Comparison of Incremental Shuttle Walking Test, 6-Minute Walking Test, and Cardiopulmonary Exercise Stress Test in Patients with Myocardial Infarction.

BACKGROUND This study aimed to analyze the correlations among peak oxygen uptake (VO2) in cardiopulmonary exercise test (CPX), incremental shuttle walking test (ISWT), and 6-minute walking test (6MWT) distances in patients with myocardial infarction (MI). Additionally, we aimed to determine the relationship between the maximum heart rate (HRmax) and the rate of perceived exertion (RPE) among the tests and compare the changes in heart rate to verify the clinical benefit of the submaximal stress test. MATERIAL AND METHODS We analyzed the correlation by using the ISWT and 6MWT at 30-min intervals after 24 h of CPX in patients with MI. The differences in HRmax and RPE between the tests were also compared. Additionally, changes in heart rate were analyzed using descriptive statistics. RESULTS The ISWT distance was more strongly correlated with peak VO2 (r=.823: 95% CI, 0.681-0.910) than was 6MWT (r=0.776: 95% CI, 0.683-0.870). HRmax in the CPX demonstrated a significant correlation with that in the ISWT and 6MWT (P<0.05), with the ISWT (r=0.815: 95% CI, 0.451-0.996) having a stronger correlation than the 6MWT (r=0.664: 95% CI, 0.146-0.911). The value of RPE was significantly different (P<0.05); however, there was no significant correlation. Changes in heart rate in the 6MWT plateaued after the initial increase, while the heart rate in the ISWT and CPX increased gradually. CONCLUSIONS We recommend the ISWT as a submaximal exercise test to evaluate exercise capacity in patients with MI.

Elastic Dynamic Sling on Subluxation of Hemiplegic Shoulder in Patients with Subacute Stroke: A Multicenter Randomized Controlled Trial.

Background: Shoulder subluxation occurs in 17−64% of hemiplegic patients after stroke and develops mostly during the first three weeks of hemiplegia. A range of shoulder orthoses has been used in rehabilitation to prevent subluxation. However, there is little evidence of their efficacy. AIM: This study aimed to investigate whether there is a difference in the subluxation distance, pain, and functional level of the hemiplegic upper extremity among patients with two different shoulder orthoses. Design: This is a prospective, randomized controlled trial with intention-to-treat analysis. SETTING: Multicenter, rehabilitation medicine department of two university hospitals in South Korea. Population: Forty-one patients with subacute stroke with shoulder subluxation with greater than 0.5 finger width within 4 weeks of stroke were recruited between January 2016 and October 2021. Methods: The experimental group used an elastic dynamic sling while sitting and standing to support the affected arm for eight weeks. The control group used a Bobath sling while sitting and standing. The primary outcome was to assess the distance of the shoulder subluxation on radiography. The secondary outcomes were upper-extremity function, muscle power, activities of daily living, pain and spasticity. Result: The horizontal distance showed significant improvement in the elastic dynamic sling group, but there were no significant differences in the vertical distance between the elastic dynamic and Bobath sling groups. Both groups showed improvements in upper-extremity movements and independence in daily living after 4 and 8 weeks of using shoulder orthoses, and the differences within the groups were significant (p < 0.05). However, there were no significant differences in upper-extremity movements and independence in daily living between the two groups. Conclusions: The subluxation distance showed better results in the elastic dynamic sling, which has both proximal and distal parts, than in the Bobath sling, which holds only the proximal part. Both shoulder orthoses showed improvements in the modified Barthel index, upper-extremity function, and manual muscle testing.

Comparisons of Prehospital Delay and Related Factors Between Acute Ischemic Stroke and Acute Myocardial Infarction.

