Fracture Liaison Service in Korea: 2022 Position Statement of the Korean Society for Bone and Mineral Research

Osteoporosis and osteoporotic fractures cause socioeconomic concerns, and medical system and policies appear insufficient to prepare for these issues in Korea, where the older adult population is rapidly increasing. Many countries around the world are already responding to osteoporosis and osteoporotic fractures by adopting fracture liaison service (FLS), and such an attempt has only begun in Korea. In this article, we introduce the operation methods for institutions implementing FLS and characteristics of services, and activities of the FLS Committee for FLS implementation in the Korean Society for Bone and Mineral Research. In addition, we hope that the current position statement will contribute to the implementation of FLS in Korea and impel policy changes to enable a multidisciplinary and integrated FLS operated under the medical system.

Reference Standards for Nerve Conduction Studies of Individual Nerves of Lower Extremity With Expanded Uncertainty in Healthy Korean Adults

Objective@#To develop a set of reference standards for tibial motor, common peroneal motor, sural sensory, and superficial peroneal sensory nerve conduction studies (NCSs) with expanded uncertainty in a healthy Korean population. @*Methods@#Standardized procedures were conducted for individual lower extremity NCSs of 199 healthy participants in their 20s (n=100) and 50s (n=99). Mean values and expanded uncertainties for parameters were analyzed with thorough consideration of multiple uncertainty factors under the International Guide to the Expression of Uncertainty in Measurement. In addition, side-to-side differences in onset latency, amplitude, and nerve conduction velocity (NCV) were analyzed. @*Results@#Mean (reference range) for distal onset latency, baseline to negative peak amplitude, NCV of tibial motor nerve in males in their 20s were 4.3 ms (3.1–5.4 ms), 7.1 mV (3.4–10.9 mV), and 50.7 m/s (42.2–59.3 m/s), respectively; sural sensory nerve baseline to negative peak amplitude in males in their 20s was 21.7 μV (8.3–35.2 μV). Including the aforementioned data, we present a vast dataset of normative mean values and expanded uncertainties for NCSs of the leg in a healthy Korean population. Furthermore, upper limits for normal side-to-side differences for onset latency, amplitude, and NCV of each nerve are suggested. @*Conclusion@#To our knowledge, this is the first study to present the reference standards of leg NCSs with consideration for multifactorial uncertainties in an Asian population. We expect these results to help practitioners make reliable and reproducible clinical decisions.

A Malignant Tumor in the Calf Muscles Misdiagnosed as a Myofascial Trigger Point

Tumors are rare causes of calf pain and usually present insidiously. A 69-year-old woman developed sudden severe pain and a hard palpable mass in her left calf that persisted for 6 months without a history of trauma. Although a myofascial trigger point was initially suspected, subsequent ultrasonography revealed two well-defined heterogeneous masses in the calf muscle. Magnetic resonance imaging revealed a multi-lobulated mass involving the soleus, tibialis posterior muscle, and deep peroneal neurovascular bundle, suggesting a soft tissue sarcoma. Fluorine-18-fluorodeoxyglucose positron emission tomography revealed a heterogeneous hypermetabolic lesion in the left calf, suggesting malignancy. The patient received an incisional biopsy of her left calf lesion and was diagnosed with leiomyosarcoma. The patient underwent a wide excision with partial fibulectomy of the left calf and received chemotherapy for metastasis in the left upper lobe of the lung. Although rare, soft tissue sarcoma should be considered in the differential diagnosis if calf pain and a palpable mass persist despite conservative management, and imaging studies are essential for distinguishing tumors from other causes of calf pain.

Clinical Practice Guideline for Postoperative Rehabilitation in Older Patients With Hip Fractures

