Abstract

Physical Therapy

SCHEDULE
Session 1:

11：00 ~ 12：00

Session chair: Prof. Morio Kawamura
Session chair: Associate Prof. Kazuto Ishida
1.

Effects of selective attention task on postural adjustment during choince step reaction.
Kazuki Uemura

2.

Effects of motor skills training on motor function and neural plasticity following
intra-cerebral hemorrhage in rats.

3.

Keigo Tamakoshi

Interaction between down-regulation of KCC2 expression in plasma membranes of spinal
motoneuron and spasticity after stroke in mice.

Takuya Toda

Session 2 : 13 : 30 ~ 14：30

Session chair: Prof. Sang Hyun Cho
4.

A Comparison of Trapezius Muscle Activity While Performing a Dictation Task, Sitting in an
Auditorium Chair and a Classroom.

5.

Tae Jim Kim

Muscle activation of the gluteus maximus and hamstrings during prone hip extension withknee flexion in three hip abduction positions.

6.

Sunyoung Kang

Janda's sensorimotor training in the upper crossed syndrome.

Jae Jin Lee－15 minutes rest –Session 3 : 14 : 45 ~ 15：25

Session chair: Prof. Sumio Yamada
7.

Feasibility of Emerging devise for Electrical Muscle Stimulation immediately after
Cardiovascular Surgery.

8.

Kotaro Iwatsu

The effect of internet based cardiac rehabilitation with pulse monitoring device on
improvement of exercise tolerance and coronary risk factor modification: a pilot study.
Yuta Hagiwara－15 minutes rest –Session 4 : 15：40 ~ 16：20

Session chair: Prof. Sang Hyun Cho
9.

Immediate Effects of Soft Tissue Massage on Acromiohumeral Distance, Anterior Translationof Humeral Head, and Glenohumeral Range of Motion in Subjects With Posterior Shoulder
Muscle Tightness: A Preliminary Study.

Sil-Ah Choi

10. Effects of Breathing Maneuver and Sitting Posture on Muscle Activity in Inspiratory
Accessory Muscles in Patients with Chronic Obstructive Pulmonary Disease.
Ki-song Kim

EFFECTS OF SELECTIVE ATTENTION TASK ON POSTURAL ADJUSTMENT
DURING CHOICE STEP REACTION
K. Uemura1,2), Y.Uchiyama1)
1) Program in Physical and Occupational Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
2) Research Fellow of the Japan Society for the Promotion of Science
Introduction
A delayed choice step reaction has been shown to be amarker of increased risk of falling in older adults. Avoiding afall depends not only on a person’s sensorimotor function but
also on cognitive processes that allow appropriate corrective
responses to be selected. Anticipatory postural adjustment(APA) was originally defined as a change in postural control
associated with voluntary movements, potential error in the
direction of which (indicating a motor program error)
account for slow choice step reaction [1].
Tests that have been previously used for assessing thephysical performance, including walking speed and step
reaction time, could not evaluate the multiple aspects ofpostural control deficits and the potential mechanism of
movement prolongation. Given that an initial motor program
error leads to incorrect and prolonged APA, processing andjudgment may be vital and critical in determining theaccuracy and speed of step execution. Selective attention task
have been used to measure conflict resolution and visualinterference effects [2]. Assessing stepping performance in
response to the selective task may enable us to investigate theprocessing and judgment during movement initiation. The
purposes of this study is to develop the assessment methodsof postural control addressing cognitive process, such as
judgment and attention, during movement.

The vertical force data during the step execution werecollected using 2 separate force platforms. Figure 1 shows data
for the vertical force under both feet as a percentage of bodyweight, obtained during the 2 trials of step execution by theright foot. Figure 1A shows a trial in which the initial APA wasin the correct direction (i.e., increased force under the swing
foot to be lifted). Figure 1B shows a trial in which the initial
APA was in the wrong direction (i.e., increased force under the
initial stance leg), which delayed the step. Errors in the directionof the initial weight transfer (APA errors) were measured. Step
execution time was calculated as the time from cue to footcontact. Individual phases of step execution were calculated
according to the following definitions: (a) reaction phase, thetime from cue to APA onset (even if it was an error); (2) APA
phase, the time from APA onset to foot-off; (c) swing phase, thetime from foot-off to foot contact.

Materials and Methods
The contents of this research were 1) to determine
whether visual interference of slective attention task has any
effect on the initial motor program and choice step execution,2) to examine the effects of a speed or accuracy strategy on
response interference control, 3) to examine the effects ofaging on the reactive strategy and execution speed of choice
stepping. These experimental procedures were approved by
the local ethics committee (Graduate School of Medicine,
Nagoya University, approval no. 11-514).
Study 1
Subjects:Twenty healthy young subjects participated inthis study; these included 8 women and 12 men, with a mean SD age of 22.5  0.9 years.
Methods:They were instructed to execute forward
stepping as quickly and accurately as possible on the side
indicated by the central arrow (←, left vs. →, right), moving
their foot 30 cm on each step trial. In 1 block (neutral
condition), only 1 arrow was shown in the same central
location on the display. In the other block, flanker task wasused as the selective attention task. In flanker condition, thevisual display contained 5 arrows; the participants wereasked to indicate the direction the central arrow was pointing
while ignoring the 2 flanking arrows on each side. In half thetrials, the flanking arrows pointed in the same direction as thecentral arrow cue (←←←←← or →→→→→; congruent
condition), while in the other half, the flanking arrows
pointed in the opposite direction (←←→←← or →→←→→; incongruent condition).

Figure 1. Two example data of the step execution trials.
First, 1-way repeated-measures analysis of variance[ANOVA; task condition] was used to analyze the individual
response times and errors. To determine the effects of theconditions and the APA errors on step execution time, we useda linear mixed model with condition and APA error as the fixedfactors and the participants as the random factor.
Study 2
Subjects:Eighteen healthy young subjects participated in thisstudy, of whom 8 were women and 10 were men, with a meanage  SD of 21.9  1.5 years.
Methods: The emphasis placed in the instructions waschanged in 3 ways. For the control instruction, participants wereinstructed to execute choice forward stepping as quickly andaccurately as possible. For the accuracy instruction,
participants were instructed to focus on making an accurate
response without losing too much speed. For the speed
instruction, participants were instructed to focus on speeding
their responses and be less concerned about making errors,
but not to the point of simply guessing a response [3]. Other
experimental protocols and analysis were same with study 1.
Study 3
Subjects:Twenty-two healthy young subjects (gender, 9female; age, 21.9 ± 1.4 years) and 21 healthy older adults(gender, 10 female, age, 72.6 ± 4.9 years) participated in thisstudy. Older participants were included based on thefollowing criteria: (1) free of neurological and orthopaedic
disorders that might affect gait and/or cognitive function, (2)the ability to ambulate independently, (3) the Mini-Mental
State Examination score greater than 24, (4) absence ofserious visual impairment.
Methods: Experimental protocols and analysis were samewith study 1. Two-way repeated-measures ANOVA (taskcondition× age group) was used in the statistical analysis ofindividual response times and errors. We used a linear mixed
model approach to determine the effects of condition, andpresence or absence of APA error on step characteristics inindividual group.
Results
Study 1
APA errors rate, step execution time, reaction phase, andAPA phase significantly increased in the incongruent
condition compared to the neutral and congruent conditions.
The linear mixed model revealed that the presence or absenceof APA errors affects the individual timing of stepping indifferent ways. In trials with APA errors, step execution
times and APA phases were significantly lengthened for all 3
conditions in a similar manner. On the other hand, thereaction phase was lengthened in trials with correct APAs.
Study 2
Interaction effects between instruction and condition
showed that APA error was increased in response to theflanker task but step execution time was shortened with aspeed strategy compared to an accuracy strategy. There wasno statistical difference in step error rate between individual
instructions in all conditions. The linear mixed model
revealed that the presence of APA errors delays step
execution time for all instruction methods. However, there isan interaction effect between conditions and APA errors only
for the speed instruction, which suggests that the flanker
interference task prolongs the step execution time of trials
with APA errors more than simple choice reaction (i.e.,
neutral condition).
Study 3
Older group showed increased APA error rate compared
to young group in the all task condition, and prolonged step
execution time particularly in the incongruent condition.
Linear mixed model found that interaction effect between
APA error and condition was seen only in older group, whichindicates that presence of APA error increases total step
execution time prominently in incongruent condition (fig 2).
Discussion
Visual interference of selective attention task prolongs
step execution, which mainly derived from initial motor
program errors and its correction (i.e., prolonged APA), eventhough the reaction phase was prolonged in trials with correct
APAs for cautious judgment. (Uemura K et al, Effects of visualinterference on initial motor program errors and execution times
in the choice step reaction. Gait & Posture. In Revision)

Figure 2. Effect of APA errors on the step execution time
Speed strategy, compared to an accuracy strategy, increased
potential APA error in response to the selective attention task
but step error rate remained unchanged, step execution time wasshortened. However, in subjects who are more susceptible to
APA errors during step initiation, an emphasis on speed might
affect stepping performance adversely, because the flanker
interference task prolongs the step execution time of trials with
APA errors more than simple choice reaction only for the speed
instruction. It is also important to keep the purpose andcharacteristics of the subjects in mind when manipulating task
instructions.
Several age-related differences in choice stepping in responseto the selective attention task were seen. Interaction effectbetween condition and group indicated that visual interference
effect of flanker task affect reaction, APA phase and step
execution in different manners. Visual interference, caused byincongruent condition, prolonged APA phase and step execution
time particularly in older group in relative to young group.
Usually, the step execution time in the trials with APA errors
was longer than those without APA errors in young adults(Study 1), whereas older adults showed that step execution timein trials with APA errors increased prominently in theincongruent condition compared to neutral and congruent
condition. Therefore older adults might be vulnerable topotential motor program error caused by interference effect.
Conclusions
We have developed the assessment methods of posturalcontrol, to analyze stepping performance in response to aselective attention task including potential motor program error.
In the future, we should examine the effects of motor or
cognitive deficits and risk of falling on the judgment process
and step execution performance in response to a selective
attention task.
References
1
Cohen RG, Nutt JG, Horak FB: Errors in posturalpreparation lead to increased choice reaction times for step
initiation in older adults. J Gerontol A Biol Sci Med Sci 20112
Hedge A, Marsh NW: The effect of irrelevant spatial
correspondences on two-choice response-time. Acta Psychol(Amst) 1975;39:427-439.
3
Wylie SA, van den Wildenberg WP, Ridderinkhof KR,
Bashore TR, Powell VD, Manning CA, Wooten GF: The effectof speed-accuracy strategy on response interference control inparkinson's disease. Neuropsychologia 2009;47:1844-1853.
Author address

E-Mail: uemura.kazuki@a.mbox.nagoya-u.ac.jp

Effects of motor skills training on motor function and neural plasticity following intracerebral hemorrhage in rats
K.Tamakoshi and K.Ishida
Department of Physical and Occupational Therapy, Nagoya University Graduation School of Medicine, Nagoya, Japan

Introduction
Intracerebral hemorrhage (ICH) is a cerebral vascular
accident characterized by long-term impairments of motor
function and activities of daily living (ADL). It is wellknown that rehabilitation is effective for functional recovery
after intracerebral hemorrhage. A variety of rehabilitation
strategies, such as environmental enrichment [1]), simple
exercises(e.g., treadmill [2]), and forced-use therapies (e.g.,“constraint-induced movement therapy” [3]) have been
exermined in rodent ICH models. Learning new motor skills
might brought in neuronal structural and functional
plasticity,which has not been observed with simple
movement repetition. It was reported that motor skills
training promotes cerebral plasticity and motor functional
recovery more than simple exercise in stroke rats [4]. Motorskill training after brain damage leads to adaptive neuralplasticity which suggests that the mechanisms involved inlearning a new task also play an important role inmaintenance and reorganization of the injured cortex.
However, it is not well-known about the effects of motor
skills training following stroke, especially ICH. In this study,
we investigated the effects of motor skills training on the
motor functional recovery and synaptic plasticity following
intra-striatal hemorrhage in rats.
Materials and Methods
Experimental animals: Adult male Wistar rats (250~270 g, 8week-old) were used. Rats were housed at 23℃ during 12h
light/dark cycle with food and water access ad libitum
through the experiment. Animal care and surgical procedures
were performed in accordance with the animal careguidelines of the Nagoya University. All efforts were madeto minimize the suffering and the number of animals used.
They were randomly assigned to sham or ICH. Each group
was divided into two subgroups: acrobatic training andcontrol (no exercise) group. Therefore, four groups were
included in this study: SHAM, SHAM+AT, ICH, andICH+AT.
Surgery: ICH was induced as described in previous
studies[2,5]. Rats were anesthetized with sodium
pentobarbital (45 mg/kg, i.p.) following injection of atropine
sulfate and placed on a stereotaxic frame. Through a hole
drilled in the skull, a needlewas implanted into the left
striatum at the following coordinates: 3.0 mm lateral to themidline, 0.2 mm anterior to coronal suture, and depth 6.0 mm
deep from the surface of the brain. 1.2 µl saline containing
0.24 U of bacterial collagenase (TypeⅣ; Sigma-Aldrich, St.
Louis, MO, USA) was infused over 6 min. The needle
remained in place for an additional 7 min after the infusion
and was subsequently withdrawn slowly. Sham operated
animals were injected with 1.2 μl of saline instead ofcollagenase.
Motor skills training: ICH-AT group rats were trained fivekinds of acrobatic course, such as grid platform, rope ladder,parallel bars, rope, and barriers, as previously described thatthese courses requires rats to learn a variety of skilled
forelimb, hindlimb, and coordinated whole-body movement.

