Transcranial direct current stimulation combined with amantadine in repetitive mild traumatic brain injury in rats.

BACKGROUND: Balance and memory deficits are common in patients with repetitive mild traumatic brain injury (mTBI). OBJECTIVE: To investigate the combined effects of amantadine and transcranial direct current stimulation (tDCS) on balance and memory in repetitive mTBI rat models. METHODS: In this prospective animal study, 40 repetitive mTBI rats were randomly assigned to four groups: tDCS, amantadine, combination of amantadine and anodal tDCS, and control. The tDCS group received four sessions of anodal tDCS for four consecutive days. The amantadine group received four intraperitoneal injections of amantadine for four consecutive days. The combination group received four intraperitoneal injections of amantadine and anodal tDCS for four consecutive days. Motor-evoked potential (MEP), rotarod test, and novel object test results were evaluated before mTBI, before treatment, and after treatment. RESULTS: All groups showed significant improvements in the rotarod and novel object tests, particularly the combination group. The combination group showed a significant improvements in duration (p < 0.01) and maximal speed in the rotarod test (p < 0.01), as well as an improvement in novel object ratio (p = 0.05) and MEP amplitude (p = 0.05) after treatment. The combination group exhibited a significant increase in novel object ratio compared to the tDCS group (p = 0.04). The GFAP integral intensity of the left motor cortex and hippocampus was the lowest in the combination group. CONCLUSION: Combination treatment with amantadine and tDCS had positive effects on balance and memory recovery after repetitive mTBI in rats. Therefore, we expect that the combination of amantadine and tDCS may be a treatment option for patients with repetitive mTBIs.

Transcranial direct current stimulation for balance and gait in repetitive mild traumatic brain injury in rats.

BACKGROUND: Balance impairment and lack of postural orientation are serious problems in patients with repetitive mild traumatic brain injury (mTBI). OBJECTIVE: To investigate whether anodal transcranial direct current stimulation (tDCS) over the primary motor cortex (M1) can improve balance control and gait in repetitive mTBI rat models. METHODS: In this prospective animal study, 65 repetitive mTBI rats were randomly assigned to two groups: the tDCS group and the control group. To create repetitive mTBI model rats, we induced mTBI in the rats for 3 consecutive days. The tDCS group received one session of anodal tDCS over the M1 area 24 h after the third induced mTBI, while the control group did not receive tDCS treatment. Motor-evoked potential (MEP), foot-fault test, and rotarod test were evaluated before mTBI, before tDCS and after tDCS. The Mann-Whitney U test and Wilcoxon signed rank test were used to assess the effects of variables between the two groups. RESULTS: Anodal tDCS over the M1 area significantly improved the amplitude of MEP in the tDCS group (p = 0.041). In addition, rotarod duration was significantly increased in the tDCS group (p = 0.001). The foot-fault ratio was slightly lower in the tDCS group, however, this was not statistically significant. CONCLUSION: Anodal tDCS at the M1 area could significantly improve the amplitude of MEP and balance function in a repetitive mTBI rat model. We expect that anodal tDCS would have the potential to improve balance in patients with repetitive mTBI.

Anodal Transcranial Direct Current Stimulation Provokes Neuroplasticity in Repetitive Mild Traumatic Brain Injury in Rats.

Repetitive mild traumatic brain injury (rmTBI) provokes behavioral and cognitive changes. But the study about electrophysiologic findings and managements of rmTBI is limited. In this study, we investigate the effects of anodal transcranial direct current stimulation (tDCS) on rmTBI. Thirty-one Sprague Dawley rats were divided into the following groups: sham, rmTBI, and rmTBI treated by tDCS. Animals received closed head mTBI three consecutive times a day. Anodal tDCS was applied to the left motor cortex. We evaluated the motor-evoked potential (MEP) and the somatosensory-evoked potential (SEP). T2-weighted magnetic resonance imaging was performed 12 days after rmTBI. After rmTBI, the latency of MEP was prolonged and the amplitude in the right hind limb was reduced in the rmTBI group. The latency of SEP was delayed and the amplitude was decreased after rmTBI in the rmTBI group. In the tDCS group, the amplitude in both hind limbs was increased after tDCS in comparison with the values before rmTBI. Anodal tDCS after rmTBI seems to be a useful tool for promoting transient motor recovery through increasing the synchronicity of cortical firing, and it induces early recovery of consciousness. It can contribute to management of concussion in humans if further study is performed.