Objective@#The incidence of hip fractures is increasing worldwide with the aging population, causing a challenge to healthcare systems due to the associated morbidities and high risk of mortality. After hip fractures in frail geriatric patients, existing comorbidities worsen and new complications are prone to occur. Comprehensive rehabilitation is essential for promoting physical function recovery and minimizing complications, which can be achieved through a multidisciplinary approach. Recommendations are required to assist healthcare providers in making decisions on rehabilitation post-surgery. Clinical practice guidelines regarding rehabilitation (physical and occupational therapies) and management of comorbidities/complications in the postoperative phase of hip fractures have not been developed. This guideline aimed to provide evidence-based recommendations for various treatment items required for proper recovery after hip fracture surgeries. Methods Reflecting the complex perspectives associated with rehabilitation post-hip surgeries, 15 key questions (KQs) reflecting the complex perspectives associated with post-hip surgery rehabilitation were categorized into four areas: multidisciplinary, rehabilitation, community-care, and comorbidities/complications. Relevant literature from four databases (PubMed, EMBASE, Cochrane Library, and KoreaMed) was searched for articles published up to February 2020. The evidence level and recommended grade were determined according to the grade of recommendation assessment, development, and evaluation method. Results A multidisciplinary approach, progressive resistance exercises, and balance training are strongly recommended. Early ambulation, weigh-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested. This multidisciplinary approach reduced the total healthcare cost. @*Conclusion@#This guideline presents comprehensive recommendations for the rehabilitation of adult patients after hip fracture surgery.

Clinical Practice Guideline for Postoperative Rehabilitation in Older Patients With Hip Fractures

Objective@#The incidence of hip fractures is increasing worldwide with the aging population, causing a challenge to healthcare systems due to the associated morbidities and high risk of mortality. After hip fractures in frail geriatric patients, existing comorbidities worsen and new complications are prone to occur. Comprehensive rehabilitation is essential for promoting physical function recovery and minimizing complications, which can be achieved through a multidisciplinary approach. Recommendations are required to assist healthcare providers in making decisions on rehabilitation post-surgery. Clinical practice guidelines regarding rehabilitation (physical and occupational therapies) and management of comorbidities/complications in the postoperative phase of hip fractures have not been developed. This guideline aimed to provide evidence-based recommendations for various treatment items required for proper recovery after hip fracture surgeries. Methods Reflecting the complex perspectives associated with rehabilitation post-hip surgeries, 15 key questions (KQs) reflecting the complex perspectives associated with post-hip surgery rehabilitation were categorized into four areas: multidisciplinary, rehabilitation, community-care, and comorbidities/complications. Relevant literature from four databases (PubMed, EMBASE, Cochrane Library, and KoreaMed) was searched for articles published up to February 2020. The evidence level and recommended grade were determined according to the grade of recommendation assessment, development, and evaluation method. Results A multidisciplinary approach, progressive resistance exercises, and balance training are strongly recommended. Early ambulation, weigh-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested. This multidisciplinary approach reduced the total healthcare cost. @*Conclusion@#This guideline presents comprehensive recommendations for the rehabilitation of adult patients after hip fracture surgery.

Current Status of Videofluoroscopic Swallowing Study Practice in Korea through Surveying Experts and Conducting Field Study / 대한연하장애학회지

Methods@#We developed a questionnaire related to VFSS protocols and test diet. It was sent to the expert physicians who directly implementing VFSS in 35 training hospitals, which were sent out and collected by e-mail from December 7, 2017 to February 19, 2018. Among them, 12 out of 28 hospitals selected randomly and we conducted field survey including observing the process of the VFSS. @*Results@#The most common protocol was to provide a test sample with 7 stages (28.1%). In the order of provided test samples, ‘the small amount of liquid’ was the most provided in the 1st stage (53.1%). Among the used samples of thin liquid level, the mixing ratio of the liquid samples and barium was not uniform among each institution. ‘Yogurt (semi-solid type)’ was the most commonly used sample for ‘nectar thick’ and ‘honey thick’ diet. Various samples were used on ‘pudding thick’ diet. @*Conclusion@#These results indicate that, in the 32 Korean general hospitals, each hospital uses samples depending on experience or according to its own standards rather than unified standard among the institutions. Thus, the protocols for each hospital are not standardized, which make them difficult to the accurate sharing of information about the test results. Therefore, it will be necessary to make a consensus for the protocol and establish nationwide standard of VFSS through future research

Correlation Between Mechanography and Clinical Parameters at Six Months After Hip Fracture Surgery

