Early Neurodevelopmental Assessments of Neonates Discharged From the Neonatal Intensive Care Unit: A Physiatrist’s Perspective

The survival rate of children admitted in the neonatal intensive care unit (NICU) after birth is on the increase; hence, proper evaluation and care of their neurodevelopment has become an important issue. Neurodevelopmental assessments of individual domains regarding motor, language, cognition, and sensory perception are crucial in planning prompt interventions for neonates requiring immediate support and rehabilitation treatment. These assessments are essential for identifying areas of weakness and designing targeted interventions to improve future functional outcomes and the quality of lives for both the infants and their families. However, initial stratification of risk to select those who are in danger of neurodevelopmental disorders is also important in terms of cost-effectiveness. Efficient and robust functional evaluations to recognize early signs of developmental disorders will help NICU graduates receive interventions and enhance functional capabilities if needed. Several age-dependent, domain-specific neurodevelopmental assessment tools are available; therefore, this review summarizes the characteristics of these tools and aims to develop multidimensional, standardized, and regular follow-up plans for NICU graduates in Korea.

Sensory Based Feeding Intervention for Toddlers With Food Refusal: A Randomized Controlled Trial

Objective@#To investigate the effect of sensory-based feeding treatment for toddlers with food refusal compared with only providing nutrition education. @*Methods@#Thirty-two toddlers with food refusal were randomly assigned to an intervention group or the control group. Toddlers in the intervention group received the sensory-based feeding intervention and the duration was for 1 hour for 5 days per week for 4 weeks, and then 1 hour, once a week for 8 weeks. Subjects in both the intervention and control groups received nutritional education once every 4 weeks for 12 weeks. The participants were evaluated at their entry into the study and 12 weeks later based on height, weight, behavior at mealtime using the Behavioral Pediatrics Feeding Assessment Scale (BPFAS), and sensory processing ability using the Infant/Toddler Sensory Profile. @*Results@#Sixteen toddlers were included in each group. Two subjects in the intervention group and four toddlers in the control group were excluded from the final analysis. Significant improvements in child or parent subscales of the BPFAS were observed in the intervention group. In contrast, there were no significant improvements in any BPFAS scores in the control group. @*Conclusion@#Sensory-based feeding intervention was effective for improving mealtime behavior in toddlers with food refusal. Therefore, a sensory-based feeding intervention could be considered as an intervention approach to address feeding disorders in toddlers.

Parents' Perspectives and Clinical Effectiveness of Cranial-Molding Orthoses in Infants With Plagiocephaly

OBJECTIVE: To investigate the clinical effectiveness of and parents’ perspectives on cranial-molding orthotic treatment. METHODS: Medical charts were reviewed for 82 infants treated for plagiocephaly with cranial-molding orthoses in our clinic from April 2012 to July 2016 retrospectively. Infants who were clinically diagnosed with positional plagiocephaly and had a Cranial Vault Asymmetry Index (CVAI) of more than 3.5% were included. Pre- and post-treatment CVAI was obtained by three-dimensional head-surface laser scan. Parents’ perceptions of good outcome (satisfaction) were evaluated with the Goal Attainment Scale (GAS). The GAS score assessed how much the parent felt that his or her initial goal for correcting the skull asymmetry was achieved after the treatment. RESULTS: The compliance with cranial-molding orthoses was 90.2% (74 of 82 infants). There were 53 infants (65% of the 82 infants) who had adverse events with the cranial-molding orthoses during the study. Heat rash was found in 29 cases (35.4%) and was the most common adverse event. The mean GAS T-score was 51.9±10.2. A GAS T-score of 0 or more was identified for 71.6% of parents. The GAS T-score was significantly related to the age (p < 0.001), the initial CVAI, and the difference of CVAI during the treatment (p < 0.001). CONCLUSION: Parents’ perception of good outcome was correlated with the anthropometric improvement in cranialmolding orthotic treatment in infants with plagiocephaly. A high percentage of parents felt that the treatment met their initial goals in spite of a high occurrence of adverse events.

