Development of the Korea Dysarthria Test Following Stroke

Objective@#To develop an objective and quantitative clinical evaluation tool that can be used for diagnosis and severity assessment of dysarthria in patients with stroke. @*Methods@#A prototype test comprising 23 items was developed to test the function of each speech organ. The scoring of the prototype test was based on the analysis of the result values obtained from 50 healthy individuals. The test was performed for 50 patients with stroke who were suspected to have dysarthria. For evaluating the correlation between each prototype test item and the Urimal Test of Articulation and Phonation (U-TAP), the odds ratio was obtained for each result, based on which the final test items for composing the Korea Dysarthria Test (KDT) were selected. The validity of the test was evaluated using the receiver operator characteristic (ROC) curve and the area under the curve. We used the intraclass correlation coefficients to quantify inter- and intra-rater reliability. The Spearman correlation coefficient was used for examining the correlation between the KDT and the Speech Mechanism Screening Test and U-TAP. @*Results@#Among the 23 prototype test items, 16 exhibiting significant results were finally selected as the KDT. The higher score of the KDT is reflected the better speaking function. The sensitivity and specificity of the KDT were shown to be high at the cutoff value of 76.50 point. @*Conclusion@#KDT is a useful evaluation tool for dysarthria, showing a significant correlation with SMST and U-TAP.

Development of a Dysphagia Screening Test for Preterm Infants (DST-PI)

OBJECTIVE: To explore both the early prediction and diagnosis of dysphagia in preterm infants as an important developmental aspect as well as the prevention of respiratory complications, we developed the simple and-easy-to-apply Dysphagia Screening Test for Preterm Infants (DST-PI) to predict supraglottic penetration and subglottic aspiration. METHODS: Fifty-two infants were enrolled in a videofluoroscopic swallowing study (VFSS) due to clinical suspicions of dysphagia. Thirteen items related to supraglottic penetration or subglottic aspiration were initially selected from previous studies for the DST-PI. Finally, 7 items were determined by linear logistic regression analysis. Cutoff values, sensitivity, specificity, and the area under the ROC curve (AUC) of the DST-PI for predicting supraglottic penetration or subglottic aspiration were calculated using a ROC curve. For inter-rater reliability, the kappa coefficient was calculated. RESULTS: Seven items were selected: ‘gestational age,’‘history of apnea,’‘history of cyanosis during feeding,’‘swallowing pattern,’‘coughs during or after feeding,’‘decreased oxygen saturation within 3 minutes of feeding,’ and ‘voice change after feeding.’ The Spearman correlation coefficient between the DST-PI and the penetration-aspiration scale (PAS) was 0.807 (p<0.001). The sensitivity and specificity at different cutoff values for detecting supraglottic penetration and subglottic aspiration were 96.6% and 76.9% at 3.25, and 88.9% and 75.8% at 6.25, respectively. CONCLUSION: The DST-PI is a valid and reliable dysphagia screening test for supraglottic penetration or subglottic aspiration in preterm infants that is easy to apply in a clinical context.

Relationship Between Electrodiagnosis and Various Ultrasonographic Findings for Diagnosis of Carpal Tunnel Syndrome

OBJECTIVE: To investigate the relationship between electrodiagnosis and various ultrasonographic findings of carpal tunnel syndrome (CTS) and propose the ultrasonographic standard that has closest consistency with the electrodiagnosis. METHODS: Ultrasonography was performed on 50 female patients (65 cases) previously diagnosed with CTS and 20 normal female volunteers (40 cases). Ultrasonography parameters were as follows: cross-sectional area (CSA) and flattening ratio (FR) of the median nerve at the levels of hamate bone, pisiform bone, and lunate bone; anteroposterior diameter (AP diameter) of the median nerve in the carpal tunnel; wrist to forearm ratio (WFR) of median nerve area at the distal wrist crease and 12 cm proximal to distal wrist crease; and compression ratio (CR) of the median nerve. Independent t-test was performed to compare the ultrasonographic findings between patient and control groups. Significant ultrasonographic findings were compared with the electrodiagnosis results and a kappa coefficient was used to determine the correlation. RESULTS: CSA and FR of median nerve at the hamate bone level, CSA of median nerve at pisiform bone level, AP diameter of median nerve within the carpal tunnel, CSA of median nerve at the distal wrist crease and WFR showed significant differences between patient and control groups. WFR showed highest concordance with electrodiagnosis (κ=0.71, p<0.001). CONCLUSION: These findings suggested the applicability of ultrasonography, especially WFR, as a useful adjunctive tool for diagnosis of CTS.

