Exercise-Induced Pain Reduction and Its Central Mechanism in Patients with Chronic Pain

For the effective rehabilitation of chronic pain, it is necessary to know the changes in the pain networks of patients with chronic pain. There is a need for attention to changes in emotional pain networks and cognitive pain networks. In patients with chronic pain, post-exercise pain reduction is less pronounced than in those without chronic pain. In order to achieve the exercise effect, emotional problems must be considered in addition to the patient's physical changes. In addition, a detailed prior explanation is needed to raise the expectations for exercise effect, moreover, in order to continue exercising for a safe and long period, exercise suitable for patients should be selected and low-intensity exercise protocols should be provided.

An Exploration of the Neural Network of Lance-Adams Syndrome: a Case Report

Lance-Adams syndrome (LAS) is a rare neurological disorder that may occur after cardiopulmonary resuscitation. The LAS is usually caused by hypoxic changes.Neuroimaging studies show that the brain pathology of LAS patients is not uniform, and the pathophysiology of the myoclonus can vary from patient to patient. Our case study contributes to this etiological heterogeneity by neuroimaging and transcranial magnetic stimulation (TMS). In patients with rare brain conditions such as LAS, a combination of brain stimulation methods, such as TMS, and diffusion tensor imaging can provide insights into this condition's pathophysiology. These insights can facilitate the development of more effective therapies.

Changes in Pharyngeal Width Over Time as an Indicator of Dysphagia in Stroke Patients

Objective@#To verify the pharyngeal width at rest as a measurement that could be used to assess changes in the degree of dysphagia over time in stroke patients. @*Methods@#In a cohort of stroke patients, we performed serial measurements of the pharyngeal width at the midpoints of the second (C2) and third (C3) cervical vertebral bodies using lateral neck X-rays while the patients were at rest. The JOSCYL width, a parameter named after the first initial of each developers’ surname and defined as the average value of the upper and lower pharyngeal widths, was used to formulate the JOSCYL scale, which was calculated as the JOSCYL width × 100eck circumference. All patients also underwent serial videofluoroscopic swallowing studies (VFSSs). The Spearman correlation analysis was used to detect correlations between the serial VFSS results, JOSCYL widths, and JOSCYL scale values. @*Results@#Over time, we observed significant positive and negative correlations of change in the JOSCYL width and scale with changes in the Penetration-Aspiration Scale and the Dysphagia Outcome and Severity Scale scores, respectively. @*Conclusion@#The JOSCYL width and JOSCYL scale clearly reflected changes in dysphagia in stroke patients over time. These parameters may provide an easier method for evaluating whether post-stroke dysphagia has been alleviated.

Predictive Value of Pharyngeal Width at Rest (JOSCYL Width) for Aspiration in Elderly People

OBJECTIVE: To develop a new tool for aspiration risk prediction based on pharyngeal width at rest in older adults with symptoms of aspiration. METHODS: Lateral cervical spine roentgenograms were obtained from 33 older adult patients who complained of dysphagia and from 33 healthy, age-matched controls. Pharyngeal width at rest was measured at two points. We named the average of these two pharyngeal widths ‘JOSCYL Width’, calculated ‘JOSCYL Scale’, and compared these parameters between dysphagia and control groups. Correlations of individual JOSCYL Width and JOSCYL Scale, with Penetration Aspiration Scale (PAS) and Dysphagia Outcome and Severity Scale (DOSS) scores were analyzed for the dysphagia group. To determine optimal cutoff points for predicting aspiration, a receiver operating characteristic curve analysis was performed on JOSCYL Width and JOSCYL Scale. RESULTS: Both JOSCYL Width and JOSCYL Scale of the dysphagia group were larger than those of the control group (p<0.001). The correlation between JOSCYL Width and severity of dysphagia was significant for the dysphagia group (PAS p=0.007; DOSS p=0.012). The correlation between JOSCYL Scale and the severity of dysphagia was also significant for the dysphagia group (PAS p=0.009; DOSS p=0.011). Optimal cutoffs for JOSCYL Width and JOSCYL Scale for predicting aspiration were 20.0 mm and 5.9, respectively. CONCLUSION: JOSCYL Width and JOSCYL Scale can be new indicators for predicting aspiration in older adults. They are both precise and easy to use.