Epidural Neuroplasty with Single Bolus Injection versus Continuous Infusion of Steroid in Patients with Spinal Stenosis

OBJECTIVE: To compare the efficacy of epidural adhesiolysis with a single bolus steroid injection (EAS) and continuous steroid infusion (EAC).METHOD: Thirty-one patients were allocated to the EAS group (10 patients) and EAC group (21 patients). EAS received single bolus of 10 mg of dexamethasone. EAC received a total of 96 mL dexamethasone solution (20.0 mg of dexamethasone) for 48 hrs. Oswestry Disability Index (ODI) was evaluated before, one month after the procedure. Three months after the procedure, the Patient’s Global Impression of Change (PGIC) was evaluated.RESULTS: Pre-treatment ODI was 38.3 ± 3.1 in EAS and 46.40 ± 4.0 in EAC. One month later, ODI was decreased to 35.60 ± 3.33, 43.08 ± 6.96 in each group (p=0.174). Three months later, 2 patients in the EAS (20.0%) and 8 patients in EAC (38.1%) showed ‘much improvement’ in PGIC, 5 patients in EAS (50.0%) and 6 patients in EAC (38.1%) showed ‘slight improvement’, 3 patients in EAS (30.0%) and 7 patients in EAC (33.3%) showed ‘no improvement’ (χ2=1.588, p=0.510).CONCLUSION: Epidural adhesiolysis with continuous infusion did not show any superiority than single bolus injection.

Verification of Reliability and Validity of the Feeding and Swallowing Scale for Premature Infants (FSSPI)

OBJECTIVE: To propose a new scale, the Feeding and Swallowing Scale for Premature Infants (FSSPI), based on videofluoroscopic swallowing study (VFSS) findings and to verify the reliability and validity of the FSSPI. METHODS: One hundred thirty preterm infants who had undergone VFSS were enrolled in this retrospective study. The FSSPI was developed by referring to the Baby Regulated Organization of Subsystems and Sucking approach. The FSSPI score for each VFSS video was evaluated by a physiatrist as well as by three experienced speech-language pathologists. To verify the reliability of the FSSPI, the inter-evaluator and intra-evaluator associations for the FSSPI scores were analyzed. To verify the validity of the FSSPI, the association between FSSPI scores and clinical characteristics including prognosis-related factors was analyzed. RESULTS: The mean gestational age was 27.3±2.8 weeks. The FSSPI showed a high degree of both intra-rater reliability and inter-rater reliability. Also, there was a significant negative correlation between the FSSPI score and corrected age (CA) at the time of performing VFSS. Further, a significant positive correlation was observed between the FSSPI score and CA at the time of achieving full oral feeding. A significant negative correlation was observed between the FSSPI score and weight gain, between the 1st and 2nd month after birth, and between the 2nd and 3rd month after birth, respectively. CONCLUSION: In this study, we proposed a new clinical scale using VFSS to reflect the development of feeding and swallowing skills in preterm infants. Further, we verified the reliability and validity of the scale.

Korean Database of Cerebral Palsy: A Report on Characteristics of Cerebral Palsy in South Korea

OBJECTIVE: To introduce the Korean Database of Cerebral Palsy (KDCP) and to provide the first report on characteristics of subjects with cerebral palsy (CP). METHODS: The KDCP is a nationwide database of subjects with CP, which includes a total of 773 subjects. Characteristics such as demography, birth history, onset and type of CP, brain magnetic resonance imaging (MRI) findings, functional ability and accompanying impairments, were extracted and analyzed. RESULTS: Preterm delivery and low birth weight were found in 59.51% and 60.28% of subjects, respectively. Postnatally acquired CP was 15.3%. The distribution of CP was 87.32%, 5.17%, and 1.81% for spastic, dyskinetic, and ataxic types, respectively. Functional ability was the worst in dyskinetic CP, as compared to other types of CP. Speech-language disorder (43.9%), ophthalmologic impairment (32.9%), and intellectual disability (30.3%) were the three most common accompanying impairments. The number of accompanying impairments was elevated in subjects with preterm birth and low birth weight. Brain MRI showed normal findings, malformations, and non-malformations in 10.62%, 9.56%, and 77.35% of subjects, respectively. Subjects with normal MRI findings had better functional ability than subjects with other MRI findings. MRI findings of a non-malformation origin, such as periventricular leukomalacia, were more common in subjects with preterm birth and low birth weight. CONCLUSION: The KDCP and its first report are introduced in this report, wherein the KDCP established agreement on terminologies of CP. This study added information on the characteristics of subjects with CP in South Korea, which can now be compared to those of other countries and ethnicities.

