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Background: Botulinum toxin type A is widely used for treating spasticity. Neuronox (Neu-BoNT/A), a newly manufactured botulinum toxin a, has not yet been investigated for its efficacy and safety in the treatment of post-stroke upper limb spasticity. Objective: We evaluated the efficacy and safety of Neuronox (Neu-BoNT/A) compared with BOTOX (onabotulinum toxin A) for treating post-stroke upper limb spasticity. Methods: In total, 196 stroke patients with moderate to severe upper limb spasticity were randomly assigned to either Neuronox or BOTOX intervention. The wrist flexors were mandatory and elbow, finger, and thumb flexors were optional muscles to be injected. Assessments were performed at baseline and 4, 8, and 12 weeks after the intervention. The primary outcome measure was the change from baseline of the Modified Ashworth Scale (MAS) at the wrist flexors at week 4. Secondary outcome measures included the change of MAS at each visit, response rate, Disability Assessment Scale (DAS), Carer Burden Scale, and Global Assessment of treatment benefit. Results: Primary outcome measures were -1.39±0.79 and -1.56±0.81 in the Neuronox and BOTOX groups, respectively. The difference was within the noninferiority margin of 0.45 (95% upper limit=0.40). There were no significant differences between the groups in the secondary outcome and safety measures, except the change of the MAS at the elbow flexors at week 12 (-0.88±0.75 in the Neuronox group, -0.65±0.74 in the BOTOX group; P=0.0429). Both groups showed significant improvements in the MAS, DAS, and Carer Burden Scale at weeks 4, 8, and 12. Conclusion: Neuronox showed equivalent efficacy and safety compared with BOTOX for treating post-stroke upper limb spasticity. Trial Registration: ClinicalTrials.gov [ABSTRACT FROM AUTHOR]

Background: Interpreting the impact of hand osteoarthritis (OA) on hand function is complicated owing to the multiple digits and joints in the hand. Questions/purpose: We determined the impact of digit-related radiographic OA on hand function in patients 65 years or older. Methods: We evaluated hand radiographs in 196 men and 182 women older than 65 years without shoulder or elbow pain who participated in the Korean Longitudinal Study on Health and Aging. Using the Kellgren and Lawrence criteria, we graded the 15 joints in each hand from 0 to 4 for OA, and evaluated hand function by measuring DASH scores and grip and pinch strength of dominant hands. We performed multiple linear regression analyses to evaluate associations between hand functions and the sum of Kellgren and Lawrence grade of each digit. Results: The sums of Kellgren and Lawrence grades for thumbs and middle fingers were independently associated with grip strength, and the sums of the Kellgren and Lawrence grades for thumbs and index fingers were independently associated with pinch strength after controlling for age and sex. DASH scores were independently associated with OA of the thumb, or index or middle finger, but not with OA of the ring or small finger. Conclusions: This study revealed cumulative effects of joint involvement and Kellgren and Lawrence grades of thumb and middle finger OA on grip strength, and thumb and index finger OA on pinch strength. Furthermore, OA of either of three radial digits was associated with more severe upper extremity disabilities. Level of Evidence: Level IV, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: (1) To compare the kinematic motion of the hyoid bone and the epiglottis in healthy controls and a sample of patients with dysphagia of different etiologies, and (2) to evaluate the potential value of kinematic swallowing analysis to differentiate the mechanism of dysphagia. Methods: We performed two-dimensional video motion analysis of the hyoid bone using videofluoroscopic images in nine controls without any swallowing difficulty, and seven patients with supratentorial stroke, three patients with inflammatory myopathy who showed dysphagia. Main outcome measures were: (1) horizontal and vertical excursion of the hyoid bone, and rotation of the epiglottis, and (2) trajectory of the hyoid bone and epiglottis during swallowing. Results: Horizontal excursion of the hyoid bone and rotation of the epiglottis were reduced in patients with myopathy as compared to control and patients with stroke (P <0.05). Patients with dysphagia showed different patterns as compared to control in trajectory analysis according to their etiology. Conclusion: We conclude that extent and pattern of movement of the hyoid bone and the epiglottis during swallowing were different according to etiology of dysphagia, and swallowing motion analysis could be applied to differentiate the mechanism of dysphagia. [Copyright &y& Elsevier]

To determine whether the potency of botulinum toxin A (BTA) decreases after being reconstituted with normal saline and stored in refrigerator, we injected one side of the extensor digitorum brevis muscle with 2.5 units of botulinum toxin A that had been immediately reconstituted with saline, and the contralateral side with identical material that had been reconstituted and stored in a refrigerator for preselected periods (1, 2, and 4 weeks) in 32 healthy volunteers. Mean compound muscle action potential amplitudes expressed as a percentage of the baseline amplitude were more reduced in sides injected with immediately reconstituted BTA than in sides injected with BTA stored for 1 week or more ( P < 0.05). No bacterial growth was observed in any stored BTA samples. Storage of reconstituted BTA at low temperatures may affect the potency of the toxin. Therefore, the use of BTA after refrigerated storage is not recommended. © 2006 Movement Disorder Society [ABSTRACT FROM AUTHOR]

Depression and anxiety may be significant prognostic factors after myocardial infarction (MI). Thus, we investigated depression and anxiety prevalence among older MI survivors and their impact on mortality, stroke, and recurrent MI. This population-based cohort study used the Korean National Health Insurance Service database for data concerning individuals aged 66 years who participated in the National Screening Program from 2009 to 2016. Overall, 11,721 individuals with MI history and 58,605 age- and sex-matched controls were included and followed up until 2019. The presence of depression and anxiety was assessed 2 years before and after participation in the program. Mortality and major adverse outcomes, defined as a composite outcome comprising mortality, stroke, and recurrent MI, were analyzed. Depression and anxiety prevalence among MI survivors was 20.4 % and 30.3 %, respectively. Crude odds ratios for depression and anxiety, compared with the control group, were 1.207 (1.148–1.269) and 1.078 (1.032–1.126), respectively. During the follow-up, individuals with depression, anxiety, or both showed increased hazard ratios (HRs) for mortality and major adverse outcomes; after adjustments, their HRs were 1.442 (1.182–1.759), 1.129 (0.960–1.328), and 1.498 (1.263–1.776), respectively, for mortality and 1.505 (1.289–1.758), 1.158 (1.021–1.314), and 1.530 (1.337–1.751), respectively, for major adverse outcomes. Although this was a nationwide cohort study, the MI, depression, and anxiety diagnoses were based on diagnostic codes. Higher depression and anxiety prevalence was observed among older MI survivors. Depression and anxiety occurrence correlated with increased adverse clinical outcomes after adjustments. [Display omitted] • A higher prevalence of depression and anxiety was observed in older myocardial infarction (MI) survivors. • The presence of depression and anxiety was associated with adverse clinical outcomes. • Cardiac rehabilitation models should prioritize the identification and management of depression and anxiety after MI. [ABSTRACT FROM AUTHOR]

Background: Central post‐stroke pain (CPSP) has a detrimental effect on the quality of life of post‐stroke patients. However, no definitive and effective method has been established yet for the treatment of CPSP. Objective: We aimed to examine the applicability of single‐injection peripheral nerve blocks (PNBs) for the treatment of CPSP. Subjects: In this retrospective study, we included 22 patients (mean age = 56.3 years; 13 men and 9 women) diagnosed with CPSP who visited an outpatient rehabilitation clinic in Seoul National University Bundang Hospital between December 2018 and April 2020. Methods: The patients underwent ultrasound‐guided single‐injection PNB (lidocaine + epinephrine [1: 200,000]) according to the primary site of pain. The level of pain (measured using a numeric rating scale) was recorded before and after the PNB, and the occurrence of adverse events were also measured. The primary outcome of this study was the amount of pain reduction after PNB. Secondary outcome measures obtained 1 month after the PNB included the pain reduction rate 1 month after the PNB, the patient‐reported satisfaction and effectiveness regarding the PNB, intention for re‐injection, and the patients' willingness to recommend this procedure to others. Results: The mean pain reduction after PNB was 3.3 ± 2.8. PNB was associated with pain reduction that persisted for greater than 1 month in 68% (15/22) of the patients. Thirteen of 22 patients reported a pain reduction of 50% or more. The mean pain reduction rate was 43.6%. Of the 22 patients, 13 were willing to undergo a second round of treatment with PNB. Nine of them underwent the procedure. No adverse events were observed in this study. Conclusions: Our study provides preliminary data suggesting that PNB could be an effective and feasible method to treat CPSP. [ABSTRACT FROM AUTHOR]

