Sun Im

Inter-rater Reliability of Videofluoroscopic Dysphagia Scale

Objective To investigate the inter-rater agreement using the Videofluoroscopic Dysphagia Scale (VDS). Method The present study was designed as a multicenter, single-blind trial. A Videofluoroscopic Swallowing Study (VFSS) was performed using the protocol described by J.A Logemann. Thick-fluid, pureed food, mechanically altered food, regularly textured food, and thin-fluid boluses were sequentially swallowed. Each participant received a 3 ml bolus followed by a 5 ml bolus of each food material, in the order mentioned above. All study procedures were video recorded. Discs containing these video recordings in random order were distributed to interpreters who were blinded to the participant information. The video recordings were evaluated using a standardized VDS sheet and the inter-rater reliability was calculated. Results In total, 100 patients participated in this study and 10 interpreters analyzed the findings. Inter-rater reliability was fair in terms of lip closure (κ: 0.325), oral transit time (0.253), delayed triggering of pharyngeal swallowing (0.300), vallecular residue (0.275), laryngeal elevation (0.345), pyriform sinus residue (0.310), coating of the pharyngeal wall (0.310), and aspiration (0.393). However, other parameters of the oral phase were lower than those of the pharyngeal phase (0.06-0.153). Moreover, the summation of VDS reliability (intraclass correlation coefficient: 0.556) showed moderate agreement. Conclusion VDS shows a moderate rate of agreement for evaluating the swallowing function. However, many of the parameters demonstrated a lower rate of agreement, particularly the oral phase parameters.

Effects of joint effusion on proprioception in patients with knee osteoarthritis: a single-blind, randomized controlled clinical trial

OBJECTIVE To assess the effects of joint effusion on proprioceptive status in patients with knee osteoarthritis (OA). DESIGN A single-blind, randomized, controlled clinical trial in 40 female subjects aged 50 years and over with painful knee OA. All subjects were randomly assigned to either the control or experimental group. A volume of 20 mL of normal saline was injected into the knee joint cavity of subjects in the experimental group under ultrasonographic guidance. Proprioceptive acuity was assessed by active repositioning of the lower limb using an electrogoniometer to measure knee joint position sense (JPS) under both non-weight-bearing (NWB) and weight-bearing (WB) conditions twice, with a 20-min rest interval. The experimental group performed the task twice (Test 1 and Test 2) before and within 5 min after joint infusion. The control group also performed Test 1 and Test 2 without joint infusion. The outcome of interest was the absolute angular error (AAE), ignoring the direction of the error, between the randomized target angle and the patients reproduced angle of JPS values. RESULTS Compared with the control group, JPS was significantly compromised in the experimental group in the NWB test after joint infusion (P=0.025). However, no significant differences in the angular error were observed between Test 1 and Test 2 in the control group for the NWB or WB test or in the experimental group for the WB test after infusion (P>0.05). CONCLUSIONS This study showed that joint effusion impairs proprioceptive function in osteoarthritic knee joints.

Anatomic localization of motor entry points and intramuscular nerve endings in the hamstring muscles

PurposeTo elucidate the location of motor entry points (MEPs) and intramuscular nerve endings of the hamstring muscles.MethodsWe dissected 50 cadaveric lower extremities to identify the MEPs, where the nerve branch first pierced the muscle belly, and the proximal and distal limit points (PLPs and DLPs, respectively) of the terminal intramuscular nerve endings. These points were measured in relation to a reference line, expressed in x-coordinate, which connected the superior medial aspect of ischial tuberosity to the proximal aspect of the medial femoral epicondyle. We also expressed the MEP in y-coordinate, which is perpendicular to the x-coordinate connecting the superior medial aspect of ischial tuberosity to the lateral aspect of the greater trochanter. Finally, these distances were translated into percentage distances in relation to the total length of the reference lines and their mean values were calculated.ResultsFor the long head of biceps femoris muscles, the MEPs were located at 41.5 and 36.3% distance of the x and y coordinates, while the PLP and DLP were located at 39.7 and 72.9% distance of the x-coordinate. For the short head, the corresponding data were 56.2, 59.7, 58.9 and 80.2%. The semitendinosus showed two innervations zones; the data for the upper and lower zones were 20.3, 18.9, 18.6, 36.8% and 59.9, 21.4, 56.6, 79.1%, respectively. For the semimembranosus, the data were 62.2, 18.8, 55.9 and 89.1%.ConclusionsThe parameters provided from this study should help increase the efficacy and precision of motor point injections to the hamstring muscles.

