Pain and Weakness on Unilateral Upper Extremity Diagnosed as Brachial Plexopathy after Herpes Zoster Infection

Motor paralysis is a less common neurologic complication of herpes zoster. Until now, a few cases have been reported, and most of these cases showed brachial plexopathy involving one or two segments. We report a patient with pain and weakness on upper extremity diagnosed as brachial plexopathy after herpes zoster infection. An 88-year-old female patient complained not only tingling sense, pain, and swelling on right whole arm, but also weakness on this right upper extremity. On physical examination, weakness is seen in right shoulder abductionㆍshoulder flexionㆍelbow flexionㆍelbow extensionㆍ wrist extension (grade 4), finger flexionㆍfinger abductionㆍfinger extensionㆍfinger DIP flexion (grade 3). In electrodiagnostic study and magnetic resonance imaging study, she was diagnosed as the brachial plexopathy, whole branch involved. This is the only case of post-herpetic brachial plexopathy involving whole branch in domestic.

Pain and Weakness on Unilateral Upper Extremity Diagnosed as Brachial Plexopathy after Herpes Zoster Infection

Motor paralysis is a less common neurologic complication of herpes zoster. Until now, a few cases have been reported, and most of these cases showed brachial plexopathy involving one or two segments. We report a patient with pain and weakness on upper extremity diagnosed as brachial plexopathy after herpes zoster infection. An 88-year-old female patient complained not only tingling sense, pain, and swelling on right whole arm, but also weakness on this right upper extremity. On physical examination, weakness is seen in right shoulder abductionㆍshoulder flexionㆍelbow flexionㆍelbow extensionㆍ wrist extension (grade 4), finger flexionㆍfinger abductionㆍfinger extensionㆍfinger DIP flexion (grade 3). In electrodiagnostic study and magnetic resonance imaging study, she was diagnosed as the brachial plexopathy, whole branch involved. This is the only case of post-herpetic brachial plexopathy involving whole branch in domestic.

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.

Clinical and Radiological Evaluation After Chemical Synovectomy With Rifampicin in Hemophilic Arthropathy: Korean Experience With a 2-Week Interval Protocol

OBJECTIVE: To assess the clinical outcome of chemical synovectomy with rifampicin in hemophilic arthropathy by using the World Federation of Hemophilia (WFH) scoring system and plain radiograph. METHODS: We performed rifampicin synovectomy (RS) on 30 joints of 28 hemophilic patients diagnosed as hemophilic arthropathy stage I–III (based on Fernandez-Palazzi clinical classification). Clinical status (bleeding frequency, pain, joint physical status) and radiological staging were evaluated as parts of the WFH scoring system before and 1 year after RS. The patients were divided into two groups by the Arnold-Hilgartner scale of the initial X-ray as stage 3 or less for the low-stage group (n=17) and over 3 for the high-stage group (n=13). RESULTS: Total WFH joint physical scores were reduced after injection, and the number of bleeding episodes and pain showed especially significant improvement. For other subscores of the WFH joint physical score, only swelling, range of motion, and crepitus showed statistically significant improvement. According to the severity of the radiologic finding, the WFH joint physical score of both the low-stage and high-stage groups showed significant improvement. In the radiological aspect, the low-stage group, without joint space narrowing at the initial plain radiograph, showed no further aggravation after injection. However, in the high-stage group, radiology found aggravation regardless of the procedure. CONCLUSION: It is suggested that chemical synovectomy with rifampicin may prevent hemarthrosis and improve clinical symptoms. Especially in the early stage of arthropathy without joint-space narrowing, it seems to have an additional benefit that delays radiological aggravation and preserves joint status.