Cerebellar brain inhibition (CBI), a neural connection between the cerebellum and primary motor cortex (M1), has been researched as a target pathway for neuromodulation to improve clinical outcomes in various neurological diseases. However, conflicting results of anodal cerebellar transcranial direct current stimulation (acb-tDCS) on M1 excitability indicate that additional investigation is required to examine its precise effect. This study aimed to gather evidence of the neuromodulatory effect of acb-tDCS on the M1 using functional near-infrared spectroscopy (fNIRS). Sixteen healthy participants were included in this cross-over study. Participants received real and sham acb-tDCS randomly, with a minimum 1-week washout period between them. The anode and cathode were placed on the right cerebellum and the right buccinator muscle, respectively. Stimulation lasted 20 min at an intensity of 2 mA, and fNIRS data were recorded for 42 min (including a 4-min baseline before stimulation and an 18-min post-stimulation duration) using eight channels attached bilaterally on the M1. acb-tDCS induced a significant decrease in oxyhemoglobin (HbO) concentration (inhibitory effect) in the left (contralateral) M1, whereas it induced a significant increase in HbO concentration (excitatory effect) in the right (ipsilateral) M1 compared to sham tDCS during (p < 0.05) and after stimulation (p < 0.01) in a group level analysis. At the individual level, variations in response to acb-tDCS were observed. Our findings demonstrate the neuromodulatory effects of acb-tDCS on the bilateral M1 in terms of neuronal hemodynamics. [ABSTRACT FROM AUTHOR]

Botulinum toxin type A (BTX-A) injection is a commonly used therapeutic intervention for upper limb spasticity in stroke patients. This study was designed as a randomized, active-drug-controlled, double-blind, multicenter, phase 3 clinical trial to evaluate the safety and efficacy of Liztox® in comparison to onabotulinum toxin A (Botox®) for individuals with post-stroke upper limb spasticity. The primary outcome was the alteration in wrist flexor muscle tone from the initial assessment to the fourth week, evaluated using the modified Ashworth scale (MAS). Secondary outcomes included MAS score changes for the wrist at weeks 8 and 12 from baseline; MAS score changes for finger and elbow flexors; and changes in the Disability Assessment Scale (DAS), Subject's Global Assessment (SGA), the Investigator's Global Assessment (IGA), and Caregiver Burden Scale (CBS) at weeks 4, 8, and 12 from baseline. The MAS score for wrist flexor spasticity decreased by −1.14 ± 0.59 in the Liztox® group and −1.22 ± 0.59 in the Botox® group from baseline to week 4. The difference [97.5% confidence interval (CI)] between the test and control groups was 0.08 [−∞, 0.26], confirming the non-inferiority of the test group compared to the control group. Furthermore, there were consistent improvements in the IGA, SGA, and CBS scores across all assessment intervals, with no statistically significant variances detected between the two groups. No safety-related concerns were reported during the study. In conclusion, Liztox® injection proved to be a secure and efficacious intervention for managing upper extremity spasticity in post-stroke patients. [ABSTRACT FROM AUTHOR]

We investigated the activation pattern of the motor cortex (M1) and parietal cortex during immersive virtual reality (VR)-based mirror visual feedback (MVF) of the upper limb in 14 patients with chronic stroke and severe upper limb hemiparesis and in 21 healthy controls. Participants performed wrist extension with unaffected wrists (dominant side in controls). In the MVF condition, movement of the affected hand was synchronized with that of the unaffected hand. In the no-MVF condition, only the movement of unaffected hand was shown. Mu suppression in bilateral M1 and parietal cortex and mu coherence were analyzed. In patients with stroke, MVF induced significant mu suppression in both the ipsilesional M1 and parietal lobes (p = 0.006 and p = 0.009, respectively), while mu suppression was observed in the bilateral M1 (p = 0.003 for ipsilesional and p = 0.041 for contralesional M1, respectively) and contralesional parietal lobes in the controls (p = 0.036). The ipsilesional mu coherence between the M1 and parietal cortex in patients with stroke was stronger than controls, regardless of MVF condition (p < 0.001), while mu coherence between interhemispheric M1 cortices was significantly weaker in patients with stroke (p = 0.032). Our findings provide evidence of the neural mechanism of MVF using immersive VR in patients with stroke. [ABSTRACT FROM AUTHOR]

The prevalence of dysphagia is increasing, resulting in socioeconomic burden, but previous reports have only been based on a limited populations. Therefore, we aimed to investigate the nationwide incidence and prevalence of dysphagia requiring medical attention to provide adequate information for healthcare planning and resource allocation. In this nationwide retrospective cohort study, the data of adults aged ≥20 years recorded from 2006 to 2016 were sourced from the Korean National Health Insurance Service database. Medical claim codes based on ICD-10-CM were used to define dysphagia and possible causes. The annual incidence and prevalence of dysphagia were calculated. Cox regression was used to estimate dysphagia risk in people with possible dysphagia etiology. Survival analysis was performed to estimate the mortality and hazard ratio of dysphagia. The crude annual incidence of dysphagia increased continuously from 7.14 in 2006 to 15.64 in 2016. The crude annual prevalence of dysphagia in 2006 was 0.09% and increased annually to 0.25% in 2016. Stroke (odds ratio [OR]: 7.86, 95% confidence interval [CI]: 5.76–6.68), neurodegenerative disease (OR: 6.20, 95% CI: 5.76–6.68), cancer (OR: 5.59, 95% CI: 5.17–6.06), and chronic obstructive pulmonary disease (OR: 2.94, 95% CI: 2.71–3.18) were associated with a high risk of dysphagia. The mortality in the dysphagia group was 3.12 times higher than that in the non-dysphagia group (hazard ratio: 3.12, 95% CI: 3.03–3.23). The incidence and prevalence of dysphagia requiring medical attention are increasing annually. The increasing trend was conspicuous in the geriatric population. The presence of stroke, neurodegenerative disease, cancer, and chronic obstructive pulmonary disease is associated with a high risk of dysphagia. Therefore, adequate screening, diagnosis, and management of dysphagia in the older population must be emphasized in geriatric healthcare. [ABSTRACT FROM AUTHOR]

Purpose: Most previous reports on dysphagia in cancer have focused on specific cancer types, particularly head and neck cancer. Therefore, we aimed to investigate the incidence of dysphagia in patients with various cancers using a nationwide database in South Korea. Methods: This was a retrospective cohort study using the National Health Insurance Service database. Claim codes were used for the selection criteria and operational definitions. The total population data from 2010 to 2015 were extracted. The crude incidence of dysphagia was calculated per 1,000 person-years. The multivariate adjusted Cox proportional hazards regression was used to determine the effects of different cancers on the incidence of dysphagia. Results: People with cancer had a lower income and suffered from a higher risk of comorbidities compared to people without cancer. The risk of dysphagia increased in all types of cancers, particularly in the oral cavity and pharynx (hazard ratio [HR]: 20.65, 95% confidence interval [CI]: 17.73–24.06), esophagus (HR: 18.25, 95% CI: 15.66–21.26), larynx (HR: 12.87, 95% CI: 10.33–16.02), and central nervous system (HR: 12.42, 95% CI: 10.33–14.94). Conclusions: The risk of dysphagia was significantly higher in the cancer group than in the non-cancer group. As the survival of cancer patients is improving with the development of new treatments, more attention should be paid to dysphagia in the management of cancer. Prompt and appropriate multidisciplinary interventions for dysphagia are necessary to improve the recovery and quality of life in cancer patients. [ABSTRACT FROM AUTHOR]

