Factors Affecting Activities of Daily Living in Severely Disabled Stroke Patients

To investigate factors which affect the activities of daily living (ADL) in severely disabled stroke patients. Medical records of 64 post-stroke patients were reviewed retrospectively. All patients had had rehabilitation for 3 months, and their ADL was assessed using the Korean version of Modified Barthel Index at the time of admission and after 3 months. We also investigated age, onset duration of stroke and the Korean version of Mini-Mental State Examination (K-MMSE) at the time of admission. The ability to roll over, sit, sit to stand, transfer, ambulation, climbing stairs, sitting balance and standing balance were evaluated at the time of admission and after 3 months, either. The factors affecting ADL were K-MMSE and functional ability, such as the ability to roll over, come to sit, sit to stand, sitting and standing balance. The most important factors were the level of K-MMSE and the ability to come to sit. The ability to sit up and the K-MMSE score are the independent factors that can predict the ADL after rehabilitation in severely disabled stroke patient.

Rehabilitation of Drivers with Brain Injury Using Virtual Reality Based Driving Simulator

OBJECTIVE: To investigate the effect of driving-simulator based training for the persons with brain injury. METHOD: Twenty-seven brain injury patients and 19 healthy volunteers were included in this study. Driving simulator program was composed of an aptitude test (which have 4 items) and simulated road driving. The brain injury patients had 4 sessions of driving simulator training with assessment performed during the first and the last session. Healthy volunteers underwent only one driving simulator session for assessment. To evaluate subjective satisfaction in terms of training effect and the sense for the real, a survey was administered after the training. RESULTS: In brain injury patients, there were significant improvements in both aptitude test and simulated road driving test after training (p <0.01). There were no significant differences between the scores of patients taken at the last session and the scores of healthy volunteers, while the scores of patients taken at the first session were significantly lower than those of healthy volunteers. The patients group reported positively in terms of training effect (81.5%) and the sense for the real (62.9%). CONCLUSION: A driving-simulator based training was effective for brain injury patients to regain driving skill.

Application of Cognitive Perceptual Assessment for Driving (CPAD) for the Brain Injured Patients: A preliminary study

OBJECTIVE: To evaluate the utility of Cognitive Perceptual Assessment for Driving (CPAD) through the on-road test in predicting the actual road driving skills in brain injured patients. METHOD: 25 brain injured patients with actual driving experience before the occurrence of diseases participated in the handicapped driving adaptation training program of our hospital as the subjects of the study, and one round of CPAD and on-road test were performed. CPAD evaluations and on-road tests for all patients were evaluated by the same therapist. RESULTS: 11 patients passed the CPAD and all of them passed the on-road test. 3 patients failed from CPAD and they turned out to be failed at the on-road test. The mean CPAD score of the on-road test passed group was 53.6 which was significantly different from the mean 43.6 CPAD score acquired by the on-road test failed group by showing a significant difference between two groups (p<0.05). Among the 11 patients who received the borderline CPAD score, 9 patients passed the on-road test. CONCLUSION: CPAD is considered to be useful in predicting the actual road driving skills of brain injured patients who previously had driving experiences before the occurrence of the diseases.

The Importance of Motivation and Dropping Out from Treatment in Constraint-induced Movement Therapy for Stroke Patients

