To compare the low frequency (1 Hz) repetitive transcranial magnetic stimulation (rTMS) with high frequency (20 Hz) rTMS on motor functional improvement of the affected upper extremity in subacute stroke patients.
Forty patients with subacute ischemic stroke participated in this study. The first group received 10 sessions of 20 Hz rTMS at ipsilesional M1 area and the other group received 10 sessions of 1 Hz rTMS at contralesional M1 area. Motor training of the hemiparetic hand was conducted after each rTMS train. All the patients received conventional occupational therapy immediately after each rTMS session. Manual function test (MFT), Fugl-Meyer Assessment scale (FMS), Modified Barthel Index (MBI), Brunnstrom recovery stage, and grip strength were used to assess motor function before, at the end of, and one month after the last session of rTMS.
No adverse side effects were reported during the course of the experiment using rTMS. No significant difference in motor function of the affected upper extremity was observed between the two groups before rTMS. Significant improvements in MFT, FMS, MBI, and Brunnstrom stage were observed in the both groups at the end of the last rTMS session and one month later (p<0.05). No significant difference was found between the two groups (p>0.05).
There was no significant difference in motor function of the affected upper extremity between 1 Hz and 20 Hz rTMS during the subacute period of ischemic stroke. Thus, we cannot conclude which has a greater effect.
Citations
To investigate the effect of low-frequency repetitive transcranial magnetic stimulation (rTMS) and neuromuscular electrical stimulation (NMES) on post-stroke dysphagia.
Subacute (<3 months), unilateral hemispheric stroke patients with dysphagia were randomly assigned to the conventional dysphagia therapy (CDT), rTMS, or NMES groups. In rTMS group, rTMS was performed at 100% resting motor threshold with 1 Hz frequency for 20 minutes per session (5 days per week for 2 weeks). In NMES group, electrical stimulation was applied to the anterior neck for 30 minutes per session (5 days per week for 2 weeks). All three groups were given conventional dysphagia therapy for 4 weeks. We evaluated the functional dysphagia scale (FDS), pharyngeal transit time (PTT), the penetration-aspiration scale (PAS), and the American Speech-Language Hearing Association National Outcomes Measurement System (ASHA NOMS) swallowing scale at baseline, after 2 weeks, and after 4 weeks.
Forty-seven patients completed the study; 15 in the CDT group, 14 in the rTMS group, and 18 in the NMES group. Mean changes in FDS and PAS for liquid during first 2 weeks in the rTMS and NMES groups were significantly higher than those in the CDT group, but no significant differences were found between the rTMS and NMES group. No significant difference in mean changes of FDS and PAS for semi-solid, PTT, and ASHA NOMS was observed among the three groups.
These results indicated that both low-frequency rTMS and NMES could induce early recovery from dysphagia; therefore, they both could be useful therapeutic options for dysphagic stroke patients.
Citations
Effectiveness of Neuromuscular Electrical Stimulation on Post-Stroke Dysphagia: A Systematic Review of Randomized Controlled Trials
To evaluate the effects of the implementation of critical pathway (CP) in stroke patients treated at a single university hospital.
A retrospective medical review collected data from 497 patients who had suffered acute stroke in the rehabilitation center. Stroke outcomes were compared between before and after the implementation of CP based on factors including demographic factors, stroke characteristics, pre-existing medical conditions, medical complications, functional states, and length of stay (LOS).
After the implementation of CP, the patients showed significantly higher stage for upper proximal (p=0.008) and lower extremity (p=0.001) on Brunnstrom stage and significantly lower scores for modified Rankin Scale (p=0.003) at transfer. For those with pre-existing medical conditions, there were significantly increased osteoarthritis (p=0.002) and valvular heart disease (p=0.011). Regarding medical complications during acute inpatient rehabilitation, there were significantly decreased shoulder pain (p=0.001) and dysphagia (p=0.017), and significantly increased gastrointestinal symptoms (p=0.001). Functional gain and efficiency of stroke patients during rehabilitation center hospitalization did not significantly change after implementation of CP. But, shorter LOS of total hospitalization, pre-rehabilitation center hospitalization, and rehabilitation center hospitalization were evident.