Background: Assistive hand exoskeletons are promising tools to restore hand function after cervical spinal cord injury (SCI) but assessing their specific impact on bimanual hand and arm function is limited due to lack of reliable and valid clinical tests. Here, we introduce the Berlin Bimanual Test for Tetraplegia (BeBiTT) and demonstrate its psychometric properties and sensitivity to assistive hand exoskeleton-related improvements in bimanual task performance. Methods: Fourteen study participants with subacute cervical SCI performed the BeBiTT unassisted (baseline). Thereafter, participants repeated the BeBiTT while wearing a brain/neural hand exoskeleton (B/NHE) (intervention). Online control of the B/NHE was established via a hybrid sensorimotor rhythm-based brain-computer interface (BCI) translating electroencephalographic (EEG) and electrooculographic (EOG) signals into open/close commands. For reliability assessment, BeBiTT scores were obtained by four independent observers. Besides internal consistency analysis, construct validity was assessed by correlating baseline BeBiTT scores with the Spinal Cord Independence Measure III (SCIM III) and Quadriplegia Index of Function (QIF). Sensitivity to differences in bimanual task performance was assessed with a bootstrapped paired t-test. Results: The BeBiTT showed excellent interrater reliability (intraclass correlation coefficients > 0.9) and internal consistency (α = 0.91). Validity of the BeBiTT was evidenced by strong correlations between BeBiTT scores and SCIM III as well as QIF. Wearing a B/NHE (intervention) improved the BeBiTT score significantly (p < 0.05) with high effect size (d = 1.063), documenting high sensitivity to intervention-related differences in bimanual task performance. Conclusion: The BeBiTT is a reliable and valid test for evaluating bimanual task performance in persons with tetraplegia, suitable to assess the impact of assistive hand exoskeletons on bimanual function. [ABSTRACT FROM AUTHOR]

Despite the effectiveness of telephone-based interventions for medical adherence and improved blood pressure, studies on the effect of such interventions on physical activity (PA) are needed. Therefore, we investigated the impact of a telephone-based intervention on PA in patients with subacute stroke. This pre-post study included patients who participated in an education program for stroke rehabilitation before being discharged to home, with a modified Rankin scale (mRS) score of ≤ 3. Patients hospitalized in 2020 (intervention group) received a nurse-led telephone-based intervention with a PA measurement once monthly during the 3 months after discharge. Those hospitalized in 2019 (historical controls) only received a PA measurement 3 months after discharge. Physical activity was assessed via a questionnaire by phone. In addition, demographics, medical history, smoking, mRS scores, and Patient Health Questionnaire-9 data were collected. The study included 139 participants (73 in intervention, 66 in control). The intervention group had a higher proportion of patients with mRS of 0–1 and a shorter length of hospital stay than the historical controls. Three months post-discharge, a significantly higher proportion of participants were physically active in the intervention group (48 [71.6%] vs. control group, 25 [34.7%]). In addition, the intervention group had a significantly higher median energy expenditure (924 vs. 297 MET-min/week) than the control group. The OR of the intervention for achieving 'physically active' individuals was 4.749 (95% CI, 2.313–9.752) before and 5.222 (95% CI, 1.892–14.419) after adjusting for possible confounders. A telephone-based intervention improved PA three months after stroke. Further studies with larger sample size and long-term follow-up are needed. [ABSTRACT FROM AUTHOR]

Meal-assistance robots (MARs) help feed meals to users with disabilities or who need help consuming their meals. Although such MARs have been introduced in various fields, guidelines for evaluating MARs are limited. This study aims to develop comprehensive guidelines to assess the user experience (UX) of MAR designs considering its social interaction characteristics between humans and robots. Participants from three groups (patients, doctors, and caregivers) with different perspectives on MARs were recruited and a focus group interview was conducted to collect their UXs with MARs. The three groups showed different UXs with MARs in user interface design, robot arm motion, and safety and mobility. In addition, based on the literature review, eight UX features (usability, emotion, value, naturalness, assistance, acceptance, personality, and culture) are proposed to evaluate MAR interfaces. The proposed comprehensive design guideline will be particularly useful in evaluating and designing the UX of MARs. [ABSTRACT FROM AUTHOR]

Background: High-intensity repetitive task-specific practice might be the most effective strategy to promote motor recovery after stroke, and electromechanical-assisted gait training represents one of the treatment options. However, there is still difficulty in clarifying the difference between conventional gait training and electromechanically assisted gait training.Methods: The study is a multicenter, randomized, parallel-group clinical trial for stroke patients. Three clinical research centers in Korea (Dongguk University Ilsan Hospital, Chungnam National University Hospital, and Seoul National University Bundang Hospital) will participate in the clinical trial and 144 stroke patients will be registered. Enrolled patients are assigned to two groups, an experimental group and a control group, according to a randomization table. In addition, patients are treated for half an hour (one session) five times a week for 4 weeks. Both groups carry out basic rehabilitation (central nervous system development therapy and strength exercise) and the experimental group executes robotic walking rehabilitation treatment, and the control group executes conventional gait rehabilitation treatment. The primary endpoint variable is the Functional Ambulation Category (FAC) that determines the degree of independent walking and is measured before, after, and after 4 weeks of treatment. Secondary endpoint variables are 11 variables that take into account motor function and range, measured at the same time as the primary endpoint variable.Discussion: There are still insufficient data on the effectiveness of electromechanical-assisted gait training for stroke patients and large-scale research is lacking. Thus, the research described here is a large-scale study of stroke patients that can supplement the limitations mentioned in other previous studies. In addition, the clinical studies described here include physical epidemiological analysis parameters that can determine walking ability. The results of this study can lead to prove the generalizable effectiveness and safety of electromechanical-assisted gait training with EXOWALK®.Trial Registration: Clinical Research Information Service (CRIS), Republic of Korea KCT0003411, Registered on 30 October 2018. [ABSTRACT FROM AUTHOR]

Aim The most appropriate muscle index for the definition of sarcopenia has not been agreed on. We aimed to investigate the associations of muscle mass and strength with 5-year mortality and low physical performance. Methods We included 560 participants aged 65 years or older in the analysis. Muscle and fat mass were assessed by dual-energy X-ray absorptiometry. Leg muscle and grip strength were measured using dynamometers. The clinical outcomes were 5-year mortality and low physical performance ( Short Physical Performance Battery score < 9) in 5 years. Associations between muscle indices and clinical outcomes were analyzed. A Cox proportional hazard model for mortality and a logistic regression model for physical performance were used. Results Decreases in leg muscle and grip strength were significantly associated with 5-year mortality and low physical performance in both sexes. Total muscle mass in men and appendicular skeletal mass in both sexes were associated with mortality, but not with low physical performance. Lower leg muscle strength ( OR 0.107; P = 0.020) was an independent predictor of low physical performance in women after adjusting for age, fat, cognition, and depression. Lower leg muscle ( OR 0.123; P = 0.031) and lower grip strength ( OR 0.950; P = 0.012) were independent predictors of low physical performance in men. Conclusions Muscle strength is a better indicator of 5-year adverse clinical outcomes of mortality and low physical performance than muscle mass. Muscle strength was an independent predictor of low physical performance in 5 years. Geriatr Gerontol Int 2016; 16: 577-585. [ABSTRACT FROM AUTHOR]

Evaluating and quantifying the upper-limb functions are essential to planning effective patient rehabilitation. The box and block test (BBT) is a conventional, simple, and easy-to-apply assessment tool that is used in hospitals, and previous studies have demonstrated its usefulness in stroke rehabilitation. Using a conventional depth-sensing camera, the authors developed a virtual box and block test (VBBT) system for hand, finger, and grasping assessments based on the BBT used for the grasping ability test in hospitals. Such a virtual upper-limb-function assessment tool that can be implemented in a home setting could be a key component in a home-based virtual rehabilitation system. Comparison results between the real and virtual BBTs show the possibilities for virtualizing conventional and unsupervised assessments. [ABSTRACT FROM AUTHOR]

