Reliability of Suprahyoid and Infrahyoid Electromyographic Measurements during Swallowing in Healthy Subjects / 대한연하장애학회지

Objective@#To evaluate the reliability of suprahyoid and infrahyoid electromyography (EMG) measurement during swallowing. @*Methods@#In all, 10 healthy volunteers were evaluated for the following surface EMG (sEMG) parameters in the suprahyoid and infrahyoid muscles during swallowing: onset latency, offset latency, duration, peak latency, maximal amplitude during swallowing, and the area under curve (AUC) of the rectified EMG signal. The sEMG was recorded while the participants swallowed five times each of the four fluid volumes (saliva, 2 ml, 5 ml, and 20 ml of water), totaling to 20 swallows. Moreover, the intra-participant variability per parameter was evaluated using the coefficient of variation (CV). @*Results@#Suprahyoid muscles were activated 0.095 s (95% CI, 0.062-0.128) earlier than the infrahyoid muscles.Maximal amplitudes during the 20 ml swallow were 17.484 (−1.543-36.512) and 13.490 (1.254-25.727) μV higher than values obtained during the 2 ml swallow in the suprahyoid and infrahyoid muscles, respectively. Furthermore, the AUC of the rectified EMG signal increased with the volume of swallow in both muscle groups (P=0.003, suprahyoid; P＜0.002, infrahyoid). The intra-individual variabilities of offset latency, duration, and maximal amplitude were relatively low (＜30% CV) in both muscle groups with respect to other parameters. The assessment of each parameter using EMG was highly reliable, with an intraclass correlation coefficient of ＞0.8. @*Conclusion@#Among the variable sEMG parameters assessed, the offset latency, duration, and maximal amplitude were the least variable. Although reliability on the rater side showed good results, the swallow-to-swallow variability of the parameters need to be considered in swallowing studies using sEMG.

Reliability of Suprahyoid and Infrahyoid Electromyographic Measurements during Swallowing in Healthy Subjects / 대한연하장애학회지

Objective@#To evaluate the reliability of suprahyoid and infrahyoid electromyography (EMG) measurement during swallowing. @*Methods@#In all, 10 healthy volunteers were evaluated for the following surface EMG (sEMG) parameters in the suprahyoid and infrahyoid muscles during swallowing: onset latency, offset latency, duration, peak latency, maximal amplitude during swallowing, and the area under curve (AUC) of the rectified EMG signal. The sEMG was recorded while the participants swallowed five times each of the four fluid volumes (saliva, 2 ml, 5 ml, and 20 ml of water), totaling to 20 swallows. Moreover, the intra-participant variability per parameter was evaluated using the coefficient of variation (CV). @*Results@#Suprahyoid muscles were activated 0.095 s (95% CI, 0.062-0.128) earlier than the infrahyoid muscles.Maximal amplitudes during the 20 ml swallow were 17.484 (−1.543-36.512) and 13.490 (1.254-25.727) μV higher than values obtained during the 2 ml swallow in the suprahyoid and infrahyoid muscles, respectively. Furthermore, the AUC of the rectified EMG signal increased with the volume of swallow in both muscle groups (P=0.003, suprahyoid; P＜0.002, infrahyoid). The intra-individual variabilities of offset latency, duration, and maximal amplitude were relatively low (＜30% CV) in both muscle groups with respect to other parameters. The assessment of each parameter using EMG was highly reliable, with an intraclass correlation coefficient of ＞0.8. @*Conclusion@#Among the variable sEMG parameters assessed, the offset latency, duration, and maximal amplitude were the least variable. Although reliability on the rater side showed good results, the swallow-to-swallow variability of the parameters need to be considered in swallowing studies using sEMG.

