Stroke Impact Scale 3.0: Reliability and Validity Evaluation of the Korean Version

OBJECTIVE: To establish the reliability and validity the Korean version of the Stroke Impact Scale (K-SIS) 3.0. METHODS: A total of 70 post-stroke patients were enrolled. All subjects were evaluated for general characteristics, Mini-Mental State Examination (MMSE), the National Institutes of Health Stroke Scale (NIHSS), Modified Barthel Index, Hospital Anxiety and Depression Scale (HADS). The SF-36 and K-SIS 3.0 assessed their health-related quality of life. Statistical analysis after evaluation, determined the reliability and validity of the K-SIS 3.0. RESULTS: A total of 70 patients (mean age, 54.97 years) participated in this study. Internal consistency of the SIS 3.0 (Cronbach's alpha) was obtained, and all domains had good co-efficiency, with threshold above 0.70. Test-retest reliability of SIS 3.0 required correlation (Spearman's rho) of the same domain scores obtained on the first and second assessments. Results were above 0.5, with the exception of social participation and mobility. Concurrent validity of K-SIS 3.0 was assessed using the SF-36, and other scales with the same or similar domains. Each domain of K-SIS 3.0 had a positive correlation with corresponding similar domain of SF-36 and other scales (HADS, MMSE, and NIHSS). CONCLUSION: The newly developed K-SIS 3.0 showed high inter-intra reliability and test-retest reliabilities, together with high concurrent validity with the original and various other scales, for patients with stroke. K-SIS 3.0 can therefore be used for stroke patients, to assess their health-related quality of life and treatment efficacy.

Relationship Between Cognitive Perceptual Abilities and Accident and Penalty Histories Among Elderly Korean Drivers

OBJECTIVE: To investigate the relationship between cognitive perceptual abilities of elderly drivers based on the Cognitive Perceptual Assessment for Driving (CPAD) test and their accident and penalty histories. METHODS: A total of 168 elderly drivers (aged ≥65 years) participated in the study. Participant data included CPAD scores and incidents of traffic accidents and penalties, attained from the Korea Road Traffic Authority and Korea National Police Agency, respectively. RESULTS: Drivers' mean age was 70.25±4.1 years and the mean CPAD score was 52.75±4.72. Elderly drivers' age was negatively related to the CPAD score (p<0.001). The accident history group had marginally lower CPAD scores, as compared to the non-accident group (p=0.051). However, incidence rates for traffic fines did not differ significantly between the two groups. Additionally, the group that passed the CPAD test had experienced fewer traffic accidents (3.6%), as compared to the group that failed (10.6%). The older age group (12.0%) had also experienced more traffic accidents, as compared to the younger group (2.4%). CONCLUSION: Overall, elderly drivers who experienced driving accidents had lower CPAD scores than those who did not, without statistical significance. Thus, driving-related cognitive abilities of elderly drivers with insufficient cognitive ability need to be further evaluated to prevent traffic accidents.

Age Specificity in General and Rehabilitation Medical Services in Children With Cerebral Palsy

OBJECTIVE: To review the medical utilization in children with cerebral palsy according to age and discern particularities METHODS: From January 2007 to December 2007, 10,659 children and adolescents between 1 and 18 years of age who had filed national insurance claims for a diagnosis of cerebral palsy were selected. Age was chosen as an independent variable, and the population was categorized into specific age groups to verify any differences in medical service utilization. Admission duration to rehabilitation, number of visits to rehabilitation outpatient clinics, numbers of admission dates and outpatient clinic visits for general medical services, number of rehabilitation utilizations, and type of rehabilitations treatment were selected as dependent variables. One-way ANOVA was used for statistical evaluation, and analysis was done with SAS software. RESULTS: In general medical use, adolescences diagnosed with cerebral palsy had the highest mean admission duration (p<0.001). The mean visit day to outpatient clinics for general medical services was highest for infants (p<0.001). In rehabilitation treatment, infants diagnosed with cerebral palsy had the highest mean admission duration (p<0.001). The mean visit day to outpatient clinics for rehabilitation treatment was highest for infants (p<0.001). CONCLUSION: Significant differences in use of general and rehabilitation medical services among pediatric age groups with cerebral palsy were evident. This implies that particular attention is necessary when setting up a national medical care policy for patient with cerebral palsy.