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 4 weeks post-injection. MAS of each injected muscle, Disability Assessment Scale (DAS), and Caregiver Burden Scale were also assessed at baseline and 4, 8, and 12 weeks after the injection. Global Assessment Scale (GAS) was evaluated on the last visit at 12 weeks. The change of MAS for wrist flexor between baseline and 4 weeks 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. [ABSTRACT FROM AUTHOR]

Electromechanical-assisted gait training may be an effective intervention to promote motor recovery after brain injury. However, many studies still have difficulties in clarifying the difference between electromechanical-assisted gait training and conventional gait training. To evaluate the effectiveness of electromechanical-assisted gait training compared to that of conventional gait training on clinical walking function and gait symmetry of stroke patients. We randomly assigned patients with stroke (n = 144) to a control group (physical therapist-assisted gait training) and an experimental group (electromechanical gait training). Both types of gait training were done for 30 min each day, 5 days a week for 4 weeks. The primary endpoint was the change in functional ambulatory category (FAC). Secondary endpoints were clinical walking functions and gait symmetries of swing time and step length. All outcomes were measured at baseline (pre-intervention) and at 4 weeks after the baseline (post-intervention). FAC showed significant improvement after the intervention, as did clinical walking functions, in both groups. The step-length asymmetry improved in the control group, but that in the experimental group and the swing-time asymmetry in both groups did not show significant improvement. In the subgroup analysis of stroke duration of 90 days, FAC and clinical walking functions showed more significant improvement in the subacute group than in the chronic group. However, gait symmetries did not show any significant changes in either the subacute or the chronic group. Electromechanically assisted gait training by EXOWALK was as effective as conventional gait training with a physiotherapist. Although clinical walking function in the subacute group improved more than in the chronic group, gait asymmetry did not improve for either group after gait training. Trial registration: KCT0003411 Clinical Research Information Service (CRIS), Republic of Korea. [ABSTRACT FROM AUTHOR]

Prism Adaptation (PA) is used to alleviate spatial neglect. We combined immersive virtual reality with a depth-sensing camera to develop virtual prism adaptation therapy (VPAT), which block external visual cues and easily quantify and monitor errors than conventional PA. We conducted a feasibility study to investigate whether VPAT can induce behavioral adaptations by measuring after-effect and identifying which cortical areas were most significantly activated during VPAT using functional near-infrared spectroscopy (fNIRS). Fourteen healthy subjects participated in this study. The experiment consisted of four sequential phases (pre-VPAT, VPAT-10°, VPAT-20°, and post-VPAT). To compare the most significantly activated cortical areas during pointing in different phases against pointing during the pre-VPAT phase, we analyzed changes in oxyhemoglobin concentration using fNIRS during pointing. The pointing errors of the virtual hand deviated to the right-side during early pointing blocks in the VPAT-10° and VPAT-20° phases. There was a left-side deviation of the real hand to the target in the post-VPAT phase, demonstrating after-effect. The most significantly activated channels during pointing tasks were located in the right hemisphere, and possible corresponding cortical areas included the dorsolateral prefrontal cortex and frontal eye field. In conclusion, VPAT may induce behavioral adaptation with modulation of the dorsal attentional network. [ABSTRACT FROM AUTHOR]

Background: To apply transcranial electrical stimulation (tES) to the motor cortex, motor hotspots are generally identified using motor evoked potentials by transcranial magnetic stimulation (TMS). The objective of this study is to validate the feasibility of a novel electroencephalography (EEG)-based motor-hotspot-identification approach using a machine learning technique as a potential alternative to TMS.Methods: EEG data were measured using 63 channels from thirty subjects as they performed a simple finger tapping task. Power spectral densities of the EEG data were extracted from six frequency bands (delta, theta, alpha, beta, gamma, and full) and were independently used to train and test an artificial neural network for motor hotspot identification. The 3D coordinate information of individual motor hotspots identified by TMS were quantitatively compared with those estimated by our EEG-based motor-hotspot-identification approach to assess its feasibility.Results: The minimum mean error distance between the motor hotspot locations identified by TMS and our proposed motor-hotspot-identification approach was 0.22 ± 0.03 cm, demonstrating the proof-of-concept of our proposed EEG-based approach. A mean error distance of 1.32 ± 0.15 cm was measured when using only nine channels attached to the middle of the motor cortex, showing the possibility of practically using the proposed motor-hotspot-identification approach based on a relatively small number of EEG channels.Conclusion: We demonstrated the feasibility of our novel EEG-based motor-hotspot-identification method. It is expected that our approach can be used as an alternative to TMS for motor hotspot identification. In particular, its usability would significantly increase when using a recently developed portable tES device integrated with an EEG device. [ABSTRACT FROM AUTHOR]

Background: Musculoskeletal complaints influence general health status, but the relative contribution of concurrent upper and lower extremity disabilities on patient perceptions of general health is unclear. Questions/Purposes: We evaluated whether two regional instruments (DASH and WOMAC) reflect a patient's perception of general health measured using the SF-36 and determined whether general health components are explained by upper and lower extremity disabilities. Methods: We recruited 272 randomly chosen participants 65 years or older without a history of surgery for musculoskeletal disease or trauma who participated in the Korean Longitudinal Study on Health and Aging. Upper extremity disability was determined with the DASH score and lower extremity disability with the WOMAC; as a measure of general health, we obtained SF-36 scores. Multivariate regression modeling was used to assess the relative contributions made by upper and lower extremity disabilities to general health. Results: The DASH and WOMAC each was correlated with the physical component summary (PCS) scale and with the mental component summary (MCS) scale to differing extents. Multivariate regression analyses revealed that WOMAC alone, DASH alone, and WOMAC and DASH accounted for 24%, 19%, and 26% of the variance in the PCS scale. However, only the DASH was associated with the MCS scale but accounted for only 2% of the variance. Conclusions: We found that in a community-based elderly population, perceived general physical health is associated with upper and lower extremity disabilities, whereas perceived general mental health is associated with only upper extremity disabilities, but to a small extent. Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

To investigate whether the disinhibition of the unaffected hemisphere (UH) is related with the lesion location or integrity of the corticospinal tract, we evaluated the intracortical excitability of hand motor cortex in the UH using a paired-pulse transcranial magnetic stimulation paradigm short intracortical inhibition (sICI) and intracortical facilitation (ICF) in 30 subacute stroke survivors. The participants were then classified according to the lesion locations (cortical versus subcortical) and the presence of motor-evoked potential (MEP) response on the paretic hand (MEP+ versus MEP−). The sICI and ICF in the UH were compared according to lesion location and presence of paretic MEP. The sICI and ICF in the UH were comparable between MEP+ and MEP− groups. However, in terms of lesion location, intracortical inhibition was present in patients with subcortical lesions, whereas the patients with cortical lesions showed significant disinhibition in the UH. In conclusion, these findings support that the disinhibition of UH in subacute stage is related to the location of lesion rather than the integrity of the corticospinal tract. [ABSTRACT FROM AUTHOR]

This study investigated the changes in motor evoked potential (MEP) amplitude and motor behavior index when paired associative stimulation (PAS), a conjoint stimulation of a peripheral nerve and the motor cortex, was applied in a rat stroke model. The PAS was applied to 19 rats and sham stimulation was applied to 15 rats. One part of PAS consisted of peripheral electrical stimulation of the soleus muscle and the other part was transcranial magnetic stimulation of the motor cortex. The stimulation was repeated for 30 min with a frequency of 0.05 Hz. Five sessions of PAS were applied over 5 consecutive days. The motor behavior index was higher in the PAS group than in the sham stimulation group at 7 d after ischemic brain injury. There was no lasting difference between the PAS animals and the sham stimulation group in MEP amplitude although MEP amplitude was increased immediately after PAS. MEP amplitude can be increased by the PAS paradigm in rats as well as in humans and PAS has potential therapeutic value for motor recovery after brain injury. [ABSTRACT FROM AUTHOR]

