Delayed-Onset Dysphagia after Whiplash Injury: A Case Report / 대한연하장애학회지

Various symptomatic complaints, including dysphagia, have been reported by patients with whiplash injury, which greatly impacts their life. There are few reports on the treatment and progression of dysphagia following whiplash injuries. This case report describes a patient who presented with delayed dysphagia after a whiplash injury. A 37-year-old female visited the Department of Rehabilitation Medicine of our institution and presented with delayed dysphagia one year after a traffic accident. At the time of the accident, the patient was diagnosed with a whiplash injury and had no symptoms of dysphagia. A videofluoroscopic swallowing study revealed decreased laryngeal elevation and impaired upper esophageal sphincter opening in the pharyngeal phase. The Penetration-Aspiration Scale score was 3 for pureed food and 7 for liquid food. Laryngeal needle electromyography showed abnormal spontaneous activity in both cricothyroid muscles. The patient underwent swallowing rehabilitation for oropharyngeal dysphagia. There were recurrences of improvement and deterioration during the treatment period. However, after five months, problems related to swallowing improved until there were no complaints. Our study indicates a differentiated treatment approach and the importance of continuous rehabilitation for dysphagia after a whiplash injury.

Dysphagia after Multiple Fractures of the Neck Structures Due to Near-Hanging: A Case Report / 대한연하장애학회지

Although hanging is the most common method of suicide in Korea, there are few reports of dysphagia following laryngeal injuries due to near-hanging. This is a case report of a patient who complained of dysphagia after a complex fracture of the neck structures caused due to attempted suicide by hanging. A 51-year-old male visited our hospital with neck injuries after a near-hanging episode. Laryngoscopy suspected dislocation of the right arytenoid cartilage. A computed tomography (CT) scan revealed fractures of the right hyoid bone and thyroid cartilage, as well as soft tissue emphysema. A closed reduction for the dislocation of the right arytenoid cartilage was performed. After surgery, oral feeding was attempted five days after surgery but stopped due to a large amount of aspiration. After two weeks, a videofluoroscopic swallowing study (VFSS) revealed a decreased laryngeal elevation and severe impairment of the upper esophageal sphincter opening. The patient was then given rehabilitation for oropharyngeal dysphagia to restore swallowing function. Four months after the injury, VFSS showed that the residue in the pyriform sinus after multiple swallowing attempts decreased compared to the previous studies. However, oral diet and enteral feeding were combined due to the patient experiencing early fatigue due to swallowing difficulties.Our observations, in this case, show that it was necessary to provide treatment through a multidisciplinary approach coupled with long-term follow-up for patients with dysphagia after complex fractures by near-hanging.

The Korean Dysphagia Society (KDS) Position Statement for Oropharyngeal Dysphagia / 대한연하장애학회지

Oropharyngeal dysphagia is a clinical condition caused by various underlying diseases and is characterized by difficulty in swallowing. Diagnosis and treatment of oropharyngeal dysphagia require multidisciplinary consultations. This position statement for oropharyngeal dysphagia was developed by The Korean Dysphagia Society (KDS) to outline its position on oropharyngeal dysphagia. The clinical practice guideline, position statements, a recent meta-analysis, a systematic review, and randomized controlled trials for oropharyngeal dysphagia were all performed. An expert Delphi survey was also done to achieve a consensus of opinion on this position statement. This position statement for oropharyngeal dysphagia aims to help make evidence-based decisions in clinical practice, improve clinical evaluation and manage oropharyngeal dysphagia in Korea.

Quantitative Evaluation of Post-stroke Spasticity Using Neurophysiological and Radiological Tools: A Pilot Study

OBJECTIVE: To determine the possibility of a new measurement tool using electromyography and ultrasonography for quantitative spasticity assessment in post-stroke patients. METHODS: Eight hemiplegic stroke patients with ankle plantarflexor spasticity confirmed by a Modified Ashworth Scale (MAS) were enrolled. Spasticity was evaluated using the MAS and Modified Tardieu Scale (MTS). Each subject underwent surface electromyography (sEMG) using the Brain Motor Control Assessment (BMCA) protocol and was compared with a healthy control group. Using ultrasonography, muscle architecture and elasticity index were measured from the medial gastrocnemius muscle (GCM) on the affected and unaffected sides. RESULTS: MAS and MTS revealed significant correlation with sEMG activity. The fascicle length and pennation angle were significantly decreased in the medial GCM on the hemiplegic side compared with the unaffected side. The elasticity index of the spastic medial GCM was significantly increased compared with the unaffected side. The MTS X and R2–R1 values were significantly correlated with the elasticity index in the hemiplegic GCM. The relationship between clinical evaluation tools and both BMCA and sonoelastography was linear, but not statistically significant in the multiple regression analysis. CONCLUSION: The BMCA protocol and ultrasonographic evaluation provide objective assessment of post-stroke spasticity. Further studies are necessary to conduct accurate assessment and treatment of spasticity.

