Benefits of Robot-Assisted Upper-Limb Rehabilitation from the Subacute Stage after a Stroke of Varying Severity: A Multicenter Randomized Controlled Trial.

BACKGROUND: The aim of this study was to compare the clinical effectiveness of robot-assisted therapy with that of conventional occupational therapy according to the onset and severity of stroke. METHODS: In this multicenter randomized controlled trial, stroke patients were randomized (1:1) to receive robot-assisted therapy or conventional occupational therapy. The robot-assisted training group received 30 min of robot-assisted therapy twice and 30 min of conventional occupational therapy daily, while the conventional therapy group received 90 min of occupational therapy. Therapy was conducted 5 days/week for 4 weeks. The primary outcome was the Wolf Motor Function Test (WMFT) score after 4 and 8 weeks of therapy. RESULTS: Overall, 113 and 115 patients received robot-assisted and conventional therapy, respectively. The WMFT score after robot-assisted therapy was not significantly better than that after conventional therapy, but there were significant improvements in the Motricity Index (trunk) and the Fugl-Meyer Assessment. After robot-assisted therapy, wrist strength significantly improved in the subacute or moderate-severity group of stroke patients. CONCLUSIONS: Robot-assisted therapy improved the upper-limb functions and activities of daily living (ADL) performance as much as conventional occupational therapy. In particular, it showed signs of more therapeutic effectiveness in the subacute stage or moderate-severity group.

Clinical Practice Guideline for Stroke Rehabilitation in Korea-Part 1: Rehabilitation for Motor Function (2022).

This clinical practice guideline (CPG) is the fourth edition of the Korean guideline for stroke rehabilitation, which was last updated in 2016. The development approach has been changed from a consensus-based approach to an evidence-based approach using the Grading of Recommendations Assessment Development and Evaluation (GRADE) method. This change ensures that the guidelines are based on the latest and strongest evidence available. The aim is to provide the most accurate and effective guidance to stroke rehabilitation teams, and to improve the outcomes for stroke patients in Korea. Fifty-five specialists in stroke rehabilitation and one CPG development methodology expert participated in this development. The scope of the previous clinical guidelines was very extensive, making it difficult to revise at once. Therefore, it was decided that the scope of this revised CPG would be limited to Part 1: Rehabilitation for Motor Function. The key questions were selected by considering the preferences of the target population and referring to foreign guidelines for stroke rehabilitation, and the recommendations were completed through systematic literature review and the GRADE method. The draft recommendations, which were agreed upon through an official consensus process, were refined after evaluation by a public hearing and external expert evaluation.

Rehabilitation for Impaired Attention in the Acute and Post-Acute Phase After Traumatic Brain Injury: A Narrative Review.

Impaired attention is the most common and debilitating cognitive deficit following a traumatic brain injury (TBI). Attention is a fundamental function that profoundly influences the performance of other cognitive components such as memory and execution. Intriguingly, attention can be improved through cognitive rehabilitation. This narrative review summarizes the essential elements of rehabilitation for attention problems in acute and post-acute TBI. In the acute phase of mild TBI, investigations into the medical history and daily life performance, neurological examination, screening and management of concomitant sleep-wake disorders or neuropsychiatric disorders, and support and education on the natural course of concussion are covered. Rehabilitation for patients with moderate-to-severe TBI consists of serial assessment for patients with disorders of consciousness and a post-traumatic confusion state. In the post-acute phase after TBI, components of rehabilitation include investigating medical history; neurological, imaging, and electrophysiological tests; evaluation and treatment of factors that may impact attention, including sleep-wake, emotional, and behavioral disorders; evaluation of attention function; and cognitive rehabilitation as a matter of course. We summarized metacognitive strategy, direct attention training, computer-based cognitive interventions, medication, and environmental control as interventions to enhance attention.

Ocular Manifestations, Visual Field Pattern, and Visual Field Test Performance in Traumatic Brain Injury and Stroke.