Could One-Hand Compression for a Small Child Cause Intra-abdominal Injuries?

PURPOSE: We examined the question of whether one-hand chest compression for a small child could compress intraabdominal organs. METHODS: We retrospectively examined medical charts and multidirectional computed tomography (MDCT) images obtained from children aged 1 to 18 years who presented to the hospital from March 2002 to March 2012. We measured the length of the sternum (Stotal) and the length of the lower half of the sternum (Stotal/2~X). We also measured the distance from the diaphragm to the midpoint of the sternum (Stotal/2~D) and half the width of an adult hand (Wtotal/2). Finally, we counted the number of instances at each age in which Stotal/2~X and Stotal/2~D were less than Wtotal/2. RESULTS: This study included records and MDCT images for 301 children with a mean age of 12.05+/-5.59 years. We also enrolled 47 adult rescuers (25 men, 53.2%) with a mean age of 23.20+/-2.13 years. The mean Wtotal/2 was 4.62+/-0.46 cm. All 1-year-old children had Stotal/2~X and Stotal/2~D less than Wtotal/2. Among children aged 2 years, six (60.0%) had Stotal/2~X and Stotal/2~D less than Wtotal/2. Among children aged 3 years, four (26.7%) had Stotal/2~X and Stotal/2~D less than Wtotal/2, and among those aged 4 years, two (13.3%) had Stotal/2~X and Stotal/2~D less than Wtotal/2. However, Stotal/2~X and Stotal/2~D were greater than Wtotal/2 in children aged 5 years or more. CONCLUSION: Our measurements indicate that one-hand chest compression for a small child could cause intraabdominal organ injury.

Effect of Ultrasonography-Guided Botulinum Toxin Type A Injection in Holmes' Tremor Secondary to Pontine Hemorrhage: Case Report

Holmes' tremor is a low-frequency rest and intentional tremor secondary to various insults, including cerebral ischemia, hemorrhage, trauma, or neoplasm. Pharmacologic treatment is usually unsuccessful, and some cases require surgical intervention. We report a rare case of Holmes' tremor secondary to left pontine hemorrhage in a 29-year-old Asian male patient who developed 1.6-Hz postural and rest tremor of the right hand. He responded markedly to ultrasonography-guided botulinum toxin type A injection. To our knowledge, this is the first report of Homes' tremor treated with ultrasonography-guided botulinum toxin type A injection with favorable results.

The Selection of the Appropriate Computer Interface Device for Patients With High Cervical Cord Injury

In order to determine the most suitable computer interfaces for patients with high cervical cord injury, we report three cases of applications of special input devices. The first was a 49-year-old patient with neurological level of injury (NLI) C4, American Spinal Injury Association Impairment Scale (ASIA)-A. He could move the cursor by using a webcam-based Camera Mouse. Moreover, clicking the mouse could only be performed by pronation of the forearm on the modified Micro Light Switch. The second case was a 41-year-old patient with NLI C3, ASIA-A. The SmartNav 4AT which responds according to head movements could provide stable performance in clicking and dragging. The third was a 13-year-old patient with NLI C1, ASIA-B. The IntegraMouse enabling clicking and dragging with fine movements of the lips. Selecting the appropriate interface device for patients with high cervical cord injury could be considered an important part of rehabilitation. We expect the standard proposed in this study will be helpful.

