Objective Criteria for Judging Walking Independence in a Convalescent Rehabilitation Ward for Hemiparetic Stroke：A Study Using Decision Tree Analysis / The Japanese Journal of Rehabilitation Medicine

Objective：This study aimed to clarify the objective criteria for assessing walking independence using cane in patients with stroke in the convalescent rehabilitation ward.Methods：Participants were in-patients with hemiparetic stroke who could walk with a cane, and they were categorized into the independent (ID) and supervised (SV) walking groups. Stroke impairment assessment set-motor for lower extremity (SIAS-LE), trunk control test (TCT), Berg balance scale (BBS), 10-m walking speed (m/s), and functional independence measure-cognitive (FIM-C) were assessed. ID and SV used the scores at the time of independent walking and at the discharge time, respectively. Additionally, falls after independence were investigated. Statistical analysis was performed using univariate analysis and decision tree analysis.Results：In total, 148 patients (ID：n=101, 68±13 years, SV：n=47, 79±12) were included. Significant differences were observed in walking speed, TCT score, BBS score, and FIM-C score between the groups. Moreover, walking speed, FIM-C score, and BBS score were selected in the decision tree analysis in this order and divided into five groups namely：1) walking speed ≥ 0.42 and FIM-C ≥ 22 (percentage of independent patients 97％/percentage of fallers 5％), 2.) walking speed ≥ 0.42, FIM-C＜22, and BBS ≥ 50 (100％/0％), 3.) walking speed ≥ 0.42, FIM-C＜22, and BBS＜50 (52％/8％), 4.) walking speed＜0.42, and BBS ≥ 28 (49％/28％), and 5) walking speed＜0.42 and BBS＜28 (0％/0％). The overall percentage of fallers was 8.9％, with group 4 having the highest number of fallers.Conclusion：Walking speed, FIM-C, and BBS, in decreasing order, were involved in walking independence. Patients with low walking speed were more likely to fall. Therefore, careful assessment of walking independence is particularly required.

Clinical Applications of Heart Rate Variability in Neurological Disorders

Heart rate variability (HRV) is a useful marker for predicting mortality and cardiovascular events in cardiac diseases. Various time- and frequency-domain parameters are used for assessing HRV. The time-domain measures include standard deviation of the NN intervals (SDNN), standard deviation of the average NN interval, root mean square of the successive differences SDNN index, NN50 count, and pNN50, while the power spectrum that is used the most widely in frequency-domain analyses is divided into low frequency (LF), high frequency (HF), LF norm, HF norm, and LF/HF. The HF band is modulated by the parasympathetic nervous system, while the LF band is modulated by both the sympathetic and parasympatheticnervous systems. Altered or reduced HRV parameters have been shown to be related to cardiovascular events in patients with various neurological disorders, such as parkinsonian syndromes, dementia, cerebrovascular disorder, and epilepsy. Furthermore, analyses of HRV have attempted to distinguish different diseases and evaluate the degree of disability. This article discusses the clinical use of HRV in the neurological field.

Movement Disorders Following Cerebrovascular Lesions in Cerebellar Circuits

Cerebellar circuitry is important to controlling and modifying motor activity. It conducts the coordination and correction of errors in muscle contractions during active movements. Therefore, cerebrovascular lesions of the cerebellum or its pathways can cause diverse movement disorders, such as action tremor, Holmes' tremor, palatal tremor, asterixis, and dystonia. The pathophysiology of abnormal movements after stroke remains poorly understood. However, due to the current advances in functional neuroimaging, it has recently been described as changes in functional brain networks. This review describes the clinical features and pathophysiological mechanisms in different types of movement disorders following cerebrovascular lesions in the cerebellar circuits.