Each course was one meter length from starting to end point
placed dark box, and required rats to spontaneously traverse for25 days (4 trials a day) from 4 days after surgery. Almost rats
were assisted occasionally by experimenters to avoid fallingfrom each course from 4 to 6 days after surgery.

Figure 1 Acrobatic training
Behavioral testing: Motor Deficit Score (MDS) is composed offollowing four tests; (1) observation of spontaneously ipsilateralcircling, graded from 0 (no circling) to 3 (continuous circling),(2) bilateral forepaw grasp, which measures the ability to holdonto a 2 mm diameter steel rod, graded 0 for a rat with normal
forepaw grasping behavior to 3 for a rat unable to grasp with theforepaw, (3) contralateral hindlimb retraction, which measured
the ability of the animal to replace the hindlimb after it was
displaced laterally by 2-3 cm, graded from 0 (immediate
replacement) to 3 (replacement after minutes or no replacement),and (4) beam walking ability, graded 0 for a rat that readily
traverses a 2.4-cm-wide, 80-cm-long beam to 3 for a rat unable
to stay on the beam for 10 s. MDS was calculated as the sum of
the grades on the four tests, and evaluated at 1, 3, 7, 11, 14, 21
and 28 days after surgery. Beam walking test (a 2.4 cm and 1
cm wide, 80-cm-long beam) was performed at 1, 3, 7, 11, 14, 21
and 28 days after surgery, as described previously. Before
surgery, all rats were trained two trials every other day until
traverse a beam with no more than two foot slips. Performance
was rated on the 7 point scale: (1) the rat is unable to place theaffected hindpaw on the horizontal surface of the beam; (2) it
places the beam and maintains balance but is unable to traverse
the beam; (3) the rat traverses the beam dragging the affected
hindpaw; (4) it traverses the beam and once places the affected
hindpaw on the horizontal surface of the beam; (5) the rat
crosses the beam and places the affected hindpaw on thehorizontal surface of the beam to aid less than half its steps; (6)the rats uses the affected hindpaw to aid more than half its steps
and, (7) the rat traverses the beam with no more than two footslips.
Histology: At 29 days after surgery, rats were sacrificed underdeep anaesthesia with sodium pentobarbital. They weretranscardially perfused with 0.9 % saline followed by phosphatebuffer (pH 7.5) containing 5% paraformaldehyde. The brains
were removed and postfixed in the same fixative. Then, 50 µm
thick coronal sections were taken every 450 µm from +1.8 to 1.7 using a cryostat after overnight cytoprotection in 30%
sucrose solution. The volume of tissue lost and the cortical
thickness were calculated by Image J version 1.42 (Nationalinstitutes of Health, USA) using eight Hematoxillin-Eosin
stained sections. And, the number of neurons were counted
using Nissl stained sections. To investigate functional
activation of remaining cortex, Neuronal activation was
examined by immunohistochemistry of ∆FosB positive cells,
which is cumulatively and persistently expressed in responseto repeated neuronal activation. Immunocytochemistry for
ΔFosB was used. Numbers of ΔFosB positive cells in thebilateral sensorimotor cortex at 14 and 29 days after surgery
were counted. Cell counts were then normalized to 1mm2.
Protein assay: Protein level of PSD-95 was analysed using
western blotting. PSD-95, a synaptic scaffolding proteinwith multiple protein–protein interaction domains, isenriched in the postsynaptic density (PSD) and is an
important regulator of synaptic strength and plasticity. At 14
and 29 days after surgery, animals placed under deep
anesthesia with sodium pentobarbital (45 mg/kg, i.p.),transcardially perfused with phosphate buffered saline (PBS,
pH7.4), and their brains removed.
.
Results
MDS of ICH-AT animals were significantly improved
compared with ICH only animals at 11 and 14 days after ICH(Figure 2). A wide (Figure 3, left) and narrow (Figure3,
right) beam walking ability of ICH-AT was significantly
higher than ICH. The volume of tissue lost and cortical
thickness were no significant differences between ICH and
ICH-AT animals. The numbers of ΔFosB positive cells of
ICH-AT were increased more than those of ICH at bilateral
sensorimotor cortices at 14 days. PSD-95 protein levels of
ICH-AT group were increased in bilateral sensorimotor
cortices at 28 days and in bilateral striata at 14 days.

**

Days after surgery

Figure 2 Motor Deficit Score

** *

*

Discussion
These data suggest that motor skills training could enhance theneural activity and synaptic plasticity associated proteins atbilateral sensorimotor cortices and striata, and promote motor
functional recovery after intracerebral hemorrhage in rats.
The volume of tissue lost and cortical thickness were
unchanged by motor skills training following ICH. Previous
research reported that reaching training didn’t improve lesion
volume following ICH. Motor skills training may have brought
benefite recovery of motor function even though tissue loss was
not prevented after ICH. Thus motor function may be improvedby neural plasticity, not by tissue damage change.
∆FosB positive neurons in bilateral sensorimotor cortex wereincreased by motor skills training at 14 days. ∆FosB protein wasused as the maker of neural activity in this study. Motor skills
training caused persistent neural activity until 14 days.
PSD95 was investigated to demonstrate an effect of motor
skills training on synaptic plasticity in the sensorimotor cortex
and striatum after ICH. PSD95 was increased in bilateral
striatum at 14 days and sensorimotor at 28 days by motor skills
training following ICH. Improved motor function may be aneffect of synaptic plasticity in striatum at early phase and insensorimotor at late phase.
Conclusion
We demonstrated that motor skills training after ICH in rats
improved motor function, and enhanced neural activity andsynaptic plasticity in the striatum and sensorimotor cortex.

References[1].Chen GF, Zhang YF, Long Q, Wen W, Xu MQ, and Yang
YL. : Effects of environmental enrichment on the repair andproliferation of neurons in neonatal rats with hypoxic-ischemic
brain damage. Zhongguo Dang Dai Er Ke Za Zhi 14: 139-143,
2012.
[2].Takamatsu Y, Ishida A, Hamakawa M, Tamakoshi K, JungCG, and Ishida K.: Treadmill running improves motor function
and alters dendritic morphology in the striatum after
collagenase-induced intracerebral hemorrhage in rats. Brain Res
1355: 165-173, 2010.
[3].Ishida A, Tamakoshi K, Hamakawa M, Shimada H,
Nakashima H, Masuda T, Hida H, and Ishida K.: Early onset offorced impaired forelimb use causes recovery of forelimbskilled motor function but no effect on gross sensory-motor
function after capsular hemorrhage in rats. Behav Brain Res
225: 126-134, 2011.
[4] Jones TA, Chu CJ, Grande LA, Gregory AD.: Motor skills
training enhances lesion-induced structural plasticity in the
motor cortex of adult rats. J Neurosci 19 :10153-10163,1999[5] Altumbabic, M., Peeling, J., Del Bigio, M.R.,.
Intracerebralhemorrhage in the rat: effects of hematoma
aspiration. Stroke 29: 1917–1923,1998
Author address

E-Mail: tamakoshi.keigo@f.mbox.nagoya-u.ac.jp

Days after surgery

Figure 3 Beam Walking test

Days after surgery

INTERACTION BETWEEN DOWN-REGULATION OF KCC2 EXPRESSION IN PLASMAMEMBRANES OF SPINAL MOTONEURON AND SPASTICITY AFTER STROKE IN MICE
T.Toda1), K. Ishida.1), S. Lee1)
1) Department of Physical Therapy, Graduate School of Health Sciences, Nagoya University, Nagoya, Japan
Introduction
Spasticity is one of the well known upper motor neuron
syndromes resulting from the brain and spinal cord injuries.
Many stroke patients suffer from spasticity and theprevalence of spasticity is reported 42.6% in stroke patientswith limb paresis[1]. Furthermore, the spasticity adversely
affects quality of life and can reduce a person's function to
perform activities daily living. Although it has been clinicallystudied for many years until now, the exact mechanisms arestill unclear. Recently, the study as the spasticity mechanism
has been revealed that down-regulation of the K+/Clcotransporter 2 (KCC2) induced spasticity after spinal cord
injury. The decrease of KCC2 induces that the action of aminobutyric acide A (GABAA) and glycine receptors
change form inhibitory action to excitatory action, and so the
motoneurons develop hyper-excitability[2]. This result led us
to hypothesize that this disinhibition of motoneuron underlies
spasticity after stroke. The aim of this study is that toinvestigate whether the expression of KCC2 was actually
down-regulation in the affected motoneurons
Materials and Methods
Animals: Adult male C57BL/6J mice weighting 25-30 g(SLC, Shizuoka, Japan) were used. All procedures wereapproved by the Nagoya University Guidelines for the Careand Use of Laboratory Animals.
Photothrombotic Stroke model: Adult mice wereanesthetized using somnopentyl (50 mg/kg body weight,
Kyoritsu, Tokyo, Japan). We injected into the tail vein ofmice with Rose Bengal (10 mg/ml, 0.03 mg/g body weight,
Sigma, St. Louis, USA). The light beam exposed to therostral and caudal forelimb areas on the skull for 15 min. We
made a forelimb primary and non primary motor cortex
lesion. Sham animals received the same injection of Rose
Bengal but were not exposed a light.
Electrophysiological measurement: The Hoffman reflex(H-reflex) is characterized that the amplitude decreases
depend on frequency of stimulation (rate-dependent
depression: RDD). The RDD is gradually induced byrepeated stimulations at high frequency than 0.1 Hz, andamplitude of H-reflex reduces to less than 80% at 5
Hz[3].We measured H-reflex until 21 days after stroke forspasticity assessment. Animals were anesthetized withketamine (200 mg/kg additional dosage: 1/2 initial dose
every 45 min, CS pharmaceutical Co., Nagoya, Japan), andwe stimulated the ulnar nerve at 0.1 Hz with increasing
current intensities for determining the minimum intensity to
evoking H-reflex and this currents were used. After that we
stimulated the ulnar nerve 23 times at 0.1, 0.5, 1, 2 and 5 Hz
with 2 min intervals between each frequency. We recorded
the H-reflex in the both abductor muscles of little finger ofright and left forelimbs. We calculated the mean of theamplitude of H-reflex.
Immunohistochemical analysis: At 7 days after stroke weperformed immunohistochemical staining for histologicalevaluation. We sampled a spinal cord at cervical level (C4C7). The samples were cut coronally at 20 m thickness
using a cryostat and mounted onto slides. The coronal

