The Clinical Features of Preschool Children With Speech and Language Disorder and the Role of Maternal Language

Objective@#To retrospectively review the characteristics of preschool children with speech and language disorders to determine their clinical features and compares the average degrees of language delay based on hospital visit purposes, language developmental delay causes, and maternal language. @*Methods@#One thousand one hundred two children (832 males, 270 females) with the chief complaint of language or speech problems who underwent language assessment for the first time were included. Their medical records, including demographic data, language environments, and family history of language problems and other developmental problems, were collected. Furthermore, the results of language and developmental assessments and hearing tests were collected. @*Results@#Among the children enrolled in this study, 24% had parental problems and 9% were nurtured by their grandparents. The average degree of language delay did not differ regarding purposes of hospital visits. The average degree of language delay was greatest in children with autism spectrum disorders and least in children with mixed receptive–expressive language disorders. In children with mothers who do not speak Korean as their native language, social quotients in the social maturity scale were less than 70. @*Conclusion@#Language environment is an essential factor that may cause speech and language disorders. Moreover, maternal language seems to affect the social quotient of the social maturity scale.

Fall Risk Assessment of Rural Elderly Population in Korea

OBJECTIVE: To investigate the risk factors for fall in the elderly population residing in rural areas of Korea and provide useful data for their prevention. METHODS: As part of farmers’ health promotion project, a retrospective study was conducted with a total of 350 elderly people recruited from March 2016 to December 2016. These subjects were divided into two groups: 254 non-fallers and 96 fallers. A person who fell to the floor at least once in the past year was defined as a faller. Participants were asked to visit the hospital once. The demographic characteristics, social environment, and educational levels were surveyed using a questionnaire. Physical examination was performed in the following order: cognitive function, lower leg strength and torque, body composition, and knee image test. RESULTS: Statistically significant factors for falls in univariate analysis were female gender, age, living alone, educational level less than middle school, skeletal muscle mass, Mini-Mental State Exam, knee osteoarthritis, hip torque, hip power mean, knee torque, and knee power mean. Multivariate analysis was performed to identify variables most relevant to falls among statistically significant factors in univariate logistic analysis. It was confirmed that female gender and age of 70–79 years were statistically significant factors related to falls. CONCLUSION: Female gender and elderly status (70–79 years) are important risk factors for falls in rural areas underscoring the need for special attention when considering risk factors for falls among the elderly living in rural areas.

Dynamic postural stability in patients with diabetic peripheral neuropathy and relationship to presence of autonomic neuropathy

@#Diabetic neuropathy is a common complication that can negatively influence balance and is a major cause of falls. We evaluated the association between postural sway and diabetic autonomic neuropathy (DAN) among patients with diabetic peripheral neuropathy (DPN). Patients with DPN documented by typical symptoms with abnormal results of nerve conduction study were included and postural stability was assessed using dynamic posturography. Composite autonomic scoring scale (CASS) score was calculated by evaluating sudomotor, cardiovagal, and adrenergic functions. CASS score ≥2 indicated DAN and the severity of DAN was indicated by the CASS scores divided into three subscales of 10-point total CASS: none or mild autonomic failure (0-3), moderate failure (4-6), and severe failure (7-10). A total of 34 patients comprised the DAN group (n=19) and non-DAN group (n=15). Patients with DAN had higher prevalence of diabetic retinopathy(p=0.011), higher urine albumin-creatinine ratio (p = 0.009), and lower HbA1c levels (p<0.001) than those with non-DAN. With regard to dynamic postural instability, the presence (p=0.025) as well as the severity of DAN (p<0.05) was associated with postural instability in the eyes-opencondition. Interestingly, the poorer dynamic postural instability in moderate/severe DAN compared to mild DAN was observed only in medio-lateral direction and this association remained significant after adjusting for age, sex, and glycemic control state (HbA1c). In patients with DAN accompanied by DPN, the dynamic postural instability was affected by visual feedback and medio-lateral directional instability was closely associated with the severity of DAN.

Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016

“Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” is the 3rd edition of clinical practice guideline (CPG) for stroke rehabilitation in Korea, which updates the 2nd edition published in 2014. Forty-two specialists in stroke rehabilitation from 21 universities and 4 rehabilitation hospitals and 4 consultants participated in this update. The purpose of this CPG is to provide optimum practical guidelines for stroke rehabilitation teams to make a decision when they manage stroke patients and ultimately, to help stroke patients obtain maximal functional recovery and return to the society. The recent two CPGs from Canada (2015) and USA (2016) and articles that were published following the 2nd edition were used to develop this 3rd edition of CPG for stroke rehabilitation in Korea. The chosen articles' level of evidence and grade of recommendation were decided by the criteria of Scotland (2010) and the formal consensus was derived by the nominal group technique. The levels of evidence range from 1++ to 4 and the grades of recommendation range from A to D. Good Practice Point was recommended as best practice based on the clinical experience of the guideline developmental group. The draft of the developed CPG was reviewed by the experts group in the public hearings and then revised. “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” consists of ‘Chapter 1; Introduction of Stroke Rehabilitation’, ‘Chapter 2; Rehabilitation for Stroke Syndrome, ‘Chapter 3; Rehabilitation for Returning to the Society’, and ‘Chapter 4; Advanced Technique for Stroke Rehabilitation’. “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” will provide direction and standardization for acute, subacute and chronic stroke rehabilitation in Korea.

Prevalence and Related Characteristics of Carpal Tunnel Syndrome Among Orchardists in the Gyeongsangnam-do Region

OBJECTIVE: To determine the prevalence and related characteristics of carpal tunnel syndrome (CTS) in orchardists and to investigate the association between electrodiagnostic severity and physical examinations. METHODS: Between July 2013 and September 2014, 377 subjects (174 men and 203 women) visited the Gyeongsang National University Hospital's Center for Farmer's Safety and Health. All the subjects underwent electrodiagnostic tests and physical examination, including Phalen's test, Tinel's sign, and Durkan's carpal compression test (CCT). The subjects were classified into 2 groups, the normal group and the CTS group, according to electrodiagnostic test results. To determine the related characteristics of CTS, potential variables, including age, sex, drinking, smoking, body mass index, waist circumference, and total work time, were compared between the 2 groups. The association between electrodiagnostic severity and physical examinations was analyzed. RESULTS: CTS was diagnosed in 194 subjects based only on electrodiagnostic test results, corresponding to a prevalence of 51.5%. Among the variables, mean age (p=0.001) and total work time (p=0.007) were significantly correlated with CTS. With respect to the physical examinations, low specificities were observed for Tinel's sign, Phalen's test, and Durkan's CCT (38.4%, 36.1%, and 40.9%, respectively) in the subjects aged ≥65 years. In addition, Phalen's test (p=0.003) and Tinel's sign (p=0.032) in men and Durkan's CCT (p=0.047) in women showed statistically significant differences with increasing CTS severity. The odds ratio was 2.066 for Durkan's CCT in women according to the multivariate logistic regression analysis. CONCLUSION: CTS prevalence among orchardists was high, and Durkan's CCT result was significantly quantitatively correlated with the electrodiagnostic test results. Therefore, Durkan's CCT is another reliable examination method for CTS.

An infant with cerebellar tumor presenting with torticollis as the only initial symptom

Torticollis is an usual symptom that can be the result of various disorders, such as sternocleidomastoid muscle pathology, bony abnormalities of the cervical spine, disorders of the central or peripheral nervous system, various ocular diseases, and brain tumors, especially in children. A 12-month-old male visited our hospital because of torticollis. He was normal on systemic examination, with no neurological abnormality, and his cervical spine CT was also normal. About 4 weeks later, he revisited the emergency department due to vomiting with altered mental status, and was diagnosed with a cerebellar tumor with hemorrhage. Although torticollis is known to be an important sign of a posterior fossa tumor, associated neurological or ocular symptoms are usually present. We report here a patient with posterior fossa tumor where torticollis was the only initial presenting symptom.