Falls in Korean Polio Survivors: Incidence, Consequences, and Risk Factors.

Falls and fall-related injuries are important issue among polio survivors. The purpose of this study was to determine the incidence of, and consequences and factors associated with falls among Korean polio survivors. A total of 317 polio survivors participated in this study. All participants completed a questionnaire including fall history, symptoms related to post-polio syndrome and other information through a telephone interview. Among them, 80 participants visited our clinic for additional physical measurements and tests. Of the 317 respondents, 68.5% reported at least one fall in the past year. Of the fallers, 42.5% experienced at least one fall during one month. Most falls occurred during ambulation (76.6%), outside (75.2%) and by slipping down (29.7%). Of fallers, 45% reported any injuries caused by falls, and 23.3% reported fractures specifically. Female sex, old age, low bone mineral density, the presence of symptoms related to post-polio syndrome (PPS), poor balance confidence, short physical performance battery and weak muscle strength of knee extensor were not significantly associated with falls. Only leg-length discrepancy using spine-malleolar distance (SMD) was a significant factor associated with falls among Korean polio survivors. Our findings suggest that malalignment between the paralytic and non-paralytic limb length should be addressed in polio survivors for preventing falls.

Delirium After Traumatic Brain Injury: Prediction by Location and Size of Brain Lesion.

OBJECTIVE: To examine (1) the location of brain lesion that would predict post-traumatic delirium and (2) the association between volume of brain lesion and occurrence of delirium in patients with traumatic brain injury (TBI). METHODS: A retrospective study was conducted by reviewing medical records of 68 TBI patients, categorized into two groups: the delirious group (n=38) and non-delirious group (n=30). The location and volume of TBI were investigated with the 3D Slicer software. RESULTS: The TBI region in the delirious group mainly involved the frontal or temporal lobe (p=0.038). All 36 delirious patients had brain injury on the right side (p=0.046). The volume of hemorrhage in the delirious group was larger by about 95 mL compared to the non-delirious group, but this difference was not statistically significant (p=0.382). CONCLUSION: Patients with delirium after TBI had significantly different injury site and side, but not lesion size compared to patients without delirium.

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 COVID-19 in conjunction with early awake extracorporeal membrane oxygenation support: a case report.

The coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 can lead to acute respiratory distress syndrome. Awake venovenous extracorporeal membrane oxygenation is known to be effective in patients with critical COVID-19 and respiratory failure. This report describes the rehabilitation course and functional progress of a 63-year-old man who contracted severe COVID-19 and underwent awake venovenous extracorporeal membrane oxygenation. He started rehabilitation from the time of isolation while receiving venovenous extracorporeal membrane oxygenation and underwent a 30-day course of inpatient comprehensive rehabilitation. He regained functional independence and cognitive abilities and was able to walk without assistance at hospital discharge without any complications. This study demonstrates the feasibility of starting rehabilitation for COVID-19 early while the patient is on awake venovenous extracorporeal membrane oxygenation and eventually achieving a favorable outcome.

Analysis of symptomatic recurrences of common bile ducts stones after endoscopic removal: Factors related to early or multiple recurrences.