Kinetic Modeling of the Hyoid Movement During Swallowing and the Comparison with Surface Electromyographic Activity: A Preliminary Study / 대한연하장애학회지

Objective@#The purpose of this study was to understand the mechanism of normal hyoid movement during swallowing by calculating the activity of each muscle involved in the hyoid movement and propose a new kinetic modeling of hyoid movement using videofluoroscopy images. @*Methods@#Eight healthy volunteers with an average age of 56.8 swallowed 2-ml of diluted barium under videofluoroscopy. A video image was digitized to analyze the movement of the hyoid bone. The activity of the muscles acting on the hyoid bone was calculated from the movement of the hyoid bone using kinetic modeling. A surface electromyogram was measured simultaneously with videofluoroscopy, and the muscle force calculated by kinetic modeling was compared with the muscle force measured by surface EMG. @*Results@#The muscles acting on the hyoid bone were divided into three groups according to the direction of force and analyzed. The contraction of the retractor muscle group was observed as a median of 433 ms (95% CI 264-602, P=0.012) earlier than the contraction of protractor muscle group in all subjects. Generally, the peak activity of each muscle group was observed in the order of retractor (0 ms), protractor (592 ms, 95% CI 429-755), and depressor (717 ms, 95% CI 535-899) muscle group. The contraction of the protractor muscle measured by surface electromyography showed an earlier onset latency with a median of 82 2 ms (95% CI 615-102 9, P=0.012 ) compared to the contraction of the protractor muscle calculated by kinetic modeling. @*Conclusion@#Kinetic modeling reflects the pattern of contraction in the order of retractor, protractor, depressor muscle groups, as previously known. And it was possible to evaluate the activity of the retractor muscle, which is difficult to evaluate by electromyogram.

Correlation between Salivary Mucin Concentration and Viscosity -An Exploratory Study in Healthy People / 대한연하장애학회지

Objective@#To analyze the rheological and biochemical properties of saliva in healthy adults. @*Methods@#The subjects were seven healthy young adults (20-39 years). The whole saliva was collected by the spitting method between 9:00 am and 12:00 am. Unstimulated saliva was collected first, which was followed by the collection of stimulated saliva using citric acid was collected. The viscosity was measured using a capillary viscometer to examine the rheological properties. The MUC5B concentration was analyzed using an enzyme-linked immunosorbent assay (ELISA) for the biochemical properties. @*Results@#Ten and five minutes were required on average for unstimulated saliva and stimulated saliva, respectively, to collect the minimum amount needed for analysis (8 ml). The flow rate increased from 1.037±0.323 ml/min to 1.823± 0.660 ml/min after stimulation (P=0.018). Citric acid stimulation also increased the MUC5B concentration in the saliva from 3.706±3.575 μg/ml to 6.928±2.03 μg/ml (P=0.028). The viscosity of saliva, however, did not show a significant difference between with (1.1±0.164 cSt) or without (1.019±0.08 cSt) stimulation (P=0.128). A positive correlation was observed between the flow rate and MUC5B concentration (Spearman’s rho=0.547, P=0.043). On the other hand, there was no significant correlation between the MUC5B concentration and viscosity both in the unstimulated and stimulated saliva (P=0.939 and 0.819, respectively). @*Conclusion@#No significant correlation was observed between the MUC5B concentration and viscosity. Considering the time required to collect samples, an analysis of the stimulated saliva appears feasible in various research settings.The feasibility of these analysis methods should be examined in a patient population.

Epiglottic Retroflexion is a Key Indicator of Functional Recovery of Post-stroke Dysphagia

Objective@#To evaluate the longitudinal changes of swallowing kinematics based on videofluoroscopic swallowing studies (VFSSs) in subacute stroke patients grouped according to the method of dietary intake. @*Methods@#Sixty-nine subacute stroke patients who had taken at least 2 successive VFSSs were included. Subjects were allocated into 3 groups according to the degree of swallowing function recovery—not improved group (tube feeding recommended to patients at both studies), improved group (tube feedings recommended initially to patients and oral feeding recommended at follow-up study), and well-maintained group (oral feeding at both studies recommended to patients). Initial VFSS was performed during the subacute stage of stroke, 1 to 12 weeks after the onset of stroke, and follow-up VFSS was performed at least once. Kinematic variables were calculated by two-dimensional motion analysis of multiple structures, including the hyoid bone, epiglottis, and vocal cord. Changes of kinematic variables were analyzed in serial VFSSs. @*Results@#At the initial VFSS, the well-maintained group showed significantly larger angles of epiglottic folding than the not improved group, while at the follow-up VFSS, the improved and the well-maintained groups showed significantly larger epiglottic folding angles than the not improved group. The distribution of epiglottic folding angles was in a dichotomous pattern, and each cluster was related to the swallowing function. @*Conclusion@#This study showed that improved epiglottic folding angles are associated with the recovery of the swallowing process and suitability for oral feeding among various kinematic variables in subacute stroke patients.