sections were incubated in 0.1% tripsin for 5 min at room
temperature and blocking solution as 5% normal donkey serum
diluted with Triton buffer (0.1% TritonX-100 in PBS) for ChAT
antibody and 5% normal goat serum diluted in Triton buffer for
KCC2 antibody, respectively. After that, the sections wereincubated in goat anti-Choline Acetyltransferase (ChAT)
antibody (1:100, AB144P, Millipore, Tokyo, Japan) and rabbit
polyclonal anti-KCC2 antibody (1:500, 07-432, Millpore,
Tokyo, Japan) at 4°C for overnight. The secondary antibodies
were used Alexa Fluor 568 diluted donkey anti-goat
immunoglobulin G (1:250; A11058, Invitrogen, Eugene, OR)
and Alexa Fluor 488 diluted goat anti-rabbit immunoglobulin G(1:500, A11008, Invitrogen, NY, USA) diluted in blocking
solution for 1 hour at room temperature, respectively.
Semi-quantification analysis for KCC2: We analysed 6
coronal sections per cervical segments (C4-7), 5 motoneurons
per sections. We used a laser scanning confocal microscope(400 × magnification, A1Rsi-Nikon). All images were
processed and measured the intensity of immunolabeling within
the plasma membrane by using with imageJ. We calculated
ratios of labeled pixel areas per somatic perimeters.
Measurement and statistics: All static test were performedat the level of significance of 0.05 by two-tailed test using oneway ANOVA, post hoc test Turkey-Kramer’s and MannWhitney’s U test.
Results
The rate-dependent depression of Hoffman reflex in affectedmuscle of stroke animals was significantly decreased after
stroke: RDD of H-reflex is known to reduce at high frequencyof stimulation in individual and animals with spasticity[3-4].
The mainly cause is considered the depression of synaptic
efficiency due to a decrease of transmitter released from thesynapses following activation of Ia afferents[4]. We recorded
the evoked muscle potential at 7 days after stroke and shamsurgery. The latency time of the recorded M-wave was 1-3 ms,
and the recorded H-reflex was 5-7 ms. The amplitude of Hreflex reduced at 5 Hz compared with at 0.1 Hz in sham (Fig.1ab), while in stroke, the amplitude of H-reflex remained high at 5
Hz (Fig.1c-d), that is, the RDD was reduced.

RDD reduced significantly at 5 Hz in stroke animal from
3 days until 21 days after stoke (Fig.2, p < 0.01)

In affect side RDD of H-reflex was significantly
decreased: We compared RDD of H-reflex in sham andaffect and non affect sides in stroke before surgery, and so
RDD of H-reflex was similarly observed in all groups(Fig.3a). In 7 days after stroke, RDD of H-reflex in affectside was significantly decreased at 2 and 5 Hz compared withsham group (Fig.3b, p < 0.01). Additionally RDD of H-reflex
in affect side was significantly decreased at 5 Hz comparedwith non affect side in stroke group (Fig.3b, p < 0.05)

Discussion
We confirmed the decrease of KCC2 expressions in the
motoneuron of stroke mice with spasticity by semiquantification immunohistochemical analysis. KCC2-positive
areas was significantly decreased in plasma membranes ofmotoneurons in affect side at 7 days after stroke. This result
presents a possibility that down-regulation contributes tospasticity after stroke.
KCC2, which is only channel of Cl¯ extrusion in neuron,works in order to maintain low intracellular chloride
concentration. Therefore down-regulation of KCC2 underlie ashift of GABA-mediated action from inhibition to excitation[5].
KCC2 expression is known to decrease following neuronal
stress[6-7]. In this study, KCC2-postive area in plasma
membranes of motoneurons reduced to a less than 60%
compared with sham surgery. Previous study reports that KCC2
expression in postnatal 5-8 days rats, in which the shift fromdepolarizing to hyperpolarizing inhibitory postsynaptic
potentials had already occurred, is a less than 70% comparewith adult rats[8]. Another study reports that KCC2 expression
in hippocampal neurons decrease a less than 50% after
oxidative stress and a less than 70% 6 hour after seizure activity
and hyper excitability, and so GABA-mediated action change toexcitability from inhibitory[6]. For these reasons, decrease of
KCC2 in this study is enough amount to change in inhibitory
receptor to excitability.
Conclusions
This study presented a possibility that down-regulation of
KCC2 contributes to spasticity after stroke. In future, we will
investigate to reveal the exact mechanisms of spasticity after
stroke.

KCC2-positive areas in plasma membrane weredecreased after stroke: We analyzed the density pixel of
KCC2 labeled in plasma membranes of motoneurons in 7days after stroke, and so there was a significant decrease of
KCC2-positive areas in plasma membranes of motoneurons
in spinal ventral horn of all cervical levels compared withsham and non affect side in stroke (Fig.4, p < 0.01). These
results suggested that down-regulation of KCC2 expression
at plasma membranes of motoneurons in affect side spinal
cord.

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homeostasis and GABAergic signaling in human temporal lobe
epilepsy. 2007;27):9866-9873.
[8] A. Stil, S. Liabeuf, et al. Developmental up-Regulation of
the Potassium-Chloride Cotransporter Type 2 in the Rat Lumbar
Spinal Cord. 2009;164):809-821.
Author address
E-Mail: toda.takuya@h.mbox.nagoya-u.ac.jp

A Comparison of Trapezius Muscle Activity While Performing a Dictation Task,
Sitting in an Auditorium Chair and a Classroom Chair
Tae-jin Kim, B.H.Sc., P.T.1), Sang-hyun Cho, Ph.D., M.D.2), Heon-seock Cynn, Ph.D., P.T.2)
1) Department of Physical Therapy, The Graduate School, Yonsei University2) Department of Physical Therapy, College of Health Science, Yonsei University

Introduction
Auditorium chairs on a University campus are lesscompatible to Korean Industrial Standard (KS) thanclassroom chairs on the same campus. Due to variations inbody size of students, gaze levels from student’s eyes to theblackboard are different. During class hours, students movetheir eyes and neck repeatedly for writing. Auditorium
chairs, which are designed for students who sit on the backline in order to increase concentration by securing one’s
attention, were not made with consideration for students’
movement character. Prolonged sitting position affects
muscle activity of the neck and shoulders and induces
various secondly musculoskeletal problems, such asmuscle myalgia, muscle strain, and so on (cotton et al.,
2002; Jensen et al., 1993; Mandal, 1981; Waris, 1980). The
purpose of this study was to investigate the effect of thetwo different types of chairs on trapezius muscle activation
during performance of dictation tasks.
Methods
Seventeen university students, each of whom was within±1 standard deviation of the mean Korean standard bodysize, voluntarily participated in this study. The subjects sat
on two different types of chairs randomly and performed
dictation tasks for 10 minutes. The dictation tasks included
three different gaze levels (upward,downward, and horizontal direction at eye level).

(%RVC). Normalization of EMG data could make itpossibly to compare both between and within subjects
repeated measure EMG signals.
APDF analysis
Amplitude Probability Distribution Function (APDF) was
performed for analysis of muscle activity. The APDF
method introduced by Jonsson (1988) is the traditional
solution for such a data reduction. It is calculated based ona recording over time. This function is integrated in orderto yield a cumulative probability function. The amplitude
can be normalized according to any of the approaches(%RVC or %MVC) and it can represent relative muscle
contraction level. Figure 1 shows the APDF plot of theupper trapezius muscle of subject 1 during performance ofa dictation task of downward gaze on an auditorium chair.
X-axis is %RVC domain and Y-axis is Amplitude
probability (.0~1.0) of each %RVC. The indexes of APDF
are 10th, 50th, 90th, and 99th percentile, and the MATLAB(MathWorks Inc., Natick, Massachusetts, U.S.A.) program
was used for these four indexes.

Surface EMG collection and signal processing
Surface electromyography was used for collection ofelectrical signals from both the upper and lower trapezius
muscles. The Noraxon Telemyo 2400T system (Noraxon,
USA Inc., USA) was used to capture the EMG signals withsampling rates of 1500Hz. All EMG data were processed ina hardware filter (10Hz high-pass filter and 1500Hz lowpass filter) and software filter (Butterworth 10Hz high-passand 400Hz low-pass filter). Root mean square (RMS)
values were calculated from raw EMG data over aconsecutive time window (.125 s) and these RMS EMG
data were normalized with reference voluntary contraction

Figure 1. APDF plot of the upper trapezius muscle of subject 1

Statistical anTo find the within subject effects of eachpercentile of APDF, 3-way ANOVA (2 muscle sides x 2
chair types x 3 gaze levels) with repeated measure was
performed. And post-hoc analysis followed by Bonferroni
adjustment. PASW statistics ver. 18 was used inperformance of these statistical analyses.

Results
The findings of this study were 1) The backrest-point
height of the auditorium chair and the height, length andwidth of the connected desk were shorter than what wassuggested by the KS. Another difference was that theauditorium chair had a larger angle of the backrest,
compared to the classroom chair. 2) Regarding withinsubject effect, the sole statistically significant difference
was found between activation of the upper trapezius
muscle. The upper trapezius muscle's %RVC in the APDF
10th-50th-90th percentile was statistically higher forparticipants sitting in the auditorium chair than forparticipants sitting in the classroom chair (p<.05). 3) Aninteraction effect was observed between the “two chairtypes” and the “two muscle-sides” in the APDF 10th-50th
percentile (p<.05). 4) An interaction effect was observed
between the “two chair-types” and the “three gaze-levels"in the APDF 90th percentile (p<.05).
Discussion
If one sustains posture for a few minute, muscles repeat
contraction, and micro-resting were performed in order toavoid fatigue. If this micro-resting is decreased, APDF 10th
percentile will increase. Also, if the muscle activity is
increased, the 50th, 90th, and 99th percentiles of APDF
will also increase. According to Jonsson(1998), when the10th percentile of APDF was high, muscle fatigue will beeasily induced by an increase in muscle activity. And recent
research has demonstrated the relationship of several
indexes like 50th, 90th and 99th percentiles, as well as the10th percentile of APDF between muscle activity andmuscle pain (Blangsted et al., 2003; Østensvik, 2009; Szeto
et al., 2005; Westgaard et al., 2001). According to our
results, the upper trapezius muscle's %RVC in the APDF
10th-50th-90th percentile was statistically higher forparticipants sitting in the auditorium chair than forparticipants sitting in the classroom chair. This means thatmicro-resting of the upper trapezius muscle’s on theauditorium chair is less than that of the classroom chair.
Conclusion
The findings of this study indicated that maintaining a
writing posture for a prolonged period of time in anauditorium chair resulted in significantly increased
activation of the left upper trapezius muscle, compared to aclassroom chair.
Key words: Amplitude Probability Distribution
Function; Chair; Surface electromyography; Trapezius
muscle.
References
Blangsted AK, Hansen K, Jensen C. Muscle activity duringcomputer-based office work in relation to self-reported job

demands and gender. Eur J Appl Physiol. 2003;89(34):352-358.
Cotton LM, O'Co nnell DG, Palmer PP, et al. Mismatch of
school desks and chairs by ethnicity and grade level in
middle school. Work. 2002;18(3):269-280.
Østensvik T, Veiersted KB, Nilsen P. A method to quantify
frequency and duration of sustained low-level muscle
activity as a risk factor for musculoskeletal discomfort. J
Electromyogr Kinesiol. 2009;19(2):283-294.
Jensen C, Nilsen K, Hansen K, et al. Trapezius muscle load
as a risk indicator for occupational shoulder-neckcomplaints. Int Arch Occup Environ Health.
1993;64(6):415-423.
Jonsson B. The static load component in muscle work. Eur
J Appl Physiol Occup Physiol. 1988;57(3):305-310.
Mandal AC. The seated man (Homo Sedens) the seatedwork position: Theory and practice. Appl Ergon.
1981;12(1):19-26.
Szeto GP, Straker LM, O'Su llivan PB. A comparison ofsymptomatic and asymptomatic office workers performing
monotonous keyboard work-1: Neck and shoulder muscle
recruitment patterns. Man Ther. 2005;10(4):270-280.
Waris P. Occupational cervicobrachial syndromes. A review.
Scand J Work Environ Health. 1980;5suppl3:3-14.
Westgaard RH, Vasseljen O, Holte KA. Trapezius muscle
activity as a risk indicator for shoulder and neck pain infemale service workers with low biomechanical exposure.
Ergonomics. 2001;44(3):339-353.
Corresponding Author address
Sang-hyun Cho, fastcloud@yonsei.ac.kr