To determine whether multiple sessions of electrical stimulation (ES) applied to neck muscles improve swallowing function and whether this improvement is accompanied by cortical reorganization in patients with dysphagia, before-after trials were performed on eight subjects. ES was applied for 1 hour, 5 days a week for 2 weeks. Swallowing function significantly improved after 2 weeks of ES, and this change was found to correlate with cortical reorganization measured by corticobulbar output maps. This study suggests that multiple sessions of ES applied to the neck muscles improve swallowing function via a mechanism involving long-term cortical reorganization. [ABSTRACT FROM AUTHOR]

This study investigated the changes in the cortical excitability with a paired-pulse transcranial magnetic stimulation (TMS) model after a botulinum toxin type A (BTA) injection in normal humans. Ten healthy subjects were enrolled in the study, which involved applying paired TMS to the motor cortex and recording the motor evoked potentials (MEP) before and after the BTA injection. BTA (2.5 mouse units) was injected into the right extensor digitorium brevis muscle. The amplitudes of MEP during rest and the cortical silent period (CSP) for the period of the tonic muscle contraction were measured at an interstimulus interval (ISI) of 3 ms and 20 ms. One month and three months after BTA injection, the level of intracortical inhibition increased significantly at an ISI of 3 ms and the intracortical facilitation decreased at an ISI of 20 ms. The duration of CSP shortened significantly at an ISI of 3 ms 1 month after BTA injection, which was also shortened significantly at an ISI of 20 ms. These findings were maintained until 3 months after the injection. It was concluded that cortical excitability could be modified by BTA injection in normal humans. [ABSTRACT FROM AUTHOR]

Abstract: The present study has investigated the relationship between the severity of motor impairment and motor cortex excitability in the unaffected hemisphere (UH) after unilateral stroke. Forty-four patients with hemiparesis after single event of unilateral stroke were investigated. We used paired conditioning-test transcranial magnetic stimulation (TMS) to investigate intracortical inhibition (ICI) and intracortical facilitation (ICF) in the UH. Responses from the patients with reliable motor-evoked potentials (MEP) on the affected side (mild group) were compared with those of patients without MEP (severe group) and those of a population of 15 control subjects. ICI at interstimulus interval (ISI) of 1 and 5 ms was significantly reduced in the affected hemisphere in comparison to the control group. We found that ICF at ISI of 20 ms was significantly reduced in the UH of patients compared with control group. ICI at ISI of 1 ms was significantly reduced in the UH only in the mild group with cortical lesion. Motor cortex disinhibition and reduced facilitation may occur after unilateral hemispheric stroke. This change was demonstrated only in patients with mild cortical lesion, which suggests that motor cortex disinhibition is indicative of compensatory mechanisms. [Copyright &y& Elsevier]

The aim of this study was to confirm the excitability profile of human cortical circuits on the motor evoked potential (MEP) and the silent period (SP) after paired transcranial magnetic stimulation (TMS) with variable interstimulus intervals (ISI), and to compare the time courses of MEP and SP after paired TMS at variable ISIs. MEPs were elicited at the hypothenar muscles at rest, and during tonic muscle contraction by applying paired TMS to the motor cortex. The authors measured the MEP amplitude during rest and the duration of SP during tonic muscle contraction at various ISIs. The response to paired stimuli was inhibited by an ISI of 1–5 ms and facilitated by an ISI of 10–20 ms. The SP at an ISI of 1–5 ms was shorter than that at the single suprathreshold stimulus, but the SP at an ISI of 15–25 ms was longer than this. A significant correlation was observed between the MEP amplitude and the duration of SP at ISIs of 1–20 ms and for a CS of 80% of threshold. These results may provide useful data for the study of the function of cortical excitability in disease states and suggest that the neural circuits underlying MEP and SP differ partly. [ABSTRACT FROM AUTHOR]

Background: For patients with gait impairment due to neurological disorders, body weight-supported treadmill training (BWSTT) has been widely used for gait rehabilitation. On a conventional (passive) treadmill that runs at a constant speed, however, the level of patient engagement and cortical activity decreased compared with gait training on the ground. To increase the level of cognitive engagement and brain activity during gait rehabilitation, a self-paced (active) treadmill is introduced to allow patients to actively control walking speed, as with overground walking.Methods: To validate the effects of self-paced treadmill walking on cortical activities, this paper presents a clinical test with stroke survivors. We hypothesized that cortical activities on the affected side of the brain would also increase during active walking because patients have to match the target walking speed with the affected lower limbs. Thus, asymmetric gait patterns such as limping or hobbling might also decrease during active walking.Results: Although the clinical test was conducted in a short period, the patients showed higher cognitive engagement, improved brain activities assessed by electroencephalography (EEG), and decreased gait asymmetry with the self-paced treadmill. As expected, increases in the spectral power of the low γ and β bands in the prefrontal cortex (PFC), premotor cortex (PMC), and supramarginal gyrus (SG) were found, which are possibly related to processing sensory data and planning voluntary movements. In addition, these changes in cortical activities were also found with the affected lower limbs during the swing phase. Since our treadmill controller tracked the swing speed of the leg to control walking speed, such results imply that subjects made substantial effort to control their affected legs in the swing phase to match the target walking speed.Conclusions: The patients also showed reduced gait asymmetry patterns. Based on the results, the self-paced gait training system has the potential to train the symmetric gait and to promote the related cortical activities after stroke. Trial registration Not applicable. [ABSTRACT FROM AUTHOR]

Background. The prediction of motor recovery after stroke is an important issue, and various prediction models have been proposed using either clinical behavioral or neurological biomarkers. This study sought to identify the effects of clinical behavioral biomarkers combined with corticospinal tract (CST) injury measurement on the prediction of motor recovery after stroke. Methods. The region of interest was drawn on the normalized brain magnetic resonance imaging scans of patients with first-ever unilateral hemispheric stroke, and the degree of CST injury was calculated in a total of 67 such subjects. Patients who had initial minor deficits and showed a ceiling effect on motor recovery were excluded. To predict the follow-up Fugl-Meyer assessment (FMA) scores, correlation and regression analyses were performed using various clinical behavioral biomarkers, including age, sex, lesion location, and initial FMA scores and CST injury measurements. Results. Only the initial FMA-upper extremity (UE) score was statistically correlated with the follow-up FMA-UE score at ≥2 months after the onset (adjusted R 2 = 0.626), and the relationship between CST injury and follow-up FMA-UE score was unclear (n = 53). Hierarchical clustering between the initial and follow-up FMA-UE scores showed three clusters. After exclusion of a cluster with an initial FMA-UE ≥ 35, the prediction of the follow-up FMA-UE score was possible by incorporating the initial FMA-UE score and CST injury measurements (n = 39). However, the explanatory power decreased (adjusted R 2 = 0.445), and the unique contribution of the CST injury (10.1%) was lower than that of the initial FMA-UE score (26.7%). With respect to the FMA-lower extremity score, CST injury was not related to recovery. Conclusions. Motor recovery of the upper and lower extremities after stroke could be predicted using the initial FMA score. CST injury was significant for the prediction of motor recovery of the upper extremity in patients with severe initial motor deficits (FMA-UE < 35); however, its portion of prediction of motor recovery was low. The prediction of poststroke motor recovery using the initial motor deficit was not improved by the addition of CST injury measurements. [ABSTRACT FROM AUTHOR]

Promoting physical activities is important for medical and functional recovery after stroke. Therefore, an accurate and convenient measurement of physical activities is necessary to provide feedback on functional status and effects of rehabilitative interventions. We assessed the feasibility, reliability, and validity of wearing accelerometers to monitor physical activities of stroke patients by estimating energy expenditure. This was a prospective observational quantitative study conducted in an inpatient rehabilitation unit. Twenty-four patients with subacute stroke were enrolled. They wore accelerometers on wrists and ankles for three consecutive weekdays. The feasibility was evaluated by daily wear-time. The test-retest reliability was determined by intra-class correlation coefficient. The validity was evaluated by comparing accelerometeric data to behavior mappings using Mann-Whitney U test, Spearman’s rho correlation coefficient (r) and Bland-Altman plots. Average wearing time for four accelerometers was 20.99 ± 3.28 hours per day. The 3-day accelerometer recording showed excellent test-retest reliability. For sedentary activities, wrist accelerometers showed higher correlation with direct observation than ankle accelerometers. For light to moderate activities, ankle accelerometers showed higher correlation with direct observation than wrist accelerometers. Overall, combined models of accelerometers showed higher correlation with direct observation than separate ones. Wearing accelerometers for 24 h may be useful for measuring physical activities in subjects with subacute stroke in an inpatient rehabilitation unit. [ABSTRACT FROM AUTHOR]

