Korean Database of Cerebral Palsy: A Report on Characteristics of Cerebral Palsy in South Korea.

OBJECTIVE: To introduce the Korean Database of Cerebral Palsy (KDCP) and to provide the first report on characteristics of subjects with cerebral palsy (CP). METHODS: The KDCP is a nationwide database of subjects with CP, which includes a total of 773 subjects. Characteristics such as demography, birth history, onset and type of CP, brain magnetic resonance imaging (MRI) findings, functional ability and accompanying impairments, were extracted and analyzed. RESULTS: Preterm delivery and low birth weight were found in 59.51% and 60.28% of subjects, respectively. Postnatally acquired CP was 15.3%. The distribution of CP was 87.32%, 5.17%, and 1.81% for spastic, dyskinetic, and ataxic types, respectively. Functional ability was the worst in dyskinetic CP, as compared to other types of CP. Speech-language disorder (43.9%), ophthalmologic impairment (32.9%), and intellectual disability (30.3%) were the three most common accompanying impairments. The number of accompanying impairments was elevated in subjects with preterm birth and low birth weight. Brain MRI showed normal findings, malformations, and non-malformations in 10.62%, 9.56%, and 77.35% of subjects, respectively. Subjects with normal MRI findings had better functional ability than subjects with other MRI findings. MRI findings of a non-malformation origin, such as periventricular leukomalacia, were more common in subjects with preterm birth and low birth weight. CONCLUSION: The KDCP and its first report are introduced in this report, wherein the KDCP established agreement on terminologies of CP. This study added information on the characteristics of subjects with CP in South Korea, which can now be compared to those of other countries and ethnicities.

The Effect of Nebulized Glycopyrrolate on Posterior Drooling in Patients with Brain Injury: Two Cases of Different Brain Lesions.

Posterior drooling, which can lead to substantial respiratory morbidity, including unexplained lung diseases and recurrent pneumonia, is an important issue in the rehabilitation unit. There are various treatment options for posterior drooling, including pharmacologic therapy, oral motor or behavioral therapy, biofeedback, local glandular injection of botulinum toxin, irradiation, and surgery. Among them, nebulized glycopyrrolate has the following advantages: It is noninvasive and is relatively free of central adverse effects because it does not cross the blood-brain barrier unlike other anticholinergics. Although there has been one case report regarding the effectiveness of nebulized glycopyrrolate for drooling in a motor neuron patient, there have not been any reports on its effectiveness for posterior drooling. Herein, we report two cases (an 82-year-old male bilateral hemiplegic stroke patient and a 1-year-old female cerebral palsy infant with bilaterally spastic hemiplegia of posterior drooling treated with nebulized glycopyrrolate) and identify salivary aspiration and the effect of nebulized glycopyrrolate using radionuclide salivagram. Considering its advantages and effectiveness, nebulized glycopyrrolate should be considered as one of the reliable methods to manage posterior drooling in patients with impaired cognition or swallowing difficulties, such as severe brain injury.

Clinical Usefulness of Sonoelastography in Infants With Congenital Muscular Torticollis.

OBJECTIVE: To evaluate the clinical usefulness of sonoelastography in infants with congenital muscular torticollis (CMT). METHODS: The medical records of 215 infants clinically diagnosed with CMT were retrospectively reviewed. Fifty-three infants met the inclusion criteria as follows: 1) infants diagnosed as CMT with a palpable neck mass before 3 months of age, 2) infants who were evaluated initially by both B-mode ultrasonography and sonoelastography, and 3) infants who had received physical therapy after being diagnosed with CMT. We checked the thickness of the sternocleidomastoid (SCM) muscles in B-mode ultrasonography, strain ratio of the SCM muscles in sonoelastography, and treatment duration. We evaluated the correlation between the treatment duration and the following factors: SCM muscle thickness, ratio of SCM muscle thickness on the affected to unaffected side (A/U ratio), and strain ratio. RESULTS: Both the thickness of the affected SCM muscle and the A/U ratio did not show significant correlation with the treatment duration (p=0.66, p=0.90). The strain ratio of the affected SCM muscle was significantly greater than that of the unaffected SCM muscle (p<0.001), and the strain ratio showed significant correlation with the treatment duration (p=0.001). CONCLUSION: Sonoelastography may be a useful adjunctive tool to B-mode ultrasonography for evaluating infants with CMT, especially when predicting their rehabilitation outcomes.

