and leg muscles contracted earlier, but the hip adductors contracted later in older adults compared to young adults (p<0.05). The older adults squatted in a shallow and heel-off posture during forward reaching tasks. Therefore, older adults had increased lateral flexion of the head to compensate for insufficient knee flexion during the squat-to-reach movement and required increased activity of the posture muscles to maintain lateral stability.
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http://dx.doi.org/10.1016/j.gaitpost.2010.10.088DOI Listing
January 2011

Impact of visual and somatosensory deprivation on dynamic balance in adolescent idiopathic scoliosis.

Spine (Phila Pa 1976) 2010 Nov;35(23):2084-90

Department of Physical Therapy, Medicine and Nursing College, Hungkuang University, Shalu, Taichung, Taiwan.

Study Design: A cross-sectional study of balance control in adolescents with idiopathic scoliosis (AIS).

Objective: To investigate the impact of visual and somatosensory deprivation on the dynamic balance in AIS patients and to discuss electromyographic (EMG) and posture sway findings.

Summary Of Background Data: Most studies focus on posture sway in quiet standing controls with little effort on examining muscle-activated patterns in dynamic standing controls.

Methods: Twenty-two AIS patients and 22 age-matched normal subjects were studied. To understand how visual and somatosensory information could modulate standing balance, balance tests with the Biodex stability system were performed on a moving platform under 3 conditions: visual feedback provided (VF), eyes closed (EC), and standing on a sponge pad with visual feedback provided (SV). Muscular activities of bilateral lumbar multifidi, gluteus medii, and gastrocnemii muscles were recorded with a telemetry EMG system.

Results: AIS patients had normal balance index and amplitude and duration of EMG similar to those of normal subjects in the balance test. However, the onset latency of right gastrocnemius was earlier in AIS patients than in normal subjects. In addition, body-side asymmetry was noted on muscle strength and onset latency in AIS subjects. Under EC condition, lumbar multifidi, and gluteus medii activities were higher than those under SV and VF conditions (P < 0.05). Under SV condition, the medial-lateral tilting angle was less than that under VF and EC conditions. In addition, the active duration of right gluteus medius was shorter under SV condition (P < 0.05).

Conclusion: The dynamic balance control is particularly disruptive under visual deprivation with increasing lumbar multifidi and gluteus medii activities for compensation. Sponge pad can cause decrease in frontal plane tilting and gluteus medii effort. The asymmetric muscle strength and onset timing are attributed to anatomic deformation as opposed to neurologic etiological factors.
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http://dx.doi.org/10.1097/BRS.0b013e3181cc8108DOI Listing
November 2010