Proportion of Aspiration Pneumonia Cases Among Patients With Community-Acquired Pneumonia: A Single-Center Study in Korea

OBJECTIVE: To investigate the proportion of aspiration pneumonia cases among patients with community-acquired pneumonia in Korea. METHODS: This retrospective study included patients with community-acquired pneumonia who had been admitted to the emergency department of a university-affiliated tertiary hospital in Gyeonggi Province, Korea between January 1, 2016 and December 31, 2016. Among these patients, those with aspiration pneumonia were identified using ICD-10 codes (J69.*). Patients with recurrent pneumonia were excluded, as were those who were immunocompromised. The proportion of cases of aspiration pneumonia was calculated, and the characteristics and clinical outcomes of patients with aspiration pneumonia and non-aspiration pneumonia were compared. RESULTS: The proportion of aspiration pneumonia cases among patients with community-acquired pneumonia was 14.2%. Patients with aspiration pneumonia were significantly more likely to be older (p<0.001) and male (p<0.001), and to have a higher confusion, uremia, respiratory rate, blood pressure, and age ≥65 years (CURB-65) score (p<0.001) as compared to patients with non-aspiration pneumonia. They were also more likely to require admission to the intensive care unit (p<0.001) and a longer hospital stay (p<0.001). CONCLUSION: Aspiration pneumonia accounts for 14.2% of all cases of community-acquired pneumonia in Korea. These data may contribute to the establishment of healthcare strategies for managing aspiration pneumonia among Korean adults.

Influence of Supraglottic Swallow on Swallowing Kinematics: Comparison between the Young and the Elderly / 대한연하장애학회지

OBJECTIVE: This study was conducted to evaluate the influence of supraglottic swallowing maneuver on swallowing kinematics using kinematic analysis of a videofluoroscopic swallowing study (VFSS). METHOD: Twenty healthy volunteers (10 in a young group ( < 40 years) and 10 in an elderly group (≥60 years)), participated in this study. After structured instruction by a skilled physician, the subjects swallowed 5 ml of diluted barium in the neutral position without any swallowing maneuvers, as well as with supraglottic swallow maneuver under digital videofluoroscopy, three times each. Kinematic analysis was conducted by digitization of video files for movements of hyolaryngeal structures, including the hyoid bone, larynx, arytenoid, and epiglottis. We measured the maximum displacements and velocities of the hyolaryngeal structures during swallowing. RESULT: The most remarkable change in supraglottic swallow was the maximum vertical displacement (mm) of the hyoid bone during swallowing in both groups (11.5±3.34–19.7±6.88 in the young group, P=0.009; 13.4±2.13–22.8±5.35 in the elderly group, P < 0.001). For velocity variables, patterns of change differed between the young and elderly groups. In the young group, the maximum vertical velocities of the larynx and arytenoid were decreased (P < 0.05), but in the elderly group, the maximum 2D velocity of hyoid bone, maximum horizontal and 2D velocity of the larynx and maximum horizontal velocity of the arytenoid were increased (P < 0.05). There were no significant differences in changes between the young and elderly groups. CONCLUSION: This study showed that supraglottic swallow could affect hyolaryngeal movements, particularly vertical hyoid movement, during swallowing. Beneficial kinematic changes in supraglottic swallow were more pronounced in the elderly group. Therefore, supraglottic swallow may contribute to swallowing improvement by enhancing hyolaryngeal movements during swallowing, in addition to laryngeal closure.