As persons with stroke are surviving longer, monitoring and managing their quality of life is becoming important. We reviewed the Korea National Health and Nutrition Examination Survey (KNHANES) in order to evaluate the health-related quality of life (HRQoL) in stroke survivors as measured by the Euro Quality of Life-5D (EQ-5D), and to find out influencing factors. A total of 42,500 subjects were enrolled in the KNHANES, and 575 of them were persons with stroke. The EQ-5D index was lower in persons with stroke than those without stroke, when adjusted for age and sex (with stroke: 0.757±0.012, without stroke: 0.948±0.001, p < .0001). Dimension-specific influencing factors of HRQoL were observed in persons with stroke; mobility problems increased with old age; self-care problems increased with old age and depression; usual activity problems increased with old age, low income, absence of economic activity, and depression; pain/discomfort problems increased with low income. The EQ-5D index was lower in stroke survivors with older age, hypertension, diabetes mellitus, and lack of regular exercise. This is the first study to utilize nationally representative data of the Korean population to investigate the effect of stroke on HRQoL and explore the dimension-specific influencing factors. Further development of rehabilitative interventions for post-stroke depression, vocational rehabilitation, and tailored programs for encouraging physical activity may be needed to improve the HRQoL in Korean stroke survivors. [ABSTRACT FROM AUTHOR]

The conventional tools to measure spasticity exhibited insufficient test-retest or inter-rater reliability. Therefore, the spasticity measurement using an isokinetic device has been proposed to improve these reliabilities of the angle of catch (AoC) measurements; however, this proposal has not been investigated in a standardized manner. In this study, the comparison of the AoC measurement was performed using two modes (isokinetic and manual motion) to investigate whether the standardized isokinetic motion could increase the reliabilities. Motion consistency was calculated using a newly developed index. To analyze the effect of the motion standardization, AoC were estimated using EMG data for both modes, and to compare the measurement reliability, AoC for isokinetic mode was estimated using both EMG and torque data. Although the test-retest reliability for manual motion was excellent, the use of isokinetic motion improved it to the level of extremely excellent. Intraclass correlation coefficient (ICC) for the inter-rater reliability of manual motion was 0.788, which was near the lower limit of the excellent. Isokinetic motion improved it to the ICC of 0.890 and 0.931 based on the EMG and torque, respectively. These improvements in reliabilities reduced the measurement errors, sample size, and need for the same rater in clinical trials. [ABSTRACT FROM AUTHOR]

Motion analysis of the hyoid bone via videofluoroscopic study has been used in clinical research, but the classical manual tracking method is generally labor intensive and time consuming. Although some automatic tracking methods have been developed, masked points could not be tracked and smoothing and segmentation, which are necessary for functional motion analysis prior to registration, were not provided by the previous software. We developed software to track the hyoid bone motion semi-automatically. It works even in the situation where the hyoid bone is masked by the mandible and has been validated in dysphagia patients with stroke. In addition, we added the function of semi-automatic smoothing and segmentation. A total of 30 patients’ data were used to develop the software, and data collected from 17 patients were used for validation, of which the trajectories of 8 patients were partly masked. Pearson correlation coefficients between the manual and automatic tracking are high and statistically significant (0.942 to 0.991, P-value<0.0001). Relative errors between automatic tracking and manual tracking in terms of the x-axis, y-axis and 2D range of hyoid bone excursion range from 3.3% to 9.2%. We also developed an automatic method to segment each hyoid bone trajectory into four phases (elevation phase, anterior movement phase, descending phase and returning phase). The semi-automatic hyoid bone tracking from VFSS data by our software is valid compared to the conventional manual tracking method. In addition, the ability of automatic indication to switch the automatic mode to manual mode in extreme cases and calibration without attaching the radiopaque object is convenient and useful for users. Semi-automatic smoothing and segmentation provide further information for functional motion analysis which is beneficial to further statistical analysis such as functional classification and prognostication for dysphagia. Therefore, this software could provide the researchers in the field of dysphagia with a convenient, useful, and all-in-one platform for analyzing the hyoid bone motion. Further development of our method to track the other swallowing related structures or objects such as epiglottis and bolus and to carry out the 2D curve registration may be needed for a more comprehensive functional data analysis for dysphagia with big data. [ABSTRACT FROM AUTHOR]

Virtual home-based rehabilitation is an emerging area in stroke rehabilitation. Functional assessment tools are essential to monitor recovery and provide current function-based rehabilitation. We developed the Fugl-Meyer Assessment (FMA) tool using Kinect (Microsoft, USA) and validated it for hemiplegic stroke patients. Forty-one patients with hemiplegic stroke were enrolled. Thirteen of 33 items were selected for upper extremity motor FMA. One occupational therapist assessed the motor FMA while recording upper extremity motion with Kinect. FMA score was calculated using principal component analysis and artificial neural network learning from the saved motion data. The degree of jerky motion was also transformed to jerky scores. Prediction accuracy for each of the 13 items and correlations between real FMA scores and scores using Kinect were analyzed. Prediction accuracies ranged from 65% to 87% in each item and exceeded 70% for 9 items. Correlations were high for the summed score for the 13 items between real FMA scores and scores obtained using Kinect (Pearson’s correlation coefficient = 0.873, P<0.0001) and those between total upper extremity scores (66 in full score) and scores using Kinect (26 in full score) (Pearson’s correlation coefficient = 0.799, P<0.0001). Log transformed jerky scores were significantly higher in the hemiplegic side (1.81 ± 0.76) compared to non-hemiplegic side (1.21 ± 0.43) and showed significant negative correlations with Brunnstrom stage (3 to 6; Spearman correlation coefficient = -0.387, P = 0.046). FMA using Kinect is a valid way to assess upper extremity function and can provide additional results for movement quality in stroke patients. This may be useful in the setting of unsupervised home-based rehabilitation. [ABSTRACT FROM AUTHOR]

Background: Early identification of patients with stroke-induced aphasia is essential because it is a significant disability affecting daily life and is linked to poor functional outcome after stroke. However, most patients with stroke are unable to undergo aphasia evaluation and detection and therefore remain undiagnosed. The purpose of this study is to develop a valid, reliable mobile aphasia screening test (MAST) for patients in remote locations. Materials and Methods: To accomplish this, we enrolled patients with (n =30) and without (n =30) stroke-induced aphasia. A MAST, which adopted the Korean version of the shortened version of the Frenchay Aphasia Screening Test (K-FAST), was designed as an iPad® (Apple, Cupertino, CA) application. To validate the MAST, we compared its performance with that of the Korean version of the Western Aphasia Battery (K-WAB) and conventional shortened FAST paper version (K-FAST). We analyzed interrater and internal reliability, using Cronbach's alpha coefficient, and assessed the diagnostic sensitivity, specificity, and power. Results: There was significant correlation between K-FAST and MAST (intraclass correlation coefficient [ICC]=0.995, p <0.001). MAST also had a high correlation with K-WAB (ICC=0.752, p <0.001). Interrater reliability was very high (ICC=0.999, p <0.001). The test had high sensitivity (90.0%) and specificity (73.3%) with an accuracy of 0.930 (95% confidence interval=0.853-1.000). The MAST is a valid and reliable tool for detecting aphasia in patients with stroke. Conclusions: This telescreening test may overcome the limitations of test administration and may be a convenient and cost-effective alternative to the existing aphasia screening tests for patients with stroke. [ABSTRACT FROM AUTHOR]

