Dae Heon Song

Characteristics of dysphagia in children with cerebral palsy, related to gross motor function.

ObjectiveThe aim of this study was to report the characteristics of dysphagia in children with cerebral palsy (CP), related to gross motor function. DesignVideofluoroscopic swallow study was performed in 29 children with CP, according to the manual of Logemann. Five questions about oromotor dysfunction were answered. Gross motor function level was classified by the Gross Motor Function Classification System Expanded and Revised. ResultsThe results of the videofluoroscopic swallowing studies showed that reduced lip closure, inadequate bolus formation, residue in the oral cavity, delayed triggering of pharyngeal swallow, reduced larynx elevation, coating on the pharyngeal wall, delayed pharyngeal transit time, multiple swallow, and aspiration were significantly more common in the severe group (Gross Motor Function Classification System Expanded and Revised IV or V). As for aspiration, 50% of the children with severe CP had problems, but only 14.3% of them with moderate (Gross Motor Function Classification System Expanded and Revised III) CP and none of them with mild CP had abnormalities. In addition, five of the seven aspiration cases occurred silently. ConclusionsThis study shows that dysphagia is closely related to gross motor function in children with CP. Silent aspiration was observed in the moderate to severe CP groups. Aspiration is an important cause of medical problems such as acute and chronic lung disease, and associated respiratory complications contribute significantly in increasing morbidity and mortality in these patient groups. Therefore, the authors suggest that early dysphagia evaluation including videofluoroscopic swallow study is necessary in managing feeding problems and may prevent chronic aspiration, malnutrition, and infections.

Botulinum toxin type A for neuropathic pain in patients with spinal cord injury.

To evaluate the analgesic effect of botulinum toxin type A (BTX‐A) on patients with spinal cord injury‐associated neuropathic pain.

Comparative Study of Biological Activity of Four Botulinum Toxin Type A Preparations in Mice

BACKGROUND Units of available botulinum toxin preparations are not interchangeable, and the dose‐conversion ratios between such preparations remain controversial. OBJECTIVE To compare the efficacy and safety of four botulinum toxin type A preparations. MATERIALS AND METHODS Murine gastrocnemius compound muscle action potentials (CMAPs) were recorded before and after injecting the four botulinum toxin preparations (onabotulinumtoxinA, abobotulinumtoxinA, new botulinum toxin, and incobotulinumtoxinA). RESULTS In all preparations, CMAP amplitudes decreased until 4 days after receiving the injection and then gradually recovered. On postinjection day 84, the amplitudes returned to baseline in all groups except the high‐dose groups. CMAP amplitude in the contralateral limb also decreased up to postinjection days 4 to 7 and then gradually returned to baseline by postinjection day 28. CONCLUSION The dose‐conversion ratio between onabotulinumtoxinA and abobotulinumtoxinA was determined to be 1:2.6; previous reports of 1:3 were considered too high. A dose‐conversion ratio between onabotulinumtoxinA and new botulinum toxin of 1:1 was deemed appropriate. OnabotulinumtoxinA and incobotulinumtoxinA demonstrated a dose‐conversion ratio of 1:1.07. The efficacy of incobotulinumtoxinA was slightly lower than that of onabotulinumtoxinA. These dose‐conversion ratios are applicable solely from an efficacy standpoint and not for safety. This study was conducted in mice, so it may not translate perfectly to human applications.

Efficacy and Safety of a New Botulinum Toxin Type A Free of Complexing Proteins

MT10107 is botulinum neurotoxin type A derived drug which utilizes the 150 kDa portion without complexing proteins and human serum albumin contents. To evaluate the efficacy and the safety of MT10107, it was compared with onabotulinumtoxinA in this double-blind, randomized controlled trial. Twenty-five healthy males received a randomly selected dose of MT10107 into the extensor digitorum brevis (EDB) muscle of one foot, and an equivalent dose of onabotulinumtoxinA (BOTOX) was injected into the contralateral EDB muscle. While efficacy of the administered substance was determined by measuring paretic effects on the EDB, the local spread of toxin effects was evaluated by the paretic effects on the nearby abductor hallucis (AH) and abductor digiti quinti (ADQ) muscles. Paretic effects were defined as the percentage of reduction of the compound muscle action potential (CMAP) amplitudes, measured at 14, 30, 90 days after the injection, compared to the baseline value. Intergroup (MT10107 and onabotulinumtoxinA) differences were not significant in the percentage reduction of the amplitudes in the EDB muscles. In this study, there was no significant difference in efficacy and safety between the two test drugs. MT10107 may be effective and safe as much as onabotulinumtoxinA to produce the desired paretic effect.

Determination of Injection Site in Flexor Digitorum Longus for Effective and Safe Botulinum Toxin Injection

Objective To determine the optimal injection site in the flexor digitorum longus (FDL) muscle for effective botulinum toxin injection. Methods Fourteen specimens from eight adult Korean cadavers were used in this study. The most proximal medial point of the tibia plateau was defined as the proximal reference point; the most distal tip of the medial malleolus was defined as the distal reference point. The distance of a line connecting the proximal and distal reference points was defined as the reference length. The X-coordinate was the distance from the proximal reference point to the intramuscular motor endpoint (IME), or motor entry point (MEP) on the reference line, and the Y-coordinate was the distance from the nearest point from MEP on the medial border of the tibia to the MEP. IME and MEP distances from the proximal reference point were evaluated using the raw value and the X-coordinate to reference length ratio was determined as a percentage. Results The majority of IMEs were located within 30%-60% of the reference length from the proximal reference point. The majority of the MEPs were located within 40%-60% of the reference length from the proximal reference point. Conclusion We recommend the anatomical site for a botulinum toxin injection in the FDL to be within a region 30%-60% of the reference length from the proximal reference point.