Practical Assessment of Dysphagia in Stroke Patients

OBJECTIVE: To develop a quantitative and organ-specific practical test for the diagnosis and treatment of dysphagia based on assessment of stroke patients. METHODS: An initial test composed of 24 items was designed to evaluate the function of the organs involved in swallowing. The grading system of the initial test was based on the analysis of 50 normal adults. The initial test was performed in 52 stroke patients with clinical symptoms of dysphagia. Aspiration was measured via a videofluoroscopic swallowing study (VFSS). The odds ratio was obtained to evaluate the correlation between each item in the initial test and the VFSS. A polychotomous linear logistic model was used to select the final test items. RESULTS: Eighteen of 24 initial items were selected as significant for the final tests. These 18 showed high initial validity and reliability. The Spearman correlation coefficient for the total score of the test and functional dysphagia scale was 0.96 (p<0.001), indicating a statistically significant positive correlation. CONCLUSION: This study was carried out to design a quantitative and organ-specific test that assesses the causes of dysphagia in stroke patients; therefore, this test is considered very useful and highly applicable to the diagnosis and treatment of dysphagia.

Medical Management for Intractable Pain Arising From Primary Sjogren Syndrome Involving Both Brain and Spinal Cord: A Case Report

Primary Sjogren syndrome, which involves lesions in both the brain and spinal cord, is rarely reported. Related symptoms, such as intractable pain due to central nervous system involvement, are very rare. A 73-year-old woman diagnosed with primary Sjogren syndrome manifested with subacute encephalopathy and extensive transverse myelitis. She complained of severe whole body neuropathic pain. Magnetic resonance imaging demonstrated a non-enhancing ill-defined high intensity signal involving the posterior limb of the both internal capsule and right thalamus on a T2 fluid-attenuated inversion recovery image. Additionally, multifocal intramedullary ill-defined contrast-enhancing lesion with cord swelling from the C-spine to L-spine was also visible on the T2-weighted image. Her intractable pain remarkably improved after administration of concomitant oral doses of gabapentin, venlafaxine, and carbamazepine.

Inpatient Course and Length of Hospital Stay in Patients with Brain Disorders in South Korea: A Population-based Registry Study

OBJECTIVE: To describe inpatient course and length of hospital stay (LOS) for people who sustain brain disorders nationwide. METHOD: We interviewed 1,903 randomly selected community-dwelling patients registered as 'disabled by brain disorders' in 28 regions of South Korea. RESULTS: Seventy-seven percent were initially admitted to a Western medicine hospital, and 18% were admitted to a traditional Oriental medicine hospital. Forty-three percent were admitted to two or more hospitals. Mean LOS was 192 days. Most patients stayed in one hospital for more than 4 weeks. The transfer rate to other hospitals was 30-40%. Repeated admissions and increased LOS were related to younger onset age, higher education, non-family caregiver employment, smaller families, and more severe disability. CONCLUSION: Korean patients with brain disorders showed significantly prolonged LOS and repeated admissions. Factors increasing burden of care influenced LOS significantly.