PURPOSE: To analyze ocular manifestations, visual field (VF) pattern, and VF test performance in traumatic brain injury (TBI) and stroke patients. METHODS: This retrospective, cross-sectional study included 118 patients (236 eyes) with TBI and stroke who had undergone VF testing by standard automated perimetry with the central 24-2 threshold test. Clinical features including best-corrected visual acuity (BCVA), intraocular pressure (IOP), ocular manifestations, and VF test results including VF defect pattern, reliability, and global indices were analyzed and compared between the TBI and stroke patients. RESULTS: In TBI patients, ocular manifestations included strabismus (11.1%), cataract (4.2%), and glaucoma suspect (2.8%), whereas in stroke patients, cataract (15.2%), strabismus (8.5%), diabetic retinopathy (4.9%), extraocular movement (EOM) limitation (3.0%), glaucoma suspect (3.0%), nystagmus (2.4%), drusen (1.2%), and vitreous hemorrhage (1.2%) were found. The VF test results showed that 47 eyes (85.5%) in TBI and 86 (65.2%) in stroke had VF defect; in TBI, the scattered pattern was the most common (56.4%), followed by homonymous hemianopsia (14.5%), homonymous quadrantanopia (10.9%), and total defect (3.6%), whereas in stroke, homonymous hemianopsia was the most common (31.8%), followed by scattered pattern (16.7%), homonymous quadrantanopia (12.1%), and total defect (4.5%). Only 15 eyes (27.3%) in TBI and 32 (24.2%) in stroke showed reliable VF indices. The mean deviation (MD) was -10.5 ± 7.1 dB in TBI and -9.5 ± 6.8 dB in stroke, and the pattern standard deviation (PSD) was 4.9 ± 3.3 dB in TBI and 6.1 ± 3.9 dB in stroke, without statistically significant differences between the two groups. CONCLUSION: Various ocular manifestations were found, and a considerable proportion of patients were experiencing VF defects and showed unreliable VF test performance. Our findings suggest that accurate evaluation and rehabilitation of visual function should be a matter of greater concern and emphasis in the management of TBI and stroke patients, besides systemic diseases.

Nutrition Management in Patients With Traumatic Brain Injury: A Narrative Review.

Traumatic brain injury (TBI) is a major cause of long-term physical and psychological disability and death. In patients with TBI, undernutrition is associated with an increased mortality rate, more infectious complications, and worse neurologic outcomes. Therefore, timely and effective nutritional therapy is particularly crucial in the management of TBI to improve patients' prognoses. This narrative review summarizes the issues encountered in clinical practice for patients with neurotrauma who receive acute and post-acute in-patient rehabilitation services, and it comprehensively incorporates a wide range of studies, including recent clinical practice guidelines (CPGs), with the aim of better understanding the current evidence for optimal nutritional therapy focused on TBI patients. Recent CPGs were reviewed for 6 topics: 1) hypermetabolism and variation in energy expenditure in patients with TBI, 2) delayed gastric emptying and intolerance to enteral nutrition, 3) decision-making on the route and timing of access in patients with TBI who are unable to maintain volitional intake (enteral nutrition versus parenteral nutrition), 4) decision-making on the enteral formula (standard or immune-modulating formulas), 5) glycemic control, and 6) protein support. We also identified areas that need further research in the future.

Very early environmental enrichment protects against apoptosis and improves functional recovery from hypoxic-ischemic brain injury.

Appropriate rehabilitation of stroke patients at a very early phase results in favorable outcomes. However, the optimal strategy for very early rehabilitation is at present unclear due to the limited knowledge on the effects of very early initiation of rehabilitation based on voluntary exercise (VE). Environmental enrichment (EE) is a therapeutic paradigm for laboratory animals that involves complex combinations of physical, cognitive, and social stimuli, as well as VE. Few studies delineated the effect of EE on apoptosis in very early stroke in an experimental model. Although a minimal benefit of early rehabilitation in stroke models has been claimed in previous studies, these were based on a forced exercise paradigm. The aim of this study is to determine whether very early exposure to EE can effectively regulate Fas/FasL-mediated apoptosis following hypoxic-ischemic (HI) brain injury and improve neurobehavioral function. C57Bl/6 mice were housed for 2 weeks in either cages with EE or standard cages (SC) 3 h or 72 h after HI brain injury. Very early exposure to EE was associated with greater improvement in motor function and cognitive ability, reduced volume of the infarcted area, decreased mitochondria-mediated apoptosis, and decreased oxidative stress. Very early exposure to EE significantly downregulated Fas/FasL-mediated apoptosis, decreased expression of Fas, Fas-associated death domain, cleaved caspase-8/caspase-8, cleaved caspase-3/caspase-3, as well as Bax and Bcl-2, in the cerebral cortex and the hippocampus. Delayed exposure to EE, on the other hand, failed to inhibit the extrinsic pathway of apoptosis. This study demonstrates that very early exposure to EE is a potentially useful therapeutic translation for stroke rehabilitation through effective inhibition of the extrinsic and intrinsic apoptotic pathways.

