Min Kyun Sohn

Effect of Transcranial Direct Current Stimulation on Postural Stability and Lower Extremity Strength in Hemiplegic Stroke Patients

Objective To evaluate the effect of anodal transcranial direct current stimulation (tDCS) over the lesioned leg motor cortex, which can enhance the strength and coordination of the contralateral lower extremity and furthermore, enhance the postural stability of the hemiplegic subject. Methods Anodal or sham stimulation on the lesioned cortex of a lower extremity was delivered to 11 ambulatory hemiplegic patients. The stimulation intensity was 2 mA. All subjects took part in two 10-minute tDCS sessions consisting of anodal stimulation and sham stimulation. The interval period between real and sham stimulation was 48 hours. The order was counter-balanced among the subjects. Before and after each stimulation session, static postural stability was evaluated with eyes opened and closed. Also, the isometric strength of the hemiplegic side of the treated knee was measured before and after each stimulation session. Repeated measure ANOVA was used to determine the statistical significance of improvements in postural stability and strength. Results There was significant improvement for overall stability index with eyes opened and closed after anodal tDCS (p<0.05). Isometric strength of the lesioned quadriceps tended to increase after anodal tDCS (p<0.05). Postural stability and quadriceps strength were not changed after sham stimulation. Conclusion Anodal tDCS has potential value in hemiplegic stroke patients to improve balance and strengthen the affected lower extremity.

Effectiveness of Initial Extracorporeal Shock Wave Therapy on the Newly Diagnosed Lateral or Medial Epicondylitis

Objective To evaluate the effectiveness of initial extracorporeal shock wave therapy (ESWT) for patients newly diagnosed with lateral or medial epicondylitis, compared to local steroid injection. Method An analysis was conducted of twenty-two patients who were newly confirmed as lateral or medial epicondylitis through medical history and physical examination. The ESWT group (n=12) was treated once a week for 3 weeks using low energy (0.06-0.12 mJ/mm2, 2,000 shocks), while the local steroid injection group (n=10) was treated once with triamcinolone 10 mg mixed with 1% lidocaine solution. Nirschl score and 100 point score were assessed before and after the treatments of 1st, 2nd, 4th and 8th week. And Roles and Maudsley score was assessed one and eight weeks after the treatments. Results Both groups showed significant improvement in Nirschl score and 100 point score during the entire period. The local steroid injection group improved more in Nirschl score at the first week and in 100 point score at the first 2 weeks, compared to those of the ESWT group. But the proportion of excellent and good grades of Roles and Maudsley score in the ESWT group increased more than that of local steroid injection group by the final 8th week. Conclusion The ESWT group improved as much as the local steroid injection group as treatment for medial and lateral epicondylitis. Therefore, ESWT can be a useful treatment option in patients for whom local steroid injection is difficult.

Spasticity and electrophysiologic changes after extracorporeal shock wave therapy on gastrocnemius.

Objective To evaluate the spasticity and electrophysiologic effects of applying extracorporeal shock wave therapy (ESWT) to the gastrocnemius by studying F wave and H-reflex. Method Ten healthy adults and 10 hemiplegic stroke patients with ankle plantarflexor spasticity received one session of ESWT on the medial head of the gastrocnemius. The modified Ashworth scale (MAS), tibial nerve conduction, F wave, and H-reflex results were measured before and immediately after the treatment. The Visual Analogue Scale (VAS) was used during ESWT to measure the side effects, such as pain. Results There were no significant effects of ESWT on the conduction velocity, distal latency and amplitude of tibial nerve conduction, minimal latency of tibial nerve F wave, latency, or H-M ratio of H-reflex in either the healthy or stroke group. However, the MAS of plantarflexor was significantly reduced from 2.67±1.15 to 1.22±1.03 (p<0.05) after applying ESWT in the stroke group. Conclusion After applying ESWT on the gastrocnemius in stroke patients, the spasticity of the ankle plantarflexor was significantly improved, with no changes of F wave or H-reflex parameters. Further studies are needed to evaluate the mechanisms of the antispastic effect of ESWT.

