Validation of a Paper and Pencil Test Battery for the Diagnosis of Minimal Hepatic Encephalopathy in Korea.

The aim of this study was to validate a new paper and pencil test battery to diagnose minimal hepatic encephalopathy (MHE) in Korea. A new paper and pencil test battery was composed of number connection test-A (NCT-A), number connection test-B (NCT-B), digit span test (DST), and symbol digit modality test (SDMT). The norm of the new test was based on 315 healthy individuals between the ages of 20 and 70 years old. Another 63 healthy subjects (n = 31) and cirrhosis patients (n = 32) were included as a validation cohort. All participants completed the new paper and pencil test, a critical flicker frequency (CFF) test and computerized cognitive function test (visual continuous performance test [CPT]). The scores on the NCT-A and NCT-B increased but those of DST and SDMT decreased according to age. Twelve of the cirrhotic patients (37.5%) were diagnosed with MHE based on the new paper and pencil test battery. The total score of the paper and pencil test battery showed good positive correlation with the CFF (r = 0.551, P < 0.001) and computerized cognitive function test. Also, this score was lower in patients with MHE compared to those without MHE (P < 0.001). Scores on the CFF (32.0 vs. 28.7 Hz, P = 0.028) and the computer base cognitive test decreased significantly in patients with MHE compared to those without MHE. Test-retest reliability was comparable. In conclusion, the new paper and pencil test battery including NCT-A, NCT-B, DST, and SDMT showed good correlation with neuropsychological tests. This new paper and pencil test battery could help to discriminate patients with impaired cognitive function in cirrhosis (registered at Clinical Research Information Service [CRIS], https://cris.nih.go.kr/cris, KCT0000955).

A Study on Verification of Equivalence and Effectiveness of Non-Pharmacologic Dementia Prevention and Early Detection Contents : Non-Randomly Equivalent Design.

OBJECTIVE: The aim of this study was to verify the equivalence and effectiveness of the tablet-administered Korean Repeatable Battery for the Assessment of Neuropsychological Status (K-RBANS) for the prevention and early detection of dementia. METHODS: Data from 88 psychiatry and neurology patient samples were examined to evaluate the equivalence between tablet and paper administrations of the K-RBANS using a non-randomly equivalent group design. We calculated the prediction scores of the tablet-administered K-RBANS based on demographics and covariate-test scores for focal tests using norm samples and tested format effects. In addition, we compared the receiver operating characteristic curves to confirm the effectiveness of the K-RBANS for preventing and detecting dementia. RESULTS: In the analysis of raw scores, line orientation showed a significant difference (t=-2.94, p<0.001), and subtests showed small to large effect sizes (0.04-0.86) between paper- and tablet-administered K-RBANS. To investigate the format effect, we compared the predicted scaled scores of the tablet sample to the scaled scores of the norm sample. Consequently, a small effect size (d≤0.20) was observed in most of the subtests, except word list and story recall, which showed a medium effect size (d=0.21), while picture naming and subtests of delayed memory showed significant differences in the one-sample t-test. In addition, the area under the curve of the total scale index (TSI) (0.827; 95% confidence interval, 0.738-0.916) was higher than that of the five indices, ranging from 0.688 to 0.820. The sensitivity and specificity of TSI were 80% and 76%, respectively. CONCLUSION: The overall results of this study suggest that the tablet-administered K-RBANS showed significant equivalence to the norm sample, although some subtests showed format effects, and it may be used as a valid tool for the brief screening of patients with neuropsychological disorders in Korea.

The Korean Repeatable Battery for the Assessment of Neuropsychological Status-Update : Psychiatric and Neurosurgery Patient Sample Validity.