Association Between Walking and Low Back Pain in the Korean Population: A Cross-Sectional Study

OBJECTIVE: To investigate if walking is independently associated with low back pain (LBP) in the general population. METHODS: This cross-sectional study used public data from the Fourth and Fifth Korean National Health and Nutrition Examination Survey. Subjects included 5,982 community-dwelling adults aged ≥50 years. Presence of current LBP was defined as LBP for 1 month or more in the past 3 months. Walking was measured as total walking duration for the past week and subjects were divided into four quartiles. Independent effect of walking on LBP was determined using odds ratios (OR) adjusted for age, sex, osteoporosis, depression or anxiety, and radiographic lumbar spondylosis. RESULTS: Prevalence of LBP was 26.4% in this population. Older people and women had higher prevalence of current LBP. Prevalence of obesity and osteoporosis was higher in subjects with current LBP and quality of life was poorer in subjects with current LBP. Adjusted logistic regression model revealed that older age (OR, 1.655; p=0.018), female sex (OR, 2.578; p<0.001), radiographic lumbar spondylosis (OR, 2.728; p<0.001), depression or anxiety (OR, 5.409; p<0.001), and presence of osteoporosis (OR, 1.467; p=0.002) were positively associated with current LBP. Walking decreased prevalence of current LBP proportionally (2nd quartile OR, 0.795; 3rd quartile OR, 0.770; and 4th quartile OR, 0.686 compared with the 1st quartile of walking). CONCLUSION: Walking was negatively associated with LBP. Further studies are needed to reveal causal relationship of this phenomenon.

Diagnostic Challenge of Diffusion Tensor Imaging in a Patient With Hemiplegia After Traumatic Brain Injury

A 51-year-old man showed hemiplegia on his right side after a traumatic brain injury (TBI). On initial brain computed tomography (CT) scan, an acute subdural hemorrhage in the right cerebral convexity and severe degrees of midline shifting and subfalcine herniation to the left side were evident. On follow-up brain magnetic resonance imaging (MRI), there were multiple microhemorrhages in the left parietal and occipital subcortical regions. To explain the occurrence of right hemiplegia after brain damage which dominantly on the right side of brain, we used diffusion tensor imaging (DTI) to reconstruct the corticospinal tract (CST), which showed nearly complete injury on the left CST. We also performed motor-evoked potentials, and stimulation of left motor cortex evoked no response on both sides of upper extremity. We report a case of patient with hemiplegia after TBI and elucidation of the case by DTI rather than CT and MRI.

Relation Between Respiratory Muscle Strength and Skeletal Muscle Mass and Hand Grip Strength in the Healthy Elderly

OBJECTIVE: To evaluate sarcopenic indices in relation to respiratory muscle strength (RMS) in elderly people. METHODS: This study included 65 volunteers over the age of 60 (30 men and 35 women). The skeletal muscle mass index (SMI) was measured using bioimpedance analysis. Limb muscle function was assessed by handgrip strength (HGS), the Short Physical Performance Battery (SPPB), and gait speed. RMS was addressed by maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) using a spirometer. The relationships between RMS and other sarcopenic indices were investigated using the Pearson correlation coefficients and multiple regression analysis adjusted for age, HGS, and SPPB. RESULTS: Both MIP and MEP were positively correlated with SMI (r=0.451 and r=0.388, respectively, p<0.05 in both). HGS showed a significant correlation with both MIP and MEP (r=0.560, p<0.01 and r=0.393, p<0.05, respectively). There was no significant correlation between gait speed and either MIP or MEP. The SPPB was positively correlated with MEP (r=0.436, p<0.05). In the multiple regression analysis, MIP was significantly associated with HGS and SMI (p<0.001 and p<0.05, respectively), while MEP was related only with HGS (p<0.05). CONCLUSION: This study suggests that respiratory muscles, especially inspiratory muscles, are significantly related to limb muscle strength and skeletal muscle mass. The clinical significance of MIP and MEP should be further investigated with prospective studies.