Identifying the KAT6B Mutation via Diagnostic Exome Sequencing to Diagnose Say-Barber-Biesecker-Young-Simpson Syndrome in Three Generations of a Family

Diagnostic exome sequencing (DES) is a powerful tool to analyze the pathogenic variants leading to development delay (DD) and intellectual disability (ID). Recently, heterozygous de novo mutation of the histone acetyltransferase encoding gene KAT6B has been recognized as causing a syndrome with congenital anomalies and intellectual disability, namely Say-Barber-Biesecker-Young-Simpson (SBBYS) syndrome. Here we report a case of SBBYS syndrome in a third generation Korean family affected with a missense mutation in KAT6B, c.2292C>T p.(His767Tyr) identified by DES. This is the first confirmed familial inherited mutation of the KAT6B reported worldwide. Our case emphasizes again the importance of basic physical examination and taking a family history. Furthermore, advances in genetic diagnostic tools are becoming key to identifying the etiology of DD and ID. This allows a physiatrist to predict the disease's clinical evolution with relative certainty, and offer an appropriate rehabilitation plan for patients.

Evidence Based Review of Neuromuscular Electrical Stimulation for Swallowing / 대한연하장애학회지

Neuromuscular electrical stimulation (NMES) is a relatively new therapeutic approach for dysphagia, involving the application of electrical current across the skin to excite the nerve or muscle tissue. Recently, investigators are trying to establish a scientific basis for NMES, but there is still debate over the effect of NMES in dysphagia rehabilitation. Moreover, there is a paucity of evidence about patient selection, electrode placement, stimulation parameters, and application duration. This paper is aimed to review recent evidence of NMES for dysphagia management.

Posterior Deltoid-to-Triceps Tendon Transfer for Elbow Extension in a Tetraplegia Patient: A Case Report

In tetraplegia patients, activities of daily living are highly dependent on the remaining upper limb functions. In other countries, upper limb reconstruction surgery to improve function has been applied to diverse cases, but few cases have been reported in Korea. The current authors experienced a case of posterior deltoid-to-triceps tendon transfer and rehabilitation in a complete spinal cord injury with a C6 neurologic level, and we introduce the case-a 36-year-old man-with a literature review. The patient's muscle strength in C5 C6 muscles were normal, but C7 muscles were trace, and the Spinal Cord Independence Measure III (SCIM III) score was 24. The tendon of the posterior deltoid was transferred to the triceps brachii muscle, and then the patient received comprehensive rehabilitative treatment. His C7 muscle strength in the right upper extremity was enhanced from trace to fair, and his SCIM III score improved to 29.

The Effect of Post-Stroke Depression on Rehabilitation Outcome and the Impact of Caregiver Type as a Factor of Post-Stroke Depression

OBJECTIVE: To evaluate the effect of post-stroke depression (PSD) on rehabilitation outcome and to investigate the risk factors of PSD, especially, the role of caregivers type (family or professional) in subacute stroke patients. METHODS: Two hundred twenty-six stroke patients were enrolled retrospectively. All the subjects' basic characteristics, Korean version of the Beck Depression Inventory (K-BDI), Korean version of the Modified Barthel Index (K-MBI), and the modified Rankin Scale (mRS) were recorded when the patient was transferred into the Department of Rehabilitation Medicine and at the time of discharge. The results were statistically analyzed by using SPSS ver. 20.0. RESULTS: The patients' K-BDI score showed a significantly negative association with K-MBI at discharge (beta=-0.473, p<0.001) and a significantly positive association with the mRS score at discharge (beta=0.316, p<0.001). Patients with lesions on the left hemisphere (odds ratio [OR], 3.882; 95% confidence interval [CI], 1.726-8.733) and professional caregiver support (OR, 0.028; 95% CI, 0.012-0.065) had a higher rate of depression. CONCLUSION: Depression was prevalent in stroke patients, and it had a negative effect on patients' functional outcome. Patients who had a lesion on the right hemisphere had less depression. The type of caregiver was related to the incidence of subacute PSD, and family caregivers were found to lower the frequency of stroke patients' depression.

