Heeyoune Jung

The Cervical Range of Motion as a Factor Affecting Outcome in Patients With Congenital Muscular Torticollis

Objective To investigate the factors affecting rehabilitation outcomes in children with congenital muscular torticollis (CMT). Methods We retrospectively reviewed the medical records of 347 patients who were clinically suspected as having CMT and performed neck ultrasonography to measure sternocleidomastoid (SCM) muscle thickness. Fifty-four patients met the inclusion criteria. Included were demographic characteristics as well as measurements of cervical range of motion (ROM), SCM muscle thickness, and the abnormal/normal (A/N) ratio, defined as the ratio of SCM muscle thickness on the affected to the unaffected side. Results Subjects were divided into three groups depending on degree of cervical ROM (group 1A: ROM>60, n=12; group 1B: 60≥ROM>30, n=31; group 1C: ROM≤30, n=11), the SCM muscle thickness (Th) (group 2A: Th<1.2 cm, n=23; group 2B: 1.2≤Th<1.4 cm, n=18; group 2C: Th≥1.4 cm, n=13), and the A/N ratio (R) (group 3A: R<2.2, n=19; group 3B: 2.2≤R<2.8, n=20; group 3C: R≥2.8, n=15). We found that more limited cervical ROM corresponded to longer treatment duration. The average treatment duration was 4.55 months in group 1A, 5.87 months in group 1B, and 6.50 months in group 1C. SCM muscle thickness and the A/N ratio were not correlated with treatment duration. Conclusion Infants with CMT who were diagnosed earlier and had an earlier intervention had a shorter duration of rehabilitation. Initial cervical ROM is an important prognostic factor for predicting the rehabilitation outcome of patients with CMT.

Effects of Extracorporeal Shock Wave Therapy on Spasticity in Patients after Brain Injury: A Meta-analysis.

[Purpose] The purpose of this meta-analysis was to assess the effects of extracorporeal shock wave therapy (ESWT) on reducing spasticity immediately and 4 weeks after application of ESWT. [Subjects and Methods] We searched PubMed, TCL, Embase, and Scopus from their inception dates through June 2013. The key words “muscle hypertonia OR spasticity” were used for spasticity, and the key words “shock wave OR ESWT” were used for ESWT. Five studies were ultimately included in the meta-analysis. [Results] The Modified Ashworth Scale (MAS) grade was significantly improved immediately after ESWT compared with the baseline values (standardized mean difference [SMD], −0.792; 95% confidence interval [CI], −1.001 to −0.583). The MAS grade at four weeks after ESWT was also significantly improved compared with the baseline values (SMD, −0.735; 95% CI, −0.951 to −0.519). [Conclusion] ESWT has a significant effect on improving spasticity. Further standardization of treatment protocols including treatment intervals and intensities needs to be established and long-term follow up studies are needed.

Usefulness of the Scale for the Assessment and Rating of Ataxia (SARA) in Ataxic Stroke Patients.

Objective To examine the usefulness of the Scale for the Assessment and Rating of Ataxia (SARA) in ataxic stroke patients. Method This was a retrospective study of 54 patients following their first ataxic stroke. The data used in the analysis comprised ambulation status on admission and scores on the SARA, the Korean version of the Modified Barthel Index (K-MBI) and the Berg Balance Scale (BBS). The subjects were divided into four groups by gait status and into five groups by level of dependency in activities of daily living (ADLs) based on their K-MBI scores. Data were subjected to a ROC curve analysis to obtain cutoff values on the SARA for individual gait status and levels of activity dependency. The correlations between the SARA, K-MBI and BBS scores were also computed. Results There was significant correlation between the SARA and the K-MBI scores (p<0.001), and this correlation (r=-0.792) was higher than that found between the BBS and the K-MBI scores (r=0.710). The SARA scores of upper extremity ataxia categories were significantly related to the K-MBI scores of upper extremity related function (p<0.001). The SARA scores were also significantly correlated negatively with ambulation status (p<0.001) and positively with ADL dependency (p<0.001). In the ROC analysis, patients with less than 5.5 points on the SARA had minimal dependency in ADL, while those with more than 23 points showed total dependency. Conclusion SARA corresponds well with gait status and ADL dependency in ataxic stroke patients and is considered to be a useful functional measure in that patient group.

The Relation between Postvoid Residual and Occurrence of Urinary Tract Infection after Stroke in Rehabilitation Unit.