OBJECTIVE: This study aimed to validate the Korean version of the Repeatable Battery for the Assessment of Neuropsychological Status Update (K-RBANS). METHODS: We performed a retrospective analysis of 283 psychiatric and neurosurgery patients. To investigate the convergent validity of the K-RBANS, correlation analyses were performed for other intelligence and neuropsychological test results. Confirmatory factor analysis was used to test a series of alternative plausible models of the K-RBANS. To analyze the various capabilities of the K-RBANS, we compared the area under the receiver operating characteristic (ROC) curves (AUC). RESULTS: Significant correlations were observed, confirming the convergent validity of the K-RBANS among the Total Scale Index (TSI) and indices of the K-RBANS and indices of intelligence (r=0.47-0.81; p<0.001) and other neuropsychological tests at moderate and above significance (r=0.41-0.63; p<0.001). Additionally, the results testing the construct validity of the K-RBANS showed that the second-order factor structure model (model 2, similar to an original factor structure of RBANS), which includes a first-order factor comprising five index scores (immediate memory, visuospatial capacity, language, attention, delayed memory) and one higher-order factor (TSI), was statistically acceptable. The comparative fit index (CFI) (CFI, 0.949) values and the goodness of fit index (GFI) (GFI, 0.942) values higher than 0.90 indicated an excellent fit. The root mean squared error of approximation (RMSEA) (RMSEA, 0.082) was considered an acceptable fit. Additionally, the factor structure of model 2 was found to be better and more valid than the other model in χ2 values (Δχ2=7.69, p<0.05). In the ROC analysis, the AUCs of the TSI and five indices were 0.716-0.837, and the AUC of TSI (AUC, 0.837; 95% confidence interval, 0.760-0.896) was higher than the AUCs of the other indices. The sensitivity and specificity of TSI were 77.66% and 78.12%, respectively. CONCLUSION: The overall results of this study suggest that the K-RBANS may be used as a valid tool for the brief screening of neuropsychological patients in Korea.

Motor outcome prediction using diffusion tensor tractography in pontine infarct.

We investigated whether the integrity of the corticospinal tract classified by diffusion tensor tractography (DTT) can predict the motor outcome in 25 patients with pontine infarct. DTTs were obtained in the early stage of stroke (5-30 days) and were classified into two groups (type A: the integrity of corticospinal tract was preserved around the infarct; type B: corticospinal tract was interrupted). DTT type A patients showed better motor function than the type B patients at 6 months after onset. DTT obtained at the early stage of pontine infarct appears to have predictive value for motor outcome in patients with pontine infarct.

Effect of constraint-induced movement therapy with modified opposition restriction orthosis in chronic hemiparetic patients with stroke.

OBJECTIVES: Constraint-induced movement therapy (CIMT) has been demonstrated to be effective in improving hemiparetic upper extremity function in stroke patients, but few studies have been performed to assess orthosis modification. We investigated the effect of the newly designed small orthosis named modified opposition restriction orthosis (MORO) in chronic hemiparetic patients with stroke. DESIGN: Twenty-one stroke patients were randomly assigned to the CIMT group or control group. Thirteen patients in the CIMT group wore MORO confining the thumb and index finger for at least 5 hours of each day, 7 days a week for 8 weeks. The affected upper extremity function was evaluated using the manual function test (MFT), Purdue Pegboard (PP) score, and motor activity log (MAL) at pre and post-CIMT. RESULTS: Four of the 13 patients in the CIMT group dropped out due to motivational problems, and 9 patients remained in the CIMT group at the end of the study. The patients in the CIMT group showed a mean improvement of 195.8% on MAL AOU (Amount of Use), 24.6% on PP score, and 5.5% on MFT. CONCLUSION: This new MORO would be effective for use in a CIMT program in chronic hemiparetic patients with stroke.

Brain activation pattern according to exercise complexity: a functional MRI study.

The aim of this study was to compare the areas of brain activation between complex and simple exercises in a unimanual hand and to assess the possibility of an exercise task for paretic hands following stroke. The subjects included 11 healthy right-handed volunteers. The complex exercise was a wooden ball rotation task with the unimanual hand and the simple exercise was a hand grasp task performed during a functional MRI scan. Stronger activation of the left primary sensorimotor cortex, the left premotor area, and the ipsilateral cerebellum emerged when the complex movement was performed. Ipsilateral activity was located in the primary sensory cortex and premotor area, and contralateral activity was shown in the left cerebellum. These results suggest that a unimanual ball rotation task may be appropriate for rehabilitation of a movable paretic hand in an early stage of stroke recovery, which should provide motor and sensory input using external stimuli, while the simple motor task may appropriate in a compensatory stage, and should inhibit the ipsilateral activity due to maladaptive plasticity.

Stress and Heart Rate Variability: A Meta-Analysis and Review of the Literature.

OBJECTIVE: Physical or mental imbalance caused by harmful stimuli can induce stress to maintain homeostasis. During chronic stress, the sympathetic nervous system is hyperactivated, causing physical, psychological, and behavioral abnormalities. At present, there is no accepted standard for stress evaluation. This review aimed to survey studies providing a rationale for selecting heart rate variability (HRV) as a psychological stress indicator. METHODS: Term searches in the Web of Science®, National Library of Medicine (PubMed), and Google Scholar databases yielded 37 publications meeting our criteria. The inclusion criteria were involvement of human participants, HRV as an objective psychological stress measure, and measured HRV reactivity. RESULTS: In most studies, HRV variables changed in response to stress induced by various methods. The most frequently reported factor associated with variation in HRV variables was low parasympathetic activity, which is characterized by a decrease in the high-frequency band and an increase in the low-frequency band. Neuroimaging studies suggested that HRV may be linked to cortical regions (e.g., the ventromedial prefrontal cortex) that are involved in stressful situation appraisal. CONCLUSION: In conclusion, the current neurobiological evidence suggests that HRV is impacted by stress and supports its use for the objective assessment of psychological health and stress.

