A Case Report of Golf-Swing-Induced T2∼T3 Clay-Shoveler’s Fractures

Clay-shoveler’s fractures are rare stress-type avulsion fractures of the spinous processes especially in sports. There have been two case reports that discussed clay-shoveler’s fractures in golf. A 36-year-old beginner golfer presented with a pain in the back after practicing golf swing. No fractures were detected using cervical radiography; however, computed tomography (CT) and magnetic resonance imaging (MRI) revealed T2∼T3 spinous process fractures. The patient was treated conservatively and his pain subsided. The mechanism of injury is speculated to that of clay-shoveler’s fractures. Therefore, if a golfer suffers persistent pain in the cervicothoracic region, clay-shoveler’s fracture is one possibility to consider.

A Case Report of Golf-Swing-Induced T2∼T3 Clay-Shoveler’s Fractures

Clay-shoveler’s fractures are rare stress-type avulsion fractures of the spinous processes especially in sports. There have been two case reports that discussed clay-shoveler’s fractures in golf. A 36-year-old beginner golfer presented with a pain in the back after practicing golf swing. No fractures were detected using cervical radiography; however, computed tomography (CT) and magnetic resonance imaging (MRI) revealed T2∼T3 spinous process fractures. The patient was treated conservatively and his pain subsided. The mechanism of injury is speculated to that of clay-shoveler’s fractures. Therefore, if a golfer suffers persistent pain in the cervicothoracic region, clay-shoveler’s fracture is one possibility to consider.

Combined Therapy With Functional Electrical Stimulation and Standing Frame in Stroke Patients

OBJECTIVE: To investigate the effects of combination functional electrical stimulation (FES) and standing frame training on standing balance in stroke patients. METHODS: Patients who had hemiparesis and postural instability after stroke were randomly assigned to one of the two groups; study group underwent FES on the quadriceps and tibialis anterior muscle simultaneously with standing balance training. The control group received standing frame training and FES separately. Both the groups received their respective therapies for 3 weeks. Stability index in Biodex Balance master system, Berg Balance Scale (BBS), manual muscle test, the Korean version of Modified Barthel Index, and Korean version of Mini-Mental State Examination were used to evaluate the effects of the treatment. RESULTS: In total, 30 patients were recruited to the study group and 30 to the control group. Three weeks after treatment, both the groups showed improvement in postural stability scores and physical and cognitive functions. When changes in postural stability were compared between the groups, the study group showed more significant improvement than the control group with regards to the scores of BBS and the stability indices. CONCLUSION: In this study, we found the therapeutic effectiveness of combined therapy of FES and standing frame in subacute stroke patients. The presented protocol is proposed as time-saving and can be applied easily in the clinical setting. Thus, the proposed combined therapy could be a useful method for improving standing balance in subacute stroke patients.

Effect of Decreased Skeletal Muscle Index and Hand Grip Strength on Functional Recovery in Subacute Ambulatory Stroke Patients

OBJECTIVE: To investigate the effect of decreased Skeletal Muscle Index (SMI) and hand grip strength on functional recovery in subacute ambulatory stroke patients. METHODS: Subacute stroke patients who were referred to the rehabilitation center were recruited. Decreased SMI and hand grip strength were diagnosed according to the Asian Working Group on Sarcopenia. Diagnostic criteria were decreased SMI and decreased unaffected hand grip strength. SMI was measured by bioelectrical impedance analysis. Unaffected hand grip strength was measured with a hand dynamometer. Patients were divided into two groups, decreased group (DG) and not-decreased group (NDG), according to the presence of decreased SMI and hand grip strength. Both groups received conventional stroke rehabilitation for 3 weeks. All patients were evaluated at the baseline and at 3 weeks after treatment. Functional status was evaluated with 4-meter walk test (4MWT), 6-minute walk test (6MWT), Timed Up and Go test (TUG), and Modified Barthel Index (MBI). RESULTS: Both groups showed improvement in 4MWT, TUG, and MBI. NDG showed improvement in 6MWT. Comparing improvements between the two groups, NDG showed more improvement in 6MWT and TUG than DG. CONCLUSION: The presence of decreased SMI and hand grip strength had negative effects on functional recovery in subacute ambulatory stroke patients.

Effect of Combined Therapy of Robot and Low-Frequency Repetitive Transcranial Magnetic Stimulation on Hemispatial Neglect in Stroke Patients