An infant with cerebellar tumor presenting with torticollis as the only initial symptom

Torticollis is an usual symptom that can be the result of various disorders, such as sternocleidomastoid muscle pathology, bony abnormalities of the cervical spine, disorders of the central or peripheral nervous system, various ocular diseases, and brain tumors, especially in children. A 12-month-old male visited our hospital because of torticollis. He was normal on systemic examination, with no neurological abnormality, and his cervical spine CT was also normal. About 4 weeks later, he revisited the emergency department due to vomiting with altered mental status, and was diagnosed with a cerebellar tumor with hemorrhage. Although torticollis is known to be an important sign of a posterior fossa tumor, associated neurological or ocular symptoms are usually present. We report here a patient with posterior fossa tumor where torticollis was the only initial presenting symptom.

Retrospective Assessment of the Implementation of Critical Pathway in Stroke Patients in a Single University Hospital

OBJECTIVE: To evaluate the effects of the implementation of critical pathway (CP) in stroke patients treated at a single university hospital. METHODS: A retrospective medical review collected data from 497 patients who had suffered acute stroke in the rehabilitation center. Stroke outcomes were compared between before and after the implementation of CP based on factors including demographic factors, stroke characteristics, pre-existing medical conditions, medical complications, functional states, and length of stay (LOS). RESULTS: After the implementation of CP, the patients showed significantly higher stage for upper proximal (p=0.008) and lower extremity (p=0.001) on Brunnstrom stage and significantly lower scores for modified Rankin Scale (p=0.003) at transfer. For those with pre-existing medical conditions, there were significantly increased osteoarthritis (p=0.002) and valvular heart disease (p=0.011). Regarding medical complications during acute inpatient rehabilitation, there were significantly decreased shoulder pain (p=0.001) and dysphagia (p=0.017), and significantly increased gastrointestinal symptoms (p=0.001). Functional gain and efficiency of stroke patients during rehabilitation center hospitalization did not significantly change after implementation of CP. But, shorter LOS of total hospitalization, pre-rehabilitation center hospitalization, and rehabilitation center hospitalization were evident. CONCLUSION: After the implementation of CP, patients less often developed complications and displayed no changes in functional gain and efficiency. They had shorter LOS of total hospitalization, pre-rehabilitation center hospitalization and rehabilitation center hospitalization.

Terson Syndrome after Subarachnoid Hemorrhage Occurred by Thrombolysis and Mechanical Thrombectomy to Treat Acute Ischemic Stroke: A Case Report

Terson syndrome is a vitreous hemorrhage associated with subarachnoid hemorrhage. This can be caused by spontaneous, aneurysmal rupture or traumatic subarachnoid hemorrhage, but never has been reported as a consequence of hemorrhage due to thrombolysis and thrombectomy treatments of acute ischemic stroke patient. A 48-year-old man presented with left sided weakness was diagnosed as cerebral infarction on right middle cerebral artery territory due to complete occlusion of right distal internal carotid, middle cerebral, and anterior cerebral artery. He underwent thrombolysis and mechanical thrombectomy, and subarachnoid hemorrhage developed. Later, visual disturbance on right eye occurred so he was consulted to ophthalmology. Vitreous hemorrhage was found and surgery was recommended after two weeks of observation. After pars planar vitrectomy, visual acuity improved, along with functional ability. Therefore, possibilities of Terson syndrome in patients with subarachnoid hemorrhage have to be kept in mind to improve not only visual acuity but also rehabilitation outcome.

