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Introduction Previous studies reported that statin use was related to a lower risk of pneumonia in the general population. This study investigated the association between statin use and pneumonia risk in patients with Parkinson's disease (PD). Methods Patients that had been newly diagnosed with PD between 2004 and 2006 in the 2002–2017 National Health Insurance Service database in South Korea were identified. PD patients who had received one or more statin prescriptions, and experienced pneumonia during the observation period were included in the self-controlled case series (SCCS) analysis. Patients who had no previous statin prescription record were included in the Cox proportional hazard model with a time-varying covariate (statin use). The risk of pneumonia in PD patients with statin use was estimated after adjusting potential confounders. Results Of the 10,159 patients with PD, 337 individuals were eligible for the SCCS analysis. The median duration of statin exposure was 2.63 years (IQR, 0.83–5.83). The incidence of pneumonia was reduced in the statin-exposed period compared to the unexposed period (incidence rate ratio, 0.88; 95% CI, 0.86–0.91). A total of 8,022 patients were included in the Cox proportional hazard model. Statin use was related to a significantly reduced pneumonia risk (adjusted hazard ratio, 0.69; 95% CI, 0.62–0.78). Conclusions Statin use was associated with a lower risk of pneumonia in PD patients. Statins might affect pneumonia occurrence by lowering cholesterol levels or slowing the progression of PD as neuroprotective agents. Further clinical studies are needed to delineate our findings with the underlying biological mechanisms.

Background Unilateral vocal cord paralysis may result from nerve compression by tumors or direct nerve injuries during tumor resections, which can cause dysphonia or dysphagia, and reduced quality of life. Objectives This prospective, single-group study aimed to investigate the effect of percutaneous injection laryngoplasty on voice and swallowing function in patients with cancer-related unilateral vocal cord paralysis. Methods Patients underwent percutaneous injection laryngoplasty with hyaluronic acid under local anesthesia. Stroboscopy and videofluoroscopic swallowing study were conducted to evaluate the voice- and swallowing-related outcome measures, respectively. The participants were evaluated before injection laryngoplasty, as well as after two weeks and three months. Results Injection laryngoplasty significantly improved the glottal gap, vocal fold position, Maximum Phonation Time, and Voice Handicap Index-10. Post-hoc analysis using Bonferroni correction showed that the improvements occurred within two post-treatment weeks and remained at three post-treatment months. In the subgroup analysis, the patients who underwent injection laryngoplasty within 8 weeks from onset showed significantly higher improvements in the videofluoroscopic dysphagia scale and swallowing function than the patients who received the procedure after 8 weeks or more. Conclusion Percutaneous injection laryngoplasty improves glottal closure and voice in patients with cancer-related unilateral vocal cord paralysis. Early injection laryngoplasty may lead to greater benefits on swallowing function. Level of evidence 4.

Objectives Varying early survival rates have been reported across studies on patients with Parkinson's disease (PD). In this study, we reported the 10-year relative survival rate of patients with PD using a nationwide database. Design This was a population-based cohort study. Setting and Participants We identified incident PD cases from 2004 to 2006 using the PD registration codes from the National Health Insurance Service database covering the entire South Korean population. Methods Relative survival up to 10 years was evaluated by adjusting all-cause survival for expected survival, estimated from population life tables and matched by sex, age, and year of diagnosis. Results Of the 10,159 patients with PD, 4675 (46.0%) patients survived 10 years after diagnosis. Relative survival rates decreased with time after diagnosis (0.972 after 1 year, 0.772 after 5 years, and 0.588 after 10 years). Ten-year relative survival gradually decreased with age at diagnosis. Men had a lower relative survival rate than women 2 years post diagnosis, and if they were older than 60 years. Conclusions and Implications Patients diagnosed with PD are expected to have a lower 10-year relative survival. In the real world, patients with PD might have lower survival than the general population even in the early disease stage. Our results suggest further efforts to prevent premature mortality among patients with PD.

This retrospective cohort study investigated the risk and mortality rate due to aspiration pneumonia in patients with Parkinson’s disease (PD) using a nationwide database. We identified 10,159 newly diagnosed PD patients between 2004 and 2006, and four age- and sex-matched controls for each PD patient from the National Health Insurance Service database in Korea. We analyzed the relative risk of aspiration pneumonia and mortality after the first occurrence of aspiration pneumonia until 2017. Throughout the study period, PD patients showed a higher incidence of aspiration pneumonia than their matched controls (3.01 vs. 0.59 events per 1,000 person-years), and they were at an increased risk of aspiration pneumonia (hazard ratio = 4.21; 95% confidence interval, 3.87–4.58). After the first occurrence of aspiration pneumonia, the mortality rate of PD patients was 23.9% after one month, 65.2% after 1 year, and 91.8% after 5 years, while that of controls was 30.9%, 67.4%, and 88.9%, respectively. Patients with PD are at an increased risk of aspiration pneumonia, and approximately two-thirds of the patients die within a year after experiencing aspiration pneumonia. Further studies are warranted to prevent aspiration pneumonia and implement proper treatments to prevent death after aspiration pneumonia in patients with PD.

Supplemental digital content is available in the text., Coronavirus disease 2019 might have an impact on patients with Parkinson disease because of the neuroinvasive potential. Herein, we report the case of a patient with Parkinson disease who developed severe and prolonged oropharyngeal dysphagia after a coronavirus disease 2019 infection. A 73-yr-old male patient with Parkinson disease was diagnosed with coronavirus disease 2019 and admitted to a tertiary care hospital. Before hospitalization, he was assessed at Hoehn and Yahr stage 4 and showed no symptoms of dysphagia. After admission, the patient gradually recovered; however, he was fed through a nasogastric tube. A videofluoroscopic swallowing study revealed a severe oropharyngeal dysphagia with a severely delayed oral phase. Therefore, he underwent percutaneous gastrostomy tube insertion. After discharge, although he received swallowing therapy for 4 mos, he still had severe dysphagia, which made him dependent on enteral feeding. We speculate that the impact of coronavirus disease 2019 on dopaminergic and nondopaminergic mechanisms could lead to the development of dysphagia in this patient. The present case suggests that clinicians must have a high index of suspicion without dismissing the possibility of dysphagia and subsequent aspiration pneumonia in coronavirus disease 2019 patients with Parkinson disease.