OBJECTIVE: To investigate the effect of upper limb rehabilitation combining robot with low-frequency repetitive transcranial magnetic stimulation (rTMS) on unilateral spatial neglect in stroke patients. METHODS: Patients who had hemispatial neglect after right hemisphere stroke were randomly divided into rTMS only group, robot only group, and combined group. All groups received conventional neglect therapy and additional treatment for each group. rTMS group received rTMS therapy. Robot group received robot therapy, while combined group received both therapies. The effect of therapy was assessed with Motor-Free Visual Perception Test-3 (MVPT-3), line bisection test, star cancellation test, Catherine Bergego Scale (CBS), Mini-Mental State Examination (MMSE), and the Korean version of Modified Barthel Index (K-MBI). These measurements were evaluated before and after treatment. RESULTS: For each group, 10 patients were recruited. There were no significant differences in baseline characteristics or initial values among the three groups. Two weeks after the therapy, all groups showed significant improvement in MVPT-3, line bisection test, star cancellation test, CBS, MMSE, and K-MBI. However, changes in measurements showed no significant differences among groups. CONCLUSION: Treatment effect of the combined therapy of robotic therapy and low-frequency rTMS therapy for hemispatial neglect was not statistically different from that of each single treatment. RESULTS: of this study did not prove the superiority of any of the three treatments. Further study with large number of patients is needed to evaluate the superiority of these treatments.

Effects of Hand Training During the Aftereffect Period of Low-Frequency rTMS in Subacute Stroke Patients

OBJECTIVE: To investigate the effects of hand training using low-frequency repetitive transcranial magnetic stimulation (rTMS) within the aftereffect period on hand function in patients with subacute stroke. METHODS: The subacute stroke patients with hand weaknesses were divided randomly into two groups. Patients in the intervention group underwent hand training within the aftereffect period, that is, immediately after receiving low-frequency rTMS treatment. Patients in the control group underwent hand training 2 hours after the low-frequency rTMS treatment. A manual function test (MFT) for ‘grasp and pinch’ and ‘hand activities’; a manual muscle test (MMT) for ‘grasp’, ‘release’, and ‘abductor pollicis brevis (APB)’; and the Modified Ashworth Scale for finger flexion were performed and measured before and immediately after combined therapy as well as 2 weeks after combined therapy. RESULTS: Thirty-two patients with hand weakness were enrolled in this study. The intervention group patients showed more improvements in grasp MMT and MMT APB tested immediately after combined therapy. However, the changes in all measurements were not significantly different between the two groups 2 weeks after the combined therapy. In both groups, hand functions improved significantly immediately after combined therapy and 2 weeks after combined therapy. CONCLUSION: Hand training immediately after low-frequency rTMS showed more rapid improvement in the motor power of hands than hand training conducted 2 hours after low-frequency rTMS. Our results suggest that conducting hand training immediately after low-frequency rTMS could be an improved useful therapeutic option in subacute stroke patients.

Effect of Caregiver Driven Robot-Assisted In-Ward Training in Subacute Stroke Patients: A Case Series

OBJECTIVE: To evaluate the effect of caregiver driven robot-assisted in-ward training in subacute stroke patients. METHODS: A retrospective evaluation was performed for patients treated with caregiver driven robot-assisted in-ward training to retain gait function from June 2014 and December 2016. All patients received more than 2 weeks of caregiver driven robot-assisted in-ward training after undergoing conventional programs. The robot was used as a sitting device, a standing frame, or a high-walker depending on functional status of the patient. Patients were evaluated before and after robot training. Patient records were assessed by Korean version of Modified Barthel Index (K-MBI), Functional Independence Measure (FIM), and Functional Ambulation Category (FAC). RESULTS: Initially, patients used the robot as a sitting device (n=6), a standing frame (n=7), or a partial body-weight support high-walker (n=2). As patient functions were improved, usage level of the robot was changed to the next level. At the end of the treatment, the robot was used as a sitting device (n=1), a standing frame (n=6), or high-walker (n=8). Scores of K-MBI (Δ17.47±10.72) and FIM (Δ19.80±12.34) were improved in all patients. CONCLUSION: Patients' usage level of the robot and functional scores were improved. Therefore, performing additional caregiver driven robot-assisted in-ward training is feasible and beneficial for subacute stroke patients.

Associating Factors Regarding Nasogastric Tube Removal in Patients With Dysphagia After Stroke

OBJECTIVE: To demonstrate associating factors regarding nasogastric tube (NGT) removal in patients with dysphagia after stroke. METHODS: This study is a retrospective medical chart review. Patients were divided into non-brain stem (NBS) and brain stem (BS) groups. A videofluoroscopic swallowing study was conducted until swallowing functions were recovered. Initial disease status was measured using the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS). Risk factors related to stroke were evaluated. The penetration-aspiration scale (PAS) was used as the swallowing test. Functional status was measured by Mini-Mental Status Examination (MMSE) and Modified Barthel Index (MBI). Within each group, initial evaluations and their subsequent changes were compared according to the NGT removal status. Correlation between the NGT removal time and other initial factors were evaluated. RESULTS: Ninety-nine patients were allocated to the NBS group and 39 to the BS group. In NBS, age, PAS, MMSE, and MBI were significantly different according to the NGT removal status. In BS, smoking and PAS were significantly different. In NBS, changes in PAS, MMSE, and MBI were significantly different according to the NGT removal status. In BS, only PAS change was significantly different. In NBS, initial NIHSS, mRS, MMSE, and MBI were correlated with removal time. CONCLUSION: In stroke patients with NTG, younger age, better initial disease and functional status seems to remove NGT in NBS stroke. Therefore, when deciding to remove NGT, those three factors should be considered discreetly.

