Han Young Jung

The Relative Contributions of the Medial Sural and Peroneal Communicating Nerves to the Sural Nerve

The medial sural cutaneous nerve (MSCN) and peroneal communicating nerve (PCN) conjoin in the calf area to form the sural nerve (SN). In previous anatomic studies, there was unresolved debate as to the main contributor to the sural nerve, and the relative contributions of MSCN and PCN had not been studied. The purpose of this study is to determine their relative neurophysiologic contributions to the SN by nerve conduction study (NCS). A total of 47 healthy subjects (25 males and 22 females, mean age 29.6 ± 10.4 yrs, range 20-59 yrs) participated in the study. This study employed the orthodromic nerve conduction technique: stimulation at the ankle and recording at the mid calf (SN); specifically, we preformed stimulation at the mid calf (MSCN, PCN) and recording at 14 cm proximal to the middle of the popliteal fossa (MSCN) and fibular head (PCN). The onset and peak latencies (ms) were SN 2.3 ± 0.2 and 3.0 ± 0.2; MSCN 2.1 ± 0.2 and 2.8 ± 0.2; and PCN 2.1 ± 0.2 and 2.8 ± 0.2. The peak-to-peak amplitudes (µV) and areas (nVsec) of the SN, MSCN, and PCN were 9.7 ± 3.9, 7.0 ± 4.7, and 5.0 ± 3.2; and 7.2 ± 2.9, 5.7 ± 3.4, and 4.0 ± 2.4, respectively. The side-to-side difference was not statistically significant. The main contributor to the SN was found to be the MSCN. The relative contribution ratio of the MSCN to the PCN was 1.37:1 by amplitude and 1.42:1 by area. However, in 32.9% of the subjects, the contribution of the PCN was greater than that of the MSCN.

Flumazenil does not affect intracortical motor excitability in humans: a transcranial magnetic stimulation study

OBJECTIVE The motor cortex may be subject to tonic inhibitory drive. One inhibitory mechanism is supported by activity at benzodiazepine (BZP) receptors. In this study we investigate whether or not the BZP antagonist, flumazenil, increases cortical motor excitability in humans. METHODS Eight healthy subjects received a 1 mg intravenous (i.v.) loading dose of flumazenil followed by a 0.5 mg i.v. infusion over the next 30 min. Before, during, and 1 h after flumazenil infusion, we measured cortical motor excitability using transcranial magnetic stimulation (TMS). This included resting motor threshold (rMT), paired-pulse measurements of intracortical inhibition and facilitation (ICI and ICF), recruitment curve (RC), and silent period (SP). We also measured F response and compound muscle action potential (CMAP) with peripheral nerve stimulation. The study was carried out using a randomized, double-blind crossover design controlled with a saline infusion. RESULTS None of the measures of cortical or peripheral excitability were significantly affected by drug administration. CONCLUSIONS Our findings suggest that flumazenil has no effect on cortical motor excitability in normal humans. SIGNIFICANCE There does not appear to be any tonic activity at benzodiazepine receptors in the normal resting human motor cortex.

Forgotten Denture in a Hemiplegic Patient

ABSTRACTA 74-yr-old man developed left hemiplegia because of a right middle cerebral artery territory infarction and also had clinical features of dysphagia and speech difficulty. At that time, he complained of neck pain, but the symptom was ignored because he had a nasogastric tube and had been diagnosed with a huge epiglottic cyst that had already shown several symptoms such as severe hoarseness and throat discomfort. A videofluoroscopic swallowing study was planned to find out the cause and the type of dysphagia. On the videofluoroscopic swallowing study, a foreign body was found at the hypopharynx. Surprisingly, it was confirmed as a denture. After removing the denture, the patient’s swallowing and speech difficulty were significantly improved. This case emphasizes the need for elderly stoke patients presenting with dysphagia or communication problems to receive more careful history taking and a more complete physical examination, with the cooperation of several clinical departments.

Korean Brain Rehabilitation Registry for Rehabilitation of Persons with Brain Disorders: Annual Report in 2009

This first annual report provides a description of patients discharged from rehabilitation facilities in Korea based on secondary data analysis of Korean Brain Rehabilitation Registry V1.0 subscribed in 2009. The analysis included 1,697 records of patients with brain disorders including stroke, traumatic brain injury, brain tumor and other disorders from 24 rehabilitation facilities across Korea. The data comprised 1,380 cases of stroke, 104 cases of brain injury, 55 cases of brain tumor, and 58 cases of other brain diseases. The functional status of each patient was measured using the Korean version of the Modified Barthel Index (KMBI). The average change in the KMBI score was 15.9 for all patients in the inpatient rehabilitation facility. The average length of stay for inpatient rehabilitation was 36.9 days. The transfer rates to other hospitals were high, being 62.4% when all patients were considered. Patients with brain disorders of Korea in 2009 and measurable functional improvement was observed in patients. However, relatively high percentages of patients were not discharged to the community after inpatient rehabilitation. Based on the results of this study, consecutive reports of the status of rehabilitation need to be conducted in order to provide useful information to many practitioners.