MUSCLE ACTIVATION OF THE GLUTEUS MAXIMUS AND HAMSTRINGSDURING PRONE HIP EXTENSION WITH KNEE FLEXION
IN THREE HIP ABDUCTION POSITIONS
Sunyoung Kang1), Hye-Seon Jeon2) ,Ohyun Kwon2), Heon seock Cynn2),
1) Dept. of Physical Therapy, College of Health Science, Yonsei University2) Dept. of Physical Therapy, College of Health Science, Yonsei University
Dept. of Ergonomic Therapy, The Graduate School of Health and Environment, Yonsei University
Introduction
The direction of fiber alignment within a muscle is
known to influence the effectiveness of muscle contraction[1]. When the line of action of the muscle matches the line offiber of the muscle, the effect of muscle contraction is
augmented [2]; however, most of the commonly used clinicalgluteus maximus (GM) exercises do not consider the
downward and outward fiber alignment within the muscle
and no study has considered the effect of hip abduction
position in relation to muscle fiber arrangement during GM
exercises. Therefore, the purpose of this study was toinvestigate the EMG amplitude and relative onset differenceof the GM and HAM during prone hip extension with knee
flexion (PHEKF) exercise in three hip abduction positions(0°, 15°, and 30° hip abduction). We hypothesized that the
EMG amplitude of the GM would increase and the EMG
onset of the GM would be earlier than that of the HAM in the
30° hip abduction position.
Materials and Methods
Subjects: Thirty healthy subjects (18 men, 12 women)
were recruited at Yonsei University in Korea (age: 22.8 ± 2.9
yrs, body mass: 66.9 ± 10.8 ㎏, height: 170.3 ± 4.1 ㎝). The
exclusion criteria included (1) a history of lumbar, sacroiliac
or lower limb injury within the past year, (2) past or present
neurological, musculoskeletal, and cardiopulmonary diseases,and (3) lumbar or hip pain when performing PHEKF. Fourmusculoskeletal examinations of the lower extremities were
performed to avoid compensations related to muscle
shortness around hip joint; thomas test, ober’s test, adduction
contracture test, and active straight-leg raises [3]. Prior toparticipation in the experimental data collection, the principal
investigator explained the entire procedure to the subjects.
This study was approved by the Yonsei University Wonju
Campus Human Studies Committee and all participants gave
written informed consent.
Experimental Apparatus: EMG data from the GM and
HAM of the dominant leg were collected using a Noraxon
Telemyo 2400T system (Noraxon, Inc., Scottsdale, AZ,
USA). The EMG electrodes were placed in parallel to themuscle fibers according to the methods described by Cram[4]. The reference electrode was attached to right anterior
superior iliac spine (ASIS). For normalization, the mean
RMS of three trials of 5-second maximal voluntary isometriccontraction (MVIC) was calculated for each muscle. MVIC
data were obtained in the manual muscle testing positions
recommended by Kendall [5]. The data for each trial wereexpressed as a percentage of the calculated mean RMS of
the %MVIC, and the mean %MVIC of three trials was used
for statistical analysis.
The baseline EMG was calculated by averaging the EMG
activity for 5-seconds in a resting position. The onset of
EMG activity of each muscle was determined when the EMG

amplitude exceeded two standard deviations of the baseline
level for a minimum of 50 ms. The relative onset difference
between the GM and HAM was calculated by the following
equation:
relative onset difference = GM onset - HAM onset (in ms)
A positive value indicates that the HAM fired before the GM.
When the GM fires earlier than the HAM, the relative onset
difference becomes a negative value [6].
Experimental Procedure: Each participant was positioned
prone on a therapeutic table with their feet shoulder-width apartand arms at their sides. 0°, 15°, and 30° hip abduction angles
were guided by a board beneath the lower extremity. The hip
abduction angle was considered the line between the ASIS andmid-point of the patella based on the starting position. For the
PHEKF exercise, at the starting position, the subject was asked
to bend his or her knee to 90° and relax by resting their leg on a
vertically positioned wooden device [7]. Two vertical wooden
guides were aligned with the lower extremity to limit
substitutions by knee flexion or hip rotation of the examined leg.
Then the participant was given a verbal cue to lift their
dominant leg toward the ceiling until the patella was lifted 5 ㎝
off of the supporting surface, and then asked to maintain theextended hip for 5 seconds. The subjects performed the PHEKF
exercise three times for each hip abduction position with a 30 sinter-trial period and a 2-minute rest period was given between
the positions.
Data analysis: All dependent variables were presented as themean ± standard deviation (SD). Repeated measures analysis ofvariance (ANOVA) with the Bonferroni correction was used tocompare the EMG amplitude and relative onset differencesamong the three hip abduction positions. The level of statisticalsignificance was set at 0.05. The Statistical Package for theSocial Sciences for Windows version 18.0 (SPSS, Inc., Chicago,
IL, USA) was used for all statistical analyses.
Results
EMG Amplitude: The GM and HAM amplitudes during
PHEKF exercise were significantly different among the three
hip abduction positions (p < 0.001). Our post hoc comparison
revealed that GM amplitude was greatest in the 30° hip
abduction position, followed by 15° and then 0° hip abduction
during PHEKF exercise (padj < 0.001). On the other hand, theHAM amplitude at 0° hip abduction was significantly greaterthan at 15° and 30° hip abduction (padj = 0.008). There was no
significant difference in the EMG amplitudes in the HAM
between the 15° and 30° hip abduction positions during PHEKF(padj = 0.049) (Fiqure 1).
EMG Onset : the relative onset differences were a significant
different acrosee the three hip abduction positions (p < 0.001).

Post hoc comparisons revealed significant differences
between each of the hip abduction positions. The relative
onset difference was greatest in the 0° hip abduction position,
followed by 15° and then 30° hip abduction during PHEKF
exercise (Fiqure 2).

Fiqure 1. EMG amplitude of the GM and HAM in three hip abduction
positions. The means and SDs are show as bars and hatches. *padj <0.05/3.

Fiqure 2. The relative onset difference between the gluteus maximus
and hamstrings in three hip abduction positions.
Relative onset difference = GM onset - HAM onset.
Means and SDs are shown as bars and hatches. * padj < 0.05/3.

Discussion
In this study, the subjects performed PHEKF exercise inthree different hip abduction positions (0°, 15°, and 30°). The
results of this study showed when the angle of hip abduction
is greater, the GM amplitude increases and the HAM
amplitude decreases.
In general, the location of muscle attachment and joint
position are critical in effective motion production since they
are the determining factors in the generation of torque or aturning moment at the joint [1]. The GM muscle isconsidered a fusiform muscle that are composed of fibers thatrun parallel to the longitudinal axis of the muscle. In order to
optimize muscle activation, the muscle fibers should lie inthe same direction as the line of pull of the muscle [2,8]. The
GM arises from the posterior gluteal line of the ilium and theposterior surface of the sacrum and coccyx, and is directed
downward and outward into the iliotibial tract and the gluteal
tuberosity of the femur [9]. By performing hip abduction
during PHEKF exercise, the direction of muscle pull runs
parallel to the fiber of the muscle, leading to increased EMG
amplitude.
Synergistic muscles such as the HAM and GM in hip
extension produce movement around a joint, work together
and influence each other through movement patterns [6].
Under the assumption that the movement occurs in the samerange of motion, increased EMG amplitude of one muscle
can create efficiencies in the movement, thereby decreasing
the workload of another muscle [10]. In this study, we canspeculate that the decreased activity of the HAM in abducted
position may associated with the increased activity of theGM during PHEKF exercise as a synergistic muscle. These
results suggest that performing hip abduction during hip

extension could be a good strategy to selectively increase GM
activation.
Another finding of this study was that the relative onset
difference between GM and HAM at the 15 and 30° hip
abduction positions was negative, meaning that the GM wasfiring in advance of the HAM. This change in relative EMG
onset could be explained by the function of the GM muscle asabductor of the hip [9]. In this experiment, subjects started toperform PHEKF exercise in abducted hip position andmaintained hip abduction while performing the exercise. This
led to activation of the GM as a hip abductor, and increased its
responsiveness to the load applied to maintain the position
during the exercise. When compared of relative onset
differences between 15° and 30° hip abduction, GM firing in
30° hip abduction occurred earlier than in 15° hip abduction.
This result implies that performing PHEKF in 30° hip abduction
position may be an effective method to reduce delyaed GM
onset and may be beneficial for preventing motor control
dysfunction of the hip extensors.
Conclusions
These findings indicate that performing PHEKF
exercise in the 30° hip abduction position may berecommended as an effective way to selectively activate
the GM and to reduce the delay in GM firing inasymptomatic individuals. This finding provides
preliminary evidence that GM amplitude and onset time
can be modified by the extent of hip abduction. However,this suggestion needs to be confirmed that this change
could be maintained and transferred to functional
movements in future research.
References[1] Soderberg GL. Muscle mechanics and pathomechanics.
Their clinical relevance. Phys Ther. 1983;63(2):216-20.
[2] Smidt GL, Rogers MW. Factors contributing to theregulation and clinical assessment of muscular strength.
Phys Ther. 1982;62(9):1283-90.
[3] Magee D. Orthopedic Physical Assessment. 4th ed.
Philadelphia 2002;WB saunders:692-7.
[4] Cram J, Kasman G, Holtz J. Introduction to surface
electromyography.
Gaithersburg,
Maryland:
Aspen
Publishers 1998.
[5] Kendall F, McCreary E, Provance P. Muscles: Testing andfunction with posture and pain. 2005;5th ed.
[6] Chance-Larsen K, Littlewood C, Garth A. Prone hip
extension with lower abdominal hollowing improves therelative timing of gluteus maximus activation in relation tobiceps femoris. Man Ther. 2010;15(1):61-5.
[7] Sakamoto ACL, Teixeira-Salmela LF, Rodrigues De Paula
F, Guimarães CQ, Faria CDCM. Gluteus maximus andsemitendinosus activation during active prone hip extension
exercises. Rev Bras Fisioter. 2009;13(4):335-42.
[8] Landers KA, Hunter GR, Wetzstein CJ, Bamman MM,
Weinsier RL. The interrelationship among muscle mass,strength, and the ability to perform physical tasks of dailyliving in younger and older women. J Gerontol A Biol Sci
Med Sci. 2001;56(10):B443-B8.
[9] Frank H, Netter R. The CIBA collection of medical
illustrations.1987;volume 8.musculoskeletal system.
[10] Devlin L. Recurrent posterior thigh symptoms detrimental
to performance in rugby union: Predisposing factors. Sports
Med. 2000;29(4):273-87.
Author address

E-Mail: rloveush@hanmail.net

JANDA’S SENSORIMOTOR TRAINING IN THE UPPER CROSSED SYNDROME
Jae Jin Lee1), Do Hyeon Kim1), Kyung Hoon Yu2), Young Ki Cho3), Sung (Joshua) Hyun You1)
1) Movement Healing Lab., Department of Physical Therapy, Yonsei University, Wonju, Republic of Korea
2) Glory Hospital, Incheon, Republic of Korea
3) Team of Physical Medicine & Rehabilitation, Asan Medical Center, Seoul, Republic of Korea

