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Objective: To assess whether performing exercises during hemodialysis reduces the risk of developing intradialytic hypotension and enhances exercise capacity in patients with chronic kidney disease., Methods: This study included patients aged ≥18 years undergoing hemodialysis. Participants performed exercises using a portable lower extremity ergometer during hemodialysis sessions for 3 weeks. Data regarding walking distance, knee strength, quality of life, fat-free mass, arterial pressure, blood pressure, heart rate, frequency of intradialytic hypotension, fatigue, and duration of hemodialysis were collected and analyzed., Results: Significant improvements in walking distance and knee strength were observed following the implementation of exercise training during hemodialysis. Although there was no significant reduction in the frequency of intradialytic hypotension, a decreasing trend was noted. Other parameters such as quality of life and fatigue did not show significant changes., Conclusion: Using a portable ergometer during hemodialysis improved exercise capacity and knee strength in patients with chronic kidney disease. There was a trend toward reduced intradialytic hypotension, suggesting potential cardiovascular benefits. Further research with larger sample sizes is needed to confirm these findings.

Objective: To determine the effects of an integrated training device for strength and balance on extremity muscle strength, postural balance, and cognition in older adults using a combination with various rehabilitation training games, in which balance, strength, and cognitive training were configured in a single device., Methods: This prospective study included 20 healthy participants aged 65-85 years. Participants trained for 30 minutes daily, 3 days weekly, for 6 weeks with an integrated training device for strength and balance (SBT-120; Man&Tel Inc., Gumi, Korea). Main outcomes were measured using the Korean Mini-Mental State Examination (K-MMSE), Korean version of the Montreal Cognitive Assessment (K-MoCA), Timed Up and Go Test (TUG), Functional Reach Test (FRT), Berg Balance Scale (BBS), and Manual Muscle Test. Measurements were taken at three time points: T0 (pretreatment), T1 (immediately after treatment), and T2 (4 weeks after treatment)., Results: All 20 patients completed the training, and TUG, FRT, and BBS scores significantly improved at T1 and T2 compared to T0. Mean TUG scores decreased by 0.99±2.00 at T1 and 1.05±1.55 at T2 compared to T0. Mean FRT scores increased by 6.13±4.26 at T1 and 6.75±4.79 at T2 compared to T0. BBS scores increased by 0.60±0.94 at T1 and 0.45±1.15 at T2 compared to T0. Moreover, muscle strength and cognition (K-MMSE and K-MoCA scores) increased after training., Conclusion: Our findings suggest that an integrated training device for strength and balance can be a safe and useful tool for older adults.

Objective: To assess the altered pattern of intracortical excitability of the affected and unaffected hemispheres in stroke patients using paired-pulse transcranial magnetic stimulation (TMS)., Methods: We evaluated intracortical inhibition (ICI) and intracortical facilitation (ICF) in both hemispheres at acute and subacute stages of 103 stroke patients using paired-pulse TMS. The patients were divided into two groups: mild-to-moderate patients whose motor evoked potential (MEP) was recorded in the affected hemisphere; and severe patients whose MEP was not recorded in the affected hemisphere., Results: In mild-to-moderate patients, the value of ICI in the affected hemisphere was increased from 70.3% to 77.9% and the value of ICI in the unaffected hemisphere was decreased from 74.8% to 70.3% with eventual progression in acute to subacute stages of stroke. In severe patients, the value of ICI in the unaffected hemisphere was increased from 65.4% to 75.6%. The changes in ICF were not significantly different in this study., Conclusion: We conclude that the unaffected hemisphere was more disinhibited than the affected hemisphere in acute phase of mild-to-moderate stroke, and the affected hemisphere was more disinhibited in the subacute stage. The unaffected hemisphere was inhibited in severe cases in acute-to-subacute phases of stroke. This finding facilitates appropriate neuromodulation of acute-to-subacute phases in mild-to-severe stroke patients.