The Effect of Extracorporeal Shock Wave Therapy on Lower Limb Spasticity in Subacute Stroke Patients

OBJECTIVE: To evaluate the effect of extracorporeal shock wave therapy (ESWT) on lower limb spasticity in subacute stroke patients. METHODS: We studied thirty hemiplegic subacute stroke patients with ankle plantar flexor spasticity. ESWT was applied for 1 session/week, with a total of 3 sessions at the musculotendinous junction of medial and lateral gastrocnemius muscles. Patients were evaluated both clinically and biomechanically at baseline, after sham stimulation, and at immediately 1 week and 4 weeks after ESWT. For clinical assessment, Modified Ashworth Scale (MAS), clonus score, passive range of motion of ankle, and Fugl-Myer Assessment for the lower extremity were used. A biomechanical assessment of spasticity was conducted by an isokinetic dynamometer. Two parameters, peak eccentric torque (PET) and torque threshold angle (TTA), were analyzed at the velocities of 60degrees/sec, 180degrees/sec, and 240degrees/sec. RESULTS: After sham stimulation, there were no significant changes between each assessment. MAS and PET (180degrees/sec and 240degrees/sec) were significantly improved immediately and 1 week after ESWT. However, these changes were not significant at 4 weeks after ESWT. PET (60degrees/sec) and TTA (60degrees/sec, 180degrees/sec, and 240degrees/sec) were significantly improved immediately after ESWT. Yet, these changes were not significant at 1 week and 4 weeks after ESWT as well. CONCLUSION: Lower limb spasticity in subacute stroke patients was significantly improved immediately after ESWT. Although the therapeutic effect of ESWT reduced with time and therefore was not significant at 4 weeks after ESWT, the degree of spasticity was lower than that of the baseline. Future studies with a larger sample of patients are warranted in order to verify the protocols which can optimize the effect of ESWT on spasticity.

Middle Cerebral Artery Territory Infarction Caused by Giant Middle Cerebral Artery Dissecting Aneurysm

Dissecting aneurysm of the intracranial arteries is a rare cause of stroke. This condition may induce both ischemic stroke and hemorrhagic stroke by occlusion of the parent artery via direct distortion and stretching, compression secondary to growth of the aneurism, and distal embolization of any intra-aneurysmal thrombi. A patient with an infarction in the right middle cerebral artery territory and a mass lesion located in the right basal ganglia and temporal lobe was examined in this study. The consequent workup suggested that the mass lesion was a huge dissecting aneurysm that had resulted in a cerebral infarction.

Middle Cerebral Artery Territory Infarction Caused by Giant Middle Cerebral Artery Dissecting Aneurysm

Dissecting aneurysm of the intracranial arteries is a rare cause of stroke. This condition may induce both ischemic stroke and hemorrhagic stroke by occlusion of the parent artery via direct distortion and stretching, compression secondary to growth of the aneurism, and distal embolization of any intra-aneurysmal thrombi. A patient with an infarction in the right middle cerebral artery territory and a mass lesion located in the right basal ganglia and temporal lobe was examined in this study. The consequent workup suggested that the mass lesion was a huge dissecting aneurysm that had resulted in a cerebral infarction.

Incidentally Discovered Direct Carotid-Cavernous Fistula in a Patient With Anterior Choroidal Artery Territory Infarction

Direct carotid cavernous fistula (CCF), which is an abnormal communication between the intracavernous carotid artery and the cavernous sinus, is a very rare condition that is generally associated with head trauma, intracavernous aneurysms, and certain connective-tissue diseases. The case of a patient with an infarction in the anterior choroidal artery territory is described herein. Cerebral angiography was performed during consecutive workups to investigate the discrepancy between the magnetic resonance angiography data. An unexpected direct CCF of the ipsilateral side of the infarction was found. It is possible that the CCF had influenced the development of the infarction in the anterior choroidal artery territory.