Normative Temporal Data of Hyolaryngeal Movements during Swallowing / 대한연하장애학회지

OBJECTIVE: This study evaluated the temporal variables of hyolaryngeal movements during normal swallowing using kinematic analysis of the video fluoroscopic swallowing study (VFSS) to present the normal cut-off values of those variables. METHODS: Seventy-five healthy volunteers (17 men, 58 women) without swallowing dysfunctions were recruited to examine the swallowing of 2-ml diluted barium by a VFSS. Kinematic analysis was conducted by digitization of video files for movements of hyolaryngeal structures, including the vocal cords, hyoid bone, and epiglottis during normal swallowing. The time points and duration of hyolaryngeal movements were measured. The time points were the start point, maximal point, and the end point of the LE (Laryngeal Elevation), HE (Hyoid Excursion), and EF (Epiglottic Folding). The durations of LE, HE, and EF were obtained by subtracting the time of the start point from the time of the maximal point. The onset time of LE was defined as the reference time point (0 sec). The upper and lower limits of the 95% confidence interval were adopted as the normal cut-off values for the temporal variables of hyolaryngeal movements after transformation to a normal distribution. If a transformation formula to a normal distribution was not found in a variable, the values of the 2.5–97.5 percentile were adopted. RESULTS: The cut-off values of the maximal and end points of the LE were 0.281 to 0.916 sec, and 0.830 to 2.205 sec, respectively. The cut-off values of the start, maximal and end points of the HE were −0.233 to 0.400 sec, 0.320 to 0.874 sec, and 0.889 to 2.055 sec, respectively. The cut-off values of the start, maximal, and end points of the EF were 0.017 to 0.483 sec, 0.364 to 1.055 sec, and 0.774 to 1.773 sec, respectively. The cut-off values of the duration of LE, HE, and EF were 0.281 to 0.916 sec, 0.258 to 0.767 sec, and 0.255 to 0.787 sec, respectively. CONCLUSION: This study presented the normal cut-off values of temporal variables of hyolaryngeal movements during normal swallowing. This study can serve as a basis for classifying and analyzing the patterns of patients with dysphagia.

Changes in Hyolaryngeal Movement During Swallowing in the Lateral Decubitus Posture

OBJECTIVE: To investigate the differences in hyolaryngeal kinematics at rest and during swallowing in the upright sitting (UP) and the lateral decubitus (LD) postures in healthy adults, and delineating any potential advantages of swallowing while in the LD posture. METHODS: Swallowing was videofluoroscopically evaluated in 20 healthy volunteers in UP and LD postures, based on the movements of hyoid bone, vocal folds, and the bolus head. Parameters included the Penetration-Aspiration Scale (PAS), horizontal and vertical displacement, horizontal and vertical initial position, horizontal and vertical peak position, time to peak position of the hyoid bone and vocal folds, and pharyngeal transit time (PTT). RESULTS: Nine participants were rated PAS 2 in the UP and 1 was rated PAS 2 in the LD (p=0.003) at least 1 out of 3 swallows each posture. The hyoid and vocal folds showed more anterior and superior peak and initial positions in the LD. In addition, swallowing resulted in greater vertical and smaller horizontal displacement of the hyoid in LD posture compared with UP. Time to peak position of the hyoid was shorter in LD. The maximal vertical and horizontal displacement of the vocal folds, and PTT were comparable between postures. CONCLUSION: The results showed that the peak and initial positions of the hyoid and larynx and the pattern of hyoid movement varied significantly depending on the body postures. This study suggests that the LD posture was one of the safe feeding postures without any increased risk compared with UP posture.

The Effect of Balloon Dilatation and/or Botulinum Toxin Injection on the Severe Dysphagic Patients with Cricopharyngeal Dysfunction: Case Series / 대한연하장애학회지

OBJECTIVE: To investigate changes of swallowing function after ballooning dilatation (BD) and the Botox injection (BI) into the cricopharyngeus muscle in patients with severe dysphagia. METHOD: Nine severe dysphagic patients with cricopharyngeal dysfunction (CPD) who underwent BD and/or BI into the cricopharyngeal muscle were retrospectively reviewd. Patients who had severe dysphagia (Functional Oral Intake Scale (FOIS)≤2) after at least 3 months of the conventional swallowing therapy were included by a thorough review of medical records with videofluoroscopic swallowing study (VFSS). Before and after several interventions (BD and/or BI), swallowing function was evaluated using VFSS. RESULT: Among 9 patients, 5 underwent both BD and BI, and the other 4 patients underwent only BD. Four among 9 cases showed that interventions were effective. Of the 5 cases with both BD and BI, 2 cases were effective for treatment of CPD. In all the effective 4 cases, pyriform sinus residue seemed to be related with FOIS. Of those cases, one case had long-term effect (more than 4 months) and the other 3 case had short term effect (less than 4 months). CONCLUSION: Interventions were effective in 4 among 9 cases with severe CPD and the therapeutic effect was sustained for more than 4 months. The results suggest that in CPD patients, the BD or BI into UES could be considered in selected patients.

