[Purpose] Guidelines and clarity regarding the information for deciding the need for walking sticks and the suitability of these sticks is insufficient. This study aimed to evaluate the suitability of walking stick and its effects on the balance in the elderly. [Subjects and Methods] A total of 39 elderly subjects aged between 65–95 years (mean age, 76.15 ± 8.35 years) and living in the Residential Aged Care and Rehabilitation Center were included. Sociodemographic data of the individuals, the material of the walking stick, who made the decision of usage and length of walking sticks were questioned. The Berg Balance Scale (BBS) scores were used to evaluate balance. [Results] Subjects’ BBS scores while using the walking stick were higher than that without the walking stick. A significant difference was observed in BBS scores obtained with the stick and without the stick, according to body mass index parameters. Majority of the subjects also started to use walking sticks by themselves. No significant difference was observed between the ideal length and actual length of the walking stick was used. [Conclusion] Our study demonstrated that the elderly generally decide to use walking stick by themselves and chose the appropriate materials; which improves their balance.
[Purpose] The purpose of this study was to provide useful information for future treatments and to organize rehabilitation programs for anterior cruciate ligament injury by assessing isokinetic muscle strength and laxity of knee joints in athletes with anterior cruciate ligament injuries. [Subjects and Methods] Thirty-one high school athletes with anterior cruciate ligament injuries participated in this study. Isokinetic muscle strength at 60°/sec and anterior cruciate ligament laxity for non-involved and involved sides, classified on the basis of the severity of anterior cruciate ligament injury, were assessed. [Results] A comparison of isokinetic muscle strength measured from the non-involved and involved sides showed a significant difference in the maximum strength and knee flexor muscle strength. For laxity, a significant difference was observed in the anterior drawer test results obtained with a force of 88 N. [Conclusion] In conclusion, this study has shown that the assessment of isokinetic muscle strength and ligament laxity from athletes with anterior cruciate ligament injury should be utilized to provide baseline data for prevention and prediction of injury.
[Purpose] The purpose of this study was to determine the effects of deep-breathing and proprioceptive neuromuscular facilitation stretching exercises on upper limb lymphedema in stroke patients. [Subjects and Methods] The study consisted of 10 patients with lymphedema that had occurred after stroke. Neurodevelopmental treatment was applied in the same manner as that used for the existing treatment. The subjects performed deep-breathing and stretching exercises three times per week for 4 weeks (12 sessions total). Body water volume in the upper limbs was measured before and after exercise by using an InBody S10 analyzer. [Results] Performance of deep-breathing and stretching exercises significantly reduced body water volume in both the affected and unaffected arms. The extracellular-to-total cellular fluid volume ratio in the affected arm improved to 0.379 after exercise, although this change was not significant. [Conclusion] The results of the present study show that deep-breathing and proprioceptive neuromuscular facilitation stretching exercises reduce upper extremity lymphedema in stroke patients.
[Purpose] The aim of this study was to evaluate the differences in the ambulation patterns and knee joint performance between people with and without patellofemoral pain. The present study also aimed to utilize these results as a basis for the development of pain-alleviating and performance-improving treatment programs. [Subjects and Methods] Subjects consisted of 32 adult females diagnosed with patellofemoral pain syndrome and 25 adult females without patellofemoral pain (controls). Contact ratio patterns during ambulation and isokinetic muscle strength around the knee joint were measured in both groups and then compared. [Results] Ambulation patterns, specifically the contact ratios of the left forefoot and right forefoot, differed significantly between patients with patellofemoral pain syndrome and controls. An isokinetic muscle strength test demonstrated that left and right knee extensor and flexor torques also significantly differed between these two groups. [Conclusion] Basic analysis based on ambulation patterns and muscle strength can be used to indicate functional recovery from patellofemoral pain syndrome and provide insight into improving the rehabilitation of patients.
[Purpose] The purpose of this study was to determine the effects of assisted aquatic movement and horseback riding therapies on emotion and brain activation in patients with cerebral palsy. [Subjects and Methods] Thirty-two right-handed patients with cerebral palsy (18 male, 14 female) whose ages ranged from 8 to 48 years participated in this experiment. Their cerebral palsy levels ranged from 1 to 3. The participants were assigned to one of three groups according to the experimental conditions: an assisted aquatic movement therapy group, a horseback riding therapy group, or a control group. Electroencephalograms, the Feeling Scale and the Felt Arousal Scale were examined as dependent variables. [Results] Analysis of self-reported data demonstrated a significant positive improvement in the emotions of participants in the assisted aquatic movement therapy group in comparison with the control group. With regard to the electroencephalogram analysis, the results of this study showed increased alpha power in the assisted aquatic movement therapy group compared with the horseback riding and control groups. [Conclusion] The results of this study suggest that professionals can consider assisted aquatic movement therapy as an effective therapeutic intervention for the improvement of mental health and brain activation.
[Purpose] Occlusion training with low-intensity resistance exercises and blood flow restriction increases muscle cross-sectional area and strength. This form of training is used in rehabilitation; therefore, the aim of this study was to examine the effect of one occlusion training session on the cardiovascular response to bouts of exercise. [Subjects and Methods] Two groups took part: a control group without blood flow restriction and an experimental group with blood flow restriction. A single training session was used with the exercise intensity set at 40% of the one repetition maximum. Maximum voluntary contraction, arterial blood pressure, and electrocardiogram measurements were performed. [Results] Heart rate was slightly higher in the control group. The performed training had no effect on diastolic blood pressure in either group, however, a tendency for a small systolic blood pressure increase was observed during the session in the experimental group. JT interval changes did not reveal significant differences between groups. There were no significant changes in ST-segment depression during the exercise or at rest. A lower tendency for JT/RR increases was observed during the repeated exercise tasks with partial blood flow restriction. [Conclusion] Low intensity exercises carried out with a partial blood flow restriction do not result in significant overload of cardiac function.
[Purpose] The purpose of this study was to investigate the effects of a pelvic belt on the activities of trunk and lower extremity muscles in normal adults. [Subjects and Methods] The subjects were 20 normal individuals without a history of orthopedic problems. The pelvic compression belt (The Com-Pressor, OPTP, Minneapolis, MN, USA) was an adjustable body belt with four elastic compression bands that provide stabilizing pressure and was designed to adjust the amount of force applied and to alter sites of compression. The body belt was placed below the anterior superior iliac spine, and stabilizing pressure was applied to the belt using the elastic compression bands in the bridge position after confirming the site of compression. [Results] The subjects showed a significant decrease in muscle activation in the erector spinae, oblique internus abdominis, rectus femoris, and biceps femoris while wearing the pelvic belt. [Conclusion] The use of a pelvic compression belt with external pelvic compression might improve pelvic joint stability and alter neuromotor control of the lumbopelvic and thigh muscles.