The quantitative assessment of functional impairment and its correlation to infarct volume in rats with transient middle cerebral artery occlusion

The purpose of this study was to quantitatively assess motor activity and sensory functions and to determine their relationships to infarct severity by measuring infarct volume in rats with transient ischemic stroke. Male Sprague-Dawley rats (11 weeks old, n = 42) were randomly divided into 4 separate groups; a sham operation group, and 1-h, 2-h and 3-h middle cerebral artery occlusion (MCAO) groups. Percent weights borne on paretic hind limbs were measured consecutively for 7 days starting from the day before the induction of ischemia. Fifty percent withdrawal threshold values of forepaws and hindpaws were measured using von-Frey hairs. Infarct volumes in the three ischemic groups, which were significantly different (p < 0.01) from each other, were found to increase in size with ischemic time. The percent weight borne on paretic hind limb in the three MCAO groups were significantly lower than that in the sham group, and this functional deficit remained significant throughout the observational period (p < 0.01). A significant correlation was found between infarct volumes and percent weight borne on paretic hind limbs after ischemia (-0.7 < rho < -0.4, p < 0.05). In contrast the 50% withdrawal threshold values of paretic forepaws and hindpaws in the three ischemic groups were not significantly different from those of the sham controls. Motor test findings, which were used to assess reductions in paretic hind limb weightbearing, were shown to be correlated with infarct volume. The present study shows that this test could be used as a tool to objectively and quantitatively assess functional outcome in MCAO rats.

Leg Edema With Deep Venous Thrombosis-Like Symptoms as an Unusual Complication of Occult Bladder Distension and Right May-Thurner Syndrome in a Stroke Patient: A Case Report

Overt bladder distension can compress the iliac vessels and result in lower extremity swelling mimicking deep venous thrombosis (DVT). This phenomenon has been reported in patients with bladder outlet obstruction due to prostatism but no report has been made in relation to poststroke urinary retention (UR). The authors experienced a rare case of abrupt leg edema with DVT-like symptoms due to iliac vein compression by an overdistended bladder that had developed after cerebrovascular stroke. A 74-year-old woman with left striatocapsular infarction and situs inversus presented with severe right leg swelling. Imaging studies revealed external compression of the right iliac veins by an overdistended bladder and underlying May-Thurner syndrome (MTS). The presence of situs inversus totalis resulted in the rare clinical finding of a right-sided MTS. The patients symptoms were largely attributable to external compression of right iliac veins by bladder distension and they resolved completely after prompt bladder drainage. Follow-up imaging findings showed complete regression of right external iliac vein stenosis. This case provides the first description of lower extremity swelling manifest as an unusual complication from UR in a stroke patient. Proper and strict bladder screening with appropriate management should be implemented as important therapeutic components during the rehabilitative management of stroke patients.

Prevalence of pre-stroke low bone mineral density and vertebral fracture in first stroke patients.

PURPOSE After stroke, many factors contribute to the loss of bone mineral density (BMD) and fracture. Pre-stroke low BMD and vertebral fracture may pose a greater risk of fractures and further contribute to additional functional loss. The purposes of this study were to assess pre-stroke BMD and vertebral fracture in patients with first stroke. METHODS Forty-eight patients with first stroke events were included. To reflect pre-stroke BMD, the patients who underwent bone densitometry tests within 30 days from stroke onset were selected. BMD was checked at the lumbar spine and both femurs (total hip and femoral neck). Thoracic and lumbar spine X-rays were performed. RESULTS Of the 48 stroke patients, 21 (43.8%) had osteoporosis and 19 (39.6%) had osteopenia. X-ray evaluation showed that 12 (25.0%) had one or more lumbar or thoracic vertebral fractures and 8 (16.7%) had two or more vertebral fractures. Of the 12 patients who had one or more vertebral fractures, 4 (33.3%) were previously aware of the fact that they had a vertebral fracture. CONCLUSION Results showed a high prevalence of pre-stroke low BMD and vertebral fracture in patients experiencing first stroke. Bone loss progresses rapidly in the acute stages of stroke, and such a high prevalence of pre-stroke low BMD and vertebral fracture may pose a greater risk of fractures and further contribute to additional functional loss. Therefore, early screening and active management of osteoporosis from the acute stages of stroke is critical.

Assessment of the Medial Dorsal Cutaneous, Dorsal Sural, and Medial Plantar Nerves in Impaired Glucose Tolerance and Diabetic Patients With Normal Sural and Superficial Peroneal Nerve Responses

OBJECTIVE This study evaluated the nerve conduction study (NCS) parameters of the most distal sensory nerves of the lower extremities—namely, the medial dorsal cutaneous (MDC), dorsal sural (DS), and medial plantar (MP) nerves—in diabetic (DM) and impaired glucose tolerance (IGT) patients who displayed normal findings on their routine NCSs. RESEARCH DESIGN AND METHODS Standard NCSs were performed on healthy control (HC), DM, and IGT groups (N = 147). The bilateral NCS parameters of the MDC, DS, and MP nerves were investigated. The Toronto Clinical Scoring System (TCSS) was assessed for the DM and IGT groups. RESULTS The mean TCSS scores of the IGT and DM groups were 2.5 ± 2.3 and 2.8 ± 2.2, respectively. No significant differences between the two groups were observed. After adjustment of age and BMI, the DM group showed significant NCS differences in DS and MDC nerves compared with the HC group (P < 0.05). These differences were also exhibited in the left DS of the IGT group (P = 0.0003). More advanced NCS findings were observed in the DM group. Bilateral abnormal NCS responses in these distal sensory nerves were found in 40 and 16% of DM and IGT patients, respectively. CONCLUSIONS These results showed that the simultaneous assessment of the most distal sensory nerves allowed the detection of early NCS changes in the IGT and DM groups, even when the routine NCS showed normal findings.