Objective: To translate the English version of the London Chest Activity of Daily Living scale (LCADL) into a Korean version and to determine the reliability and validity of the Korean version in patients with chronic obstructive pulmonary disease (COPD)., Methods: The English version of LCADL was translated into Korean and back-translated into English. Subsequently, the back-translated version was reviewed and compared with the original, and thus the final K-LCADL was obtained. To evaluate the validation of the K-LCADL, patients simultaneously completed a pulmonary function test, a 6-Minute Walk Test (6MWT), and questionnaires, including the modified Medical Research Council (mMRC) dyspnea scale, the Korean version of the St. George's Respiratory Questionnaire (K-SGRQ), the Korean version of the COPD Assessment Test (K-CAT), and the Korean version of the EuroQoL-5 Dimensions (K-EQ-5D). To assess test-retest reliability, the K-LCADL was again administered to the same patients within 2 weeks from initial assessment., Results: A total of 94 patients participated in the present study. The total K-LCADL score was positively correlated with the K-SGRQ (r=0.802, p<0.001), the mMRC dyspnea scale (r=0.603, p<0.001), and the K-CAT score (r=0.714, p<0.001), and negatively correlated with the K-EQ-5D (r=-0.764, p<0.001), 6MWT (r=-0.635, p<0.001), forced expiratory volume in one second 1 (r=-0.416, p=0.002), and forced vital capacity (r=-0.397, p=0.023). Intraclass correlation coefficient of the K-LCADL was 0.951 (p<0.001)., Conclusion: The K-LCADL is a reliable and valid questionnaire for evaluating limitation of activities of daily living in patients with COPD., Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.

Objective: To compare the respiratory muscle strength between patients with stable and acutely exacerbated (AE) chronic obstructive pulmonary disease (COPD) at various stages., Methods: A retrospective medical record review was conducted on patients with COPD from March 2014 to May 2016. Patients were subdivided into COPD stages 1-4 according to the Global Initiative for Chronic Obstructive Lung Disease guidelines: mild, moderate, severe, and very severe. A rehabilitation physician reviewed their medical records and initial assessment, including spirometry, maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), COPD Assessment Test, and modified Medical Research Council scale. We then compared the initial parameters in patients with a stable condition and those at AE status., Results: The AE group (n=94) had significantly lower MIP (AE, 55.93±20.57; stable, 67.88±24.96; p=0.006) and MIP% (AE, 82.82±27.92; stable, 96.64±30.46; p=0.015) than the stable patient group (n=36). MIP, but not MEP, was proportional to disease severity in patients with AE and stable COPD., Conclusion: The strength of the inspiratory muscles may better reflect severity of disease when compared to that of expiratory muscles., Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported.

Objective: To investigate the effects of the newly developed Spine Balance 3D system on the balance and gait abilities of hemiplegic stroke patients., Methods: Twenty-eight hemiplegic patients with chronic stroke were randomly assigned to an experimental (n=14) or control group (n=14). The experimental and control groups performed balance training by using the newly developed Spine Balance 3D system and the well-known Biodex Balance System 30 minutes per day, three times a week for 7 weeks. The Berg Balance Scale (BBS), 10-m walking test (10mWT), Timed Up and Go Test (TUG), Functional Reach Test (FRT), the Korean version of the Fall Efficacy Scale-International (KFES-I), trunk muscle strength and stability were evaluated before and after 7 weeks of intervention., Results: The 10mWT improved significantly (p=0.001) in the experimental group (using the Spine Balance 3D system) but not in the control group, and core muscle strength, which we checked using Spine Balance 3D system evaluation program, improved more in the experimental group as well. The results of the BBS, FRT, TUG, KFES-I, and Biodex Balance System evaluation program improved in both groups after 7 weeks of balance training., Conclusion: We suggest that the newly-developed Spine Balance 3D system can be a more useful therapeutic tool for gait and dynamic balance rehabilitation in hemiplegic patients than a conventional 2D-based balance training system. A large-scale randomized controlled study is needed to prove the effect of this system., Competing Interests: No potential conflict of interest relevant to this article was reported.

Axial mesodermal dysplasia complex (AMDC) arises in variable combinations of craniocaudal anomalies such as musculoskeletal deformities, neuroschisis, or rhombencephalic developmental disorders. To the best of our knowledge, the co-existence of AMDC with associated musculoskeletal anomalies, medullary neuroschisis with mirror movements, and cranial nerve anomalies has not yet been reported. Here, we report the case of a 4-year-old boy whose clinical features were suggestive of Goldenhar syndrome and Poland syndrome with Sprengel deformity. Moreover, he showed mirror movements in his hands suspected of rhombencephalic malformation, and infranuclear-type facial nerve palsy of the left side of his face, the opposite side to the facial anomalies of Goldenhar syndrome. After conducting radiological studies, he was diagnosed with medullary neuroschisis without pontine malformations and Klippel-Feil syndrome with rib anomalies. Based on these findings, we propose that clinical AMDC can be accompanied by a wide variety of musculoskeletal defects and variable degrees of central nervous system malformations. Therefore, in addition to detailed physical and neurological examinations, imaging studies should be considered in AMDC.