[Purpose] The purpose of this study was to compare the internal and external rotation of the dominant and nondominant shoulders of adolescent female tennis players. The correlation between the shoulder rotation range of motion and the player’s ranking was also analyzed. [Subjects and Methods] Twenty-one female junior tennis players who were 13 to 18 years old participated in this study. A standard goniometer was used to measure the internal and external rotation of both glenohumeral joints. The difference in internal and external rotation was calculated as the glenohumeral rotation deficit. The year-end ranking of each player was obtained from the Chinese Taipei Tennis Association. [Results] The internal rotation of the dominant shoulder was significantly smaller than that of the nondominant shoulder. Moreover, player ranking was significantly and negatively correlated with the internal rotation range of motion of both shoulders. On the other hand, the correlations of the internal and external rotation ranges of motion with the age, height, and weight were not significant. [Conclusion] The flexibility of the glenohumeral internal rotation is smaller in the dominant shoulder than of the nondominant shoulder in these junior female tennis players. Flexibility of the glenohumeral internal rotation may be a factor affecting performance in junior female tennis players.
[Purpose] The aim of the study was to investigate the effect of kinesio tape on pain, range of motion, and disability of the shoulder. [Subjects and Methods] Seventy-four female patients who underwent modified radical mastectomy participated in this study. They were randomly divided into two groups, an experimental group that received kinesio tape for the shoulder joint in addition to a conventional physiotherapy program and a control group that received the physiotherapy program only. Outcome measures included the Visual Analogue Scale, shoulder range of motion, and Shoulder Pain and Disability Index. [Results] The experimental group showed significant differences in all outcome measures both within and between groups. The control group only showed a significant within group difference in shoulder flexion. [Conclusion] Clinicians should be able to recognize the benefits achieved through the use of adjunct treatment options such as kinesio tape in comparison with benefits that can be obtained through the use of individual modalities in physical therapy. Kinesio tape can be suggested and recommended for postmastectomy patients, especially for shoulder pain, range of motion, and disability.
[Purpose] The purpose of this study was to demonstrate the use of bioelectrical impedance analysis as an appropriate rehabilitation therapy evaluation tool for stroke hemiplegic patients. [Subjects and Methods] A group of 20 stroke patients diagnosed with stroke hemiplegia who underwent stroke rehabilitation from October to November 2015 participated in this study. Using bioelectrical impedance analysis, stroke hemiparalysis patients were examined, and the affected and non-affected sides were compared. This correlation between impedance measurement values and rehabilitation therapy as an assessment tool was determined. [Results] According to the whole-body bioimpedance measurements, prediction markers, reactances, and phase angles, there were significant differences between the non-affected and affected sides, and bioimpedance had a positive correlation with hand grip power, manual dexterity of hand function, and ability to perform activities of daily living. [Conclusion] There were significant differences between the impedance values of the affected and non-affected sides of hemiplegic stroke patients. These results suggest that bioelectrical impedance analysis can be used as an assessment during the rehabilitation of stroke patients.
[Purpose] The objective of this study is to investigate the effect of visual biofeedback using ulatrasonography on the functional improvement of deep trunk muscle. [Subjects and Methods] This study selected ten healthy people without orthopedic history and information on the study. The average ages, heights, and weights were 22.70 ± 2.06 years old, 171.15 ± 9.18 cm, and 66.86 ± 8.88 kg in the experimental group, respectively. The abdominal drawing-in maneuver were executed for subjects through monitoring the status of muscle contraction using ultrasonic waves. And motor control exercises were performed during 6 weeks, 20 minutes/day and three times/week. We collected the data using electromyography MP150 system (BIOPAC system Inc., CA, USA) in order to measure trunk muscle activation. [Results] The subjects showed significant improvements in Internal oblique abdominis and lumbar multifidus muscle after intervention. [Conclusion] Visual biofeedback training using ultrasonography might be effective in improving function of the deep trunk muscle.
[Purpose] The purpose of this study was to investigate the difference in elbow joint position sense in children. [Subjects and Methods] Nineteen healthy children volunteered as subjects for this study. Joint position sense was assessed by asking the children to flex their elbows between 30° to 110° while blindfolded. The error range of elbow movement was analyzed with Compact Measuring System 10 for three-dimensional motion. To analyze data, descriptive statistics and paired t-test analysis were performed by using IBM SPSS Statistics 20.0. [Results] A significantly lower error was found in 30° right elbow flexion than 110° right elbow flexion (p<0.05). No significant difference was found between 30° and 110° left elbow flexion. [Conclusion] These results indicate that in children, joint position sense errors decrease as joint angles approach 30° flexion.
[Purpose] The aim of this study was to translate the Selective Control Assessment of the Lower Extremity (SCALE) tool from English to Japanese and to assess the reliability and validity of the Japanese version of the SCALE (SCALE-J) tool in Japanese patients with spastic cerebral palsy. [Subjects and Methods] The SCALE tool was translated into Japanese in accordance with the published guidelines. In total, 55 patients with spastic cerebral palsy were enrolled in the present study. Reliability by internal consistency (Cronbach’s α), intrarater reliability, inter-rater reliability, and convergent validity by comparing Gross Motor Function Classification System (GMFCS) scores were examined. [Results] The Cronbach’s α value of the SCALE-J tool was 0.97–0.98, whereas that of the intrarater and inter-rater reliability ranged from 0.93 to 0.96. The Spearman correlation coefficient revealed a good relationship between the SCALE tool and the GMFCS. [Conclusion] The SCALE-J tool was found to be reliable and valid; therefore, the SCALE tool may be useful for evaluation in clinical practice.