OBJECTIVE: To assess the effect of motivation for treatment and to find out causes of dropping out from treatment in performing the constraint-induced movement therapy (CIMT). METHOD: Forty six stroke patients were treated with CIMT for 2 weeks. Prior to and after treatment, Fugl-Meyer motor assessment (FMA), Wolf motor function test (WMFT), box and block test (BBT), and 9 hole peg test, motor activity log (MAL) were performed, and for the evaluation of treatment motivation, motivation score (MS) was assessed in 24 patients. RESULTS: After 2 weeks of CIMT treatment, the mean value of FMA increased by 15.1%, WMFT by 19.5%, BBT by 35.8%, the time of 9 hole peg test decreased by 20.2%, and the "How well" sub-score of the increased MAL was 59.6% (p<0.05). Larger improvement of FMA score was observed in patients with high MS (p<0.05). Twelve out of 46 patients were dropped, 5 patients (18.5%) among 27 right side hemiplegic patients and 7 patients (38.9%) of 19 left side hemiplegic patients gave up the treatment in the middle, and the MS score of the quitted patients (35.3 point) was lower than that of patients who did not quit (40.5 point) (p<0.05). CONCLUSION: After 2 weeks of CIMT treatment, larger improvement of movement capacity was observed in patients with high motivation. Among patients with low treatment motivation and old age, many patients were dropped out during CIMT.

The Effect of Modified Constraint-induced Movement Therapy for the Stroke Patients in Inpatient Setting

OBJECTIVE: To evaluate the effectiveness of the modified constraint-induced movement therapy (CIMT) for inpatient rehabilitation of the stroke patients. METHOD: Twenty-four patients admitted by subacute or chronic stroke were enrolled and divided into two groups, experimental and control groups. The experimental group (n=13) received the CIMT five days a week for 2 weeks. Less affected arm was restrained for 14 hours a day, practicing purposeful activities with more affected arm for 6 hours a day in group setting. The control group (n=11) received conventional occupational therapy for the same period. The outcome was measured by Fugl-Meyer MotorAssessment (FMA), Brunnstrom stage, Jebsen hand function test, grip strength, Box and Block test, nine hole peg test, Functional Independence Measure (FIM), and Motor Activity Log (MAL). RESULTS: The experimental group showed significantly higher improvements (p<0.05) in FMA, Brunnstorm stage, Jebsen hand function test, grip strength, Box and Block test, FIM, and MAL. CONCLUSION: Modified CIMT delivered in group setting is considered to be an effective treatment to improve functional use of the hemiparetic arm of stroke patients in inpatient setting.

Nutritional Assessment of Geriatric Stroke Patients in a Rehabilitation Hospital

OBJECTIVE: It was aimed to evaluate the nutritional status of geriatric stroke patients admitted to a convalescent and rehabilitation hospital and the clinical usefulness of the mini-nutritional assessment (MNA) to identify malnutrition in elderly stroke patients. METHOD: We performed a nutritional evaluation using the MNA questionnaire, anthropometric, haematological, and biochemical parameters in 30 stroke patients. Malnutrition was defined if there were abnormalities in at least one of the following parameters: serum values of albumin and transferrin, hemoglobin and total lymphocytes in blood, and body mass index. The sensitivity, specificity, and predictive values of MNA for malnutrition were assessed. RESULTS: The mean age of patients was 69.5 years and mean body mass index was 22.8 kg/m2. The prevalence of malnutrition was 46.7% while malnutrition or risk of malnutrition by MNA was 80%. The sensitivity, specificity, and positive/negative predictive values of MNA for malnutrition were respectively 92.9%, 31.3%, 54.2%, and 83.3% with a cutoff point lower than 23.5. There was a significant difference of hemoglobin value between malnourished and nourished group (p<0.05). CONCLUSION: Malnutrition was common in geriatric stroke patients. MNA was a useful screening tool to exclude nourished geriatric patients.

Cognitive Perceptual Assessment Tool for Evaluation of Driving Ability of Persons with Brain Injury

OBJECTIVE: To develop an evaluation tool of cognitive perceptual function for safe driving of the brain injured patients and to check the suitability of the tool. METHOD: Cognitive Perceptual Assessment for Driving (CPAD) was constructed with 8 tasks of depth perception, sustained attention, divided attention, Stroop test, digit span test, field dependence, trail making test A, and trail making test B. The predriving assessment with CPAD and road test were applied to 101 brain injured patients. The reliability and the validity of CPAD, and the cut-off score to resume driving were determined. RESULTS: The CPAD scores of pass group (n=46) and fail group (n=55) for on-road test were 51.67+/-5.53 and 44.30+/-8.44 respectively (p=0.0001). The internal consistency of the CPAD measured by Cronbach's alpha was 0.85. The cut-off score based on 95% confidence interval was 53 or above for pass group, 42 or below for fail group, 43~52 for borderline group. The positive and negative predictive value was 90.7% and 50.3%, respectively. CONCLUSION: The CPAD could be useful for the evaluation of driving ability of persons with brain injury.