ABSTRACT: Early or multiple recurrences of symptomatic common bile duct (CBD) stones are troublesome late complications after endoscopic stone removal. We aimed to determine the factors related to early or multiple recurrences of CBD stones.We retrospectively analyzed patients who underwent endoscopic CBD stone extraction in a single institute between January 2006 and December 2015. Patients were divided into 2 groups according to the number and interval of CBD stone recurrences: single versus multiple (≥2) and early (<1.5 years) versus late (≥1.5 years) recurrence.After exclusion, 78 patients were enrolled and followed up for a median of 1974 (IQR: 938-3239) days. Twenty-seven (34.6%) patients experienced multiple recurrences (≥2 times), and 26 (33.3%) patients experienced early first recurrence (<1.5 years). In the multivariate analysis, CBD angulation was independently related to multiple CBD stone recurrence (OR: 4.689, P = .016), and endoscopic papillary large balloon dilation was independently related to late first CBD stone recurrence (OR: 3.783, P = .025). The mean CBD angles were more angulated with increasing instances of recurrence (0, 1, 2, 3, and ≥4 times) with corresponding values of 150.3°, 148.2°, 143.6°, 142.2°, and 126.7°, respectively (P = .011). The period between the initial treatment and first recurrence was significantly longer than the period between the first and second recurrence (P = .048).In conclusion, greater CBD angulation is associated with the increased number of CBD stone recurrence, and EPLBD delays the recurrence of CBD stones after endoscopic CBD stone removal.

Delayed occurrence of spinal arachnoiditis following a caudal block.

CONTEXT: Spinal arachnoiditis is a rare disease caused by fibrosis and adhesion of the arachnoid membrane due to chronic inflammation. The causes of arachnoiditis are infection, spinal surgery, intraspinal injection of steroid or myelography dye, and spinal anesthesia. METHOD: Case report. FINDINGS: A 60-year-old woman presented with progressive weakness and sensory change of both legs and urinary symptoms. She had received a single caudal block 6 months before symptom onset. Magnetic resonance imaging of the thoraco-lumbar spine showed an intradural extramedullary tumor at the T5-T7 level. She underwent laminectomy and tumor resection. The pathological finding was arachnoiditis. After surgery, a rehabilitation program of strengthening exercises of both lower extremities and gait training was started. At 2-month follow-up, she was able to walk with orthoses and performed daily activities with minimal assistance. CONCLUSION: Symptoms of spinal arachnoiditis occurred 6 months after a single caudal block in this woman. Clinicians should be aware of this possible delayed complication.

Acute ischemic stroke lasting for 5 days without definite lesions on diffusion-weighted magnetic resonance imaging in a patient with severe leukoaraiosis.

The reported frequency of false-negative diffusion-weighted magnetic resonance imaging (DWI) cases is 3.5%-25%. However, territorial stroke (eg, middle cerebral artery territory) with negative DWI is very rare. We report a case of territorial ischemic stroke persisting for 5 days without identification of a definite lesion on DWI but with decreased perfusion on perfusion computed tomography in a patient with underlying severe leukoaraiosis. This case suggests that severe leukoaraiosis might be responsible for the negative finding on DWI in acute ischemic stroke.

Association Between Length of Stay in the Intensive Care Unit and Sarcopenia Among Hemiplegic Stroke Patients.

OBJECTIVE: To discuss the association between the length of stay at the intensive care unit (ICU) and sarcopenia among hemiplegic stroke patients. METHODS: This study evaluated 66 hemiplegic stroke patients with history of ICU admission using handgrip strength and bioelectrical impedance analysis to obtain height-adjusted appendicular skeletal muscle mass. The diagnosis of sarcopenia was made according to the muscle mass based on the Asian Working Group for Sarcopenia. The patients were divided into sarcopenic and non-sarcopenic groups. The two groups were statistically analyzed, and the significant factors with differences were studied. A multivariate logistic regression analysis was performed to examine the association between length of stay in the ICU and sarcopenia, after adjusting for potential confounders. RESULTS: Among 66 hemiplegic patients with an ICU admission history, 12 patients were diagnosed with sarcopenia. Sarcopenia patients showed lower scores on the Korean version of the Modified Barthel Index and the Korean version of the Mini-Mental State Examination. Additionally, patients with sarcopenia had a longer length of stay in the ICU, and univariate and multivariate analyses confirmed that the ICU length of stay was significantly related to sarcopenia (adjusted odds ratio=1.187; 95% confidence interval, 1.019-1.382; p=0.028). CONCLUSION: The length of stay in the ICU was significantly associated with sarcopenia in hemiplegic stroke patients.