Background Prehospital delay is an important contributor to poor outcomes in both acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We aimed to compare the prehospital delay and related factors between AIS and AMI. Methods and Results We identified patients with AIS and AMI who were admitted to the 11 Korean Regional Cardiocerebrovascular Centers via the emergency room between July 2016 and December 2018. Delayed arrival was defined as a prehospital delay of >3 hours, and the generalized linear mixed-effects model was applied to explore the effects of potential predictors on delayed arrival. This study included 17 895 and 8322 patients with AIS and AMI, respectively. The median value of prehospital delay was 6.05 hours in AIS and 3.00 hours in AMI. The use of emergency medical services was the key determinant of delayed arrival in both groups. Previous history, 1-person household, weekday presentation, and interhospital transfer had higher odds of delayed arrival in both groups. Age and sex had no or minimal effects on delayed arrival in AIS; however, age and female sex were associated with higher odds of delayed arrival in AMI. More severe symptoms had lower odds of delayed arrival in AIS, whereas no significant effect was observed in AMI. Off-hour presentation had higher and prehospital awareness had lower odds of delayed arrival; however, the magnitude of their effects differed quantitatively between AIS and AMI. Conclusions The effects of some nonmodifiable and modifiable factors on prehospital delay differed between AIS and AMI. A differentiated strategy might be required to reduce prehospital delay.

Effect of Cardiac Rehabilitation on Left Ventricular Diastolic Function in Patients with Acute Myocardial Infarction.

Cardiac rehabilitation (CR) improves symptoms and survival in patients with acute myocardial infarction (AMI). We studied the change of diastolic function and its prognostic impact after CR. After reviewing all consecutive AMI patients from January 2012 to October 2015, we analyzed 405 patients (mean, 63.7 ± 11.7 years; 300 males) with baseline and follow-up echocardiographic examinations. We divided them into three groups according to their CR sessions: No-CR group (n = 225), insufficient-CR group (CR < 6 sessions, n = 117) and CR group (CR ≥ 6 sessions, n = 63). We compared echocardiographic parameters of diastolic dysfunction including E/e' ratio > 14, septal e' velocity < 7 cm/s, left atrial volume index (LAVI) > 34 mL/m2, and maximal TR velocity > 2.8 m/s. At baseline, there were no significant differences in all echocardiographic parameters among the three groups. At follow-up echocardiographic examination, mitral annular e' and a' velocities were higher in the CR group (p = 0.024, and p = 0.009, respectively), and mitral E/e' ratio was significantly lower (p = 0.009) in the CR group. The total number of echocardiographic parameters of diastolic dysfunction at the baseline echocardiography was similar (1.29 vs. 1.41 vs. 1.52, p = 0.358). However, the CR group showed the lowest number of diastolic parameters at the follow-up echocardiography (1.05 vs. 1.32 vs. 1.50, p = 0.017). There was a significant difference between the No-CR group and CR group (p = 0.021). The presence of CR was a significant determinant of major adverse cardiovascular events in the univariate analysis (HR = 0.606, p = 0.049). However, the significance disappeared in the multivariate analysis (HR = 0.738, p = 0.249). In conclusion, the CR was significantly associated with favorable diastolic function, with the highest mitral e' and a' velocity, and the lowest mitral E/e' ratio and total number of echocardiographic parameters of diastolic dysfunction at the follow-up echocardiographic examinations in AMI patients.

Contemporary Status of Acute Myocardial Infarction in Korean Patients: Korean Registry of Acute Myocardial Infarction for Regional Cardiocerebrovascular Centers.

BACKGROUND: This study aimed to present the development process and characteristics of the Korean Registry of Acute Myocardial Infarction for Regional Cardiocerebrovascular Centers (KRAMI-RCC). METHODS: We developed KRAMI-RCC, a web-based registry for patients with AMI. Patients from 14 RCCs were registered for more than three years from July 2016. It includes an automatic error-checking system, and user training and on-site monitoring are performed to manage data quality. RESULTS: A total of 11,700 AMI patients were registered in KRAMI-RCC over three years (73.9% men). The proportions of patients with ST-elevation and non-ST-elevation myocardial infarction at discharge were 43.4% and 56.6%, respectively. Of the total three-year patients, 5.6% died in the hospital, and 4.4% died 12 months after discharge. The case fatality within 12 months was 9.7%. Pre-hospital care data showed delayed arrival time after onset of symptoms (median 153 min) and low transportation rate by public ambulance (25.2%). Post-hospital care data showed lower participation rate in the second rehabilitation program (16.8%). CONCLUSIONS: The recently developed KRAMI-RCC registry has been more focused on pre-hospital and post-hospital data, which will be helpful in understanding the current state of AMI disease management and in making policy decisions to reduce case fatality in Korea.

Attentional and neurophysiologic effects of repetitive transcranial magnetic stimulation.