Compound heterozygous variants including a novel copy number variation in a child with atypical ataxia-telangiectasia: a case report.

BACKGROUND: Ataxia-telangiectasia is a rare autosomal recessive, neurodegenerative disorder caused by alterations in the ATM gene. The majority of ATM pathogenic variants are frameshift or nonsense variants which are predicted to truncate the whole ATM protein. Herein, we report on an ataxia telangiectasia child with atypical phenotype who was identified as compound heterozygous for two ATM variants involving a previously described pathogenic single nucleotide variation (SNV) and a novel copy number variation (CNV). CASE PRESENTATION: A 6-year-old boy presented with delayed development and oculomotor apraxia. Brain magnetic resonance imaging showed interval development of mild atrophy in the cerebellum. Serum alpha fetoprotein level was in normal range. Next-generation sequencing and single-nucleotide polymorphism array tests were performed. Next-generation sequencing revealed a heterozygous nonsense pathogenic variant in ATM, c.742C > T (p.Arg248Ter) inherited from the father. Single-nucleotide polymorphism array revealed a compound heterozygous CNV, arr[GRCh37] 11q22.3(10851766-108183226) × 1, 31460 bp (exons 24-40 deletion of ATM) inherited from the mother, which was validated by reverse transcription-polymerase chain reaction analysis (RT-PCR). We demonstrated that this variant (NM_000051.4:c.3403_6006del) generated a product of in-frame deletion of exon 24-40 of ATM (p.Ser1135_Gln2002del). CONCLUSIONS: The compound heterozygosity for ATM variants involving a previously described pathogenic SNV and a novel CNV may be associated with the atypical clinical manifestations. This clinical report extends the genetic and phenotypic spectrum of ATM pathogenic variants in atypical ataxia-telangiectasia, thus making implementation of advanced analysis beyond the routine next-generation sequencing an important consideration in diagnosis and rehabilitation services for children with ataxia-telangiectasia.

Cross-cultural adaptation and psychometric validation of the Korean version of rehabilitation complexity scale for the measurement of complex rehabilitation needs.

ABSTRACT: The aim of this study was to translate and cross-culturally adapt the Rehabilitation Complexity Scale-Extended version 13 (RCS-E v13) to develop the Korean version of the Rehabilitation Complexity Scale (KRCS), and to explore its reliability, and concurrent and construct validity.This research was an observational study of a series of consecutive rehabilitation inpatients who were previously assessed with KRCS and grouped with the Korean rehabilitation patient group version 1.1 (KRPG v1.1). Translation and cross-cultural adaptation of the RCS-E v13 were implemented according to internationally recognized standards. Four hundred thirty inpatients diagnosed with complex neurological or musculoskeletal disabilities were enrolled. Physiatrists were asked to finish the KRCS at admission and to complete a second time with an interval of a minimum of 3 weeks to a maximum of 4 weeks for reliability evaluation. At discharge, the KRCS was completed a third time to explore constructive validity.The Cronbach-α was 0.63. The intraclass correlation coefficient values of the total score, Medical, Nursing, Care, Therapy Disciplines, Therapy Intensity, and Especial Needs domains were 0.86, 0.69, 0.84, 0.83, 0.74, 0.74, and 0.79, respectively (P < .01). The scale was repeatable (Spearman rho 0.69-0.86) and correlated strongly with disability measures (Spearman rho 0.37-0.50). Exploratory factor analysis revealed 2 clear factors ("Medical/Nursing" and "Care/Therapy Disciplines/Therapy Intensity/Equipment"). The goodness-of-fit index in the confirmatory factor analysis was 0.87. The KRCS was associated with a higher explanatory power for rehabilitation resources and length of stay than the KRPG v1.1.Our data suggest that the KRCS is a feasible, reliable, and valid tool that is appropriate for the measurement of clinical complexity in Korean intensive rehabilitation units. Further, it may provide case-mix adjustment to improve the rehabilitation delivery system in Korea.

Comparisons between Locomat and Walkbot robotic gait training regarding balance and lower extremity function among non-ambulatory chronic acquired brain injury survivors.