Supplemental digital content is available in the text., Objective The aims of this study were to investigate changes in regional brain volume after concussion (mild traumatic brain injury) and to examine the relationship between change in brain volume and cognitive deficits. Design Twenty-eight patients with mild traumatic brain injury and 27 age-matched controls were included in this study. Magnetic resonance imaging (3 T) data were obtained from the participants. Structural brain volume changes were examined using tensor-based morphometry, which identifies regional structural differences in the whole brain, including cerebrospinal fluid, gray matter, and white matter. Volume contraction and expansion were compared between groups using a two-sample t test. The association between time post-injury or neurocognitive function and volumetric changes was examined using regression analysis. Results Individuals with mild traumatic brain injury exhibited volume reduction in the brainstem, including the pontine reticular formation. Regional cerebral volume changes were not associated with time post-injury but were significantly associated with neurocognitive function, especially with executive card sorting test, forward digit span test, and performance on verbal learning test. The greater regional cerebral volume was associated with better cognitive performance after mild traumatic brain injury. Conclusion Decreased brainstem volume may indicate its vulnerability to traumatic injury, and cerebral volume in specific regions was positively associated with patients’ cognitive function after injury.

Toxoplasma gondii is an obligate intracellular protozoan parasite that can invade various organs in the host body, including the central nervous system. Chronic intracranial T. gondii is known to be associated with neuroprotection against neurodegenerative diseases through interaction with host brain cells in various ways. The present study investigated the neuroprotective effects of chronic T. gondii infection in mice with cerebral ischemia experimentally produced by middle cerebral artery occlusion (MCAO) surgery. The neurobehavioral effects of cerebral ischemia were assessed by measurement of Garcia score and Rotarod behavior tests. The volume of brain ischemia was measured by triphenyltetrazolium chloride staining. The expression levels of related genes and proteins were determined. After cerebral ischemia, corrected infarction volume was significantly reduced in T. gondii infected mice, and their neurobehavioral function was significantly better than that of the uninfection control group. Chronic T. gondii infection induced the expression of hypoxia-inducible factor 1-alpha (HIF-1α) in the brain before MCAO. T. gondii infection also increased the expression of vascular endothelial growth factor after the cerebral ischemia. It is suggested that chronic intracerebral infection of T. gondii may be a potential preconditioning strategy to reduce neural deficits associated with cerebral ischemia and induce brain ischemic tolerance through the regulation of HIF-1α expression.

Objective To evaluate the longitudinal changes of swallowing kinematics based on videofluoroscopic swallowing studies (VFSSs) in subacute stroke patients grouped according to the method of dietary intake.Methods Sixty-nine subacute stroke patients who had taken at least 2 successive VFSSs were included. Subjects were allocated into 3 groups according to the degree of swallowing function recovery—not improved group (tube feeding recommended to patients at both studies), improved group (tube feedings recommended initially to patients and oral feeding recommended at follow-up study), and well-maintained group (oral feeding at both studies recommended to patients). Initial VFSS was performed during the subacute stage of stroke, 1 to 12 weeks after the onset of stroke, and follow-up VFSS was performed at least once. Kinematic variables were calculated by two-dimensional motion analysis of multiple structures, including the hyoid bone, epiglottis, and vocal cord. Changes of kinematic variables were analyzed in serial VFSSs.Results At the initial VFSS, the well-maintained group showed significantly larger angles of epiglottic folding than the not improved group, while at the follow-up VFSS, the improved and the well-maintained groups showed significantly larger epiglottic folding angles than the not improved group. The distribution of epiglottic folding angles was in a dichotomous pattern, and each cluster was related to the swallowing function.Conclusion This study showed that improved epiglottic folding angles are associated with the recovery of the swallowing process and suitability for oral feeding among various kinematic variables in subacute stroke patients.

Background Rehabilitation therapy using a virtual reality (VR) system for stroke patients has gained attention. However, few studies have investigated fully immersive VR using a head-mount display (HMD) for upper extremity rehabilitation in stroke patients. Objective To investigate the feasibility, preliminary efficacy, and usability of a fully immersive VR rehabilitation program using a commercially available HMD for upper-limb rehabilitation in stroke patients. Design A feasibility study. Setting Two rehabilitation centers. Participants Twelve stroke patients with upper extremity weakness. Interventions Five upper extremity rehabilitation tasks were implemented in a virtual environment, and the participants wore an HMD (HTC Vive) and trained with appropriate tasks. Participants received a total of 10 sessions two to three times a week, consisting of 30 minutes per session. Main outcome measures Both patient participation and adverse effects of VR training were monitored. Primary efficacy was assessed using functional outcomes (Action Research Arm Test, Box and Block Test, and modified Barthel Index), before and after the intervention. Usability was assessed using a self-reported questionnaire. Results Three patients discontinued VR training, and nine patients completed the entire training sessions and there were no adverse effects due to motion sickness. The patients who received all sessions showed significant functional improvement in all outcome measures after training (P Conclusions A fully immersive VR rehabilitation program using an HMD for rehabilitation of the upper extremities following stroke is feasible and, in this small study, no serious adverse effects were identified. Level of evidence IV.

BACKGROUND Despite the importance of understanding penetration-aspiration (PA) in patients with stroke, the pathophysiology of PA remains unclear. OBJECTIVES This study aimed to investigate the temporal characteristics of PA in post-stroke patients in terms of the timing of the PA event and hyolaryngeal incoordination. METHODS Fifty-eight swallows (38 stroke patients), showing PA when swallowing a thin liquid, were included. The timing of PA was classified kinematically as before or during the swallow. The movement sequence of vertical laryngeal elevation, horizontal hyoid excursion, and epiglottic rotation were compared with healthy controls. Spatiotemporal measurements, videofluoroscopic dysphagia scale parameters were compared between subgroups. RESULTS Thirteen swallows (22.4%) were classified as PA before the swallow and 45 were classified as PA during the swallow (77.6%). Among the PA during the swallow, 26 (57.8%) swallows exhibited abnormal sequences of hyolaryngeal movements and 19 (42.2%) swallows showed normal sequences of hyolaryngeal movements compared with healthy controls. The onset time of horizontal hyoid excursion (P = 0.028), the time to maximal horizontal hyoid excursion (P = 0.010), and maximal epiglottic rotation (P = 0.030) were significantly more delayed in the PA during the swallow group than in the PA before the swallow group. In the swallows with abnormal sequential movements, the onset of horizontal hyoid excursion occurred significantly later than the onset of epiglottic rotation (P

Objective To investigate the proportion of aspiration pneumonia cases among patients with community-acquired pneumonia in Korea.Methods This retrospective study included patients with community-acquired pneumonia who had been admitted to the emergency department of a university-affiliated tertiary hospital in Gyeonggi Province, Korea between January 1, 2016 and December 31, 2016. Among these patients, those with aspiration pneumonia were identified using ICD-10 codes (J69.*). Patients with recurrent pneumonia were excluded, as were those who were immunocompromised. The proportion of cases of aspiration pneumonia was calculated, and the characteristics and clinical outcomes of patients with aspiration pneumonia and non-aspiration pneumonia were compared. Results The proportion of aspiration pneumonia cases among patients with community-acquired pneumonia was 14.2%. Patients with aspiration pneumonia were significantly more likely to be older (p