The Effects of Equine-assisted Activities and Therapy on Resting-state Brain Function in Attention-deficit/Hyperactivity Disorder: A Pilot Study

OBJECTIVE: Equine-assisted activities and therapy (EAA/T) have been used as adjunct treatment options for physical and psychosocial rehabilitation. However, the therapeutic effects on resting-state brain function have not yet been studied. The aim of this study is to investigate the effects of EAA/T on participants with attention-deficit/hyperactivity disorder (ADHD) by comparing resting-state functional magnetic resonance imaging (rs-fMRI) signals and their clinical correlates. METHODS: Ten participants with ADHD participated in a 12-week EAA/T program without any medication. Two rs-fMRIs were acquired for all participants before and after EAA/T. For estimating therapeutic effect, the regional homogeneity (ReHo) method was applied to capture the changes in the regional synchronization of functional signals. RESULTS: After the EAA/T program, clear symptom improvement was found even without medication. Surface-based pairwise comparisons revealed that ReHo in the right precuneus and right pars orbitalis clusters had significantly diminished after the program. Reduced ReHo in the right precuneus cluster was positively correlated with changes in the scores on DuPaul’s ADHD Rating Scale-Korean version. CONCLUSION: Our results indicate that EAA/T is associated with short-range functional connectivity in the regions related to the default mode network and the behavioral inhibition system, which are associated with symptom improvement.

Overall Profile of a Pediatric Multidisciplinary Feeding Clinic

OBJECTIVE: To evaluate the overall profile of children with feeding disorders and their relationships to medical conditions in an outpatient feeding clinic of a tertiary hospital. METHODS: The medical records of 143 children who had visited the feeding clinic between January 2010 and June 2014 were reviewed retrospectively. The presence of a feeding disorder (feeding behavior disorder, dysphagia, and/or failure to thrive [FTT]) and the children's medical conditions were examined by a physiatrist. RESULTS: Half of the patients (n=74, 51.7%) were under 15 months of age, and 68 (47.6%) were born preterm. Ninety-three patients (65.0%) met the criteria for any combination of feeding behavior disorder, dysphagia, or FTT. Cardiorespiratory disease was the most common medical condition; children with this condition were more likely to show sensory food aversion and FTT. Feeding behavior disorders were significantly associated with gastrointestinal problems, and dysphagia was significantly related to almost all medical conditions. CONCLUSION: A multidisciplinary approach to children with feeding difficulties is proposed for comprehensive evaluation and treatment because combinations of feeding problems are very common among children. This overall profile could provide clinicians with a clear understanding of the complexity of feeding disorders and their relationships with various medical conditions in children.

The Effect of Hippotherapy and Medication on Children with Attention Deficit Hyperactivity Disorder: A Pilot Study / 신경정신의학

OBJECTIVES: This study researched the clinical effects of hippotherapy and medication in attention deficit hyperactivity disorder (ADHD) children. METHODS: The study employed an open label randomized controlled trial. Participants were 10 children of ages between 6 and 12 years. These subjects were placed in 2 groups : the hippotherapy group and the medication group. Evaluation tools used in this study include Affective Disorders and Schizophrenia-Present and Lifetime Version- Korean Version, the Wechsler Intelligence Scale for Children-IV, Korean Child Behavior Check List (K-CBCL), ADHD rating scale (ARS), Clinical Global Impression (CGI), and Quantitative electroencephalography (QEEG). RESULTS: Grossly scores of investigator-administered ADHD rating scale (ARS-I), K-CBCL, and CGI-Severity of Illness scale were improved in both the hippotherapy and the medication group. The ARS-I scores of the Hippotherapy group were not significantly different from baseline after 12 weeks. In the QEEG, theta/beta ratio of Pz area in the hippotherapy group was significantly different from baseline. Children treated with medication showed significant difference from baseline in ARS-I, K-CBCL subscales, and QEEG. CONCLUSION: The use of hippotherapy could be a viable treatment strategy as a part of a multimodal therapy for children with ADHD. This pilot study provides good prospects for future studies to document these positive trends on larger samples.