Objective: To investigate changes in the core temperature and body surface temperature in patients with incomplete spinal cord injuries (SCI). In incomplete SCI, the temperature change is difficult to see compared with complete spinal cord injuries. The goal of this study was to better understand thermal regulation in patients with incomplete SCI., Methods: Fifty-six SCI patients were enrolled, and the control group consisted of 20 healthy persons. The spinal cord injuries were classified according to International Standards for Neurological Classification of Spinal Cord Injury. The patients were classified into two groups: upper (neurological injury level T6 or above) and lower (neurological injury level T7 or below) SCIs. Body core temperature was measured using an oral thermometer, and body surface temperature was measured using digital infrared thermographic imaging., Results: Twenty-nine patients had upper spinal cord injuries, 27 patients had lower SCIs, and 20 persons served as the normal healthy persons. Comparing the skin temperatures of the three groups, the temperatures at the lower abdomen, anterior thigh and anterior tibia in the patients with upper SCIs were lower than those of the normal healthy persons and the patients with lower SCIs. No significant temperature differences were observed between the normal healthy persons and the patients with lower SCIs., Conclusion: In our study, we found thermal dysregulation in patients with incomplete SCI. In particular, body surface temperature regulation was worse in upper SCIs than in lower injuries. Moreover, cord injury severity affected body surface temperature regulation in SCI patients.

Terson syndrome refers to oculocerebral syndrome of retinal and vitreous hemorrhage associated with spontaneous subarachnoid hemorrhage or all forms of intracranial bleeding. Recent observations have indicated that patients with spontaneous subarachnoid hemorrhage have an 18% to 20% concurrent incidence of retinal and vitreous hemorrhages with about 4% incidence of vitreous hemorrhage alone. Clinical ophthalmologic findings may have significant diagnostic and prognostic value for clinicians. Here we report a 45-year-old female patient who suffered from blurred vision after subarachnoid hemorrhage. She was diagnosed as Terson syndrome. After vitrectomy, she recovered with normal visual acuity which facilitated the rehabilitative process. We also performed visual evoked potentials to investigate abnormalities of visual dysfunction. Based on this case, we emphasize the importance of early diagnosis of Terson syndrome.

Objective: To investigate whether motor evoked potential (MEP) amplitude ratio measurements are sufficiently objective to assess functional activities of the extremities. We also delineated the distribution between the presence or absence of MEPs and the Medical Research Council (MRC) scale for muscle strength of the extremities., Methods: We enrolled 183 patients with first-ever unilateral hemiplegia after stroke. The MEP parameters were amplitude ratio (amplitude of affected side/amplitude of unaffected side) recorded at the first dorsal interosseous (FDI) and tibialis anterior (TA) muscles. We performed frequency analyses using the MRC scale for muscle strength and the presence or absence of evoked MEPs. Change on the MRC scale, hand function tests (HFTs), and the Modified Barthel Index (MBI) subscore were compared between the evoked MEP and absent MEP groups using the independent t-test. Receiver operating characteristic curves were used to determine the optimal cutoff scores for the MEP amplitude ratio using the HFT results and MBI subscores. Correlations between the MEP amplitude ratio and the MRC scale, HFTs, and MBI subscore were analyzed., Results: About 10% of patients with MRC scale grades 0-2 showed evoked MEPs at the FDI muscle, and 4% of patients with MRC scale grades 3-5 did not show MEPs. About 18% of patients with MRC scale grades 0-2 showed evoked MEPs at the TA muscle, and 4% of patients with MRC scale grades 3-5 did not show MEPs. MEP amplitude increased with increasing MRC scale grade. The evoked MEP group had more significant changes on the MRC scale, HFT, and the climbing stair score on the MBI than those in the group without MEPs. Larger MEP amplitude ratios were observed in patients who had more difficulty with the HFTs and ambulation. The MEP amplitude ratio was significantly correlated with the MRC scale, HFT, and MBI subscore., Conclusion: We conclude that the MEP amplitude ratio may be useful to predict functional status of the extremities in patients who suffered stroke.