[Purpose] The purpose of this study was to elucidate the relationship between knee muscle strength and knee pain in activities of daily living, based on consideration of the difference between extension and flexion strength (Q − H) and the hamstring:quadriceps (H:Q) ratio in patients with knee osteoarthritis. [Subjects and Methods] The participants were 78 females with knee osteoarthritis, and a total of 133 knees that had not been treated surgically were the targets of this research. The legs were divided according to dominance. Isometric knee extension and flexion muscle strength and knee pain during activities of daily living were measured. The H:Q ratio (flexion/extension muscle strength) and the difference between extension and flexion strength, (extension muscle strength/weight) minus (flexion muscle strength/weight), that is, Q − H, were calculated. The correlation between these indices and the knee pain score during activities of daily living was investigated. [Results] Greater knee pain during activities of daily living was related to lower knee extension muscle strength and Q − H in both the dominant and nondominant legs. Knee flexion muscle strength and the H:Q ratio were not significantly correlated with knee pain during any activities of daily living. [Conclusion] Knee extension muscle strength and Q − H were found to be significantly correlated with knee pain during activities of daily living, whereas the H:Q ratio was not.
[Purpose] To compare the effects of treadmill training with partial body weight support (TTPBWS) and conventional physical therapy (PT) on subjects with anterior cruciate ligament reconstructions. [Subjects and Methods] A total of 40 subjects were randomly allocated to either a treatment group or a control group. Subjects received either treadmill training with partial body weight support (treatment group) or conventional physical therapy (control group). The circumferences of the lower extremities, Holden classifications, 10-meter walking times and the International Knee Documentation Committee (IKDC) scores were compared at 12 and 24 weeks post-operation. The knee joint stability was tested at 24 weeks post-operation using a KT-1000. [Results] Significant differences were found between the two groups at the 12 weeks post-operation. For most of the measures, there was no significant difference between the groups at 24 weeks post-operation. Interestingly, for most of the measures, there was no significant difference between their values in the treatment group at 12 weeks and their values in the control group at 24 weeks post-operation. [Conclusion] The function of a subject’s lower extremities can be improved and the improvement was clearly accelerated by the intervention of treadmill training with partial body weight support, without compromising the stability of the knee joints in a given follow-up period.
[Purpose] The purpose of this investigation was to assess whether or not restriction of visual information influences the kinematics of sit-to-stand (STS) performance in children. [Subjects and Methods] Five girls with congenital blindness (CB) and ten healthy girls with no visual impairments were randomly selected. The girls with congenital blindness were placed in one group and the ten girls with no visual impairments were divided into two groups of five, control and treatment groups. The participants in the treatment group were asked to close their eyes (EC) for 20 minutes before the STS test, whereas those in the control group kept their eyes open (EO). The performance of the participants in all three groups was measured using a motion capture system and two force plates. [Results] The results show that the constraint duration of visual sensory information affected the range of motion (ROM), the excursion of the dominant side ankle, and the ROM of the dominant side knee in the EC group. However, only ankle excursion on the non-dominant side was affected in the CB group, and this was only observed in the sagittal plane. [Conclusion] These results indicate that visual memory does not affect the joint angles in the frontal and transverse planes. Moreover, all of the participants could perform the STS transition without falling, indicating; the participants performed the STS maneuver correctly in all planes except the sagittal one.
[Purpose] The purpose of this study was to examine the effects of increasing the intensity of functional electrical stimulation delivered to abdominal muscles during quiet breathing on respiratory flow, vital signs and pain in healthy subjects. [Subjects and Methods] Electrical stimulation was delivered bilaterally using one pair of high-conductivity gel-skin plate electrodes, placed on both sides of the abdomen, to nine healthy males. Subjects were required to breathe normally through a face mask for 2 minutes while in a supine position. The stimulation intensity was incrementally increased by 10 mA until reaching 100 mA. Respiratory parameters, vital signs and pain based on the visual analog scale were measured for each intensity of electrical stimulation. [Results] Transcutaneous oxygen saturation showed a slight upward trend in association with increasing stimulation intensity, but there were no significant changes in pulse or blood pressure. Respiratory flow, tidal volume, and minute ventilation increased significantly as the stimulation intensity rose. [Conclusion] This study revealed that functional electrical stimulation can be safely delivered to human abdominal muscles without causing vital sign abnormalities. It was also found that the appropriate intensity level of electrical stimulation for achieving effects on respiratory flow while also minimizing pain is 60–80 mA.
[Purpose] This study aimed to compare the effects of two different mobilization techniques in the management of patients with adhesive capsulitis. [Subjects and Methods] Thirty non-diabetic men and women with adhesive capsulitis were randomly allocated to the reverse distraction group (n=15) or Kaltenborn group (n=15). The reverse distraction technique and Kaltenborn’s caudal and posterior glides (grades III and IV) were applied 10–15 times along with conventional physical therapy for 18 treatment sessions in 6 weeks. Pain was measured with a visual analog scale, abduction and external rotation range of motion with goniometry, hand behind back reach with inch tape, and functional disability with the Flexilevel scale of shoulder function before and after the treatment. [Results] Although all the variables improved significantly in both groups after 18 intervention sessions, reverse distraction was significantly better than Kaltenborn’s caudal and posterior glides in decreasing pain and improving abduction range of motion and functional scores. [Conclusion] This study supports the clinical use of reverse distraction as an alternative to conventional mobilization techniques to decrease pain and improve range of motion and functional scores in patients with adhesive capsulitis.
[Purpose] The aim of this study was to investigate the effect of an intensive sensorimotor stimulation program on the motor function of chronic hemiparetic patients. [Subjects and Methods] The subjects were three chronic stroke patients whose sensory function was intact, who had Mini-Mental State Examination − Korean version scores of more than 26, and manual muscle test scores of more than fair for affected shoulder and elbow. The research design was an A-B single subject experimental design. The intervention consisted of 4 baselines phase sessions, and 12 sensorimotor stimulation phase sessions. The sensory and motor stimulation was performed for 30 minutes per session. The efficacy of the program was evaluated by the Box and Block test, and the 10-second test. [Results] Box and Block test and 10-second test scores of each subject improved after the 8 weeks intervention. [Conclusion] The intensive sensorimotor stimulation program for the upper extremity may be an efficacious method for improving the function of the affected limb of chronic stroke patients.