Incidentally Discovered Direct Carotid-Cavernous Fistula in a Patient With Anterior Choroidal Artery Territory Infarction

Direct carotid cavernous fistula (CCF), which is an abnormal communication between the intracavernous carotid artery and the cavernous sinus, is a very rare condition that is generally associated with head trauma, intracavernous aneurysms, and certain connective-tissue diseases. The case of a patient with an infarction in the anterior choroidal artery territory is described herein. Cerebral angiography was performed during consecutive workups to investigate the discrepancy between the magnetic resonance angiography data. An unexpected direct CCF of the ipsilateral side of the infarction was found. It is possible that the CCF had influenced the development of the infarction in the anterior choroidal artery territory.

Medial Antebrachial Cutaneous Nerve Injury After Brachial Plexus Block: Two Case Reports

Medial antebrachial cutaneous (MABC) nerve injury associated with iatrogenic causes has been rarely reported. Local anesthesia may be implicated in the etiology of such injury, but has not been reported. Two patients with numbness and painful paresthesia over the medial aspect of the unilateral forearm were referred for electrodiagnostic study, which revealed MABC nerve lesion in each case. The highly selective nature of the MABC nerve injuries strongly suggested that they were the result of direct nerve injury by an injection needle during previous brachial plexus block procedures. Electrodiagnostic studies can be helpful in evaluating cases of sensory disturbance after local anesthesia. To our knowledge, these are the first documented cases of isolated MABC nerve injury following ultrasound-guided axillary brachial plexus block.

Lance-Adams Syndrome

It is not common for a patient who survives cardiac arrest to experience significant neurologic impairment such as acute and chronic post-hypoxic myoclonus, known as Lance-Adams syndrome. This syndrome is predominantly characterized by myoclonus that starts days to weeks after cardiopulmonary resuscitation in patients who regained consciousness. Although several cases of LAS were reported, the decisive treatment method has not been established. We report a 43 year old man with Lance-Adams syndrome who showed long-term improvement through treatment with anti-myoclonic agents and participation in a rehabilitation program.

The Effect of Human Placental Extract on Rheumatoid Arthritis in an Animal Model

OBJECTIVE: To assess the efficacy of human placental extract (HPE) in an animal model of rheumatoid arthritis (RA). METHOD: We used (i) KRN C57BL/6 TCR transgenic x NOD mice (KBx/N) serum transfer arthritis and (ii) collagen-induced arthritis (CIA) mice to evaluate the effi cacy of HPE (1 ul or 100 ul, intra-peritoneal, three times per week) on RA. Incidence, severity of arthritis, and hind-paw thickness were quantifi ed. Joint destruction was analyzed using modifi ed mammographic imaging. Histopathological analysis for inflammation, cartilage, and osteoclasts was performed using Hematoxylin-eosin (H-E), safranin-O, and tartrate-resistant acidic phosphatase (TRAP). ELISAs were used for detection of various cytokines in serum and joint tissue. RESULTS: There were no significant differences in incidence of arthritis, clinical scores of arthritis, and hind-paw thickness between HPE-treated and vehicle-treated groups for up to 2 weeks in the KBx/N serum transfer arthritis model. Histopathological analysis also showed no differences 2 weeks after treatment. Levels of TNF-alpha, IL-1beta, IL-6, IL-10, and RANKL in serum and joint tissues were similar in all groups. Furthermore, there were no differences in clinical, radiological, and histological parameters between HPE-treated and vehicle-treated group for 3 weeks in the CIA model. CONCLUSION: Systemic treatment with HPE has no beneficial effects on arthritis in animal models of RA. Therefore, indiscreet use of HPE in RA should be forbidden.