Effects of repeated steroid injection at subacromial bursa with different interval.

OBJECTIVE: To evaluate the effects of repeated steroid injection at subacromial bursa with different interval for patient with periarticular shoulder disorder. METHODS: Group A (n=10) received subacromial bursa injection only on their first visit, group C (n=10) received the injection on their first visit and one week later, and group B (n=10) received the injection on their first visit and two weeks later. All injections were done with a combination of 40 mg (1.0 mL) of triamcinolone and 5.0 mL 0.5% lidocaine (6 mL total). We examined the active range of motion (AROM) of the shoulder joint, visual analogue scale (VAS), and shoulder disability questionnaire (SDQ) at baseline at 1, 2, and 4 weeks after the initial injection. RESULTS: In VAS, comparing the changes in VAS between groups, group B showed significant improvements compared with group A or C at 4 weeks after the initial injection (p<0.05). In SDQ, comparing the changes in SDQ between the groups, group B and C showed more improvement than group A at 4 weeks after the initial injection, but these results were not statistically significant (p>0.05). In AROM, comparing the changes in AROM of external rotation between groups, group B and C showed significant improvement compared with group A at 4 weeks after the initial injection (p<0.05). CONCLUSION: It may be more effective in pain relief for patients with periarticular disorder to receive subacromial bursa injections twice with 2-week interval, as opposed to once.

Effects of subacromial bursa injection with corticosteroid and hyaluronidase according to dosage.

OBJECTIVE: To evaluate effects of subacromial bursa injection with steroid according to dosage and to investigate whether hyaluronidase can reduce steroid dosage. METHODS: Thirty patients with periarticular shoulder disorder were assigned to receive subacromial bursa injection once a week for two consecutive weeks. Ten patients (group A) underwent subacromial bursa injection with triamcinolone 20 mg; another group of ten patients (group B) with hyaluronidase 1,500 IU and triamcinolone 20 mg; and the other ten patients (group C) with triamcinolone 40 mg. We examined the active range of motion (AROM) of the shoulder joint, visual analogue scale (VAS), and shoulder disability questionnaire (SDQ) at study entry and every week until 1 week after the 2nd injection. RESULTS: All groups showed statistically significant improvements in VAS after 1st and 2nd injections. When comparing the degree of improvement in VAS, there were statistically significant differences between groups C and A or B, but not between groups A and B. SDQ was statistically significantly improved only in groups B and C, as compared to pre-injection. There were statistically significant differences in improvement of SDQ after the 2nd injection between groups C and A or B. Statistically significant improvements in AROM were shown in abduction (groups B and C) and in flexion (group C only). CONCLUSION: Repeated high-dose (40 mg) steroid injection was more effective in terms of pain relief and functional improvements of shoulder joint than medium-dose (20 mg) steroid injection in periarticular disorder. Hyaluronidase seems to have little additive effect on subacromial bursa injection for reducing the dosage of steroid.

Therapeutic benefit of repetitive transcranial magnetic stimulation for severe mirror movements: A case report.

Congenital mirror movements retard typical hand functions, but no definite therapeutic modality is available to treat such movements. We report an 8-year-old boy with severe mirror movements of both hands. His mirror movements were assessed using the Woods and Teuber grading scale and his fine motor skills were also evaluated by the Purdue Pegboard Test. A 2-week regimen of repetitive transcranial magnetic stimulation produced markedly diminished mirror movement symptoms and increased the fine motor skills of both hands. Two weeks after the completion of the regimen, mirror movement grades had improved from grade 4 to 1 in both hands and the Purdue Pegboard Test results of the right and left hands also improved from 12 to 14 or 13. These improvements were maintained for 1 month after the 2-week repetitive transcranial magnetic stimulation regimen. After 18 months, the mirror movement grade was maintained and the Purdue Pegboard test score had improved to 15 for the right hand while the left hand score was maintained at 13. This occurred without any additional repetitive transcranial magnetic stimulation or other treatment. These findings suggest that repetitive transcranial magnetic stimulation for this patient had a therapeutic and long-term effect on mirror movements.

The additive effects of hyaluronidase in subacromial bursa injections administered to patients with peri-articular shoulder disorder.