Anatomic localization of motor points for the neuromuscular blockade of hand intrinsic muscles involved in thumb-in-palm.

Im S, Han SH, Choi JH, Lee JH, Ko YJ, Lee JI, Kim HW: Anatomic localization of motor points for the neuromuscular blockade of hand intrinsic muscles involved in thumb-in-palm. Am J Phys Med Rehabil 2008;87:703–709. Objective:To determine the location of the motor points and intramuscular branches for the muscles involved in thumb-in-palm and the abductor pollicis brevis muscle, the latter of which, because of its anatomic proximity, may be inadvertently blocked. Design:Hand intrinsic muscles from 20 fresh cadavers were dissected. The point of nerve entry to the muscle belly and the points where the intramuscular endings were located most proximally and distally were defined in relation to a reference line connecting the hook of hamate and the head of the first metacarpal bone. Results:We were able to define a region, located from 66.08% ± 8.67% to 70.28% ± 10.62% of the reference line, with the hook of hamate as starting point, where intramuscular endings for the thumb-in-palm muscles were dense and farther from the intramuscular endings for the abductor pollicis brevis. The region around 40% of the reference line was the point where the intramuscular endings were most dense for the abductor pollicis brevis. Conclusion:The results may provide guidelines that could help in localizing the appropriate points for the neuromuscular blockade of thumb-in-palm muscles and, at the same time, help in minimizing the inadvertent block of the abductor pollicis brevis.

The association between the severity of poststroke depression and clinical outcomes after first-onset stroke in Korean patients

OBJECTIVE The purpose of the present study is to evaluate the association between poststroke depression (PSD) and clinical outcomes in first-onset stroke patients who are undergoing a rehabilitation program. METHODS The present study included 180 inpatients that were recruited consecutively and followed up over a 6-month observational period. Poststroke depression was diagnosed using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Symptoms of depression and clinical outcomes were assessed using the Beck Depression Inventory, the modified Barthel Index (MBI) and the Mini Mental State Examination (MMSE). All patients were assessed at baseline and at the end of the 6-month observational period. RESULTS Of the 180 patients, 127 (70.6%) were diagnosed with minimal-to-mild depression (MMD), and 53 (29.4%) were diagnosed with moderate-to-severe depression (MSD). The mean change in MBI scores from baseline to 6 months was significantly higher (P=.029) in the MMD group (23.8) than in the MSD group (8.6). The odds ratio for an unfavorable outcome (MBI score <60) in patients with MSD was approximately 3.5 in relation to patients with MMD. The mean change in MMSE score (4.4 versus 7.4) was not significantly different between the MMD and MSD groups. CONCLUSION The present findings suggest that the severity of PSD may be associated with clinical outcomes in Korean patients 6 months after a first-onset stroke. Our data agree with previous findings, which indicate that clinicians should carefully evaluate symptoms of depression in stroke patients during routine clinical practice. The methodological shortcomings of the present study may require further studies with adequate power and improved design to clarify the association between PSD and clinical outcomes following stroke.

Ischemic Stroke in Rats Enhances Bone Resorption in Vitro

We hypothesized that the formation and differentialtion of osteoclasts are accelerated and the potential of bone resorption is increased in the hemiplegic bone marrow in the early stage of stroke. We randomly divided white female Sprague-Dawley (SD) rats (n = 30) into two groups, stroke (n = 15) and sham group (n = 15). On the 7th day after stroke, after cutting away the epiphyses of the femurs and tibias, diaphyseal channels were flushed using α-minimum essential medium (α-MEM) and bone marrow cells were collected. Bone marrow stem cells, which were extracted from the femur and tibia, were cultured on the 7th day after middle cerebral artery occlusion. We then estimated the ratio of non-adherent cells to total bone marrow cells that included osteoclast precursor cells. After culturing these cells separately, cells that tested positive on the tartrate resistant acid phosphatase (TRAP) were counted and bone resorption was evaluated by using the OAAS™ plate. In comparison to the control group, the stroke group showed a higher increase of non-adherent cells in the hemiplegic side bone marrow. In addition, after the primary culture, the stroke group showed an increased number of TRAP positive cells and a higher degree of bone resorption estimated by OAAS™ plate. As a result, osteoclastogenesis and osteoclast differentiation are accelerated and the potential of bone resorption is increased in the hemiplegic bone marrow and these changes are detected as early as within the first week after middle cerebral artery occlusion in SD rats.