Han Gil Seo

Effect of Focal Muscle Vibration on Calf Muscle Spasticity: A Proof-of-Concept Study

Focal vibration has been studied for its ability to reduce spasticity in patients with upper motor neuron lesions, but adequate stimulation parameters remain unclear. Focal muscle vibration with adequate parameters may facilitate gait rehabilitation in patients with lower limb spasticity.

Efficacy and safety of NABOTA in post-stroke upper limb spasticity: a phase 3 multicenter, double-blinded, randomized controlled trial.

Botulinum toxin A is widely used in the clinics to reduce spasticity and improve upper limb function for post-stroke patients. Efficacy and safety of a new botulinum toxin type A, NABOTA (DWP450) in post-stroke upper limb spasticity was evaluated in comparison with Botox (onabotulinum toxin A). A total of 197 patients with post-stroke upper limb spasticity were included in this study and randomly assigned to NABOTA group (n=99) or Botox group (n=98). Wrist flexors with modified Ashworth Scale (MAS) grade 2 or greater, and elbow flexors, thumb flexors and finger flexors with MAS 1 or greater were injected with either drug. The primary outcome was the change of wrist flexor MAS between baseline and 4weeks post-injection. MAS of each injected muscle, Disability Assessment Scale (DAS), and Caregiver Burden Scale were also assessed at baseline and 4, 8, and 12weeks after the injection. Global Assessment Scale (GAS) was evaluated on the last visit at 12weeks. The change of MAS for wrist flexor between baseline and 4weeks post-injection was -1.44±0.72 in the NABOTA group and -1.46±0.77 in the Botox group. The difference of change between both groups was 0.0129 (95% confidence interval -0.2062-0.2319), within the non-inferiority margin of 0.45. Both groups showed significant improvements regarding MAS of all injected muscles, DAS, and Caregiver Burden Scale at all follow-up periods. There were no significant differences in all secondary outcome measures between the two groups. NABOTA demonstrated non-inferior efficacy and safety for improving upper limb spasticity in stroke patients compared to Botox.

Effortful swallow enhances vertical hyolaryngeal movement and prolongs duration after maximal excursion

Effortful swallowing (EFS) is a common compensatory swallowing manoeuver for dysphagia patients. We investigated the influence of EFS on temporal and spatial characteristics of the movements of the hyoid bone, larynx and epiglottis in healthy subjects. A total of 41 volunteers swallowed 10 mL of diluted barium solution using two swallowing strategies: usual and effortful swallowing (USS and EFS). The motions of the hyoid bone, larynx and epiglottis were tracked using frame-by-frame kinematic motion analysis of videofluoroscopic images. Maximal velocities and maximal displacements of hyoid and larynx, the maximal angle of the epiglottic tilt, and the durations of hyoid excursion, laryngeal elevation and epiglottic tilt were measured. Compared to USS, EFS was associated with significantly greater vertical displacement of the hyoid (P < 0.001), vertical and horizontal displacement of the larynx (P = 0.003, P = 0.019), and maximal angle of the epiglottic tilt (P = 0.001). In addition, the durations of the vertical and horizontal excursions of the hyoid, vertical excursion of the larynx and the epiglottic tilt were greater in EFS, compared with USS. Effortful swallowing was also associated with significantly greater maximum velocities of the hyoid and larynx during swallowing. In conclusion, the EFS manoeuver facilitates vertical speed and distance of hyolaryngeal excursion and epiglottic tilt and extends the duration of excursion and the epiglottic tilt, especially after reaching maximal excursion in healthy subjects. These results confirm the temporal and kinematic benefits of airway protection induced by the EFS manoeuver.

Neuronox versus BOTOX in the Treatment of Post-Stroke Upper Limb Spasticity: A Multicenter Randomized Controlled Trial.