EMG Activity of Masseter Muscles in the Elderly According to Rheological Properties of Solid Food

OBJECTIVE: To assess the impact of aging on masticatory muscle function according to changes in hardness of solid food. METHODS: Each of fifteen healthy elderly and young people were selected. Subjects were asked to consume cooked rice, which was processed using the guidelines of the Universal Design Foods concept for elderly people (Japan Care Food Conference 2012). The properties of each cooked rice were categorized as grade 1, 2, 3 and 4 (5×10³, 2×10⁴, 5×10⁴, and 5×10⁵ N/m²) respectively. Surface electromyography (sEMG) was used to measure masseter activity from food ingestion to swallowing of test foods. The raw data was normalized by the ratio of sEMG activity to maximal voluntary contraction and compared among subjects. The data was divided according to each sequence of mastication and then calculated within the parameters of EMG activities. RESULTS: Intraoral tongue pressure was significantly higher in the young than in the elderly (p<0.05). Maximal value of average amplitude of the sequence in whole mastication showed significant positive correlation with hardness of food in both young and elderly groups (p<0.05). In a comparisons between groups, the maximal value of average amplitude of the sequence in whole mastication and peak amplitude in whole mastication showed that mastication in the elderly requires a higher percentage of maximal muscle activity than in the young, even with soft foods (p<0.05). CONCLUSION: sEMG data of the masseter can provide valuable information to aid in the selection of foods according to hardness for the elderly. The results also support the necessity of specialized food preparation or products for the elderly.

Swallowing Function Defined by Videofluoroscopic Swallowing Studies after Anterior Cervical Discectomy and Fusion: a Prospective Study

This study evaluated factors related to swallowing dysfunction after anterior cervical discectomy and fusion (ACDF) using videofluoroscopic swallowing studies (VFSS). Preoperative and postoperative VFSSs were done with 5 mL diluted barium. Oral transit time, pharyngeal delay time, pharyngeal response time (PRT), and pharyngeal transit time were measured. Hyoid bone movement and upper esophageal sphincter (UES) diameter were measured serially. Thickness of prevertebral soft tissue was measured from digitized VFSS images. In results, 12 of 20 patients showed abnormal postoperative VFSS findings. PRT decreased significantly after surgery. Hyoid bone movement did not change significantly after surgery. The maximal distance of UES opening decreased significantly after surgery, and the higher the level of surgery (C3 > C4 > C5 > C6), the greater the decrease in maximal distance of the UES opening after surgery. The time to widest opening of the UES was prolonged significantly. At the C3 and C4 levels, the change in prevertebral soft tissue thickness of patients with VFSS abnormalities was significantly greater than those without abnormalities. In conclusion, patients after ADCF with their highest surgery level at C3 and C4 showed more abnormal VFSS findings, significantly increased soft tissue thickness, and decreased maximal distance of UES opening. VFSS provided objective data related with swallowing dysfunction after ACDF.

Relationship Between Respiratory Muscle Strength and Conventional Sarcopenic Indices in Young Adults: A Preliminary Study

OBJECTIVE: To investigate the relationships between respiratory muscle strength and conventional sarcopenic indices such as skeletal muscle mass and limb muscle strength. METHODS: Eighty-nine young adult volunteers who had no history of medical or musculoskeletal disease were enrolled. Skeletal muscle mass was measured by bioelectrical impedance analysis and expressed as a skeletal muscle mass index (SMI). Upper and lower limb muscle strength were evaluated by hand grip strength (HGS) and isometric knee extensor muscle strength, respectively. Peak expiratory flow (PEF), maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP) were evaluated using a spirometer to demonstrate respiratory muscle strength. The relationships between respiratory muscle strength and sarcopenic indices were investigated using Pearson correlation coefficients and multiple linear regression analysis adjusted by age, height, and body mass index. RESULTS: MIP showed positive correlations with SMI (r=0.457 in men, r=0.646 in women; both p<0.01). MIP also correlated with knee extensor strength (p<0.01 in both sexes) and HGS (p<0.05 in men, p<0.01 in women). However, PEF and MEP had no significant correlations with these sarcopenic variables. In multivariate regression analysis, MIP was the only independent factor related to SMI (p<0.01). CONCLUSION: Among the respiratory muscle strength variables, MIP was the only value associated with skeletal muscle mass.