The Usefulness of Trunk Accelerometry in Evaluating Walking Ability of Hemiparetic Patients

OBJECTIVE: Accelerometer is a convenient device that can easily measure human movement. The purpose of this study was to evaluate its usefulness in the assessment of hemiparetic gait after stroke. METHOD: Twenty hemiparetic stroke patients were enrolled in the study. A portable accelerometer was attached between L3,4 intervertebral area. Vertical and medio-lateral acceleration was measured while walking 10 m. Walking ability of each subject was classified by Functional Walking Category (FWC). RESULTS: Accelerometric parameters, such as walking speed, a mean amount of peak vertical acceleration in one gait cycle, mean peak value of unaffected side, peak vertical acceleration ratio, step time ratio were significantly higher in groups of FWC 4, 5, 6 than in groups of FWC 2, 3. In subjects using cane there was an extra peak other than peaks observed in non-users. Mean peak value, step length of unaffected side and cadence were significantly higher in non-users than in users. CONCLUSION: Trunk accelerometer can be used as an objective method to evaluate walking ability in hemiparetic patients after stroke.

Long-term Effects of Day Hospital Program in Stroke Rehabilitation

OBJECTIVE: Comprehensive poststroke rehabilitation includes continuum of care after discharge from hospital. Day hospital is a milieu-oriented outpatient rehabilitation program that offers continuous rehabilitation service to promote psychosocial adaptation and quality of life. This study is to evaluate long-term effects of day hospital program in stroke patients. METHOD: Forty-eight stroke patients who received day hospital program for 2 or more months after inpatient rehabilitation program and 42 control stroke patients, who received only inpatient rehabilitation program, responded telephone interview for the study. Outcome measurement included the Korean Activities of Daily Living (K-ADL), the Korean Instrumental Activities of Daily Living (K- IADL) and the Medical Outcome Study 8-item Short Form Survey (SF-8). RESULTS: There was no difference in many item scores of K-ADL between day hospital group and control group, but the item scores of dressing, washing face and hands were significantly higher in control group. Among the item scores of K-IADL, except managing money, most item scores of K-IADL were no significant difference between day hospital group and control group. All item scores of SF-8 were significantly higher in day hospital group than control group. CONCLUSION: Day hospital is an effective rehabilitation program to enhance health-related quality of life for stroke patients.

The Interrater and Intrarater Reliability of Korean Wolf Motor Function Test

OBJECTIVE: To verify the interrater and intrarater reliability of Korean Wolf Motor Function Test (K-WMFT) for assessing upper extremity function after stroke. METHOD: Twenty patients with chronic hemiparesis after stroke participated in the study. The Wolf Motor Function Test consists of 15 functional tasks. Performances were timed and rated by functional ability scale. The K-WMFT were administered to the subjects by an occupational therapist. All test sessions were videotaped and scored by 2 physiatrists and another occupational therapist to examine interrater reliability. They were reevaluated at a later time by the same occupational therapist to examine intrarater reliability. RESULTS: Intraclass correlation coefficient of the performance time of K-WMFT was 0.94 and that of the functional ability scale of K-WMFT was 0.99. Intrarater correlation coefficient of the performance time of K-WMFT was 1.00 and that of the functional ability scale of K-WMFT was 0.97. CONCLUSION: The interrater and intrarater reliability of K- WMFT were verified. K-WMFT can be used as a reliable tool to measure upper extremity function of the stroke patients in Korea.

