Clinical Practice Guidelines for Oropharyngeal Dysphagia / 대한연하장애학회지

Objective@#Dysphagia is a common clinical condition characterized by difficulty in swallowing. It is sub-classified into oropharyngeal dysphagia, which refers to problems in the mouth and pharynx, and esophageal dysphagia, which refers to problems in the esophageal body and esophagogastric junction. Dysphagia can have a significant negative impact one’s physical health and quality of life as its severity increases. Therefore, proper assessment and management of dysphagia are critical for improving swallowing function and preventing complications. Thus a guideline was developed to provide evidence-based recommendations for assessment and management in patients with dysphagia. @*Methods@#Nineteen key questions on dysphagia were developed. These questions dealt with various aspects of problems related to dysphagia, including assessment, management, and complications. A literature search for relevant articles was conducted using Pubmed, Embase, the Cochrane Library, and one domestic database of KoreaMed, until April 2021. The level of evidence and recommendation grade were established according to the Grading of Recommendation Assessment, Development and Evaluation methodology. @*Results@#Early screening and assessment of videofluoroscopic swallowing were recommended for assessing the presence of dysphagia. Therapeutic methods, such as tongue and pharyngeal muscle strengthening exercises and neuromuscular electrical stimulation with swallowing therapy, were effective in improving swallowing function and quality of life in patients with dysphagia. Nutritional intervention and an oral care program were also recommended. @*Conclusion@#This guideline presents recommendations for the assessment and management of patients with oropharyngeal dysphagia, including rehabilitative strategies.

Hemoptysis in Quadriplegia with Atrial Fibrillation Who Was Taking Edoxaban: a Case Report

The direct-acting oral anticoagulants (DOACs) would be the standard treatment for the prevention of stroke and thromboembolism in nonvalvular atrial fibrillation patients. The adverse effects of greatest concern are bleeding especially major bleeding. We present a case of a patient with a history of nonvalvular atrial fibrillation and pacemaker, who developed severe anemia after massive hemoptysis while taking DOAC; however, he has continued taking DOAC. Through this case, we have summarized the current management of major bleeding associated with anticoagulation and discuss the optimal regimen for restarting of anticoagulation therapy.

Development of a Short Version of ICF Core Set for Stroke Adapted for Rehabilitation in Korea: a Preliminary Study

This study aimed to develop a short version of the International Classification of Functioning, Disability, and Health (ICF) core set and verify functioning levels of patients for stroke rehabilitation in Korea. Using the Delphi technique, a 3-round consensus process was conducted. Thirty multidisciplinary rehabilitation experts from different hospitals completed the consensus study. The questionnaire for this study adopted the comprehensive ICF core set for stroke developed by the Geyh group. A 7-point Likert-type scale was used by participants to weigh the impact of each category on activities of daily living or rehabilitation after a stroke. The consensus of ratings was assessed with Spearman's rho and inter-quartile range indices. A core set to assess functioning levels of patients with stroke was developed from those categories. A short version of ICF core set to assess and verify functioning levels of patients with stroke was developed for 12 categories, including 3 categories (consciousness, muscle power, and attention) from body functions, 1 (structure of brain) from body structures, 5 (eating, walking, moving around, changing basic body position, and carrying out daily routine) from activities and participation, and 3 (individual attitudes of immediate family members, immediate family, and personal care providers/personal assistants) from environmental factors. This preliminary study developed a Delphi consensus process, gathering statistical evidence and expert commands based on the short version of ICF core set for rehabilitation of stroke patients in Korea.