Pregnancy is a risk factor for stroke in young women, but the effect of delivery on recovery and rehabilitation after stroke has not been elucidated in pregnant patients with stroke. This case report presents a pregnant patient with stroke who recovered successfully after cesarean delivery during rehabilitation. The possible effect of oxytocin is discussed as a factor promoting recovery from stroke. Level of Evidence V

Stooped posture, which is usually aggravated during walking, is one of the typical postural deformities in patients with parkinsonism. However, the degree of stooped posture is difficult to quantitatively measure during walking. Furthermore, continuous feedback on posture is also difficult to provide. The purpose of this study is to measure the degree of stooped posture during gait and to investigate whether vibration feedback from sensor modules can improve a patient’s posture. Parkinsonian patients with stooped posture were recruited for this study. Two wearable sensors with three-axis accelerometers were attached, one at the upper neck and the other just below the C7 spinous process of the patients. After being calibrated in the most upright posture, the sensors continuously recorded the sagittal angles at 20 Hz and averaged the data at every second during a 6 min walk test. In the control session, the patients walked with the sensors as usual. In the vibration session, sensory feedback was provided through vibrations from the neck sensor module when the sagittal angle exceeded a programmable threshold value. Data were collected and analyzed successfully in a total of 10 patients. The neck flexion and back flexion were slightly aggravated during gait, although the average change was &lt, 10° in most patients in both measurement sessions. Therefore, it was difficult to evaluate the effect of sensory feedback through vibration. However, some patients showed immediate response to the feedback and corrected their posture during gait. In conclusion, this preliminary study suggests that stooped posture could be quantitatively measured during gait by using wearable sensors in patients with parkinsonism. Sensory feedback through vibration from sensor modules may help in correcting posture during gait in selected patients.

Background Patients with parkinsonism have higher inactivity levels than the general population, and this results in increased comorbidities. Although exercise has benefits for motor function and quality of life (QOL) in patients with parkinsonism, these patients face many barriers to exercise participation, such as lack of motivation, fatigue, depression, and time constraints. Recently, the use of mobile apps has been highlighted as a remote exercise management strategy for patients with chronic diseases. Objective This study aimed to evaluate the effects of home-based exercise management with a customized mobile app on the exercise amount, physical activity, and QOL of patients with parkinsonism. Methods This was a prospective, open-label, single-arm pilot study. The therapist installed the app in the smartphones of the participants and educated them on how to use the app. The therapist developed an individualized multimodal exercise program that consisted of stretching, strengthening, aerobic, balance and coordination, and oral-motor and vocal exercises. Participants were encouraged to engage in an 8-week home-based exercise program delivered through a customized app. The alarm notifications of the app provided reminders to exercise regularly at home. The primary outcome was the exercise amount. The secondary outcomes were assessed using the International Physical Activity Questionnaire (IPAQ), Parkinson’s Disease Questionnaire-39 (PDQ-39), and Geriatric Depression Scale (GDS). The usability of the customized app was assessed using a self-report questionnaire. Results A total of 21 participants with parkinsonism completed the intervention and assessment between September and December 2020 (mean age: 72 years; women: 17/21, 81%; men: 4/21, 19%). The participants reported a significant increase in the total amount of exercise (baseline: mean 343.33, SD 206.70 min/week; 8-week follow-up: mean 693.10, SD 373.45 min/week; P Conclusions Exercise management with a customized mobile app may be beneficial for improving exercise adherence, physical activity levels, depression management, and QOL in patients with parkinsonism. This remotely supervised technology-based, reinforcing, and multimodal exercise management strategy is recommended for use in patients with parkinsonism. In addition, this program proved useful as an alternative exercise management strategy during the COVID-19 pandemic when patients with Parkinson disease were less physically active than before and showed aggravation of symptoms. However, additional clinical trials are needed to evaluate the efficacy of this exercise program in a large population and to confirm its disease-modifying effects.

Background: Although there have been many trials and interventions for reducing upper-extremity impairment in stroke survivors, it remains a challenge. A novel intervention is needed to provide high-repetition task-specific training early after stroke. Objective: This study aimed to investigate the effect of smart glove training (SGT) for upper-extremity rehabilitation in patients with subacute stroke. Methods: A prospective, multicenter, randomized, controlled study was conducted in patients with upper-extremity hemiparesis with Brunnstrom stage for arm 2-5 in the subacute phase after stroke. Eligible participants were randomly allocated to the SGT group or the control group. The SGT group underwent 30 min of standard occupational therapy plus 30 min of upper-extremity training with smart glove. The control group underwent standard occupational therapy for 30 min plus upper-extremity self-training (homework tasks at bedside) for 30 min. All participants underwent each intervention 5 days/week for 2 consecutive weeks. They were evaluated before, immediately after, and 4 weeks after the intervention. The primary outcome measure was the change in the score of the Fugl-Meyer assessment of the upper extremity (FMA-UE). Results: Twenty-three patients were enrolled. Repeated-measures analysis of covariance after controlling for age and disease duration showed significant time × group interaction effects in the FMA-UE, FMA-distal, and FMA-coordination/speed (p = 0.018, p = 0.002, p = 0.006). Repeated-measures analysis of variance showed significant time × group interaction effects in the FMA-UE, FMA-distal, and Box and Block Test (p = 0.034, p = 0.010, p = 0.046). Mann-Whitney U-test showed a statistically higher increase in the FMA-UE and FMA-distal in the SGT group than in the control group (p = 0.023, p = 0.032). Conclusion: Upper-extremity rehabilitation with a smart glove may reduce upper-extremity impairment in patients with subacute stroke. Clinical Trial Registration: ClinicalTrials.gov (NCT02592759).