[Purpose] The purpose of present study were to develop an out-patient satisfaction questionnaire to be used in health care system, from which the underlying dimensions could be derived and individual patient scores calculated, and to evaluate some of the questionnaire’s psychometric properties. [Subjects and Methods] Forty out-patient of local hospital reply both the questionnaire used in previous study and newly designed questionnaire. To identifying validity, the statistical linear relationship between the total score of the primary questionnaire and newly designed questionnaire, which were analyzed. The test-retest reliability has been investigated by using a single measure intra class correlation. [Results] The average satisfaction of the previous questionnaire were significantly correlated with newly designed questionnaire. The intra-lass correlation coefficient of the each items of newly designed questionnaire were strong. Total score of the previous questionnaire had the lowest test-retest reliability, Cronbach’ s alpha coefficient for the newly designed questionnaire score showed acceptable inter-item reliability. [Conclusion] The out-patients’ satisfaction questionnaire developed in present study, which had appropriate validity, reliability, and acceptability.
[Purpose] This study was designed to determine the effect of a respiration rehabilitation program on daily activities, satisfaction with leisure, and quality of sleep of patients with chronic obstructive pulmonary disease. [Subjects and Methods] The program was conducted three times a week for 12 weeks (a total of 36 times) with 20 patients aged between 50 and 70 years old. The Frenchay Activity Index was used to determine the instrumental activities of daily living before and after the intervention. The Korean scale of satisfaction with leisure was employed to determine the satisfaction with leisure, and the Korean version of the Pittsburgh Sleep Quality Index was used to measure the quality of sleep. [Results] The total score of all three instruments (instrumental activities of daily living (IADL), satisfaction with leisure, and quality of sleep) improved significantly after the intervention. [Conclusion] In conclusion, the scores of all three instruments (IADL, satisfaction with leisure, and quality of sleep) improved significantly after the intervention, indicating that the respiration rehabilitation program was effective at improving the overall quality of life for patients with chronic obstructive pulmonary disease.
[Purpose] The aim of this study was to clarify the effects of an automated stride assistance device on gait parameters and energy cost during walking performed by healthy middle-aged and young females. [Subjects and Methods] Ten middle-aged females and 10 young females were recruited as case and control participants, respectively. The participants walked for 3 minutes continuously under two different experimental conditions: with the device and without the device. Walking distance, mean walking speed, mean step length, cadence, walk ratio and the physiological cost index during the 3-minutes walk were measured. [Results] When walking with the stride assistance device, the step length and walk ratio of the middle-aged group were significantly higher than without it. Also, during walking without assistance from the device, the physiological cost index of the middle-aged group significantly increased; whereas during walking with assistance, there was no change. The intergroup comparison in the middle-aged group showed the physiological cost index was lower under the experimental condition with assistance provided, as opposed to the condition without the provision of assistance. [Conclusion] The results of this study show that the stride assistance device improved the gait parameters of the middle-aged group but not those of young controls.
[Purpose] The purpose of this study was to determine if an inclined treadmill with rhythmic auditory stimulation gait training can improve balance and gait ability in stroke patients. [Subjects and Methods] Thirty participants were randomly divided into three groups: inclined treadmill with rhythmic auditory stimulation training group (n=10), inclined treadmill training group (n=10), and treadmill training group (n=10). For all groups, the training was conducted for 4 weeks, 30 minutes per session, 5 times per week. Two subjects dropped out before study completion. [Results] All variables of balance and gait, except for the timed up and go test in the treadmill group, significantly improved in all groups. Moreover, all variables showed a more significant improvement in the inclined treadmill with rhythmic auditory stimulation group when compared with the other groups. Timed up and go test, Berg balance scale, 6 m walking test, walking speed, and symmetric index were significantly improved in the inclined treadmill group when compared with the treadmill group. [Conclusion] Thus, for stroke patients receiving gait training, inclined treadmill with rhythmic auditory stimulation training was more effective in maintaining balance and gait than inclined treadmill without rhythmic auditory stimulation or only treadmill training.
[Purpose] Fatigue may be an important contributing factor to non-contact anterior cruciate ligament injuries in sports. The purpose of this study was to evaluate the effects of controlled lower limb fatigue, induced by a short-term, high-intensity exercise protocol, on the profile of the ground reaction force during landings from single-leg anterior drop-jumps. [Subjects and Methods] Twelve healthy males, 18 to 24 years old, performed single-leg anterior drop-jumps, from a 20 cm height, under two conditions, ‘fatigue’ and ‘non-fatigue’. Short-term fatigue was induced by high-intensity interval cycling on an ergometer. Effects of fatigue on peak vertical ground reaction force, time-to-peak of the vertical ground reaction force, and loading rate were evaluated by paired t-test. [Results] Fatigue shortened the time-to-peak duration of the vertical ground reaction force by 10% (non-fatigue, 44.0 ± 16.8 ms; fatigue, 39.6 ± 15.8 ms). Fatigue also yielded a 3.6% lowering in peak vertical ground reaction force and 9.4% increase in loading rate, although these effects were not significant. [Conclusion] The effects of fatigue in reducing time-to-peak of the vertical ground reaction force during single-leg anterior drop-jumps may increase the risk for non-contact anterior cruciate ligament injury in males.
[Purpose] This study examined the quality of life of homebound elderly hemiparetic stroke patients with cognitive impairment and the factors affecting their quality of life. [Subjects and Methods] The subjects of the study were 17 home-based elderly hemiparetic stroke patients with cognitive impairment (8 males and 9 females, average age: 76.3 ± 10.5 years old). Their physical and psychological conditions, quality of life and other items were investigated. Nishimura’s Mental State Scale for the Elderly was used for the cognitive impairment assessment. The Functional Independence Measure was used to assess activities of daily living, and the Japanese Quality of Life Inventory for the Elderly with Dementia was used to assess quality of life. [Results] The subjects’ quality of life was affected by their cognitive impairment level and independence of activities of daily living. However, no correlations were observed between the quality of life of the homebound elderly hemiparetic stroke patients with cognitive impairment, age, gender or care-need level. [Conclusion] In order to improve the quality of life of homebound elderly hemiparetic stroke patients with cognitive impairment, assistance helping them to maintain their cognitive abilities and on-going rehabilitation for improving activities of daily living independence are required.
[Purpose] This study was conducted to investigate the effects of forced breathing exercise on the trunk functions of chronic low back pain patients. [Subjects and Methods] Twenty-four patients with chronic low back pain were randomly divided into groups of respiratory effort and trunk stabilization exercises. The exercises were performed for 45 minutes, 3 times per week for 6 weeks. Spinal stabilization was measured as the compensation of thesagittal angle joint in relation to the lumbar external load. [Results] After the intervention, the forced breathing and stabilization exercise groups showed a significant difference in lumbar spine stabilization between the first and second stress tests and the control group also showed a significant difference after the intervention. The M1 and M2 tests of lumbar spine stabilization revealed no significant differences between the groups. [Conclusion] The results of this research demonstrate that forced breathing exercise therapy is effective at improving the trunk stability and daily living activities of chronic low back pain patients.