The Effect of Early Neuromuscular Electrical Stimulation Therapy in Acute/Subacute Ischemic Stroke Patients With Dysphagia

OBJECTIVE: To compare the outcome of an early application of neuromuscular electrical stimulation (NMES) combined with traditional dysphagia therapy (TDT) versus traditional dysphagia therapy only in acute/subacute ischemic stroke patients with moderate to severe dysphagia by videofluoroscopic swallowing study (VFSS). METHODS: Fifty-seven dysphagic stroke patients were enrolled in a VFSS within 10 days after stroke onset. Patients were randomly assigned into two treatment groups. Thirty-one patients received NMES combined with TDT (NMES/TDT group) and 26 patients received TDT only (TDT group). Electrical stimulation with a maximal tolerable intensity was applied on both suprahyoid muscles for 30 minutes, 5 days per week during 3 weeks. The swallowing function was evaluated at baseline and 3, 6, and 12 weeks after baseline. Outcomes of the VFSS were assessed using the Functional Oral Intake Scale (FOIS). RESULTS: The mean ages were 63.5+/-11.4 years in the NMES/TDT group and 66.7+/-9.5 years in the TDT group. Both groups showed a significant improvement on the FOIS after treatment. The FOIS score was significantly more improved at 3 and 6 weeks after baseline in the NMES/TDT group than in the TDT group (p<0.05). CONCLUSION: An early application of NMES combined with TDT showed a positive effect in acute/subacute ischemic stroke patients with dysphagia. These results indicated that the early application of NMES could be used as a supplementary treatment of TDT to help rehabilitate acute/subacute dysphagic stroke patients by improving their swallowing coordination.

The Effect of Early Neuromuscular Electrical Stimulation Therapy in Acute/Subacute Ischemic Stroke Patients With Dysphagia

OBJECTIVE: To compare the outcome of an early application of neuromuscular electrical stimulation (NMES) combined with traditional dysphagia therapy (TDT) versus traditional dysphagia therapy only in acute/subacute ischemic stroke patients with moderate to severe dysphagia by videofluoroscopic swallowing study (VFSS). METHODS: Fifty-seven dysphagic stroke patients were enrolled in a VFSS within 10 days after stroke onset. Patients were randomly assigned into two treatment groups. Thirty-one patients received NMES combined with TDT (NMES/TDT group) and 26 patients received TDT only (TDT group). Electrical stimulation with a maximal tolerable intensity was applied on both suprahyoid muscles for 30 minutes, 5 days per week during 3 weeks. The swallowing function was evaluated at baseline and 3, 6, and 12 weeks after baseline. Outcomes of the VFSS were assessed using the Functional Oral Intake Scale (FOIS). RESULTS: The mean ages were 63.5+/-11.4 years in the NMES/TDT group and 66.7+/-9.5 years in the TDT group. Both groups showed a significant improvement on the FOIS after treatment. The FOIS score was significantly more improved at 3 and 6 weeks after baseline in the NMES/TDT group than in the TDT group (p<0.05). CONCLUSION: An early application of NMES combined with TDT showed a positive effect in acute/subacute ischemic stroke patients with dysphagia. These results indicated that the early application of NMES could be used as a supplementary treatment of TDT to help rehabilitate acute/subacute dysphagic stroke patients by improving their swallowing coordination.

Functional Outcomes of Patients with Severe MCA Infarction after Decompressive Craniectomy

OBJECTIVE: To compare the functional outcomes between surgical treatment and conservative medical treatment for severe middle cerebral artery (MCA) infarction. METHOD: This is comparative analysis of prospectively documented data with 25 patients have malignant MCA infarction. Ten patients in Group A (male 7, female 3) received surgical treatment such as decompressive craniectomy, and fifteen patients in Group B (male 10, female 5) received conservative medical treatment. We defined MCA infarction as "severe" when it concerned both the deep and superficial areas of the MCA or when the Functional Independence Measure (FIM) was lower to 75 on admission to our department. Functional status was measured using modified Rankin Scale (mRS), FIM, Motricity Index (MI) and Trunk Control Test (TCT). All evaluations were measured at baseline and 90 days after stroke. RESULTS: Mean age were 55.0 +/- 8.6 and 58.7 +/- 12.3 in Group A and B. Rt. MCA infarction were 4 in Group A and 5 in Group B. Lt. MCA infarction were 5 in Group A and 10 in Group B. Baseline functional status between two groups was not significantly different. Each group showed functional improvement according to the time. When compared changes between two groups, arm Motricity Index, K-MMSE, mRS and FIM were no significant difference between two groups. Leg segments of MI and TCT was significantly improved in Group A more than B at 90 days after baseline evaluation (p<0.05). CONCLUSION: Decompressive craniectomy improved motor function of affected leg and trunk in patients with severe MCA infarction more than conservative medical treatment alone.