Twenty-seven healthy subjects were randomly assigned to 1 of 2 equal groups : (1) experimental group (active stimulation) and (2) control group (sham stimulation). A total of 10 Hz repetitive transcranial magnetic stimulation was delivered to the left dorsolateral prefrontal cortex at 80% of the resting motor threshold. The reaction time of the correct response, omission error, and commission error of the auditory and visual continuous performance test scores were measured. The motor evoked potentials, resting motor threshold, short-interval intracortical inhibition, and intracortical facilitation was recorded in the right first dorsal interosseous muscle to determine motor cortex excitability. The reaction time and commission error of the auditory continuous performance test were reduced significantly after 10 Hz repetitive transcranial magnetic stimulation (P < 0.05). Resting motor threshold and short-interval intracortical inhibition was significantly decreased after active repetitive transcranial magnetic stimulation (P < 0.05), with no changes in the latency and amplitude of the motor evoked potentials and intracortical facilitation. In conclusion, high-frequency repetitive transcranial magnetic stimulation to the left dorsolateral prefrontal cortex is shown to improve the attentional function and may be simultaneously associated with changes in neurophysiological activity.

The feasibility study of Computer Cognitive Senior Assessment System-Screen (CoSAS-S) in critically ill patients with sepsis.

PURPOSE: Early cognitive assessment in the intensive care unit (ICU) is essential to monitor cognitive dysfunction after critical illness. We have implemented a Computer Cognitive Senior Assessment System-Screen (CoSAS-S) which is a brief, objective, and tablet-based cognitive screening test as a mobile platform to detect any cognitive problems in ICUs. This study aimed to evaluate the feasibility and initial validation of a tablet-based CoSAS-S in critically ill patients with sepsis. MATERIALS AND METHODS: Thirty-six eligible patients completed CoSAS-S, Mini-Mental State Examination-Korean Version (MMSE-K) and Korean Version of Montreal Cognitive Assessment (K-MoCA) for validity testing at the ICU. RESULTS: Eighty-eight percent of programmed assessments were completed by the sample. Spearman correlations of the CoSAS-S with MMSE-K (rho=0.613-0.874, p<0.00) and K-MoCA scores (rho=0.666-0.897, p<0.001) were moderate to high. Intra-class correlation coefficient (ICC) of total CoSAS-S score between two raters was 0.93 (p<0.001; 95% CI=0.82-0.97), suggesting the inter-rater reliability of CoSAS-S was excellent. CONCLUSIONS: Support was found for the feasibility and validity of CoSAS-S. The application of CoSAS-S could identify the cognitive functioning of the patients. Utility of CoSAS-S in other clinical populations should be tested.

Detection of voice changes due to aspiration via acoustic voice analysis.

OBJECTIVE: Aspiration can occur during swallowing. The present study investigated the feasibility of identifying aspiration risk (AR) via acoustic voice parameters. MATERIALS AND METHODS: In total, 165 patients scheduled for a videofluoroscopic swallowing study (VFSS) were included. The patients were divided into two groups (AR and non-AR) based on their VFSS results. The AR group, which had ingested materials on or below the vocal folds, included 59 patients (42 males and 17 females). The non-AR group, which showed normal swallowing, included 106 patients (49 males and 57 females). The major cause of swallowing disorders was a stroke. A sustained vowel/a/for at least 3s was recorded before and after swallowing. Eight acoustic voice parameters were measured using PRAAT, including fundamental frequency, standard deviation of F0, jitter, relative average perturbation (RAP), shimmer, amplitude perturbation quotient (APQ), harmonic-to-noise ratio (HNR), and noise-to-harmonic ratio (NHR). Changes in each acoustic voice parameter before and after the VFSS were compared between the two groups with a repeated-measures mixed analysis of variance. RESULTS: Only RAP showed a statistically significant interaction between group (non-AR and AR) and time (pre- and post-swallowing; p=0.030). RAP decreased after swallowing in the AR group; however, it increased in the non-AR group. Jitter and NHR increased in the non-AR group but decreased in the AR group after swallowing, but the difference was not statistically significant. CONCLUSIONS: Our results suggest that the accumulation of pasty food in the vocal folds may modify vocal fold vibration and change voice quality in patients with penetration/aspiration. Several acoustic voice parameters, especially jitter, RAP, and NHR, were affected by AR. Thus, acoustic voice analysis may be helpful in making a diagnosis of AR as a supplementary tool for standard swallowing study including VFSS or fiberoptic examination.