OBJECTIVE: To evaluate the additive effects of hyaluronidase combined with steroids in patients with peri-articular shoulder disorder. METHOD: Thirty patients with peri-articular shoulder disorder were given subacromial bursa injections once a week for three consecutive weeks. Fifteen patients (Group A) underwent subacromial bursa injections with hyaluronidase 1,500 IU, triamcinolone 40 mg and 0.5% lidocaine (total 6 ml). Another fifteen patients (Group B) underwent the same injections with triamcinolone 40 mg and 0.5% lidocaine (total 6 ml). We examined the active range of motion (AROM) in the shoulder, used a visual analogue scale (VAS) for measurement, and administered a shoulder disability questionnaire (SDQ) at the commencement of the study and then every week until one week after the third injection. RESULTS: There were no significant difference between group A and B before the injections took place (p>0.05). Statistically significant improvement was seen in the VAS, SDQ, and AROM of flexion, abduction, internal rotation at one week after the first and second injections compared with the parameters measured at previous visits in both groups (p<0.05), except the SDQ between one week after the first and second injections in group B (p>0.05). Improvement in all parameters measured at one week after the third injection compared with the measurement values at one week after the second injection were not statistically significant in both groups (p>0.05). However, group A (the hyaluronidase group) showed significantly greater improvements than group B in terms of their SDQ and AROM of internal rotation scores one week after the three injections had taken place (p<0.05). CONCLUSION: Peri-articular shoulder disorder patients who underwent subacromial bursa injections using hyaluronidase and steroids showed greater functional improvements than those who were given only steroid injections.

Effect of botulinum toxin type a on morphology of salivary glands in patients with cerebral palsy.

OBJECTIVE: To investigate the effect of botulinum toxin type A (BTXA) on drooling and the morphologic change of the salivary gland in patients with cerebral palsy. METHOD: Eight cerebral palsy patients suffering from severe drooling participated in this study. BTXA was injected into both submandibular and parotid glands under intravenous sedation and with ultrasound guidance (1 unit/gland/kg: maximum 100 units) in an outpatient or inpatient procedure. The severity of drooling was measured before injection and 3 weeks after injection using the Teacher Drooling Scale, the Drooling Score-severity, frequency and the Visual Analog Scale. To investigate the morphologic change of the salivary glands, the size of salivary glands were measured before injection and 3 weeks after injection using computed tomography of the neck. The measurement values were analyzed by Wilcoxon signed rank test. RESULTS: Statistically significant improvements were shown in all three parameters for assessing the severity of drooling after BTXA injections (p<0.05). Size of the salivary glands were significantly decreased at 3 weeks after BTXA injection (p<0.05). CONCLUSION: Salivary gland injection with BTXA could be a useful treatment method to reduce drooling in patients with cerebral palsy and decreased size of salivary glands may partially explain the mechanism.

Subacromial Bursa Injection of Hyaluronate with Steroid in Patients with Peri-articular Shoulder Disorders.

OBJECTIVE: To investigate the additive effect of sono-guided subacromial bursa injection of hyaluronate with steroid in patients with peri-articular shoulder disorders. METHOD: This prospective randomized controlled trial involved 26 patients who had shoulder pain. Group A, consisting of 13 patients, was treated with a sono-guided subacromial bursa injection containing a mixture of 0.5% lidocaine (5 ml) and triamcinolone 40 mg (1 ml), followed by injection with sodium hyaluronate (2 ml) once a week for 3 weeks. The other 13 patients (Group B) were treated with a sono-guided subacromial bursa injection containing a mixture of 0.5% lidocaine (5 ml) and triamcinolone 40 mg (1 ml) once a week for 3 weeks. The effects were assessed using a visual analogue scale (VAS) of shoulder pain, active range of motion (AROM), shoulder function assessment scale (SFA), shoulder disability questionnaire (SDQ) at study entry and every week from first injection until 4 weeks after the 1(st) injection (= 2 weeks after 3(rd) injection). RESULTS: (1) Demographic features and all parameters measured before injection did not show a significant difference between the 2 groups. (2) Statistically significant improvements were shown in VAS, SFA, SDQ during the 1(st), 2(nd), and 4(th) week after the first injection in both groups (p<0.05). (3) SFA showed significant improvement at 1 week after injection only in group A (p<0.05). (4) AROM of internal rotation showed significant improvement at week 4 after the 1(st) injection only in group A (p<0.05). CONCLUSION: Subacromial bursa injection of hyaluronate with steroid in patients with peri-articular shoulder disorders has additive effects on functional improvement of the affected shoulder, including the AROM of internal rotation.