Relationship Between Gross Motor Function and Daily Functional Skill in Children With Cerebral Palsy

OBJECTIVE: To investigate the relationship between gross motor function and daily functional skill in children with cerebral palsy (CP) and to explore how this relationship is moderated by the Gross Motor Function Classification System, Bimanual Fine Motor Function (BFMF), neuromotor types, and limb distribution of CP. METHODS: A cross-sectional survey of 112 children with CP (range, 4 years to 7 years and 7 months) was performed. Gross motor function was assessed with the Gross Motor Function Measure-66 (GMFM-66) and functional skill was assessed with the Pediatric Evaluation of Disability Inventory-Functional Skills Scale (PEDI-FSS). RESULTS: GMFM-66 scores explained 49.7%, 67.4%, and 26.1% of variance in the PEDI-FSS scores in the self-care, mobility, and social function domains, respectively. Significant moderation by the distribution of palsy and BFMF classification levels II, III, and IV was found in the relationship between GMFM-66 and PEDI-FSS self-care. Further significant moderation by the distribution of palsy was also observable in the relationship between GMFM-66 and PEDI-FSS mobility. CONCLUSION: These findings suggest that limb distribution and hand function must be considered when evaluating gross motor function and functional skills in children with CP, especially in unilateral CP.

Correction: Relationship Between Gross Motor Function and Daily Functional Skill in Children With Cerebral Palsy

We found that a number of tables were inadvertently omitted.

Videofluoroscopic Swallowing Study Findings in Full-Term and Preterm Infants With Dysphagia

OBJECTIVE: To determine the clinical characteristics and videofluoroscopic swallowing study (VFSS) findings in infants with suspected dysphagia and compare the clinical characteristics and VFSS findings between full-term and preterm infants. METHODS: A total of 107 infants (67 full-term and 40 preterm) with suspected dysphagia who were referred for VFSS at a tertiary university hospital were enrolled in this retrospective study. Clinical characteristics and VFSS findings were reviewed by a physiatrist and an experienced speech-language pathologist. The association between the reasons of referral for VFSS and VFSS findings were analyzed. RESULTS: Mean gestational age was 35.1+/-5.3 weeks, and mean birth weight was 2,381+/-1,026 g. The most common reason for VFSS referral was 'poor sucking' in full-term infants and 'desaturation' in preterm infants. The most common associated medical condition was 'congenital heart disease' in full-term infants and 'bronchopulmonary dysplasia' in preterm infants. Aspiration was observed in 42 infants (39.3%) and coughing was the only clinical predictor of aspiration in VFSS. However, 34 of 42 infants (81.0%) who showed aspiration exhibited silent aspiration during VFSS. There were no significant differences in the VFSS findings between the full-term and preterm infants except for 'decreased sustained sucking.' CONCLUSION: There are some differences in the clinical manifestations and VFSS findings between full-term and preterm infants with suspected dysphagia. The present findings provide a better understanding of these differences and can help clarify the different pathophysiologic mechanisms of dysphagia in infants.

