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.

Role of Cortico-ponto-cerebellar Tract from Supplementary Motor Area in Ataxic Hemiparesis of Supratentorial Stroke Patients

Cortical lesions of the supplementary motor area (SMA) are important in balance control and postural recovery in stroke patients, while the role of subcortical lesions of the SMA has not been studied. This study aimed to investigate the subcortical projections of the SMA and its relationship with ataxia in supratentorial stroke patients. Thirty-three patients with hemiparesis were divided into 3 groups (severe ataxia, n = 9; mild to moderate ataxia, n = 13; no ataxia, n = 11). Ataxia severity was assessed using the Scale for Ataxia Rating Assessment. Diffusion tensor imaging analysis used the fractional anisotropy (FA) values and tract volume as parameters of white matter tract degeneration. The FA values of regions related to ataxia were analyzed, that is the SMA, posterior limb of the internal capsule, basal ganglia, superior cerebellar peduncle, middle cerebellar peduncle, inferior cerebellar peduncle, and cerebellum. Tract volumes of the corticostriatal tract and cortico-ponto-cerebellar (CPC) tract originating from the SMA were evaluated. There were significant differences among the 3 groups in FA values of the subcortical regions of the CPC tract. Furthermore, the volume of the CPC tract originating from the SMA showed significant negative correlation with ataxia severity. There was no correlation between ataxia and corticostriatal tract volume. Therefore, we found that subcortical lesions of the CPC tract originating from the SMA could contribute to ataxia severity in stroke patients with ataxic hemiparesis.

Status of Rehabilitation After Ischemic Stroke: A Korean Nationwide Study

OBJECTIVE: To investigate the post-stroke rehabilitation status according to stroke severity using the database of the Korean Health Insurance Review and Assessment Service. METHODS: The data of patients admitted to the neurology departments of 12 hospitals within 7 days of onset of ischemic stroke were collected. A total of 2,895 patients hospitalized between November 2010 and December 2011 were included. The patients were classified into three groups according to their initial National Institutes of Health Stroke Scale (NIHSS) scores (mild, ≤5; moderate, >5 and ≤13; and severe, >13). Length of hospital stay (LoS) with rehabilitation, NIHSS score after acute care, and scores on modified Rankin Scale (mRS) were examined at 1 year post-stroke according to stroke severity and ongoing rehabilitation. RESULTS: The total LoS for ongoing rehabilitation significantly increased with stroke severity (mild, 91.66±149.70; moderate, 197.26±241.93; severe, 263.50±275.75 days; p < 0.01). However, the proportion of LoS with ongoing rehabilitation to the total LoS tended to decline with increasing stroke severity (mild, 77.93±29.50, p < 0.01; moderate, 71.83±32.13; severe, 62.29±37.19). The home discharge rate of the group that underwent continuous inpatient rehabilitation was significantly higher in patients with moderate and severe stroke, respectively (14.2% vs. 0.0%, p < 0.001; 7.4% vs. 0.0%, p=0.032). CONCLUSION: This study showed that intermittent rehabilitation was often provided after acute care, whereas ongoing rehabilitation positively affected rate of home discharge in patients with moderate and severe stroke in Korea. These results represent evidence for improving the healthcare system to promote adequate rehabilitation in the future.

Is WHODAS 2.0 Useful for Colorectal Cancer Survivors?

OBJECTIVE: To compare the disability level of colorectal cancer survivors with and without stoma by using the Korean version of the 12-item, interview-administered World Health Organization Disability Assessment Schedule 2.0 (Korean version of WHODAS 2.0). METHODS: This is a multicenter (five tertiary university hospitals and the Korea Ostomy Association) and cross-sectional survey. Colorectal cancer survivors with and without stoma were interviewed. Survey measured disability level using the Korean version of WHODAS 2.0 and health-related quality of life using the SF-36. RESULTS: A significant difference was observed between patients with and without a stoma in two subdomains: getting around (31.1 vs. 20.3; p=0.013) and participation in society (32.3 vs. 22.2; p=0.028). After adjusting for age, gender, and time since surgery, having a stoma was associated with severe to extreme disabilities in participation (OR=2.72, p=0.045). The Korean version of WHODAS 2.0 showed satisfactory internal consistency (r=0.96) and convergent validity. CONCLUSION: Patients with stoma participated less in society than those without stoma. The Korean version of WHODAS 2.0 is a reliable and valid instrument for measuring disability in Korean colorectal cancer patients.

Current State and Prospects of Development of Blood-based Biomarkers for Mild Traumatic Brain Injury

The current understanding of the pathophysiology of mild traumatic brain injury (mTBI) is, without doubt, incomplete. Nevertheless, we tried to summarize the state-of-the-art explanation of how the brain is continuously injured even after a single impact. We also reviewed the real struggle of diagnosing mTBI, which culminated in showing the potential of blood-based biomarkers as an alternative or complementary way to overcome this difficulty. Pathophysiology of mTBI is subdivided into primary and secondary injuries. Primary injury is caused by a direct impact on the head and brain. Secondary injury refers to the changes in energy metabolism and protein synthesis/degradation resulting from the biochemical cascades as follows; calcium influx, mitochondrial dysfunction, fractured microtubules, and Wallerian degeneration, neuroinflammation, and toxic proteinopathy. Since the diagnosis of mTBI is made through the initial clinical information, it is difficult and inaccurate to diagnose mTBI without the absence of a witness or sign of head trauma. Blood-based biomarkers are expected to play an important role in diagnosing mTBI and predicting functional outcomes, due to their feasibility and the recent progress of targeted proteomics techniques (i.e., liquid chromatography tandem mass spectrometry [LC-MS/MS]).

Prediction of Post-stroke Falls by Quantitative Assessment of Balance

OBJECTIVE: To evaluate characteristics of the postural instability in patients with stroke and to present a prediction model of post-stroke falls. METHODS: Patients with a first-ever stroke who had been evaluated by the Balance Master (BM) at post-stroke 3 months (±1 month) between August 2011 and December 2015 were enrolled. Parameters for the postural instability, such as the weight bearing asymmetry (WBA) and postural sway velocity (PSV), were obtained. The fall events in daily lives were assessed via structured telephone interview with a fall related questionnaire. RESULTS: A total of 71 patients (45 men; 45 with ischemic stroke) were enrolled in this study. All subjects underwent BM evaluation at 3.03±0.40 months after stroke. The mean WBA was 17.18%±13.10% and mean PSV (measured as °/s) were noted as 0.66±0.37 (eyes-open on firm surface), 0.89±0.75 (eyes-closed on firm surface), 1.45±1.09 (eyes-open on soft surface), and 3.10±1.76 (eyes-closed on soft surface). A prediction model of post-stroke falls was drawn by multiple logistic regression analysis as follows: Risk of post-stroke falls = -2.848 + 1.878 x (PSV(ECSS)) + 0.154 x (age=1 if age≥65; age=0 if age<65). CONCLUSION: The weight bearing asymmetry and postural sway were significantly increased in patients with stroke. Older age and impaired postural control increased the risk of post-stroke falls.