Correlation Between Duration From Injury and Bone Mineral Density in Individuals With Spinal Cord Injury

Objective@#To investigate the correlation between bone mineral density (BMD) and duration of injury in individuals with spinal cord injury (SCI). @*Methods@#Patients with SCI who visited the outpatient department between January 2009 and January 2019 were enrolled. Patients’ most recent dual energy X-ray absorptiometry images were reviewed. According to the 2007 International Society for Clinical Densitometry guidelines, vertebrae with a local structural change were excluded when deriving spine BMD. If one or no vertebra is suitable for evaluation, spine BMD was judged as “improper for assessment”. Correlation analysis was performed between duration from injury and BMD Z-scores of the hip and spine. @*Results@#Among 83 individuals with SCI, the spines of 44 were judged as improper for assessment. The correlation analysis showed a significant negative relationship between the duration from injury and femur neck BMD (r=-0.40, p<0.01) and total proximal femur BMD (r=-0.39, p<0.01). However, no significant correlation was found between the duration from injury and spine BMD Z-score. @*Conclusion@#The duration of SCI correlated with hip BMD, but not with spine BMD. Further, more than half of the individuals with SCI could not undergo spinal assessment due to local structural changes. Therefore, spine BMD measurement is not an appropriate method for predicting future fracture risk in those with SCI.

Clinical Practice Guideline for Postoperative Rehabilitation in Older Patients With Hip Fractures

Objective@#The incidence of hip fractures is increasing worldwide with the aging population, causing a challenge to healthcare systems due to the associated morbidities and high risk of mortality. After hip fractures in frail geriatric patients, existing comorbidities worsen and new complications are prone to occur. Comprehensive rehabilitation is essential for promoting physical function recovery and minimizing complications, which can be achieved through a multidisciplinary approach. Recommendations are required to assist healthcare providers in making decisions on rehabilitation post-surgery. Clinical practice guidelines regarding rehabilitation (physical and occupational therapies) and management of comorbidities/complications in the postoperative phase of hip fractures have not been developed. This guideline aimed to provide evidence-based recommendations for various treatment items required for proper recovery after hip fracture surgeries. Methods Reflecting the complex perspectives associated with rehabilitation post-hip surgeries, 15 key questions (KQs) reflecting the complex perspectives associated with post-hip surgery rehabilitation were categorized into four areas: multidisciplinary, rehabilitation, community-care, and comorbidities/complications. Relevant literature from four databases (PubMed, EMBASE, Cochrane Library, and KoreaMed) was searched for articles published up to February 2020. The evidence level and recommended grade were determined according to the grade of recommendation assessment, development, and evaluation method. Results A multidisciplinary approach, progressive resistance exercises, and balance training are strongly recommended. Early ambulation, weigh-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested. This multidisciplinary approach reduced the total healthcare cost. @*Conclusion@#This guideline presents comprehensive recommendations for the rehabilitation of adult patients after hip fracture surgery.

Clinical Practice Guideline for Postoperative Rehabilitation in Older Patients With Hip Fractures

Objective@#The incidence of hip fractures is increasing worldwide with the aging population, causing a challenge to healthcare systems due to the associated morbidities and high risk of mortality. After hip fractures in frail geriatric patients, existing comorbidities worsen and new complications are prone to occur. Comprehensive rehabilitation is essential for promoting physical function recovery and minimizing complications, which can be achieved through a multidisciplinary approach. Recommendations are required to assist healthcare providers in making decisions on rehabilitation post-surgery. Clinical practice guidelines regarding rehabilitation (physical and occupational therapies) and management of comorbidities/complications in the postoperative phase of hip fractures have not been developed. This guideline aimed to provide evidence-based recommendations for various treatment items required for proper recovery after hip fracture surgeries. Methods Reflecting the complex perspectives associated with rehabilitation post-hip surgeries, 15 key questions (KQs) reflecting the complex perspectives associated with post-hip surgery rehabilitation were categorized into four areas: multidisciplinary, rehabilitation, community-care, and comorbidities/complications. Relevant literature from four databases (PubMed, EMBASE, Cochrane Library, and KoreaMed) was searched for articles published up to February 2020. The evidence level and recommended grade were determined according to the grade of recommendation assessment, development, and evaluation method. Results A multidisciplinary approach, progressive resistance exercises, and balance training are strongly recommended. Early ambulation, weigh-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested. This multidisciplinary approach reduced the total healthcare cost. @*Conclusion@#This guideline presents comprehensive recommendations for the rehabilitation of adult patients after hip fracture surgery.