Hippotherapy in Adult Patients with Chronic Brain Disorders: A Pilot Study

OBJECTIVE: To investigate the effects of hippotherapy for adult patients with brain disorders. METHOD: Eight chronic brain disorder patients (7 males, mean age 42.4+/-16.6 years) were recruited. The mean duration from injury was 7.9+/-7.7 years. The diagnoses were stroke (n=5), traumatic brain disorder (n=2), and cerebral palsy (n=1). Hippotherapy sessions were conducted twice a week for eight consecutive weeks in an indoor riding arena. Each hippotherapy session lasted 30 minutes. All participants were evaluated by the Berg balance scale, Tinetti Performance-Oriented Mobility Assessment, 10 Meter Walking Test, Functional Ambulatory Category, Korean Beck Depression Inventory, and Hamilton Depression Rating Scale. We performed baseline assessments twice just before starting hippotherapy. We also assessed the participants immediately after hippotherapy and at eight weeks after hippotherapy. RESULTS: All participants showed no difference in balance, gait function, and emotion between the two baseline assessments before hippotherapy. During the eight-week hippotherapy program, all participants showed neither adverse effects nor any accidents; all had good compliance. After hippotherapy, there were significant improvements in balance and gait speed in comparison with the baseline assessment (p<0.05), and these effects were sustained for two months after hippotherapy. However, there was no significant difference in emotion after hippotherapy. CONCLUSION: We could observe hippotherapy to be a safe and effective alternative therapy for adult patients with brain disorders in improving balance and gait function. Further future studies are warranted to delineate the benefits of hippotherapy on chronic stroke patients.

Erratum: A Comparison of the Korean-Ages and Stages Questionnaires and Denver Developmental Delay Screening Test

No abstract available.

Clinical Usefulness of Schedule for Oral-Motor Assessment (SOMA) in Children with Dysphagia

OBJECTIVE: To investigate the clinical usefulness of the Schedule for Oral-Motor Assessment (SOMA) in children with dysphagia by comparing findings of SOMA with those of the videofluoroscopic swallowing study (VFSS). METHOD: Both SOMA and VFSS were performed in 33 children with dysphagia (21 boys and 12 girls; mean age 17.3+/-12.1 months) who were referred for oropharyngeal evaluation. Ratings of oral-motor functions indicated by SOMA were based upon the cutting score of each specific texture of food (puree, semi-solids, solids, cracker, liquid-bottle, and liquid-cup). Abnormalities of either the oral phase, or the pharyngeal phase as indicated by VFSS were assessed by a physician and a speech-language pathologist. RESULTS: There was significant consistency between the findings of SOMA and the oral phase evaluation by VFSS (Kappa=0.419, p=0.023). SOMA reached 87.5% sensitivity, 66.6% specificity, and 95.4% positive predictive value when compared with the oral phase of the VFSS. We were able to evaluate oral-motor function by using SOMA in 6 children who were unable to complete the oral phase evaluation by VFSS, due to fear and crying during the study. The findings of SOMA failed to show any consistency with the pharyngeal phase evaluation by VFSS (Kappa=-0.105, p=0.509). CONCLUSION: These results suggest that SOMA is a reliable method for evaluation of oral-motor function in children with dysphagia. In particular, SOMA is recommended for children that were unable to complete the oral phase evaluation by VFSS due to poor cooperation.

A Comparison of the Korean-Ages and Stages Questionnaires and Denver Developmental Delay Screening Test

OBJECTIVE: To evaluate concurrent validity between the Korean-Ages and Stages Questionnaires (K-ASQ) and the Denver Developmental Screening Test II (DDST II), and to evaluate the validity of the K-ASQ as a screening tool for detecting developmental delay of Korean children. METHOD: A retrospective chart review was done to examine concurrent validity of the screening potentials for developmental delay between the K-ASQ and the DDST II (n=226). We examined validity of the K-ASQ compared with Capute scale (n=141) and Alberta Infant Motor Scale (AIMS) (n=69) as a gold standard of developmental delay. Correlation analysis was used to determine the strength of the associations between tests. RESULTS: A fair to good strength relationship (k=0.442, p<0.05) was found between the K-ASQ and the DDST II. The test characteristics of the K-ASQ were sensitivity 76.3-90.2%, specificity 62.5-76.5%, positive likelihood ratio (PLR) 2.41-3.40, and negative likelihood ratio (NLR) 0.16-0.32. CONCLUSION: Evidence of concurrent validity of the K-ASQ with DDST II was found. K-ASQ can be used for screening of developmental delay.