Effect and appropriate restriction period of constraint-induced movement therapy in hemiparetic patients with brain injury: a brief report.

OBJECTIVE: To investigate the effect on fine motor ability and the appropriate restriction period of constraint-induced movement therapy in hemiparetic patients with brain injury. DESIGN: Nine chronic hemiparetic patients with brain injury were studied. After confirming the cessation of further recovery of fine motor ability by Purdue pegboard test and motor function by the Medical Research Council for three consecutive weeks, the affected hand was restricted with an opposition restriction orthosis. The fine motor ability of the affected hand was assessed weekly using Purdue pegboard test and the orthosis was taken off when the Purdue pegboard score showed no further increase over three consecutive weeks. RESULTS: Purdue pegboard score increased in all patients. The mean post-treatment Purdue pegboard score (10.7) was significantly increased over that of pre-treatment (8.7) (p < 0.05). The mean restriction period was 3.6 weeks (range, 2 to 5 weeks). CONCLUSION: Constraint-induced movement therapy is an effective therapeutic method to improve the fine motor ability of the hemiparetic hand of brain-injured patients. It can be assumed that the appropriate restriction period is best decided individually, on a case by case basis, according to the time that maximizes the hand function of the affected hand.

Alcohol neurolysis of tibial nerve motor branches to the gastrocnemius muscle to treat ankle spasticity in patients with hemiplegic stroke.

OBJECTIVE: To evaluate the effectiveness of alcohol neurolysis of tibial nerve motor branches to the gastrocnemius muscle for the treatment of ankle plantarflexor spasticity in patients with hemiplegic stroke. DESIGN: Case series. SETTING: Inpatient and outpatient clinics in the rehabilitation department of a university hospital. PARTICIPANTS: Twenty-two patients with hemiplegic stroke (mean age, 48y). INTERVENTIONS: Motor branch block (MBB) of the tibial nerve to the gastrocnemius muscle with 50% ethyl alcohol in cases of spastic ankle. MAIN OUTCOME MEASURES: The severity of spasticity was assessed using the Modified Ashworth Scale (MAS) score of ankle plantarflexor, clonus score of the ankle, and the passive range of motion (PROM) of ankle dorsiflexion. RESULTS: The MAS score was reduced in 17 (77%) of 22 patients during the 6-month follow-up, and spasticity reappeared at the level of the pre-MBB state in 5 patients (23%). The mean values of all parameters were significantly improved. The changes of mean values from the pre-MBB to the 6-month post-MBB stage were as follows: MAS score, 3.3+/-0.7 versus 1.7+/-1.1; clonus score, 1.6+/-0.7 versus 0.4+/-0.8; and PROM, 17.1 degrees +/-13.0 degrees versus 28.6 degrees +/-4.7 degrees. No serious complications were observed during the 6-month follow-up period. CONCLUSIONS: MBB of the tibial nerve to the gastrocnemius muscle is an effective and safe procedure for relieving localized spasticity of the ankle plantarflexors.

Diffusion tensor magnetic resonance imaging of microstructural abnormalities in children with brain injury.

We present two pediatric cases demonstrating that diffusion tensor imaging is more efficient at revealing microstructural abnormalities of the brain than conventional magnetic resonance imaging because it enables measurements of the directionality and integrity of white matter fiber tracts. One patient suffered from left hemiparesis, and the other had right hemiparesis. However, whereas conventional magnetic resonance imaging showed only the findings of traumatic contusional hemorrhages in the left temporal and parietal lobes of the first patient and focal encephalomalacia in the left anterior thalamus of the second patient, diffusion tensor imaging successfully disclosed microstructural abnormalities in the right cerebral peduncle of the midbrain of the first patient and in the posterior limb of the left internal capsule of the second. Theses two cases demonstrate that diffusion tensor imaging is more capable than magnetic resonance imaging at detecting the microstructural pathologic lesions that are responsible for clinical motor weakness, especially when conventional magnetic resonance imaging has failed to detect subtle structural abnormalities.