Development-assistance Strategies for Stroke in Low- and Middle-income Countries

While communicable diseases still pose a serious health threat in developing countries, previously neglected health issues caused by non-communicable diseases such as stroke are rapidly becoming a major burden to these countries. In this review we will discuss the features and current status of stroke in low- and middle-income countries (LMICs). Overall the global burden of hemorrhagic stroke is larger than ischemic stroke, with a disproportionately greater burden, measured in incidence and disability-adjusted life-years, regionally localized in LMICs. Patients in poorer countries suffer due to insufficient primary care needed to control risk factors such as hypertension, and inadequate emergency care systems through which sudden events should be managed. In light of these situations, we emphasize two strategic points for development assistance. First, assistance should be provided for bolstering, integrating, and coordinating both the primary health and emergency care systems, in order to prevent stroke and strengthen stroke management, respectively. Second, the assistance needs to focus on programs at the community level, to reduce life-style risks of stroke in a more sustainable manner, and to improve stroke outcomes more effectively.

An Important Consideration when Using Botulinum Toxin Injections for Treating Claw Foot Deformity / The Japanese Journal of Rehabilitation Medicine

Objectives : In this study, we assessed the muscle contraction pattern of each toe by stimulating the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles in patients with claw foot deformity caused by spasticity in the lower extremity in order to increase the benefit of their botulinum toxin treatments. Subjects and Methods : Fifteen post-stroke patients (11 male and 4 female ; mean age, 62.3 years) were recruited for the study. In this observational study, the muscle contraction patterns of the hallux and digits on electrical stimulation of the FHL or FDL were examined by two doctors, and the data was then analyzed. In addition, the FHL and FDL were identified in 6 feet from 3 cadaver specimens below the ankle to near the end of each muscle on each toe. Results : In muscles that could be observed, muscle contraction was observed in the hallux in every subject and in the second digit in 92.3% subjects when the FHL was stimulated electrically. Muscle contraction was not observed in the second digit in 64.3% of the subjects when the FDL was stimulated electrically. In the cadaver dissections, the tendons of the FHL sent fibers to the FDL tendons in all 6 feet examined. Conclusion : In conclusion, when botulinum toxin is to be injected into the FHL or FDL muscle for treating claw foot deformity in patients with lower extremity spasticity, especially when the treatment target is the second digit, the injection should be performed not only in the FDL muscle, but also in the FHL muscle to increase the effectiveness of the treatment.

Intracranial Vasculopathy in a Patient with Systemic Sclerosis: Atherosclerotic or Moyamoya-Like Disease?

No abstract available.

High Prevalence of Peripheral Arterial Disease in Korean Patients with Coronary or Cerebrovascular Disease

This prospective study surveyed the prevalence of peripheral arterial disease (PAD) in Korean patients with coronary arterial disease (CAD) or cerebrovascular disorder (CVD). From March 2010, 576 hospitalized patients in cardiovascular or stroke center were enrolled as the study group. Ankle-brachial index (ABI) was measured and the cut-off point for diagnosing PAD was or = 50 yr was enrolled as the control group. The prevalence of PAD was significantly higher in the study group than the control group (7.6% vs 1.7%; P < 0.001). To analyze the relationship of other vascular diseases and PAD, the patients were regrouped; group A (no CAD or CVD), group B (CAD only), group C (CVD only), and group D (CAD and CVD). Compared with group A, those with other vascular diseases (group B, C, D) had significantly higher prevalence of PAD, diabetes, dyslipidemia, renal insufficiency and claudication. The trend that patients with CAD or CVD are at risk of PAD is observed in this cross-sectional study in Koreans. Routine ABI measurement is recommended in these high-risk groups for early detection and proper management of PAD.

Factors for Approving Cerebrovascular Disorders and Cardiovascular Diseases as Work-related Diseases in Chronically Overworked Workers / 대한산업의학회지

OBJECTIVES: This study was conducted to analyze the factors that affected the decision of claims for cerebrovascular disorders and cardiovascular diseases in chronically overworked workers, that submitted their claims after the reformation of approval standards in the Industrial Accident Compensation Insurance Act on 1 July 2008. METHODS: Of 2909 cases, who claimed between January 1. and December 31. 2009, 1046 cases were selected based on their worker's compensation record and investigated following 6 provincial committees for work-related diseases. The approval rate and odds ratio were analyzed with respect to the general characteristics, past medical history and work-related information using a logistical regression and Student t-test. RESULTS: Of the 1046 selected cases, the approval rate was 18.5%(194 cases). In the multivariate logistical regression analysis, the factors for approving cerebrovascular disorders and cardiovascular diseases as work-related diseases were found to be the average working time over the last 1 week, occupational category, gender, age, death or survival, the presence of an associated disease, claimed province, and smoking. CONCLUSION: Factors for approving claims of cerebrovascular disorders and cardiovascular diseases as work-related diseases were the average working time over last 1 week, gender, age, death or survival, claimed disease, presence of associated disease, claimed province, smoking.