The Effects of Shoulder Slings on Balance in Patients With Hemiplegic Stroke.

OBJECTIVE: To investigate the effects of a shoulder sling on balance in patients with hemiplegia. METHODS: Twenty-seven hemiplegic stroke patients (right 13, left 14) were enrolled in this study. The subjects' movement in their centers of gravity (COGs) during their static and dynamic balance tests was measured with their eyes open in each sling condition-without a sling, with Bobath's axillary support (Bobath sling), and with a simple arm sling. The percent times in quadrant, overall, anterior/posterior, and medial/lateral stability indexes were measured using a posturography platform (Biodex Balance System SD). Functional balance was evaluated using the Berg Balance Scale and the Trunk Impairment Scale. All balance tests were performed with each sling in random order. RESULTS: The COGs of right hemiplegic stroke patients and all hemiplegic stroke patients shifted to, respectively, the right and posterior quadrants during the static balance test without a sling (p<0.05). This weight asymmetry pattern did not improve with either the Bobath or the simple arm sling. There was no significant improvement in any stability index during either the static or the dynamic balance tests in any sling condition. CONCLUSION: The right and posterior deviations of the hemiplegic stroke patients' COGs were maintained during the application of the shoulder slings, and there were no significant effects of the shoulder slings on the patients' balance in the standing still position.

Effect of transcranial direct current stimulation on postural stability and lower extremity strength in hemiplegic stroke patients.

OBJECTIVE: To evaluate the effect of anodal transcranial direct current stimulation (tDCS) over the lesioned leg motor cortex, which can enhance the strength and coordination of the contralateral lower extremity and furthermore, enhance the postural stability of the hemiplegic subject. METHODS: Anodal or sham stimulation on the lesioned cortex of a lower extremity was delivered to 11 ambulatory hemiplegic patients. The stimulation intensity was 2 mA. All subjects took part in two 10-minute tDCS sessions consisting of anodal stimulation and sham stimulation. The interval period between real and sham stimulation was 48 hours. The order was counter-balanced among the subjects. Before and after each stimulation session, static postural stability was evaluated with eyes opened and closed. Also, the isometric strength of the hemiplegic side of the treated knee was measured before and after each stimulation session. Repeated measure ANOVA was used to determine the statistical significance of improvements in postural stability and strength. RESULTS: There was significant improvement for overall stability index with eyes opened and closed after anodal tDCS (p<0.05). Isometric strength of the lesioned quadriceps tended to increase after anodal tDCS (p<0.05). Postural stability and quadriceps strength were not changed after sham stimulation. CONCLUSION: Anodal tDCS has potential value in hemiplegic stroke patients to improve balance and strengthen the affected lower extremity.

Motor unit number estimation and motor unit action potential analysis in carpal tunnel syndrome.

OBJECTIVE: To evaluate the clinical significance of motor unit number estimation (MUNE) and quantitative analysis of motor unit action potential (MUAP) in carpal tunnel syndrome (CTS) according to electrophysiologic severity, ultrasonographic measurement and clinical symptoms. METHOD: We evaluated 78 wrists of 45 patients, who had been diagnosed with CTS and 42 wrists of 21 healthy controls. Median nerve conduction studies, amplitude and duration of MUAP, and the MUNE of the abductor pollicis brevis were measured. The cross sectional area (CSA) of the median nerve at the pisiform and distal radioulnar joint level was determined by high resolution ultrasonography. Clinical symptom of CTS was assessed using the Boston Carpal Tunnel Questionnaire (BCTQ). RESULTS: The MUNE, the amplitude and the duration of MUAP of the CTS group were significantly different from those found in the control group. The area under the ROC curve was 0.944 for MUNE, 0.923 for MUAP amplitude and 0.953 for MUAP duration. MUNE had a negative correlation with electrophysiologic stage of CTS, amplitude and duration of MUAP, CSA at pisiform level, and the score of BCTQ. The amplitude and duration of MUAP had a positive correlation with the score of BCTQ. The electrophysiologic stage was correlated with amplitude but not with the duration of MUAP. CONCLUSION: MUNE, amplitude and duration of MUAP are useful tests for diagnosis of CTS. In addition, the MUNE serves as a good indicator of CTS severity.