KSNR Clinical Consensus Statements: Rehabilitation of Patients with Parkinson's Disease.

Clinical consensus statements (CCSs) aim to improve care for patients with Parkinson's disease (PD) and reduce the variability of rehabilitation methods in clinical practice. A literature search was conducted to find available evidence on the rehabilitation of patients with PD and to determine the scope of CCSs. The selection of PD rehabilitation domains and key questions was done using the modified Delphi method in 43 expert panels. These panels achieved a consensus on 11 key questions regarding rehabilitation assessment and goal setting, gait and balance, activities of daily living, and swallowing and communication disorders. After the completion of an agreement procedure, 11 key consensus statements were developed by the consensus panel. These statements addressed the needs of rehabilitation as a continuum in patients with PD. They included the appropriate rehabilitation initiation time, assessment items, rehabilitation contents, and complication management. This agreement can be used by physiatrists, rehabilitation therapists, and other practitioners who take care of patients with PD. The consensus panel also highlighted areas where a consensus could not be reached. The development of more focused CCS or clinical practice guidelines that target specific rehabilitation approaches is considered the next needed step.

Colonoscopic lesions in patients with spinal cord injury.

BACKGROUND/OBJECTIVE: In spinal cord injury (SCI), loss of central or peripheral neural control causes neurogenic bowel. Patients may not exhibit the typical signs and symptoms of gastrointestinal disease. Few studies have looked at the risk of gastrointestinal disease in this group and the indications for preventive screening. The objective of this study was to study colonoscopic lesions in patients with SCI and determine whether there are any differences in the prevalence of lesions between SCI and control patients. DESIGN: Case control study. METHODS: Twenty-five patients with SCI were compared with 41 control patients who received colonoscopy at the same time. Mann-Whitney test for continuous variable, and Fisher exact test for frequency variables were used. OUTCOME MEASURES: Demographic information, duration of SCI, and colonoscopy findings were gathered. RESULTS: Colonic lesions were observed in 52% of patients with SCI and in 41.5% of control patients. Most frequent lesions in SCI group were inflammatory bowel disease (16%) and polyp (16%), followed by proctitis (12%) and hemorrhoid (12%). In the control group, hemorrhoid (17.1%) was most common, followed by polyp (12.2%) and melanosis coli (9.8%). No significant differences were found between the 2 groups. In the SCI group, no significant differences in lesions were found among the patients with cervical, thoracic, and lumbar SCI in the SCI group. Duration of SCI did not affect the pattern of colonoscopic lesions. CONCLUSION: Patients with SCI had the same incidence of colonscopic lesions as control patients. Inflammatory bowel disease, which is a risk factor for cancer, was the most common findings in the SCI group, although there was no significant difference from the control group. In patients with SCI, colonoscopy screening is warranted at the same frequency as for the general population.

Spinal epidural abscess associated with moxibustion-related infection of the finger.

OBJECTIVE: To describe a spinal epidural abscess that originated from cellulitis after moxibustion. METHODS: Case report. FINDINGS: A 78-year-old woman with diabetes mellitus was diagnosed with tetraplegia due to a cervical spinal epidural abscess extending to the thoracic spinal epidural space. The abscess was caused by osteomyelitis and cellulitis of the right third finger, which had been cauterized repeatedly with moxa. After surgical decompression and drainage of the spinal epidural abscess and comprehensive rehabilitation, motor strength and functional level improved. CONCLUSIONS: This case illustrates the risk of spinal epidural abscess in persons with diabetes mellitus who present with focal cellulitis and osteomyelitis.

A simple rat model of mild traumatic brain injury: a device to reproduce anatomical and neurological changes of mild traumatic brain injury.

