Effect of Repetitive Transcranial Magnetic Stimulation in Post-stroke Patients with Severe Upper-Limb Motor Impairment

Repetitive transcranial magnetic stimulation (rTMS) has been known to improve the motor function through modulation of excitability in the cerebral cortex. However, most studies with rTMS were limited to post-stroke patients with mild to moderate motor impairments. The effect of rTMS on severe upper-limb motor impairment remains unclear. Therefore, this study investigated the effects of rTMS on the upper extremity function in post-stroke patients with severe upper-limb motor impairment. Subjects were divided into 3 groups, low-, high-frequency rTMS and control group were received stimulation 10 times for 2 weeks. The motor scale of Fugl-Meyer Assessment (FMA) and cortical excitability on the unaffected hemisphere were measured before and after performing 10 rTMS sessions. The motor scale of upper extremity FMA (UE-FMA) and shoulder component of the UE-FMA were significantly improved in both low- and high-frequency rTMS groups. However, no significant improvement was observed in the wrist and hand components. No significant differences were noted in low- and high-frequency rTMS groups. The amplitude of motor evoked potential on the unaffected hemisphere showed a significant decrease in the low- and high-frequency stimulation groups. rTMS may be helpful in improving upper extremity motor function even in post-stroke patients with severe upper-limb motor impairment.

Effect of Repetitive Transcranial Magnetic Stimulation in Post-stroke Patients with Severe Upper-Limb Motor Impairment

Repetitive transcranial magnetic stimulation (rTMS) has been known to improve the motor function through modulation of excitability in the cerebral cortex. However, most studies with rTMS were limited to post-stroke patients with mild to moderate motor impairments. The effect of rTMS on severe upper-limb motor impairment remains unclear. Therefore, this study investigated the effects of rTMS on the upper extremity function in post-stroke patients with severe upper-limb motor impairment. Subjects were divided into 3 groups, low-, high-frequency rTMS and control group were received stimulation 10 times for 2 weeks. The motor scale of Fugl-Meyer Assessment (FMA) and cortical excitability on the unaffected hemisphere were measured before and after performing 10 rTMS sessions. The motor scale of upper extremity FMA (UE-FMA) and shoulder component of the UE-FMA were significantly improved in both low- and high-frequency rTMS groups. However, no significant improvement was observed in the wrist and hand components. No significant differences were noted in low- and high-frequency rTMS groups. The amplitude of motor evoked potential on the unaffected hemisphere showed a significant decrease in the low- and high-frequency stimulation groups. rTMS may be helpful in improving upper extremity motor function even in post-stroke patients with severe upper-limb motor impairment.

Esophagostomy as an Alternative to Gastrostomy for Dysphagia in Muscular Dystrophy: A Case Report / 대한연하장애학회지

Many people with muscular dystrophy develop dysphagia that can result in an inability to use the oral route in severe cases. In such cases, an alternative feeding method is selected, including a nasogastric tube or a gastrostomy.This case report describes a 40-year-old man with muscular dystrophy who was managed for swallowing difficulty and respiratory failure. Oromotor muscle weakness caused prolonged mealtimes, difficulty with swallowing a solidform diet, aspiration signs, and weight loss. Consequently, an alternative feeding method was required. An abdominal radiograph showed massive aerophagia, and the transverse colon was located over the stomach. As a result, the colon interfered with the puncture route, which could lead to colon perforation. Therefore, cervical esophagostomy was selected, where the patient obtained nutrition through a cervical esophagostomy tube. This case showed that when gastrostomy cannot be performed due to aerophagia, cervical esophagostomy can successfully support nutrition for the mid to long-term in muscular dystrophy patients.

Effect of Repetitive Transcranial Magnetic Stimulation in Post-stroke Patients with Severe Upper-Limb Motor Impairment

Repetitive transcranial magnetic stimulation (rTMS) has been known to improve the motor function through modulation of excitability in the cerebral cortex. However, most studies with rTMS were limited to post-stroke patients with mild to moderate motor impairments. The effect of rTMS on severe upper-limb motor impairment remains unclear. Therefore, this study investigated the effects of rTMS on the upper extremity function in post-stroke patients with severe upper-limb motor impairment. Subjects were divided into 3 groups, low-, high-frequency rTMS and control group were received stimulation 10 times for 2 weeks. The motor scale of Fugl-Meyer Assessment (FMA) and cortical excitability on the unaffected hemisphere were measured before and after performing 10 rTMS sessions. The motor scale of upper extremity FMA (UE-FMA) and shoulder component of the UE-FMA were significantly improved in both low- and high-frequency rTMS groups. However, no significant improvement was observed in the wrist and hand components. No significant differences were noted in low- and high-frequency rTMS groups. The amplitude of motor evoked potential on the unaffected hemisphere showed a significant decrease in the low- and high-frequency stimulation groups. rTMS may be helpful in improving upper extremity motor function even in post-stroke patients with severe upper-limb motor impairment.