OBJECTIVE: To investigate the correlation between mechanography and clinical parameters in older people at 3 and 6 months after hip fracture surgery.METHODS: A longitudinal follow-up study was conducted in university hospitals with 38 patients at 3 months and 29 patients at 6 months after hip fracture surgery. Subjects 65 years and older completed measurements on the Berg Balance Scale (BBS), Functional Ambulation Category (FAC), walking ability by Koval, Korean version of the fatigue, resistance, ambulation, illnesses, and loss of weight (K-FRAIL) scale, and hand grip strength. The Romberg test with center of foot pressure (COP), chair rise test (CRT), and maximal power (W/kg) were conducted using the Leonardo Mechanograph.RESULTS: COP area and pathway length were correlated with BBS at 3 and 6 months. Change in BBS was correlated with change in COP area, but not with change in COP length. COP area and pathway length were correlated with K-FRAIL at 3 months after hip fracture surgery. The same COP variables showed correlations with FAC and walking ability by Koval at 6 months after surgery. Maximal power during CRT had correlation with chair rise time but not with other clinical parameters.CONCLUSION: The study revealed correlations between mechanography and clinical parameters in older people at 3 and 6 months after hip fracture surgery. Both the clinical assessment and objective test with mechanography may be required for the quantitative and sensitive measurement of postural balance and lower limb muscle power.

Oligomeric Procyanidins (OPCs) Inhibit Procollagen Type I Secretion of Fibroblasts

Wound healing is composed of a complex process that requires harmonies of various cell populations where fibroblasts play the main role. Oligomeric procyanidins (OPC) are main components of grape (Vitis vinifera) seed extracts, and recent studies showed OPC's effects on inflammation, cell migration, and proliferation. We investigated the effect of OPC on fibroblasts to regulate wound healing process. Human dermal fibroblast known as Hs27 cells were treated with various concentrations of OPC (0, 2.5, 5, 10, and 20 µg/µl). Cell cytotoxicity was evaluated by the Cell Counting Kit assay, and the expression levels of secreted procollagen were analyzed. Procollagen levels in OPC treated cells exposed to transforming growth factor beta 1 (TGF-β1) or ascorbic acid were evaluated using Western blot and immunocytochemistry. Relative mRNA expressions of procollagen, molecular chaperone such as HSP47, P4H were determined by real-time PCR in OPC treated cells. OPC showed no cytotoxicity on Hs27 cells at every concentration but inhibited procollagen secretion in a dose-dependent manner. The inhibitory effect also appeared under TGF-β1 induced collagen overproduction. Immunocytochemistry showed that higher levels of intracytoplasmic procollagen were accumulated in TGF-β1 treatment group, whereas ascorbic acid induced a release of accumulated procollagen under OPC treatment. The mRNA expressions of procollagen, molecular chaperone were not affected by OPC, but procollagen level was increased when exposed to TGF-β1. OPC inhibits procollagen secretion from fibroblasts with no effects on cell proliferations even under the environment of TGF-b1-induced collagen overproduction. OPC could regulate the diseases and symptoms of abnormal overabundant collagen production.

Recovery of Proprioception in the Upper Extremity by Robotic Mirror Therapy: a Clinical Pilot Study for Proof of Concept

A novel robotic mirror therapy system was recently developed to provide proprioceptive stimulus to the hemiplegic arm during a mirror therapy. Validation of the robotic mirror therapy system was performed to confirm its synchronicity prior to the clinical study. The mean error angle range between the intact arm and the robot was 1.97 to 4.59 degrees. A 56-year-old male who had right middle cerebral artery infarction 11 months ago received the robotic mirror therapy for ten 30-minute sessions during 2 weeks. Clinical evaluation and functional magnetic resonance imaging (fMRI) studies were performed before and after the intervention. At the follow-up evaluation, the thumb finding test score improved from 2 to 1 for eye level and from 3 to 1 for overhead level. The Albert's test score on the left side improved from 6 to 11. Improvements were sustained at 2-month follow-up. The fMRI during the passive motion revealed a considerable increase in brain activity at the lower part of the right superior parietal lobule, suggesting the possibility of proprioception enhancement. The robotic mirror therapy system may serve as a useful treatment method for patients with supratentorial stroke to facilitate recovery of proprioceptive deficit and hemineglect.