Effect of Stimulation Polarity of Transcranial Direct Current Stimulation on Non-dominant Hand Function

Objective To evaluate motor excitability and hand function on the non-dominant side according to the polarity of transcranial direct current stimulation (tDCS) on the motor cortex in a healthy person. Method tDCS was applied to the hand motor cortex for 15 minutes at an intensity of 1 mA in 28 healthy right-handed adults. Subjects were divided randomly into four groups: an anodal tDCS of the non-dominant hemisphere group, a cathodal tDCS of the non-dominant hemisphere group, an anodal tDCS of the dominant hemisphere group, and a sham group. We measured the motor evoked potential (MEP) in the abductor pollicis brevis and Jabsen-Taylor hand function test (JTT) in the non-dominant hand prior to and following tDCS. All study procedures were done under double-blind design. Results There was a significant increase in the MEP amplitude and a significant improvement in the JTT in the non-dominant hand following anodal tDCS of the non-dominant hemisphere (p<0.05). But there was no change in JTT and a significant decrease in the MEP amplitude in the non-dominant hand following cathodal tDCS on the non-dominant hemisphere and anodal tDCS of the dominant hemisphere. Conclusion Non-dominant hand function is improved by increased excitability of the motor cortex. Although motor cortex excitability is decreased in a healthy person, non-dominant hand function is maintained. A homeostatic mechanism in the brain might therefore be involved in preserving this function. Further studies are warranted to examine brain functions to clarify this mechanism.

Korean Stroke Cohort for functioning and rehabilitation (KOSCO): study rationale and protocol of a multi-centre prospective cohort study

BackgroundDevelopment of a long-term stroke care plan requires serial assessment of long-term patient function and consideration of caregiver mood. However, to date, few comprehensive cohort studies have included both stroke patients and caregivers.Methods/DesignKOSCO is a large, multi-centre prospective cohort study for all acute first-ever stroke patients admitted to participating hospitals in nine distinct areas of Korea. This study is designed as a 10-year, longitudinal follow-up investigating the residual disabilities, activity limitations, and quality of life issues arising in patients suffering from first-ever stroke. The main objectives of this study are to identify the factors that influence residual disability and long-term quality of life. The secondary objectives of this study are to determine the risk of mortality and recurrent vascular events in patients with acute first-ever stroke. We will investigate longitudinal health behaviors and patterns of healthcare utilization, including stroke rehabilitation care. We will also investigate the long-term health status, mood, and quality of life in stroke patient caregivers. In addition, we will identify baseline and ongoing characteristics that are associated with our secondary outcomes.DiscussionKOSCO is a prospective, multi-centre, 10-year longitudinal follow-up study investigating the residual disabilities, activity limitations, and quality of life issues arising in patients suffering from first-ever stroke.

Effects of Acute Low Back Pain on Postural Control

Objective To evaluate the changes in static and dynamic postural control after the development of acute low back pain. Methods Thirty healthy right-handed volunteers were divided into three groups; the right back pain group, the left back pain group, and the control group. 0.5 mL of 5% hypertonic saline was injected into L4-5 paraspinal muscle for 5 seconds to cause muscle pain. The movement of the center of gravity (COG) during their static and dynamic postural control was measured with their eyes open and with their eyes closed before and 2 minutes after the injection. Results The COGs for the healthy adults shifted to the right quadrant and the posterior quadrant during their static and dynamic postural control test (p<0.05). The static and dynamic instability index while they had their eyes closed was significantly increased than when they had their eyes open with and without acute back pain. After pain induction, their overall and anterior/posterior instability was increased in both the right back pain group and the left back pain group during the static postural control test (p<0.05). A right deviation and a posterior deviation of the COG still remained, and the posterior deviation was greater in the right back pain group (p<0.05). Conclusion The static instability, particularly the anterior/posterior instability was increased in the presence of acute low back pain, regardless of the visual information and the location of pain.

Effect of obesity on functional outcomes at 6 months post-stroke among elderly Koreans: a prospective multicentre study

Objectives We examined whether obesity based on body mass index (BMI) was a predictor of functional independence measure (FIM) at 6 months after ischaemic stroke onset while adjusting for stroke risk factors and covariates and stratifying by age group. Design This is an interim report of the Korean Stroke Cohort for Functioning and Rehabilitation that was designed as a nested case study within a nationwide hospital-based cohort. Setting We identified all patients who were admitted to nine representative hospitals in Korea from 2012 until 2014 under a diagnosis of acute first-ever ischaemic stroke. The hospitals were selected from the metropolitan district, mid-sized cities and a small-sized city. Participants The sample included 2057 patients with acute ischaemic stroke who were at least 18 years old. Primary and secondary outcome measures We divided participants into two age levels (<65 and ≥65 years). Participants were classified into five groups according to their baseline BMI at admission: underweight (BMI<18.5), normal (18.5≤BMI<23), overweight (23≤BMI<25), obese (25≤BMI<30) and extremely obese (30≤BMI). Results The proportion of patients who were aged ≥65 years was 55.0%. The proportions of underweight, normal, overweight, obese and extremely obese patients were 2.6%, 24.3%, 29.6%, 37.2% and 6.3%, respectively, in the <65 years group and 5.5%, 34.5%, 27.9%, 28.8% and 3.3%, respectively, in the ≥65 years group. In a multiple linear regression, the 6-month FIM after stroke in the elderly group was significantly associated with being extremely obese (7.95, p<0.05) after adjusting for confounding variables. In the <65 years group, the 6-month FIM was not associated with any weight category. Conclusions This nationwide hospital-based cohort study showed that extreme obesity is a predictor of a good 6-month FIM, especially in patients with ischaemic stroke who are at least 65 years of age.