Increased white matter diffusivity associated with phantom limb pain

BACKGROUND: We utilized diffusion tensor imaging (DTI) to evaluate the cerebral white matter changes that are associated with phantom limb pain in patients with unilateral arm amputation. It was anticipated that this would complement previous research in which we had shown that changes in cerebral blood volume were associated with the cerebral pain network. METHODS: Ten patients with phantom limb pain due to unilateral arm amputation and sixteen healthy age-matched controls were enrolled. The intensity of phantom limb pain was measured by the visual analogue scale (VAS) and depressive mood was assessed by the Hamilton depression rating scale. Diffusion tensor-derived parameters, including fractional anisotropy, mean diffusivity, axial diffusivity (AD), and radial diffusivity (RD), were computed from the DTI. RESULTS: Compared with controls, the cases had alterations in the cerebral white matter as a consequence of phantom limb pain, manifesting a higher AD of white matter in both hemispheres symmetrically after adjusting for individual depressive moods. In addition, there were associations between the RD of white matter and VAS scores primarily in the hemispheres related to the missing hand and in the corpus callosum. CONCLUSIONS: The phantom limb pain after unilateral arm amputation induced plasticity in the white matter. We conclude that loss of white matter integrity, particularly in the hemisphere connected with the missing hand, is significantly correlated with phantom limb pain.

Global Synchronization Index as an Indicator for Tracking Cognitive Function Changes in a Traumatic Brain Injury Patient: A Case Report

Traumatic brain injury is a main cause of long-term neurological disability, and many patients suffer from cognitive impairment for a lengthy period. Cognitive impairment is a fatal malady to that limits active rehabilitation, and functional recovery in patients with traumatic brain injury. In severe cases, it is impossible to assess cognitive function precisely, and severe cognitive impairment makes it difficult to establish a rehabilitation plan, as well as evaluate the course of rehabilitation. Evaluation of cognitive function is essential for establishing a rehabilitation plan, as well as evaluating the course of rehabilitation. We report a case of the analysis of electroencephalography with global synchronization index and low-resolution brain electromagnetic tomography applied, for evaluation of cognitive function that was difficult with conventional tests, due to severe cognitive impairment in a 77-year-old male patient that experienced traumatic brain injury.

Cerebral Blood Volume Magnetic Resonance Imaging

Cerebral blood volume (CBV) is a hemodynamic correlate of oxygen metabolism and changes due to neuronal activity. CBV alteration may precede other hemodynamic correlates and provide an early indication of hemodynamic impairment. CBV can be easily quantified using magnetic resonance imaging (MRI); moreover, CBV MRI has a strong point of high resolution compared to other neuroimaging modalities. The early and accurate assessments of cerebral metabolism and the brain map with the high resolution of CBV MRI enable advanced neurorehabilitation examinations in a neuroimaging study.

Changes in Diffusion Metrics of the Red Nucleus in Chronic Stroke Patients With Severe Corticospinal Tract Injury: A Preliminary Study

OBJECTIVE: To explore plastic changes in the red nucleus (RN) of stroke patients with severe corticospinal tract (CST) injury as a compensatory mechanism for recovery of hand function. METHODS: The moderate group (MG) comprised 5 patients with synergistic hand grasp movement combined with limited extension, and the severe group (SG) included 5 patients with synergistic hand grasp movement alone. The control group (CG) included 5 healthy subjects. Motor assessment was measured by Motricity Index (MI). Diffusion tensor imaging was analyzed using fractional anisotropy (FA) and radial diffusivity (RD) in the individual regions of interest (ROIs)—bilateral internal capsule and anterior pons for CST injury and bilateral RN for rubrospinal tract (RST) injury. RESULTS: The SG showed a significantly lower MI score than the MG mainly due to differences in hand subscores. Significantly reduced FA was observed in both MG and SG compared with CG, while SG showed increased MD and RD in the affected ROIs of CST, and increased FA on the unaffected side compared with CG. However, in the RN ROI, a significantly increased FA and decreased RD on the unaffected side similar to the affected side were found only in the SG. The relative index of FA was lower and RD in SG was higher than in CG in RST. CONCLUSION: The diffusion metrics of RST showed changes in patients with severe CST injury, suggesting that RST may play a role in the recovery of hand function in patients with severe CST injury.

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.

Correction: Risk Factors for Delirium During Acute and Subacute States of Various Disorders in Patients Admitted to Rehabilitation Units

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Risk Factors for Delirium During Acute and Subacute Stages of Various Disorders in Patients Admitted to Rehabilitation Units