Introduction
Cervical crossed syndrome (CCS) is a common
musculoskeletal
impairment,
resultingfromtheneuromuscular imbalance between the tonic-flexor (i.e.,
overactive and tight sternocleidomastoid, SCM; upper
trapezius, UT; pectoralis major, PM) and phasic-extensor(underactive longus colli, LC; lower trapezius, LT) systems
within the sensorimotor system [1]. This muscle imbalance
impairment is often associated with a prolonged habitualforward head posture (FHP) in response to a functional task
demand (i.e., a desk computer work), subsequently leads toadaptive neuromechanical changes in postural and movement
patterns [1, 2]. The neuromuscular imbalance (i.e.,
recruitment patterns, length and tension) between the flexorand extensor systems alters arthrokinematic movement,
thereby leading to joint decentration and associateddeterioration or cervical spine pathology [1].
Conventionally, the resistive, isometric neck flexion
exercise (RIE) has been used to improve deep neck flexor
stability and to correct this impairment [3], but its therapeutic
efficacy and underlying mechanisms remains unclear. It is
unknown whether or not LC is selectively activated while theantagonistic UT and SCM are reciprocally deactivated. It isbelived that the isometric contraction of neck flexor alongwith concurrent activation of the shoulder and elbow flexors
as in RIE may further strengthen the neck flexor system
which is prone to be overactive. Janda developed thesensorimotor training (SMT) to restore neuromuscular
imbalance [1], which involves isometric exercise to activate
LC while inhibiting SCM and UT using elastic band(theraband). Nevertheless, underlying mechanism of thisapproach was rarely studied. Hence, our specific aim is todetermine the intervention-related changes in the muscle
activation patterns (muscle imbalance ratio, MIR) andmuscle thickness data between two interventions. Our basic
premise was that Janda's SMT would increase greater
activation in underactive LC while inhibiting overactive UTand SCM when compared RIE.
Methods
1. Subjects: Eighteen subjects (7 female) volunteered forthis study. The mean age was 244 years (range 20-35 years).
Inclusion criteria entailed those individuals with FHP(anterior deviation of the lobe of the ear more than 1cm tothe plumb line [5]), but were free from any neuromotor or
musculoskeletal impairments. Informed consents wereobtained prior to the study.
2. Measurements
2.1. Ultrasonography(US): SonoAce (X8, Medison Co.,
Ltd, Korea) with a 10MHz transducer was used to measure
SCM and LC thickness unilaterally (right side) during restand both exercises. The subjects were seated with both arms
rested on the laps and neutral head and neck position. The
LC was identified by palpating the thyroid cartilage marked 2
cm below this level in a relaxed position. The transducer wasthen placed perpendicular to the vertical axis of cervical spine
and the US image was obtained 3 times [4].
2.2. Electromyography (EMG): The EMG device (WEMG8 System, LXM 5308; Laxtha, Daejeon, Korea) was used tocollect muscle activation data. EMG data were collected
simultaneously from the SCM, UT, LT and PM. The sampling
rate was 1024 Hz, and the EMG signal was amplified with an
overall gain of 1785 and digitized by using Telescan 3.03
software (Laxtha). Band-pass (20–450 Hz) and notch filters (60Hz) were used. EMG data was expressed as a percentage of root
mean square (RMS) of maximum voluntary isometriccontraction (%MVIC). Onset time for each muscle was set tothree standardized deviation of the mean resting amplitude.
2.3. Handheld dynamometer(HHD): The handheld
dynamometer (Commander muscle tester, JTECH MEDICAL,
USA) was used to determine and monitor submaximal isometricresistance (20% of maximum isometric contraction) applied
throughout the entire experimental tests and intervention so as
to ensure consistent measurement and feedback.
3. Procedure: All subjects performed SMT and RIE withmaximum effort and the effort was measured by HHD placed on
the hand which detects the pressure caused by exercises. Then
subjects performed 3times each exercise for data collection with
20% of maximum effort. During the exercises US imaging and
EMG data were collected.
3.1. SMT: The subjects placed both hands on forehead tohold an elastic band which encircles head and gently extended
their arms against an elastic band. Simultaneously, they were
instructed to perform cervical retraction.
3.2. RIE: The subjects placed both hand on against theforehead and gently pressed the forehead. The HHD was placed
between hands and forehead to detect the intensity of theexercise.
4. Statistical analysis: Paired t-test was used to compare
muscle thickness change for SCM and LC, to compare muscle
activity patterns for SCM, PM, UT and LT between SMT and
RIE. The level of statistical significance was set at p<0.05.
Results
1. Muscle thickness: There was significant difference of
SCM thickness change between two exercises. SCM thickness
was decreased during SMT wherease it was increased during
RIE (p=0.00). Otherwise significant increae of lateraldemension(LD) thickness of LC was observed during SMT
compared to RIE (p=0.02). During SMT, anterior posterior(AP)thickness of LC was also increased more than RIE but it was notstatistically significant (p=0.29) (Table 1).
2. Muscle activity: Muscle activity of LT was increased
significanlty during SMT compared to RIE (p=0.00). During
RIE, SCM (p=0.01) and PM (p=0.04) activity was significantly
increased compared to SMT (Table 2).
During SMT, muscle onset order was LT(0.09±0.19),
PM(0.11±0.21), SCM(0.25±0.16), UT(0.32±0.12) while onset
order duing RIE was LT(0.14±0.14), SCM(0.21±0.10),
PM(0.23±0.10), UT(0.25±0.06) (Fig. 1).

Table 1 Comparison of muscle thickness increase between
SMT and RIE
Increase of muscle
thickness

SMT

RIE

t

p

SCM thickness(mm)-0.03±0.11

0.27±0.14

7.95

0.00*

LC LD(mm)0.21±0.08

0.06±0.16

-3.73

0.02*

LC AP(mm)
-1.08
0.29
0.11±0.22
0.05±0.07
SCM thickness: SCM thickness during SMT or RIE - SCM thickness
during rest

LC AP: LC anterior posterior thickness during SMT or RIE - LCanterior posterior thickness during rest
LC LD: LC lateral dimension thickness during SMT or RIE - LClateral dimension thickness during rest

joint centration during neck movement in individuals withcervical pathology associated muscle imbalance in FHP. UTand SCM overactivation with LC underactivation are importantbiomakers for CCS associated with FHP, rounded shoulder,shoulder impingement and headache [1, 6]
Taken together, our novel findings suggest that Janda’s
SMT approach is useful to improve muscle imbalance syndrome.
Hence, our results provide clinical insight for effective
therapeutic exercise in individuals with neuromuscular
imbalance and associated CCS.
Conclusions
Our present study first demonstrated that SMT was more
beneficial for LC and LT activation than the RIE. This finding
suggests that SMT could be appropriated therapeutic exercise
for the patient with CCS.

Table 2 Comparison of muscle imbalance ratio(agonist/antagonist) between SMT and RIE

Muscleimbalance ratio
SCM/UT

SMT

RIE

t

p

0.41±0.19

0.56±0.12

3.25

0.01*

PM/(UT+LT)

0.52±0.10

0.62±0.27

2.25

0.04*

LT/UT
-3.90
0.72±0.30
0.55±0.27
SCM/UT: %MVIC of SCM/%MVIC of UT
PM/(UT+LT): %MVIC of PM/%MVIC of UT+LT
LT/UT: %MVIC of LT/%MVIC of UT*: p<0.05

0.00*

SMT

RIE
UT

UT

LT

LT

SCM

SCM

PM

PM

Fig. 1 Comparison of muscle onset time between SMT
and RIE

Discussion
The present study highlighted the efficacy andneuromotor control mechanism of Janda’s SMT whencompared to RIE. As we anticipated, our findings
demonstrated that Janda’s SMT is effective therapeutic
exercise for FHP compared to RIE.
US imaging data showed that SMT significantly
increased LC muscle thickness and decreased SCM whencompared with RIE, suggesting a superior effect on muscle
activation of the deep neck stabilizer. A correlational study
showed that muscle thickness in US represents muscle
activation [7, 8]. Similarly, our EMG analysis of muscle
imbalance ratio revealed that muscles (SCM, PM, UT) thatare prone to overactivation were decreased while the muscle(LT) that is prone to inhibition was increased in EMG
amplitude measurements in the SMT. This finding
corroborates Janda’s notion that SMT is more benefical for
restoring muscle imbalance between the tonic-flexor andphasic-extensor systems, in a such way that it reciprocallydeactivate the overactive antagonist (i.e., UT) and facilitate
the underactive agonist (i.e., LT). Consequently, this restored
muscle imbalance can correct altered cervical spinealignment, length-tension relationship, creating a optimal

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Measurement of muscle contraction with ultrasound imaging.
Muscle Nerve. 2003;27(6):682-92.
Author address

E-Mail: neurorehab@yonsei.ac.kr; cymdyb@naver.com

Feasibility of Emerging devise for Electrical Muscle Stimulation immediately after
Cardiovascular Surgery
Kotaro IWATSU 1), Sumio YAMADA 2)
1) Program in Physical and Occupational Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
2) Department of Rehabilitation Science, Nagoya University Graduate School of Medicine, Nagoya, Japan
Introduction
After surgical trauma, muscle protein is wasted because ofaccelerated protein catabolism1-3). Since loss of muscle
protein is accompanied by a loss of muscle strength which
induces functional decline of patients after cardiovascularsurgery, preservation of skeletal muscle protein is of majorclinical issue in postsurgical rehabilitation.
Electrical muscle stimulation (EMS) has been focused with
substantial clinical interest that could induce sufficientmuscle activities without patients’ cooperation even
immediately after surgery 4-7). However, EMS devices used inclinical practice were limited to induce sufficient muscle
torque response because of pain.
We, therefore, aimed to examine feasibility of our new
EMS experimental system which allowed us to prescribe
EMS based on maximal voluntary contraction (MVC) withless pain in patients immediately after cardiovascular surgery.
Materials and Methods
Patient population
Patients were consecutively included if they at least 20
years of age and were intended for elective major
cardiovascular surgery (coronary artery bypass surgery,valvular surgery, aortic surgery, or combined surgery).
Exclusion criteria were: age under 20 years, chronic renal
failure (estimated glomerular filtration rate: eGFR<30
ml/min./1.73m2), peripheral arterial disease (Fonteinclassification ≧ Ⅲ , psychiatric disease, neuromusculardisease, and dementia (Mini-Mental State Examination <18
points). Patients with technical obstacles that did not allow
the implementation of EMS such as intra-aortic balloon
pumping were also excluded, but patients with pacemaker
were included. Informed consent was obtained from eachpatient as approved by the Ethics Review Committee of
Nagoya University Graduate School of Medicine (1272).
Study Protocol
In all cases, measurement of MVC and determination of theintensity of EMS were performed on the day before theoperation. After surgery, EMS was implemented on thebilateral quadriceps and triceps surae muscles daily fromsecond to sixth day after surgery (5 sessions). The duration of
the session was 60minutes. Blood pressure, heart rate,electrocardiogram and muscle soreness during EMS weremonitored by physiotherapist in each session. Blood pressure,heart rate and rhythm were measured by Patient Monitor
system (IntelliVue MP70, PHILIPS). Muscle soreness wasassessed by the Faces pain scale (16).
EMS
In this study, stimulus pattern of EMS was the variablefrequency train which was developed in our laboratory totheoretically optimize muscle contraction as voluntary
contraction and to induce 20% MVC without pain. The
variable-frequency train included initial two high-frequency(200Hz) bursts at the onset of low-frequency (20Hz)
stimulation. The waveform of EMS was a symmetricbiphasic square wave. The stimulator was configured todeliver a direct electrical current for 10 seconds followed by
30 seconds of rest. The intensities of the stimulation were set

at 10% or 20% of MVC and the repetitions of 10%-10%20%MVC were prescribed throughout the session.
Feasibility Assessment
Feasibility criteria was established as follows: 1) more than
80% of participants who could complete more than 4 of 5
sessions, 2) change in systoic blood pressure during EMS<20mmHg, 3) change in heart rate during EMS <20bpm, 4)
incidence of new onset post-operative atrial fibrillation (POAF)
during study period < 30% in CABG, <40% in valvular surgery,and <50% in combined and aortic surgery. In this study, wedefined successful EMS session as the session in which patient
could receive EMS for 30minutes and over.
Statistics
Data for descriptive statistics are expressed as percentages, or
mean±SD. Data are analyzed for all days that EMS had been
applied during the enrollment period
Results
Patient population
From November 2011 to August 2012, a total of 95 patients
intended for elective cardiovascular surgery were included inthis study and 40 patients fulfilled exclusion criteria or refused
to participate. The study population consisted of 55 patients.
Patient demographics are listed in Table1
Table1. Patients Demographics
Demographics
Age, yrs
Male, %
Body mass index, kg/m2

n=46
65.7 ± 11.6
76.1%
23.6 ± 3.3

Operative procedure
CABG, no (%)

19 (41.3%)

Valvelar, no (%)

17 (37.0%)

Aortic, no (%)

6 (13.0%)

Combined, no (%)

Time from surgery to initial EMS session, days

4 (8.7%)1.3±0.5

Intravenous drugs at 1st EMS session
Norepinephrine, no (%)

9 (19.6%)

Dobutamine, no (%)

15 (32.6%)

Dopamine, no (%)

9 (19.6%)

Milrinone, no (%)

4 (8.7%)

Furosemide, no (%)

4 (8.7%)

Carperitide , no (%)

2 (4.3%)

Nicardipine, no (%)

7 (15.2%)

Nicorandil, no (%)

18 (39.1%)

landiolol, no (%)

3 (6.5%)

Feasibility of EMS
Thirty-seven out of Forty-five (82.2%) patients had
successively completed 4-5 sessions. None of patients did notexperience the change in systolic blood pressure>20 mmHg
and/or heart rate>20bpm during EMS. Response to EMS insystolic blood pressure and heart rate at first EMS session wasshown in Table 2.