The Effect of Comprehensive Hand Repetitive Intensive Strength Training (CHRIST) Using Motion Analysis in Children with Cerebral Palsy

OBJECTIVE: To investigate the effect of Comprehensive Hand Repetitive Intensive Strength Training (CHRIST) on upper limb function in children with cerebral palsy using motion analysis. METHOD: The subjects in this study included 19 children (10 males, 9 females, mean age=8.8 years) with cerebral palsy. The experimental group (n=10) received CHRIST and general rehabilitation therapy. The control group (n=9) received a home program as well as general rehabilitation therapy. Both groups received 30 sessions of CHRIST or home program training for 60 minutes per session 3 times a week during the 10-week period. The reaching movements were captured by a motion analysis system. Kinematic variables including movement time (MT), mean velocity (MV), normalized jerk score (NJS), mean angular velocity (MAV) and normalized jerk score of the shoulder, elbow and wrist joint with comfortable and fast speed were analyzed between groups and the pre-post training group. RESULTS: After pre- and post-training experimental group, MT, MV, NJS, MAV of shoulder, elbow, wrist and NJS of elbow and wrist improved significantlyin reaching movement of both comfortable and fast speed (p<0.05). However, After pre- and post-training control group, MV improved significantlyin reaching movement of only comfortable speed (p<0.05). Between two groups, MT and MAV of the elbow at comfortable speed and NJS of the elbow at fast speed were statisticallysignificant (p<0.05). CONCLUSION: CHRIST proved to be an effective intervention for improving upper limb extremity function of reaching movement in children with cerebral palsy.

The Linguistic Validation and Reliability of the Korean Version 'Qualiveen Questionnaire'

OBJECTIVE: To translate the English Qualiveen questionnaire which was developed to measure the specific impact of urinary problems on the quality of life of patients with neurogenic bladder into Korean and validate it. METHOD: First, we made the Korean version Qualiveen questionnaire through translation and cross-cultural adaptation followed by the international guideline. This process consisted of 6 steps including translation, reconciliation, back translation into English and debriefing. And then to assess the reliability and construct validity of the questionnaire, 32 patients with neurogenic bladder conducted the Korean Qualiveen questionnaire twice at an interval between three and four weeks. RESULTS: We translated and arbitrated a total of 151 questions. In step of the backward translation, we went through discussion and corrected 12 questions. We found out that 7 questions delivered inaccurate meanings or were unhandy items such as method of writing age or date in debriefing process. A reliability study revealed strong internal consistency (Cronbach's alpha coefficients above 0.7 for all domains) and test-retest reliability (Pearson's coefficient range from 0.524 to 0.837). The sub-domain strongly correlated with each other (Pearson's coefficient range from 0.625 to 0.936) in the construct validity study. CONCLUSION: The Korean version of the Qualiveen Questionnaire was successfully translated and validated.

Transfer Activities in Patients with Spinal Cord Injury after Discharge from Hospital

OBJECTIVE: To investigate the transfer activities in patients with spinal cord injury (SCI) after discharge, and assess the caregivers' pain related to patient transfer in the community residence. METHOD: One hundred seventeen SCI patient and 35 caregivers for the patients dependent on bed-wheelchair transfer activities were included. As for SCI patients, motor index score (MIS), one transfer item from the Korean version of modified Barthel index (K-MBI), and three items related to transfers from the spinal cord independence measure (SCIM) II were evaluated. Regarding caregivers, musculoskeletal pain with patient transfer, ease-of-use and safety of transfer methods including an electric-powered lift were measured. RESULTS: The degree of transfer activity changed in 21 patients (17.9%). During follow-up, all patients with SCI at and above C6 showed dependent transfer activities. Eight from 10 patients with SCI at C7, and all patients with SCI at and below C8 performed independent bed-wheelchair transfer activities. Thirty caregivers complained of chronic musculoskeletal pain. The degree of pain at the time of patient transfer was significantly lower in those who used electric-powered lifts compared to manual transfer methods. Caregivers using electric-powered lifts showed significantly better ease-of-use scale than those using manual transfer methods. However, there was no significant difference in the safety scale. CONCLUSION: The use of electric-powered lifts is essential for patients who cannot perform independent transfers, especially those with SCI at and above C7.