Management of Severe Bilateral Ptosis in a Patient With Midbrain Infarction: A Case Report

Ptosis could be caused by oculomotor nerve palsy in the midbrain infarction. Bilateral ptosis has been reported in several reports, which focused on clinical characteristics of midbrain infarction. Little research attention has been paid to the treatment of patients with bilateral ptosis in midbrain infarction. We experienced a case of severe bilateral ptosis occurring after midbrain infarction. The patient could not open her eyes, perform basic activities or achieve effective rehabilitation. Neurogenic ptosis can improved after the underlying cause is treated. However, in this case, bilateral ptosis was not improved after conservative care for 6 months and the patient remained limited in activities of daily living and mobility. Surgical correction of bilateral ptosis was done by the resection of both Mullers muscles. After surgical correction, the bilateral ptosis was much improved and the effect persisted for at least 6 months.

Anatomical localization of the motor entry point in the thyroarytenoid muscle.

Introduction: The aim of this study was to localize the motor entry point (MEP) of the thyroarytenoid muscle. Methods: Eight cadaver larynges were dissected. A virtual plane was used to represent the MEP in a coordinate (X/Y/Z) system. The inferior border of the thyroid cartilage was linked to the center of the anterior arc of the cricoid cartilage (the Y‐axis). The X‐axis was set perpendicular to the Y‐axis; the Z‐axis passed through the posterior border of the thyroid lamina from the height of the insertion point. Results: The mean X, Y, and Z coordinates were 6.2 mm, 9.1 mm, and 11.0 mm, respectively. The calculated angles of the lateral and superior deflections were 29.4° and 35.8°, respectively. The calculated insertion depth, that is, the distance from the insertion point to the MEP, was 15.6 mm. Conclusions: These results may help to improve the accuracy of needle insertion during diagnostic laryngeal electromyography or laryngeal electromyography‐guided injections. Muscle Nerve 51: 72–75, 2015

Anatomic localization of motor points of wrist flexors.

ObjectiveThe aim of this study was to determine the location of the motor points and the intramuscular branches of the wrist flexors in relation to bony landmarks. DesignSixteen limbs from eight adult cadavers were anatomically dissected. The motor branch points of the flexor carpi radialis and flexor carpi ulnaris muscles and the proximal limit points and the distal limit points in relation to a reference line connecting the medial epicondyle and the pisiform bone or one connecting the medial epicondyle and the base of the second metarcarpal bone were identified. ResultsFor the flexor carpi radialis muscles, the motor branch points were located at a distance of 27% ± 6% of the reference line, whereas the proximal limit points and the distal limit points were located at a distance of 21% ± 5% and 37% ± 8% of the reference line. For the flexor carpi ulnaris muscles, the corresponding data were 32% ± 8%, 23% ± 6%, and 43% ± 9%. ConclusionsThe results may assist in enhancing accuracy when localizing points for neuromuscular blockade of the wrist flexors. The optimal area for flexor carpi radialis muscle injection is at a quarter point and that for flexor carpi ulnaris muscle injection is at one-third point along each reference line from the medial epicondyle.

Intractable Abdominal Pain in a Patient With Spinal Cord Injury: A Case Report

Patients with spinal cord injury (SCI) may experience several types of chronic pains. Abdominal pain in patients with SCI has gained limited attention and little is yet known about its characteristics and mechanisms. It often has been regarded as visceral pain associated with constipation and distention. Neuropathic pains localized in the abdomen have rarely been reported. We experience a case of intractable abdominal pain in a patient with SCI, neither of visceral pathology nor of musculoskeletal origin. The nature of pain fulfilled the diagnostic criteria for neuropathic pains. The pain was therefore regarded as neuropathic and managed accordingly. The first- and second-line oral drugs available were being performed, unfortunately, adequate pain control was not achieved. We tried an intrathecal lidocaine injection as another treatment option, and the injection had considerable effects.

Accuracy of Ultrasound-Guided and Non-ultrasound-Guided Botulinum Toxin Injection Into Cadaver Salivary Glands

Objective To compare the accuracy of ultrasound (US)-guided and non-US-guided botulinum toxin (BTX) injection into the salivary glands (parotid and submandibular glands) of cadavers. Methods Two rehabilitation physician injected dye into three sites in the salivary glands (two sites in the parotid gland and one site in the submandibular gland) on one side of each cadaver (one was injected on the right side, while the other was injected on the left side), using either a non-US-guided injection procedure based on superficial landmarks or a US-guided procedure. Orange dye was used for the US-guided procedure, and green dye was used for the blind procedure. Two physicians uninvolved with the injection procedures and who were blinded to the method of injection dissected the cadavers to identify whether the dye was accurately injected into each target site. Results The accuracies of the blind and US-guided injections into the parotid gland were 79.17% and 95.83%, respectively. In the submandibular gland, the accuracies of the blind and US-guided injections were 50.00% and 91.67%, respectively. The difference in accuracy between the two procedures was statistically significant only in the submandibular gland (p=0.025). There were no significant differences in the accuracy of US-guided and non-US-guided injections between the two physicians for the two sites in the parotid gland (p=0.278 and p=0.146, respectively). Conclusion US-guided BTX injection into the submandibular gland offers significantly greater accuracy over blind injection. For the treatment of drooling by injecting BTX into the submandibular gland, clinicians should consider using US guidance for improved accuracy.