Background Cognitive training using virtual reality (VR) may result in motivational and playful training for patients with mild cognitive impairment and mild dementia. Fully immersive VR sets patients free from external interference and thus encourages patients with cognitive impairment to maintain selective attention. The enriched environment, which refers to a rich and stimulating environment, has a positive effect on cognitive function and mood. Objective The aim of this study was to investigate the feasibility and usability of cognitive training using fully immersive VR programs in enriched environments with physiatrists, occupational therapists (OTs), and patients with mild cognitive impairment and mild dementia. Methods The VR interface system consisted of a commercialized head-mounted display and a custom-made hand motion tracking module. We developed the virtual harvest and cook programs in enriched environments representing rural scenery. Physiatrists, OTs, and patients with mild cognitive impairment and mild dementia received 30 minutes of VR training to evaluate the feasibility and usability of the test for cognitive training. At the end of the test, the usability and feasibility were assessed by a self-report questionnaire based on a 7-point Likert-type scale. Response time and finger tapping were measured in patients before and after the test. Results Participants included 10 physiatrists, 6 OTs, and 11 patients with mild cognitive impairment and mild dementia. The mean scores for overall satisfaction with the program were 5.75 (SD 1.00) for rehabilitation specialists and 5.64 (SD 1.43) for patients. The response time of the dominant hand in patients decreased after the single session of cognitive training using VR, but this was not statistically significant (P=.25). There was no significant change in finger tapping in either the right or left hand (P=.48 and P=.42, respectively). None of the participants reported headaches, dizziness, or any other motion sickness after the test. Conclusions A fully immersive VR cognitive training program may be feasible and usable in patients with mild cognitive impairment and mild dementia based on the positive satisfaction and willingness to use the program reported by physiatrists, OTs, and patients. Although not statistically significant, decreased response time without a change in finger tapping rate may reflect a temporary increase in attention after the test. Additional clinical trials are needed to investigate the effect on cognitive function, mood, and physical outcomes.

Background Low-frequency repetitive transcranial magnetic stimulation (rTMS) over the contralesional motor cortex (M1) has demonstrated beneficial effects on motor recovery, but evidence among patients with subacute stroke is lacking. We aimed to investigate whether 1-Hz rTMS over the contralesional M1 versus sham rTMS could improve arm function in patients with subacute ischemic stroke when combined with rehabilitative motor training. Methods In total, 77 patients who were within 90 days after their first-ever ischemic stroke were enrolled and randomly allocated to either real (n = 40) or sham rTMS (n = 37). We delivered 1-Hz 30-minute active or sham rTMS before each daily 30-minute occupational therapy sessions over a 2-week period. The primary endpoint was changes in the Box and Block Test (BBT) score immediately after the end of treatment (EOT). Secondary analyses assessed changes in Fugl-Meyer assessment, Finger Tapping Test (FTT), Brunnstrom stage, and grip strength. Clinical Trial Registration ClinialTrials.gov (NCT02082015). Results Changes in BBT immediately after the end of treatment did not differ significantly between the 2 groups ( P = .267). Subgroup analysis according to cortical involvement revealed that real rTMS resulted in improvements in BBT at 1 month after EOT (17.4 ± 9.8 real vs 10.9 ± 10.3 sham; P = .023) and Brunnstrom stage of the hand immediately after EOT (0.6 ± 0.5 real vs 0.2 ± 0.5 sham; P = .023), only in the group without cortical involvement. Conclusion The effects of real and sham rTMS did not differ significantly among patients within 3 months poststroke. The location of stroke lesions should be considered for future clinical trials.

Traumatic brain injury (TBI), a global public health concern, may lead to death and major disability. While various short-term, small-sample, and cross-sectional studies on TBI have been conducted in South Korea, there is a lack of clarity on the nationwide longitudinal TBI trends in the country. This retrospective study investigated the epidemiological TBI trends in South Korea, using a population-based dataset of the National Health Insurance (2008&ndash, 2017). The crude and age adjusted TBI incidence and mortality values were calculated and stratified by age, sex, and TBI diagnosis. The age-adjusted incidence per 100,000 people increased until 2010 and showed a decreasing trend (475.8 cases in 2017) thereafter, however, a continuously decreasing age-adjusted mortality trend was observed (42.9 cases in 2008, 11.3 in 2017). The crude incidence rate increased continually in those aged &gt, 70 years across all the TBI diagnostic categories. The mortality per 100,000 people was significantly higher among participants aged &ge, 70 years than in the other age groups. We observed changing trends in the TBI incidence, with a continuously decreasing overall incidence and a rapidly increasing incidence and high mortality values in older adults. Our findings highlight the importance of active TBI prevention in elderly people.

Background Robot-assisted gait training (RAGT) was developed to restore gait function by promoting neuroplasticity through repetitive locomotor training and has been utilized in gait training. However, contradictory outcomes of RAGT have been reported for patients with Parkinson’s disease (PD). In addition, the mechanism of the RAGT treatment effect is still unknown. This study aims to investigate the effects of RAGT on gait velocity in patients with PD and to unveil the mechanisms of these effects. Methods This is a prospective, single-blind, single-center, randomized controlled trial. Eligible participants will be randomly allocated to: 1) a Walkbot-S™ RAGT group or 2) a treadmill training group. The participants will receive three 45-min sessions of each intervention per week for 4 weeks. Gait speed during RAGT will be targeted to the maximal speed depending on the participant’s height; the same principle will be applied to the treadmill training group to match the training intensity. The primary outcome measure is gait speed measured by the 10-Meter Walk Test at a comfortable pace under single-task conditions. Secondary outcomes include dual-task interference, the Berg Balance Scale, Timed Up and Go test, the Korean version of the Falls Efficacy Scale-International, New Freezing of Gait Questionnaire, Movement Disorder Society-sponsored revision of the Unified Parkinson’s Disease Rating Scale, and functional connectivity measured by resting-state functional magnetic resonance imaging. Baseline assessments (T0) will be conducted to acquire clinical characteristics and outcome measure values before the intervention. Postintervention assessments (T1) will compare immediate efficacies within 3 days after the intervention. Follow-up assessments (T2) will be conducted 1 month after the intervention. Considering an alpha of 0.05 and a power of 80%, the total number of participants to be recruited is 44. Discussion This study will reveal the effect of RAGT using an exoskeletal robot, not only on gait speed, but also on gait automaticity, balance function, fall risk, quality of life, and disease severity. In addition, the study will shed new light on the mechanism of the RAGT effect by evaluating changes in gait automaticity and brain functional networks. Trial registration ClinicalTrials.gov, NCT03490578. Registered on 21 March 2018. Electronic supplementary material The online version of this article (10.1186/s13063-018-3123-4) contains supplementary material, which is available to authorized users.

Cervical dystonia is a common issue in patients with athetoid cerebral palsy. Botulinum toxin injection to dystonic cervical muscles is a well-recognized treatment option, but it is known to be associated with dysphagia. Previously reported cases of dysphagia after botulinum toxin injection to the sternocleidomastoid muscle were related to the regional spread of toxin to the pharyngeal muscles. We report a unique case of posture-dependent dysphagia due to preactivation of the suprahyoid and infrahyoid muscles to compensate for impaired head stabilization by the weakened sternocleidomastoid muscle while swallowing. This case suggests a possible mechanism of dysphagia in patients with athetoid cerebral palsy.

