Yoon Kyum Shin

Comparative neuroimaging in children with cerebral palsy using fMRI and a novel EEG-based brain mapping during a motor task – A preliminary investigation

PURPOSE The purpose of this study was to compare topographical maps using a novel EEG-based brain mapping system with fMRI in normal and children with cerebral palsy (CP) during a grasping motor task. METHOD A normal child (mean ± SD = 13 ± 0 yrs) and four children with CP (mean ± SD = 10.25 ± 2.86 yrs) were recruited from a local community school and medical center. A novel EEG-based brain mapping system with 30 scalp sites (an extension of the 10-20 system) and a 3T MR scanner were used to observe cortical activation patterns during a grasping motor task. DESIGN Descriptive analysis. RESULTS In the EEG brain mapping data, the sensorimotor cortex (SMC) and inferior parietal cortex (IPC) were activated in all of the children. The children with CP showed additional activation areas in the premotor cortex (PMC), superior parietal cortex (SPC), and prefrontal cortex (PFC). In the fMRI brain mapping data, SMC activation was observed in all of the children, and the children with CP showed additional activation areas in the PMC and primary somatosensory cortex (PSC). DISCUSSION The EEG-based topographical maps were equivalent to the maps obtained from fMRI during the grasping motor task. The results indicate that our novel EEG-based brain mapping system is useful for probing cortical activation patterns in normal children and children with CP.

A novel EEG-based brain mapping to determine cortical activation patterns in normal children and children with cerebral palsy during motor imagery tasks

PURPOSE The purpose of this study was to compare EEG topographical maps in normal children and children with cerebral palsy (CP) during motor execution and motor imagery tasks. METHOD Four normal children and four children with CP (mean age 11.6 years) were recruited from a community medical center. An EEG-based brain mapping system with 30 scalp sites (extended 10--20 system) was used to determine cortical reorganization in the regions of interest (ROIs) during four motor tasks: movement execution (ME), kinesthetic-motor imagery (KMI), observation of movement (OOM), and visual motor imagery (VMI). ROIs included the primary sensorimotor cortex (SMC), premotor cortex (PMC), and supplementary motor area (SMA). DESIGN Descriptive analysis. RESULTS Normal children showed increased SMC activation during the ME and KMI aswell as SMC and visual cortex (VC) activation during KMI. Children with CP showed similar activation in the SMC and other motor network areas (PMC, SMA, and VC). During the OOM and VMI tasks, the VC or occipital area were primarily activated in normal children, whereas the VC, SMC, and bilateral auditory areas were activated in children with CP. DISCUSSION This is the first study demonstrating different neural substrates for motor imagery tasks in normal and children with CP.

Changes in Hyolaryngeal Movement and Swallowing Function After Neuromuscular Electrical Stimulation in Patients With Dysphagia

Objective To investigate immediate changes in hyolaryngeal movement and swallowing function after a cycle of neuromuscular electrical stimulation (NMES) on both submental and throat regions and submental placement alone in patients with dysphagia. Methods Fifteen patients with dysphagia were recruited. First, videofluoroscopic swallowing study (VFSS) was performed before NMES. All patients thereafter received a cycle of NMES by 2 methods of electrode placement: 1) both submental and throat regions and 2) submental placement alone concomitant with VFSS. The Penetration-Aspiration Score (PAS) and the NIH-Swallowing Safety Scale (NIH-SSS) were measured for swallowing function. Results During swallowing, hyolaryngeal descent significantly occurred by NMES on both submental and throat regions, and anterior displacement of hyolaryngeal complex was significant on submental placement alone. NMES on submental placement alone did not change the PAS and NIH-SSS. However, NMES on both submental and throat regions significantly reduced the NIH-SSS, although it did not change the PAS. Patients with no brainstem lesion and with dysphagia duration of <3 months showed significantly improved the NIH-SSS. Conclusion Immediate hyolaryngeal movement was paradoxically depressed after NMES on both submental and throat regions with significant reductions in the NIH-SSS but not the PAS, suggesting improvement in pharyngeal peristalsis and cricopharyngeal functions at the esophageal entry rather than decreased aspiration and penetration. The results also suggested that patients with dysphagia should be carefully screened when determining motor-level NMES.

Effect of Rhythmic Auditory Stimulation on Hemiplegic Gait Patterns.