Background Botulinum toxin type A is widely used for treating spasticity. Neuronox (Neu-BoNT/A), a newly manufactured botulinum toxin a, has not yet been investigated for its efficacy and safety in the treatment of post-stroke upper limb spasticity. Objective We evaluated the efficacy and safety of Neuronox (Neu-BoNT/A) compared with BOTOX (onabotulinum toxin A) for treating post-stroke upper limb spasticity. Methods In total, 196 stroke patients with moderate to severe upper limb spasticity were randomly assigned to either Neuronox or BOTOX intervention. The wrist flexors were mandatory and elbow, finger, and thumb flexors were optional muscles to be injected. Assessments were performed at baseline and 4, 8, and 12 weeks after the intervention. The primary outcome measure was the change from baseline of the Modified Ashworth Scale (MAS) at the wrist flexors at week 4. Secondary outcome measures included the change of MAS at each visit, response rate, Disability Assessment Scale (DAS), Carer Burden Scale, and Global Assessment of treatment benefit. Results Primary outcome measures were -1.39±0.79 and -1.56±0.81 in the Neuronox and BOTOX groups, respectively. The difference was within the noninferiority margin of 0.45 (95% upper limit=0.40). There were no significant differences between the groups in the secondary outcome and safety measures, except the change of the MAS at the elbow flexors at week 12 (-0.88±0.75 in the Neuronox group, -0.65±0.74 in the BOTOX group; P=0.0429). Both groups showed significant improvements in the MAS, DAS, and Carer Burden Scale at weeks 4, 8, and 12. Conclusion Neuronox showed equivalent efficacy and safety compared with BOTOX for treating post-stroke upper limb spasticity. Trial Registration ClinicalTrials.gov NCT01313767

Robotic Mirror Therapy System for Functional Recovery of Hemiplegic Arms.

Mirror therapy has been performed as effective occupational therapy in a clinical setting for functional recovery of a hemiplegic arm after stroke. It is conducted by eliciting an illusion through use of a mirror as if the hemiplegic arm is moving in real-time while moving the healthy arm. It can facilitate brain neuroplasticity through activation of the sensorimotor cortex. However, conventional mirror therapy has a critical limitation in that the hemiplegic arm is not actually moving. Thus, we developed a real-time 2-axis mirror robot system as a simple add-on module for conventional mirror therapy using a closed feedback mechanism, which enables real-time movement of the hemiplegic arm. We used 3 Attitude and Heading Reference System sensors, 2 brushless DC motors for elbow and wrist joints, and exoskeletal frames. In a feasibility study on 6 healthy subjects, robotic mirror therapy was safe and feasible. We further selected tasks useful for activities of daily living training through feedback from rehabilitation doctors. A chronic stroke patient showed improvement in the Fugl-Meyer assessment scale and elbow flexor spasticity after a 2-week application of the mirror robot system. Robotic mirror therapy may enhance proprioceptive input to the sensory cortex, which is considered to be important in neuroplasticity and functional recovery of hemiplegic arms. The mirror robot system presented herein can be easily developed and utilized effectively to advance occupational therapy.

Clinical Characteristics Associated With Aspiration or Penetration in Children With Swallowing Problem

Objective To evaluate demographic characteristics of children with suspected dysphagia who underwent videofluoroscopic swallowing study (VFSS) and to identify factors related to penetration or aspiration. Methods Medical records of 352 children (197 boys, 155 girls) with suspected dysphagia who were referred for VFSS were reviewed retrospectively. Clinical characteristics and VFSS findings were analyzed using univariate and multivariate analyses. Results Almost half of the subjects (n=175, 49%) were under 24 months of age with 62 subjects (18%) born prematurely. The most common condition associated with suspected dysphagia was central nervous system (CNS) disease. Seizure was the most common CNS disorder in children of 6 months old or younger. Brain tumor was the most important one for school-age children. Aspiration symptoms or signs were the major cause of referral for VFSS in children except for infants of 6 months old or where half of the subjects showed poor oral intake. Penetration or aspiration was observed in 206 of 352 children (59%). Subjects under two years of age who were born prematurely at less than 34 weeks of gestation were significantly (p=0.026) more likely to show penetration or aspiration. Subjects with congenital disorder with swallow-related anatomical abnormalities had a higher percentage of penetration or aspiration with marginal statistical significance (p=0.074). Multivariate logistic regression analysis revealed that age under 24 months and an unclear etiology for dysphagia were factors associated with penetration or aspiration. Conclusion Subjects with dysphagia in age group under 24 months with preterm history and unclear etiology for dysphagia may require VFSS. The most common condition associated with dysphagia in children was CNS disease.

Kinematic Changes in Swallowing After Surgical Removal of Anterior Cervical Osteophyte Causing Dysphagia: A Case Series

This retrospective case series included five patients who underwent surgical resection of the cervical anterior osteophyte due to dysphagia. Videofluoroscopic swallowing studies (VFSSs) were performed before and after surgery on each patient, and kinematic analysis of the video clips from the VFSS of a 5-mL liquid barium swallow was carried out. Functional oral intake improved after surgery in 3/4 patients who had required a modified diet before surgery. Kinematic analysis showed increases in the maximal hyoid vertical movement length (13.16±5.87 to 19.09±4.77 mm, p=0.080), hyoid movement velocities (170.24±84.71 to 285.53±104.55 mm/s, p=0.043), and upper esophageal sphincter opening width (3.97±0.42 to 6.39±1.32 mm, p=0.043) after surgery. In conclusion, improved upper esophageal sphincter opening via enhancement of hyoid movement after cervical anterior osteophyte resection may be the kinetic mechanism of improved swallowing function.