Recovery of a partially damaged corticospinal tract in a patient with intracerebral hemorrhage: a diffusion tensor image study.

PURPOSE: We hypothesized that diffusion tensor imaging (DTI) could be useful for exploring corticospinal tract (CST) regeneration if longitudinal changes of diffusion anisotropy can be detected. In this study, we explored the recovery of a CST partially damaged by intracerebral hematoma in a patient by DTI. METHODS: A 61-year-old female patient and six age-matched control subjects were evaluated. The patient presented with complete paralysis of the left extremities, which occurred at the onset of a spontaneous intracerebral hemorrhage (ICH) in the right corona radiata and internal capsule. Over the five-month period following onset, motor function of the affected extremities slowly recovered to the normal range. Two longitudinal DTIs were acquired from the patient (at 3 weeks and 5 months from onset) and one DTI from the control subjects. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) were measured using a region of interest (ROI) method. RESULTS: On the 3-week DTI, FA values of ROIs in the ICH regions in the affected hemisphere were significantly lower, and ADC values of ROIs in the same areas were significantly higher than those of the control subjects (p<0.002). However, both mean FA and ADC values of the affected hemisphere in the 5-month DTI showed no significant differences versus those of the control.

Prognostic factors of neurocognitive and functional outcomes in junior and senior elderly patients with traumatic brain injury undergoing disability evaluation or appointed disability evaluation.

OBJECTIVE: This study explored the relationships among demographic (DVs) and clinical variables (CVs), neurocognitive (NOs) and functional outcome (FO) that could be used as prognostic factors for old aged patients with traumatic brain injury (TBI) undergoing or appointed disability evaluation (DE) after treatment. METHODS: A total of 162 subjects with TBI above the age of 55 years undergoing DE or appointed to do so after treatments were selected. The patients were divided into two subgroups according to age : a junior elderly group 55 to 64 years old and a senior elderly group over the age of 65. NOs and FO were evaluated using the Seoul Neuropsychological Screening Battery and Clinical Dementia Rating scale. RESULTS: Gender, age, and education level were shown to significantly impact the recovery of NOs after TBI. Other DVs and CVs such as area of residency, occupation, type of injury, or loss of consciousness were not found to significantly affect the recovery of NOs after TBI. Analysis of the relationships among DVs, CVs and NOs demonstrated that gender, age, and education level contributed to the variance of NOs. In FO, loss of consciousness (LOC) was included to prognostic factor. CONCLUSION: Gender, age and education level significantly influence the NOs of elderly patients with TBI. LOC may also serve as a meaningful prognostic factor in FO. Unlike younger adult patients with TBI, old aged patients with TBI did not show global faking-bad or malingering attitudes to DE for compensation, but assume that they could faking their performance in a test set available visual feedback.

Development of a Cognitive Level Explanation Model in Brain Injury : Comparisons between Disability and Non-Disability Evaluation Groups.

OBJECTIVE: We investigated whether Disability Evaluation (DE) situations influence patients' neuropsychological test performances and psychopathological characteristics and which variable play a role to establish an explanation model using statistical analysis. METHODS: Patients were 536 (56.6%) brain-injured persons who met inclusion and exclusion criteria, classified into the DE group (DE; n = 300, 56.0%) and the non-DE group (NDE; n = 236, 44.0%) according to the neuropsychological testing's purpose. Next, we classified DE subjects into DE cluster 1 (DEC1; 91, 17.0%), DE cluster 2 (DEC2; 125; 23.3%), and DE cluster 3 (DEC3; 84, 15.7%) via two-step cluster analysis, to specify DE characteristics. All patients completed the K-WAIS, K-MAS, K-BNT, SCL-90-R, and MMPI. RESULTS: In comparisons between DE and NDE, the DE group showed lower intelligence quotients and more severe psychopathologic symptoms, as evaluated by the SCL-90-R and MMPI, than the NDE group did. When comparing the intelligence among the DE groups and NDE group, DEC1 group performed worst on intelligence and memory and had most severe psychopathologic symptoms than the NDE group did. The DEC2 group showed modest performance increase over the DEC1 and DEC3, similar to the NDE group. Paradoxically, the DEC3 group performed better than the NDE group did on all variables. CONCLUSION: The DE group showed minimal "faking bad" patterns. When we divided the DE group into three groups, the DEC1 group showed typical malingering patterns, the DEC2 group showed passive malingering patterns, and the DEC3 group suggested denial of symptoms and resistance to treatment.