Determinant of Quality of Life in Patients with Chronic Cerebral Infarct

This study investigated how physical and cognitive function and psychological factors affected the health-related quality of life (HRQoL, hereafter HQ) of stroke patients in South Korea. The study enrolled 32 right-handed subjects with chronic cerebral infarction with disability and preserved cognitive function (Mini-Mental State Examination ≥ 20). Physical disability was assessed using the modified Rankin Scale (mRS) and Korean modified Barthel Index (KMBI). Quality of life was measured using the World Health Organization Quality of Life-Abbreviated form (WHOQOL-BREF, hereafter WB) and the 36-Item Short-form Health Survey (SF-36) in face-to-face interviews. Psychological distress was investigated using the Beck Depression Inventory Scale-II. The associations of each domain of WB and SF-36 were investigated using Pearson correlation analyses. Physical disability was negatively correlated with HQ in the SF-36. The physical function and bodily pain scales of the SF-36 were negatively correlated with physical disability. The general health domain of the SF-36 was negatively correlated with psychological scores. Emotional status was associated with physical health, social relationships, and general health in HQ. In summary, the severity of physical disability was associated with the patient's general and physical health and body pain. These findings suggest the importance of psychological, cognitive, and physiological interventions for improving the quality of life of patients after cerebral infarction.

Determinant of Quality of Life in Patients with Chronic Cerebral Infarct

This study investigated how physical and cognitive function and psychological factors affected the health-related quality of life (HRQoL, hereafter HQ) of stroke patients in South Korea. The study enrolled 32 right-handed subjects with chronic cerebral infarction with disability and preserved cognitive function (Mini-Mental State Examination ≥ 20). Physical disability was assessed using the modified Rankin Scale (mRS) and Korean modified Barthel Index (KMBI). Quality of life was measured using the World Health Organization Quality of Life-Abbreviated form (WHOQOL-BREF, hereafter WB) and the 36-Item Short-form Health Survey (SF-36) in face-to-face interviews. Psychological distress was investigated using the Beck Depression Inventory Scale-II. The associations of each domain of WB and SF-36 were investigated using Pearson correlation analyses. Physical disability was negatively correlated with HQ in the SF-36. The physical function and bodily pain scales of the SF-36 were negatively correlated with physical disability. The general health domain of the SF-36 was negatively correlated with psychological scores. Emotional status was associated with physical health, social relationships, and general health in HQ. In summary, the severity of physical disability was associated with the patient's general and physical health and body pain. These findings suggest the importance of psychological, cognitive, and physiological interventions for improving the quality of life of patients after cerebral infarction.

Determinant of Quality of Life in Patients with Chronic Cerebral Infarct

This study investigated how physical and cognitive function and psychological factors affected the health-related quality of life (HRQoL, hereafter HQ) of stroke patients in South Korea. The study enrolled 32 right-handed subjects with chronic cerebral infarction with disability and preserved cognitive function (Mini-Mental State Examination ≥ 20). Physical disability was assessed using the modified Rankin Scale (mRS) and Korean modified Barthel Index (KMBI). Quality of life was measured using the World Health Organization Quality of Life-Abbreviated form (WHOQOL-BREF, hereafter WB) and the 36-Item Short-form Health Survey (SF-36) in face-to-face interviews. Psychological distress was investigated using the Beck Depression Inventory Scale-II. The associations of each domain of WB and SF-36 were investigated using Pearson correlation analyses. Physical disability was negatively correlated with HQ in the SF-36. The physical function and bodily pain scales of the SF-36 were negatively correlated with physical disability. The general health domain of the SF-36 was negatively correlated with psychological scores. Emotional status was associated with physical health, social relationships, and general health in HQ. In summary, the severity of physical disability was associated with the patient's general and physical health and body pain. These findings suggest the importance of psychological, cognitive, and physiological interventions for improving the quality of life of patients after cerebral infarction.