OBJECTIVE: To assess the risk factors for delirium in patients admitted to a rehabilitation unit for acute or subacute neurological or musculoskeletal disorders. METHODS: We reviewed the medical records of 537 patients admitted to a rehabilitation unit and selected 398 patients in the acute or subacute stage of various neurological or musculoskeletal disorders. Among them, patients who had suffered from delirium were categorized into the delirium group (n=65), and the other patients were categorized into the non-delirium group (n=333). As potential risk factors for delirium, the patients' diagnosis, underlying disease, demographic data, hospital stay duration, surgery, and laboratory findings were reviewed, and the differences between the two groups with respect to independent risk factors were analyzed. RESULTS: The average age in the delirium group was higher; the hospital stay and pre-transfer periods were longer. A large proportion of the patients were admitted for musculoskeletal disorders, and many patients had diabetes mellitus, dementia, and depression as underlying diseases. Laboratory tests revealed increases in the white blood cells (WBC), glucose, blood urea nitrogen (BUN), total bilirubin, aspartate transaminase (AST), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels in the delirium group, while the hemoglobin, calcium, phosphorus, protein, albumin, and potassium levels were decreased. Depression, musculoskeletal disorders, traumatic brain injury, elevated WBC, BUN, AST, and CRP levels, and decreased potassium and phosphorus levels were identified as independent risk factors for delirium. CONCLUSION: Risk factors treatable before delirium onset were identified in rehabilitation patients in acute and subacute stages of various disorders. Early diagnosis and prevention of these risk factors could decrease delirium occurrence and increase rehabilitation effectiveness.

Novel Information on Anatomic Factors Causing Grasp Reflex in Frontal Lobe Infarction: A Case Report

We report a patient with a severe limitation of function in the right hand resulting from grasp reflex following a stroke affecting the left anterior cerebral artery region. We describe, using diffusion tensor tractography (DTT), a disconnection between the bilateral frontal lobes via the corpus callosum. The patient could not control his right hand at all, even though his bilateral corticospinal tracts were intact. We noted that over the infarcted lesion on DTT, the white matter was invisible from the corpus callosum to the prefrontal cortex. These findings reflected a unique pattern of white-matter disconnection between the ipsilateral medial frontal lobe and ipsilateral and contralateral frontal cortex causing hand function deterioration in the form of severe grasp reflex.

Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012

"Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012" is a 2nd edition of clinical practice guideline (CPG) for stroke rehabilitation in Korea, which updates the 1st edition published in 2009. After 1st stroke rehabilitation CPG, many studies concerning stroke rehabilitation have been published and the necessity for update has been raised. The Korea Centers for Disease Control and Prevention supported the project "Development of Clinical Practice Guideline for Stroke Rehabilitation" in 2012. Thirty-two specialists in stroke rehabilitation from 18 universities and 3 rehabilitation hospitals and 10 consultants participated in this project. The scope of this CPG included both ischemic and hemorrhagic stroke from the acute to chronic stages. The purpose of this CPG is to provide guidelines for doctors and therapists to make a decision when they manage stroke patients and ultimately, to help stroke patients obtain maximal functional recovery and return to the society. "Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012" consists of 'Chapter 1; Introduction of Stroke Rehabilitation', 'Chapter 2; Rehabilitation for Stroke Syndrome, 'Chapter 3; Rehabilitation for Return to the Society', and 'Chapter 4; Advanced Technique for Stroke Rehabilitation'. Both the adaptation and de novo development methods were used to develop this 2nd edition of CPG. The appraisal of foreign CPGs was performed using 'Korean appraisal of guidelines for research and evaluation II' (K-AGREE II); moreover, four CPGs from Scotland (2010), Austrailia (2010), USA (2010), Canada (2010) were chosen for adaptation. For de novo development, articles that were published following the latest foreign CPGs were searched from the database system, PubMed, Embase, and Cochrane library. Literatures were assessed in the aspect of subjects, study design, study results' consistency, language and application possibility in the Korean society. 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. GPP (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.

Motor Symptoms in Brain Stem Lesion

Palatal tremor and Kernohan-Woltman notch phenomenon are rare motor symptoms that can show up in patients with lesion in brain stem or cerebellum. Patients with palatal tremor accompany ataxia, internuclear ophthalmoplegia, dysphagia, dysarthria and Kernohan-Woltman notch phenomenon causes ipsilateral motor deficits. Although its rarity, these conditions exhibit unexpected symptoms as well as considerable disability, which can raise etiologic and prognostic concerns for rehabilitation team. These two motor symptoms are discussed in this review.

Videofluoroscopy-Guided Balloon Dilatation for the Opening Dysfunction of Upper Esophageal Sphincter by Postoperative Vagus Nerve Injury: A Report on Two Cases

Dysphagia secondary to peripheral cranial nerve injury originates from weak and uncoordinated contraction-relaxation of cricopharyngeal muscle. We report on two patients who suffered vagus nerve injury during surgery and showed sudden dysphagia by opening dysfunction of upper esophageal sphincter (UES). Videofluoroscopy-guided balloon dilatation of UES was performed. We confirmed an early improvement of the opening dysfunctions of UES, although other neurologic symptoms persisted. While we did not have a proper comparison of cases, the videofluoroscopy-guided balloon dilatation of UES is thought to be helpful for the early recovery of dysphagia caused by postoperative vagus nerve injury.