Mirror Writing after Thalamic Hemorrhagic Stroke: A Case Report

Mirror-writing is the process of reversing individual letter and composing word sequence in opposite direction. Unintentional mirror writing has been observed in young children learning to write and interpreted as the manifestation of different cognitive impairments. It is very rare that normal right-handed adult shows mirror writing. However, the acquired "mirror writing" may be shown in left hemispheric stroke, neurodegenerative disease, and diffuse cerebral disorders. To explain this event, some assumption have been indicated such as the motor, the visual dominance, the supplementary motor area, the visio-spatial, the visual word-form, the hemispatial factor or directional and the reflected graphemic representation hypotheses. It is reported that the lesions which causes the "Mirror-writing" are the parietal lobe, basal ganglia, thalamus and right supplementary motor area, etc. We reported a case of "mirror-writing" with left thalamic hemorrhagic stroke.

Virtual reality based stroke rehabilitation

Virtual reality (VR) is defined as an approach to user-computer interface that involves real-time simulation of an environment, scenario, or activity that allows for user interaction via multiple sensory channels. In recent years, virtual reality has grown immensely with rapid advancement of VR technologies in the field of stroke rehabilitation. In this paper, current VR applications to the field of rehabilitation are reviewed. In the field of stroke rehabilitation, many clinical trials related to VR-based assessment and treatment have been performed to assess and treat arm dysfunction, walking ability, visuospatial problems, cognitive dysfunction, etc. Among them, VR is beneficial in improving arm function when compared with conventional therapy with limited evidence. Whether VR improves walking, visuospatial problems, or cognitive function has not been well established yet. However, VR can simulate the real environment without the risks arising from errors, and can also give a sense of immersion in the simulated environment and a concomitant feeling of 'presence'. Moreover, VR provides the motivation of gaming factors. With these advantages, VR will be one of the major advanced technologies for assessment and managing post-stroke dysfunction in the future.

Effects of Ankle Foot Orthosis on Post-stroke Hemiplegic Gait -A Meta-analysis-

OBJECTIVE: The aim of this meta-analysis was to investigate the effects of ankle foot orthosis on adult post-stroke hemiplegic patients' walking ability and pattern. METHOD: We searched for the case controlled clinical trials about the effects of ankle foot orthosis (AFO) for walking ability and pattern using quantitative gait analysis in adult post-stroke patients, which published between January 1950 and July 2012 in PubMed, and searching engine of Journal of Korean Academy of Rehabilitation Medicine. The mean standardized difference (MSD) and a 95% confidence interval (CI) were estimated for gait ability and pattern using fixed effect models. RESULTS: Sixteen of the 56 articles were included in this analysis. The selected studies involved a total of 274 patients. The walking speed, cadence, the portion of double limb supporting, stride length on affected side, the portion of swing period on unaffected side, and symmetry of swing period were improved by AFO. The oxygen cost was decreased by AFO. The AFO did improve ankle dorsiflexion at initial contact, maximal ankle dorsiflexion at swing phase, but the ankle plantar flexion at push-off did not. CONCLUSION: The ankle foot orthosis has some evidence to improve the walking ability and gait pattern in post-stroke hemiplegic patients.

Improvement of Chronic Post-Stroke Hemiparetic Upper Limb Function after 2 Week Trascranial Direct Current Stimulation