After the implementation of CP, patients less often developed complications and displayed no changes in functional gain and efficiency. They had shorter LOS of total hospitalization, pre-rehabilitation center hospitalization and rehabilitation center hospitalization.
Citations
To determine the cutoff value of the pharyngeal residue for predicting reduction of aspiration, by measuring the residue of valleculae and pyriformis sinuses through videofluoroscopic swallowing studies (VFSS) after treatment with neuromuscular electrical stimulator (VitalStim) in stroke patients with dysphagia.
VFSS was conducted on first-time stroke patients before and after the VitalStim therapy. The results were analyzed for comparison of the pharyngeal residue in the improved group and the non-improved group.
A total of 59 patients concluded the test, in which 42 patients improved well enough to change the dietary methods while 17 did not improve sufficiently. Remnant area to total area (R/T) ratios of the valleculae before treatment in the improved group were 0.120, 0.177, and 0.101 for solid, soft, and liquid foods, respectively, whereas the ratios for the non-improved group were 0.365, 0.396, and 0.281, respectively. The ratios of the pyriformis sinuses were 0.126, 0.159, and 0.121 for the improved group and 0.315, 0.338, and 0.244 for the non-improved group. The R/T ratios of valleculae and pyriformis sinus were significantly lower in the improved group than the non-improved group in all food types before treatment. The R/T ratio cutoff values were 0.267, 0.250, and 0.185 at valleculae and 0.228, 0.218, and 0.185 at pyriformis sinuses.
In dysphagia after stroke, less pharyngeal residue before treatment serves as a factor for predicting greater improvement after VitalStim treatment.
Citations
To determine whether cognitive function is associated with white matter hyperintensities (WMH) in patients with infratentorial stroke.
This was a retrospective, cross-sectional study. Twenty-four first-ever infratentorial stroke patients between 18 and 60 years of age were enrolled. WMH was evaluated by the Fazekas scale and the Scheltens scale. Cognitive functions were assessed using the Korean Mini-Mental Status Examination (K-MMSE), Rey-Osterrieth Complex Figure Test, and the Seoul Computerized Neuropsychological Test Battery (SCNT) at one month after stroke. All participants were divided into two groups based on the presence of WMH (no-WMH group and WMH group). General characteristics and cognitive functions were compared between the groups.
There were no significant differences in general characteristics, such as age, stroke type, hypertension history, and education level between the two groups. However, K-MMSE in the WMH group was significantly lower compared to the no-WMH group (p<0.05). The verbal learning test score in SCNT was significantly higher in the no-WMH group compared to the WMH group (p<0.05). Executive function in the no-WMH group tended to be higher compared to the WMH group.
Impairment of cognitive function in patients with infratentorial stroke appeared to be associated with WMH. WMH should be carefully evaluated during rehabilitation of infratentorial stroke patients.
Citations
To evaluate the cardiovascular response during head-out water immersion, underwater treadmill gait, and land treadmill gait in stroke patients.
Ten stroke patients were recruited for underwater and land treadmill gait sessions. Each session was 40 minutes long; 5 minutes for standing rest on land, 5 minutes for standing rest in water or on treadmill, 20 minutes for treadmill walking in water or on land, 5 minutes for standing rest in water or on treadmill, and 5 minutes for standing rest on land. Blood pressure (BP) and heart rate (HR) were measured during each session. In order to estimate the cardiovascular workload and myocardial oxygen demand, the rate pressure product (RPP) value was calculated by multiplying systolic BP (SBP) by HR.
SBP, DBP, mean BP (mBP), and RPP decreased significantly after water immersion, but HR was unchanged. During underwater and land treadmill gait, SBP, mBP, DBP, RPP, and HR increased. However, the mean maximum increases in BP, HR and RPP of underwater treadmill walking were significantly lower than that of land treadmill walking.
Stroke patients showed different cardiovascular responses during water immersion and underwater gait as opposed to standing and treadmill-walking on land. Water immersion and aquatic treadmill gait may reduce the workload of the cardiovascular system. This study suggested that underwater treadmill may be a safe and useful option for cardiovascular fitness and early ambulation in stroke rehabilitation.