The Effect of Increased Training Time for Patients with Feeding Tubes in a Kaifukuki Rehabilitation Ward / The Japanese Journal of Rehabilitation Medicine

After April 2006, the Japanese Ministry of Health and Labor raised the permitted training time from 6 to 9 units (1 unit of training time corresponds to 20 minutes of exercise with a therapist) for patients in a kaifukuki (convalescent) rehabilitation ward. We examined the effect of the increased rehabilitative training time on patients using feeding tubes in a kaifukuki rehabilitation ward after an initial cerebrovascular disorder, with a particular focus on improving swallowing disorders. Our study was comprised of post-stroke patients with feeding tubes who underwent rehabilitation from April 2001 to March 2006 (<i>N</i>=14, 6-unit group) and from April 2006 to March 2009 (<i>N</i>=16, 9-unit group). All patients went to the ward within two months after suffering a stroke. There was no significant difference in the Functional Independence Measure(FIM) efficiency or length of hospital stay between the two groups. Feeding tube removal was more common in the 9-unit group compared to the 6-unit group (81.3% vs. 35.7%, <i>p</i><0.05), and the 9-unit group also had more training time per day. Logistic regression analysis showed that the increased training time per day spent with a speech therapist contributed to improving swallowing disorders (<i>p</i><0.01).

Current State and Future Challenges facing Kaifukuki Rehabilitation Wards / The Japanese Journal of Rehabilitation Medicine

Currently, there are more than 53,000 beds in kaifukuki rehabilitation wards throughout Japan. The development of kaifukuki rehabilitation wards is proceeding smoothly in terms of quantity. It is suggested that, with this development, the activities of daily living of patients will significantly improve, leading to an increase in the likelihood of patients returning home when a large unit of daily rehabilitation training is provided via one of these kaifukuki rehabilitation wards. The tasks remaining to be completed for the optimal realization of the kaifukuki rehabilitation wards are to reduce the disparity in the number of beds among prefectures, to realize a mature team approach to the rehabilitation program, to encourage full-time ward physicians of the rehabilitation department to exercise leadership, to enhance subacute medical services, to enhance human resources such as nurses and rehabilitation specialists and to improve the education and training system for the staff. Other major tasks remaining are to strengthen the cooperation between kaifukuki rehabilitation wards and acute hospitals, by which such rehabilitation wards will become capable of actively accepting patients from an early stage, and to establish cooperation between kaifukuki rehabilitation wards and the home care system.

Validation of the Nursing Outcomes Classification on Cerebrovascular Patients / 성인간호학회지

PURPOSE: The purpose of this study was to assess the importance and contribution of 9 nursing outcomes and their indicators that could be applied to cerebrovascular patients. METHODS: Data were collected from 175 neurosurgical nurses working at two university affiliated hospitals and five secondary hospitals located in Gwang-ju. The Fehring method was used to estimate outcome content validity(OCV) and outcome sensitivity validity(OSV) of nursing outcomes and their indicators. Stepwise regression was used to evaluate relationship between outcome and its indicators. RESULTS: The core outcomes identified by the OCV were Tissue Perfusion: Cerebral, Nutritional Status, Neurological Status, and Wound Healing: Primary Intention, whereas highly supportive outcomes identified by the OSV were Oral Health, Self-Care: ADL, and Nutritional Status. All the critical indicators selected for Fehring method were not included in stepwise regression model. By stepwise regression analysis, the indicators explained outcomes from 19% to 52% in importance and from 21% to 45% in contribution. CONCLUSION: This study identified core and supportive outcomes and their indicators which could be useful to assess the physical status of cerebrovascular patients. Further research is needed for the revision and development of nursing outcomes and their indicators at neurological nursing area.