Carmen Luque-Siles, Tomas Gallego-Izquierdo, Jose Jesus Jímenez-Rejano, Susana Granados de-la-Orden, Gustavo Plaza-Manzano, Africa López-Illescas-Ruiz, Alejandro Ferragut-Garcías, Natalia Romero-Franco, Patricia Martín-Casas, Daniel Pecos-Martín
[Purpose] To examine the intrasession and intersession reliability and the absolute reliability of three functional dynamic tests—forward-lunge, step-up-over and sit-to-stand tests—using computerized dynamic posturography. [Subjects and Methods] An intra-test and test-retest, repeated measure study was designed. Forty-five healthy subjects twice carried out the forward-lunge test, step-up-over test, and sit-to-stand test on two days, one week apart. The intrasession and intersession reliabilities as judged by the intraclass correlation coefficient (ICC) and the minimal detectable change of the three functional tests were calculated. [Results] Excellent to very good intrasession reliability of the forward-lunge test (ICC range of 0.9–0.8) was found. Very good to good intrasession reliability of the step-up-over test (ICC range of 0.9–0.5) was found and very good intrasession reliability of the sit-to-stand test (ICC range of 0.8–0.7) was found. The minimal detectable change at the 95% confidence level of most of the measures was lower than 30%. [Conclusion] The forward-lunge, step-up-over and sit-to-stand tests are reliable measurement tools.
[Purpose] This study investigated the reliability of the Special Support System. [Subjects and Methods] Eighteen female and 14 male volunteers participated in this study. Participants were asked to sit on the Special Support System with their chins tucked in, spines straight, pelvis neutrally positioned, and their hands placed on their thighs. They were also asked to flex their hips, knees, and ankles to approximately 90 degrees and to put their feet flat on the floor. The total contact area, mean total pressure, as well as mean and peak pressures of each quadrant were each measured 15 times. Test-retest reliability was analyzed for inflated air pressure, and pressure redistribution values by using intraclass correlation coefficients. [Results] The intraclass correlation coefficient was greater than 0.89 for inflated air pressure and greater than 0.92 for total contact area, mean total pressure, and each quadrant’s mean and peak pressure. [Conclusion] The findings suggest that the Special Support System is reliable and can be used as an alternative method for redistributing sitting pressure.
[Purpose] The purpose of this study was to design a physical activity questionnaire reflecting on the basic principles and recommendations of exercise and to examine its reliability. [Subjects and Methods] 342 males and 374 females from the community centers (senior center, residential culture center, sport center, and YWCA center) participated in this study. [Results] The test-retest reliability of the physical activity questionnaire, measured with an interval of three months, being between 0.61 and 0.91 signifies that the questionnaire was useful instrument for assessing physical activity levels. [Conclusion] This study found that the simple physical activity questionnaire containing the frequency, duration, intensity, overall length, and type of activities that the person performed during their leisure time was reliable.
[Purpose] To determine the intra- and inter-rater agreement of a mobile application, PostureScreen Mobile® (PSM), that assesses static standing posture. [Subjects and Methods] Three examiners with different levels of experience of assessing posture, one licensed physical therapist and two untrained undergraduate students, performed repeated postural assessments of 10 subjects, fully clothed or minimally clothed, using PSM on two nonconsecutive days. Anterior and right lateral images were captured and seventeen landmarks were identified on them. Intraclass correlation coefficients (ICCs) were calculated for each of 13 postural measures to evaluate inter-rater agreement on the first visit (fully or minimally clothed), as well as intra-rater agreement between the first and second visits (minimally clothed). [Results] Eleven postural measures were ultimately analyzed for inter- and intra-rater agreement. Inter-rater agreement was almost perfect (ICC≥0.81) for four measures and substantial (0.60<ICC≤0.80) for three measures during the fully clothed exam. During the minimally clothed exam, inter-rater agreement was almost perfect for four measures and substantial for four measures. Intra-rater agreement between two minimally clothed exams was almost perfect for two measures and substantial for five measures. [Conclusion] PSM is a widely available, inexpensive postural screening tool that requires little formal training. To maximize inter- and intra-rater agreement, postural screening using this mobile application should be conducted with subjects wearing minimal clothing. Assessing static standing posture via PSM gives repeatable measures for anatomical landmarks that were found to have substantial or almost perfect agreement. Our data also suggest that this technology may also be useful for diagnosing forward head posture.
[Purpose] The purpose of this study was to examine the relationships between manual dexterity and the Unified Parkinson’s Disease Rating Scale-Motor Exam as a clinical tool for quantifying upper extremity function in persons with Parkinson’s disease. [Subjects and Methods] Thirty-two persons with idiopathic Parkinson’s disease participated in this study. This study measured two clinical outcomes, the box-and-block test and the Unified Parkinson’s Disease Rating Scale-Motor Exam, to investigate the relationships between manual dexterity and the Unified Parkinson’s Disease Rating Scale-Motor Exam. [Results] The box-and-block test on the more affected side was positive relationship with the box-and-block test on the less affected side. The Unified Parkinson’s Disease Rating Scale-motor exam score had a negative correlation with the box-and-block test results for both sides. [Conclusion] A positive association was noted between manual dexterity and motor function in patients with idiopathic Parkinson disease. The results of this study suggest that the box-and-block test and the Unified Parkinson’s Disease Rating Scale-Motor Exam are good clinical measures that quantify upper extremity function and are necessary for the accurate evaluation of patients and to plan intervention strategies.
[Purpose] The purpose of this study was to investigate the activation of back and lower limb muscles in subjects who were performing a squat exercise at different angles of trunk flexion. [Subjects and Methods] Twenty healthy subjects (age 21.1± 1.8 years, height 168.7 ± 8.2 cm, weight 66.1 ± 12.3 kg) volunteered. The activation of the erector spinae muscle, rectus femoris muscle, gluteus maximus muscle and biceps femoris muscle was observed while the subjects performed squat exercises with a trunk flexion of 0°, 15°, and 30°. [Results] The erector spinae muscle, gluteus maximus muscle, and biceps femoris muscle were activated more during the squat exercise with the trunk flexion at 30° than the exercise with the trunk flexion at 0°. The rectus femoris muscle showed a tendency to decrease as the truck flexion increased. [Conclusion] Squat exercise be executed while maintaining an erect trunk posture if one wishes to strengthen the quadriceps muscle while reducing the load on the lower back.