The Cost of Brain Disorder: Individual and Social Cost

OBJECTIVE: To estimate the cost of brain disorders from individual and social aspects. METHOD: This study employed two complementary methodologies for the estimation: individual survey and collective statistics. The survey recruited 1903 disabled persons, staying at home, registered at public health center as brain disorders. They were asked about epidemiologic, clinical variables, medical cost, employment status and pre-/post-morbid incomes. Collective statistics included mortality data from the national statistical office, report on wage structure report from the ministry of labor and national health insurance statistical yearbook from the national health insurance corporation. Individual cost of brain disorders was estimated by summing direct medical cost and indirect cost from productivity loss (job loss or decreased income). Social cost also comprised direct medical cost and indirect cost; indirect cost corresponded to productivity loss due to healthcare utilization, job loss, decreased income and premature death. RESULTS: Individual cost of brain disorders was 164,041,000 Korean Won (KRW) per patient. 93.3% of the subjects of the survey who were pre-morbidly employed lost their job and the income of those who maintained employment decreased to 51.5% of original income on average. Social cost of brain disorder in 2005 was 9,901,057,327,000 KRW. Major part of social cost was due to job loss. CONCLUSION: Brain disorder imposes substantial amount of economic cost, individually and socially. Especially job loss from disability after brain disorder takes up the largest portion. The results of the study are expected to serve as a foundation for future research and healthcare policy.

The Change in Family Structure and Income for Community-dwelling Patients with Brain Disorders

OBJECTIVE: To find out the changes of the family structure and familial total income of Korean patients with the brain disorders and associated factors. METHOD: A total of 1,903 patients with brain disorders in Korea were enrolled and drew up the questionnaires about their socioeconomic state and family supports, including pre- and post-disorder family structure, compositions of their family income, and employment of caregivers. RESULTS: A 38.2% of subjects experienced the change in numbers of cohabiting family, decrement in 30.3% and increment in 7.9%. Prior to brain disorders, 48.6% of patients earned their living by themselves, but only 2.8% did after brain disorders. Separation and divorce increased, especially three times more in male patients than in females. A 16.6% of patients employed caregivers, and used them 6.2 days per week, 18 hours a day on average. CONCLUSION: This study reemphasized the worsening socioeconomic state of patients with brain disorders and their families. Increasing tendency of social isolation was also noted.

Utilization and Satisfaction of Rehabilitation Service in Patients with Brain Disorders in Korea

OBJECTIVE: To investigate the utilization of medical rehabilitation services and the degree of satisfaction about rehabilitation services in patients with brain disorders. METHOD: A total of 1903 patients agreed to participate in this study and were interviewed from September 2005 to May 2006. The subjects completed the questionnaires about the utilization of medical rehabilitation services and the degree of satisfaction with those treatments. Pearson's chi-square test, Student t-test and frequency analysis were used for statistical analysis. RESULTS: A 78.0 percent of patients received inpatient rehabilitation treatment. A 66.9 percent of all patients were served of only physical therapy and 31.6 percent received both physical and occupational therapy. The main reason why patients could not have a chance to experience rehabilitation treatment was associated with environmental problems, such as the ignorance of the need about rehabilitation treatment, or the insufficient communication between doctors and patients. Most patients (54.6%) were satisfied with the rehabilitation treatment. However, as the number of admission was increased, patients tended to be less satisfied with the rehabilitation treatment. CONCLUSION: The inpatient rehabilitation treatment was limitedly served to patients with brain disorders mostly when the patients required rehabilitation services. It is necessary to provide more effective and various rehabilitation services to patients under the comprehensive guideline of the process of rehabilitation services.

The Development of Ankle Control Elastic Band for Improvement in Walking of Hemiplegic Patients

OBJECTIVE: The aims of this study were to verify that the newly developed ankle control elastic band (ACE band) can improve the gait pattern of hemiplegic patients by assessment of objective and subjective data. METHOD: ACE band consisted of medial ring, lateral ring, and elastic band was devised and 11 ambulatory stroke patients were evaluated with gait measurements, functional ambulation categories (FAC), functional reach test (FRT), and questionnaires for the effect of ACE band. Gait measurements were of 10 m walking time, cadence, stride length, stride period, stance phase, single support time, and single support time asymmetry ratio. RESULTS: Gait measurements with the ACE band showed significant improvement (p<0.05 or p<0.01). FAC and FRT with the ACE band were significantly increased (p<0.01), and the questionnaires suggested that wearing the ACE band helped improve toe dragging, swinging leg forward, taking weight through foot, confidence of gait, safety of gait, gait distance and gait velocity. CONCLUSION: ACE band was invented for improvement of hemiplegic gait, and its evaluation of gait measurements, FAC, FRT, and questionnaire showed that the ACE band was effective for hemiplegic gait after stroke.