Mild traumatic brain injury typically involves temporary impairment of neurological function. Previous studies used water pressure or rotational injury for designing the device to make a rat a mild traumatic brain injury model. The objective of this study was to make a simple model of causing mild traumatic brain injury in rats. The device consisted of a free-fall impactor that was targeted onto the rat skull. The weight (175 g) was freely dropped 30 cm to rat's skull bregma. We installed a safety device made of acrylic panel. To confirm a mild traumatic brain injury in 36 Sprague-Dawley rats, we performed magnetic resonance imaging (MRI) of the brain within 24 h after injury. We evaluated behavior and chemical changes in rats before and after mild traumatic brain injury. The brain MRI did not show high or low signal intensity in 34 rats. The mobility on grid floor was decreased after mild traumatic brain injury. The absolute number of foot-fault and foot-fault ratio were decreased after mild traumatic brain injury. However, the difference of the ratio was a less than absolute number of foot-fault. These results show that the device is capable of reproducing mild traumatic brain injury in rats. Our device can reduce the potential to cause brain hemorrhage and reflect the mechanism of real mild traumatic brain injury compared with existing methods and behaviors. This model can be useful in exploring physiology and management of mild traumatic brain injury.

Lymphedema Associated With Primary Amyloidosis: A Case Study.

We reported on a 60-year-old man presenting lymphedema of both lower extremities and scrotum for 3 years with unknown cause. We took a computed tomography scan of the lower extremities as a follow-up. There were diffuse subcutaneous edema in both lower extremities and multiple enlarged lymph nodes along the para-aortic and bilateral inguinal areas. For further evaluation, biopsy of an enlarged inguinal lymph node was taken, yielding a diagnosis of primary amyloidosis. A treatment of chemotherapy for amyloidosis was recommended for him. To our knowledge, this is the first report of lymphedema presenting with primary amyloidosis in Asia. This case suggests that primary amyloidosis could be one of the differential diagnoses in patients with lymphedema in the lower extremities.

A combination of Korean mistletoe extract and resistance exercise retarded the decline in muscle mass and strength in the elderly: A randomized controlled trial.

Given the increased concerns about the degenerative decline in the physical performance of the elderly, there is a need for developing effective strategies to suppress the age-related loss of skeletal muscle mass and functional capacity through a lifestyle intervention. This randomized controlled trial examined whether a combination of Korean mistletoe extract (KME) supplement and exercise affected muscle mass, muscle function, and targeted molecular expressions. Sixty-seven subjects aged 55-75years were assigned to placebo, low-dose (1g/d), or high-dose (2g/d) of KME for 12weeks. The body composition was significantly changed in the high-dose group during the intervention period as determined by skeletal muscle mass (P=0.040), fat free mass (P=0.042), soft lean mass (P=0.023), skeletal muscle index (P=0.041), fat-free mass index (P=0.030), percent body fat (P=0.044), and fat mass to lean mass ratio (P=0.030). Knee strength was measured by Cybex, demonstrating a significant effect in the KME groups compared to the placebo group (P=0.026 for peak torque and P=0.057 for set total work), which was more pronounced after adjusting for age, gender, protein, and energy intake (P=0.009 for peak torque and P=0.033 for set total work). The dynamic balance ability was remarkably improved in the high-dose group over a 12-week period as determined by Timed "Up and Go" (P=0.005 for fast walk test and P=0.024 for ordinary walk test). Consistent with these results, RT-PCR, multiplex analyses, and immunocytofluorescence staining revealed that a high-dose KME supplementation was effective for suppressing intracellular pathways related to muscle protein degradation, but stimulating those related to myogenesis. In particular, significant differences were found in atrogin-1 mRNA (P=0.002 at a single administration and P=0.001 at a 12-week administration), myogenin mRNA (P<0.0001 at a single administration and P=0.040 at a 12-week administration), and insulin growth factor 1 receptor phosphorylation (P=0.002 at a 12-week administration). These results suggest that KME supplementation together with resistance exercise may be useful in suppressing the age-related loss of muscle mass and strength in the elderly.