The Effect of Human Placental Extract on Rheumatoid Arthritis in an Animal Model

OBJECTIVE: To assess the efficacy of human placental extract (HPE) in an animal model of rheumatoid arthritis (RA). METHOD: We used (i) KRN C57BL/6 TCR transgenic x NOD mice (KBx/N) serum transfer arthritis and (ii) collagen-induced arthritis (CIA) mice to evaluate the effi cacy of HPE (1 ul or 100 ul, intra-peritoneal, three times per week) on RA. Incidence, severity of arthritis, and hind-paw thickness were quantifi ed. Joint destruction was analyzed using modifi ed mammographic imaging. Histopathological analysis for inflammation, cartilage, and osteoclasts was performed using Hematoxylin-eosin (H-E), safranin-O, and tartrate-resistant acidic phosphatase (TRAP). ELISAs were used for detection of various cytokines in serum and joint tissue. RESULTS: There were no significant differences in incidence of arthritis, clinical scores of arthritis, and hind-paw thickness between HPE-treated and vehicle-treated groups for up to 2 weeks in the KBx/N serum transfer arthritis model. Histopathological analysis also showed no differences 2 weeks after treatment. Levels of TNF-alpha, IL-1beta, IL-6, IL-10, and RANKL in serum and joint tissues were similar in all groups. Furthermore, there were no differences in clinical, radiological, and histological parameters between HPE-treated and vehicle-treated group for 3 weeks in the CIA model. CONCLUSION: Systemic treatment with HPE has no beneficial effects on arthritis in animal models of RA. Therefore, indiscreet use of HPE in RA should be forbidden.

Reliability of the Pinch Strength with Digitalized Pinch Dynamometer

OBJECTIVE: To examine the intra-rater, inter-rater, and inter-instrumental reliability of the digitalized pinch muscle strength dynamometer. METHOD: Thirty normal subjects were examined for pinch strength, using both the Preston pinch gauge and the digitalized pinch dynamometer. The participants performed all pinch strength tests in the seated position as recommended by the American Society of Hand Therapists (ASHT). Three successive measurements were taken for each hand. The mean of the three trials was used for data analysis. The pinch strength tests performed used a repeated measure design and measurements were taken by each rater. RESULTS: The relationship between the Preston pinch gauge and the digitalized pinch dynamometer in pinch strength was reliable (the ICC were 0.821 and 0.785 in rater 1 and rater 2 respectively). The relationship between the first session and second session in pinch strength using the digitalized pinch dynamometer was reliable (the ICC were 0.872 and 0.886 in rater A and rater B respectively). The relationship between rater A and rater B in pinch strength using the digitalized pinch dynamometer was reliable (the ICC was 0.754). CONCLUSION: The pinch strength measurement using the digitalized pinch dynamometer is reliable within the rater and between raters. Thus, the Preston pinch gauge and the digitalized dynamometer measure grip strength equivalently, and can be used interchangeably.

The Availability of Radiological Measurement of Tibial Torsion: Three-Dimensional Computed Tomography Reconstruction

OBJECTIVE: To assess the intra-rater and inter-rater reliability for measuring tibial torsion measurements by a radiographic method using three-dimensional computed tomography reconstruction (3D-CT) and to compare the physical measures to those of 3D-CT. METHOD: The study included 33 children who presented with intoeing gait. Tibial torsion was measured by 3D-CT. Distal reference point was the bimalleolar axis. Proximal reference points were the transtibial axis and posterior condylar axis. Physical measurements included thigh-foot angle (TFA) and bimalleolar angle (BMA). 3D-CT measurement and physical measurement were performed twice at both lower extremities by each rater. The intra-rater and inter-rater reliability were calculated by intraclass correlation coefficiency (ICC). The relationship between radiological and physical examination was calculated by Spearman correlation coefficient. RESULTS: The 3D-CT measures for tibial torsion were reliable within individual raters and between different raters. However, physical measures for tibial torsion were reliable within an individual rater but not reliable between raters. The 3D-CT measures by any proximal reference axis were more reliable within a rater and between raters than physical measurements. There was no significant impact introduced by the selection of the proximal reference axis. The correlation coefficiency between 3D-CT and physical measurement methods was low. CONCLUSION: Because the 3D-CT measurements for tibial torsion are more reliable than physical measurements, we recommend that accurate diagnosis of internal tibial torsion should be detected by using 3D-CT measurements. Also, considering the disadvantages of radiological measurements, physical measurement may be used for short term follow-up by same raters, as intra-rater reliability is relatively good.