The Effects of Body Mass Composition and Cushion Type on Seat-Interface Pressure in Spinal Cord Injured Patients

OBJECTIVE: To investigate the effects of body mass composition and cushion type on seat-interface pressure in spinal cord injured (SCI) patients and healthy subjects. METHODS: Twenty SCI patients and control subjects were included and their body mass composition measured. Seat-interface pressure was measured with participants in an upright sitting posture on a wheelchair with three kinds of seat cushion and without a seat cushion. We also measured the pressure with each participant in three kinds of sitting postures on each air-filled cushion. We used repeated measure ANOVA, the Mann-Whitney test, and Spearman correlation coefficient for statistical analysis. RESULTS: The total skeletal muscle mass and body water in the lower extremities were significantly higher in the control group, whilst body fat was significantly higher in the SCI group. However, the seat-interface pressure and body mass composition were not significantly correlated in both groups. Each of the three types of seat cushion resulted in significant reduction in the seat-interface pressure. The SCI group had significantly higher seatinterface pressure than the control group regardless of cushion type or sitting posture. The three kinds of sitting posture did not result in a significant reduction of seat-interface pressure. CONCLUSION: We confirmed that the body mass composition does not have a direct effect on seat-interface pressure. However, a reduction of skeletal muscle mass and body water can influence the occurrence of pressure ulcers. Furthermore, in order to minimize seat-interface pressure, it is necessary to apply a method fitted to each individual rather than a uniform method.

Effects of Robot-assisted Upper Limb Training on Hemiplegic Patients

OBJECTIVE: To investigate the effects of short-term robot-assisted upper limb training on hemiplegic patients compared to conventional physical therapy. METHOD: This study was a prospective, single-blinded, randomized controlled trial. Eighteen hemiplegic patients due to brain lesions were randomly assigned to: (1) robot-assisted upper limb training and conventional upper limb physical therapy for 30 min a day, respectively (Robot group); or (2) conventional upper limb physical therapy for 30 min twice a day (Conventional group). All interventions were provided for 2 weeks, 5 times a week. Each patient was evaluated at pre- and post-treatment by the Fugl-Meyer assessment-upper extremity (FMA-UE), Jebsen hand function test (JHFT), grip power, modified Barthel index-upper extremity (MBI-UE), line bisection test, and Albert test. RESULTS: The Robot group showed significant improvement in FMA-UE (pre: 13.22 +/- 14.20, post: 21.67 +/- 15.84; p = 0.018), MBI-UE (pre: 14.33 +/- 7.42, post: 16.56 +/- 6.95; p = 0.041), and line bisection test (pre: 25.15 +/- 34.48, post: 14.93 +/- 28.38; p = 0.043). The Conventional group showed significant improvement only in MBI-UE (pre: 9.22 +/- 6.06, post: 15.56 +/- 6.19; p = 0.008). The improvement in MBI-UE was larger in the Conventional group than Robot group (6.33 +/- 3.28 vs. 2.22 +/- 2.49; p = 0.014). CONCLUSION: This study suggests that short-term robot-assisted upper limb training may improve upper limb function in hemiplegic patients. However, proper physical therapy may be needed to transfer improved upper limb function to activity of daily living. In addition, goal-directed reaching tasks using a robot are expected to be a treatment option for hemineglect.

Harris lines observed in human skeletons of Joseon Dynasty, Korea / 대한해부학회지

The Harris line (HL), caused by bone-growth arrest and manifesting on X-rays as a radiopaque transverse line in the metaphysis of the long bones, is an indicator reflecting stress conditions such as disease or malnutrition. HL frequency has been assumed to differ between pre-modern and modern societies, as reflective of increased caloric intake and overall nutritional improvements attendant on industrialization. To determine if such a change occurred in Korea, in the present study we compared the respective HL statuses in medieval Joseon and modern Korean population samples. HLs were found in 39.4% (28/71) of the Joseon Koreans. Whereas only 27.5% (11/40) of the males showed an HL, fully 54.8% (17/31) of the females exhibited it. Notably, HLs were observed in only 16.4% (35/213) of the modern Koreans; more remarkably still, the HL rate was almost the same between the sexes, 16.7% (20/120) for the males and 16.1% (15/93) for the females. The HL frequency was much higher in the Joseon Koreans than in their modern counterparts, reflecting the improvement of nutritional status that had been achieved in the course of South Korea's modernization. This HL-frequency decrease was much more obvious in the female populations. The higher HL frequency among the Joseon females might reflect the relatively poor nutritional condition of females in pre-modern Korean society.