Citations
To obtain information on the socioeconomic, medical, and functional status of polio survivors, and to use these results as the preliminary data for establishing the middle-aged cohort of polio survivors.
The subjects were recruited based on the medical records of multiple hospitals and centers. They were assessed through a structured questionnaire over the phone. Post-poliomyelitis syndrome (PPS) was identified according to the specified diagnostic criteria. Differences between polio survivors with or without PPS were evaluated, and the risk factors for PPS were analyzed by the odds ratio (OR).
Majority of polio survivors were middle-aged and mean age was 51.2±8.3 years. A total of 188 out of 313 polio survivors met the adopted criteria for PPS based on the symptoms, yielding a prevalence of 61.6%. Mean interval between acute poliomyelitis and the development of PPS was 38.5±11.6 years. Female gender (OR 1.82; confidence interval [CI] 1.09-3.06), the age at onset of poliomyelitis (OR 1.75; CI 1.05-2.94), the use of orthoses or walking aids (OR 2.46; CI 1.44-4.20), and the history of medical treatment for paralysis, pain or gait disturbance (OR 2.62; CI 1.52-4.51) represented independent risk factors for PPS.
We found that the majority of Korean polio survivors entered middle age with many medical, functional, and social problems. Female gender, early age of onset of poliomyelitis, the use of orthoses or walking aids, and the history of medical treatment for paralysis, pain or gait disturbance were identified as the significant risk factors for PPS. A comprehensive and multidisciplinary plan should be prepared to manage polio survivors considering their need for health care services and the risk factors for late effects, such as PPS.
Citations
To compare the effect of two different hand exercises on hand strength and vascular maturation in patients who underwent arteriovenous fistula surgery.
We recruited 18 patients who had chronic kidney disease and had undergone arteriovenous fistula surgery for hemodialysis. After the surgery, 10 subjects performed hand-squeezing exercise with GD Grip, and other 8 subjects used Soft Ball. The subjects continued the exercises for 4 weeks. The hand grip strength, pinch strength (tip, palmar and lateral pinch), and forearm circumference of the subjects were assessed before and after the hand-squeezing exercise. The cephalic vein size, blood flow velocity and volume were also measured by ultrasonography in the operated limb.
All of the 3 types of pinch strengths, grip strength, and forearm circumference were significantly increased in the group using GD Grip. Cephalic vein size and blood flow volume were also significantly increased. However, blood flow velocity showed no difference after the exercise. The group using Soft Ball showed a significant increase in the tip and lateral pinch strength and forearm circumference. The cephalic vein size and blood flow volume were also significantly increased. On comparing the effect of the two different hand exercises, hand-squeezing exercise with GD Grip had a significantly better effect on the tip and palmar pinch strength than hand-squeezing exercise with Soft Ball. The effect on cephalic vein size was not significantly different between the two groups.
The results showed that hand squeezing exercise with GD Grip was more effective in increasing the tip and palmar pinch strength compared to hand squeezing exercise with soft ball.
Citations
To delineate whether cortical plasticity induced by continuous theta burst stimulation (cTBS) differed according to catechol-O-methyltransferase (
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.
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.
In healthy older persons, cTBS-induced motor plasticity was reduced in the COMT Val/Val group as compared with the 158Met carrier group.
Citations
To evaluate the clinical utility of the electrically calculated quantitative pain degree (QPD) and to correlate it with subjective assessments of pain degree including a visual analogue scale (VAS) and the McGill Pain Questionnaire (MPQ).
We recruited 25 patients with low back pain. Of them, 21 patients suffered from low back pain for more than 3 months. The QPD was calculated using the PainVision (PV, PS-2100; Nipro Co., Osaka, Japan). We applied electrodes to the medial forearm of the subjects and the electrical stimulus was amplified sequentially. Minimum perceived current (MPC) and pain equivalent current (PEC) were defined as minimum electrical stimulation that could be sensed by the subject and electrical stimulation that could trigger actual pain itself. To eliminate individual differences, we defined QPD as the following: QPD=PEC-MPC/MPC. We scored pre-treatment QPD three times at admission and post-treatment QPD once at discharge. The VAS, MPQ, and QPD were evaluated and correlations between the scales were analyzed.