Reliability and Validity of Korean Version of National Institutes of Health Stroke Scale: Multi-center study

OBJECTIVE: To assess the inter-tester and test-retest reliability and validity after developing of Korean version of National Institutes of Health Stroke Scale (NIHSS). METHOD: This research was conducted on 27 patents with stroke with less than 12 months since the onset of disease. Five physiatrists translated NIHSS into Korean. Video taping were used for objective scorings. Four physiatrists conducted scorings in order to seek for inter-tester reliability and one conducted scorings three weeks interval for test-retest reliability. Six physiatrists conducted scorings in order to seek for concurrent validity with the original NIHSS and four conducted scorings for validity with other impairment scale. Each score was analyzed based on Spear-man correlation coefficient. RESULTS: According to inter-tester reliability for Korean version of NIHSS, rho value reached over 0.70, with over 0.72 concerning test-retest reliability. The test on concurrent validity with the original NIHSS reached over 0.70 at rho value, with over 0.653 for MMSE, Motricity index, Brunnstrom stage. CONCLUSION: Newly developed Korean version of NIHSS showed high inter-tester and test-retest reliabilities, together with high concurrent validity with the original and other impairment scales, to be regarded to be used as primary impairment scale for patients with stroke.

Effect of Hot Pack Therapy on the Blood Flow of Lower Extremities

OBJECTIVE: To evaluate quantitative changes in arterial blood flow in the legs and systemic changes in blood flow after hot pack therapy on a leg. METHOD: It was conducted on 60 legs of 30 adults without the symptom of peripheral vascular disease. The blood flow of both popliteal arteries were recorded before and after hot pack therapy on a leg. Also, the blood pressure and pulse rate were recorded every two minutes using a pulsimeter. T-test was done to examine differences between blood flow of the popliteal artery on both legs before and after hot pack therapy. Paired t-test was used to examine differences in each leg before and after hot pack therapy and systemic effect after hot pack therapy. RESULTS: After hot pack therapy, there were statistically meaningful changes in all the variables except the popliteal arterial diameter in a leg with hot pack therapy, whereas there were no significantly meaningful changes in a leg without therapy. Pulse rate was changed significantly, but blood pressures were not. CONCLUSION: There were an increase in regional arterial blood velocity and blood flow, skin temperature, and a reduction in peripheral resistance in a leg with hot pack therapy, but no meaningful changes without thrapy. There is no evidence of reflex vasodilatation. There is no meaningful changes in blood pressure, but an increase in pulse rate.

The Significance of Motivation for Rehabilitation in Stroke Patients

OBJECTIVE: The purpose of this study was to investigate the factors associated with motivation for rehabilitation in stroke patients and to identify the relationship between their motivation and functional outcome. METHOD: Subjects were 23 stroke patients who admitted to rehabilitation wards. Volitional Questionnaire (VQ) for assessing patients' motivation, personal and environmental variables, modified Barthel index (MBI), Beck depression inventory (BDI), minimental status examination (MMSE) and neurobehavioral cognitive status examination (NCSE), visual reaction time (VRT) and auditory reaction time (ART) were obtained at 1 week after admission, and then MBI was measured again after 4 weeks. RESULTS: VQ score was not related to the personal and environmental variables, but significantly related to BDI, MMSE, NCSE, VRT, ART, follow up score of MBI 4 weeks later and MBI gain. CONCLUSION: Motivation was more associated with neuropsychological status than personal or environmental factors and significant factor of functional outcome. Therefore, physicians and physiotherapists should attempt to promote motivation of their patients during rehabilitation.