Objective To determine the relation between postvoid residual (PVR) and the occurrence of urinary tract infection (UTI) in stroke patients. Method One hundred and eighty-eight stroke patients who were admitted to an inpatient rehabilitation unit and who did not have UTI on admission (105 males, 83 females, mean age 67.1 years) were included in this study. The PVR was measured 3 times within 72 hours after admission. Mean PVR, demographic variables, K-MMSE (Korean Mini-Mental State Examination), initial K-MBI (Korean Modified Barthel Index), Foley catheter indwelling time and stroke type were defined and the relation to the occurrence of UTI was analyzed. Results UTI occurred in 74 patients (39.4%) during admission to the rehabilitation unit. There were significant differences between the UTI and non-UTI groups in K-MMSE, K-MBI, Foley catheter indwelling time (p<0.01). However, age, gender, stroke location and type were not associated. The occurrence of UTI was 4.87 times higher in the patients with a mean PVR over 100 ml than in those with a mean PVR <100 ml. The mean PVR was 106.5 ml in the UTI group, while it was 62.7 ml in the non-UTI group (p<0.01). PVR was not associated with age. Conclusion The UTI rate is higher when the mean PVR is over 100 ml irrespective of gender and age. Close monitoring of PVR and appropriate intervention is needed to reduce the occurrence of UTI in stroke patients.

Korean Version of the Scale for the Assessment and Rating of Ataxia in Ataxic Stroke Patients

Objective To investigate the intra-rater and inter-rater reliability and usefulness of the Korean version of the Scale for the Assessment and Rating of Ataxia (K-SARA) in ataxic stroke patients. Methods The original SARA was translated into Korean, back translated to English, and compared to the original version. Stroke patients (n=60) with ataxia were evaluated using the K-SARA by one physiatrist and one occupational therapist. All subjects were rated twice. We divided the subjects into 5 groups by Functional Ambulation Category (FAC) and 3 groups based on the ataxia subscale of the National Institutes of Health Stroke Scale (NIHSS). The mean K-SARA scores representing each group of FAC and the ataxia subscale of NIHSS were compared. Results The test-retest correlation coefficient of the K-SARA was 0.997 by the therapist and 1.00 by the physiatrist (p<0.001). The inter-rater correlation coefficient of the K-SARA was 0.985 (p<0.001). The ataxia subscale of NIHSS did not correlate with K-SARA. There was a significant difference in the mean K-SARA score by FAC (p<0.001). Conclusion K-SARA is a reliable and valid measure of ataxia in stroke patients in Korea.

Use of videofluoroscopic swallowing study in patients with aspiration pneumonia.

Objective To investigate the clinical characteristics of dysphagic elderly Korean patients diagnosed with aspiration pneumonia as well as to examine the necessity of performing a videofluoroscopic swallowing study (VFSS) in order to confirm the presence of dysphagia in such patients. Method The medical records of dysphagic elderly Korean subjects diagnosed with aspiration pneumonia were retrospectively reviewed for demographic and clinical characteristics as well as for VFSS findings. Results In total, medical records of 105 elderly patients (81 men and 24 women) were reviewed in this study. Of the 105 patients, 82.9% (n=87) were admitted via the emergency department, and 41.0% (n=43) were confined to a bed. Eighty percent (n=84) of the 105 patients were diagnosed with brain disorders, and 68.6% (n=72) involved more than one systemic disease, such as diabetes mellitus, cancers, chronic cardiopulmonary disorders, chronic renal disorders, and chronic liver disorders. Only 66.7% (n=70) of the 105 patients underwent VFSS, all of which showed abnormal findings during the oral or pharyngeal phase, or both. Conclusion In this study, among 105 dysphagic elderly patients with aspiration pneumonia, only 66.7% (n=70) underwent VFSS in order to confirm the presence of dysphagia. As observed in this study, the evaluation of dysphagia is essential in order to consider elderly patients with aspiration pneumonia, particularly in patients with poor functional status, brain disorders, or more than one systemic disease. A greater awareness of dysphagia in the elderly, as well as the diagnostic procedures thereof, particularly VFSS, is needed among medical professionals in Korea.