Background/Aims: Dysphagia, a symptom of multiple system atrophy (MSA), is a major clinical concern. In this study, we investigate the characteristics of early oropharyngeal dysphagia (OD) in patients with MSA, and the differences between MSA subtypes. Methods: Patients enrolled in the study had previously been diagnosed with MSA at the clinic of the Department of Neurology, and had been referred for a videofluoroscopic swallowing study (VFSS), between 2005 and 2014, to check for dysphagia. The clinical characteristics and VFSS findings were analyzed and compared between the MSA subtypes. Results: This study enrolled 59 patients with MSA (24 men; 31 with MSA-P, 21 with MSA-C, and 7 with MSA-PC). Dysphagia symptoms were mostly limited to aspiration symptoms (90.48%) in patients with MSA-C, while difficulty in swallowing, increased mealtime, and drooling were frequent in those with MSA-P. The most common VFSS finding amongst patients was vallecular residue (n = 53, 89.8%), followed by penetration/aspiration (n = 40, 67.8%), and coating of the pharyngeal wall (n = 39, 66.1%). Comparison analysis between subtypes showed that apraxia and vallecular residue were more frequent and severe in MSA-P than in MSA-C (p = 0.033 and p = 0.010, respectively). Conclusion: Understanding early OD characteristics in patients with MSA and the differences between MSA subtypes could be helpful in managing dysphagia in patients with MSA. Several dysphagia symptoms similar to those of Parkinson disease were frequently observed in MSA-P, but not in MSA-C. A follow-up study is needed to elucidate the natural course of OD in MSA patients and the difference between MSA subtypes.

OBJECTIVE The aim of this study was to investigate the association between grip strength on the unaffected side and post-stroke functional improvement. DESIGN A total of 127 patients with unilateral stroke were included in this study. Demographic data, clinical data on initial grip strength, initial National Institutes of Health Stroke Scale, admission and discharge Modified Barthel Index (MBI), and stroke profiles were retrospectively reviewed. RESULTS Univariate and multiple linear regression analyses were carried out to evaluate the predictive values of each variable. In the model for discharge MBI, age, initial National Institutes of Health Stroke Scale, grip strength on the unaffected side, lesion side, and admission MBI were shown to be independent predictors. Meanwhile, grip strength on the unaffected side, lesion side, and admission MBI had significant predictive values in the model for difference between admission and discharge MBI. CONCLUSION The current study suggests for the first time that grip strength on the unaffected side is an independent predictor for short-term functional gain and outcome after stroke. This result may change post-stroke rehabilitation strategies to emphasize exercises to prevent loss of muscle strength. In addition, this implies the possibility of a relationship between sarcopenia and post-stroke function. Further research is needed to reveal the effect of sarcopenia on stroke patients and its mechanism.

The purpose of this study was to compare the swallowing function and kinematics in stroke patients with and without tracheostomies. In this retrospective matched case-control study, we compared stroke patients with (TRACH group, n = 24) and without (NO-TRACH group, n = 24) tracheostomies. Patients were matched for age, sex, and stroke-type. Swallowing function was evaluated using the videofluoroscopic dysphagia scale (VDS) and functional oral intake scale (FOIS) obtained from videofluoroscopic swallow study (VFSS) images. Swallowing kinematics were evaluated using a two-dimensional kinematic analysis of the VFSS images. Mean duration of tracheostomy was 132.38 ± 150.46 days in the TRACH group. There was no significant difference in the total VDS score between the TRACH (35.17 ± 15.30) and NO-TRACH groups (29.25 ± 16.66, p = 0.247). FOIS was significantly lower in the TRACH group (2.33 ± 1.40) than in the NO-TRACH group (4.33 ± 1.79, p = 0.001). The TRACH group had a significantly lower maximum vertical displacement (15.23 ± 7.39 mm, p = 0.011) and velocity (54.99 ± 29.59 mm/s, p = 0.011), and two-dimensional velocity (61.07 ± 24.89 mm/s, p = 0.013) of the larynx than the NO-TRACH group (20.18 ± 5.70 mm, 82.23 ± 37.30 mm/s, and 84.40 ± 36.05 mm/s, respectively). Maximum horizontal velocity of the hyoid bone in the TRACH group (36.77 ± 16.97 mm/s) was also significantly lower than that in the NO-TRACH group (47.49 ± 15.73 mm/s, p = 0.032). This study demonstrated that stroke patients with tracheostomies had inferior swallowing function and kinematics than those without tracheostomies. A prospective longitudinal study is needed to elucidate the effect of a tracheostomy on swallowing recovery in stroke patients.

In the context of stroke rehabilitation, simple structures and user-intent driven actuation are relevant features to facilitate neuroplasticity as well as deliver a sufficient number of repetitions during a single therapy session. A novel robotic treatment device for distal upper limb rehabilitation in stroke patients was developed, and a usability test was performed to assess its clinical feasibility. The rehabilitation robot was designed as a two-axis exoskeleton actuated by electric motors, consisting of forearm supination/pronation and hand grasp/release, which were selected based on a kinematic analysis of essential daily activities. A vision-assisted algorithm was utilized for user-intent extraction in a human-in-the-loop concept. A usability test was performed on six physiatrists, five biomedical engineers, five rehabilitation therapists, two chronic stroke patients, and two caregivers of the patients. After sufficient instruction, all subjects tested the robot for a minimum of 10 min and completed the evaluation form using a 7-point Likert scale. The participants found the device interesting (5.7 &plusmn, 1.2), motivating (5.8 &plusmn, 0.9), and as having less possibility of causing injury or safety issues (6.1 &plusmn, 1.1), however, the appropriateness of difficulty (4.8 &plusmn, 1.9) and comfort level (4.9 &plusmn, 1.3) were found to be relatively low. Further development of the current device would provide a good treatment option as a simple, low-cost, and clinically feasible rehabilitation robot for stroke.

(1) Background: White matter changes among individuals with mild-to-moderate traumatic brain injury (TBI) may be sensitive imaging markers reflecting functional impairment, particularly in the context of post-concussion syndrome. The objective of this study was to examine the altered white matter integrity in mild-to-moderate TBI patients compared with age-matched normal controls. (2) Methods: Diffusion tensor imaging data from 15 individuals with TBI and 15 control subjects were retrospectively obtained. We investigated and compared white matter integrity in both groups, with regard to fractional anisotropy (FA), radial diffusivity (RD), and axial diffusivity (AD) and examined the relationship with cognitive dysfunction and impaired balance in patients. (3) Results: In comparison with controls, the TBI patients had significantly decreased FA as well as increased RD, in the right corticospinal tract. Decreased RD was observed in the left cerebellar area near the middle cerebellar peduncle. Decreased AD was observed in the left inferior cerebellar peduncle, showing positive correlation with poor balance control. We observed decreased FA and increased AD in the left superior longitudinal fasciculus showing positive and negative correlation, respectively, with cognitive function in the TBI group. (4) Conclusions: Altered white matter integrity in mild-to-moderate TBI cases may be indicative of cognitive dysfunction and impaired balance.