ABSTRACT: Lower limb rehabilitation exoskeleton robots connect with the human body in a wearable way and control the movement of joints in the gait rehabilitation process. Among treadmill-based lower limb rehabilitation exoskeleton robots, Lokomat (Hocoma AG, Volketswil, Switzerland) has 4 actuated joints for bilateral hips and knees whereas Walkbot (P&S Mechanics, Seoul, Korea) has 6 bilateral actuated joints for bilateral hips, knees, and ankles. Lokomat and Walkbot robotic gait training systems have not been directly compared previously. The present study aimed to directly compare Lokomat and Walkbot robots in non-ambulatory chronic patients with acquired brain injury (ABI).The authors conducted a single-center, retrospective, cross-sectional study of 62 subjects with ABI who were admitted to the rehabilitation hospital. Patients were divided into 2 groups: Lokomat (n = 28) and Walkbot (n = 34). Patients were subjected to robot-assisted gait training (RAGT) combined with conventional physical therapy for a total of 14 (8-36) median (interquartile range) sessions. Baseline characteristics, including age, sex, lag time post-injury, ABI type, paralysis type, intervention sessions, lower extremity strength, spasticity, and cognitive function were assessed. Functional ambulation category (FAC) and Berg balance scale (BBS) were used for outcome measures.There were no significant differences in baseline characteristics between the groups. Baseline FAC score was 1 (0-2) in Lokomat and 1 (0-1) in Walkbot group. After the intervention, FAC scores improved significantly to 2 (1-3) in both groups (P < .05). Lokomat and Walkbot groups showed significantly enhanced BBS from 5 (2.75-24.25) and 15 (4-26.5) to 15 (4-26.5) and 22 (12-40), respectively (P < .05). Degree of improvements in both group were not significantly different with regard to balance (P = .56) and ambulatory ability (P = .74).This study indicates that both Locomat and Walkbot robotic gait training combined with conventional gait-oriented physiotherapy are promising intervention for gait rehabilitation in patients with chronic stage of ABI who are not able to walk independently.

Environmental Enrichment Enhances Cav 2.1 Channel-Mediated Presynaptic Plasticity in Hypoxic-Ischemic Encephalopathy.

Hypoxic-ischemic encephalopathy (HIE) is a devastating neonatal brain condition caused by lack of oxygen and limited blood flow. Environmental enrichment (EE) is a classic paradigm with a complex stimulation of physical, cognitive, and social components. EE can exert neuroplasticity and neuroprotective effects in immature brains. However, the exact mechanism of EE on the chronic condition of HIE remains unclear. HIE was induced by a permanent ligation of the right carotid artery, followed by an 8% O2 hypoxic condition for 1 h. At 6 weeks of age, HIE mice were randomly assigned to either standard cages or EE cages. In the behavioral assessments, EE mice showed significantly improved motor performances in rotarod tests, ladder walking tests, and hanging wire tests, compared with HIE control mice. EE mice also significantly enhanced cognitive performances in Y-maze tests. Particularly, EE mice showed a significant increase in Cav 2.1 (P/Q type) and presynaptic proteins by molecular assessments, and a significant increase of Cav 2.1 in histological assessments of the cerebral cortex and hippocampus. These results indicate that EE can upregulate the expression of the Cav 2.1 channel and presynaptic proteins related to the synaptic vesicle cycle and neurotransmitter release, which may be responsible for motor and cognitive improvements in HIE.

The Socioeconomic Burden of Acquired Brain Injury among the Korean Patients over 20 Years of Age in 2015-2017: a Prevalence-Based Approach.

Acquired brain injury (ABI) is a leading cause of serious long-term disability resulting in substantial economic costs for post-ABI care. This study was conducted to estimate the socioeconomic burden of persons with ABI in Korea. We used a prevalence-based approach and societal perspective to estimate the direct medical, non-medical costs and indirect costs of ABI, including stroke, traumatic brain injury (TBI), and non-traumatic ABI (anoxia, brain tumor, encephalitis, meningitis, hydrocephalus, and other brain disorders) from 2015 to 2017. The study population included patients with ABI over 20 years of age and analyzed according to insurance types encompassing National Health Insurance and automobile insurance. The socioeconomic burden of ABI was 4.67, 5.18, and 5.73 trillion KRW (approximately 4,162, 4,612, and 5,106 million USD) from 2015 to 2017 and around 0.3% of Korea's GDP annually. Estimating by disease, the socioeconomic cost was 72.4% for stroke, 18.6% for TBI, and 9.0% for non-traumatic ABI. Calculated by cost component, medical costs and non-medical costs showed a slight increase every year. Through this study, establishment of rehabilitation systems maximizing the health and quality of life for injured persons remain the key public health strategy for ABI to reduce socioeconomic burden and financial policies to support patients should be needed.