Influence of the Swallowing Posture and Liquid Thickness on the Ease of Pill Swallowing in Healthy Adults / 대한연하장애학회지

OBJECTIVE: To investigate the influence of the swallowing posture and liquid thickness on the easiness of pill swallowing in healthy adults. METHOD: The subjects were 12 healthy young group (19-40 years) and 10 elderly group (65- years). Each subject was examined under videofluoroscopy while swallowing barium-containing placebo pills with six different methods: free fluid with neutral (FN), chin down (FD), chin up (FU), head rotated to left (FL), head rotated to right postures (FR), and thickened fluid with neutral posture (TN). The subjects rated their ease of pill swallowing on a 5-point Likert scale. Time variables were evaluated from the videofluoroscopy images. RESULT: FD, FU and FL were rated significantly less comfortable than FN for pill swallowing. Duration from the start signal to the mandible angle and to laryngeal elevation was significantly prolonged with FD and FL compared to FN. Duration from the start signal to the upper esophageal sphincter was significantly prolonged with FD compared to FN. There were no significant differences on either easiness of swallowing or the time variables between FN and TN. Duration from the start signal to the mandible angle and to the upper esophageal sphincter was significantly longer in the elderly group than the young group with all swallowing methods except FU. In the elderly group, duration from the start signal to laryngeal elevation was significantly shorter with FU than FN. CONCLUSION: Chin down posture is uncomfortable and prolong swallowing time during pill swallowing. In the neutral posture, pill swallowing with thickened fluid is comparable to that with free fluid. Chin up posture may shorten pill swallowing time in elderly.

The Intra- and Inter-rater Reliability and the Learning Curve for a Simple Neurological Score for Rats

OBJECTIVE: To measure the intra- and inter-rater reliability of a simple sensorimotor performance test for rats, and to evaluate the learning efficiency of a novice rater for the test. METHOD: Middle cerebral arteries were occluded by intraluminal sutures in 25 male Sprague-Dawley rats (10~12 weeks old). The sensorimotor performance test was performed by a novice and an experienced rater, with each rater performing the test twice each week for 3 consecutive weeks. A ten-minute standardized video about the rating method was shown to the novice rater after the second test each week. RESULTS: The intra- and inter-rater agreement was determined using Cohen's weighted kappa coefficient. The intra-rater reliability was initially poor for the novice (κ [95% confidence interval], 0.31[-0.02, 0.64]), but it improved significantly after 3-week self education using the standardized video (0.81 [0.69, 0.93], showing almost perfect agreement. The reliability of the experienced researcher was good at all times (κ = 0.64, 0.76, 0.71, for week 1, 2, 3, respectively), indicating substantial agreement. The inter-rater reliability showed clear improvement after self-education (κ = 0.44, 0.69, 0.69, for week 1, 2, 3, respectively). Although the total sum score was highly reliable, some of the individual items showed lower intra-and inter-rater agreement. However, each rater showed greater within-rater variability for different subtests. CONCLUSION: The simple sensorimotor performance test showed high degree of intra- and inter-rater agreement when performed by experienced or properly educated raters. The inaccuracy of the novice was rectified by 3-week self-education using a video.

Characteristics of Dysphagia in Severe Traumatic Brain Injury Patients: A Comparison With Stroke Patients

OBJECTIVE: To compare the swallowing characteristics of dysphagic patients with traumatic brain injury (TBI) with those of dysphagic stroke patients. METHODS: Forty-one patients with TBI were selected from medical records (between December 2004 to March 2013) and matched to patients with stroke (n=41) based on age, sex, and disease duration. Patients' swallowing characteristics were analyzed retrospectively using a videofluoroscopic swallowing study (VFSS) and compared between both groups. Following thorough review of medical records, patients who had a history of diseases that could affect swallowing function at the time of the study were excluded. Dysphagia characteristics and severity were evaluated using the American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale, clinical dysphagia scale, and the videofluoroscopic dysphagia scale. RESULTS: There was a significant difference in radiological lesion location (p=0.024) between the two groups. The most common VFSS finding was aspiration or penetration, followed by decreased laryngeal elevation and reduced epiglottis inversion. Swallowing function, VFSS findings, or quantified dysphagia severity showed no significant differences between the groups. In a subgroup analysis of TBI patients, the incidence of tube feeding was higher in patients with surgical intervention than in those without (p=0.011). CONCLUSION: The swallowing characteristics of dysphagic patients after TBI were comparable to those of dysphagic stroke patients. Common VFSS findings comprised aspiration or penetration, decreased laryngeal elevation, and reduced epiglottis inversion. Patients who underwent surgical intervention after TBI were at high risk of tube feeding requirement.