[Purpose] There is insufficient evidence related to exercise programs that are safe and efficacious for pregnant women with abnormal glucose metabolism. Tai Chi Yuttari-exercise is an exercise program with validated safety and efficacy in improving physical function in the elderly. In this study, we investigated this program’s inhibitory effects on plasma glucose elevation when it was adapted to a pregnancy model. [Subjects and Methods] Twelve 18- to 19-year-old females without a history of pregnancy were randomly assorted into two groups: an intervention group, for which six subjects were outfitted with mock-pregnancy suits and asked to perform Tai Chi Yuttari-exercise, and a control group who did not perform exercise. The intervention group had a mean Borg Scale score of 11.1 ± 0.9 during the exercise. [Results] No significant intragroup differences were observed in fasting, baseline, or post-intervention/observation plasma glucose levels. On the other hand, the intergroup change in plasma glucose levels after intervention/observation was significant when comparing the intervention and control groups: −1.66 ± 7.0 and 9.42 ± 6.57 mg/dl, respectively. [Conclusion] Tai Chi Yuttari-exercise appears to effectively inhibit plasma glucose elevation at intensity and movement levels that can be safely applied to pregnant women with abnormal glucose metabolism.
[Purpose] This study aimed to examine the effect of motor imagery on the accuracy of motion and the excitability of spinal neural function. [Subjects and Methods] Thirty healthy volunteers (males, 15; females, 15; mean age, 20.3 ± 1.0 years) were recruited. F-waves was recorded at rest, while holding a sensor, and while using motor imagery. Next, subjects learned 50% maximum voluntary contraction. The pinch force was measured without visual feedback before and after motor imagery. F-waves were analyzed with respect to persistence and the F/M amplitude ratio. Correction time and coefficient of variation were calculated from the pinch force. [Results] Persistence and F/M amplitude ratio ware significantly higher in the holding sensor and motor imagery conditions than in the resting condition. In addition, persistence under motor imagery was significantly higher than that in the holding sensor condition. No significant differences were observed in relative values of correction time and coefficient of variation between the two pinch action conditions. The pinch force in task 2 approximated a more authentic 50%MVC than that in task 1. [Conclusion] Motor imagery increases the excitability of spinal neural function, suggesting that it also affects accurate control of muscle force.
Giovane Galdino, Andreia Maria Silva, José Angelo Bogão, Marcos Paulo Braz de Oliveira, Hayslenne Andressa Gonçalves de Oliveira Araújo, Maísa Sodoco Oliveira, Ana Clara Desiderio Maldonado, Herick Ulisses de Oliveira, Juliana Bassalobre Carvalho Borges
[Purpose] The purpose of present study was associate the increase of respiratory muscle strength with blood pressure levels in hypertensive subjects who underwent an aerobic exercise program. [Subjects and Methods] 90 hypertensive subjects were divided in two groups: intervention and control. All participants had an interview with a physiotherapist and were evaluated by 6-minute walk test, maximal inspiratory pressure, maximal expiratory pressure, heart rate, systolic blood pressure and diastolic blood pressure, before and after the 8 weeks. In the intervention group, the subjects underwent aerobic exercise program, 2 times a week for 8 weeks [Results] After the program, the levels of blood pressure were significantly reduced and the distance walked in the 6-minute walk test and the respiratory muscle strength were increased, compared to pre intervention and control group values. However, there was no correlation between the results provided by 6-minute walk test, maximal inspiratory pressure and maximal expiratory pressure with systolic arterial blood pressure levels. Nonetheless, the distance walked correlated with respiratory muscle strength values, in the intervention group. [Conclusion] The present study demonstrated that the aerobic training was effective in reducing the arterial blood pressure in hypertensive subjects associated with an improvement of physical conditioning and respiratory muscle strength.
[Purpose] This study was conducted in order to compare muscle activation level on the affected and unaffected limb according to the recovery level of upper limb between bilateral activity with hands clasped and bilateral activity with pilates ring. [Subjects and Methods] Twenty inpatient who have had a stroke were recruited. Subjects were divided into two groups by the Fugl-Meyer Assessment of Motor Function score of moderately recovered group and well recovered group. The muscles activation of upper extremity and Co-Contraction Ratio (CCR) were analyzed. [Results] In the muscles activation of the well group, trapezius, anterior deltoid, and triceps muscles of affected side and biceps muscles of both sides were significantly higher when activity with pilates ring than activity with hands clasped. CCR of both side in the well group was significantly decreased during activity with pilates ring and in the moderate group, CCR of affected side was significantly decreased during activity with pilates ring. [Conclusion] Bilateral activity with a pilates ring is more effective than activity with hands clasped for the facilitation of muscle activation and coordination in stroke patients.
[Purpose] The purpose of this study was to compare the item difficulty degree between the Pediatric Balance Scale and Fullerton Advanced Balance scale for children with cerebral palsy. [Subjects and Methods] Forty children with cerebral palsy (male=17, female=23) voluntarily participated in the study. Item difficulty was expressed in the Rasch analysis using a logit value, with a higher value indicative of increasing item difficulty. [Results] Among the 24 items of the combined Pediatric Balance Scale and Fullerton Advanced Balance scale, the most difficult item was “Walk with head turns”, whereas, the easiest item was “Sitting with back unsupported and feet supported on the floor”. Among the 14 items of the Pediatric Balance Scale, 9 items (item 1, 2, 3, 4, 5, 6, 7, 11, and 12) had negative logit values, whereas for the Fullerton Advanced Balance scale, only 1 item (item 1) had a negative logit value. [Conclusion] The Fullerton Advanced Balance scale is a more appropriate tool to assess balance ability than the Pediatric Balance Scale in in a group of higher functioning children with cerebral palsy.