Does Hip Bone Density Differ between Paretic and Non-Paretic Sides in Hemiplegic Stroke Patients? and Its Relationship with Physical Impairment.

BACKGROUND: Bone loss after stroke escalates the risk of fractures, mainly in the hip, leading to further disability in individuals with stroke. We aimed to investigate the skeletal effect of bone mineral density (BMD) based on the duration of onset of stroke, compare the BMD of the paretic and non-paretic sides, and elucidate the relationship between BMD and disability variables. METHODS: The 31 male hemiplegic stroke patients between 20 and 70 years of age with cerebral infarction or hemorrhage were considered in this study. Subacute and chronic cases included 13 and 18 patients with lag time from the onset of 1 to 6 months and beyond 6 months, respectively. BMD in the lumbar, paretic, and non-paretic hip as well as the disability variables were analyzed retrospectively. RESULTS: The subacute group showed a significant reduction in the femoral neck BMD on the paretic side compared to that on the non-paretic side based on T-scores (P=0.013). Bone loss was significantly correlated with lower limb muscle strength and overall physical impairment (P<0.05). The chronic group demonstrated significant reduction in femur neck and total femur BMD on the paretic side compared to that on the non-paretic side based on T-scores (P=0.002 and P<0.001, respectively). T-scores of BMD in the chronic phase were not significantly associated with the clinical parameters. CONCLUSIONS: Early screening of bilateral hip BMD in the early stages after stroke, monitoring, and timely implementation of prevention strategies are important to minimize subsequent bone loss and prevent possible complications in patients who experience stroke.

Neurobehavioral recovery in patients who emerged from prolonged disorder of consciousness: a retrospective study.

BACKGROUND: We investigated the clinical course of patients with prolonged disorders of consciousness (PDoC), predictors of emergence from PDoC (EDoC), and the temporal dynamics of six neurobehavior domains based on the JFK Coma Recovery Scale-Revised (CRS-R) during the recovery. METHODS: A total of 50 traumatic and non-traumatic patients with PDoC were enrolled between October 2014 and February 2017. A retrospective analysis of the clinical findings and neurobehavioral signs was conducted using standardized methodology such as CRS-R. The findings were used to investigate the incidence and predictors of EDoC and determine the cumulative pattern of neurobehavioral recovery at 6 months, 1 year, and 2 years post-injury. RESULTS: The results showed that 46% of the subjects emerged from PDoC after 200 median days (64-1197 days) of injury onset. The significant predictors of EDoC included minimally conscious state (MCS) (vs. vegetative state), higher auditory, communication, arousal, total CRS-R scores, shorter lag time post-injury, and the absence of intra-axial lesions. In terms of cumulative recovery of motor and communication signs in patients who emerged from PDoC, 39 and 32% showed EDoC at 6 months post-injury, and 88 and 93% exhibited EDoC at 2 years post-injury, respectively. CONCLUSIONS: Nearly half of the patients with PDoC recovered consciousness during inpatient rehabilitation. MCS, shorter lag time, the absence of intra-axial lesions, higher auditory, communication, arousal, and total CRS-R scores were important predictors for EDoC. Motor scores in the early stage of recovery and communication scores after prolonged intervals contributed to the higher levels of cumulative EDoC.

The Effect of Environmental Enrichment on Glutathione-Mediated Xenobiotic Metabolism and Antioxidation in Normal Adult Mice.