Reduction of Continuous Theta Burst Stimulation-Induced Motor Plasticity in Healthy Elderly With COMT Val158Met Polymorphism

OBJECTIVE: To delineate whether cortical plasticity induced by continuous theta burst stimulation (cTBS) differed according to catechol-O-methyltransferase (COMT) gene polymorphism in healthy older adults. METHODS: Eighteen healthy older volunteers (mean age 73.78+/-5.04; 12 females and 6 males) were recruited. Volunteers randomly assigned in either a sham-first or real cTBS first group participated in two separate TMS visits with at least a 2-day wash-out period. Genotyping was carried out at baseline by a separate researcher who was blinded. cTBS was delivered in a hot spot over M1 at an active motor threshold of 80%. Motor evoked potentials (MEPs) were obtained at 120% of the resting motor threshold before and after sham/cTBS. RESULTS: The relative MEP to baseline was significantly decreased 0 and 10 minutes post-stimulation and increased 40 minutes post-stimulation, as compared with the sham condition. Immediately after cTBS, the Val/Val group had a significantly reduced relative MEP value, as compared with the MET carrier group. CONCLUSION: In healthy older persons, cTBS-induced motor plasticity was reduced in the COMT Val/Val group as compared with the 158Met carrier group.

Dementia due to Meningovascular Syphilis in Medial Temporal Lobe and Cognitive Rehabilitation

The temporal lobe is essential in saving declarative memory and plays an important role along with the cerebral neocortex in creating and maintaining long-term memory. Damage to the temporal lobe is expected to result in cognitive impairment or dementia, which has characteristic symptoms such as cognitive and behavioral dysfunction and decreasing self-reliance in activities of daily living. We report on a patient, who suffered from dementia due to meningovascular syphilis affecting the medial temporal lobe, and on the outcome of cognitive rehabilitation.

Dementia due to Meningovascular Syphilis in Medial Temporal Lobe and Cognitive Rehabilitation

The temporal lobe is essential in saving declarative memory and plays an important role along with the cerebral neocortex in creating and maintaining long-term memory. Damage to the temporal lobe is expected to result in cognitive impairment or dementia, which has characteristic symptoms such as cognitive and behavioral dysfunction and decreasing self-reliance in activities of daily living. We report on a patient, who suffered from dementia due to meningovascular syphilis affecting the medial temporal lobe, and on the outcome of cognitive rehabilitation.

Effect of Premotor Cortex Stimulation on Motor Learning in Basal Ganglial Hemorrhage Patients

OBJECTIVE: To investigate the effects of high frequency (10 Hz) repetitive transcranial magnetic stimulation (rTMS) on visuospatial motor learning, stimulated on the premotor cortex in basal ganglia hemorrhage patients. METHOD: Nine patients were randomized to receive real and sham rTMS. We subdivided into two groups according to the integrity of the corticospinal tract measured by diffusion tensor tractography. The implicit visuospatial learning paradigm composed of numbers 1 to 4, in which 12 sequential numbers (2-3-1-4-3-2-4-1-3-4-2-1) were incorporated randomly. We obtained the mean fraction anisotrophy (FA) and apparent diffusion coefficient (ADC) values from the corticospinal tract and subdividing into two groups by calculating the relative value (laterality %). RESULTS: rTMS on the premotor cortex was effective only in simple motor learning but not in visuospatial learning in group analysis. The primary motor cortex excitability after the premotor cortex stimulation has been changed significantly. Subdividing into two groups according to the integrity of the corticospinal tract using the ADC value, the low ADC value group showed significant reduction of the visuospatial response time. CONCLUSION: High frequency rTMS on the premotor cortex was effective in simple motor learning and also in the group who maintained more integrity of the corticospinal tract in basal ganglia hemorrhage.

Multivalent Effect of Isokinetic Muscular Strengthening Exercise in Aged Persons

OBJECTIVE: To investigate the multivalent effects of isokinetic strengthening exercises in aged person. METHOD: Sixrteen physically active elderly men and women (age 64.40+/-3.66) were recruited. The subjects underwent a 12-week knee flexor/extensor isokinetic exercise program of concentric contractions at a velocity of 180 degrees/sec of the both knee twice a week for 12 weeks. Training was carried out on the isokinetic dynamometer. The subjects were evaluated with muscular strength at 90 degrees/sec, endurance at 180 degrees/sec, cardio-pulmonary function, balance, mood and life quality at baseline, 4-week, 8-week and 12-week. RESULTS: Six of 16 people gave up in the middle of the course, 10 people completed a muscle strengthening exercise program. Muscular strength, balance, mood and life quality improved. CONCLUSION: Isokinetic exercise of the knee joint muscle was carried out and showed the result of multivalent effect in old age. Therefore strengthening exercise in aged persons was thought to be provided for welfare policy of an aging society as well as personal health improvement.