Purpose The purpose of our study was to investigate the effect of gait training with rhythmic auditory stimulation (RAS) on both kinematic and temporospatial gait patterns in patients with hemiplegia. Materials and Methods Eighteen hemiplegic patients diagnosed with either cerebral palsy or stroke participated in this study. All participants underwent the 4-week gait training with RAS. The treatment was performed for 30 minutes per each session, three sessions per week. RAS was provided with rhythmic beats using a chord progression on a keyboard. Kinematic and temporospatial data were collected and analyzed using a three-dimensional motion analysis system. Results Gait training with RAS significantly improved both proximal and distal joint kinematic patterns in hip adduction, knee flexion, and ankle plantar flexion, enhancing the gait deviation index (GDI) as well as ameliorating temporal asymmetry of the stance and swing phases in patients with hemiplegia. Stroke patients with previous walking experience demonstrated significant kinematic improvement in knee flexion in mid-swing and ankle dorsiflexion in terminal stance. Among stroke patients, subacute patients showed a significantly increased GDI score compared with chronic patients. In addition, household ambulators showed a significant effect on reducing anterior tilt of the pelvis with an enhanced GDI score, while community ambulators significantly increased knee flexion in mid-swing phase and ankle dorsiflexion in terminal stance phase. Conclusion Gait training with RAS has beneficial effects on both kinematic and temporospatial patterns in patients with hemiplegia, providing not only clinical implications of locomotor rehabilitation with goal-oriented external feedback using RAS but also differential effects according to ambulatory function.

Exploring Erythropoietin and G-CSF Combination Therapy in Chronic Stroke Patients

Erythropoietin (EPO) and granulocyte-colony stimulating factor (G-CSF) are known to have neuroprotective actions. Based on previous reports showing the synergistic effects of EPO+G-CSF combination therapy in experimental models, we investigated the safety of EPO+G-CSF combination therapy in patients with chronic stroke. In a pilot study, 3 patients were treated with EPO and G-CSF for 5 consecutive days, with follow-up on day 30. In an exploratory double-blind study, 6 patients were allocated to treatment with either EPO+G-CSF or placebo. Treatment was applied once a day for 5 days per month over 3 months. Participants were followed up for 6 months. To substantiate safety, vital signs, adverse events, and hematological values were measured on days 0, 5, and 30 in each cycle and on day 180. Functional outcomes were determined on day 0 and 180. In the laboratory measurements, EPO+G-CSF combination therapy significantly elevated erythropoietin, CD34+ hematopoietic stem cells, white blood cells, and neutrophils on day 5 of each cycle. There were no observations of serious adverse events. In the functional outcomes, the grip power of the dominant hand was increased in the EPO+G-CSF treatment group. In conclusion, this exploratory study suggests a novel strategy of EPO+G-CSF combination therapy for stroke patients.

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.

The Effect of Treadmill Exercise on Gait Efficiency During Overground Walking in Adults With Cerebral Palsy

Objective To investigate the effect of treadmill walking exercise as a treatment method to improve gait efficiency in adults with cerebral palsy (CP) and to determine gait efficiency during overground walking after the treadmill walking exercise. Methods Fourteen adults with CP were recruited in the experimental group of treadmill walking exercise. A control group of 7 adults with CP who attended conventional physical therapy were also recruited. The treadmill walking exercise protocol consisted of 3-5 training sessions per week for 1-2 months (total 20 sessions). Gait distance, velocity, VO2, VCO2, O2 rate (mL/kg·min), and O2 cost (mL/kg·m) were assessed at the beginning and at the end of the treadmill walking exercise. The parameters were measured by KB1-C oximeter. Results After the treadmill walking exercise, gait distance during overground walking up to 6 minutes significantly increased from 151.29±91.79 to 193.93±79.01 m, and gait velocity increased from 28.09±14.29 to 33.49±12.69 m/min (p<0.05). Energy efficiency evaluated by O2 cost during overground walking significantly improved from 0.56±0.36 to 0.41±0.18 mL/kg·m (p<0.05), whereas O2 rate did not improve significantly after the treadmill walking exercise. On the other hand, gait velocity and O2 cost during overground walking were not significantly changed in the control group. Conclusion Treadmill walking exercise improved the gait efficiency by decreased energy expenditure during overground walking in adults with CP. Therefore, treadmill walking exercise can be an important method for gait training in adults with CP who have higher energy expenditure.