Objective: To investigate neuroradiological and neurophysiological characteristics of patients with dyskinetic cerebral palsy (CP), by using magnetic resonance imaging (MRI), voxel-based morphometry (VBM), diffusion tensor tractography (DTT), and motor evoked potential (MEP)., Methods: Twenty-three patients with dyskinetic CP (13 males, 10 females; mean age 34 years, range 16-50 years) were participated in this study. Functional evaluation was assessed by the Gross Motor Functional Classification System (GMFCS) and Barry-Albright Dystonia Scale (BADS). Brain imaging was performed on 3.0 Tesla MRI, and volume change of the grey matter was assessed using VBM. The corticospinal tract (CST) and superior longitudinal fasciculus (SLF) were analyzed by DTT. MEPs were recorded in the first dorsal interossei, the biceps brachii and the deltoid muscles., Results: Mean BADS was 16.4±5.0 in ambulatory group (GMFCS levels I, II, and III; n=11) and 21.3±3.9 in non-ambulatory group (GMFCS levels IV and V; n=12). Twelve patients showed normal MRI findings, and eleven patients showed abnormal MRI findings (grade I, n=5; grade II, n=2; grade III, n=4). About half of patients with dyskinetic CP showed putamen and thalamus lesions on MRI. Mean BADS was 20.3±5.7 in normal MRI group and 17.5±4.0 in abnormal MRI group. VBM showed reduced volume of the hippocampus and parahippocampal gyrus. In DTT, no abnormality was observed in CST, but not in SLF. In MEPs, most patients showed normal central motor conduction time., Conclusion: These results support that extrapyramidal tract, related with basal ganglia circuitry, may be responsible for the pathophysiology of dyskinetic CP rather than CST abnormality.

Objective: To translate the English Victorian Institute of Sport Assessment for patellar tendinopathy (VISA-P) questionnaire into a Korean version and to determine the reliability and validity of the Korean version., Methods: The English VISA-P questionnaire was translated into Korean according to the internationally recommended guidelines. Then, 28 adolescent elite volleyball athletes (average age, 16 years; range, 14 to 19 years) were asked to complete the questionnaire three times (before examination, after examination, and 1 week later) for reliability. They were evaluated through a physical examination and ultrasonography to diagnosis patellar tendinopathy., Results: The internal consistency of the VISA-P questionnaire by Cronbach's alpha was 0.80 for the first, 0.78 for the second, and 0.79 for the third assessment. The intraclass correlation coefficient (ICC) between the first and second assessments was 0.97. The ICC between the second and third assessments was 0.96. The mean VISA-P scores were 67.6±15.7 for the patellar tendinopathy group (n=23) and 92.6±8.6 for the normal group (n=5). There were significantly lower VISA-P scores in the patellar tendinopathy group compared to the normal group., Conclusion: The translated Korean version VISA-P questionnaire has good internal consistency, test-retest reliability and validity. In addition, this study indicated that most adolescent elite volleyball athletes had patellar tendon problems. Therefore, the Korean version VISA-P is a useful self-administered outcome score of athletes with patellar tendinopathy.

Objective: To examine the effects of age, gender and bolus consistency in normal populations using the temporal measurement of Pharyngeal Transit Duration (PTD), which reflects the duration of bolus flow from the ramus of the mandible to the upper esophageal sphincter., Method: 40 normal and healthy subjects had Videofluoroscopic Swallowing Examinations (VFSEs) of 5 ml thin and nectar thick liquids, and puree consistencies. A slow motion and frame by frame analysis was performed. Three-way analysis of variance (ANOVA) was performed to examine the main effect and interactions, and paired t-tests for the three consistency comparisons., Results: Older subjects had a significantly longer PTD than younger subjects (p<0.01). In addition, men had significantly shorter PTDs than women (p<0.01). Puree showed a significantly longer PTD than the other two consistencies, regardless of age and gender (p<0.05)., Conclusion: PTD is an indicative of motor weakness in pharyngeal swallowing secondary to aging. In addition, the results supported the assumption that there is a functional difference in pharyngeal swallowing between men and women. It is expected that the results of this study will be used for further investigation of patients with dysphagia.

Objective: To evaluate and compare the organization of descending motor pathways to upper extremity muscles among healthy children., Method: The healthy children were 16 males and 7 females aged 1-19 years (average, 9 years), and eight healthy adults were enrolled as the control group. Transcranial magnetic stimulation was applied to bilateral motor cortices, and motor evoked potentials (MEPs) were recorded using surface electrodes from the first dorsal interossei (FDI), the biceps brachii (BIC), and the deltoid (DEL) muscles. The onset latency, central motor conduction time (CMCT), and amplitude were obtained during a relaxed state., Results: MEPs of FDI were obtained from subjects aged 13 months. The frequency of obtaining MEPs in proximal and distal muscles increased with age, although there was a less frequent incidence of obtaining MEPs in the proximal BIC and DEL muscles compared with those in the distal FDI muscle. MEP amplitudes increased with age, whereas latencies were relatively constant. CMCTs showed a similar pattern of maturation, and adult values were obtained by 13-years-of-age., Conclusion: These results suggest that the proximal and distal muscles of the upper extremities show different maturation and organization patterns.