Result showed significant test-retest reliability (ICC=0.967, p<0.001) and the correlation between QDP and MPQ was significant (at admission SRCC=0.619 and p=0.001; at discharge SRCC=0.628, p=0.001). However, the correlation between QPD and VAS was not significant (at admission SRCC=0.240, p=0.248; at discharge SRCC=0.289, p=0.161).
Numerical values measured with PV showed consistent results with repeated calculations. Electrically measured QPD showed an excellent correlation with MPQ but not with VAS. These results demonstrate that PV is a significantly reliable device for quantifying the intensity of low back pain.
Citations
To assess the efficacy of trigger point injection into brachialis muscle for rotator cuff disease patients with upper arm pain.
A prospective, randomized, and single-blinded clinical pilot trial was performed at university rehabilitation hospital. Twenty-one patients clinically diagnosed with rotator cuff disease suspected of having brachialis myofascial pain syndrome (MPS) were randomly allocated into two groups. Effect of ultrasound (US)-guided trigger point injection (n=11) and oral non-steroidal anti-inflammatory drug (NSAID) (n=10) was compared by visual analog scale (VAS).
US-guided trigger point injection of brachialis muscle resulted in excellent outcome compared to the oral NSAID group. Mean VAS scores decreased significantly after 2 weeks of treatment compared to the baseline in both groups (7.3 vs. 4.5 in the injection group and 7.4 vs. 5.9 in the oral group). The decrease of the VAS score caused by injection (ДVAS=-2.8) was significantly larger than caused by oral NSAID (ДVAS=-1.5) (p<0.05).
In patients with rotator cuff disease, US-guided trigger point injection of the brachialis muscle is safe and effective for both diagnosis and treatment when the cause of pain is suspected to be originated from the muscle.
Citations
To evaluate the analgesic effect of intrathecal gabapentin therapy on secondary hyperalgesia in a rat model of persistent muscle pain.
Intrathecal catheters were implanted into rats. Mechanical secondary hyperalgesia was induced by repeated intramuscular injections of acidic solution into the gastrocnemius muscle. Gabapentin was administrated intrathecally. Rats were allocated to control and experimental (gabapentin 30, 100, 300, and 1,000 µg) group. After gabapentin administration, mechanical withdrawal threshold was measured every 15 minutes and the motor function was measured 30 minutes later.
Mechanical hyperalgesia was evoked after the second acidic buffer injection. There was a significant improvement on the mechanical threshold after administration of 100, 300, and 1,000 µg gabapentin compared to pre-injection and the control group. The analgesic effect continued for 105, 135, and 210 minutes, respectively. To discern side effects, motor function was measured. Motor function was preserved in both groups after gabapentin administration, except for rats who received 1,000 µg gabapentin.
Intrathecal gabapentin administration produces dose-dependent improvements in mechanical hyperalgesia in a persistent muscle pain rat model. This implicates the central nervous system as having a strong influence on the development of persistent mechanical hyperalgesia. These results are helpful in understanding the pathophysiology of secondary hyperalgesia and in the treatment of patients with chronic muscle pain.
Citations
Occipital condyle fractures (OCFs) with selective involvement of the hypoglossal canal are rare. OCFs usually occur after major trauma and combine multiple fractures. We describe a 38-year-old man who presented with neck pain and a tongue deviation to the right side after a traffic accident. Severe limitations were detected during active and passive range of neck motion in all directions. A physical examination revealed a normal gag reflex and normal mobility of the palate, larynx, and shoulder girdle. He had normal taste and general sensation in his tongue. However, he presented with a tongue deviation to the right side on protrusion. A videofluoroscopic swallowing study revealed piecemeal deglutition due to decreased tongue mobility but no aspiration of food. Plain X-ray film findings were negative, but a computed tomography study with coronal reconstruction demonstrated a right OCF involving the hypoglossal canal. An electrodiagnostic study revealed evidence of right hypoglossal nerve palsy. We report a rare case of isolated hypoglossal nerve palsy caused by an OCF.