Late-Onset Post-radiation Lymphedema Provoked by Bee Venom Therapy: A Case Report

Lymphedema is a common complication associated with cancer itself or with cancer treatment. Lymphedema infrequently occurs after drug therapy. Bee venom is one of the materials used in acupuncture, and it has been used in the treatment of a variety of inflammatory diseases including arthritis. We report a 74-year-old male patient with late-onset post-radiation lymphedema provoked by bee venom therapy. He was free of lymphedema for 5 years after the complete remission of prostate cancer which had been treated with transurethral resection and radiation therapy. The patient developed left leg swelling after undergoing bee venom therapy for left hip pain. Computed tomography and lymphoscintigraphy showed lymphedema without tumor recurrence or infection. The lymphatic system was suspected to be injured by bee venom therapy and lymphedema was provoked. Bee venom therapy should be used cautiously in patients prone to lymphedema.

Successful Treatment of Burn-Induced Digital Ischemic Ulcer with Stellate Ganglion Block: Case Report

The Stellate ganglion block (SGB) could be used to treat sympathetic dependent circulatory insufficiency. We report a 36-year-old female patient with burn-induced refractory ischemic ulcer in distal phalanges. The patient admitted in department of plastic surgery for second degree burn wound in the right second through fifth fingertips. Continuous dressing treatment was conducted. However digital burn wounds were not healed but seems to be refractory. The upper extremity angiography revealed decreased perfusion and the fingertip wounds were diagnosed as ischemic ulcer. Despite of botulinum toxin injection into the perineural tissue and aspirin prescription, burn wounds showed ulcerative necrotic change. The SGBs were performed twice a week for 3 weeks to restore vasoconstriction of the upper extremity arteries. The follow-up angiography showed significant improvement of fingertip perfusion. Consequently, wounds were completely healed. In conclusion, SGB could be a rational option to overcome burn-induced digital ischemia refractory to other medical therapy.

Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016

“Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” is the 3rd edition of clinical practice guideline (CPG) for stroke rehabilitation in Korea, which updates the 2nd edition published in 2014. Forty-two specialists in stroke rehabilitation from 21 universities and 4 rehabilitation hospitals and 4 consultants participated in this update. The purpose of this CPG is to provide optimum practical guidelines for stroke rehabilitation teams to make a decision when they manage stroke patients and ultimately, to help stroke patients obtain maximal functional recovery and return to the society. The recent two CPGs from Canada (2015) and USA (2016) and articles that were published following the 2nd edition were used to develop this 3rd edition of CPG for stroke rehabilitation in Korea. The chosen articles' level of evidence and grade of recommendation were decided by the criteria of Scotland (2010) and the formal consensus was derived by the nominal group technique. The levels of evidence range from 1++ to 4 and the grades of recommendation range from A to D. Good Practice Point was recommended as best practice based on the clinical experience of the guideline developmental group. The draft of the developed CPG was reviewed by the experts group in the public hearings and then revised. “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” consists of ‘Chapter 1; Introduction of Stroke Rehabilitation’, ‘Chapter 2; Rehabilitation for Stroke Syndrome, ‘Chapter 3; Rehabilitation for Returning to the Society’, and ‘Chapter 4; Advanced Technique for Stroke Rehabilitation’. “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” will provide direction and standardization for acute, subacute and chronic stroke rehabilitation in Korea.

Therapeutic Experience on Stance Control Knee-Ankle-Foot Orthosis With Electromagnetically Controlled Knee Joint System in Poliomyelitis

A 54-year-old man with poliomyelitis had been using a conventional, passive knee-ankle-foot orthosis (KAFO) with a drop ring lock knee joint for about 40 years. A stance control KAFO (SCKAFO) with an electromagnetically controlled (E-MAG) knee joint system was prescribed. To correct his gait pattern, he also underwent rehabilitation therapy, which included muscle re-education, neuromuscular electrical stimulation, strengthening exercises for the lower extremities, and balance training twice a week for about 4 months. Both before and after rehabilitation, we conducted a gait analysis and assessed the physiological cost index in energy expended during walking in a locked-knee state and while he wore a SCKAFO with E-MAG. When compared with the pre-rehabilitation data, the velocity, step length, stride length, and knee kinematic data were improved after rehabilitation. Although the SCKAFO with E-MAG system facilitated the control of knee motion during ambulation, appropriate rehabilitative therapy was also needed to achieve a normal gait pattern.