Objective: To compare the voice onset time (VOT) differences of Korean stops in the initial and intervocalic positions between the aphasic patients with peculiarities of aspiration and a control group., Method: We examined 15 aphasic patients (nine males, six females) who had suffered a stroke (average age 49.7 years) and 15 healthy controls (average age 47.4 years). An aphasia examination was made by an aphasia battery of three standard tests and VOT was analyzed instrumentally. Stop consonants in the initial and intervocalic position were measured to categorize them according to aphasia types, place of articulation, and manner of articulation., Results: VOT of the aphasic patients with peculiarities of aspiration had a greater difference than that of the controls, indicating that the temporal non-coordination between the laryngeal adjustment and oral articulators of aphasic patients happens due to the VOT of stops in the initial and intervocalic positions (p<0.05)., Conclusion: VOT of stop consonants in the initial position produced by aphasic patients tends to be proportional to their breathing. It can cause glottal width and make aphasic patients' VOT duration longer. Lastly, the method to measure the VOT of aphasic patients is more significant for the types of phonation than for the places of articulation, and makes it possible to induce abnormal VOT.

Epilepsy is an intractable disease, though many treatment modalities have been developed. Recently, noninvasive transcranial direct current stimulation (tDCS), which can change brain excitability, was introduced and has been applied for therapeutic purposes regarding epilepsy. A suppression of seizures was experienced by cathodal tDCS in a medication refractory pediatric epileptic patient. The patient was an 11-year-old female who had focal cortical dysplasia of the cerebral hemisphere. The patient was treated with antiepileptic drugs but the mean seizure frequency was still eight episodes per month. The tDCS cathode was placed at the midpoint of P4 and T4 in the 10-20 EEG system where the abnormal wave was observed on a sleep EEG. Two mA of tDCS was applied 20 minutes a day, five days a week for two weeks. During a two-month period after treatment termination, only six seizure attacks occurred, and the duration of each seizure episode also decreased. tDCS was applied under the same conditions for another two weeks. For two months after the second treatment session, only one seizure attack occurred, and it showed great improvement compared to the eight seizure attacks per month before the tDCS treatment. The medications were not changed, and there were no notable side effects that were caused by tDCS.

Objective: To evaluate normal healthy persons without spasticity to observe normal findings of the elbow stretch reflex using a newly developed, portable, hand-driven spasticity-measuring system., Method: Thirty normal persons without any disease involving the central or peripheral nervous system were enrolled in this study. The portable hand-driven isokinetic system is able to measure the joint angle, angular velocity, electromyographic (EMG) signals, and torque during elbow passive extension-flexion. One set of 10 passive elbow extension and flexion movements was performed for data acquisition at each angular velocity, including 60, 90, 120, 150 and 180 degrees per second (°/sec). Electromyographic data were collected from the biceps brachii and the triceps brachii. Torque data were collected from sensors around the wrist., Results: We were able to detect EMG activity and torque in all subjects by using the new portable hand-driven isokinetic system. EMG activity and torque increased with incremental increase of angular velocities. The joint angle of maximal EMG activity according to different angular velocities did not show any significant difference (116°-127° in elbow extension and 37°-66° in elbow flexion). The joint angles of maximal torque according to different angular velocities were not significantly different either., Conclusion: Using the portable hand-driven isokinetic system on the elbows of normal subjects, we were able to obtain expected results. By considering our normal findings of the elbow stretch reflex using this system, we propose that the various aspects of spasticity-related data can be measured successfully.

Objective: To evaluate the motor innervation of trunk muscles in traumatic brain injury patients., Method: Twenty patients (12 men and 8 women) with traumatic brain injury were enrolled in this study. Their mean age was 41 years. Motor evoked potentials (MEPs) were performed on the motor cortex. Electromyographic activities were recorded from the bilateral rectus abdominis muscles, the external oblique abdominal muscles, and the 4th and 9th thoracic erector spinae muscles. The onset latency and amplitude of contralateral and ipsilateral MEPs were measured. All patients were assessed by the Korean version of the Berg Balance Scale (K-BBS) to investigate the relationship between the frequency of MEPs in trunk muscles and gait ability., Results: The mean frequency of ipsilateral MEPs was 23.8% with more damaged hemisphere stimulation, while the contralateral MEPs showed a mean frequency of 47.5% with more damaged hemisphere stimulation in traumatic brain injury patients. The latencies and amplitudes of MEPs obtained from the more damaged hemisphere were not significantly different from those of the less damaged hemisphere. There was no correlation between the manifestation of MEPs in trunk muscles and gait ability., Conclusion: The ipsilateral and contralateral corticospinal pathways to trunk muscles are less likely to be activated in traumatic brain injury patients because of direct injury of the descending corticospinal motor tract or decreased excitability of the corticospinal tract from prefrontal contusion.