Effects of Asymmetrical Weight Bearing during Straight and Circular Walking in Hemiplegic Patients

OBJECTIVE: The purpose of this study was to compare and analyze the difference of weight bearing between affected and intact feet during straight or circular walking in hemiplegic patients. METHOD: 16 hemiplegic patients who could walk without assistive devices were included in this study. We used insole foot-pressure system to measure weight bearing ratio of both feet during walking. We assessed walking speed and pressure ratio during straight or circular walking at their comfortable gait speed. RESULT: Pressure ratio of affected foot showed negative correlation with walking time irrespective of walking direction. Pressure ratio of affected foot and walking time during circular walking to the affected side was significantly higher and slower respectively than that to the intact side. CONCLUSION: Asymmetrical weight bearing of both feet during walking is highly correlated with walking ability in hemiplegic patients and pressure ratio of affected foot may be simple and useful determinant of walking ability.

Emery Dreifuss muscular Dystrophy: A case report

Emery-Dreifuss muscular dystrophy(EDMD) is a very rare, has never reported in Korea, relatively benign muscle disorder caused by defects of emerin. The clinical triad include 1) early contracture of the elbows, Achilles tendons, and postcervical muscles, 2) progressive weakness and atrophy in a humeroperoneal distribution, and 3) cardiomyopathy characterized by conduction defect. Heart block is a frequent cause of death. The detection of this disorder is important because insertion of a cardiac pacemaker can be life saving. As emerin was not found in biopsies from patients affected by EDMD and most mutations in EDMD are null, the immunohistochemical diagnosis can be easily performed by detection the absence of emerin. We report a 14-year-old boy with slowly progressive scapuloperoneal muscle weakness and atrophy, and contracture of the Achilles tendons, elbows and postcervical muscles. Muscle biopsy showed marked atrophy of myofiber and increased intermysial fibrosis and immunohistochemical study showed emerin deficiency.

Evaluation of Standing Balance in Hemiplegic Patients Using the Functional Reach Test

OBJECTIVE: To examine the validity of the fuctional reach test (FRT) for evaluation of standing balance in hemiplegic patients. METHOD: Twenty three hemiplegic patients who were capable of standing without assistive devices were assessed on the FRT only with intact upper limb, the one-legged stance, the timed up and go test (TUG), the 10 meter walking time (10 mWT), the 'Hauser' ambulation index (AI), and the standing balance of Bohannon. RESULTS: The forward reach of FRT demonstrated significant correlation with the TUG and the 10 mWT (p<0.01), but no significant relationship with the one-legged stance, standing balance of Bohannon and AI. CONCLUSION: The forward reach of FRT may be simple and useful tool for assessing the clinical balance function and reflecting gait ability and fall-down risk in hemiplegic patients.

The Effect of Subacromial Massage for Hemiplegic Shoulder: Ramdomized Controlled Study

OBJECTIVE: Shoulder pain in hemiplegia is common and serious problem, but is not completely understood and somewhat controversial. This preliminary study attempt to evaluate the effect and usefulness of subacromial massage in the management of hemiplegic shoulder. METHOD: In this ramdomized controlled trial, twenty nine hemiplegic patients with shoulder pain and limitation of motion were treated with either subacromial massage (treatment group) or massage on the supra-acromial area (control group). Outcome measurement of pain intensity, and range of motion were obtained by blinded assessment. RESULTS: After massage, in treatment group, mean active range of shoulder motion was increased by 14.3degrees in abduction, 9.0degrees in flexion, 10.3degrees in external rotation and 13o in internal rotation versus 3.9degrees in abduction, 7.5degrees in flexion, 4.3degrees in external rotation and 6.4degrees in internal rotation in control group. The mean pain intensity decreased from VAS 5.47 to 3.8 in treatment group and from VAS 4.57 to 3.71 in control group. This result was statistically significant, except in increment of active range of motion of flexion and external rotation of shoulder joint. CONCLUSION: Subacromial massage was used in an effort to increase shoulder motion and to reduce shoulder pain in hemiplegic patients. There were increase in shoulder motion especially abduction, and decrease shoulder pain in study group compared with control group. Further investigation in the form of long term follow up studies is needed.