Patients with non-ambulatory cerebral palsy have higher sclerostin levels and lower bone mineral density than patients with ambulatory cerebral palsy

Bone loss is a serious clinical issue in patients with cerebral palsy (CP). Sclerostin has garnered interest as a key mechanosensor in osteocytes, leading to considerations of the therapeutic utilization of anti-sclerostin medications. This study was undertaken to determine associations among mechanical unloading, sclerostin levels, and bone imbalance in patients with CP. A total of 28 patients with CP participated in this cross-sectional study. The following measurements were taken: anthropometrics, clinical diagnosis of CP subtype and ambulatory status, bone mineral density (BMD) z-scores at the lumbar spine and hip, and blood biochemical markers, including sclerostin, parathyroid hormone (PTH), osteocalcin, C-terminal telopeptide, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, creatinine, calcium, and phosphorus. In analysis according to CP subtype, patients with spastic CP showed significantly lower BMD z-scores at the lumbar spine and femur neck regions than patients with dyskinetic CP. In analysis according to ambulatory status, patients with non-ambulatory CP showed significantly lower BMD z-scores at all lumbar spine and femoral sites, lower PTH and creatinine levels, and higher plasma sclerostin levels than patients with ambulatory CP. In regression analysis, ambulatory status was a significant determinant of plasma sclerostin levels. This study is the first to report on sclerostin levels and BMD in patients with CP, based on the hypothesis that patients who lack sufficient weight-bearing activities would show increased sclerostin levels and decreased BMD scores, compared with patients who sustain relatively sufficient physical activity. Therefore, this report may provide clinical insights for clinicians considering ambulatory status, sclerostin levels, and bone loss in patients with CP.

Changes in gait patterns induced by rhythmic auditory stimulation for adolescents with acquired brain injury

The effects of rhythmic auditory stimulation (RAS) on gait in adolescents with acquired brain injury (ABI) were investigated. A total of 14 adolescents with ABI were initially recruited, and 12 were included in the final analysis (n = 6 each). They were randomly assigned to the experimental (RAS) or the control (conventional gait training) groups. The experimental group received gait training with RAS three times a week for 4 weeks. For both groups, spatiotemporal parameters and kinematic data, such as dynamic motions of joints on three‐dimensional planes during a gait cycle and the range of motion in each joint, were collected. Significant group differences in pre–post changes were observed in cadence, walking velocity, and step time, indicating that there were greater improvements in those parameters in the RAS group compared with the control group. Significant increases in hip and knee motions in the sagittal plane were also observed in the RAS group. The changes in kinematic data significantly differed between groups, particularly from terminal stance to mid‐swing phase. An increase of both spatiotemporal parameters and corresponding kinematic changes of hip and knee joints after RAS protocol indicates that the use of rhythmic cueing may change gait patterns in adolescents with ABI.

Effects of novel tubing gait on neuromuscular imbalance in cerebral palsy.

BACKGROUND Gait impairments from a neuromuscular imbalance are crucial issues in cerebral palsy. The purpose of our study was to compare the effects of the assistive tubing gait (ATG) and assistive-resistive tubing gait (ARTG) on improving the vasti and hamstring muscle imbalance during the initial contact to mid-stance phases in individuals with spastic diplegic cerebral palsy (CP). METHODS Fourteen age-matched individuals including seven normal individuals (11.7 years) and seven individuals with CP (12.9 years) were recruited. All participants underwent electromyography (EMG) measurement of the unilateral vasti and hamstring muscle activity during the three gait training conditions of no-tubing gait (NTG), ATG, and ARTG. A statistical one-way repeated-measure analysis of variance (ANOVA) was used to determine differences in the vasti and hamstring activity, the vasti/hamstring ratio, and the knee joint angle across the three gait training conditions for each group. RESULTS The initial vasti and hamstring muscle imbalance in CP was significantly improved by applying the ARTG compared with the ATG. The vasti/hamstring ratio during the ARTG was compatible with the ratio value obtained from the NTG of normal individuals. The knee joint angle in CP was not improved in this short-term intervention. CONCLUSIONS The ARTG proportionately increased the vasti activation and reciprocally inhibited the hamstring activity, subsequently improving the neuromuscular imbalance associated with the flexed-knee gait in individuals with spastic diplegic CP.