Relationship Between Grip and Pinch Strength and Activities of Daily Living in Stroke Patients

OBJECTIVE: To investigate the relationship between grip and pinch strength and independence in activities of daily living (ADL) in stroke patients. METHODS: Medical records of 577 stroke patients from January 2010 to February 2013 were retrospectively reviewed. Patients' grip and pinch strength of both hemiplegic and non-hemiplegic hands and the Korean version of Modified Barthel Index (K-MBI) score were collected. These patients were divided into three groups: group A (onset duration: 3 months and or =2 years). The correlation between grip and pinch strength and the K-MBI score was analyzed. RESULTS: In group A (95 patients), the K-MBI score was significantly (p<0.05) correlated with the grip and pinch strength of both hands in patients with right hemiplegia. Significant (p<0.05) correlation between the K-MBI score and the grip and pinch strength of the hemiplegic hand was shown in patients with left hemiplegia. In group B (69 patients) and group C (73 patients), the K-MBI score was significantly (p<0.05) correlated with the grip and pinch strength of the hemiplegic hand. CONCLUSION: Stroke patients in subacute stage mainly performed activities of daily living using their dominant hand. However, independence in ADL was associated with the strength of the affected dominant hand. For stroke patients in chronic and late chronic stages, their hand power of the affected hand was associated with independence in ADL regardless whether the dominant hand was affected.

The Relationship Between Initial Trunk Performances and Functional Prognosis in Patients With Stroke

OBJECTIVE: To confirm the relationship between initial trunk performance and functional outcomes according to gait ability, and whether initial trunk performance is of predictive value in terms of functional prognosis in patients with stroke. METHODS: We reviewed 135 patients who suffered from stroke. Trunk performance of the patients was evaluated using the Trunk Impairment Scale (TIS). The patients were divided into 2 groups according to gait ability at initial stage of stroke. Correlation analyses were performed to assess relationship between initial TIS and functional outcomes. We also evaluated the relationship between initial TIS and the Korean version of Modified Barthel Index (K-MBI) subitems. Finally, stepwise multiple regression analyses were performed to examine the predictive validity of initial TIS and its subscales with functional outcomes. RESULTS: For both groups, initial TIS was correlated with K-MBI and Functional Ambulation Categories at 4 weeks after stroke; however, the relationship did not remain stable at 6 months in ambulatory patients. All K-MBI subitems, which were associated with trunk movement, as well as others about basic skills was correlated with initial TIS. Finally, when of subscales TIS, dynamic sitting balance (TIS-D) was included in by stepwise multiple regression analyses, high proportion of the explained variance was represented. CONCLUSION: The strong relationship between trunk performance and functional outcomes in patients with stroke emphasizes the importance of trunk rehabilitation. Indeed, an evaluation of a patient's initial TIS after stroke, especially TIS-D, could be helpful in predicting patient's functional prognosis.

Reliability and Validity of Isometric Knee Extensor Strength Test With Hand-Held Dynamometer Depending on Its Fixation: A Pilot Study

OBJECTIVE: To determine the reliability and validity of hand-held dynamometer (HHD) depending on its fixation in measuring isometric knee extensor strength by comparing the results with an isokinetic dynamometer. METHODS: Twenty-seven healthy female volunteers participated in this study. The subjects were tested in seated and supine position using three measurement methods: isometric knee extension by isokinetic dynamometer, non-fixed HHD, and fixed HHD. During the measurement, the knee joints of subjects were fixed at a 35degrees angle from the extended position. The fixed HHD measurement was conducted with the HHD fixed to distal tibia with a Velcro strap; non-fixed HHD was performed with a hand-held method without Velcro fixation. All the measurements were repeated three times and among them, the maximum values of peak torque were used for the analysis. RESULTS: The data from the fixed HHD method showed higher validity than the non-fixed method compared with the results of the isokinetic dynamometer. Pearson correlation coefficients (r) between fixed HHD and isokinetic dynamometer method were statistically significant (supine-right: r=0.806, p<0.05; seating-right: r=0.473, p<0.05; supine-left: r=0.524, p<0.05), whereas Pearson correlation coefficients between non-fixed dynamometer and isokinetic dynamometer methods were not statistically significant, except for the result of the supine position of the left leg (r=0.384, p<0.05). Both fixed and non-fixed HHD methods showed excellent inter-rater reliability. However, the fixed HHD method showed a higher reliability than the non-fixed HHD method by considering the intraclass correlation coefficient (fixed HHD, 0.952-0.984; non-fixed HHD, 0.940-0.963). CONCLUSION: Fixation of HHD during measurement in the supine position increases the reliability and validity in measuring the quadriceps strength.