Nutritional Status of Patients with Brain Disorder during the First Six Months

OBJECTIVE: Patients with brain disorder manifest hypermetabolism, increased energy expenditure, and increased protein loss. Nutritional support can prevent loss of immunocompetence, and can decrease morbidity and mortality associated with brain disorder. Thus, we aimed to determine the nutritional status by measuring body mass index (BMI) in patients with brain disorder during the first 6 months and identify factors related to malnutrition in this study. METHOD: We enrolled 244 patients from January 2008 to December 2009. The patients were classified into two groups: BMI under 18.5 were categorized as malnourished, while BMI over 18.5 as not malnourished. Extracted data includes demographic characteristics, type of brain disorder, functional independence measure (FIM) and Korea mini-mental status exam (K-MMSE) scores, history of diabetes mellitus (DM), and laboratory data. Feeding method was classified into oral and enteral tube feeding. RESULTS: The prevalence of malnourished patients was 13.1% (32 out of 244 patients). There was significant difference of total lymphocyte count (TLC) between the two groups. And there was no significant difference of correlation in other parameters. Analysis of feeding method showed that 11.4% of oral feeding patients were malnourished, compared to 17.4% of tube feeding patients who were categorized as malnourished. The tube feeding group tends to be more malnourished. CONCLUSION: The results of this study can be a guide for active rehabilitation of patients with brain disorder, and further studies regarding functional outcome and complications related to early nutritional status is needed.

Usefulness of Videofluoroscopic Swallow Study in Treacher Collins Syndrome With Cleft Palate: A Case Report

A 3-year-old girl had multiple anomalies compatible with Treacher Collins Syndrome (TCS). From the neonatal period, sucking was poor, making tube feeding necessary. Excessive saliva was retained in the oral cavity. Nasal leakage caused by the cleft palate was observed when she spoke. The initial videofluoroscopic swallow study (VFSS) showed a poor posterior bolus transit and nasopharyngeal regurgitation. A delayed swallow reflex and bolus stasis at the vallecular and pyriform sinuses were recognized. Based on the VFSS findings, the patient underwent palatoplasty at 20 months of age. At approximately 23 months of age, a follow-up VFSS was performed; poor posterior bolus transit, nasopharyngeal regurgitation, and delayed swallow reflex were not observed. Finally, the patient was able to eat ground or chopped foods and solid foods orally. We deem VFSS to be helpful in deciding the appropriate management of dysphagia in TCS.

Ultrasonographic Diaphragmatic Motion Analysis and Its Correlation With Pulmonary Function in Hemiplegic Stroke Patients

OBJECTIVE: To evaluate diaphragmatic motion via M-mode ultrasonography and to correlate it with pulmonary function in stroke patients. METHODS: This was a preliminary study comprised of ten stroke patients and sixteen healthy volunteers. The M-mode ultrasonographic probe was positioned in the subcostal anterior region of the abdomen for transverse scanning of the diaphragm during quiet breathing, voluntary sniffing, and deep breathing. We analyzed diaphragmatic motion and the relationship between diaphragmatic motion and pulmonary function. RESULTS: All stroke patients had restrictive pulmonary dysfunction. Compared to that exhibited by control subjects, stroke patients exhibited a significant unilateral reduction in motion on the hemiplegic side, primarily during volitional breathing. Diaphragmatic excursion in right-hemiplegic patients was reduced on both sides compared to that in control subjects. However, diaphragmatic excursion was reduced only on the left side and increased on the right side in left-hemiplegic patients compared to that in control subjects. Left diaphragmatic motion during deep breathing correlated positively with forced vital capacity (rho=0.86, p=0.007) and forced expiratory volume in 1 second (rho=0.79, p=0.021). CONCLUSION: Reductions in diaphragmatic motion and pulmonary function can occur in stroke patients. Thus, this should be assessed prior to the initiation of rehabilitation therapy, and M-mode ultrasonography can be used for this purpose. It is a non-invasive method providing quantitative information that is correlated with pulmonary function.