OBJECTIVE: To investigate whether transcranial direct current stimulation (tDCS) could improve the motor function of hemiparetic upper limb in chronic stroke patients through randomized double-blinded, sham-controlled study. METHOD: Twenty chronic post-stroke hemiparetic patients participated in this study. They were randomly assigned into either tDCS or sham group. Anodal tDCS was delivered on lesional primary motor cortex for 20 minutes in tDCS group and 30 seconds in sham group. Just after stimulation, both groups performed the shaping exercise for 30 minutes. Total 10 stimulation sessions (5 session/week for 2 weeks) were administered. Fugl-Meyer motor assessment, box and block test, grasp strength and FIM were assessed before stimulation, after 1 week of stimulation, after 2 weeks of stimulation, and 2 weeks after stimulation. RESULTS: The upper extremity score of Fugl-Meyer motor assessment and box and block test improved significantly in tDCS group compared to sham group (p<0.05). Their improvement lasted significantly for 2 week after stimulation. However, FIM, lower extremity score of Fugl-Meyer motor assessment and grasp power did not improved significantly in tDCS group compared to sham group. CONCLUSION: tDCS can improve the motor function of hemiparetic upper limb in chronic post-stroke patients, and the effects lasted after stimulation. tDCS may be used as an additional tool for stroke rehabilitation.

Nonfluent Crossed Aphasia after Right Middle Cerebral Artery Infarction: A case report

Crossed aphasia refers to language disturbance induced by unilateral right hemisphere (non-language dominant) injury in right-handed people who had no previous history of brain damage. Crossed aphasia occurs in less than 2 percent who developed a aphasia. We report a case of a 49-year-old right handed man with language disturbance after right middle cerebral infarction. He showed nonfluent crossed aphasia with Gerstman syndrome such as right-left disorientation, finger agnosia, acalculia and agraphia, but not with apraxia and neglect. At 7 weeks after onset, language function indicated improvement in spontaneous speech and at 19 weeks after onset, improvement in spontaneous speech, comprehension, repetition, naming and reading.

Mirror-writing after Corpus Callosum Lesion Induced by Both Posterior Cerebral Artery Infarction: A case report

"Mirror-writing" is the simultaneous process of reversing individual letters and composing word strings in reverse direction. It is reported that the lesions which cause "mirror-writing" are left parietal lobe, left basal ganglia, right supplementary motor area, left supplementary motor area, left cingulate gyrus, and left angular gyrus. To explain this phenomenon, several theories have been proposed such as the motor, the visual dominance, the supplementary motor area, the visio-spatial, the visual word- form, the hemisaptial factor or directional and the reflected graphemic representation hypotheses. With reviewing some of literatures, we present a case of "mirror- writing" of posterior corpus callosum lesion which is not included in the aforementioned those.

Factors Affecting Drooling in Adult Patients with Traumatic Brain Injury

OBJECTIVE: To investigate whether drooling in patients with traumatic brain injury (TBI) is due to hypersalivation or cognitive dysfunction or disability. METHOD: The subjects were 24 TBI patients with drooling and 17 TBI patients without drooling and 20 unaffected healthy volunteers who had no known physical or mental disabilities. All participants had no known history of diabetes mellitus, hypertension, thyroid dysfunction or chronic alcoholism. And, we excluded the subjects who take the anticholinergics, beta-agonist or steroid. Salivary pH and flow rate were compared between the TBI groups and the control group. We also measured Korean mini-mental state examination (K-MMSE) and disability rating scale (DRS) and compared mean values between TBI groups. RESULTS: There was no statistical difference in the mean salivary pH and flow rate between the tested groups. The drooling severity and frequency showed no correlation with salivary flow rate in all groups. The drooling severity and frequency showed significant correlations with K-MMSE, but not with DRS in TBI groups. CONCLUSION: The results of this study suggested that the cause of drooling in patients with TBI may not be the hypersalivation and functional disability, but cognitive dysfunction.