The Role of Regular Physical Therapy on Spasticity in Children With Cerebral Palsy

OBJECTIVE: To investigate the effect of physical therapy (PT) intervention on spasticity in patients with cerebral palsy (CP), and to assess the degree of deterioration of spasticity when regular PT is interrupted in those patients. METHODS: We recruited 35 children with spastic CP who visited our hospital for PT, and whose Modified Tardieu Scale (MTS) scores were serially recorded including before and after a 10-day public holiday time frame period. The outcome measures were the angle of range of motion (ROM) of dorsiflexion of the ankle joint (R1 and R2) in the knee flexion and extension positions as assessed using the MTS. RESULTS: The range of dorsiflexion of the ankle joint (R1 and R2) after the holiday period was significantly decreased as compared with that measured ROM noted before the holiday period, regardless of the knee position, age, or gross motor function. The dynamic component of the MTS (R2–R1) showed a slight decrease in the knee flexion position. CONCLUSION: Interruption of regular PT aggravated spasticity and decreased ankle joint ROM in children with spastic CP. Our findings suggest that regular PT in the care continuum for children with CP is crucial for the maintenance of ROM in the spastic ankle joints.

A Man with Dysphagia after Cervical Esophagogastrostomy: A Case Report / 대한연하장애학회지

Dysphagia caused by a functional gastric outlet obstruction is rare and the natural course of a functional gastric outlet obstruction is unclear. This paper reports a patient with dysphagia and a functional gastric outlet obstruction after a cervical esophagogastrostomy. A 62-year-old man with a history of esophageal cancer and cervical esophagogastrostomy presented with dysphagia and discomfort during meals. A videofluoroscopic swallowing study (VFSS) with barium revealed a mild increase in the post-swallow remnants and delayed emptying of the gastric outlet, reflecting a functional gastric outlet obstruction at the diaphragm. One month later, VFSS revealed a worsened functional gastric outlet obstruction at the diaphragm. A delayed chest X-ray showed worsened delayed emptying of the gastric outlet. A cervical esophagogastrostomy for early esophageal cancer can cause functional gastric outlet obstruction, presenting as dysphagia and discomfort during meals. Physicians should be concerned about dysphagia and the functional changes in the esophagus in patients with a cervical esophagogastrostomy.

The Changes for Strength of Oropharyngeal Muscles in Patients with Dementia and Dysphagia

Although dysphagia is an important health problem and one of the determinants of quality of life in patients with dementia, the neurophysiologic changes of dysphagia in dementia have not been fully uncovered, yet. we investigated the changes of strength of tongue lip and pharyngeal muscles in patients with dementia. This study included 30 subjects with dementia. In all subjects, clinical assessments consisted of the Iowa Oral Performance Instrument (IOPI) for tongue and lip, surface electromyography (sEMG) with Vital stim plus on suprahyoid muscles, the Mini-Mental State Examination, and Clinical Dementia Rating (CDR) scales. All subjects were classified into 3 groups according to severity; CDR 1, 2, and 3. There was no difference between IOPI and sEMG among all 3 groups. The values of tongue and lip IOPI from all 3 dementia groups were significantly lower than values of control. The comparisons for values of tongue and lip IOPI among 3 dementia group were not different from each other. The sEMG of suprahyoid muscles were not different between all 3 dementia groups and control. These findings are supportive of dysphagia therapy for oral phase would be beneficial for the restoration of swallowing function in patients with dementia and dysphagia.

Delayed Extensive White Matter Injury Caused by a Subdural Hemorrhage and Role of Corticospinal Tract Integrity

A subdural hemorrhage (SDH) is a common disorder with usually good prognosis. Most SDHs resolve with or without with minimal sequelae. We present a case report of a patient with SDH, who had delayed extensive white matter injury with disruptions of corticospinal tracts (CSTs) by diffusion tensor imaging (DTI) and showed abysmal prognosis, despite long-term rehabilitation. A 62-year-old man with an SDH underwent burr hole trephination for hematoma removal. Within 7 days, the hemorrhage diminished. At 12 weeks after the onset, the patient's weakness did not improve, and a follow-up magnetic resonance imaging revealed extensive leukomalacia, especially in the white matter. The DTI for CST revealed severe injury of CST integrity. He did not re-gain muscle strength and functional independence, despite 3 months of inpatient rehabilitation. This case describes SDH with delayed extensive white matter injury and exceptional poor prognosis and urges caution in that the SDH may induce very variable functional recovery. Besides, DTI for CST would be useful in predicting the long-term functional prognosis in extensive white matter injury.