Background The gold standard in dysarthria assessment involves subjective analysis by a speech–language pathologist (SLP). We aimed to investigate the feasibility of dysarthria assessment using automatic speech recognition. Methods We developed an automatic speech recognition based software to assess dysarthria severity using hidden Markov models (HMMs). Word-specific HMMs were trained using the utterances from one hundred healthy individuals. Twenty-eight patients with dysarthria caused by neurological disorders, including stroke, traumatic brain injury, and Parkinson's disease were participated and their utterances were recorded. The utterances of 37 words from the Assessment of Phonology and Articulation for Children test were recorded in a quiet control booth in both groups. Patients were asked to repeat the recordings for evaluating the test–retest reliability. Patients' utterances were evaluated by two experienced SLPs, and the consonant production accuracy was calculated as a measure of dysarthria severity. The trained HMMs were also employed to evaluate the patients' utterances by calculating the averaged log likelihood (aLL) as the fitness of the spoken word to the word-specific HMM. Results The consonant production accuracy reported by the SLPs strongly correlated (r = 0.808) with the aLL, and the aLL showed excellent test–retest reliability (intraclass correlation coefficient, 0.964). Conclusion This leads to the conclusion that dysarthria assessment using a one-word speech recognition system based on word-specific HMMs is feasible in neurological disorders., Graphical Abstract

This study aimed to investigate spatiotemporal characteristics of the hyoid bone during swallowing in patients with Parkinson's disease (PD) and dysphagia. Spatiotemporal data of the hyoid bone was obtained from videofluoroscopic images of 69 subjects (23 patients with PD, 23 age- and sex-matched healthy elderly controls, and 23 healthy young controls). Normalized profiles of displacement/velocity were analyzed during different periods (percentile) of swallowing using functional regression analysis, and the maximal values were compared between the groups. Maximal horizontal displacement and velocity were significantly decreased during the initial backward (P = 0.006 and P 0.001, respectively) and forward (P = 0.008 and P 0.001, respectively) motions in PD patients compared to elderly controls. Maximal vertical velocity was significantly lower in PD patients than in elderly controls (P = 0.001). No significant difference was observed in maximal displacement and velocity in both horizontal and vertical planes between the healthy elderly and young controls, although horizontal displacement was significantly decreased during the forward motion (51st-57th percentiles) in the elderly controls. In conclusion, reduced horizontal displacement and velocity of the hyoid bone during the forward motion would be due to combined effects of disease and aging, whereas those over the initial backward motion may be considered specific to patients with PD.

Vallecular cysts are formed when the duct of a mucous gland or lingual tonsillar crypt is dilated owing to obstruction from inflammation, irritation, or trauma. Small cysts are usually asymptomatic; however, cyst growth results in dysphagia, odynophagia, and acute airway complications. As complete transoral laser excision of a vallecular cyst often results in cyst resolution and improved symptoms, proper diagnosis and management of vallecular lesions are important. We describe the evaluation and treatment of a 53-year-old man with a history of intracerebral hemorrhage in the left basal ganglia who presented with dysphagia caused by a vallecular cyst.

OBJECTIVEThis study aimed to investigate the feasibility and safety of intraoperative motor evoked potential (MEP) monitoring in infants less than 3 months of age.METHODSThe authors investigated 25 cases in which infants younger than 3 months (mean age 72.8 days, range 39–87) underwent neurosurgery between 2014 and 2017. Myogenic MEPs were obtained through transcranial electrical stimulation. In all cases, surgery was performed under total intravenous anesthesia, maintained with remifentanil and propofol.RESULTSMEPs were documented in 24 infants, the sole exception being 1 infant who was lethargic and had 4-limb weakness before surgery. The mean stimulation intensity maintained during monitoring was 596 ± 154 V (range 290–900 V). In 19 of 24 infants MEP signals remained at ≥ 50% of the baseline amplitude throughout the operation. Among 5 cases with a decrease in intraoperative MEP amplitude, the MEP signal was recovered in one during surgery, and in the other case a neurological examination could not be performed after surgery. In the other 3 cases, 2 infants had relevant postoperative weakness and the other did not show postoperative neurological deficits. Postoperative weakness was not observed in any of the 20 infants who had no deterioration (n = 19) or only temporary deterioration (n = 1) in MEP signal during surgery.CONCLUSIONSTranscranial electrical MEPs could be implemented during neurosurgery in infants between 1 and 3 months of age. Intraoperative MEP monitoring may be a safe adjunct for neurosurgical procedures in these very young patients.

There have been no quantitative studies on dysphagia and its impact on quality of life (QOL) of adults with cerebral palsy (CP). In this cross-sectional study, we aimed to investigate the characteristics of dysphagia symptoms and their impact on QOL in adults with CP on a full oral diet compared with healthy adults. Additionally, we aimed to determine the factors affecting dysphagia-related QOL in this population. We enrolled adults with CP on full oral diet (N = 117) and healthy individuals (N = 117) and interviewed them using the swallowing-quality of life (SWAL-QOL) questionnaire which includes 14 items regarding dysphagia symptoms and 30 items regarding swallowing-related QOL. The functional status of each participant with CP was evaluated using the gross motor function classification system, the manual ability classification system (MACS), and the Functional Oral Intake Scale (FOIS). Among pharyngeal symptoms, choking on food was reported most frequently (sometimes or more 76.9%), followed by coughing and choking on liquid. Among oral symptoms, chewing problems were reported most frequently (sometimes or more 59.8%), followed by food dribbling from the mouth (sometimes or more 53.8%). Compared to healthy adults, those with CP reported worse QOL across all SWAL-QOL items, with the lowest scores obtained for meal duration, followed by communication, burden, fatigue, sleep, and eating desire. On multiple linear regression analysis, higher MACS level, lower FOIS level, and older age were predictors of worse SWAL-QOL score. Among adults with CP, it is necessary to evaluate swallowing function and establish an active intervention plan even if a full oral diet is established.