Table 2. Cardiovascular response at 1st EMS session
RestCV
at rest⊿10min⊿20min⊿30min⊿40min⊿50min⊿60minCV
at EMS

sysBp

106.7
(97.3-112.7)

3.5(2.1-5.5)

3.3(-1.7-7.3)

3.3(-3.7-6.0)

1.3(-11.6-14.3)

2.7(-0.9-5.8)

0.3(-5.3-4.7)

1.3(-5.3-4.7)

3.7(2.7-4.3)

HR

84.7(74.7-92.0)

1.3(0.7-2.6)

0.0(-1.3-1.7)

0.7(-0.3-3.0)

0.0(-1.3-2.3)

1.0(-1.0-3.3)

0.7(-1.0-3.3)

1.3(-1.3-3.7)

2.2(0.9-4.1)

sysBp, systolic blood pressure; HR, heart rate; CV, coefficient of variance. Data are presented as median (interquartile range)

There was not clinically significant change in systolic bloodpressure and heart rate. Incidence of POAF was 20.0% (3/15)
in CABG, 18.2% (2/11) in valvular surgery, and 16.6% (1/6)
in combined and aortic surgery (Table 3). The two patients
who received CABG manifested paroxysmal AF during ES.
Five out of 45 patients (11.1%) dropped out due to muscle
soreness or fatigue at first ES session after the operation.
Table3. Criteria for Success of Feasibility and Associated
Outcomes
Criteria for
Success of FeasibilityStudyoutcome>80% of participants cancomplete ≧4 of 5 sessions

41 of 46
(89.1%)

Systolic blood pressure

In all of participants,changes in systolic bloodpressure from rest to EMS
do not excess 20mmHg

100%Heart rate

In all of participants,changes in heart rate fromrest to EMS do not excess
20bpm

100%

Incidence of POAF

< 30% in CABG

5 of 19(26.3%)< 40% in valvular surgery

3 of 17(18.8%)< 50% in aortic or combined
surgery

3 of 10(30.0%)

VariableCompliance
Cardiovascular response to EMS

Discussion
Clinically insignificant responses of systolic blood pressureand heart rate, incidence of POAF, and good complement
rate indicated that emerging new EMS which can induce
strong muscle contraction can be safely implemented even
immediately after cardiovascular surgery. In our knowledge,
this is first study that reports the feasibility and safety of suchan aggressive EMS intervention.
The intensities of EMS in previous studies were limited at
intensities able to cause visible contractions (<5% of MVC)
4-7)
. In contrast, our study demonstrates that EMS inducing
stronger muscle contraction at 10% and 20% of MVC is
feasible in patients immediately after cardiovascular surgery.
Since there is the dose-response relationship between muscle
protein synthetic response and intensity of muscle
contraction 8), EMS which induces higher intensity muscle
contractions might be more effective for preventing loss ofmuscle protein. Thus, our study suggests that more effective
EMS intervention for preventing muscle protein degradation
after cardiovascular surgery is feasible and safe in terms ofcardiovascular response to EMS.
Conclusions
New EMS which can induce stronger muscle contraction isboth feasible and safe even immediately after cardiovascularsurgery. This preliminary report provides a basis of carryingout our future research to examine the effects of our new

EMS on prevention of muscle loss after cardiovascular surgery.
References
1) Biolo G, Toigo G, Ciocchi B, et al. Metabolic response to
injury and sepsis: changes in protein metabolism. Nutrition
1997;13:52S–57S
2) Peterson B, Wernerman J, Waller SO, et al. Elective
abdominal surgery depresses muscle protein synthesis andincreases subjective fatigue: effects lasting more than 30
days. BrJ Surg 1990; 77: 796-800
3) Caso G, Vosswinkel JA, Garlick PJ, et al. Altered protein
metabolism following coronary artery bypass graft (CABG)
surgery. Clin Sci (Lond) 2008; 114: 339-46.
4) Needham DM, Truong AD, Fan E. Technology to enhancephysical rehabilitation of critically ill patients. Crit Care Med.
2009; 37: S436-41.
5) Vinge O, Edvardsen L, Jensen F, et al. Effect oftranscutaneous electrical muscle stimulation on postoperativemuscle mass and protein synthesis. Br J Surg. 1996; 83: 3603.
6) Strasser EM, Stättner S, Karner J, et al. Neuromuscularelectrical stimulation reduces skeletal muscle protein
degradation and stimulates insulin-like growth factors in anage- and current-dependent manner: a randomized,
controlled clinical trial in major abdominal surgical patients.
Ann Surg. 2009; 249: 738-43.
7) Gerovasili V, Stefanidis K, Vitzilaios K, et al. Electricalmuscle stimulation preserves the muscle mass of critically illpatients: a randomized study. Crit Care. 2009; 13: R161.
8) Kumar V, Selby A, Rankin D, Age-related differences in thedose-response relationship of muscle protein synthesis toresistance exercise in young and old men. J Physiol. 2009;
587: 211-7.
Author address

E-Mail: iwatsu.kotaro@e.mbox.nagoya-u.ac.jp

The effect of internet based cardiac rehabilitation with pulse monitoring device on
improvement of exercise tolerance and coronary risk factor modification: a pilot study.
Y. Hagiwara1), H. Nagata2), H. Hirayama3), Y. Kono4), H. Ishii5), S. Yamada4)
1) Program in Rehabilitation, Nagoya University Graduate School of Medicine
2) Department of Rehabilitation, Nagoya Daini Red Cross Hospital3) Department of Cardiovascular Medicine, Nagoya Daini Red Cross Hospital4) Department of Rehabilitation science, Nagoya University Graduate School of Medicine
5) Department of Cardiology, Nagoya University Graduate School of Medicine
Introduction
Cardiac rehabilitation (CR) has been proved beneficial inincreasing exercise capacity and reducing coronary risk
factors. Despite the documented benefits of CR, attendanceat the CR program is remained much poor. The previous
study reported that the overall rate of participation of acute
myocardial infarction (AMI) patients in CR in Japan was
estimated at 4.8-11.7% [1]. The barriers of time and distancewere reported the reason for this low participation rate [2].
These problems could be overcome by home based CR,
which patients could perform CR whenever and wherever
they want. Telehealth intervention (phone, e-mail andinternet) was considered as one of the strategies supported
for home based CR [3, 4]. However, previous studies did notuse sensor device for monitoring exercise. Thus wedeveloped a new system for internet based CR with using
pulse monitoring device (PMD). By using PMD, we could
perform exercise prescription by means of objective data andpatient could manage the exercise intensity at CR. This study
aimed to investigate the effect of internet based CR with
PMD in increasing exercise tolerance and reducing risk
factors.
Materials and Methods
Subjects: We recruited the patients with AMI who underwent
percutaneous coronary intervention at Nagoya Daini Red
Cross Hospital. Inclusion criteria were patients with AMI
who met the criteria for risk classification for exercise
training: Class B from the statement of American Heart
Association. We excluded the patients with inaccessible tocomputers, hemodialysis, chronic atrial fibrillation,orthopedic or neurogenic disorders and cognitive impairment.
Procedures: This study was constructed as a case series
design to investigate the effects of internet based CR with
PMD. The CR program started one month after discharge
and performed 8 weeks. For primary outcomes, we assessed
exercise tolerance and coronary risk factors before and after
CR program. And we also measured physical activity forsecondary outcomes. The study protocol was approved by the
Ethics Review Board of Nagoya University School of
Medicine, and written informed consent was obtained fromall of the patients.
Exercise tolerance: Each patient underwent cardiopulmonary
exercise testing (CPX) at a progressively increasing work
rate to maximum tolerance on a cycle ergometer. The test
protocol was in accordance with the recommendations of theAmerican College of Sports Medicine [5]. We assessed
oxygen uptake at anaerobic metabolic threshold (ATVO2)
and peak point (PeakVO2) as exercise capacity by using theanalysis equipment for respiratory gas exchange.
Coronary risk factors: We assessed body mass index (BMI),
home blood pressure (Home BP), lipid profiles, glycatedhemoglobin and smoking habits as coronary risk factors.

Home BP was defined as the average of consecutive 7 days. We
evaluated serum high-density lipoprotein cholesterol (HDL-C),
low-density lipoprotein cholesterol (LDL-C) and hemoglobin
A1c (HbA1c) by using standard methods from fasting samples.
Smoking habits was determined by self-report questionnaire.
Physical activity: The mean daily step count and the duration of
low-, moderate- and high-intensity physical activity were used
(total count over 7 days/7) for 1 week as an index of thephysical activity of the patient. Low-, moderate- and highintensity activity correspond to less than 3.0 METs, 3.0～6.0
METs and more than 6.0 METs, respectively. To estimate thedaily physical activity, an electrical accelerometer (Kenz
Lifecorder, Suzuken, Nagoya, Japan) was selected. All patientswere instructed on how to put on the accelerometer themselves
and use the accelerometer 24 h/day for 1 week, except whilebathing and sleeping.
Intervention: We gave patients to PMD (figure1), the laptop
pre-installed with the application software and educationmaterials about lifestyle modification for secondary prevention.
The patients entered their records of home BP, weight, andimplementation status of exercise. These data could be sent to
Nagoya University through the internet and we could confirm
patients' status at university. The patients were received exercise
prescription which was determined based on their CPX data andtheir self-monitored pulse rate by using the PMD. As PMD wasconnected to the laptop, the exercise records were automaticallysent to Nagoya University. We performed some advice about
exercise and feedback based on PMD data once a week for the
first 4weeks, once two weeks for the next 4weeks.
Data analysis: A paired-t test was used to compare thedifferences in exercise tolerance and coronary risk factors
between pre and post-intervention. All analyses were performed
with the SPSS 16.0 software package (SPSS Inc., Tokyo, Japan).
A p-value of less than 0.05 was considered statisticallysignificant.

Figure 1 Pulse monitoring device (PMD)
The patients could monitor their pulse rateduring home exercise.