Diagnosis and Clinical Course of Unexplained Dysphagia

OBJECTIVE: To investigate the final diagnosis of patients with unexplained dysphagia and the clinical and laboratory findings supporting the diagnosis. METHODS: We retrospectively analyzed 143 patients with dysphagia of unclear etiology who underwent a videofluoroscopic swallowing study (VFSS). The medical records were reviewed, and patients with a previous history of diseases that could affect swallowing were categorized into a missed group. The remaining patients were divided into an abnormal or normal VFSS group based on the VFSS findings. The clinical course and final diagnosis of each patient were examined. RESULTS: Among the 143 patients, 62 (43%) had a previous history of diseases that could affect swallowing. Of the remaining 81 patients, 58 (72.5%) had normal VFSS findings and 23 (27.5%) had abnormal VFSS findings. A clear cause of dysphagia was not identified in 9 of the 23 patients. In patients in whom a cause was determined, myopathy was the most common cause (n=6), followed by laryngeal neuropathy (n=4) and drug-induced dysphagia (n=3). The mean ages of the patients in the normal and abnormal VFSS groups differed significantly (62.52±15.00 vs. 76.83±10.24 years, respectively; p<0.001 by Student t-test). CONCLUSION: Careful history taking and physical examination are the most important approaches for evaluating patients with unexplained swallowing difficulty. Even if VFSS findings are normal in the pharyngeal phase, some patients may need additional examinations. Electrodiagnostic studies and laboratory tests should be considered for patients with abnormal VFSS findings.

Erratum: Inpatient Stroke Rehabilitation Outcomes in Korea Derived from the Korean Brain Rehabilitation Centers' Online Database System for the Years 2007 to 2011

In this article (J Korean Med Sci 2015; 30: 644-50), one author's name is misspelled. Correct Sung-Hun Im into Seong Hoon Lim.

Inpatient Stroke Rehabilitation Outcomes in Korea Derived from the Korean Brain Rehabilitation Centers' Online Database System for the Years 2007 to 2011

The purpose of this report was to provide information for patients receiving inpatient rehabilitation after stroke and to identify the possible factors influencing functional outcome after inpatient rehabilitation. Stroke patients (n = 5,212) who were discharged from the Departments of Rehabilitation Medicine (RM) of university hospitals and rehabilitation hospitals from 2007 through 2011 were participants. Prevalence, age, transfer time after onset, length of stay (LOS), functional status at admission and discharge were analyzed. In all stroke subjects, cerebral infarctions (67%) were more common than hemorrhages. Cerebral infarctions in the middle cerebral artery territory were most common, while the basal ganglia and cerebral cortex were the most common areas for hemorrhagic stroke. The LOS decreased from 45 to 28 days. Transfer time after onset decreased from 44 to 30 days. Shorter transfer time after onset was correlated with better discharge functional status and shorter LOS. Initial functional status was correlated with discharge functional status. In ischemic stroke subtypes, cerebellar and brainstem strokes predicted better outcomes, while strokes with more than one territory predicted poorer outcomes with more disabilities. In hemorrhagic stroke subtypes, initial and discharge functional status was the lowest for cortical hemorrhages and highest for brainstem hemorrhages. This report shows that LOS and transfer time after onset has been decreased over time and initial functional status and shorter transfer after onset are predictors of better functional outcome at discharge.

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.