Impact of Sitting Time on Seat-Interface Pressure of Spinal Cord Injured Patients

OBJECTIVE: To examine changes in seat-interface pressure in wheelchair seated spinal cord injured patients. METHOD: Twenty-six spinal cord injured patients, who were motor complete tetraplegic and paraplegic patients, were included in this study. After 5 cm air-filled cushion (ROHO(R)) was placed on their own wheelchair seat, patients were seated on wheelchair with neutral position for sixty minutes. The interface pressure and contact area of buttock was measured every 5 minutes. RESULTS: Significant increases of interface pressure were found in maximal and mean interface pressure during 0 to 25 minutes of sitting (p<0.05). An increased tendency of contact area of buttock was observed during sitting time but it was not significant. CONCLUSION: There were no significant changes of interface pressure after 25 minutes of sitting in spinal cord injured patients. Therefore, twenty-five minutes may be a reasonable sitting time before interface pressure is recorded.

Study on the Changes of Voiding Methods of Patients with SCI after Discharge: Focusing on the Patients Participating in the Regular Urinary Tract Surveillance Program

OBJECTIVE: To examine how consistently patients with spinal cord injured (SCI) after discharge use the clean intermittent catheterization (CIC). METHOD: The participants were 146 SCI patients hospitalized for regular urinary tract surveillance program, who resided in a community for over one year after discharge. The mean age was 40.3 years old and the mean time after injury was 6.2 years, consisted of 118 males and 28 females, and of 68 tetraplegics and 78 paraplegics. RESULTS: At discharge, the CIC as a voiding methods was used by 97 patients, Valsalva or reflexic voiding by 43, indwelling catheterization by 3, and diaper voiding by 3. Atfollow-up, CIC was used by 96, Valsalva or reflexic voiding by 37, indwelling catheterization by 7, and diaper voiding by 6. Among 97 patients who used CIC at discharge, 83 consistently used the CIC (compliance=85.5%). The patients with tetraplegia showed 82.9% of compliance while the patients with paraplega showed 88.0% of compliance, but there was no statistical difference. CONCLUSION: The compliance with the CIC method was comparatively high (85.5%). The CIC method can be effectively applied to the management of neurogenic bladder for the SCI patients residing in a community after discharge.

Cognitive Perceptual Assessment Tool for Evaluation of Driving Ability of Persons with Brain Injury

OBJECTIVE: To develop an evaluation tool of cognitive perceptual function for safe driving of the brain injured patients and to check the suitability of the tool. METHOD: Cognitive Perceptual Assessment for Driving (CPAD) was constructed with 8 tasks of depth perception, sustained attention, divided attention, Stroop test, digit span test, field dependence, trail making test A, and trail making test B. The predriving assessment with CPAD and road test were applied to 101 brain injured patients. The reliability and the validity of CPAD, and the cut-off score to resume driving were determined. RESULTS: The CPAD scores of pass group (n=46) and fail group (n=55) for on-road test were 51.67+/-5.53 and 44.30+/-8.44 respectively (p=0.0001). The internal consistency of the CPAD measured by Cronbach's alpha was 0.85. The cut-off score based on 95% confidence interval was 53 or above for pass group, 42 or below for fail group, 43~52 for borderline group. The positive and negative predictive value was 90.7% and 50.3%, respectively. CONCLUSION: The CPAD could be useful for the evaluation of driving ability of persons with brain injury.

The Effects of Pressure Relief Methods at Wheelchair Seated Spinal Cord Injured Patients

OBJECTIVE: To find most effective pressure relief method in wheelchair seated spinal cord injured patients and to evaluate effectiveness of trunk lateral bending, trunk pulling and trunk forward flexion methods in practical environment METHOD: Twenty spinal cord injury patients were included in this study. After 5 cm air-filled cushion (ROHO(R)) was placed on wheelchair seat, patients were seated on wheelchair with neurtal position and interface pressure of buttock was measured by X-sensor 4.0 system. Patients took a posture lateral bending, trunk pulling, forward flexion methods. Mean and maximal pressure of buttock were measured at each pressure relief methods. RESULTS: Mean and maximal pressure of buttock were reduced by 90degrees trunk forward flexion (p<0.05). In trunk lateral bending method, pressure was reduced in non-weight bearing side of buttock, but pressure was highly elevated in weight bearing side. In trunk pulling method, pressure was elevated in both weigth bearing and non-weight bearing side. CONCLUSION: 90degrees trunk forward flexion method can be recommended to wheelchiar seated spinal cord injured patients for pressure relief of buttock.