Dysphagia after Occipitocervical Posterior Fusion and Significance of Occipitoaxial Angle: case report

Occipitocervical posterior fusion itself is an uncommon cause of severe dysphagia. But occipitocervical malalignment after posterior fusion can be a cause of severe dysphagia. A 46-year-old man was referred to the department of rehabilitation medicine because of swallowing difficulty. He complained of severe dysphagia immediately after the occipitocervical posterior fusion. From the lateral view of video-fluoroscopic swallowing study (VFSS), we could conclude that the mechanical cricopharyngeal relaxation failure was a direct cause of his dysphagia and this was due to malalignment of the occipitocervical fixation. His occipitoaxial angle was fixed in hyperflexed position and this lead to the severe dysphagia and even dyspnea. After the revision operation, his dysphagia and dyspnea symptom was dramatically resolved. The occipitoaxial angle can be a useful index, which measure the anatomic relation of the occiput and the cervical vertebrae on sagittal plane, on evaluation of the swallowing function in the patient who had occipitocervical posterior fusion.

The Relationship between Weight of Backpack and Backpain in Primary School Children in Korea

OBJECTIVE: To investigate school children's backpack loads, its association with backpack loads and backpain, school-children's perception of their backpack loads, school conditions, and personal factors that determine backpack loads in Korea. METHOD: We weighed the backpacks of 642 school children in three elementary schools in Suwon city. A validated questionnaire evaluating backpain, features of backpack carrying and subjective perceptions of backpack loads was administered to 450 schoolchildren. The data were divided into two groups, those who had experienced backpain and those who had not. Each group was analyzed according to backpack load, perception of backpack load, school condition and personal factors. RESULTS: The mean weight of the backpack was 2.65 kg, which was 7.85% of mean body weight. The number of children whose backpack loads exceeded 15% of their body weight was 3.3%. 34.5% of children experienced backpain and backpack weight and backpack weight/body weight ratio were significantly higher in the group who experienced backpain. Time spent carrying of backpacks was longer and more students reported heaviness and fatigue when carrying backpacks in the same group. There was a difference in manners of carrying of backpacks and locker usage between the two groups. An improper method of backpack carrying, which is more than 10 cm below the waistline was noted in 85% of the school children. CONCLUSION: Carrying a heavier backpack is related to backpain in schoolchildren and a wide investigation should be performed concerning backpack loads of school children in Korea. Adequate backpack load guidelines should be determined.

Proposal for Early Diagnosis of Congenital Muscular Torticollis: Case-based Approach: Report of two cases

Congenital muscular torticollis (CMT) is called 'pseudotumor of infancy' because it is commonly discovered and diagnosed within 14~28 days after birth as a sternomastoid tumor. We report two cases of CMT which presented as head tilt without any palpable neck mass immediately after birth but later developed into sternomastoid tumors. Serial ultrasonography confirmed increased echogenicities of the sternocleidomastoid muscles. We think that these findings are prodromal signs of sternomastoid tumors. Close physical examination by a neonatologist is crucial for an early diagnosis of CMT. Neonates with head tilt and increased ecogenicity of the sternocleidomastoid muscle on ultrasonography should be carefully followed up to see whether neck mass develops later. The authors suggest that CMT is not a static entity but rather one that progress to mass alteration after birth.

The Additional Effect of Tear after Passive Exercise during Distension Arthrography in Patients with Frozen Shoulder

OBJECTIVE: To evaluate the effect of tear after passive ROM exercise during distension arthrography in patients with frozen shoulder. METHOD: Fifteen patients (male: 7, female: 8, mean 57.5 years old) who had complained of shoulder pain with decreased ROM at least 3 months prior were enrolled. Distension arthrogrphy of 35 ml of fluid which contained 10 ml of 1% lidocaine, 1 ml of depomedrol (40 mg), 19 ml of normal saline, and 5 ml of radiocontrast material was injected by a single physician. Then if there was no capsular tear, passive ROM exercise was performed for two minutes. RESULTS: In seven of the thirteen patients, the occurrence of capsular tear was observed after only distension arthrography. In five of the six patients without capsular rupture, the occurrence of capsular tear was observed by passive ROM exercise after distension arthrography. Two patients were interrupted because of severe pain. Clinical outcomes of occurrence of capsular tear by conventional distension arthrography and by passive ROM exercise after distension arthrography were similar. CONCLUSION: Passive ROM exercise after distension arthrography could serve as an effective method of capsular tear in patients with frozen shoulder.