Obesity and Pulmonary Function in Polio Survivors.

OBJECTIVE: To examine the correlation between obesity and pulmonary function in polio survivors. METHODS: This study was conducted based on a questionnaire survey and physical examination. The questionnaire included gender, age, paralyzed regions, physical activity levels, and accompanying diseases. The physical examination included measuring body mass index, waist circumference, muscle power, total fat amount, body fat percentage, and lean body mass. In addition, pulmonary function was tested based on forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), ratio of FEV1 to FVC, and chest circumference. Five university hospitals and a local health clinic participated in this study. RESULTS: Pearson and partial correlation coefficients that used data collected from 73 polio survivors showed that obesity had a negative correlation with pulmonary function. CONCLUSION: This study found that pulmonary function has a negative correlation with obesity for polio survivors. Therefore, it is necessary to develop specialized exercise programs to help polio survivors reduce their weight and strengthen their respiratory muscles.

Analysis of diaphragmatic movement before and after pulmonary rehabilitation using fluoroscopy imaging in patients with COPD.

BACKGROUND: The diaphragm is the principal inspiratory muscle. The purpose of this study was to assess improvements in diaphragmatic movement before and after pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD), using a fluoroscopy-guided chest X-ray. PATIENTS AND METHODS: Among 117 patients with COPD receiving pulmonary rehabilitation who underwent the initial fluoroscopy-guided chest X-ray and pulmonary function test, 37 of those patients who underwent both initial and follow-up fluoroscopy and pulmonary function tests were enrolled in this study. After hospital education, participants received pulmonary rehabilitation through regular home-based training for at least 3 months by the same physiatrist. We assessed the changes in diaphragm area with fluoroscopy-guided posteroanterior chest X-rays between pre- and postpulmonary rehabilitation. To minimize radiation hazards for subjects, the exposure time for fluoroscopy to take chest X-rays was limited to less than 5 seconds. RESULTS: There were significant improvements (2,022.8±1,548.3 mm(2) to 3,010.7±1,495.6 mm(2) and 2,382.4±1,475.9 mm(2) to 3,315.9±1,883.5 mm(2); right side P=0.001 and left side P=0.019, respectively) in diaphragmatic motion area during full inspiration and expiration in both lungs after pulmonary rehabilitation. Pulmonary function tests showed no statistically significant difference between pre- and postpulmonary rehabilitation. CONCLUSION: The study suggests that the strategy to assess diaphragm movement using fluoroscopy is a relatively effective tool for the evaluation of pulmonary rehabilitation in COPD patients in terms of cost and time savings compared with computed tomography or magnetic resonance imaging.

Therapeutic effect of repetitive magnetic stimulation combined with speech and language therapy in post-stroke non-fluent aphasia.

OBJECTIVE: To investigate the therapeutic effect of repetitive transcranial magnetic stimulation (rTMS) and speech and language therapy (SLT) on the improvement of performance on the Korean-version of the Western Aphasia Battery (K-WAB) in post-stroke non-fluent aphasic patients. METHODS: Twenty post-stroke, non-fluent aphasic patients were enrolled and assigned to one of two groups: a case group (n = 10) or a control group (n = 10). Participants were recruited from the inpatient clinic of the Physical and Rehabilitation Medicine Department of Bundang Jesaeng General Hospital from March 2011 to January 2012. The case group received rTMS and SLT and the control group received SLT; both groups received these therapies for four weeks. Language functioning was evaluated using K-WAB before and after treatment. RESULTS: There were no significant differences between the groups' baseline characteristics and initial values (p > 0.05). After four weeks of therapy, there were significant improvements in repetition and naming in the case group (p < 0.05). However, there was no significant improvement in the control group (p > 0.05). CONCLUSIONS: rTMS combined with SLT can be an effective therapeutic method for treating aphasia in post-stroke non-fluent aphasic patients, although additional controlled and more systemic studies should be conducted.