Robotic-assisted gait training combined with transcranial direct current stimulation in chronic stroke patients: A pilot double-blind, randomized controlled trial

BACKGROUND Although robotic-assisted gait training (RAGT) is becoming a standard method in stroke rehabilitation, its effect on chronic stroke patients is uncertain. OBJECTIVE This study aimed to investigate whether anodal transcranial direct current stimulation (tDCS) enhances the effect of RAGT on functional ambulation in chronic stroke patients. METHODS Chronic hemiplegic stroke patients with a Functional Ambulatory Category (FAC) score≤4 were randomly assigned to either the RAGT with anodal tDCS (Anodal) group the sham tDCS (Sham) group. The patients were provided with RAGT for 45 min after allocated tDCS on the leg motor cortex in the impaired hemisphere for 20 min every weekday for 2 weeks. The primary outcome measure was the FAC, and the secondary outcome measures included 10-m walking test, 6-min walking test, Berg Balance Scale, Fugl-Meyer assessment of the lower extremity, Medical Research Council Scale, and motor-evoked potential (MEP) parameters. They were evaluated before treatment (T0), immediately after treatment (T1), and 4 weeks after the end of treatment (T2). RESULTS Twenty-one patients were finally included. The percentage of participants who achieved improvement in the FAC score was greater in the Anodal group than in the Sham group, and the difference was significant at T2 (66.7% vs. 12.5%, p = 0.024). In secondary outcome measures, the Anodal group showed greater improvement in the 6-min walking test than the Sham group at T2 (56.49±38.87 vs. 23.59±17.00, p = 0.038). The changes in the MEP parameters were not significantly different between the two groups. CONCLUSION This pilot study suggested that anodal tDCS on the leg motor cortex in the impaired hemisphere may facilitate the effect of RAGT on functional ambulation in chronic stroke patients. Larger clinical trials will be needed to confirm the effect of RAGT combined with tDCS in chronic stroke patients based on the present study.

Computer-assisted detection of swallowing difficulty

To evaluate classification performance of a support vector machine (SVM) classifier for diagnosing swallowing difficulty based on the hyoid movement data attained from videofluoroscopic swallowing study, the hyoid kinematics during the swallowing of 2 mL of liquid barium solution were analyzed for 90 healthy volunteers and 116 dysphagic stroke patients. SVM was used to classify the kinematic results as normal or dysfunctional swallowing. Various kernel functions and kernel parameters were used for optimization. Features were selected to find an optimal feature subset and to minimize redundancy. Accuracy, sensitivity, specificity, and area under a receiving operating characteristic curve (AUC) were used to assess the discrimination performance. In 19 out of 26 features, mean comparison revealed a significant difference between healthy subjects and dysphagic patients. By reducing the number of features to 10, an AUC of 0.9269 could be reached. Common features showing the best classification in both kernel functions included forward maximum excursion time, upward maximum excursion time, maximum excursion length, upward maximum velocity time, upward maximum acceleration time, maximum acceleration, maximum acceleration time, and mean acceleration. SVM-based classification method with the use of kernel functions showed an outstanding (AUC of 0.9269) discrimination performance for either healthy or dysphagic hyoid movement during swallowing. We expect that this classification method will be useful as an adjunct diagnostic tool by providing automatic detection of swallowing dysfunction as well as a research tool providing deeper understanding of pathophysiology.

Robot-Assisted Gait Training in a Patient With Hereditary Spastic Paraplegia

Robot‐assisted gait training has been investigated for restoring walking through activity‐dependent neuroplasticity in persons with various neurologic disorders. This case report presents the outcome of robot‐assisted gait training combined with physiotherapy in a 28‐year‐old man with pure hereditary spastic paraplegia. The patient participated in 25 training sessions over 6 weeks. Improvements were noted in his walking speed and balance after the training, but gait kinematics and kinetics showed no remarkable changes before and after the training. Robot‐assisted gait training may be useful for providing intensive gait training in patients with hereditary spastic paraplegia because the patients walking speed and balance improved after the training.