Comparison of TMS and DTT for predicting motor outcome in intracerebral hemorrhage.

BACKGROUND: TMS (transcranial magnetic stimulation) and DTT (diffusion tensor tractography) have different advantages in evaluating stroke patients. TMS has good clinical accessibility and economical benefit. On the contrary, DTT has a unique advantage to visualize neural tracts three-dimensionally although it requires an expensive and large MRI machine. Many studies have demonstrated that TMS and DTT have predictive values for motor outcome in stroke patients. However, there has been no study on the comparison of these two evaluation tools. In the current study, we compared the abilities of TMS and DTT to predict upper motor outcome in patients with ICH (intracerebral hemorrhage). METHODS: Fifty-three consecutive patients with severe motor weakness were evaluated by TMS and DTT at the early stage (7-28 days) of ICH. Modified Brunnstrom classification (MBC) and the motricity index of upper extremity (UMI) were evaluated at onset and 6 months after onset. RESULTS: Patients with the presence of a motor evoked potential (MEP) in TMS or a preserved corticospinal tract (CST) in DTT showed better motor outcomes than those without (p=0.000). TMS showed higher positive predictive value than DTT. In contrast, DTT showed higher negative predictive value than TMS. CONCLUSIONS: TMS and DTT had different advantages in predicting motor outcome, and this result could be a reference to predict final neurological deficit at the early stage of ICH.

Memory Dysfunctions after Mild and Moderate Traumatic Brain Injury : Comparison between Patients with and without Frontal Lobe Injury.

OBJECTIVE: The purpose of this study was to assess memory dysfunction in patients with mild and moderate traumatic brain injury (TBI) with and without frontal lobe injury (FLI). METHODS: The subjects were 110 TBI patients, who had recovered from the acute clinical phase, and comprised 20 (18.2%) mild TBI (MTBI) patients with FLI, 16 (14.5%) MTBI patients without FLI, 51 (46.4%) moderate TBI (MOTBI) patients with FLI and 23 (20.9%) MTBI patients without FLI. All patients were administrated the Korean version of the Memory Assessment Scale (K-MAS). RESULTS: Almost all the Summary Scale scores on the K-MAS failed to show any differences between TBI patients with and without FLI, but differences did emerge by types at severities. TBI patients with FLI showed higher Global Memory ability than TBI patients without FLI if their TBI was only mild, but when their TBI was more severe, this finding was reversed, and TBI patients with FLI showed lower Verbal and Global Memory abilities than TBI patients without FLI. CONCLUSION: Different kinds of assessment tools are needed for the measurement of memory abilities in TBI patients with FLI, and that the selection of the appropriate tool depends on the severity of the TBI.

The effect of premorbid demographic factors on the recovery of neurocognitive function in traumatic brain injury patients.

OBJECTIVE: Premorbid demographic backgrounds of injured individuals are likely to reflect more accurately the status of patients with traumatic brian injury (TBI) than clinical factors. However, the concrete study about the relationship between the demographic factors and neurocognitive function in TBI patients has not been reported. The object of this study was to evaluate the effect of premorbid demographic factors on the recovery of neurocognitive function following TBI. METHODS: From July 1998 to February 2007, 293 patients (male: 228, female: 65) with a history of head injury, who had recovered from the acute phase, were selected from our hospital to include in this study. We analyzed the effect of premorbid demographic factors including age, sex, educational level and occupation on the recovery of neurocognitive function in each TBI subgroup as defined by Glasgow Coma Scale (GCS) score. Intelligence and memory are components of neurocognitive function, and the Korean Wechsler Intelligence Scale (K-WAIS) and the Korean memory assessment scale (K-MAS) were used in this study. The results were considered significant at p<0.05. RESULTS: The higher level of education was a good prognostic factor for intelligence regardless of GCS score and younger age group showed a better result for memory with an exception of severe TBI group. In the severe TBI group, the meaningful effect of demographic factors was not noted by the cause of influence of severe brain injury. CONCLUSION: The demographic factors used in this study may be helpful for predicting the precise prognosis and developing an appropriate rehabilitation program for TBI patients.