Can MRI Findings Help to Predict Neurological Recovery in Paraplegics With Thoracolumbar Fracture

Objective To evaluate the usefulness of various magnetic resonance imaging (MRI) findings in the prognosis of neurological recovery in paraplegics with thoracolumbar fracture using association analysis with clinical outcomes and electrodiagnostic features. Methods This retrospective study involved 30 patients treated for paraplegia following thoracolumbar fracture. On axial and sagittal T2-weighted MRI scans, nerve root sedimentation sign, root aggregation sign, and signal intensity changes in the conus medullaris were independently assessed by two raters. A positive sedimentation sign was defined as the absence of nerve root sedimentation. The root aggregation sign was defined as the presence of root aggregation in at least one axial MRI scan. Clinical outcomes including the American Spinal Injury Association impairment scale, ambulatory capacity, and electrodiagnostic features were used for association analysis. Results Inter-rater reliability of the nerve root sedimentation sign and the root aggregation sign were κ=0.67 (p=0.001) and κ=0.78 (p<0.001), respectively. A positive sedimentation sign was significantly associated with recovery of ambulatory capacity after a rehabilitation program (χ2=4.854, p=0.028). The presence of the root aggregation sign was associated with reduced compound muscle action potential amplitude of common peroneal and tibial nerves in nerve conduction studies (χ2=5.026, p=0.025). Conclusion A positive sedimentation sign was significantly associated with recovery of ambulatory capacity and not indicative of persistent paralysis. The root aggregation sign suggested the existence of significant cauda equina injuries.

Hepatic Encephalopathy With Corticospinal Tract Involvement Demonstrated by Diffusion Tensor Tractography

A 50-year-old man with liver cirrhosis and esophageal varix for 3 years was diagnosed with hematemesis and treated for a bleeding varix. However, bleeding recurred 11 days later, and he developed drowsiness with left hemiparesis. His left upper and lower extremity muscle strengths based on the manual muscle test at the onset were grade 2/5 and 1/5, respectively. The Babinski sign was positive. His serum ammonia level was elevated to 129.9 µg/dL (normal, 20-80 µg/dL). Magnetic resonance imaging revealed restriction on diffusion and T2-hyperintensities with decreased apparent diffusion coefficient values in the bilateral frontoparietooccipital cortex. The effect was more severe in the right hemisphere and right parietooccipital cortices, which were compatible with hepatic encephalopathy. Although the patients mental status recovered, significant left-sided weakness and sensory deficit persisted even after 6 months. Diffusion tensor tractography (DTT) performed 3 months post-onset showed decreased volume of the right corticospinal tract. We reported a patient with hepatic encephalopathy involving the corticospinal tract by DTT.

Retrograde Degeneration in the Corticospinal Tract Following Pontine Stroke

high-frequency stepping gait training program within the intensities defined. Stepping data indicated that subjects received an average daily stepping dosage of 2000-8000 steps per day, well above previously reported values. Conclusions: It is possible to implement a high-intensity, highfrequency stepping gait training program within an acute inpatient rehabilitation setting for the stroke population. However, future research concerning therapy intensity and frequency of stepping should be designed with a larger sample size.

Hepatic Encephalopathy Involving Corticospinal Tract Presented With Hemiparesis Resembling Acute Stroke: Case Report

Disclosures: L. C. Issac, No Disclosures: I Have Nothing To Disclose. Case Description: A 39-year-old man developed acute weakness in all of his limbs shortly after immersing himself in a hot-tub while vacationing in Florida. He was initially diagnosed with Guillain Barre Syndrome (GBS) and received intravenous immunoglobulin and steroids, and plasmapharesis, with minimal improvement. He was transferred to a comprehensive inpatient spinal cord injury (SCI) rehabilitation facility in his home state, where examination showed a sixth cervical level (C6)American Spinal Association Impairment Scale (AIS) B incomplete tetraplegic SCI with impaired pinprick sensation below this level that didnot followadistal-proximal pattern. Light touch and proprioception were intact. He also had significant hyperreflexia. Setting: Freestanding rehabilitation hospital. Results or Clinical Course: The findings favored spinal cord infarction. Computed tomography angiogram and echocardiograms were negative for an embolic source. Repeat cervical spine magnetic resonance imaging revealed abnormal enhancement in the anterior spinal cord spanning C4 through the second thoracic (T2) level; interval decreased signal enhancement with internal volume loss suggested myelomalacia. Therefore, he was diagnosed with an anterior spinal cord infarction of unknown etiology. After 8 weeks of rehabilitation, his exam improved to C6 AIS C, with trace right knee extension and ankle plantarflexion. He attained independence with power wheelchair mobility and performed upper body dressing with minimal assistance, but required maximal assistance for lower body activities of daily living and transfers. He was discharged home with home therapies. Discussion: Anterior spinal cord infarction uncommonly occurs in the cervical region and without a clear etiology. This unusual case demonstrates the importance of careful neurological examination and recognition of exam findings associated with various spinal cord conditions. Conclusions: Spinal cord infarction can occur in the cervical region and diagnosis may be delayed when an ischemic source cannot be identified.