Progress of Acupuncture and Tuina for Shoulder Joint Subluxation Following Apoplexy / 针灸推拿医学（英文版）

The treatments of shoulder joint subluxation following apoplexy with acupuncture, tuina, acupoint injection, and comprehensive methods in recent 10 years were reviewed. By comparing and analyzing the clinical effects of different methods, acupuncture combing with rehabilitation therapy is considered as a satisfactory one in treating subluxation following apoplexy.

Treatment of 40 Cases of Poststroke Shoulder-Hand Syndrome by Acupuncture / 针灸推拿医学（英文版）

Acupuncture and rehabilitation therapies were used to treat 40 cases of shoulder-hand syndrome, the results show that integration of acupuncture and rehabilitation can increase therapeutic effects and shorten treatment courses to accelerate recovery.

Treatment of 28 Cases of Hiccup Following Cerebral Infarction by Acupuncture / 针灸推拿医学（英文版）

Twenty-eight cases of Hiccup Following Cerebral Infarction were treated by Acupuncture, Of the 28 cases, 12 cases were cured, 13 cases were effective, 3 cases were remarkable effect, with an effective rate of 89.3%.

Treatment of Swallowing Dysfunction after Cerebral Apoplexy by Acupuncture: A Report of 56 Cases / 针灸推拿医学（英文版）

Fifty-six patients with swallowing dysfunction after cerebral apoplexy were treated by acupuncture and swallowing function training. The curative effect is satisfactory and the total effective rate was 96.4%.

Effect of increased Training Time in a Convalescence Rehabilitation Ward / The Japanese Journal of Rehabilitation Medicine

We examined the effect of increased rehabilitative training time on patients with cerebrovascular disorders at a convalescent rehabilitation ward in Japan. After April 2006, the Japanese Ministry of Health and Labor raised the permitted training time from 6 to 9 units (1 unit of training time corresponds to 20 minutes of exercise with a therapist) for patients in a convalescent rehabilitation ward. We compared patients who underwent rehabilitation during the period from April 2006 to March 2008 (9-unit group, 131 patients) with those rehabilitated from April 2003 to March 2006 6-unit group, 153 patients) in the convalescent rehabilitation ward of our hospital. The patients were evaluated with FIM instruments at admission and discharge. Length of hospital stay and rate of return to the patient's home were also examined. The 9-unit group had a shorter hospital stay, and higher FIM efficiency scores, and also a higher rate of home return compared with the 6-unit group.

A Comparative Study of Patient Discharge Disposition in a Convalescent Rehabilitation Unit—An Analysis of Cerebrovascular Disorder and Disuse Syndrome Cases— / The Japanese Journal of Rehabilitation Medicine

To assess the factors affecting home return after convalescent rehabilitation, we retrospectively compared such items between the patients returning home (subgroup I) and those requiring long-term institutionalization (subgroup II) as follows : the patient's ADL level before admission and the their living environment, the serial changes in their ADL after admission, the duration of acute care, and the length of stay. Subjects comprised 32 patients with cerebrovascular disorder (CVD) and 22 with disuse syndrome (DS) and each of these two groups was divided into subgroup I and II (<i>n</i>=19 and 13 in the CVD group, 11 and 11 in the DS group, respectively). In the CVD group, the mean age of subgroup I was significantly lower than that of subgroup II (65.4±14.0 and 80.3±10.9, respectively). The FIM scores (total, motor, cognition) in subgroup I were significantly higher than those in subgroup II, both at the time of admission and discharge. In the FIM motor items, the scores for mobility and locomotion significantly improved at discharge. In the DS group, there was no difference in the ages between the subgroups (80.5±11.0 and 81.5±11.2, respectively). Subgroup I had more family members and showed a significant increase in their scores for self-care and mobility after admission. In conclusion, home return appears most related to improvement in motor ADL, and this improvement was further influenced by age and cognitive function in the CVD group and by the number of family members in the DS group.