Driving State of the Brain Injured after Driver Training Program at the National Rehabilitation Center

OBJECTIVE: To investigate the actual driving state of the brain injured who had received driver training program. METHOD: We conducted a follow up survey with 64 brain injured who had received driver training program at the National Rehabilitation Center. 29 subjects were first attempting to obtain a license (First obtaining group) while 35 subjects were trying to re-obtain a license after being handicapped (Re-obtaining group). The contents of the survey were compared between first obtaining group and re-obtaining group, and between hemiplegic side. RESULTS: 41 subjects obtained license in regard to the total 64 subjects in which 39% of theses were actually driving. Licensed rate was 55% for first obtaining group and 71% for re-obtaining group. Driving rate was 56% for first obtaining group and 28% for re-obtaining group. Comparing to hemiplegic side, left hemiplegics (54%) showed a tendency to have higher rate of accident than right hemiplegics (0%) without statistical significance. CONCLUSION: Licensed rate of the brain injured was 64%, and driving rate and accident rate were 39% and 38%, respectively. Left hemiplegics, especially, had a higher rate of accident than right hemiplegics.

Gait Analysis Using Accelerometer in Stroke Patients

OBJECTIVE: The aim of this study is to evaluate the acceleration of the center of mass (COM) of the body in stroke patients. METHOD: Seventeen stroke patients and 9 normal subjects were participated. Three dimensional gait analysis was used to classify gait phases for the reference. The accelerometer held over the COM were used to record vertical and medio- lateral accelerations of the COM of the body. Modified Ashworth scale and Brunnstrom stage were used to evaluate the clinical status of stroke patients. RESULTS: In normal subjects, the acceleration showed symmetric pattern. The maximum peak of vertical acceleration occurred in loading response. In stroke patients, the acceleration wave was characterized by asymmetry and polyphasicity. Maximum peak in affected side was higher than that in unaffected side (p<0.05). There were significant correlations between several elements of hemiplegic gait and the correspondent acceleration values; interval of successive peak I in vertical acceleration vs. step time, walking velocity and swing symmetry ratio vs. mean peak I, swing symmetry ratio vs. affected side peak I, step length symmetry ratio vs. peak I symmetry ratio. CONCLUSION: The accelerometer can be an easy and useful way to evaluate gait characteristics in stroke patients.

Development and Application of Cognitive Perceptual Assessment for Driving of People with Brain Injury - Comparison with Cognitive Behavioral Driver's Inventory

OBJECTIVE: We developed the Cognitive Perceptual Assessment for Driving (CPAD) to assess the driving ability of people with acquired brain injury. To find out the usefulness of this tool as a screening test for safe driving, we compared it with the Cognitive Behavioral Driver's Inventory (CBDI). METHOD: Subjects were 101 people with acquired brain injury who had driven a car before the injury. Each subject was evaluated with CPAD and CBDI. CPAD consisted of 8 tasks and 10 variables. We calculated CPAD score using 10 variables and compared CPAD with CBDI result and score. RESULTS: The average CPAD score was 49.65 7.97. According to CBDI test, the number of CBDI passing group was 36, borderline group was 27, and failing group was 38. CPAD variables and score showed significant correlation with CBDI score (p<0.05). There was significant difference in CPAD variables and score among the 3 groups (p<0.05). CONCLUSION: CPAD can be a useful tool for assessing the driving ability of the people with acquired brain injury.

Age-Related Differences in Rehabilitation Outcome in Cervical Spinal Cord Injury Patients

BACKGROUND: The growing number of spinal cord injured individuals facing old age makes the understanding of age related limitations increasingly important. This study was to investigate the age-related differences in rehabilitation outcome according to the level of cervical spinal cord injury and each category of activity of daily living(ADL). METHODS: Subjects were 79 adults with tetraplegia all of whom were admitted in National Rehabilitation Hospital. The level of injury was classified into upper cervical(C4, C5), mid-cervical(C6), and lower cervical(C7, C8) spinal cord injury. Eight ADL categories including feeding, grooming, bathing, dressing, toileting, bed-transfer, toilet/tub transfer, and indoor mobility were assessed using the scale of Spinal Cord Independence Measure. Age related differences were examined by separating the sample into two age groups(> or =40 and <40 years) RESULTS: There was no age related difference in rehabilitation outcome in upper cervical cord injury patients. In mid-cervical cord injury level, ADL capacities differed only in the feeding and grooming activities. In lower cervical cord injury level, older patients showed lower rehabilitation outcome than younger counterparts in all ADL categories examined. CONCLUSION: Along with injury level, age should be considered when formulating rehabilitation plans and functional prognostic statements in tetraplegic patients.