Background/Aims: The early cognitive continuum has been emphasized recently. We sought to characterize the functional and physical aspects of the cognitive continuum in subjects with no cognitive impairment (NCI), subjective cognitive impairment (SCI), nonamnestic (NA-MCI), and amnestic mild cognitive impairment (A-MCI). Furthermore, we identified the potential diagnostic utility of specific functional tasks. Methods: A total of 702 participants, aged ≥65 years and defined as NCI, SCI, NA-MCI, and A-MCI according to the original Petersen criteria, were included. They completed the Korean basic (K-ADL) and Instrumental Activities of Daily Living Scales (K-IADL) and the Performance-Oriented Mobility Assessment (POMA). Results: Significant differences were observed between the different cognitive status groups in three items and total scores on the K-ADL, six items and total scores on the K-IADL and POMA. Controlling for confounding factors revealed that subjects from the A-MCI group performed poorly at bathing, shopping, handling money, and the sum of assorted functional items. Conclusion: These findings demonstrated the declining feature of functional and physical performance according to the cognitive continuum, with A-MCI being discriminative with respect to specific functional tasks as compared to milder cognitive statuses. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Highlights: [•] This is a study investigating the mechanism of repetitive transcranial magnetic stimulation in the cellular level. [•] Repetitive transcranial magnetic stimulation over the cerebellum has effects on glucose metabolism in the cerebellar cortex. [•] Repetitive transcranial magnetic stimulation could change gene expression and protein synthesis in the cerebellar synapse. [Copyright &y& Elsevier]

Although it has been reported that strengthening exercise in stroke patients is beneficial for their motor recovery, there is little evidence about which exercise method is the better option. The purpose of this study was to compare isotonic and isokinetic exercise by surface electromyography (EMG) analysis using standardized methods. Nine stroke patients performed three sets of isotonic elbow extensions at 30% of their maximal voluntary isometric torque followed by three sets of maximal isokinetic elbow extensions with standardization of mean angular velocity and the total amount of work for each matched set in two strengthening modes. All exercises were done by using 1-DoF planner robot to regulate exact resistive torque and speed. Surface electromyographic activity of eight muscles in the hemiplegic shoulder and elbow was recorded. Normalized root mean square (RMS) values and co-contraction index (CCI) were used for the analysis. The isokinetic mode was shown to activate the agonists of elbow extension more efficiently than the isotonic mode (normalized RMS for pooled triceps: 96.0±17.0 (2nd), 87.8±14.4 (3rd) in isokinetic, 80.9±11.0 (2nd), 81.6±12.4 (3rd) in isotonic contraction, F[1,8]=11.168; P =0.010) without increasing the co-contraction of muscle pairs, implicating spasticity or synergy. [ABSTRACT FROM AUTHOR]

Objectives To investigate the relationship between dysphagia and mild cognitive impairment ( MCI) in older adults residing in an independent-living facility in Korea. Design Population-based, cross-sectional study. Setting Seongnam, Korea. Participants Korean men and women aged 65 and older living in a typical South Korean city (n = 415) were enrolled in the Korean Longitudinal Study on Health and Aging. Measurements Dysphagia was assessed using the Standardized Swallowing Assessment ( SSA). Cognitive function was evaluated using the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease Neuropsychological Assessment Battery, digit span test, and lexical fluency test. MCI was diagnosed using operational diagnostic criteria and further classified into amnestic and nonamnestic MCI. Results Men with nonanmestic MCI had a greater likelihood of having dysphagia (odds ratio ( OR) = 3.77, 95% confidence interval ( CI) = 1.12-12.72) than men without MCI. Men with nonanmestic MCI were almost six times as likely to have dysphagia ( OR = 5.78, 95% CI = 1.15-29.27) as men with no neurological disorder after adjusting for age, education level, current smoking and drinking, diabetes mellitus, and apolipoprotein E-4 carrier status. Conclusion Men with nonamnestic MCI were more likely to have dysphagia than were their counterparts without MCI, whereas this difference was not found in men with amnestic MCI and women. Assessment of executive functions that interfere with planning of motor activities may be useful in predicting dysphagia and in planning preventive and therapeutic strategies for older men. [ABSTRACT FROM AUTHOR]

Abstract: The aim of the study is to compare factors associated with physical performance in older individuals with severe knee osteoarthritis and those with less-severe osteoarthritis. This is an ancillary cross-sectional study to a population-based cohort study focusing on Koreans age 65 years or older. The analysis included 553 subjects with information about knee pain, depressive symptoms, and comorbidities collected by self-reported questionnaire, and body weight, knee osteoarthritis severity, muscle strength, and physical measures by observer-rated tests. Stepwise logistic regression analyses were performed with physical performance as an outcome variable and the others as independent variables across radiographic knee osteoarthritis severity. In the minimal-to-moderate-severity group, muscle strength, knee pain, BMI, and age were related to poor performance (OR [CI] 0.81 [0.73–0.90], 1.12 [1.03–1.21], 0.87 [0.79–0.96], and 1.09 [1.05–1.14], respectively). In the severe group, muscle strength was the only factor significantly associated with poor performance (OR [CI] 0.72 [0.58–0.89]). Muscle strength, knee pain, and BMI were important determinants of physical performance in the older population with knee osteoarthritis. In severe knee osteoarthritis patients, muscle strength was the only significant determinant. [Copyright &y& Elsevier]

Background: the relationship between muscle mass and physical performance has not been consistent among studies.Objective: to clarify the relationship between muscle mass and physical performance in older adults with weak muscle strength.Design: cross-sectional analysis using the baseline data of 542 older men and women from the Korean Longitudinal Study on Health and Aging.Methods: dual X-ray absorptiometry, isokinetic dynamometer and the Short Physical Performance Battery (SPPB) were performed. Two muscle mass parameters, appendicular skeletal mass divided by weight (ASM/Wt) and by height squared (ASM/Ht2), were measured. We divided the participants into a lower-quartile (L25) group and an upper-three-quartiles (H75) group based on the knee-extensor peak torque. Correlation analysis and logistic regression models were used to assess the association between muscle mass and low physical performance, defined as SPPB scores <9, after controlling for confounders.Results: in the L25 group, no correlation between mass and SPPB was detected, whereas the correlation between peak torque and SPPB was significant and higher than that in the H75 group. Results from the logistic models also showed no association between muscle mass and SPPB in the L25 group, whereas muscle mass was associated with SPPB in the H75 group.Conclusion: muscle mass was not associated with physical performance in weak older adults. Measures of muscle strength may be of greater clinical importance in weak older adults than is muscle mass per se. [ABSTRACT FROM AUTHOR]

Purpose: Transcranial direct current stimulation (tDCS) combined with swallowing training might improve swallowing function in patients with post-stroke dysphagia. We investigate the effects of transcranial direct current stimulation (tDCS) combined with swallowing training on post-stroke dysphagia. Methods: Sixteen patients with post-stroke dysphagia, diagnosed using video fluoroscopic swallowing (VFSS), were randomly assigned into two groups: (1) anodal tDCS group (1 mA for 20 min), or (2) sham group (1 mA for 30 s). Patients received anodal tDCS or sham over the pharyngeal motor cortex of the affected hemisphere during 30 min of conventional swallowing training for 10 days. Functional dysphagia scale (FDS) scores based on VFSS were measured at baseline and immediately and 3 months after the intervention. The effect of tDCS on dysphagia was analyzed using a generalized linear model (GLM) with repeated measures. Results: After the intervention, FDS scores improved in both groups without significant differences. However, 3 months after the intervention, anodal tDCS elicited greater improvement in terms of FDS compared to the sham group (β = -7.79, p = 0.041) after controlling for age, National Institutes of Health Stroke Scale (NIHSS) score, lesion size, baseline FDS score, and time from stroke onset. Conclusions: Anodal tDCS applied over the affected pharyngeal motor cortex can enhance the outcome of swallowing training in post-stroke dysphagia. Our results suggest that non-invasive cortical stimulation has a potential role as an adjuvant strategy during swallowing training in patients with post-stroke dysphagia. [ABSTRACT FROM AUTHOR]