Evaluating the Differential Electrophysiological Effects of the Focal Vibrator on the Tendon and Muscle Belly in Healthy People

OBJECTIVE: To investigate the electrophysiological effects of focal vibration on the tendon and muscle belly in healthy people. METHODS: The miniaturized focal vibrator consisted of an unbalanced mass rotating offset and wireless controller. The parameters of vibratory stimulation were adjusted on a flat rigid surface as 65 microm at 70 Hz. Two consecutive tests on the different vibration sites were conducted in 10 healthy volunteers (test 1, the Achilles tendon; test 2, the muscle belly on the medial head of the gastrocnemius). The Hoffman (H)-reflex was measured 7 times during each test. The minimal H-reflex latency, maximal amplitude of H-reflex (Hmax), and maximal amplitude of the M-response (Mmax) were acquired. The ratio of Hmax and Mmax (HMR) and the vibratory inhibition index (VII: the ratio of the Hmax after vibration and Hmax before vibration) were calculated. The changes in parameters according to the time and site of stimulation were analyzed using the generalized estimating equation methods. RESULTS: All subjects completed the two tests without serious adverse effects. The minimal H-reflex latency did not show significant changes over time (Wald test: chi2=11.62, p=0.07), and between the two sites (chi2=0.42, p=0.52). The changes in Hmax (chi2=53.74, p<0.01), HMR (chi2=20.49, p<0.01), and VII (chi2=13.16, p=0.02) were significant over time with the adjustment of sites. These parameters were reduced at all time points compared to the baseline, but the decrements reverted instantly after the cessation of stimulation. When adjusted over time, a 1.99-mV decrease in the Hmax (chi2=4.02, p=0.04) and a 9.02% decrease in the VII (chi2=4.54, p=0.03) were observed when the muscle belly was vibrated compared to the tendon. CONCLUSION: The differential electrophysiological effects of focal vibration were verified. The muscle belly may be the more effective site for reducing the H-reflex compared to the tendon. This study provides the neurophysiological basis for a selective and safe rehabilitation program for spasticity management with focal vibration.

Analgesic Effect of Intrathecal Gabapentin in a Rat Model of Persistent Muscle Pain

OBJECTIVE: To evaluate the analgesic effect of intrathecal gabapentin therapy on secondary hyperalgesia in a rat model of persistent muscle pain. METHODS: Intrathecal catheters were implanted into rats. Mechanical secondary hyperalgesia was induced by repeated intramuscular injections of acidic solution into the gastrocnemius muscle. Gabapentin was administrated intrathecally. Rats were allocated to control and experimental (gabapentin 30, 100, 300, and 1,000 microg) group. After gabapentin administration, mechanical withdrawal threshold was measured every 15 minutes and the motor function was measured 30 minutes later. RESULTS: Mechanical hyperalgesia was evoked after the second acidic buffer injection. There was a significant improvement on the mechanical threshold after administration of 100, 300, and 1,000 microg gabapentin compared to pre-injection and the control group. The analgesic effect continued for 105, 135, and 210 minutes, respectively. To discern side effects, motor function was measured. Motor function was preserved in both groups after gabapentin administration, except for rats who received 1,000 microg gabapentin. CONCLUSION: Intrathecal gabapentin administration produces dose-dependent improvements in mechanical hyperalgesia in a persistent muscle pain rat model. This implicates the central nervous system as having a strong influence on the development of persistent mechanical hyperalgesia. These results are helpful in understanding the pathophysiology of secondary hyperalgesia and in the treatment of patients with chronic muscle pain.