Olfactory bulb (OB) plays an important role in protecting against harmful substances via the secretion of antioxidant and detoxifying enzymes. Environmental enrichment (EE) is a common rehabilitation method and known to have beneficial effects in the central nervous system. However, the effects of EE in the OB still remain unclear. At 6 weeks of age, CD-1® (ICR) mice were assigned to standard cages or EE cages. After 2 months, we performed proteomic analysis. Forty-four up-regulated proteins were identified in EE mice compared to the control mice. Gene Ontology analysis and Kyoto Encyclopedia of Genes and Genomes Pathway demonstrated that the upregulated proteins were mainly involved in metabolic pathways against xenobiotics. Among those upregulated proteins, 9 proteins, which participate in phase I or II of the xenobiotic metabolizing process and are known to be responsible for ROS detoxification, were validated by qRT-PCR. To explore the effect of ROS detoxification mediated by EE, glutathione activity was measured by an ELISA assay. The ratio of reduced glutathione to oxidized glutathione was significantly increased in EE mice. Based on a linear regression analysis, GSTM2 and UGT2A1 were found to be the most influential genes in ROS detoxification. For further analysis of neuroprotection, the level of iNOS and the ratio of Bax to Bcl-2 were significantly decreased in EE mice. While TUNEL+ cells were significantly decreased, Ki67+ cells were significantly increased in EE mice, implicating that EE creates an optimal state for xenobiotic metabolism and antioxidant activity. Taken together, our results suggested that EE protects olfactory layers via the upregulation of glutathione-related antioxidant and xenobiotic metabolizing enzymes, eventually lowering ROS-mediated inflammation and apoptosis and increasing neurogenesis. This study may provide an opportunity for a better understanding of the beneficial effects of EE in the OB.

Role of local government in responding to environmental health challenges: a case study of Chungnam.

The purpose of this study is to introduce the establishment process, policy target, and projects for "Chungnam's master plan on environmental health policy (2017-2020)" as the local government's role in addressing local environmental health challenges. We first analyzed existing studies and social issues on the media related to "Chungnam's master plan" to understand Chungnam's environmental health status and discussed domestic and international policy trends and related plans. An environmental health perception questionnaire survey and a Delphi expert questionnaire survey were conducted among provincial residents to collect various actors' opinions on Chungnam's environmental health issues and policy. An expert advisory panel was launched, and a residents' voice workshop and cities-and-guns-policy-suggestion workshop were held. The vision of Chungnam's environmental health policy is minimizing environmental hazards. We finally selected "Pleasant environment, healthy people, happy Chungnam" to represent the will to shape a pleasant environment and prevent and manage health damages for a happy Chungnam. We selected five strategies based on status analysis and a review of domestic and international policy trends and related plans and identified 2 targets (policy objectives) to accomplish the strategies. The strategies to achieve the first target, "Leader in environmental health policy: Chungnam," include 'Empowering active provincial capabilities,' 'Setting up province-specific systems for environmental health surveys and research,' and 'Preventing and managing newly emerging pollutants.' The strategies for the second target, "Everyone is healthy: Chungnam," include 'Relieving health inequalities among vulnerable regions and residents' and 'Enlarging the resident-friendly environmental health policy.' We developed 29 projects in total, according to these strategies. The establishment of "Chungnam's master plan" is highly valuable; we developed it through discussion involving diverse actors to address environmental health challenges together. It is necessary to continue to strengthen participation, communication, and cooperation among actors to develop an environmental health policy model for the future.

Clinical Implications of Assisted Peak Cough Flow Measured With an External Glottic Control Device for Tracheostomy Decannulation in Patients With Neuromuscular Diseases and Cervical Spinal Cord Injuries: A Pilot Study.

OBJECTIVE: To investigate the clinical usefulness and significance of an external control device substituting for glottic function in determining the feasibility of decannulation in tracheostomized patients with neuromuscular diseases and cervical spinal cord injuries whose assisted peak cough flow (APCF) was unmeasurable or <160L/min. DESIGN: Before-after trial. SETTING: Inpatient setting in a university hospital. PARTICIPANTS: Tracheostomized patients (N=16; 11 with neuromuscular diseases and 5 with cervical spinal cord injuries) were recruited. INTERVENTIONS: Unassisted peak cough flow (UPCF) and APCF were measured with and without an external glottic control device. Among patients whose APCF without the device was <160L/min, if their APCF with the device was measured as ≥160L/min, they were decannulated. After decannulation, UPCF and APCF were measured again. MAIN OUTCOME MEASURES: APCF with and without an external glottic control device as well as APCF after decannulation. RESULTS: After successful decannulation, APCFs were greater than or equal to those measured with the device before decannulation. No patients underwent intubation or retracheostomy, and there were no respiratory complications. CONCLUSIONS: The external glottic control device substituting for innate glottic function is beneficial for determining tracheostomy decannulation. It provides an objective and accurate APCF. It is particularly helpful for patients whose APCF is ≥160L/min while using the device, even if APCF is <160L/min without this device.

Changes in hyolaryngeal movement and swallowing function after neuromuscular electrical stimulation in patients with Dysphagia.

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