[Purpose] Over the years physiotherapy has been recognized as a popular mode of treatment that decreases the disability and dependency rate of patients. However, there is still a need for its recognition in multidisciplinary health care structures. If a physician were well aware of how a physical therapist could help with treatment if patients and prevent complications, hospital patient load could be decreased to a greater extent. The aim of this study was to study the awareness, perception and beliefs of physicians working in Saudi Arabia about physiotherapy. [Subjects and Methods] Three hundred fifteen members of the Saudi Commission for Health Specialties (SCFHS) with different specialties, nationalities, designation, and work experience, working in various hospitals in 5 regions of Saudi Arabia were invited to participate in this study. A 22-item questionnaire was used for data collection including sections on physicians’ demographics, educational levels and knowledge about physiotherapy. [Results] After applying the inclusion and exclusion criteria, data from 280 respondents was used for analysis. Seventy-five percent of respondents reported to having some knowledge of physiotherapy, and 11% of them referred patients to physiotherapy departments regularly, while 14% referred patients occasionally. To the best of our knowledge, this is first study performed in Saudi Arabia to evaluate awareness of physicians about the physiotherapy profession. [Conclusion] The results of this study highlight the need to organize various workshops and lectures about the effectiveness of physiotherapy in various diseases for physicians, on a regular basis, to update them with evidence-based treatment. It is the responsibility of physical therapists to raise the perceptions of other healthcare professionals about their profession.
[Purpose] The purpose of this study was to examine changes in the muscle tone and stiffness of the lumbar region while individuals adopted the static prone position using sling suspension. [Subjects and Methods] The subjects were 30 healthy women in their 20s. The muscle tone and stiffness of the upper and lower lumbar regions of the sling suspension group and a control group were measured using myotonmetory as they maintained the static prone positon. [Results] The sling suspension group showed statistically significant declines in the muscle tone and stiffness of the upper lumbar region 5–10 min after adopting the initial prone position. They also showed statistically significant declines in the muscle tone and stiffness of the lower lumbar region immediately after being suspended in the slings and a statistically significant decline in the muscle tone of the lower lumbar region 5–10 min after adopting the initial prone position during which the sling suspension was applied. In contrast, the muscle tone and stiffness of the lumbar region of the control group increased while maintaining the static prone position. [Conclusion] The static prone position performed on a treatment table using sling suspension can be an effective intervention for reducing the muscle tone and stiffness of the lumbar region.
[Purpose] The evaluation of sitting balance is important for the prevention of falls in older adults, especially those who have a disability involving the lower extremities. However, no studies have been designed to assess a patient’s dynamic sitting balance using a sequential protocol. The objective of this study was to investigate the psychometric properties of the sequential weight-shifting (SWS) test. [Subjects and Methods] Twenty-three older adults who were physically dependent with regard to ambulation were recruited by convenience sampling. In study 1, 10 participants performed the SWS test and repeated the procedure 1 week later. In study 2, 23 participants were assessed using the SWS test, forward and lateral reach tests in a sitting position, tests of shoulder flexor and hand grip strength, an eye-hand coordination test, mobility tests, and pulmonary function tests. The test-retest reliability of the SWS test and its correlations with the different physical dimensions were examined. [Results] The intraclass correlation coefficient (3,1) of the SWS test was 0.67. The results of the SWS test correlated significantly with forward reach in the sitting position, arm muscle strength, eye-hand coordination, mobility, and pulmonary function (all p<0.05). [Conclusion] The SWS test demonstrated satisfactory psychometric properties and can be considered a useful functional approach for the measurement of sitting balance.
[Purpose] This study investigates effects of extracorporeal shock wave therapy on nerve growth factor expression in stroke in rats. [Subjects and Methods] Sixteen eight-week-old Sprague-Dawley rats were used and randomly divided into two groups: an experimental group, a control group. The experimental group received extracorporeal shock wave therapy after the stroke. The spinal cord encompassing the lumbar 4-lumbar 5 level was then removed for Western blot analysis. [Results] There was a significant difference in nerve growth factor expression between the groups after the impairment. [Conclusion] Application of extracorporeal shock wave therapy increased the expression of nerve growth factor and nerve growth factor postulated to promote nerve growth factor upregulation through formation of a microenvironment at the spinal cord level related to the injured area.
[Purpose] The purpose of this study was to evaluate the amount of physical activity of the patients with critical limb ischemia consecutively in order to clarify the characteristics of physical activity of critical limb ischemia. [Subjects and Methods] Twelve patients who were eligible for the 2 months of consecutive evaluation of the amount of physical activity were enrolled in the study (men: 11; woman: 1; mean age: 64.4 [range: 44–80]). A pedometer with an accelerometer was used for the measurement of the number of steps walked as an index of the amount of physical activity. Participants were asked to lead a regular life and no instruction was given as to the number of steps. [Results] The average number of daily steps walked was 2,323 steps (range: 404–6,505). There was no clear tendency in the number of amputation site-specific steps walked. There was also no correlation between the number of steps walked and age as well as the maximum strength of the knee-extension muscle, skin perfusion pressure of the sole and the dorsum, and QOL scores. [Conclusion] The number of steps walked of the patients with critical limb ischemia was remarkably low and no significant association with health-related QOL.
[Purpose] The purpose of the study was to assess the muscle activity change of the tibialis posterior, flexor digitorum longus, and peroneus longus during gait with orthoses. [Subjects and Methods] Sixteen healthy males participated in this study. Activity of each muscle was measured by using fine-wire and surface electromyography. Gait task was performed by the participants barefoot, with footwear and with orthoses. The electromyography data from a stance phase of each gait trial were used for analysis. The stance phase was divided into contact, midstance, and propulsion phases. The data from ten participants were extracted for final analysis, as electromyography measurements were unsuccessful for the other six. [Results] The results demonstrated that orthoses significantly reduced the tibialis posterior muscle activity in the propulsion phase compared to that in the barefoot condition. Although there was a significant difference in the midstance phase, post hoc analysis did not indicate significant differences among the phases. No significant electromyography amplitude change was detected in flexor digitorum longus and peroneus longus. [Conclusion] Orthothes reduced the tibialis posterior activity level during gait. This result may be beneficial for patients with injuries related to excessive activity of tibialis posterior.
[Purpose] This study aimed to examine the effects of an 8-week modified Pilates program on the variability of inter-joint coordination in the elderly during walking. [Subjects and Methods] Twenty elderly participants with no recent history of orthopedic abnormalities (age, 67.9 ± 2.7 years; height, 163.7 ± 8.9 cm; weight, 67.1 ± 11.6 kg) were recruited for this study and randomly allocated to a modified Pilates exercise group or a control group. Three-dimensional motion analysis was performed on both groups to evaluate the effects of the Pilates exercise. [Results] There was no significant difference in the joint variability of the ankle, knee, and hip joints between the groups, both before training and after training. However, there was a significant increase in the hip-knee deviation phase value in the exercise group after the program was completed, and this increase was also significant when compared with that in the control group. [Conclusion] This study has demonstrated that an 8-week modified Pilates exercise program can have a positive impact on the gait of elderly participants, potentially by enhancing neuromuscular adjustment, which may have positive implications for reducing their fall risk.