Efficacy of Epidural Neuroplasty Versus Transforaminal Epidural Steroid Injection for the Radiating Pain Caused by a Herniated Lumbar Disc

OBJECTIVE: To compare the treatment effects of epidural neuroplasty (NP) and transforaminal epidural steroid injection (TFESI) for the radiating pain caused by herniated lumbar disc. METHODS: Thirty-two patients diagnosed with herniated lumbar disc through magnetic resonance imaging or computed tomography were included in this study. Fourteen patients received an epidural NP and eighteen patients had a TFESI. The visual analogue scale (VAS) and functional rating index (FRI) were measured before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment. RESULTS: In the epidural NP group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.00+/-1.52, 4.29+/-1.20, 2.64+/-0.93, 1.43+/-0.51 and those of FRI were 23.57+/-3.84, 16.50+/-3.48, 11.43+/-2.44, 7.00+/-2.15. In the TFESI group, the mean values of the VAS before the treatment, and at 2 weeks, 4 weeks and 8 weeks after the treatment were 7.22+/-2.05, 4.28+/-1.67, 2.56+/-1.04, 1.33+/-0.49 and those of FRI were 22.00+/-6.64, 16.22+/-5.07, 11.56+/-4.18, 8.06+/-1.89. During the follow-up period, the values of VAS and FRI within each group were significantly reduced (p<0.05) after the treatment. But there were no significant differences between the two groups statistically. CONCLUSION: Epidural NP and TFESI are equally effective treatments for the reduction of radiating pain and for improvement of function in patients with a herniated lumbar disc. We recommend that TFESI should be primarily applied to patients who need interventional spine treatment, because it is easier and more cost-effective than epidural NP.

Treatment of dysphagia in patients with brain disorders

Dysphagia is caused by various pathologic conditions of which brain disorders are the major etiology. If food materials enter an airway, aspiration pneumonia or serious asphyxia can develop, which necessitates early detection and proper management of dysphagia. Diagnosis of dysphagia includes history taking, physical examination, bedside screening tests, videofluoroscopic swallowing study (VFSS), and fiberoptic endoscopic examination of swallowing (FEES). Dysphagia management or rehabilitation consists of direct and indirect training methods. The direct one consists of modification of the texture and viscosity (using fluid thickener) of the diet, and diverse compensatory techniques for posture change (chin tuck, head rotation, and head tilt), airway protection (supraglottic swallowing and super-supraglottic swallowing) and improvement of bolus passage (effortful swallowing, multiple swallowing, Mendelsohn maneuver). Indirect training methods without using food are made up of thermal tactile stimulation, electrical stimulation of suprahyoid or infrahyoid muscles, repetitive transcranial magnetic stimulation, and strengthening of the tongue or pharyngeal muscles involved in swallowing (Shaker's exercise and vocal cord adduction exercise). Oral hygiene, adequate hydration, and nutritional support are also crucial. Although the prognosis of dysphagia is favorable with proper rehabilitation, enteral feeding through percutaneous endoscopic gastrostomy or an oroesophageal tube would be helpful to patients who have unresolved dysphagia for some time. Further large-scale clinical studies will be needed to establish evidence on various training methods for dysphagia management.

Endocrinologic Complications after Traumatic Brain Injury

The endocrinologic complications such as adrenal insufficiency and hypopituitarism are common after traumatic brain injury (TBI) portending poor rehabilitation outcome. Anterior pituitary dysfunction presents as hypothyroidism, hypogonadism, growth hormone deficiency, adrenal insufficiency and hyperprolactinemia, whereas posterior pituitary dysfunction includes syndrome of inappropriate antidiuretic hormone and central diabetes insipidus. Careful history taking and physical examination are essential to detect these abnormalities early. Laboratory tests such as serum/urine sodium and osmolality, thyroid hormone, testosterone, estradiol, cortisol, prolactin, growth hormone or IGF-1 are also necessary. Screening of endocrinologic functions is recommended especially in patients with moderate or severe TBI, skull base fracture or diffuse axonal injury 3 to 6 months after injury. Further studies are needed to reveal the effect of early correction of endocrinologic abnormality on long-term functional outcome.