A Man Presenting with Sudden Weakness and Pain of the Right Hand, by Non-Small Cell Lung Cancer with Brain Metastases

Unexplained pain and weakness, i.e., without obvious predisposing factors, are often encountered by physiatrists and efforts should be made to determine the cause. A 63-year-old male presented with radiating pain in his right arm and mild weakness of the right hand. An electrodiagnostic examination revealed distal symmetric sensory polyneuropathy in the upper and lower extremities, and denervation potentials in the forearm muscles, which were inconsistent with the cervical spine MRI images and symptoms. A predisposing undiscovered disease was revealed, i.e., squamous cell carcinoma in the lung; brain metastasis affecting the left primary motor cortex was also detected. Therefore, we concluded that the pain and weakness were related to paraneoplastic syndrome and brain metastases of the hand knob. The observed denervation potentials were characterized as trans-synaptic changes in the brain metastasis. This case highlights the importance of unexplainable focal pain and weakness in the increasing prevalence of cancer.

Subtle Dysphagia as an Initial Presentation of Hidden Malignancy: A Report of 2 Cases / 대한연하장애학회지

Subtle dysfphagia, which is increased post-swallowing remnants, is a frequent finding in the elderly with various etiologies. These changes in swallowing are frequently overlooked by physicians. On the other hand, subtle changes evident on a videofluoroscopic swallowing study (VFSS) may suggest hidden disease. Therefore, clinicians should evaluate incidental dysphagia. Case 1: A 65-year-old man with no relevant medical history, presented with dysphagia and residual sensation during meals. VFSS showed moderate post-swallowing remnants in the vallecular fossa and pyriformis sinus. Further examination revealed prostate cancer with multiple bone metastases including the skull. Case 2: A 60-year-old man complained of residual sensation after swallowing, which started 2 months ago. He had a history of lung cancer. Pharyngeal residue was observed on VFSS. A brain metastasis was observed on MRI. Post-swallowing residue is often neglected or overlooked by clinicians who regard them as the features of aging. The present cases show that mild dysphagia with increased post-swallowing remnants may be an initial presentation of a hidden malignancy with metastasis. Physicians should consider unexplained dysphagia or tongue atrophy as possible initial presentations of hidden malignancies.

Sinking Skin Flap Syndrome or Syndrome of the Trephined: A Report of Two Cases

Decompressive craniectomy (DC) is commonly performed in patients with intracranial hypertension or brain edema due to traumatic brain injury. Infrequently, neurologic deteriorations accompanied by sunken scalp may occur after DC. We report two patients with traumatic subdural hemorrhage who had neurologic deteriorations accompanied by sunken scalp after DC. Neurologic function improved dramatically in both patients after cranioplasty. Monitoring for neurologic deterioration after craniectomy is advised. For patients showing neurologic deficit with a sunken scalp, early cranioplasty should be considered.

Central Hypoventilation Syndrome in Posterior Circulation Stroke Treated by Respiratory Rehabilitation: a Case Report

Central hypoventilation syndrome is a rare and fatal condition resulting from various central nervous system disorders that is characterized by a failure of automatic breathing. We report a case of central hypoventilation syndrome following posterior circulation stroke whose pulmonary function was improved by respiratory rehabilitation. A 59-year-old woman with a history of hemorrhagic stroke of the bilateral cerebellum was hospitalized due to pneumonia. A portable ventilator was applied via tracheostomy, recurrent episodes of apnea and hypercapnia impeded weaning. A respiratory rehabilitation program including chest wall range of motion exercise, air stacking exercise, neuromuscular electrical stimulation (NMES) on abdominal muscles, upper extremity ergometer, locomotor training, high-frequency chest wall oscillator, mechanical insufflation, and exsufflation was employed, as spirometry showed a severe restrictive pattern. A spontaneous breathing trial was started, and a portable ventilator was applied for 8 hours, only during nighttime, to prevent sudden apneic event. After 4 weeks of treatment, follow-up spirometry showed much improved respiratory parameters. This case suggests that respiratory rehabilitation can improve pulmonary function parameters and quality of life in central hypoventilation syndrome.