The Evaluation of Bony Union after Posterior Occipitocervical Fusion / 대한척추외과학회지

STUDY DESIGN: The results of posterior occipitocervical fusions were analyzed retrospectively based on the results of post-operative radiographs. OBJECTIVES: To investigate subjective methods for the evaluation of occipitocervical stabilization by posterior fusion. SUMMARY OF LITERATURE REVIEW: Few studies have been performed that describe the methods utilized for the evaluation of the union of the instrumented segments. MATERIALS AND METHODS: Occipitocervical fusions were performed in 16 patients from 1995 to 2004. The patients underwent occipitocervical fusions with autogenous iliac bone grafting and wire fixation (5), loop and sublaminar wire fixation (3), C-D occipitocervical rod (2), and contoured reconstruction plate (6). The stability and failure of the instrumentation in the fusion sites were evaluated with flexion/extension lateral radiographs. The stability was evaluated by a change in the degrees and distances between the occiput and cervical vertebrae. RESULTS: Two of five patients who had undergone wire fixation with autogenous bone grafting were considered to have a nonunion because of persistent segmental instability: greater than 2 degrees and 2 mm three months postoperatively. In the other patients, we were unable to determine the presence of a solid fusion mass at the fusion site, because of overlapping of the instrumentation devices and graft bones. However, since there was no definite motion that indicated segmental instability and instrumentation breakage or loosening on flexion and extension radiographs, we considered these as stable fixations. CONCLUSION: It was difficult to evaluate whether or not the grafts were incorporated into the recipient sites, due to the complexity of the occipitocervical junction and the overlapping of the instrumentation. After removal of the external immobilization 3 months postoperatively, although flexion/extension radiographs taken 6 months postoperatively, demonstrated no motion at the fusion site, the occipitocervical fusions were judged to be stabilized rather than fused.

The Positive Rate of Serum Rheumatoid Factor in Health Screening Subjects and Related Factors

BACKGROUND: This study was done to estimate the prevalence of Rheumatoid Factor (RF) positive rate in adult Korean population and to investigate the association between rheumatoid factor positive rate and related factors. METHODS: The database from 4,678 subjects, who visited a general health screening center of an university hospital during 1 year period were surveyed. RF was tested using a commercial latex test kit, HBsAg by RIA of 3rd generation, anti-HCV by EIA of 3rd generation and serum AST, ALT by enzyme kinetic method. Syphilis was checked using RPR test and TPHA. Lung diseases (tuberculosis, IPF) were screened using chest X-ray. Flukes was checked by sedimentation method and cestodes was by direct method in stool tests. Smokers were based on history on health screening. RESULTS: 1) The positive rate of RF was 4.4%, HBsAg was 5.9%, anti-HCV was 1.5% and ALT>35 IU/L was 18.4%. The number of syphilis subjects was 19, lung diseases was 119, parasitic diseases was 43, and smokers was 1,299. 2) RF positive rate of males was 4.0%, females was 5.3%. Therefore, the positivity of females was higher than males and RF positivite rate was increased in the higher age groups. 3) RF positive rate in HBsAg (+) subjects was 18.1% and HBsAg (-) was 3.6% and in anti-HCV (+) subjects was 10.3% and anti-HCV (-) was 4.3%. 4) RF positive rate of subjection both positive reactions of RPR test and TPHA, namely, syphilis tests was 21.1%. 5) RF positive rate of parasitic diseases was 4.7%, lung diseases was 2.5% and smokers was 4.2%. 6) RF positive rate was highly associated with HBsAg, syphilis, anti-HCV, female sex, age in order of sequence. CONCLUSION: The positive rate of RF in healthy Korean adults can be estimated to be 4.5% and shows high association with hepatitis B and C virus infection in addition to syphilis, age and sex.

Clinicopathological Features of Malignant Lymphoma Detected by Colonoscopy: An Analysis According to the Endoscopic Classification / 대한소화기내시경학회지

BACKGROUND/AIMS: There have been only a few endoscopic studies of lower intestinal lesions of malignant lymphoma. The aims of this study were to classify the ileocolonic lymphomas according to the colonoscopic findings and to reveal the clinicopathological relationship according to the classes. METHODS: Subjects were 24 cases of ileocolonic lymphomas. We evaluated the clinicopathological features according to their endoscopic findings. RESULTS: The chief complaints were abdominal pain, bleeding, and abdominal mass. Twenty-six lesions from 22 patients, excluding 2 multiple lymphomatous polyposis, were endoscopically classified as follows: fungating (10 lesions), ulcerofungating (7 lesions), infiltrative (5 lesions), ulceroinfiltrative (3 lesions), and ulcerative (1 lesion). The location of the lesions was the terminal ileum in 11 lesions, the colon in 10 lesions, and both regions in 5 lesions. Within the large bowel, the cecum was involved most frequently, followed by the ascending colon and the remainder. Most of pathological types were the diffuse large cell and the large cell immunoblastic. There was no relationship between the endoscopic findings and the histologic types. Eight cases were manifested as intussusception. CONCLUSIONS: Ileocolonic lymphomas can be classified endoscopically into five types. Among the types, fungating and ulcerofungating types are the most frequent.