Effects of Music Therapy on Mood in Stroke Patients

PURPOSE: To investigate the effects of music therapy on depressive mood and anxiety in post-stroke patients and evaluate satisfaction levels of patients and caregivers. MATERIALS AND METHODS: Eighteen post-stroke patients, within six months of onset and mini mental status examination score of over 20, participated in this study. Patients were divided into music and control groups. The experimental group participated in the music therapy program for four weeks. Psychological status was evaluated with the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) before and after music therapy. Satisfaction with music therapy was evaluated by a questionnaire. RESULTS: BAI and BDI scores showed a greater decrease in the music group than the control group after music therapy, but only the decrease of BDI scores were statistically significant (p=0.048). Music therapy satisfaction in patients and caregivers was affirmative. CONCLUSION: Music therapy has a positive effect on mood in post-stroke patients and may be beneficial for mood improvement with stroke. These results are encouraging, but further studies are needed in this field.

Improvement of Chronic Post-Stroke Hemiparetic Upper Limb Function after 2 Week Trascranial Direct Current Stimulation

OBJECTIVE: To investigate whether transcranial direct current stimulation (tDCS) could improve the motor function of hemiparetic upper limb in chronic stroke patients through randomized double-blinded, sham-controlled study. METHOD: Twenty chronic post-stroke hemiparetic patients participated in this study. They were randomly assigned into either tDCS or sham group. Anodal tDCS was delivered on lesional primary motor cortex for 20 minutes in tDCS group and 30 seconds in sham group. Just after stimulation, both groups performed the shaping exercise for 30 minutes. Total 10 stimulation sessions (5 session/week for 2 weeks) were administered. Fugl-Meyer motor assessment, box and block test, grasp strength and FIM were assessed before stimulation, after 1 week of stimulation, after 2 weeks of stimulation, and 2 weeks after stimulation. RESULTS: The upper extremity score of Fugl-Meyer motor assessment and box and block test improved significantly in tDCS group compared to sham group (p<0.05). Their improvement lasted significantly for 2 week after stimulation. However, FIM, lower extremity score of Fugl-Meyer motor assessment and grasp power did not improved significantly in tDCS group compared to sham group. CONCLUSION: tDCS can improve the motor function of hemiparetic upper limb in chronic post-stroke patients, and the effects lasted after stimulation. tDCS may be used as an additional tool for stroke rehabilitation.

Assessment of Post-Stroke Cognitive Dysfunction Using 3-Dimensional Virtual Reality Program

OBJECTIVE: To test the feasibility of newly developed 3- dimensional virtual reality (VR) program for assessing the post-stroke cognitive dysfunction. METHOD: Thirty five post-stroke patients and twenty normal healthy subjects were recruited in this study, and post-stroke patients were classified into three groups according to the severity of cognitive dysfunction. We developed three dimensional virtual reality program to assess the cognitive function with virtual subway environment from taking a subway to arriving at one's destination. The total score, number of success and cue were obtained during completing virtual tasks. We investigated the test-retest reliability, and the parameters of the 3-dimensional VR program were compared with Korean Mini-mental status examination. RESULTS: All parameters of the VR program were significantly correlated with MMSE score (p<0.01), and showed the significant difference between patient subgroups and control group (p<0.05). The test-retest reliability of the VR program was significantly high (p<0.01). CONCLUSION: Three dimensional virtual reality program may be helpful to assess the cognitive function in patients with stroke.

The Comparison of Post-stroke Related Depression Scales

OBJECTIVE: To compare the characteristics between geriatric depression scale (GDS), Hamilton depression rating scale (HDRS) and post-stroke depression scale (PSDS) in the aspect of diagnosis and severity assessment for post-stroke depression. METHOD: 45 post-stroke patients were included for this study. Subjects were classified through DSM-IV criteria into three different groups; depression-free, minor depression and major depression. GDS, HDRS, PSDS were also assessed in all subjects simultaneously. Three depression assessment scales were compared between groups based on DSM-IV criteria, and the sensitivity and specificity using cut-off value were analyzed. RESULTS: All scales showed the significant differences between depression group and depression-free group. GDS showed higher sensitivity and specificity than HDRS and PSDS and GDS showed the significant difference between minor depression and no depression group, but other scales did not. HDRS and PSDS in major depression group showed the significant differences compared with minor depression group (p<0.05), but GDS did not. CONCLUSION: GDS may be more useful to identify the presence of depression compared to GDRS and PSDS. However, to measure the severity of depression, HDRS and PSDS may be more useful than GDS.