Utilization Status of Public Health and Medical Rehabilitation Services by the Persons with Disabilities in Community

OBJECTIVE: To survey the utilization status of public health and medical rehabilitation services by the persons with disabilities in community. METHOD: The subjects were 118 patients who were admitted to National Rehabilitation Center from January 1998 to December 2001 and agreed with home-visit. The subjects were assessed of disability level with functional scales, utilization rate of public health and medical rehabilitation services, utilization facilities, and service contents. RESULTS: The subjects included 78 pesons with stroke, 20 persons with spinal cord injury, 9 pesons with traumatic brain injury, and 11 persons with other diseases. Only 28.0% of the low-functional group used public health and medical rehabilitation services, showing a low utilization rate than the high-functional group (43.2%). 17 out of 24 persons who used rehabilitation clinics were in the low-functional group and 9 out of 13 persons who used welfare agency were in the high-functional group (p=0.012). In two groups, most frequent utilization out of the service contents was the exercise therapy. CONCLUSION: The utilization rate of public health and medical rehabilitation services in communities was 32.8%. It is necessary to supply the persons with disabilities in community with the rehabilitation service for the continuum of rehabilitation.

Electromechanical Gait Trainer for Gait Rehabilitation for Patients with Stroke

We developed an electromechanical gait trainer for rehabilitation of the persons with disabilities, which was designed to simulate normal gait with partial body weight support. The purpose of this study was to apply it to stroke patients and to evaluate its usability. Four nonambulatory stroke patients had 20 sessions of gait training with newly developed gait trainer for 5 to 6 weeks. Knee and ankle joint angles were measured by electrogoniometer during training. Main outcome was assessed by functional ambu lation category (level 0~5). Knee and ankle joint angles during exercise in the gait trainer showed repetitive pattern of gait-like movement similar to normal gait, though it was variable among the subjects. Functional ambulation category levels after training were 2 in 3 patients and 1 in 1 patient. The electromechanical gait trainer was a useful device for gait retraining in stroke patients with severe neurologic impairments.

Driving State of the Brain Injured after Driver Training Program at the National Rehabilitation Center

OBJECTIVE: To investigate the actual driving state of the brain injured who had received driver training program. METHOD: We conducted a follow up survey with 64 brain injured who had received driver training program at the National Rehabilitation Center. 29 subjects were first attempting to obtain a license (First obtaining group) while 35 subjects were trying to re-obtain a license after being handicapped (Re-obtaining group). The contents of the survey were compared between first obtaining group and re-obtaining group, and between hemiplegic side. RESULTS: 41 subjects obtained license in regard to the total 64 subjects in which 39% of theses were actually driving. Licensed rate was 55% for first obtaining group and 71% for re-obtaining group. Driving rate was 56% for first obtaining group and 28% for re-obtaining group. Comparing to hemiplegic side, left hemiplegics (54%) showed a tendency to have higher rate of accident than right hemiplegics (0%) without statistical significance. CONCLUSION: Licensed rate of the brain injured was 64%, and driving rate and accident rate were 39% and 38%, respectively. Left hemiplegics, especially, had a higher rate of accident than right hemiplegics.

Gait Analysis Using Accelerometer in Stroke Patients

OBJECTIVE: The aim of this study is to evaluate the acceleration of the center of mass (COM) of the body in stroke patients. METHOD: Seventeen stroke patients and 9 normal subjects were participated. Three dimensional gait analysis was used to classify gait phases for the reference. The accelerometer held over the COM were used to record vertical and medio- lateral accelerations of the COM of the body. Modified Ashworth scale and Brunnstrom stage were used to evaluate the clinical status of stroke patients. RESULTS: In normal subjects, the acceleration showed symmetric pattern. The maximum peak of vertical acceleration occurred in loading response. In stroke patients, the acceleration wave was characterized by asymmetry and polyphasicity. Maximum peak in affected side was higher than that in unaffected side (p<0.05). There were significant correlations between several elements of hemiplegic gait and the correspondent acceleration values; interval of successive peak I in vertical acceleration vs. step time, walking velocity and swing symmetry ratio vs. mean peak I, swing symmetry ratio vs. affected side peak I, step length symmetry ratio vs. peak I symmetry ratio. CONCLUSION: The accelerometer can be an easy and useful way to evaluate gait characteristics in stroke patients.