Relationship between Clinical Outcomes and Cardiopulmonary Resuscitation Time in Patients with Acute Myocardial Infarction Treated by Extracorporeal Membrane Oxygenation-Assisted Primary Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES@#Extracorporeal membrane oxygenation (ECMO) support is increasingly used in primary percutaneous coronary intervention (PCI) during cardiopulmonary resuscitation (CPR) to treat acute myocardial infarction (AMI) patients who experienced cardiogenic shock. However, to date, there have been no studies on the relationship between clinical outcomes and CPR time in such patients with AMI treated by ECMO-assisted primary PCI.@*METHODS@#From July 2008 to March 2016, we analyzed data from 42 AMI with cardiogenic shock patients who underwent CPR and were treated by ECMO-assisted primary PCI. The primary outcome was 30-day in-hospital mortality after primary PCI. The predictors of mortality were determined using a Cox proportional hazards model.@*RESULTS@#Thirty-day in-hospital mortality was observed for 33 patients (78.6%). The mean CPR time was 37.0±37.3 minutes. The best cut-off CPR time value associated with clinical outcome was calculated to be 12.5 minutes using receiver operating characteristic curve analysis. Multivariate analysis revealed that CPR time of > 12.5 minutes was an independent predictor of 30-day mortality (adjusted hazard ratio, 4.71; 95% confidence interval, 1.30–17.406; p=0.018).@*CONCLUSIONS@#Despite ECMO support, the clinical outcomes of AMI patients with a complication of cardiogenic shock remain poor. Prolonged CPR time is associated with a poor prognosis in patients with AMI treated by ECMO-assisted primary PCI.

Relationship between Clinical Outcomes and Cardiopulmonary Resuscitation Time in Patients with Acute Myocardial Infarction Treated by Extracorporeal Membrane Oxygenation-Assisted Primary Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) support is increasingly used in primary percutaneous coronary intervention (PCI) during cardiopulmonary resuscitation (CPR) to treat acute myocardial infarction (AMI) patients who experienced cardiogenic shock. However, to date, there have been no studies on the relationship between clinical outcomes and CPR time in such patients with AMI treated by ECMO-assisted primary PCI. METHODS: From July 2008 to March 2016, we analyzed data from 42 AMI with cardiogenic shock patients who underwent CPR and were treated by ECMO-assisted primary PCI. The primary outcome was 30-day in-hospital mortality after primary PCI. The predictors of mortality were determined using a Cox proportional hazards model. RESULTS: Thirty-day in-hospital mortality was observed for 33 patients (78.6%). The mean CPR time was 37.0±37.3 minutes. The best cut-off CPR time value associated with clinical outcome was calculated to be 12.5 minutes using receiver operating characteristic curve analysis. Multivariate analysis revealed that CPR time of > 12.5 minutes was an independent predictor of 30-day mortality (adjusted hazard ratio, 4.71; 95% confidence interval, 1.30–17.406; p=0.018). CONCLUSIONS: Despite ECMO support, the clinical outcomes of AMI patients with a complication of cardiogenic shock remain poor. Prolonged CPR time is associated with a poor prognosis in patients with AMI treated by ECMO-assisted primary PCI.

Cervical Spine Malformations Associated With a 5q34-5q35.2 Micro-interstitial Deletion: A Case Report

We report a female proband carrying a de novo 5q34-q35.2 deletion breakpoint, and review the unique skeletal phenotype and possible genotype related to this mutation. The patient presented with a persistent head tilt and limited head rotation. Non-contrast-enhanced three-dimensional computed tomography of the cervical spine revealed several malformations including a bone cleft in the right pars interarticularis, a bone defect in both C5 lamina and the transverse foramen at C2–C3, agenesis of the right articular process of C5, bony fusion of C4–C5, and subluxation of the craniocervical joints. Several deformities of the cervical spine seen in this patient have not been associated with the 5q deletion. A review of 5q-related mutations suggests that abnormalities associated with MSX2 gene might cause cervical spine abnormalities.