Objective. Although evidence and guidelines recommend appropriate rehabilitation from the beginning of diagnosis in patients with Parkinson’s disease (PD), there is a lack of data addressing the utilization of rehabilitation therapies for these patients in practice. The aim of this study is to investigate the rate of rehabilitation therapy utilization over time in patients with PD using a nationwide cohort in Korea. Methods. Patients were identified using the registration code for PD in the program for rare, intractable disease from the National Health Insurance Service-National Sample Cohort database, which consists of 979,390 Korean residents. Data were divided into four periods: 2004–2006, 2007–2009, 2010–2012, and 2013–2015. We assessed the utilization of rehabilitation therapies and the associated patient characteristics. Results. The numbers of patients with PD were 384 in 2004, 855 in 2007, 1,023 in 2010, and 1,222 in 2013. The numbers of physiatrist visits per person were 0.58, 0.96, 1.97, and 2.91, in the respective periods. Among the patients, 35–40% had claims for physical therapy, 16–19% for occupational therapy, and 4–6% for swallowing therapy. There were no remarkable differences between these rates between the study periods. Sex, age, income, disability, and levodopa-equivalent dose were significantly associated with the utilization of rehabilitation therapy. Conclusion. This study demonstrated that the rate of rehabilitation therapy utilization did not change remarkably in patients with PD from 2004 to 2015 in Korea although the number of physiatrist visits increased dramatically. The present evidence and guidelines may have not been adequately integrated into clinical practice during the period of study. Additional efforts may be warranted to provide adequate rehabilitation therapies in clinical practice for patients with PD.

We investigated the progression of oropharyngeal dysphagia in patients with multiple system atrophy (MSA), with particular emphasis on MSA subtype variation. Fifty-nine MSA patients (31 MSA-P, 21 MSA-C, and 7 MSA-PC) who had undergone at least one videofluoroscopic swallowing study (VFSS) to evaluate dysphagia symptoms were included. Clinical data and VFSS findings were retrospectively evaluated using the videofluoroscopic dysphagia scale (VDS), and the results of each MSA subtype group were compared. The median latency to onset of diet modification from onset of MSA symptoms was 5.995 (95% CI 4.890–7.099) years in all MSA patients, 5.036 (95% CI 3.605–6.467) years in MSA-P, and 6.800 (95% CI 6.078–7.522) years in MSA-C (P = 0.035). The latency to onset of diet modification from onset of dysphagia symptoms was 2.715 (95% CI 2.132–3.298) years in all MSA patients, 2.299 (95% CI 1.194–3.403) years in MSA-P, and 5.074 (95% CI 2.565–7.583) years in MSA-C (P = 0.039). The latencies to onset of tube feeding from onset of MSA symptoms and dysphagia symptoms were 7.003 (95% CI 6.738–7.268) years and 3.515 (95% CI 2.123–4.907) years, respectively, in all MSA patients, without significant difference between subtypes. In the patients who underwent VFSS follow-up for ≥ 1 year, 6 oral VDS items significantly worsened; only two pharyngeal items exhibited significant changes. Patients with MSA-P commenced diet modification earlier than patients with MSA-C, despite no significant difference in the latency to onset of tube feeding. Deterioration of dysphagia may be more pronounced in the oral function of MSA patients.

Botulinum toxin A is widely used in the clinics to reduce spasticity and improve upper limb function for post-stroke patients. Efficacy and safety of a new botulinum toxin type A, NABOTA (DWP450) in post-stroke upper limb spasticity was evaluated in comparison with Botox (onabotulinum toxin A). A total of 197 patients with post-stroke upper limb spasticity were included in this study and randomly assigned to NABOTA group (n=99) or Botox group (n=98). Wrist flexors with modified Ashworth Scale (MAS) grade 2 or greater, and elbow flexors, thumb flexors and finger flexors with MAS 1 or greater were injected with either drug. The primary outcome was the change of wrist flexor MAS between baseline and 4weeks post-injection. MAS of each injected muscle, Disability Assessment Scale (DAS), and Caregiver Burden Scale were also assessed at baseline and 4, 8, and 12weeks after the injection. Global Assessment Scale (GAS) was evaluated on the last visit at 12weeks. The change of MAS for wrist flexor between baseline and 4weeks post-injection was -1.44±0.72 in the NABOTA group and -1.46±0.77 in the Botox group. The difference of change between both groups was 0.0129 (95% confidence interval -0.2062-0.2319), within the non-inferiority margin of 0.45. Both groups showed significant improvements regarding MAS of all injected muscles, DAS, and Caregiver Burden Scale at all follow-up periods. There were no significant differences in all secondary outcome measures between the two groups. NABOTA demonstrated non-inferior efficacy and safety for improving upper limb spasticity in stroke patients compared to Botox.

The oro-esophageal tube (OE tube) is widely used in dysphagia patients although its success rate for transition to oral feeding is reported only in stroke patients. The aim of this study was to evaluate the feasibility and outcome of OE tube feeding for patients with dysphagia resulting from various etiologies. The authors reviewed the medical records of 1995 dysphagic patients that had undergone videofluoroscopic swallowing study (VFSS) in a tertiary hospital from April 2002 through December 2009. Of these, 97 patients were recommended to use OE tube feeding based on the VFSS findings. Follow-up VFSS were performed on 54 patients. The mean duration of tube use at the time of follow-up VFSS was 274 days. We evaluated clinical information including age, sex, diet, etiology of dysphagia, location of lesions, duration of intervention, and complications of OE tube feeding. Initially, all 54 patients were fed using the OE tube. After their last follow-up evaluation, 19 patients (35.2 %) resumed full oral feeding without the OE tube, 12 patients (22.2 %) used partial OE tube feeding, and 23 patients (42.6 %) continued OE tube feeding only. Full oral feeding was achieved again most often in brain tumor, stroke, and head and neck cancer patients (54.5, 27.3, and 20.0 %, respectively). Mild adverse events, such as blood-tinged sputum, nausea, dyspepsia, and regurgitation of food, were reported in 4 patients. OE tube feeding is a feasible feeding method also in conditions other than stroke such as brain tumors, and head and neck cancers.

Objective To evaluate demographic characteristics of children with suspected dysphagia who underwent videofluoroscopic swallowing study (VFSS) and to identify factors related to penetration or aspiration. Methods Medical records of 352 children (197 boys, 155 girls) with suspected dysphagia who were referred for VFSS were reviewed retrospectively. Clinical characteristics and VFSS findings were analyzed using univariate and multivariate analyses. Results Almost half of the subjects (n=175, 49%) were under 24 months of age with 62 subjects (18%) born prematurely. The most common condition associated with suspected dysphagia was central nervous system (CNS) disease. Seizure was the most common CNS disorder in children of 6 months old or younger. Brain tumor was the most important one for school-age children. Aspiration symptoms or signs were the major cause of referral for VFSS in children except for infants of 6 months old or where half of the subjects showed poor oral intake. Penetration or aspiration was observed in 206 of 352 children (59%). Subjects under two years of age who were born prematurely at less than 34 weeks of gestation were significantly (p=0.026) more likely to show penetration or aspiration. Subjects with congenital disorder with swallow-related anatomical abnormalities had a higher percentage of penetration or aspiration with marginal statistical significance (p=0.074). Multivariate logistic regression analysis revealed that age under 24 months and an unclear etiology for dysphagia were factors associated with penetration or aspiration. Conclusion Subjects with dysphagia in age group under 24 months with preterm history and unclear etiology for dysphagia may require VFSS. The most common condition associated with dysphagia in children was CNS disease.