Effects of Night Sleep on Motor Learning Using Transcranial Magnetic Stimulation

Objective To investigate the effects of night sleep on motor cortical excitability with TMS (transcranial magnetic stimulation) and finger tapping performance. Method Eight volunteers were enrolled to investigate the effects of day wake or night sleep on motor learning and finger performance. Each subject underwent a finger tapping task over a 12 hour period, which was employed to evaluate the motor cortical excitability affected by motor learning. Starting at 9:00 am for the day wake cycle and restarting at 9:00 pm for the night sleep cycle. The finger tapping task was the index finger of the non-dominant hand with the Hangul word personal computer (PC) training program. The data was assessed by comparing the changes observed with the cortical excitability and finger tapping performance tests between the day wake and night sleep after equivalent amounts of training. Results The results showed that in paired-pulse techniques, there was a significant decrease of intracortical inhibition (ICI) in the morning following the night sleep cycle (p<0.05), but no significant change was seen in the ICI in the evening for the day wake cycle. In addition a significant decrease of the ICI was observed in comparison to the morning following the night sleep cycle and the evening following the day wake cycle (p<0.05). The 140% recruitment curve (RC) and accuracy of the finger tapping performance demonstrated a significant improvement for both cycles (p<0.05). Conclusion Through this study, we observed that the Hangul typing practice requires both explicit and implicit skill learning. And also the off-line learning during a night of sleep may be affected by an inhibitory neurotransmitter related synaptic plasticity and by the time dependent learning with recruitments of remote or less excitable motor neurons in the primary motor cortex.

The associations between insomnia and health-related quality of life in rehabilitation units at 1 month after stroke

OBJECTIVE The principal objective of this study was to investigate the relationship between insomnia and health-related quality of life (HRQoL) during the early stage of stroke rehabilitation. METHODS The subjects were 214 first-time stroke patients admitted to a rehabilitation unit at one of three Korean hospitals. Within 7days after stroke, functions were evaluated using; the Berg Balance Scale, the Modified Barthel Index, the Mini Mental State Examination, the Frontal Assessment Battery, Screening Tests for Aphasia and Neurologic-Communication Disorders, and the National Institute of Health Stroke Scale. Insomnia, depression, anxiety, and HRQoL were investigated at one month after stroke. Insomnia was defined as presence of at least one of the four following; difficulty initiating sleep, difficulty maintaining sleep, early morning awakening, and non-restorative sleep. HRQoL was assessed using the Short Form Health survey SF-8. Depression and anxiety were measured using the Hospital Anxiety Depression Scale. Multivariate linear regression analysis was conducted to examine the association between insomnia and HRQoL. RESULTS The prevalence of insomnia at one month after stroke was 59.5%. Patients with insomnia were more likely to be older and female and to have depression and anxiety. Patients with insomnia had poorer physical and mental HRQoL. By multivariate analyses, physical HRQoL was significantly associated with type of stroke, hypnotic usage, balancing function, and insomnia. Mental HRQoL was significantly associated with balancing function, depression, and insomnia. CONCLUSION Insomnia was found to be negatively associated with physical and mental HRQoL in stroke patients during the early stage of rehabilitation.

Monitoring of Functioning Status in Subjects With Chronic Stroke in South Korea Using WHODAS II.

Objective To follow up the long-term functioning in a community through assessing personal background and status based on the International Classification of Functioning, Disability and Health (ICF) after a stroke, by using a Korean version of World Health Organization Disability Assessment Scale II (K-WHODAS II). Methods We surveyed 146 patients diagnosed at the first-onset of acute stroke and discharged after Inha University Hospital, and 101 patients answered the K-WHODAS II survey. We analyzed the relationship of six functioning domains of K-WHODAS II with K-MMSE (Korean version of Mini-Mental State Examination) and K-MBI (Korean version of Modified Barthel Index) at admission and discharge, and personal background. All subjects were divided into five groups, according to the disease durations, to assess the functional changes and the differences of K-MMSE and K-MBI at the admission and discharge. Results K-MBI and K-MMSE at admission and discharge showed no significant differences in all five groups, respectively (p>0.05), reflecting no baseline disparity for long-term follow-up. All subjects showed positive gains of K-MBI and K-MMSE at discharge (p<0.05). The six functioning domains and total scores of K-WHODAS II had decreasing trends until 3 years after the stroke onset, but rose thereafter. Higher scores of K-MBI and K-MMSE, younger age, women, working status, higher educational level, and living with a partner were correlated with lower scores of K-WHODAS II (p<0.05). Conclusion The long-term functioning after stroke was affected not only by cognitive and motor status in hospital, but also by certain kinds of personal background. K-WHODAS II may be used to monitor functioning status in a community and to assess personal backgrounds in subjects with chronic stroke.

