Kyung-Lim Joa

Evaluation of the brain activation induced by functional electrical stimulation and voluntary contraction using functional magnetic resonance imaging

BackgroundTo observe brain activation induced by functional electrical stimulation, voluntary contraction, and the combination of both using functional magnetic resonance imaging (fMRI).MethodsNineteen healthy young men were enrolled in the study. We employed a typical block design that consisted of three sessions: voluntary contraction only, functional electrical stimulation (FES)-induced wrist extension, and finally simultaneous voluntary and FES-induced movement. MRI acquisition was performed on a 3.0 T MR system. To investigate activation in each session, one-sample t-tests were performed after correcting for false discovery rate (FDR; p < 0.05). To compare FES-induced movement and combined contraction, a two-sample t-test was performed using a contrast map (p < 0.01).ResultsIn the voluntary contraction alone condition, brain activation was observed in the contralateral primary motor cortex (MI), thalamus, bilateral supplementary motor area (SMA), primary sensory cortex (SI), secondary somatosensory motor cortex (SII), caudate, and cerebellum (mainly ipsilateral). During FES-induced wrist movement, brain activation was observed in the contralateral MI, SI, SMA, thalamus, ipsilateral SII, and cerebellum. During FES-induced movement combined with voluntary contraction, brain activation was found in the contralateral MI, anterior cingulate cortex (ACC), SMA, ipsilateral cerebellum, bilateral SII, and SI.The activated brain regions (number of voxels) of the MI, SI, cerebellum, and SMA were largest during voluntary contraction alone and smallest during FES alone. SII-activated brain regions were largest during voluntary contraction combined with FES and smallest during FES contraction alone. The brain activation extent (maximum t score) of the MI, SI, and SII was largest during voluntary contraction alone and smallest during FES alone. The brain activation extent of the cerebellum and SMA during voluntary contraction alone was similar during FES combined with voluntary contraction; however, cerebellum and SMA activation during FES movement alone was smaller than that of voluntary contraction alone or voluntary contraction combined with FES. Between FES movement alone and combined contraction, activated regions and extent due to combined contraction was significantly higher than that of FES movement alone in the ipsilateral cerebellum and the contralateral MI and SI.ConclusionsVoluntary contraction combined with FES may be more effective for brain activation than FES-only movements for rehabilitation therapy. In addition, voluntary effort is the most important factor in the therapeutic process.

The Correlation between Modified Ashworth Scale and Biceps T-reflex and Inter-rater and Intra-rater Reliability of Biceps T-reflex.

Objective To establish a correlation between the modified Ashworth scale (MAS) and amplitude and latency of T-reflex and to demonstrate inter-rater and intra-rater reliability of the T-reflex of the biceps muscle for assessing spasticity after stroke. Method A total of 21 patients with hemiplegia and spasticity after ischemic stroke were enrolled for this study. The spasticity of biceps muscle was evaluated by an occupational therapist using the MAS. The mean value of manual muscle test of biceps muscles was 2.3±0.79. Latency and amplitude of T-reflex were recorded from biceps muscles by two physicians. The onset latency and peak to peak amplitude of the mean of 5 big T-reflex were measured. The examinations were carried out by two physicians at the same time to evaluate the inter-rater reliability. Further, one of the physicians performed the examination again after one week to evaluate the intra-rater reliability. The correlations between MAS and T-reflex, and the intra- and inter-rater reliability of biceps T-reflex were established by calculating the Spearman correlation coefficients and the intra-class correlation coefficients (ICCs). Results Amplitude of the biceps T-reflex increased with increasing level of MAS (rs=0.464 and 0.573, respectively, p<0.01). ICCs of latency and amplitude of biceps T-reflex were 0.914 and 0.822. The Spearman correlation coefficients of latency and amplitude of biceps T-reflex were 0.937 and 0.635, respectively (p<0.01). Conclusion Biceps T-reflex demonstrates a good quantitative measurement and correlation tool with MAS for spasticity, and also shows acceptable inter- and intra-rater reliability, which can be used for patients with spasticity after stroke.

Immediate effect of Walkbot robotic gait training on neuromechanical knee stiffness in spastic hemiplegia: A case report

PURPOSE The purpose of this study was to investigate the immediate effect of Walkbot gait training on knee joint stiffness in an individual with spastic hemiplegia. METHOD A woman with hemiparetic stroke underwent a 30-minute Walkbot robotic-assisted gait training session. Knee flexion stiffness associated with hamstring spasticity and knee extension torques during the terminal swing phase was determined before and after the intervention using the Walkbot-STIFF measurement system. DESIGN Descriptive case analysis. RESULTS Knee joint extension kinematic at the terminal swing phase increased from 2.44° to -0.28°. Knee joint torque increased from 0.26 Nm to 0.32 Nm. The knee flexion stiffness decreased from 0.0083 Nm/degree to 0.0022 Nm/degree following the training. CONCLUSIONS The Walkbot robotic-assisted locomotor training was effective for reducing knee joint stiffness and improving extensor torque during functional gait. Moreover, the Walkbot-STIFF system was useful for assessing and monitoring spasticity during locomotor training.

Clinical significance of the double-peak sensory response in nerve conduction study of normal and diabetic patients.

Objective The aim of this study was to understand the meaning of the double-peak responses in digital nerve conduction study in normal and diabetic patients. Design This was a cross-sectional and correlative study. Sixty healthy subjects (10 people per decade from 20 to 79 yrs of age; 26 men; mean age, 48 yrs) and 60 diabetic patients (10 people per decade from 22 to 79 yrs of age; 36 men, mean age, 53 yrs) were included. The composite score of the nerve conduction study was obtained. Orthodromic sensory nerve conduction studies were performed on the median nerves using submaximal stimulation. The latencies and amplitudes of first and second peaks were measured. The Toronto clinical scoring system for diabetic neuropathy was applied to all diabetic patients. Results The first and second peak latencies of both 3- and 4-cm interpeak distance in diabetic patients were significantly increased compared with those of age-matched control subjects (P < 0.05). The correlation between the Toronto clinical scoring system and first and second peak latency and amplitude were significantly high, and the correlation between the composite score and first and second peak latency and amplitude was also related. Conclusions The double-peak response represents the far distal nerve pathophysiology. The authors suspect that they will find an increasing role in diagnosing the peripheral neuropathy, which starts at the distal nerve in centripetal pattern.

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.

Autonomic dysreflexia-induced reversible posterior leukoencephalopathy syndrome in patients with spinal cord injury: two case reports.

Abstract Background/objectives To report two cases of reversible posterior leukoencephalopathy syndrome (RPLS) in patients with traumatic cervical spinal cord injury. Design Case report. Setting Rehabilitation Inpatient Unit, Pusan National University Hospital, Yangsan-si, Korea. Results Two men with spastic tetraplegia developed autonomic dysreflexia. Use of antihypertensive medication and Foley catheter insertion prevented further episodes of acute arterial hypertension and development of new symptoms. Conclusion RPLS can occur in the setting of autonomic dysreflexia in patients with traumatic cervical cord injury. The prompt recognition of this syndrome is of importance to prevent further morbidity and mortality in patients with spinal cord injury.

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.