Results
11 AMI patients who could not attend outpatient CR
program participated in this study between December 2010
and December 2011. Results were expressed as mean ±standard deviation (Table1). ATVO2, PeakVO2 and HDL-C
were significantly increased, and LDL-C was significantly
decreased during the intervention period. Similarly, there
were significant increase in daily step counts and duration ofphysical activity in moderate to high intensity. On the other
hand there were no significant changes in BMI, Home SBP,
Home DBP, and HbA1c.
Table 1 Changes in exercise tolerance and coronary risk
factors at baseline and after 8-week CR program
Baseline

8-week CR
programP

AT VO2(ml/min/kg)

12.0

±

2.1

13.5

±

2.5

0.014*

Peak VO2(ml/min/kg)

21.6

±

5.0

24.0

±

4.6

0.004*

BMI(kg/m2)

23.6

±

3.6

23.4

±

3.4

0.296

Home SBP(mmHg)

120.4

±

19.8

115.5

±

19.4

0.361

Home DBP（mmHg）

77.4

±

12.4

79.3

±

10.9

0.680

HDL-C
(mg/dL)

39.7

±

7.0

50.0

±

15.8

0.007*

LDL-C(mg/dL)

118.0

±

38.9

84.5

±

27.6

0.011*

HbA1c
(%)

6.1

±

1.3

5.7

±

0.6

0.120

*P<0.05 compared to baseline (paired t-test)
AT VO2: oxygen uptake at anaerobic metabolic threshold
Peak VO2: oxygen uptake at peak point
BMI: Body mass index
SBP: Systolic blood pressure
DBP: Diastolic blood pressure
HDL-C: High-density lipoprotein cholesterol
LDL-C: Low-density lipoprotein cholesterol
Discussion
The results of our study demonstrated that internet based
CR with PMD has favorable effects on ATVO2, PeakVO2
and lipid profile in AMI patients. To our knowledge, this is
the first study to demonstrate the effect of internet based CR
program on exercise tolerance and coronary risk factors.
Exercise capacity significantly increased after 8-week
CR program. The rate of improvement of AT VO2 andPeakVO2 were 12.5% and 11.1%, respectively. In theprevious study which compared active outpatient CR
participants with non-active participants [6], the active CR
participants showed a significantly greater improvement inexercise capacity than non-active participants (15.6% vs8.6%). Thus, it seemed that internet based CR could act as
an alternative to conventional outpatients CR. By using PMD,
patients could manage their exercise duration and intensity.
As a result, daily step counts and duration of physical activity
over moderate intensity were significantly increased after
internet based CR. The increase of physical activity might
contribute to increasing exercise capacity.

There were significantly increased in HDL-C and decreased
LDL-C. The magnitudes of the HDL-C and LDL-C chnage
were 25.9% and 28.4%, respectively. Previous studies havereported that the mean change of HDL-C by exercise was 9.0%[7], and by medications was 5.9% [8]. Therefore, the results ofthe present study might have combined effects of exercise andmedications. On the other hand, there is no consensus theeffects of exercise on reducing LDL-C. Thus, it was difficult todetermine the effects of internet based CR on reducing LDL-C
on the basis of this study.
The small sample size and the only intervention group
might affect the results or our findings. Therefore, this study
could function as a preliminary study to demonstrate the effectof internet based CR. However, our results were obtained in a
selected AMI patients considered a representative sample of themost AMI patients who supposed to apply for internet based CR.
Further research was required to compare the efficacy of
conventional and internet based CR.
Conclusions
The results of our study suggest that internet based CR with
PMD may have a favorable effect on increasing exercise
capacity and reducing coronary risk factors. Further research isneeded to establish the usefulness of internet based CR.
References[1]Goto Y, Itoh H, Adachi H. et al. Use of Exercise Cardiac
Rehabilitation After Acute Myocardial Infarction. –Comparison Between Health Insurance-Approved and NonApproved Hospitals in Japan –. Circ J 2003; 67: 411 – 415.
[2]Ades PA, Waldmann ML, McCann WJ, et al. Predictors ofcardiac rehabilitation participation in older coronary patients.
Arch Intern Med; 1992; 152: 1033 – 1035.
[3]Mittag O, China C, Hoberg E, et al. Outcomes of cardiac
rehabilitation with versus without a follow-up intervention
rendered by telephone (Luebeck follow-up trial): overall andgender-specific effects. Int J Rehabil Res; 2006; 29: 295 –302.
[4]Southard BH, Southard DH, Nuckolls J, et al. Clinical trial of
an internet-based case management system for secondary
prevention of heart disease. J Cardiopulm Rehabil 2003; 23:341 – 448.
[5]Hanson P. Clinical exercise testing. In: Blair SN, Painter P,
Pate RR, Smith LK, Taylor CB, editors. Resource manual for
guidelines for exercise testing and prescription. Philadelphia:
Lea & Febiger; 1998. p. 205–22.
[6]Kamakura T, Kawakami R, Nakanishi M, et al. Efficacy ofout-patient cardiac rehabilitation in low prognostic risk
patients after acute myocardial infarction in primaryintervention era. Circ J 2011; 75: 315-321.
[7]Kelley G, Kelley K, Franklin B. Aerobic exercise and lipids
and lipoproteins in patients with cardiovascular disease: ameta-analysis of randomized controlled trials. J Cardiopulm
Rehabil 2006; 26 (3):131-139[8]Teramoto T, Shimano H, Yokote K, et al. Effects ofpitavastatin(LIVALO Tablet) on high density lipoproteincholesterol (HDL-C) in hypercholesterolemia. J Atheroscler
Thromb 2009; 16(5): 654-61.

Author: Yuta Hagiwara

E-Mail: hagiwara.yuta@h.mbox.nagoya-u.ac.jp
Corresponding Author: Sumio Yamada
E-Mail: yamadas@met.nagoya-u.ac.jp

Immediate Effects of Soft Tissue Massage on Acromiohumeral Distance, Anterior
Translation of Humeral Head, and Glenohumeral Range of Motion in Subjects
With Posterior Shoulder Muscle Tightness: A Preliminary Study
Sil-Ah Choi1), Ji-Hyun Lee1), Tae-Lim Yoon1), Heon-Seock Cynn2)
1)2)Department of Physical Therapy, The Graduate School, Yonsei University, Wonju, Korea
Department of Physical Therapy, College of Health Science, Yonsei University, Wonju, Korea

Introduction
Shoulder impingement syndrome is one of the mostcommon musculoskeletal problems and is related tonarrowing of the acromiohumeral distance (AHD). AHD was
defined as the shortest distance between the inferior surfaceof the acromion and superior aspect of the humeral head
(Kalra et al, 2010). Reduced AHD may be associated withlimited glenohumeral (GH) horizontal adduction and internalrotation, while increased AHD may relieve the symptoms ofcompression of the subacromial space structures (Kalra et al,
2010; McClure et al, 2007).
Especially, posterior shoulder muscle tightness such as
posterior deltoid and teres minor is frequently observed insubjects with shoulder impingement syndrome because theposterior portion of the shoulder muscle tightness causes
anterior and superior translation of the humeral head in
relation to the glenoid fossa (McClure et al, 2007; Tyler et al,2000).
Ultrasonography (US) as an imaging modality is lesscostly and more practical than magnetic resonance imaging(MRI) or computed tomography (CT), and has establishedconcurrent validity with radiographic AHD measures (r =0.77-0.85). However, the effects of soft tissue massage on
AHD and anterior translation of the humeral head have notbeen investigated in subjects with posterior shoulder muscle
tightness using US.
Thus, the purpose of this study was to determine theimmediate effect of soft tissue massage on AHD, anteriortranslation of the humeral head, and GH range of motion(ROM) in subjects with posterior shoulder muscle tightness.
Materials and Methods
Subjects: We recruited 27 subjects (14 male, 13 female)with a 10° or greater difference in the range of GH horizontal
adduction between right and left sides (Park et al, 2010). The
age of subjects was 21.37±1.75 years, height was
169.07±8.41 cm, and weight was 61.51±11.55 kg. Prior tocollecting data, the examiner informed subjects of allprocedures. Subjects read and signed written consent forms.
The study protocol was approved by Yonsei University
Wonju Campus Human Studies Committee.
Instrumentation: US was utilized with 7.5 MHz linear
transducer (SonoAce X8, Medison Co., Ltd, Seoul, Korea) tomeasure AHD and anterior translation of humeral head. An
industrial digital inclinometer (GemRed DBB, Gain Express
Holdings, Ltd., Hong Kong, China) was used for measuring
the range of GH horizontal adduction and internal rotation inthis study.
Inclinometer measurement of the ROM of GH horizontal
adduction: The subject was positioned supine on thetherapeutic table and the test shoulder with the elbow in 90°
of flexion and the shoulder abducted 90°. The examiner
stabilized the lateral border of the scapula by providing a
posteriorly directed force. The examiner grasped the subject’s

forearm, and then moved the humerus into horizontal adduction
passively until the end-feel. The assistant examiner placed adigital inclinometer aligned with the midline of the humerus.
The angle between the humerus and a vertical line to therapeutictable was measured (Intraclass correlation coefficient; ICC =0.93) (Moore et al, 2011; Park et al, 2010).
Inclinometer measurement of the ROM of GH internalrotation: The subject was positioned supine with the shoulder
abducted 90° and the elbow flexed 90°. A folded towel wasplaced under the distal humerus so that the humerus was alignedin the scapular plane. The pressure biofeedback unit was placed
between the therapeutic table and the subject’s scapula forstabilizing the scapula. The elastic bag of the pressure
biofeedback unit was inflated up to 40mmHg, and the humerus
was passively rotated internally. When the pressure changes±2mmHg from 40mmHg during passive GH internal rotation,
an examiner stopped passive internal rotation and determined
this ROM as GH internal rotation without compensation. In thisposition, the assistance examiner placed a digital inclinometeron the dorsal surface of the forearm aligned with the long axisof the ulna. The angle between the forearm and a vertical line totherapeutic table was measured (ICC = 0.93) (Lunden et al,
2010; Kim et al, 2010; Moore et al, 2011).
US measurement of AHD: AHD was measured between theinferior surface of the acromion and the superior aspect of
humerus. Placement of the US transducer was standardized,with its location on the posterior to middle portion of theacromion in the coronal plane, and then the transducer wasplaced parallel to the superior aspect of the acromion so thatboth the acromion and humerus were visualized (ICC= 0.92)(Kalra et al, 2010; Nové-Josserand et al, 1996).
US measurement of anterior translation of humeral head:
We modified an US method that was first described by CourtPayen et al (1995). The transducer was placed on the anterior
aspect of the shoulder. Two well-defined bony structures could
be identified anteriorly: the greater tuberosity of the humerus
and the coracoid process of the scapula. We defined the amountof anterior translation of humeral head as the difference between
the coracoid process and the greater tuberosity of the humerus
head (ICC=0.86).
Soft tissue massage on posterior deltoid and teres minor:
We applied deep gliding massage which is one of the soft tissue
massage therapy techniques for myofascial release (Sherman etal, 2006). The subject was in the side-lying position on the side
not being massaged and the subject’s shoulder and elbow being
massaged were placed in 90° of flexion with humerus in neutral
rotation. The scapula of subject’s shoulder being massaged wasstabilized in a full retraction by examiner's hand. For the soft
tissue massage, the examiner palpated posterior deltoid andteres minor. Posterior deltoid is located in two finger breadths
caudal to the posterior margin of the acromion, and teres minor
is located in one-third of the way between the acromion and theinferior angle of the scapula along the lateral border (Yang etal, 2012). The examiner’s thumb was placed on the target
muscles, and then the examiner applied pressure firmly into
target muscles while asking the subject to slowly turn thetrunk backward. This intervention was performed in 5
repetitions with each repetitions lasting for 20 second andresting period of 10 seconds between repetitions (Park et al,2010). The intensity of massage was modulated individuallyby the subject’s reaction to pain or discomfort. If the subject
complained of discomfort or pain, the intensity of soft tissue
massage was reduced.
Data Analysis
Descriptive statistics were calculated for all variables.
Kolmogorov-Smirnov Z-tests were performed to assess
normality of distribution. Paired t-test was used to compare
AHD, anterior translation of the humeral head, and the rangeof GH horizontal adduction and internal rotation before andafter soft tissue massage. The statistical significance level
was set at 0.05. All statistical analyses were performed using
PASW statistics version 18.0 (SPSS, Inc., Chicago, IL).
Results
All dependent variables were found to approximate anormal distribution (Kolmogorov-Smirnov Z-test, p>0.05).
AHD increased significantly from 1.13±0.13 to 1.22±0.17
after the soft tissue massage (p<0.05). The difference
between the coracoid process and the greater tuberosity of
the humerus head increased slightly from 0.32±0.31 to
0.34±0.34 after the soft tissue massage. This increment
indicates the humeral head was moved posteriorly in the
glenoid fossa and that is to say that anterior translation of thehumeral head was reduced after soft tissue massage.
However, this increment was not significant (p=.40). Also therange of horizontal adduction and internal rotation in GH
joint increased significantly from 22.45±5.12 to 31.08±5.30
and from 61.63±9.48 to 68.11±9.06, respectively (p<0.05).
Discussion
In this study, we investigated the effects of soft tissue
massage on AHD, anterior translation of humeral head andthe ROM of GH joint in subjects with posterior shoulder
muscle tightness. To the best of our knowledge, this study isthe first trial to measure AHD and anterior translation of
humeral head to determine the effect of soft tissue massage toposterior shoulder muscle tightness by using US.
After soft tissue massage, AHD increased significantly by
8% and the amount of anterior translation of the humeral
head decreased by 6%, however, this reduction was not
significant. Additionally, we assessed the range of horizontal
adduction and internal rotation of GH joint before and after
soft tissue massage. There were significant increment of therange of horizontal adduction and internal rotation by 38%
and 10% respectively. These ROM findings are in agreementwith the results from previous studies that soft tissue massage
increased the angle of horizontal adduction and internalrotation significantly.
Our study has several limitations. First, our findings could
not be generalized to patient population because healthy
young subject with a 10° or greater difference in the range of
GH horizontal adduction between right and left sides
participated in this study. Second, this study was a crosssectional study to see the immediate effect of soft tissue
massage. Therefore longitudinal study should be undertaken
recruiting old subjects with shoulder impingement syndromeor anterior translation syndrome to confirm the effects of soft
tissue massage on posterior shoulder muscle tightness. Third,