Purpose: Previous reports have suggested that noninvasive cortical stimulation could influence speech production in patients with chronic stroke. Here, we evaluated the hypothesis that cathodal transcranial DC stimulation (ctDCS), a technique that decreases excitability of stimulated cortical sites, applied over a healthy right Broca's homologue area could improve picture naming in patients with post-stroke aphasia. Methods: Ten right-handed patients with post-stroke aphasia were enrolled in this double blind, counterbalanced sham-controlled, crossover study. Each patient received an intervention of ctDCS (2 mA for 20 min) and of sham tDCS (2 mA for 1 min) daily for 5 consecutive days in a randomized crossover manner with a minimum interval of one week between interventions, over a healthy right Broca's homologue area using a left supraorbital anode and simultaneous daily sessions of conventional word-retrieval training. The primary endpoint measure of this study was a standardized, validated Korean version of the Boston Naming Test, which is a measure of picture naming skills. Results: ctDCS was not found to have any adverse effects. Furthermore, significantly improved picture naming (p = 0.02) was observed at 1 hour following the last (5th) ctDCS treatment session, but no changes were observed after sham tDCS. Conclusion: These results demonstrate that cathodal tDCS over the right healthy Broca's homologue area with a left supraorbital anodal location can improve picture naming task performance in post-stroke aphasia. [ABSTRACT FROM AUTHOR]

Background and Purpose: Intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) has demonstrated favorable clinical outcomes in a 3-6 h window in patients selected with perfusion/diffusion mismatch. However, the advantages of combined IV and intraarterial (IA) thrombolysis after 3 h of stroke onset are unexplored.Methods: Acute ischemic stroke patients with persistent occlusion of intracranial large arteries were screened prospectively for thrombolysis by evaluating perfusion/diffusion mismatch on MRI. The IV rt-PA was initiated within 3-6 h, and additional urokinase (UK) was then administered via the IA route after angiography.Results: Four patients had middle cerebral artery occlusion and one patient had an internal carotid artery occlusion. The median time from the symptom onset to the initiation of IV therapy and to the initiation of IA treatment was 215 +/- 30 min and 292 +/- 41 min, respectively. The median National Institutes of Health Stroke Scale (NIHSS) scores were as follows: initial, 13; immediately after IA treatment, 8; at 24 h, 5; and at 7 days, 3. The Thrombolysis in Myocardial Infarction (TIMI) score after the completion of thrombolysis was 2-3. Four patients without intracerebral hemorrhage recovered completely or exhibited mild disability and one patient with hemorrhage also demonstrated a favorable outcome.Conclusion: This preliminary result suggests that if a significant perfusion/diffusion mismatch on MRI is identified, a sequential combination thrombolysis of IV rt-PA and IA UK is potentially beneficial in moderate to severe acute ischemic stroke patients who are treated within 3-6 h after symptom onset. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to assess the sexual function and activity in male patients on clean intermittent catheterization with neurogenic bladder due to spinal cord injury. Methods: Eighty-nine patients (mean age 37.6 years with a range of 18–66) were included in the study. We requested all subjects to complete a questionnaire including the 5-item version of the International Index of Erectile Function (IIEF-5). Results: Of 89 patients, 60 (67.4%) reported having attempted no sexual intercourse over the past 6 months and 28 (31.5%) presented with IIEF-5 scores less than or equal to 21 points. When subjects were stratified according to the years since injury, 50.0% (16 of 32) with less than 2 years post-injury had no sexual activity, while 77.2 (44 of 57) with 2 years or more post-injury did ( P = 0.027). Patients with sexual activity were 40.4% (23 of 57) and 18.8% (6 of 32) in patients who were able and unable to perform self-catheterization, respectively ( P = 0.037). Patients with less than 2 years post-injury had 3.3-fold higher risk (odds ratio 3.33; 95% confidence interval 1.01–10.97; P = 0.048) of no sexual activity than those with 2 years or more post-injury on the multivariate model. The other parameters were not appreciably related to sexual activity. Conclusion: Our results demonstrate that sexual activity as well as erectile function is poor in this population. In addition, our findings suggest that years since injury may influence sexual activity of patients with spinal cord injury. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To determine the psychological and social status of patients using clean intermittent catheterization for neurogenic bladder according to health-related quality of life (HRQOL). Methods: We conducted a prospective trial involving 132 patients (81 men and 51 women, mean age 41.8 years, range 18 to 80 years) using clean intermittent catheterization because of neurogenic bladder secondary to spinal cord injury. The 150 controls (90 men and 60 women) lived in the same region as the patients and were frequency matched to ensure equal age and sex distributions. HRQOL was measured using the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36). Results: The SF-36 scores did not reveal any significant differences between the men and women in the patient group. The SF-36 scores of the patients were significantly lower than those of the general population. When patients and controls were divided into two groups according to sex and age, the SF-36 scores of the patients were significantly lower than the controls across both sex and all age groups, other than the energy and vitality scale, the differences for which were not statistically significant in women and those younger than 50 years. Conclusions: Our findings suggest that patients using clean intermittent catheterization because of neurogenic bladder secondary to spinal cord injury generally exhibit a reduced quality of life in all health domains as assessed by the SF-36. [Copyright &y& Elsevier]

Subcortical aphasia develops as a result of damage to subcortical brain areas without loss of cortical functions. Although earlier voxel-based lesion-symptom mapping (VLSM) studies have shown possible neural correlates for aphasia, it remains to be clarified which brain regions are associated with subcortical aphasia. The aim of this study was to investigate the neural substrates associated with subcortical aphasia in patients with stroke using VLSM and atlas-based analyses to explore the involvement of white matter tracts and subcortical structures. Fifty patients with subacute subcortical stroke without cortical involvement were retrospectively enrolled: 24 with and 26 without aphasia. We performed VLSM and atlas-based analyses of the patients' fluid-attenuated inversion recovery images and found that the left perisylvian white matter, left fronto-occipital fasciculus, uncinate fasciculus, and forceps minor were significantly more greatly affected in the aphasia than in the non-aphasia group. The left anterior thalamic radiation, cingulum (cingulate gyrus), and superior longitudinal fasciculus also showed higher involvement in this group (marginal significance). Among the subcortical regions, the left caudate and putamen were more greatly involved in the aphasia group. Our findings confirm language processing as one of the integrated sensory-motor processes that occur in the region around the left sylvian fissure. Our atlas-based analysis approach can be used to complement VLSM analyses. • The aim of this study was to investigate the structural neural substrates of subcortical aphasia using VLSM. • The significantly affected white matter tracts in the aphasia group were the left IFO, UNC, and forceps minor. • Left caudate and putamen were more affected lesions in aphasia group compared to non-aphasic group. [ABSTRACT FROM AUTHOR]

Neurorehabilitation for stroke is important for upper limb motor recovery. Conventional rehabilitation such as occupational therapy has been used, but novel technologies are expected to open new opportunities for better recovery. Virtual reality (VR) is a technology with a set of informatics that provides interactive environments to patients. VR can enhance neuroplasticity and recovery after a stroke by providing more intensive, repetitive, and engaging training due to several advantages, including: (1) tasks with various difficulty levels for rehabilitation, (2) augmented real-time feedback, (3) more immersive and engaging experiences, (4) more standardized rehabilitation, and (5) safe simulation of real-world activities of daily living. In this comprehensive narrative review of the application of VR in motor rehabilitation after stroke, mainly for the upper limbs, we cover: (1) the technologies used in VR rehabilitation, including sensors; (2) the clinical application of and evidence for VR in stroke rehabilitation; and (3) considerations for VR application in stroke rehabilitation. Meta-analyses for upper limb VR rehabilitation after stroke were identified by an online search of Ovid-MEDLINE, Ovid-EMBASE, the Cochrane Library, and KoreaMed. We expect that this review will provide insights into successful clinical applications or trials of VR for motor rehabilitation after stroke. [ABSTRACT FROM AUTHOR]