Background Although robotic-assisted gait training (RAGT) is becoming a standard method in stroke rehabilitation, its effect on chronic stroke patients is uncertain. Objective This study aimed to investigate whether anodal transcranial direct current stimulation (tDCS) enhances the effect of RAGT on functional ambulation in chronic stroke patients. Methods Chronic hemiplegic stroke patients with a Functional Ambulatory Category (FAC) score≤4 were randomly assigned to either the RAGT with anodal tDCS (Anodal) group the sham tDCS (Sham) group. The patients were provided with RAGT for 45 min after allocated tDCS on the leg motor cortex in the impaired hemisphere for 20 min every weekday for 2 weeks. The primary outcome measure was the FAC, and the secondary outcome measures included 10-m walking test, 6-min walking test, Berg Balance Scale, Fugl-Meyer assessment of the lower extremity, Medical Research Council Scale, and motor-evoked potential (MEP) parameters. They were evaluated before treatment (T0), immediately after treatment (T1), and 4 weeks after the end of treatment (T2). Results Twenty-one patients were finally included. The percentage of participants who achieved improvement in the FAC score was greater in the Anodal group than in the Sham group, and the difference was significant at T2 (66.7% vs. 12.5%, p = 0.024). In secondary outcome measures, the Anodal group showed greater improvement in the 6-min walking test than the Sham group at T2 (56.49±38.87 vs. 23.59±17.00, p = 0.038). The changes in the MEP parameters were not significantly different between the two groups. Conclusion This pilot study suggested that anodal tDCS on the leg motor cortex in the impaired hemisphere may facilitate the effect of RAGT on functional ambulation in chronic stroke patients. Larger clinical trials will be needed to confirm the effect of RAGT combined with tDCS in chronic stroke patients based on the present study.

Hypersalivation is one of the intractable symptoms of anti‐N‐methyl‐d‐aspartate receptor (NMDAR) encephalitis. While anticholinergic medications partially improve the hypersalivation, they can aggravate the autonomic dysfunctions associated with anti‐NMDAR encephalitis. Thus, we investigated the efficacy and safety of botulinum toxin type A injection on hypersalivation refractory to anticholinergics in six patients with anti‐NMDAR encephalitis. Hypersalivation was well‐controlled without remarkable adverse reaction over 16 weeks after botulinum toxin type A, although two patients were reinjected at 12 weeks due to reaggravation of hypersalivation. Our findings suggest that botulinum toxin type A might be a better choice than anticholinergics for management of hypersalivation in patients with anti‐NMDAR encephalitis.

The goal of rehabilitation for stroke victims in acute stage has been primarily focused on preventing immobility-related complications such as deep vein thrombosis, cardiopulmonary deconditioning, pressure ulcer, and joint contractures. Early mobilization is the first-line preventive strategy for most of these complications. Although many clinical guidelines for stroke management recommend starting mobilization as soon as patients are medically stabilized, the definition of mobilization remains unclear, and the supporting evidence has been insufficient. In the phase III A Very Early Rehabilitation Trial for Stroke (AVERT), mobilization started very early (

Objectives To investigate the characteristics of oropharyngeal dysphagia in adults with dyskinetic cerebral palsy (DCP) and cervical dystonia (CD). Design Exploratory observational cross-sectional study. Setting University hospital. Participants Seventeen patients with DCP (8 men, 9 women; age, 45.7±6.3y) enrolled in a randomized controlled trial on the effects of botulinum toxin injection on CD. Interventions Not applicable. Main Outcome Measures Baseline clinical assessments and videofluoroscopic swallowing studies (VFSSs) were conducted. VFSS findings were evaluated using the videofluoroscopic dysphagia scale (VDS) and the penetration-aspiration scale (PAS). The Gross Motor Function Classification System (GMFCS) and Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores were also assessed. Relationships between outcomes were evaluated using Spearman’s rank correlation. Results The clinical assessment revealed abnormalities in chewing (n=10, 58.8%), tongue movement (n=10, 58.8%), and laryngeal elevation (n=8, 47.1%). The most common abnormality on the VDS was inadequate mastication (n=13, 76.5%), followed by premature bolus loss, vallecular residue, and penetration/aspiration (all: n=10, 58.8%). A maximum PAS score of 8 was observed in 8 of 17 patients (47.1%). Total and pharyngeal VDS scores were significantly correlated with TWSTRS scores (ρ=0.543, P=.024 and ρ=0.539, P=.026, respectively); the VDS oral score did not correlate with the TWSTRS score (ρ=0.446, P=.073). There was no significant correlation between VDS score and GMFCS level (ρ=0.212, P=.414). Conclusions This preliminary observational study presents the characteristics of oropharyngeal dysphagia in adults with DCP and CD. Pharyngeal stage difficulties were negatively correlated with severity of CD, but not with GMFCS level. Screening for dysphagia may be recommended in adults with DCP and severe CD.

Stooping is a posture which is described as an involuntary forward bending of the thoracolumbar spine. Conventionally, the stooped posture (SP) in Parkinson&rsquo, s disease patients is measured in static or limited movement conditions using a radiological or optoelectronic system. In the dynamic condition with long movement distance, there was no effective method in preference to the empirical assessment from doctors. In this research, we proposed a practical method for estimating the SP with a high accuracy where accelerometers can be mounted on the neck or upper back as a wearable sensor. The experiments with simulated subjects showed a high correlation of 0.96 and 0.99 between the estimated SP angle and the reference angles for neck and back sensor position, respectively. The maximum absolute error (0.9 and 1.5 degrees) indicated that the system can be used, not only in clinical assessment as a measurement, but also in daily life as a corrector.

Previous studies of the effects of body fat on bone mineral density (BMD) have shown conflicting results depending on the age, sex, and menopausal status of the subjects. The purpose of the present study was to investigate the effects of body fat on BMD using data from the Fifth Korea National Health and Nutrition Examination Survey, which was conducted in 2010. Our data were drawn from a relevant population within the survey's range of participants, yielding a total of 4,138 subjects aged 20-93 years (1,133 men