Usefulness of the Simplified Cough Test in Evaluating Cough Reflex Sensitivity as a Screening Test for Silent Aspiration

OBJECTIVE: To assess cough reflex sensitivity using the simplified cough test (SCT) and to evaluate the usefulness of SCT to screen for silent aspiration. METHODS: The healthy control group was divided into two subgroups: the young (n=29, 33.44+/-9.99 years) and the elderly (n=30, 63.66+/-4.37 years). The dysphagic elderly group (n=101, 72.95+/-9.19 years) consisted of patients with dysphagia, who suffered from a disease involving central nervous system (ischemic stroke 47, intracerebral hemorrhage 27, traumatic brain injury 11, encephalitis 5, hypoxic brain damage 3, and Parkinson disease 8). The SCT was performed using the mist of a 1% citric acid from a portable nebulizer. The time from the start of the inhalation to the first cough was measured as the cough latency. All the dysphagic patients underwent the videofluoroscopic swallowing study. RESULTS: The cough latency was more significantly prolonged in the healthy elderly group than in the healthy young group (p<0.001), and in the dysphagic elderly group than in the healthy elderly group (p<0.001). The sensitivity and specificity of SCT were 73.8% and 72.5% for detecting aspiration in the dysphagic patients, and 87.1% and 66.7% for detecting silent aspiration in the aspirated patients. CONCLUSION: Cough latency measured with the SCT reflects the impairment of cough reflex in healthy elderly and dysphasic subjects. The results of this study show that the SCT test can be a valuable method of screening aspiration with or without cough in dysphasic patients.

Drug Induced Parkinsonism Caused by the Concurrent Use of Donepezil and Risperidone in a Patient With Traumatic Brain Injuries

A 69-year-old male patient with previous history of traumatic brain injury 5 months ago was admitted to the Department of Neuropsychiatry because of aggressive behavior and delusional features. After starting on 2 mg of risperidone per day, his delusion, anxiety, and aggressive behavior gradually improved. Two weeks later, he was given 10 mg of donepezil per day for his mild cognitive impairment. After 6 weeks of admission in the Department of Neuropsychiatry, he showed parkinsonian features including difficulty in walking, decreased arm swing during walking, narrowed step width, scooped posture, bradykinesia, tremor, and sleep disorder. To rule out the primary Parkinsonism, dopamine transporter imaging technique [18F]fluoropropyl-carbomethoxy-iodopropyl-nor-beta-tropane positron emission tomography-computed tomography (18F]FP(IT PET-CT)) was performed, and dopamine transporter activity was not decreased. We considered that his parkinsonian features were associated with the combination of risperidone and donepezil. Both drugs were stopped and symptoms rapidly disappeared in several days.

Anomalous Course of the Extensor Pollicis Longus With Multiple Absences of Thumb Muscles

We report a rare case of a 10-year-old girl with anomalous course of extensor pollicis longus (EPL) muscle, which exists with absence of thenar muscles and muscles in the 1st extensor compartment. Her chief complaint was severe atrophy on the right thenar eminence. On physical examination, there was no obvious functional abnormality on her right thumb. On magnetic resonance imaging, we found that the abductor pollicis brevis, opponens pollicis, abductor pollicis longus, and extensor pollicis brevis muscles were absent. The tendon of the EPL muscle was found, but it had abnormal insertion on the radial side of the proximal phalanx, not on the distal phalanx. This variation was thought to have played a major role in compensating for impaired abduction of the thumb, which is usually accompanied by agenesis of major abductors of the thumb.