Effect of Magnetic Stimulation in Spinal Cord on Limb Angiogenesis and Implication: A Pilot Study

OBJECTIVE: To investigate the effect of repetitive magnetic stimulation (rMS) of the spinal cord on limb angiogenesis in healthy rats and explore its implication for the treatment of lymphedema. METHOD: Twelve adult male Sprague-Dawley rats were divided into four groups as follows: sham rMS followed by tissue harvest 5 minutes later (group 1, n=2), 1 Hz rMS and tissue harvest 5 minutes later (group 2, n=3), 20 Hz rMS and tissue harvest 5 minutes later (group 3, n=3), 20 Hz rMS and tissue harvest 30 minutes later (group 4, n=4). Animals were treated with 20-minute rMS with 120% of the motor threshold on their left side of upper lumbar spinal cord. Expression of angiogenic factors, that is, Akt, phospho-Akt (pAkt), endothelial nitric oxide synthase (eNOS), phospho-eNOS (p-eNOS) were measured by western blot. Bilateral hindlimb muscles (quadriceps and gastrocnemius) were harvested. RESULTS: Expression of Akt in left quadriceps increased in group 4 compared with group 2 and 3 (3.4 and 5.3-fold each, p=0.026). Expression of eNOS in left plus right quadriceps markedly increased in group 3 and 4 compared with group 1 and 2 (p=0.007). Expressions of eNOS, Akt and p-eNOS, pAkt in gastrocnemius were not comparable between four groups (p>0.05). CONCLUSION: Repetitive magnetic stimulation of the spinal cord may exert an angiogenic effect closely linked to lymphangiogenesis. It has clinical implication for the possible therapy of lymphedema caused by breast, cervical or endometrial cancer operation. Future studies with the specific lymphatic endothelial cell markers are required to confirm the effect of rMS on lymphangiogenesis.

Electrical Stimulation of the Suprahyoid Muscles in Brain-injured Patients with Dysphagia: A Pilot Study

OBJECTIVE: To investigate the therapeutic effects of repetitive electrical stimulation of the suprahyoid muscles in brain-injured patients with dysphagia. METHOD: Twenty-eight brain-injured patients who showed reduced laryngeal elevation and supraglottic penetration or subglottic aspiration during a videofluoroscopic swallowing study (VFSS) were selected. The patients received either conventional dysphagia management (CDM) or CDM with repetitive electrical stimulation of the suprahyoid muscles (ESSM) for 4 weeks. The videofluoroscopic dysphagia scale (VDS) using the VFSS and American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) swallowing scale (ASHA level) was used to determine swallowing function before and after treatment. RESULTS: VDS scores decreased from 29.8 to 17.9 in the ESSM group, and from 29.2 to 16.6 in the CDM group. However, there was no significant difference between the groups (p=0.796). Six patients (85.7%) in the ESSM group and 14 patients (66.7%) in the CDM group showed improvement according to the ASHA level with no significant difference between the ESSM and CDM groups (p=0.633). CONCLUSION: Although repetitive neuromuscular electrical stimulation of the suprahyoid muscles did not further improve the swallowing function of dysphagia patients with reduced laryngeal elevation, more patients in the ESSM group showed improvement in the ASHA level than those in the CDM group. Further studies with concurrent controls and a larger sample group are required to fully establish the effects of repetitive neuromuscular electrical stimulation of the suprahyoid muscles in dysphagia patients.

Inter-rater Agreement for the Clinical Dysphagia Scale

OBJECTIVE: To investigate the inter-rater agreement for the clinical dysphagia scale (CDS). METHOD: Sixty-seven subjects scheduled to participate in a video-fluoroscopic swallowing study (VFSS) were pre-examined by two raters independently within a 24-hour interval. Each item and the total score were compared between the raters. In addition, we investigated whether subtraction of items showing low agreement or modification of rating methods could enhance inter-rater agreement without significant compromise of validity. RESULTS: Inter-rater agreement was excellent for the total score (intraclass correlation coefficient (ICC): 0.886). Four items (lip sealing, chewing and mastication, laryngeal elevation, and reflex coughing) did not show excellent agreement (ICC: 0.696, 0.377, 0.446, and kappa: 0.723, respectively). However, subtraction of each item either compromised validity, or did not improve agreement. When redefining 'history of aspiration' and 'lesion location' items, the inter-rater agreement (ICC: 0.912, 0.888, respectively) and correlation with new videofluoroscopic dysphagia score (PCC: 0.576, 0.577, respectively) were enhanced. The CDS showed better agreement and validity in stroke patients compared to non-stroke patients (ICC: 0.917 vs 0.835, PCC: 0.663 vs 0.414). CONCLUSION: The clinical dysphagia scale is a reliable bedside swallowing test. We can improve inter-rater agreement and validity by refining the 'history of aspiration' and 'lesion location' item.