though we tried to provide a consistent pressure and maintainexact position of the US transducer during data collection,measurement error was likely to occur. So a hands-free methodof attaching the transducer to subjects, like a transducer holder,
may be considered in the future studies. Fourth, since our study
is a preliminary study with one group pretest and posttest design,
randomized controlled trial is warranted to validate the resultsof our study.
Conclusions
Our findings indicate that soft tissue massage on posteriordeltoid and teres minor result in significantly greater increase in
AHD, slight decrease in anterior translation of humeral head,significantly increased the range of GH horizontal adduction
and internal rotation in subjects with posterior shoulder muscle
tightness. Therefore, soft tissue massage can be recommended
as an effective method to increase AHD and the range of GH
horizontal adduction and internal rotation.
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anterior approach. European Journal of Ultrasound.1995;2:283287[2] Kalra N, Seitz AL, Boardman ND 3rd, Michener LA, Effectof posture on acromiohumeral distance with arm elevation in
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Author address
E-Mail: cynn@yonsei.ac.kr

Effects of Breathing Maneuver and Sitting Posture on Muscle Activity in Inspiratory
Accessory Muscles in Patients with Chronic Obstructive Pulmonary Disease
Ki-song Kim, M.P.H., P.T.1, Heon-seock Cynn, Ph.D., P.T.2,
Oh-yun Kwon, Ph.D., P.T.2, and Chung-hwi Yi, Ph.D., P.T.2
1

Department of Rehabilitation Therapy, The Graduate School, Yonsei University
Department of Physical Therapy, College of Health Science, Yonsei University
Institute of Health Science, Yonsei University

2

Introduction
Breathing training [1] and a sitting posture with aforward-leaning trunk [2] have been advocated as therapeuticinterventions in patients with chronic obstructive pulmonary
disease (COPD) to relieve dyspnea and improve pulmonary
function. However, the effects of a forward-leaning position
on inspiratory muscle activity remain unclear. Thus, thisstudy was performed to compare the tidal volume (TV),respiratory rate (RR), and activity of respiratory accessory
muscles during quiet natural breathing (QB) and pursed lips
breathing (PLB) in three different sitting positions: a neutral
position (NP), with arm support (WAS) in a forward-leaning
position, and with arm and head support (WAHS) in a
forward-leaning position in patients with COPD.
Materials and Methods
Subjects: Twelve male subjects (age = 68.2 ± 8.2 years;
weight = 60.4 ± 6.9 kg; height = 1.7 ± 0.4 m; body massindex = 21.3 ± 2.0 kg/m2) diagnosed with COPD wererecruited from the Division of Pulmonary Medicine,
Department of Internal Medicine, Gangnam Severance
Hospital, Yonsei University College of Medicine, Yonsei
University Health System, Seoul, Korea. All subjects wereclassified as stage 2 or 3 COPD (forced expiratory volume in
1 s percent predicted (FEV1 %pred) (50.75 ± 9.27)) by theGOLD criteria [3].
Measurement
tools:
Inductive
respiratory
plethysmography and surface electromyography were
performed using an Embla N7000 (Embla Systems,
Broomfield, CO) to enable the simultaneous acquisition andrecording of respiratory parameters (TV and RR) and surface
electromyographic measurements (muscle activity).
Procedures: Prior to enrollment in the study, all subjects
received a training session for PLB. For the quiet natural
breathing (QB) maneuver, patients were instructed to breathin their normal habitual comfortable breathing style with nospecific training. Breathing maneuvers and sitting postures tobe tested were selected by randomized ballots to eliminate
any possible test order effect. All subjects felt relaxed andcomfortable after a familiarization period of 5 min.
Data analysis: Two-way (2 × 3) analysis of variancewith repeated measures was employed for comparing the twobreathing maneuvers (QB, PLB) and three different positions(neutral position, WAS position, WAHS position). In thecase of significant differences between test positions,
Bonferroni’s post hoc test was performed. In all analyses, Pvalues <0.05 were deemed to indicate statistical significance.
Results
1. TV and RR
For TV, there was no interaction between breathing
pattern and position (F = 0.132, P = 0.877). There was asignificant main effect of breathing method (F = 90.017, P <0.001), but there was no significant main effect of position (F =0.837, P = 0.446). TV in PLB was significantly greater than thatin QB. For RR, there was no interaction between breathing
pattern and position (F = 1.462, P = 0.253). There was asignificant main effect of breathing method (F = 50.702, P <0.001), but there was no significant main effect of position (F =1.387, P = 0.271).
2. Muscle activity
For scalene muscle (SM) activity, there was no interaction
between breathing pattern and position (F = 0.830, P = 0.449).
However, there were significant main effects of breathing
method (F = 19.550, P = 0.001) and position (F = 7.466, P =0.003). Muscle activity in PLB was significantly greater thanthat in QB. Bonferroni’s post hoc test showed that the muscle
activity in WAHS was increased significantly compared withthat in NP (P = 0.017). Muscle activity was not significantly
different between WAHS and WAS (P = 0.070) or between
WAS and NP (P = 0.495). For sternocleidomastoid muscle(SCM) activity, there was no interaction between breathing
pattern and position (F = 0.650, P = 0.532), but significant main
effects of breathing method (F = 5.751, P = 0.035) and position(F = 24.124, P < 0.001) were observed. Muscle activity in PLB
was significantly greater than that in QB. Bonferroni’s post hoc
test showed that the muscle activity in WAHS was increased
significantly compared with that in NP (P = 0.001), and themuscle activity in WAS was increased significantly comparedwith that in NP (P < 0.001). No significant difference in muscle
activity between WAHS and WAS (P = 0.154) was observed.
For pectorals major (PM) muscle activity, the results showed nointeraction between breathing pattern and position (F = 1.138, P= 0.359) and no significant main effect of breathing method (F= 3.940, P = 0.073), but a significant main effect of position (F= 4.662, P = 0.037) was observed. Bonferroni’s post hoc test
showed significant muscle activity differences among the threesitting positions used in this study. Muscle activity in WAS was
increased significantly compared with that in NP (P = 0.025)
and in WAHS (P = 0.029). Muscle activity in WAHS was
increased significantly compared with that in NP (P = 0.039).
Discussion
The findings of this study showed that TV was significantly
greater in PLB than in QB and that RR was significantly lower
in PLB than in QB, supporting the research hypothesis. The
increased TV during PLB was probably due largely to theincreased pressure in extra-thoracic airways and thus to a
reduced cost of breathing due to decreased intrinsic positiveend-expiratory pressure (PEEP). Many patients with COPD use
PLB in an attempt to produce extrinsic PEEP to reduce lung
hyperinflation and dyspnea [4]. The increased TV observed inour study may be explained by a recent study that described thatdeflation of the abdomen and inflation of the rib cagecontributed to increased tidal volume of the chest wall during
PLB [5].
In contrast to PLB, TV and RR did not differ
significantly with sitting position. Thus, the research
hypothesis regarding breathing position was not supported by
the results of this study. These findings are consistent with arecent study by Bhatt et al. [6], who found no significant
differences in FEV1, the ratio of forced expiratory volume toforced vital capacity (FEV1/FVC), maximum inspiratory
pressure (MIP), maximal expiratory pressure (MEP),
diaphragmatic movements during tidal breathing, or forced
breathing in the sitting, supine, or sitting leaning forwardwith the hands supported on the knees (tripod position) inpatients with COPD.
Patients with severe COPD frequently lean forward,
bracing their arms. A position bracing the elbows on a table
increased ventilatory capacity significantly in four healthymen, and this effect could be helpful information for COPD
patients, whose diaphragms are flattened and ineffective, assuch patients depend more on the inspiratory muscles of therib cage [7]. TV and RR did not differ significantly in
relation to sitting position in this study. We had no data on
inspiratory duty cycle or FRC according to different sitting
posture; thus, our results do not provide complete
information about postural changes in lung volumes.
The muscle activities of the SM and SCM in PLB weresignificantly greater than those in QB in this study. Given
that the SM and SCM attach between the cervical spine andthe upper two ribs, increased muscle activity in these muscles
during inspiration in patients with COPD can be interpreted
as an attempt to increase intrathoracic volume by elevating
the upper ribs and sternum [8]. Increased SCM activity in
PLB compared with QB is consistent with the results of aprevious study indicating increased inspiratory rib cage
expansion and recruitment of respiratory accessory muscles
and reduced diaphragm recruitment during inspiration of
PLB compared with tidal breathing [9].
In this study, muscle activities of the SM and SCM in a
forward-leaning position, both WAHS and WAS, weregreater than those in NP, even though the increased muscle
activity of the SM in WAS relative to NP failed to reachstatistical significance. Several mechanisms may explainthese results. First, it is possible that increased activity of the
SM and SCM overcame restricted downward movement of
the diaphragm. The forward-leaning position results inincreased intra-abdominal pressure by approximating the ribs
to the pelvis, making it difficult for the diaphragm to descendcaudally during inspiration [10, 11]. A second possibility is
the reversal of muscle action by the stabilizing force of thehand on the face in WAHS and of the forearm on the thigh in
WAS. As the hands or forearms are stabilized, the sternum,
clavicle, and rib cage can be pulled upward by the SM andSCM.
In this study, the PM showed the greatest muscle activity
in WAS, followed by WAHS, and the lowest PM activity
was observed in NP. These results may be explained byreversal of muscle contraction. When the distal limb segment
is stabilized, the proximal limb segment can be mobilized.
Decreased activity of the PM in WAHS, compared with thatin WAS, may be attributable to increased SM and SCM
activity in WAHS. However, muscle activities of the major
muscles of respiration, including the diaphragm andintercostal muscles, were not measured, so the effects ofchanges in the activity of accessory muscles during different
breathing maneuvers and of various positions on major muscle
activity could not be determined in this study.
Conclusions
The results suggest that in COPD, PLB induced a favorable
breathing pattern (increased TV and reduced RR) comparedwith QB. Additionally, WAS and WAHS positions induced
increased muscle activity of the inspiratory accessory muscles
during inspiration versus NP. Differential involvement ofaccessory respiratory muscles can be readily studied in COPD
patients, allowing monitoring of respiratory load duringpulmonary rehabilitation.
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Corresponding Author address

E-Mail: pteagle@yonsei.ac.kr; kskim68@yuhs.ac