The Effect of Rheological Properties of Foods on Bolus Characteristics After Mastication

OBJECTIVE: To evaluate the effects of physical properties of foods on the changes of viscosity and mass as well as the particle size distribution after mastication. METHOD: Twenty subjects with no masticatory disorders were recruited. Six grams of four solid foods of different textures (banana, tofu, cooked-rice, cookie) were provided, and the viscosity and mass after 10, 20, and 30 cycles of mastication and just before swallowing were measured. The physical properties of foods, such as hardness, cohesiveness, and adhesiveness, were measured with a texture analyzer. Wet sieving and laser diffraction were used to determine the distribution of food particle size. RESULTS: When we measured the physical characteristics of foods, the cookie was the hardest food, and the banana exhibited marked adhesiveness. Tofu and cooked-rice exhibited a highly cohesive nature. As the number of mastication cycles increased, the masses of all foods were significantly increased (p<0.05), and the viscosity was significantly decreased in the case of banana, tofu, and cooked-rice (p<0.05). The mass and viscosity of all foods were significantly different between the foods after mastication (p<0.05). Analyzing the distribution of the particle size, that of the bolus was different between foods. However, the curves representing the particle size distribution for each food were superimposable for most subjects. CONCLUSION: The viscosity and particle size distribution of the bolus were different between solid foods that have different physical properties. Based on this result, the mastication process and food bolus formation were affected by the physical properties of the food.

Asymmetry of the Isokinetic Trunk Rotation Strength of Korean Male Professional Golf Players

OBJECTIVE: To determine whether there is side to side difference of the trunk rotation muscle in Korean male professional golf players. Healthy controls who did not play golf were also evaluated and compared with professional golf players. METHOD: Fifty-one professional golf players and 50 healthy controls participated in this study. Bilateral isokinetic trunk rotation strength that represented the aiming side and non-aiming side trunk rotator function in a golf swing and other parameters were evaluated using the Biodex System III Isokinetic Dynamometer at angular velocities of 30, 60, and 120 degree per second. RESULTS: The professional golf players' peak torque and total work on their aiming sides were significantly higher than on their non-aiming side at all angular velocities. Additionally, the golf players' peak torque on their aiming side was significantly higher than those of the healthy controls only at the 60 degree per second angular velocity, but there was a slight and consistent trend in the others. Finally, the difference between the aiming side and the non-aiming side of the professional golf players and the healthy controls was also significant. CONCLUSION: The aiming side rotation strength of the male professional golf players was higher than that of non-aiming side. The controls showed no side-to-side differences. This finding is attributed to the repetitive training and practice of professional golf players. A further study is needed to investigate if the strengthening of the trunk rotation muscle, especially on the aiming side, could improve golf performance.

Severe Spastic Trismus without Generalized Spasticity after Unilateral Brain Stem Stroke

A 62-year-old female patient diagnosed with left brain stem stroke 2 months ago was admitted to our clinic for rehabilitation. She had no generalized spasticity on both extremities, but could open her mouth only approximately 2 mm between her upper and lower teeth due to severe trismus. On needle electromyography, the left masseter muscle showed paradoxically increased muscle activity during mouth opening. We injected 50 units of type A botulinum toxin (Botox(R)) into the left masseter muscle, and 20 units into the left temporalis muscle with guidance of ultrasonography. The interincisal distance increased to 8 mm on the 3rd day after injection, and 9 mm on the 4th day. One month later, the interincisal distance increased to 14 mm. The increased interincisal distance was maintained for 13 months after injection, and the quality of hygienic care and compliance of oral stimulation therapy also improved.