Citations
Holmes' tremor is a low-frequency rest and intentional tremor secondary to various insults, including cerebral ischemia, hemorrhage, trauma, or neoplasm. Pharmacologic treatment is usually unsuccessful, and some cases require surgical intervention. We report a rare case of Holmes' tremor secondary to left pontine hemorrhage in a 29-year-old Asian male patient who developed 1.6-Hz postural and rest tremor of the right hand. He responded markedly to ultrasonography-guided botulinum toxin type A injection. To our knowledge, this is the first report of Homes' tremor treated with ultrasonography-guided botulinum toxin type A injection with favorable results.
Citations
Cerebral venous sinus thrombosis (CVST) is an uncommon cause of cerebral infarction, compared to arterial diseases. It is often unrecognized at initial presentation due to the diversity of causes and clinical manifestations. A 29-year-old female patient complained of severe headache and presented at the emergency room with altered consciousness. Brain computed tomography and brain magnetic resonance image revealed the left sigmoid sinus thrombosis with venous hemorrhagic infarction (VHI) in the left temporal lobe. The patient had no past medical and family history of bleeding diathesis. The laboratory finding at the admission showed severe iron-deficiency anemia (IDA), and protein C and S activities were decreased. After the neurosurgery, iron replacement, and neurorehabilitation, the patient had a good recovery. There has been no known recurrence. We report our therapeutic intervention on a very rare case of CVST and VHI, with IDA as a probable cause of cerebral thrombosis.
Citations
Central pontine myelinolysis (CPM) classically occurs in alcoholics, malnourished individuals, chronic liver diseases, and rapid correction of hyponatremia. This report presents locked-in syndrome due to CPM following rapid correction of hyponatremia. A 44-year-old male came to the hospital due to a short period of loss of consciousness. He was alert and had no focal neurological abnormalities at admission. The serum sodium concentration was 118 mEq/L and was corrected to 134 mEq/L in the first 18 hours. One week later, progressive weakness in limbs developed and he progressed to a complete quadriplegic state and bulbar palsy, with only eye blinking preserved. Brain magnetic resonance imaging revealed a characteristic hyperintense signal abnormality in both pons, so he was diagnosed to locked-in syndrome caused by CPM. The patient gradually improved following continuous intensive rehabilitation for more than 2 years. He was able to move all joint muscles against gravity in generally and he could gait under supervision.
Citations
A 3-year-old girl had multiple anomalies compatible with Treacher Collins Syndrome (TCS). From the neonatal period, sucking was poor, making tube feeding necessary. Excessive saliva was retained in the oral cavity. Nasal leakage caused by the cleft palate was observed when she spoke. The initial videofluoroscopic swallow study (VFSS) showed a poor posterior bolus transit and nasopharyngeal regurgitation. A delayed swallow reflex and bolus stasis at the vallecular and pyriform sinuses were recognized. Based on the VFSS findings, the patient underwent palatoplasty at 20 months of age. At approximately 23 months of age, a follow-up VFSS was performed; poor posterior bolus transit, nasopharyngeal regurgitation, and delayed swallow reflex were not observed. Finally, the patient was able to eat ground or chopped foods and solid foods orally. We deem VFSS to be helpful in deciding the appropriate management of dysphagia in TCS.
Citations
Congenital muscular torticollis (CMT) and craniosynostosis are diseases that cause plagiocephaly and craniofacial asymmetry in children. In our literature review, we did not find any report of concurrent manifestation of CMT and craniosynostosis. A 41-month-old boy visited our hospital with left torticollis, right laterocollis, and craniofacial asymmetry as the main findings. During clinical examination, prominent right sternocleidomastoid muscle and limited range of motion of the neck were noted, and right CMT was confirmed by magnetic resonance imaging of the neck. Three-dimensional computed tomography of the skull, which was conducted due to the unusual appearance of the skull with a large head circumference, mild brachycephaly, as well as left plagiocephaly, revealed premature closure of the sagittal suture. Thus, we report the first case that showed concurrence of CMT and sagittal synostosis. We recommend that concurrently manifested craniosynostosis needs to be examined if the subject with CMT displays unusual craniofacial asymmetry to a greater extent than deformational plagiocephaly.
Citations
First
Prev