Development and Application of Cognitive Perceptual Assessment for Driving of People with Brain Injury - Comparison with Cognitive Behavioral Driver's Inventory

OBJECTIVE: We developed the Cognitive Perceptual Assessment for Driving (CPAD) to assess the driving ability of people with acquired brain injury. To find out the usefulness of this tool as a screening test for safe driving, we compared it with the Cognitive Behavioral Driver's Inventory (CBDI). METHOD: Subjects were 101 people with acquired brain injury who had driven a car before the injury. Each subject was evaluated with CPAD and CBDI. CPAD consisted of 8 tasks and 10 variables. We calculated CPAD score using 10 variables and compared CPAD with CBDI result and score. RESULTS: The average CPAD score was 49.65 7.97. According to CBDI test, the number of CBDI passing group was 36, borderline group was 27, and failing group was 38. CPAD variables and score showed significant correlation with CBDI score (p<0.05). There was significant difference in CPAD variables and score among the 3 groups (p<0.05). CONCLUSION: CPAD can be a useful tool for assessing the driving ability of the people with acquired brain injury.

Influence of Aphasia on the Cognitive Screening Test in Stroke Patients with Unilateral Cerebral Hemispheric Lesion

OBJECTIVE: To evaluate the influence of aphasia on the cognitive screening test in stroke patients with unilateral cerebral hemispheric lesions. METHOD: We evaluated 51 hemiplegic patients with unilateral cerebral hemispheric lesions using CT or MRI. We divided the subjects into three groups according to the presence of aphasia and motor weakness: right hemiplegic patients with aphasia, right hemiplegic patients without aphasia, and left hemiplegic patients. Functional Independence Measure (FIM), Mini-Mental Status Examination (MMSE) and Neurobehavioral Cognitive Screening (NCSE) Tests were applied in all patients. RESULTS: No differences were observed in motor FIM scores between three groups. Total FIM and cognitive FIM scores of the right hemiplegic patients with aphasia were lower than those of the other two groups. MMSE and several sub-items of NCSE (orientation, attention, comprehension, repetition, naming and calculation) showed the same results. But the mean scores of memory, similarity, and judgement items in NCSE were higher in the left hemiplegic patients than the right hemiplegic patients. No differences were observed in the construction score. CONCLUSION: All three cognitive screening tests used in this study were remarkably influenced by the ability of the language function of the patients. Lack of adequate items to detect right cerebral hemispheric lesions were also noticed.

Biomechanical Analysis of Sit-to-stand Transfer in Stroke Patients: Comparison between Stable and Labile Surfaces

OBJECTIVE: To establish the degree of modulating influence of the type of surfaces (whether stable or labile) on the dynamic balance responses during the sit-to-stand transfers in both stroke patients and healthy controls. METHOD: We evaluated sit-to-stand balance by Balance Master (NeuroCom, USA) in 30 hemiparetic patients and 10 healthy controls. All subjects were requested to perform sit-to-stand transfers three times each on the both stable and labile surfaces. Four balance indices (weight transfer time, rising index, COG sway velocity, left/right weight symmetry) were obtained. RESULTS: In hemiparetic patients, decreased rising index, increased COG sway velocity, increasing left/right weight asymmetry were noticed. During sit-to-stand transfers from sitting on labile surfaces to standing, rising index increased and left/right weight asymmetry increased in hemiparetic patients, but not in healthy controls. This implies that the maximum vertical force exerted by legs during the rise phase increased, but the differences of weight borne by each leg during the active rising phase increased in hemiparetic patients. CONCLUSION: Weight bearing exercise on the affected leg as well as strengthening exercise of legs are considered to be essential to decrease the falls during sit-to-stand transfer in stroke patients.