The Analysis of Sit-to-Stand Motion in Stroke Patients

OBJECTIVE: The ability to get up from a chair is an important component in maintaining independence and a prerequisite for upright mobility for stroke patients. The purpose of this study was to compare the sit-to-stand movement in stroke patients with that in healthy adult. METHOD: Twenty-three stroke patients and thirty-seven young healthy subjects were included in this study. Subjects sat on an adjustable chair with their feet on force plates and performed the standing up movement at a self-paced, comfortable speed. The study patients were tested barefoot. The changes in joint angle, maximal moment, power, and ground reaction force in lower limb were calculated using 3 dimensional motion analyzer throughout the sit-to-stand transfer. RESULTS: The mean time needed was significantly longer in stroke patients than in young healthy subjects. Pelvic tilting and hip flexion angle at initial and final angle were significantly greater in stroke patients than in young healthy subjects. Maximal momentum, power and change of ground reaction force in ankle joint were significantly lower in stroke patients than in young healthy subjects. Hip external rotation angle at standing point showed significant correlation with maximal hip external rotation and slow walking speed during the comfortable walking. CONCLUSION: We concluded that the analysis of sit-to-stand movement in stroke patients may provide a useful guide for gait recovery and training.

Sleep Apnea Syndrome and Prognosis in Stroke Patients

OBJECTIVE: The purpose of this study was to evaluate the prognostic value of sleep apnea syndrome in stroke patients by polysomnography. METHOD: Fifteen patients with ischemic stroke were studied with polysomnography. Medical history, sleep history, location of stroke, and severity of neurological deficit were recorded. Patients were observed by physician for evidence of snoring and excessive daytime sleepiness. Functional abilities were measured with the use of the Modified Barthel Index (MBI). To evaluate the autonomic nervous system, heart rate variability (HRV) study was done. RESULTS: Mean SaO2 during polysomnography was 88.2%, and mean recording time was 321 minutes. Apnea types were obstructive, mixed, and central. Respiratory Distress Index (RDI) correlated with functional outcome and mean SaO2. HRV study showed no significant changes under the orthostatic stress in apnea patients. CONCLUSION: We concluded that the sleep apnea syndrome could be a prognostic factor in rehabilitation outcome of stroke.

Effect on Diarrhea of Dietary Soluble Fiber Added to Nasogastric Tube-Fed Formulas in Stroke or Traumatic Brain Injury Patients

OBJECTIVE: The purpose of this study was to investigate the effect of dietary soluble fibers added to nasogastric tube-fed formulas and to compare the difference of the degree of diarrhea according to the amount of dietary soluble fibers in stroke or traumatic brain injury patients for comprehensive rehabilitative management. METHOD: Fifty-two stroke or traumatic brain injury patients fed by nasogastric tube due to dysphagia were included. They received fiber-free formulas for the first 30 days and then they were randomly assigned to three groups, including the control (fiber-free) group, moderate fiber (3.5 gm fiber/L) group and high fiber (7 gm fiber/L) group. Each group received their respective formulas for the next 30 days. We compared diarrhea score and frequency. RESULTS: In the control group, the degree of diarrhea was not changed with time. In the moderate and high fiber groups, daily diarrhea score and monthly diarrhea frequency were low compared to the control group (p<0.05). Also, the incidence of pseudomembraneous colitis was low in fiber groups. CONCLUSION: We concluded that adding dietary soluble fibers to nasogastric tube-fed formulas may be helpful to reduce the diarrhea and the development of pseudomembraneous colitis. The proper fiber amount will be determined through the following more case studies.