Dissecção espontânea das artérias carótidas e vertebrais em uma população multiétnica / Spontaneous carotid and vertebral arteries dissection in a multiethnic population

A dissecção espontânea das artérias carótidas e vertebrais (DEACV) é considerada uma causa rara de acidente vascular cerebral, particularmente em países com população multiétnica. O objetivo desse estudo foi avaliar características clínicas e de neuroimagem dos pacientes com DEACV em uma população multiétnica. Foram estudados 66 pacientes com diagnóstico de DEACV em dois hospitais terciários de São Paulo. Aplicou-se um questionário inicial e os pacientes foram seguidos prospectivamente. Dos pacientes estudados, 82 por cento eram brancos, 53 por cento eram homens e a média de idade foi 41,7 anos. Os fatores de risco cardiovasculares mais freqüentes foram hipertensão arterial e tabagismo. Outros aspectos avaliados foram história prévia de enxaqueca, tratamento inicial e prognóstico. Concluiu-se que apesar da população estudada ser multiétnica, houve um marcante predomínio de brancos. A análise das características clínicas e de neuroimagem dos pacientes com DEACV possibilita um melhor conhecimento da doença, levando a um diagnóstico precoce e tratamento mais adequado.

Spontaneous dissection of the carotid and vertebral arteries (SDCVA) is considered a rare cause of stroke, particularly in countries with multiethnic population. The objective was to evaluate the clinical and neuroimaging features of patients with SDCVA from a multiethnic population. Sixty-six patients diagnosed with SDCVA were studied at two tertiary hospitals at São Paulo. An initial questionnaire was completed and patients were followed prospectively. Among the patients studied, 82 percent were caucasian, 53 percent were male and the average age was 41.7 years old. The most frequent cardiovascular risk factors found were systemic hypertension and tobacco use. Other aspects evaluated were history of previous migraine, initial treatment and prognosis. In conclusion, although the population studied was multhiethnic, there was a marked predominance of caucasians. The analysis of clinical and neuroimaging data from patients with SDCVA allows a better understanding of the disease, leading to an earlier diagnosis and more appropriate treatment.

Analysis of 10,811 Cases with Acute Ischemic Stroke from Korean Stroke Registry: Hospital-Based Multicenter Prospective Registration Study

BACKGROUND: Although several hospital-based stroke studies were published, there has not been any reliable data representing the clinical characteristics of stroke in Korea. We analyzed the clinical characteristics of patients with ischemic stroke registered in the Korean Stroke Registry (KSR), which is the largest prospective hospital-based nation-wide stroke registry in Korea. METHODS: The KSR provided standardized protocols for collecting data, which includes the data of demographics, subtypes of stroke, risk factors, and neurological outcome at discharge. The brain imaging studies, including CT or MRI, were performed in all cases. RESULTS: KSR registered 10,811 patients of acute ischemic stroke between Nov. 2002 and Jun. 2004. The large-artery atherosclerosis was the most common subtype (37.3%), followed by small vessel occlusion (30.8%). Hypertension (65.4%) was the most common risk factor, followed by smoking (34.5%) and diabetes (28.3%). Although most of the hypertensive and diabetic patients had been diagnosed before the stroke, less than 45.4% and 32.5% of them were under regular control. The steno-occlusive lesion of extracranial carotid artery was only 29.3% and the ratio of intra- to extracranial artery disease was more than 2 in KSR. Only 20.5% of patients were admitted within 3 hours after stroke onset and 2.1% were treated with intravenous thrombolysis. In-hospital case-fatality was 5.2%, which is relatively comparable to those of previous studies. CONCLUSIONS: The KSR provided informative data in understanding the clinical characteristics of ischemic stroke in Korea. Further analysis of KSR will facilitate clinical trials and development of guidelines for the management of stroke patients.

Subtypes of Vascular Dementia

Vascular dementia is defined as a clinical syndrome of acquired intellectual impairment resulting from a brain injury due to a cerebrovascular disorder. It incorporates various vascular pathophysiological mechanisms and changes in the brain, and has diverse cause and clinical manifestations. The main suptypes of vascular dementia include 1) multi-infarct dementia, 2) strategic infarct dementia, and 3) subcortical vascular dementia. Both multi-infarct dementia and strategic infarct dementia show heterogeneity in etiologies, changes of the brain, as well as clinical manifestations. On the contrary, subcortical vascular dementia is suggested to be a more homogenous group. To better understand the clinical features of vascular dementia, cases corresponding to each subtype of vascular dementia are briefly discussed this review.