The Development of PC-based Mini-Mental Status Examination

OBJECTIVE: The aim of this study is to develop the PC-based Mini-mental Status Examination (PC-MMSE) including its protocol to improve the reliability of MMSE, to have convenience for administration, and to evaluate the test-retest reliability. METHOD: The factors of decreasing the reliability on MMSE are analyzed such as following. 1) The way of question, pronunciation, and loudness of speech can be different between the test-retest or tester-tester, 2) the learning effect can occur when the test is repeatedly administrated, and 3) the test protocol is not determined in detail. The PC-MMSE and its protocol are designed to solve this problem. PC-MMSE has been developed to have functions such as following. 1) It was made constant verbal stimulation, 2) the question contents of the same level of difficulty in changeable items were developed and some of those can be randomly selected, and 3) it was made the adminstration of test and the management on the test results, conveniently. Protocol on PC-MMSE was also developed for standardization in the administration of test. These two tests of PC-MMSE on 26 stroke patients are administrated for the evaluation of test-retest reliability. RESULTS: The test-retest Spearman's correlation coefficient of PC-MMSE is 0.967 (p<0.01). The Spearman's correlation coefficient of PC-MMSE which is related with sex, education, lesion site, and hemiplegic side is more than 0.89. CONCLUSION: The PC-MMSE and its protocol are thought to be useful for the repeated evaluation of cognitive function.

Evaluation of the Knee Extension Force in Korean Adults Using a Manual Muscle Tester

OBJECTIVE: The purpose of this study was to determine the knee extension force of healthy Korean adults by using a hand-held dynamometer and evaulate the relationship of knee extension force between each decade. METHOD: One hundred and twenty healthy subjects (60 males, 60 females) between the ages of 20 and 79 years were tested for knee extension force by using Nicholas Manual Muscle Tester (MMT). Data were analyzed for means, standard deviations, test-retest reliability and correlation with variables by using the SPSS(R) software package. RESULTS: The mean value of the knee extension force was 25.9 +/- 5.8 kg in the males and 16.5 +/- 4.1 kg in the females. Significant difference between each decade was found in the males but not in the females. The knee extension force of the males was stastically correlated with all of variables, i.e., age, weight and height, but the knee extension force of the females, was correlated only with weight. Intratester correlation coefficients were high for the Nicholas MMT to measure the knee extension force for healthy adults. Also the difference between the dominant and nondominant side for the knee extensor force was not significant, stastically. CONCLUSION: This MMT may be useful to quickly and objectively evaluate force in the clinical setting.

Usefulness of Manual Medicine Therapy in Adhesive Capsulitis of Shoulder

OBJECTIVE: The purpose of this study was to determine the usefulness of manual medicine therapy in adhesive capsulitis of shoulder. METHOD: Twelve patients with adhesive capsulitis of shoulder were treated with the muscle energy technique of Greenman in manual medicine therapy. The muscle energy technique of Greenman was repeated 6 times for each subject. The therapeutic effect of manual medicine therapy was assessed by the shoulder range of motion (ROM) and visual analogue scale (VAS) before and after the treatment. Two patients took the fluoroscopic examination before and after the treatment. RESULTS: After the manual medicine therapy, active range of shoulder motion were increased by 30.0degrees in forward flexion, by 21.2degrees in abduction, by 11.2degrees in external rotation, and by 18.7degrees in internal rotation, respectively. The visual analogue scale was decreased after treatment. None of the subjects complained pain during treatment. The mobility of shoulder joint was improved and the rhythm of scapulohumeral joint was restored. CONCLUSION: The manual medicine therapy is an effective, tolerable and noninvasive treatment method for the painful adhesive capsulitis of shoulder.