Frenkel’s exercise on lower limb sensation and balance in subacute ischemic stroke patients with impaired proprioception

@#Few reliable studies have used standardized outcome measures to examine the effectiveness of sensory interventions to treat somatosensory impairment. The aim of this study is to examine the effectiveness of Frenkel’s exercise for improving lower limb sensation, balance, motor function, functional ambulation, and activities of daily living in subacute ischemic stroke patients with impaired proprioception. Methods: This retrospective cohort study enrolled 14 patients suffering subacute ischemic stroke between 7 to 30 days of onset who showed reduced proprioception in the lower limbs. They were divided into two groups: intervention group (performed Frenkel’s exercise, 15 minutes per day, 15 days over a period of 3 weeks, n=7) and control group (received conventional physical therapy instead, n=7). Outcome measurements included the kinesthetic and light touch sensation subscales of the Nottingham Sensory Assessment (NSA) for the lower limb, the Korean version of the Berg balance scale (K-BBS), the Functional Ambulation Classification (FAC), the Motricity Index (MI), and the Korean version of the Modified Barthel Index (K-MBI). Results: Patients in both groups showed significant improvements on the kinesthetic and tactile sensation subscale of the NSA for the lower limb, the K-BBS, the FAC, and the K-MBI, but not the MI, from baseline to post-intervention at 3 weeks. When compared between the two groups, significant improvements were only seen in the kinesthetic sensation subscale of the NSA for the lower limb and the K-BBS (p<0.05). Conclusions: Frenkel’s exercise improves sensory and balance recovery among subacute ischemic stroke patients with impaired proprioception and minimal lower limb motor weakness.

Evaluation of Salivary Aspiration in Brain-Injured Patients With Tracheostomy

OBJECTIVE: To determine the useful tool for evaluating salivary aspiration in brain-injured patients with tracheostomy. METHODS: Radionuclide salivagram and laryngoscopy was done in 27 brain-injured patients with tracheostomy. During salivagram, 99mTc sulfur colloid was placed sublingually in the supine position, and 50-minute dynamic images and 2-hour delayed images were obtained. Salivary aspiration was detected when the tracer was entered into the major airways or lung parenchyma. Laryngoscopy was done by otolaryngologists, and saliva aspiration, saliva pooling, and vocal cord palsy were evaluated. Videofluoroscopic swallowing study was done in patients who were able to undergo the test. RESULTS: The detection rate of salivary aspiration was 44.4% with salivagram, and 29.6% with laryngoscopy. The correlation of the two tests was 70.4%. Of the laryngoscopy findings, salivary pooling had significant correlation with positive salivagram results (p=0.04). Frequent need of suction correlated with salivary aspiration in both salivagram (p=0.01) and laryngoscopy (p=0.01). Patients with negative results in salivagram or laryngoscopy had higher rates of progressing to oral feeding or tapering tracheostomy. Two patients developed aspiration pneumonia, and both patients only showed aspiration in salivagram. CONCLUSION: Brain-injured patients with tracheostomy have a high risk of salivary aspiration. Evaluation of salivary aspiration is important, as it may predict aspiration pneumonia and aids in clinical decisions of oral feeding or tracheostomy removal. Salivagram is more sensitive than laryngoscopy, but laryngoscopy may be useful for evaluating structural abnormalities or for follow-up examinations to assess the changes.

Cerebellar Atrophy Following Long Term Phenytoin Overdose: A case report

Phenytoin is a commonly used antiepileptic drug, and its narrow therapeutic index causes various toxicities. Although acute toxicity commonly causes ataxia, few cases have been reported of permanent cerebellar atrophy. A 49-year-old female with epilepsy was prescribed oral phenytoin. After three years of medication, seizure was controlled, but she developed unsteady gait and dysarthria. On admission, the patient showed severe bilateral ataxia, gingival hypertrophy, nystagmus, and dysarthria. Phenytoin toxicity was the impression, and phenytoin was omitted. Serum phenytoin level was 46.9 mg/L (therapeutic range being 10~20 mg/L). Brain magnetic resonance imaging (MRI) was performed to rule out other brain lesions, and diffuse cerebellar atrophy was revealed. After rehabilitation, mild bilateral ataxia remained, standing balance was poor, and the patient was able to walk 70 meters with minimal assist using roller walker. We review a case of chronic phenytoin toxicity that manifested as cerebellar ataxia and later showed atrophy of cerebellum.