Successful Conservative Treatment: Multiple Atypical Fractures in Osteoporotic Patients After Bisphosphate Medication

AbstractBisphosphonates have been commonly used for the treatment of osteoporosis. However, there have been recent case reports of atypical fractures citing their long-term use, which inhibits the turnover of bone components.A 64-year-old woman visited the outpatient clinic with pain in her right thigh and ambulation difficulty. We found fractures at both pedicles of L4 vertebra. subtrochanteric region of right femur, and left femoral shaft upon a radiologic examination. She had taken intravenous ibandronic sodium for osteoporosis over 3 years.We changed the bishophonates to a parathyroid hormone because it was suspected that the multiple fractures were caused by the medication. Further, rehabilitation, including progressive weight bearing, was started. After 3 months of the conservative treatment, she was able to walk independently.In conclusion, it is necessary to evaluate the possibility of atypical fractures in osteoporotic patients when they complain of lower extremity pain and to consider alternative treatments instead of bisphosphonates.

Inpatient stroke rehabilitation outcomes in Korea derived from the Korean Brain Rehabilitation Centers' online database system for the years 2007 to 2011.

The purpose of this report was to provide information for patients receiving inpatient rehabilitation after stroke and to identify the possible factors influencing functional outcome after inpatient rehabilitation. Stroke patients (n = 5,212) who were discharged from the Departments of Rehabilitation Medicine (RM) of university hospitals and rehabilitation hospitals from 2007 through 2011 were participants. Prevalence, age, transfer time after onset, length of stay (LOS), functional status at admission and discharge were analyzed. In all stroke subjects, cerebral infarctions (67%) were more common than hemorrhages. Cerebral infarctions in the middle cerebral artery territory were most common, while the basal ganglia and cerebral cortex were the most common areas for hemorrhagic stroke. The LOS decreased from 45 to 28 days. Transfer time after onset decreased from 44 to 30 days. Shorter transfer time after onset was correlated with better discharge functional status and shorter LOS. Initial functional status was correlated with discharge functional status. In ischemic stroke subtypes, cerebellar and brainstem strokes predicted better outcomes, while strokes with more than one territory predicted poorer outcomes with more disabilities. In hemorrhagic stroke subtypes, initial and discharge functional status was the lowest for cortical hemorrhages and highest for brainstem hemorrhages. This report shows that LOS and transfer time after onset has been decreased over time and initial functional status and shorter transfer after onset are predictors of better functional outcome at discharge.

Absent median somatosensory evoked potential is a predictor of type I complex regional pain syndrome after stroke

Abstract Purpose: The objective was to determine whether the abnormal finding of somatosensory evoked potentials (SEPs) associated with the development of type I complex regional pain syndrome (CRPS) after stroke. Methods: This was a retrospective study conducted from January, 2003, to December, 2007. Seventy patients were confirmed as CRPS type I, and one hundred and eighty-two patients were assigned to the control group. The initial clinical data were reviewed including age, gender, main type of stroke, lateralization and location of the lesion, presence of glenohumeral subluxation, and the development of CRPS. Somatosensory evoked potentials tests (SEP) in median nerve (N20) and posterior tibial nerve (P37) were performed. Results: CRPS groups revealed significantly higher incidence of the absent and abnormal hemiplegic median SEP, hemorrhagic stroke, and glenohumeral subluxation (GHS). Binary logistic regression analysis indicated that GHS (exp.(B) = 4.083, p < 0.01) with the absent median SEP (exp.(B) = 3.246, p < 0.01) were significant independent predictors of CRPS onset. Conclusions: In conclusion, GHS and the absent median SEP at sub-acute phase of stroke were primary predictors of the onset of post-stoke CRPS. Implications for Rehabilitation Recent investigations have suggested that autonomic, motor and somatosensory abnormalities of CRPS are impairments involving the central nervous system (CNS) as well as the peripheral neurogenic inflammatory process. However, the understanding of the pathophysiology of CRPS is still far from complete. The absence of SEP at the sub-acute stage of stroke correlated with the onset of post-stroke CRPS type I. The SEP evaluation at the sub-acute period after stroke might be generally used for predicting the concomitant development of post-stroke CRPS type I as well as functional recovery after stroke.