Development of Medical Students Interpersonal Skills and Understanding of the Roles which Non-Faculty Hospital Personnel through an Experience-Based Learning Program / 한국의학교육

Gachon Medical School developed an "Experience-based Sharing Program" as a component of its "Patients, Doctors and Society" course. The program was designed to familiarize preclinical students with the various roles which patients and hospital personnel take on in the hospital setting by directly experiencing these roles and performing the same daily routines that these personnel perform. The unit was organized as a 6-day program for 2nd and 3rd year students during the winter recess. Distinguishing features of the course are that it encouraged (1) the active participation of students in the daily hospital activities which various hospital personnel perform other than providing direct medical care within the hospital setting, (2) non-faculty hospital personnel to function as educational facilitators, (3) the development of medical students interpersonal skills with various groups of hospital staff and patients, and (4) students to engage in self-evaluation by requiring them to report on their experience. We conclude that the program is useful and essential in motivating students to understand the roles of their future coworkers in medical practice, in developing students interpersonal skills with the goal that they will be better doctors, and in encouraging paramedical personnel to be facilitators in educating medical students.

Effect of Rhythmic Stimulation of Music on Hemiplegic Gait

OBJECTIVE: We used music as a rhythmic cue in gait training of patients with hemiplegia and analysed its effect on gait parameters. METHOD: Twenty hemiplegic patients were included in the study. Gait cycle, foot contact area, and center of pressure pathway were measured by F-scan with and without music. Four subjects were followed after 3 weeks of gait training using rhythmic cue with music. RESULTS: 1) In involved limb, stance phase was slightly increased from 65.8+/-9.9% to 67.8+/-7.9%, and single limb support was changed from 17.1+/-6.3% to 17.2+/-6.2%, without statistical significance. 2) Stance and swing symmetry was slightly increased from 0.77+/-0.13 and 0.52+/-0.21 to 0.83+/-0.09 and 0.54+/-0.16 respectively, without statistical significance. 3) Foot contact area and anteroposterior distance of center of pressure were not changed significantly. 4) All 4 subjects who were followed after 3 weeks showed increased single limb support of involved limb (from 14.5% to 18.8%) and swing symmetry (from 0.47 to 0.67). CONCLUSION: Though it was not proved to be effective for every hemiplegics, use of rhythmic cue with music in gait training may be helpful in some patients. Further study is needed to confirm these results.

A Study on Driver Training Program for the Handicapped at the National Rehabilitation Center

OBJECTIVE: To evaluate the results of driver training program for the handicapped. METHOD: Retrospective study on the 699 disabled who participated in the two-months driver training program at the NRC (National Rehabilitation Center) from January 1995 to May 1998. RESULTS: 1) Of these subjects, 70.4% were men and 29.6% were women. 2) According to the disability grading system by the Ministry of Health and Social Welfare of Korea, 19.2% of the subjects had the first grade disability, 28.2% the second grade, 26.3% the third grade, 18.3% the fourth grade, 6.3% the fifth grade, and 1.4% the sixth grade. 3) The licensing rate was 74.6% for the first grade, 64.7% for the second grade, 70.9% for the third grade, 73.6% for the fourth grade, 55.8% for the fifth grade, and 70% for the sixth grade. 4) The licensing rate was the highest in the subjects with spinal cord injury (79.2%) and the lowest in the subjects with stroke (45.0%). 5) Overall, 78.2% of subjects licensed with automatic transmission and 21.8% with hand- control. On the other hand, in the subjects with spinal cord injury, 42.5% licensed with automatic transmission and 57.5% with hand-control. CONCLUSION: The mean licensing rate of this program was 69.2%. Further study is required for the effect of cognitive function on driving test and various driving aids to promote the licensing rate for the handicapped.