[Purpose] To study the correlation among proprioception, muscle strength, and balance. [Subjects and Methods] A balance testing system (Biodex Balance System, BBS) and an isokinetic testing system (Biodex System 4, BS4) were used to test related indexes in 24 healthy young females. [Results] With the knee joint at 15 degree flexion, proprioception was significantly correlated with Limits of Stability-Time values, and was highly significantly correlated with Limits of Stability-Overall and Athlete Single Leg Medial/Lateral values. The sense of force was significantly correlated with Limits of Stability-Overall and Athlete Single Leg-Overall values. Quadriceps strength was significantly associated with Limits of Stability-Overall, Athlete Single Leg Medial/Lateral, and Athlete Double Leg-Overall values. The ratio of Quadriceps to Hamstring strength was significantly correlated with Athlete Single Leg Medial/Lateral, and Athlete Single Leg-Overall values. With the knee joint at 45°, proprioception was highly significantly correlated with dynamic balance, and was significantly correlated with double foot support under static balance; force sense had a high correlation with Limits of Stability-Overall, but no correlation with other indexes. Quadriceps strength had a significant correlation with dynamic and static balance; the ratio of Quadriceps/Hamstring had a highly significant correlation with Limits of Stability-Overall, Athlete Single Leg-Anterior/Posterior and Athlete Single Leg-Overall. [Conclusion] At different knee angles, the correlation differs among proprioception, force sense, quadriceps strength, the Quadriceps/Hamstring ratio, and balance.
[Purpose] The purpose of this study was to examine research trends in physical therapy through analysis of articles published at the 2015 World Confederation for Physical Therapy Congress. [Subjects and Methods] A total of 1,339 were analyzed (presentations: 346, posters: 993). The number of papers per subject area, number of oral presentations and posters, and the number of moderator nations and regional publications were analyzed by subject area. The mean and standard deviation was used for statistical analysis. [Results] Of 1,339 items published, the musculoskeletal spine was the most common theme, with 89. Among oral presentations, 24 had cardiorespiratory themes; among poster presentations, themes related to the elderly were the most common, at 76. Eleven moderators were from Australia, and the most frequent regional source of papers was Japan, with 238. [Conclusion] The 2015 WCPT Congress published papers in a variety of subject areas; Australia and the UK presented many papers, but Japan had the most of any region, at 238.
[Purpose] The aim of this study was to ascertain the effect of comprehensive rehabilitation therapy on a quadriplegic patient with meningiomatosis and severe dysphagia. [Subject and Methods] Meningiomatosis is defined as multiple meningiomas involved in several intracranial regions, which occurs more frequently in elderly patients. The prognosis of meningiomatosis is mostly reported as benign, but the prognosis for some malignant cases can be poor. Furthermore, dysphagia in elderly patients with brain lesions may lead to foreign body aspiration, which can be fatal. The removable type of dental prosthesis is a common cause of aspiration, but aspiration is rare with the fixed type. [Results] This report presents a rare case of bronchial aspiration involving a fixed dental prosthesis in an elderly meningiomatosis patient that was improved following comprehensive rehabilitation therapy. [Conclusion] Thorough evaluation and individualized assessment of rehabilitation goals is recommended for the care of severe comorbid elderly patients.
[Purpose] Untreated early-onset scoliosis may eventually progress to more than 90° after growth, cause severe health problems, and increase chance of mortality. Therefore, surgical intervention is often indicated prior to the development of a life-threatening deformity. This case report aims to reveal how a 76-year-old male patient with curves exceeding 110° is functioning with minimal difficulty. [Subject and Methods] The patient, who has never had surgical intervention for scoliosis, can perform his everyday activities. His curves were 111° thoracic and 118° lumbar when he presented at the author’s office in January 2015. [Results] The patient reported that he rarely needs a physician and participates in endurance sports like jogging. Despite this, the patient recognizes his restrictive ventilation disorder (shortness of breath) when he is inactive. The patient complained of shortness of breath and cosmetic concerns. [Conclusion] The current guidelines indicate that early-onset scoliosis should be operated at a young age; however, this protocol is not supported by high-quality evidence. Notably, patients with curvatures exceeding 100° after puberty may have a reasonable quality of life when they lead an active life with regular participation in endurance sports and physical rehabilitation.
[Purpose] This study prescribed pain-free range exercises for a female amateur skier who complained of limitations in her shoulder range of motion, and pain caused by protective spasms; the tester evaluated the effects of such exercise on pain. [Subject and Methods] A 23-year-old female who complained of pain of 3 weeks in duration in the right glenohumoral and scapulothoracic joints was enrolled. [Results] After pain-free range exercises, the visual analog pain score was 2 and the shoulder flexion and abduction angles improved compared to the initial values. [Conclusion] Thus, this study suggests muscle-strengthening exercises within the pain-free range, rather than simple pain treatments, as therapy for acute muscle injuries in skiers.
[Purpose] This pilot study analyzed the degradation of spatial learning ability caused by hypothyroidism using aerobic and anaerobic exercise. [Subjects and Methods] The experiments were performed on 11, four-week-old male Sprague-Dawley rats. Hypothyroidism-induced rats receiving propylthiouracil (PTU) treatment were divided into aerobic exercise, anaerobic exercise, and control groups. Each group performed exercise and rest for four weeks. Changes in lethargy, memory deterioration, and thyroid function were measured in each group by blood analysis and open field and Morris water maze tests. [Results] After four weeks, blood analysis revealed that the thyroid hormone levels had returned to normal in the aerobic exercise, anaerobic exercise, and control groups, whereas the open field and Morris water maze tests showed that the aerobic and anaerobic exercise groups had faster recovery compared to that of the control group. In addition, comparison of aerobic and anaerobic groups showed that the anaerobic exercise group had faster recovery compared to that of the aerobic group. [Conclusion] The findings of this study suggest that exercise helped to improve lethargy and deteriorated spatial learning ability caused by hypothyroidism and to recover function in rats. Anaerobic exercise was more beneficial than aerobic exercise in alleviating symptoms.
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