Return to work after stroke: The KOSCO Study.

OBJECTIVE To investigate the return to work status of patients with first-ever stroke with functional independence 6 months post-stroke. DESIGN Prospective cohort study. PARTICIPANTS Nine hundred and thirty-three patients with functional independence at 6 months after stroke onset. METHODS A complete post-enumeration survey was performed through a review of the medical records for first admission. In addition, structured self-administered questionnaires and a face-to-face interview were performed assessing occupational status, quality of life, and emotional status at 6 months after stroke. RESULTS Of the patients in this study, 60.0% returned to work at 6 months after stroke. Sex, age, educational level, and comorbidity level were independent factors related to return to work. The rate of return to work in female patients under 65 years of age was similar to that of male patients 65 years of age or older. Stroke patients who returned to work showed better emotional statuses than those who did not return to work. CONCLUSION Many stroke patients did not return to work despite functional independence at 6 months after stroke. Based on the results of this study, we suggest providing appropriate vocational rehabilitation for stroke patients and proper education for employers to increase the rate of early return to work in stroke patients.

Chronic Kidney Disease and Functional Outcomes 6 Months after Ischemic Stroke: A Prospective Multicenter Study

Background: The aim of this study was to investigate whether chronic kidney disease (CKD) predicts the outcome of the Functional Independence Measure (FIM) and the Korean version of the modified Barthel Index (K-MBI) 6 months after stroke with adjustment for age, gender, education, smoking, drinking, obesity, hypertension, diabetes mellitus, dyslipidemia, the FIM or K-MBI at discharge and the National Institutes of Health Stroke Scale (NIHSS) score 7 days post stroke. Methods: This study is an interim report of the Korean Stroke Cohort for Functioning and Rehabilitation. The sample included 2,037 ischemic stroke patients aged 18 years or older. The FIM and K-MBI scores were assessed at discharge and at 6 months after the onset of stroke. The estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. CKD was defined as an eGFR <60 ml/min/1.73 m2. Results: Overall, the mean age was 65.5 (±12.4) years. The proportion of men was 62.6%. The proportion of CKD cases was 12.7%. The means of the 6-month FIM and K-MBI were 109.8 (±27.9) and 87.0 (±26.4), respectively. In multiple linear regressions, the 6-month FIM after stroke was significantly associated with CKD (-2.85, p < 0.05), age (-0.29, p < 0.01), the FIM at discharge (0.46, p < 0.01) and the 7-day NIHSS score (-1.71, p < 0.01). Additionally, the post-stroke 6-month K-MBI was significantly associated with CKD (-2.88, p < 0.01), age (-0.27, p < 0.01), the K-MBI at discharge (0.46, p < 0.01) and the 7-day NIHSS score (-1.55, p < 0.01). Conclusions: This nationwide hospital-based cohort study showed that CKD might predict poor 6-month FIM and K-MBI scores in ischemic stroke patients.

Impact of central facial palsy and dysarthria on quality of life in patients with stroke: The KOSCO study

BACKGROUND There are a few reports on the impact of central facial palsy and dysarthria on quality of life (QOL) in stroke patients. OBJECTIVE To investigate the impact of central facial palsy on QOL compared with dysarthria during the chronic phase in patients with first-ever strokes. METHODS This study represents an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation study. We selected data from patients with functional independence of 0 or 1 by the modified Rankin Scale at 6 months after stroke onset, who showed an impairment only in National Institute of Health Stroke Scale items 4 (facial palsy) or 10 (dysarthria). Assessments included the European Quality of Life-5 Dimensions (EQ-5D) and the Geriatric depression scale-short form (GDS-SF). RESULTS Data from 149 patients were selected for this analysis from 3,929 patients who were followed up at 6 months. Thirty-nine and 110 patients were classified into the facial palsy and dysarthria groups, respectively. The groups did not differ significantly in baseline characteristics or functional assessments. EQ-5D was significantly lower in the facial palsy group than in the dysarthria group at 6 months after stroke (p = 0.036). GDS-SF was significantly higher in the facial palsy group than in the dysarthria group (p = 0.005). CONCLUSIONS The results of this study revealed that central facial palsy clearly has a more negative impact on QOL than dysarthria in chronic stroke patients with functional independence.