Clinical Characteristics Associated With Aspiration or Penetration in Children With Swallowing Problem

OBJECTIVE: To evaluate demographic characteristics of children with suspected dysphagia who underwent videofluoroscopic swallowing study (VFSS) and to identify factors related to penetration or aspiration. METHODS: Medical records of 352 children (197 boys, 155 girls) with suspected dysphagia who were referred for VFSS were reviewed retrospectively. Clinical characteristics and VFSS findings were analyzed using univariate and multivariate analyses. RESULTS: Almost half of the subjects (n=175, 49%) were under 24 months of age with 62 subjects (18%) born prematurely. The most common condition associated with suspected dysphagia was central nervous system (CNS) disease. Seizure was the most common CNS disorder in children of 6 months old or younger. Brain tumor was the most important one for school-age children. Aspiration symptoms or signs were the major cause of referral for VFSS in children except for infants of 6 months old or where half of the subjects showed poor oral intake. Penetration or aspiration was observed in 206 of 352 children (59%). Subjects under two years of age who were born prematurely at less than 34 weeks of gestation were significantly (p=0.026) more likely to show penetration or aspiration. Subjects with congenital disorder with swallow-related anatomical abnormalities had a higher percentage of penetration or aspiration with marginal statistical significance (p=0.074). Multivariate logistic regression analysis revealed that age under 24 months and an unclear etiology for dysphagia were factors associated with penetration or aspiration. CONCLUSION: Subjects with dysphagia in age group under 24 months with preterm history and unclear etiology for dysphagia may require VFSS. The most common condition associated with dysphagia in children was CNS disease.

Comparison of Different Gum-Based Thickeners Using a Viscometer and Line Spread Test: A Preliminary Study

OBJECTIVE: To compare fluid thickeners composed of starch polysaccharide (STA), guar gum-based polysaccharide (GUA), and xanthan gum-based polysaccharide (XAN) with the use of a viscometer and a line spread test (LST) under various measurement conditions. METHODS: The viscosity of thickened fluid with various concentrations (range, GUA 1%-4%, XAN 1%-6%, STA 1%-7%, at intervals of 1%) was measured with a rotational viscometer with various shear rates (1.29 s-1, 5.16 s-1, 51.6 s-1, and 103 s-1) at a temperature of 35degrees C, representing body temperature. The viscosity of STA showed time dependent alteration. So STA was excluded. Viscosities of GUA and XAN (range of concentration, GUA 1%-3%, XAN 1%-6%, at intervals of 1%) were measured at a room temperature of 20degrees C. LST was conducted to compare GUA and XAN (concentration, 1.5%, 2.0%, and 3.0%) at temperatures of 20degrees C and 35degrees C. RESULTS: The viscosities of 1% GUA and XAN were similar. However, viscosity differences between GUA and XAN were gradually larger as concentration increased. The shear thinning effect, the inverse relationship between the viscosity and the shear rate, was more predominant in XAN than in GUA. The results of LST were not substantially different from GUA and XAN, in spite of the difference in viscosity. However manufacturers' instructions do not demonstrate the rheological properties of thickeners. CONCLUSION: The viscosities of thickened fluid were different when the measurement conditions changed. Any single measurement might not be sufficient to determine comparable viscosity with different thickeners. Clinical decision for the use of a specific thickener seems to necessitate cautious consideration of results from a viscometer, LST, and an expert's opinion.

Kinematic Changes in Swallowing After Surgical Removal of Anterior Cervical Osteophyte Causing Dysphagia: A Case Series

This retrospective case series included five patients who underwent surgical resection of the cervical anterior osteophyte due to dysphagia. Videofluoroscopic swallowing studies (VFSSs) were performed before and after surgery on each patient, and kinematic analysis of the video clips from the VFSS of a 5-mL liquid barium swallow was carried out. Functional oral intake improved after surgery in 3/4 patients who had required a modified diet before surgery. Kinematic analysis showed increases in the maximal hyoid vertical movement length (13.16+/-5.87 to 19.09+/-4.77 mm, p=0.080), hyoid movement velocities (170.24+/-84.71 to 285.53+/-104.55 mm/s, p=0.043), and upper esophageal sphincter opening width (3.97+/-0.42 to 6.39+/-1.32 mm, p=0.043) after surgery. In conclusion, improved upper esophageal sphincter opening via enhancement of hyoid movement after cervical anterior osteophyte resection may be the kinetic mechanism of improved swallowing function.